Comparing Guidelines for Insomnia Treatment in China and Korea: Focusing on Traditional Medicine
Article information
Abstract
Objectives:
This study aimed to compare clinical practice guidelines for insomnia in China and Korea, with a particular focus on traditional medicine (TM) approaches.
Methods:
A comparative study was conducted on insomnia guidelines from the Chinese Neuropsychiatric Association (CG), the Korean Neuropsychiatric Association (KG), and the Society of Korean Medicine Neuropsychiatry (TKG). The comparison items, including definitions, evaluations, and treatment, were determined through collaborative work involving a panel of five traditional medicine experts (two traditional Chinese medicine doctors and three Korean medicine doctors) with research or clinical experience in insomnia.
Results:
While both countries’ guidelines align with international standards, they differ in evaluation and treatment, especially regarding TM. CG integrates TM holistically alongside Western medicine, recommending Chinese patent medicines, herbal therapies based on pattern identification, and various nonpharmacological TM methods, such as acupuncture and traditional exercises. In contrast, Korea has a bifurcated system. KG adheres strictly to DSM-5 and minimally references TM (mentioning valerian but not recommending it), while the TKG specifically details traditional Korean medicine treatments, including pattern identification tools, specific herbal formulas with evidence grading (e.g., Guibi-tang, Ondam-tang), and acupuncture, but offers limited integration with Western approaches, such as CBT-I or pharmacotherapy.
Conclusion:
The guidelines reflect distinct approaches shaped by differing healthcare systems and cultural contexts. Future collaborative research is needed to establish criteria for treatment duration and combination therapies for TM treatments.
I. Introduction
Insomnia is a common clinical sleep disorder characterized by difficulty falling asleep, maintaining sleep, or waking up too early. Chronic insomnia significantly affects the patient’s quality of life and increases the risk of developing cardiovascular1, metabolic2, neurological3, or psychiatric disorders4. According to a 2017 meta-analysis, the prevalence of insomnia in the general population of China is approximately 15%5. A study by Cho et al.6 showed that the prevalence of insomnia symptoms in South Korea ranges from 17% to 23%. Among them, the prevalence of insomnia meeting DSM-IV diagnostic criteria is 5%7. The spread of the COVID-19 virus has, to some extent, increased the proportion of individuals affected by insomnia8. The diagnosis and treatment of insomnia have made continuous progress, and clinical practice guidelines vary between countries due to differences in culture, healthcare resources, and research advancements. Since 2010, both China and Korea have been developing and updating their clinical practice guidelines for insomnia, and place great importance on traditional medicine (TM) and Western medicine, leading to significant advancements in clinical practice and research. However, due to cultural differences and variations in healthcare systems, discrepancies in guidelines may arise9. Additionally, Korea has developed separate clinical guidelines for insomnia in TM and Western medicine, necessitating a comparison of all three guidelines between Korea and China.
The aim of this study is to provide scientific evidence to optimize diagnostic and therapeutic strategies and to offer strong support for more precise and efficient treatment plans for patients in both countries.
II. Methods
1. Research Subjects
The selection of guidelines was based on the most recent versions published by key professional organizations in each country: the Sleep Disorders Group of the Neurology Branch of the Chinese Medical Association, the Korean Neuropsychiatric Association, and the Society of Korean Medicine Neuropsychiatry. The specific guidelines selected for this study were: “Chinese Guideline for Diagnosis and Treatment of Insomnia (2023)” (hereinafter referred to as the Chinese guidelines, CG)10, the 2019 edition of “Korean Clinical Practice Guidelines for the Diagnosis and Treatment of Insomnia in Adults” (hereinafter referred to as the Korean guidelines, KG)11, and the 2021 edition of “Korean Medicine Clinical Practice Guideline for Insomnia (version 2.0)” (hereinafter referred to as the traditional Korean medicine guidelines, TKG)12.
