Efficacy of moxibustion for poststroke depression: A meta-analysis

Abstract

Poststroke depression (PSD) is a frequent neuropsychiatric complication that adversely affects recovery and quality of life in stroke survivors. Moxibustion, a traditional Chinese therapy, has been increasingly explored as an adjunctive treatment for PSD, but its clinical efficacy remains uncertain. This meta-analysis aimed to evaluate the impact of moxibustion on depressive symptoms and clinical outcomes in patients with PSD. A comprehensive search of 7 electronic databases, including PubMed, Embase, Web of Science, the Cochrane Library, China National Knowledge Infrastructure, WanFang Data, and SinoMed, was performed from inception to July 25, 2025, without language restrictions. Twelve randomized controlled trials (RCTs) comprising 819 participants met the inclusion criteria. Pooled analysis showed that moxibustion significantly reduced Hamilton Depression Rating Scale (HAMD) scores compared with control interventions (standardized mean difference = –1.20; 95% confidence interval [CI]: –1.65 to –0.76), indicating a clinically meaningful improvement in depressive symptoms. Eight RCTs reported clinical effective rates, and the combined results demonstrated a significant advantage for moxibustion (risk ratio = 1.15; 95% CI: 1.07–1.24). Sensitivity analysis confirmed the robustness of the findings, and no significant publication bias was detected. These results suggest that moxibustion is an effective and well-tolerated complementary therapy for PSD, potentially enhancing the outcomes of conventional treatment. Further large, high-quality multicenter trials are needed to validate these findings and establish standardized treatment protocols.

1. Introduction

Stroke is a leading cause of long-term disability and mortality worldwide, with significant impacts on neurological, cognitive, and emotional functioning. Among the psychological sequelae following stroke, poststroke depression (PSD) represents one of the most common and debilitating complications. The prevalence of PSD has been estimated to range from 20 to 65%, depending on diagnostic criteria, time of assessment, and population characteristics.^[1,2] PSD not only impairs rehabilitation outcomes and functional recovery but also increases the risk of recurrent stroke, institutionalization, and mortality. Despite its high clinical burden, effective management of PSD remains a substantial challenge in poststroke care. Current pharmacological treatments for PSD primarily involve the administration of selective serotonin reuptake inhibitors and other classes of antidepressants.^[3] While these agents are frequently used, their application is often limited by potential adverse effects, drug interactions, delayed onset of action, and poor adherence, particularly in elderly or comorbid stroke survivors.^[4] Moreover, evidence suggests that antidepressants may increase the risk of bleeding or interact with antiplatelet and anticoagulant therapies, raising safety concerns in this vulnerable population. Therefore, there is growing interest in non-pharmacological and complementary therapeutic approaches that offer comparable efficacy with fewer side effects.^[5]

Moxibustion, a traditional Chinese medicine (TCM) intervention, involves the burning of Artemisia vulgaris (mugwort) near specific acupuncture points to stimulate circulation and regulate the flow of Qi (vital energy). Moxibustion has been historically used for neurological, gastrointestinal, gynecological, and psychiatric conditions. In the context of PSD, moxibustion is hypothesized to exert antidepressant effects through multiple mechanisms, including modulation of the hypothalamic-pituitary-adrenal axis, enhancement of cerebral blood flow, neuroprotective activity, and regulation of neurotransmitters such as serotonin (5-HT), dopamine (DA), and norepinephrine (NE).^[6,7] Preclinical studies have demonstrated that moxibustion may reduce depressive-like behaviors in rodent models via anti-inflammatory and anti-oxidative pathways. In recent years, several randomized controlled trials (RCTs) have investigated the clinical efficacy of moxibustion for PSD. These studies have reported variable results, with some indicating significant improvements in depressive symptoms, quality of life, and neurological function, while others failed to demonstrate robust benefits compared to standard care or placebo.^[8,9] In addition, variations in moxibustion techniques (e.g., direct vs indirect), acupoint selection, treatment duration, and outcome measures have led to considerable heterogeneity across studies, making it difficult to draw definitive conclusions about its therapeutic value.

