Table of Contents Author Guidelines Submit a Manuscript
Evidence-Based Complementary and Alternative Medicine
Volume 2019, Article ID 8961748, 13 pages
https://doi.org/10.1155/2019/8961748
Review Article

Efficacy Comparison of Different Acupuncture Treatments for Primary Insomnia: A Bayesian Analysis

School of Traditional Chinese Medicine, Jinan University, Guangzhou 510632, China

Correspondence should be addressed to Xiaoyin Chen; nc.ude.unj@niyoaixnehct

Received 26 April 2019; Accepted 30 July 2019; Published 3 September 2019

Academic Editor: Arroyo-Morales Manuel

Copyright © 2019 Huachong Xu et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background. Acupuncture treatments are used frequently in the treatment of primary insomnia considering its less side effect. However, most treatment choices are made just based on personal experience among different forms of acupuncture. This study compared the effectiveness of different forms of acupuncture for primary insomnia by using network meta-analysis. Methods. All randomized controlled trials (RCTs) of acupuncture treatments for primary insomnia were searched in seven databases from the date of database inception to January 6, 2019, including PubMed, Web of Science, Embase, Cochrane Library, Wanfang database, China National Knowledge Infrastructure (CNKI) database, and VIP Chinese Science and Technique Journals (CQVIP) database. After screening, the effectiveness rate was extracted from the included RCTs as primary outcomes. The network meta-analysis was performed by Review Manager 5.3, Stata13.0, and GeMTC 0.14.3. Results. Forty-two studies were included, which contained 3304 participants among 6 interventions. Based on the ranking probability and compared to western medicine, scalp acupuncture (OR = 8.12, 95% CI (4.07,16.81)) is considered to be the most effective method, followed by electroacupuncture (OR = 6.29, 95% CI (3.36, 12.67)), electroacupuncture combined scalp acupuncture (OR = 5.20, 95% CI (2.43,11.28)), warm acupuncture (OR = 3.79, 95% CI (1.85,8.16)), and conventional acupuncture (OR = 2.86, 95% CI (2.05,3.95)). There was no significant difference between the results of direct and indirect comparisons. Conclusions. The finding indicated that five acupuncture methods may be all effective in the treatment of primary insomnia, and scalp acupuncture seems to be the best treatment. However, the overall quality of the included trials could only be ranked as medium to low quality, and higher quality RCTs are warranted for sufficient evidence.

1. Introduction

Primary insomnia is one of the most common clinical diseases in the world, which is defined as sleeplessness without a medical, psychiatric, or environmental cause [1, 2]. Approximately 30% of the world’s adults have been plagued by sleep disorders, and 6 to 10 percent can be diagnosed as insomnia [3, 4]. Long-term insomnia mostly causes physical and psychological damage, which increases the risk of other diseases [5, 6], reduces the quality of life [7], and ultimately causes psychological [8, 9] and economic burden [10, 11]. As a public health problem, insomnia has not received enough recognition and has not been effectively resolved.

Currently, treatments for primary insomnia include medications and nondrugs. Medications, including benzodiazepines, melatonin, and other sedatives, can alleviate some of the symptoms but often cause adverse reactions such as excessive sedation, tolerance, addiction, and neurological toxicity [12, 13]. Cognitive-behavioral therapy (CBT) is recommended as an effective nondrug therapy [14], but it is difficult to popularize due to its rare resources and expensive costs [15, 16].

In China, acupuncture is considered as an effective alternative treatment for insomnia because of its low side effects and easy availability. As a safe and effective natural therapy, acupuncture therapy has been added to the latest version of Guidelines for the Diagnosis and Treatment of Insomnia in China [17] by the China Sleep Research Association. Meanwhile, many clinical randomized trials [1821] and systematic analysis [2226] have shown that a variety of acupuncture treatments are significantly better than drug therapy in primary insomnia. There are many types of acupuncture treatment, including conventional acupuncture [21], warm acupuncture [27], electroacupuncture [28], scalp acupuncture [29], combined acupuncture [30], and so on. However, these previous studies have only demonstrated the effectiveness of single acupuncture treatment against their own control intervention for primary insomnia. Meanwhile, these previous systematic reviews [2226] have only considered all the acupuncture treatments as a whole to study its effectiveness. Clinically, the choice of different acupuncture therapies is often based on the doctor’s personal experience. Lack of authoritative selection guidelines may often lead to an unsatisfactory effect and longer course of treatment for acupuncture therapies. Therefore, the comparison of the efficacy is still lacking and necessary among various acupuncture therapies.

With more new research evidence being included, a network meta-analysis was performed to critically evaluate the current evidence from RCTs involving conventional acupuncture, scalp acupuncture, electroacupuncture, warm acupuncture, electroacupuncture combined scalp acupuncture, and western medicine. This study was committed to comparing the effectiveness of different acupuncture treatments for primary insomnia and finding a better acupuncture treatment selection guideline for clinicians and patients.

2. Methods

2.1. Search Strategy

Seven electronic databases including PubMed, Web of Science, Embase, Cochrane Library, Wanfang database, China National Knowledge Infrastructure (CNKI) database, and VIP Chinese Science and Technique Journals (CQVIP) database were systematically searched from the date of database inception to January 6, 2019, to identify eligible RCTs. The languages of the trials were restricted to English or Chinese. The following keywords were used in search strategies: (“Acupuncture” OR “Acupuncture Therapy” OR “Scalp Acupuncture” OR “Electroacupuncture” OR “Warm Acupuncture”) AND (“Insomnia” OR “Sleep Initiation and Maintenance Disorders”) AND (“Randomized Controlled Trial” OR “Randomized”). The search strategy for each database was based on its own unique characteristics. The search strategy for Embase is shown in Figure 1, and similar search terms were adopted for the other databases.

