Natural treatments for insomnia

Definition: Treatment of the inability to fall asleep or to get restful sleep.

Principal proposed natural treatments: Melatonin, valerian (alone or with hops or melissa)

Other proposed natural treatments: Acupuncture or acupressure, ashwagandha, astragalus, biofeedback, chamomile, 5-hydroxytryptophan, gamma-aminobutyric acid, He shou wu, hops, kava, lady’s slipper orchid, magnesium, passionflower, probiotics, relaxation therapies, St. John’s wort, skullcap

Introduction

Many people have a serious problem getting a good night’s sleep because life simply becomes too busy to get the eight hours that are really needed. To make matters worse, many people have insomnia. When a person does get to bed, they may stay awake thinking for hours, and sleep itself may be restless instead of refreshing.

Most people who sleep substantially less than eight hours a night experience a variety of unpleasant symptoms. The most common are headaches, mental confusion, irritability, malaise, immune deficiencies, depression, and fatigue. Complete sleep deprivation can lead to hallucinations and mental collapse.

The best way to improve sleep involves making lifestyle changes—eliminating caffeine and sugar from one’s diet, avoiding stimulating activities before bed, adopting a regular sleeping time, and gradually turning down the lights. More complex behavioral approaches to improving sleep habits can also be adopted.

Many drugs are available to help with sleep. Sonata, Lunesta, Ambien, Restoril, Ativan, and Xanax are medications that are widely used for sleep problems. Of these, only Lunesta has been tested and approved for long-term use. All these medications are, in essence, tranquilizers and, therefore, have a potential for dependence and abuse. The sleep-inducing drug Rozerem (ramelteon) acts like an enhanced version of the supplement melatonin and is not thought to have such potential.

Antidepressants can also be used to correct sleep problems. Low doses of certain antidepressants immediately bring on sleep because their side effects include drowsiness. However, this effect tends to wear off with repeated use. For chronic sleeping problems, full doses of antidepressants can sometimes be helpful. Antidepressants are believed to work by actually altering brain chemistry, which produces a beneficial effect on sleep. Trazodone and amitriptyline are two of the most commonly prescribed antidepressants when improved sleep is desired, but most other antidepressants also can be helpful.

Principal Proposed Natural Treatments

Although the scientific evidence is not definitive, the herb valerian and the hormone melatonin are widely accepted as treatments for certain forms of insomnia.

Valerian. Valerian has a long traditional use for insomnia, and it is an accepted over-the-counter treatment for insomnia in Germany, Belgium, France, Switzerland, and Italy. However, the evidence that it really works remains inconclusive. A systematic review concluded that valerian is safe but probably not effective for treating insomnia. However, there have been some positive results, with both valerian alone and valerian combined with other herbs.

Valerian is most commonly recommended to be used as needed for occasional insomnia. However, the results of the largest and best-designed positive study found benefits only regarding long-term improvement of sleep. In this double-blind, placebo-controlled trial, one-half of the participants took 600 milligrams (mg) of an alcohol-based valerian extract one hour before bedtime, while the other one-half took placebo. Valerian did not work right away. For the first couple of weeks, valerian and placebo had similar effects. However, by day twenty-eight, valerian’s effectiveness increased. Effectiveness was rated as good or very good by participant evaluation in 66 percent of the valerian group and in 61 percent by doctor evaluation, whereas in the placebo group, only 29 percent were so rated by participants and doctors.

Although positive, these results are a bit confusing, because in another large study, valerian was effective immediately. Other studies, most of relatively low quality, found immediate benefits too. To further confuse the matter, four later studies of valerian failed to find evidence of any benefit; one was a four-week study that included 135 people given valerian and 135 given placebo.

A study of 184 people that tested a standardized combination of valerian and hops had mixed results. Researchers tested quite a few aspects of sleep (such as time to fall asleep, length of sleep, and number of awakenings) and found evidence of benefit in a few. This use of multiple outcome measures makes the results somewhat unreliable.