Given the increasing clinical interest and accumulating evidence, a systematic evaluation of the efficacy of moxibustion in the treatment of PSD is warranted. Therefore, this meta-analysis aims to synthesize current RCT data to determine the overall therapeutic effectiveness and safety profile of moxibustion for patients with poststroke depression. By quantitatively assessing clinical outcomes such as depression severity scores and response rates, this study seeks to provide a comprehensive evidence-based appraisal to inform clinical decision-making and guide future research in integrative stroke rehabilitation.

2. Methods

2.1. Search strategy

This study was approved by the Ethics Committee of the Third People’s Hospital of Longgang District Shenzhen. This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.^[10] A comprehensive literature search was performed to identify RCTs evaluating the efficacy of moxibustion in the treatment of PSD. Seven electronic databases were systematically searched from their inception to July 25, 2025: PubMed, The Cochrane Library, Web of Science, Embase, China National Knowledge Infrastructure (CNKI), WanFang Data, and SinoMed. No restrictions were applied regarding language or publication status. In addition, gray literature sources such as conference proceedings, dissertations, and trial registries were also screened when available to minimize publication bias. There were no restrictions on language or publication status. The search strategy utilized a combination of Medical Subject Headings (MeSH), Emtree terms, and relevant free-text keywords to ensure comprehensive coverage. The core search terms included combinations of the following: “moxibustion,” “moxa,” “Artemisia,” “poststroke depression,” “PSD,” “stroke,” “cerebrovascular accident,” “depressive disorder,” and “randomized controlled trial.” Boolean operators (AND, OR) and database-specific syntax were used to maximize retrieval sensitivity. Reference lists of included studies and relevant reviews were also manually screened to identify additional eligible publications not captured in the initial database queries. The complete database-specific search strategies are detailed in Table S1 (Supplemental Digital content, https://links.lww.com/MD/Q732).

2.2. Inclusion criteria and exclusion criteria

Inclusion criteria

• 1)Study Design: RCTs, regardless of blinding or allocation concealment.
• 2)Participants: Adults (≥18 years) diagnosed with poststroke depression (PSD) according to recognized diagnostic criteria (e.g., DSM, ICD, CCMD, or clinical rating scales such as HAMD).
• 3)Interventions: The intervention group received moxibustion therapy alone or in combination with conventional antidepressant treatment.
• 4)Comparators: The control group received conventional antidepressant therapy, placebo, sham moxibustion, or no treatment.
• 5)Outcomes: Studies that reported at least one of the following outcomes: improvement in depressive symptoms (e.g., reduction in Hamilton Depression Rating Scale scores), total effective rate, or incidence of adverse events.

Exclusion criteria

• 1)Study type: Nonrandomized studies, observational studies, case reports, reviews, editorials, conference abstracts, animal studies, or theoretical articles.
• 2)Participants: Studies involving patients with depression not induced by stroke or those with severe psychiatric comorbidities (e.g., schizophrenia, bipolar disorder).
• 3)Interventions: Studies that used moxibustion in both intervention and control groups, or where moxibustion was not a primary intervention.
• 4)Outcomes: Studies that did not report quantifiable clinical outcomes related to depression or that lacked sufficient data for effect size estimation.
• 5)Duplication: Duplicate publications, or studies with overlapping data, in which case the most complete or latest version was retained.

2.3. Literature screening and data extraction

Data extraction was performed independently by 2 reviewers using a predesigned standardized form. The extracted data included the first author’s name and publication year, total sample size, and the number of participants allocated to treatment and control groups. Participant demographics were recorded, including age range or mean age ± standard deviation for both groups. Intervention details were documented, such as the type of moxibustion therapy administered (e.g., moxibustion alone or in combination with Chinese herbal medicine (CHM), acupuncture, psychotherapy, fluoxetine, or other basic treatments), the type of control intervention (e.g., fluoxetine, acupuncture, or conventional care), treatment frequency (e.g., once daily or weekly), and total treatment duration (ranging from 3 to 12 weeks). Outcome measures extracted included standardized depression rating scales such as the Hamilton Depression Rating Scale (HAMD) and the Modified Edinburgh-Scandinavian Stroke Scale, as well as clinical effectiveness indicators such as total effective rate. Clinical effective rate was defined in most included trials according to commonly used Chinese guidelines (e.g., ≥50% reduction in HAMD score defined as “markedly effective,” ≥25% reduction as “effective,” and < 25% as ‘ineffective’). The effective rate was then calculated as (markedly effective + effective)/ total cases. Although minor variations existed among studies, all definitions were linked to reductions in HAMD scores, thus ensuring comparability across trials. In cases where multiple interventions or composite therapies were used, each component was recorded. Disagreements in data extraction were resolved through discussion with a third investigator to ensure accuracy and consistency.