Figure 1: The search strategy for Embase.
2.2. Inclusion Criteria
2.2.1. Types of Trials

The included study must be a clinical randomized controlled trial published in the journal, with languages limited to Chinese and English.

2.2.2. Participants

Participants must be between 18 and 75 years of age, regardless of gender, disease duration, and severity. Patients with primary insomnia should be diagnosed with at least one of the international or domestic authorized diagnostic criteria, such as International Classification of Disease Tenth Revision (ICD-10), the Chinese Classification of Mental Disorders Third Revision (CCMD-3), and the Chinese Classification of Mental Disorders Second Edition-Revision (CCMD-2-R).

2.2.3. Interventions and Comparison

The interventions for the experimental group must be conventional acupuncture, electroacupuncture, warm acupuncture, scalp acupuncture, or a combination treatment of these methods; additionally, the interventions for the control group were western medicine or other acupuncture treatment different from the experimental group. Western medicine must be drugs recommended in international authorized clinical guidelines.

2.2.4. Outcomes

Effectiveness rate was the primary outcome. Effectiveness rate is reported by measuring insomnia symptom improvement according to standards of five different versions. Effectiveness includes those who have recovered and have a significant improvement over their original symptoms. Five different version standards [23] include Guiding Principles for Clinical Study of New Chinese Medicines, Standards for Diagnosis and Curative Effect of Chinese Medical Symptom, Sleep Efficiency Calculation published by WHO, Guiding Principles for Clinical Study of New Chinese Medicines combined with PSQI reducing rate, and PSQI reducing rate.

2.3. Exclusion Criteria

Exclusion criteria include (1) duplicate studies; (2) insomnia being identified with a clear cause such as medical, psychiatric, or environmental cause; (3) studies without clear outcomes for effectiveness rate; (4) trials that failed to offer accurate data for extraction; and (5) trials with low readability.

2.4. Study Selection and Data Extraction

Study selection and data extraction were conducted with Endnote X9 and Excel 2018. Firstly, study titles and abstracts were screened by two independent reviewers after removing duplicate studies in EndNote. Secondly, they would read the full text of relevant studies after title-abstract screen, according to inclusion and exclusion criteria. If any disagreement arises, the final decision would be made by the third reviewer. Finally, included studies would be coded and extract the following data: study characteristics (author and year of publication); participant characteristics (diagnose criteria, age, disease course, and cases of each group); intervention information (measures of intervention and control, treatment duration, follow-up period, and adverse events); and outcome (definition used in the study).

2.5. Study Quality Evaluation

According to the Cochrane risk of bias assessment tool [31], the quality evaluation of included RCTs was conducted by two reviewers independently using Review Manager 5.3. The following aspects were evaluated: (1) random sequence generation; (2) allocation concealment; (3) blinding of participants and personnel; (4) blinding of outcome assessment; (5) incomplete outcome data; (6) selective reporting; and (7) other bias. Any disagreements would be analyzed by the third reviewer.

2.6. Statistical Analysis

Odds ratio (OR) was adopted for dichotomous outcomes (effectiveness rate) in all studies. The confidence interval (CI) was set at 95%; was regarded as statistically significant. Statistical evaluation of inconsistency and production of network graphs were conducted using the network and network graphs packages in Stata 13.0. The results of the inconsistency test would be used to decide whether to adopt a consistency model.

Then, Bayesian analysis was performed using GeMTC 0.14.3 (Generate Mixed Treatment Comparisons) with the MCMC (Markov Chain Monte Carlo) method, and it estimated the posterior probability according to the prior probability. Estimations and inferences would be conducted when the MCMC has reached a stable convergence state. The parameters of GeMTC are set as follows: the initial value is set to 2.5; the number of simulation iterations is set to 50,000; 20,000 adjustment iterations are performed first to eliminate the influence of the initial value; and the step size (sparse interval) is set to 10 when the number of chains is 4. The potential scale reduced factor (PSRF) reflects the convergence of the model. When the PSRF is close to 1 (means the convergence is good), the consistency of the homogeneity model would be considered reliable enough for follow-up analysis. Finally, the figure of ranking probability was generated for all interventions and the node-splitting method was adopted to evaluate local inconsistency.

3. Results

3.1. Literature Search Results

A total of 3593 records were identified through database searching. After duplicates removed and titles-abstracts screened, 233 potentially eligible studies were retrieved in full text. Based on full-text screening, 191 papers were excluded with the following reasons: have no relevant outcome; republication; no RCTs; or low-quality studies. Finally, 42 RCTs were included in the Bayesian analysis. 3 of them are in English, and the other 39 are in Chinese including 30 articles from the catalogue of statistical sources of Chinese scientific papers (considered to be better journals in China). The specific literature search and screening process are presented in the PRISMA 2009 Flow Diagram (as shown in Figure 2).

