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Research Article

Acupuncture and Counselling for Depression in Primary Care: A Randomised Controlled Trial

  • Hugh MacPherson mail,

    hugh.macpherson@york.ac.uk

    Affiliation: Department of Health Sciences, University of York, York, United Kingdom

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  • Stewart Richmond,

    Affiliation: Department of Health Sciences, University of York, York, United Kingdom

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  • Martin Bland,

    Affiliation: Department of Health Sciences, University of York, York, United Kingdom

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  • Stephen Brealey,

    Affiliation: Department of Health Sciences, University of York, York, United Kingdom

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  • Rhian Gabe,

    Affiliation: Department of Health Sciences, University of York, York, United Kingdom

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  • Ann Hopton,

    Affiliation: Department of Health Sciences, University of York, York, United Kingdom

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  • Ada Keding,

    Affiliation: Department of Health Sciences, University of York, York, United Kingdom

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  • Harriet Lansdown,

    Affiliation: Department of Health Sciences, University of York, York, United Kingdom

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  • Sara Perren,

    Affiliation: Department of Health Sciences, University of York, York, United Kingdom

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  • Mark Sculpher,

    Affiliation: Centre for Health Economics, University of York, York, United Kingdom

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  • Eldon Spackman,

    Affiliation: Centre for Health Economics, University of York, York, United Kingdom

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  • David Torgerson,

    Affiliation: Department of Health Sciences, University of York, York, United Kingdom

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  • Ian Watt

    Affiliation: Hull York Medical School, University of York, York, United Kingdom

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  • Published: September 24, 2013
  • DOI: 10.1371/journal.pmed.1001518
  • Featured in PLOS Collections

Reader Comments (2)

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Placebo effect?

Posted by Alex55 on 26 Sep 2013 at 19:40 GMT

The authors wrote, "Because this trial was a pragmatic trial, these findings cannot indicate which aspects of acupuncture and counseling are likely to be most or least beneficial. Nevertheless they do provide an estimate of the overall effects of these complex interventions..."

Pragmatic trial or no, I'm concerned that it there was no control for the placebo effect of acupuncture, which usually is done by utilizing "fake" points. It's encouraging that there appears to be some benefit for relieving depression over and above "usual care." However, labeling that technique as "acupuncture"--with its implication of specialized knowledge and training--without ruling out a significant placebo effect is premature, in my opinion.

If anyone has information or an opinion to the contrary, I'd welcome seeing it.

No competing interests declared.

RE: Placebo effect?

seanbarkes replied to Alex55 on 27 Sep 2013 at 08:34 GMT

Hello Alex55,
As this is a pragmatic trial, by definition, the placebo element to all the interventions involved is irrelevant. Any intervention will inevitably involve a placebo component: the acupuncture, the counselling AND the standard care. Even if we hypothetically assume that the effect of all three interventions was entirely due to placebo, the pragmatic healthcare policy maker promotes the intervention with the best results; in this case acupuncture.

Competing interests declared: I am an acupuncturist

RE: Placebo effect?

franjb68 replied to Alex55 on 23 Oct 2013 at 15:46 GMT

Hi Alex55

All the treatments included 'usual care'. So acupuncture and counseling were "extras" over the usual care.

Not too strange that patients with extra care feel better than the ones without it.

I support your demand of control for the placebo effect. As seanbarkes says, 'any intervention will inevitably involve a placebo component', so two interventions should have more placebo effect than just one.

No competing interests declared.

RE: Placebo effect?

TrialManager replied to Alex55 on 07 Nov 2013 at 11:58 GMT

In reply to comments by Alex55 we, the authors, would like to clarify the difference between clinical trials that focus on efficacy and those which concentrate on effectiveness. The former seeks to disentangle specific from non-specific treatment effects, by comparing highly standardised interventions against sham or placebo comparators within carefully controlled and largely artificial research environments. Trials of effectiveness, which include the ACUDep trial, seek to address a different research question. Their purpose is to evaluate how a new treatment compares against standard treatment provision within a real world environment. Such studies are also referred to as pragmatic trials. This emphasises the fact that ‘experimental’ and ‘control’ interventions are delivered in such a way as to closely mimic variations in actual practice, thereby enhancing external validity. Moreover, findings are expressed in terms of outcomes which are meaningful to patients concerned, and are generally of much greater relevance to healthcare policy makers than trials of efficacy. We would like to note that non-specific treatment effects are not unique to acupuncture. Indeed such effects are undoubtedly inherent components of every type of treatment involving any form of consultation process. We are therefore somewhat bemused as to why the commentator appears preoccupied by placebo effects in relation to acupuncture, but not those arising from counselling or usual care, which also featured in our study. For further discussion as to this issue we would like to refer readers to the following article:

MacPherson H. Pragmatic clinical trials. Complementary Therapies in Medicine. 2004; 12: 134-140.

No competing interests declared.