Chinese Herbal Medicine for Insomnia: Evidence, Practice and Opinions A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy Xiaojia Ni BMed, MMed, GZUCM School of Health and Biomedical Sciences College of Science, Engineering and Health RMIT University March 2018 Declaration I certify that except where due acknowledgement has been made, the work is that of the author alone; the work has not been submitted previously, in whole or in part, to qualify for any other academic award; the content of the thesis is the result of work which has been carried out since the official commencement date of the approved research program; any editorial work, paid or unpaid, carried out by a third party is acknowledged; and, ethics procedures and guidelines have been followed. Xiaojia Ni March 2018 ii Acknowledgements First and foremost, I would like to express my deepest thanks to my husband Shuang for his love, encouragement and endless support. I would like to express my sincere gratitude to my primary supervisor Professor Charlie Changli Xue for his continuous guidance and support. I would like to extend my gratitude to Associate Professor Anthony Lin Zhang and Dr Johannah Linda Shergis for their invaluable guidance in the stimulation of ideas, critical thinking, academic writing and candidature management. My sincere thanks also go to Dr Stella Stylianou for her suggestion on statistical analysis, Dr Yan Li for her experience in practising traditional Chinese medicine and Dr Xinfeng Guo for his suggestion on evidenced-based Chinese medicine. Special thanks go to Professor Chuanjian Lu and Professor Yubo Lv for their ongoing motivations in translating Chinese medicine evidence into clinical practice. I am grateful for the opportunity in undertaking a PhD and the scholarship offered by the China – Australia International Research Centre for Chinese Medicine (CAIRCCM), a joint initiative of the Guangdong Provincial Academy of Chinese Medical Sciences, China and RMIT University, Australia with the strategic support from the State Administration of Traditional Chinese Medicine of the People’s Republic of China. Appreciations also go to Guangdong Provincial Association of Traditional Chinese Medicine, China, and Guangdong Provincial Association of Integrative Medicine, China, for their assistance in the survey implementation. I would also like to sincerely thank those Chinese medicine practitioners voluntarily participating in the survey and interview. Without their support, the thesis would not be possible. I would also like to thank other individuals contributing to the study, including Dr Fuchang Lu, Dr Chen Zhou, Dr La Zhang and Dr Yuan Ming Di. Further, I express my appreciation to the training of social science studies by the Institute of Population Research, Peking University, China, and the short course ‘Qualitative Research Methods for Public Health’ at Monash University, Australia. I would also like to acknowledge Professor Zehuai Wen for volunteering his precious time in discussing the soundness of the methodological design, Professor Jeremy Grimshaw (Campbell Collaboration) for providing the key literature on iii evidence translation and Associate Professor Yaolong Chen (Chinese GRADE Centre) for providing his wonderful insights into clinical practice guidelines and evidence quality. Last but not least, I would like to express my thanks to my dearest friends Anna, La, Songpei, Jason, Yiyi and Eunyeong for their peer support, and to Auntie Shana and Auntie Rebecca for their help with my daily life in Australia. iv Contents Declaration ................................................................................................................................. ii Acknowledgements .................................................................................................................. iii Contents ..................................................................................................................................... v Publications ............................................................................................................................ viii List of Figures ............................................................................................................................ x List of Tables ............................................................................................................................ xi Abbreviations ........................................................................................................................... xii Summary .................................................................................................................................. 14 Chapter 1. Introduction ............................................................................................................ 18 1.1. Background ................................................................................................................... 18 1.2. Rationale........................................................................................................................ 18 1.3. Aims and Research Questions ....................................................................................... 19 1.4. Significance ................................................................................................................... 20 1.5. Scope and Organisation of the Thesis ........................................................................... 21 Chapter 2. Overview of Insomnia Diagnosis and Treatment ................................................... 23 2.1. Introduction ................................................................................................................... 23 2.2. Definition of Insomnia .................................................................................................. 23 2.3. Epidemiology of Insomnia ............................................................................................ 23 2.4. Pathophysiology of Insomnia ........................................................................................ 26 2.5. Diagnosis of Insomnia ................................................................................................... 27 2.6. Insomnia Treatment....................................................................................................... 32 2.7. Chinese Medicine for Insomnia .................................................................................... 36 2.8. Summary ....................................................................................................................... 45 Chapter 3. Clinical Evidence of Chinese Herbal Medicine for Insomnia: A Systematic Review and Meta-Analysis .......................................................................................... 46 3.1. Introduction ................................................................................................................... 46 3.2. Methods ......................................................................................................................... 47 3.3. Results ........................................................................................................................... 51 3.4. Discussion ..................................................................................................................... 87 3.5. Conclusion ..................................................................................................................... 91 Chapter 4. Traditional Use of Chinese Herbal Medicine for Insomnia: A Systematic Analysis of the Historical Literature ........................................................................................... 92 4.1. Introduction ................................................................................................................... 92 4.2. Methods ......................................................................................................................... 92 4.3. Results ........................................................................................................................... 96 v 4.4. Discussion ................................................................................................................... 103 4.5. Conclusion ................................................................................................................... 106 Chapter 5. Methodology of a Mixed-Method Design ............................................................ 107 5.1. Introduction ................................................................................................................. 107 5.2. Methodological Paradigm ........................................................................................... 108 5.3. Overall Design............................................................................................................. 112 5.4. Strategy of Inquiry ...................................................................................................... 112 5.5. Framework of Data Analysis....................................................................................... 114 5.6. Ethical Considerations................................................................................................. 114 5.7. Development of the Survey Instrument and Pilot Survey ........................................... 115 5.8. Discussion ..................................................................................................................