Acupuncture for schizophrenia: Cochrane systematic review
Assessed as up to date: 2014/08/19
Acupuncture, with many categories such as traditional acupuncture, electroacupuncture, laser acupuncture, and acupoint injection, has been shown to be relatively safe with few adverse effects. It is accessible and inexpensive, at least in China, and is likely to be widely used there for psychotic symptoms.Objectives
To review the effects of acupuncture, alone or in combination treatments compared with placebo (or no treatment) or any other treatments for people with schizophrenia or related psychoses.Search methods
We searched Cochrane Schizophrenia Group’s Trials Register (February 2012), which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO and clinical trials registries. We also inspected references of identified studies and contacted relevant authors for additional information.Selection criteria
We included all relevant randomised controlled trials involving people with schizophrenia-like illnesses, comparing acupuncture added to standard dose antipsychotics with standard dose antipsychotics alone, acupuncture added to low dose antipsychotics with standard dose antipsychotics, acupuncture with antipsychotics, acupuncture added to Traditional Chinese Medicine (TCM) drug with TCM drug, acupuncture with TCM drug, electric acupuncture convulsive therapy with electroconvulsive therapy.Data collection and analysis
We reliably extracted data from all included studies, discussed any disagreement, documented decisions and contacted authors of studies when necessary. We analysed binary outcomes using a standard estimation of risk ratio (RR) and its 95% confidence interval (CI). For continuous data, we calculated mean differences with 95% CI. For homogeneous data we used fixed-effect model. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.Main results
After an update search in 2012 the review now includes 30 studies testing different forms of acupuncture across six different comparisons. All studies were at moderate risk of bias.
When acupuncture plus standard antipsychotic treatment was compared with standard antipsychotic treatment alone, people were at less risk of being 'not improved' (n = 244, 3 RCTs, medium-term RR 0.40 CI 0.28 to 0.57, very low quality evidence). Mental state findings were mostly consistent with this finding as was time in hospital (n = 120, 1 RCT, days MD -16.00 CI -19.54 to -12.46, moderate quality evidence). If anything, adverse effects were less for the acupuncture group (e.g. central nervous system, insomnia, short-term, n = 202, 3 RCTs, RR 0.30 CI 0.11 to 0.83, low quality evidence).
When acupuncture was added to low dose antipsychotics and this was compared with standard dose antipsychotic drugs, relapse was less in the experimental group (n = 170, 1 RCT, long-term RR 0.57 CI 0.37 to 0.89, very low quality evidence) but there was no difference for the outcome of 'not improved'. Again, mental state findings were mostly consistent with the latter. Incidences of extrapyramidal symptoms - akathisia, were less for those in the acupuncture added to low dose antipsychotics group (n = 180, 1 RCT, short-term RR 0.03 CI 0.00 to 0.49, low quality evidence) - as dry mouth, blurred vision and tachycardia.
When acupuncture was compared with antipsychotic drugs of known efficacy in standard doses, there were equivocal data for outcomes such as 'not improved' using different global state criteria. Traditional acupuncture added to TCM drug had benefit over use of TCM drug alone (n = 360, 2 RCTs, RR no clinically important change 0.11 CI 0.02 to 0.59, low quality evidence), but when traditional acupuncture was compared with TCM drug directly there was no significant difference in the short-term. However, we found that participants given electroacupuncture were significantly less likely to experience a worsening in global state (n = 88, 1 RCT, short-term RR 0.52 CI 0.34 to 0.80, low quality evidence).
In the one study that compared electric acupuncture convulsive therapy with electroconvulsive therapy there were significantly different rates of spinal fracture between the groups (n = 68, 1 RCT, short-term RR 0.33 CI 0.14 to 0.81, low quality evidence). Attrition in all studies was minimal. No studies reported death, engagement with services, satisfaction with treatment, quality of life, or economic outcomes.Authors' conclusions
Limited evidence suggests that acupuncture may have some antipsychotic effects as measured on global and mental state with few adverse effects. Better designed large studies are needed to fully and fairly test the effects of acupuncture for people with schizophrenia.
Shen Xiaohong, Xia Jun, Adams Clive E
Acupuncture for schizophrenia
Although acupuncture or Traditional Chinese Medicine has been practised for over 2000 years in China and the Far East, especially in Korea and Japan, it is a relatively new form of treament for physical and psychological conditions in the West. Acupuncture inserts needles into the skin to stimulate specific points of the body (acupoints). The aim is to achieve balance and harmony of the body.
Schizophrenia is a serious mental illness and is usually treated using antipsychotic medication. However, although effective, antipsychotic medication can cause side-effects (such as sleepiness, weight gain and even dribbling). Acupuncture has been shown to have very few negative effects on the individual and could be more socially acceptable and tolerable for people with mental health problems. Acupuncture may also be less expensive than drugs made by pharmaceutical companies, so reducing costs to individuals and health services.
