MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

This systematic review examined the efficacy of acupressure on depression. Literature searches were performed on PubMed, PsycINFO, Scopus, Embase, MEDLINE, and China National Knowledge (CNKI). Randomized clinical trials (RCTs) or single-group trials in which acupressure was compared with various control methods or baseline (i.e. no treatment) in people with depression were included. Data were synthesized using a random-effects or a fixed-effects model to analyze the impacts of acupressure treatment on depression and anxiety in people with depression. The primary outcome measures were depression symptoms quantified by various means. Subgroups were created, and meta-regression analyses were performed to explore which factors are relevant to the greater or lesser effects of treating symptoms.

A total of 14 RCTs (1439 participants) were identified. Analysis of the between-group showed that acupressure was effective in reducing depression [Standardized mean differences (SMDs) = -0.58, 95%CI: -0.85 to -0.32, P < 0.0001] and anxiety (SMD = -0.67, 95%CI: -0.99 to -0.36, P < 0.0001) in participants with mild-to-moderate primary and secondary depression. Subgroup analyses suggested that acupressure significantly reduced depressive symptoms compared with different controlled conditions and in participants with different ages, clinical conditions, and duration of intervention. Adverse events, including hypotension, dizziness, palpitation, and headache, were reported in only one study.

The authors concluded that the evidence of acupressure for mild-to-moderate depressive symptoms was significant. Importantly, the findings should be interpreted with caution due to study limitations. Future research with a well-designed mixed method is required to consolidate the conclusion and provide an in-depth understanding of potential mechanisms underlying the effects.

I think that more than caution is warranted when interpreting these data. In fact, it would have been surprising if the meta-analyses had NOT generated an overall positive result. This is because in several studies there was no attempt to control for the extra attention or the placebo effect of administering acupressure. In most of the trials where this had been taken care of (i.e. patient-blinded, sham-controlled studies), there were no checks for the success of blinding. Thus it is possible, even likely that many patients correctly guessed what treatment they received. In turn, this means that the outcomes of these trials were also largely due to placebo effects.

Overall, this paper is therefore a prime example of a biased review of biased primary studies. The phenomenon can be aptly described by the slogan:

RUBBISH IN, RUBBISH OUT!

18 Responses to Acupressure is effective for depression? I’m afraid not!

  • Dear Prof. Ernst,
    what is your opinion on antidepressant drugs? Since the same issue (lack of blinding) could influence antidepressants trials too.
    And what’s your opinion on the placebo effect (I mean true placebo)? Do you think it’s powerful? Could antidepressants just be placebos? Should we maximize the placebo component in clinical practice?
    I know that often alternative medicines use the placebo effect to legitimate their therapies. It doesn’t make any sense: if a therapy is just placebo effect, why do they call it homeopathy (or whatever), just call it placebo! If the placebo effect is valuable, we can study how to maximize it in practice, without needing alternative therapies.

    • what is your opinion on antidepressant drugs? NOT MY AREA OF EXPERTISE. AS FAR AS I CAN SEE, SOME ARE MILDLY EFFECTIVE
      Since the same issue (lack of blinding) could influence antidepressants trials too. LESS IMPORTANT IN DRUG TRIALS
      And what’s your opinion on the placebo effect (I mean true placebo)? Do you think it’s powerful? NO, BUT IT EXISTS.
      Could antidepressants just be placebos? THEY SEEM TO RELY SOMEWHAT BUT NOT TOTALLY ON PLACEBO EFFECTS
      Should we maximize the placebo component in clinical practice? YES
      I know that often alternative medicines use the placebo effect to legitimate their therapies. It doesn’t make any sense: if a therapy is just placebo effect, why do they call it homeopathy (or whatever), just call it placebo! If the placebo effect is valuable, we can study how to maximize it in practice, without needing alternative therapies. EXACTLY!

    • I caught the tail end of trials for lofepramine in the 1980s: there were no issues with blinding, as we on the wards were given pre-prepared packs of bland looking tablets by pharmacy to give to the participating patients, so we had no idea if we were giving out lofepramine, placebo or the comparator AD – everything was made up to look exactly the same – we were not responsible for any of the monitoring tests used in the trial, as they were carried out by specific researchers who were not part of the ward staff and nor were we asked to offer any views on those patients. The pharmacy did not know which patients on the ward were part of the trial, just that they had to follow the instructions to prepare identical looking tablets in identical packs to be sent out for Patient A, B or C or whatever.

      I was pretty happy about the level of blinding.

