The study design
This clinical trial was designed as a randomized, single-blind study with sham-acupuncture serving as the control. The trial protocol has received approval from the Medical Ethics Committee of the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine under the reference number 2023KL-077. Additionally, it has been registered with the China Clinical Trial Registration Center (https://www.chictr.org.cn/), bearing the registration number ChiCTR2300076292. This study was carried out in strict adherence to the principles outlined in the Declaration of Helsinki and Good Clinical Practice Guidelines. The enrolment will start on February 2024. The research will be carried out at the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine. The reporting for this protocol will strictly follow the Standard Protocol Recommendations for Interventional Trials (SPIRIT) (table S1).
Randomization and blinding
In this study, two sets of random numbers were generated using R language software in a 1:1 ratio. These sets of numbers were then placed in opaque envelopes, and individuals who were not involved in the experiment retained these envelopes. Patients selected an envelope at random based on their order of visit to determine their group assignment. Given the unique nature of acupuncture therapy, this trial was designed as a single-blind trial. In this study, the operator, assessor, and statistician roles are kept separate. Patients are separated by curtains during the treatment to prevent any interaction between them.
Patients
Participants for this trial will be recruited from two sources: the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine and the Chengdu community. Recruitment will be carried out through the design of advertisements, which will be disseminated both online and offline using platforms like WeChat, websites, and others. The eligibility of potential participants will be evaluated by psychiatric experts, applying rigorous inclusion and exclusion criteria. Individuals who meet the inclusion criteria and choose to participate voluntarily will be required to sign a written informed consent form before the study commences. This informed consent process ensures that participants are fully aware of the trial's objectives, procedures, and potential risks, and that they have freely chosen to take part in the study.
Application selection
The acupuncture needles used in this study are sourced from Huatuo, a brand known for disposable acupuncture needles produced by Suzhou Medical Supplies Factory in China. The manufacturer holds the following credentials: Manufacturer's License Number: Su Food and Drug Administration of Machinery Production 20010020. Registration Certificate Number: 201622770970. The acupuncture needles have the following specifications: 0.30 mm in diameter and are available in lengths of 25 mm and 40 mm. Streitberger needle is chosen for sham acupuncture.
Intervention
The acupuncture group will receive verum acupuncture and antidepressant medication treatment, while the sham acupuncture group will receive sham acupuncture and antidepressant medication treatment.
Verum acupuncture
Based on previous clinical experience, the selected acupuncture points for this experiment include: Zhongwan (CV12), Guanyuan (CV4), Neiguan (PC6), Zusanli (ST36), Sanyinjiao (SP6). The location of these acupuncture points will be in accordance with the standards outlined in the 2010 World Health Organization guidelines (ISBN: 9787117123327), with specific details provided in the accompanying Fig. 1 and Table 1.
Table 1
Acupoints | Location |
Zhongwan (CV12) | On the midline of the abdomen, approximately 4 cun (Chinese inches) above the umbilicus, or at the midpoint between the umbilicus and the xiphoid process of the sternum. |
Guanyuan (CV4) | On the midline of the abdomen, approximately 3 cun (Chinese inches) below the umbilicus. |
Neiguan (PC6) | In the middle of the anterior forearm, 2 cun (Chinese inches) above the wrist crease, between the tendons of the flexor carpi radialis and palmaris longus muscles. |
Zusanli (ST36) | Three cun (Chinese inches) below the lateral eye of the knee, at a point one horizontal finger's width from the outer edge of the anterior tibial crest. |
Sanyinjiao (SP6) | Located on the inner side of the lower leg, 3 cun (Chinese inches) above the tip of the medial malleolus, just behind the posterior border of the tibia. |
Each patient will undergo an 8-week acupuncture treatment regimen, receiving acupuncture three times per week, with each session lasting 30 minutes. Prior to the commencement of treatment, all subjects are required to assume a supine position on the treatment bed, and the designated acupuncture points will be disinfected using 75% alcohol. Plastic discs are secured to the treatment area, and acupuncture needles are inserted through the plastic discs to penetrate the skin.
Sham acupuncture
The design of sham acupuncture is intended for placebo control. The procedure for sham acupuncture is essentially the same as for verum acupuncture, with the only difference being the use of blunt-tipped needles for sham acupuncture, while sharp-tipped needles are used for verum acupuncture. This ensures that during sham acupuncture, the blunt-tipped needles simulate the sensation of verum acupuncture without piercing the skin.
Antidepressant medication
Flupentixol and melitracen tablets (flupentixol 0.5mg and melitracen 10mg pet tablet; H. Lundbeck A/S; Imported Drug License No. H20130126) are used. One tablet each morning for 8 weeks.
