Efficacy and safety of a polyherbal sedative-hypnotic formulation NSF-3 in primary insomnia in comparison to zolpidem: a randomized controlled trial

Effects of Mamsyadi Kwatha in primary insomnia - A randomized controlled trial

BACKGROUND

Insomnia is the second most commonly presenting symptom, after pain, in clinics. Insomnia prevalence in India is 28.1 %.

OBJECTIVE

This study explores the effect of Mamsyadi Kwatha in the management of primary insomnia.

MATERIALS AND METHODS

Fifty patients attending KLE Ayurveda hospital meeting the diagnostic criteria of primary insomnia (DSM IV TR) were enrolled. Patients were randomly divided into two groups: group MK and TK. Intervention in group MK was 24 ml of Mamsyadi Kwatha twice a day and in group TK was 24 ml of Tagaradi Kwatha twice a day for 30 days. Assessment was done through primary outcome measures like Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS), insomnia severity index (ISI). Secondary outcome measures were sleep diary recordings of past 15 days and depression anxiety and stress scale (DASS). Follow ups were at base line, 15th and 30th day of interventions. Laboratory assessments of liver function test, haemoglobin, and serum creatinine levels were carried at base line and 30th day of intervention.

RESULTS

Effect on primary and secondary outcomes showed that both the drugs were comparable. = Within group comparison of both the drugs showed that they produced significant improvement in PSQI, ESS, ISI, sleep diary variables, and DASS. However, Mamsyadi kwath has additional benefit of early recovery in total sleep. Both the drugs showed good safety profile evaluated through serum creatinine and liver function tests.

CONCLUSION

The effects of Mamsyadi Kwatha is comparable to Tagaradi Kwatha. Both drugs produced significant improvement in clinical assessments of insomnia, anxiety, depression, and stress.

Common herbs for stress: The science and strategy of a botanical medicine approach to self-care

Frontline healthcare workers have reported elevated levels of stress and increase prevalence of burnout symptoms since the onset of the COVID-19 pandemic. With these heightened levels of stress and burnout comes a need for more evidence-based interventions to address these symptoms earlier, in both a safe and effective way. Some common botanical medicines have a measurable effect on perceived stress, neurotransmitter levels, and circulating cortisol levels indicating their ability to modify the stress response. Botanical medicines are often relatively low cost, increasingly available in retail stores and online marketplaces, and show relatively low reports of adverse effects, making these medicinal herbs an important option for addressing work-related stress for healthcare workers.

Modulation of the metabolite content of the unicellular rhodophyte Porphyridium purpureum using a 2-stage cultivation approach and chemical stressors

There have been growing interests in microalgal biotechnology for the biorefining of bioactive compounds such as carotenoid pigments, ω-3 fatty acids, antioxidants or antimicrobials for sectoral applications in the pharmacology, nutraceutical and cosmetic fields. This study focused on the unicellular marine rhodophyte Porphyridium purpureum CCAP 1380/1 A, which was cultivated via a two-stage batch growth mode for 10 days using hydrogen peroxide (H₂O₂), the phytohormone methyl jasmonate (MJ) and three plant extracts (Passiflora incarnata, Panax ginseng and Valeriana officinalis). The microalgal biomass was then analysed for its protein, phycoerythtin, carbohydrate and pigment composition together with its pigment content and antioxidant activity. Of note, MJ increased the protein and phycoerythtin content (up to 225 µg BSA eq./mg DW and 15 mg/ml, respectively) while both the MJ and H₂O₂ treatments increased carotenoid pigment yields (β-carotene and zeaxanthin, up to 5 and 4 mg/g, respectively). Carbohydrates were enhanced ∼10 fold by the Valeriana officinalis treatment (up 192 μg starch eq./mg). Overall, neutral lipids and antioxidants were mostly negatively affected by the plant extracts. The greatest antioxidant activity registered was obtained with the H₂O₂ treatment (15 μmol Trolox eq./g DW with TEAC assay). P. purpureum contains multiple valuable compounds of commercial interest. These results indicate that they can be favorably modulated using specific cultivation regimes and chemical enhancers, thereby facilitating the exploitation of the biomass by applying a suitable co-refinery pipeline.

