Anxiety About Sleep: Could Herbal Medicines Help?

“I have 5 years of anxiety about not being able to sleep to overcome,” began a query I received a month ago. “Once triggered, it is difficult to stop this downward spiral and sleep.”

Without a doubt, anxiety about sleep is one of the hardest aspects of insomnia to beat. Cognitive behavioral therapy for insomnia can help to reduce sleep-related anxiety, as can other adjunctive therapies. But here’s an alternative treatment that might lead to calmer nights: plant-based medicines found to be effective for anxiety.

Insomnia-driven sleep anxiety & herbal medicines“I have 5 years of anxiety about not being able to sleep to overcome,” began a query I received a month ago. “Once triggered, it is difficult to stop this downward spiral and sleep.”

Without a doubt, anxiety about sleep is one of the hardest aspects of insomnia to beat. Cognitive behavioral therapy for insomnia can help to reduce sleep-related anxiety, as can other adjunctive therapies. But here’s an alternative treatment that might lead to calmer nights: plant-based medicines found to be effective for anxiety.

Anxiety About Sleep: How It Develops

Anxiety about sleep is learned, and the learning is largely unconscious. The anxiety may develop during a stressful situation when you’re having trouble with sleep. You might be in a tight spot at work or in the midst of a contentious divorce. You might be worried about a new breast lump or how to make ends meet for the next 6 months.

Whatever the stress, it keeps you up at night and soon it extends to worry about sleep itself. What happens if you can’t get enough sleep? What if you’re too sleep deprived to meet the next work deadline? What negative effects will insomnia have on your long-term health?

Once anxiety becomes focused on sleep, it’s hard to root out. The triggers may remain unknown: a darkening sky, evening birdsong, the bed itself. A simple glance at the clock can set off alarms in your head. (“It’s already midnight and I’m still too wired to sleep!”) And feelings of anxiety — muscle tension, a rapid heartbeat, bodily warmth and perspiration — can sabotage sleep. If night after night this pattern is reinforced, no wonder it’s hard to break.

Herbal Remedies for Anxiety

Anxiety about sleep is situational, and therapies shown in clinical trials to lower sleep-related anxiety — cognitive behavioral therapy for insomnia (CBT-I), yoga, and mindful stress reduction — are probably the most reliable paths to relief. Exercise has stress-reducing effects as well. But GABA is the neurotransmitter most prominently associated with calming the brain, and plant-based medicines that act on the GABA system may be helpful, too.

A team of Australian researchers recently conducted a systematic review of plant-based medicines for anxiety including both clinical (human) and preclinical (in vitro and animal) studies. Following are herbal medicines the evidence shows are mostly likely to have anxiety-reducing effects.

Kava (Piper methysticum)

Kava, native to the South Pacific, is the hands-down winner when it comes to the amount of evidence amassed in support of its effectiveness as an herbal remedy for anxiety. “The number of positive findings from human studies of P. methysticum within randomised, well-controlled trials . . . supports its use as a treatment for various anxiety disorders and associated symptoms, demonstrating broad clinical utility,” the authors write.

The main active ingredients in kava are called kavalactones. Kava supplements contain specific concentrations of these kava extracts and are available in tablet form or as a tincture. See my earlier blog post for an in-depth treatment of kava’s effects on anxiety and sleep and possible adverse effects.

Valerian (Valeriana officinalis)

Valerian, native mainly to Europe, looks like the next most-promising herbal with anxiety-reducing properties. The root extract has been used as a sedative and anti-anxiety medicine for millennia. Tests on human subjects have found that valerian is particularly effective at reducing subjective feelings of anxiety that arise in stressful situations.

Two human studies suggest that valerian doesn’t negatively impact psychomotor and cognitive performance the way the benzodiazepines (medications often prescribed to reduce anxiety) tend to do. So regarding safety, valerian has a relatively clean bill of health.

Passion flower (Passiflora incarnata)

Passion flower, native to the Americas, has been used for millennia as an herbal remedy for anxiety and trouble sleeping. Investigators in 4 clinical trials studied its anxiety-reducing effects in patients who were about to undergo surgery. Results showed that passion flower significantly reduced anxiety in comparison with placebo. In fact, its effects were similar to those of anti-anxiety benzodiazepine medications, including, in one of the studies, reductions in blood pressure and heart rate.

Two more studies involving use of passion flower in people with anxiety disorders showed the herb’s anti-anxiety effects were similar to those produced by benzodiazepines.

Ashwagandha (Withania somnifera)

Ashwagandha, traditionally used in Indian Ayurvedic medicine, is a plant in the nightshade family. (It’s sometimes called Indian ginseng.) Ashwagandha powder, prepared from the root, leaves, or whole plant and taken orally, has been prescribed to reduce anxiety and improve sleep for centuries. Today it’s available as a dietary supplement in powder, capsule, and tablet forms.

