Clinical Roundup: How Do You Treat Insomnia in Your Practice?—Part 2

299ALTERNATIVE AND COMPLEMENTARY THERAPIES DOI: 10.1089/act.2010.16508 • MARY ANN LIEBERT, INC. • VOL. 16 NO. 5OCTOBER 2010

Integrative Medicine for Diagnosis and Treatment

Insomnia is one of the most common symptoms encoun-tered in clinical practice and is highly prevalent in our society, a cited incidence of from 10% to 30% of the U.S. population affected.1 Evaluation and treatment of patients for insomnia is complex, and as many as 35%–44% of patients who have insomnia are thought to have an underlying medical or phar-macologic cause for their sleeplessness.1

Despite this high prevalence, once other causes of insomnia have been excluded and primary insomnia has been diagnosed, there are a wide variety of treatments available to patients. The following is a review of evidence-based complementary and alternative medicine (CAM) options available to patients. Al-though there are arsenals of pharmacologic treatments, using an integrative medicine approach to treating insomnia may improve outcomes and, as a result, quality of life (QoL) of pa-tients.2 Managing insomnia can be approached in the follow-ing stepwise fashion3,4:

(1) Clinical history—Obtaining a thorough history of the in-somnia, a medical history, an occupational history, and a current and past drug history, is key for helping determine the cause of insomnia. This will differentiate if the patient’s insomnia is secondary to a physical illness (Table 11,3,4); has behavioral (see below), pharmaceutical-, or drug-relat-ed causes (Table 21,3,4); or is truly primary insomnia, of unknown etiology. Patients with insomnia are also more likely to use CAM therapies,5 and it is important to obtain information from patients about such usage. Obtaining all of this information can guide the formulation of a safe, evidence-based, integrative medicine plan to manage the patient’s insomnia.

(2) Physical examination and laboratory testing—A thorough physi-cal examination, followed by appropriate laboratory investi-gations to identify physical causes of insomnia or drug inter-actions must be performed.

(3) Behavioral/lifestyle modifications—Once secondary causes of insomnia are determined and addressed, advising pa-tients about behavioral/lifestyle modifications will help

them to improve their sleep quality. This “sleep hygiene” includes6:

•Exposuretosunlight(approximately5–10minutesper day)•Avoidanceofalcohol•Avoidanceofcaffeineandnicotine,especiallyafternoon•Regularexercise,butnotexerciserightbeforebedtopre vent further stimulation•Nodaytimenapping•Nostimulatingdrugsduringlateevening•Apleasantsleepenvironmentinadarkbedroom,setat a comfortable temperature, with a comfortable bed•Avoidanceoftelevisionorcomputerworkpriortobed•Relaxationtechniques,suchasmeditation,priortobed.

There is an arsenal of conventional and alternative ther-apies we prescribe to treat insomnia. If any physical condi-tion is identified, we use conventional therapy7 to which we may add biologically8 or mind–body based9 CAM therapies (Tables 39–18 and 41,3,4,19–24), both of which are evidence-based CAM therapies. Dosages of biologically based therapies shown in Table 3 are from research ex-amples, but the patient’s age, weight, and medical history must be taken into account when using biologically based treatments and dosages.

Clinical Roundup How Do You Treat Insomnia in Your Practice?—Part 2

*This is part 2 of a two-part article.

Table 1. Comorbid Causes of Insomnia

• Cardiovascular—hypertension, chronic heart failure

• Pulmonary—chronic obstructive pulmonary disease, allergic rhinitis, obstructive sleep apnea

• Gastrointestinal—gastroesophagel reflux disease, acid peptic disease

• Central nervous system—stroke, seizures, restless leg syndrome

• Psychiatric—anxiety, depression, psychosis, fibromyalgia

• Pain—Inflammation such as arthritis, cancer, trauma, etc.

• Endocrine—hyperthyroidism, menopause

• Other—pruritis, urinary incontinence

Adapted from refs 1,3, & 4.

