Randomized Single-Blind Multicenter Trial Comparing the Effects of Standard and

Augmented Acupuncture Protocols on Sleep Quality and Depressive Symptoms in

Patients with Depression

Xiuyun Wen1#, Qian Wu2#, Jianhua Liu3, Zhenhua Xu3, Li Fan3, Xiaokai Chen4, Qing He5,

Rui Ma3, Yanan Wu2, Shuo Jiang6, Shujun Xu3, Wenbin Fu3*

1
Baoan Hospital, Southern Medical University, Shenzhen 518101, China

2
The Second Clinical Medical College, Guangzhou University of Chinese Medicine,

Guangzhou 510405, China

3
Department of Acupuncture and Moxibustion, Guangdong Provincial Hospital of TCM,

Guangzhou 510120, China

4
The third People’s Hospital of Huizhou City, Huizhou 516002, China

5
Traditional Chinese Medicine Research Center of Hong Kong Baptist University, Hong

Kong, China

6
Department of Acupuncture and Moxibustion, Zhejiang Provincial Hospital of TCM,

Hangzhou 310000, China

#
They contributed equally to this work.

*
Corresponding author:

Wenbin Fu

Department of Acupuncture and Moxibustion, Guangdong Provincial Hospital of TCM,

Guangzhou 510120, China

Tel: +86-13808888626

1
Fax: +86-21-64085875

Email: fuwenbinmed220@sina.com

Running title: Acupuncture for depression and sleep quality

E-mail addresses for all authors:

Xiuyun Wen: wxymeddling@163.com

Qian Wu: wuqian@163.vip.com

Jianhua Liu: jyhf08@sina.com

Zhenhua Xu: xzh197011@163.com

Li Fan: 15626666@163.com

Xiaokai Chen: 740939513@163.com

Qing He: heqhzh@yahoo.com.cn

Rui Ma: 13826499444@163.com

Yanan Wu: wuynannan@sina.com

Shuo Jiang: jiangshuo1230@126.com

Shujun Xu: xushujun@vip.163.com

Wenbin Fu: fuwenbinmed220@sina.com

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Abstract

The study was aimed to compare the effects of standard and augmented acupuncture on

depressive symptoms and sleep disturbances in patients with depression. This is a

randomized, single-blind, multicenter trial. 140 subjects with clinical insomnia (score of >7

on the Pittsburgh Sleep Quality Index (PSQI)) were randomized to the standard (LI4, LIV3,

EX-HN3, and GV20) or augmented (LI4, LIV3, EX-HN3, GV20, LU7, and KID6, including

intradermal needles for sustained treatment) acupuncture groups. Participants received two

sessions weekly for six weeks. In this randomized, single-blind, multicenter trial, The

primary outcomes were improvements in PSQI and the Hamilton Rating Scale (HAMD).

Secondary outcomes were treatment credibility and adverse events. Outcomes were assessed

at baseline, week 3, end of treatment, and 4-week follow-up. From the 105 randomized

patients, 89 completed the trial and were included in the final analyses. Better efficacy was

observed in the augmented group compared with the standard acupuncture to improve the

PSQI and HAMD at week 3, end of treatment, and 4-week follow-up (all P<0.05). The

HAMD scores improved with time, except between end of treatment and 4-week follow-up,

while in the standard group, HAMD scored improved from baseline to week 3, and stopped

improving thereafter. The PSQI scores improved with time in the two groups, except between

end of treatment and 4-week follow-up. Compared with the standard protocol, the augmented

acupuncture protocol had a better efficacy to treat depression and to improve sleep quality of

patients with depression.

Keywords: Acupuncture; depression; sleep disturbance; augmented acupuncture formula;

confluent points.

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1. Introduction

Depression is a major public health issue and has a substantial impact on the individuals

and the society. In the clinical setting, the patients complain of a lack of interest in life and

activities, and show low self-esteem, dizziness, fatigue, feelings of uselessness, suicidal

thoughts, and sleep disturbances (including insomnia and hypersomnia) (Chen et al., 2013).

Patients with depression most frequently complain about difficulties in getting asleep,

frequent waking at night and early morning, and having nightmares (Bosch, de Rover,

Staudte, Lim, & van den Noort, 2015; M. M. Ohayon, 2002; Maurice M Ohayon, 2005).

About 75% of all depressed patients complain of difficulties in falling asleep or maintaining

sleep (Hamilton, 1989; Tsuno, Besset, & Ritchie, 2005; Yates et al., 2007). Studies have

shown that insomnia has a negative impact on daytime life of healthy subjects, including

alertness, attention, concentration, memory, and mood (Soldatos, 1994; Van Dongen, Maislin,

Mullington, & Dinges, 2003). Some patients are inclined to report emotional distress and

recurrent health problems instead of sleep disturbances in the clinic. Different studies have

established that insomnia and psychiatric disorders, especially depression, are tightly

associated to each other (M. M. Ohayon, Caulet, & Lemoine, 1998; Riemann, 2008). Based

on data on depression and insomnia among adolescents (Roberts & Duong, 2013), insomnia

has a direct effect on the risk for major depression.

Treatment of depression and insomnia are important to improve the quality of life of the

patients (Chen et al., 2013). Many studies discussed the efficacy of acupuncture in treating

and relieving the symptoms of depression (MacPherson, Sinclair-Lian, & Thomas, 2006;

Sherman et al., 2005; H. Wang et al., 2008). The standard acupuncture treatment protocol is

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based on a point selection established on the basis of the traditional Chinese medicine (TCM)

pattern of depression. Liver Qi stagnation is the most important pathogenesis of depression in

Chinese medicine, causing symptoms like lack of interest in life and activities and low

self-esteem. LI-4 (He Gu), LIV-3 (Tai Chong), EX-HN-3 (Yin Tang), and GV-20 (Bai Hui)

are the points of the standard acupuncture protocol to regulate ‘Liver Qi’ (Chen et al., 2013).

Studies have shown that this standard protocol can also relieve depression symptoms (Fan et

al., 2012; Fu et al., 2009; Liu et al., 2012). In the augmented acupuncture protocol, the two

empirical points LU-7 (Lie Que) and KID-6 (ZhaoHai) are added to the standard protocol.