      Re ADs: if the effect is all placebo it is one which has kept me alive and I’m glad of that. I don’t doubt an element of placebo when I first started, as I got a positive response far quicker than I was expecting, given that I was accustomed to giving the standard spiel about “give it a month” to patients. However, subsequent experience over many years and several different episodes makes me dount that all of my benefit has been placebo.

      • The evidence behind antidepressants looks confused. Different meta-analyses (or systematic reviews) have shown a very small difference between drug response and placebo response: so small that it could be clinically insignificant (see ref. 1).
        That small difference could be due to lack of blinding (partially because side effects tell patients which group they are in): so knowing you are in the drug group might enhance the placebo effect (see ref. 2 for a discussion).
        I think more research is needed and they shouldn’t be used as a first option (might be worth first trying psychotherapy).

        References:
        [1] Horowitz, M., & Wilcock, M. (2022). Newer generation antidepressants and withdrawal effects: reconsidering the role of antidepressants and helping patients to stop. Drug and Therapeutics Bulletin, 60(1), 7-12.
        [2] Kirsch, I. (2019). Placebo effect in the treatment of depression and anxiety. Frontiers in Psychiatry, 10, 407.

        • Some form of talking therapy first is a standard recommendation in the UK. However, evidence for efficacy of the various talking therapies is even more confused than that for ADs – I spent an awful lot of time reading around the subject and my long essay thingy for my counselling course was a critique of Rogers’ core conditions.

          And you still haven’t explained why there is a problem with blinding here: some vague stuff about possible side effects (not everyone experiences AD side effects to any noticeable extent) could be applied to most meds. Unless this is a broader point about blinding in any drug trial. And that’s before you get to what the participants understand about how any trial and blinding actually works (I have a very long story about my late mother-in-law and her participation in a trial, the short version of which is that she could never, ever get her head round how it all worked and was convinced that they kept switching which drug she was on and reported side effects unknown to anyone).

          • Psychotherapies are all diffent. One of the more credible is CBT, and it works great for depression: it’s effective just like drugs [1] and in the long term is even better than drugs [2] and it has no side effects. But maybe some therapies may be better for some people, so many options are available. Also, some evidence shows a positive effect of physical exercise, why do not try it?! (https://www.cochrane.org/CD004366/DEPRESSN_exercise-for-depression)
            In regard to the blinding issue, I’ve already provided an article where you can find a discussion ([3]): patients sometimes know which group they are in, and the drug-placebo difference is bigger when subjets used AD priorly (maybe they are able to distinguish them from placebo). Also, when you compare AD to an active placebo (that mimics side effects) you don’t see any drug effect at all [4].
            There are even trials where AD are given saying “this is just a placebo”, in that case, their efficacy drops ridiculously (can’t find the paper right now).
            So I’m not saying AD shouldn’t be used at all, but caution is needed since they have side effects and other options are available.
            And when I say that AD rely a lot on the placebo effect, I’m not saying they don’t work: they work, but not due to their chemistry.

            [1] Sinyor M, Fefergrad M, Zaretsky A. Cognitive behavioural therapy or antidepressants for acute depression? BMJ 2015; 351 :h6315 doi:10.1136/bmj.h6315
            [2] Fournier, J.C., Forand, N.R., Wang, Z. et al. Initial Severity and Depressive Relapse in Cognitive Behavioral Therapy and Antidepressant Medications: An Individual Patient Data Meta-analysis. Cogn Ther Res (2022). https://doi.org/10.1007/s10608-021-10281-x
            [3] Kirsch, I. (2019). Placebo effect in the treatment of depression and anxiety. Frontiers in Psychiatry, 10, 407.
            [4] Moncrieff, J., Wessely, S., & Hardy, R. (2004). Active placebos versus antidepressants for depression. The Cochrane database of systematic reviews, 2004(1), CD003012. https://doi.org/10.1002/14651858.CD003012.pub2

        • @Fab

          “The evidence behind antidepressants looks confused”

          Medical Science doesn’t exactly know the reason behind many of the mental illnesses today. Is is any wonder that the evidence behind antidepressants is shabby when they are attempting to find a solution for a problem of which they cannot identify the cause ?
          Like much of science based medicine, they are treating the symptoms, not the cause.
          It’s a good business formula…. sell pills that don’t cure = $$

          • Lots of people would like to just take a pill and feel better, especially if addressing the underlying cause of their depression would be traumatic for them and shake things up. For example, if they’re depressed as a result of having grown up in a way that damaged them psychologically, and they’re currently in a bad personal situation as a result.

  • Sham acupuncture as a placebo seems problematic, because acupressure is also thought to be an effective treatment.

