Acupuncture and moxibustion for malignant tumor patients with psychological symptoms of insomnia, anxiety and depression: a systematic review and Meta-analysis

doi:10.19852/j.cnki.jtcm.20230313.001

Abstract

Abstract:

OBJECTIVE: To evaluate the efficacy and safety of acupuncture and moxibustion therapy (AMT) for cancer-related psychological symptoms (CRPS) of insomnia, depression and anxiety.

METHODS: Seven databases were searched for randomized controlled trials (RCT) comparing AMT to routine care or conventional drug for alleviating CRPS of insomnia, depression, and anxiety before April 2020. Two independent reviewers performed the data extraction and assessed the risk of bias.

RESULTS: A total of 30 RCTs involving 2483 cancer patients were enrolled. The pooled analysis indicated that the treatment group was significantly better than the control group in improving the depression effective rate [RR= 1.29, 95% CI(1.12, 1.49), P =0.0004], the quality of life (QOL) [MD =1.11, 95% CI(0.80, 1.42), P < 0.000 01], and reducing Self-rating Anxiety Scale (SAS) [MD =﹣7.75, 95% CI(﹣10.44, ﹣5.05), P < 0.000 01]. But there was no statistically significant difference between two groups in improving the insomnia effective rate [RR= 1.18, 95% CI(0.93, 1.51), P =0.18]. The subgroup analysis showed the effectiveness of different intervention on CRPS. Compared with routine care, AMT helps relieve CRPS better evaluated by Pittsburgh Sleep Quality Index (PSQI), Hamilton Depression Scale (HAMD), and Self-rating Depression Scale (SDS), and depression effective rate. Compared with conventional drug, AMT performs better evaluated by SDS, depression effective rate and QOL. Moreover, the conventional drug showed higher treatment efficacy on improving insomnia effective rate compared with AMT. Compared to conventional drug, AMT plus conventional drug resulted in a significant reduction on CRPS such as PSQI, HAMD, SDS, and SAS, and also had a meaningful improvement on insomnia effective rate, depression effective rate and QOL. Fewer published reports were found on the adverse events of AMT than the conventional drug.

CONCLUSION: The results suggested that AMT might be effective in improving CPRI; however, a definite conclusion could not be drawn because the quality of trials are low. Further large-scale and high-quality RCTs to verify the efficacy and safety of AMT on CRPS are still warranted.

Key words: acupuncture, moxibustion, neoplasms, sleep initiation and maintenance disorders, depression, anxiety, review

MA Fangfang, ZHANG Hewei, LI Bingxue, CHENG Peiyu, YU Mingwei, WANG Xiaomin. Acupuncture and moxibustion for malignant tumor patients with psychological symptoms of insomnia, anxiety and depression: a systematic review and Meta-analysis[J]. Journal of Traditional Chinese Medicine, 2023, 43(3): 441-456.