2.4. Quality assessment

The methodological quality of the included RCTs was assessed using the Cochrane Risk of Bias 2.0 (RoB 2.0) tool.^[2] Two independent reviewers evaluated each study across 5 bias domains: bias arising from the randomization process; bias due to deviations from intended interventions; bias due to missing outcome data; bias in measurement of the outcome; and bias in selection of the reported result. Each domain was rated as “low risk of bias,” “some concerns,” or “high risk of bias” according to the guidance provided by the Cochrane Collaboration.^[11] Disagreements between reviewers were resolved through discussion or consultation with a third reviewer.

2.5. Statistical analyses

All statistical analyses were conducted using Review Manager (RevMan) version 5.4 (The Cochrane Collaboration, London, United Kingdom) and Stata version 18.0 (StataCorp LLC, College Station ). Effect sizes for dichotomous outcomes were calculated using risk ratios (RRs) with corresponding 95% confidence intervals (CIs), while continuous outcomes were analyzed using standardized mean differences (SMDs). Heterogeneity among studies was assessed using the chi-square test (Cochran Q) and quantified with the I² statistic. A fixed-effect model was applied when heterogeneity was low (I² < 50% and P > .10); otherwise, a random-effects model was used. Sensitivity analyses were performed to evaluate the robustness of the pooled results by sequentially excluding individual studies. Publication bias was assessed using funnel plots and quantitatively evaluated by Egger test when 10 or more studies were included in a comparison. A P-value < .05 was considered statistically significant unless otherwise specified.

3. Results

3.1. Search results and study selection

A total of 561 records were identified through the comprehensive database and register searches, including 533 records from electronic databases and 28 from trial registers. After removing 218 duplicate records, 112 records deemed ineligible by automation tools, and 65 records excluded for other reasons, 166 unique records remained for screening. Title and abstract screening led to the exclusion of 136 records that did not meet the inclusion criteria. The full texts of 33 potentially eligible articles were sought for retrieval; 3 reports could not be obtained. The remaining 30 articles underwent full-text assessment for eligibility. Of these, 18 articles were excluded for the following reasons: review articles (n = 8), sequentially published articles (n = 2), insufficient data available for analysis (n = 3), and clinical trials without control groups (n = 5). Ultimately, 12 studies met the inclusion criteria and were included in the final qualitative and quantitative syntheses. The study selection process is summarized in the PRISMA flow diagram^[12–23] (Fig. 1).

Figure 1.

PRISMA flow diagram of study selection. PRISMA = preferred reporting items for systematic reviews and meta-analyses.

3.2. Study characteristics

A total of 12 RCTs were included in this meta-analysis, encompassing 819 participants diagnosed with poststroke depression. The sample sizes of the included studies ranged from 32 to 120 participants, with an approximately equal distribution between treatment and control groups. The age of participants varied widely across studies, with reported ranges from 24 to 90 years and mean ages generally between the mid-50s and mid-60s. The treatment interventions in all studies involved moxibustion either as a monotherapy or in combination with other therapeutic modalities, such as CHM, fluoxetine, acupuncture, basic care, or psychotherapy. The control groups predominantly received standard care, which included antidepressant medication (e.g., fluoxetine), acupuncture, CHM, psychotherapy, or a combination of these therapies, depending on the study design. Treatment frequencies were most commonly once daily, although one study employed a once-weekly schedule. The duration of interventions ranged from 3 to 12 weeks, with the majority lasting between 4 and 8 weeks. Overall, the included RCTs were heterogeneous in terms of treatment combinations, duration, and frequency, but collectively provided sufficient data to evaluate the efficacy of moxibustion in patients with poststroke depression (Table 1).

Table 1.