Other studies have compared valerian (either alone or with hops or melissa) with benzodiazepine drugs. Most of these studies found the herbal treatment approximately as effective as the drug, but because of the absence of a placebo group, these results are less than fully reliable. Mixed results like these suggest that valerian is, at most, modestly helpful for improving sleep.

Valerian should not be taken while taking sleeping medication or medication for anxiety, diarrhea, or pain.

Melatonin. The body uses melatonin as part of its normal control of the sleep-wake cycle. The pineal gland makes serotonin and then turns it into melatonin when exposure to light decreases. Strong light (such as sunlight) slows melatonin production more than weak light, and a completely dark room increases the amount of melatonin made. Taking melatonin as a supplement seems to stimulate sleep when the natural cycle is disturbed. It may also have a direct sedative effect.

Although not all studies were positive, reasonably good evidence indicates that melatonin is helpful for insomnia related to jet lag. One of the best supporting studies was a double-blind, placebo-controlled study that enrolled 320 travelers crossing six to eight time zones. The participants were divided into four groups and given a daily dose of five mg of standard melatonin, five mg of slow-release melatonin, 0.5 mg of standard melatonin, or placebo. The group that received five mg of standard melatonin slept better, took less time to fall asleep, and felt more energetic and awake during the day than the other three groups. Mixed results have been seen in studies involving the use of melatonin for ordinary insomnia, insomnia in swing-shift workers, and insomnia in elderly people.

A four-week double-blind trial evaluated the benefits of melatonin for children with difficulty falling asleep. A total of forty children who had experienced this type of sleep problem for at least one year were given either placebo or melatonin at a dose of five mg. The results showed that the use of melatonin helped participants fall asleep significantly more easily. Benefits were also seen in a similar study of sixty-two children with this condition. The long-term safety of melatonin usage has not been established. One should not give a child melatonin except under physician supervision.

Many people stay up late on Friday and Saturday nights and then find it difficult to go to sleep at a reasonable hour Sunday night. A small, double-blind, placebo-controlled study found evidence that the use of melatonin 5.5 hours before the desired Sunday bedtime improved the ability of participants to fall asleep.

Benefits were seen in a small double-blind trial of persons in a pulmonary intensive care unit. It is difficult to sleep in an ICU, and the resulting sleep deprivation is not helpful for those recovering from disease or surgery. In this study of eight hospitalized persons, three mg of controlled-release melatonin significantly improved sleep quality and duration.

Blind people often have trouble sleeping on any particular schedule because there are no light cues available to help them get tired at night. A small, double-blind, placebo-controlled crossover trial found that the use of melatonin at a dose of ten mg per day synchronized participants’ sleep schedules.

Some people find it impossible to fall asleep until early morning, a condition called delayed sleep phase syndrome. Melatonin may be beneficial for this syndrome.

In addition, people trying to stop using sleeping pills in the benzodiazepine family may find melatonin helpful. A double-blind, placebo-controlled study of thirty-four persons who regularly used such medications found that melatonin at a dose of two mg nightly (controlled-release formulation) could help them discontinue the use of the drugs. There can be risks in discontinuing benzodiazepine drugs, however, so persons should consult a physician for advice.

Other Proposed Natural Treatments

Aromatherapy, the use of scented oils from fresh herbs, is likely to be effective in treating insomnia. One literature review found that aromatherapy treatments appeared to promote sleep and that it was, therefore, vital to develop specific guidelines for the efficient use of aromatherapy as a treatment to improve sleep quality.

