Natural Health Advisory

Insomnia is now at epidemic levels. Up to half of Americans suffer from at least one of the four cardinal insomnia symptoms:1,2

• Difficulty falling asleep
• Inability to stay asleep
• Waking up in the early morning
• Experiencing nonrestorative sleep

Almost a quarter of the US population meets the strict diagnostic criteria for insomnia disorder, in which the sleep disturbance (or associated daytime fatigue) causes significant distress or impairment in important areas of functioning.3

The insomnia surge appears to be getting worse. Researchers are stunned by the striking increase in the number of people visiting doctors’ offices complaining of sleep problems and the number of sleeping pills being prescribed.4

Why a good night’s sleep is so important

The importance of sleep for mental and physical functioning cannot be overstated. You cannot be healthy without adequate sleep. Of the many crucial physiologic processes that happen during sleep, some of the most important include the following:

• Maintenance and repair of the brain’s and body’s cells, organs, and tissues
• Increased secretion of the body’s most important anti-aging hormone—growth hormone
• The regulation of several other important hormones, including cortisol for stress tolerance; melatonin for sleep/wake cycles, antioxidant defenses, and immune function; and leptin and ghrelin for weight and appetite control5
• Enhanced immune function.6

You need sufficient quality and quantity of sleep for these physiological processes to occur. This is how you maintain physical health, mental clarity, a healthy memory, a stable mood, overall energy, and stress tolerance. It’s also extremely important for controlling weight, appetite, metabolism, blood sugar regulation, and more.

Normally, it should take less than 30 minutes to fall asleep, and you should be able to sleep uninterrupted by arousals or awakenings for at least seven hours.7 Adults need seven to eight hours of actual sleep per night, but almost 30% of Americans get just six hours or less.8 This is unfortunate since sleeping six or less hours is associated with fatigue and excessive daytime sleepiness, as well as many chronic diseases including obesity, diabetes, and cardiovascular disease (such as high blood pressure, strokes, and heart disease).9

Conventional treatment of insomnia

Conventional insomnia treatment guidelines call for education about the rules of good sleep hygiene and either psychological and behavioral interventions, pharmacological interventions, or a combination of the two.1 Since psychological and behavioral therapy is also a top natural treatment for insomnia, it is covered in that section, below.

Sleep Hygiene

Sleep hygiene—behaviors that promote good sleep quality and quantity—is a core component of insomnia treatment and is essential for maintaining quality sleep. Although there is insufficient evidence to indicate that sleep hygiene alone is effective in the treatment of chronic insomnia, everyone suffering from sleep problems benefits from being aware of the rules of good sleep hygiene and following them as much as possible, in combination with other therapies.1,37

• Avoid caffeine and nicotine, especially late in the day.
• Avoid exercise during the four hours before bedtime; daily exercise is beneficial to sleep, but can interfere if done close to bedtime.
• Avoid large meals in the evening.
• Avoid too much alcohol in the evening.
• Avoid taking naps.
• Go to sleep and wake up at the same times each day.
• Keep the bedroom at a comfortable temperature.
• Make the bedroom as dark and quiet as possible.
• Avoid activities that are exciting, emotional, or demand high concentration near bedtime.
• Set aside a time to relax before bed and use relaxation techniques.

Sleeping pills

Drug therapy for insomnia is the most common conventional treatment.10 Drugs called non-benzodiazepine receptor agonists (also called hypnotics) are most commonly prescribed. These include zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata). These drugs are moderately effective in the short-term, widely available and, when effective, begin working rapidly.
The disadvantages are the potential for side effects, dependence, and tolerance over time. Potential adverse effects of these drugs include residual sedation (with impairment of driving ability, memory, and psychomotor performance), falls, undesired behaviors during sleep, rebound insomnia, and drug interactions.1,10

Tolerance and dependence develop, and the higher the dose and the longer you use sleeping pills like zolpidem, the more intensely you become physically dependent on these drugs to be able to sleep.12 Perhaps the most important disadvantage is that medications are usually not curative, leading to long-term treatment over many years despite a lack of safety and efficacy data for their use beyond one to two years.10

Natural sleep enhancer: cognitive-behavioral therapy

Of all the behavioral/psychological treatments, cognitive behavior therapy for insomnia (CBT-I) has the most evidence supporting its efficacy. The treatment involves changing sleep-related behaviors and thoughts over the course of approximately four to eight sessions that occur weekly or every other week for 30 to 60 minutes each. Participants are taught how to alter anxious sleep-related thoughts and how to restore homeostatic regulation of sleep through sleep restriction therapy. They are also taught relaxation techniques, sleep hygiene, and stimulus-control therapy to establish a learned association between the bed and sleeping.

