This past 1.5 years of covid has spawned even more folks struggling with insomnia and anxiety. At least that has been true in my clinical practice. Insomnia includes insufficient sleep, difficulty falling asleep (sleep latency) and poor sleep. Insomnia can cause multiple problems including a decline in cognitive function, depression, low immunity and cardiovascular disease, but it can also be a result of anxiety, depression, chronic pain, medications, lifestyle habits, sleep apnea, hormonal issues, thyroid disorders and more.
Pharmaceutical options include over the counter and prescription medications. Sometimes they work, sometimes not, but all are associated with potential side effects. The effects I have the most concern about are potential dependency and/or cognitive decline over time. There is a long menu of nutritional and herbal supplement options as well. Again though, sometimes they work, sometimes not. Fortunately, the biggest downside is just the not working part as side effects are few and far between, and benign – like maybe feeling groggy upon waking. Amongst the menu of options that include melatonin, valerian, tryptophan, passionflower, hops, magnesium and more, I find that the best treatment outcomes occur when there has been an effort to diagnose underlying cause. A simple example: if a peri or postmenopausal woman is having interrupted sleep due to nightsweats, then the solution is to treat the nightsweats due to the normal hormonal changes. The solution is not melatonin, tryptophan, magnesium, etc. If the underlying cause is possibly hyperthyroid, then that must be tested and treated and once corrected, then sleep becomes normal again. Don’t forget, there could be more than one thing going on to explain the insomnia.
One herb that has emerged as almost mainstream now is Ashwagandha. I think this is one of those Covid silver lining phenomena. Those who have been prescribing and using botanicals for some time, are familiar with this Ayurvedic rejuvenating adaptogen. It has a long history of traditional uses for a wide range of issues, but at its basic level, it acts as an adaptogen and antioxidant. As a role in sleep issues, it is likely acting to improve the stress adaptation mechanisms, cortisol circadian rhythm, and acting on GABA receptors.
The current study was conducted as a randomized, double-blind, placebo-controlled, parallel group clinical trial, looking at the efficacy and safety of ashwagandha root extract for insomnia and anxiety. Adults aged 18-50 years in India, were recruited to two arms of the study. Exclusion criteria included previously diagnosed sleep disorders, presence of clinically significant physical or psychological disorders, history of substance dependence or alcohol abuse in the past year, tobacco use during nighttime awakenings, history of seizures or head trauma, having traveled across ≥ four time zones or worked night shifts in the seven days preceding the study or planning to do so during its course, regular use of any drug except a few noted, and pregnancy or lactation. Insomnia patients were randomized to ashwagandha or placebo. The ashwagandha root extract was made by water extraction and standardization to >5.0% withanolides of 300 mg powder per capsule. Participants took one capsule twice daily with water or milk for eight weeks. Seventy-three individuals completed the study.
The primary outcome was sleep latency with secondary outcomes of total sleep time, sleep efficiency, total time in bed and waking after sleep onset. Polysomnography is the accepted gold standard in sleep assessment, however, this trial used actigraphy, a devise monitor worn on the wrist or ankle, that records detailed sleep patterns. It is considered an accurate and continuous monitoring device.
Standard tools of sleep assessment were also used including The Pittsburgh Sleep Quality Index (PSQI) and Hamilton Anxiety Scale-A (HAM-A) scores. Sleep information from all tools were assessed at baseline, week four, and week eight. None of the participants used any concomitant medications.
Commentary: The use of ashwagandha showed significant improvement in sleep at 8 weeks. Mental alertness upon waking and anxiety also improved compared to baseline. Overall sleep quality improved significantly in both placebo and ashwagandha but more so in the botanical group. Overall, insomnia, including sleep latency, sleep quality, total sleep time and mental alertness on rising in the morning improved with the use of ashwagandha. Time in bed was not altered by ashwagandha.
I’m not surprised by these results. Ashwagandha has a long historical track record in being used as a tonic with the ability to regulate cortisol and the sleep cycle. An important clinical trial was also published in 2020 in the journal Sleep Medicine:
In this randomized, double-blind, placebo-controlled trial, 150 healthy subjects scoring high on non-restorative sleep measures were given 120 mg of standardized ashwagandha extract once daily for six weeks. ( Deshpande A, et al. A randomized, double blind, placebo-controlled study evaluated the effects of ashwagandha extract on sleep quality in health adults. Sleep Medicine. Vol 72, August 2020: pages 28-36)
A 72% increase in self-reported sleep quality was found for the treatment group, compared with 29% in the placebo group. The treatment group showed significant improvement in sleep efficiency, total sleep time and sleep latency and wake after sleep onset after six weeks. Quality of life scores in physical, psychological and environment domains also showed significant improvement in the ashwagandha group.
As an adaptogen, or stress reducer, it’s hard to do better than ashwagandha, or Indian Ginseng. Studies have shown that ashwagandha may help reduce cortisol levels and in one study in chronically stressed adults, those who supplemented with ashwagandha had significantly greater reductions in cortisol, compared with the control group and in the higher doses, there was a 30% reduction in cortisol. (Auddy B, et al. JANA 2008. 11;1: 50-58). One can find much support in the historical and botanical literature in reducing stress and anxiety over the course of several weeks. My habit is to follow-up with patients in 8 weeks regarding the use of ashwagandha for anxiety and/or chronic insomnia. Patients may need immediate help prior to this like using truly sedating sleep aids (valerian, tryptophan, Benadryl or others) and/or anxiolytics such as L-theanine or Kava. These may help the immediate issue for short term, but the ashwagandha helps to treat the underlying cortisol dysregulation and stress adaptation mechanisms that bring lasting results.
Reference: Langade D, Thakare V, Kanchi S, Kelgane S. Clinical evaluation of the pharmacological impact of ashwagandha root extract on sleep in healthy volunteers and insomnia patients: double-bind, randomized, parallel-group, placebo-controlled study. J Ethnopharmacol. January 2021;264:113276.