16.5ACT_pages.indd 299 10/15/10 3:10:53 PM

300

ALTERNATIVE AND COMPLEMENTARY THERAPIES • OCTOBER 2010

MARY ANN LIEBERT, INC. • VOL. 16 NO. 5

References

1. Harsora P, Kessman J. Nonpharmacological management of chronic insom-nia. Am Fam Physician 2009;79:125–130.2. National Center for Complementary and Alternative Medicine. Sleep Disorders and CAM: At a Glance. Online document at: http://nccam.nih.gov/health/sleep/ataglance.htm Accessed May 19, 2010.

3. Schutte-Rodin S, Broch L, Buysse D, et al. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med 2008;4:487–504.

4. National Institutes of Health. State of the Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults. NIH Cons-ens Sci Statements 2005;2:1–30.

5. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Rep 2008; 12:1–23.

Table 3. Biologically Based Complementary and Alternative Medicine (CAM) Therapies for Treating InsomniaSubstance (references) Dosage Adverse effects Drug interactions

Melatonin9–13 3 mg/day Headache, nausea, drowsiness, Reduces efficacy of calcium channel irritability, & orthostatic hypotension blockers, & selective serotonin reuptake inhibitors; increases bleeding with war- farinValerian root14–16 400–900 Headache, liver dysfunction, Central nervous system depressants mg/day drowsiness, & gastrointestinal (benzodiazapine) cause respiratory symptoms such as diarrhea depressionLavender aromatherapy2,17 NA Drowsiness NoneChamomile2,18 1 cup of tea Drowsiness, skin reactions, & Mild diuretic action atopic dermatitis

Websites on evidence-based CAM researchhttp://nccam.nih.gov/health/sleep/ataglance.htm www.naturalstandard.com/N/A, not applicable.

Table 4. Mind–Body-Based Complementary and Alternative Medicine (CAM) Therapies for Treating Insomnia

Treatments & references Efficacy Adverse effects

Acupuncture19,20 Helpful for treating Infection, pain & limited use in immunocompromised primary insomnia patients or patients with bleeding disorders

Yoga19,21 Increases quality of sleep No significant side-effects

Music therapy19,22–24 Increases quality of sleep No significant side-effects

Meditation, hypnotism, Increased quality of sleep No significant side-effects progressive muscle relaxation, biofeedback, & prayer19,22–24

Website on evidence-based CAM research

http://nccam.nih.gov/health/sleep/ataglance.htm

Adapted from refs. 1,3 & 4.

• Alcohol• Antidepressantssuchasbuproprion&selectiveserotonin reuptake inhibitors• Antihypertensives,suchasmethyl-dopa• Anticholinergics• Beta-blockers• Bronchodilators,suchastheophylline• Cimetidine• Centralnervoussystemstimulants,suchasamphetamines• Diuretics

• Someherbalmedications• Illicitdrugs• Nicotine• Phenytoin(Dilantin®)• Steroids• Stimulantlaxatives

Table 2. Drugs/Medications That May Cause Insomnia

Adapted from References 1,3, & 4.

