To evaluate the current evidence for effectiveness of acupuncture for posttraumatic stress disorder (PTSD) in the form of a systematic review, a systematic literature search was conducted in 23 electronic databases. Grey literature was also searched. The key search terms were “
Posttraumatic stress disorder (PTSD) develops following a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress [
Current first-line PTSD therapies include trauma-focused cognitive behavioral therapy (CBT), stress inoculation training, and pharmacotherapies [
Acupuncture is commonly recognized worldwide as a mainstream CAM therapy. Acupuncture is the practice of inserting a needle or needles into certain points in the body, known as meridian acupuncture points, for therapeutic or preventive purposes [
Additionally, acupuncture is widely used in mental disorders such as anxiety disorders [
There have been two reviews published on acupuncture or its variants for PTSD [
Following the COSI model [
The key search terms were “(acupuncture OR acup*) AND (stress disorders, post-Traumatic OR posttraumatic stress disorder OR posttraumatic stress disorder OR PTSD).” MeSH strategy was applied to ensure the most powerful search where applicable. Search strategies were adjusted for each of the databases. Personal contacts were made with the original authors of the searched studies to identify any potential missing data from the publications.
Two psychiatrists (J. H. Lim and H. W. Kang) actively participated in the study selection process based on clinical expertise, and two experienced researchers (B. C. Shin, C. Cindy) monitored the whole process of systematic review. All reviewers were fully trained in the systematic review process executed.
The review was not restricted by study design, however, study should be prospective clinical trials. We included RCTs and nonrandomized controlled trials that compared acupuncture or its variants with a control or control groups. We also included uncontrolled clinical trials (UCTs) of acupuncture for PTSD to give our research question a more solid ground or to make recommendations for future research. However, we separately analyzed RCTs and others, and interpreted more weighted on RCTs because of research quality following the validity of evidence. No restrictions were imposed on studies with regard to blinding, languages, or year published.
We selected all studies including patients with PTSD diagnosed by any set of criteria, DSM-IV or ICD-10, regardless of gender, age, nationality, or outpatient therapy or inpatient therapy.
Clinical trials investigating any type of needling acupuncture, specifically classical acupuncture, electroacupuncture, auricular acupuncture were included. We also included trials that included acupuncture as a more complex intervention, that is, acupuncture plus another intervention if the comparison group was that other intervention. We included trials using control groups with no treatment, sham/placebo acupuncture, and conventional treatments for PTSD patients. We excluded laser acupuncture and acupoint stimulation such as acupressure, moxibustion, tapping, and so forth because of the lack of needling. We excluded trials with controls that acted as “healthy participants.”
The most recent guideline for treatment of PTSD [
After screening titles and abstracts retrieved through our search, we excluded all articles that did not match our inclusion/exclusion criteria according to the predefined eligibility criteria mentioned above. Then, expected inclusions were carefully read in full text, and final inclusion was decided by two independent reviewers (Y. D. Kim, I. Heo) by matching method. If studies were written in languages incomprehensible for the reviewers, all articles not written in native language were translated by colleagues. Then we first classified these by the eligibility criteria. If there was a need for full text review, we evaluated these after translation. Data were extracted independently based on predefined characteristics to describe each study (refer to Table
Summary of randomized controlled trials and prospective clinical trials of acupuncture for posttraumatic stress disorder.
