Depression is a leading contributor to illness and global burden of disease.1 Depression and anxiety lead to financial and economic loss each year. Globally, 67% of financial resources are directed toward mental health services.1 Demand for mental health services has reached an unprecedented level, especially in cases of depression, while conventional treatment outcomes are often ineffective.2 Therefore, there is an urgent call by the World Health Organization (WHO) for all countries to rethink their approach to mental health and to treat the depression epidemic with the urgency that it deserves.1
In any one year, three million Australians are living with symptoms of depression or anxiety.3 Among these are women with postnatal depression (PND). It is estimated that more than one in 10 women experience clinically significant depression in the first year after giving birth, and a similar incidence has been reported during pregnancy.4 Over 40% of Australians diagnosed with a mental health disorder have a chronic physical illness, which may contribute to a further deterioration of their mental health.3 Postnatal depression can occur anytime within the first year postpartum.5
Postnatal depression is a serious mental health condition that can have implications for parental wellbeing and the mother-child relationship, as well as the cognitive development, social competence and behavioral outcomes of the child.6 One out of four cases of PND can lead to chronic depression.7 Women suffer from PND at their most vulnerable time and if untreated, the condition could last for years.
The significant morbidity associated with maternal mental health conditions is not only a risk for the mother but also the infant and other family members. Adequate treatment of PND is therefore important for the functioning of the family and an optimal parent-infant relationship.5,6
Treatment of PND usually involves psychological approaches (such as behavioral activation, cognitive behavioral therapy and interpersonal psychotherapy) in combination with the use of antidepressants (such as tricyclic antidepressants and selective serotonin reuptake inhibitors). However, the outcomes of these treatments are debatable.8 For example, alongside their side effects, antidepressants often have practical disadvantages, such women's preference to avoid medication while breastfeeding.9 In addition to that, 40% of women with PND do not respond to antidepressants, and for 50–80% of women, there is a risk that antidepressants will result in a relapse or recurrence.8 Exploring effective alternative options for the treatment of PND without side effects and practical disadvantages is therefore important.
An alternative to the medical model focused on treatment with antidepressants is traditional Chinese medicine (TCM). Traditional Chinese medicine considers the body system as a whole and emphasizes the role of the body in healing, and is considered a healing art. The use of TCM is common in Chinese culture to regain the required balance and correct proportion of the five elements (wood, fire, earth, metal and water) in the body.10 Mental health is considered in the holistic approach, as physical health is believed to impact upon it and vice versa. In the treatment of depression, TCM focuses on balancing the five elements within the liver, heart, spleen, lungs and kidneys.
Acupuncture, which has been practiced for more than 4000 years in China, is an integral part of TCM.10 In just a few decades, acupuncture has become the most popular and widely recognized TCM therapy used in the western world. It is well accepted, for instance, as an effective treatment for chronic pain.10
Chinese medicine believes qi (inner energy) is crucial to optimal health and illnesses are caused by the imbalance of qi flow. Acupuncture involves using needles to pierce particular points of the body to restore balance of qi and treat disease.10
A review on clinical trials conducted by the WHO in 2003 identified 28 health issues, including depression, in which acupuncture proved to be effective.10 Later studies have further evidenced that acupuncture treatment is a promising method for treating depression.11-14
With the encouraging results,11-13 women suffering from PND may also consider acupuncture as an alternative treatment option to alleviate this condition. Two randomized controlled trials found that acupuncture was effective for treating major perinatal depression.15,16 However, another trial on PND found that there were no effect differences between electro-acupuncture and sham acupuncture for PND.17
A preliminary search was conducted in December 2017 to identify existing review protocols and completed systematic reviews on the topic of interest. The preliminary search included searches in PubMed, CINAHL, Cochrane Library, Epistemonikos and PROSPERO. Neither systematic reviews nor review protocols on this specific topic were identified.
The objective of this review is therefore to synthesize the best available evidence on the effectiveness of acupuncture as an adjunct treatment for women with PND.