These two points are used to improve the sleep quality of the patients. In “Huang Di Nei

Jing”, the lung takes the responsibility of Qi stagnation. Lie Que is a confluence point that

connects the conception vessel. The branches of the conception vessel enter the kidney

meridian, governing vessel, and thoroughfare vessel; hence, the conception vessel is capable

of Qi and blood production and translation. Besides, the Lie Que acupoint regulates the lung

Qi movement by directing the Qi downward. Zhao Hai is an acupoint on the kidney meridian

of foot shaoyin, which links with the Yin Heel. Therefore, treating Zhao Hai invigorates the

kidney and prompts deep sleep. Furthermore, an embedded needle technique has proved to be

effective against chronic diseases or for diseases demanding a longer retention time.

Therefore, this acupuncture technique is used to extend the effective treatment period in

optimized acupuncture protocols (Chen et al., 2013).

Nevertheless, there a few studies comparing the standard and augmented protocols to treat

depressive symptoms and sleep disturbances in patients with depression. Therefore, the

present study aimed to evaluate the efficacy of the standard and augmented acupuncture

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protocols on depressive symptoms and sleep disturbances in patients with depression.

2. Patients and Methods

2.1 Study Design and Ethics

This study was a multicenter, randomized, controlled trial designed to compare the

efficacy of standard vs. augmented acupuncture protocols on depressive symptoms and sleep

disturbance in patients with depression. The present study was designed, conducted, and

reported according to the Good Clinical Practices and the revised Standards for Reporting

Interventions in Clinical Trials Acupuncture (STRICTA) (Hugh et al., 2010). Ethical approval

was obtained from the Institutional Ethics Committee of the Guangdong Provincial Hospital

of Traditional Chinese Medicine (No.: 2008GL-26). All participants had signed an informed

consent. The trial was approved by the ethical committee before the enrolment of the first

patient until the last follow-up visit. The trial was registered in the Chinese Clinical Trial

Registry (ChiCTR-TRC-00000481) on May 13th, 2011. The authors confirm that all ongoing

and related trials for this drug/intervention are registered. This study has been officially

registered after patient enrolment because of delays due to system upgrades at the Chinese

Clinical Trial Registry.

2.2 Participants

The study was conducted at the Department of Acupuncture and Moxibustion, Guangdong

Provincial Hospital of Traditional Chinese Medicine, China. The other two branch centers

were the Second People’s Hospital of Zhaoqing City and People’s Hospital of Huizhou City.

Participants were recruited from January 2009 to October 2011. Patient recruitment was

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carried out at all three centers. Patients recruited from Guangdong Provincial Hospital of

TCM, China, the Second People’s Hospital of Zhaoqing City, and the People’s Hospital of

Huizhou City. Recruitment was conducted through advertisement in the acupuncture

departments, referrals from doctors, and acupuncturists.

The inclusion criteria were: 1) depression according to the Chinese Classification of

Mental Disorders-3 (CCMD-3): mainly associated with low mood and at least four of the

following symptoms: a) loss of interest, no pleasure; b) energy loss or fatigue; c)

psychomotor lag or vehement; d) low self-evaluation, remorse, or with a sense of guilt; e)

difficulty in association and imagination or awareness of thinking decline; f) idea to die or

suicide, self injury behavior recurrence; g) sleep disorders such as insomnia, waking up early,

or too much sleep; h) decreased appetite or significant weight loss; or i) hypophrodisia; 2)

difficulty in falling asleep (>30 minutes), dreaminess, waking up during sleep (>2 times),

early waking up, and inability to fall asleep again after waking up; 3) Hamilton rating scale

for depression (HAMD) score >20 and <35; 4) Pittsburgh Sleep Quality Index (PSQI)

score >7; 5) conscious without aphasia or mental impairment and able to read and answer the

questions on the rating scales; 6) aged 16-50 years; and 7) course of depression insomnia was

between 2 weeks and 2 years. Subjects were excluded if they: 1) were currently on

psychoactive drugs, including anti-depressants or herbal anti-depressants; 2) were pregnant; 3)

had serious heart, brain, liver, kidney, or hematopoietic system diseases; 4) were afraid of

needling, or 5) could not cooperate with their doctors.

The participants were not paid for participation, but acupuncture treatment was free of

charge.

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 The withdrawal or dropout criteria were: 1) the participant was willing to withdraw or on

request of his/her legal representative; 2) according to the investigator’s opinion, if the

participant developed a serious disease like heart disease or pneumonia; 3) in the

investigator’s opinion, if the compliance of the participant was inadequate; or 4) if the

participant had adverse reactions to acupuncture. Withdrawal reason was documented. The

investigators were instructed to provide the treatment to the dropped out participants if they

required it, but the results were considered as missing information. Drop-outs were excluded

from the analyses.

The assessment of depression and insomnia symptoms using the HAMD and PSQI were

performed by independent research assistants, who were blinded to group allocation and trial

protocol. All evaluations and result analysis were performed by professionals blinded to

grouping.

2.3 Randomization and Blinding

Eligible subjects were randomly assigned to either group in a 1:1 ratio by an independent

administrator. A sequence number, seed number, center number, and allocation result were

generated for each participant using the PEMS version 3.1 software. Sealed consecutively

numbered envelopes were then used for allocation. Practitioners did not take part in the

randomization process. Participants were told that ‘This study is to evaluate the therapeutic

effects of augmented acupuncture formula for treating depressive symptoms and sleep quality.

You will either received standard or augmented acupuncture formula depending on

randomization.’ Participants in the different groups were in separate rooms during

acupuncture treatment to avoid discussing their treatments, which could introduce bias. Due

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to the nature of the intervention, it was impossible to blind the acupuncturists in the study.

2.4 Treatment protocols

The patients received 12 treatment session, at two sessions per week, with a minimum

interval of two days between sessions, for six consecutive weeks. All acupuncture treatments

were performed in a quiet treatment room, at about 25°C. Acupuncturists participating in the

trial were trained in the study procedure and had general acupuncture licenses in China.

