At this point in our understanding of sleep, there is little doubt about its importance in promoting good mental and physical health. The question that has yet to be answered is whether taking a medicine or supplement to induce sleep will have the same health benefits of “natural” sleep. Nevertheless, in this article, which is in response to a reader question, I would like to discuss some of the commonly used remedies for sleep and their data, if any, to support their use.

One of the most commonly used nonprescription agents for sleep is alcohol. In fact, recent surveys have suggested that up to 28 percent of individuals with insomnia turn to alcohol for its sedating properties. The sedating nature of alcohol is not in doubt, but it is the effect on sleep quality that is most remarkable. Although alcohol can decrease the time it takes to fall asleep, it also has the ability to suppress rapid eye movement (REM) sleep in the first half of the night.

Although REM sleep does return to normal amounts in the second half of the night as the alcohol wears off, the remaining sleep is often fragmented by multiple brief awakenings. Although the precise function of REM sleep is unknown, much research points to its importance in memory function, so altering the amount and continuity of REM sleep may have significant daytime consequences.

What is most disturbing is the lasting effect on sleep in recovered alcoholics. It appears that the sleep fragmentation by multiple awakenings persists many years after quitting alcohol. The adverse effects of alcohol appear to occur at any amount over one to two drinks and certainly the effects are only magnified at higher amounts.

Along with alcohol, the second most commonly used over-the-counter agent for sleep is diphenhydramine and similar products (the most common brand is Benedryl, which is also the active ingredient in many “PM” compounds).

The most notable effect of diphenhydramine is on thinking and reaction time. Many studies support that at least at the 50 mg dose, diphenhydramine is more impairing than alcohol at the legal limits of intoxication (0.08 to 0.1 percent). Studies using driving simulators

one and a half to three hours after taking diphenhydramine show an unacceptable inability to stay within the lane of traffic.

Although these studies were performed sooner after taking the drug, it should be noted that diphenhydramine can last at least 12 to 14 hours in the body. Further studies have shown persistent effects on reaction time even upon awakening in the morning. Interestingly, although impairment was easy to demonstrate with testing, the study participants themselves denied that they felt any impairment. In studies to support sleep benefits of diphenhydramine, there are an equal number of studies that show no difference from a sugar pill as there are that show any degree of sleep improvement.

Valerian root and chamomile are also often used as over-the-counter herbal aids to promote sleep. Valerian root does have some relatively small but positive studies to show a decrease in the time to fall asleep and a decrease in the number of awakenings during the night. There is conflicting data that valerian root might increase an important deep stage of sleep, called slow wave sleep.

Some studies suggest the sleep benefits do not occur until after many nights of consecutive use. There is little if any long-term data to determine if any of these possible benefits are sustained, and there is little guidance as to the most effective dose ranges. Both valerian root and chamomile appear to have a similar mechanism of action. Although in different ways, they are active at the same brain regions and chemical pathways as sedating prescription medications such as Ambien and Lunesta. The over-the- counter herbals appear to be less potent than their prescription-requiring counterparts.

There are many other herbal supplements that have been described over the years as sleep aids. There include lemon balm, lavender, hops, passion flower, ylang ylang and kava kava. Kava kava has been banned in many countries because of reported cases of associated liver failure and death. Some of the data linking these events to kava kava is in question, but nevertheless there are significant safety concerns.

Lavender, chamomile and ylang ylang have been proposed as aromatherapy agents to promote sleep, but little data guides the appropriate mode and timing of treatment. Hops, passion flower and lemon balm have too little data in the literature to support their use for sleep. More research will need to be done regarding the preparation and dosing of all of these substances.

Melatonin is another often- used over-the-counter agent to promote sleep. The summary of 20 to 30 years of research is that melatonin is a very weak sleep-inducing agent. Although there is variation, the summary of most completed studies is that melatonin can decrease the time to fall asleep by only four minutes on average.

The other major drawback is that the consistency of melatonin preparations varies by brand and can even vary bottle to bottle. Although some of the issues of quality and safety are less than they were in the past, now that all melatonin is synthetically produced rather than being purified from animal brains, there is little regulatory oversight of all dietary and herbal supplements.

Where melatonin plays an important role is in its ability to treat circadian rhythm disorders, such as jet lag. Most recent research has shown that the timing and dosing of melatonin is essential for it to have benefit, but when precisely dosed for the individual, there is a high success rate.

Certainly the negative or absent data regarding the many of the above-mentioned sleep agents does not serve as a tacit promotion for prescription sleep aid medications. The prescription sleep aids have all been associated with significant side effects of varying degrees of severity. Also, many of the prescription sleep aids have associated concerns of dependence and tolerance (loss of effect over time).

Still the safest and most effective of all sleep-

promoting treatments is non-medication cognitive behavioral therapy. Cognitive behavioral therapy involves treatments as simple as strict bed and wake times to more-involved office sessions with a psychologist or other trained therapist.

Although many of the above-mentioned supplements are reasonably safe, discuss any new over-the- counter treatments first with your primary care provider, as there can be significant interactions with prescription medications and other unpredictable side effects.

Dr. Reploeg sees patients at The Corvallis Clinic and is the medical director of Samaritan Sleep Disorders Center.