Figure 2: Study selection process.
3.2. Study Characteristics

Forty-two included RCTs were done between 2004 and 2018 containing a total of 3304 participants. There were 1686 patients in the intervention group and 1618 in the control group. The interventions of 42 trials included conventional acupuncture, electroacupuncture, scalp acupuncture, warm acupuncture, and electroscalp acupuncture, of which 18 were treated with conventional acupuncture, 6 with electroacupuncture, 7 with scalp acupuncture, 5 with warm acupuncture, and 6 with electroscalp acupuncture. In addition, the control group of 34 trials was treated with western drugs, and the remaining 8 trials were treated with conventional acupuncture. The duration of treatment for these studies ranged from 10 days to 8 weeks. The drugs included estazolam (24 trials), clonazepam (2 trials), zopiclone (2 trials), diazepam (3 trials), alprazolam (1 trial), zolpidem (1 trial), and nitrazepam (1 trial). All included trials have clear diagnostic criteria and outcome criteria. Characteristics of included studies are shown in Table 1.

Table 1: Characteristics of included studies.
3.3. Adverse Event and Follow-Up

Adverse events were mentioned in 7 trials. Two trials reported minor bleeding in the acupuncture group, but the spirit was good; the western medicine group had poor mentality during the day [19, 43]. One trial detailed the adverse events: 1 patient in the acupuncture treatment group felt nausea without vomiting, 2 patients had migraine headache, and the symptoms were relieved after rest; in the Western medicine group, there were 3 patients with obvious mouth pain, 5 patients with dizziness, nausea, and appetite, and 3 patients with decreased disease [44]. The other trial found that 2 patients in the acupuncture treatment group had fainting due to long retention, hypoglycemia, and symptom relief after rest [39]. Another trial found that 4 patients in the acupuncture group felt pain, which could be resolved by acupuncture adjustment and verbal communication; 10 patients in the control group had a wake-up headache; and 7 patients developed dizziness [53]. One of the trials clearly indicated that the acupuncture treatment group was safer than the drug control group, while the other trial concluded that both interventions were equally safe [27, 54]. No patient was reported to withdraw from the study due to adverse events.

Follow-up was adopted to only 5 trials [19, 47, 50, 51, 56] for lasting effect ranging between 2 weeks and 3 months. Two studies concluded that the long-term efficacy of the acupuncture group was better than that of the drug group. Two studies suggested that the recurrence rate of the treatment group was lower than that of the control group. The remaining study showed no significant difference of efficacy between the treatment group and the control group after 3 months of follow-up.

3.4. Risk of Bias for Research Quality Evaluation

The assessment results showed a medium quality for all the included literatures. All studies referred to randomization, but only 28 studies described detailed and reliable random grouping methods, 23 of which used random number tables and 5 used computer software. Both concealment of allocation and blinding of outcome were not mentioned in all studies. Due to the special nature of acupuncture treatment, blinding was not used in all studies. Therefore, there is a high risk of performance bias in literature quality assessment. The detailed evaluation is shown in Figures 3 and 4.

Figure 3: Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies.
Figure 4: Risk of bias summary: review authors’ judgements about each risk of bias item for each included study (reproduced from Peng Pang et al. [66] (under the Creative Commons Attribution License/Public Domain)).
3.5. Network Map for Interventions

Network map among 6 interventions was made by Stata 13.0 (as shown in Figure 5). The size of the points in the graph is proportional to the weight of the sample number of interventions, and the thickness of the lines in the figure is also proportional to the correlation between the two interventions. The figure shows that the sample of conventional acupuncture and western medicine ranked in the top two in this study. The other four interventions are directly compared with conventional acupuncture and western drugs, but there are no direct comparisons between any two of them. Thus, the network meta-analysis was performed to combine direct comparison with indirect comparison.

Figure 5: Network meta-analysis of eligible comparisons for efficacy. Note: 1, western medicine; 2, conventional acupuncture; 3, electroacupuncture; 4, scalp acupuncture; 5, warm acupuncture; 6, electroacupuncture combined scalp acupuncture.
3.6. Results of Network Meta-Analysis

According to the result of the inconsistency test (), there is no significant heterogeneity in the data. The local inconsistency test was shown in loop inconsistency map: all the 95% CIs include zero, and all the IF are close to zero. Hence, a consistency model was selected for the network meta-analysis, and the results are shown in Table 2.

Table 2: Network meta-analysis comparisons.

Firstly, compared with western medicine, the following interventions can significantly improve the effectiveness of primary insomnia treatment: conventional acupuncture (OR = 2.86, 95% CI (2.05, 3.95), ), electroacupuncture (OR = 6.29, 95% CI (3.36, 12.67), ), scalp acupuncture (OR = 8.12, 95% CI (4.07,16.81), ), warm acupuncture (OR = 3.79, 95% CI (1.85, 8.16), ), and scalp acupuncture plus electroacupuncture (OR = 5.20, 95% CI (2.43, 11.28), ). Secondly, compared with conventional acupuncture, the following methods showed significant improvement: electroacupuncture (OR = 2.18, 95% CI (1.10, 4.68), ) and scalp acupuncture (OR = 2.86, 95% CI (1.48, 5.72), ). The remaining paired comparisons showed no significant differences in effectiveness rate of treatment.

3.7. Comparison of the Effectiveness of Different Interventions

The figure of ranking probability was generated based on the MCMC theory for probability evaluation (Figure 6). In the six treatments for primary insomnia included in this study, scalp acupuncture is considered to be the most effective method, followed by electroacupuncture, electroacupuncture combined scalp acupuncture, warm acupuncture, conventional acupuncture, and finally western medicine.

Figure 6: The rank probability of efficacy for included interventions. Note. 1, western medicine; 2, conventional acupuncture; 3, electroacupuncture; 4, scalp acupuncture; 5, warm acupuncture; 6, electroacupuncture combined scalp acupuncture.

