Acupuncture for Insomnia: An Update

This summer I saw a cousin of mine who lives in San Francisco. He was using acupuncture for insomnia and happy with the results.

I’ve always wondered about acupuncture as a potential treatment for insomnia, so now and then I check the literature. Here’s a summary of recent thinking about it.

Insomnia may respond to acupuncture treatmentsThis summer I saw a cousin of mine who lives in San Francisco. He was using acupuncture for insomnia and happy with the results.

Back when I lived on the West Coast, I tried acupuncture for help in managing stress (the usual trigger for my insomnia) and also got results. A single session of acupuncture—followed by use of foul-smelling herbs I was to boil and drink as tea—really helped to calm me down.

I still wonder about acupuncture as a potential treatment for insomnia, so now and then I check the literature. Here’s a summary of recent thinking about it.

Why Might Acupuncture Work for Insomnia?

The underlying problem for people with insomnia is said to be hyperarousal. Insomniacs’ brains are unusually active at night, suggesting hyperarousal of the central nervous system. Whether and how acupuncture could calm the brain is yet to be worked out.

There’s also evidence that insomniacs are more physiologically aroused than normal sleepers. We tend to have elevated metabolic rates and, at night, lower heart rate variability, suggesting involvement of the autonomic nervous system (the system controlling things we can’t consciously direct, such as breathing and heartbeat). Hyperarousal in insomniacs suggests too much activity of the sympathetic branch of the autonomic nervous system (associated with stress and the fight-or-flight response).

Acupuncture has a direct effect on the autonomic nervous system, say Wei Huang and colleagues at the Emory University School of Medicine. It’s been shown to influence known indicators of autonomic activities such as blood pressure, heart rate, and heart rate variability. It’s used to manage cardiovascular diseases such as hypertension and cardiac arrhythmia. It’s also been shown to regulate neurotransmitters and hormones important to the sleep–wake cycle.

Acupuncture may work by tamping down the physiological arousal that makes it harder for insomniacs to go to sleep and stay asleep at night. But how it does so remains unknown.

What About Clinical Trials?

Some reviewers have found that acupuncture has overall positive effects on sleep. Study participants have reported that acupuncture helps them:

  • Fall asleep more quickly
  • Sleep more efficiently
  • Sleep longer
  • Have better-quality sleep

Other reviewers have not found convincing evidence that acupuncture helps people sleep longer or better. A survey of literature through 2011 concludes that there’s not enough “high-quality evidence” either to support or refute acupuncture as an effective treatment for insomnia.

A Standard Hard to Meet

By high-quality evidence reviewers often mean the results of double-blinded, randomized clinical trials—the gold standard for studies of a treatment on human beings. This type of study involves comparing an active treatment to a sham treatment (a medication to a placebo pill, for example), assigning participants to either the active treatment or the placebo treatment in a random manner, and making sure that neither participants nor clinicians know who’s getting what.

This standard is hard to meet in studies of acupuncture, David Mischoulon says in a commentary in the Journal of Clinical Psychiatry. Fake acupuncture—needles placed in positions known not to affect sleep, or acupuncture with nonpenetrating needles—is often used as a sham treatment. But acupuncture practitioners always know whether they’re administering active or fake treatment and may subtly communicate this to trial participants, compromising study results.

Also, the contribution of the “placebo effect” to acupuncture study results is apparently considerable. Says Mischoulon, “We found that believing that one was receiving an active intervention seemed to correlate with clinical improvements more so than which intervention was actually received.”

Mischoulon and others have proposed different types of sham treatments for use in future acupuncture trials. Hopefully they will supply the high-quality evidence needed to settle the issue of whether and in which situations acupuncture might work as a treatment for insomnia.

Different Acupuncture Points

Meanwhile, other researchers have trained their attention on which acupuncture points seem to help insomniacs the most. These are believed to have calming effects:

  • PC-4 Ximen (in the middle of the forearm with palm side up)
  • GV-14 Dazhui (on the back at the base of the neck)
  • PC-6 Neiguan (just above the wrist with palm side up)
  • EX-HN1 Sishencong (at the top of the head)
  • BL-15 Xinshu (on the upper back just right of the spine)

In summary, the evidence on acupuncture’s effectiveness for insomnia is still mixed. But it’s got one big advantage over sleeping pills. Its safety and lack of side effects have been demonstrated again and again.

If you’ve tried acupuncture for relief from insomnia, please let us know how it worked.

