Insomnia and Its Implications

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

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Treatment Protocols for Chronic Insomnia

Insomnia may be treated both with symptom relieving therapies as well as protocols to address the underlying causes and contributors. A thorough holistic protocol will address each individual and also include behavioral and cognitive changes that may help promote a sound sleep. The choice of a more complex therapeutic protocol will provide for a great possibility that the need for therapy will be unnecessary in the near future, and that overall health will be improved. Since the associated health problems seen in chronic insomnia may impact quality of life, the ability to achieve more at work, and are associated with more severe health problems with aging, this protocol is also potentially preventive and saving the patient from future diseases and need for therapy. It is very important for patients to realize that Complementary Medicine is not an "alternative" to pharmaceutical sleep medication, but a type of medicine that addresses each individual holistically and works to solve an array of health problems affecting sleep, associated with poor sleep quality, and that need to be addressed in therapy. Simply taking a sleeping pill to get a little longer sleep does not address these important health concerns, and does not solve all the problems. Complementary and Integrative Medicine and Traditional Chinese Medicine (CIM/TCM) provides a thorough and holistic assessment of the varied underlying health problems causing chronic insomnia, and a step-by-step approach to resolving these problems. While this approach is more complex that just taking a sleeping pill, intelligent patients will realize the need to address their whole health to avoid a pattern or worsening, and threatening, disease. Use of Complementary and Integrative Medicine (CIM) can also help decrease drug dependency and thus reduce the risks of side effects and adverse effects of long-term use, as well as help alleviate the rebound insomnia experienced by so many patients with a chronic frequent use of sleep medications.

Standard medicine usually prescribes a one-size-fits-all approach in treating insomnia with a pharmaceutical, often ignoring questions of risk versus benefit. Sleep medications are considered controlled substances due to their effects being used for recreational abuse, and the propensity for addiction. Leaving these sleep medications where they are available for children to abuse them has become a big problem in the United States, as well as the acquiring of an addiction to these drugs without realizing it. Integration of healthier protocols to treat insomnia and poor sleep quality helps eliminate these concerns.

Ambien, or zolpidem, has become the current favorite in prescription for insomnia, and is a sedative and hypnotic, as is Lunesta and Sonata. Drug interactions with adverse effects (Carbamazepin for mood disorders, Cimetidine/Tagamet for stomach acidity, Clarythromycin antibiotic, Fluvoxamine/Luvox SSRI anxiety medication) have been noted, sometime increasing the effects by competing for enzymes that break the drug down. Abnormal behavior due to central nervous system effects have also been well documented, with numerous reports of behavioral changes, complex behaviors during the sleep state such as sleep driving, and even hallucinations, sometimes tactile, have been noted in warnings associated with use. Alcohol and other CNS depressants appear to increase the risk of these adverse CNS effects and behaviors, and impair alertness and motor coordination. Often the patient with chronic insomnia does use alcohol to help fall asleep, and is prescribed other CNS depressants to treat depression and anxiety, making this combination problematic. Ambien is also associated with worsening depression, and withdrawal effects are common with abrupt discontinuation, disrupting the REM sleep cycle and causing daytime cognitive problems, thus leading to drug dependency. Older patients are cautioned that cognitive performance may be impacted by these sedative hypnotics. Side effects noted in 10-29 percent of studied patients include somnolence, dizziness and headache, sometimes only onsetting after chronic use, and thus not clearly associated with the drug use by the patient. A 2013 U.S. FDA warning was added that specified that for patients taking the common delayed release form, that avoidance of driving and other activities that required mental alertness was not recommended the day after taking Ambien, as excessive blood levels could persist into the day, diminishing mental function. Ambien also comes with a Class C pregnancy caution, with neonatal respiratory depression reported when used near term, and affecting postnatal lactation, with small amounts secreted into breast milk. The reasons to limit the use of hypnotic sleep medications are increasing every year, and still we do not see a common recommendation by the treating doctor to try Complementary and Integrative Medicine (CIM) to correct the problem, despite the growing body of scientific evidence supporting TCM and sleep hygiene protocols (see study links in Additional Information).

Since nonbenzodiazepine hypnotics like Ambien (zolpidem) are intended for short-term use only, with prescribing guidelines recommending use for only 2-6 weeks, even when utilizing these sleeping prescriptions, treating the underlying health problems causing insomnia with Complementary and Integrative Medicine is recommended. In addition, only a few small studies have investigated the use of Ambien (zolpidem) for longer than the recommended 2-6 weeks, and these studies showed that the drug was not effective in maintaining sleep, and is more useful for problems falling to sleep, not fitful or waking sleep (Annals of Clinical Psychiatry 18(1): 49-56; Rosenberg BP). By understanding and tackling the potential causes and contributors to insomnia, adopting better sleep hygiene habits, and utilizing Complementary Medicine in the form of acupuncture, herbal and nutrient medicine, these problems and adverse health effects of sleep medication are greatly reduced. In addition, the only side effects of acupuncture, herbal and nutrient medicine is better overall health. By integrating CIM/TCM into your treatment strategy you are receiving an array of benefits, not just a substitute for sleeping pills. The benefits from an array of treatment protocols in CIM/TCM are now proven, as studies cited in Additional Information at the end of this long article clearly show, with links to the studies themselves. There are direct aids to better sleep quality from various herbal and nutrient medicines, but the benefits from other protocols in CIM/TCM are also very important to the patient with chronic sleep disorders, and none of these protocols demand that one stop utilizing standard treatment protocols. The goals of CIM/TCM therapy should be to be able to reduce dependency on problematic medications and CPAP device use eventually to insure better quality of life, less adverse side effects, and to prevent an array of associated health problems. Even if one is entirely satisfied with standard treatment, there is no denying that comorbid conditions need to be addressed with a more holistic plan.

