Supplementary appendix appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to

Supplementary appendixThis appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors.

Supplement to: Thirthalli J, Zhou L, Kumar K, et al. China–India Mental Health Alliance. Traditional, complementary, and alternative medicine approaches to mental health care and psychological wellbeing in India and China. Lancet Psychiatry 2016; published online May 18. http://dx.doi.org/10.1016/S2215-0366(16)30025-6.

1

Appendix 1

“Registered Medical Practitioners” (RMPs) of India:

The term “Registered medical practitioners” (RMP) is used to denote non-formally trained healthcare

providers who provide a mix of AYUSH and biomedical treatments. The origin of the term RMP dates

to 1933, when the colonial government introduced a system of provision of state registration for

unqualified people with successful medical practice for ten years or evidence of apprenticeship with

experienced practitioners1. Today, although only MBBS/BDS or AYUSH-qualified doctors are legally

permitted to register and practice medicine, the term RMP has persisted. Some RMPs have acquired

degrees and diplomas from non-authentic sources2,3

. A number of them have taken to the practice of

medicine after having acquired experience in the healthcare field as traditional birth attendants or

assistants to qualified physicians. They account for about half of healthcare providers4. As they provide

affordable, around the clock, fast, friendly care and as they are located nearby, they have a fair degree

of acceptance by the community; further, they permit deferred payment or payment in kind5, which

contributes to their popularity among the poor. Prescription practices of the RMPs6 and symptom

profile of patients that seek treatment with them7 suggest that a large number of those with mental

disorders consult them. Case studies suggest patients visit RMP with the same types of symptoms they

present to formally trained practitioners, and in many cases believe them to be just as competent for

common illnesses.

2

Appendix 2

Dawa aur dua: The fusion of medicine and prayer8:

Sayyad Ali Mira Dattar dargah is a Muslim Shrine in Unava village in the state of Gujarat, India. The

dargah has visitors from around the world, irrespective of caste, creed and religion. A large proportion

of these have a variety of mental disorders. In a first-of-its-kind initiative, the state government, an

NGO called Altruist and trustees of the dargah have come together to provide psychiatric care for them.

The basic idea of not antagonizing the beliefs of the individuals who seek help there and of providing

psychiatric care closely working with their faith seem to have been successful. The faith-healers at the

shrine have been trained by the members of the NGO to identify mental illnesses. After providing

religious care for those with psychiatric problems, the faith-healers direct them to the psychiatric

outpatient clinic, which is located inside the dargah. Psychiatrists and psychologists have been

providing medical and psychological care respectively since 2008. On an average, 15 – 20 patients

receive the fusion of care in this center daily. The successful collaboration between the faith-healers

and biomedical specialists has encouraged similar experiments elsewhere9.

Psychiatrist working with the faith-healers in Tamil Nadu

3

References:

1. George A, Iyer A. Unfree markets: socially embedded informal health providers in northern

Karnataka, India. Social science & medicine 2013; 96: 297-304.

2. Ashtekar S, Mankad D. Who cares? Rural health practitioners in Maharashtra. Economic and

Political Weekly 2001 Feb 3 - 10: 448 - 53.

3. Kumar R, Jaiswal V, Tripathi S, Kumar A, Idris M. Inequity in health care delivery in India: the

problem of rural medical practitioners. Health Care Analysis 2007; 15(3): 223-33.

4. Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D. What is the role of informal healthcare

providers in developing countries? A systematic review. PloS one 2013; 8(2): e54978.

5. May C, Roth K, Panda P. Non-degree allopathic practitioners as first contact points for acute

illness episodes: insights from a qualitative study in rural northern India. BMC health services research

2014; 14(1): 182.

6. Ecks S, Basu S. “We Always Live in Fear”: Antidepressant Prescriptions by Unlicensed Doctors

in India. Culture, Medicine, and Psychiatry 2014; 38(2): 197-216.

7. Rao P. Profile and practice of private medical practitioner in rural India. Health and population

2005; 28(1).

8. Hamlai M. Dava & Dua Program. http://thealtruist.org/dava-dua-program/ (accessed May 10,

2016).

9. The Hindu. Dawa-dua programme gaining momentum. Feb 20, 2014.

http://www.thehindu.com/todays-paper/tp-national/tp-tamilnadu/dawadua-programme-gaining-moment

um/article5708147.ece (accessed May 10, 2016).

4

Supplementary table-1: State-wise distribution of AYUSH practitioners

State / Union

Territory

Average

number

of

beds per

hospital

Distribution of

AYUSH

dispensaries

in India

Distribution of

AYUSH

registered

practitioners in

India (%)

Distribution of

AYUSH

practitioners

per 10 million

population

Distribution

of

AYUSH

undergradu

ate colleges

Distribution of

average admission

capacity to

undergraduate

institutions

Distribution of

AYUSH

postgraduate

Colleges

Distribution of

average

admission

capacity to

post-graduate

institutions (%)

A & N islands 5

Andhra Pradesh 58 3% 3.1 2624 1% 1.00% 2% 1.20%

Arunachal Pradesh 11 1972

Assam 51 0.40%

Bihar 119 9% 18.2 12129 5% 4.60% 2% 1.70%

Chandigarh 40

Chhattisgarh 48 4% 1656 1.60% 0.50%

Delhi 132 1.4 5680 1.30% 3%

Goa 0 7689

Gujarat 51 3% 5.8 6704 6% 7.10% 4% 2.20%

Haryana 68 1.8 4933 1.50%

Himachal pradesh 21 4% 8391 1.20%

J & K 38 3892

Jharkhand 70

Karnataka 49 3% 5.6 6497 15% 14.00% 21% 23.60%

Kerala 31 6% 4.6 9940 5% 4.10% 6% 6.00%

5

Madhyapradesh 30 7% 8.5 8168 8% 9.40% 5% 3.00%

Maharashtra 89 2% 18.4 11550 23% 25.30% 34% 37.20%

Manipur 15

Meghalaya 10

Mizoram 10

Odisha 65 5% 1.9 3183 2% 1.40% 1%

Puducherry 0

Punjab 0 3% 1.4 3526 3% 3.10% 1.40%

Rajasthan 11 15% 2.3 2380 4% 4.30% 2% 4.00%

Tamil Nadu 9 4% 4.4 4330 6% 5.50% 3% 4.10%

Tripura 15

Uttar pradesh 6 8% 12.2 4264 8% 6.60% 7% 5.00%

Uttarakhand 5 2547

West Bengal 73 8% 6.3 4910 3% 3.00% 2% 1.70%

Others 0 16% 4.1 11% 6.30% 8% 6.90%

6

Supplementary table-2: Number of consultations in government-run AYUSH centers for different

conditions in 2013-14

Sl.No. System Names of included conditions No. of

patients

Percentage

1. Cardiovascular system Heart Disease/Cardiovascular

Hypertension/heart

31669 0.11%

2. Head

and Neck

1. Dental Disease

2. ENT

3. Eye diseases

4. Shiroroga (Diseases of

head including

headaches)

5. Sinusitis

6. Tonsilitis

583996 2.03%

3. Endocrine Endocrine disorders 227 0.00079%

4. Gastro intestinal system 1. Acid Peptic Disease

2. Amlapitta (gastritis)

3. Amoebiasis

4. Constipation

5. Diarrhoea

6. Gastric ulcer etc

7. Kabj (Constipation)

8. Gastrointestinal system

9. Hepatitis

10. Intestinal infections

11. Loss of appetite

12. Pravahika

13. Typhoid

14. Udara

15. Vomiting

16. Worms (Parasitic infestations)

6218474 21.62%

5. General 1. Anaemia

2. Fever/General

3. General debility

4. Obesity

5. Others

5965695 20.75%

6. Genito urinary/Genito

rectal

1. Genito-rectal

2. Genito-Urinary Diseases

3. Sexually Transmitted diseases

(STD)

319297 1.11%

7

4. Urinary system

7. Gynaecology Female disorders 1369182 4.76%

8. Metabolic disorders 1. Diabetes/HTN

2. Metabolic disorder

64846 0.23%

9. Nervous system Nervous system 444823 1.55%

10. Orthopaedic and

Musculoskeletal

(including nervous

system complaints)

1. Amavata (Rheumatoid Arthritis)

2. Arthritis (Osteoarthritis)

3. Avabahuka (frozen shoulder and

related disorders)

4. Backache

5. Chickungunya

6. Knee pain

7. Musculokeletal & connective

tissue

8. Orthopedic

9. Paralysis

10. Myalgia

11. Spondylosis

12. Vatakantaka (ankle and heel

sprains/calcaneal spur)

13. Vatavyadhi (Nervous system

disorders)

14. Sciatica

3735655 12.99%

11. Paediatrics Paediatrics 9944 0.03%

12. Psychology Psychiatric diseases 1911 0.007%

13. Respiratory diseases 1. Asthma

2. Bronchitis

3. Common cold

4. Cough

5. Respiratory system

5757855 20.03%

14. Skin 1. Kandu (diseases characterized

by urticaria)

2. Skin and subcutaneous

3. Vitiligo

3299721 11.48%

15. Surgical & Ano-rectal 1. Calculi

2. Lipoma

3. Piles/fistula

4. Shalya roga (Diseases requiring

surgery)

5. Warts

661318 2.30%

Total 28749613

8

9

Supplement Table 3: Systematic Reviews and Meta-analyses on the Effectiveness of Acupuncture on Mental Illnesses

Referenc

e

Studies Conditions

treated

Interventions Comparisons Results Author’s conclusions

Cao H

(2013)1

12 RCTs Vascular mild

cognitive

impairment

Acupuncture alone

or combined with

cognitive function

training, or

rehabilitation, or

medication

Cognitive

function training,

rehabilitation,

medication

The methodological quality of all included trials

was unclear and/or they had a high risk of bias.

Meta-analysis showed acupuncture in conjunction

with other therapies could significantly improve

Mini-Mental State Examination scores (mean

difference 1.99, 95% CI 1.09 to 2.88, random

model, p<0.0001, 6 trials). No included trials

mentioned any adverse events of the treatment.

The current clinical evidence

is not of sufficient quality for

wider application of

acupuncture to be

recommended for the

treatment of vascular mild

cognitive impairment.

Cheng

HM

(2012) 2

20 RCTs Smoking Acupoint

stimulation, alone

or combined with

education

Nicotine gum, no

treatment, sham

acupuncture/laser,

placebo,

relaxation,

self-monitoring,

education

Three studies had a Jadad score of 3 or higher. A

significant effect of acupoint stimulation was found

in smoking cessation rates and cigarette

consumption at immediate, 3- and 6-month

follow-ups, with effect sizes 1.24 (95%CI 1.07 to

1.43), -2.49 (95%CI -4.65 to -0.34), 1.70 (95%CI

1.17 to 2.46), and 1.79 (95%CI 1.13 to 2.82),

respectively.

Multi-modality treatments,

especially acupuncture

combined with smoking

cessation education or other

interventions, can help

smokers to eschew smoking

during treatment, and to

avoid relapse after treatment.

Cheuk

DKL

(2012)3

33 RCTs Insomnia

without major

co-morbid

conditions, or

with

Acupuncture,

acupressure, alone

or as an adjunct

treatment

Placebo, sham

acupuncture or

acupressure, using

alone or as an

adjunct treatment

Compared with no treatment or sham/placebo,

acupressure resulted in more people with

improvement in sleep quality (OR 13.08, 95% CI

1.79 to 95.59; OR 6.62, 95% CI 1.78 to 24.55).

Compared with other treatment alone, acupuncture

All trials had high risk of

bias and were heterogeneous.

The effect sizes were

generally small with wide

confidence intervals. Due to

10

schizophrenia,

depression,

heroin

withdrawal,

end-stage renal

disease, or

post-stroke

as an adjunct treatment might marginally increase

the proportion of people with improved sleep

quality (OR 3.08, 95% CI 1.93 to 4.90). On

subgroup analysis, only needle acupuncture but not

electroacupuncture showed benefits.

poor methodological quality,

high levels of heterogeneity

and publication bias, the

current evidence is not

sufficiently rigorous to

support or refute acupuncture

for treating insomnia.

Cho S-H

(2009)4

11 RCTs Alcohol

dependence

Acupuncture alone

or combined with

conventional

treatments

Sham acupuncture

alone or

combined with

conventional

treatments

Only 2 of 11 trials reported satisfactorily all quality

criteria. Among the 9 studies reported craving, 5

reported significant reductions.

The poor methodological

quality and the limited

number of the trials do not

allow any conclusion about

the efficacy of acupuncture

for treatment of alcohol

dependence.

D’Albert

o A

(2004) 5

6 RCTs Cocaine/crack

abuse

Auricle acupuncture Sham

acupuncture,

relaxation

Of the six RCTs reviewed, two reported a positive

outcome while four were negative in their

conclusions.

This review could not

confirm that acupuncture

was an effective treatment

for cocaine abuse.

Dennis

CL

(2013)6

6 RCTs Antenatal

depression

Massage,

acupuncture, bright

light therapy,

omega-3 oil

Non-specific

acupuncture,

standard care, dim

light placebo,

placebo

In a trial with 35 women acupuncture specifically

treating symptoms of depression, compared with

non-specific acupuncture, did not significantly

decrease the number of women with clinical

depression or depressive symptomatology

immediately post-treatment (RR 0.47, 95% CI 0.11

to 2.13; MD -3.00, 95% CI -8.10 to 2.10).

The evidence is inconclusive

to allow us to make any

recommendations for

depression-specific

acupuncture, maternal

massage, bright light

therapy, and omega-3 fatty

11

However, women who received depression-specific

acupuncture were more likely to respond to

treatment compared with those receiving

non-specific acupuncture (RR 1.68, 95% CI 1.06 to

2.66).

acids for the treatment of

antenatal depression.