2. Procedure for Guideline Comparison
For the selection of review items and the derivation of conclusions in this study, a panel of five experts was established, comprising three Korean medicine doctors and two Chinese medicine doctors, all possessing research or clinical experience in insomnia. This panel composition was intentionally chosen to facilitate an in-depth comparison of the traditional medicine approaches to insomnia management in both countries. In October 2024, the expert panel convened for a face-to-face meeting to collaboratively determine the research objectives and the key areas for guideline comparison. The identified comparison items included the definition, clinical evaluation, and treatment of insomnia as addressed in each guideline.
Based on the selected comparison items, the original texts of the guidelines from each country (in Chinese and Korean) were translated into English and summarized to create the foundational data for comparative analysis. Subsequently, the content for each item was organized into a tabular format to enable a clear comparison. The resulting comparison table was shared with the expert panel via an online platform, and opinions regarding the accuracy and interpretation of the content were exchanged through email correspondence. In April 2025, a final online meeting was held where all five experts confirmed their agreement with the content and reached a final consensus (Fig. 1).
Conceptual framework of this study.
KM : Korean medicine, TCM : traditional Chinese medicine.
III. Results
1. Definition
Korean and Chinese guidelines generally define insomnia as a symptom caused by insufficient sleep duration and/or poor sleep quality, leading to impaired daytime functioning10-12. The definitions and diagnoses of insomnia in the Chinese and Korean guidelines are consistent in their core content, yet there are certain differences. Both acknowledge that insomnia is a subjective experience, involving dissatisfaction with sleep duration and/or quality, and must be accompanied by daytime functional impairment or emotional and physical discomfort. However, there are differences in the specific diagnostic criteria: KG and TKG follow the criteria outlined in the “Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition” (DSM-5)13, emphasizing that the core symptoms of insomnia (difficulty falling asleep, difficulty maintaining sleep, early awakening) must occur at least three times per week and persist for at least three months. CG places more emphasis on the broad manifestations of insomnia, in addition to the core symptoms, also including prolonged sleep onset latency (>30 minutes), increased number of nocturnal awakenings (≥2 times), and reduced total sleep time (<6.5 hours), and provides a more detailed description of the daytime functional impairments caused by insomnia (such as fatigue, cognitive impairment, mood fluctuations, etc.), with a greater focus on comprehensively considering the individual circumstances of the patient, and emphasizing the overall nature of the symptoms and their impact on daily life.
2. Clinical Evaluation
Both the Chinese and Korean guidelines focus on four aspects in clinical evaluation: medical history collection, physical examination, subjective assessment, and objective assessment. The medical history collection in three guidelines focuses on the manifestations of insomnia, its course, sleep-wake rhythm, use of medications, and other relevant historical details. The KG particularly emphasize the collection of psychiatric/psychological history and specify the recommended strength of each evaluation item. Additionally, CG and KG recommend routine laboratory tests to exclude systemic diseases and identify the underlying causes of insomnia. The KG specifically mention that circadian rhythm disorders can be assessed through the measurement of circadian rhythm markers (such as melatonin, core body temperature)14. The TKG introduced an acupuncture clinical study that set melatonin as an outcome and presented sleep assessment methods using melatonin and cortisol15. However, it did not provide separate recommendations and noted that there can be significant variability between individuals in these tests. Similarly, the CG also do not provide specific recommendations on this matter. In terms of subjective assessment, CG and KG recommend the use of sleep diaries to gain a comprehensive understanding of the patient’s sleep and daytime condition16. However, the KG also point out that this method may have the limitation of exacerbating insomnia. Furthermore, TKG introduced only one clinical study using sleep diaries but did not mention the necessity of using sleep diaries17. In scale assessments, the KG place more emphasis on evaluating the severity of insomnia, daytime sleepiness, sleep-disordered breathing, and the sleep-wake cycle, whereas the CG further focus on the evaluation of emotional states. TKG mentioned that the Pittsburgh sleep quality index (PSQI) and Insomnia severity index (ISI) are frequently used and introduced the pattern identification tool for insomnia. The pattern identification tool for insomnia is a self-report questionnaire developed in 2016 through a literature review and expert consensus. This questionnaire consists of items corresponding to A. Mind and spirit, B. Whole body, C. Head, neck, and face, D. Chest and diaphragm, E. Abdomen and digestive state, F. Urinary and reproductive system, and G. Bowel and bladder. It aims to diagnose insomnia patients and explore a holistic treatment approach18,19.