Sleep Tracking? No. Now It’s Sleep Training

You can train to run a marathon. You can train yourself to recognize Chopin. But can you train yourself to sleep (or train yourself not to have insomnia)?

Michael Schwartz, creator of the Sleep On Cue iPhone app, says yes.

Insomnia sufferers may learn how to sleep with this iPhone appYou can train to run a marathon. You can train yourself to recognize Chopin. But can you train yourself to sleep (or train yourself not to have insomnia)?

Michael Schwartz, creator of the Sleep On Cue iPhone app, says yes.

Sleep training “appears to work via conditioning,” Schwartz said in a recent email exchange. “People ‘learn’ the act of falling asleep. I have found it to be helpful for those who struggle to fall asleep initially and/or struggle to return to sleep during the night.”

But why do insomniacs need to learn to sleep when for most people sleep is effortless?

Intensive Sleep Retraining

The idea of sleep training is based on intensive sleep retraining (ISR), an insomnia treatment originally developed by sleep researchers in Australia. It grew out of sleep studies showing that many insomniacs fall asleep more quickly and sleep longer than we think we do.

Schwartz has observed this phenomenon firsthand in his work as a registered sleep technologist in the United States.

“It seems [that insomniacs] who are taking a traditional hypnotic . . . tend to overestimate sleep time,” he says. “Then if the insomniac begins a tapering of the medication, it swings to an underestimation of sleep time.”

Unlearning and Relearning Sleep

The question of why so many insomniacs tend to underestimate sleep time has not been definitively answered. ISR proponents suggest that insomniacs’ trouble sleeping is conditioned, resulting from poor sleep habits, worry about sleep loss, and negative beliefs about sleep. Eventually we lose touch with what falling asleep actually feels like.

So the goal of treatment is to retrain insomnia sufferers in the experience of falling asleep. Proponents claim that sufficient practice (within the prescribed protocol) will make our perceptions more accurate (i.e., more in sync with objective sleep tests, which indicate we’re sleeping longer) and restore confidence in our ability to sleep.

The Challenge and the Payoff

The ISR treatment as originally prescribed is short but onerous. You spend 25 nearly sleepless hours in a sleep lab. Every 30 minutes, you get a chance to fall asleep (and if you fall asleep, you’re woken up). At the end of the 25-hour period, you’ve had lots of practice falling asleep . . . and you’re very sleep deprived.

But after the initial 25 hours the benefits of ISR are immediate. With loads of sleep pressure built up by the next night and instructions on how to proceed, insomniacs who undergo ISR have experienced improved sleep starting at Day 2. The gains continue, research has shown, for at least 6 months.

A Sleep Training App

An insomnia treatment that involves wiring patients up in a sleep lab and round-the-clock supervision by sleep technicians is very expensive (which may be the reason nobody’s doing ISR in the United States). So when a call came out to get ISR out of the lab and make it available to insomniacs at home, Schwartz went to work.

“After reading the ‘call to action’ article by the notable insomnia researchers, I began thinking about how to detect sleep onset without expensive amplified EEG recording,” Schwartz said. He came up with several ideas before landing on the idea of an iPhone app.

“My ‘ah-ha’ was to realize that a call (tone) and response (slight movement) with a smartphone might be the ticket,” Schwartz said, “and it seems to work well.” Here’s how:

  • You lie down in bed holding your iPhone. Each time the phone emits a tone, you shake it slightly.
  • If the app doesn’t detect a shake, it assumes you’re asleep and vibrates to wake you up.
  • A message then comes on the screen: “Do you think you fell asleep?” You press yes or no.
  • You’re then instructed to leave the bed for a few minutes. The phone vibrates again to indicate when to return to the bed for the next sleep trial.
  • You decide when to end each training session. The screen then displays a graph with information about your sleep ability and your awareness of your sleep.

Modified ISR

The Sleep On Cue protocol is very similar to the ISR protocol, allowing for repeated, short sleep onset opportunities with sleep–wake estimation and confirmation. But Schwartz felt he needed to make ISR more palatable for home users.

“So I decided to reduce each sleep trial time slightly after each successful sleep attempt, as well as to prompt the user to leave the bed for just a couple minutes between sleep trials,” he said. “These two features allow more sleep trials in a shorter amount of time.

“I suggest . . . that sleep training should be done around bedtime for a couple of hours following any poor night of sleep. So maybe 10 sleep trials. Put the phone down and go to sleep when done, review the summary graph in the morning.”

