Step #1 should be for your grandmother to discuss this problem with her physician. Many times elderly people are on multiple medications and these can have undesirable effects. It may be possible to adjust her meds or eliminate one or more drugs to diminish these symptoms.

One herb that may be helpful in insomnia is valerian - but use of this should also be discussed with her doctor beforehand.

Has your grandmother been tested for Alzheimer's disease? I only ask because some of those symptoms are compatible, though not necessarily diagnostic, and proper testing could rule it out, or else show early signs of it and she'd then need to be properly treated by her doctors.

In addition to valerian, I've used hops tincture with good effect, myself. It's pretty bitter, but if she can take the bitterness, it's a nice, mild sedative. Not sure how it would work long-term, though. I've only used it occasionally when I was having trouble falling asleep, awoke in the middle of the night, or stressed out at work.

I agree that if she is already on medicine(s), then consideration needs to be given to possible interactions.

There is one tea out there that I have found relaxing before bed - don't remember the name but it had catnip, hops, passionflower, chamomile, and a few other things. I think I got it from a grocery store or pharmacy. Some people swear by chamomile, but (alone) it doesn't do much for me.

Valerian + hops is another good combination... hops act on the melatonin receptors, and combining it with valerian improves the effectiveness.

Passion flower herb and Skullcap are also very relaxing as a evening tea; they affect the GABA receptors like valium and xanax, but are milder and not associated with the impaired coordination or memory loss when consumed at normal levels that cut the anxiety and promote rest (1-2 cups tea).

Melatonin is another thing to consider - 0.75 to 1.5 mg works pretty good for me (I split the 3 mg tablets into halves or quarters). Too much melatonin makes me groggy in the morning, but the smaller doses usually don't if I take it at 9:00 and get to bed by 9:30 or 10:00.

It should be noted that we don't have good evidence how well most herbal remedies for insomnia will work long-term, as well as potential problems in chronic use. I suspect that any product that works by a mechanism similar to valium has the potential for abuse.

Passiflora, by the way, has only been studied for the most part in rodents.

One herb to avoid is kava, banned in numerous countries due to the potential for liver damage.

Many good herbal suggestions are already made so I'll suggest a non-herbal one. Your grandmother should get to the root of her insomnia's cause. It might be medicine related. It could be food/drink related - caffeine late in the day gets many people. It could be lack of exercise. Or??? If your grandma could make note of when she gets up, when she goes to bed, what and when she eats/drinks, what/when medicine she takes, and so on a pattern might emerge. Surely this information would help any medical professional she might consult with as well.

As well as looking for a cause, she can also do these simple things:

- go out and get some fresh air.
- get age/activity-level appropriate exercise.
- Don't read or watch tv from the bed. I understand that these can help set up insomnia patterns. Use the bed for sleeping.
- Do something relaxing in the evening before bed - a warm bath, reading, knitting, sitting down with a nice cup of herbal tea, or whatever.
- Watch out for naps throwing off a sleep cycle. Also have regular times to go to sleep/wake up.

Sometimes the simplest things can help the most.

FataMorgana

Passiflora has been studied by the medical community primarily in rodents. And in animal studies, passiflora did not cause dependency, and was far less likely to cause problems with memory or coordination compared to valium when both were given at anxiolytic doses. This is consistent with the experiential/clinical knowledge of herbalists.

Some European kava preparations may have been harmful. Researchers at the University of Hawaii investigated and came up with some interesting facts:

"Experts were unable to explain how a plant used in island cultures for 2,000 years could suddenly be so toxic, causing liver damage that was fatal in some cases.

Now researchers led by Tang believe they may have found the key: Peelings from the stem bark of kava plants apparently were used to create the extract for the herbal supplements, and may be to blame for liver failure and liver-related injuries that included hepatitis and cirrhosis.

Traditional kava drinkers discard the peelings, but Tang and his team learned from a trader in Fijian kava that European pharmaceutical companies eagerly bought up the peelings when demand for kava extract soared in Europe in 2000 and 2001."

Here is a link that might be useful: UH scientists may have solved kava mystery

Lot of "ifs" in that article, which seems to focus on the kava bans' damage to an economically important Hawaiian crop.

If peelings were implicated in the cases of liver damage, if the kava peelings have a negative effect on the human liver in cell cultures not caused by the leaves, if that effect translates to animals (and most importantly, humans), and if kava leaf tea can be shown to be free of toxicity in human studies, then it could be declared safe. Maybe the economic interests benefiting from kava trade could support research into these questions. From the linked article:

"Just to be safe, people should avoid tea or anything else made from the leaves or stems of the plant, according to C.S. Tang, professor of molecular biosciences and biosystems engineering at UH-Manoa."

