Page 50 - Demo

CONTINUING PROFESSIONAL DEVELOPMENT
THE COMPLEMENTARY APPROACH
Stress management
Alterations in diurnal cortisol levels that are consistent with changes in hypothalamic-pituitary- adrenal axis (HPA) regulation result in shorter sleep duration, lower sleep efficiency, and insomnia.4 As cortisol is affected by stress, the CAM practitioner will often focus on addressing stress as a causative factor in sleep disorders.
As part of an overall strategy, relaxation techniques may be recommended to assist with emotional regulation and stress reduction. These may include meditation, progressive muscle relaxation, deep breathing, guided imagery, tai chi and yoga.2,16
Mindfulness-based stress reduction (MBSR) programs have gained particular attention in recent years with several studies highlighting benefits for improving sleep duration,17 as well as reducing pain (a common cause of sleep disturbance).18 In older adults, mindfulness interventions are significantly better than sleep hygiene education in improving sleep disturbance and related daytime impairment.19
Herbal interventions
Sour cherry (Prunus cerasus) contains both melatonin and anti-inflammatory substances, and its use has been associated with modest improvements in self- reported sleep, although further research is required to confirm and elucidate the benefits.20,21
Many of the herbal medicines utilised for sleep disorders have an anxiolytic effect and several have been investigated for their effects on sleep and anxiety. These include valerian (Valeriana officinalis), kava (Piper methysticum) and passionflower (Passiflora incarnata), which were previously discussed in detail in Australian Pharmacist (February 2015).
Although the evidence is inconclusive, some studies have reported that 600 mg daily of a concentrated valerian extract (LI 156) taken for 6 weeks improves subjective measures of sleep quality and is at least as efficacious as 10 mg daily of oxazepam taken
for 6 weeks.22 Valerian may be used alone or in combination with other herbs such as passionflower, hops and lemon balm.23,24 For some, valerian may have a paradoxical stimulating effect, and ongoing use of valerian over several weeks may be required to experience benefits.25
Limited evidence exists for the use of kava in sleep disturbances associated with anxiety.26,27 When taken at recommended doses (120–240 mg of kavalactones daily), kava is likely to be safe, however use in patients with compromised liver function is not advised.28
Passionflower is another popular herbal option for insomnia and anxiety. Anxiolytic effects may
be responsible for improvements in short-term subjective sleep quality associated with the use of passionflower tea (2 g daily).29
As a general rule, most herbal medicines used for sleep disturbance tend to be more relaxing, creating an environment where sleep may come more easily, rather than overtly sedating. For this reason, they may not be as effective for acute use as the stronger pharmaceutical sedative medicines, but also tend to be less likely to cause next morning drowsiness.
Conclusion
Sleep disorders can cause significant impairment
in daytime functioning and can have an impact
on mood and performance, as well as increasing
the risk of depression and cardiovascular disease. People with persistent insomnia may benefit from referral for CBT training, and from recommendations for sleep hygiene and stress management strategies. Several herbal medicines have also
been investigated for their use in sleep disorders, although current evidence is limited and further high-quality human trials are needed to confirm effects. These herbs are most likely to be effective when they address the underlying cause of insomnia such as anxiety.
“Passionflower is another popular herbal option for insomnia and anxiety.”
48 Australian Pharmacist January 2017 I ©Pharmaceutical Society of Australia Ltd.
Find more information in APF23
Further information about kava (page 487) and valerian (page 505), including counselling points, is available in the 23rd edition of the Australian Pharmaceutical Formulary and Handbook (APF23).