In objective measures, polysomnography (PSG) is primarily used for the differential diagnosis and efficacy evaluation of insomnia-related disorders, such as sleep apnea, periodic limb movement disorder, and REM sleep behavior disorder, especially in patients with poor response to pharmacological or psychological treatments20. However, the KG further point out that PSG in insomnia evaluation may be affected by the testing environment, leading to the first-night effect or the reverse first-night effect21, and routine use is not recommended due to cost and time limitations. The TKG also mentioned PSG as the gold standard for diagnosing insomnia, while explaining its drawbacks, including high testing costs, testing convenience, and the limitation of representing only one night’s sleep results. The multiple sleep latency test (MSLT) is used to differentiate narcolepsy and other diseases that cause daytime sleepiness, but both CG and KG do not recommend it as a routine method for evaluating daytime sleepiness in insomnia patients22. The actigraphy, as a non-invasive monitoring tool, can assess circadian rhythms and sleep-wake patterns. The CG emphasize its role as an alternative assessment for total sleep time in the absence of PSG and its supplementary function in cognitive behavioral therapy for insomnia (CBT-I), whereas the KG point out its value in the efficacy evaluation after insomnia treatment, highlighting its cost-effectiveness while also mentioning its limitations due to the lack of EEG information and insufficient standardization of the equipment. Similarly, the TKG mentioned that the actigraphy has the advantage of continuously monitoring sleep patterns and possesses a certain level of reliability and validity, but it also noted that due to limitations in program operation, it is difficult to apply it universally in clinical settings. On the other hand, the CG mention that wearable devices and remote monitoring equipment have improved the limitations of the actigraphy, offering portability and enabling multi-parameter monitoring23, which is not mentioned in the KG and TKG.
3. Treatment
1) Psychological and behavioral treatment
CBT-I is an important component of psychological and behavioral therapy, and the CG and KG explicitly list it as the first-choice and first-line treatment for chronic insomnia24. The KG provide detailed instructions on the implementation of CBT-I, offering strong clinical guidance. The CG introduce two modes of CBT-I, further emphasizing that in cases where insomnia is associated with cerebrovascular diseases, chronic obstructive pulmonary disease (COPD), or psychiatric disorders, CBT-I can be used alone or combined with repetitive transcranial magnetic stimulation (rTMS), pharmacological treatment, acupuncture, or light therapy, all of which are strongly recommended. The CG also strongly recommend CBT-I for special populations such as the elderly, pregnant women, and children and adolescents. Additionally, the CG further simplify CBT-I into Brief Treatment for Insomnia (BTI), highlighting the effectiveness of the behavioral therapy component, and based on the 3P model of insomnia, provide technical options for psychological and behavioral treatment from seven aspects: triggers/events, cognitive biases, pre-sleep anxiety, engaging in entertainment/work in bed, prolonged time in bed, irregular sleep-wake schedules, and insufficient physical activity. Additionally, it emphasized the importance of meditation therapies, including mindfulness, and mentioned mindfulness-based cognitive therapy (MBCT) that combines cognitive behavioral therapy, as well as progressive muscle relaxation17. The CG also strongly recommended mindfulness relaxation alongside the previously mentioned methods, introducing techniques such as meditation, progressive muscle relaxation, guided imagery, and breathing techniques.