Figures/Tables 6

References 80

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Study		Sample size (T/C)		Age year (T/C)		Gender (Male /Female)						Disease diagnosis					Control						Intervention			Main treated acupoints and treatment frequency			Course		Outcome measure
Chen YH et al 2013³³		30/30		T: 38-83 C: 24-82		T: 18/12 C: 20/10						Gastric cancer +anxiety and depression					Routine care						Moxibustion+C			MT: Zusanli (ST36), Xuehai (SP10), Sanyinjiao (SP6) and Zhongwan (CV12). 1 time per day for 30 min			2 w		SDS, SAS
Chen J 2018³⁴		18/18		T: 66.43±5.43 C: 65.13±5.98		T: 10/8 C: 9/9						Tumor+depression					Paroxetine 20-60 mg/d+anti-tumor therapy						Acupuncture +moxibustion+c			AT: Neiguan (PC6), Shenmen (TF4), Yifeng (SJ17), Baihui (GV20), Sishencong (EX-HN1), Hegu (LI4) and Taichong (LR3). 1 time per day for 30 min MT: Guanyun (CV4) and Zusanli (ST36). 1 time per day for 30 min			6 w		HAMD, depression efficiency
Dan ZJ 2013³⁵		27/28		T: 52.222±7.153 C: 51.296±6.866		T: 14/13 C: 16/12						Tumor+insomnia					Estazolam 1mg/d						Acupuncture +boxed moxibustion			AT: Baihui (GV 20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day for 30 min MT: Shenque (CV8) and Guanyun (CV4). 1 time per day for 30 min			7 d		Sleep efficiency, PSQI
Deng XY et al 2018³⁶		30/30		T: 48.93±4.03 C: 50.13±4.09		T: 12/18 C: 16/14						Tumor+depression					Sertraline 10 mg/d+ anti-tumor therapy						Acupuncture+Electric acupuncture			AT: Yinlingquan (SP9), Fenglong (ST40), Hegu (LI4), Neiguan (PC6), Taichong (LR3), Sanyinjiao (SP6), Yintang (EX-HN3) and Baihui (GV 20). 2 times per week for 30 min EA: Yinlingquan (SP9) and Fenglong (ST40). 2 times per week for 30 min			4 w		HAMD, QLQ-C30
Deng XY et al 2019³⁷		30/30		T: 53±9 C: 49±11		T: 11/19 C: 10/20						Tumor+depression					Sertraline 50 mg/d						Acupuncture+C			AT: Hegu (LI4), Taichong (LR3), Neiguan (PC6), Shenmen (TF4), Zusanli (ST36), Sanyinjiao (SP6), Yintang (EX-HN3) and Baihui (GV 20). 2 times per weekfor 30 min			4 w		HAMD, QLQ-C30
Feng Y et al 2011³⁸		40/40		T: 63.80±5.47 C: 63.60±4.26		T: 26/14 C: 27/13						Malignant neoplasms+insomnia and depression					Fluoxetine 20 mg/d						Acupuncture+C			AT: Fenglong (ST40), Yinlingquan (SP9), Xuehai (SP10), Sanyinjiao (SP6), Yintang (EX-HN3), Baihui (GV 20), Sishencong (EX-HN1), Neiguan (PC6) and Shenmen (TF4). 1 time per day for 20-30 min			30 d		SDS, HAMD, depression efficiency, PSQI
Feng XT et al 2019³⁹		70/70		35-78 (61.51±6.24)		61/79						Liver cancer+anxiety and depression					Paroxetine 20 mg/d						Acupuncture +chinese herb+c			AT: the acupoints of liver meridian and heart meridian, Shenmen (TF4), Danzhong (CV 17), Taichong (LR3), Qimen (LR14) and Xingjian (LR2). 5 times per weekfor 30 min			8 w		SDS, SAS
Liao LL 2019⁴⁰		35/34		T: 63.63±16.30 C: 63.18±15.04		T: 14/21 C: 13/21						Tumor+insomnia					Routine care						Intradermal needling +moxibustion			IN: Yintang (EX-HN3) and Shenmen (TF4). 2~3 times per week; 3~4 times per day (acupressing 1~2 min per point) MT: Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day (5 min per point)			2 w		PSQI
Liu YL 2017⁴¹		30/30		T: 51.63±9.14 C: 54.63±9.89		T: 10/20 C: 12/18						Tumor+depression					Routine care						Thermal moxibustion			MT: Baihui (GV 20), Shenmen (TF4), Neiguan (PC6), Taichong (LR3) and Ganshu (BL18). 1 time per day (20 min per point)			21 d		HAMD, depression efficiency
Liu XF et al 2019⁴²			40/40		T: 46.37±14.53 C: 49.32±13.22	Female					Breast cancer+anxiety and depression					Diosmin tablets 2.7 g/d						Needle warming moxibustion				Jianyu (LI15), Waiguan (SJ5), Yinlingquan (SP9), Quchi (LI11), Shuifen (IN9) and Zusanli (ST36). 1 time per 2 days for 30 min			28 d		SDS, SAS, QLQ-C30
Liu YP et al 2019⁴³			40/40		T: 63±13 C: 63±12	T: 24/16 C: 20/20					Tumor+depression					Escitalopram 10 -20 mg/d						Acupuncture+C				AT: Taichong (LR3), Hegu (LI4), Baihui (GV 20) and Yintang (EX-HN3). 5 times per week for 30 min			12 w		HAMD
Mo ZY et al 2017⁴⁴			58/60		T: 48.22±10.28 C: 48.60±11.02	Female					Breast cancer+anxiety and depression					Routine care						Ginger moxi-bustionwithbox				MT: Hegu (LI4), Zusanli (ST36), Taichong (LR3) and Yongquan (KI1). 2 times per day for 30 min			7 d		SDS, SAS
Pei Y et al 2010⁴⁵			31/36		T: 51.76±10.21 C: 48.34±8.79	Female					Breast cancer+anxiety and depression					Citalopram 20 mg/d						Acupuncture				AT: Feishu (BL13), Xinshu (BL15), Geshu (BL17), Ganshu (BL18), Pishu (BL20) and Shenshu (BL23). 5 times per week for 30 min			6 w		SDS, SAS, HAMD
Peng XH et al 2017⁴⁶			93/97		T: 59.36±12.54 C: 60.95±11.11	T: 68/36 C: 68/36					Tumor+insomnia					Estazolam 1 mg/d						Acupuncture +moxibustion				AT: Baihui (GV 20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day for 30 min MT: Shenque (CV8) and Guanyun (CV4). 1 time per day for 30 min			7 d		Sleep efficiency
Shen LP et al 2016⁴⁷			50/50		T: 54. 93±14.45 C: 58. 09±12.11	T: 28/22 C: 31/19					Lung cancer+insomnia					Zolpidem 10 mg/d+ Paroxetine 20 mg/d (if needed)						Acupuncture+Electric acupuncture+C				AT: Zhaohai (KI6), Shenmai (BL62), Shenmen (TF4), Yintang (EX-HN3), Sishencong (EX-HN1), Anmian(Extra 8), Hegu (LI4), Taichong (LR3), Zusanli (ST36), Qihai (CV6) and Quchi (LI11). 1 time per day for 30 min EA: Shenmen (TF4), Anmian(Extra 8), Sishencong (EX-HN1), Hegu (LI4), Taichong (LR3), Zusanli (ST36), Qihai (CV6) and Quchi (LI11). 1 time per day for 30 min			4 w		SDS, SAS, PSQI
Shi Y et al 2014⁴⁸			40/40		NR	NR					Tumor+insomnia					Diazepam 5 mg/d						Scalp-acupuncture				AT: Baihui (GV 20), Sishencong (EX-HN1). 1 time per day for 60 min SA: Ezhongxian (MS2~3). 1 time per day for 60 min			7 d		PSQI
Song JR et al 2015⁴⁹			60/60		NR	NR					Tumor+insomnia					Estazolam 1 mg/d						Acupuncture boxed moxibustion				AT: Baihui (GV20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day for 30 min MT: Shenque (CV8) and Guanyun (CV4). 1 time per day for 30 min			7 d		Sleep efficiency, PSQI
Liu XF et al 2019⁴²			40/40		T: 46.37±14.53 C: 49.32±13.22			Female		Breast cancer+anxiety and depression					Diosmin tablets 2.7 g/d					Needle warming moxibustion					Jianyu (LI15), Waiguan (SJ5), Yinlingquan (SP9), Quchi (LI11), Shuifen (IN9) and Zusanli (ST36). 1 time per 2 days for 30 min			28 d		SDS, SAS, QLQ-C30