Outcomes were evaluated at baseline, week 3, end of treatment (immediately after the last

treatment session), and 4-week follow-up (the patient visited the clinic at 4 weeks after the

last treatment session). Three doctors were involved in this study, all of them with an

experience in acupuncture and moxibustion of at least 5 years. Before study, all three doctors

received a training in acupuncture at the Guangdong Provincial Hospital of Traditional

Chinese Medicine. The training included: patients screening and specific operation with

specification including acupuncture point positioning, acupuncture and needle-embedding.

2.4.1 Needle selection

All needles used in this study were 0.35×25mm and were produced by Suzhou Tianxie

Acupuncture Instruments Co. Ltd, China. The intradermal needle were manufactured by

Suzhou Medical Instrument Factory, China. The needle was 3-mm long with a circular head

and a needle tip.

2.4.2 Standard acupuncture protocol

Patients assigned to the control group were needled at the following points: HeGu (LI-4),

TaiChong (LIV-3), YinTang (EX-HN-3), and BaiHui (GV-20). These acupoints are typical for

treating depression in terms of TCM theory. The skin on the acupoints area was disinfected

9
with 75% alcohol. Sterilized disposable needles (0.35 mm in diameter and 25 mm in length)

were inserted at a depth of 10-20 mm obliquely or perpendicularly into the acupoints.

Practitioners twisted and thrusted the needles to achieve a “Deqi” sensation (described as

numb, distended, and aching). The needles were left for 30 min and then removed. Patients

were then required to take six deep breaths at intervals of one minute, and to repeat the same

breathing until the needles were removed.

2.4.3 Augmented acupuncture formula

On the basis of the standard acupuncture formula, the LieQue (LU-7) and ZhaoHai (KID-6)

points were added. After removing the needles, intradermal needles were used for

embedding in the skin or subcutaneously for relatively long time to consolidate the treatment

effect. Two groups of points including XinShu (Bl-15) with ShenShu (Bl-23) and DanShu

(Bl-19) with AnMian (N-HN-54) were used alternatively. The effectiveness of the set of

optimized formulas had been well proven in the practice by our senior acupuncturists at the

Guangdong Provincial Hospital of TCM (Chen et al., 2013). The acupuncture manipulation

was similar to that of the control group. The practitioners inserted the intradermal needles

obliquely (at about 15°to the skin) underneath the skin. 3M medical proof fabric was used to

keep the needle in place until the next treatment (a smaller one of about 5×5mm under the

circular head of the needle and a bigger one about 10×10mm upon the needle). Before the

start of the following treatment, the embedded needles were removed by the practitioners.

2.5 Primary outcomes

Symptoms of depression were assessed using the HAMD. The PSQI was used to assess

sleep disturbances. Both of them were the primary outcomes for effectiveness evaluation.

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These values were obtained at baseline, week 3, end of treatment, and 4-week follow-up.

HAMD and PSQI were administered by independent research assistants who were blind to

grouping.

The HAMD was developed by Hamilton (Hamilton, 1960, 1967), and has been widely

used as the main outcome measure in randomized clinical trials (RCTs) for antidepressant

studies. In this study, a validated Chinese version of HAMD-24 was used (Fan et al., 2015).

Validity, reliability, and sensitivity of this scale are well proven, with higher scores indicating

more severe depressive symptoms. Interpretation of HAMD scores: <8, no depression; 8-20,

may have depression; 20-35, definitive depression; and >35 severe depression. The PSQI was

introduced in 1989 (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) and is a valuable

tool to assess sleep-related problems. The present study used a validated Chinese version of

the PSQI (Fan et al., 2015).

2.6 Secondary outcomes

The Credibility of Treatment Rating Scale (CTRS) was used to assess treatment credibility.

Questions include “perceived logic of the treatment,” “confidence in the treatment to alleviate

your complaint”, “confidence in recommending the treatment to your friends who have

similar complaints", and “likelihood that the treatment would alleviate your other

complaints.” The CTRS was completed after the second session and at the end of treatment.

A lower score suggests greater confidence towards the received treatment (Vincent, 1990).

2.7 Sample Size Calculation

For depression insomnia, few reports were available about clinical trials of acupuncture.

based on early randomized controlled pre-clinical trials in Guangdong provincial hospital of

11
TCM, HAMD and PSQI scores were used for sample size determination. It was estimated

that a conservative 40% of patients would be cured by the conventional acupuncture protocol

70% by the augmented protocol. Considering a 15% drop out rate, a total of 80 patients was

needed.

2.8 Statistical analysis

Baseline differences between participants in the treatment and control groups were

examined using the chi-square test or Mann-Whitney test, as appropriate. The intervention

effect over time was assessed using multivariate analysis of variance (MANOVA). SPSS 20.0

(IBM, Armonk, NY, USA) was used to perform all statistical analyses. P<0.05 was

considered statistically significant.

3. Results

3.1 Participants

A total of 173 participants were screened and 105 were randomized. Figure 1 provides

the patient flowchart. Demographic characteristics were well balanced between two groups

(Table 1). Sixteen participants (15.2%) withdrew during the study period, eight in the

augmented treatment group (15.7%), and eight in the standard group (14.8%). The reasons

withdrawal are reported in Figure 1. Finally, 89 patients were included in the final analyses.

3.2 Primary outcomes

From baseline to four weeks after treatment, the HAMD scores in the augmented group

showed a significantly greater reduction than that in the standard group (P<0.001, Figure 2).

In addition, all the factors of the HAMD except ‘diurnal variation’ showed greater reductions

12
in the augmented group than in the standard group at the end of treatment and 4-week

follow-up (all P<0.05, Table 2).

Table 3 shows the differences of PSQI between the two groups and Figure 3 shows that

there were significant differences in the PSQI scores between the two groups from baseline to

4-week follow-up (P<0.001). The differences in the subcomponent scores of the PSQI

between the two groups significant in all areas except habitual sleep efficiency (all P<0.05,

Table 3).

3.3 Correlations analyses

Table 4 shows that there were correlations between the grouping and HAMD scores

(r=0.224, P<0.001), time and HAMD scores (r=-0.566, P<0.001), grouping and PSQI scores

(r=0.186, P<0.001), and time and PSQI scores (r=-0.654, P<0.001).