In 5 clinical trials, ashwagandha was found to have at least one significant anti-anxiety, anti-stress benefit compared with control conditions. Another very recent clinical trial involving participants with chronic stress compared the use of 600 mg of ashwagandha extract daily to placebo capsules taken over 8 weeks. Significantly greater stress reduction occurred with the extract, as did decreases in salivary cortisol (a biomarker of stress and anxiety). See my earlier blog post for more information on ashwagandha’s effects on stress, anxiety, and sleep.

Chamomile (Matricaria recutita)

Chamomile, a flowering plant in the daisy family, is plentiful throughout Europe and Asia. It’s been used for millennia, mainly as a tea, for its calming and sedative effects. In an 8-week clinical trial in patients with generalized anxiety disorder (GAD), participants taking 220 mg of chamomile 1 to 4 times daily showed significantly greater reductions in anxiety than controls. In another 8-week study involving patients with GAD taking a 500-mg capsule of chamomile 3 times a day, 58% of the participants showed significant reductions in anxiety.

In a strange twist, a study of the effects of chamomile in 34 patients with insomnia found that chamomile was effective at improving sleep and daytime stamina but did not reduce symptoms of anxiety.

Final Caveat

If you plan to try herbal medicine as an alternative treatment for anxiety about sleep, consult a naturopath or other health professional about the correct dose. At least do some research yourself.

And don’t expect momentary relief. Herbal medicines, said Jerome Sarris, an author of the Australian review paper whom I also interviewed for The Savvy Insomniac, “generally take longer to work, whereas some people just want that quick fix. I think they may have more of a role in long-term assistance.” So use herbal medicines as indicated and wait at least a few weeks to start looking for results.

An Ayurvedic Herb for Better Sleep

Might Ayurvedic medicine—traditional medicine practiced in India for 3,000 years—offer an effective treatment for insomnia?

If you’re looking for an alternative treatment vetted by scientists in controlled clinical trials, the answer is no. But an Indian herb called ashwagandha is receiving attention as a substance that might help people with several health conditions, including chronic stress, anxiety, and memory loss. It’s also being studied as a possible sleep aid. Here’s more about it.

Insomnia may respond to treatment with ashwagandhaMight Ayurvedic medicine—traditional medicine practiced in India for 3,000 years—offer an effective treatment for insomnia?

If you’re looking for an alternative treatment vetted by scientists in controlled clinical trials, the answer is no. But an Indian herb called ashwagandha is receiving attention as a substance that might help people with several health conditions, including chronic stress, anxiety, and memory loss. It’s also being studied as a possible sleep aid. Here’s more about it.

Ashwagandha (Withania somnifera)

Ayurvedic medicine is a holistic healing system. Patients are generally prescribed a combination of herbs, special diets, and daily practices aimed at promoting overall health rather than eliminating a specific problem like insomnia.

But the Latin somnifera means sleep-inducing, and ashwagandha powder, prepared from the root, leaves, or whole plant and taken orally, has been prescribed to improve sleep for centuries. A handful of laboratory studies on rodents have provided evidence for ashwagandha’s sleep-inducing effects. Results of some studies suggest that ashwagandha leaf extract may also protect rats from the consequences of sleep deprivation.

Authors of a recently published paper in PLOS ONE have identified a specific component of the ashwagandha leaf that puts mice to sleep. Following is a summary of their findings.

An Active Component That Promotes Sleep

Biologically active components in ashwagandha include withanolides—naturally occurring steroids—and triethylene glycol, or TEG. TEG is currently used in various manufacturing processes, but how it impacts biological systems is largely unknown. In this study, investigators wanted to find out if one or the other of these substances had sleep-inducing effects.

Via a complicated extraction process, the researchers isolated each of these compounds, mixing them with alcohol and water so they could be administered orally to mice. Here are the results:

  • Compared with the alcoholic medium alone, the alcoholic extract containing a high amount of active withanolides had no effect on the sleep–wake system of the mice.
  • Compared with water alone, the extract containing lots of TEG induced a significantly greater amount of non-REM, or quiet, sleep—without affecting the amount or nature of REM sleep.
  • Commercially available TEG was also administered to the mice in 10, 20, and 30-mg doses. The larger the dose, the more non-REM sleep the mice got over a 12-hour period and the more quickly they fell asleep.

The authors conclude that while low to moderate levels of TEG clearly induce sleep in laboratory animals, possible “toxicological properties of TEG need to be studied in detail before its used is advised in humans.”

Meanwhile, Is Ashwagandha Safe for Humans?

It depends on where you ask the question. Indian practitioners of Ayurvedic medicine have been prescribing it for centuries. A handful of scientific studies also attest to the safety of this herb when used short term in therapeutic doses. (Long-term effects are unknown.)