Liu YP et al 2019⁴³			40/40		T: 63±13 C: 63±12			T: 24/16 C: 20/20		Tumor+depression					Escitalopram 10-20 mg/d					Acupuncture+C					AT: Taichong (LR3), Hegu (LI4), Baihui (GV 20) and Yintang (EX-HN3). 5 times per week for 30 min			12 w		HAMD
Mo ZY et al 2017⁴⁴	58/60				T: 48.22±10.28 C: 48.60±11.02		Female		Breast cancer+ anxiety and depression					Routine care							Ginger moxi-bustionwithbox			MT: Hegu (LI4), Zusanli (ST36), Taichong (LR3) and Yongquan (KI1). 2 times per day for 30 min			7 d			SDS, SAS
Pei Y et al 2010⁴⁵	31/36				T: 51.76±10.21 C: 48.34±8.79		Female		Breast cancer+anxiety and depression					Citalopram 20 mg/d							Acupuncture			AT: Feishu (BL13), Xinshu (BL15), Geshu (BL17), Ganshu (BL18), Pishu (BL20) and Shenshu (BL23). 5 times per week for 30 min			6 w			SDS, SAS, HAMD
Peng XH et al 2017⁴⁶	93/97				T: 59.36±12.54 C: 60.95±11.11		T: 68/36 C: 68/36		tumor+insomnia					Estazolam 1 mg/d							Acupuncture +moxibustion			AT: Baihui (GV 20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day for 30 min MT: Shenque (CV8) and Guanyun (CV4). 1 time per day for 30 min			7 d			Sleep efficiency
Shen LP et al 2016⁴⁷	50/50				T: 54. 93±14.45 C: 58. 09±12.11		T: 28/22 C: 31/19		Lung cancer+insomnia					Zolpidem 10 mg/d+ Paroxetine 20 mg/d (if needed)							Acupuncture+Electric acupuncture+C			AT: Zhaohai (KI6), Shenmai (BL62), Shenmen (TF4), Yintang (EX-HN3), Sishencong (EX-HN1), Anmian(Extra 8), Hegu (LI4), Taichong (LR3), Zusanli (ST36), Qihai (CV6) and Quchi (LI11). 1 time per day for 30 min EA: Shenmen (TF4), Anmian(Extra 8), Sishencong (EX-HN1), Hegu (LI4), Taichong (LR3), Zusanli (ST36), Qihai (CV6) and Quchi (LI11). 1 time per day for 30min			4 w			SDS, SAS, PSQI
Shi Y et al 2014⁴⁸	40/40				NR		NR		Tumor+insomnia					Diazepam 5 mg/d							Scalp-acupuncture			AT: Baihui (GV 20), Sishencong (EX-HN1). 1 time per day for 60 min SA: Ezhongxian (MS2-3). 1 time per day for 60 min			7 d			PSQI
Song JR et al 2015⁴⁹	60/60				NR		NR		Tumor+insomnia					Estazolam 1 mg/d							Acupuncture boxed moxibustion			AT: Baihui (GV20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day for 30 min MT: Shenque (CV8) and Guanyun (CV4). 1 time per day for 30 min			7 d			Sleep efficiency, PSQI
Wang Y 2015⁵⁰	40/40				NR		Female		Breast cancer+anxiety and depression					Routine care							Five-element acupuncture+ wheat grain moxibustion			The acupoints according to five-element acupuncture therapy. 1 time per week			6 w			SDS, SAS
Wang BN et al 2019⁵¹	40/40				T: 52.47±9.62 C: 50.16±7.34		Female		Breast cancer+insomnia					Routine care							Intradermal needling			IN: Shenmen (TF4), Sanyinjiao (SP6), Anmian (Extra 8), Zusanli (ST36) and Taibai (SP3). 5 times per week; 3 times per day (acupressing 1 min per point)			4 w			PSQI
Wang WG et al 2020⁵²	40/40				T: 39.52±8.35 C: 39.36±9.27		T: 24/16 C: 22/18		Brain tumor+ Depression							Routine care			Acupuncture					AT: Neiguan (PC6), Renzhong (GV26), Sanyinjiao (SP6), Chize (LU5), Jiquan (HT1), Fengchi (GB20), Weizhong (BL40), Tianzhu (BL10) and Wangu (BL12). 2 time per day for 30 min			4 w			SDS, SAS
Wei S 2019⁵³			33/33		49.21±6.32		Female						Gynecological malignant tumor+insomnia					Alprazolam 0.4 mg/d	Thunder-fire moxibustion+C					MT: Shenmen (TF4), Neiguan (PC6), Sanyinjiao (SP6)，Xinshu (BL15), Pishu (BL20), Zusanli (ST36), Danshu (BL19) and Qiuxu (GB40). 1 time per day for 30 min			2 w			PSQI, Sleep efficiency, QLQ-C30
Xia Q et al 2017⁵⁴			23/23		NR		18/28						Tumor+depression					fluoxetine 20 mg/d	Scalp-acupuncture					SA: Dingzhongxian (MS5), Ezhongxian (MS1), Epangxian(MS2~ MS4), Nieqianxian (MS10), Niehouxian (MS11). 6 times per week for 30 min			4 w			HAMD, SDS, depression efficiency
Xia WM et al 2019⁵⁵			37/37		T: 47.6±8.2 C: 46.2±7.5		T: 10/27 C: 13/24						Thyroid cancer+ insomnia, anxiety and depression					Routine care	Moxibustion					MT: Baihui (GV 20). 1 time per day for 20 min			7 d			SDS, SAS, PSQI
Zeng XL 2015⁵⁶			29/28		T: 60.28±10.22 C: 61.71±11.58		T: 12/17 C: 13/15						Tumor+depression					Sertraline 50 mg/d	Acupuncture +moxibustion					AT: Neiguan (PC6), Shenmen (TF4), Laogong (PC8), The Stabilizing Four-Shen points and the Four-Shen pointsof Jin's Three-needle Therapy. 1 time per day for 60 min. MT: 1 time per 2 days for 20 min.			4 w			HAMD, SDS, QLQ-C30
Zhang YT 2017⁵⁷			35/34		T: 64.06±9.155 C: 64.46±10.947		T: 18/17 C: 14/20						Tumor+insomnia					Routine care+Estazolam 1 mg/d (if needed)	Thermal moxibustion+C					MT: Shenque (CV8), Xinshu (BL15), Pishu (BL20), Shenmen (TF4) and Sanyinjiao (SP6). 1 time per day (20 min per point)			7 d			PSQI
Zhang CH et al 2017⁵⁸			32/32		T: 56.9±5.7 C: 56.8±6.1		T: 13/19 C: 14/18						Tumor+depression					Amitriptyline 50-150 mg/d	Acupuncture +chinese herb+c					AT: Zusanli (ST36), Sanyinjiao (SP6), Feishu (BL13) and Yinlingquan (SP9). 3 times per week for 30 min			6 w			HAMD, depression efficiency
Zhang YL et al 2017⁵⁹			31/31		18-65 (53.55±11.60)		38/24						Colorectal cancer+anxiety and depression					Loperamide 4 mg/d	Needle warming moxibustion					Guanyun (CV4), Shenque (CV8), Tianshu (ST25) and Zusanli (ST36). 1 time per day (10 min per point)			7 d			SDS, SAS
Zhang B 2017⁶⁰			30/30		T: 59.8±4.3 C: 58.4±5.2		T: 13/17 C: 15/15						Tumor+depression					Chinese herb	Five-element acupuncture+C					The acupoints according to five-element acupuncture therapy. 1 time per week			6 w			HAMD
Zhao YL 2015⁶¹			93/97		T: 59.36±12.541 C: 60.95±11.112		T: 60/33 C: 66/31						Tumor+insomnia					Estazolam 1 mg/d	Acupuncture+moxibustion					AT: Baihui (GV 20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day for 30 min MT: Shenque (CV8) and Guanyun (CV4). 1 time per day for 30 min			7 d			Sleep efficiency, PSQI
Zhu JJ et al 2017⁶²			50/50		T: 63.38±8.34 C: 62.78±7.85		T: 37/13 C: 38/12						Liver cancer+depression					Escitalopram 10 mg/d	Cake-separated moxibustion +Chinese herb					MT: Fengfu (GV16), Geshu (BL17) and Danshu (BL19). 1 time per day for 30 min			6 w			HAMD, depression efficiency