3.4 Mixed models for HAMD scores

The HAMD score was taken as a dependent variable to explore the effects of group and

time as well as their crossover effect on HAMD scores. According to Table 5, there was a

crossover effect between group and time factors (F=12.739, P<0.001). The HAMD scores

were statistically different between the two groups (F=12.302, P=0.001). HAMD scores at

different time points were also significantly different (F=171.232, P<0.001). According to

Table 6, the HAMD scores of the standard group were higher than that of the augmented

group (T=-5.695, P<0.001). For the time factor, one month after treatment was used as

reference, and the baseline parameters were significantly different from that of the standard

group (T=10.502, P<0.001); 3 weeks after treatment was significantly different from the

standard group (T=2.969, P=0.003); but end of treatment was not significantly different from

13
the control group (T=-0.969, P=0.333). Since there was a crossover effect of time and group,

fine comparisons were made between the two groups at each time point (Table 7) and within

each individual group at different time points (Bonferroni correction). The results showed

that in the augmented group, the HAMD scores improved with time, except between end of

treatment and 4-week follow-up, while in the standard group, HAMD scored improved from

baseline to week 3, and stopped improving thereafter.

3.5 Mixed models for PSQI scores

According to Table 8, there was a crossover effect between group and time factors

(F=15.679, P<0.001). The PSQI scores were significantly different between the two groups

(F=10.301, P=0.002). The PSQI scores at different time points were also significantly

different (F=205.942, P<0.001). According to Table 9, PSQI scores of the standard group

were higher than that of the augmented group (T=-5.220, P<0.001). When considering the

time factor, baseline values were significantly different from that of the standard group

(T=11.986, P<0.001); values at 3 weeks after treatment were significantly different from that

of the standard group (T=5.457, P<0.001); but values at the end of treatment were not

significantly different from that of the standard group (T=1.726, P=0.086). Since there was a

crossover effect of time and group, fine comparisons were made between the two groups at

each time point (Table 10) and within each individual group at different time points

(Bonferroni correction). The results showed that the PSQI scores improved with time in the

two groups, except between end of treatment and 4-week follow-up.

3.6 Adverse events

During the trial, two subjects in the standard group reported discomforts at the needle sites

14
and one complained of insomnia worsening. In the augmented group, hematoma (n=2) and

pain at acupoints (n=2) were reported (Table 11). Most adverse events were mild in severity.

No patient withdrew due to adverse events.

4. Discussion

The present study compared two acupuncture approaches designed specifically to treat

depression. The interesting aspect of this study is the comparison between standard and

augmented acupuncture protocols. The results showed that the augmented protocol was

significantly better in improving sleep quality and depressive symptoms in participating

subjects. The augmented acupuncture protocol could be a good treatment option for

depression and insomnia.

Depression has various clinical manifestations and insomnia is one of the most frequent

symptoms. Depression was once classically viewed as a cause of insomnia, but a growing

body of epidemiological studies suggested that insomnia may itself be a risk factor for

depression (Ford & Kamerow, 1989; Roberts, Shema, Kaplan, & Strawbridge, 2000).

Depression and insomnia apparently affect each other in a bi-directional manner. Studies have

shown that patients with mood disorders have higher rates of sleep problems than the general

population, On the other hand, patients with sleep disturbance are more likely to have

depression than good sleepers (Kaneita et al., 2006; M. M. Ohayon & Hong, 2006; Taylor,

Lichstein, Durrence, Reidel, & Bush, 2005). Therefore, depression and insomnia should be

treated as a whole.

A recent study showed that acupuncture can effectively improve the quality of life of

15
patients with depression (Fan et al., 2016). A meta-analysis concluded that acupuncture is an

effective treatment for depression (H. Wang et al., 2008) and previous studies showed that

acupuncture was as effective as antidepressants for the treatment of depression (Leo & Ligot,

2007). A recent meta-analysis showed that acupuncture improved both the HAMD and PSQI

score (J. Wang, Wang, Wang, & Zhang, 2015). Acupuncture therapy was also found effective

in study on patients with depression where HAMD score was used for evaluation (Zhou, Li,

Zhou, & Pan, 2015). A recent study showed that the standard protocol used in the present

study was efficient for the treatment of depression insomnia (Chen et al., 2013). The present

study refined the results of this previous study and showed that adding two acupoints and

embedded needles resulted in further improvements. Nevertheless, two recent Cochrane

reviews strongly suggest that acupuncture has no effect on insomnia (Cheuk, Yeung, Chung,

& Wong, 2012) or depression (Smith, Hay, & Macpherson, 2010). Additional studies in

various populations are still necessary to determine the exact contribution of acupuncture to

the treatment of depression and insomnia.

The balance of Yin and Yang is central in TCM. This balance covers a number of aspects

including physical, psychological, nutritional, social, and environmental factors. TCM

emphasizes the need for bodily and mental balance (MacPherson et al., 2014). Therefore,

TCM pays a great attention to quality of life, which include sleep quality and depressive

symptoms (Fan et al., 2016). According to the principles of TCM, it is appropriate to select

the acupoints according to the depression condition of each individual patient. Therefore,

additional studies are necessary to determine whether specific patients could benefit more

from specific acupoints. In addition, gender differences should be taken into account (Fan et

16
al., 2015).

Side effects of acupuncture are generally minor. In a survey by Ernst et al. (Ernst, Strzyz,

& Hagmeister, 2003), out of 3535 patients, 2.2% of the patients showed hematoma and

increasing pain. In current study, 2.3% of the patients experienced hematoma and pain.

Studies on acupuncture and depression are complicated to design, conduct, and evaluate

because of the different patterns obtained using different groups of patients and because of

effect sizes for comparison (Rothman, Wiens, & Chan, 2012). For the present study, for

overcoming the issue, strict inclusion criteria were used (Patel, Doku, & Tennakoon, 2003).

In a randomized trial study by Schroer et al. (Schroer, Kanaan, MacPherson, & Adamson,

2012), acupuncture was used to treat depression in order to explore model validity and the

related issue of credibility in relation to designing a pragmatic trial. It was observed that there

was no significant difference in treatment credibility according to the Medical Research

Council (MRC) criteria when using a mixed method approach. In the present study, there was

no difference in treatment credibility between the two groups.

The present study has a number of limitations. First, there was no negative control group.