16.5ACT_pages.indd 300 10/15/10 3:10:54 PM

301



6. Morin CM, Bootzin RR, Buysse DJ, et al. Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998–2004). Sleep 2006; 29:1398–1414. 7. Morin AK, Jarvis CI, Lynch AM. Therapeutic options for sleep-maintenance and sleep-onset insomnia. Pharmacotherapy 2007;27:89–110.8. Wheatley D. Medicinal plants for insomnia: A review of their pharmacology, efficacy and tolerability. J Psychopharmacol 2005;19:414–421.9. Buscemi N, Vandermeer B, Hooton N, et al. The efficacy and safety of exog-enous melatonin for primary sleep disorders: A meta-analysis. J Gen Int Med 2005;20:1151–1158.10. Natural Standard. Melatonin. Online document at: www.naturalstandard.com/index-abstract.asp?create-abstract=/monographs/herbssupplements/me latonin.asp Accessed May 19, 2010.11. Brzezinski A, Vangel MG, Wurtman RJ, et al. Effects of exogenous mela-tonin on sleep: A meta-analysis. Sleep Med Rev 2005;9:41–50.12. Buscemi N, Vandermeer B, Pandya R, et al. Melatonin for Treatment of Sleep Disorders: Evidence Report/Technology Assessment No. 108 [AHRQ Publication No. 05-E002-2]. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ), 2004.13. Shamseer L, Vohra S. Complementary, holistic, and integrative medicine: Melatonin. Pediatr Rev 2009;30:223–228. 14. Bent S, Padula A, Moore D, et al. Valerian for sleep: A systematic review and meta-analysis. Am Journal Med 2006;119:1005–1012.15. Fernández-San-Martin MI, Masa-Font R, Palacios-Soler L, et al. Effec-tiveness of valerian on insomnia: A meta-analysis of randomized placebo-con-trolled trials. Sleep Med 2010;11:505–511.16. Taibi DM, Landis CA, Petry H, Vitiello MV. A systematic review of valerian as a sleep aid: Safe but not effective. Sleep Med Rev 2007;11: 209–230.17. Lewith GT, Godfrey AD, Prescott P. A single-blinded, randomized pilot study evaluating the aroma of Lavandula augustifolia as a treatment for mild insomnia. J Altern Complement Med 2005;11:631–637.18. Andres C, Chen WC, Ollert M, et al. Anaphylactic reaction to camomile tea. Allergol Int 2009;58:135–136. 19. Kierlin L. Sleeping without a pill: Nonpharmacologic treatments for in-somnia. J Psychiatric Pract 2008;14:403–407.20. Cheuk DK, Yeung WF, Chung KF, et al. Acupuncture for insomnia. Co-chrane Database Syst Rev 2007;3:CD005472.21. Chen KM, Chen MH, Chao HC, et al. Sleep quality, depression state, and health status of older adults after silver yoga exercises: Cluster randomized trial. Int J Nurs Stud 2009;46:154–163.22. Passarella S, Duong MT. Diagnosis and treatment of insomnia. Am J Health Syst Pharm 2008;65:927–934. 23. Means MK, Lineberger MD, Edinger JD. Nonpharmacologic treatment of insomnia. Curr Treat Options Neurol 2008;10:342–349.24. Meolie AL, Rosen C, Kristo D, et al. Oral nonprescription treatment for insomnia: An evaluation of products with limited evidence. J Clin Sleep Med 2005;1:173–187.

—Surya Karri MD MPHDepartment of Neurosurgery

Massachusetts General Hospital/Harvard Medical School Boston, MA

Katherine Anne Gergen Barnett, MDIntegrative Medicine Clinical Services Boston University School of Medicine

Department of Family MedicineBoston Medical Center

Boston, MA

River Rock Meditation

I initially provide basic education regarding sleep hygiene, such as advising no screen time 1 hour before bedtime, limit-ing fluids to prevent nocturia, and determining that a patient is neither eating too close to bedtime nor awakening hungry be-cause of insufficient consumption of food, which can manifest as agitation. It is also imperative to ensure that the patient is having a bowel movement daily. Constipation, preventing the natural discharge of heat in the body, can result in insomnia.

After attending to the abovementioned possibilities, the single most effective intervention I use is teaching patients a meditation that draws their attention to Yong Quan (Gushing Spring), the first acupuncture point of the Kidney channel. It is the only point on the sole of the foot and is located between the second and third metatarsal bones, one third the distance from the webs of the toes to the heel.

In my river rock meditation (see box), the patient places a small skipping stone beneath this point on each foot while seated in a chair and proceeds to conduct a basic meditative

River Rock MeditationTell Your Patients

By Amy C. Darling, LAc, MAcOM

1. Find 2 small rocks, optimally a round and a flat one. Sit in a chair and place the rocks on the floor beneath your feet in the depression created when you point your toes, just behind the balls of the feet. Choose stones that do not cause discomfort or are so large as to prevent your feet from comfortably resting on the ground.

2. If doing this exercise during the daytime, keep your eyes slightly open, with your gaze resting several feet in front of you. If doing this exercise before bed or to address issues of insomnia, close your eyes.