Study		Sample size (T/C)		Age year (T/C)		Gender (Male /Female)						Disease diagnosis					Control						Intervention			Main treated acupoints and treatment frequency			Course		Outcome measure
Chen YH et al 2013³³		30/30		T: 38-83 C: 24-82		T: 18/12 C: 20/10						Gastric cancer +anxiety and depression					Routine care						Moxibustion+C			MT: Zusanli (ST36), Xuehai (SP10), Sanyinjiao (SP6) and Zhongwan (CV12). 1 time per day for 30 min			2 w		SDS, SAS
Chen J 2018³⁴		18/18		T: 66.43±5.43 C: 65.13±5.98		T: 10/8 C: 9/9						Tumor+depression					Paroxetine 20-60 mg/d+anti-tumor therapy						Acupuncture +moxibustion+c			AT: Neiguan (PC6), Shenmen (TF4), Yifeng (SJ17), Baihui (GV20), Sishencong (EX-HN1), Hegu (LI4) and Taichong (LR3). 1 time per day for 30 min MT: Guanyun (CV4) and Zusanli (ST36). 1 time per day for 30 min			6 w		HAMD, depression efficiency
Dan ZJ 2013³⁵		27/28		T: 52.222±7.153 C: 51.296±6.866		T: 14/13 C: 16/12						Tumor+insomnia					Estazolam 1mg/d						Acupuncture +boxed moxibustion			AT: Baihui (GV 20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day for 30 min MT: Shenque (CV8) and Guanyun (CV4). 1 time per day for 30 min			7 d		Sleep efficiency, PSQI
Deng XY et al 2018³⁶		30/30		T: 48.93±4.03 C: 50.13±4.09		T: 12/18 C: 16/14						Tumor+depression					Sertraline 10 mg/d+ anti-tumor therapy						Acupuncture+Electric acupuncture			AT: Yinlingquan (SP9), Fenglong (ST40), Hegu (LI4), Neiguan (PC6), Taichong (LR3), Sanyinjiao (SP6), Yintang (EX-HN3) and Baihui (GV 20). 2 times per week for 30 min EA: Yinlingquan (SP9) and Fenglong (ST40). 2 times per week for 30 min			4 w		HAMD, QLQ-C30
Deng XY et al 2019³⁷		30/30		T: 53±9 C: 49±11		T: 11/19 C: 10/20						Tumor+depression					Sertraline 50 mg/d						Acupuncture+C			AT: Hegu (LI4), Taichong (LR3), Neiguan (PC6), Shenmen (TF4), Zusanli (ST36), Sanyinjiao (SP6), Yintang (EX-HN3) and Baihui (GV 20). 2 times per weekfor 30 min			4 w		HAMD, QLQ-C30
Feng Y et al 2011³⁸		40/40		T: 63.80±5.47 C: 63.60±4.26		T: 26/14 C: 27/13						Malignant neoplasms+insomnia and depression					Fluoxetine 20 mg/d						Acupuncture+C			AT: Fenglong (ST40), Yinlingquan (SP9), Xuehai (SP10), Sanyinjiao (SP6), Yintang (EX-HN3), Baihui (GV 20), Sishencong (EX-HN1), Neiguan (PC6) and Shenmen (TF4). 1 time per day for 20-30 min			30 d		SDS, HAMD, depression efficiency, PSQI
Feng XT et al 2019³⁹		70/70		35-78 (61.51±6.24)		61/79						Liver cancer+anxiety and depression					Paroxetine 20 mg/d						Acupuncture +chinese herb+c			AT: the acupoints of liver meridian and heart meridian, Shenmen (TF4), Danzhong (CV 17), Taichong (LR3), Qimen (LR14) and Xingjian (LR2). 5 times per weekfor 30 min			8 w		SDS, SAS
Liao LL 2019⁴⁰		35/34		T: 63.63±16.30 C: 63.18±15.04		T: 14/21 C: 13/21						Tumor+insomnia					Routine care						Intradermal needling +moxibustion			IN: Yintang (EX-HN3) and Shenmen (TF4). 2~3 times per week; 3~4 times per day (acupressing 1~2 min per point) MT: Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day (5 min per point)			2 w		PSQI
Liu YL 2017⁴¹		30/30		T: 51.63±9.14 C: 54.63±9.89		T: 10/20 C: 12/18						Tumor+depression					Routine care						Thermal moxibustion			MT: Baihui (GV 20), Shenmen (TF4), Neiguan (PC6), Taichong (LR3) and Ganshu (BL18). 1 time per day (20 min per point)			21 d		HAMD, depression efficiency
Liu XF et al 2019⁴²			40/40		T: 46.37±14.53 C: 49.32±13.22	Female					Breast cancer+anxiety and depression					Diosmin tablets 2.7 g/d						Needle warming moxibustion				Jianyu (LI15), Waiguan (SJ5), Yinlingquan (SP9), Quchi (LI11), Shuifen (IN9) and Zusanli (ST36). 1 time per 2 days for 30 min			28 d		SDS, SAS, QLQ-C30
Liu YP et al 2019⁴³			40/40		T: 63±13 C: 63±12	T: 24/16 C: 20/20					Tumor+depression					Escitalopram 10 -20 mg/d						Acupuncture+C				AT: Taichong (LR3), Hegu (LI4), Baihui (GV 20) and Yintang (EX-HN3). 5 times per week for 30 min			12 w		HAMD
Mo ZY et al 2017⁴⁴			58/60		T: 48.22±10.28 C: 48.60±11.02	Female					Breast cancer+anxiety and depression					Routine care						Ginger moxi-bustionwithbox				MT: Hegu (LI4), Zusanli (ST36), Taichong (LR3) and Yongquan (KI1). 2 times per day for 30 min			7 d		SDS, SAS