Testimonials on the Sleep On Cue website suggest the app has been helpful for users, including users coming off sleeping pills. According to Schwartz, tests verifying the accuracy and clinical effectiveness of a modified version of the app are under way in Australia right now.

“The best user of my app is someone who is committed to sleep training,” he said, “who can grasp the idea of ISR and how it can help.”

If you try this app, let us know how you fare.

Tart Cherries: Helpful to Sleep but Harder to Find?

First, the good news: a small body of research suggests that tart cherry juice holds promise as an alternative treatment for insomnia, especially in older adults.

Now for the bad news: tart cherry juice, already pricey, is set to become pricier still as growers weigh whether to give up on cherries and plant apple trees instead. Here’s more on the benefits of tart cherry juice for sleep and why it may soon become scarce.

Insomnia, alternative treatment tart cherry juice not so plentifulFirst, the good news: a small body of research suggests that tart cherry juice holds promise as an alternative treatment for insomnia, especially in older adults.

Now for the bad news: tart cherry juice, already pricey, is set to become pricier still as growers weigh whether to give up on cherries and plant apple trees instead. Here’s more on the benefits of tart cherry juice for sleep and why it may soon become scarce.

Sleep Benefits of Tart Cherry Juice

A handful of studies conducted on the effects of tart, or Montmorency, cherry juice on sleep suggest it may be helpful for people with insomnia:

  • It may help you sleep longer. In a randomized controlled trial (RCT) published in 2012, drinking tart cherry juice concentrate mixed with 8 oz. of water twice daily for 7 days increased the total sleep time of 20 healthy volunteers by an average of 39 minutes.
  • Seven older adults with insomnia slept over an hour longer after 2 weeks of drinking 8 oz. of tart cherry juice twice a day. Results of a randomized crossover trial presented at the 2014 meeting of the American Society of Nutrition (still unpublished) showed that participants’ total sleep time increased by an average of 84 minutes.
  • Tart cherry juice may cut down on nighttime wake-ups and improve sleep quality. In an RCT published in 2010, drinking 8 oz. of tart cherry juice twice daily for 2 weeks significantly cut down on wake-ups and insomnia severity in 15 older adults with sleep maintenance insomnia.
  • The same twice-daily regimen of tart cherry juice had similar effects on the sleep of 30 healthy young, middle-aged, and older adults in a study published in 2013. Older participants’ sleep improved the most.

The evidence is not conclusive: these studies were small and only two looked specifically at the effects of tart cherry juice on people with insomnia. Still, unless you dislike or can’t tolerate tart cherries, drinking tart cherry juice twice a day is worth consideration as an alternative treatment for persistent insomnia.

Melatonin and Tryptophan-Enhancing Effects

Montmorency cherries are rich in melatonin, a sleep-friendly hormone secreted by the pineal gland at night. Melatonin production often falls off as people age, and lower levels of endogenous melatonin can make it harder to get to sleep and stay asleep at night. Tart cherry juice may exert its soporific effects mainly by increasing levels of melatonin at night.

Another mechanism by which tart cherry juice may benefit sleep can be found in the effect it has on tryptophan. Tryptophan is an amino acid humans need but cannot produce themselves, so it must be gotten in food. Tryptophan is a precursor to both melatonin and serotonin, a neurotransmitter important to sleep. Researchers who conducted the 2014 study found that tart cherry juice inhibited the degradation of tryptophan, thereby making more of it available for serotonin synthesis.

The sleep benefits of Montmorency cherry juice may be due to both its melatonin and tryptophan-enhancing effects.

Climate Change and Market Forces

But some fruit growers are now on the verge of abandoning cherry orchards and planting apple trees instead. Two factors are behind the change, according to an Interlochen Public Radio report last week:

  1. Most of the nation’s tart cherries are grown in northern Michigan, where almost the entire cherry crop was lost in 2012 due to an early spring followed by over 2 weeks of below-freezing temperatures. Cherry trees planted in Michigan are actually shipped from nurseries in the Pacific Northwest. Extreme weather events there have killed off thousands of cherry saplings. Michigan orchardists who want to continue producing cherries now can’t buy enough young cherry trees to replenish aging stock.
  2. Also, the demand for apples is on the rise, and growers are planting high-density varieties so they can plant many more trees per acre of land. Commercial nurseries are now struggling to keep pace with the demand for apple trees. Nursery owners may decide that planting for small specialty crops like cherries just isn’t worth it any more.

Now back to trouble sleeping: if you find that tart cherry juice helps you sleep, you’d be wise to stock up on it now.