Valerian Root in Treating Sleep Problems and Associated Disorders-A Systematic Review and Meta-Analysis

Sleep problems are widely prevalent and associated with various comorbidities including anxiety. Valerian (Valeriana officinalis L.) is a popular herbal medicine used as a sleep aid, however the outcomes of previous clinical studies are inconsistent. This study was conducted to update and re-evaluate the available data in order to understand the reason behind the inconsistent outcomes and to provide a broader view of the use of valerian for associated disorders. PubMed, ScienceDirect, and Cochrane Library were searched to retrieve publications relevant to the effectiveness of valerian as a treatment of sleep problems and associated disorders. A total of 60 studies (n=6,894) were included in this review, and meta-analyses were performed to evaluate the effectiveness to improve subjective sleep quality (10 studies, n=1,065) and to reduce anxiety (8 studies, n=535). Results suggested that inconsistent outcomes were possibly due to the variable quality of herbal extracts and that more reliable effects could be expected from the whole root/rhizome. In addition, therapeutic benefits could be optimized when it was combined with appropriate herbal partners. There were no severe adverse events associated with valerian intake in subjects aged between 7 and 80 years. In conclusion, valerian could be a safe and effective herb to promote sleep and prevent associated disorders. However, due to the presence of multiple active constituents and relatively unstable nature of some of the active constituents, it may be necessary to revise the quality control processes, including standardization methods and shelf life.

Medicinal Plants for Insomnia Related to Anxiety: An Updated Review

Sleep disorders are common among the general population and can generate health problems such as insomnia and anxiety. In addition to standard drugs and psychological interventions, there are different complementary plant-based therapies used to treat insomnia and anxiety. This review aimed to find and examine the most recent research on the use of herbal medicines for treating anxiety and insomnia as compiled from clinical trials, as well as to assess the safety and efficacy of these medicines and to elucidate their possible mechanisms of action. The process entailed a search of PubMed, Scopus, and the Cochrane Library databases from 2010 to 2020. The search terms included "sleep disorder", "insomnia", "sedative", "hypnotic", "anxiety", "anxiolytic", and "clinical trial", combined with the search terms "herbs" and "medicinal plants", in addition to individual herbal medicines by both their common and scientific names. This updated review, which focuses mainly on clinical trials, includes research on 23 medicinal plants and their combinations. Essential oils and their associations have also been reviewed. The efficacy of medicinal plants depends on treatment duration, types of study subjects, administration route, and treatment method. More clinical trials with an adequate, standardized design are necessary, as are more preclinical studies to continue studying the mechanisms of action. As a result of our work, we can conclude that the 3 plants with the most potential are valerian, passionflower, and ashwagandha, with the combination of valerian with hops and passionflower giving the best results in the clinical tests.

Use of Plant-Derived Natural Products in Sleep Disturbances

Sleep disorders have a high prevalence both in the general population and especially in specific populations such older adults and oncologic patients. Impacting on quality of life, they often translate in drug prescription, with consequent increased risk of drug-drug interactions and adverse drug reactions. In the last years several products derived from plants have been developed with the aim of treating insomnia with lower risk of side effects. Despite several studies have been performed with this aim, the available evidence is inconclusive, and reviews summarizing the most recent evidences on the effectiveness of plant-derived products in treating insomnia are lacking.This narrative review aims at summarizing the evidences of the mechanism of action, effectiveness and safety of the most commonly used plant-derived products for the treatment of sleep disorders (Valerian, Lemon balm, Passionflower, Chamomile, Hops, and Jujube).

