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Acupuncture for schizophrenia: a systematicreview and meta-analysis
M. S. Lee,1,2 B.-C. Shin,3 P. Ronan,4 E. Ernst2
Introduction
Schizophrenia is a mental illness that is among the
worlds ten most important causes of long-term dis-
ability (1). Antipsychotic medications are the main-
stay for managing schizophrenia. The adverse events
associated with such treatments lead patients to seek
complementary and alternative medicine (CAM),
usually as adjuncts to conventional medicine (2,3).
The main motivation for using CAM is the hope for
improvements in mood and alleviation of psychiatric
symptoms (4). In many countries, the social circum-
stances of people with schizophrenia limit their abil-
ity to access CAM (5).
Acupuncture is one of the most popular types of
CAM. It is sometimes used as a treatment for schizo-
phrenia (3) and claimed to be effective in improving
mood including anxiety and depression (4,6,7). Con-
sidering these facts, it is pertinent to investigate the
effectiveness of acupuncture for treating schizophre-
nia. Currently, two reviews of this subject are available
(8,9). Unfortunately, they included only publications
published before 2001 and are now out of date.
The objective of this systematic review was to
summarise and critically assess the evidence from
randomised clinical trials (RCTs) for or against the
effectiveness of acupuncture in treating schizophre-
nia.
SUMMARY
Background: Acupuncture is one of the most popular types of complemen-
tary alternative medicine. It is sometimes used as a treatment for schizophrenia.Aims: The objective of this review is to assess systematically the clinical evidence
for or against acupuncture as a treatment for schizophrenia. Methods: We
searched 20 databases from their inception to May 2009 without language restric-
tions. All randomised clinical trials (RCTs) of acupuncture, with or without electrical
stimulation or moxibustion for patients with schizophrenia were considered for
inclusion. Results: Thirteen RCTs, all originating from China, met the inclusion cri-
teria. One RCT reported significant effects of electroacupuncture (EA) plus drug
therapy for improving auditory hallucunations and positive symptom compared with
sham EA plus drug therapy. Four RCTs showed significant effects of acupuncture
for response rate compared with antipsychotic drugs [n = 360, relative risk (RR):
1.18, 95% confidence interval (CI): 1.031.34, p = 0.01; heterogeneity:
s2 = 0.00, v2 = 2.98, p = 0.39, I2 = 0%]. Seven RCTs showed significant effectsof acupuncture plus antipsychotic drug therapy for response rate compared with
antipsychotic drug therapy (n = 457, RR: 1.15, 95% CI: 1.041.28, p = 0.008,
heterogeneity: s2 = 0.00, v2 = 6.56, p = 0.36, I2 = 9%). Two RCTs tested laseracupuncture against sham laser acupuncture. One RCT found beneficial effects of
laser acupuncture on hallucination and the other RCT showed significant effects of
laser acupuncture on response rate, Brief Psychiatric Rating Scale and clinical glo-
bal index compared with sham laser. The methodological quality was generally
poor and there was not a single high quality trial. Conclusion: These results pro-
vide limited evidence for the effectiveness of acupuncture in treating the symptoms
of schizophrenia. However, the total number of RCTs, the total sample size and
the methodological quality were too low to draw firm conclusions. As all studies
originated from China, international studies are needed to test whether there is
any effect.
Review CriteriaWe included all randomised clinical trials of
acupuncture to treat human patients suffering from
schizophrenia after searching 20 databases from
their inception to May 2009, without language
restrictions.
Message for the ClinicAcupuncture is one of the most popular types of
CAM. It is sometimes used as a treatment for
schizophrenia. The results of our systematic review
and meta-analysis provided limited evidence for the
effectiveness of acupuncture in treating the
symptoms of schizophrenia.
1Division of Standard Research,
Korea Institute of Oriental
Medicine, Daejeon, South Korea2Complementary Medicine,
Peninsula College of Medicine
& Dentistry, Universities of
Exeter & Plymouth, Exeter, UK3Department of Oriental
Rehabilitation Medicine, School
of Oriental Medicine, Pusan
National University, Yangsan,
South Korea4Department of Social Work,
Community and Mental Health,
Canterbury Christ Church
University, Kent, UK
Correspondence to:
Myeong Soo Lee, Division of
Standard Research, Korea
Institute of Oriental Medicine,
461-24, Jeonmin-dong,
Yuseong-gu, Daejeon 305-811,
Korea
Tel.: + 82 42 868 9266
Fax: + 82 42 863 9464
Email: [email protected];
Disclosure
None.