According to the Gelman Rubin-Brooks diagnostic method, the convergence diagnostic plot was drawn and it showed that the median value of the reduction factor and 97.5% tend to be stable after 25,000 iterations, and then the Bayesian model was calculated to 25,000 iterations. The parameter PSRF moves close to 1, indicating satisfactory convergence (Table 3). Finally, the local inconsistency was performed using the node-splitting method. The values of all the comparison groups were greater than 0.05, indicating that the direct comparisons were consistent with the indirect comparisons (Table 4).

Table 3: The PSRF value.
Table 4: Node-splitting test result.
3.8. Publication Bias

According to the funnel plot (Figure 7), we found no obvious publication bias. Furthermore, we conducted verification by Egger’s test (Figure 8) and found no publication bias ().

Figure 7: Comparison-adjusted funnel plot for the network meta-analysis.
Figure 8: Egger’s publication bias plot ().

4. Discussion

Repeated insomnia may have many, yet largely unknown, repercussions for health and well-being. Most clinical studies and experimental studies have shown that acupuncture is effective for primary insomnia. Thus, this study combines the results of the previous studies with network meta-analysis to compare the efficacy of different acupuncture methods in the treatment of primary insomnia and finally rank them according to the efficacy.

As of now, this study is the first network meta-analysis of primary insomnia. Different from previous systematic analysis [2226], it has incorporated the direct comparison and indirect comparison of various acupuncture therapies into the study. The internal comparison of acupuncture therapy is more helpful in exploring the specific role and connotation of them. Before the study, we found that a previous protocol [67] on the network meta-analysis of acupuncture for primary insomnia has been published. And, in accordance with the review protocol, we made some improvements based on actual conditions. In the inclusion criteria, in order to improve the homogeneity and feasibility of the research results, the control drug was designated as western medicine and does not include traditional Chinese medicine or proprietary Chinese medicine with unclear mechanism of action. In the choice of software, we use GeMTC instead of Stata for the final simulation iteration, of which the iterative conditions are stricter and more stable, so the results obtained have higher feasibility. Actually, results of the PSRF and the test of local inconsistency had proved that an appropriate model has been successfully established.

Since ancient times, acupuncture has been used to treat primary insomnia in China. Chinese medicine believes that the occurrence of insomnia is closely related to mood, constitution, disease, and environment and ultimately blamed to the imbalance between yin and yang. Acupuncture is believed to balance the body and restore its physiological function by inserting thin needles at specific acupoints [68]. Moreover, the modern biological mechanism of acupuncture treatment of primary insomnia is not fully revealed. Studies have shown that acupuncture can regulate some insomnia by regulating some neurotransmitters [23, 69], such as norepinephrine, serotonin, dopamine, acetylcholine, and γ-aminobutyric acid [70], and reducing glutamate levels [71]. Acupuncture may also increase melatonin, which involves sleep-wake adjustment [72, 73]. Acupuncture can improve sleep quality by enhancing the blood supply to brain tissue, the elasticity of blood vessels, and the excitability of related sites on the cerebral cortex [23]. Consistent with the above existing theory, scalp acupuncture is considered to be the best treatment for primary insomnia in this study. Experimental studies have found that sleep and wakefulness regulation is one of the basic functions of the brain, and there are specific sleep-inducing regions in the brain [7]. As a novel treatment using traditional acupuncture and modern medical cerebral cortical positioning theory, scalp acupuncture is a method of acupuncture treatment of certain areas of the scalp to treat primary insomnia. Additionally, although both the scalp acupuncture and the electroacupuncture have a good therapeutic effect, the combined treatment of them seems to be less effective, which may be caused by the small number of studies in the combination therapy. Lastly, we found that all acupuncture treatments are better than medications while only two of them have significant difference with conventional acupuncture. At the same time, there is no significant difference between any two of the other four acupuncture treatment besides conventional acupuncture, which may need more clinical trials to be carried out.

Our study still has some limitations. Firstly, the overall quality of the included trials could only be ranked as medium to low quality, which usually affects the strength of the evidence to some extent. Higher quality clinical RCTs should be performed, with reference to authoritative criteria for random methods, allocation concealment, blinding methods, and so on. Secondly, acupoint selection between acupunctures of different therapies or between the same therapy may be inconsistent and empirical, and the techniques of acupuncturists may differ, both of which may increase the heterogeneity of the study. Future clinical studies can focus on studying the effects of specific acupoints on the treatment of insomnia, but this may be contradictory with the principle of acupuncture treatment based on syndrome differentiation. Finally, most of the included studies tend to have short treatment duration and lack of follow-up, which is still not enough to indicate the long-term effect of acupuncture. On the whole, higher quality RCTs are warranted.

5. Conclusion

This study indicated that the included five acupuncture methods may be effective and safe in improving the condition of patients with primary insomnia, and scalp acupuncture seems to be a better treatment for primary insomnia. However, the overall quality of the included trials could only be ranked as medium to low quality, and higher quality RCTs are warranted for sufficient evidence.

Conflicts of Interest

The authors declare that they have no competing interests.

Authors’ Contributions

X. Y. Chen and H. C. Xu conceived and designed the study. H. C. Xu, Y. C. Shi, Y. K. Xiao, and S. Z. Wu searched the literature. L. Deng, P. Pang, and P. Liu selected the articles and extracted the data. H. C. Xu and Y. C. Shi analyzed the data. H. C. Xu, L. Deng, P. Pang, and X. Y. Chen interpreted the data and contributed to the manuscript. All authors read and approved the final manuscript. H. C. Xu and Y. C. Shi contributed equally to this work.