Characteristics of the included randomized controlled trials.

Author	Year	Sample size (n, T/C)	Age range (yr)	Mean ± SD (yr)	Treatment frequency	Treatment duration	Treatment group intervention	Control group intervention
Gan	2021	82 (41/ 41)	NA	T: 52.20 ± 4.51; C: 51.98 ± 4.67	1 time/d	12 wk	Moxibustion + CHM	CHM
Wang	2021	60 (30/ 30)	NA	T: 63.23 ± 7.24; C: 64.03 ± 8.46	1 time/wk	12 wk	Moxibustion + fluoxetine	Fluoxetine
Zhai	2021	48 (24/ 24)	NA	T: 56.27 ± 7.59; C: 57.01 ± 6.72	1 time/d	6 wk	Moxibustion + acupuncture	Acupuncture
Deng	2019	64 (32/ 32)	T: 24–90; C: 35–85	T: 57 ± 16.31; C: 58.88 ± 14.10	NR	8 wk	Moxibustion + basic treatment + psychotherapy	Basic treatment + psychotherapy
Miao	2018	32 (16/ 16)	T: 40–79; C: 39–78	T: 64.97 ± 9.45; C: 64.13 ± 9.26	1 time/d	8 wk	Moxibustion + fluoxetine	Fluoxetine
Luo	2017	64 (32/ 32)	NA	T: 60.29 ± 8.35; C: 61.27 ± 9.85	1 time/d	4 wk	Moxibustion + acupuncture	Acupuncture
Shan	2017	60 (30/ 30)	T: 44–64; C: 46–65	T: 55.45 ± 3.16; C: 56.49 ± 3.19	1 time/d	8 wk	Moxibustion	Fluoxetine
Niu	2015	120 (60/ 60)	48–75	T: 58.64 ± 8.92; C: 60.23 ± 10.51	1 time/d	6 wk	Moxibustion + fluoxetine + acupuncture	Fluoxetine + acupuncture
Wang	2015	45 (23/ 22)	T: 32–78; C: 30–75	T: 55 ± 5; C: 50 ± 1	1 time/d	3 wk	Moxibustion + acupuncture	Acupuncture
Deng	2014	80 (40/ 40)	NA	T: 63.60 ± 7.80; C: 64.55 ± 8.60	1 time/d	4 wk	Moxibustion + psychotherapy	Fluoxetine + psychotherapy
Zou	2014	54 (27/ 27)	NA	T: 61.43 ± 9.62; C: 59.36 ± 10.23	1 time/d	3 wk	Moxibustion + CHM	CHM
Jiang	2013	60 (30/ 30)	40–75	T: 61.45 ± 5.32; C: 60.37 ± 7.13	1 time/d	6 wk	Moxibustion + fluoxetine	Fluoxetine

C = control group, CHM = Chinese herbal medicine, NA = not available, T = treatment group.

3.3. Risk of bias assessment

The methodological quality of the included RCTs was generally moderate to high based on the Cochrane Risk of Bias 2.0 assessment tool. Most studies demonstrated a low risk of bias for random sequence generation, incomplete outcome data, and other sources of bias, indicating that the randomization procedures and data integrity were largely adequate. However, several studies did not clearly report allocation concealment or blinding procedures, resulting in an unclear or high risk of selection and performance bias in these domains. A few studies also showed potential issues in blinding of outcome assessment and selective reporting, though these were less common. Overall, the majority of studies were judged to have a low risk of bias across most domains, but the lack of detailed reporting on allocation concealment and blinding represents the primary methodological limitation. These factors should be considered when interpreting the pooled findings of this meta-analysis (Fig. 2).

Figure 2.

Risk of bias assessment of the included randomized controlled trials.

3.4. Effect of moxibustion on HAMD scores in patients with poststroke depression

A total of 12 RCTs reported changes in the HAMD scores following treatment, allowing for quantitative synthesis. A high level of heterogeneity was detected among the included studies (I² = 87.3%, P < .001), suggesting substantial variability in study populations, intervention protocols, or methodological quality. Therefore, a random-effects model was employed to account for this heterogeneity and to provide a more conservative estimate of the overall effect. The pooled analysis demonstrated that moxibustion significantly reduced HAMD scores compared with control interventions (SMD = –1.20, 95% CI: –1.65 to–0.76), indicating a clinically meaningful improvement in depressive symptoms among patients with poststroke depression (Fig. 3A). This finding supports the therapeutic potential of moxibustion as a complementary treatment modality for depression in the poststroke population.