Pei Y et al 2010⁴⁵			31/36		T: 51.76±10.21 C: 48.34±8.79	Female					Breast cancer+anxiety and depression					Citalopram 20 mg/d						Acupuncture				AT: Feishu (BL13), Xinshu (BL15), Geshu (BL17), Ganshu (BL18), Pishu (BL20) and Shenshu (BL23). 5 times per week for 30 min			6 w		SDS, SAS, HAMD
Peng XH et al 2017⁴⁶			93/97		T: 59.36±12.54 C: 60.95±11.11	T: 68/36 C: 68/36					Tumor+insomnia					Estazolam 1 mg/d						Acupuncture +moxibustion				AT: Baihui (GV 20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day for 30 min MT: Shenque (CV8) and Guanyun (CV4). 1 time per day for 30 min			7 d		Sleep efficiency
Shen LP et al 2016⁴⁷			50/50		T: 54. 93±14.45 C: 58. 09±12.11	T: 28/22 C: 31/19					Lung cancer+insomnia					Zolpidem 10 mg/d+ Paroxetine 20 mg/d (if needed)						Acupuncture+Electric acupuncture+C				AT: Zhaohai (KI6), Shenmai (BL62), Shenmen (TF4), Yintang (EX-HN3), Sishencong (EX-HN1), Anmian(Extra 8), Hegu (LI4), Taichong (LR3), Zusanli (ST36), Qihai (CV6) and Quchi (LI11). 1 time per day for 30 min EA: Shenmen (TF4), Anmian(Extra 8), Sishencong (EX-HN1), Hegu (LI4), Taichong (LR3), Zusanli (ST36), Qihai (CV6) and Quchi (LI11). 1 time per day for 30 min			4 w		SDS, SAS, PSQI
Shi Y et al 2014⁴⁸			40/40		NR	NR					Tumor+insomnia					Diazepam 5 mg/d						Scalp-acupuncture				AT: Baihui (GV 20), Sishencong (EX-HN1). 1 time per day for 60 min SA: Ezhongxian (MS2~3). 1 time per day for 60 min			7 d		PSQI
Song JR et al 2015⁴⁹			60/60		NR	NR					Tumor+insomnia					Estazolam 1 mg/d						Acupuncture boxed moxibustion				AT: Baihui (GV20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day for 30 min MT: Shenque (CV8) and Guanyun (CV4). 1 time per day for 30 min			7 d		Sleep efficiency, PSQI
Liu XF et al 2019⁴²			40/40		T: 46.37±14.53 C: 49.32±13.22			Female		Breast cancer+anxiety and depression					Diosmin tablets 2.7 g/d					Needle warming moxibustion					Jianyu (LI15), Waiguan (SJ5), Yinlingquan (SP9), Quchi (LI11), Shuifen (IN9) and Zusanli (ST36). 1 time per 2 days for 30 min			28 d		SDS, SAS, QLQ-C30
Liu YP et al 2019⁴³			40/40		T: 63±13 C: 63±12			T: 24/16 C: 20/20		Tumor+depression					Escitalopram 10-20 mg/d					Acupuncture+C					AT: Taichong (LR3), Hegu (LI4), Baihui (GV 20) and Yintang (EX-HN3). 5 times per week for 30 min			12 w		HAMD
Mo ZY et al 2017⁴⁴	58/60				T: 48.22±10.28 C: 48.60±11.02		Female		Breast cancer+ anxiety and depression					Routine care							Ginger moxi-bustionwithbox			MT: Hegu (LI4), Zusanli (ST36), Taichong (LR3) and Yongquan (KI1). 2 times per day for 30 min			7 d			SDS, SAS
Pei Y et al 2010⁴⁵	31/36				T: 51.76±10.21 C: 48.34±8.79		Female		Breast cancer+anxiety and depression					Citalopram 20 mg/d							Acupuncture			AT: Feishu (BL13), Xinshu (BL15), Geshu (BL17), Ganshu (BL18), Pishu (BL20) and Shenshu (BL23). 5 times per week for 30 min			6 w			SDS, SAS, HAMD
Peng XH et al 2017⁴⁶	93/97				T: 59.36±12.54 C: 60.95±11.11		T: 68/36 C: 68/36		tumor+insomnia					Estazolam 1 mg/d							Acupuncture +moxibustion			AT: Baihui (GV 20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day for 30 min MT: Shenque (CV8) and Guanyun (CV4). 1 time per day for 30 min			7 d			Sleep efficiency
Shen LP et al 2016⁴⁷	50/50				T: 54. 93±14.45 C: 58. 09±12.11		T: 28/22 C: 31/19		Lung cancer+insomnia					Zolpidem 10 mg/d+ Paroxetine 20 mg/d (if needed)							Acupuncture+Electric acupuncture+C			AT: Zhaohai (KI6), Shenmai (BL62), Shenmen (TF4), Yintang (EX-HN3), Sishencong (EX-HN1), Anmian(Extra 8), Hegu (LI4), Taichong (LR3), Zusanli (ST36), Qihai (CV6) and Quchi (LI11). 1 time per day for 30 min EA: Shenmen (TF4), Anmian(Extra 8), Sishencong (EX-HN1), Hegu (LI4), Taichong (LR3), Zusanli (ST36), Qihai (CV6) and Quchi (LI11). 1 time per day for 30min			4 w			SDS, SAS, PSQI
Shi Y et al 2014⁴⁸	40/40				NR		NR		Tumor+insomnia					Diazepam 5 mg/d							Scalp-acupuncture			AT: Baihui (GV 20), Sishencong (EX-HN1). 1 time per day for 60 min SA: Ezhongxian (MS2-3). 1 time per day for 60 min			7 d			PSQI