Understanding the most Common herbal and nutrient sleep aids

While each of us wants the simplest and least expensive remedy for our health problems, this often leads to limited benefits, adaptation to the remedy, and frustration in the long run. Simple sleep aids provide us with safe and valuable tools, but often do not solve the problem. A professional assessment and treatment of the underlying causes of insomnia are often needed for a fully successful course of therapy. Nevertheless, some very simple and benign herbal and nutrient medicines have been shown to be remarkably effective. These aids to improved sleep quality are not all that is offered in CIM/TCM, but they are an essential first line of care, and are not intended to be used daily, but only as needed, in the dose that is useful, not standardized. Misconceptions about these simple and benign sleep aid in herbal and nutrient medicine abound, and hopefully this information will clarify these medicines.

A 2015 study at the University of Hong Kong School of Chinese Medicine found that a majority of Chinese participants with chronic insomnia showed a positive outlook on their individual patterns of sleep, influenced by traditional concepts of sleep expectation, with expectations that aging and other natural conditions would alter the sleep pattern, leading to less anxiety about changing sleep patterns (PMID: 26391848). Such study mirrors recent advice from sleep experts in Western societies, that the expectation that all individuals should have the same amount of sleep and sleep patterns is counterproductive to achieving the best possible sleep quality, instead increasing sleep anxiety, which often creates poor quality of rest. A more individualized and holistic approach to sleep duration and quality is needed, and the one-size-fits-all approach with medications that often leave the patient impaired during the day is not a sensible approach. The goals in treatment for chronic insomnia in Complementary Medicine should not be limited to just achieving longer sleep in the short term, although many benign herbal and nutrient medicines are effective for this goal as well, but to actually achieve the best individualized quality of sleep possible, and to correct the health problems that are causing or associated with insomnia. These varied herbal and nutrient medicines for sleep need to be properly matched to the individual and of high quality, with correct dosage, and should fit into a broader and more holistic treatment protocol. Understanding the options is very helpful. The intelligent patient and Complementary Medicine physician will address the underlying health problems to solve this chronic health problem and prevent the array of alarming conditions that are clearly associated with chronic insomnia. Pharmaceutical sleep medications do not address these health issues, and integration of Complementary Medicine to treat chronic insomnia is very important. A clear history of discouragement of Integrative Medicine is seen in standard medicine, with the only clear goal to increase pharmaceutical profits. Making use of short courses of therapy with a TCM physician, or Licensed Acupuncturist and herbalist, as well as adopting better sleep hygiene habits, and perhaps utilizing short courses of Cognitive and Behavioral Therapy for Insomnia, is sensible, and may quickly and finally resolve insomnia and related health problems, and more importantly, provide each patient for the tools to achieve the best quality of sleep in the future without drug dependency.

Herbal medicine provides an array of options that need to be individualized in treating It is no coincidence that the 3 most popular herbal and nutrient medicines for insomnia and anxiety in the 1990s were attacked by the medical industry. St. John's Wort (Hypericum), Kava-kava (Piper myristicum), and the common amino acid L-tryptophan were all attacked with massive campaigns to convince the public and the medical professionals that there were dangers associated with use. These herbs have been used for many centuries without problems, but when they became so popularly effective that they dramatically cut into sales of benzodiazepine medications, they suddenly were found to be potentially hazardous by the medical industry. To date, there are virtually no cases of harm, only anecdotal evidence. Numerous scientific studies at prestigious universities in the United States have now concluded that these herbal chemicals present no danger with either toxicity or drug interactions. L-tryptophan, an amino acid found in all meat and many plant foods, was temporarily taken off the market when a contaminated batch led to the deaths of 3 individuals in the United States. The Centers for Disease Control and Prevention (CDC) quickly found that the cause of death was a bacteria that had mysteriously contaminated the manufacturer in Japan. Despite this fact, the temporary ban was not lifted for about 9 years, while all other countries in the world allowed the free purchase of L-tryptophan. Despite the fact that an essential amino acid that was part of our normal food chain and physiology could not be a toxic substance, medical doctors continue, even today, to insist that L-tryptophan is potentially dangerous, and the FDA continues to provide indeterminant guidance. This cynical and unscientific advice is perhaps the greatest example of how deception has become a common part of medicine today, and how it relates only to profit, not patient benefits.