Acknowledgments

This study was supported by the National Natural Science Foundation of China (Nos. 81830114, 81774164, and 81473557) and the Natural Science Foundation of Guangdong, China (No. 2017A030313737).

References

  1. T. Roth, “Insomnia: definition, prevalence, etiology, and consequences,” Journal of Clinical Sleep Medicine, vol. 3, no. 5, pp. S7–S10, 2007. View at Google Scholar
  2. M.-M. Charles and B. Ruth, “Chronic insomnia,” The Lancet, vol. 379, no. 9821, pp. 1129–1141, 2012. View at Publisher · View at Google Scholar · View at Scopus
  3. A. P. Association, Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association, Arlington, VA, USA, 5th edition, 2013.
  4. K. Doghramji, “The epidemiology and diagnosis of insomnia,” American Journal of Managed Care, vol. 12, no. 8, pp. S214–S220, 2006. View at Google Scholar
  5. M. S. Khan and R. Aouad, “The effects of insomnia and sleep loss on cardiovascular disease,” Sleep Medicine Clinics, vol. 12, no. 2, pp. 167–177, 2017. View at Publisher · View at Google Scholar · View at Scopus
  6. L. Meng, Y. Zheng, and R. Hui, “The relationship of sleep duration and insomnia to risk of hypertension incidence: a meta-analysis of prospective cohort studies,” Hypertension Research, vol. 36, no. 11, pp. 985–995, 2013. View at Publisher · View at Google Scholar · View at Scopus
  7. P. Meerlo, A. Sgoifo, and D. Suchecki, “Restricted and disrupted sleep: effects on autonomic function, neuroendocrine stress systems and stress responsivity,” Sleep Medicine Reviews, vol. 12, no. 3, pp. 197–210, 2008. View at Publisher · View at Google Scholar · View at Scopus
  8. R. C. Cox and B. O. Olatunji, “A systematic review of sleep disturbance in anxiety and related disorders,” Journal of Anxiety Disorders, vol. 37, pp. 104–129, 2016. View at Publisher · View at Google Scholar · View at Scopus
  9. J. Schwarz, A. Gerhardsson, W. van Leeuwen et al., “Does sleep deprivation increase the vulnerability to acute psychosocial stress in young and older adults?” Psychoneuroendocrinology, vol. 96, pp. 155–165, 2018. View at Publisher · View at Google Scholar · View at Scopus
  10. R. J. Ozminkowski, S. Wang, and J. K. Walsh, “The direct and indirect costs of untreated insomnia in adults in the United States,” Sleep, vol. 30, no. 3, pp. 263–273, 2007. View at Publisher · View at Google Scholar · View at Scopus
  11. M. Daley, C.-M. Morin, M. LeBlanc, J.-P. Gregoire, and J. Savard, “The economic burden of insomnia: direct and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good sleepers,” Sleep, vol. 32, no. 1, pp. 55–64, 2009. View at Google Scholar
  12. S. M. Bertisch, S. J. Herzig, J. W. Winkelman, and C. Buettner, “National use of prescription medications for insomnia: NHANES 1999–2010,” Sleep, vol. 37, no. 2, pp. 343–349, 2014. View at Publisher · View at Google Scholar · View at Scopus
  13. K. R. Tan, U. Rudolph, and C. Lüscher, “Hooked on benzodiazepines: GABAA receptor subtypes and addiction,” Trends in Neurosciences, vol. 34, no. 4, pp. 188–197, 2011. View at Publisher · View at Google Scholar · View at Scopus
  14. R. Zachariae, M. S. Lyby, L. M. Ritterband, and M. S. O’Toole, “Efficacy of internet-delivered cognitive-behavioral therapy for insomnia-a systematic review and meta-analysis of randomized controlled trials,” Sleep Medicine Reviews, vol. 30, pp. 1–10, 2016. View at Publisher · View at Google Scholar · View at Scopus
  15. E. E. Matthews, J. T. Arnedt, M. S. McCarthy, L. J. Cuddihy, and M. S. Aloia, “Adherence to cognitive behavioral therapy for insomnia: a systematic review,” Sleep Medicine Reviews, vol. 17, no. 6, pp. 453–464, 2013. View at Publisher · View at Google Scholar · View at Scopus
  16. M. L. Perlis and M. T. Smith, “How can we make CBT-I and other BSM services widely available?” Journal of Clinical Sleep Medicine, vol. 4, no. 1, pp. 11–13, 2008. View at Google Scholar
  17. C. S. R. Association, “Guidelines for the diagnosis and treatment of insomnia in China,” National Medical Journal of China, vol. 97, no. 24, pp. 1844–1856, 2017. View at Google Scholar
  18. A. Bo, L.-G. Si, Y.-H. Wang et al., “Clinical trial research on Mongolian medical warm acupuncture in treating insomnia,” Evidence-Based Complementary and Alternative Medicine, vol. 2016, Article ID 6190285, 10 pages, 2016. View at Publisher · View at Google Scholar · View at Scopus
  19. X.-H. Chen, Y. Li, Y. Kui et al., “Sleep disorder treated mainly with flying needling therapy:a clinical randomized controlled research,” Chinese Acupuncture and Moxibustion, vol. 33, no. 2, pp. 97–100, 2013. View at Google Scholar