A couple other points of interest from the article:

"Experts were unable to explain how a plant used in island cultures for 2,000 years could suddenly be so toxic, causing liver damage that was fatal in some cases."

This is a common theme that turns up in defense of potentially toxic herbs, including aristolochia (which has caused kidney failure resulting in the need for victims to get kidney transplants). With aristolochia, some also wondered how a traditional Chinese herb with a long record of use could be so toxic? Must be that those ignorant Westerners didn't use it the traditional way, or something.
What these apologists fail to take into account is that in ancient cultures, life expectancy was much lower than it is now, and other diseases and toxic exposures (to heavy metals in mining, for instance) were rampant. In addition, medical understanding was primitive - so it's likely that herbal toxicities were not well recognized or understood.

I also like the quote in the article that blames "pharmaceutical companies" for cases of kava toxicity. I guess it's just not politic to blame supplement or "natural products" companies. ;)

Good points, FM. This is why broad participation in these forums is so beneficial. Thanks!

Another thing that hasn't been mentioned yet is dream pillows. Some of them are very relaxing, and can even give very pleasant dreams. A number of sites sell them, one of which is blessedmaineherbs.com. I bought several from a mybackyard.com a few years ago, and they were great, but unfortunately, she went out of business. :-( It *is* possible for some sensitive people to get wild dreams from dream pillows that they don't find pleasant (particularly true of children), and in that case you'd probably be best to avoid a pillow that contains mugwort.

Also, you can purchase essential oils, such as lavender or lemon balm, at many health-food stores. Just a drop of oil on the pillow can send your grandma (or you!) off to la-la land.

there's a couple of things to consider -

the first being that if she's already on ANY meds at all, testing different ones is to be done under strict observation, and near-clinical precision. are YOU willing to sit with her for 48 hours to observe the effects of a full cycle? work with her doctor to get blood work done?

if not - stick with things like yoga, aromatherapy, Bach flower essences, and massage - things that aren't going to leave her disoriented, or groggy, or in any of the dozen states she could get hurt in.

now - treating stress in any form is a tricky thing - but the start is to understand it. WHY is she anxious? is she alone? is she feeling her mortality? does she miss having a pet, or feel unable to care for one she has? does she miss being a functioning, contributing family member? are her joints keeping her awake at night?

what are the parameters of her insomnia? is she simply old enough to be returning to a child's sleeping pattern of several hours on, several hour off? my mom (79 next month) gets four hours at night, and 2-6 more during the day, depending on whether she naps after lunch or not. this is what her body is happy with, so that's what her body gets.

if I had to pick one zero-impact thing to look into, it would have to be the Bach essences - those particularly, not the hundred and one 'new' systems that promote a thousand and one flowers, and sound like they were developped by Shirley McClaine's idiot sister. - Dr Bach is old-fashioned, but so is anyone with any sense ;)

what matters is that you're looking for answers - that alone is sometimes enough to make older people feel less helpless and isolated.

Actually, all indications from millions of people taking kava shows that the liver toxicity of kava root is less than that of acetominophen, the active ingredient in tylenol and many other over-the-counter medicines. Yet the fear-factor is much higher for kava. And the fact that the stems and leaves contain something that has been shown to be hepatotoxic (in animal studies) while the root is not is consistent with the epidemiological studies.

Aristolochia has been implicated in kidney failure resulting in the need for victims to get kidney transplants - but this occurred when it was an unlabeled adulterant in a product that was not subjected to quality control. And even then, it is not clear that this was in fact the cause - there was a cluster of kidney failure at a Belgian weight loss clinic, which may have been due to aristolochia and/or a variety of other medicines that were administered. And aristolochia is a minor herb in Chinese medicine, which is not administered in the doses or duration seen in Belgium a few decades ago.

>> "I also like the quote in the article that blames "pharmaceutical companies" for cases of kava toxicity. I guess it's just not politic to blame supplement or "natural products" companies. ;)"

Actually, in Germany, most of the herbal medicines are in fact manufactured and sold by pharmaceutical companies; the construction of 'mainstream' and 'alternative' ideology is done differently there.

I also find it funny how many who dismiss the traditional uses of whole plants in particular ways apply the same logic when it comes to food - they argue that we should eat fruits and vegetables (fresh, or as traditionally cooked), not use some extract of one particular compound or class of compounds. And they point to the research that shows that whole tomatoes may reduce the risk of many types of cancer while beta-carotene purified from tomatoes (or alfalfa or wherever) may actually increase the risk of some cancers.