But an article in Medline Plus lists a number of safety concerns. People who are pregnant and breast feeding, who have diabetes, or who have an auto-immune disorder should steer clear of ashwagandha. The herb can interact with various medications and supplements, too.

For a definitive reading on whether ashwagandha could work as a treatment for insomnia we’ll have to wait and see. But it’s widely available as a dietary supplement in powder, capsule, and tablet forms. Of course, dietary supplements are less well regulated by the FDA than prescription medications. Quality is not assured.

But if you’re looking for better sleep and tempted to try ashwagandha, consult a practitioner of Ayurvedic medicine or a naturopath about whether the herb might have something to offer you.

Tart Cherries: Helpful to Sleep but Harder to Find?

First, the good news: a small body of research suggests that tart cherry juice holds promise as an alternative treatment for insomnia, especially in older adults.

Now for the bad news: tart cherry juice, already pricey, is set to become pricier still as growers weigh whether to give up on cherries and plant apple trees instead. Here’s more on the benefits of tart cherry juice for sleep and why it may soon become scarce.

Insomnia, alternative treatment tart cherry juice not so plentifulFirst, the good news: a small body of research suggests that tart cherry juice holds promise as an alternative treatment for insomnia, especially in older adults.

Now for the bad news: tart cherry juice, already pricey, is set to become pricier still as growers weigh whether to give up on cherries and plant apple trees instead. Here’s more on the benefits of tart cherry juice for sleep and why it may soon become scarce.

Sleep Benefits of Tart Cherry Juice

A handful of studies conducted on the effects of tart, or Montmorency, cherry juice on sleep suggest it may be helpful for people with insomnia:

  • It may help you sleep longer. In a randomized controlled trial (RCT) published in 2012, drinking tart cherry juice concentrate mixed with 8 oz. of water twice daily for 7 days increased the total sleep time of 20 healthy volunteers by an average of 39 minutes.
  • Seven older adults with insomnia slept over an hour longer after 2 weeks of drinking 8 oz. of tart cherry juice twice a day. Results of a randomized crossover trial presented at the 2014 meeting of the American Society of Nutrition (still unpublished) showed that participants’ total sleep time increased by an average of 84 minutes.
  • Tart cherry juice may cut down on nighttime wake-ups and improve sleep quality. In an RCT published in 2010, drinking 8 oz. of tart cherry juice twice daily for 2 weeks significantly cut down on wake-ups and insomnia severity in 15 older adults with sleep maintenance insomnia.
  • The same twice-daily regimen of tart cherry juice had similar effects on the sleep of 30 healthy young, middle-aged, and older adults in a study published in 2013. Older participants’ sleep improved the most.

The evidence is not conclusive: these studies were small and only two looked specifically at the effects of tart cherry juice on people with insomnia. Still, unless you dislike or can’t tolerate tart cherries, drinking tart cherry juice twice a day is worth consideration as an alternative treatment for persistent insomnia.

Melatonin and Tryptophan-Enhancing Effects

Montmorency cherries are rich in melatonin, a sleep-friendly hormone secreted by the pineal gland at night. Melatonin production often falls off as people age, and lower levels of endogenous melatonin can make it harder to get to sleep and stay asleep at night. Tart cherry juice may exert its soporific effects mainly by increasing levels of melatonin at night.

Another mechanism by which tart cherry juice may benefit sleep can be found in the effect it has on tryptophan. Tryptophan is an amino acid humans need but cannot produce themselves, so it must be gotten in food. Tryptophan is a precursor to both melatonin and serotonin, a neurotransmitter important to sleep. Researchers who conducted the 2014 study found that tart cherry juice inhibited the degradation of tryptophan, thereby making more of it available for serotonin synthesis.

The sleep benefits of Montmorency cherry juice may be due to both its melatonin and tryptophan-enhancing effects.

Climate Change and Market Forces

But some fruit growers are now on the verge of abandoning cherry orchards and planting apple trees instead. Two factors are behind the change, according to an Interlochen Public Radio report last week:

  1. Most of the nation’s tart cherries are grown in northern Michigan, where almost the entire cherry crop was lost in 2012 due to an early spring followed by over 2 weeks of below-freezing temperatures. Cherry trees planted in Michigan are actually shipped from nurseries in the Pacific Northwest. Extreme weather events there have killed off thousands of cherry saplings. Michigan orchardists who want to continue producing cherries now can’t buy enough young cherry trees to replenish aging stock.
  2. Also, the demand for apples is on the rise, and growers are planting high-density varieties so they can plant many more trees per acre of land. Commercial nurseries are now struggling to keep pace with the demand for apple trees. Nursery owners may decide that planting for small specialty crops like cherries just isn’t worth it any more.

Now back to trouble sleeping: if you find that tart cherry juice helps you sleep, you’d be wise to stock up on it now.