Acupressure or acupuncture may be helpful for insomnia, but the supporting evidence remains weak. A single-blind, placebo-controlled study involving eighty-four nursing home residents found that real acupressure was superior to sham acupressure for improving sleep quality. Treated participants fell asleep faster and slept more soundly. In a similar study, researchers found that performing acupressure on a single point on both wrists for five weeks improved sleep quality among residents of long-term-care facilities more than lightly touching the same point. Another single-blind, controlled study reported benefits with acupuncture but failed to include a proper statistical analysis of the results. For this reason, no conclusions can be drawn from the report. In a third study, ninety-eight people with severe kidney disease were divided into three groups: no extra treatment, twelve sessions of fake acupressure (not using actual acupressure points), or twelve sessions of real acupressure. Participants receiving real acupressure experienced significantly improved sleep compared to those receiving no extra treatment. However, fake acupressure was just as effective as real acupressure. Also, a small placebo-controlled trial involving sixty adults with insomnia found that three weeks of electroacupuncture improved sleep efficiency and decreased wake time after sleep onset.

In a trial involving twenty-eight women, six weeks of auricular acupuncture, in which needles are placed in the outer ear, was more effective than sham acupuncture. However, in a carefully conducted review of ten randomized trials involving auricular acupuncture or acupressure (using magnetic pellets), researchers were unable to draw conclusions because of the poor quality of the studies.

Preliminary evidence suggests that Tai Chi, a traditional Chinese practice involving graceful movements combined with meditation, may benefit people who have trouble sleeping. In one randomized study, a certain form of Tai Chi was more effective than health education after twenty-five weeks in persons with moderate insomnia.

Numerous controlled studies have evaluated relaxation therapies for the treatment of insomnia. These studies are difficult to summarize because many of the trials involved therapy combined with other methods, such as biofeedback, sleep restriction, and paradoxical intent (trying not to sleep). The type of relaxation therapy used in the majority of these trials was progressive muscle relaxation. Overall, the evidence indicates that relaxation therapies may be somewhat helpful for insomnia, although not dramatically so. For example, in a controlled study of seventy people with insomnia, participants using progressive relaxation showed no meaningful improvement in the time taken to fall asleep or in the duration of sleep, but they reported feeling more rested in the morning. In another study, twenty minutes of relaxation practice was required to increase sleeping time by thirty minutes.

One small double-blind study found a particular Ayurvedic herbal combination helpful for insomnia. Herbs used for anxiety are commonly recommended for insomnia too. As noted, hops and lemon balm have been studied in combination with valerian, but there is not enough data to assess their efficacy when used alone. Hops should not be taken when taking sleeping medication. One double-blind study found that the antianxiety herb kava taken alone may aid sleep for people whose insomnia is associated with anxiety and tension. However, a fairly large study failed to find kava helpful for ordinary insomnia. There are serious concerns that kava may occasionally cause severe liver disorders.

The substance GABA (gamma-aminobutyric acid) is a naturally occurring neurotransmitter that is used within the brain to reduce the activity of certain nerve systems, including those related to anxiety. For this reason, GABA supplements are sometimes recommended for treatment of anxiety-related conditions, such as insomnia. However, there are no studies whatsoever supporting the use of GABA supplements for this purpose. It appears that, when taken orally, GABA cannot pass the blood-brain barrier and, therefore, does not even enter the brain.

Slight evidence exists to support the use of magnesium or probiotics (healthy bacteria) for insomnia in older adults.

The herb St. John’s wort and the supplement 5-hydroxytryptophan have shown promise as treatments for depression. Because prescription antidepressants can aid sleep, these natural substances have been suggested for insomnia. However, there is no direct evidence that they are effective. A double-blind trial of twelve persons without insomnia found no sleep-promoting benefit with St. John’s wort.

A systematic review of chamomile as an effective treatment for insomnia, sleep quality, anxiety, generalized anxiety disorders reported that the only randomized control trial to evaluate chamomile's effect on insomnia did not find evidence that it changed the severity of the condition, and suggested that larger randomized control would be needed to determine chamomile's effectiveness in treating insomnia. The review's meta-analysis did find that chamomile was effective and safe for improving sleep quality, however.

Other herbs reputed to offer both antianxiety and anti-insomnia benefits include ashwagandha, astragalus, He shou wu, lady’s slipper, passionflower, and skullcap. However, there is no supporting evidence to indicate that any of these really work. Finally, many supplements might offer benefits for improving mental function during periods of sleep deprivation.

Bibliography

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