Insomnia

Insomnia

Role for acupuncture and melatonin

Abstract

“Sleep may be the price you pay so your brain can be plastic the next day,” is an intriguing statement by Cirelli and Tononi (Cirelli 2008). The 2002 Canadian Community Health Survey (CCHS) showed that as many as 18% of participants averaged less than five hours of sleep per night (Shields 2005). Sleep is a vital and recurrent function in daily life. It is thought to be an essential component of good health and hypothesized to have the following functions: energy conservation, memory consolidation, regeneration of substrates, and rest. Lack of sleep can have a negative impact on a person’s career, physical activity level, social interaction, mental aptitude and quality of life. There can be a severe economic burden caused by lack of sleep related to motor vehicle accidents, decreased workplace productivity, absenteeism from commitments and health-care costs from co-morbidities. Melatonin and acupuncture are two natural therapies with large bodies of evidence supporting their use in the management of insomnia.

Features of Sleep and Insomnia

Insomnia is defined as a state of insufficient sleep; it can include difficulties in falling asleep, staying asleep or a combination of both (Balch 2006). Acute insomnia is thought to last less than one to three months on average and consists of difficulty getting to sleep, continuing sleep, and/or sleep is poor quality; resulting in compromised daytime function (AASM 2005). Chronic insomnia can be defined as a failure to get a full night’s sleep on the majority of days in a month. The deleterious impact of insomnia must be considered as an issue on its own and/or as a sign of an underlying major medical diagnoses. There is a plethora of evidence from cognitive, endocrine, neurological, and behavioral disciplines that links insomnia to stress and that attributes insomnia to a state of hyper-arousal and receptor imbalance. Risk factors associated with insomnia include female gender, widowed or single status, low education or income, being unemployed, smoking status, stress, chronic disease, pain, restriction of activity and health dissatisfaction (Sutton 2001).

Sleep is divided into two types: rapid eye movement (REM) and non REM sleep (NREM) with four associated stages, of which the first three are NREM. The four stages of sleep are as follows: Stage one consists of light sleep where one is easily awakened, while stage two consists of theta activity and alpha waves interrupted by k complexes and sleep spindles. Stage three is a deep sleep that consists of slow brain waves, known as delta waves, accompanied by a lack of reaction to environmental stimuli. Stage four consists of the deepest sleep (REM), without major muscle movements (Dement 1975). It is also noted that in this phase, electroencephalogram (EEG) waves are similar to those of an awakened individual.

The Etiology and Physiology of Insomnia

The etiological basis for insomnia includes but is not limited to disturbances in circadian rhythms, stress, genetic conditions, other co-morbid diagnoses, drugs, alcohol, medications and hormonal imbalances. Physiological mechanisms of insomnia include theories that involve the central and autonomic nervous systems (CNS, and ANS respectively). People with insomnia and poor sleep are found to be more alert on daytime alertness tests, such as the multiple sleep latency test (MSLT) (Bonnet 1995, Seidel 1984). They are thought to have altered electroencephalographic (EEG) activity, (beta/gamma) waves at night (Krystal 2002).

Neurological imaging diagnostics such as single photon emission computed tomography (SPECT), positron emission tomography (PET), or proton magnetic resonance spectroscopy (MRS) have shown that insomniacs may have selective hyperactive brain coordinates (Nofzinger 2004, Smith 2002, Winkelman 2008). A highly active ANS that is found in insomniacs coincides with higher metabolic rates, body temperatures, and heart rates (Freedman 1982). There is a reinforced activation of the hypothalamic-pituitaryadrenal (HPA) axis by corticotrophin-releasing hormone (CRH) (Vgontzas 2001). Additionally, high cortisol levels maintain an increased sympathetic tone. Overall, these explanations suggest that therapeutics designed to restore the balance between the ANS and CNS, by mediating sympathetic and parasympathetic tone, could improve insomnia and optimize sleep quality.

Beyond pharmacotherapy, there are a large number of natural therapeutic options available to patients with insomnia such as melatonin, passionflower, 5-hydroxy tryptophan, L-theanine and acupuncture. It has been suggested that benzodiazepine, melatonin and histamine receptor antagonist activity have all been theoretically linked to insomnia. Supplements should be chosen with the associated mechanisms of action in mind, given the variation in pharmacokinetics. In addition to nutritional applications of treatment, eastern therapeutic strategies such as Traditional Chinese Medicine (TCM) methods have also been efficacious.

Eastern Perspectives in Insomnia

TCM etiologies of insomnia include but are not limited to anger, worry, overwork, excessive sexual activity, irregular diet, and a term known as gall bladder timid and residual heat (Maciocia 2008). It is thought that abnormal yin organs are unable to house essence, thereby causing the person to be restless and awake. The state of the mind and the ethereal soul are crucial to proper sleep. Additionally, internal organ disharmony disrupts essence and essence disrupts the mind; essence and Qi are the roots of the mind and without proper rooting of the mind, insomnia could result (Maciocia 2008). Sleep is contingent on normal functioning of the heart/mind, liver/ethereal soul and the kidneys/will power.