Di YM

(2014)7

25 RCTs Nicotine

dependence

Ear-acupuncture/ac

upressure (EAP/R),

stimulation

including needle,

pressure, electricity,

laser, and

combination of

these

Sham

acupuncture,

wait-list or no

intervention, oral

placebo, medical

therapy, smoking

cessation (SC)

body acupuncture,

advice or

behavioural

therapy

Pool 1: the 12 valid SC-specific EAP/R

interventions were superior to inactive EAP/R

controls at end of treatment (RR = 1.77 [1.39,

2.25]), three months follow-up (RR = 1.54 [1.14,

2.08]), and six months follow-up (RR = 2.01, [1.23,

3.28]) but data were insufficient at 12 months. In

Pool 2: there was no superiority or inferiority for

EAP/R at end of treatment or at 3 and 6 month

follow-ups compared to SC-specific behavioural

therapy or SC-specific body acupuncture.

Meta-analysis results derived

from relatively small-sized

trials. Larger, well-controlled

studies using biochemical

confirmation of SC are

needed.

Fan L

(2010)8

20 RCTs Depressive

disorders or

depression

Acupuncture, alone

or plus massage by

acupoints or

Chinese herb

formula

Sham

acupuncture,

antidepressants

Meta-analysis showed that acupuncture

monotherapy exhibited similar efficacy to Western

medicine for treating depression: combined effect

size OR = 1.66, 95% CI: 0.59-4.65, combined effect

value test: Z = 0.97, P = 0.33. Comparison of the

efficacy of acupuncture combination therapy with

Western medicine demonstrated a combined effect

size OR = 2.46, 95% CI: 1.64-3.71 and combined

effect of the value of Z = 4.32 (P < 0.01), implying

The efficacy of acupuncture

monotherapy was similar to

Western medicine for

treating depression.

However, efficacy of

combination therapy remains

uncertain due to inadequate

study design

(implementation of

12

that there was insufficient evidence to prove a

superior effect of acupuncture combination therapy

over Western medicine. In terms of HAMD and

SDS scores, the weighted mean difference was

-2.01 and -8.68, respectively, with 95% CI: -3.48 to

0.53, -11.21

to -6.16 (P < 0.01), suggesting that acupuncture

efficacy was significantly better than the control

group.

randomization and blinding,

sample size estimation, and

data processing methods).

Gates S

(2006)9

7 RCTs Cocaine

dependence

Acupuncture

combined with

standard care

Sham acupuncture

combined with

standard care

All included RCTs were of generally low

methodological quality. No differences between

acupuncture and sham acupuncture were found for

attrition RR 1.05 (95% CI 0.89 to 1.23) or

acupuncture and no acupuncture: RR 1.06 (95% CI

0.90 to 1.26) neither for any measure of cocaine or

other drug use.

There is currently no

evidence that auricular

acupuncture is effective for

the treatment of cocaine

dependence. The evidence is

not of high quality and is

inconclusive.

Gordon

D

(2013)10

22 RCTs Dental phobia

or anxiety

Various forms of

CBT, relaxation

training,

benzodiazepine

premedication,

music distraction,

hypnotherapy,

acupuncture (1

RCT), nitrous oxide

Wait list,

psychoeducation,

placebo

acupuncture, no

treatment

The RCT in acupuncture indicated: auricular

acupuncture = midazolam > placebo acupuncture,

no treatment. The RCT compared lavender oil scent

with no scent shower dental anxiety did not differ

between conditions, and state anxiety was lower in

lavender scent condition.

Cognitive techniques,

relaxation, and techniques to

increase patients’ sense of

control over dental care are

also efficacious but perform

best when combined with

repeated, graduated

exposure. Other

interventions require further

13

sedation, and the

use of lavender oil

scent (1 RCT)

study in randomized trials

before conclusions about

their efficacy are warranted.

Guo XX

(2008) 11

22 RCTs Dementia Acupuncture Western

medications

Only two out of the 22 RCTs are of high quality

based on Jadad score. Meta-analysis was performed

based on 19 trials. The total OR is 3.72 [95%CI

2.73 to 5.07]. The funnel plot was a proximately

symmetry, which indicated that the curative effect

of acupuncture groups was better than the control

groups (Z= 8.32, P < 0.0001).

Acupuncture therapy is

effective on dementia

according to the domestic

clinical literatures. However,

the quality of the studies

needs further improving and

increasing.

Huang

YF

(2011) 12

13 RCTs Perimenopausal

depression

Acupuncture, alone

or plus

antidepressants

Antidepressants Meta-analyses showed that the effective rate in the

acupuncture combined with western medicine

group was higher when compared with western

medicine [OR=1.01, 95%CI 1.38, 5.51] and also

the cure rate [OR=2.91, 95%CI 1.82, 4.65]. As for

acupuncture compared with western medicine, no

significant difference was noted in effective rate

[OR=1.08, 95%CI 0.64, 1.83], cure rate [OR=1.04,

95%CI 0.70, 1.56] and the HAMD score at week 2

[WMD=-0.35, 95%CI -3.43, 2.72]; at week 4

[WMD=0.01, 95%CI -1.96, 1.98]; at week 6

[WMD=-0.19, 95%CI -2.57, 2.18]. GRADE

evidence classification is very low. The incidence

of adverse events of acupuncture (1.5%) was lower

than western medicine group (12.5%).

Acupuncture was a relative

safe method with few

adverse reactions. In

combination with western

medicine, acupuncture in the

treatment of perimenopausal

depression reducing HAMD

rate shown potentially valid

tendency, while acupuncture

compared to western

medicine therapy showed no

statistical difference. Further

researches were required to

define the role of

acupuncture in the treatment

14

of perimenopausal

depression neurosis.

Jorm AF

(2004)13

Not

reported

Anxiety

disorders or

participants with

anxiety

symptoms

34 treatments

groups under 4

categories:

medicines and

hemoeopathic

remedies, physical

treatments,

lifestyle, and

dietary changes

Placebo in most

studies, western

medicines in a

few studies

108 treatments were identified and grouped under

the categories of medicines and homoeopathic

remedies, physical treatments, lifestyle, and dietary

changes. We give a description of the 34 treatments

(for which evidence was found in the literature

searched), the rationale behind the treatments, a

review of studies on effectiveness, and the level of

evidence for the effectiveness studies.

The treatments with the best

evidence of effectiveness are

kava (for generalised

anxiety), exercise (for

generalised anxiety),

relaxation training (for

generalised anxiety, panic

disorder, dental phobia and

test anxiety). There is more

limited evidence to support

the effectiveness of

acupuncture, music,

autogenic training and

meditation for generalised

anxiety

Jorm AF

(2006)14

Not

reported

Children or

adolescents with

depressive

disorder or

elevated

depressive

symptoms

A variety of

complementary and

self-help treatments

including herbs,

homeopathy,

acupuncture, Tai

chi, yoga, etc

Not reported Relevant evidence was available for glutamine,

S-adenosylmethionine, St John’s wort, vitamin C,

omega-3 fatty acids, light therapy, massage, art

therapy, bibliotherapy, distraction techniques,

exercise, relaxation therapy and sleep deprivation.

However, the evidence was limited and generally of

poor quality. The only treatment with reasonable

supporting evidence was light therapy for winter

Given that antidepressant

medication is not

recommended as a first line

treatment for children and

adolescents with mild to

moderate depression, and

that the effects of

psychological treatments are

15

depression. modest, there is a pressing

need to extend the range of

treatments available for this

age group.

Kalavap

alli R

(2007)15

6 RCTs

and 13

other

studies

Insomnia

(information

about primary

or secondary

insomnia were

not available)

Acupuncture No control or no

treatment or

diazepam

Despite the limitations of the reviewed studies, all

of them consistently indicate significant

improvement in insomnia with acupuncture.

Acupuncture may be useful

in the treatment of insomnia

associated with other

psychiatric (major

depression, anxiety

disorders, etc.) and or

medical conditions, however,

the available data is not

strong.

Lee MS

(2009)16

13 RCTs Schizophrenia Acupuncture alone

or combined with

antipsychotics

Antipsychotics

alone or

combined with

sham acupuncture

The methodological quality was generally poor and

there was not a single high quality trial. One RCT

reported significant effects of electroacupuncture

(EA) plus drug therapy for improving auditory

hallucinations and positive symptom compared

with sham EA plus drug therapy. Four RCTs

showed significant effects of acupuncture for

response rate compared with antipsychotic drugs

(RR: 1.18, 95%CI: 1.03–1.34). Seven RCTs

showed significant effects of acupuncture plus

antipsychotic drug therapy for response rate

compared with antipsychotic drug therapy (RR:

These results provide limited

evidence for the

effectiveness of acupuncture

in treating the symptoms of

schizophrenia. However, the

total number of RCTs, the

total sample size and the

methodological quality were

too low to draw firm

conclusions.

16

1.15, 95% CI: 1.04–1.28).

Lee MS

(2009)17

3 RCTs Alzheimer’s

disease

Electroacupuncture

alone or plus herbs

or perphenazine

Nimodipine,

herbs,

Hupperzine,

psychological

consultation,

perphenazine

The methodological quality of the trials was poor.

Results of two RCTs on cognitive function

suggested no significant effect in favour of

acupuncture. One RCT reported favourable effects

of drug therapy compared with acupuncture for

activities of daily living, while the other failed to

so. The meta-analysis of these data showed

significant effects of drug therapy compared with

acupuncture (WMD -1.29; 95% CIs: -1.77 to

-0.80).

The existing evidence does

not demonstrate the


for AD

Leo RJ

(2007)18

9 RCTs Depressive

disorder or

individuals with

depressive

symptoms

Acupuncture alone

or combined with

antidepressants

Wait list, sham

acupuncture,

needling of true

acupuncture

points unrelated

to the prevailing

depression,

antidepressants,

massage

The Jadad scores of five out of the nine RCTs were

lower than 2. The odds ratios derived from

comparing acupuncture with control conditions

within the RCTs suggests some evidence for the

utility of acupuncture in depression. General trends

suggest that acupuncture modalities were as

effective as antidepressants employed for treatment

of depression in the limited studies available for

comparison. However, placebo acupuncture

treatment was often no different from intended

verum acupuncture.

Despite the findings that the

odds ratios of existing

literature suggest a role for


of depression, the evidence

thus far is inconclusive.

Leung

MCP

(2013) 19

3 human

studies and

9 animal

Stroke and

vascular

dementia

Acupuncture Sham acupuncture The results of human studies were inconsistent. Further high-quality human

studies with greater

statistical power are needed

17

studies to determine the


and an optimal protocol.

Li XH

(2012) 20

14 RCTs

for needle

acupunctur

e; 13 RCTs

for

electro-acu

puncture;

29 RCTs

for

Acupunctu

re plus

antidepress

ants

Post-stroke

depression

1) Needle

acupuncture;

2) Electro-acupun

cture (EA);

3) Acupuncture

plus

antidepressants

Antidepressants 1) Six out of the 14 RCTs are of high quality

based on Jadad scores. Meta-analysis showed

that comparing to antidepressants, needle

acupuncture treatment for PSD was more

effective at the end of 6 weeks (OR=3.03, 95%

CI 1.32, 6.94).

2) Five out of 13 RCTs are of high quality based

on Jadad scores. Meta-analysis showed that the

EA improved stroke patients with depression

more effective than fluoxetine (OR=1.94,

95%CI 1.12, 3.36).

3) Three trials out of 29 RCTs are high quality

based on Jadad scores. Meta-analysis showed

that patients suffered from PSD treated with

EA together with fluoxetine improved much

better than those merely treated with fluoxetine

(WMD= -2.50, 95%CI -3.40 to -1.60).

This research preliminarily

evinces that acupuncture

therapy and combined

acupuncture with

antidepressants are more

effective than the use of

antidepressants alone.

However, the quality of

researches are low.

Lin JG

(2012) 21

10 RCTs Opiate addiction Acupuncture No treatment,

Sham

acupuncture,

western medicines

The majority agreed on the efficacy of acupuncture

as a strategy for the treatment of opiate addiction.

Cannot establish the efficacy

of acupuncture in the

treatment of opiate addiction

because the majority of these

studies were classified as

18

having low quality.

Liu TT

(2009) 22

11 RCTs Opiate addiction Acupuncture

combined with

opioid agonist

treatment

Opioid agonists

alone

Jadad score of each of the 11 included RCTs was 2.

Withdrawal-symptom scores were lower in

combined treatment trials than in agonist-alone

trials on withdrawal days 1, 7, 9, and 10. Combined

treatment also produced lower reported rates of side

effects and appeared to lower the required dose of

opioid agonist. There was no significant difference

on relapse rate after 6 months.

This meta-analysis suggests

that acupuncture combined

with opioid agonists can

effectively be used to

manage the withdrawal

symptoms. One limitation of

this meta-analysis is the poor

quality of the methodology

of some included trials.

Ma TM

(2007) 23

6 RCTs Anxiety

disorders

Acupuncture Medication, not

specifically

described

Homogeneity test was made among the trials and

no significant difference between the acupuncture

and non-acupuncture groups. Fixed effect model

was used. ORP =1.76, 95% CI (1.34 to 2.32), there

was significant difference between the acupuncture

group and medicine group as the interventions used

to treat anxiety while there was no difference

between the two group on the influence in HAMA.

The Meta analysis results

was a trend in favor of

acupuncture effectiveness. It

seems no serious adverse

reactions have been found.

But there was no sufficient

reliable evidence due to the

low quality of the trials and

possible publication bias.

Further randomized, double

blind controlled trials are

needed.

Meeks

TW

(2007) 24

33 RCTs Late-life

depression,

anxiety, and

Various

complimentary and

alternative

Placebo, wait list,

treat as usual,

sham

67% of the 33 included studies were positive.

Positive studies have lower quality than negative

studies.

Most studies have substantial

methodological limitation. A

few well-conducted studies

19

sleep

disturbance

medicines including

yoga, Tai chi,

Qigong, meditation,

single herbs,

Chinese herb

formulae,

acupuncture,

acupressure, etc

acupuncture/acupr

essure, western

medications

suggested therapeutic

potential of mind-body

interventions for sleep

disturbance, acupressure for

sleep and anxiety.