Secondly, only the patients in the augmented group received extended treatment with

embedded needles, and we could not determine if the better efficacy observed in the

augmented group was due to the embedded needles or the additional acupoints. For now, the

augmented protocol should be considered as a whole. Thirdly, the follow-up was short and it

is unsure whether the remission could be sustained over a prolonged period. Fourthly, only

the patients were blinded. It is difficult to realize double-blind designs in acupuncture

research because the acupuncturist has to be aware of the method applied.

17
 Despite of these limitations, the present study provided important data on the treatment of

depression insomnia using acupuncture. The augmented acupuncture protocol has definitive

advantages for the treatment of depression symptoms and sleep disturbances. Further studies

with improved project design are needed to accurately determine the use of acupuncture for

the treatment of depressive symptoms and sleep disturbances in patients with depression.

In conclusion, augmented acupuncture formula proved to be effective in the treatment of

depression and improved the sleep quality in patients who already had depression.

Funding

This project was supported by the Science and Technology Planned Project of Guangdong

province (Clinical study of acupuncture treatment for depression insomnia), No.

2008B030301206. The National Natural Science Foundation of China (Mechanism Research

of Acupuncture Treatment for Anti-depressant Based Glutamic Acid Circulation Mediated by

Glias Cells) No. 81173348.

Conflict of interests

The authors declare that they have no conflict of interests.

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References

Bosch, P., de Rover, P., Staudte, H., Lim, S., & van den Noort, M. (2015). Schizophrenia,

depression, and sleep disorders: their traditional Oriental medicine equivalents. J

Acupunct Meridian Stud, 8(1), 17-22. doi: 10.1016/j.jams.2014.06.001

Buysse, D. J., Reynolds, C. F., 3rd, Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The

Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research.

Psychiatry Res, 28(2), 193-213

Chen, Y. F., Liu, J. H., Xu, N. G., Liang, Z. H., Xu, Z. H., Xu, S. J., & Fu, W. B. (2013).

Effects of acupuncture treatment on depression insomnia: a study protocol of a

multicenter randomized controlled trial. Trials, 14, 2. doi: 10.1186/1745-6215-14-2

Cheuk, D. K., Yeung, W. F., Chung, K. F., & Wong, V. (2012). Acupuncture for insomnia.

Cochrane Database Syst Rev(9), CD005472. doi: 10.1002/14651858.CD005472.pub3

Ernst, G., Strzyz, H., & Hagmeister, H. (2003). Incidence of adverse effects during

acupuncture therapy-a multicentre survey. Complement Ther Med, 11(2), 93-97

Fan, L., Fu, W., Chen, Z., Xu, N., Liu, J., Lu, A., . . . Ou, A. (2016). Curative effect of

acupuncture on quality of life in patient with depression: a clinical randomized

single-blind placebo-controlled study. J Tradit Chin Med, 36(2), 151-159

Fan, L., Fu, W. B., Xu, N. G., Liu, J. H., Fan, L., & Ou, A. H. (2012). [Impacts of acupuncture

and moxibustion on outcome indeices of depression patients' subjective reports].

Zhongguo Zhen Jiu, 32(5), 385-389

Fan, L., Gong, J., Fu, W., Chen, Z., Xu, N., Liu, J., . . . Xie, H. (2015). Gender-Related

Differences in Outcomes on Acupuncture and Moxibustion Treatment Among

19
 Depression Patients. J Altern Complement Med, 21(11), 673-680. doi:

10.1089/acm.2015.0068

Ford, D. E., & Kamerow, D. B. (1989). Epidemiologic study of sleep disturbances and

psychiatric disorders. An opportunity for prevention? JAMA, 262(11), 1479-1484.

Jama the Journal of the American Medical Association, 262(11), 1479-1484

Fu, W. B., Fan, L., Zhu, X. P., He, Q., Wang, L., Zhuang, L. X., . . . Yan, J. (2009).

Depressive neurosis treated by acupuncture for regulating the liver--a report of 176

cases. J Tradit Chin Med, 29(2), 83-86

Hamilton, M. (1960). A rating scale for depression. Journal of Neurology Neurosurgery &

Psychiatry, 23(1), : 56–62.

Hamilton, M. (1967). Development of a rating scale for primary depressive illness. British

Journal of Social & Clinical Psychology, 6(4), 278-296

Hamilton, M. (1989). Frequency of symptoms in melancholia (depressive illness). British

Journal of Psychiatry, 154(2), 201-206

Hugh, M. P., Altman, D. G., Richard, H., Li, Y., Wu, T., Adrian, W., & David, M. (2010).

Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture

(STRICTA): Extending the CONSORT Statement. Plos Medicine, 7(3), 140-155

Kaneita, Y., Ohida, T., Uchiyama, M., Takemura, S., Kawahara, K., Yokoyama, E., . . . Fujita,

T. (2006). The relationship between depression and sleep disturbances: a Japanese

nationwide general population survey. J Clin Psychiatry, 67(2), 196-203

Leo, R. J., & Ligot, J. S., Jr. (2007). A systematic review of randomized controlled trials of

acupuncture in the treatment of depression. J Affect Disord, 97(1-3), 13-22. doi:

20
 10.1016/j.jad.2006.06.012

Liu, J. H., Wu, Z. F., Sun, J., Jiang, L., Jiang, S., & Fu, W. B. (2012). Role of AC-cAMP-PKA

Cascade in Antidepressant Action of Electroacupuncture Treatment in Rats. Evid

Based Complement Alternat Med, 2012, 932414. doi: 10.1155/2012/932414

MacPherson, H., Newbronner, L., Chamberlain, R., Richmond, S. J., Lansdown, H., Perren,

S., . . . Spilsbury, K. (2014). Practitioner perspectives on strategies to promote

longer-term benefits of acupuncture or counselling for depression: a qualitative study.

PLoS One, 9(9), e104077. doi: 10.1371/journal.pone.0104077

MacPherson, H., Sinclair-Lian, N., & Thomas, K. (2006). Patients seeking care from

acupuncture practitioners in the UK: a national survey. Complement Ther Med, 14(1),

20-30. doi: 10.1016/j.ctim.2005.07.006

Ohayon, M. M. (2002). Epidemiology of insomnia: what we know and what we still need to

learn. Sleep Med Rev, 6(2), 97-111

Ohayon, M. M. (2005). Prevalence and correlates of nonrestorative sleep complaints.