Figure 3.

Forest plot of the effect of moxibustion on HAMD scores (A) and sensitivity analysis of HAMD score outcomes (B). HAMD = Hamilton Depression Rating Scale.

To examine the robustness and reliability of the meta-analytic results, a sensitivity analysis was performed by systematically excluding each study one at a time and recalculating the pooled SMDs. The results of this leave-one-out sensitivity analysis revealed no significant changes in the direction or magnitude of the effect size, confirming the stability of the findings across studies (Fig. 3B). These results suggest that no single study disproportionately influenced the overall outcome, thereby enhancing the credibility of the conclusions.

3.5. Effect of moxibustion on clinical effective rate in poststroke depression

Eight RCTs reported the clinical effective rate as an outcome measure, allowing for quantitative synthesis. Heterogeneity analysis revealed no significant between-study heterogeneity (I² = 0.0%, P = .673), indicating that the included trials were methodologically and clinically comparable with respect to participant characteristics and intervention protocols. Consequently, a fixed-effects model was employed to calculate the pooled effect estimate. The meta-analysis demonstrated that moxibustion significantly increased the clinical effective rate compared with control interventions (RR = 1.15, 95% CI: 1.07–1.24), suggesting a favorable therapeutic effect of moxibustion in improving depressive symptoms among patients with poststroke depression (Fig. 4). This result indicates that patients receiving moxibustion were approximately 15% more likely to achieve clinical improvement than those in the control groups.

Figure 4.

Forest plot of the effect of moxibustion on the clinical effective rate.

3.6. Publication bias

The funnel plots of the included studies were symmetric (Fig. 5), and Egger test (all P > .05) indicated no significant publication bias, supporting the robustness of the meta-analysis results.

Figure 5.

Funnel plot for publication bias assessment.

4. Discussion

The present meta-analysis demonstrates that moxibustion therapy is associated with a significant improvement in depressive symptoms among poststroke patients. Specifically, patients receiving moxibustion showed a markedly greater reduction in HAMD scores compared to control groups, indicating a large effect size in favor of moxibustion. This magnitude of effect is clinically meaningful, suggesting that moxibustion can substantially alleviate depression severity in the poststroke population. The improvement was not limited to rating scale scores; the clinical effective rate – a composite measure of symptom improvement – was about 15% higher in the moxibustion group than in controls. In practical terms, patients treated with moxibustion were more likely to achieve significant relief from depressive symptoms than those receiving usual care or other control interventions, underlining the therapeutic value of this complementary treatment. These findings support the efficacy of moxibustion as an adjuvant intervention for poststroke depression, consistent with its roots in TCM and its proposed antidepressant mechanisms. Notably, mechanistic studies in animal models have shown that moxibustion can increase central serotonin levels by promoting the brain’s uptake of tryptophan and shifting its metabolism toward 5-HT (serotonin) production.^[24] This neurochemical modulation provides a biological rationale for the observed antidepressant effects of moxibustion in clinical settings. Moreover, moxibustion’s holistic approach – involving stimulation of acupoints to restore Qi balance – may contribute to overall improvement in mood and neurological recovery poststroke, though such traditional explanations are complementary to the biomedical mechanisms.