In the case of an herb being extracted with methylene chloride or some other solvent, the product may have different properties than the herb. Not that such methods are inherently wrong, just that they can be different.

Here is a link that might be useful: Ethanolic Extract of Kava Root does not cause Liver Toxicity in Rats

To respond to your points:

Kava is relevant to the discussion since it's been proposed as a relaxant/sleep aid. Acetominophen is not used for this purpose, so it's not relevant. There are herbal preparations and over-the-counter products which may be useful as sleep aids, and have not been linked to liver damage like kava.

As for aristolochia and the many cases of severe kidney damage to which it's been linked - medical detective work has indeed shown that this Chinese herb was at fault. This link talks about how the toxic element in this herb was found to be part of an altered form of DNA in victims. Such changes are felt to be part of the process by which the herb induces cancer:

"Kidney failure is not the only toxicity of Chinese herbal medicines containing aristolochic acid . In 2000, an article in the New England Journal of Medicine reported the pathological findings of 39 patients with Chinese-herb nephropathy who were evaluated for urinary tract cancers. It was found that almost 50% of the people with Chinese Herb nephropathy had evidence of cancers involving the ureter, bladder and renal pelvis. Most of the remaining patients (who did not have cancer obvious cancer) had evidence of lesions that are precursors for cancer.

Aristolochia has been found as an ingredient in herbal products even though it wasn't on the label, which is why I'd be careful about consuming any commercially sold herbal mixtures, and entirely avoid those imported from China.

To get back to kava, here's a summary of a newly released research study supporting evidence that this herb is toxic to the liver.
If some way can be found to make kava safe for people to use, that'd be great. Currently, I don't think it's wise to take it.

It's getting very difficult these days to draw a sharp distinction between supplement companies and pharmaceutical firms. The "natural products" industry in the U.S. now has $22.5 billion dollars in sales annually. With all that income comes the responsibility to sell us safe and effective products.

By the way, chinacat has some very good points about looking at lifestyle issues and expectations. Many times we're too eager to have someone pop a pill or take an herb without looking at these factors first.

:) Thanks, Eric - I'm a real bear about that stuff from both ends - especially when you're trying to treat something without knowing if it's environmental, mental/emotional, or physical/biochemical in nature.

besides - I have a very broad definition of 'drug' - I don't care if it's synthetic or not, if it affects my mood, or the functioning of my body, it gets treated the same way I treat other drugs - and I'm not inclined to trust Merck's Manual any more than I'm inclined to trust an abbey herbal from the 15th century ;)

*chuckle* and here you are talking about income creating responsibility...I think the industry's retort to that's been 'how do you think we got so rich?', nu?

You say that Kava is relevant to this discussion because it is a relaxant, but that acetominophen is not .... strange then that you would invoke the dangers of aristolochia, which is not used as a relaxant. Of course, it is not really so strange if you are trying to paint herbal medicine as inherently dangerous while ignoring the fact that there is no zero-risk medicine, and that commonly used OTC medicines pose a real risk of inducing liver failure. I'm all for a rational discussion of kava, as I want to know the risks of what I take. And all evidence points to the few cases of liver failure that were associated with kava being due to the consumption of leaf and stem, not the root.

As a doctor, do you routinely tell patients to take tylenol for mild fevers and strained muscles? Or do you tell them that acetominophen is one of the most common cause of liver failure in the US, and that it might kill them? The evidence that acetominophen is potentially fatal is not in dispute, and yet people are willing to accept that risk, because (as with Kava) it is a small risk, and zero risk is not possible.

Yes, there is a study that show that exposing isolated cultured rat liver cells to large doses of kava can cause toxicity - but when when whole rats or mice are fed kava in moderate doses (which are still large enough to have an anti-anxiety effect), then these toxic effects are not seen. And study after study on humans in Polynesia show that kava consumption may be associated with a possible transient elevation of one or two liver enzymes, but no evidence of the fulminant liver failure that was seen in Europe among people taking certain brands of extract.

And how is this 'Natural Products Industry' defined? One industry trade group webpage I saw includes specialty organic foods, in-store restaurants and juice/smoothie sales, natural cosmetics and toiletries, cleaning products, housewares and pet products in their totals, along with vitamins, minerals and herbs.

"You say that Kava is relevant to this discussion because it is a relaxant, but that acetominophen is not .... strange then that you would invoke the dangers of aristolochia, which is not used as a relaxant."