2) Physical treatment
Physical treatment is relatively safe, non-invasive, easy to administer, and well-accepted, making it a viable treatment option for insomnia. CG, TKG, and KG have similarities and differences in their recommendations for physical treatments (see Table 1). CG and KG recommend light therapy as an important non-pharmacological intervention, believing it has a positive effect on improving insomnia symptoms by regulating the circadian rhythm. CG emphasize that light therapy affects melatonin secretion and alertness, and note that its effect size is limited, requiring further research to optimize treatment parameters25. The KG, however, focus more on the role of light therapy in adjusting the timing of the core body temperature nadir and achieving circadian rhythm phase shifts26, and provide detailed recommendations for light intensity and duration. In terms of exercise therapy, CG, TKG, and KG recognize its potential value in improving sleep quality by enhancing sleep stability and stabilizing the circadian rhythm, but they emphasize it from different perspectives. CG mention practices such as Baduanjin, Tai Chi, jogging, and racket sports, but do not provide clear recommendations. TKG recommended Tai Chi and Qigong, assigning evidence grades of B and C to each, respectively27,28. The KG, through a meta-analysis29, summarize the positive effects of exercise therapy on various sleep parameters (such as sleep onset latency, sleep efficiency, and total sleep time), and believe its efficacy can be comparable to that of CBT-I or pharmacological treatment, and suggest its potential as an important non-pharmacological intervention. Additionally, the Chinese guidelines also recommend a range of non-invasive neuromodulation techniques (such as transcranial magnetic stimulation30, transcranial electrical stimulation31, and transcutaneous auricular vagus nerve stimulation (ta-VNS)32), with some techniques receiving high recommendation levels, demonstrating a more comprehensive selection of technologies and innovative applications; The KG do not address these techniques, instead favoring traditional methods such as light therapy and exercise therapy. Overall, CG reflect the diversity and exploratory nature of technological approaches, while the KG emphasize the broad applicability and practical operability of traditional interventions. The TKG values evidence and practicality, introducing methods that can serve as alternatives to standard therapies.
Comparison of Physical Treatment Recommendations among CG, TKG, and KG
3) Traditional medicine treatment
All three guidelines focus on the application of non-pharmacological therapies, CG emphasize the principles of TM syndrome differentiation and treatment, recommending Chinese patent medicines and herbal therapies, and also point out that TM non-pharmacological treatments such as acupuncture, massage, and moxibustion33 can significantly improve sleep quality and alleviate patients’ anxiety and depression, and suggest research directions for traditional exercises like Baduanjin and Tai Chi34. TKG, being a guideline specialized in this field, provides a detailed explanation of the process similar to what is described in the CG, and presents its flow. TKG classifies the syndrome differentiations into six categories and offers corresponding prescriptions for each. The six syndrome differentiations and their corresponding prescriptions are as follows: Insomnia due to excessive thinking/worry (思結不睡) - Guibi-tang (歸脾湯), Deficiency of nutritive blood (營血不足) - Bohyelansin-tang (補血安神湯), Yangsim-tang (養心湯), Yin deficiency with internal heat (陰虛內熱) – Chunwangbosim-dan (天王補心丹), Soyo-san (逍遙散), Deficiency and timidity of the heart and gallbladder (心膽虛怯) - Ondam-tang (溫膽湯), Stagnation of phlegm and saliva (痰涎鬱結) - Chungsimdodam-tang (淸心導痰湯), Disharmony of the stomach (胃中不和) - Hyangsayangyi-tang (香砂養胃湯). TKG presents evidence and recommendation grades for various treatments including herbal medicine alone, the combination of herbal medicine and sleep medications (Western medicine), acupuncture alone, and acupuncture combined with sleep medications. Additionally, it also provides evidence and recommendation grades for the combination of traditional treatments. However, unlike CG, it does not recommend single herbal component extracts or patented products. KG discussed phytotherapy such as valerian and hops35, but did not mention traditional Korean medicine at all, and did not recommend them as their clinical importance has not been confirmed. Overall, CG and TKG place greater emphasis on syndrome differentiation and treatment based on TM theories, while the KG adopt a more cautious attitude toward herbal therapies, questioning their clinical efficacy. See Table 2 for details.
