Insomnia, also known as sleeplessness, is a sleep disorder where people have trouble sleeping. They may have difficulty falling asleep, or staying asleep as long as desired.
According to a survey by the Office of National Statistics (ONS 2000), around 29% of adults reported experiencing sleep problems the week before interview. Such problems are more common in women (34%) than men (24%) (ONS 2000).
Insomnia that is not due to an organic cause is defined as a condition of unsatisfactory quantity and/or quality of sleep lasting for a considerable period of time (WHO 2007). It includes difficulty falling asleep, difficulty staying asleep, or early final wakening (WHO 2007; American Psychiatric Association, 2000).
Symptoms of insomnia:
• Difficulty falling asleep despite being tired
• Waking up frequently during the night
• Trouble getting back to sleep when awakened
• Unrefreshing sleep
• Relying on sleeping pills or alcohol to fall asleep
• Waking up too early in the morning
• Daytime drowsiness, fatigue, or irritability
• Difficulty concentrating during the day
Causes of insomnia
Causes of acute insomnia can include:
• Significant life stress (such as losing or changing your job, death of a loved one, divorce, moving home).
• Emotional or physical discomfort.
• Environmental factors like noise, light or extreme temperatures (hot or cold) that interfere with sleep.
• Some medicines (for example those used to treat colds, allergies, depression, high blood pressure and asthma) may interfere with sleep.
• Interferences in your normal sleep routine (such as jet lag or switching from a day to night shift).
Causes of chronic insomnia include:
• Chronic stress
• Pain or discomfort at night.
The choice of treatments for insomnia depends on both the duration and nature of presenting symptoms. People should be given advice on appropriate routines to encourage good sleep, such as avoiding stimulants and maintaining regular sleeping hours with a suitable environment for sleep (NICE 2004). Other non-pharmacological interventions, such as cognitive behavioural therapy, are used for the management of persistent insomnia (NICE 2004). Drugs to induce sleep (hypnotics) can provide relief from the symptoms of insomnia, but do not treat any underlying cause. Expert bodies have long advised that use of hypnotics for insomnia should be limited to short courses for acutely distressed patients (Joint Formulary Committee 2009).
Despite this, in England, around 10 million prescriptions for hypnotics are dispensed every year (PCA 2007). Around 80% of all such prescriptions are for people aged 65 years or over (Curren 2003), and many patients remain on the drugs for months or years (Taylor 1998). Such prescribing carries many potential hazards for patients, including risk of dependence, accidents and other adverse effects on health (Joint Formulary Committee 2009).
How acupuncture can help
Reviews are consistent in showing that most trials have found acupuncture (or acupressure or related procedures) to be significantly more effective than hypnotic drugs (usually benzodiazepines), no treatment, or sham acupuncture (Sun 2010, Cao 2009, Yeung 2009, Lee 2008, Cheuk 2007). Meta-analysis supports these conclusions.
In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body's homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the 'analytical' brain, which is responsible for insomnia and anxiety (Hui 2010).
Research has shown that acupuncture treatment may specifically be of benefit in people with insomnia by:
• increasing nocturnal endogenous melatonin secretion (Spence et al 2004).
• stimulating opioid (especially b-endorphin) production and µ-opioid receptor activity (Cheng et al 2009).
• increasing nitric oxide synthase activity and nitric oxide content, helping to promote normal function of brain tissues, which could help to regulate sleep (Gao et al 2007).
• increasing cerebral blood flow (Yan 2010)
• reducing sympathetic nervous system activity, hence increasing relaxation (Lee 2009a)
• regulating levels of neurotransmitters (or their modulators) such as serotonin, noradrenaline, dopamine, GABA and neuropeptide Y; hence altering the brains's mood chemistry to help to increase relaxation and reduce tension (Lee 2009b; Samuels 2008; Zhou 2008).
Acupuncture can be safely combined with conventional medical treatments for insomnia, such as benzodiazepines, helping to reduce their side effects and enhance their beneficial effects (Cao et al 2009).
American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders (4th Ed., Text Revision). Washington DC: American Psychiatric Association.
Curran HV et al. Older adults and withdrawal from benzodiazepine hypnotics in general practice: effects on cognitive function, sleep, mood and quality of life. Psychol Med 2003; 33: 1223-37.
Joint Formulary Committee. British National Formulary. Edition 58. London: Royal Pharmaceutical Society of Great Britain and British Medical Association, September 2009.
[online]. Technology appraisal 77. Available: http://www.nice.org.uk/nicemedia/pdf/TA077fullguidance.pdf
Office of National Statistics 2000. Psychiatric Morbidity among Adults living in Private Households. [online] Available: http://www.statistics.gov.uk/downloads/theme_health/psychmorb.pdf
Prescription cost analysis (PCA). 2007 [online]. Available: http://www.ic.nhs.uk/cmsincludes/_process_document.asp?sPublicationID=1206971516809&sDocID=3884.
Taylor S et al. Extent and appropriateness of benzodiazepine use. Results from an elderly urban community. Br J Psychiatry 1998; 173: 433-8.
What's wrong with prescribing hypnotics? Drug and Therapeutics Bulletin 2004; 42:89-93.
World Health Organization 2007. International Statistical Classification of Disease 10th revision (ICD-10) [online]. Available: http://apps.who.int/classifications/apps/icd/icd10online/