Linked Comment: Samuels. Int J Clin Pract 2009; 63: 15535.
META-ANALYS IS
2009 Blackwell Publishing Ltd Int J Clin Pract, November 2009, 63, 11, 162216331622 doi: 10.1111/j.1742-1241.2009.02167.x
-
Methods
Data sourcesThe following electronic databases were searched from
inception up to May 2009: Medline, AMED, British
Nursing Index, CINAHL, EMBASE, PsycInfo, The
Cochrane Library 2009 (Issue 2), six Korean Medical
Databases (Korean Studies Information, DBPIA,
Korea Institute of Science and Technology Informa-
tion, Research Information Centre for Health Data-
base, Korean Medline, and Korean National Assembly
Library), four Chinese Medical Databases (China
Academic Journal, Century Journal Project, China
Doctor Master Dissertation Full Text DB, andChina Proceedings Conference Full Text DB) and
three Japanese Medical Databases. The search terms
used were acupuncture AND schizophrenia. We also
manually searched our departmental files and relevant
journal [Focus on Alternative and Complementary
Therapies (FACT) and Forschende Komplementar-
medizin und Klassische Naturheilkunde (Research in
Complementary and Classical Natural Medicine) up
to May 2009]. In addition, the references in all located
articles were manually searched for further relevant
articles.
Study selectionAll articles were included that reported an RCT in
which human patients with schizophrenia were
treated with needle acupuncture with or without elec-
trical stimulation. Trials were included if they
employed acupuncture as the sole treatment or as an
adjunct to other treatments (if the control group also
received the same concomitant treatment as the
acupuncture group). Trials testing other forms of
acupuncture, such as laser acupuncture or moxibus-
tion were included. Those comparing two different
forms of acupuncture and those in which no clinical
data were reported were excluded. Any trials with
acupuncture as a part of a complex intervention were
also excluded. No language restrictions were also
imposed. Dissertations and abstracts were included.
Data extraction and assessment of risk of biasHard copies of all articles were obtained and read in
full. All articles were read by two independent review-
ers (MSL, BCS), and data from the articles were vali-
dated and extracted according to predefined criteria.
Risk of bias was assessed using the Cochrane classi-
fication in four criteria: randomisation, blinding,
withdrawals and allocation concealment (10). Consid-
ering that it is very hard to blind therapists to the use
of acupuncture, we assessed patient and assessor
blinding separately. Discrepancies were resolved
through discussions between two reviewers (MSL,
BCS) and if needed, by seeking the opinion of a third
reviewer (EE). There were no disagreements between
the three reviews about the assessment of risk of bias.
Data synthesisTo summarise the effects of acupuncture on
outcomes (response rate), we abstracted the risk
estimates (relative risk: RR) and weighted mean
differences (WMD), and 95% confidence interval
(CI) was calculated using the Cochrane Collabora-
tions software [Review Manager (RevMan) Version
5.0 for Windows; The Nordic Cochrane Centre,
Copenhagen, Denmark]. For studies with insufficient
information, we contacted the primary authors to
acquire and verify data wherever possible. The vari-
ance of the change was imputed using a correlation
factor of 0.4 as suggested by the Cochrane Collabora-
tion. If appropriate, we then pooled the data across
studies using random effects models (if excessive
statistical heterogeneity did not exist). The v2 test, s2
and the Higgins I2 test were used to assess hetero-
geneity (11).
