What has more evidence for supporting Pregnancy-Related Mood and Anxiety Disorders (PMADS) in pregnancy, massage or acupuncture?

Massage Has Stronger Evidence for PMADS Support in Pregnancy

Based on current research evidence, massage therapy demonstrates more robust support for treating pregnancy-related mood and anxiety disorders (PMADS) compared to acupuncture, with multiple systematic reviews and meta-analyses showing moderate effects on both depression and anxiety symptoms.

Evidence Quality and Strength

Massage Therapy Evidence

• A 2020 systematic review and meta-analysis of massage therapy found moderate effects on both depressive symptoms (MD = -5.95% CI = -8.11 to -3.80) and anxiety (SMD = -0.59,95% CI = -1.06 to -0.12) compared to usual care 1

• A 2019 systematic review examining multiple complementary therapies found massage reduced the severity of antenatal depression in 149 women (SMD -0.73,95% CI -1.07 to -0.39) 2

• A 2021 systematic review of 12 RCTs demonstrated massage during pregnancy reduced stress, depression, anxiety, increased serotonin and dopamine levels, and showed only minor transient side effects 3

• Massage therapy has been shown to decrease cortisol levels, reduce excessive fetal activity, and lower rates of prematurity, likely mediated through increased vagal activity 4

Acupuncture Evidence

• The same 2019 systematic review found acupuncture reduced the number of women diagnosed with antenatal depression (RR 1.68,95% CI 1.06-2.66) in only one trial 2

• Acupuncture evidence is limited to a single trial showing benefit, whereas massage has multiple trials with consistent findings across different populations 2

Clinical Application Algorithm

For Mild PMADS (Recent Onset <2 Weeks)

• Monitor symptoms closely with follow-up within 1-2 weeks 5
• Recommend exercise and social support as initial interventions 5
• Consider partner-delivered relaxation massage as an acceptable, feasible approach that women find both feasible and acceptable 6

For Moderate PMADS

• Cognitive behavioral therapy (CBT) remains first-line treatment, supported by 246 RCTs showing improved symptoms with no treatment-related harms 5
• Add massage therapy as an adjunctive intervention, particularly for women preferring non-pharmacological approaches 1, 3
• Partner-delivered massage programs can be implemented starting at 28-32 weeks gestation 6

For Severe PMADS

• Initiate CBT immediately while considering pharmacotherapy (SSRIs, particularly sertraline) 5, 7
• Massage can be used as complementary therapy alongside evidence-based treatments 1
• Psychiatric consultation should occur within 1-2 weeks 5

Safety Considerations

• Massage during pregnancy is safe in healthy women without complications when started after 12 weeks gestation 3
• Only minor and transient side effects have been reported in trials 3
• Precautions include avoiding massage in women with anticoagulation therapy, and ensuring appropriate draping for women with altered body image concerns 8
• Seven RCTs excluded women with difficult pregnancies or preexisting complications, suggesting caution in high-risk pregnancies 3

Implementation Specifics

• Partner-delivered massage programs require an initial workshop followed by self-directed practice 6
• Massage should be delivered by trained therapists when possible, as the evidence base primarily involves licensed therapists 8
• Both partner-delivered and professionally-delivered massage show benefits for reducing anxiety and depression symptoms 6, 1

Critical Limitations

• The overall risk of bias was high or unclear for the majority of massage studies, limiting the strength of recommendations 1, 2
• None of the massage trials had low risk of bias 1
• Acupuncture evidence is even more limited, based on a single trial 2
• More high-quality research with postnatal follow-up and maternal-neonatal outcomes is needed for both modalities 2

Common Pitfalls to Avoid

• Do not delay evidence-based treatment (CBT or pharmacotherapy) while pursuing complementary therapies for moderate-to-severe PMADS 5
• Do not overlook comorbid depression when treating anxiety, as 56% of anxiety disorder cases have comorbid depression 5
• Do not assume massage alone is sufficient for moderate-to-severe symptoms; it should complement, not replace, evidence-based treatments 5, 1
• Do not use massage as monotherapy when CBT or pharmacotherapy is indicated based on severity 5, 7