Tryptophan is one of the 20 standard amino acids that comprise food proteins, and is an essential amino acid, meaning that we need to get this molecule from food, and that our bodies depend on it but cannot manufacture the amino acid in sufficient quantity to maintain health. This is why it is called essential. The synthesis of tryptophan as a nutrient medicine was achieved in 1901, and the use of the supplement was common throughout most of the twentieth century. Tryptophan serves as the biochemical precursor to a number of important protein molecules in the body, including serotonin, niacin, and auxin. When genetic or immune problems lead to poor absorption of tryptophan, reduced blood plasma levels cause depression. This may occur in lactose intolerance as well as fructose intolerance. When malabsorption occurs, our symbiotic bacteria in the intestines, or biota, create the needed tryptophan. Decreased absorption coupled with an imbalance of normal symbiotic flora and fauna in the gut may lead to a tryptophan deficiency and symptoms of depression, anxiety and insomnia. Since a relatively high concentration of tryptophan is found in such foods as egg white, cod, soybean, pumpkin seed, and parmesan cheese, as well as meat, the possibility that there is a toxicity is nonexistent. Supplementation with L-tryptophan was found to be highly successful for a large percentage of patients that suffered from a deficiency, or who suffered from a deficiency of serotonin or niacin in the brain. A metabolite of tryptophan, 5HTP (5-hydroxytryptophan), has been found to readily metabolize into either tryptophan or melatonin as needed in the brain, and this supplement, a chemical found in the Chinese herb Griffonia seed, has also been found to be helpful in the treatment of insomnia. Both L-tryptophan and 5HTP readily cross the blood-brain barrier to reach our central nervous system. Since the regulation and modulation of neurotransmitters is so controlled and labile in our brains, though, a simple dosing with tryptophan or 5HTP may not alter the balance of neurotransmitters in the brain dramatically. This type of supplementation, within a more complete treatment protocol, though, can provide the bioavailability of creation and modulation of neurotransmitters to achieve a normal homeostatic balance.

St. John's Wort, or Hypericum perforatum, is one of about 370 species of hypericum tree found growing around the world. The leaves and flowers are used as medicinal extracts, and two species of hypericum, japonicum and triquetrifolium, are used in common Chinese herbology. In China, Hypericum japonicum whole plant extract contains the antioxidants quercetin and quercitrin, and glycosides provide detoxificant, heat and phlegm clearing action, and the herb is used to treat hepatitis and other liver ailments, and serves to induce greater bile flow (choleretic). The herb Hypericum triquetrifolium or chinensis, Jin ci tau, contains aromatic compounds, hypericin, diones etc., and the glycoside hyperin, as well as a valuable essential oil, that is similar to the type of St. John's Wort we use now in the United States as a treatment of insomnia and mild depression. Research in China has also found that this Hypericum extract can prevent retroviral diseases such as HIV, and acts as a anti-viral medication as well. The herbal extract is a valuable treatment for hepatitis. In Germany, St. John's Wort is now commonly prescribed for mild depression and supported in medical guidelines with evidence from stage 3 human clinical randomized trials. In the United States, the greatest problem with the herbal extract is the lack of standardization and regulation, which leads to many products being of poor quality. Use of an assured professional product is recommended for an assured effect. Hypericum perforatum extract is believed to have a broad effect on neurotransmitter regulation in the brain, acting as a serotonin reuptake inhibitor, as well as a reuptake inhibitor of 5-HT, dopamine, and norepinephrine (noradrenaline), but in a modulatory manner. Hyperforin, a chemical constituent, has also been shown to have an affinity for GABA and glutamate receptors, helping to calm mood fluctuation and neuroexcitotoxicity. Standardized extracts are not recommended, as the other chemicals in St. John's Wort also are found to exert antidepressive and calming effects, and the synergy of chemicals is thought to be better than a single chemical in the herb. Extracts of Passiflora, which are also approved as a treatment for insomnia in Germany, are shown to enhance the utilization of Hypericum chemicals in the brain.

The goals of therapy with these herbal and nutrient chemicals is to provide the brain with an increased bioavailability of neurotransmitters, a modulatory effect that increases homeostatic balance of neurotransmitters, and a calming of mood excitability. This should be accomplished with a minimum effective dosage, which is variable between individuals. Starting with a low dosage, and increasing the dosage until the desired effect occurs is recommended. Recent research has found that a combination of herbal and nutrient chemicals may aid the homeostatic metabolism better, with a lower dosage. The combination of 5-HTP, P5P (a Vitamin B6 needed in the metabolic cycle), St. John's Wort, and melatonin, is often the most effective formula to treat insomnia. High-quality professional products are essential to success as the U.S. FDA does not regulate these products.