I was responding to your suggestion that if an herb has "2,000 years" of usage, surely there couldn't be much risk in taking it. Aristolochia is a prime example of the dangers of trusting in folklore rather than evidence-based herbal medicine.

"Of course, it is not really so strange if you are trying to paint herbal medicine as inherently dangerous"

It is strange that you'd make this claim, seeing as how I suggested the original poster look into a herbal relaxant near the beginning of this discussion.

"...commonly used OTC medicines pose a real risk of inducing liver failure."

I know of no OTC sleep aids that have been linked to fulminant hepatitis requiring liver transplantation, as kava has.

"Yes, there is a study that show that exposing isolated cultured rat liver cells to large doses of kava can cause toxicity"

Actually, the study I linked to involved human liver cells. No study solely involving tissue culture or rodents can be regarded as anywhere near definitive - which is why controlled studies in human beings establishing safety and efficacy are needed for kava. As things stand right now, we don't have that evidence. And we do have alternatives for sleep aid (including herbal and non-herbal remedies) that have a better established record of safety.

"And how is this 'Natural Products Industry' defined? One industry trade group webpage I saw includes specialty organic foods, in-store restaurants and juice/smoothie sales, natural cosmetics and toiletries, cleaning products, housewares and pet products in their totals, along with vitamins, minerals and herbs."

If you're going to include all those other items, annual natural products industry sales are far higher than the $22.5 billion dollars a year I mentioned (that figure came from a USA Today article last week on adulteration of dietary supplements taken by athletes). This source cites over $56 billion dollars in sales of natural products including food, beverages and other items. A Mother Jones article from 2003 describes how annual dietary supplement sales went from $4 billion in 1994 to nearly 18 billion by 2003; given the industry's continued growth that $22.5 billion figure for current annual sales sounds like it's in the ballpark for dietary supplements (including herbs) alone.
Surely the industry could spare a small fraction of that money for increased research into herbs.

Eric, that is the worst science I have seen in a long time. The article you cited found that kava had adverse effects in mouse mitochondria and human HepG2 cells. HepG2 cells are cancer cells, which behave quite differently from normal cells.

This fatal flaw in such logic was spelled out quite clearly in an article on using a few abnormal cultured cells to model the liver: "Prediction of liver toxicity and compound responses continues to be a major challenge for the pharmaceutical industry. In vitro studies on liver cells have been developed to reduce or replace animal experiments. However, most of the tests in use are based on cell lines which do not necessarily represent normal cell physiology." PMID: 17361318

Many cancer cells are considered Âgreedy as they hyper-accumulate various chemicals. Cancer cells over-express genes associated with growth, but typically turn down (or off) other genes associated with normal metabolism. This is the whole basis of cancer chemotherapy  certain compounds are more toxic to cancerous cells than to normal cells.

Here are few other studies that demonstrate that being toxic to HepG2 cells indicates ABSOLUTELY NOTHING with respect to normal cells in an organism:

Ascorbate (Vitamin C) induces apoptotic cell death in a dose-dependent manner in HepG2 cells. PMID: 15646799 (Is it time to ban foods that contain vitamin C?).

Vitamin K causes programmed cell death in HepG2 cell lines. 17088989

Naringenin, quercetin and other flavones (abundant in many fruits, vegetables, & herbs) are toxic in cancer cell lines like HepG2, but are non-toxic in normal cells. PMID: 18074851

Toxicity of iron nanoparticles was studied in HepG2 and turkey embryos. HepG2 cells accumulated Âexcessively high amounts while the livers of whole animals did not. Conclusion: "Iron uptake in cell culture does not reflect the in vivo situation." PMID: 18061126

Smilax (Sarsparilla) and other herbs reduce the vitality of HepG2 cells, and are thus identified as a potential resource in preventing and treating cancer. PMID: 17996228, 15916774

First you were arguing that the kava study I cited was invalid because it involved mouse cells. When it was pointed out to you that human cells were studied, now you're claiming that the results are invalid because a cell line derived from a tumor was used.

Cancer cell lines are used in research for a very good reason - they are "immortal" and can be reproduced indefinitely in tissue culture, permitting extended study. Of course their behavior is not a perfect reflection of what will necessarily happen in a living human because so many other factors are involved in metabolizing a drug or herb - which is why we also use animal studies and human trials in deciding on a product's safety and usefulness.

In the case of kava, we have evidence of toxicity based on human and mouse cellular damage, toxicity in live rats, evidence of liver cell damage in humans in lab tests (which you noted) and numerous case reports of severe liver damage in people (multiple countries banning kava after reports surfaced of 11 cases of hepatic failure leading to liver transplantation, with several deaths).