Mills EJ

(2005) 25

9 RCTs Cocaine

dependence

Acupuncture Relaxation,

anti-craving

medication and

brainwave

modification,

psychosocial

treatment

The pooled odds ratio estimating the effect of

acupuncture on cocaine abstinence at the last

reported time-point was 0.76 (95% CI, 0.45 to 1.27,

P = 0.30, I2 = 30%, Heterogeneity P = 0.19).

This systematic review and

meta-analysis does not

support the use of

acupuncture for the treatment

of cocaine dependence.

Mukaino

Y (2005)

26

6 RCTs Depressive

disorders

Acupuncture alone

or combined with

antidepressants

Sham

acupuncture,

waiting list,

antidepressants

The evidence is inconsistent on whether manual

acupuncture is superior to sham, and suggests that

acupuncture was not superior to waiting list.

Evidence suggests that the effect of

electroacupuncture may not be significantly

different from antidepressants, weighted mean

difference -0.43(95% CI -5.61 to 4.76).

The evidence from

controlled trials is

insufficient to conclude

whether acupuncture is an

effective treatment for

depression, but justifies

further trials of

electroacupuncture.

Pilkingto

n K

10 RCTs Generalised

anxiety disorder

Acupuncture Sham

acupuncture, drug

Positive findings are reported for acupuncture in the

treatment of generalised anxiety disorder or anxiety

Overall, the promising

findings indicate that further

20

(2007)27

or anxiety

neurosis or

perioperative

anxiety

therapy neurosis but there is currently insufficient research

evidence for firm conclusions to be drawn. There is

some limited evidence in favour of acupuncture in

perioperative anxiety.

research is warranted in the

form of well designed,

adequately powered studies.

Rathbon

e J

(2005)28


or combined with

antipsychotics

Antipsychotics

alone

BPRS endpoint data (short term) favoured the

combined acupuncture and antipsychotic group

(WMD -4.31 CI -7.0 to -1.6), although

dichotomised BPRS data ’not improved’

confounded this outcome with equivocal data.

We found insufficient

evidence to recommend the

use of acupuncture for

people with schizophrenia.

The numbers of participants

and the blinding of

acupuncture were both

inadequate.

Ravindra

n AV

(2013)29

Not

reported

Mood and

anxiety

disorders

Physical therapies

including Yoga and

acupuncture; herbal

remedies;

Nutraceuticals

Placebo

alone/placebo

plus western

medicines/sham

acupuncture

In unipolar depression, there is Level 2 evidence for

Free and Easy Wanderer Plus (FEWP), and Level 3

for exercise and yoga. In bipolar depression, there

is evidence of Level 3 for FEWP. In anxiety

conditions, exercise augmentation has Level 3

support in generalized anxiety disorder and panic

disorder.

While several CAM

therapies show some

evidence of benefit as

augmentation in depressive

disorders, such evidence is

largely lacking in anxiety

disorders. The general dearth

of adequate safety and

tolerability data encourages

caution in clinical use.

Robinso

n N

(2011)30

1 RCT and

8 others

for

A variety of

conditions

including pain,

Shiatsu or

acupressure

Sham points, care

as usual

Category 2 evidence was present for anxiety related

to surgery. Fairly good evidence existed for

agitation in dementia compared to control, although

Evidence is improving in

quantity, quality and

reporting, but more research

21

Shiatsu; 8

MA/SR,

39 RCTs,

and 24

other

studies for

acupressur

e

dementia, stress,

anxiety, sleep

problems, etc.

generalisability was limited by small sample size,

lack of control, and high attrition.

is needed, particularly for

Shiatsu, where evidence is

poor. Acupressure may be

beneficial for pain, nausea

and vomiting and sleep.

Sarris J

(2011)31

20 RCTs Insomnia Acupuncture,

acupressure, natural

pharmacotherapies,

Tai chi, Yoga

Sham

acupuncture,

sleep hygiene

device, placebo,

health education,

exercise, wait list,

western medicines

There was evidentiary support in the treatment of

chronic insomnia for acupressure (d =1.42-2.12),

Tai chi (d= 0.22-2.15), yoga (d= 0.66-1.20), mixed

evidence for acupuncture and L-tryptophan, and

weak and unsupportive evidence for herbal

medicines such as valerian.

Future researchers are urged

to use acceptable

methodology, including

appropriate sample sizes and

adequate controls.

Sarris J

(2012)32

14 RCTs Obsessive

compulsive

disorder,

trichotillomania

Nutrients, herbal

medicines,

acupuncture,

mindfulness

meditation, Yoga,

relaxation, alone or

as adjunct treatment

Placebo, western

medicines, wait

list, mindfulness

meditation,

decoupling

In OCD, tentative evidentiary support was found

for mindfulness meditation (d=0.63),

electroacupuncture (d=1.16), and kundalini yoga

(d=1.61). Better designed studies using the nutrient

glycine (d=1.10), and traditional herbal medicines

milk thistle (insufficient data for calculating d) and

borage (d=1.67) also revealed positive results. A

study showed that N-acetylcysteine (d=1.31) was

effective in TTM. Mixed evidence was found for

myo-inositol (mean d=0.98). St John's wort, EPA,

While several studies were

positive, these were

un-replicated and commonly

used small samples. This

precludes firm confidence in

the strength of clinical effect.

22

and meridiantapping are ineffective in treating

OCD.

Shen X

(2014)33


or combined with

standard, low dose

antipsychotics or

herbs

Standard dose

antipsychotics,

herbs, electric

compulsive

therapy

When acupuncture plus standard antipsychotic

treatment was compared with standard

antipsychotic treatment alone, people were at less

risk of being ’not improved’ (n = 244, 3 RCTs,

medium-term RR 0.40 CI 0.28 to 0.57, very low

quality evidence). When acupuncture was added to

low dose antipsychotics and this was compared

with standard dose antipsychotic drugs, relapse was

less in the experimental group (n = 170, 1 RCT,

long-term RR 0.57 CI 0.37 to 0.89, very low quality

evidence) but there was no difference for the

outcome of ’not improved’. When acupuncture was

compared with antipsychotic drugs of known

efficacy in standard doses, there were equivocal

data for outcomes such as ’not improved’ using

different global state criteria.

All studies were at moderate

risk of bias. Limited

evidence suggests that

acupuncture may have some

antipsychotic effects as

measured on global and

mental state with few

adverse effects.

Smith

CA

(2010)34

30 RCTs Depression Acupuncture, alone

or combined with

antidepressants

Sham

acupuncture, no

treatment, wait

list,

pharmacological

treatment, other

structured

There was a high risk of bias in the majority of

trials. There was insufficient evidence of a

consistent beneficial effect from acupuncture

compared with a wait list control or sham

acupuncture control. Two trials found acupuncture

may have an additive benefit when combined with

medication compared with medication alone. A

Insufficient evidence to

recommend the use of

acupuncture for people with

depression.

23

psychotherapies,

standard care

subgroup of participants with depression as a

co-morbidity experienced a reduction in depression

with manual acupuncture compared with SSRIs.

The majority of trials compared manual and electro

acupuncture with medication and found no effect

between groups.

Sniezek

DP

(2013)35

6 RCTs Women with

depressive or

anxiety

disorders

Acupuncture alone

or combined with

counseling

Counseling , sham

acupuncture,

nonspecific

acupuncture alone

or plus massage,

patient education

The quality of research varied heavily. There was a

significant difference between acupuncture and at

least one control in all six trials.

Overall, there is a lack of

high-quality research on the


for treating anxiety and

depression in women. With

respect to six reviewed

studies, there is high-level

evidence to support the use

of acupuncture for treating

major depressive disorder in

pregnancy.

Stub T

(2011)36

4 SRs and

26 RCTs

Depressive

disorders

Acupuncture Sham

acupuncture,

antidepressants,

massage, wait list,

non-specific

acupuncture

The methodological quality of the trial reports was

generally low. A significant beneficial effect was

found for acupuncture in improvement of

depression compared to pooled control measured by

Hamilton Rating Scale for Depression

(WMD−3.10, 95% CI−4.91 to−1.99). Subgroup

analysis suggested that electro-acupuncture

(WMD−0.68, 95% CI−1.49 to 0.13) and TCM

Current evidence from this

meta-analysis of randomized

trials shows that acupuncture

is effective in reducing

severity of depression and

that TCM- and electro

acupuncture may have

similar effect as current usual

24

acupuncture (WMD 0.79, 95% CI−0.93 to 2.52),

were not statistically different from medication.

care. More rigorous trials are

needed and long-term effects

should be investigated if

acupuncture is to be

recommended for clinical

use.

Thachil

AF

(2007)37

7 SRs, 9

RCTs, and

3 others

Depressive

disorders

Herbs, nutritional

therapy,

acupuncture,

exercise, complex

homeopathy, yoga,

traditional Chinese

medicine

Placebo,

antidepressants,

psychotherapy

Grade 1 evidence on the use of St. John's wort,

Tryptophan/5-Hydroxytryptophan, S-adenosyl

methionine, Folate, Inositol, Acupuncture and

Exercise in Depressive disorders, none of which

was conclusively positive. We found RCTs at the

Grade 2 level on the use of Saffron, Complex

Homoeopathy and Relaxation training in

Depressive disorders, all of which showed

inconclusive results. Other RCTs yielded

unequivocally negative results. Studies below this

level yielded inconclusive or negative results.

None of the CAM studies

show evidence of efficacy in

depression according to the

hierarchy of evidence. The

RCT model and the

principles underlying many

types of CAM are dissonant,

making its application in the

evaluation of those types of

CAM difficult.

Tian TT

(2012) 38


disease (AD)

Acupuncture Nimodipine,

Huperzine A,

Almitrine and

Raubasine,

donepezil,

Oxygen

Meta-analysis showed significant differences in

acupuncture vs. Huperzine A (WMD=-0.81, 95%

CI -1.02 to -0.59), acupuncture vs. donepezil

(WMD=-1.42, 95%CI -2.32 to -0.52), acupuncture

vs. Oxygen (WMD=4.85, 95%CI 4.62 to 5.08),

while no significant differences were found in other

comparisons.

Inconclusive due to low

quality and small sample size

of the reviewed trials.

Wahbeh 17 RCTs Posttraumatic Complementary Waitlist, CBT, Scientific evidence of benefit for posttraumatic Several complementary and

25

H

(2014)39

and 16

other

studies

stress disorder

(PTSD)

medicine including

acupuncture,

meditation, yoga,

etc

supportive

counseling,

medication,

psychotherapy,

massage, EMDR,

exposure, placebo

stress disorder was strong for repetitive transcranial

magnetic stimulation and good for acupuncture,

hypnotherapy, meditation, and visualization.

Evidence was unclear or conflicting for

biofeedback, relaxation, Emotional Freedom and

Thought Field therapies, yoga, and natural

products.

alternative medicine

modalities may be helpful for

improving posttraumatic

stress disorder symptoms.

Future research should

include larger, properly

randomized, controlled trials

with appropriately selected

control groups and rigorous

methodology.

Wang H

(2008)40

8 RCTs Depression Acupuncture Sham acupuncture Our results confirmed that acupuncture could

significantly reduce the severity of depression. The

pooled standardized mean difference of the

‘Improvement of depression’ was −0.65 (95% CI

−1.18, −0.11) by random effect model. However,

no significant effect of active acupuncture was

found on the response rate (RR 1.32, 95% CI 0.83

to 2.10) and remission rate (RR 1.30, 95% CI 0.57

to 2.95).

Although this meta-analysis

might be discounted due to

the low quality of individual

trials, it supported that

acupuncture was an effective

treatment that could

significantly reduce the

severity of disease in the

patients with depression.

Wang L

(2008) 41

14 RCTs Depressive

disorder

Acupuncture Antidepressants Only four of the trials used double blind method.

Meta-analysis indicated that there was no

significant difference between the effective rates of

acupuncture treatment and medication, and

acupuncture treatment was better than

Amitriptyline in improvement of HAMD scores,

Both acupuncture and

medication possibly are

effective for depression with

good safety. However,

because of lower

methodological quality of the

26

but no significant differences as compared with

other drugs.

trials, this conclusion needs

further be confirmed.

White A

(2006)42

13

controlled

studies

Nicotine

dependence

Ear acupuncture,

alone or plus

psychotherapy or

counselling

Psychotherapy

plus illustration or

medication, sham

ear acupuncture,

‘incorrect point’

acupuncture,

hypnosis, advice

Combining ten studies showed auricular

acupuncture at ‘correct’ points to be more effective

than control interventions, odds ratio 2.24 (95% CI

1.61, 3.10). Comparisons of three higher quality

studies suggest that ‘correct’ and ‘incorrect’ point

acupuncture is no different (odds ratio 1.22, CI

0.72, 2.07); and two studies showed that ‘incorrect’

point acupuncture may be more effective than other

interventions (odds ratio 1.96, CI 1.00, 3.86).

Auricular acupuncture

appears to be effective for

smoking cessation, but the

effect may not depend on

point location. This calls into

question the somatotopic

model underlying auricular

acupuncture and suggests a

need to re-evaluate sham

controlled studies which

have used ‘incorrect’ points.

White

AR

(2014)43

38 RCTs Nicotine

dependence

acupuncture,

acupressure, laser

stimulation or

electrostimulation

no intervention,

sham acupuncture

or acupressure,

nicotine

replacement

therapy,

psychological

intervention

Based on three studies, acupuncture was not shown

to be more effective than a waiting list control for

long term abstinence, with wide confidence

intervals and evidence of heterogeneity (RR 1.79,

95%CI 0.98 to 3.28). Compared with sham

acupuncture, the RR for the short-term effect of

acupuncture was 1.22 (95%CI 1.08 to 1.38), and for

the long-term effect was 1.10 (95%CI 0.86 to 1.40).

Acupuncture was less effective than nicotine

replacement therapy. There was no evidence that

acupuncture is superior to psychological

interventions in the short- or long-term. There is

Although pooled estimates

suggest possible short-term

effects there is no consistent,

bias-free evidence that

acupuncture, acupressure, or

laser therapy have a

sustained benefit on smoking

cessation for six months or

more. However, lack of

evidence and methodological

problems mean that no firm

conclusions can be drawn.