Plant Extracts for Sleep Disturbances: A Systematic Review

Background

Sleep complaints are common health issues in the general population. These conditions are associated with poorer physical and psychological activity, and they may have important social, economic, and personal consequences. In the last years, several food supplements with different plant extracts have been developed and are currently taken for improving sleep. Study Objectives. The aim of this study is to systematically review recent literature on oral plant extracts acting on sleep disorders distinguishing their action on the different symptoms of sleep complaints: difficulty in initiating or maintaining sleep, waking up too early, and quality of sleep.

Methods

We searched the PubMed database up to 05/03/2020 based on data from randomized, double-blind, placebo-controlled trials, noncontrolled trials, and cohort studies conducted in children and adult subjects. The search words used contained the following terms: oral food supplement and sleep disorders and the like. The most studied compounds were further analyzed with a second search using the following terms: name of the compound and sleep disorders. We selected 7 emerging compounds and 38 relevant reports.

Results

Although nutraceutical natural products have been used for sleep empirically, there is a scarcity of evidence on the efficacy of each product in clinical studies. Valerian and lavender were the most frequently studied plant extracts, and their use has been associated (with conflicting results) with anxiolytic effects and improvements in quality and duration of sleep.

Conclusions

Sleep aids based on plant extracts are generally safe and well tolerated by the population. More high-quality research is needed to confirm the effectiveness of food supplements containing plant extracts in sleep complaints; in particular, it would be interesting to evaluate the association between plant extracts and sleep hygiene guidelines and to identify the optimal products to be used in a specific symptom of sleep complaint, giving more appropriate tools to the medical doctor.

Rice bran extract supplement improves sleep efficiency and sleep onset in adults with sleep disturbance: A randomized, double-blind, placebo-controlled, polysomnographic study

We previously reported that rice bran extract supplement (RBS) administration to mice decreased sleep latency and induced non-rapid eye movement (NREM) sleep via inhibition of the histamine H₁ receptor. Based on this, we performed the first clinical trial to investigate whether RBS would be beneficial to subjects with disturbed sleep. We performed a randomized, double‐blinded, placebo‐controlled, 2-week study. Fifty subjects with sleep disturbance were enrolled and received either RBS (1,000 mg/day) or placebo. Polysomnography was performed, and Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale (ESS), and Fatigue Severity Scale were administered at the initiation and termination of the study. Compared with the placebo, RBS led to significant polysomnographic changes, including decreased sleep latency (adjusted, P = 0.047), increased total sleep time (P = 0.019), and improved sleep efficiency (P = 0.010). Additionally, the amount of stage 2 sleep significantly increased in the RBS group. When adjusted for caffeine intake, wakefulness after sleep onset, total wake time, and delta activity tended to decrease in the RBS group. RBS administration decreased ESS scores. There were no reported serious adverse events in both groups. RBS improved sleep in adults with sleep disturbance. Trial registration: WHO ICTRP, KCT0001893.

Do recent research studies validate the medicinal plants used in British Columbia, Canada for pet diseases and wild animals taken into temporary care?

ETHNOPHARMACOLOGICAL RELEVANCE

There are insufficient safe and effective treatments for chronic pain in pets. In cases such as osteoarthritis there is no commercially available cure and veterinarians use NSAIDs to manage pain. Pet owners may have to plan for a lifetime of plant-based treatment for the conditions that lead to chronic pain in pets. Phytopharmacotherapies have the advantage of being less toxic, cheap or free, readily available, are more likely to be safe for long-term use and have the potential to reset the immune system to normal functioning.

AIM OF THE STUDY

To examine the recently published medicinal plant research that matches unpublished data on ethnoveterinary medicines (EVM) used for pets in Canada (British Columbia) to see if the EVM data can provide a lead to the development of necessary drugs.

MATERIALS AND METHODS

In 2003 semi-structured interviews were conducted with 60 participants who were organic farmers or holisitic medicinal/veterinary practitioners obtained using a purposive sample. A draft manual prepared from the data was then evaluated by participants at a participatory workshop that discussed the plant-based treatments. A copy of the final version of the manual was given to all research participants. In 2018, the recently published research matching the EVM data was reviewed to see if the EVM practices could serve as a lead for further research.