What's scary to me is that kava's toxicity is felt by some to be idiosyncratic - meaning that certain people are especially susceptible to its liver toxicity, and there's no way to predict who's at risk. Is it worth taking the chance of dying to use an herbal relaxant?

>>> "When it was pointed out to you that human cells were studied, now you're claiming that the results are invalid because a cell line derived from a tumor was used."

That is correct - isolated liver tumor cells are a poor predictor of whole liver response. They commonly give false indications that innocuous or beneficial compounds are a threat to the liver.

>>> " ... evidence of liver cell damage in humans in lab tests (which you noted)"

No, I have noted transient elevation of liver enzymes. That is not the same as liver damage; while some types of liver damage do cause an elevation of liver enzymes, the genes that produce liver enzymes can also be up-regulated in the absence of any damage or disease.

>>> "I was responding to your suggestion that if an herb has "2,000 years" of usage, surely there couldn't be much risk in taking it."

I suggested no such thing. There are modern epidemiological studies that have concluded that "There is no evidence for serious liver damage in kava-using populations in Pacific Island societies or in Indigenous Australians who have used aqueous kava extracts... Liver function changes in users of aqueous kava extracts appear to be reversible and begin to return to baseline after 1 to 2 weeks abstinence from kava. No evidence for irreversible liver damage has been found." (PMID 14677792)

>>> "numerous case reports of severe liver damage in people (multiple countries banning kava after reports surfaced of 11 cases of hepatic failure leading to liver transplantation, with several deaths)."

And what was the bottom line of that review that you cited? "The risk-to-benefit ratio of kava extracts, nevertheless, remains good in comparison with that of other drugs used to treat anxiety."

So your complaint is not that other anti-anxiety medicines are more toxic than kava - it is that kava is toxic at all?

Some countries banned all kava as a precaution, that does not reflect the current evidence that particular contaminated products were responsible for the problems you describe in Europe.

>>> "What's scary to me is that kava's toxicity is felt by some to be idiosyncratic - meaning that certain people are especially susceptible to its liver toxicity, and there's no way to predict who's at risk."

More fear-mongering. Isn't the same is true of most drugs? Idiosyncratic reactions are an unavoidable fact of life. There are also idiosyncratic reactions to common foods (shellfish, latex, cashews, peanuts, etc). Risk cannot be abolished, it can only be estimated so that people make rational decisions. Do you think we should ban peanut butter and lobster, or would big orange warning labels be enough to deal with the life-threatening idiosyncratic reactions to them?

>>> "Is it worth taking the chance of dying to use an herbal relaxant?"

In the west, kava has been used predominantly by people with anxiety and panic disorders; these conditions are associated with an impaired quality of life as well as increased risk of fatal sudden heart problems due to an overactive nervous system. PMID: 17513215, etc. Kava has been demonstrated effective for treating such disorders, and to repeat from the article you linked to, the risk-to-benefit ratio of kava is good in comparison with that of other drugs used to treat anxiety."

You might as well ask "is it worth driving to a cinema just to watch a movie when there is a very real risk of being in a car crash and dying? Is that experience worth risking your life for?" Such 'reasoning' is irrational.

Much of what you're stating, including the claim that liver cell testing is useless in predicting drug toxicity, reflects your personal opinion and is not the standard by which we determine the safety of drugs.

To go back to that report suggesting that kava compared favorably to antianxiety drugs, did you notice the following line: "...the potential for drug interactions (with kava) and/or the potentiation of the toxicity of other compounds is large." Is kava really the drug we want to give Grandma, when she's already on other medications with which it could interact negatively, and about which her physician would likely not be informed?

We can quote dueling studies and nitpick their conclusions ad nauseaum, but the bottom line remains: numerous countries have banned kava because of the risk of liver failure, the FDA warns against its use and despite the appeals to folklore, controlled human studies establishing that it's a safe effective drug are lacking.

It's too bad the kava producers are losing out on a cash crop, but there are safer alternatives available.

>> Is kava really the drug we want to give Grandma, when she's already on other medications with which it could interact negatively, and about which her physician would likely not be informed?

It was not clear if the Grandma referred to in the first post was having side effects from other medicines given to treat insomnia/anxiety (and she wanted to discontinue those and try something else) or if she was having side effects from meds given to treat other conditions. So I stated in my first post in this thread: "I agree that if she is already on medicine(s), then consideration needs to be given to possible interactions."

