Introduction
Many people have a serious problem getting a good night’s sleep. Lives have become simply too busy for many to get the eight hours really needed. To make matters worse, many people have insomnia. When a person does get to bed, he or she may stay awake thinking for hours. 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 be adopted too.
Many drugs can also help with sleep. Such medications as Sonata, Lunesta,
Ambien, Restoril, Ativan, and Xanax are widely used for sleep problems. Of these,
only Lunesta has been tested for long-term use. All of these medications are in
essence tranquilizers and, therefore, have a potential for
dependence and abuse; the newer 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. Trazadone 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 today 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 inconsistent and incomplete. 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 affects. 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. The most recent trial, a two-week study of 405 people, reported “modest benefits at most.”
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.
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 does 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 5 mg of standard melatonin, 5
mg of slow-release melatonin, 0.5 mg of standard melatonin, or placebo. The group
that received 5 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 5 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 persons 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, 3 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 10 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 2 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
Acupressure or acupuncture may be helpful for
insomnia, but the supporting evidence remains weak. A single-blind,
placebo-controlled study involving 84 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 did 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, an ancient Chinese practice
involving graceful movements combined with meditation, may benefit some 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.
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.
One small study hints that the fragrance of lavender essential oil might aid sleep. Slight evidence exists to support the use of magnesium or probiotics (healthy bacteria) for insomnia in the elderly.
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.
Other herbs reputed to offer both antianxiety and anti-insomnia benefits include ashwagandha, astragalus, chamomile, He shou wu, lady’s slipper, passionflower, and skullcap. However, there is no supporting evidence to indicate that any of these really work. Finally, a number of supplements might offer benefits for improving mental function during periods of sleep deprivation.
Bibliography
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Lewith, G. T., et al. “A Single-Blinded, Randomized Pilot Study Evaluating the Aroma of Lavandula augustifolia as a Treatment for Mild Insomnia.” Journal of Alternative and Complementary Medicine 11 (2005): 631-637.
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