Archives of Internal Medicine, 165(1), 35-41

Ohayon, M. M., Caulet, M., & Lemoine, P. (1998). Comorbidity of mental and insomnia

disorders in the general population. Compr Psychiatry, 39(4), 185-197

Ohayon, M. M., & Hong, S. C. (2006). Prevalence of major depressive disorder in the general

population of South Korea. J Psychiatr Res, 40(1), 30-36. doi:

10.1016/j.jpsychires.2005.02.003

Patel, M. X., Doku, V., & Tennakoon, L. (2003). Challenges in recruitment of research

participants. Advances in Psychiatric Treatment, 9(9), 229-238

21
Riemann, D. (2008). Insomnia and comorbid psychiatric disorders. Sleep Medicine, 8 Suppl

4(1), S15-20

Roberts, R. E., & Duong, H. T. (2013). Depression and insomnia among adolescents: a

prospective perspective. J Affect Disord, 148(1), 66-71. doi:

10.1016/j.jad.2012.11.049

Roberts, R. E., Shema, S. J., Kaplan, G. A., & Strawbridge, W. J. (2000). Sleep complaints

and depression in an aging cohort: A prospective perspective. Am J Psychiatry, 157(1),

81-88. doi: 10.1176/ajp.157.1.81

Rothman, M. D., Wiens, B. L., & Chan, I. S. F. (2012). Design and Analysis of

Non-inferiority Trials. Boca Raton: Chapman&Hall/CRC.

Schroer, S., Kanaan, M., MacPherson, H., & Adamson, J. (2012). Acupuncture for depression:

exploring model validity and the related issue of credibility in the context of

designing a pragmatic trial. CNS Neurosci Ther, 18(4), 318-326. doi:

10.1111/j.1755-5949.2011.00243.x

Sherman, K. J., Cherkin, D. C., Eisenberg, D. M., Erro, J., Hrbek, A., & Deyo, R. A. (2005).

The practice of acupuncture: who are the providers and what do they do? Ann Fam

Med, 3(2), 151-158. doi: 10.1370/afm.248

Smith, C. A., Hay, P. P., & Macpherson, H. (2010). Acupuncture for depression. Cochrane

Database Syst Rev(1), CD004046. doi: 10.1002/14651858.CD004046.pub3

Soldatos, C. R. (1994). Insomnia in relation to depression and anxiety: epidemiologic

considerations. J Psychosom Res, 38 Suppl 1, 3-8

Taylor, D. J., Lichstein, K. L., Durrence, H. H., Reidel, B. W., & Bush, A. J. (2005).

22
 Epidemiology of insomnia, depression, and anxiety. Sleep, 28(11), 1457-1464

Tsuno, N., Besset, A., & Ritchie, K. (2005). Sleep and depression. Journal of Clinical

Psychiatry, 66(10), 1254-1269

Van Dongen, H. P., Maislin, G., Mullington, J. M., & Dinges, D. F. (2003). The cumulative

cost of additional wakefulness: dose-response effects on neurobehavioral functions

and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep,

26(2), 117-126

Vincent, C. (1990). Credibility assessment in trials of acupuncture. Complementary Medical

Research, 4, 8-11

Wang, H., Qi, H., Wang, B. S., Cui, Y. Y., Zhu, L., Rong, Z. X., & Chen, H. Z. (2008). Is

acupuncture beneficial in depression: a meta-analysis of 8 randomized controlled

trials? J Affect Disord, 111(2-3), 125-134. doi: 10.1016/j.jad.2008.04.020

Wang, J., Wang, J., Wang, L., & Zhang, Y. (2015). [Senile insomnia treated with integrated

acupuncture and medication therapy: a randomized controlled trial]. Zhongguo Zhen

Jiu, 35(6), 544-548

Yates, W. R., Mitchell, J., John Rush, A., Trivedi, M., Wisniewski, S. R., Warden, D., . . .

Gaynes, B. N. (2007). Clinical features of depression in outpatients with and without

co-occurring general medical conditions in STAR*D: confirmatory analysis. Prim

Care Companion J Clin Psychiatry, 9(1), 7-15

Zhou, X., Li, Y., Zhou, Z., & Pan, S. (2015). [Clinical observasion of acupuncture in patients

with depression and its impact on serum 5-HT]. Zhongguo Zhen Jiu, 35(2), 123-126

23
Figure legends

Figure 1 Flow chart of subject recruitment, and analysis in randomized controlled

acupuncture clinical trial

Figure 2 Changes in severity of depression with acupuncture treatment represented by

HAMD Score from baseline till 4 weeks follow up. (Group Standard is represented by

imaginary line and Group Augmented is represented by solid line). *: p<0.05.

Figure 3 Changes in sleep quality with acupuncture treatment from baseline till 4 weeks after

treatment. (Group Standard is represented by imaginary line and Group Augmented is

represented by solid line). *: p<0.05.

24
Tables

Table 1. Demographic and clinical characteristics of the participants

Standard Augmented Chi-square

Variables P- value
(n=46) (n=43) or Z

Sex 0.652 0.419

Male 21 (45.7%) 16 (32.7%)

Female 25 (54.3%) 27 (62.8%)

Age (y) 38.2±12.9 42.2±14.7 1.344 0.183

Course (m) 24 (1,144) 19 (1,120) -1.865 0.062

Pretreatment 0.984 0.321

Yes 23 (50.0%) 17 (39.5%)

No 23 (50.0%) 26 (60.5%)

Baseline HAMD score 29.8±3.2 28.3±3.7 -1.984 0.051

Baseline PSQI score 16.4±2.6 17.0±3.0 1.046 0.099

Data are presented as mean ±SD or number (%).

PSQI: Pittsburgh Sleep Quality Index; HAMD: Hamilton Rating Scale.

25
Table 2. Changes of HAMD factors and total scores at baseline, before the sixth treatment,

end of treatment, and 4-week follow up.