3. Become aware of your breathing. Breathe through your nose, easily and naturally. Do not intentionally force your breath. Imagine the point on the bottom of each foot as open, as if you are breathing through that spot.

4. Check in with your body. Begin at the top of your head and move down to your feet. Register areas of tightness and pressure. Take a moment to breathe into each region of the body and relax areas of discomfort. Direct your attention continually back to the breath. Slowly descend your atten-tion to the bottom of your feet; the areas holding the rocks.

5. In order to sustain your focus, at the end of each exhale, mentally utter a single word or count from 1 to 10. For example, breathe in, out, IN, OUT, “ONE,” “TWO,” or in, out “CALM” in, out, “PEACE,” etc.

6. Continue for 5–20 minutes. When your focus drifts, which it will, draw it back to the soles of your feet. Begin back at “ONE” or return to your single word. When you finish, sit quietly for several minutes before moving into your next activity.

Note: In times of stress, anxiety, heart palpitations, or sleep disturbance, your body will have a physical memory and associated relaxation response with the sole of your foot. Do not worry about measuring the progress or success of your meditation. Simply be-gin cultivating awareness of your breath and rooting through the sole of your foot.

16.5ACT_pages.indd 301 10/13/10 11:28:14 AM

302



body scan, beginning at the top of the head and working slowly down toward the feet, breathing naturally and re-laxing while proceeding. If a patient practices the medita-tion even 5 minutes per day at bedtime, once the patient lays down, he or she can simply open awareness of the foot, thereby drawing excessive mental activity away from the head, and opening the most grounding point in the body, the origin of the Kidney channel.

My favorite illustration of how this works was a 9-year old patient who presented with both chronic constipation and sleeping problems. I made dietary recommendations and in-troduced the mother to a simple foot massage she could do to help her daughter before bedtime. Two weeks later, when the young girl returned, her mother reported that the girl was now moving her bowels regularly. “And sleep?” I asked. “Really good,” responded the young girl. “And what do you think has helped that,” I asked. “Oh, now, I just massage my own feet at night and go right to sleep,” she answered.

—Amy C. Darling, LAc, MAcOMSeattle, WA

Autogenic Training

As a medical practitioner and Autogenic Training (AT) therapist for many years, I have had the opportunity to observe, document, and listen to the accounts of hundreds of patients concerning the effects of AT on sleep.

These effects have been confirmed by a recent long-term study carried out at the Royal London Homoeopathic Hos-pital showing significant changes in sleep patterns, with improvements in sleep latency, duration, and efficiency and reductions in medication, daytime dysfunction, anxiety, and depression.1

AT is a psychophysiologic-based form of autonomic self-regulation—a structured meditative practice. The patient learns a set of simple meditative exercises, which focus the mind on the body’s experience of relaxation. This leads to a reduction in excessive sympathetic tone and a better balance between sympathetic and parasympathetic activity.2

AT is recommended for addressing a wide range of health con-ditions, especially those in which stress plays a major role in pro-ducing or maintaining ill-health. This makes AT ideal for treat-ing insomnia, which is commonly associated with chronic health problems. AT is a tool helping patients cope with stress and anxiety, which can be both the consequences and causes of sleep problems.

In our research, worry, stress, anxiety, and depression were identified as causes of insomnia for 52% of patients. By focusing on the person and his or her well-being as a whole, rather than the patient’s particular condition, AT can break the vicious cycle of behavioral and cognitive factors perpetuating the problem.3

AT as a behavioral, holistic self-management approach to insomnia is drug-free. This approach is in line with current U.K. guidelines for treating insomnia.4

References

1. Robinson N, Bowden A, Lorenc A. Can improvements in sleep be used as an indicator of the wider benefits of Autogenic Training and CAM research in general? Eur J Integr Med 2010;2:57–62.2. Luthe W, Schultz JH. Autogenic Therapy: Applications in Psychotherapy. New York: Grune-Stratton, 1969.3. Bowden A. Autogenic Training as a non drug approach to anxiety, panic attacks and insomnia. J Holist Care 2002;3:12–14.4. National Institute for Clinical Excellence (NICE). Insomnia—Newer Hyp-notic Drugs: Guidance. [report no.: TA77]. London: NICE, 2005.

