針 灸 與 中 藥 預 防 及 治 療 失 眠 Prevention and treatment for insomnia using acupuncture and/or Chinese herbal medicine

針 灸 與 中 藥 預 防 及 治 療 失 眠 Prevention and treatment for insomnia using acupuncture and/or Chinese herbal medicine Dr. Chung Ka Fai Associate Professor Department of Psychiatry, University of Hong Kong 香 港 大 學 精 神 醫 學 系 臨 床 副 教 授 鍾 家 輝 醫 生

Epidemiology Around 9-15% in the general population suffer from insomnia symptoms, including difficulty initiating sleep ( 難 入 睡 ), maintaining sleep ( 難 維 持 睡 眠 ) and non-restorative sleep ( 睡 醒 後 不 能 得 到 休 息 ) that are associated with daytime consequences.

Consequences of Insomnia 失 眠 導 致 的 問 題 - Depression/ anxiety/suicide - Alcohol and drug abuse or dependence - Pain - Fatigue, irritability, impaired concentration, - Traffic accidents Hypertension Reduced quality of life and immune functions Heart disease Obesity

Treatment for insomnia 失 眠 的 治 療 Prescribed drugs 處 方 藥 物 (Benzodiazepine, Zopiclone, Zolpidem, Trazodone) Over-the-counter drugs 非 處 方 藥 物 (Promethazine, Melatonin, Western herbs) TCM 中 醫 (Chinese herbal formula, acupuncture, others) Cognitive behavioral therapy 認 知 行 為 治 療 Other complementary and alternative medicine therapies 另 類 療 法

How we have studied the TCM treatments for insomnia 我 們 過 往 有 關 中 醫 治 療 失 眠 的 研 究 Systematic reviews ( 系 統 性 文 獻 回 顧 ) Randomized placebo-controlled trials ( 隨 機 安 慰 對 照 研 究 ) Pragmatic randomized clinical trials in TCM settings ( 實 用 性 中 醫 臨 床 試 驗 )

Conclusion 結 論 The majority of the previous studies were of low methodological quality. In general, the TCM treatments were shown to produce better sleep than placebo, Western medication, psychotherapy, and non-treated controls. There was insufficient high-quality evidence and therefore better designed studies were needed.

Traditional Acupuncture Group Acupoints selected 傳 統 針 灸 組 bilateral Ear Shenmen ( 神 門 ), Sishencong EX-HN1 ( 四 神 聰 ), Anmian ( 安 眠 ) EX, and unilateral Yintang EX-HN3 ( 印 堂 ) and Baihui GV20 ( 百 會 ).

Minimal Acupuncture Group 微 針 灸 組 Superficial needling at non-acupoints ( 非 穴 位 位 置 淺 針 ) Deltoideus Upper arm

Minimal Acupuncture Group 微 針 灸 組 Forearm Lower Leg

Placebo Acupuncture Group 安 慰 針 灸 組 Placebo Acupuncture Non-invasive telescopic placebo needles ( 非 穿 透 性 伸 縮 安 慰 針 ) designed by Streitberger (1998) were used Blunt tip Handle slides over the needle without penetrating the skin

Therapeutic components Specific Acupoint 準 確 穴 位 位 置 De qi effect & deep needling 得 氣 及 深 刺 Electric stimulation 電 刺 激 Skin penetration 穿 透 皮 膚 構 成 治 療 要 素 Traditional Acup 中 醫 針 灸 Minimal Acup 微 針 灸 Placebo Acup 安 慰 針 Placebo effect 安 慰 作 用

Outcome assessment Sleep diary ( 睡 眠 日 記 ) 結 果 評 估 Subjective insomnia scales ( 主 觀 睡 眠 測 量 ) Actigraph ( 腕 動 計 ) - Estimate sleep pattern by recording patient s wrist movement for 3 consecutive nights

Sleep Efficiency % 100 Sleep Sleep Efficiency Measured by Sleep Diary Diary 睡 眠 日 記 量 度 的 睡 眠 效 率 Acupuncture Placebo 90 # 80 70 60 Baseline Week 1 Week 2 Week 3 1-week Posttreatment # Electroacupuncture group showed a significantly greater SE at 1-week posttreatment when compared with the Placebo Acupuncture group (P = 0.002, ANCOVA using baseline measure as a covariate) Sleep Efficiency = Total Sleep Time / Total Bed Time 100%

Total Score 20 19 18 17 16 15 14 13 12 11 10 Insomnia Severity Index (ISI) Score 失 眠 嚴 重 指 數 Insomnia Severity Index (ISI) score Acupuncture Placebo Baseline Week2 Week 3 1- week Posttreatment No significant difference between Electroacupuncture and Placebo Acupuncture groups

Sleep Efficiency % Sleep Efficiency Measured by Actigraphy 腕 動 計 量 度 的 睡 眠 效 率 # Baseline 1-week Posttreatment # Electroacupuncture group showed a significantly greater SE at 1-week posttreatment when compared with the Placebo Acupuncture group (P = 0.04, ANCOVA using baseline measure as a covariate)

Total Score Insomnia Severity Index (ISI) Score 失 眠 嚴 重 指 數 22 20 Treatment period 18 16 14 12 * * * * 10 Baseline Week 1 Week 2 End of treatment 1-week Posttreatment 4-week Posttreatment * Electroacupuncture and Minimal Acupuncture groups showed a significantly greater ISI improvement when compared with the Placebo Acupuncture group (Mixed effects model, P =0.04)

Sleep Efficiency (%) Sleep Efficiency Measured by Sleep Diary 睡 眠 日 記 量 度 的 睡 眠 效 率 90 Treatment period 80 * 70 60 Baseline Week 1 Week 2 End of treatment 1-week Posttreatment 4-week Posttreatment * Minimal Acupuncture groups showed a significantly greater SE when compared with the Placebo Acupuncture group (Mixed effects model, P =0.01)

Sleep Efficiency (%) Sleep Efficiency Measured by Actigraphy 腕 動 計 量 度 的 睡 眠 效 率 100 90 80 Baseline 1-week Posttreatment 4-week Posttreatment No significant difference between the Electroacupuncture, Minimal Acupuncture, and Placebo Acupuncture groups (Mixed effects model, P > 0.05)

Conclusion 結 論 Electroacupuncture and minimal acupuncture were more effective than placebo acupuncture in treating insomnia. There were no significant differences between electroacupuncture and minimal acupuncture in all outcome measures. Adverse events related to acupuncture were mild in severity.

Other Completed / Ongoing / Planned studies 其 他 已 完 成 / 進 行 中 / 計 劃 中 的 研 究 Systematic review on the classification of insomnia using the TCM system Systematic review on pattern-based TCM treatment of insomnia Randomized placebo-controlled trial to compare traditional and minimal acupuncture that used compatible acupuncture sites Randomized placebo-controlled trial to compare the efficacy and safety of Gui Pi Tang ( 歸 脾 湯 ), Suan Zao Ren Tang ( 酸 棗 仁 湯 ) and Tian Wang Bu Xin Dan ( 天 王 補 心 丹 ) for insomnia

Future studies 今 後 研 究 Pragmatic clinical trial to compare individualized therapist-prescribed patternbased acupuncture ( 醫 師 辨 證 取 穴 ) vs. standardized acupuncture ( 標 準 統 一 取 穴 ) for insomnia

Acknowledgement 致 謝 Dr. Jerry WF Yeung 楊 頴 輝 醫 師 / 博 士 Dr. SP Zhang 張 世 平 醫 師 / 博 士 Dr. ZJ Zhang 張 樟 進 醫 師 / 博 士