Comparison of Traditional Medicine Treatment Recommendations between Chinese and Korean Guidelines
4) Pharmacological treatment
Insomnia is a sleep disorder characterized by difficulty in falling asleep, maintaining sleep, or early awakening, leading to impaired daytime functioning. Therefore, the main purpose of pharmacological treatment is to shorten sleep latency, increase total sleep time, and improve sleep efficiency. This is achieved through sedative, hypnotic36, and anxiolytic37 pharmacological effects, ultimately aiming to enhance overall sleep quality. While CG and KG provide a detailed introduction to pharmacological treatment, TKG only briefly introduces the application and limitations of this treatment, as well as the effects of combined treatment with traditional therapies. See Supplementary table 1 for a comparison of the pharmacological treatment recommendations in the CG and KG.
(1) Timing and duration of medication
Both the CG and KG emphasize selecting the timing of medication based on sleep needs. For example, patients may take medication before sleep to help fall asleep quickly, or use short half-life medications if they wake up at night with sufficient time before their expected wake-up time to help resume sleep. However, the KG place greater emphasis on aligning medication timing with the “physiological sleep-wake cycle” recommending that patients take medication 7 hours before their morning wake-up time to optimize effectiveness. In contrast, the Chinese guidelines primarily adjust medication timing based on actual sleep needs, offering a more flexible “as-needed” approach, such as taking medication immediately when unable to fall asleep or using short-acting medications if waking at night with more than 5 hours before the expected wake-up time. It does not specifically mention alignment with the physiological sleep rhythm. Regarding treatment duration, both countries recommend keeping pharmacological treatment as short as possible, typically no longer than 4 weeks. They also advise regular evaluation of the patient’s condition during long-term medication use and adjustment of the treatment plan if necessary. However, the KG adopt a more cautious approach, explicitly positioning medication as an adjunctive intervention and prioritizing CBT-I. In contrast, the Chinese guidelines note that certain medications, such as zolpidem and eszopiclone, have evidence supporting long-term use. Nevertheless, given the potential risk of dependency, they still recommend transitioning to intermittent use after 4 weeks of treatment. The recommended frequency for intermittent treatment is 3 to 5 times per week, with specific operational guidance provided. About TM, TKG described the treatment duration from individual clinical studies that serve as the basis for the guideline recommendations, but it did not draw any conclusions regarding the treatment duration and frequency of traditional treatment methods, mentioning that further research is needed to address this limitation in the future. CG also did not provide the treatment duration and frequency for traditional treatments. Overall, KG place greater emphasis on aligning treatment with physiological rhythms and prioritizing CBT-I. In contrast, CG are more inclined to flexibly adjust treatment strategies to accommodate individual patient needs.
