CBT-I pips acupuncture in insomnia

Inspired by Garland et al 2019.[1]

Selfie in the Ozone Bar on the 118th floor of the ICC tower looking over Hong Kong Island. Thanks to Karen Chan for guiding us to the Ozone layer on this occasion, and to Gill and Dave Keefe for first taking me 4 years ago.

This paper popped up on my routine PubMed search this morning. I read the message as I was walking home at around 6am. It was a lovely sunny morning and I felt bright and more clear headed than normal. It was as if I had had a great night’s sleep and no alcohol the night before. But that was not the case. Last night I was in the Ozone Bar Hong Kong – one of the highest rooftop bars in the world, sitting on the 118th floor of the ICC Tower looking over Hong Kong Island from Kowloon. I had just finished 4 days of teaching and was heading for the redeye flight to Heathrow taking off just before midnight local time. I had a couple of glasses of white wine at 160HKD a glass (about £16), and that was the end of my dollars, so I headed to the airport. Incidentally, the cost of two tickets on the airport express was about the same price as a glass of wine in the ozone layer :O. Fortunately, I had access to a lounge at the airport and free flowing supply of more sedating beverages. Before I go any farther, I should note that alcoholic drinks are by no means recommended in insomnia – quite the opposite according to the expert Matthew Walker in his highly recommended book Why We Sleep.

Cloudy Bay Sauv Blanc was the cheapest wine available at £16 a glass!

Ozone Bar Hong Kong May 2019

So why was I feeling so clear headed this morning? More so than when I have had 7-8 hours sleep in my own bed! Because it wasn’t really morning in my brain, it was 1pm Hong Kong time and I had had plenty of time to sober up.

Anyway, enough of this morning’s experiences, and down to business on this paper. It is a very nice pragmatic trial of acupuncture versus cognitive behaviour therapy for insomnia (CBT-I) in 160 cancer patients.[1] It comes from the Integrative Medicine Service at the Memorial Sloan Kettering Cancer Center in New York. This centre has a very good research reputation and you can be assured that acupuncture will have been given a very fair trial. Indeed the 80 patients that were randomised to acupuncture received 10 sessions of acupuncture over 8 weeks. 8-16 needles were used per session, and although these were the rather fine ones (0.16mm diameter), pain outcomes did favour the acupuncture group. The contact time was greater in the acupuncture group with a total of 330 minutes as opposed to 240 in the CBT-I group, who were seen 7 times in the 8 weeks.

The primary outcome was the insomnia severity index (ISI),[2] and at 8 weeks both groups improved by more than 8 points – a value representing clinically meaningful improvement.[3] CBT-I was significantly better however, scoring 2.6 points further reduction on ISI at 8 weeks, and this reduction was also maintained at 20 weeks follow-up. There was no difference between the groups in measures of anxiety, depression, fatigue or well-being.

8 points reduction on ISI represents a clinically meaningful improvement

Morin et al 2011 [3]

The authors point out that a meta-analysis of RCTs of CBT-I reported a pooled reduction in ISI of 7.83 (within group change) compared with 3.51 in the control groups (usual care, waiting list or sleep education).[4] So acupuncture in the present trial performed considerably better than the controls in that meta-analysis.

So, a good result for CBT-I, giving clinicians a clear guide of the priority of choice of interventions. In future perhaps the two things can be combined if acupuncture practitioners train in CBT-I. This would seem to be sensible and efficient for a cancer pain population with insomnia at any rate.


1         Garland SN, Xie SX, DuHamel K, et al. Acupuncture Versus Cognitive Behavioral Therapy for Insomnia in Cancer Survivors: A Randomized Clinical Trial. J Natl Cancer Inst Published Online First: 9 April 2019. doi:10.1093/jnci/djz050

2         Savard M-H, Savard J, Simard S, et al. Empirical validation of the Insomnia Severity Index in cancer patients. Psychooncology 2005;14:429–41. doi:10.1002/pon.860

3         Morin CM, Belleville G, Bélanger L, et al. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep 2011;34:601–8. doi:10.1093/sleep/34.5.601

4         Johnson JA, Rash JA, Campbell TS, et al. A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Med Rev 2016;27:20–8. doi:10.1016/j.smrv.2015.07.001

Declaration of interests MC