Augmented
Variables Standard (n=46) T/Z P
(n=43)

6.6±2. 6.7±2. -0.02

Baseline 6.5 (2,12) 7 (2,13) 0.983
1 2 1

5.3±2. 5.4±2. -0.36

Week 3 5 (1,11) 6 (1,10) 0.718
2 1 2
Anxiety/Somatic
End of 4.8±2. 4.0±1. -1.61
5 (1,10) 4 (1,8) 0.107
treatment 3 7 2

4-week 5.4±2. 3.5±1. -3.49 <0.0

5 (2,11) 3 (0,7)
follow-up 5 6 6 01

0.6±0. 0.6±0. -0.12

Baseline 1 (0,2) 1 (0,1) 0.897
6 5 9

0.4±0. 0.4±0. -0.17

Week 3 0 (0,2) 0 (0,2) 0.863
6 6 2
Weight loss
End of 0.6±0. 0.4±0. -2.09
1 (0,2) 0 (0,1) 0.036
treatment 5 5 7

4-week 0.6±0. 0.3±0. -2.31

1 (0,2) 0 (0,1) 0.021
follow-up 5 5 5

Cognitive 6.7±1. 6.0±1. -1.71

Baseline 6 (3,11) 6 (3,10) 0.086
impairment 6 9 6

26
 5.7±2. 4.9±1. -1.31
Week 3 5 (2,12) 5 (1,9) 0.188
2 8 7

End of 4.9±2. 3.7±1. -2.23

5 (1,11) 4 (0,7) 0.025
treatment 5 6 8

4-week 5.3±2. 3.5±1. -3.93 <0.0

5 (1,11) 3 (0,7)
follow-up 3 6 2 01

1.1±0. 1.0±1. -0.71

Baseline 1 (0,3) 1 (0,3) 0.476
9 0 3

0.8±1. 0.8±1. -0.43

Week 3 0 (0,4) 1 (0,3) 0.663
1 0 5
Diurnal variation
End of 0.8±1. 0.7±0. -0.27
0 (0,3) 0 (0,3) 0.786
treatment 1 9 1

4-week 0.8±1. 0.5±0. -1.10

0 (0,3) 0 (0,3) 0.269
follow-up 1 8 5

6.1±1. 5.7±1. -1.65

Baseline 6 (3,10) 6 (3,9) 0.098
4 0 7

5.1±1. 4.6±1. -2.16

Week 3 5 (3,8) 4 (2,9) 0.031
2 5 0
Retardation
End of 4.3±1. 3.7±1. -1.58
4 (1,8) 4 (0,7) 0.114
treatment 4 3 2

4-week 4.4±1. 3.3±1. -3.11

4 (2,8) 3 (0,7) 0.002
follow-up 3 5 4

27
 4.8±1. 4.7±1. -0.17
Baseline 5 (2,6) 5 (2,6) 0.861
2 3 5

4.0±1. 3.8±1. -0.97

Week 3 4 (1,6) 4 (2,6) 0.330
2 1 5
Sleep disorders
End of 3.3±0. 2.7±1. -2.30
3 (2,5) 3 (0,5) 0.021
treatment 8 2 0

4-week 3.2±1. 2.5±1. -2.59

3 (1,6) 3 (0,5) 0.009
follow-up 0 3 5

3.9±1. 3.7±1. -0.75

Baseline 4 (1,7) 4 (1,6) 0.448
2 1 8

3.3±1. 2.8±1. -1.65

Week 3 3 (0,6) 3 (0,5) 0.098
2 1 7
Desperation
End of 3.1±1. 2.2±1. -2.91
3 (0,7) 2 (0,5) 0.004
treatment 3 3 5

4-week 2.9±1. 2.0±1. -3.15

3 (0,7) 2 (0,5) 0.002
follow-up 4 3 3

29.8±3 30 28.3±3 29 1.98

Baseline 0.051
.2 (22,35) .7 (22,35) 4

24.5±5 23.5 22.7±5 24 1.55

HAMD scores Week 3 0.123
.7 (17,39) .6 (11,31) 6

End of 21.8±7 21 17.4±5 17 3.27

0.002
treatment .3 (11,41) .2 (8,27) 1

28
 4-week 22.5±7 21 15.6±5 17 4.81 <0.0

follow-up .5 (10,42) .9 (5,27) 9 01

HAMD: Hamilton Rating Scale.

29
Table 3. Change of PSQI factors and total scores at baseline, before the sixth treatment, end

of treatment, and 4-week follow up.

Group Standard Group

Variables T/Z P
(n=46) Augmented(n=43)

-1.3 0.18
Baseline 2.4±0.6 2 (1,3) 2.6±0.5 3 (2,3)
22 6

-1.1 0.25
Week 3 1.9±0.7 2 (1,3) 1.7±0.6 2 (1,3)
Subjective sleep 48 1

quality End of -3.7 <0.0

1.5±0.6 1 (1,3) 1.1±0.3 1 (1,2)
treatment 44 01

4-week -2.7 0.00

1.3±0.5 1 (0,3) 1.0±0.4 1 (0,2)
follow-up 26 6

-0.1 0.85
Baseline 2.9±0.4 3 (2,3) 2.8±0.5 3 (1,3)
82 6

2.5 -0.2 0.83

Week 3 2.4±0.7 2.4±0.6 2 (1,3)
(1,3) 11 3
Sleep latency
End of -3.2 0.00
2.1±0.8 2 (1,3) 1.6±0.6 2 (1,3)
treatment 43 1