27

limited evidence that acupressure is superior to

sham acupressure for short-term outcomes (RR

2.54, 95% CI 1.27 to 5.08), but no trials reported

long-term effects. The pooled estimate for studies

testing continuous auricular stimulation suggested a

short-term benefit compared to sham stimulation

(RR 1.69, 95%CI 1.32 to 2.16); subgroup analysis

showed an effect for continuous acupressure (RR

2.73, 95%CI 1.78 to 4.18) but not acupuncture with

indwelling needles (RR 1.24, 95%CI 0.91 to 1.69).

At longer follow-up the CIs did not exclude no

effect (RR 1.47, 95% CI 0.79 to 2.74). The

combined evidence on electrostimulation suggests

it is not superior to sham electrostimulation

(short-term abstinence: RR 1.13, 95% CI 0.87 to

1.46; long-term abstinence: RR 0.87, 95% CI 0.61

to 1.23).

Electrostimulation is not

effective for smoking

cessation.

Xie YY

(2014) 44

17 RCTs Vascular

dementia

Acupuncture plus

traditional Chinese

herb formulae

Nor reported Response rate in acupuncture plus herbs was better

than in other treatment.

Acupuncture plus herbs is a

potentially effective

approach for the treatment of

vascular dementia. However,

the quality of included trials

was low.

Xiong J

(2009) 45

9 RCTs Depression

neurosis

Acupuncture Antidepressants Meta-analyses showed that the total effective rate in

the acupuncture group was similar when compared

Acupuncture is not inferior

to western medicine, and it is

28

with Dailixin (RR= 1.01, 95%CI 0.82 to 1.23) on

20 d, fluoxetine (RR= 1.06, 95%CI 0.82 to 1.37) at

week 8, but showing difference between

acupuncture and fluoxetine (RR= 1.15, 95CI 1.07

to 1.22) at week 12. As for the HAMD score, no

significant difference was noted between

acupuncture and Dailixin (WMD= 0.45, 95%CI –

2.47 to 3.37) at 20 d, or amitriptyline at week 6, or

fluoxetine on 30 d, and weeks 4, 8, 12; there was a

difference between acupuncture and amitriptyline

observed at week 1 (WMD= – 2.67, 95%CI – 4.38

to – 0.96) and week 2 (WMD= – 2.18, 95%CI –

3.28 to – 1.08). In terms of the SDS scores,

significant difference was found between

acupuncture and fluoxetine (WMD= – 4.26, 95%CI

– 6.67 to – 1.85) at week 6, but no difference at

week 4 and 12.

worth noting that

acupuncture is associated

with few adverse reactions.

Further large-scale trials are

required to define the role of


of depression neurosis.

Xiong J

(2010) 46

20 RCTs Post-stroke

depression

Acupuncture Antidepressants Meta-analyses showed that the total effective

according with 24 HAMD score rate in the

acupuncture group was different when compared

with fluoxetine (RR=1.15, 95% CI 1.07 to 1.24) at

week 8, but showing similar results between

acupuncture and fluoxetine at weeks 4 and 6. The

total effective according with 17 HAMD score rate

in the acupuncture group was similar when

Acupuncture is not inferior

to western medicine, and it is

worth noting that

acupuncture is associated

with few adverse reactions.

Further large-scale trials are

required to define the role of


29

compared with fluoxetine or amitriptyline. As for

the 24 HAMD score，no significant difference was

noted between acupuncture and fluoxetine at weeks

2, 6, 8, and 24; difference between acupuncture and

fluoxetine observed at week 1 (WMD=-3.80,

95%CI -7.64 to 0.04) and week 4 (WMD=-1.34,

95%CI -2.67 to -0.02); no difference between

acupuncture and amitriptyline/diapazem. As for the

24 HAMD score, significant difference was noted

between acupuncture and fluoxetine at week 4

(WMD=-1.15, 95%CI -2.01 to -0.30), but showing

similar results at weeks 2 and 6, as well as

acupuncture and amitriptyline. In terms of the SDS

scores, significant differences were noted between

acupuncture and fluoxetine or amitriptyline.

of post stroke depression.

Xu Y

(2014) 47

20 RCTs Post-stroke

depression

(PSD)

Acupuncture Western medicine Only two trials are of high quality based on Jadad

scores. Comparing to the Western medicine,

acupuncture showed better recovery rates [OR

=1.43, 95%CI 1.16 to 1.77], effectiveness

[OR=2.36, 95%CI 1.84 to 3.03)], and improved

HAMD score [SMD=-0.42, 95%CI -0.52, -0.32].

Meta-analysis showed that the cumulative PSD

acupuncture treatment in the cure rate, efficiency

and improving HAMD scores were better than

western medicine, but its detection by time and

Meta-analysis showed that

the acupuncture treatment of

PSD in cure rate, efficiency

and improve the HAMD

score is better than western

medicine. Higher quality,

larger sample randomized

controlled trials are

warranted.

30

sample volume trends, found that stability is not

high.

Yeung

WF

(2012) 48

40 RCTs Insomnia acupressure,

reflexology, and

auricular

acupressure, alone

or combined with

herbs or western

medications

Music therapy,

waitlist, no

treatment, western

medications,

sham acupuncture

Only nine studies scored three or more by the Jadad

scale, and all had at least one domain with high risk

of bias. Meta-analyses of the moderate-quality

RCTs found that acupressure as monotherapy fared

marginally better than sham control. Studies that

compared auricular acupressure and sham control

showed equivocal results. It was also found that

acupressure, reflexology, or auricular acupressure

as monotherapy or combined with routine care was

significantly more efficacious than routine care or

no treatment.

Owing to the methodological

limitations of the studies and

equivocal results, the current

evidence does not allow a

clear conclusion on the

benefits of acupressure,

reflexology, and auricular

acupressure for insomnia.

Yue SJ

(2009) 49

6 RCTs Generalized

anxiety disorder

(GAD)

Acupuncture Antidepressants The response rates between acupuncture and

antidepressants did not show significant difference

in all included three trials, while the adverse events

in acupuncture group were significantly less in two

trials.

Our review indicated that

acupuncture might have

similar effect and less

adverse events comparing to

antidepressants in treating

patients with GAD.

However, the quality of

included trials was low.

Zhang B

(2014)50

16 RCTs Opioid

addiction

Acupuncture Sham

acupuncture,

drug, methadone,

placebo,

Four studies from Western countries did not report

any clinical gains in the treatment of psychological

symptoms associated with opioid addiction. 10 of

12 studies from China have reported positive

This review and

meta-analysis could not

confirm that acupuncture

was an effective treatment

31

Buprenorphine,

no treatment

findings regarding the use of acupuncture to treat

the psychological symptoms associated with opioid

addiction. The methodological quality of the

included studies was poor. The meta-analysis

indicated that there was a significant difference

between the treatment group and the control group

for anxiety and depression associated with opioid

addiction, although groups did not differ on opioid

craving.

for psychological symptoms

associated with opioid

addiction. However,

considering the potential of

acupuncture demonstrated in

the included studies, further

rigorous randomized

controlled trials with long

follow up are warranted.

Zhang

GC

(2012)51

15 Post-stroke

depression

Acupuncture Antidepressants All included trials were of low to moderate quality.

Comparison between the acupuncture group and the

Western medicine group for the curative rate on

PSD revealed an OR of 1.48, 95% CI = [1.11 1.97].

Comparison of obviously effective rate shows that

OR=1.39, 95% CI=[1.08 1.80]. Comparison of

effective rate shows that OR=0.83, 95% CI=[0.63

1.09].

Acupuncture has a higher

curative rate than Western

medicine in treating

post-stroke depression.

Zhang J

(2014)52

17 RCTs Post-stroke

depression

Filiform needle

acupuncture

Antidepressant

drugs

Meta-analysis showed that after 4 weeks of

treatment, clinical effective rate was better in

patients treated with acupuncture than those treated

with antidepressants (RR=1.11, 95%=1.03-1.21).

At 6 weeks, clinical effective rates were similar. At

2 weeks after acupuncture, Hamilton Depression

Scale was lower than in antidepressants group

(mean difference=-2.34, 95% CI -3.46 to -1.22). At

Therapeutic effects of

filiform needle acupuncture

were better than those of

antidepressant drugs.

32

4 weeks, scores were similar.

Zhang

ZJ

(2010)53

35 RCTs

with Jadad

scores >3

Depressive

disorders

including major

depressive

disorder and

post-stroke

depression

Acupuncture alone

or combined with

antidepressants

Sham acupuncture

or antidepressants

alone

The efficacy of acupuncture as monotherapy was

comparable to antidepressants alone in improving

clinical response and alleviating symptom severity

of MDD, but not different from sham acupuncture.

No sufficient evidence favored the expectation that

acupuncture combined with antidepressants could

yield better outcomes than antidepressants alone in

treating MDD. Acupuncture was superior to

antidepressants and waitlist controls in improving

both response and symptom severity of PSD. The

incidence of adverse events in acupuncture

intervention was significantly lower than

antidepressants.

Acupuncture therapy is safe

and effective in treating

MDD and PSD, and could be

considered an alternative

option for the two disorders.

The efficacy in other forms

of depression remains to be

further determined.

Zhong

BL

(2008) 54

7 RCTs

with Jadad

scores >4

Depressive

disorders

Acupuncture Waitlist, sham

acupuncture,

antidepressants

In one study, there was a statistically significant

difference between acupuncture and waitlist groups

on the Hamilton Rating Scale for Depression

(HAMD) score (WMD = - 4.79, 95% CI : - 6.17,

-3.14) ; In another study, no statistically significant

difference was found between electroacupuncture

and fluoxetine groups (WMD = - 1.15, 95% CI: -

4.24, 1.94); In the other two studies, no statistically

significant difference was found between

acupuncture combined with auricular acupuncture

and fluoxetine groups on the HAMD score (WMD

Based on current evidence,

acupuncture is a promising

treatment for depress ion.

Electroacupuncture for major

depressive disorder and

acupuncture combined with

auricular acupuncture for

depressive neuros is have the

same effectiveness as

fluoxetine. The safety of

acupuncture is good with

33

= - 0.87, 95% C I: - 2.08, 0.35). slight and transient adverse

effect. More follow-up

studies are needed for

evaluating the long-term

effect of acupuncture for

depression.

34

Supplement Table 4: Systematic Reviews and Meta-analyses on the Effectiveness of Traditional Chinese Herbs on Mental Illnesses

Referenc

e

Studies Conditions

treated


Butler L

(2013)55

5 SRs and

8 RCTs

Depressive

disorders

Chinese Herb

formulas, alone or

plus antidepressants

or placebo

antidepressants

Antidepressants,

alone or plus

placebo herbs

The mean Jadad score of 8 trials was 2.4 (out of 5)

and 3 trials scored more than 3. Positive results

were reported: no significant differences from

medication, greater effect than medication or

placebo, reduced adverse event rates when

combined or compared with antidepressants.

Despite promising results,

particularly for Xiao Yao San

and its modifications, the

effectiveness of Chinese herbal

medicine in depression could

not be fully substantiated based

on current evidence.

Chen DF

(2010) 56

61 RCTs

for

Alzheimer’

s disease;

335 RCTs

for

vascular

dementia

Alzheimer’s

disease,

vascular

dementia

Chinese Herb

formulas

Cholinesterase

Inhibitors,

metabolic

enhancement

The results of meta-analysis of AD showed that in

the comparison with Cholinesterase Inhibitors, the

TCM is not better than the Cholinesterase Inhibitors

in the standards of the MMSE’s increased score

[OR=0.78, 95%Cl 0.53, 1.13], the percentage of

MMSE’s increased score [OR=1.41, 95%Cl 0.80,

2.48] and the difference of MMSE’s scores before

and after treatment [WMD=-0.17, 95%Cl -2.76 to

0.56)]. In the comparison with the drugs of

Metabolic enhanced, the TCM is better than the

drugs of Metabolic enhanced in the standard of the

effectiveness of traditional Chinese medical

syndrome [OR=2.60, 95%Cl 1.35, 5.00], but in the

standard of the difference of MMSE’s scores before

Generally speaking, the quality

of clinical research literature of

Chinese Medicine in treatment

with AD and VD is not

satisfactory, which need to be

enhanced further. The results of

meta-analysis show that the

curative effect of Chinese

Medicine in treatment with AD

is not better than the

Cholinesterase Inhibitors, and

the effect of Chinese Medicine

is better than the drugs of

Metabolic in treatment with AD

35

and after treatment [WMD=1.97, 95%Cl -0.39,

4.33], the TCM is not better than the drugs of

Metabolic enhanced.

The results of meta-analysis of VD showed that the

TCM is better than the drugs of Metabolic

enhanced in the standards of the difference of

MSSE’s scores before and after treatment

[WMD=0.96, 95%CI 0.13, 1.78], the therapeutic

indices which is counted by the scores of TCM

symptoms [OR=1.68, 95%CI 1.25, 2.26] and the

effectiveness of traditional Chinese medical

syndrome; but in the standards of the percentage of

MMSE’s increased score [OR=1.32, 95%Cl 0.98,

1.77], the difference of BBS’s scores before and

after treatment [WMD=0.21, 95%Cl -0.17, 0.59]

and the difference of ADL’s scores before and after

treatment [WMD=0.28, 95%Cl -0.55, 1.11], the

TCM is not better than the drugs of Metabolic

enhanced.

and VD.

Guo Q

(2014) 57

12 RCTs Vascular

dementia

Chinese Herb

formulas, alone or

plus western

medications

Western

medications

Chinese herb, alone or plus western medications,

showed better response rate than western

medications (95% CI 1.20 to 1.51), and higher

MMSE scores (95% CI 1.33 to 2.40).

Chinese herbs for the treatment

of vascular dementia is better

than Western medicine alone.

However, further large,

rigorously designed trials are

warranted due to the insufficient

36

methodological rigor seen in the

trials included in this study.