Song JR et al 2015⁴⁹	60/60				NR		NR		Tumor+insomnia					Estazolam 1 mg/d							Acupuncture boxed moxibustion			AT: Baihui (GV20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day for 30 min MT: Shenque (CV8) and Guanyun (CV4). 1 time per day for 30 min			7 d			Sleep efficiency, PSQI
Wang Y 2015⁵⁰	40/40				NR		Female		Breast cancer+anxiety and depression					Routine care							Five-element acupuncture+ wheat grain moxibustion			The acupoints according to five-element acupuncture therapy. 1 time per week			6 w			SDS, SAS
Wang BN et al 2019⁵¹	40/40				T: 52.47±9.62 C: 50.16±7.34		Female		Breast cancer+insomnia					Routine care							Intradermal needling			IN: Shenmen (TF4), Sanyinjiao (SP6), Anmian (Extra 8), Zusanli (ST36) and Taibai (SP3). 5 times per week; 3 times per day (acupressing 1 min per point)			4 w			PSQI
Wang WG et al 2020⁵²	40/40				T: 39.52±8.35 C: 39.36±9.27		T: 24/16 C: 22/18		Brain tumor+ Depression							Routine care			Acupuncture					AT: Neiguan (PC6), Renzhong (GV26), Sanyinjiao (SP6), Chize (LU5), Jiquan (HT1), Fengchi (GB20), Weizhong (BL40), Tianzhu (BL10) and Wangu (BL12). 2 time per day for 30 min			4 w			SDS, SAS
Wei S 2019⁵³			33/33		49.21±6.32		Female						Gynecological malignant tumor+insomnia					Alprazolam 0.4 mg/d	Thunder-fire moxibustion+C					MT: Shenmen (TF4), Neiguan (PC6), Sanyinjiao (SP6)，Xinshu (BL15), Pishu (BL20), Zusanli (ST36), Danshu (BL19) and Qiuxu (GB40). 1 time per day for 30 min			2 w			PSQI, Sleep efficiency, QLQ-C30
Xia Q et al 2017⁵⁴			23/23		NR		18/28						Tumor+depression					fluoxetine 20 mg/d	Scalp-acupuncture					SA: Dingzhongxian (MS5), Ezhongxian (MS1), Epangxian(MS2~ MS4), Nieqianxian (MS10), Niehouxian (MS11). 6 times per week for 30 min			4 w			HAMD, SDS, depression efficiency
Xia WM et al 2019⁵⁵			37/37		T: 47.6±8.2 C: 46.2±7.5		T: 10/27 C: 13/24						Thyroid cancer+ insomnia, anxiety and depression					Routine care	Moxibustion					MT: Baihui (GV 20). 1 time per day for 20 min			7 d			SDS, SAS, PSQI
Zeng XL 2015⁵⁶			29/28		T: 60.28±10.22 C: 61.71±11.58		T: 12/17 C: 13/15						Tumor+depression					Sertraline 50 mg/d	Acupuncture +moxibustion					AT: Neiguan (PC6), Shenmen (TF4), Laogong (PC8), The Stabilizing Four-Shen points and the Four-Shen pointsof Jin's Three-needle Therapy. 1 time per day for 60 min. MT: 1 time per 2 days for 20 min.			4 w			HAMD, SDS, QLQ-C30
Zhang YT 2017⁵⁷			35/34		T: 64.06±9.155 C: 64.46±10.947		T: 18/17 C: 14/20						Tumor+insomnia					Routine care+Estazolam 1 mg/d (if needed)	Thermal moxibustion+C					MT: Shenque (CV8), Xinshu (BL15), Pishu (BL20), Shenmen (TF4) and Sanyinjiao (SP6). 1 time per day (20 min per point)			7 d			PSQI
Zhang CH et al 2017⁵⁸			32/32		T: 56.9±5.7 C: 56.8±6.1		T: 13/19 C: 14/18						Tumor+depression					Amitriptyline 50-150 mg/d	Acupuncture +chinese herb+c					AT: Zusanli (ST36), Sanyinjiao (SP6), Feishu (BL13) and Yinlingquan (SP9). 3 times per week for 30 min			6 w			HAMD, depression efficiency
Zhang YL et al 2017⁵⁹			31/31		18-65 (53.55±11.60)		38/24						Colorectal cancer+anxiety and depression					Loperamide 4 mg/d	Needle warming moxibustion					Guanyun (CV4), Shenque (CV8), Tianshu (ST25) and Zusanli (ST36). 1 time per day (10 min per point)			7 d			SDS, SAS
Zhang B 2017⁶⁰			30/30		T: 59.8±4.3 C: 58.4±5.2		T: 13/17 C: 15/15						Tumor+depression					Chinese herb	Five-element acupuncture+C					The acupoints according to five-element acupuncture therapy. 1 time per week			6 w			HAMD
Zhao YL 2015⁶¹			93/97		T: 59.36±12.541 C: 60.95±11.112		T: 60/33 C: 66/31						Tumor+insomnia					Estazolam 1 mg/d	Acupuncture+moxibustion					AT: Baihui (GV 20), Shenting (GV24), Yintang (EX-HN3), Shenmen (TF4), Zusanli (ST36) and Sanyinjiao (SP6). 1 time per day for 30 min MT: Shenque (CV8) and Guanyun (CV4). 1 time per day for 30 min			7 d			Sleep efficiency, PSQI
Zhu JJ et al 2017⁶²			50/50		T: 63.38±8.34 C: 62.78±7.85		T: 37/13 C: 38/12						Liver cancer+depression					Escitalopram 10 mg/d	Cake-separated moxibustion +Chinese herb					MT: Fengfu (GV16), Geshu (BL17) and Danshu (BL19). 1 time per day for 30 min			6 w			HAMD, depression efficiency