An important aspect of our results is the heterogeneity observed among the included trials. We detected substantial statistical heterogeneity in the HAMD outcome (I² = 87.3%, P < .001), indicating that the treatment effects varied across studies. This variability may be attributed to differences in patient populations, moxibustion protocols, and, importantly, the nature of control interventions. In the included RCTs, moxibustion was applied in diverse ways – some trials used it as a stand-alone treatment, while others combined it with antidepressants, rehabilitation, or psychotherapy. The comparators also varied, ranging from standard care and placebo to active treatments such as pharmacotherapy, acupuncture, or psychotherapy. Such diversity in control conditions is a well-recognized source of heterogeneity in meta-analyses.^[25] Comparisons with active controls (e.g., antidepressants or acupuncture) may naturally yield smaller effect sizes than those with usual care or no treatment, which could reduce the stability of pooled estimates. To enhance methodological rigor, future RCTs should consider adopting more standardized or stratified control groups, thereby allowing a clearer evaluation of the independent effects of moxibustion. Despite these variations, it is reassuring that the direction of effect consistently favored moxibustion across nearly all studies. We employed a random-effects model to account for between-study heterogeneity, and the pooled effect remained significant. Sensitivity analysis further confirmed that no single trial disproportionately influenced the results, supporting the robustness of our findings. Moreover, no heterogeneity was observed for the clinical effective rate outcome (I² = 0%), indicating consistent benefits of moxibustion on this measure. Taken together, the convergence of these analyses – a substantial reduction in depressive symptom severity and a higher clinical response rate – supports the potential role of moxibustion in managing poststroke depression.^[26,27]

Our findings align well with previously published studies and reviews examining moxibustion and related therapies for poststroke depression. A prior systematic review by Guo et al (2022) evaluated 14 RCTs (all from China) on moxibustion for poststroke depression and similarly reported that adding moxibustion to conventional treatments yielded significant improvements in HAMD scores and higher effective rates.^[25] The magnitude of effect observed in our meta-analysis is highly consistent with the estimates reported in that review. This agreement across independent analyses underscores the reliability of the evidence and suggests that the antidepressant effect of moxibustion is reproducible. Like our analysis, Guo et al also noted significant heterogeneity in depression scale outcomes but a robust overall benefit. They performed subgroup analyses based on different combinations (moxibustion with medications, acupuncture, herbal medicine, etc) and found that most combinations including moxibustion were superior to controls, echoing our conclusion that moxibustion’s benefit is generalizable across various treatment contexts.^[28] One minor difference is that our pooled RR for clinical effectiveness (15% relative improvement) is slightly lower than Guo et al’s 22% improvement. This may be due to the inclusion of a slightly different set of trials or stricter inclusion criteria in our analysis. Nonetheless, the direction of effect is the same, and both analyses reach the conclusion that moxibustion confers a meaningful added benefit in achieving clinical response.^[29]

Earlier literature had already suggested the promise of moxibustion for mood disorders after stroke, though evidence was limited. Zhang et al^[30] conducted a qualitative systematic review of moxibustion for poststroke depression, but included only 5 studies and did not perform a meta-analysis. Our results build upon and quantitatively confirm those early observations with a much larger evidence base. Beyond moxibustion, other TCM-based therapies have shown comparable antidepressant effects in stroke patients. For instance, meta-analyses on acupuncture – an intervention related to moxibustion – have found that acupuncture combined with antidepressant medication is more effective than antidepressants alone in reducing poststroke depression symptoms.^[31] This is in line with the notion that stimulating acupoints (whether via needles or moxa heat) can augment standard care for depression. Additionally, herbal medicine approaches have demonstrated efficacy; a recent meta-analysis of a traditional Chinese herbal decoction (Chaihu Jia Longgu Muli) reported significant improvements in poststroke depression outcomes compared to controls. The consistency of positive findings across moxibustion, acupuncture, and herbal treatments suggests a broader role for integrative medicine in managing poststroke depression. However, it should be noted that most of these studies, like those in our review, originate from Chinese clinical settings. Thus, while multiple modalities show benefit, they likely share similar research contexts and limitations (e.g. small trials, potential publication bias), as discussed below. Compared to Western interventions, there are relatively fewer international trials evaluating moxibustion or acupuncture for poststroke depression, but the existing evidence base uniformly points toward beneficial effects. Our meta-analysis contributes by specifically focusing on moxibustion and reinforcing that it is an effective component of a multidisciplinary approach to poststroke depression, complementing findings from prior acupuncture and herbal medicine studies.^[32,33]