First author [ref] |
Population | Study design | Sample |
Intervention/control group |
Treatment |
Main outcomes | Intergroup difference | Comments |
---|---|---|---|---|---|---|---|---|
RCT ( |
||||||||
| ||||||||
Hollifield [ |
28 out of 84 identified childhood abuse/ |
3 arm parallel, open | 84/73 | (A) AT + AAT ( |
24 sessions | (1) PTSD scale (PSS-SR) |
(1) A versus B: |
The AT group had significantly better improvements in PTSD symptoms than the WLC group. But, there was no statistically significant difference between the AT group and the CBT group. |
Zhang [ |
Earthquake | 4 arm parallel, open | 276/256 | (A) EA ( |
36 sessions | (1) PTSD scale (CAPS) |
(1) A versus D: |
The therapeutic effect of EA was not better than that of oral SSRI. |
Zhang [ |
Earthquake | 2 arm |
92/81 | (A) EA + moxa ( |
36 sessions | (1) PTSD scale (CAPS) |
(1) A versus B: |
EA plus moxa was more effective than oral SSRI therapy. |
Zhang [ |
Earthquake | 2 arm |
91/90 | (A) Acupoint Stimulation |
3~4 sessions* | (1) PTSD scale (IES-R) |
(1) A versus B: |
The acupoint stimulation plus CBT showed better efficacy than CBT therapy alone. |
| ||||||||
UCT ( |
||||||||
| ||||||||
Wang [ |
Earthquake | UCT | 69 | EA + AAT + moxa | 36 sessions | (1) The number of cured/improved/non-improved | Not applicable | Treatment was effective in 65 out of 69 (94.2%). |
Yuan [ |
Earthquake | UCT | 34 | AT | 20 sessions | (1) The number of cured/improved/non-improved | Not applicable | AT was effective in 31 out of 34 (91.2%). |
Abbreviations: RCT: randomized controlled trial; UCT: uncontrolled clinical trial; AT: classical acupuncture; EA: electro-acupuncture; moxa, moxibustion; AAT: auricular acupuncture; CBT: cognitive behavioral therapy; WLC: waitlist control; SSRI: selective serotonin reuptake inhibitors; PSS-SR: posttraumatic symptom scale-self report; HSCL-25: self-rated Hopkins symptom checklist-25; SDI: Sheehan Disability Inventory; MD: mean difference; CAPS: clinician-administered PTSD scale; HAMD: Hamilton depression rating scale; HAMA: Hamilton anxiety rating scale; IES-R: Chinese version of the incident effect scale revised; *treated a time every other day for 1 week.
Two authors (Y. D. Kim, B. C. Shin) calculated effect estimates (effect size: ES) to summarize the effects of acupuncture on each outcome by recalculation for mean and standard deviation (SD) because all original data were continuous ones. The standardized mean difference (SMD) and 95% confidence interval (CI) on each outcome measurement were calculated using Cochrane Collaboration software (Review Manager (RevMan) Version 5.1.7 for Windows. Copenhagen: The Nordic Cochrane Centre). For meta-analysis, we pooled data across studies using weighted mean difference (WMD) because same measurement was used. Random effect model was used because clinical heterogeneities were expected across the studies. To assess the heterogeneity among the trials, Chi-square test and the Higgins
The searches retrieved 136 potentially relevant articles. After screening the titles and abstracts, we excluded 120 studies (Figure
Flow chart of the trial selection process. PTSD: posttraumatic stress disorder; RCT: randomized controlled trial; UCT: uncontrolled clinical trial; AT: acupuncture.
The four RCTs evaluated 543 PTSD patients (mean sample size per arm: 49). The duration of treatment was 1 to 12 weeks. A table showing baseline clinical characteristics for each group was reported in only one RCT [
One RCT compared needle acupuncture to cognitive-behavioral therapy (CBT) and a waitlist control [
One high-quality RCT evaluated the effect of acupuncture against CBT and a waitlist control [
One RCT evaluated the effect of electroacupuncture versus oral SSRI [
One RCT assessed the effect of acupoint stimulation plus CBT in comparison to CBT alone [
Two RCTs assessed the effects of electroacupuncture plus moxibustion against oral SSRI [
The meta-analysis of electroacupuncture plus moxibustion versus oral SSRI showed a significant favorable effect of electroacupuncture plus moxibustion on outcome CAPS (2 studies,
Two UCTs evaluated acupuncture treatment for total 103 earthquake-caused PTSD patients and showed effectiveness of 94.2% [
Of all 6 studies, 2 RCTs described adverse events related to needle acupuncture [
The risk of bias was low in one RCT [
Cochrane risk of bias of included randomized controlled trials.
First author [ref] |
Hollifield [ |
Zhang [ |
Zhang [ |
Zhang [ |
---|---|---|---|---|
(1) Random sequence generation |
L |
L |
U | U |
(2) Allocation concealment |
L |
L |
U | U |
(3) Blinding of participants |
H | H | H | H |
(4) Blinding of outcome assessment |
L |
L |
U | U |
(5) Incomplete outcome data |
L |
U | U | U |
(6) Selective reporting |
U | U | U | U |
(7) Other sources of bias |
U | U | U | U |
L: low risk of bias; H: high risk of bias; U: unclear.