Risk factor		Trials (n)	Participants (n)	Mean difference (95% CI)	Heterogeneity	P value
SDS		13	1044	?9.40 (?12.21,?6.59)	<0.000 01	<0.000 01
	AMT and routine care	5	412	?13.28 (?17.92,?8.64)	<0.000 01	<0.000 01
	AMT and conventional drugs	5	312	?6.66 (?12.66,?0.65)	<0.000 01	0.03
	AMT+CD and conventional drugs	3	320	?7.44 (?9.26, ?5.63)	0.91	<0.000 01
SAS		10	861	?7.75 (?10.44, ?5.05)	<0.000 01	<0.000 01
	AMT and routine care	5	412	?8.61 (?12.38, ?4.84)	<0.000 01	<0.000 01
	AMT and conventional drugs	3	209	?7.12 (?14.61, ?0.37)	<0.000 01	0.06
	AMT+CD and conventional drugs	2	240	?6.60 (?11.32, ?1.88)	0.07	0.006
QOL		5	323	1.11 (0.80, 1.42)	0.15	<0.000 01
	AMT and conventional drugs	2	137	1.36 (0.99, 1.74)	0.31	<0.000 01
	AMT+CD and conventional drugs	3	186	0.93 (0.59, 1.28)	0.28	<0.000 01