—Ann Bowden, MB, ChB, DCH, MFHom, DipATAutogenic Training Service

Royal London Homoeopathic HospitalUniversity College London Hospitals

National Health Service Foundation TrustLondon, United Kingdom

Behavioral Techniques, Botanicals, and Homeopathics

According to the Department of Health and Human Services, more than 64 million Americans experience insomnia on a regular basis.1 It may be transient (lasting less than 1 week), acute (lasting less than 1 month), or chronic (lasting more than 1 month). It is important to determine the pattern of insomnia when attempting to clarify its underlying etiology. Difficulty with initiating sleep or transient insomnia is often associated with anxiety states and acute stress, respectively. Early morning waking is often more indicative of clinical depression and other disease states, such as pain, which can be associated with middle-of-the night waking.

In my own practice, I find behavioral techniques, botanicals, and specific homeopathic blends to be useful for addressing mild sleep disturbances. Good sleep hygiene helps the body prepare for the sleep state. I commonly recommend fixed bed-times, regular exercise (but not in the evening), a good mat-tress, a comfortable ambient temperature in the bedroom, noise reduction, and relaxation techniques, such as breathing and imagery work. Patients are also instructed to avoid alcohol and caffeinated drinks from the late afternoon onward and not to watch television before bed and not to use the bedroom for any other activity than sleeping and engaging in sex.

Valerian root is a traditional botanical sleep aid that has been shown in clinical studies to improve the subjective quality of sleep if taken over a number of weeks.2 It has a very good side-effect profile. I use it in combination with hops to avoid inducing a common paradoxical reaction that some patients have when they take valerian. In these patients, valerian causes agitation.

The homeopathic blend of passionflower, chamomile, oats, and hops is sometimes useful for addressing middle-of-the-night waking. Animal studies indicate that passionflower has a sedative effect, while the sedation effect of hops has not been thoroughly investigated clinically.3

16.5ACT_pages.indd 302 10/13/10 11:28:14 AM

303



References

1. National Institute of Neurological Disease and Stroke, National Institutes of Health (NIH). Brain Basics: Understanding Sleep: National Institute of Neurological Disease and Stroke [NIH Publication No. 06-3440-c]. Bethes-da, MD: NIH, 2007.2. Hadley S, Petry J. Valerian. Am Family Physician 2003;67:1755–1758.3. Wheatley D. Medicinal plants for insomnia: A review of their pharmacol-ogy, efficacy and tolerability. J Psychopharmacol 2005;19:414–421.

—Joseph Feuerstein MDStamford Hospital

Stamford, CTColumbia University College of Surgeons and Physicians

New York, NYand Center for Integrative Medicine and Wellness

Stamford, CT

Acupuncture

Insomnia is a common sleep disorder characterized by per-sistent difficulty with falling asleep and/or difficulty with stay-ing asleep. Although conventional pharmacologic and cogni-tive–behavioral treatments are widely used to treat insomnia, complementary and alternative therapies, such as acupuncture are also often preferred by people with insomnia. However, pharmacologic treatments should be considered as effective for short-term management of insomnia because of their efficacy and safety profile.

Acupuncture is a useful therapy in primary insomnia and in insomnia associated with psychiatric or medical conditions. Some limitations caused by pharmacotherapies—such as de-pendence, potential abuse, sedation, and cognitive impair-ment—do not generally occur with acupuncture treatment.

Although a few side-effects—such as local ecchymoses and skin irritation at needle-insertion points—may occur, there have been no serious adverse effects reported as a result of acu-puncture treatment for insomnia.1

Different acupuncture types, such as body acupuncture, acupressure, and auricular acupuncture, may be used to treat insomnia. Acupuncture may be useful for addressing many sleep parameters, such as sleep onset latency, total sleep duration, and waking after sleep onset.2 In addition, acupuncture may help patients who have poor quality of

life (QoL), anxiety, depression, fatigue, and impairments in cognitive functions.

