Acupuncture Reduces Depressive Symptoms During Pregnancy With Few Adverse Effects

From MedscapeCME Clinical Briefs

News Author: Pam Harrison
CME Author: Laurie Barclay, MD

March 3, 2010 — Targeted acupuncture may offer women with major depression a safe and effective alternative to antidepressant medication, new research suggests.

Investigators at Stanford University School of Medicine in California found that women with major depressive disorder treated with depression-specific acupuncture had a 63% response rate after 12 sessions compared with a 44.3% response rate in 2 combined control groups who were treated with either acupuncture not known to help alleviate depressive symptoms or Swedish massage.

"Pregnancy just by its nature can bring out some underlying psychiatric and emotional issues ... but treatment of depression during pregnancy is critically important so that a woman can maintain her sense of well being and take good care of herself, her fetus and, someday, her child," study coauthor Deirdre Lyell, MD, Stanford University School of Medicine, said in a statement.

Led by Rachel Manber, PhD, the study was published in the March issue of Obstetrics & Gynecology.

Response Rates Significantly Higher

For the study, investigators randomized 150 women whose pregnancies were between 12 and 30 weeks of gestation and who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for major depressive disorder and who scored at least 14 on the 17-item Hamilton Rating Scale for Depression.

Of the 141 women who eventually entered the study, 52 received depression-specific acupuncture, 49 received control acupuncture, and 49 others received Swedish massage.

Treatments were provided twice a week for the first 4 weeks and then weekly thereafter for 4 additional weeks, with each session lasting about 25 minutes.

The investigators found that response rates were significantly higher in women who received depression-specific acupuncture than for either control group. Response rates in women randomized to the 2 control interventions did not differ significantly from each other at 37.5% for the control acupuncture group vs 50% for the massage group.

On the other hand, remission rates did not differ significantly between women who received depression-specific acupuncture at 34.8% and the combined control groups at 29.5%. They also did not differ between those assigned to the control acupuncture group at 27.5% or the massage group at 31.2%.

Thirty-three of the study participants discontinued treatment before the study endpoint, 30% of them for reasons related to the pregnancy. Some women in both acupuncture groups reported transient discomfort at the point of needle insertion, and 1 woman experienced bleeding at the needle site.

Significantly fewer women who received massage reported any adverse effects compared with the 2 acupuncture groups.

Clinically Meaningful

The study authors point out that the benefits observed with depression-specific acupuncture can be considered "clinically meaningful" when assessed in a broader context of depression studies.

Although there are no randomized controlled trials of antidepressants being used during pregnancy, 1 randomized controlled trial found that interpersonal psychotherapy produced a 52% reduction in Hamilton Rating Scale for Depression scores and a 19% remission rate after 16 weeks of therapy, to which the currently study compares very favorably.

According to the study, antidepressant use during pregnancy doubled between 1999 and 2003, but many women are reluctant to take these medications because of safety concerns. In fact, in this particular study, 94% of the women involved expressed reluctance to take an antidepressant because of their pregnancy.

"Because there’s this concern about medication among pregnant women and their physicians, it’s important to find an alternative," said Dr. Manber.

Results from this study therefore suggest that this standardized acupuncture protocol could be considered a "viable treatment option" for depression during pregnancy, the investigators conclude.

Michael Thase, MD, University of Pennsylvania School of Medicine, cautions that findings from this study are preliminary, although they suggest that depression-specific acupuncture may have value in major depressive disorder in this patient population.

On the other hand, another study assessing depression-specific acupuncture in a broader population of men and women with major depressive disorder failed to find a significant effect from the modality, so evidence supporting acupuncture for the treatment of major depressive disorder is not consistent.

"Still there is reason to be cautious when prescribing antidepressants in pregnancy, and one has to weigh the pros and cons of using an antidepressant on an individual basis,” he told Medscape Psychiatry.

"If these promising findings are confirmed, it would be good to have another option to complement the focused forms of psychotherapy which are currently used for antenatal depression," he added.

The study was funded by the Agency for Healthcare Research and Quality. The study authors and Dr. Thase have disclosed no relevant financial relationships.

Obstet Gynecol. 2010;115:511-520.

Clinical Context

Major depressive disorder may occur in up to 14% of pregnant women, possibly in response to hormonal fluctuations or anticipated lifestyle changes. Depression during pregnancy has been associated with poor birth outcomes and postpartum depression. Untreated depression during pregnancy may harm the mother as well as the baby, particularly if the mother neglects prenatal care or engages in self-destructive behavior.

Although the use of antidepressants during pregnancy doubled between 1999 and 2003, many depressed women are unwilling to take these medications while pregnant because of safety issues. It is therefore important to find a nonpharmacologic, safe yet effective treatment option for depression during pregnancy. Previous studies have shown that acupuncture is an effective treatment of depression in the general population.


Study Highlights

The goal of this randomized controlled trial was to estimate the efficacy of acupuncture for depression during pregnancy.
The study sample consisted of 150 pregnant women between 12 and 30 weeks of gestation who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for major depressive disorder.
Participants were randomly assigned to receive either depression-specific acupuncture (n = 52) or 1 of 2 active controls: control acupuncture (n = 49) or Swedish massage (n = 49).
All treatments were standardized and lasted 8 weeks (12 sessions).
Junior acupuncturists blinded to treatment assignment needled participants at points prescribed by senior acupuncturists.
The main study endpoint was the Hamilton Rating Scale for Depression, performed by blinded raters at baseline and after 4 and 8 weeks of treatment.
Response rate was defined as having at least a 50% reduction in symptoms.
Analysis of continuous data was by intent-to-treat, with use of mixed-effects models.
Rate of decrease in symptom severity was greater in women who received depression-specific acupuncture vs the combined controls (d = 0.39; 95% confidence interval [CI], −1.31 to 1.65; P < .05) or control acupuncture group alone (P < .05; Cohen's-d = 0.46; 95% CI, −1.24 to 2.31).
In women who received depression-specific acupuncture, response rate (63.0%) was also significantly greater vs the combined controls (44.3%; P < .05; number needed to treat, 5.3; 95% CI, 2.8 - 75.0) and control acupuncture group (37.5%; P < .05; number needed to treat, 3.9; 95% CI, 2.2 - 19.8).
The control groups were not significantly different in symptom reduction and response rates (control acupuncture, 37.5% vs massage, 50.0%).
Rates of adverse events were not significantly different for the 3 treatment groups
Acupuncture-related adverse effects included transient discomfort at the point of needle insertion (7 participants in the control acupuncture group and 14 in the depression-specific acupuncture group) and bleeding at the needling site (1 in the depression-specific acupuncture group).
Massage-related adverse effects included transient discomfort in 5 participants.
None of these adverse effects resulted in study discontinuation.
The investigators concluded that the short acupuncture protocol tested in this study yielded symptom reduction and a response rate similar to those seen with standard depression treatments of similar length.
Study limitations include limited generalizability of the results because of the high education and socioeconomic status, predominance of Caucasians (67%), and exclusion of comorbid mental and medical disorders.
In addition, the massage therapy provided in this study was shorter vs standard practice.

Clinical Implications



Depression during pregnancy is responsive to treatment with a short acupuncture protocol, which could be a viable treatment option for depressed pregnant women. Rate of decrease in symptom severity was greater in women who received depression-specific acupuncture vs the combined controls or control acupuncture group alone.
Response rate (≥ 50% reduction in symptoms) was 63.0% in women who received depression-specific acupuncture, which was significantly greater vs the combined controls (44.3%) and control acupuncture alone (37.5%). Response rate with depression-specific acupuncture was similar to those seen with standard depression treatments of similar length.