    In most of the trials where this had been taken care of (i.e. patient-blinded, sham-controlled studies), there were no checks for the success of blinding.

    Is this often a problem with sham (non-penetrating) acupuncture? Acupuncture causes pain when the needle goes in, also sensations called deqi. Is sham acupuncture able to replicate that convincingly?

    • yes, if deqi were real – I’m not sure it is – this would be a problem for blinding trials with sham needles

      • How convincing are the sham (non-penetrating) needles to the patient in these trials?
        Does the acupuncturist know when they’re using a sham needle? In that case, the blinding would fail right at the outset, in that regard. And the acupuncturist might be motivated to make the blinding fail so far as the patient goes, as well.

        • How convincing are the sham (non-penetrating) needles to the patient in these trials?
          WE HAVE TESTED THIS AND FOUND IT TO BE SATISFACTORY: https://pubmed.ncbi.nlm.nih.gov/12512790/
          Does the acupuncturist know when they’re using a sham needle? YES
          In that case, the blinding would fail right at the outset, in that regard. THE SHAM IS FOR BLINDING THE PATIENT NOT THE THERAPIST
          And the acupuncturist might be motivated to make the blinding fail so far as the patient goes, as well. YES, HE MIGHT BUT ONE CAN PREVENT THIS, FOR INSTANCE, BY VIDEOING THE SESSIONS

          • THE SHAM IS FOR BLINDING THE PATIENT NOT THE THERAPIST

            Double-blind trials are usually considered the best. If they can’t blind the acupuncturist in acupuncture research, that could be a big quality problem.

            the acupuncturist might be motivated to make the blinding fail so far as the patient goes, as well. YES, HE MIGHT BUT ONE CAN PREVENT THIS, FOR INSTANCE, BY VIDEOING THE SESSIONS

            There are all sorts of subtle cues that the acupuncturist might give the patient. It wouldn’t necessarily be deliberately letting the patient know. That’s why usually the experimenter is supposed to not know who gets the placebo, in order to come up with good-quality evidence.

            Maybe they could get around that by making sure the acupuncturist is different from the experimenter, doesn’t know which patient they’re acupuncturing, and the patient is covered up so they can’t see the acupuncturist’s expression or mannerisms. Is that sort of thing actually done in these trials?

          • nothing is optimal
            but we can only use the best methods we have available.

          • From your study https://pubmed.ncbi.nlm.nih.gov/12512790/,

            Study 1) included 58 patients enrolled in a clinical trial of acupuncture for acute stroke. Study 2) included 63 healthy, acupuncture naïve, adult volunteers. The interventions used were real or sham acupuncture using the Park Sham Device. Study 1) was set in a district general hospital, and study 2) in a university laboratory. The outcome measure in study 1) was the form of treatment that patients believed they had received. In study 2) the outcome measure was experience of de qi, as judged by three acupuncture experts. No patient in either group(study 1) believed he or she had been treated with the sham needle. In 40 volunteers (study 2) for whom experts achieved consensus, the relative risk of experiencing de qi with real acupuncture to that with sham acupuncture was 15.38 (95% CI 2.26 to 104.86).

            That sounds like de qi is not just a placebo effect, and if researchers use people who aren’t acupuncture-naive in a trial, they would be able to tell the difference between acupuncture and sham; that it was only because the participants were acupuncture-naive that they thought the sham acupuncture was the real thing.
            Which also sounds like effective blinding might be a big problem in acupuncture research.

          • here are the full conclusions we drew in 2002:

            We conclude that the newly developed PSD is
            valid as a control procedure for trials of the
            efficacy of acupuncture, or, more specifically, the
            needle penetration aspect of treatment. Our second
            conclusion arising from this work is perhaps more
            profound. Naïve volunteers cannot distinguish
            between real needles and the sham device, yet are
            much more likely to experience de qi with the former
            than the latter. This finding gives some support to
            the existence of the phenomenon of de qi, one of
            the major concepts underlying traditional Chinese
            acupuncture. We believe that the question of
            whether or not de qi can be scientifically
            demonstrated to exist deserves further rigorous study.

            I remain unconvinced that deqi is real.

          • We conclude that the newly developed PSD is
            valid as a control procedure for trials of the
            efficacy of acupuncture, or, more specifically, the
            needle penetration aspect of treatment.

            Your study doesn’t seem to support this device as a good placebo for trials where the subjects aren’t acupuncture-naive, because real acupuncture was more likely to produce de qi by a factor of 15 – at least for that subset of 40 out of the 63 participants.
            Also because the subjects *were* acupuncture-naive.

          • if you say so

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