In conclusion, acupuncture may be an effective and safe intervention for relieving insomnia. In addition, the possible mechanisms underlying the beneficial effect of acupuncture therapy on insomnia need to be investigated with random-ized controlled trials.

References

1. Huang W, Kutner N, Bliwise DL. A systematic review of the effects of acupuncture in treating insomnia. Sleep Med Rev 2009;13:73–104.2. Cheuk DK, Yeung WF, Chung KF, Wong V. Acupuncture for insomnia. Cochrane Database Syst Rev 2007;3:CD005472.

—Saliha Karatay, MDDepartment of Physical Medicine and Rehabilitation

Medical Faculty, Ataturk UniversityErzurum, Turkey

Treatments in Psychiatric or Neurologic Settings

Insomnia is a prevalent disorder in psychiatric and neuro-logic settings. There are striking similarities in the modes of treating insomnia in a psychiatric hospital in India and in a neurologic center in China. In both of our settings, treatment is planned after an etiologic workup rather than just dealing with symptoms.

In the psychiatric outpatient department of the Central Institute of Psychiatry (CIP), in India, insomnia is most common as a comorbid condition with depression or anxi-ety disorders. For conventional therapy, we use antidepres-sants, along with a short-acting benzodiazepine (such as Alprazolam) for sleep-initiation problems and a long-act-ing benzodiazepine (such as Clonazepam) for sleep-main-tenance problems.

In the neurologic center of Daping Military Hospital, in China, insomnia mainly manifests as a comorbid problem with dementia or Parkinsonism. In dementia, benzodiazepines are usually avoided because of adverse reactions that many patients have to these drugs. For conventional therapy, we use mainly antipsychotics in slightly higher doses for treating insomnia and these are quite effective for treating such conditions. For more severe or intractable insomnia, patients are referred to psychiatric centers.

Another striking similarity between our centers, however, is the use of nonpharmacologic modalities to treat insomnia. These modalities are almost the same in both settings. The most commonly used techniques are sleep-hygiene education, stimulus control, sleep restriction, paradoxical intention, and relaxation therapy. Sleep-hygiene education consists of edu-cating patients about good sleep habits, such as avoiding caf-feine, nicotine, large meals, and straining exercises just before bedtime. Stimulus control involves elimination of distractions

Acupuncture is a useful therapy in primary insomnia and

in insomnia associated with psychiatric or medical conditions.

16.5ACT_pages.indd 303 10/13/10 11:28:15 AM

304



at bedtime. Paradoxical intention attempts to eliminate fear of not being able to sleep.

Relaxation therapies are, however, different in our respec-tive settings. In the CIP, we use breathing exercises, mus-cular-relaxation techniques, and mental imagery, whereas in the Daping Hospital, the techniques used are derived more directly from standard meditation techniques, such as Zen meditation and mindfulness techniques. In both of our settings, we find that using relaxation techniques be-fore bedtime increases the efficacy of simultaneous treatments significantly.

—Ravi Prakash MBBS, DPM Central Institute of Psychiatry

Kanke, Ranchi, IndiaXiaoJiang Jiang, MD

Department of Neurology, Daping HospitalResearch Institute of Surgery

Chongqing, China

Integrative Therapy for Postmenopausal Insomnia

Stress and emotional factors in addition to climaterium period may contribute to the high prevalence of insomnia in postmenopause. Apart from using hormone therapy (which is

not indicated in some cases) mind–body therapies may be use-ful adjunctive treatments for some women to help ease symp-toms, improve mood and quality of life (QoL), and increase a sense of well-being.

Research studies examining the role of mind–body therapies for insomnia management are still emerging, and current lit-erature has conflicting reports of efficacy. However, there are positive studies showing benefit for a number of these thera-pies, including acupuncture, relaxation exercises, yoga, and cognitive–behavioral techniques.

I and some colleagues have already reported cases of postmeno-pausal women benefiting from physiotherapy.1 There is one study reporting improvement of sleep with yoga.2 I and my colleagues have preliminary results showing improvement in sleep quality in postmenopausal women who were treated with acupuncture, and in another study, the same effects occurred when such women were treated with massage (data not published).