4-week -2.7 0.00

1.8±0.9 2 (1,3) 1.3±0.6 1 (0,3)
follow-up 45 6

-0.1 0.88
Sleep duration Baseline 2.8±0.5 3 (1,3) 2.8±0.4 3 (2,3)
44 5

30
 -1.5 0.12
Week 3 2.3±0.5 2 (1,3) 2.1±0.4 2 (1,3)
30 6

End of -3.0 0.00

2.1±0.4 2 (1,3) 1.6±0.8 2 (0,3)
treatment 59 2

4-week -4.1 <0.0

2.1±0.4 2 (1,3) 1.4±0.9 2 (0,3)
follow-up 85 01

-1.1 0.26
Baseline 2.7±0.6 3 (1,3) 2.9±0.5 3 (1,3)
07 8

-0.5 0.60
Week 3 2.1±1.0 2 (0,3) 2.3±0.8 2 (0,3)
Habitual sleep 23 1

efficiency End of -0.4 0.62

1.8±0.7 2 (0,3) 1.9±0.9 2 (0,3)
treatment 92 2

4-week -2.4 0.01

2.0±0.7 2 (0,3) 1.4±1.0 2 (0,3)
follow-up 14 6

-0.7 0.48
Baseline 1.7±0.7 2 (1,3) 1.8±0.8 2 (1,3)
07 0

-1.1 0.23
Week 3 1.5±0.6 1 (1,3) 1.3±0.5 1 (1,2)
Sleep 82 7

disturbances End of -3.3 0.00

1.3±0.5 1 (1,3) 1.0±0.2 1 (1,2)
treatment 43 1

4-week -3.8 <0.0

1.3±0.5 1 (1,3) 0.9±0.3 1 (0,1)
follow-up 99 01

31
 -0.8 0.38
Baseline 1.7±1.2 2 (0,3) 1.9±1.3 2 (0,3)
68 5

-1.3 0.18
Week 3 1.2±1.3 1 (0,3) 0.8±0.9 1 (0,3)
21 7
Sleep medication
End of -2.5 0.01
1.0±1.3 0 (0,3) 0.3±0.7 0 (0,3)
treatment 43 1

4-week -2.2 0.02

0.9±1.2 0 (0,3) 0.3±0.6 0 (0,3)
follow-up 74 3

-0.0 0.93
Baseline 2.3±0.7 2 (0,3) 2.3±0.6 2 (1,3)
77 9

-1.6 0.09
Week 3 1.9±0.7 2 (0,3) 1.7±0.6 2 (0,3)
Daytime 63 6

functioning End of -3.5 <0.0

1.7±0.7 2 (0,3) 1.1±0.7 1 (0,2)
treatment 93 01

4-week -2.8 0.00

1.5±0.8 1 (0,3) 1.0±0.8 1 (0,3)
follow-up 76 4

16 17 -1.0 0.29
Baseline 16.4±2.6 17.0±3.0
(11,21) (11,21) 46 9

13 13 1.47 0.14
PSQI scores Week 3 13.3±3.2 12.4±2.7
(7,21) (6,19) 0 5

End of 10.5 4.34 <0.0

11.6±3.5 8.7±2.7 9 (3,16)
treatment (5,20) 7 01

32
 4-week 4.69 <0.0
10.8±3.7 9 (5,18) 7.3±3.2 8 (2,16)
follow-up 5 01

PSQI: Pittsburgh Sleep Quality Index.

33
Table 4. Correlation analysis

HAMD PSQI

Correlation Correlation
P P
coefficient coefficient

Age 0.037 0.481 0.070 0.188

Disease
-0.058 0.277 -0.019 0.716
course

Group 0.224 <0.001 0.186 <0.001

Time -0.566 <0.001 -0.654 <0.001

Gender -0.066 0.216 -0.093 0.081

Treatment
-0.022 0.680 0.088 0.096
history

PSQI: Pittsburgh Sleep Quality Index; HAMD: Hamilton Rating Scale.

34
Table 5. Fixed effect type III test for the HAMD score

F P

Nodal increment 1909.040 .000

Group 12.302 .001

Time 171.232 .000

Group * Time 12.739 .000

35
Table 6. Fixed effect estimation for the HAMD score
95%CI
Coefficien
Parameters SE t P Lower Upper
t
limit limit
<0.00
Nodal increment 22.478 0.842 26.703 20.815 24.141
1
[group=1(experimental <0.00
-6.897 1.211 -5.695 -9.290 -4.504
group)] 1
[group=2(control group)] 0
<0.00
[time=1(baseline)] 7.304 0.696 10.502 5.935 8.674
1
[time=2(3 weeks)] 2.065 0.696 2.969 0.003 0.696 3.435
[time=3(end of treatment)] -0.674 0.696 -0.969 0.333 -2.044 0.696
[time=4(4 weeks of
0
follow)]
<0.00
[group=1] * [time=1] 5.440 1.001 5.436 3.469 7.410
1
<0.00
[group=1] * [time=2] 5.028 1.001 5.025 3.057 6.998
1
[group=1] * [time=3] 2.465 1.001 2.463 0.014 0.494 4.435
[group=1] * [time=4] 0

36
Table 7. Improvements in HAMD scores in time

Week End of 4-week

Fine comparison
3 treatment follow-up

Baseline <0.001 <0.001 <0.001

Week 3 <0.001 <0.001

Experimental group
End of
0.659
treatment

Baseline <0.001 <0.001 <0.001

Week 3 0.208 0.662

Control group
End of
1.000
treatment

37
Table 8. Fixed effect type III test of the PSQI score

F P

Nodal increment 2187.195 <0.001

Group 10.301 0.002

Time 205.942 <0.001

Group * Time 15.679 <0.001

38
Table 9. Fixed effect estimation of the PSQI score

95%CI

Parameters Coefficient SE t P Lower Upper

limit limit

Nodal increment 10.761 0.461 23.364 <0.001 9.853 11.669

[group=1(experimental
-3.459 0.663 -5.220 <0.001 -4.765 -2.152
group)]

[group=2(control group)] 0

[time=1(baseline)] 5.587 0.466 11.986 <0.001 4.669 6.505

[time=2(3 weeks)] 2.543 0.466 5.457 <0.001 1.626 3.461

[time=3(end of treatment)] 0.804 0.466 1.726 0.086 -0.113 1.722

[time=4(4 weeks of follow)] 0

[group=1] * [time=1] 4.087 0.671 6.095 <0.001 2.767 5.408

[group=1] * [time=2] 2.526 0.671 3.767 <0.001 1.206 3.847

[group1] * [time=3] 0.544 0.671 0.812 0.418 -0.776 1.865

[group=1] * [time=4] 0

39
Table 10. Improvements in PSQI scores in time

Week End of 4-week

Fine comparison
3 treatment follow-up

Baseline <0.001 <0.001 <0.001

Week 3 <0.001 <0.001

Experimental group
End of
0.202
treatment

Baseline <0.001 <0.001 <0.001

Week 3 0.075 0.002

Control group
End of
1.000
treatment

40
Table 11. Adverse events

Augmented (n=43) Standard (n=46) P

Discomfort 0 2 0.167

Pain 2 0 0.139

Hematoma 2 0 0.139

41