The review will consider studies that include women of reproductive age, regardless of race and ethnicity, who have been diagnosed with PND by a physician.
The review will consider, as an intervention, traditional Chinese acupuncture used as an adjunct treatment for women with PND, regardless of frequency, duration or other characteristics of acupuncture (acupuncture, electro-acupuncture, etc.) used in addition to usual conventional treatment for depression (psychological approaches and antidepressants).
The comparator is usual conventional treatment for depression (psychological approaches and antidepressants) without acupuncture as an adjunct treatment.
The outcome of interest in this review will be the level of PND, measured by any validated tools.
Types of studies
The review will consider experimental studies including pre- and poststudies, quasiexperimental, non-randomized controlled trials and randomized controlled trials.
The proposed systematic review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for systematic reviews of effectiveness evidence.18
The following are the search steps for this review: a primary partial search of MEDLINE and CINAHL, and subsequently an exploration of the text words encompassed in the title and abstract, and of the index terms applied to define the article; a second search applying all identified keywords and index terms throughout all involved databases; a third search of the reference list of all identified reports and articles for additional studies. Studies published in English and Chinese will be considered for inclusion in this review.
The history of acupuncture research was initiated in the 18th century; however, most research on acupuncture emerged in China in the middle of the 20th century.19 There has been a dramatic increase in publications since 2000, 70% of the papers were published in the past 14 years.20 For this reason, only studies from 2000 to 2018 will be included in this review.
The searched databases will be CINAHL, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), AMED, ProQuest Central, British Nursing Database, and the Chinese databases: CNKI (), WANFANG (), VIP () and CBM (SinoMed).
Initial keywords to be used will include acupuncture, clinical trials, controlled clinical trial, double blind, dry-needling, needle, needling, effectiveness, perinatal depression, postnatal depression, postpartum, randomized controlled trial and single blind. A proposed initial search strategy for MEDLINE is presented in Appendix I.
All identified citations will be imported into EndNote (Clarivate Analytics, PA, USA) and duplicates removed. Two independent reviewers will then screen titles and abstracts for assessment against the inclusion criteria. Potentially relevant studies will be retrieved in full and their citation details loaded into the Joanna Briggs Institute's System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia). Two independent reviewers will assess the full text of selected studies against the inclusion criteria. Reasons for exclusion of studies that do not meet the inclusion criteria will be reported in the systematic review. At each stage of the study selection process, any discrepancies that result from the reviewers will be reconciled over discussion, or with a third reviewer. The results of the search will be reported in full in the final report and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses flow diagram.21
Assessment of methodological quality
Two independent reviewers will assess methodological validity of all selected articles prior to inclusion in the review using the appropriate JBI critical appraisal checklists.18 Any discrepancies that result from the reviewers will be reconciled through discussion or through consultation with a third reviewer.
Quantitative data will be extracted from included articles in the review, by two independent reviewers, employing the standardized data extraction form developed by JBI. The data extracted will comprise specific details concerning the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
The authors of included primary studies will be contacted if there is a need to find any missing data.
Potentially, quantitative results will be synthesized in statistical meta-analysis using JBI SUMARI. All results will be subjected to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences or standardized mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. As recommended in the JBI Reviewer's Manual, random effects model will be used for meta-analysis if there are at least five studies included in meta-analysis; fixed-effects model will be used if there are less than five studies included in meta-analysis.18
Heterogeneity will be assessed statistically using the Chi-squared test and the I-squared index.
If the data are available, we will conduct subgroup analyses to explore the heterogeneity between the studies. Subgroups will include the following:
- Type of acupuncture:
- – Acupuncture versus penetrating or nonpenetrating sham acupuncture.
- – Acupuncture or acupuncture plus moxibustion versus conventional drugs.
- Type of control
- Duration of PND
- Cultural background
Wherever statistical pooling is unachievable, the findings will be communicated in narrative form, together with tables and figures to assist in data presentation if required.
