Letter by Dorlo Regarding Article, “Acupuncture Therapy and Incidence of Depression After Stroke”

To the Editor:

Lu et al¹ investigated the value of acupuncture in preventing depression in patients with stroke using a Taiwanese national insurance claim database. As reasonably expected, their findings were negative, in the sense that they could not prove their hypothesis that acupuncture use within 3 months of discharge is associated with a lower hazard of developing depression in stroke survivors compared with nonusers of acupuncture. Their conclusion that acupuncture use “was not associated with subsequent incidence of depression” perhaps should have been paraphrased as acupuncture has no role in the prevention of poststroke depression.

The authors nevertheless continue to insist that other clinical claims related to acupuncture exist, and they falsely maintain that “meta-analyses of clinical trials reported beneficial effects of acupuncture on depression in patients with stroke.” However, the provided references for this statement all indicate already that the level of evidence for acupuncture for poststroke depression is consistently low, biased, and of bad quality. In fact, already in 2010, a well-performed large Cochrane systematic meta-analysis on the effectiveness of acupuncture in the treatment of any type of depression, not just poststroke, summarized 30 randomized controlled clinical trials conducted on this subject and concluded that there is no evidence to recommend the use of acupuncture for people with depression,² with specifically no clinical difference in effect between true and sham acupuncture (ie, a toothpick). The only treatment for depression after stroke that is evidence-based and is consistently found to be effective is antidepressants, although safety risks should be taken into consideration. The American Heart Association and the American Stroke Association recommend the use of antidepressants for poststroke depression, although optimal type, timing, and duration still require further evaluation.³ Also for prevention, randomized controlled clinical trials have consistently identified the value of antidepressants in preventing poststroke depression, particularly selective serotonin reuptake inhibitors and following a 1-year treatment.⁴

The authors’ conclusion that “[f]urther studies are needed to clarify the effect of acupuncture on mild depression” is undesirable and outdated, given the low biological plausibility of acupuncture and the previously established absence of clinical evidence, for any kind of indication.⁵ If further research would nevertheless be conducted, it is advisable to conduct only adequately blinded, randomized clinical trials using placebo or sham acupuncture, given the well-established placebo effect of acupuncture and the high positive bias in reports^2,5; observational cohort studies without proper control should be avoided.

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