Melatonin is probably now the most well-known aid to sleep. Melatonin, or more properly, N-acetyl-5-methoxytryptamine, is a chemical that is naturally produced in the human brain, and also manufactured in plants and microbes. Melatonin acts as both a hormone and neurotransmitter, and as research progresses on this chemical, we find that it is a very valuable molecule for a wide array of processes in the body, modulating circadian rhythms (day-night changes) of many important chemicals in the body, acting as an important antioxidant, aiding immune processes, aiding central nervous system functions, such as memory, learning, and control of motor coordination, aiding thyroid function, fertility, and of course sleep. The pineal gland in the central brain produces a quantity of melatonin from 5-HTP or other neurotransmitters, when we need to fall asleep, so that our brain functions change to accommodate the sleep cycle processes. Melatonin is now an adjunct treatment for insomnia, mood disorders, migraine and cluster headaches, ADHD (attention deficit and hyperactivity disorders), neurodegeneration (Alzheimer's), delirium, fertility, diurnal cortisol imbalances, neurotoxicity, and even cancer. Melatonin is found in a number of medicinal herbs, including Feverfew, St. John's Wort flower, Scutellaria baicalensis (Huang qin), Skullcap flower (Scutellaria lateriflora), fenugreek, fennel and mustard seeds, green cardamon seed, and even flax seed. The chemical is easily extracted from herbs and foods, and is readily available to the brain. The quality of melatonin in commercial supplements is suspect, as well as actual dosage, in many cases, and a professional source is recommended. The effective melatonin dosage for adults is 3-10 mg, and should be taken a couple of hours before the desired time of sleep, and used daily to reestablish the diurnal clock, not as a calming aid to effect immediate sleep, like extracts of Valerian, Kava, California Poppy or Hypericum (St. John's Wort). While there is now a fear of potential adverse effects from higher dosage of melatonin, numerous scientific studies for decades have found no evidence of this, and it is suspected that commercial melatonin supplements may have added chemicals creating these effects.

Kava-Kava, or Piper methysticum, is a pepper plant whose roots have been used for many centuries in the Pacific islands as a relaxing drink that acts as a sedative as well a stimulating mental clarity. Meta-analysis of research of the kavalactones in Piper myethysticum by the Cochrane Collaboration Systematic Review database shows that this herbal extract is proven effective in clinical placebo-controlled human trials for social anxiety. Studies in Germany have shown that the widely reported potential for liver toxicity is low, and kava as a cause of hepatotoxicity is extremely unlikely. High dosage of Kava with more extreme alcohol consumption or liver impairment is still suspect for potential adverse effects on liver metabolism, but this has not been shown to be definitive in any actual clinical case. Kava is prescribed for short-term use with low dosage, though, which has virtually no possibility of adverse effects. As stated, the extreme campaign against this herbal extract when it became one of the most popular and effective medicines for insomnia and anxiety virtually eliminated it from the market, but no FDA warnings, cautions, or restrictions were actually implemented, and the prestigious German Commission E Monographs on herbal and drug interactions states that the use of Kava is safe. The 1998 German Commission E Monographs did not even mention liver disease in its discussion of Kava adverse effects, and the report of 4 potential cases that were unsubstantiated in 2001 prompted a thorough review of scientific evidence by this commission, which found no evidence of toxicity or adverse effects with normal dosage, and only a potential for slight drowsiness or motor impairment potentially affecting driving with a very high dosage combined with benzodiazepines.

The potential for herb-drug interactions theoretically exist because the herbal chemicals, like those in St. John's Wort, use the P450 catabolism pathway used by various pharmaceutical medications, but this has been thoroughly tested and discounted as well as likely to significantly effect circulating drug levels, which vary from individual to individual depending on the weight, general health, and level of function of the individual's liver. The fact that these drugs using the P450 pathway to break down the drug are routinely prescribed concurrantly appears to not register with prescribing doctors or patients when assessing this risk of altered circulating blood levels of drugs. The warnings in the Physician's Desk Reference (PDR) are routinely ignored by prescribing physicians concerning multiple prescriptions of pharmaceuticals that use the same catabolic pathways. No cases of actual injury from concurrent use of a low dosage of Kava with a pharmaceutical have been proven. A few cases of suspected liver toxicity in Switzerland in 2000 were studied and findings showed that the patients experienced an immune-mediated effect, possibly related to a genetic anomaly of an enzyme deficiency, resulting in a potential hypersensitivity reaction to a large dosing with a standardized acetone extract. These standardized acetone extracts are rarely prescribed since then, and high dosage prescription is very rare. Broad studies of Polynesian natives who regularly consumed kava drink noted no liver toxicity or adverse effect. What is unique in Kava use is that research has shown that a low effective dosage of Kavalactone will have an anxiolytic effect, while a large dose will have a stimulatory effect on the CNS. Therefore, for patients taking Kava to calm and sleep, the possibility of taking large dosages is just not going to happen.