Kava for Anxiety and Insomnia: Effective? Safe?

Kava (Piper methysticum) holds promise as an alternative treatment for anxiety and insomnia. But I’ve refrained from blogging about kava and kava supplements due to concerns about liver toxicity.

Now a comprehensive review funded by the National Science Foundation and published in the journal Fitoterapia has eased those concerns. I can write about kava, native to Hawaii and other Pacific islands, as I would any other medicinal plant, summarizing benefits and risks.

Kava, an alternative treatment for anxiety, may also help insomnia sufferersKava (Piper methysticum) holds promise as an alternative treatment for anxiety and insomnia. But I’ve refrained from blogging about kava and kava supplements due to concerns about liver toxicity.

Now a comprehensive review funded by the National Science Foundation and published in the journal Fitoterapia has eased those concerns. I can write about kava, native to Hawaii and other Pacific islands, as I would any other medicinal plant, summarizing benefits and risks.

Kava in Traditional Pacific Cultures

Traditional Pacific island cultures viewed the beverage they prepared from the kava root as sacred. Kava “was the food of the gods,” Hawaiian scholar Mary Kawena Pukui said. “No religious ritual was complete without it.”

Librarian-scholar Margaret Titcomb wrote that the custom of drinking kava “is of interest in Hawaii because it was a sacred drink of importance in many phases of Hawaiian life. . . . Its effect is to relax mind and body. . . . Medical kahunas (learned men) had many uses for it. . . . It was essential on occasions of hospitality and feasting, and as the drink of pleasure of the chiefs.”

Pacific islanders continue drinking kava today. Traditionally it’s mixed with water, strained by hand, and served on social occasions, often in coconut shells. Kava drinkers may consume several coconut shells of the beverage on one occasion.

Western Interest in Kava

Pacific islanders used different parts of the kava plant to treat various ailments, suggesting to Europeans who arrived in the 18th century that kava might have important medicinal uses. First the Europeans used it to treat venereal disease. By the 1880s, it was being used to relieve stress and anxiety. British herbalists have used it since the early 1900s to treat disorders of the urinary tract.

Kava in the 1990s became a popular herbal remedy for anxiety—an alternative treatment to benzodiazepine drugs such as Valium and Xanax. Consumed as a tablet or a tincture, kava supplements contain specific concentrations of kavalactones, which are extracted from the kava plant with alcohol, acetone, or water. Kavalactones are believed to be the main active ingredients in kava.

Anti-Anxiety and Sedative Effects

Studies of kava’s effects on animals show that it acts on many of the same neurotransmitter systems as anti-anxiety drugs. It results in GABA channel modulation and downregulates or inhibits systems that are active during arousal. In humans, quite a few studies have shown that kava is significantly more effective than placebo at lowering anxiety.

So far, though, only one randomized controlled trial has been conducted to investigate kava’s effects on sleep. In this 4-week study of people with sleep disturbances associated with anxiety, the authors compared 34 participants taking a kava extract with 27 participants taking placebo. By the end of the study, the kava group experienced a significant improvement in the quality of their sleep—but so did the group taking a placebo, although to a lesser extent.

So would taking a kava supplement improve the sleep of insomnia sufferers? No one knows, and no one will know unless more and better controlled studies are done. What the existing data do suggest is that kava might be helpful for people whose insomnia is closely associated with anxiety.

Why So Little Research?

Kava sales in the West fell off sharply at the turn of the 21st century. No Pacific islander was ever known to suffer liver failure related to kava, but between 1999 and 2002, 10 kava users in Europe and the United States had to undergo liver transplants. The need for the transplants was attributed to patients’ having consumed moderate doses of kava for anywhere from 2 to 12 months. Subsequently the CDC issued advisories in the United States. Germany banned kava in 2002.

On further examination, though, investigators found that kava could be implicated as a causal agent in only 3 liver failure cases. Germany overturned its ban on kava in 2014. Sales of kava products in the West are expected to rise again.

How Likely Is Liver Failure?

Why kava might trigger liver failure in a few of the millions of users is still an open question. It might have to do with

  • genetic factors;
  • the method of extraction. While the traditional drink is prepared by water extraction, extraction using acetone, ethanol, or methanol is used in the manufacture of supplements to achieve higher concentrations of kavalactones (which, most research suggests, are not themselves a source of toxicity);
  • interactions with drugs such as alcohol, barbiturates, and benzodiazepines;
  • the use of leaves, stems, and other plant parts in the manufacture of supplements rather than just the root; or
  • the use of inappropriate kava cultivars.

All these possibilities notwithstanding, instances of kava toxicity are relatively rare. Say authors of the review, “The incident rate of liver toxicity due to kava is one in 60 to 125 million patients.”

So the risk is pretty slim.

Have you tried kava for sleep or anxiety? How did you fare?