>> the FDA warns against its use

The FDA did not warn against all use of kava - if you take the time to read the advisory that you linked to, they stated "Given these reports, persons who have liver disease or liver problems, or persons who are taking drug products that can affect the liver, should consult a physician before using kava-containing supplements." That sounds reasonable and prudent, but is quite different from your interpretation that kava is so unsafe that no one should even consider taking it.

>> Much of what you're stating, including the claim that liver cell testing is useless in predicting drug toxicity, reflects your personal opinion and is not the standard by which we determine the safety of drugs.

No, I have cited articles that have outlined the limits to using liver cancer cells to predict toxicity. This is not merely my opinion. The HepG2 model is built on a rickety framework of 'ifs' and 'maybes' - and there is abundant evidence that it is not reliable. You didn't respond to the studies that found that Vitamin C and Vitamin K can cause HepG2 cells to die or express signs of damage - does this mean that these compounds are inherently dangerous?

>> numerous countries have banned kava

Yes, and these are the same European nanny-states that have banned or severely limited drugs that are freely available in the US. I remember a pharmacist over there looking at me like I was a criminal because I asked for a medicine that is over-the-counter in the US, but is a prescription-only controlled substance there. They also kept all medicines behind the counter, as the consumer cannot be trusted to obtain anything with out the intercession of a person wearing a white jacket.

>> because of the risk of liver failure

Acetaminophen is credited with over 50,000 visits to the emergency room and approximately 450 cases of fatal liver failure each year in the US. The FDA advisory mentions one transplant in the US that was ~associated~ with kava around 2002, along with 'several' less serious possible incidents.

No one is questioning if acetaminophen is safe - sometimes it is not. It is a question of relative risks - we accept the risk that something that treats many fevers and muscle aches might occasionally cause other problems. Just as we accept the risk that we might be killed driving to a theater to watch a movie. A zero-risk world is impossible, and people that react emotionally to certain risks while ignoring other (larger) risks are irrational.

>>> despite the appeals to folklore ..

I'm not appealing to folklore - I am talking about epidemiology and statistics. The number of cases of adverse effects in the US is miniscule compared to the millions of people that have taken kava. Studies in Polynesia revealed an absence of the harm that some fear.

>>studies establishing that it's a safe effective drug are lacking

You apparently are wiser than a 2007 review in the peer-reviewed journal of the American Academy of Family Physicians that concluded "Short-term use of kava is recommended for patients with mild to moderate anxiety disorders who are not using alcohol or taking other medicines metabolized by the liver, but who wish to use "natural" remedies." - They gave it an evidence rating of "A" and noted that "side effects were rare and mild".

>> It's too bad the kava producers are losing out on a cash crop, but there are safer alternatives available.

A red herring, quite irrelevant. I have no vested interest in the economics - I do not produce or sell kava. But I do take it from time to time, and I object to people like yourself with obvious biases that mis-characterize the research and the government advisories. There is evidence that kava is effective in treating anxiety related conditions, and there is evidence that the risk is low.

I think enough has been posted already about the FDA's warning on kava (they have not established its safety or recommended it for any potential users) as well as the European bans for people to decide for themselves what the stakes are.

You know, if we were talking about some highly valuable drug, the potential side effects might be worth the risk. But kava doesn't meet that standard. The American Academy of Family Physicians article you mentioned cites a review by the respected Cochrane organization, which concluded that kava has only a small effect on anxiety:

"The effect lacks robustness and is based on a relatively small sample. The data available from the reviewed studies suggest that kava is relatively safe for short-term treatment (1 to 24 weeks), although more information is required. Rigorous trials with large sample sizes are needed to clarify the existing uncertainties. Also, long-term safety studies of kava are required."

In searching for publications on kava you may have overlooked another new report. This one (in the Journal of Psychopharmacology) looked at 21 different double-blind clinical trials of anxiety treatments, incorporating two complementary/alternative medicine (CAM) therapies (including kava) and found that:

"Subjects taking CAM had worse outcomes than placebo".

Hmmm...doing worse than a sugar pill is generally not a good recommendation for a drug or herb.

apollog: "I object to people like yourself with obvious biases..."