A 2008 joint study of the six most widely reported herbal culprits in potential drug-herb interactions, St. John's Wort, Kava-kava, milk thistle, black cohosh, echinacea and goldenseal, by the Colleges of Medicine and Pharmacology at the Universities of Arkansas and Mississippi, found that evidence of inhibition of the P450 pathway of drug catabolism was found only in goldenseal. This study dealt with the CYP2D6 genetic isoform that expresses the enzymes involved in about 30% of all medication metabolism. The study involved three separate studies on humans, each with 18 participants that were randomized to receive standardized botanical extracts for 14 days on two separate occasions, with a 30-day period between the courses of herbal extract. The CYP expression was evaluated using administeration of a CYP2D6 substrate, debrisoquine 5mg, and measuring the catabolic rate with urinary analysis. The fact that the other five herbs, which have been widely reported over the years, unfairly, and without substantiation, to alter the circulating levels of key drugs prescribed, have been finally cleared of risk, is significant. Click here to see this study: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2562884; or if you have trouble accessing, click here: http://www.ncbi.nlm.nih.gov/pubmed/18214849

Kava thus is an effective medicine for insomnia, especially the type of insomnia associated with social anxiety or other anxiety disorders, works at a low dosage, and is inexpensive and safe. Besides the effects of calming anxiety, Kava-kava contains chemicals that are anti-inflammatory, analgesic, antispasmodic, and muscle relaxing. Chemicals in Kava also act as a mild MAO inhibitor (monoamine oxidase B inhibitor), which exerts anti-depressant effects. Considering the low effective dosage, Kava might be considered in a larger herbal and nutrient protocol. A combination of herbs and nutrients may work best, with dosage individualized, and short courses of acupuncture, as well as improved sleep hygiene habits will all act synergistically to achieve the best outcome.

Valeriana officianalis is another popular herbal sleep aid. Both the leaves and flowers, and the root, have been used medicinally, and contain different chemicals. A Valerian product may thus be varied in effect. The flowers and leaves during flowering contain potent anxiolytic chemicals, such as caffeic acid, but the root of the Valeriana contains valeric acid, the potent sleep aid, sedative, tranquilizing, muscle relaxant chemical that seems to be the most active aid to sleep and anxiety. Other chemicals in the root exert sedative, GABA inhibiting, and antiarrhythmic effects. The leaves also contain potent antioxidants such as quercetin, courmaric acid, and kaempferol. Valerian has been used as a remedy for insomnia since at least the time of the great Greek physicians Hippocrates and Galen, who wrote of it in about 300 BC. Scientific studies have shown that key chemicals have an affinity for the GABA receptors and may exert mild benzodiazepine effects, calming the brain. This is a popular herbal sleep aid since it promotes a deeper sleep without any drowsiness associated, and acts in a modulatory manner, sedating agitated patients and decreasing fatique in asthenic patients. Numerous studies of potential toxicity have revealed none, while a number of human placebo-controlled blinded studies have demonstrated significant effects on relieving insomnia symptoms, decreasing time to fall asleep, improving sleep quality, and decreasing awakenings.

California poppy leaf and flower, or Eschscholzia californica, extract is also now a popular sleep aid and anxiolytic. California poppy is a prolific wild plant on the west coast, is designated as the state flower, and the Antelope Valley California Poppy Reserve in northern Los Angeles County appears to become completely covered with these flowers during the peak bloom, covering 1745 acres. The chemicals in Eschscholzia californica appear to have an affinity for benzodiazepine receptors in the brain, exerting significant anxiolytic effects without side effects or toxicity. As the popularity of alcohol glycerite extracts of the leaf and flower became popular among naturopathic doctors and their patients, a report that it was illegal to harvest California poppy was widely disseminated and became a popular belief, although their is no law against picking or harvesting this state flower. This is a curious coincidence? California poppy extract has a number of beneficial chemicals, and although its anxiolytic effects are still poorly understood, it does contain berberine, a potent anti-inflammatory, zeaxanthin and rutin, anti-cancer chemicals, and mildly sedative and muscle relaxant chemicals as well. The popularity of California Poppy extract appears to be driven more by its clinical efficacy and patient popularity than scientific evidence. The overall benefits, as with many herbal extracts, are many, though.

The use of these simple sleep aids may have the best effect when the right combination of herbs and nutrients are combined, and especially when professional extracts are utilized to guarantee the right dosage and content of the pill or tincture. In addition, each individual patient may respond better with one or another of these sleep aids. Despite the obvious need to immediately relieve symtpoms of insomnia, though, the patient should be aware that a truly effective treatment will assess and treat the underlying causes and associated health problems. Even these effective sleep aids may have little effect if the patient is being kept awake by musculoskeletal and neuropathic pain, by the need to urinate at night due to prostate problems, by anxiety and depressive disorders, by hormonal imbalances and diurnal cortisol dysfunctions, by hyperthyroidism, by gastrointestinal complaints, by cardiovascular problems, by sleep bruxism and TMJ disorder, etc. The TCM physician is able to address any or all of these health problems in the therapy. Once these comorbidities are treated successfully, these simple sleep aids may be effective. In the end, treatment of the overall health will result in a better life as well as sounder sleep.

