Sleep problems

For safe use of over-the-counter medicines, herbal remedies and supplements, consult a qualified person (such as a pharmacist) before buying or taking any medicine, remedy or supplement:
– if you have a serious medical condition
– if you are breast-feeding, pregnant or planning to become pregnant
– if you suffer from allergies

Registered herbal medicines (bearing the THR logo) will have a package insert. Read this before taking the product.

Avoid taking the product if you think you may be allergic to any of the ingredients.

Do not combine over-the-counter medicines, remedies or supplements with prescribed medicines unless you have first checked with your prescriber or a pharmacist.

Seek advice from your doctor or pharmacist:
– If your symptoms do not get better
– if your symptoms get worse
– if you get new symptoms or have a side effect

The information here, including dosages, only applies to adults (over 16 years). Keep all medicines out of the reach of children.

There are several kinds of herbal ‘sleeping tablets’ that you can buy over the counter. They usually have hops, passiflora or valerian in them. The scientific evidence on them isn’t very strong, but many people say they find them helpful. As long as you keep to the recommended dose and only use them for a few days at a time, perhaps in addition to relaxation techniques, it is unlikely to be a problem.

From the way they have been described in old texts, and from what we now know of the action of many plant constituents, it is possible favourite plant remedies work particularly by nudging better function in digestion, circulation, and eliminatory processes: helping the body help itself rather than directly try to force sleep.

Researchers are now discovering that many herbal medicines have useful benefits for the body, including in healing and repair, in stabilising hormonal responses (including stress hormones, insulin and sex hormones), and in reducing long-term inflammation.

These herbs are generally safe but serious side-effects can be caused by big doses. It is therefore important to follow the directions about how much to take. Some people are allergic to certain plant families so proceed with care if you think you might have an allergy. And if you are on any other medication, check with your pharmacist whether it is safe to take a herb as well.

All sleeping medications should be used cautiously, in moderation, for as short a time as possible, and in the smallest dose that works. Though these medicines can be easily bought, they should not be used for long without consulting a doctor. Their misuse is dangerous. Do not take anything with other medicines, remedies or supplements unless you have checked with the pharmacist in your local chemist.

Summary
Anyone who takes antihistamines for hay fever will tell you they can make you sleepy. You can buy antihistamine tablets over the counter but they should only be used in the short term for sleep problems. This is because the body gets used to them, so the effects wear off over time. Diphenhydramine (e.g. Nytol and Nightcalm) and promethazine (e.g. Sominex and Phenergan Nightime) are a self-treatment drugs available over the counter at pharmacies. You may be asked about how often you take these medications, any other prescriptions, and cautioned about overuse. Take this as sensible advice. 

Evidence
Several studies of promethazine and of diphenhydramine have shown that these antihistamine drugs improve sleep in people with insomnia.

Safety
The most common side-effects are sleepiness during the day, dry mouth, and constipation. These drugs should be avoided by men with prostate problems and people with glaucoma. Elderly people may get confused and over-sedated if they use them. Antihistamines may also interact with other medication. Your pharmacist can advise on whether they are suitable for you, what dose to take and about any possible interactions. Antihistamines should not be taken with alcohol.

Cost
Antihistamines can be bought for relatively low cost from most pharmacies.

Summary
Although B vitamins are sometimes said to help insomnia we could find no research evidence for this, though we did find some evidence that they don’t work for sleep problems.

Evidence
We could not find any research showing that vitamins ease sleep problems and one study showing that B complex worsened sleep quality, though B6  increased lucid dreaming.

Safety
Vitamins are generally inexpensive and safe if not taken in large amounts. But very high doses of vitamin A, D or E can make you ill or may increase the risk of developing other health problems.

Cost
B vitamins can be bought for relatively low cost from most pharmacies and health food retailers.

Summary
There are two types of chamomile. German chamomile (Matricaria recutita) has traditionally been used to help people sleep. It can be made into a tea, and sweetened with sugar or a little honey. A relaxing essential oil made from it is used in aromatherapy.

Evidence
A meta-analysis of clinical trials as showed that chamomile does improve sleep quality.

Safety
Chamomile is generally safe but it can cause a reaction if you are allergic to flowers of the daisy family (such as daisies, chrysanthemums, geraniums).

Cost
Approximate costs will be no more than £10 per month for tea and essential oil.

Summary
Hops (Humulus lupus) is said to have sedative and sleep-enhancing effects and as the volatile oils are thought to include benefits, it has traditionally been used in pillows to aid sleep. Hops is also sometimes included in tablets that are available from healthfood shops as sleep aids.

Evidence
There have been a number of studies using hops and valerian together, which suggest that this mixture might help mild sleep problems.

Safety
Hops is generally safe but allergy has been reported in a patient who had previous severe allergic reactions to peanut, chestnut and banana. People with such allergies should probably avoid using hops.

Cost
Hops preparations can be bought for relatively low cost from most health food shops.

Summary
Lavender (Lavandula angustofolia) is a traditional sleep aid. Lavender contains an oil which, according to a few small studies, has a sedative effect. Aromatherapists use it for aromatherapy massage (see Massage in the Go See Someone section), but a few drops can also be added to your bath. It seems to have a calming effect and is said to relax muscles. Having the smell of lavender in the bedroom can help you sleep, according to some research.