My "bias" seems to be that I agree with the many physicians, researchers and health agencies that question the use of kava, and differ with you on its safety and effectiveness. I'm surprised, then, that you aren't attacking the "biases" of the authors of the American Academy of Family Physicians article that you triumphantly cited on kava. After all, the authors of that article pooh-poohed a host of other herbal remedies and supplements that you recommended earlier in this thread, such as chamomile, hops, valerian, skullcap and passionflower. From the article:

Table 2. Supplements with No Clinical Trial Evidence of Effectiveness in Anxiety Disorders
Herbal supplements

Ashwagandha (Withania somnifera); Bach flower essences; bacopa; berocca; borage juice (starflower); bugleweed (Lycopus virginicus); catnip; chamomile; damiana; fennel; feverfew; ginkgo; ginseng; golden root (Rhodiola rosea); gotu kola; hops; kanna; lemon balm; lemongrass leaves; licorice; meadowsweet; motherwort; mullein (Verbascum sinuatum); mulungu; noni (Morinda citrifolia); peppermint; pine bark extract; reishi (Ganoderma lucidum); Relora (magnolia/phellodendron); schisandra; scullcup (skullcap); verbena (blue vervain)

While I earlier suggested the original poster look into valerian, I'm not going to start denouncing the AAFP article's authors as biased against herbs just because they disagree with me. I'll continue to review evidence on herbs recommended for anxiety and/or insomnia.

I was encouraged recently to see that you'd apparently forsaken personal attacks in this forum. I regret that you're resuming this tactic, as it detracts from useful discussions. If you can't make your case without ad hominems, maybe that case isn't as strong as you think it is.

>> I think enough has been posted already about the FDA's warning on kava (they have not established its safety or recommended it for any potential users) ...

As a rule, the FDA does not recommend herbs - the fact that they do not specifically recommend kava means nothing. The FDA can ban an herb if there is clear evidence that it is unsafe. Since the 2002 advisory, the FDA has monitored the situation, but has not seen real evidence that this herb is clearly dangerous.

By implying that no one should use an herb unless recommended by the FDA, aren't you really saying that herbalism should be avoided altogether?

>> I'm surprised, then, that you aren't attacking the "biases" of the authors of the American Academy of Family Physicians article that you triumphantly cited on kava. After all, the authors of that article pooh-poohed a host of other herbal remedies and supplements that you recommended earlier in this thread, such as chamomile, hops, valerian, skullcap and passionflower.

They do have their biases - they take a conservative approach and tend not to endorse something unless there is overwhelming proof (in the form of double-blind placebo controlled trials). That's fine for them, and in the case of kava, the evidence took them past their threshold and they do suggest doctors recommend it. The fact that there is not an adequate number of such studies for every other herb does not mean that none of these are effective - it merely means that it remains unknown according to their framework.

I personally believe that there are other ways of knowing - the clinical experience of doctors or herbalists can lead to useful knowledge. And while many people dismiss personal experience as 'unscientific' I do not always do so. Many researchers believe that anxiety is a condition where people can monitor themselves and adjust their regimen, and I agree with this. Studies can tell us that a particular approach is better than placebo, but they generally cannot predict individual response.

I have taken a variety of prescription and non-prescription therapies for anxiety, and can say that kava can have dramatic, rapid beneficial effects. I also seen benefits from passiflora. Chamomile has not resulted in any noticeable changes for me - maybe some people benefit, but I do not consider it to be that effective. Hops are used more for insomnia than for anxiety - so an article on herbal approaches to anxiety might not recommend hops, even if it was written by a herbalist. Ashwagandha I have find helpful, though there is almost no research on it with regards to anxiety; many people with anxiety have tried it and found benefit, but the FDA hasn't gotten around to looking into it (and they probably won't, so looking to the FDA probably won't answer that question).

>> In searching for publications on kava you may have overlooked another new report. This one (in the Journal of Psychopharmacology) looked at 21 different double-blind clinical trials of anxiety treatments, incorporating two complementary/alternative medicine (CAM) therapies (including kava) and found that: "Subjects taking CAM had worse outcomes than placebo".

No, I am aware of that study. It reviewed 21 different studies on 7 different types of medications (8 different types if kava and homeopathy are not lumped together - unlike other categories, they are not chemically related, and do not share a common mechanism). It is not clear how many studies were actually on kava (my guess is one or two). And lumping kava in with homeopathy doesn't tell us much about kava - I don't consider homeopathy to be effective, so I am not surprised that it would bring down the score of what they define as CAM. The idea that outcomes for kava are worse than placebo is at variance with a much larger number of other studies, and is not supported by the facts. To cherry-pick one review that has a dubious design and considers only a fraction of the research on kava is shoddy science.