Functional near-infrared spectroscopy
Prior to measurement, the subjects will be instructed to sit in a comfortable chair and rest for a 5-minute duration to attain a calm state. Subsequently, they will be equipped with an elastic headband featuring 8 emitters and 7 detectors for data collection. The positions of these emitters and detectors are depicted in the Fig. 2. There are 20 channels, and the wavelengths utilized are 760 and 850 nm, with a sampling rate of 7.5 Hz. Following 8 minutes of data collection during a resting state, the subjects will undergo data collection while engaged in a language fluency test task. This task comprises a 30-second pre-task period, a 60-second task period, and a 60-second post-task period. During the pre-task and post-task periods, subjects are required to remain relaxed while avoiding falling asleep. In contrast, the task period necessitates that subjects articulate as many words as possible related to the assigned topic. To ensure the precision and consistency of observed brain areas across multiple measurements, a three-dimensional digitizer will be used to determine the three-dimensional coordinate information of the optical electrodes and channels. This methodology guarantees accurate and reliable localization of the observed brain regions.
fNIRS data processing
The data collected through fNIRS will be processed and analyzed using NIRS-KIT and NIRS-SPM, both of which are based on MATLAB. This study primarily focuses on the analysis of the collected oxygenated hemoglobin signal. To ensure data quality and reliability, the collected fNIRS data will undergo several preprocessing steps. The initial step involves data correction to address any inconsistencies or errors. Data with an excessive amount of missing information will be excluded from the analysis. Motion artifacts are corrected using the NIRS-SPM toolkit. This process is vital for eliminating disturbances in the data caused by subject movement. To remove physiological components and noise from the signal, a band-pass filter is applied. This filtering step enhances the signal's quality and makes it more suitable for subsequent analysis. These preprocessing steps are essential to ensure that the fNIRS data is of high quality and suitable for the analysis of oxygenated hemoglobin signals.
Inclusion criteria
Products that fulfill all of the following conditions will be eligible for inclusion in the study:
(1) Meet the diagnostic criteria for major depression according to the "Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition," (DSM-Ⅴ) and the "Diagnostic Efficacy Criteria for Traditional Chinese Medicine Syndrome - Depression."
(2) Fall within the age range of 18 to 65 years, regardless of gender.
(3) Exhibit a SDS score between 53 and 72 points and a SAS score less than 69 points.
(4) Have not undergone acupuncture treatment in the past month.
(5) Provide their informed consent and participate in the study on a voluntary basis.
Meeting these criteria ensures that the participants share the relevant characteristics required for the study and are suitable for assessing the effects of acupuncture treatment on depressive disorders.
Excluded criteria
Patients will be excluded from the study if they meet any of the following criteria:
(1) History of alcohol or drug abuse.
(2) Pregnant or lactating women.
(3) Individuals with severe underlying primary diseases affecting the cardiovascular, respiratory, hepatic, renal, or hematopoietic systems.
(4) Patients diagnosed with organic mental disorders or mood disorders caused by psychoactive substances or non-addictive substances, accompanied by severe impairment in social functioning.
(5) Individuals with severe skin infections at acupuncture points or other serious conditions, such as progressive malignant tumors or wasting diseases, which make them susceptible to infection and bleeding.
These exclusion criteria aim to ensure that the study population is free from factors that might confound the evaluation of acupuncture's impact on depressive disorders and minimize potential risks to participants.
Outcomes
All the outcomes measured and their corresponding assessment times involved in this study are presented in the Table 2. The research process is shown in Fig. 3.
Table 2
Study schedule for data measurements
Time point | Baseline period | After treatment |
0 week | 8 weeks | 12 weeks | 16 weeks | 20 weeks |
Enrolment | | | | | |
Eligibility screen | √ | | | | |
Sign informed consent | √ | | | | |
Inclusion/exclusion criteria | √ | | | | |
Physical examination | √ | | | | |
Randomisation | √ | | | | |
Assessments | | | | | |
SDS | √ | √ | √ | √ | √ |
SAS | √ | √ | √ | √ | √ |
SF-36 | √ | √ | √ | √ | √ |
TCM syndrome score table | √ | √ | √ | √ | √ |
Symptom elimination rate | √ | √ | √ | √ | √ |
fNIRS | √ | √ | | | |
Participants safety | | | | | |
Adverse events | | √ | | | |
Primary outcome
The study measured SDS scores before treatment and at 0, 4, 8, and 12 weeks after treatment in both groups. The purpose was to compare whether there is a statistically significant difference in SDS scores between the two groups of subjects after treatment. SDS is a widely used psychological assessment tool primarily designed to evaluate the severity of an individual's depressive symptoms and to track changes in those symptoms throughout the course of treatment. This scale is known for its simplicity and ability to intuitively reflect the subjective feelings of patients with depressive disorders, making it valuable in assessing treatment outcomes and changes in symptom severity over time. The statistical analysis of SDS scores before and after treatment in both groups will help determine the efficacy of the treatment, whether it's acupuncture or sham acupuncture, in alleviating depressive symptoms. This type of analysis is essential in evaluating the impact of the treatment intervention and assessing the overall success of the study.