Results
Study descriptionThe searches identified 87 potentially relevant articles,
of which 13 met our inclusion criteria (Figure 1). All
of the included RCTs originated from China. The key
data are summarised in Table 1 (1223). Manual acu-
puncture alone was used in four trials (13,14,16) [one
(13) of them included two different studies], electro-
acupuncture (EA) was employed in seven trials
(12,15,1721) and laser acupuncture was used in two
trials (22,23). A placebo procedure was employed in
three trials (12,22,23) and conventional pharmacolog-
ical drug therapy in 10 trials (1321). Seven of the
included trials adopted a two-arm parallel group
design (12,1621), three adopted a three-arm parallel
group design (14,22,23) and three a four-arm parallel
group design (13,15). Eight trials adopted the princi-
ples of Chinese Classification of Metal Disorders
(CCMD) second edition revision (13,14,17) or third
edition (16,1921), descriptive definitions of which
were based on the clinical description and diagnostic
guideline of ICD 10 and DSM-IV (24), for diagnosis
of Schizophrenia, and another three studies diagnosed
Schizophrenia according to DSM-III (18,23) and
DSM-IV (12). The other RCTs did not mention the
diagnostic methods employed (15,22). Subjects with
type II (negative) schizophrenia, which was described
as clinical poverty syndrome involving social with-
drawal, poverty of content and production of thought
and speech (2527), were included in four RCTs
(13,16,19,21), type I (positive) as characterised by
Acupuncture for schizophrenia 1623
2009 Blackwell Publishing Ltd Int J Clin Pract, November 2009, 63, 11, 16221633
-
hallucinations, delusions and formal thought disorder
(2527), in one RCT (13), paranoid type in two stud-
ies (22,23), hebetic type in one trial (14), all types in
two RCTs (15,20). The other two studies did not
report details about it (17,18). Most of the included
studies used response rate for each intervention and
it was generally divided into four categories including
(1) recovery, (2) marked improvement, (3) improve-
ment (4) and no change by practitioners. Table 2
shows the summary of treatment acupuncture points
and other information related with acupuncture. The
rationale for the point selection as stated was made
according to Traditional Chinese Medicine theory
(13,14,1621,23), classic book (15,17), previous
reports (12,22) or their clinical experience (12,14,19).
Assessment of risk of biasThe included trials had high risk of bias except one
recent RCT (12). Four RCTs described the methods of
randomisation (12,14,20,21). In three (12,14,20) of
them, the method was appropriate, whilst in the
fourth trial it was not (21). Details of drop-outs or
withdrawals were described in two trials (12,21). One
RCT (12) reported details about allocation conceal-
ment and ethical approval from Institutional Review
Board, whilst the others failed to do so. Three RCTs
adopted subject blinding (12,22,23) and three RCTs
employed assessor blinding (12,16,18). Adverse events
were mentioned in nine studies (1214,1823).
Outcomes
Acupuncture plus risoperidone vs. shamacupuncture plus risoperidoneOne RCT (12) tested EA plus risoperidone on Psy-
chotic Symptom Rating Scales Auditory Hallucina-
tion Subscale (PSYRATS-AH) and Positive and
Negative Symptom Scale (PANSS) compared with
Figure 1 Flow chart of trial selection process
1624 Acupuncture for schizophrenia
2009 Blackwell Publishing Ltd Int J Clin Pract, November 2009, 63, 11, 16221633
-
Tab
le1
Sum
mar
yo
fra
nd
om
ised
clin
ical
stu
die
so
fac
up
un
ctu
refo
rsc
hiz
op
hre
nia
*
Firs
tau
tho
r(y
ear)
(ref
)
Sam
ple
size
Dura
tio
no
f
schiz
op
hre
nia
(yea
rs)
Dia
gno
sis
Exp
erim
enta
l
inte
rven
tio
n
(Reg
imen
)
Co
ntr
ol
inte
rven
tio
n
(Reg
imen
)
Mai
n
outc
om
es
Mai
nre
sult
s
Inte
rgro
up
dif
fere
nce
Ris
ko
fb
ias
Che
ng(2
009)
(12)
60A
llsc
hizo
phre
nia
with
audi
tory
hallu
cina
tions
109
(aud
itory
hallu
cina
tion)
DSM
-IV
(A)
EA(s
pars
ede
nse
wav
e,
2-10
Hz,
23
mA
,
20m
in,
five
times
wee
kly
over
6w
eeks
,to
tal
30se
ssio
n,n
=30
),pl
usris
perid
one
(ave
rage
dos:
5.15
mg
day
s),
conc
omita
nt
lora
zepa
m(