  20. X.-Y. Cheng, “Clinical effect of scalp acupuncture on insomnia,” Journal of China Prescription Drug, vol. 13, no. 2, pp. 71-72, 2015. View at Google Scholar
  21. Y.-Z. Guan and H.-T. Zhang, “Study on clinical application and theory of “matrix acupunture” in treating insomnia,” Western Journal of Traditional Chinese Medicine, vol. 26, no. 10, p. 3, 2013. View at Google Scholar
  22. H. Cao, X. Pan, H. Li, and J. Liu, “Acupuncture for treatment of insomnia: a systematic review of randomized controlled trials,” The Journal of Alternative and Complementary Medicine, vol. 15, no. 11, pp. 1171–1186, 2009. View at Publisher · View at Google Scholar · View at Scopus
  23. K.-Y. Huang, S. Liang, A. Grellet, and J.-B. Zhang, “Acupuncture and moxibustion for primary insomnia: a systematic review and meta-analysis of randomized controlled trials,” European Journal of Integrative Medicine, vol. 12, pp. 93–107, 2017. View at Publisher · View at Google Scholar · View at Scopus
  24. J. L. Shergis, X. Ni, M. L. Jackson et al., “A systematic review of acupuncture for sleep quality in people with insomnia,” Complementary Therapies in Medicine, vol. 26, pp. 11–20, 2016. View at Publisher · View at Google Scholar · View at Scopus
  25. Y.-J. Sun, J.-M. Yuan, and Z.-M. Yang, “Effectiveness and safety of moxibustion for primary insomnia: a systematic review and meta-analysis,” BMC Complementary and Alternative Medicine, vol. 16, Article ID 217, 2016. View at Publisher · View at Google Scholar · View at Scopus
  26. W.-F. Yeung, K.-F. Chung, Y.-K. Leung, S.-P. Zhang, and A. C. K. Law, “Traditional needle acupuncture treatment for insomnia: a systematic review of randomized controlled trials,” Sleep Medicine, vol. 10, no. 7, pp. 694–704, 2009. View at Publisher · View at Google Scholar · View at Scopus
  27. L.-N. Kan, X.-J. He, M. Fan et al., “Clinical efficacy of acupuncture with moxibustion in treatment of heart-spleen deficiency and effects on sleep quality of insomnia,” World Science and Technology/Modernization of Traditional Chinese Medicine and Materia Medica, vol. 20, no. 9, pp. 1603–1607, 2018. View at Google Scholar
  28. F. Li, Y.-J. Ren, S. An, and D.-Y. Wang, “Clinical observation on acupuncture Jiaji therapy for insomnia,” Journal of Clinical Acupuncture and Moxibustion, vol. 30, no. 3, pp. 16–18, 2014. View at Google Scholar
  29. X.-H. Li, M. Li, J.-M. Wu, and J.-Y. Zhang, “Clinical observation of Jiao’s scalp acupuncture in the treatment of insomnia of liver depression and fire,” Guiding Journal of Traditional Chinese Medicine and Pharmacology, vol. 24, no. 21, pp. 93-94, 2018. View at Google Scholar
  30. D.-Y. Wang and Q.-Y. Xie, “Observation on therapeutic effect of cluster needling at scalp points on patients with primary insomnia,” Liaoning Journal of Traditional Chinese Medicine, vol. 40, no. 7, pp. 1284-1285, 2013. View at Google Scholar
  31. J. Higgins and S. Green, Cochrane Handbook for Systematic Reviews of Intervention, Version 5.1.0., John Wiley & Sons, Inc., Hoboken, NJ, USA, 2011, The Cochrane Collaboration.
  32. J.-P. Dong, S. Wang, W.-Y. Sun, and F. Liu, “Randomized controlled observation on head point-through-point therapy for treatment of insomnia,” Chinese Acupuncture and Moxibustion, vol. 28, no. 3, pp. 159–162, 2008. View at Google Scholar
  33. L.-N. Huang, J.-M. An, H.-L. Dong, L.-H. Dong, and J. Zhang, “Clinical study on the efficacy of scalp acupuncture for primary insomnia,” Shanghai Journal of Acupuncture and Moxibustion, vol. 30, no. 9, pp. 596-597, 2011. View at Google Scholar
  34. S.-P. Kong and Q.-W. Tan, “54 cases of insomnia treated by acupuncture with the method of regulating mind and soothing liver,” Journal of Shandong University of TCM, vol. 35, no. 1, pp. 45-46, 2011. View at Google Scholar
  35. S.-Y. Liang, “Observation on the therapeutic effect of electro-acupuncture acupoints on insomnia,” Journal of Clinical Acupuncture and Moxibustion, vol. 25, no. 3, pp. 24-25, 2009. View at Google Scholar
  36. H. Liao, Y.-J. Gao, and S. Liao, “Clinical observation on 30 cases of insomnia treated by electro-acupuncture,” Jiangsu Journal of Traditional Chinese Medicine, vol. 45, no. 7, pp. 45-46, 2013. View at Google Scholar
  37. D.-P. Liu and T. Zhang, “Clinical observation on 60 cases of insomnia treated mainly by acupoints of electro-acupuncture,” Medical Journal of Chinese People’s Health, vol. 13, pp. 1704–1728, 2010. View at Google Scholar