These findings carry important implications for clinical practice, especially in the rehabilitation and management of stroke survivors. Poststroke depression is associated with worse functional recovery and quality of life, yet standard antidepressant medications are not always fully effective or may cause side effects in this often frail patient population. The evidence that moxibustion significantly improves depressive symptoms suggests that it can be recommended as a complementary therapy alongside conventional treatments. In practical terms, incorporating moxibustion into poststroke care plans could enhance patients’ mood and engagement in rehabilitation by providing additional antidepressant effects. Notably, moxibustion and related TCM therapies tend to be low-risk and well-tolerated when performed by trained practitioners. Prior reviews have highlighted that traditional Chinese interventions offer advantages such as fewer systemic side effects and better safety profiles compared to standard pharmacotherapy.^[24] This makes moxibustion a particularly attractive option for poststroke patients who may be on multiple medications or have contraindications to high-dose antidepressants. From a clinical guideline perspective, our results support the integration of moxibustion into comprehensive poststroke depression management protocols, as an adjunct to antidepressants and psychotherapy. It is important that such therapy be delivered in a standardized manner (e.g. consistent selection of acupoints and treatment duration) and that patients are monitored for improvement. Ultimately, offering moxibustion as part of a multimodal treatment strategy could improve outcomes and patient satisfaction, providing a holistic approach to address the psychological as well as physical sequelae of stroke.^[1,34]

4.1. Strengths and limitations

This meta-analysis possesses several notable strengths. It exclusively incorporated RCTs, enhancing the credibility of the conclusions. The inclusion of 12 trials for HAMD outcomes and 8 for clinical effective rate provided a reasonable sample size and statistical power. Evaluating both continuous symptom severity and categorical response outcomes offered a comprehensive assessment of efficacy. Rigorous meta-analytic methods, including the use of random-effects models and sensitivity analyses, confirmed the robustness of the findings.

However, several limitations warrant attention. All included studies were conducted in China, mainly among ethnically Chinese participants in TCM hospital settings, which may limit generalizability and raise the possibility of cultural or publication bias. Most RCTs were relatively small in sample size, and methodological details such as randomization, allocation concealment, and blinding were often insufficiently reported, which may increase the risk of bias. In addition, the definition of “clinical effective rate” was not fully consistent across studies, potentially limiting the comparability of results. Considerable clinical heterogeneity also existed in intervention protocols, including differences in acupoint selection, treatment frequency, duration, and combination with other therapies, making the optimal regimen uncertain. Follow-up durations were generally short, leaving the long-term sustainability of moxibustion’s effects unclear. Finally, although sensitivity analysis and funnel plots did not reveal significant publication bias, the uniformly positive findings suggest that unpublished negative studies cannot be entirely excluded. Another important limitation is the lack of systematic safety reporting in the included RCTs. Few studies provided information on adverse events, and most did not evaluate safety outcomes in detail. Considering the high-risk nature of poststroke patients, the absence of comprehensive safety data is a major evidence gap that should be addressed in future clinical trials.

4.2. Future directions

Future research on moxibustion for poststroke depression should address several important gaps. Comparative studies are needed to evaluate different moxibustion methods, acupoint protocols, and dosages in order to determine the most effective treatment regimen. Long-term follow-up is essential to assess the durability of treatment effects and monitor safety outcomes, which remain insufficiently reported in current trials. Furthermore, as most existing studies have been conducted in China, validation in diverse cultural and healthcare settings is necessary to enhance the generalizability of findings. Finally, future investigations may also benefit from incorporating mechanistic studies, such as neuroimaging or microbiota analyses, to better elucidate the biological pathways underlying the antidepressant effects of moxibustion.

5. Conclusions

This meta-analysis suggests that moxibustion may reduce depressive symptom severity and improve clinical response in patients with poststroke depression. As a complementary and generally well-tolerated therapy, it has the potential to enhance conventional treatment outcomes. However, the current evidence is mainly derived from small-sample, single-center trials conducted in China, and therefore the results should be interpreted with caution. Further large-scale, multicenter, and methodologically rigorous RCTs are required to validate these findings and establish standardized treatment protocols.

Author contributions

Conceptualization: Junwei Chen, Guo Shao.

Data curation: Junwei Chen, Guo Shao.

Formal analysis: Junwei Chen, Guo Shao.

Validation: Guo Shao.

Visualization: Junwei Chen, Guo Shao.

Writing – original draft: Junwei Chen, Guo Shao.

Writing – review & editing: Junwei Chen, Guo Shao.