Dozens of studies have found that CBT-I improves sleep in 70% to 80% of participants—one study found that it is more effective than Ambien.14-18 The effects are longer lasting than sleeping pills and there are no adverse effects.13,19

CBT-I is easy to learn from books, online programs, or in-person from healthcare providers. You can find the original, Harvard-validated CBT-I protocol in both online and book formats.
The only drawbacks of CBT-I are that it can initially cause a temporary reduction in total sleep time that can lead to increased daytime sleepiness, and it can take three to four weeks to see results.

Melatonin

Another top-researched natural treatment for insomnia is melatonin, a hormone secreted by the pineal gland that plays a role in regulating the sleep-wake cycle. Normally, melatonin levels are low during the day and increase significantly at night. Melatonin levels (like most hormone levels) decrease with advancing age and may contribute to the increased frequency of insomnia in older people. Melatonin supplementation has a reputation as the best insomnia treatment for the elderly,20 but it is also effective in helping to induce and maintain sleep in children and adults.21-24
Melatonin reduces sleep onset time, increases total sleep time, and increases total quality of sleep.25 It can reduce or eliminate the need for sleeping pills.26

Most studies use doses of 2 to 5 mg at night, but smaller (and larger) doses may also be effective.27 There are also extended-release versions of melatonin that may work better for some people, particularly those people who have trouble staying asleep as opposed to those who have more trouble initiating sleep.

Three milligrams of regular (not extended release) melatonin is usually a good starting dose.28 Melatonin is well tolerated and not associated with any serious adverse side effects. Very rarely, it may cause nausea, dizziness, restlessness, or headache.29 It is not associated with tolerance (the effect is not diminished with repeated use), withdrawal symptoms, or rebound insomnia when it is discontinued.30,31 While most people will have improved morning alertness with melatonin,29 taking too high of a dose can leave some people feeling sleepy the next morning.

If 3 mg of regular melatonin leaves you feeling sleepy the following morning, try lowering the dose to 0.5 to 2 mg. If it helps you fall asleep faster, but you still wake up and can’t go back to sleep, try 2 to 3 mg of the extended release version. And if 3 mg just doesn’t work at all, try a higher dose, starting with 5 mg and experimenting with up to 20 mg.

Herbal insomnia supplements

A number of botanical medicines with sedative and/or relaxing properties have been shown to improve sleep in human studies. Many of these herbs for insomnia appear to work better when used in combination. Some of the most evidence-based herbs for insomnia are:

Magnolia and ziziphus. These extracts, used in combination, help people with mild to moderate sleep difficulties. Used traditionally used in Asia for insomnia, Magnolia officinalis bark and Ziziphus spinosa seed contain compounds that interact with GABA and serotonin receptors in the brain to decrease anxiety, and promote relaxation and sleep.32,33 Magnolia has also recently been found to have effects on cannabinoid receptors in the brain, which may also explain its beneficial effects.34

The extracts of these two herbs are combined in a modern propriety blend sold as SedaLin™ by Xymogen, Seditol® by Source Naturals and Pure Encapsulations, and Seditol® Plus by Douglas Labs.

The combination was effective in promoting relaxation and more restful sleep and reducing fatigue due to lack of sleep in an open-label study in 295 patients with mild to moderate sleep difficulties.35 Take one to two capsules one hour before bed.

Valerian, passionflower, and hops extracts combine synergistically to promote sleep. One trial randomly assigned people with insomnia to receive one tablet of this herbal combination (containing 300 mg valerian extract standardized to 0.8% total valerenic acid, 80 mg passionflower extract standardized to 4% isovitexin, and 30 mg hops extract standardized to 0.35% rutin, or 10 mg of zolpidem) for two weeks.36 The average sleep duration increased significantly and similarly with both treatments. The average amount of time it took to fall asleep was also similar in both groups and decreased significantly, as did night-time awakenings. Daytime sleepiness was not a problem in either group; adverse events were similar in both groups; and no serious adverse events were reported in either group.

What to Try First

The first step should be to make sure you are following good sleep hygiene practices. If you still experience insomnia symptoms, move on to a more structured program of cognitive behavioral therapy for insomnia. Find healthcare providers in your area that offer the program (insurance should cover it) or buy a book or online program and commit to working through all the sessions/steps. Don’t panic, it’s quicker and simpler than it sounds.

If cognitive behavioral therapy doesn’t cure your insomnia, try either 3 mg melatonin, as described above, or a combination herbal sleep formula, such as magnolia and ziziphus or valerian, passionflower, and hops.

You don’t have to live with insomnia or rely on prescription drugs for the rest of your life. Well-tested, natural insomnia solutions are available to get you sleeping through the night on a permanent basis.

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