Evidence
Several small studies suggest lavender fragrance may ease sleep problems but only one study was well-designed.

Safety
Lavender seems to be safe for most adults unless you are allergic or hypersensitive to it, in which case you should avoid it. Applying lavender oil to the skin can sometimes cause irritation.

Cost
Approximate costs will be no more than £10 per month for essential oil preparations.

Summary
Melatonin has been widely promoted as a remedy for sleeplessness caused by jet-lag. Melatonin is sold in the United States without a prescription in health food stores and drug stores. In the UK it is a prescription-only medicine called Circadin. Current research suggests that it is probably safe for most adults to use melatonin for a few days when getting over jet-lag, but its long-term side-effects (if any) are unknown.

Evidence
There is some research to suggest that melatonin is useful for jetlag and other kinds of sleep problems. Its main effect seems to be in reducing the time it takes to fall asleep.

Safety
Melatonin may interact with various medications but we don’t know which ones. It may not be safe if you are pregnant, breast-feeding, or taking other medications except for minor painkillers and oral contraceptives. We don’t know what it may do if taken for long periods. It is possible that melatonin might make you less alert. It might make migraine, depression, and certain eye diseases, such as retinitis pigmentosa worse.

Cost
Melatonin is available on prescription.

Summary
Passion flower (Passiflora incarnata) can be bought as tablets or drops, on its own or mixed with other ingredients. It has a reputation for calming down the nervous system.

Evidence
In one small study some people reported better sleep.

Safety
Passion flower is generally considered to be a safe herb with few reported serious side effects.

Cost
Approximate costs will be no more than £10 per month for passion flower preparations.

Summary
Valerian (Valeriana officinalis) is a herb that has traditionally been used for sleep problems. It is available in many over-the-counter herbal sleeping tablets and as registered herbal medicines.

Evidence
Valerian is a promising treatment for sleep problems. Research results are mixed and may reflect the different products used. It is advisable to use a well-regulated valerian as found in THR products – that is as registered traditional herbal medicines.

Safety
Most side effects from valerian are mild. For some people it has stimulating rather than relaxing effects.

Cost
The cost of a traditional herbal medicine with the THR logo on it may be up to £16 per month.

Summary
The most common reason to treat sleep problems in earlier times was in helping to convalesce from illness and injury. Before modern medicines and economic and time pressures there used to be much more attention paid to the days and weeks after the acute stage of an illness. It was considered vital to give time for full recovery, and rest and sleep were always central to traditional care plans, which often included appropriate activities, nourishing diet and appropriate ‘tonic’ medicines. Many of the most popular convalescent tonic medicines were principally applied to improve the quality of sleep at this time.

This touches on a deeper insight. It was understood that there were two main types of sleep problem. The first, not getting off to sleep, was linked to stress (it would be hard to fall asleep surrounded by dangers!). The second, waking up too much and too early, was widely seen as a sign of depletion (in modern medicine it is associated with clinical depression – a much narrower link of the same type). This second sleep problem was by definition not to be treated with sedatives, but required tonic approaches instead. This older insight into sleep problems is largely lost today.

A classic example of a convalescent sleep tonic was valerian, discussed above, whose name comes from the Latin for healing and strength. Valerian was thus primarily seen as a tonic rather than a sedative, and its effect on sleeping was in this context (this may account for reports that valerian can be stimulating for some people). Another example was St John’s Wort,  consistently understood to be a tonic remedy, especially in convalescence, and with benefits on sleep. You can see more on this plant in the DEPRESSION section. Other consistently favoured tonic remedies used for improving sleep when energies are low include ashwagandha (Withania somnifera),  a very popular tonic remedy in India and around Asia. Its botanical name refers to its ancient reputation for improving sleep.

Safety
There are few known risks in taking the herbs above. St John’s wort may interact with conventional prescriptions and should be avoided if these are critical for your health care.

It is also advisable not to buy herbs online unless from suppliers with prominent reputation (they will be concerned to protect this by ensuring quality for their products). Unfortunately there are few controls on herbal sales and many cases of adulterated or wrong products. It is always a good policy to look for a registered herbal medicine, with the THR logo on the pack. This will have its quality independently assured.

A good approach in choosing traditional herbal approaches for sleep is to see a qualified herbal practitioner. You will find well trained practitioners from a number of traditions from the website of the main umbrella body the European Herbal and Traditional Practitioners Association. This will entail extra costs but will allow you to have herbs you might not find elsewhere, and tailored to your needs.

Cost
Most herbs should be inexpensive and can be bought from specialist suppliers. A registered herbal medicine (THR) if available, will cost more – round £15 per month.  Seeing a practitioner may cost around £50 for a first visit.

Further information
There is a wide ranging review of the evidence for many of the herbs listed above in the following paper.

Herbal medicine for depression, anxiety and insomnia: a review of psychopharmacology and clinical evidence.
Sarris J, Panossian A, Schweitzer I, Stough C, Scholey A. Eur Neuropsychopharmacol. 2011 Dec;21(12):841-60.
A  wide-ranging review of the literature to ascertain mechanisms of action of various  herbal remedies, with a systematic review of controlled clinical trials for the herbal treatment of mood, anxiety and sleep disorders.
Link to Abstract