This reviews looks at the effectiveness of various types of acupuncture as treatment for people with schizophrenia. An update search for studies was carried out in 2012 and found 30 studies that randomised participants who were receiving antipsychotic medication to receive additional acupuncture or standard care.
Although some of the studies did favour acupuncture when combined with antipsychotics, the information available was small scale and rated to be very low or low quality by the review authors, so not completely provable and valid. Depression was reduced when combining acupuncture with antipsychotic medication, but again this finding came from small-scale research, so cannot be clearly shown to be true. The review concludes that people with mental health problems, policy makers and health professionals need much better evidence in order to establish if there are any potential benefits to acupuncture.
This means that the question of whether acupuncture is of benefit to people, and whether it is of greater benefit than antipsychotic medication, remains unanswered. There is not enough information to establish that acupuncture is of benefit or harm to people with mental health problems.
Benjamin Gray, Service User and Service User Expert, Rethink Mental Illness.
Implications for practice
1. For people with schizophrenia:
Acupuncture has been used for treating schizophrenia-like illnesses for over 2000 years. Though acupuncture as a complementary treatment has become more popular in the West (Zhang 2012), 29 of the 30 included studies were undertaken in China and the findings are more appropriate to a Chinese population. For this update, new studies were found to compare acupuncture added to a Traditional Chinese Medicine (TCM) drug with TCM drug, acupuncture with TCM drug, electric acupuncture convulsive therapy with electroconvulsive therapy and we separately analysed acupuncture added to standard dose antipsychotics versus standard dose antipsychotics or acupuncture adde to low dose antipsychotics versus standard dose antipsychotics. The limited evidence suggests that combining acupuncture with standard dose antipsychotics might benefit the individual's mental state especially in the short-term. Acupuncture appears to have some benefit related to relapse when added to low dose antipsychotics compared to standard dose antipsychotics along with a reduction of drug-related adverse effects.
2. For clinicians:
Adopting acupuncture to treat schizophrenia needs co-operation between psychiatrists and acupuncturists. Few data were available making the comparisons between acupuncture and antipsychotics, between acupuncture added to TCM drug and TCM, between acupuncture and TCM drug, and between electric acupuncture convulsive therapy and electroconvulsive therapy limited. Acupuncture treatment effects consists of three effects - special effects, non-special effects and psychological effects (Yang 2012). Without enough evidence, we could not draw conclusions if the effect of acupuncture when combining with antipsychotics is a placebo response. Without enough evidence we remain confused about the interaction between acupuncture and low dosage antipsychotic medication. Placebo and recognised effective drug-control in three-arm trials need to be conducted to provide strong evidence.
It is surprising that most of the studies used the Treatment Emergent Symptom Scale (TESS) or Rating Scale for Extrapyramidal Side Effects (RESES) to assess adverse effects, but few focused on acupuncture's relative adverse effects such as skin allergies. Though acupuncture has a long history, this intervention is still without a special acupuncture-relative adverse effects scale. Adverse effects of acupuncture for schizophrenia are inadequate.
3. For managers of policy makers:
Acupuncture as a valuable complementary medicine is gradually affecting the global medical treatment system. Only one study reported service outcomes and indicated that using acupuncture added to standard dose antipsychotics shorten hospitalisation days than using standard dose antipsychotics alone. This traditional treatment originating from ancient Chinese culture needs more real-word trials to evaluate the treatment method objectively and completely, not limited by assessing treatment effects and adverse effects but also focusing on social and economic conditions.
Implications for research
All studies should now comply with the Consolidated Standards of Reporting Trials (CONSORT, Moher 2001). More transparency in the reporting of randomised controlled trials, would enable readers to understand the design, conduct, analysis and interpretation, and to assess the validity of results. Although binary data is easier to interpret, where continuous data are used, some measure of variance should be provided. Data presented in graphs should be accompanied by exact numbers and standard deviations in the text.
There are further refinements of this review that could take place with better inclusion of additional data (Other outcomes authors reported, Adverse effects of acupuncture) and possibility of additional comparisons (Other comparisons of relevance to this systematic review). This review is already large and, in the future, it may be best to split this work into separate reviews per comparison with an 'overview' review.
In 2010, the STRICTA Group, CONSORT Group and the Chinese Cochrane Centre collaborated to develop STRICA (MacPherson 2010) to ensure that acupuncture trials are more accurately interpreted and more easily replicated. Further research is essential to inform both clinicians and patients about the effects of acupuncture in the treatment of schizophrenia. Trial methodology should follow both CONSORT (Moher 2001) and STRICTA guidelines.
Acupuncture is an important intervention that is likely to be widely used, at least, in China. Considering the limited data in this review, we do think that further large simple trials are indicated. This update highlights the need for standardised clinical trials, which evaluate acupuncture for people with schizophrenia, which thoroughly investigate effects of different categories of acupuncture, which investigate interaction in combination regimens, with trialists employing appropriate real-world methodology. We suggest such a design in Suggested design for a trial.
There are, however, specific issues to consider.Get full text at The Cochrane Library
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