However, further research and large randomized con-trolled trials (RCTs) are needed. What I and my colleagues

propose now is a combination of relaxation training, phys-iotherapy, yoga, massage, postures, and cognitive–behavioral therapy to improve sleep quality as well as reducing meno-pausal symptoms. This combination approach is used in the clinics I work in, which are mainly for postmenopausal women with sleep disturbances.

However there is a caveat: Mind–body therapies should not be used as replacements for conventional treatments, such as hormonal therapy or treatment with isoflavones. Instead, mind–body therapies should be used in conjunction with a pa-tient’s conventional regimen.

The preliminary findings of me and my colleagues indicate a decrease in scores on anxiety and depression scales as well as improvement in sleep quality. Some patients need lower doses of hypnotic medication during this treatment. Integra-tive therapy must be an option for treating insomnia.

References

1. Llanas AC, Hachul H., Bittencourt LRA, Tufik S. Physical therapy reduced insomnia symptoms in postmenopause. Maturitas 2008;61:281–284.2. Booth-LaForce C, Thurston RC, Taylor MR. A pilot study of a hatha yoga treatment for menopausal symptoms. Maturitas 2007;57:286–295.

—Helena Hachul, MD, PhDDepartamento de Psicobiologia

and Departamento de GinecologiaUniversidade Federal de Sao Paulo (UNIFESP)

São Paulo, Brazil

Individualized Integrative Therapy

Insomnia has high prevalence rates and is associated with significant personal and socioeconomic burdens. There are many causes of insomnia, including a broad range of medi-cal, psychiatric, and behavioral factors. In many instances, insomnia is assumed to be secondary to another primary

medical, psychiatric, or sleep disorder, which necessitates a proper differential diagnosis in order to facilitate treatment planning. Insomnia may also occur in the context of medi-cation use and substance use.

In our practice, when someone comes with a medical diag-nosis of insomnia, we start by unraveling the causes and types. The frequency of sleep disruption and the degree to which insomnia significantly affects daytime function determine the need for treatment.

Mind–body therapies should be used in conjunction with a

patient’s conventional regimen.

Chinese herbal medicines and acupuncture also have good effects

and carry no risk of addiction.

16.5ACT_pages.indd 304 10/13/10 11:28:15 AM

305



For primary insomnia, our treatment begins with nonphar-macologic therapy. We work to find the best therapy appropri-ate for the individual, which may include cognitive–behavioral therapy, exercise, relaxation, sleep restriction (paradoxical inten-tion therapy), stimulus-control therapy, yoga, massage therapy, and light therapy. Pharmacologic therapy is prescribed when immediate symptom reduction is desired, when insomnia pro-duces serious impairment, when nonpharmacologic measures do not produce the desired improvement, or when insomnia persists after treatment of an underlying medical condition. Pharmacologic agents should be prescribed for short periods only, with frequency and duration of use customized to each patient’s circumstances.

Moreover, in our practice, Chinese herbal medicines and acupuncture also have good effects and carry no risk of ad-diction. The results have been wonderful when all treatments meet the needs of the individual rather than approaching in-somnia as a “disease.”

For secondary insomnia, it is necessary to treat the prima-ry disease. Otherwise, if insomnia is severe or long-lasting, a

thorough evaluation to uncover coexisting medical, neurologic, or psychiatric illness is warranted. n

—Xue Yan, MD Qi Wang, PhD

Beijing University of Traditional Chinese MedicineBeijing, China

For this interactive feature column, Clinical Roundup, a new question is posed and then answered by experts in the f ield. For our upcoming issue, we are seeking your contributions on how you treat back pain in your practice for possible publication in the next issue of the Journal.

To order reprints of this article, e-mail Karen Ballen at: [email protected] or call (914) 740-2100.

16.5ACT_pages.indd 305 10/13/10 11:28:16 AM

Documents

Clinical Roundup: How Do You Treat Insomnia in Your Practice?—Part 2