  38. J.-Y. Liu and X.-T. Wei, “Clinical observation of electro-acupuncture in the treatment of insomnia with deficiency of heart and spleen,” Shenzhen Journal of Integrated Traditional Chinese and Western Medicine, vol. 23, no. 3, pp. 168–170, 2013. View at Google Scholar
  39. F. Liu, L. Wang, Q.-P. Wei, and Z.-H. Wang, “Clinical curative observation of applying acupuncture at shen-you time to regulate 196 cases of insomnia,” Journal of Sichuan of Traditional Chinese Medicine, vol. 33, no. 8, pp. 174–176, 2015. View at Google Scholar
  40. L. Luo, Y.-P. Hu, S.-G. Yu, and N. Li, “Observation on therapeutic effect of rolling needle therapy on insomnia,” Chinese Acupuncture and Moxibustion, vol. 26, no. 3, pp. 183–185, 2006. View at Google Scholar
  41. R.-H. Luo, K. Xu, and J. Zhou, “Clinical study on acupuncture treatment of insomnia,” Journal of Clinical Acupuncture and Moxibustion, vol. 24, no. 12, pp. 5-6, 2008. View at Google Scholar
  42. Y. Pi, Y. Tang, and J.-G. Sun, “Research on the common acupoints formulation optimization about acupuncture treatment of pprimary insomnia,” Journal of Sichuan of Traditional Chinese Medicine, vol. 36, no. 5, pp. 184–187, 2018. View at Google Scholar
  43. L.-Z. Qi, X.-P. Ma, and L. Yang, “Observation on the therapeutic effect of neck clustered needling on insomnia,” Chinese Acupuncture and Moxibustion, vol. 28, no. 12, pp. 861–864, 2008. View at Google Scholar
  44. S. Ren, J. Zhang, and X. Han, “Clinical observation of invigorating spleen and nourishing heart acupuncture treatment on insomnia,” China Journal of Traditional Chinese Medicine and Pharmacy, vol. 32, no. 9, pp. 4303–4306, 2017. View at Google Scholar
  45. Y.-M. Shi, H.-F. Zhang, and H. Hou, “39 cases of intractable insomnia treated by scalp acupuncture combined with electro-acupuncture,” Journal of Guangxi University of Chinese Medicine, vol. 19, no. 2, pp. 22–24, 2016. View at Google Scholar
  46. J. Song and Y. Han, “Therapeutic effect of acupuncture combined with Moxibustion on insomnia,” Nei Mongol Journal of Traditional Chinese Medicine, vol. 36, no. 12, pp. 125-126, 2017. View at Google Scholar
  47. C.-W. Wang, J. Kang, J.-W. Zhou, Y.-P. Hu, and N. Li, “Effect of rolling needle therapy on quality of life in the patient of non-organic chronic insomnia: a effect of rolling needle therapy on quality of life in the patient of non-organic chronic insomnia: a randomized controlled trail,” Chinese Acupuncture and Moxibustion, vol. 26, no. 7, pp. 461–465, 2006. View at Google Scholar
  48. Z.-Y. Wang, X.-G. Liu, W. Zhang, and Y. Pi, “Clinical observation on treatment of primary insomnia by acupuncture based on liver theory,” Journal of Sichuan of Traditional Chinese Medicine, vol. 33, no. 2, pp. 165–167, 2015. View at Google Scholar
  49. Y.-J. Wang, L.-H. Zhang, Y.-X. Han, and P.-P. Li, “Efficacy observation on Governor Vessel-unblocking and mind-calming acupuncture for insomnia,” Journal of Acupuncture and Tuina Science, vol. 14, no. 4, pp. 274–278, 2016. View at Publisher · View at Google Scholar · View at Scopus
  50. K.-Y. Wang, Y. Hua, Y.-B. Gao, Y.-J. Xue, and Q. Tian, “Randomized controlled trials of acupuncture and moxibustion at shendao acupoint in the treatment of insomnia,” Journal of Clinical Acupuncture and Moxibustion, vol. 32, no. 5, pp. 5–7, 2016. View at Google Scholar
  51. F.-Y. Wang, “Clinical observation on electro acupuncture of sleeping points in the treatment of insomnia,” Guangming Journal of Chinese Medicine, vol. 31, no. 16, pp. 2387–2389, 2016. View at Google Scholar
  52. Z.-W. Wang, “Clinical evaluation of warming acupuncture and moxibustion in the treatment of insomnia with deficiency of heart and spleen,” Nei Mongol Journal of Traditional Chinese Medicine, vol. 35, no. 9, p. 129, 2016. View at Google Scholar
  53. X.-J. Wang and Q. Liu, “Observation on therapeutic effect of Tongdu Tiaoshen acupuncture on insomnia,” Shanxi Journal of Traditional Chinese Medicine, vol. 34, no. 2, pp. 32-33, 2018. View at Google Scholar
  54. X. Wu, H. Hu, J. Xing, M. Zhou, and Z.-Y. Xie, “Effect of pricking Shēnmài (BL 62) and Zhàohăi (KI 6) on daytime arousal of patients with chronic insomnia: a randomized controlled trial,” World Journal of Acupuncture - Moxibustion, vol. 24, no. 4, pp. 1–23, 2014. View at Publisher · View at Google Scholar
  55. H.-B. Xu and Y.-M. Liu, “Clinical observation on treatment of insomnia by electro-acupuncture at Jiannao anshenqi point,” Journal of New Chinese Medicine, vol. 46, no. 12, pp. 173-174, 2014. View at Google Scholar