TCM theories are based on organ pair and meridian associated diagnoses resulting from either “full-excess” or “empty-deficiency” conditions. The deficiency or excess conditions are a result of imbalance in the connection between the body and the mind. The full conditions are: liver fire blazing, heart fire blazing, phlegm heat harassing the mind, heart Qi stagnation, heart blood stasis, residual heat in the diaphragm and retention of food (Maciocia 2008). The empty conditions are: heart and spleen blood deficiency, heart yin deficiency, heart and kidneys not harmonized, heart and gall bladder deficiency and liver yin deficiency (Maciocia 2008). The intent is to drain in excess conditions and support/ tonify in deficiency.

TCM strategies of acupuncture and herbal medications are individualized depending on what type of excess or deficient condition the person has. For instance, the diagnosis of insomnia as heart fire blazing is treated by needling points such as bladder 15, 44, spleen 6, Ren 15 and Du 19, with a herbal remedy known as XieXin Tang that collectively clears the heart and calms the mind (Maciocia 2008).

Evidence for the Role of Acupuncture in Insomnia

There is a large body of evidence that has shown the efficacy of acupuncture in reducing insomnia by itself or as part of a disease complex. It is effective as an independent therapy or in conjunction with other treatments. One study utilized the Pittsburgh Sleep Quality Index (PSQI) to compare acupuncture to Zolpidem (10mg) in a psychosomatic clinic of 33 patients with primary insomnia. There were significant improvements in both groups: regression analysis showed the results as a baseline PSQI score of 4.13 (p<0.001), the second score 1.32 (p=0.005), and the third 1.49 (p=0.03), confirming that acupuncture was just as effective as the medication (Tu 2012).

One systematic review examined 33 trials with 2293 patients aged 15 to 98 years of age to assess the safety and efficacy of acupuncture for insomnia alone and with other diagnoses, such as stroke, end-stage renal disease, perimenopause, pregnancy and psychiatric diagnoses. They evaluated needle, electro or magnetic acupuncture and pressure. Compared with no treatment (2 studies, 280 participants) or placebo (2 studies, 112 participants), acupressure resulted in more people with improvement in sleep quality (compared to no treatment: OR 13.08, 95% confidence interval (CI) 1.79 to 95.59; compared to placebo: OR 6.62, 95% CI 1.78 to 24.55) (Cheuk 2012). Compared with other treatment alone, acupuncture combined with other treatment was shown to marginally increase the percentage of people with improved sleep quality (13 studies, 883 participants, OR 3.08, 95% CI 1.93 to 4.90) (Cheuk 2012). Overall, needle acupuncture showed the highest efficacy out of all the subgroups. Another systematic review demonstrated through the measurement of subjective sleep outcomes that acupuncture reduced sleep latency, increased sleep and wake ratio (sleep efficiency), resulted in better sleep duration/quality, and minimal insomnia symptoms (Huang 2009).

One interesting, randomized, double blind, placebo controlled trial showed that in postmenopausal women aged 50-67 years old who had insomnia, (as measured by polysomnography exam (PSG) and questionnaires (WHOQOLBREF, Beck Depression Inventory and PSQI)), the acupuncture group had significantly lower scores on the PSQI and improved WHOQOL outcomes after five weeks; confirming that acupuncture improved sleep quality and quality of life in postmenopausal women with insomnia (Hachu 2013). Collectively, the variety of type of studies demonstrate that acupuncture has a measurable improvement on subjective and objective sleep criteria, and that this could potentially be applied to designing individualized treatment strategies for insomnia patients.

Evidence for the Role of Melatonin in Insomnia

Melatonin is a hormone secreted by the pineal gland that regulates circadian rhythm and signals conditions for sleep in the body (Fritz 2009). Administration of exogenous melatonin, typically between 1-5mg under the tongue half an hour before bed, has been shown to decrease sleep latency, increase sleep duration, and increase REM sleep (Brzezinski 2005, Buscemi 2005). Melatonin has also been demonstrated to assist in the discontinuation of benzodiazepine sleeping medications (Garfinkel1999, Kunz 2012). In a randomized controlled trial, 19 of 24 patients who discontinued benzodiazepines using melatonin continued to have good quality sleep six months later (Garkinkel 1999). Another analysis found that after receiving a prescription for melatonin, one third of patients discontinued use of benzodiazepines (Kunz 2012). Melatonin has been studied in several populations including shift workers, patients on benzodiazepines, patients with idiopathic insomnia, patients with schizophrenia, the elderly including patients with Alzheimer’s and Parkinsons, as well as children, including children with neurodevelopment conditions such as Asperger’s, epilepsy, and ADHD (Fritz 2009). Melatonin has an excellent safety profile, with the exception of concurrent use with calcium channel blockers (CCBs), a blood pressure medication; one study found a small decrease in the effect of CCBs when combined with melatonin (Grossman 2006).

Conclusion

Insomnia by itself or in association with other diagnoses can immensely decrease quality of life, as well as be an increased economic burden on the healthcare system and society. Mechanisms of action thought to be targeted are abnormal melatonin production and receptor function, as well as HPA axis imbalance. Melatonin and acupuncture have shown immense potential in insomnia management and are well supported by a large body of evidence. Melatonin has been shown in many studies to improve sleep quality and latency, morning alertness and quality of life at a dose range of 2-4 mg for approximately three weeks. Acupuncture has been shown in several studies to improve sleep efficiency, quality and overall quality of life, and even in some studies enabled patients to reduce medication, especially with individualized protocols. Collectively, these effective natural treatments in addition to targeting the root cause of disease have shown promise in reducing insomnia associated morbidity, and increasing overall wellbeing.

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