RESULTS AND CONCLUSION

Medicinal plants are used to treat a range of conditions. The injuries treated in pets in British Columbia included abscesses (resulting from an initial injury), sprains and abrasions. Dogs were also treated with medicinal plants for rheumatoid arthritis, joint pain and articular cartilage injuries. More than 40 plants were used. Anal gland problems were treated with Allium sativum L., Aloe vera L., Calendula officinalis L., Plantago major L., Ulmus fulva Michx., Urtica dioica L. and Usnea longissima Ach. Arctium lappa, Hydrangea arborescens and Lactuca muralis were used for rheumatoid arthritis and joint pain in pets. Asthma was treated with: Linum usitatissimum L., Borago officinalis L., Verbascum thapsus L., Cucurbita pepo L., Lobelia inflata L., and Zingiber officinale Roscoe. Pets with heart problems were treated with Crataegus oxyacantha L., Cedronella canariensis (L.) Willd. ex Webb & Berth, Equisetum palustre L., Cypripedium calceolus L., Pinus ponderosa Douglas ex Lawson, Humulus lupulus L., Valeriana officinalis L., Lobelia inflata L., Stachys officinalis (L.) Trev., and Viscum album L. The following plants were used for epilepsy, motion sickness and anxiety- Avena sativa L., Valeriana officinalis, Lactuca muralis (L.) Fresen., Scutellaria lateriflora L., Satureja hortensis L., and Passiflora incarnata L. Plants used for cancer treatment included Phytolacca decandra, Ganoderma lucidum, Lentinula edodes, Rumex acetosella, Arctium lappa, Ulmus fulva, Rheum palmatum, Frangula purshiana, Zingiber officinale, Glycyrrhiza glabra, Ulmus fulva, Althea officinalis, Rheum palmatum, Rumex crispus and Plantago psyllium. Trifolium pratense was used for tumours in the prostate gland. Also used were Artemisia annua, Taraxacum officinale and Rumex crispus. This review of plants used in EVM was possible because phytotherapy research of the plants described in this paper has continued because few new pharmaceutical drugs have been developed for chronic pain and because treatments like glucocorticoid therapy do not heal. Phytotherapuetic products are also being investigated to address the overuse of antibiotics. There have also been recent studies conducted on plant-based functional foods and health supplements for pets, however there are still gaps in the knowledge base for the plants Stillingia sylvatica, Verbascum thapsus, Yucca schidigera and Iris versicolor and these need further investigation.

A combination of Eschscholtzia californica Cham. and Valeriana officinalis L. extracts for adjustment insomnia: A prospective observational study

Eschscholtzia californica Cham. and Valeriana officinalis L. have long been used for the management of sleep disorders and anxiety. Use of a fixed combination of these two plant extracts (Phytostandard® d’Eschscholtzia et de Valériane, PiLeJe Laboratoire, France) was investigated in an observational study. Adults with adjustment insomnia according to the criteria of the International Classification of Sleep Disorders and with an insomnia severity index (ISI) score >7 enrolled by GPs took a maximum of four tablets of the eschscholtzia and valerian combination every night for four weeks. Within one month, ISI score decreased by approximately 30% (from 16.09 ± 3.67 at inclusion (V1) to 11.32 ± 4.78 at 4 weeks (V2); p < 0.0001). Night sleep duration significantly increased between the first and the fourth week of supplement intake, sleep efficiency increasing from 78.4% ± 12.5 to 84.6% ± 10.2 (p = 0.002). There was no improvement in sleep latency. The number of awakenings decreased by approximately 25% and their total duration by approximately 25 min. Anxiety score significantly decreased by 50% from 13.9 ± 7.3 at V1 to 6.7 ± 6.3 at V2 (p < 0.0001). The supplement was well tolerated. These results suggest that the tested combination of eschscholtzia and valerian extracts could be beneficial for the management of insomnia in adults and deserves further investigation.