(2) Drug selection
Significant differences exist between CG and KG in pharmacological treatment for insomnia. Both guidelines recommend non-benzodiazepine drugs or novel benzodiazepine receptor agonists as treatment options. However, CG explicitly strongly recommend zolpidem, eszopiclone, zaleplon, and doxepin as first-line drugs. In contrast, KG mention only zolpidem, eszopiclone, and zaleplon, without referencing doxepin, and their recommendations are all of weak strength. Additionally, the CG strongly recommend dual orexin receptor antagonists such as suvorexant, lemborexant, and daridorexant. They consider these drugs as new therapeutic targets due to their lack of addiction potential. KG only weakly recommend suvorexant for sleep maintenance disorders. For antidepressants, CG strongly recommend doxepin for insomnia patients with anxiety or depressive symptoms. KG, while mentioning trazodone, only provide a weak recommendation. Regarding antihistamines, CG strongly recommend doxylamine38 and diphenhydramine39 for the treatment of acute insomnia in pregnant patients, whereas KG explicitly discourage the use of antihistamines. Regarding melatonin, CG strongly recommend melatonin prolonged-release tablets for the treatment of insomnia in patients over 55 years old and highlight the use of melatonin receptor agonists such as ramelteon and tasimelteon in patients with insomnia and circadian rhythm disorders. In contrast, the KG do not recommend short-acting melatonin formulations and only weakly recommend prolonged-release formulations for sleep maintenance disorders in patients over 55 years old. In terms of evidence levels, the medications strongly recommended by CG are mostly based on moderate to high-level evidence, whereas those recommended by KG are largely based on low to moderate-level evidence, highlighting differences in the evidence basis and recommendation strength between the two countries’ guidelines. The Chinese guidelines mention the use of sedative antipsychotic drugs (e.g., quetiapine) and anesthetic agents (e.g., dexmedetomidine) in specific insomnia patients. However, due to adverse effects and indication limitations, their use is recommended with caution only after multidisciplinary evaluation, with low-dose quetiapine being strongly recommended for its superior sedative effects. Additionally, CG place particular emphasis on the long-term medication management for patients with chronic insomnia, recommending regular evaluations and intermittent treatment, while KG do not mention this. These differences reflect the varying emphasis between the two countries on medication selection, recommendation strength, and treatment strategies. Regarding TM treatments, TKG provides detailed descriptions of syndrome differentiation and prescriptions necessary for insomnia assessment, and explains which additional herbal medicines should be used for supplementary symptoms. It also offers recommendations and evidence levels for combination therapy with sleep medication. However, it does not clearly specify when combination therapy should be employed or when herbal medicine or acupuncture treatment is preferred. It only provides a general explanation that herbal medicine treatment is effective in chronic and intractable conditions. Similarly, CG also states that TM treatments are effective for insomnia in monotherapy or combination therapy, and provides recommendations and evidence levels, but does not describe the treatment selection methods.
5) Treatment for special populations and patients with comorbidities
CG provide detailed individualized treatment recommendations for special populations (e.g., the elderly, pregnant and lactating women, perimenopausal/ menopausal women, children/adolescents, and shift workers) and patients with comorbidities (e.g., obstructive sleep apnea, restless legs syndrome, cerebrovascular diseases, chronic obstructive pulmonary disease, type 2 diabetes, non-dipper hypertension, depression, and anxiety), as detailed in Table 3. Although KG and TKG provide some descriptions of disease groups, they do not offer specific recommendations for particular populations or patients with comorbidities.
Treatment Recommendations for Special Populations and Patients with Comorbidities in 2023 Chinese Guideline
IV. Discussion
This study is significant in that it compares the clinical practice guidelines for insomnia in China and Korea, identifying similarities and differences between the two countries, and particularly focusing on an in-depth comparison of the characteristics of TM approaches. The study results showed overall consistency in that the insomnia diagnosis and treatment guidelines in both countries are based on international mainstream theories and clinical practices. However, they also revealed different emphases and academic orientations in their detailed content.
When comparing the guidelines presented by the neuropsychiatric associations of Korea and China, a difference was observed in the definition of insomnia. KG strictly adheres to the DSM-5 criteria, while CG places greater importance on the diversity of symptoms and the individuality of patients. In clinical evaluation, both countries include subjective and objective assessments. However, Korea tends to focus on insomnia symptoms themselves and circadian rhythm biomarkers, whereas China emphasizes the assessment of emotional states and actively utilizes technologies such as actigraphy. In terms of treatment, CG and KG share the commonality of recommending cognitive behavioral therapy as the first-line treatment. However, CG emphasizes the diversity of psychological and behavioral therapies, including neuromodulation techniques, and provides a broader range of detailed guidelines in pharmacotherapy. In contrast, KG prioritizes non-pharmacological therapies and takes a cautious stance on medication use. In physical therapy, CG demonstrates diversity and innovation in treatment methods, such as non-invasive neuromodulation techniques, while Korean guidelines focus on light therapy and exercise therapy, emphasizing feasibility.