Evidence for acupuncture in the treatment of insomnia

Scientific study of the effects of acupuncture on the specific symptoms of a disease or injury present an incomplete picture. The effects of the acupuncture treatment provide the patient with a holistic stimulation of homeostatic mechanisms to restore the complete health, not just relieve the symptom. The characterization of acupuncture as a simple method to relieve a symptom, and often characterizations that acupuncture is only good for relieving the symptom of pain is a gross mistruth. Acupuncture stimulation is a part of a complete therapeutic protocol in Traditional Chinese Medicine, not the entire treatment, and TCM provides, by its very nature, a holistic and complete therapy that addresses the underlying causes of a disease or injury, as well as relief of the symptoms, utilizing herbal and nutrient medicine, advice on behavioral and cognitive changes, and physiotherapies if needed. The acupuncture stimulation may be just a part of a larger protocol, with the various treatment modalities working together to achieve a better outcome. This is not to say that acupuncture stimulation alone is not proven to treat the symptom of insomnia. On the contrary, human clinical placebo-controlled trials have proven its efficacy, but more importantly, as research progresses, the remarkable ways the acupuncture stimulation treats insomnia are revealed in in vitro and in vivo studies in the laboratory, with polysomnography, and with laboratory data.To see a 2009 meta-review of these high-quality randomized controlled human clinical trials that demonstrate that acupuncture is effective in the holistic treatment protocol for insomnia, click here: http://www.ncbi.nlm.nih.gov/pubmed/19922248 .

Examples of sound research with acupuncture in the treatment of insomnia are now numerous, although the number of double-blinded placebo-controlled large clinical trials published in standard medical journals are still few, although consistently positive. For example, in 2002, at the University of Pittsburgh, working with Kyung Hee University in Seoul, South Korea, a systematic review of the scientific studies was conducted, and the conclusion stated that acupuncture may be an effective intervention for the relief of insomnia. These researchers recognized that TCM and acupuncture sought to not only relieve the symptom, but to work on the underlying and associated health problems, and applauded this approach. The researchers stated: "As people age, they often experience insomnia, which can lead to more serious health problems. For example, if sleep is insufficient, fatigue and instability increase. These changes lead to physical and psychological weakness, which affects daily life and may bring about dangerous falls and fractures. Also depression and loneliness gradually get worse. Therefore, insomnia can produce various signs and symptoms leading to an unhealthy state. Many will seek medications to improve the quality of sleep. However, these drugs have the potential to be habit-forming and produce drug dependence; they may have a negative impact on a person's life. Other interventions, with fewer deleterious effects, for improving sleep are needed...Acupuncture therapy has the potential to produce a positive effect when used to treat insomnia (Sok 2001). Researchers in Korea have shown that using acupuncture for insomnia can produce clinically significant results" (Department of Acupuncture in Oriental Medicine 1994, Beon and An 1996, Sok and Kim 2000, Sok 2001). "The use of complementary therapies for insomnia may enable individuals to experience improved health and increase their quality of life." This study reviewed 189 separate scientific studies from all of the respected scientific medical databases. The criteria for inclusion was as strict as possible, and only 11 of these studies met this strict criteria. Most of these studies had under 100 participants, reflecting the problems with funding. The studies were conducted in clinical settings either in China or the United States. All of the studies focused on a relatively short course of therapy, with four focused on a course of therapy from 3 to 12 sessions, but the other 8 involving just one treatment. All of the studies demonstrated significant benefit. Since this meta-review in 2002, the quality and size of these studies have improved significantly.

In 2004, a study from the University of Toronto, Ontario, Canada, in coordination with the Sleep Research Laboratory and the Toronto Western Research Institute, measured the changes in endogenous melatonin secretion and various objective measures of sleep quality in response to acupuncture. Arousal index, sleep onset latency, total sleep time, and sleep efficiency were significantly improved with the acupuncture therapy, as measured with polysomnography, and anxiety scores were reduced significantly (D. Warren Spence et al; Acupuncture Increases Nocturnal Melatonin Secretion and Reduces Insomnia and Anxiety, J Neuropsychiatry Clin Neurosci 16:1 Winter 2004). Five weeks of acupuncture was performed on 18 subjects with insomnia and anxiety that had been continuous for at least 2 years. Melatonin metabolites in urine were measured diurnally, and the average concentration from midnight to 8 am increased from 24 to 35 aMT6s per Nmol. Questionaires gauging changes in concurrent depression and anxiety showed improvement as well.

Links to other acupuncture research and meta-analysis is presented below in additional information, with links to the study summaries. While the problems of study design with concocting a "placebo" acupuncture and blinding this to the physician performing acupuncture makes the study of acupuncture meeting the criteria of these pharmaceutical trials difficult, and there is insufficient funding for large clinical trials, nevertheless sound studies have consistently demonstrated benefits of a short course of acupuncture in the treatment of insomnia. The measurement of melatonin and other biochemical markers, the use of polysomnography, and the use of brain scans such as functional MRI to objectively measure these benefits insures that the benefits were not just subjective. Comparisons to standard pharmacological therapy shows better effects with these objective measurements of acupuncture over drugs, and of course no side effects or long-term adverse effects or dependency and withdrawal problems. While the clinical trial data is not ideal, is does offer proof of efficacy.

