Stimulated by Kwon et al 2021,[1] and Liou et al 2021.[2]

Photo by David Clode on Unsplash.

CBT–I – cognitive behaviour therapy for insomnia
NMA – network meta-analysis
RCT – randomised controlled trial
PSQI – Pittsburgh sleep quality index
BDNF – brain-derived neurotrophic factor

key to acronyms

I was wondering what to choose this week and it was a sunny morning, which reminded me of a rather unusual occurrence a couple of years ago that I related at the start of a blog on insomnia (CBT–I pips acupuncture in insomnia). As luck would have it I had two insomnia papers in the queue for consideration: a big NMA paper, and a small more speculative spinoff from the trial I highlighted in the previous blog.[3]

elderly people (60 years or more) with insomnia

The NMA included 28 RCTs including 2391 participants examining the effects of non-pharmacological treatments in elderly people (aged a minimum of 60 years) with insomnia. The primary outcome was the PSQI – a self-rated questionnaire with a rather complex scoring system that gives a global score from 0–21, with higher scores indicating a more severe sleep problem. A score of 5 or more has a relatively high sensitivity and specificity in distinguishing between poor and good sleepers.[4] The PSQI is discussed in more detail in a previous blog, also on insomnia – EA for sleep.

The thing I like about NMA is that, if done well, and no data is deliberately left out, you get a pretty good impression of how all the different treatments stack up against each other, even if many of them have never been directly compared. In this case a lot of the data came from China, and the direct comparison of acupuncture with benzodiazepines forms the thickest line in the network map, meaning that lots of studies compared these interventions directly.

This NMA showed that combined treatments were more likely to yield better effects than monotherapies, so acupuncture combined with benzodiazepines and benzodiazepines combined with CBT–I showed excellent effects in this population.

combined treatments were better

Previously I highlighted that CBT–I did better than acupuncture in a population of cancer survivors who were slightly younger on average, and that brings me to the exploratory spinoff paper that examined serum BDNF in the same population before and after 8 weeks of treatment with either CBT–I or acupuncture. Of the 160 subjects in the original trial, 87 both survived and provided serum samples for analysis.

BDNF – brain-derived neurotrophic factor

There were no significant findings in the whole cohort, but when analysis was restricted to those with low baseline BDNF, the acupuncture group (n=22) demonstrated a significant increase of 7.2 ng/ml and CBT–I group (n=21) a non-significant increase of 2.9 ng/ml.

This is highly speculative, of course, and some would call it a fishing trip, but it allows us to speculate on the likely differences in mechanisms between the interventions and encourages the testing of combinations as indicated in the NMA.

I should point out as well that serum BDNF did not correlate with sleep outcomes; however, in general I seem to remember that BDNF is a good thing to have about, particularly in terms of the diseases that can affect elderly brains.[5]


I am just selecting a subject for the next blog and I saw another recent paper that is relevant here.[6] It used a combination of acupuncture and CBT–I compared with CBT–I alone in post-deployment military service personnel and demonstrated improvements in sleep as well as other outcomes. This was a qualitative study embedded within an RCT, and the latter is yet to be published, although according to the study was completed in September 2020. It looks as though the acupuncture used was a standard protocol called manual standardised stress acupuncture (MSSA), as described in a previous paper by the same team.[7] The protocol holds no surprises, and includes GV20, yintang, LI4 and LR3, and they used 0.20mm diameter Seirin needles.


1          Kwon C-Y, Lee B, Cheong MJ, et al. Non-pharmacological Treatment for Elderly Individuals With Insomnia: A Systematic Review and Network Meta-Analysis. Front Psychiatry 2021;11. doi:10.3389/fpsyt.2020.608896

2          Liou KT, Garland SN, Li QS, et al. Effects of acupuncture versus cognitive behavioral therapy on brain-derived neurotrophic factor in cancer survivors with insomnia: an exploratory analysis. Acupunct Med Published Online First: 22 March 2021. doi:10.1177/0964528421999395

3          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: April 2019. doi:10.1093/jnci/djz050

4          Buysse DJ, Reynolds CF, Monk TH, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193–213. doi:10.1016/0165-1781(89)90047-4

5          Miranda M, Morici JF, Zanoni MB, et al. Brain-Derived Neurotrophic Factor: A Key Molecule for Memory in the Healthy and the Pathological Brain. Front Cell Neurosci 2019;13:363. doi:10.3389/fncel.2019.00363

6          Abanes J, Ridner SH, Rhoten B. Perceived benefits of a brief acupuncture for sleep disturbances in post-deployment military service members. J Clin Sleep Med JCSM Off Publ Am Acad Sleep Med Published Online First: 9 March 2021. doi:10.5664/jcsm.9222

7          Abanes J, Hiers C, Rhoten B, et al. Feasibility and Acceptability of a Brief Acupuncture Intervention for Service Members with Perceived Stress. Mil Med 2020;185:e17–22. doi:10.1093/milmed/usz132

Declaration of interests MC