A key feature of this study is the comparative analysis of TM perspectives, including the ≪insomnia disorder: clinical practice guideline of Korean medicine≫12 developed by the Society of Korean Medicine Neuropsychiatry. CG presented various treatment methods based on TM theory, described TM approaches on par with psychiatric medications including sleeping pills and CBT-I, and recommended TM treatments, either alone or in combination, although the evidence and recommendation levels were not high. In Korea, the guidelines were divided into KG and TKG, so we compared traditional treatments in both guidelines. As a result, KG described valerian and hops under the Phytotherapy section but indicated a position against their recommendation. Furthermore, there was no other description of TM approaches in KG. Unlike KG and CG, TKG described the content of sleeping pills and CBT-I but did not present the selection process, recommendations, or evidence levels for Western medicine. This is understood to be due to differences in the medical systems between the two countries. While Korean insomnia patients have the advantage of choosing treatment methods according to their preference, there is a risk of indiscriminate mixing of medications, duplication of treatments, or receiving only one type of treatment. Therefore, it is considered necessary to establish integrated guidelines in the future. It is also thought that the Chinese model could serve as a valuable reference for the development of an integrated model in Korea. If more flexible and multidisciplinary treatment options are provided to insomnia patients in Korea, it will contribute to meeting their complex needs and maximizing treatment effectiveness.
In a detailed look at TM treatments, CG first introduces a wide range of methods, including traditional Chinese herbal patents, herbal remedies, and non-pharmacological therapies of traditional Chinese medicine (TCM). It recommended the use of traditional Chinese herbal medicine according to syndrome differentiations and suggested combining traditional Chinese herbal medicine with sleeping pills rather than using sleeping pills alone. It also described areas not mentioned in TKG, such as patented extracts, valerian, and ashwagandha, by incorporating them into TM. In terms of non-pharmacological treatments, it introduced therapies not covered in TKG, such as acupressure, acupoint herbal patches, herbal pillows, herbal foot baths, Baduanjin, Wuqinxi, and Liu zi jue, in addition to acupuncture, Chuna (推拿), and moxibustion. However, it did not present evidence and recommendation levels for each treatment but provided levels for TCM treatment and non-pharmacological therapies of TCM. TKG developed pattern identification tool and presented six patterns along with prescriptions suitable for these patterns. It is noteworthy that it presented recommendations and evidence levels for each prescription’s use as a standalone treatment, in combination with sleeping pills, and in combination with acupuncture. This can be interpreted as reflecting the tendency of the Korean medicine community to emphasize evidence-based medicine and pursue convenience and efficiency in clinical application. Furthermore, TKG tended to emphasize meditation and relaxation therapies such as mindfulness, and biofeedback training more than CG. This proactive integration of traditional treatments with the latest non-pharmacological therapies is believed to be for the purpose of establishing independent traditional Korean medicine treatments for insomnia. Future accumulation of additional clinical research and case studies will clarify the synergistic effects between traditional treatments and non-pharmacological therapies.
It is difficult to conclude that one country places more importance on TM approaches based solely on the differences in the description of TM between CG and TKG as explained above. This implies that a simple comparison between CG and TKG regarding TM treatment may not be appropriate because CG comprehensively presents both Western medicine treatments, which correspond to standard treatments, and TM treatments, whereas TKG focuses on describing TM treatments. Like TKG, in 2016, the China Academy of Chinese Medical Sciences’ Task Force of TCM Clinical Practice Guidelines for Insomnia published the ≪TCM clinical guidelines for insomnia (失眠症中医临床实践指南)≫40, developed by the WHO/WPO insomnia research group. This guideline detailed TM treatments for insomnia. However, this study did not directly compare TKG with this TCM guideline because TKG itself provided a relatively detailed introduction to the TCM guideline and the research included in it. Moreover, compared to the 2017 edition41, CG used in this study have newly added and expanded recommendations for TM treatment. The 2017 edition offered only a brief mention, stating that ‘TCM has a long history in treating insomnia, but due to its individualized approach, it is difficult to evaluate with modern evidence-based medical models.’ However, the 2023 edition includes more detailed sections on 1. Chinese patent medicine and other herbal therapies, 2. Non-pharmacological therapies of traditional Chinese medicine, and 3. Other therapies of traditional Chinese medicine, and presents evidence and recommendation grades. This expansion indicates that both countries place great importance on TM approaches for insomnia.