Jun JH

(2014) 58

13 RCTs Depressive

disorders

GanmaiDazao

(GMDZ) decoction,

alone or plus

antidepressants

Antidepressants All of the included RCTs had a high risk of bias

across their domains. Three RCTs failed to show

favorable effects of GMDZ decoction on response

rate or HAMD score in major depression. One RCT

showed a beneficial effect of GMDZ decoction on

response rate in post-surgical depression, while

another failed to do so. Two studies showed

favorable effects on response rate in post-stroke

depression, while another two failed to do so. A

meta-analysis, however, showed that GMDZ

decoction produced better response rates than

anti-depressants in post-stroke depression (RR:

1.17, I2 = 15%). One trial failed to show any

beneficial effects of GMDZ decoction on response

rate or HAMD score in depression in an elderly

sample. Two trials tested GMDZ decoction in

combination with anti-depressants but failed to

show effects on response rate in major depression,

while another did show beneficial effects on

response rate in post-stroke depression.

This systematic review and

meta-analysis failed to provide

evidence of the superiority of

GMDZ decoction over

anti-depressant therapies for

major depression, post-surgical

depression, or depression in the

elderly, although there was

evidence of an effect in

post-stroke depression. The

quality of evidence for this

finding was low, however,

because of a high risk of bias.

Kou MJ

(2012)59

7 RCTs Depression Integrated

traditional and

Western medicine

Western medicine

alone

The included trials had generally low

methodological quality. Meta-analysis showed,

compared with Western medicine alone, integrated

Integrated traditional and

Western medicine for treatment

of depression is better than

37

traditional and Western medicine based on

syndrome differentiation could improve the effect

of treatment represented by the HAMD

[WMD=-2.39, CI (-2.96,-1.83)]. There were no

reported serious adverse effects that were related to

integrated traditional and Western medicine based

therapies in these trials.

Western medicine alone.

However, further large,

rigorously designed trials are

warranted due to the insufficient

methodological rigor seen in the

trials included in this study.

Liu TT

(2009)60

21 RCTs Heroin

addiction

Eighteen Chinese

herb formulas as

monotherapy

α2-adrenergic

agonists, opioid

agonists

Of the 21 studies, 10 were judged high in quality.

For withdrawal symptoms score relieving during

the 10-day observation, Chinese herbal medicine

was superior to α2-adrenergic agonists in relieving

opioid-withdrawal symptoms during 4–10 days

(except D8) and no difference was found within the

first 3 days. Compared with opioid agonists,

Chinese herbal medicine was inferior during the

first 3 days, but the difference became

nonsignificant during days 4–9. Chinese herbal

medicine has better effect on anxiety relieving at

late stage of intervention than α2-adrenergic

agonists, and no difference with opioid agonists.

Our meta-analysis suggests that

Chinese herbal medicine is an

effective and safety treatment

for heroin detoxification. And

more work is needed to

determine the specific effects of

specific forms of Chinese herbal

medicine.

Man SC

(2008)61


disease

Herbal medicine

(HM), single herb

or herbal formula,

alone or plus

orthodox

Placebo, or

orthodox

medications

Out of the 15HM monotherapy studies, 13 reported

HM to be significantly better than OM or placebo;

one reported similar efficacy between HM and OM.

Only the HM adjuvant study reported significant

efficacy. No major adverse events for HM were

Herb medicine can be a safe,

effective treatment for AD,

either alone or in conjunction

with orthodox medications.

However, methodological flaws

38

medications (OM) reported and HMs were found to reduce the adverse

effects arising from OM.

limited the extent to which the

results could be interpreted.

May BH

(2009) 62

13 RCTs Dementia Herb Medicine

(HM) including

Melissa officinalis,

Salvia officinalis,

and various Chinese

herbs formulae.

Ginkgo biloba was

excluded.

Placebo, no

treatment,

pharmacologic

intervention

Meta-analyses found HM more effective than no

treatment or placebo and at least equivalent to

control interventions, although the overall effect

was small. No severe adverse events were reported.

Due to the small sample size for

each herbal preparation, some

methodological weaknesses and

lack of longer term follow-up,

there is a need for further

multi-center studies with large

sample sizes.

May BH

(2009) 63

10 RCTs Mild cognitive

impairment

(MCI) and age

associated

memory

impairment

(AAMI)

Eight types of

Chinese herbs

formulae. Ginkgo

biloba was

excluded.

Placebo, no

treatment,

pharmacologic

intervention

This review found an overall benefit on some

outcome measures for the eight CHMs involved in

the 10 RCTs but methodological and data reporting

issues were evident.

The evidence for efficacy of

these herbs in MCI and AAMI

remains inconclusive.

Meeks

TW

(2007) 24

33 RCTs Late-life

depression,

anxiety, and

sleep

disturbance

Various

complimentary and

alternative

medicines including

yoga, Tai chi,

Qigong, meditation,

single herbs,

Chinese herb

Placebo, wait list,

treat as usual,

sham

acupuncture/acupr

essure, western

medications



studies.




suggested therapeutic potential

of mind-body interventions for

sleep disturbance, acupressure

for sleep and anxiety.

39

formulae,

acupuncture,

acupressure, etc

Qin X

(2013) 64

31 RCTs Vascular

Dementia

Chinese herbal

medicines

Placebo, western

medicine

Patients in the treatment group showed better

outcome than those in the control group

(Mini-Mental State Examination scores, WMD =

2.83; 95%CI: 2.55–3.12; Hasegawa Dementia Scale

scores, WMD = 2.41, 95%CI: 1.48–3.34).

Chinese herbal medicine

appears to be safer and more

effective than control measures

in the treatment of vascular

dementia. However, the

included trials were generally

low in quality.

Rathbon

e J

(2007)65

7 RCTs Schizophrenia Ginkgo biloba or

Herbs, alone or

combined with

antipsychotics

antipsychotics Results tended to favour combination treatment

compared with antipsychotic alone (Clinical Global

Impression ‘not improved/worse’ RR=0.19, 95% CI

0.1-0.6; Brief Psychiatric Rating Scale ‘not

improved/worse’ RR=0.78,95% CI 0.5-1.2; Scale

for the Assessment of Negative Symptoms ‘not

improved/worse’ RR=0.87,95% CI 0.7-1.2; Scale

for the Assessment of Positive Symptoms ‘not

improved/worse’ RR=0.69, 95% CI 0.5-1.0.

Beneficial effects of combining

herbs were indicated. Study

sizes were generally small and

pooled data were typically

derived from one or two studies.

All outcomes, therefore, were

underpowered.

Ravindra

n AV

(2013)29

Not

reported

Mood and

anxiety

disorders

Physical therapies

including Yoga and

acupuncture; herbal

remedies;

Nutraceuticals

Placebo alone,

placebo plus

western

medicines, sham

acupuncture







While several CAM therapies

show some evidence of benefit

as augmentation in depressive



disorders. The general dearth of

40

disorder. adequate safety and tolerability

data encourages caution in

clinical use.

Shu JZ

(2010) 66

9 RCTs Vascular

dementia

Bu Yang Huan Wu

Decoction,

BYHWD

Western

medications

BYHWD was more effective than Western

medicine in the treatment of vascular dementia. The

summary OR was 1.71 (95% CI 1.15 to 2.53); the

therapeutic effect of BYHWD was better than

Western medicine in improving the MMSE and

HDS score. The summary WMD was 1.60 (95% CI

0.16 to 3.03) and 2.98 (95% CI 2.34 to 3.62); there

were no obvious adverse reactions.

The general efficacy results of

BYHWD treating vascular

dementia is not clinical

significance because there is

heterogeneity. BYHWD was

more effective than western

medicine in improving the

MMSE and HDS score, but

need more high-quality research

in order to increase the strength

of the evidence.

Thachil

AF

(2007)37

7 SRs, 9

RCTs, and

3 others

Depressive

disorders

Herbs, nutritional

therapy,

acupuncture,

exercise, complex

homeopathy, yoga,

traditional Chinese

medicine

Placebo,

antidepressants,

psychotherapy












None of the CAM studies show

evidence of efficacy in


hierarchy of evidence. The RCT

model and the principles

underlying many types of CAM

are dissonant, making its

application in the evaluation of

those types of CAM difficult.

41

Wang

Y(2012)6

7

10 RCT Depression Chaihu-Shugan-San

(CSS), alone or

combined with

antidepressants

antidepressants

alone

All studies were of poor methodological quality

(Jadad score≤3) and are at high risk of bias.

Meta-analyses revealed that CSS in combination

with antidepressant drugs treatment significantly

improved depressive symptoms (WMD=−3.56;

95% CI −5.09 to −2.03) and significantly increased

effective rate (OR = 3.31; 95% CI 1.80–6.10) and

recovery rate (OR = 2.32; 95% CI 1.61–3.34)

compared with antidepressant drugs therapy. In

addition, the efficacy of CSS as monotherapy was

significantly better than antidepressants in

improving depressive symptoms (WMD=−3.09;

95% CI −5.13 to −1.06) and in creasing effective

rate (OR = 2.61; 95% CI 1.23–5.53). CSS was

comparable to antidepressants in increasing

recovery rate (OR = 1.83; 95% CI 0.84–3.98).

The present work supported that

CSS was effective and safe in

treating depressed patients.

More full-scale randomized

clinical trials with reliable

designs are recommended to

further evaluate the clinical

benefit and long-term

effectiveness of CSS for the

treatment of depression.

Wu KG

(2013) 68

13 RCTs Generalized

anxiety disorder

Chinese herb

formulae

Antidepressants,

anxiolytic

medications

Only three studies in the 13 included studies had a

Jadad score of 3 or higher. Meta-analysis showed

the efficiency rate [OR=0.98, 95%CI 0.66 to 1.44,

P=0.90], HAMA score after the end of the trial

[MD=-0.52, 95%CI -1.38 to 0.33), P=0.23].

The information currently

available can support the

opinion that the Chinese

medicinal herbs treatment and

western medicine treatment

provide the same clinical

efficacy in generalized anxiety

disorders.

Wu KG 8 RCTs Depressive Chinese herb Antidepressants As for the total effective rate, there is no statistical Based on the existing evidence,

42

(2013) 69

disorders formulae difference between treatment group and control

group in the 4 trials comparing with Fluoxetine

(OR=1.04, 95%CI 0.74 to 1.46, P=0.84), in the 2

trials comparing with Paroxetine (OR=0.57,

95%CI=0.16 to 2.08, P=0.40), in the 1 trial

comparing with Venlafaxine (OR=0. 57, 95%

CI=0.22 to 1.50, P=0.26), and in the 1 trial

comparing with Mapmtiline (OR=0.23,

95%CI=0.02 to 2.22, P=0.21). As for HAM-D

scaling rate, neither 6 trials with treatment for 6

weeks nor 1 trial for 12 weeks appear statistical

differences between treatment group and control

group (MD=0.18, 95%CI=-0.89 to 1.24, P=0.74;

MD=0.75, 95%CI=-0.56 to 2.06, P=0.26).

some Chinese herbal medicines

for treating depression appeared

efficacious. However, due to the

lack of stronger evidence, we

cannot recommend any kind of

Chinese medical herbal

fomulation as an effective

remedy for depression.

Xu EP

(2013) 70

19 RCTs Depressive

disorders

Chinese herb

formulae

Antidepressants Only 4 included trials had a Jadad score of 3 or

higher. The results of meta-analysis suggest that

there was no statistical significant difference in the

response rates between Chinese medicine

intervention group and the control group.

The curative effect of traditional

Chinese medicine and Western

medicine treatment of

depression seems similar, but

into the quality of design

document is low，

Yang M

(2014)71


disease

Natural medicines

including several

single herbs and

Fuzhisan (Chinese

Placebo,

donepezil

Apart from Ginkgo, other treatments had minimal

benefits and/or the methodological quality was

poor. In one RCT, Fuzhisan, a Chinese herbal

formula, was reported to significantly improve

Our results suggest that Ginkgo

may help established AD

patients with cognitive

symptoms but cannot prevent

43

herbs formula) ADAS-Cog scores, NPI scores and the regional

cerebral metabolic rate of glucose consumption

(rCM-Rglc), which suggests that Fuzhisan

treatment may have a positive effect on cognition,

behavior functions, and rCM-Rglc in

mild-to-moderate AD patients.

the neurodegenerative

progression of the disease.

Yeung

WF

(2014)72

296 RCTs Depressive

disorders

Chinese single

herbs or herbal

formulas, alone or


or plus placebo

antidepressants

Placebo,

antidepressants

alone or plus

placebo herbs

21 RCTs with a Jadad score >3 out of 296 RCTs

were included. Meta-analyses showed that CHM

monotherapy was better than placebo and as

effective as antidepressants in reducing Hamilton

Depression Rating Scale (HDRS) score (CHM vs.

placebo: mean difference: -7.97, 95% CI: -10.25 to

-5.70, 2 studies; CHM vs. antidepressants: mean

difference: 0.01, 95% CI: -0.28 to 0.30, 7 studies).

Despite the overall positive

results, due to the small number

of studies with sufficient

methodological quality, it is

premature to accurately

conclude the benefits and risks

of CHM for depression.

Yeung

WF

(2014)73

10 RCTs Depression GanmaiDazao

(GMDZ) decoction,

alone or plus

antidepressants

Antidepressants

alone

Methodological quality was generally low. Pooled

analysis of 5 studies which compared GMDZ with

antidepressants showed that GMDZ was

significantly more efficacious than antidepressants

in effective rate (risk ratio: 1.14, 95%CI: 1.02 to

1.27), but comparable in Hamilton Depression

Rating Scale score. The other 5 studies which

compared GMDZ plus antidepressants with

antidepressants alone, there was no significant

difference in effective rate (risk ratio: 1.24, 95%CI:

0.99 to 1.55), but the end-point HDRS score was

The overall results suggest that

GMDZ has few side effects and

the potential as an

antidepressant. Adding GMDZ

to antidepressants reduces side

effects and enhances efficacy of

antidepressants. However, due

to the small number of studies

and their limitations, further

studies with better

methodological quality and

44

significantly lower in GMDZ antidepressants

combination (mean difference: -4.25, 95%CI:

-6.50 to -2.00).

more comprehensive safety

assessment are needed to

determine the benefits and risks

of GMDZ in the treatment of

depression.