Many leading medical journals and major international editorial groups have endorsed the CONSORT statement, and the statement facilitates critical appraisal and interpretation of RCTs [
The STRICTA reporting guideline is an extension of CONSORT was designed to improve the completeness and transparency of reporting of interventions in controlled trials of acupuncture [
Reporting quality of 4 included RCTs based on revised STRICTA.
Checklist item | Hollifield et al. [ |
Zhang et al. [ |
Zhang et al. [ |
Zhang et al. [ |
---|---|---|---|---|
(1) Acupuncture rationale | ||||
(1a) Style of |
TCM | TCM | TCM | n.r. |
(1b) Reasoning for |
A paper by Napadow et al., 2005 [ |
A paper by Hollifield et al., 2007 [ |
A paper by Hollifield et al., 2007 [ |
n.r. |
(1c) Extent to which |
2 types of AT |
Fixed interventions |
Fixed interventions |
Fixed intervention |
| ||||
(2) Details of needling | ||||
(2a) Number of needle |
(1) AT: 25 plus up to 3 needles |
(1) EA: 8 needles |
EA: 8 needles | unclear. |
(2b) Names of points |
(1) AT: bilateral at LR3, PC6, HT7, ST36, SP6, GB20, BL14, 15, 18, 20, 21 and 23/unilateral at Yintang |
(1) EA: bilateral at GB20/unilateral at GV24, EX-HN1, GV20 |
(1) EA: bilateral at GB20/unilateral at GV24, EX-HN1, GV20 |
Unilateral at left PC8 |
(2c) Depth of insertion | (1) AT: 1/4 to 1/2 inch |
(1) EA: 0.5 to 1.2 cun |
EA: 0.5 to 1.2 cun | n.r. |
(2d) Responses sought | (1) AT: n.r. |
(1) EA: de-qi |
EA: de-qi | n.r. |
(2e) Needle stimulation | (1) AT: manipulation |
(1) EA: electrical stimulation, 100 Hz |
EA: electrical stimulation, |
A Japanese stimulator with 50 Hz was used |
(2f) Needle retention |
(1) AT: 25–40 min |
(A) 30 min |
30 min | Unclear, but the left PC8 was stimulated for 30 min |
(2g) Needle type | (1) AT: Viva needles, 34 g |
(1) EA: 0.30 mm |
n.r. | n.r. |
| ||||
(3) Treatment regimen | ||||
(3a) Number of |
24 sessions | 36 sessions | (1) EA: 18 sessions |
3~4 sessions* |
(3b) Frequency and |
Twice a week, 1 hour per session, 12 weeks | Three times a week, 12 weeks | (1) EA: three times a week, 6 weeks |
A time every other day for 1 week |
| ||||
(4) Other components |
||||
(4a) Details of other |
Patients were taught how to use vaccaria seeds for symptom management | (3) moxa: 30 g and 20 min/session, wooden moxibustion box 20 mm |
(2) moxa: 20 min/session | CBT |
(4b) Setting and context |
n.r. | n.r. | n.r. | n.r. |
| ||||
(5) Practitioner background | ||||
(5) Description of |
Doctor of Oriental Medicine in New Mexico with 4 years postgraduate TCM clinical experience | n.r. | n.r. | n.r. |
| ||||
(6) Control or comparator interventions | ||||
(6a) Rationale for the |
(B) A review by Bisson and Andrew, 2005 [ |
Approval of FDA | n.r. | n.r. |
(6b) Precise description |
(B) CBT |
(D) Oral SSRI (Paroxetine 20 mg, once/day, 12 weeks) |
Oral SSRI (Paroxetine 20 mg, once/day, 12 weeks) | (B) CBT |
Abbreviations: RCT: randomized controlled trial; TCM: traditional Chinese medicine; n.r: not reported; AT: classical acupuncture; EA: electro-acupuncture; moxa, moxibustion; AAT: auricular acupuncture; CBT: cognitive behavioral therapy; WLC: waitlist control; SSRI: selective serotonin reuptake inhibitors.
*treated a time every other day for 1 week.
Meta-analysis of acupuncture for posttraumatic stress disorder. PTSD: posttraumatic stress disorder; CAPS, clinician-administered PTSD scale; HAMD, Hamilton depression rating scale; HAMA, Hamilton anxiety rating scale; EA, electro-acupuncture; moxa, moxibustion; SSRI, selective serotonin reuptake inhibitors;
PTSD scale (CAPS).