>> I was encouraged recently to see that you'd apparently forsaken personal attacks in this forum. I regret that you're resuming this tactic,

I think your being too sensitive. Noting or criticizing apparent bias is not necessarily an unfair ad hominem attack. You have repeatedly mischaracterized my arguments as an appeal to folklore, you have insinuated that financial interests are behind the kava research that doesn't find it to be massively toxic, and you have invoked irrational fear over rare idiosyncratic reactions in kava while ignoring such risk from other commonly consumed medicines. You refuse to acknowledge well known limits to predicting liver toxicity using cell culture models, and dismissively suggest that I don't know how such research is done. For me to point out that you do in fact have biases and values that can color your interpretations of the research is not an unfair personal attack on you. You have consistently done the same to me.

I don't think I've "mischaracterized" your arguments (note that there is a big difference between questioning these and attacking someone personally, as you've done).

Your previous post suggested the FDA had no real problem with kava, only recommending that people who might be susceptible to severe liver damage talk to their physicians first. In reality, the FDA has a much more cautionary tone and they are particularly worried about people with liver problems and/or those on other meds which are metabolized by the liver (a large percentage of drugs overall). Given our current lax regulatory climate (aided by a few powerful politicians like Orrin Hatch), the FDA is reluctant to ban any supplements until there's substantial public outcry over deaths and injuries (as in the case of ephedra supplements).

"By implying that no one should use an herb unless recommended by the FDA, aren't you really saying that herbalism should be avoided altogether?"

No such implication was made. I earlier recommended that the initial poster look into valerian. Elsewhere I've recommended a variety of herbs for a number of conditions. The fact that I do not recommend a few that you've touted does not make me an enemy of herbalism, and I suggest you drop this unwarranted line of attack.

"I personally believe that there are other ways of knowing - the clinical experience of doctors or herbalists can lead to useful knowledge. And while many people dismiss personal experience as 'unscientific' I do not always do so."

Testimonials by themselves are only useful as a starting point for further investigation - otherwise they're useless and potentially dangerous. Some posters in this forum trust them heavily, not realizing that many "testimonials" in this forum are from commercial sellers. Other problems with testimonials include our inability to know what the herb/drug user's actual diagnosis was (some "cancer cure" testimonials have come from people who never had cancer in the first place) or what other medications they were taking. Many times people think they've had dramatic improvement in their condition, when the disease is one that is naturally prone to periods of remission and relapse (including such diverse conditions as rheumatoid arthritis and geographic tongue). As far as geographic tongue is concerned, if you were to depend only on testimonials, you'd waste time and money (and risk damaging your health) taking all sorts of supplements and drugs and making drastic dietary changes, none of which have proven value.
The argument "all of us are different" is a poor justification for testimonials. Using good science, we can predict what treatments will work for the vast majority of people. Genetic testing will make it possible to tailor treatment even further. With testimonials, you're just stabbing blindly at remedies.

"To cherry-pick one review that has a dubious design and considers only a fraction of the research on kava is shoddy science."

To mention only one of the negative studies and reviews on kava (and ignore or dismiss numerous others (cited in this thread) that support its conclusions, is misleading. Characterizing those who disagree with you as "biased", "shoddy", "nanny-state governments" and the like creates an impression that you're more interested in personal attack than informing posters based on evidence.

I acknowledge that there's some evidence that kava might be acceptable at some point as an anti-anxiety medication, especially if its toxicity becomes better understood and it becomes available in a safer form. Given the severe liver damage it's been linked to, and the slender evidence of its effectiveness for a non-life threatening condition (that safer drugs and non-drug therapy are available for), people can decide for themselves whether taking kava is a worthwhile risk.

I would vote for Rooibos as the best sleep inducing herbal tea. Been using it every night for about three years. No tolerance built up. Started off using 1&1/2 teaspoon, and no change. No side effects. The best!

Look up the side effects of the meds she is taking online, chances are they are at least partly responsible for her symptoms. If it turns out her meds do have side effects that mimic her symptoms, print that out and show it to her doctor next visit.

Drug-Herb interactions can range from non existent to downright dangerous, so check with her doctor before making any additions or subtractions to her protocol.

Her symptomology exactly describes 'stagnant liver qi' a common pattern in the population in general and especially so in those taking several medications...the liver can become overloaded, the qi energy backs up and does not flow smoothly.

still, we'd need more information to make good recommendations for her.

The best "qi" for your liver involves avoidance of drugs (herbal or pharmaceutical) that can damage the liver, unless those medications are absolutely necessary.

Best to look first at lifestyle solutions first for problems related to anxiety and insomnia. Use of any drug long-term is bound to result in problems.

Passiflora and Scullcap (laterifolia, NOT baicallensis) are the two best that I've found. Motherwort is really good too, and all three can be combined safely.