METHODS: PubMed, Embase, the Cochrane Library, Web of Science, CNKI, and Wanfang were searched from inception to February 2025 for randomised controlled trials of acupuncture-antidepressant combinations and relevant pharmacological or acupuncture-related comparators. The principal efficacy outcome was change in Hamilton Depression Rating Scale (HAMD/HDRS) scores; safety outcomes included nausea/vomiting, dry mouth, headache, and treatment discontinuation. Risk of bias was assessed using RoB 2. Random-effects Bayesian network meta-analyses were conducted in R version 3.6.0 using gemtc version 0.8.1. Mean differences or odds ratios are presented with 95% credible intervals (CrIs), together with posterior rank-position probabilities. A standardised mean difference (SMD)-based sensitivity analysis assessed the influence of pooling HAMD-17 and HAMD-24.

RESULTS: Seventy-seven trials (7,031 participants) were included in the systematic review. Within the principal connected eight-node efficacy network, manual acupuncture plus selective serotonin reuptake inhibitors produced the largest reduction versus SSRI monotherapy (mean difference -3.37; 95% CrI -3.86 to -2.89) and the highest probability of occupying Rank 8 (the most effective position). Electroacupuncture plus SSRIs was also associated with a greater reduction in HAMD scores than SSRIs alone (MD -2.98; 95% CrI -3.66 to -2.31). Manual acupuncture plus SNRIs also favoured combination treatment (MD -3.16; 95% CrI -6.03 to -0.28), although the interval was comparatively wide. The SMD sensitivity analysis retained benefit for both EA + SSRIs and MA + SSRIs relative to SSRIs, although their relative ordering differed from the raw-MD analysis. The available adverse-event networks did not identify statistically clear differences from SSRI monotherapy; however, sparse events and very wide CrIs limit the strength of this finding.

CONCLUSION: Manual acupuncture plus an SSRI was associated with the largest short-term HAMD reduction in the primary raw-MD network. Relative treatment ordering differed in the SMD sensitivity analysis. The estimates should be interpreted cautiously because clinical heterogeneity, risk-of-bias concerns, sparse safety data, and limited follow-up preclude claims of equivalent safety or a preferred first-line strategy.