Exploring the Effect of Lactium™ and Zizyphus Complex on Sleep Quality: A Double-Blind, Randomized Placebo-Controlled Trial

Acute, non-clinical insomnia is not uncommon. Sufferers commonly turn to short-term use of herbal supplements to alleviate the symptoms. This placebo-controlled, double-blind study investigated the efficacy of LZComplex3 (lactium™, Zizyphus, Humulus lupulus, magnesium and vitamin B6), in otherwise healthy adults with mild insomnia. After a 7-day single-blind placebo run-in, eligible volunteers (n = 171) were randomized (1:1) to receive daily treatment for 2 weeks with LZComplex3 or placebo. Results revealed that sleep quality measured by change in Pittsburgh Sleep Quality Index (PSQI) score improved in both the LZComplex3 and placebo groups. There were no significant between group differences between baseline and endpoint on the primary outcome. The majority of secondary outcomes, which included daytime functioning and physical fatigue, mood and anxiety, cognitive performance, and stress reactivity, showed similar improvements in the LZComplex3 and placebo groups. A similar proportion of participants reported adverse events (AEs) in both groups, with two of four treatment-related AEs in the LZComplex3 group resulting in permanent discontinuation. It currently cannot be concluded that administration of LZComplex3 for 2 weeks improves sleep quality, however, a marked placebo response (despite placebo run-in) and/or short duration of treatment may have masked a potential beneficial effect on sleep quality.

Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline

INTRODUCTION

The purpose of this guideline is to establish clinical practice recommendations for the pharmacologic treatment of chronic insomnia in adults, when such treatment is clinically indicated. Unlike previous meta-analyses, which focused on broad classes of drugs, this guideline focuses on individual drugs commonly used to treat insomnia. It includes drugs that are FDA-approved for the treatment of insomnia, as well as several drugs commonly used to treat insomnia without an FDA indication for this condition. This guideline should be used in conjunction with other AASM guidelines on the evaluation and treatment of chronic insomnia in adults.

METHODS

The American Academy of Sleep Medicine commissioned a task force of four experts in sleep medicine. A systematic review was conducted to identify randomized controlled trials, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and harms, and patient values and preferences. Literature reviews are provided for those pharmacologic agents for which sufficient evidence was available to establish recommendations. The AASM Board of Directors approved the final recommendations.

RECOMMENDATIONS

The following recommendations are intended as a guideline for clinicians in choosing a specific pharmacological agent for treatment of chronic insomnia in adults, when such treatment is indicated. Under GRADE, a STRONG recommendation is one that clinicians should, under most circumstances, follow. A WEAK recommendation reflects a lower degree of certainty in the outcome and appropriateness of the patient-care strategy for all patients, but should not be construed as an indication of ineffectiveness. GRADE recommendation strengths do not refer to the magnitude of treatment effects in a particular patient, but rather, to the strength of evidence in published data. Downgrading the quality of evidence for these treatments is predictable in GRADE, due to the funding source for most pharmacological clinical trials and the attendant risk of publication bias; the relatively small number of eligible trials for each individual agent; and the observed heterogeneity in the data. The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources. We suggest that clinicians use suvorexant as a treatment for sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use eszopiclone as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use zaleplon as a treatment for sleep onset insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use zolpidem as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use triazolam as a treatment for sleep onset insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use temazepam as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use ramelteon as a treatment for sleep onset insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use doxepin as a treatment for sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use trazodone as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use tiagabine as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use diphenhydramine as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use melatonin as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use tryptophan as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use valerian as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK).

Plants, people and traditions: ethnobotanical survey in the Lombard Stelvio National Park and neighbouring areas (Central Alps, Italy)

ETHNOPHARMACOLOGICAL RELEVANCE

The value of ethnobotanical information is now increasingly acknowledged. Our investigation added new data to the traditional knowledge on the plant uses in Italian alpine areas, where only in recent years the awareness of losing such valuable heritage stimulated interest of the scientific community and land managers in its recovery and enhancement. To this end, the present study aimed to collect and analyse information on plant species employed in Northern Italy (Lombardy Region), particularly in Alta Valtellina, an area of high naturalistic interest, where ethnobotanical knowledge is at the risk of passing covering a secondary role compared to other aspects of the local culture.