Study or subgroup | EA + Moxa | SSRI | Mean difference | Mean difference | |||||
---|---|---|---|---|---|---|---|---|---|
Mean | SD | Total | Mean | SD | Total | Weight | IV, random, 95% CI | IV, random, 95% CI | |
Zhang et al., 2010 [ |
−36.15 | 21.72 | 69 | −35.58 | 22.12 | 69 | 1.0% | −0.57 [−7.88, 6.74] |
|
Zhang et al., 2010 [ |
−17.17 | 1.84 | 46 | −13.95 | 1.76 | 46 | 99.0% | −3.22 [−3.96, −2.48] | |
|
|
|
|
|
|||||
Heterogeneity: |
|||||||||
Test for overall effect: |
Depression (HAMD).
Study or subgroup | EA + Moxa | SSRI | Mean difference | Mean difference | |||||
---|---|---|---|---|---|---|---|---|---|
Mean | SD | Total | Mean | SD | Total | Weight | IV, random, 95% CI | IV, random, 95% CI | |
Zhang et al., 2010 [ |
−7.42 | 5.58 | 69 | −6.55 | 5.1 | 69 | 6.2% | −0.87 [−2.65, 0.91] |
|
Zhang et al., 2010 [ |
−7.27 | 0.93 | 46 | −5.45 | 0.91 | 46 | 93.8% | −1.82 [−2.20, −1.44] | |
|
|
|
|
|
|||||
Heterogeneity: |
|||||||||
Test for overall effect: |
Anxiety (HAMA).
Study or subgroup | EA + Moxa | SSRI | Mean difference | Mean difference | |||||
---|---|---|---|---|---|---|---|---|---|
Mean | SD | Total | Mean | SD | Total | Weight | IV, random, 95% CI | IV, random, 95% CI | |
Zhang et al., 2010 [ |
−6.51 | 5.26 | 69 | −6.08 | 5.43 | 69 | 2.9% | −0.43 [−2.21, 1.35] |
|
Zhang et al., 2010 [ |
−5.48 | 0.75 | 46 | −4.32 | 0.75 | 46 | 97.1% | −1.16 [−1.47, −0.85] | |
|
|
|
|
|
|||||
Heterogeneity: |
|||||||||
Test for overall effect: |
This is the first systematic review and meta-analysis of prospective clinical trials on the effectiveness of acupuncture for treatment of PTSD. Only 4 RCTs and 2 UCTs met the inclusion criteria for this review. Our main finding of this review is that acupuncture is effective for PTSD based on one high-quality RCT [
The high-quality RCT showed that acupuncture had statistically significant effects compared to a waitlist control, although no statistical difference was found between acupuncture and CBT. Also the therapeutic effect of acupuncture was similar with CBT therapy based on the trial. Additionally, the clinical improvement related to acupuncture or CBT lasted for at least 3 months after the end of treatment in the high-quality RCT.
The meta-analysis showed that acupuncture plus moxibustion was superior to oral SSRI for PTSD. But, we should interpret these results with caution because the meta-analysis was based on one medium-quality RCT [
One RCT [
We found a similar pattern of reporting quality when comparing the Cochrane risk of bias [
We would like to emphasize the clinical importance of acupuncture for PTSD. Acupuncture might be useful in emergency medicine [
According to a study [
This systematic review has several limitations. First, although we made strong efforts to retrieve all RCTs on the subject, the evidence reviewed is potentially incomplete because only one rigorous study was included. Second, because there was no RCT on PTSD with a sham acupuncture control, we could not evaluate the effects of acupuncture compared to an inert placebo control [
In total, from these drawbacks we could suggest several important recommendations for future research in this area. One is a need for appropriate controls such as sham/placebo control or other relevant active controls for testing the efficacy or effectiveness of acupuncture for PTSD in the design of parallel RCT or comparative effectiveness research. The second is outcomes should be used by validated one as primary one is PTSD scale and the secondary one is depression or anxiety with safety reporting. The third is high methodological quality is strongly required, as adequate randomization with allocation concealment, blinding of participants and assessors, or sample size estimation for power of trial, with following guideline of CONSORT and STRICTA.
The results of this systematic review and meta-analysis suggest that evidence of the effectiveness of acupuncture for PTSD is encouraging but not cogent, because only two RCTs were included in meta-analysis, and it is too small to verify the efficacy of acupuncture. For the future researches, sham-controlled RCTs [
The authors report no financial relationship or other relevant to the subject of this paper.