  56. S.-F. Xu, L.-X. Zhuang, P. Yin, J.-Y. Wu, and Y. Cao, “Evaluation of clinical efficacy of heart and spleen deficiency type insomnia treated by acupuncture for regulating governor vessel and tranquilizing spirit,” Journal of Guangzhou University of Traditional Chinese Medicine, vol. 33, no. 1, pp. 31–34, 2016. View at Google Scholar
  57. Y.-B. Xuan, J. Guo, L.-P. Wang, and X. Wu, “Randomized controlled study on effect of acupuncture on sleep quality in the patients of Primary Insomnia,” Chinese Acupuncture and Moxibustion, vol. 27, no. 12, pp. 886–888, 2007. View at Google Scholar
  58. Z.-Q. Zhang, “Clinical observation on head point-through-point therapy for treatment of insomnia,” Guangming Journal of Chinese Medicine, vol. 25, no. 9, pp. 1658–1660, 2010. View at Google Scholar
  59. Q. Zhang, H.-S. Dong, C.-L. Bao, G.-B. Zhang, and G.-R. Dong, “Therapeutic observation of acupuncture with points selection based on yin-yang and qi-blood in treating insomnia,” Shanghai Journal of Acupuncture and Moxibustion, vol. 34, no. 11, pp. 1034–1037, 2015. View at Google Scholar
  60. J.-Y. Zhao and C.-C. Ji, “Clinical observation on the effect of scalp electroacupuncture on sleep quality of patients with primary insomnia,” Modern Traditional Chinese Medicine, vol. 38, no. 3, pp. 14–17, 2018. View at Google Scholar
  61. P. Zheng, “Observations on the therapeutic effect of acupuncture on insomnia,” Shanghai Journal of Acupuncture and Moxibustion, vol. 28, no. 11, pp. 632-633, 2009. View at Google Scholar
  62. Z. Zhou, X. Shi, S.-D. Li, and L. Guan, “Scalp penetration acupuncture for insomnia: a randomized controlled trial,” Journal of Chinese Integrative Medicine, vol. 8, no. 2, pp. 126–130, 2010. View at Publisher · View at Google Scholar · View at Scopus
  63. G.-R. Zhou, “Clinical observation on treating 65 cases of primary insominia by acupuncture,” Clinical Journal of Chinese Medicine, vol. 8, no. 1, pp. 39–41, 2016. View at Google Scholar
  64. B. Zhou, Z. Yuan, and H. Feng, “Observation on therapeutic effect of Tiaoshen Yishen acupuncture on 30 cases of insomnia of heart-kidney disjunction type,” Tianjin Journal of Traditional Chinese Medicine, vol. 35, no. 4, pp. 264–266, 2018. View at Google Scholar
  65. Y.-L. Zhu, “Effect observation on treatment of primary insomnia by head of a pin electric stimulation,” China Health Standard Management, vol. 6, no. 26, pp. 130–132, 2015. View at Google Scholar
  66. P. Pang, Y. Shi, H. Xu, L. Deng, S. Wu, and X. Chen, “Acupuncture methods put to the test for a tinnitus study: a Bayesian analysis,” Complementary Therapies in Medicine, vol. 42, pp. 205–213, 2019. View at Publisher · View at Google Scholar · View at Scopus
  67. J. Chen, L.-M. Lu, N.-G. Xu et al., “An effectiveness comparison of acupuncture treatments for insomnia disorder a bayesian network meta-analysis protocol,” Medicine, vol. 97, no. 35, Article ID e12060, 2018. View at Publisher · View at Google Scholar · View at Scopus
  68. X. Yin, M. Gou, J. Xu et al., “Efficacy and safety of acupuncture treatment on primary insomnia: a randomized controlled trial,” Sleep Medicine, vol. 37, pp. 193–200, 2017. View at Publisher · View at Google Scholar · View at Scopus
  69. J.-L. Yang, R. Zhang, L. Du, Y.-S. Yang, and X.-C. Liu, “Clinical observation on the neurotransmitters regulation in patients of insomnia differentiated as yang deficiency pattern treated with warm acupuncture and auricular point sticking therapy,” Zhongguo Zhen Jiu = Chinese Acupuncture & Moxibustion, vol. 34, no. 12, pp. 1165–1168, 2014. View at Google Scholar
  70. H. Simon, “Insomnia: can acupuncture help?” Pain Management, vol. 7, no. 1, pp. 49–57, 2017. View at Google Scholar
  71. Z.-Y. Liu, X.-Y. Chen, Y. Gao et al., “Involvement of GluR2 up-regulation in neuroprotection by electroacupuncture pretreatment via cannabinoid CB1 receptor in mice,” Scientific Reports, vol. 5, Article ID 9490, 2015. View at Publisher · View at Google Scholar · View at Scopus
  72. M. Nordio and F. Romanelli, “Efficacy of wrists overnight compression (HT 7 point) on insomniacs: possible role of melatonin?” Minerva Medica, vol. 99, no. 6, pp. 539–547, 2008. View at Google Scholar
  73. J.-B. Liu, S.-J. Clough, A.-J. Hutchinson, E.-B. Adamah-Biassi, M. Popovska-Gorevski, and M.-L. Dubocovich, “MT1 and MT2 melatonin receptors: a therapeutic perspective,” in Annual Review of Pharmacology and Toxicology, P. A. Insel, Ed., vol. 56, pp. 361–383, Annual Reviews, Palo Alto, CA, USA, 2016. View at Google Scholar