Comparative efficacy of acupuncture-related interventions for perimenopausal depression and anxiety: A systematic review and frequentist meta-analysis

BACKGROUND: This study aimed to compare the efficacy and safety of different acupuncture-related interventions for perimenopausal depression and anxiety using a frequentist network meta-analysis, in order to identify the most effective treatment strategies. METHOD: We systematically searched Chinese and international databases for randomized controlled trials evaluating the efficacy and safety of acupuncture for perimenopausal depression and anxiety. Studies were screened and selected based on predefined PICOS criteria. Two reviewers independently performed study selection, data extraction, risk-of-bias assessment, and evaluation of evidence certainty using the CINeMA tool. A frequentist network meta-analysis was conducted using Stata 17.0. Mean differences were used for continuous outcomes and risk ratios for binary outcomes. Heterogeneity and consistency were assessed, and Surface under the cumulative ranking curve (SUCRA) values were calculated to rank the comparative effectiveness of different acupuncture interventions. RESULT: A total of 54 randomized controlled trials were included, involving 4406 participants. The included studies were predominantly of moderate quality, with few at low or high risk of bias. According to the CINeMA assessment, the certainty of evidence for most pairwise comparisons was rated as low to moderate. Acupuncture-related interventions showed superior efficacy to Western medicine in improving clinical response rates, depressive and anxiety symptoms, menopausal complaints, and hormone levels. For clinical response, the most effective interventions were manual acupuncture (MA) + Chinese herbal medicine (CHM) (RR = 1.52, 95 % CI: 1.12-2.08) and electroacupuncture (EA) + CHM (RR = 1.49, 95 % CI: 1.05-2.12). Regarding depressive symptoms measured by the Hamilton Depression Scale (HAMD), EA + Western medicine (WM) (MD = -5.04, 95 % CI: -6.97 to -3.12) and MA + CHM (MD = -5.69, 95 % CI: -10.47 to -0.92) achieved the greatest reductions. For anxiety symptoms assessed by the Hamilton Anxiety Scale (HAMA), EA alone significantly reduced scores (MD = -8.40, 95 % CI: -14.31 to -2.49). On the Kupperman Index, MA + WM (MD = -5.37) and MA + CHM (MD = -5.00) were most effective. EA + WM also produced the largest improvement in Self-Rating Depression Scale (SDS) scores (MD = -9.10). Hormonally, MA + WM significantly increased estradiol (E2) levels (MD = 26.25), while both EA + WM and MA + CHM lowered follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels. SUCRA analysis indicated that EA + WM and MA + CHM consistently ranked among the top treatments across most outcomes. CONCLUSION: EA + WM and MA + CHM may be among the most effective acupuncture-based interventions for perimenopausal depression and anxiety. However, given the moderate quality of evidence, further high-quality trials are needed to confirm these findings.