And The Treatment Of Insomnia
Judith R. Peterson, MD
Insomnia is commonly encountered in clinical practice; reportedly, with
a prevalence of nearly 40% in certain populations. Although not commonly
used for this condition, acupuncture may be helpful in the treatment
of insomnia and has an excellent tolerability and safety profile. Increased
awareness of the potential utility of acupuncture for the treatment
of sleep impairment may result in improved patient care.
Sleep Disorders, Acupuncture, Insomnia
Insomnia and sleep disturbances are commonly-encountered clinical problems
in the outpatient setting. Insomnia may represent impaired sleep induction,
the presence of sleep fragmentation, or non-restorative sleep.1 In a
study of 218 patients in general outpatient facilities, nearly 40% complained
of insomnia.2 Prevalence rates were higher among women and those 35-54
years old.2 Insomnia is commonly reported in patients older than 65
years. Approximately 13,000 such individuals older than 65 were surveyed
by use of a clinical questionnaire,3 and more than a third of respondents
Sleep disruption complaints are often managed by the use of medications
such as benzodiazepines and tricyclic antidepressants. Sedatives and
oral hypnotics have high abuse potential and can be addicting. Tricyclic
antidepressants may have intolerable adverse effects, including dry
mouth, orthostatic hypotension, urinary retention, and cardiac conduction
self-medicate. Melatonin is widely available and may be used in an attempt
to normalize the sleep-wake cycle. However, there is a paucity of data
on the long-term safety of melatonin. The pharmacodynamics and pharmacokinetics
are not completely understood, and medication interactions with melatonin
are not known. Theorized potential adverse effects, based on animal
data, for the long-term use of melatonin include inhibition of reproductive
function and delay of puberty.4,5
Non-pharmacological interventions may attempt to change sleep hygiene,
habits, or expectations. One study used cognitive behavioral therapy
to improve sleep in a randomized, placebo-controlled trial achieving
a 55.6% response rate with such interventions.6
interventions include "light therapy," a commonly used modality
for seasonal affective disorder and sleep disruption. In an analysis
of 83 patients with seasonal affective disorder treated with bright
light therapy, Terman and Terman noted significant adverse effects:
nausea was reported in approximately 16% of patients, and headache and
shakiness were reported in more than 8%.7
Acupuncture may be uniquely beneficial in the treatment of this common
clinical problem. In a study by Lee,8 all patients reported severe insomnia
as a chief complaint; no patient slept more than 3-4 hours per night.
Seven auricular points were used in this study: Heart, Kidney, Adrenal,
Sub-Cortex, Endocrine, San Chiao, and Shen Men. In addition to these
standard 7 auricular points, Sympathetic, Occiput, and Gallbladder auricular
points were added if reactive or tender. Treatment was 3 times per week
with a typical duration of 10-12 initial treatments, followed by a 2-
to 4-week observational period; 15 of 16 patients had regimens of 15
treatments or fewer; 1 patient received 28 treatments total. Lee reported
that lidocaine injections into exclusively auricular points improved
symptoms of sleep disorder in 15 of 16 patients treated. Therapeutic
effects were still present 3 months following the conclusion of treatment.8
In a study of
outpatients in his department, Fischer9 reported similarly encouraging
results: 100% of patients treated for insomnia obtained benefit without
recurrences within 18 months of follow-up. Montakab and Langel10 diagnosed
40 patients using Chinese traditional diagnosis and performed polysomnographic
analyses of true acupuncture vs control needled patients. Objective
change was noted and found statistically significant in the true acupuncture
has been found to be an effective therapeutic tool in the treatment
of HIV-infected patients with sleep disruption syndromes. Sleep architecture
is disrupted in all stages of HIV disease. In a study by Phillips and
Skelton,11 sleep quality significantly improved with acupuncture treatment
after 5 weeks. Participants in the study were screened with a self-report
questionnaire for sleep disruption; only those with severe to moderate
disruption were eligible. Wrist actigraph analysis (which detects motion
and sleep monitoring at home), current sleep quality index as a self-report
score, and a visual analog scale of pain rating were used to assess
patient responses to treatment. Acupuncture was performed 2 times weekly
for 5 weeks. Acupuncture treatment was individualized based on Traditional
Chinese Medicine (TCM), and was reassessed during treatment. Auricular
and body points were used. Statistically significant pre- and post-treatment
values were noted for amount of sleep, time awake, and sleep quality.
Acupuncture prescriptions for insomnia will vary with the clinical scenario
and the style of acupuncture practiced by the physician. Each patient
must be assessed for clinical syndromes contributing to sleep disturbance
that may require specific medical or surgical interventions, e.g., hypercaffeinism,
hyperthyroidism, pheochromocytoma.1 Some general suggestions are found
in the medical literature for acupuncture approaches in the treatment
of insomnia. One author suggests Shen Men (HT 7) and An Mien (extra
point) for an acupuncture prescription.12
of varying acupuncture styles for the treatment of insomnia represent
an interesting research path yet to be vigorously pursued in peer-reviewed
medical literature. Additionally, comparison studies of acupuncture
and medication for the treatment of insomnia have not yet been published
in peer-reviewed literature.
Acupuncture appears to be a useful treatment approach for a common clinical
problem. In China, acupuncture is used most commonly in the treatment
of pain disorders, similar to the use of acupuncture in North America.
Acupuncture is also commonly used to treat insomnia in China, which
is not true in North America.13 This is an area in patient care where
acupuncture could be a beneficial addition to standard allopathic treatments.
Clinicians should be aware that acupuncture is a potentially valuable
adjunct in the treatment of this common clinical problem.
Guide to Signs and Symptoms. 3rd ed. Springhouse, Pa: Springhouse
FC, Morin CM, Boisclair A, Grenier V, Guay B. Insomnia: prevalence
and treatment of patients in general practice [in French]. Can Fam
MM, Zulley J, Guilleminault C, Smirne S, Priest RG. How age and
daytime activities are related to insomnia in the general population:
consequences for older people. J Am Geriatr Soc. 2001;49:360-366.
J. Safety of melatonin in long-term use. J Biol Rhythms. 1997;12:
J. Melatonin, circadian rhythms, and sleep [editorial]. N Engl J
CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological
therapies for late-life insomnia: a randomized controlled trial.
M, Terman JS. Bright light therapy: side effects and benefits across
the symptom spectrum. J Clin Psychiatry. 1999;60:799-808.
Lidocaine injection of auricular points in the treatment of insomnia.
Am J Chin Med. 1977;5:71-77.
MV. Acupuncture therapy in the outpatients-department of the University
Clinic Heidelberg [in German]. Anaesthesist. 1982;31:25-32.
H, Langel G. The effect of acupuncture in the treatment of insomnia:
clinical study of subjective and objective evaluation [in French].
Schweiz Med Wochenschr Suppl. 1994;62:49-54.
KD, Skelton WD. Effects of individualized acupuncture on sleep quality
in HIV disease. J Assoc Nurses AIDS Care. 2001;12:27-39.
Acupuncture for insomnia and acupuncture analgesia. Psychiatry Clin
Acupuncture in an outpatient clinic in China: a comparison with
the use of acupuncture in North America. South Med J. 2001;94:813-816.
Dr Judith R. Peterson is a Clinical Assistant Professor of Rehabilitation
Medicine at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania.
Judith R. Peterson, MD
1015 Chestnut St., Suite 307
Philadelphia, PA 19107