In recent years, electrical stimulation on the scalp, a common practice in acupuncture, has also demonstrated significant benefits. A meta-analysis of studies at Harvard University Medical College have shown with randomized sham controlled clinical trials that transcranial direct current electrical stimulation over the left temporal and parietal cortex produced significant benefits for insomnia, mood disorders, and CNS functionality. A low intensity milliampere stimulation for 5-30 minutes per session was used, comparable to the electroacupuncture commonly used (The Neuroscientist / Soroush Zaghi et al / 2009). Measurement of objective benefits included the use of EEG and laboratory measurement of biochemical metabolites in urine, and standard questionaires were used to measure efficacy as well. Electrical transcutaneous stimulators are now utilized in standard medicine and approved by the FDA, although insurance reimbursement is often limited to treatment of pain when a pain specialist cites a medical necessity. These studies too demonstrate that the use of electroacupuncture on the scalp and ear is a viable and effective mode of treatment.

As late as 2007, such esteemed sources of scientific meta-analysis as Cochrane, continued to report that despite large numbers of studies showing efficacy with acupuncture and electroacupuncture for insomnia, few of these were large studies, or met the highest standards of strict placebo-control and double-blinding of both the patients and treating physicians to whether the needle stimulation was real or a supposed 'placebo'. The summary of such analysis was that the research still did not sufficiently support acupuncture in standard treatment guidelines, but that this research did indicate that larger and more rigorous human clinical studies were needed and justified. Since 2007, most large medical research institutes have stated that these strict standards of supposed acupuncture placebo and double-blinding of both the patient and the treating physicians to the real versus sham acupuncture should be abandoned, as they produced impractical study designs and negatively affected outcomes, as well as preventing the investment in larger studies. Patients can now easily access supportive studies and see for themselves that acupuncture is indeed proven to work.

In 2012, a large multicenter randomized, controlled trial of the use of acupuncture point stimulation with acupressure, conducted in Taiwan at the Kaohsiung Kai-Suan Psychiatric Hospital, found that simple acupressure stimulation by nurses on geriatric patients before sleep at 3 points, shenmen (ulnar wrist, HT7), neiguan (2 inches up from the palmar wrist, between the tendons, PC6), and yongchuan (on the sole of the foot, behind the first and second metatarsal head, KI1), resulted in significant improvement over controls in all domains of subjective and objective sleep quality (PMID: 23302821). Other nursing studies in Taiwan have combined this simple point stimulation with Valerian root aromatherapy, also with significant improvements over controls in patient sleeping hours, waking frequency, and quality of sleep measured on the Stanford Sleepiness Scale (PMID: 22391336). The benefits of acupuncture stimulation are measurable even with this mild stimulation.

Serotonin and Other Neurotransmitters that Regulate Sleep: the role of chemical imbalance in the pathology of complex sleep apnea, and how to correct it

The neurotransmitters serotonin and norepinephrine (adrenaline) play an important role in the body and mind, and imbalance of these chemicals has been associated with sleep apnea and various negative health consequences of this disorder. Many anti-depressant and anti-anxiety medications have been created to achieve a higher level of these neurotransmitters in the brain tissues, such as Prozac, Cymbalta, Effexor etc. Many patients fear that chronic use of these SSNRIs have preceded the onset of sleep apnea, and are associated with the central pathology. Health experts have countered that SSNRIs could not cause sleep apnea because they actually reduce REM time, or deep sleep, the period that sleep apnea occurs. The analysis of central sleep apnea is still confounding researchers, though, and such simplistic reasoning is being questioned. There is a big problem with the limited effectiveness of the anti-depressants, as well as a big problem with an addictive cycle, as patients often have severe symptoms when trying to go off of these drugs. Many psychopharmacologists are also concerned that chronic use of SSNRIs are creating a greater usage of available serotonin and norepinephrine in the brain by blocking reuptake, but do not address the deficiencies and imbalances. Many doctors are now prescribing 5HTP and other nutrient and herbal supplements along with the drugs to try to reestablish a greater bioavailability and feedback balance of neurotransmitters in the brain.

Serotonin is created in the cells of the body, throughout the body and brain, from the amino acid tryptophan. L-tryptophan is an essential amino acid, meaning that it must be obtained from the diet and cannot be adequately manufactured in the body. Use of L-tryptophan by physicians has achieved great success in the treatment of depression and anxiety, and is used by many psychiatrists when their patients prove resistant to the serotonin reuptake inhibitors commonly prescribed. Serotonin, dopamine and norepinephrine are neurotransmitters that may also play a significant role in the mechanisms of central and complex sleep apnea disorders. Serotonin, tryptophan, and the precursor 5HTP (5-dydroxytryptophan precursor), are part of a metabolic mechanism associated with maintaining the right levels of the neurohormone melatonin, another tryptophan metabolite. While melatonin was associated mainly with the sleep cycle in the past, research in recent years has uncovered its powerful effects throughout the body, its potent antioxidant activity in the brain, and its relationship to the diurnal hormonal metabolism. Correct use of melatonin requires a low dose of 3-10 mg for adults taken daily about 2-13 hours before the desired sleep time to help reset the diurnal clock, until the desired effect. The common belief that melatonin is useful purely as a supplement to induce immediate sleep has been proven to be a wrong assumption.