Zhang X

(2014)74

7 RCTs Major

depressive

disorder

Shuganjieyu

capsule, alone or

combined with

venlafaxine

Placebo or

venlafaxine

Shuganjieyu capsule was superior than placebo in

terms of response rate (RR=2.42, 95% CI: 1.55–

3.79), remission rate (RR=4.29, 95% CI: 1.61–

11.45), the scores of the mean change from baseline

of the HAM-D17 (MD=-4.17, 95% CI: -5.61

to-2.73) and from baseline of traditional Chinese

medicine (TCM) syndrome score scale scores

(MD=-6.00, 95% CI:-8.25 to-3.75). In addition,

Shuganjieyu plus venlafaxine had a significantly

higher response rate (RR=1.56, 95% CI: 1.29–1.88)

and was superior in terms of the scores of the mean

change from baseline of the treatment emergent

symptoms scale scores (MD=-0.74, 95% CI: -1.12

to -0.35) than venlafaxine alone.

Shuganjieyu capsule is superior

to placebo in terms of overall

treatment effectiveness and

safety. Both response rate and

remission rate among patients

treated with the combination of

Shuganjieyu plus venlafaxine

were significantly higher than

those treated with venlafaxine

alone. Due to the considerable

risk of bias in majority of trials,

recommendations for practice

should be cautious.

Zhang Y

(2014)75

8 RCTs

and 2

controlled

clinical

trials

Depressive

disorder or

symptoms of

patients with

Parkinson’s

disease

Traditional Chinese

medicine combined

with conventional

drug

Conventional

drug

Only one study was of high quality (Jadad

score=3). The pooled results revealed that TCM

combined with conventional drugs significantly

improved the total scores of the unified Parkinson’s

disease rating scale (WMD =-7:35, 95% CI: -11.24

to -3.47) and the score of the Hamilton rating scale

There is evidence that TCM

may be beneficial to the

treatment of depression in

Parkinson’s disease in spite of

the methodological weakness of

the included studies.

45

for depression (HAM-D) (WMD=-4:19, 95% CI:

-5.14 to -3.24) compared with conventional drug,

respectively.

Zhao H

(2014) 76

9 RCTs Dementia Chinese herb

formulae

Western

medications

The Jadad score of 9 studies ranged from 1 to 2. By

the analysis of meta display, it was better for

treatment with the TCM purging turbidity method

of detoxification than pure western medicine

dementia. Overall curative effect, for the summary

OR=2. 85 ( 95% CI 1. 80 to 4. 51 ), difference had

statistical significance ( P＜0. 0001) ; to improve

the ADL score, the effect of pure western medicine

was better than the TCM purging turbidity method

of detoxification with WMD－4. 03 ( 95% CI -5.

14 to -2. 93) , and difference was statistically

significant ( P ＜ 0. 00001).

The effect of the TCM purging

turbidity method of

detoxification therapy in

patients with dementia，in the

overall efficiency but reducing

the ADL score, it may be better

than the pure western medicine

treatment to the overall curative

effect, but it may be worse than

the pure western medicine

treatment to improve the ADL

score, and more high quality

studies are still needed to

increase evidence.

46

Supplement Table 5: Systematic Reviews and Meta-analyses on the Effectiveness of Qigong and Tai chi on Mental Illnesses

Referenc

e

Studies Conditions

treated


D’Silva

S

(2012)77

54 trials Patients with

depressive

disorders or

other conditions

and elevated

depressive

symptom

A variety of

mind-body

practices including

yoga, meditation,

relaxation, Tai chi,

Qigong, etc

Wait list,

psychotherapy,

education,

supportive

counseling, ECT,

antidepressants,

exercise,

treatment as usual

74% of these selected quality papers demonstrated

positive effects on the improvement of depressive

symptoms. All mind-body modalities included in

the study had at least one positive study.

The use of evidence-based

mind-body therapies can

alleviate depression severity.

They could be used with

established psychiatric

treatments of therapy and

medications.

Jorm AF

(2006)14

Not

reported

Children or

adolescents with

depressive

disorder or

elevated

depressive

symptoms

A variety of

complementary and


including herbs,

homeopathy,

acupuncture, Tai

chi, yoga, etc









depression.


medication is not recommended

as a first line treatment for

children and adolescents with

mild to moderate depression,

and that the effects of


modest, there is a pressing need

to extend the range of

treatments available for this age

group.

Kim SH

(2013)78

6 RCTs

and 10

PTSD Mind-body

practices including

Thermal

biofeedback,

Most of the studies have small sample size, but

findings from the 16 publications reviewed here

Mind-body practices are

increasingly employed in the

47

other

studies

yoga, meditation,

Qigong, Tai chi, etc

narrative exposure

therapy, wait list

suggest that mind-body practices are associated

with positive impacts on PTSD symptoms.

Mind-body practices incorporate numerous

therapeutic effects on stress responses, including

reductions in anxiety, depression, and anger, and

increases in pain-tolerance, self-esteem, energy

levels, ability to relax, and ability to cope with

stressful situations.

treatment of PTSD and are

associated with positive impacts

on stress-induced illnesses such

as depression and PTSD in most

existing studies.

Meeks

TW

(2007) 24

33 RCTs Late-life

depression,

anxiety, and

sleep

disturbance

Various

complimentary and

alternative

medicines including

yoga, Tai chi,

Qigong, meditation,

single herbs,

Chinese herb

formulae,

acupuncture,

acupressure, etc

Placebo, wait list,

treat as usual,

sham

acupuncture/acupr

essure, western

medications



studies.








NG BHP

(2009) 79

26 RCTs Chronic

conditions

including 1

RCT for heroin

addict, and 1

RCT for

Qigong No treatment,

placebo,

conventional

theray

Qigong may have some effects in decreasing

depression with a weighted mean difference of 0.90

(1.08-0.71), but most of the studies have obvious

methodological limitations.

In view of its safety, minimal

cost, and potential clinical

benefit, the authors support that

health qigong can be advocated

as an adjunctive therapy for

elderly with chronic conditions.

48

depression

Oh B

(2013) 80

10 RCTs Depressive

disorder or

symptoms

Qigong alone or

combined with

mindfulness

meditation or

standard care

Educational

support group,

standard care,

exercises,

newspaper

reading, no

intervention,

lecture

Four studies reported positive results of the Qigong

treatment on depression; two reported that Qigong

effect on depression was as effective as physical

exercise. One study reported that Qigong was

comparable to a conventional rehabilitation

program, but the remaining three studies found no

benefits of Qigong on depression.

While the evidence suggests the

potential effects of Qigong in

the treatment of depression, the

review of the literature shows

inconclusive results.

Rogers

C

(2009)81

36 RCTs Older adults

with variety of

conditions

including

depression

Qigong (QG) or Tai

chi (TC)

Wait list, usual

care,

hydrotherapy,

health education,

stretching control,

newspaper

reading, aerobic

exercise, etc

Five studies evaluated the effect of TC&QG on

depression. Two studies reported significant

reductions in depression: one compared QG to

newspaper reading and one compared TC to

wait-list control.

Significant improvement in

clusters of similar outcomes

indicated interventions utilizing

TC&QG may help older adults

improve physical function and

reduce blood pressure; fall risk;

and depression.

Rosenba

um S

(2014)82

39 RCTs, 2

on Tai chi

and 1 on

Yoga

Mental illnesses Physical activity

intervention

including Tai chi

and Yoga

Usual care, social

support, wait list,

placebo, health

education

Meta-analysis revealed a large effect of physical

activity on depressive symptoms (SMD=0.80),

schizophrenia symptoms (SMD=1.0), a small effect

for anthropometry (SMD=0.24), and moderate

effects were found in aerobic capacity (SMD=0.63)

and quality of life (SMD=0.64).

Physical activity reduced

depressive symptom in people

with mental illness, reduced

symptoms of schizophrenia and

improved anthropometric

measures, aerobic capacity, and

quality of life among people

with mental illness.

49

Sarris J

(2011)31



pharmacotherapies,

Tai chi, Yoga

Sham

acupuncture,

sleep hygiene

device, placebo,

health education,


western medicines







Future researchers are urged to

use acceptable methodology,

including appropriate sample

sizes and adequate controls.

Sharma

M

(2015)83

8 RCTs

and 9 other

studies

Healthy

individuals and

patients with

various

conditions

including

anxiety and

mood disorders

Tai chi, alone or

combined with drug

therapy

Exercise,

rehabilitation,

health education,

neutral reading,

wait list, no

control, drug

therapy alone

Statistically significant results of anxiety reduction

were reported in 12 of the studies reviewed.

Despite the limitations of not all

studies using randomized

controlled designs, having

smaller sample sizes, having

different outcomes, having

nonstandardized tai chi

interventions, and having

varying lengths, tai chi appears

to be a promising modality for

anxiety management.

Tsang

HWH

(2008)84

12 RCTs Individuals with

depressive

disorders or

elevated

depressive

symptoms

Exercise including

yoga, Qigong, and

Tai chi, alone or

combined with

antidepressants

Antidepressants,

usual care, wait

list, newspaper

reading, modified

ECT

The results based on 12 RCTs indicated that both

the mindful and nonmindful physical exercises

were effective in their short-term effect in reducing

depression levels or depressive symptoms.

However, most of studies had methodological

problems that only small sample size was used, and

the maintenance effects of physical exercise were

not reported.

We recommend that more

well-controlled studies have to

be conducted in the future to

address the short- and long-term

effects of physical exercise on

alleviating depression.

50

Wang C

(2010)85

17 RCTs

and 23

other

studies

Healthy

individuals and

patients with

chronic

conditions

including

depression and

dementia

Tai chi Attention control,

exercise,

relaxation, wait

list, hydrotherapy,

health education,

psychosocial

support therapy,

neutral reading

21 of 33 randomized and nonrandomized trials

reported that Tai Chi significantly increased

psychological well-being including reduction of

stress (effect size [ES], 0.66; 95% confidence

interval [CI], 0.23 to 1.09), anxiety (ES, 0.66; 95%

CI, 0.29 to 1.03), and depression (ES, 0.56; 95%

CI, 0.31 to 0.80), and enhanced mood (ES, 0.45;

95% CI, 0.20 to 0.69) in community-dwelling

healthy participants and in patients with chronic

conditions. Seven observational studies with

relatively large sample sizes reinforced the

beneficial association between Tai Chi practice and

psychological health.

Tai Chi appears to be associated

with improvements in

psychological well-being

including reduced stress,

anxiety, depression and mood

disturbance, and increased

self-esteem. Definitive

conclusions were limited due to

variation in designs,

comparisons, heterogeneous

outcomes and inadequate

controls. High-quality,

well-controlled, longer

randomized trials are needed to

better inform clinical decisions.

Wang

CW

(2013)86

12 RCTs Patients with

mood disorders,

or chronic

disease patients

with elevated

depressive

symptoms

Qigong, alone or

combined with

drugs

Psychotherapy,

wait list, exercise,

usual care, drugs,

newspaper

reading, mindful

relaxation

The results of meta-analyses suggested a beneficial

effect of qigong on depressive symptoms when

compared to waiting-list controls or usual care only

(SMD= −0.75; 95% CI, −1.44 to −0.06), group

newspaper reading (SMD= −1.24; 95% CI, −1.64 to

−0.84), and walking or conventional exercise

(SMD= −0.52; 95% CI, −0.85 to −0.19), which

might be comparable to that of cognitive-behavioral

therapy (𝑃 = 0.54). Available evidence did not

suggest a beneficial effect of qigong exercise on

Qigong may be potentially

beneficial for management of

depressive symptoms, but the

results should be interpreted

with caution due to the limited

number of RCTs and associated

methodological weaknesses.

51

anxiety symptoms.

Wang D

(2014)87

22 RCTs Substance use

disorders

including

alcohol, drug

and nicotine

Physical exercise

including Tai chi,

Qigong, and Yoga

No exercise,

standard

treatment,

educational

meeting, no

intervention,

CBT, wellness

sessions, care as

usual, sham

Qigong

The results indicated that physical exercise can

effectively increase the abstinence rate (OR = 1.69

(95% CI: 1.44, 1.99)), ease withdrawal symptoms

(SMD =21.24 (95% CI: 22.46, 20.02)), and reduce

anxiety (SMD =20.31 (95% CI: 20.45, 20.16)) and

depression (SMD = 20.47 (95% CI: 20.80, 20.14)).

The physical exercise can more ease the depression

symptoms on alcohol and illicit drug abusers than

nicotine abusers, and more improve the abstinence

rate on illicit drug abusers than the others. Similar

treatment effects were found in three categories:

exercise intensity, types of exercise, and follow-up

periods.

The moderate and

high-intensity aerobic exercises,

designed according to the

Guidelines of American College

of Sports Medicine, and the

mind-body exercises can be an

effective and persistent

treatment for those with SUD.

Wang F

(2013)88

14 RCTs

and 1

quasi-expe

riment

Healthy

individuals or

patients with

chronic

conditions

including

depression

Qigong Wait list, lecture,

placebo, exercise,

health education,

usual care, group

therapy,

newspaper

reading

The most frequently reported psychological

benefits were decreased depressive symptoms and

improved mood, reported in seven studies. Anxiety

decreased significantly for participants practicing

Qigong compared to an active exercise group.

Meta-analyses were conducted in three studies of

patients with type II diabetes, which suggested that

Qigong was effective in reducing depression and

anxiety.

Preliminary evidence suggests

that Qigong may have positive

effects on psychological

well-being among patients with

chronic illnesses. However the

published studies generally had

significant methodological

limitations.

Wang F

(2014)89

37 RCTs

and 5

Healthy

individuals or

Tai chi, alone or

combined with

Routine

medication, wait

The studies in this review demonstrated that tai chi

interventions have beneficial effects for various

In spite of the positive

outcomes, the studies to date

52

quasi-expe

riment

patients with

chronic

conditions

including

depression

routine medication list, exercise,

health education,

psychosocial

support, sham

exercise,

populations on a range of psychological well-being

measures, including depression, anxiety, general

stress management, and exercise self-efficacy.

