Clinical Context

Depressive disorders affect more than 264 million people worldwide and more than 50 million in China. Sleep disturbance is a leading symptom in depression.

Depression and sleep issues have a bidirectional relationship. Poor sleep quality contributes to development of depression, which increases risk for insomnia. Patients with both conditions have increased risk for suicide, severe social functioning impairment, and relapse.

Study Synopsis and Perspective

Electroacupuncture (EA) may significantly improve sleep quality in patients with depression who also have insomnia, new research suggests.

In a study of almost 300 adults with depression and comorbid insomnia, change from baseline to week 8 on the Pittsburgh Sleep Quality Index (PSQI) was 3 points greater in the group receiving EA vs a group receiving sham acupuncture (SA) plus standard care, and 5 points greater vs a control group receiving standard care only. The improvements were sustained during a 24-week postintervention follow-up.

The EA group also showed significant improvement in depression, insomnia, self-rated anxiety, and total sleep time, all of which were not found in the SA or control groups.

"Based on the results of our trial, we recommend patients with depression and insomnia seek the treatment of EA as an alternative and complementary therapy for better results," study investigator Shifen Xu, PhD, from Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, China, told Medscape Medical News.

The findings were published online July 7 in JAMA Network Open.^[1]

Bidirectional Relationship

"Sleep disturbance is the prominent symptom in patients with depression," the investigators note. Depression and sleep issues have a bidirectional relationship, in that "poor sleep quality contributes to the development of depression, and having depression makes a person more likely to develop sleep issues," they write.

Patients with co-occurring depression and sleep disorders are more difficult to treat and have a greater risk for relapse and recurrence of depression, they add.

Acupuncture may be an "effective drug-free approach for helping to treat mental illness and sleep disorders," the researchers note. A previous study suggested that acupuncture may improve sleep efficacy and prolong total sleep in patients with primary insomnia.

"EA is the combination of traditional Chinese acupuncture with electric-impulse stimulation, and it can enhance the therapeutic effect of the acupoints throughout the needle retention time," Dr Xu said.

A previous pilot study of EA for depression-related insomnia showed significant improvements in sleep quality after EA treatment, but the sample size was small.

The current researchers, therefore, undertook the present study, which had a larger sample size and comparison with SA and standard care. They divided 270 adults (mean age, 50.3 years; 71.9% women) at 3 tertiary hospitals in Shanghai into 3 groups, each consisting of 90 participants.

The EA plus standard care group and the SA plus standard care group received 30-minute treatments 3 times per week for 8 weeks. The control group received standard care only.

All participants had Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5)-diagnosed depression; baseline PSQI scores greater than 7, with higher scores indicating worse sleep quality and a greater number or sleep disorders; and Hamilton Depression Rating Scales (HDRS-17) scores of 20 to 35, with higher scores indicating higher depression levels.

Patients with secondary depressive disorders attributable to other conditions, medication, or psychotic disorders were excluded, as were patients with a history of alcohol abuse or drug dependence or those who had received acupuncture within the previous year.

Of the patients who completed the 8-week intervention, 83 were in the EA group, 81 in the SA group, and 83 in the control group. Almost all participants (91.5%) completed all outcome measurements by the end of the 24-week follow-up period (also known as week 32).

Calm Mind, Balanced Mood

At the 8-week posttreatment assessment, which was the primary endpoint, the EA group had a mean reduction from baseline of 6.2 points (95% confidence interval [CI], −6.9 to −5.6) in PSQI score.

There was a significant difference in PSQI score between the EA group and the SA group (−3.6 points; 95% CI, −4.4 to −2.8; P<.001) and vs the control group (−5.1 points; −6.0 to −4.2; P<.001).

The efficacy of EA in treating insomnia was sustained during the postintervention follow-up period, when the EA group had a significantly greater reduction in PSQI score compared with the SA group (−4.7; 95% CI, −5.4 to −3.9; P<.001) and the control group (−5.0; 95% CI, −5.8 to −4.1; P<.001).

Patients receiving EA also experienced significant (all Ps<.001) improvement from baseline on secondary outcomes, including:

• Scores on the HDRS (−10.7; 95% CI, −11.8 to −9.7),
• Scores on the Insomnia Severity Index (−7.6; 95% CI, −8.5 to −6.7),
• Scores on the Self-rated Anxiety Scale (−2.9; 95% CI, −4.1 to −1.7), and
• Total sleep time, as recorded by sleep actigraphy (29.1 minutes; 95% CI, 21.5-36.7).

In addition, the EA group showed significant improvement in depression scores compared with the SA and control groups at both 8 and 32 weeks (all Ps<.001).

Participants in the EA group also had a 4.2% (95% CI, 2.6%-5.8%) higher sleep efficiency score at week 8 compared with those in the SA group (P<.001).

In addition, they had lower scores on the Insomnia Severity Index and the Self-rated Anxiety Scale and longer total sleep time compared with the control group at week 8. None of the participants reported any serious adverse events.

"Our findings constitute subjective and objective evidence of the efficacy and safety of EA with standard care in treating comorbid depression and insomnia compared with SA with standard care or standard care alone," the investigators write.

"The acupoints we used in this trial mainly act on calming mind, relieving negative mood, and balancing the yin-yang," Dr Xu added.

Viable Adjunctive Treatment

Commenting for Medscape Medical News, Albert Yeung, MD, ScD, associated director of the Mass General Depression and Clinical Research Program and associate professor of psychiatry, Harvard Medical School, Boston, Massachusetts, said that with the evidence from this study, "acupuncture and/or electroacupuncture could be a viable adjunctive treatment for depressed patients who suffer from insomnia."

Dr Yeung, who was not involved with the study, is the co-author of an accompanying editorial.^[2]

"More well-designed studies are warranted to provide evidence for integrating holistic treatment in medicine," he said.

The study was funded by grants from the National Natural Science Foundation of China, and Shanghai Municipal Health. The investigators have reported no relevant financial relationships. Although Dr Yeung also reports no relevant financial relationships, his coauthor's disclosures are listed in the original editorial.

JAMA Netw Open. Published online June 7, 2022.

Clinical Implications

• Sleep quality in patients with insomnia and depression improved significantly with EA vs SA or control at week 8 and week 32.
• EA may be a viable adjunctive treatment for depressed patients with insomnia, but more well-designed studies are needed.
• Implications for the Health Care Team: For the complex management of sleep disorders, members of the healthcare team should employ a patient-centered approach and present both pharmacologic and adjunctive non-pharmacologic options for care.

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