High levels of circulating catecholamines, or neurohormonal mediators secreted by the adrenal gland, are associated with sleep apnea. Chronic stress may induce a condition called adrenal fatique, and levels of adrenal mediators, called adrenaline in the past, and now referred to mainly as norepinephrine and cortisol, are not maintained at proper levels in a diurnal cycle (night/day). Sluggish adrenal response will often create a situation of excess cortisol during the night, causing insomnia, non-restful sleep, and anxiety, and depressed cortisol levels during the day, causing sluggishness, fatique, and slow mental response. This upset of the diurnal neurohormonal balance may have a direct as well as indirect effect on sleep apnea. Clinical adrenal pathology, such as pheochromocytomas, produce excess catecholamines and are highly associated with sleep apnea. In a similar way, subclinical adrenal fatique syndromes may also be integral to the complex pathology.

Research in 2007, cited below, revealed that excessive catecholamines have been noted in patients prescribed antidepressants. Tricyclic antidepressants and phenoxybenzamine are most implicated, but selective serotonin and norepinephrine reuptake inhibitors (SNRIs) have now also been implicated in cases of medication induced high catecholamine levels, which are noticed as false positives on tests for phiochromocytomas. 40% of these false positive results of tests for adrenal tumors are attributed to these drugs. The implications are that chronic use of these antidepressants may be indirectly associated with sleep apnea disorders, and that imbalances related to serotonin, norepinephrine, and melatonin may be central to the causative mechanisms of sleep apnea. Restoration of a natural balance of catecholamines may have a positive effect on sleep apnea. Use of natural precursors and other chemicals that help achieve a bioavailability of these neurotransmitters is an alternative to synthetic drugs that block reuptake etc. Many patients have found success by holistic restoration of health and by establising a health bioavailability of the chemistry needed for your system to achieve proper balance.

One novel therapeutic supplement now being used is a low dose combination of Vitamin B6, 5HTP, St. John's Wort, and melatonin. These four supplements act synergistically to allow your brain to better regulate the diurnal and feedback levels of neurohormones and neurotransmitters in the brain. The goal of such therapy is to eventually restablish a healthy balance and homeostasis.

Some novel therapeutic aids used to reestablish a healthy bioavailability of neurotransmitters are listed here:

  • Vitamin B6 is needed to produce serotonin, and the active form is P5P (pyroxidal 5-phosphate).
  • 5HTP from griffonia seed is a precursor to L-tryptophan and is able to cross the blood brain barrier to enter the brain tissue. 5-hydroxy tryptophan precursor also is associated with 5HT receptor types, and thus has broad modulating effects, providing tryptophan and melatonin as needed, affecting the balance of serotonin receptor metabolism, and other beneficial effects throughout the body
  • Tryptophan is found in the foods oats (steel cut unprocessed), bananas, dried dates, milk, yoghurt, cottage cheese, red meat, eggs, fish, poultry, sesame seed, chickpeas, sunflower seeds, pumpkin seeds, spirulina and peanuts. It may also be taken as an amino acid supplement, or tryptophan precursor 5HTP (extracted from griffonia seeds) may be taken to increase bioavailability in the brain.
  • Tryptophan is a complex carbohydrate with nitric oxide added. Increased or decreased nitric oxide may have implications on the bioavailability of tryptophan amino acid as an available precursor to serotonin or melatonin in the brain.
  • L-Arginine is an amino acid that is a precursor to the healthy formation and bioavailability of nitric oxide. The steady-state bioavailability of nitric oxide is determined by both its rate of formation and its rate of decomposition, and a number of chemicals contribute to a better nitic oxide metabolism in the brain and arterial tissues. Antioxidants such as superoxide dismutase have been shown to protect nitric oxide availability in the arterial endothelium, and increased concentration of free radical oxidants has been shown to decrease the nitric oxide availability. Niacin and niacin metabolites have been shown to aid nitric oxide bioavailability, and thus have been a benefit to cardiovascular health as well.
  • Melatonin is a hormone that is related to serotonin and is secreted in the diurnal cycle (day-night) to affect sleep cycles and hormonal balance in the diurnal cycle. There is a strong system of balance, or homeostasis, that the brain tries to maintain, and to promote this healthy balance, a number of factors may need to be addressed with nutrient and herbal medicine. The neurohormones GABA and dopamine are also related in this balanced equation. In addition, melatonin is a key antioxidant in the brain.