MATERIALS AND METHODS

A total of 328 people from six municipalities were interviewed using semi-structured questionnaires. Data were evaluated by quantitative parameters such as ethnobotanicity and ethnophytonomic indices, factor informant consensus (Fic), fidelity level (Fl). Abandoned and current uses were compared. Herbarium materials were prepared and conserved.

RESULTS

Inhabitants of Alta Valtellina used 212 plant species, including 19 mushrooms and 1 lichen for medicinal, food and cosmetic purposes. Despite half of medicinal uses has fallen into disuse, the plant species of this category were still collected in largest number. Digestive, respiratory and skin systems were the most frequently treated. Fic and Fl values, in addition to simple percentage data confirmed this finding. Although 40% of the known uses is now abandoned, a considerable number of them was recorded for the first time in an alpine area.

CONCLUSIONS

The study revealed that the popular knowledge of plant species is still alive in the Alta Valtellina. The prerogatives of some species are now outdated, but they leave room for other uses of the plant resources that may provide new opportunities from the scientific, cultural and economic points of view.

Updates on Nutraceutical Sleep Therapeutics and Investigational Research

Approximately 50% of the population will suffer from a sleep disorder over the course of their lifetime. There is increasing interest in nutraceuticals for these conditions. The quality of the evidence for the safety and effectiveness of using these supplements to treat sleep disorders varies substantially. In this review, we discuss the data about the effectiveness and safety of six commonly used plant-based sleep therapeutics: caffeine, chamomile, cherries, kava kava, L-tryptophan, marijuana, and valerian. We explore both historical uses of each substance and the current state of the literature.

Herbal hepatotoxicity: current status, examples, and challenges

INTRODUCTION

Herbal medicines have commonly been considered safe by the general public due to their natural origin and long history of traditional uses. In contrast to this belief, many plants produce toxic substances as secondary metabolites that are sometimes not easily distinguishable from the pharmacological active compounds. Some herbal medicines have been associated with adverse effects and toxic effects, including hepatotoxicity, which have been reversed upon discontinuation of the herbal medicine by the patient.

AREAS COVERED

This review reflects on selected herbal medicines that are associated with hepatotoxic effects including a description of the phytochemicals that have been linked to liver injury where available. Although case studies are discussed where patients presented with hepatotoxicity due to use of herbal medicines, results from both in vitro and in vivo studies that have been undertaken to confirm liver injury are also included.

EXPERT OPINION

Increasing evidence of herbal hepatotoxicity has become available through case reports; however, several factors contribute to challenges associated with causality assessment and pre-emptive testing as well as diagnosis of herb-induced liver injury.

Efficacy of Viola odorata in Treatment of Chronic Insomnia

Background:

Insomnia is the most common sleep disorder that reduces quality of life.

Objectives:

Due to side effects of hypnotic drug and the increasing demand for alternative medicine substitutes, violet oil (VO) was used in this study. VO is a known medication in Iranian traditional medicine that induces sleep in insomniac patients.

Patients and Methods:

This study was conducted as an experimental pretest-posttest evaluation on VO efficacy in 50 patients with chronic insomnia in Iranian Traditional Medicine Clinic of Mashhad University of Medical Sciences, Mashhad, Iran. Treatment consisted of intranasal drop of VO, two drops containing 66 mg of VO in each nostril nightly before sleeping for one month. All patients were asked to complete an Insomnia Severity Index (ISI) questionnaire before the start of the trial and after one month of treatment.

Results:

Improvements in sleep and ISI scores were significantly greater in patients after a month receiving VO drop in comparison with before starting treatment (P < 0.05). A few patients reported some complications about VO consumption, most of which were mild and no serious adverse event was encountered.

Conclusions:

VO can be presented as a safe, well-tolerated, and effective herbal preparation in patients with chronic insomnia.