Secondary outcomes
The study involved the assessment of subjects' SAS, SF-36, TCM syndrome score scale, and symptom elimination rate both before treatment and at 0, 4, 8, and 12 weeks after treatment. Each of these measures serves a specific purpose in assessing the subjects' well-being. SAS is primarily used to evaluate the severity of the subjects' anxiety symptoms and to track any changes in anxiety levels throughout the treatment process. SF-36 offers a comprehensive evaluation of the subjects' physical, psychological, and social aspects of life, considering both objective physiological indicators and the subjective feelings of the subjects. TCM Syndrome Score Scale is a common tool in Traditional Chinese Medicine clinical research, providing insight into the subjects' TCM syndrome manifestations and monitoring any improvements in these manifestations. Symptom Elimination Rate intuitively reflects the relief of discomforting symptoms experienced by the subjects, giving a quantitative measure of symptom improvement and reflecting the overall effectiveness of acupuncture therapy from a patient-centered perspective.
The collected fNIRS data before and after treatment will be used to analyze the function of the subjects' relevant cerebral cortex. By calculating the differentially activated brain areas within each group and comparing these areas before and after treatment, as well as between the two groups, the study aims to clarify the impact of acupuncture on the brain function of patients with depression. Additionally, correlation analysis will be used to explore whether there is mutual influence between different brain regions, providing a deeper understanding of the brain's response to acupuncture therapy in patients with depression. This comprehensive approach allows for a thorough assessment of the treatment's effects on both psychological and physiological aspects, shedding light on the holistic benefits of acupuncture in treating depressive disorders.
Adverse events reporting and safety monitoring
Throughout the study period, participants may encounter adverse reactions such as dizziness, vomiting, rash, and other symptoms. These reactions will be promptly addressed and treated appropriately. Furthermore, all adverse events (AEs) will be carefully documented in the Case Report Form (CRF) and reported to both the study leader and the Ethics Committee of the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine. To assess the differences in adverse events between different groups, a statistical analysis will be conducted using the Chi-square test or Fisher's exact test. This analysis will help determine whether there are significant variations in the occurrence of adverse reactions between the treatment and control groups, providing valuable insights into the safety of the interventions.
Sample-size calculation
Based on previous research, the Self-Rating Depression Scale (SDS) scores in the sham acupuncture group before and after treatment were 64.03 ± 2.64 and 54.93 ± 4.93, respectively[25]. It is anticipated that the difference in SDS scores before and after treatment in the acupuncture group in this experiment will be 3 points greater than that in the sham acupuncture group.
$$n=\frac{{\left({u}_{\alpha }+{u}_{\beta }\right)}^{2}\left(1+\frac{1}{k}\right){\sigma }^{2}}{{\delta }^{2}}$$
Sample size estimation for comparing two independent groups is based on a significance level (α) of 0.05 (two-sided) and a test power (1-β) of 0.9. To account for a potential dropout rate of 20%, a minimum of 59 patients in each group is required. This allocation ensures that both groups have sufficient statistical power to detect the expected differences in SDS scores.
Data analysis
For the data analysis in this study, SPSS 22.0 software was used. Here is a summary of the statistical methods employed. Continuous variables are represented using means and standard deviations (M ± SD) or medians with interquartile ranges, while categorical variables are expressed as proportions or composition ratios. A p-value (p) less than 0.05 was considered indicative of a statistically significant difference. To compare differences in age, years of education, treatment outcomes, and relative oxyhemoglobin concentration in each region between the two groups of patients, the appropriate test was selected based on whether the data conformed to normal distribution and homogeneity of variances. Independent sample T-tests were used for normally distributed data, and the independent sample Mann-Whitney U test was applied for data that did not meet the normality and homogeneity criteria. Differences in gender distribution were analyzed using the chi-square test. Efficacy-related outcome (SDS, SAS, SF-36, TCM syndrome score scale, and symptom elimination rate) measures involve repeated measurements across different time points in the trial. Paired-sample t-tests were employed to compare the effects between baseline and other time points. Independent-sample t-tests were used to compare differences between the two groups. For fNIRS data, paired-samples t-tests were used to compare the differences in relative oxyhemoglobin concentration in each region before and after treatment in the depression group. Spearman correlation analysis was employed for intra-group correlation analysis in the depression group. This analysis focused on assessing the correlation between the relative oxyhemoglobin concentration in each region and clinical variables. These statistical methods were applied to evaluate and interpret the data collected in the study and draw meaningful conclusions.
For missing data in the primary outcome, the multiple imputation method will be employed assuming that the data is missing at random (MAR). This will generate imputed missing datasets for the SDS. To evaluate the robustness of the primary analyses, sensitivity analyses will be conducted using a tipping-point approach with specified shift and scale parameters.
Data management and confidentiality
The CRF for each participant is promptly filled out and then collated and input into the computer by personnel not involved in the treatment. Data collectors are responsible for the storage, management, and verification of experimental data. All personal information of the participants, such as names, phone numbers, and addresses, will be kept anonymous to prevent any disclosure. Data for all participants will be securely stored by the researchers in a special cabinet and will be retained for at least five years following publication in a medical journal. The Ethics Committee of the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine will periodically review the progress of the trial. The Data Monitoring Committee operates independently from the sponsors and has no conflicts of interest.