Risk factor		Trials (n)	Participants (n)	Mean difference (95% CI)	Heterogeneity	P value
SDS		13	1044	?9.40 (?12.21,?6.59)	<0.000 01	<0.000 01
	AMT and routine care	5	412	?13.28 (?17.92,?8.64)	<0.000 01	<0.000 01
	AMT and conventional drugs	5	312	?6.66 (?12.66,?0.65)	<0.000 01	0.03
	AMT+CD and conventional drugs	3	320	?7.44 (?9.26, ?5.63)	0.91	<0.000 01
SAS		10	861	?7.75 (?10.44, ?5.05)	<0.000 01	<0.000 01
	AMT and routine care	5	412	?8.61 (?12.38, ?4.84)	<0.000 01	<0.000 01
	AMT and conventional drugs	3	209	?7.12 (?14.61, ?0.37)	<0.000 01	0.06
	AMT+CD and conventional drugs	2	240	?6.60 (?11.32, ?1.88)	0.07	0.006
QOL		5	323	1.11 (0.80, 1.42)	0.15	<0.000 01
	AMT and conventional drugs	2	137	1.36 (0.99, 1.74)	0.31	<0.000 01
	AMT+CD and conventional drugs	3	186	0.93 (0.59, 1.28)	0.28	<0.000 01

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