Meta-analysis was performed on three RCTs that

used depression as an outcome measure (ES=-5.97;

95 % CI=-7.06 to-4.87).

generally had significant


More RCTs with rigorous

research design are needed to

establish the efficacy of tai chi

in improving psychological

well-being and its potential to

be used in interventions for

populations with various

clinical conditions.

Wang

WC

(2009)90

15 RCTs Healthy

individuals or

patients with

chronic

conditions

including

depression

Tai chi No treatment,

health education,

walking,

meditation and

reading

Eight were high quality trials. Tai Chi intervention

was found to have a significant effect in 13 studies,

especially in the management of depression and

anxiety. However, significant findings were shown

in only six high quality studies. Moreover,

significant between group differences after Tai Chi

intervention was demonstrated in only one high

quality study. Two high quality studies in fact

found no significant Tai Chi effects.

It is still premature to make any

conclusive remarks on the effect

of Tai Chi on psychosocial

well-being.

Wayne

PM

(2014)91

11 RCTs

and 9 other

studies

Individuals aged

60 and over

(with the

exception of one

study) with and

without

Tai chi, along or

plus

antidepressants, or

plus CBT and

support group

No intervention,

exercise, social

interaction, health

education,

attention control,

dance, fall

Overall quality of RCTs was modest.

Meta-analyses of outcomes related to executive

function in RCTs of cognitively healthy adults

indicated a large effect size when Tai Chi was

compared to non-intervention controls (Hedge’s

g=0.90; p=0.043) and moderate effect size when

Tai Chi shows potential to

enhance cognitive function in

older adults, particularly in the

realm of executive functioning

and in those individuals without

significant impairment. Larger

53

cognitive

impairment.

prevention,

mahjong, simple

handicrafts,

cognition-action,

compared to exercise controls (Hedge’s g=0.51;

p=0.003). Meta-analyses of outcomes related to

global cognitive function in RCTs of cognitively

impaired adults, ranging from mild cognitive

impairment to dementia, showed smaller but

statistically significant effects when Tai Chi was

compared to both non-intervention controls

(Hedge’s g=0.35; p=0.004) and other active

interventions (Hedge’s g=0.30; p=0.002).

and methodologically sound

trials with longer follow-up

periods are needed before more

definitive conclusions can be

drawn.

Wu Y

(2013)92

6

interventio

n and 2

cross-secti

onal

studies

Healthy

individuals or

patients with

mild cognitive

impairment

Tai chi No exercise,

stretching, low

dosage Tai chi

Four (mini mental status examination, digit span

test backward, visual span test backward, and

verbal fluency test) out of nine variables were

significantly improved after Tai Chi exercise with

the effect sizes ranged from 0.20 to 0.46 (small to

medium).

Tai Chi as a mind-body exercise

has the positive effects on

global cognitive and memory

functions, and more consistent

positive effects were found on

memory function, especially

verbal working memory.

54

Supplement Table 6: Systematic Reviews and Meta-analyses on the Effectiveness of Homeopathy and Ayuveda Medicine on Mental Illnesses

Referenc

e

Studies Conditions

treated


Agarwal

V

(2007)93

3 RCTs Schizophrenia Ayurvedic herbs Chlorpromazine,

placebo

When Ayurvedic herbs were compared with

placebo, mental state ratings were mostly

equivocal. Behaviour seemed unchanged (WMD

Fergus Falls Behaviour Rating 1.14 CI -1.63 to

3.91). When the Ayurvedic herbs were compared

with chlorpromazine, people allocated herbs were

at greater risk of no improvement in mental state

compared to those allocated chlorpromazine (RR

1.82 CI 1.11 to 2.98). Finally, when Ayurvedic

treatment is compared with chlorpromazine, it is

equally (~10% attrition, n=36, RR 0.67 CI 0.13 to

3.53), but skewed data does seem to favour the

chlorpromazine group.

Ayurvedic medication may

have some effects for treatment

of schizophrenia, but has been

evaluated only in a few small

pioneering trials.

Cooper

KL

(2010)94

4 RCTs

and a

number of

other

studies

Insomnia Homeopathy

medications

Placebo All RCTs involved small patient numbers and were

of low methodological quality. None demonstrated

a statistically significant difference in outcomes

between groups, although two showed a trend

favouring homeopathic medicines. A cohort study

reported significant improvements from baseline.

The limited evidence available

does not demonstrate a

statistically significant effect of

homeopathic medicines for

insomnia treatment. Existing

RCTs were of poor quality and

were likely to have been

underpowered.

55

Davidso

n JRT

(2011)95

25 RCTs A variety of

psychiatric

disorders

including

anxiety

disorders,

insomnia,

premenstrual

syndrome,

ADHD, etc

Homeopathy Placebo Study quality varied, 6 assessed as good, 9 as fair,

and 10 as poor. Efficacy was found in the somatic

syndrome group, but not for anxiety or stress. For

other disorders, homeopathy produced mixed

effects. No placebo-controlled studies of depression

were identified.

The database on studies of

homeopathy and placebo in

psychiatry is very limited, but

results do not preclude the

possibility of some benefit.

Jorm AF

(2004)13

Not

reported

Anxiety

disorders or

participants with

anxiety

symptoms

34 treatments

groups under 4

categories:

medicines and

hemoeopathic

remedies, physical

treatments,

lifestyle, and

dietary changes

Placebo in most

studies, western

medicines in a

few studies

108 treatments were identified and grouped under

the categories of medicines and homoeopathic

remedies, physical treatments, lifestyle, and dietary

changes. We give a description of the 34 treatments

(for which evidence was found in the literature

searched), the rationale behind the treatments, a

review of studies on effectiveness, and the level of

evidence for the effectiveness studies.

The treatments with the best

evidence of effectiveness are

kava (for generalised anxiety),

exercise (for generalised

anxiety), relaxation training (for

generalised anxiety, panic

disorder, dental phobia and test

anxiety). There is more limited

evidence to support the

effectiveness of acupuncture,

music, autogenic training and

meditation for generalised

anxiety

Jorm AF

(2006)14

Not

reported

Children or

adolescents with

A variety of

complementary and





56

depressive

disorder or

elevated

depressive

symptoms


including herbs,

homeopathy,

acupuncture, Tai

chi, yoga, etc







depression.









group.

Pilkingto

n K

(2005) 96

2 RCTs

and a

number of

other

studies

Depressive

disorders and

symptoms

Homeopathy Diazepam,

fluoxetine,

placebo

Homeopathy showed some benefits in alleviating

depressive symptoms in several uncontrolled study.

The evidence for the

effectiveness of homeopathy in

depression is limited due to lack

of clinical trials of high quality.

Pilkingto

n K

(2006) 97

8 RCTs

and a

number of

other

studies

Generalised

anxiety

disorder, test

anxiety, and

anxiety related

to general

conditions

Homeopathy Placebo,

benzodiazepines

The randomised controlled trials reported

contradictory results, were underpowered or

provided insufficient details of methodology.

It is not possible to draw firm

conclusions on the efficacy or

effectiveness of homeopathy for

anxiety.

Thachil

AF

(2007)37

7 SRs, 9

RCTs, and

3 others

Depressive

disorder

Herbs, nutritional

therapy,

acupuncture,

exercise, complex

Placebo,

antidepressants,

psychotherapy









57

homeopathy, yoga,

traditional Chinese

medicine













58

Supplement Table 7: Systematic Reviews and Meta-analyses on the Effectiveness of Yoga and Meditation on Mental Illnesses

Referenc

e

Studies Conditions

treated


Arias AJ

(2006) 98

20 RCTs A variety of

illnesses

including

depressive,

anxiety, and

substance use

disorders

Yoga or meditation Waitlist, active

control, no

treatment,

7 RCTs focused on mental illness support the use of

yoga and meditation as an adjunct or independent

treatment for mood and anxiety disorders.

The results support the safety

and potential efficacy of

meditative practices for treating

certain illnesses, particularly in

nonpsychotic mood and anxiety

disorders. Clear and replicable

evidence from large,

methodologically sound studies

is lacking.

Balasubr

amaniam

M

(2013)99

16RCTs Schizophrenia,

depression,

ADHD, eating

disorder, sleep

disorder,

cognitive

disorder

Yoga alone or

combined with

pharmacotherapy

Waitlist,

ayurveda,

exercise, usual

care

Grade B evidence supporting a potential acute

benefit for yoga exists in depression (4 RCTs), as

an adjunct to pharmacotherapy in schizophrenia (3

RCTs), in children with ADHD (2 RCTs), and

Grade C evidence in sleep complaints (3 RCTs).

RCTs in cognitive disorders and eating disorders

yielded conflicting results.

There is emerging evidence

from randomized trials to

support popular beliefs about

yoga for depression, sleep

disorders, and as an

augmentation therapy.

Limitations of literature include

inability to do double-blind

studies, multiplicity of

comparisons within small

studies, and lack of replication.

Cabral P 10 RCTs Depression, Yoga as a Standard care The combined analysis of all 10 studies provided a Yoga therapy is an effective

59

(2011)100

schizophrenia,

PTSD, anxiety,

depression in

alcohol

dependence

complimentary

treatment to

standard care

pooled effect size of -3.25 (95% CI, -5.36 to -1.14). adjunct treatment for several

psychiatric disorders.

Chiesa A

(2010)101

3

neuro-ima

ging

studies; 4

controlled

studies

Healthy

individuals or

prisoners with

alcohol abuse,

substance abuse,

or PTSD

Vipassana

meditation (VM)

Treat as usual Three clinical studies in incarcerated populations

suggested that VM could reduce alcohol and

substance abuse but not post-traumatic stress

disorder symptoms in prisoners. One clinical study

in healthy subjects suggested that VM could

enhance more mature defenses and copying styles.

Current studies provided

preliminary results about

neurobiological and clinical

changes related to VM practice.

Nonetheless, few and mainly

low-quality data are available

especially for clinical studies.

Cramer

H

(2013)102

12 RCTs Depression Yoga alone or

combined with

antidepressants

Waiting list, ECT,

massage, exercise,

psychotherapy,

relaxation music,

social support

group alone or

combined with

antidepressants

Three RCTs had low risk of bias. Regarding

severity of depression, there was moderate evidence

for short-term effects of yoga compared to usual

care (SMD =−0.69; 95% CI−0.99, −0.39), and

limited evidence compared to relaxation (SMD

=−0.62; 95%CI −1.03, −0.22), and aerobic exercise

(SMD = −0.59; 95% CI −0.99, −0.18). Limited

evidence was found for short-term effects of yoga

on anxiety compared to relaxation (SMD=−0.79;

95% CI −1.3, −0.26). Subgroup analyses revealed

evidence for effects in patients with depressive

disorders and in individuals with elevated levels of

depression.

Despite methodological

drawbacks of the included

studies, yoga could be

considered an ancillary

treatment option for patients

with depressive disorders and

individuals with elevated levels

of depression.

60

Cramer

H

(2013)103

5 RCTs Schizophrenia Yoga combined

with antipsychotics

or hospital

impatient treatment

Exercise and/or

usual care

combined with

antipsychotics or

hospital impatient

treatment

Two RCTs had low risk of bias. No evidence was

found for short-term effects of yoga compared to

usual care on positive or negative symptoms.

Moderate evidence was found for short-term effects

on quality of life compared to usual care (SMD =

2.28; 95% CI 0.42 to 4.14\). These effects were

only present in studies with high risk of bias. No

evidence was found for short-term effects on social

function. Comparing yoga to exercise, no evidence

was found for short-term effects on positive

symptoms, negative symptoms, quality of life, or

social function.

This systematic review found

only moderate evidence for

short-term effects of yoga on

quality of life. As these effects

were not clearly distinguishable

from bias and safety of the

intervention was unclear, no

recommendation can be made

regarding yoga as a routine

intervention for schizophrenia

patients.

Jain FA

(2015)104

18 RCTs Depressive

disorders

Mindfulness-based

cognitive therapy

(MBCT), 8studies;

Tai Chi, 3studies;

Sudar-shan Kriya

Yoga (SKY),

2studies; and

Patañjali Yoga,

2studies; alone or


Hypnosis,

bibliotherapy,

treat as usual,

antidepressants

alone or plus

psychoeducation,

pseudo-Yoga,

wait list, ECT,

newspaper

reading, partial

SKY

Studies including patients having acute major

depressive episodes (n=10 studies), and those with

residual subacute clinical symptoms despite initial

treatment (n=8), demonstrated moderate to large

reductions in depression symptoms within the

group, and relative to control groups.

A substantial body of evidence

indicates that meditation

therapies may have salutary

effects on patients having

clinical depressive disorders

during the acute and subacute

phases of treatment. Owing to

methodologic deficiencies and

trial heterogeneity, large-scale,

randomized controlled trials

with well-described comparator

interventions and measures of

expectation are needed.

61

Jorm AF

(2006)14

Not

reported

Children or

adolescents with

depressive

disorder or

elevated

depressive

symptoms

A variety of

complementary and


including herbs,

homeopathy,

acupuncture, Tai

chi, yoga, etc









depression.











group.

Kim SH

(2013)78

6 RCTs

and 10

other

studies

PTSD Mind-body

practices including

yoga, meditation,

Qigong, Tai chi, etc

Thermal

biofeedback,

narrative exposure

therapy, wait list

Most of the studies have small sample size, but

findings from the 16 publications reviewed here

suggest that mind-body practices are associated

with positive impacts on PTSD symptoms.

Mind-body practices incorporate numerous

therapeutic effects on stress responses, including

reductions in anxiety, depression, and anger, and

increases in pain-tolerance, self-esteem, energy

levels, ability to relax, and ability to cope with

stressful situations.

Mind-body practices are

increasingly employed in the

treatment of PTSD and are

associated with positive impacts

on stress-induced illnesses such

as depression and PTSD in most

existing studies.