Appendix I: Search strategy for MEDLINE (PubMed platform)
1. WHO. Mental health atlas 2011; 1–81 Geneva, Switzerland. Available from: http://www.who.int/mental_health/publications/mental_health_atlas_2011/en/
[Internet]. Accessed January, 2018.
2. MacQueen GM, Memedovich KA. Cognitive dysfunction in major depression and bipolar disorder: assessment and treatment options. Psychiatry Clin Neurosci
2017; 71 1:18–27.
3. Beyondblue. The facts. 2017; Victoria, Australia: Beyondblue, Available from: https://www.beyondblue.org.au/the-facts
[Internet]. Accessed January, 2018.
4. Milgrom J. Depression in pregnancy and the postpartum period. InPsych
2017; 39 1:20–21.
5. O’Hara MW, McCabe JE. Postpartum depression
: current status and future directions. Annu Rev Clin Psychol
2013; 9 1:379–407.
6. Nilova V, Ward L, Hall P. Women's experiences of parenting toddlers following postnatal depression. Aust J Psychol
2017; 69 3:192–199.
7. Wylie L, Hollins Martin CJ, Marland G, Martin CR, Rankin J. The enigma of post-natal depression: an update. J Psychiatr Ment Health Nurs
2011; 18 1:48–58.
8. Andrews G, Issakidis C, Sanderson K, Corry J, Lapsley H. Utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders. Br J Psychiatry
2004; 184 6:526–533.
9. Einarson A, Selby P, Koren G. Abrupt discontinuation of psychotropic drugs during pregnancy: fear of teratogenic risk and impact of counselling. J Psychiatry Neurosci
2001; 26 1:44–48.
10. Chon TY, Lee MC. Acupuncture. Mayo Clin Proc
2013; 88 10:1141–1146.
11. Wang Z, Wang X, Liu J, Chen J, Liu X, Nie G, et al. Acupuncture treatment modulates the corticostriatal reward circuitry in major depressive disorder. J Psychiatr Res
2017; 84 (Suppl C):18–26.
12. Quah-Smith I, Suo C, Williams MA, Sachdev PS. The antidepressant effect of laser acupuncture: a comparison of the resting brain's default mode network in healthy and depressed subjects during functional magnetic resonance imaging. Med Acupunct
2013; 25 2:124–133.
13. Schroer S, Adamson J. Acupuncture for depression: a critique of the evidence base. CNS Neurosci Ther
2011; 17 5:398–410.
14. Ormsby SM, Dahlen HG, Smith CA. Women's experiences of having depression during pregnancy and receiving acupuncture treatment – a qualitative study. Women Birth
15. Manber R, Schnyer RN, Allen JJB, Rush AJ, Blasey CM. Acupuncture: a promising treatment for depression during pregnancy. J Affect Disord
2004; 83 1:89–95. 2004/11/15.
16. Manber R, Schnyer RN, Lyell D, Chambers AS, Caughey AB, Druzin M, et al. Acupuncture for depression during pregnancy: a randomized controlled trial. Obstet Gynecol
2010; 115 3:511–520.
17. Chung KF, Yeung WF, Zhang ZJ, Yung KP, Man SC, Lee CP, et al. Randomized non-invasive sham-controlled pilot trial of electroacupuncture for postpartum depression
. J Affect Disord
2012; 142 1:115–121. 2012/12/15.
18. Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Aromataris E, Munn Z. Chapter 3: Systematic reviews of effectiveness. Joanna Briggs Institute reviewer's manual
. Adelaide, Australia: The Joanna Briggs Institute; 2017; Available from https://reviewersmanual.joannabriggs.org/
. Accessed January, 2018.
19. Han JS. Acupuncture research is part of my life. Pain Med
2009; 10 4:611–618.
20. Zheng Z. Acupuncture in Australia: regulation, education, practice, and research. Integr Med Res
2014; 3 3:103–110.
21. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg
2010; 8 5:336–341.