By comparing the clinical practice guidelines for insomnia in Korea and China, and especially by highlighting the differences in TM perspectives, this study can provide important basic data for future academic exchange and cooperation between the two countries. Furthermore, it is expected to contribute to optimizing insomnia treatment strategies and providing more accurate and effective treatment to patients. However, the fact that the guidelines of both countries do not specifically present the selection criteria and treatment duration for TM treatments, the characteristics of patients and diseases for whom combination therapy may be effective, is an urgent task to be solved in the future, and this goal may be achieved sooner than expected if exchange and cooperation between the two countries proceed.
A limitation of this study is that it compared and analyzed guidelines at a specific point in time. Therefore, it should be considered that these differences may be due to temporal differences as well as cultural and institutional differences between the two countries. Consequently, the content may change as the guidelines of each country are updated in the future. Although this study focused on comparing TM, it fundamentally compared the differences in guidelines between the two countries in a broader framework. Therefore, it was not able to precisely compare the differences in herbal medicine treatments according to pattern identification, the choice of acupuncture points, and the selection criteria for non-pharmacological treatments between Korea and China. Furthermore, the experts who participated in this study were specialists in TM, and there was no participation from neuropsychiatrists or neurologists who specialize in Western medical treatment. For more specific and comprehensive comparisons in the future, the participation of Western medicine specialists is necessary.
Future research needs to compare and analyze the actual clinical effects of TM insomnia treatments in Korea and China and verify whether the effects are similarly derived in both countries. In addition, since TM has difficulty in presenting evidence-based evaluations due to the characteristic that treatment selection varies depending on the patient’s constitution, syndrome differentiations, and symptom changes, methodological research and development efforts are needed to compensate for this. Furthermore, to compare the specific procedural differences in insomnia treatment within the clinical realities of Korea and China, which this study could not perform, chart reviews or prospective cohort studies are necessary. Moreover, research on the impact of an integrative approach of Western medicine and TM on insomnia treatment would also be meaningful. Especially in Korea, further promotion and exchange efforts are needed to ensure that Western medicine practitioners can understand the clinical application and evidence of TM treatments. Through this, it will be possible to explore the possibility of multidisciplinary collaboration to provide more effective and safer treatments for insomnia patients.
V. Conclusion
This study comparing Chinese (CG) and Korean (KG, TKG) insomnia guidelines reveals both shared principles and distinct approaches, particularly concerning TM. While both countries base their guidelines on international standards, CG adopts a broader definition of insomnia and emphasizes emotional evaluation and digital technology. KG adheres strictly to DSM-5, while TKG focuses on traditional Korean medicine. Both CG and KG recommend CBT-I as first-line treatment, but CG offers more extensive pharmacotherapy guidance, whereas KG prioritizes non-pharmacological options. A key difference lies in the integration of TM. CG comprehensively incorporates it alongside Western medicine, while Korean guidelines present a more separate view. This reflects differing healthcare systems and cultural contexts. This comparative analysis provides essential data for future academic exchange and collaboration. Future research should focus on the comparative effectiveness of traditional treatments and the development of robust evaluation methods to optimize insomnia care in both countries.
Supplementary
Comparison of Recommended Medications in Chinese and Korean Guidelines
Acknowledgements
This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (RS-2024-00444922) and Korea Institute of Oriental Medicine (KSN1739121).
Declaration of interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.