Kirkwoo

d G

(2005)105

6

randomise

d and 2

nonrandom

Anxiety

disorders

including OCD,

anxiety

Yoga Meditation ,

placebo,

relaxation,

pseudo-yoga,

The reporting of study methodology was poor in

most of the studies, and there were also some

methodological inadequacies. The potential for bias

is therefore high. All eight studies reported positive

Owing to the diversity of

conditions treated and poor

quality of most of the studies, it

is not possible to say that yoga

62

ised

controlled

trials

neurosis,

psychoneurosis,

examine

anxiety, snake

phobia

anxiolytic and

antidepressant

drugs

results. is effective in treating anxiety

or anxiety disorders in general.

However, there are encouraging

results, particularly with

obsessive compulsive disorder.

Krisanap

rakornkit

T

(2006)106

2 RCTs Anxiety

disorders

Yoga plus

anti-anxiety

medicines

electromyography

-biofeedback and

relaxation

therapy,

Relaxation,

Mindfulness

Meditation,

anti-anxiety

medicines as

usual

In one study transcendental meditation showed a

reduction in anxiety symptoms and

electromyography score comparable with

electromyography-biofeedback and relaxation

therapy. Another study compared Kundalini Yoga

(KY), with Relaxation/Mindfulness Meditation.

The Yale-Brown Obsessive Compulsive Scale

showed no statistically significant difference

between groups.

The small number of studies

included in this review does not

permit any conclusions to be

drawn on the effectiveness of

meditation therapy for anxiety

disorders.

Meeks

TW

(2007) 24

33 RCTs Late-life

depression,

anxiety, and

sleep

disturbance

Various

complimentary and

alternative

medicines including

yoga, Tai chi,

Qigong, meditation,

single herbs,

Chinese herb

formulae,

acupuncture,

Placebo, wait list,

treat as usual,

sham

acupuncture/acupr

essure, western

medications



studies.








63

acupressure, etc

Mehta P

(2010)107

10 RCTs

and 8 other

studies

Individuals with

depressive

disorders or

elevated

depressive

symptoms

Yoga, alone or

combined with

antidepressants or

psychoeducation

Antidepressants,

usual care,

psychoeducation

alone or

combined with

group hypnosis,

supportive

therapy, or no

control

It was found that majority of the interventions were

able to significantly reduce depressive symptoms in

the patients under study.

Several methodological

limitations were identified in

the conduct of the intervention

trials, which future

interventions must consider.

Meyer

HB

(2012)

108

7 RCTs in

neurologic

al

disorders

and 13

RCTs in

mental

illnesses

Mood disorders,

schizophrenia,

PTSD

Yoga, alone or

combined with

antidepressants or

psychoeducation

Waitlist, exercise,

dialectic

behavioral

therapy,

psychoeducation,

antidepressants,

electroconvulsive

therapy

Of 13 randomized, controlled trials of yoga in

patients with psychiatric disorders, 10 found

significant, positive effects.

These results, although

encouraging, indicate that

additional randomized,

controlled studies are needed to

critically define the benefits of

yoga for both neurological and

psychiatric disorders.

Pilkingto

n K

(2005)

109

5 RCTs Depressive

disorders

Yoga Jacobson’s

progressive

relaxation,

modified ECT, no

treatment, partial

Yoga, wait list

It appears that yoga-based interventions may have

potentially beneficial effects on depressive

disorders.

Variation in the interventions

utilized and in the severity of

the depression reported was

encountered in the studies

located together with a lack of

details of trial methodology.

Consequently, the findings must

64

be interpreted with caution.

Posadzki

P (2014)

110

8 RCTs Alcohol, drug or

nicotine

addiction

Various types of

Yoga alone, or

combined with

cognitive

behavioral therapy

(CBT), or

combined with

methadone

CBT, waiting list,

usual care,

watching video,

methadone plus

psychotherapy,

exercise

Most of these RCTs were small with serious

methodological flaws. Seven RCTs suggested that

various types of yoga led to favourable results for

addictions compared to control. One RCT indicated

that methadone plus Yoga had no effect compared

with methadone plus psychotherapy.

Although the results of this

review are encouraging, large

RCTs are needed to better

determine the benefits of yoga

for addiction.

Ravindra

n AV

(2013)29

Not

reported

Mood and

anxiety

disorders

Physical therapies

including Yoga and

acupuncture; herbal

remedies;

Nutraceuticals

Placebo

alone/placebo

plus western

medicines/sham

acupuncture







disorder.

While several CAM therapies

show some evidence of benefit

as augmentation in depressive



disorders. The general dearth of

adequate safety and tolerability

data encourages caution in

clinical use.

Rosenba

um S

(2014)82

39 RCTs, 2

on Tai chi

and 1 on

Yoga

Mental illnesses Physical activity

intervention

including Tai chi

and Yoga

Usual care, social

support, wait list,

placebo, health

education

Meta-analysis revealed a large effect of physical

activity on depressive symptoms (SMD=0.80),

schizophrenia symptoms (SMD=1.0), a small effect

for anthropometry (SMD=0.24), and moderate

effects were found in aerobic capacity (SMD=0.63)

and quality of life (SMD=0.64).

Physical activity reduced

depressive symptom in people

with mental illness, reduced

symptoms of schizophrenia and

improved anthropometric

measures, aerobic capacity, and

quality of life among people

65

with mental illness.

Ross A

(2010)111

10 RCTs Healthy or

patients of

various

conditions

including

schizophrenia

Yoga Exercise The only RCT in schizophrenia patients showed

benefits of yoga in decreasing psychotic symptoms

than exercise.

The studies comparing the

effects of yoga and exercise

seem to indicate that, in both

healthy and diseased

populations, yoga may be as

effective as or better than

exercise at improving a variety

of health-related outcome

measures.

Sarris J

(2011)31



pharmacotherapies,

Tai chi, Yoga

Sham

acupuncture,

sleep hygiene

device, placebo,

health education,


western medicines







Future researchers are urged to

use acceptable methodology,

including appropriate sample

sizes and adequate controls.

Sarris J

(2012)32

14 RCTs Obsessive

compulsive

disorder,

trichotillomania

Nutrients, herbal

medicines,

acupuncture,

mindfulness

meditation, Yoga,

relaxation, alone or

as adjunct treatment

Placebo, western

medicines, wait

list, mindfulness

meditation,

decoupling

In OCD, tentative evidentiary support was found

for mindfulness meditation (d=0.63),

electroacupuncture (d=1.16), and kundalini yoga

(d=1.61). Better designed studies using the nutrient

glycine (d=1.10), and traditional herbal medicines

milk thistle (insufficient data for calculating d) and

borage (d=1.67) also revealed positive results. A

study showed that N-acetylcysteine (d=1.31) was

While several studies were

positive, these were

un-replicated and commonly

used small samples. This

precludes firm confidence in the

strength of clinical effect.

66

effective in TTM. Mixed evidence was found for

myo-inositol (mean d=0.98). St John's wort, EPA,

and meridiantapping are ineffective in treating

OCD.

Thachil

AF

(2007)37

7 SRs, 9

RCTs, and

3 others

Depressive

disorders

Herbs, nutritional

therapy,

acupuncture,

exercise, complex

homeopathy, yoga,

traditional Chinese

medicine

Placebo,

antidepressants,

psychotherapy





















Tsang

HWH

(2008)84

12 RCTs Individuals with

depressive

disorders or

elevated

depressive

symptoms

Exercise including

yoga, Qigong, and

Tai chi, alone or

combined with

antidepressants

Antidepressants,

usual care, wait

list, newspaper

reading, modified

ECT

The results based on 12 RCTs indicated that both

the mindful and nonmindful physical exercises

were effective in their short-term effect in reducing

depression levels or depressive symptoms.

However, most of studies had methodological

problems that only small sample size was used, and

the maintenance effects of physical exercise were

not reported.

We recommend that more

well-controlled studies have to

be conducted in the future to

address the short- and long-term

effects of physical exercise on

alleviating depression.

Uebelac

ker LA

7 RCTs

and 1

Individuals with

depressive

Yoga alone or

combined with

Progressive

relaxation, no

Although results from these trials are encouraging,

they should be viewed as very preliminary because

Yoga is a good candidate as a

possible innovative treatment

67

(2010)112

controlled

trial

disorders or

elevated

depressive

symptoms

antidepressants treatment,

psychoeducation,

ECT, wait list

the trials, as a group, suffered from substantial


for depression, but, given the

clear empirical support for other

depression treatments, we need

more rigorous research prior to

advocating for the routine use

of yoga as a treatment.

Vancam

pfort D

(2012)113

3 RCTs Schizophrenia Yoga plus

antipsychotics

Exercise or

waiting list, plus

antipsychotics

Lower Positive and Negative Syndrome Scale

(PANSS) scores were obtained after yoga compared

with exercise or waiting list control conditions.

HRQL increased more significantly after yoga than

after exercise or waiting list control conditions.

Yoga therapy can be an useful

add-on treatment to reduce

general psychopathology, and

positive and negative symptoms

and quality of life.

Wahbeh

H

(2014)39

17 RCTs

and 16

other

studies

Posttraumatic

stress disorder

(PTSD)

Complementary

medicine including

acupuncture,

meditation, yoga,

etc

Waitlist, CBT,

supportive

counseling,

medication,

psychotherapy,

massage, EMDR,

exposure, placebo

Scientific evidence of benefit for posttraumatic

stress disorder was strong for repetitive transcranial

magnetic stimulation and good for acupuncture,

hypnotherapy, meditation, and visualization.

Evidence was unclear or conflicting for

biofeedback, relaxation, Emotional Freedom and

Thought Field therapies, yoga, and natural

products.

Several complementary and

alternative medicine modalities

may be helpful for improving

posttraumatic stress disorder

symptoms. Future research

should include larger, properly

randomized, controlled trials

with appropriately selected

control groups and rigorous

methodology.

Wang D

(2014)87

22 RCTs Substance use

disorders

including

alcohol, drug

Physical exercise

including Tai chi,

Qigong, and Yoga

No exercise,

standard

treatment,

educational

The results indicated that physical exercise can

effectively increase the abstinence rate (OR = 1.69

(95% CI: 1.44, 1.99)), ease withdrawal symptoms

(SMD =21.24 (95% CI: 22.46, 20.02)), and reduce

The moderate and

high-intensity aerobic exercises,

designed according to the

Guidelines of American College

68

and nicotine meeting, no

intervention,

CBT, wellness

sessions, care as

usual, sham

Qigong

anxiety (SMD =20.31 (95% CI: 20.45, 20.16)) and

depression (SMD = 20.47 (95% CI: 20.80, 20.14)).

The physical exercise can more ease the depression

symptoms on alcohol and illicit drug abusers than

nicotine abusers, and more improve the abstinence

rate on illicit drug abusers than the others. Similar

treatment effects were found in three categories:

exercise intensity, types of exercise, and follow-up

periods.

of Sports Medicine, and the

mind-body exercises can be an

effective and persistent

treatment for those with SUD.

69

Supplement Table 8 Summary of Systematic Reviews on the Effect of One Category of TCAM Approach in Treating One Category of Mental Illness in India and China

TCM

approaches

Mental illnesses No.

of

SRs

Positive

results from

high quality

evidences

Positive results

from low

quality

evidences

Negative results

from high

quality

evidences

Negative results

from low

quality

evidences

Mixed results

from high

quality

evidences

Mixed results

from low

quality

evidences

Acupuncture

Dementia

and

cognitive

deficits

Alzheimer’s

disease17,38

2 1 1

Vascular dementia

19

1 1

Dementia 11

1 1

Mild cognitive

impairment 1

1 1

Subtotal 5 3 1 1

Acupuncture

Addiction Nicotine 2,7,42,43

5 1 2 1 1

Alcohol

dependence 4

1 1

Cocaine 5,9,25

3 2 1

Heroin 21,22,50

3 1 2

Subtotal 11 4 2 1 4

Acupuncture

Depressive

disorders

Perimenopausal

depression12

1 1

Post-stroke

depression

20,46,47,51,52

5 1 4

70

Depressive

neurosis45

1 1

Depressive

disorders

8,18,26,34,36,40,41,53,54

9 1 3 5

Subtotal 16 2 9 5

Acupuncture Insomnia 3,15

2 2

Acupuncture Schizophrenia 16,28,33

3 2 1

Acupuncture Anxiety disorders 23,27,49

3 3

Chinese herbs Depression55,58,59,67,69,70,72-75

10 1 8 1

Chinese herbs Dementia

and

cognitive

deficits

Alzheimer’s

disease61,71

2 2

Vascular

dementia57,64,66

3 3

Dementia56,62,76

3 2 1

Mild cognitive

impairment 63

1 1

Subtotal 9 8 1

Chinese herbs Schizophrenia 65

1 1

Chinese herbs Anxiety disorders68

1 1

Chinese herbs Heroin addiction60

1 1

Qigong and Tai

Chi

Depression 80,86

2 1 1

Qigong and Tai Cognitive impairment 91,92

2 1 1

71

Chi

Ayuveda

Medicine

Schizophrenia 93

1 1

Homeopathy Insomnia 94

1 1

Homeopathy Depression 96

1 1

Homeopathy Anxiety disorders97

1 1

Yoga Depression 102,107,109,112

4 4

Yoga Schizophrenia 103,113

2 1 1

Yoga Anxiety disorders105,106

2 1 1

Yoga Addiction 110

1 1

Total 80 3 50 1 6 1 19

Note: ‘Positive results’ was defined as consistent results across individual clinical trials or pooled estimates that showed at least one of the following results (based on the

authors’ conclusion): 1) equal or superior to a previously established treatment; 2) superior to placebo, waitlist control, or no treatment; 3) a combination of TCAM treatment

and an established treatment was better than the established treatment alone. ‘Mixed results’ was defined as inconsistent results across individuals clinical trials while no

pooled estimates was provided, or pooled estimates showed inconsistent findings on different outcome measures, different comparisons (i.e. superior to placebo but not as

good as an established treatment), or at different timepoints. ‘High quality’ was defined as all individual clinical trials that were analysed to reach the conclusion were of high

quality (i.e. Jadad score > 3).

*: One of the 79 studies conducted two comparisons, one based on all included RCTs regardless the quality and another based on high quality RCTs only. Therefore, 80

results based on 79 reviews were summarized.

72

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Supplementary appendix appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to