Let’s say you have trouble sleeping. You want to avoid prescription and even over-the-counter sleep drugs, which can be habit-forming and have bad side effects. You’re leaning toward a safer, natural alternative…possibly melatonin.

You’re wondering, What’s the best sleep supplement?

But that’s the wrong question.

Here’s the right one—What’s the best supplement to help me with my specific sleep problem?

To get answers, we spoke with Laurie Steelsmith, ND, LAc, a licensed naturopathic physician and acupuncturist in private practice in Honolulu. “There are lots of herbs and supplements to choose from that can help with sleep problems,” she said. “In my experience, some work better for certain situations than others. In fact, melatonin, the most popular sleep supplement, is usually not the best choice.” (We explain why below.)

She also has recommendations for lifestyle changes that may help with each specific situation. For most of her patients, these lifestyle changes—and, if needed, specific herbs and supplements tailored to their particular situations—can help restore good sleep. One caveat: “If you have a chronic medical condition or take any kind of medication, check with your doctor before taking supplements.”

Here’s what Dr. Steelsmith advises patients in her own practice….

IF YOU HAVE…TROUBLE FALLING ASLEEP

“This is usually due to a busy mind, anxious thoughts and high levels of the stress hormone cortisol in the evening, when it should be low,” said Dr. Steelsmith. Before taking supplements, do this for a week: Try a calming bath to unwind at night, or relaxation therapy such as meditation or listening to a guided imagery recording. Lower the lights, quiet the house, turn off all electronics. “If you’re still experiencing insomnia after a week, try taking one of the following supplements to help you drop more easily into sleep…and make sure you continue with the lifestyle changes.”

• This supplement, usually derived from cabbage or soy, decreases cortisol at night. “Phosphatidylserine can help optimize your reaction to stress and support the proper release of cortisol,” Dr. Steelsmith explained. She recommends a product called Seriphos—she’s been doing so for 23 years with good results—that contains 90 mg of phosphatidylserine. “Start with one pill an hour or two before bedtime taken with a small high-protein snack (such as a cracker with almond butter) for better absorption and to prevent stomach upset. If you tolerate it well and you need more support, take two pills. You can take up to two pills before bed and two in the middle of the night if you’re waking up.” Side effects are rare—occasionally, you might feel a little sleepy the next day, and very rarely, a paradoxical feeling of being more awake at bedtime. Avoid phosphatidylserine if you have kidney problems.

• Valerian root and GABA. Valerian root (an herb) and GABA (gamma-aminobutyric acid, an amino acid supplement) help to calm the nervous system. “They both bind to GABA receptors in the brain and can be taken alone or together,” said Dr. Steelsmith. The recommended dose of valerian root is 300 mg to 500 mg of a standardized extract of 0.5% essential oils taken one hour before bedtime. The recommended dose of GABA is 250 mg to 1,000 mg taken one hour before bed. “Start with GABA first to see if you get the desired effect,” she said. “I usually start patients with 250 mg at night, and increase the dose to up to 1,000 mg if necessary,” she said. (GABA can cause serious cardiovascular side effects and nightmares in very large doses—10,000 mg—and should be avoided entirely by pregnant and lactating women.) Valerian root is safe and effective for most people but side effects can occur such as headaches, insomnia, excitability and a feeling of uneasiness. “If falling asleep is still a huge effort, take both at the same time. It’s safe to take valerian root (up to 500 mg at night) and GABA (250 mg to 500 mg at night) for up to three months—while working on the underlying causes of your insomnia.”

IF YOU HAVE…TROUBLE STAYING ASLEEP

“Nighttime wakening can be one of the most difficult-to-treat sleep conditions,” said Dr. Steelsmith. One lifestyle tip: Make sure you’re eating adequate calories for dinner. “Skipping dinner causes your blood sugar level to drop, which increases cortisol in your body and can wake you up,” Dr. Steelsmith explained. “Eating a solid, healthful dinner that contains all three macronutrients—protein, fat and carbohydrate—can mitigate this.”

5-HTP. Another common culprit is too little serotonin. “This neurotransmitter makes us feel happier, calmer and more balanced and plays an important role in sleep,” Dr. Steelsmith said. To boost serotonin, she often prescribes 5-HTP. This supplement is the active form of tryptophan, an amino acid that your body needs to make serotonin. It’s often used to help people who are depressed, a condition that can be characterized by low serotonin levels. But your levels can be lower than ideal even if you aren’t experiencing depression—and if so “5-HTP supplements can help you stay asleep,” Dr. Steelsmith said. “Start with 100 mg taken at least one hour before bed, and gradually increase to 300 mg if you need it.” At these doses, side effects are rare—but don’t take this supplement if you are taking a prescription antidepressant (such as an SSRI) that also increases serotonin levels.

IF MENOPAUSAL SYMPTOMS ARE WAKING YOU UP…

Women who are in the menopausal transition (perimenopause) often have sleep problems due to hormonal fluctuations. First step: Get your hormone levels assessed to see if your estrogen is too high and progesterone too low, or if both hormones are low. If progesterone is low, chaste tree berry (see below) can balance levels, “but sometimes bioidentical hormones can help, too,” Dr. Steelsmith explained. She starts with bioidentical progesterone, and if that isn’t enough, may prescribe an estrogen cream to apply to the vagina or vulva. (For more on this topic, see Bottom Line’s video, “Bioidentical Hormones.”)

• Chaste tree berry. For women in perimenopause, this herb can help to naturally increase waning progesterone levels. “Progesterone is a calming hormone and can help even out a woman’s fluctuating hormonal levels through its action on the pituitary gland,” Dr. Steelsmith explained. It has been shown to help support healthy ovulation, which is essential for supporting progesterone levels, even during perimenopause.” She recommends the product Asensia, a chaste tree berry–containing product that contains other ingredients, including L-arginine and green tea extract, which in combination help the chaste tree berry be better utilized by your body. “It is very safe to use,” she said. “It can be used long-term, but I recommend up to one year.”

• Especially for night sweats. “Asensia can help in women who are waning in progesterone,” said Dr. Steelsmith, “and I have also found that Seriphos works great for insomnia associated with night sweats. I know, I have them!”

• Got to pee? Try to get up and do your business without turning on the lights or peeking at the clock. “But if every night you’re being wakened about the same time, you could try taking a drop of a homeopathic sleep remedy such as Quietude by Boiron. It contains homeopathic doses of hyoscyamus niger, nux moschata, passiflora incarnata and stramonium. The tablets can be placed under the tongue and allowed to dissolve while you drift off to sleep.”

IF YOU HAVE JET LAG OR WORK THE NIGHT SHIFT

If you’ve crossed a few time zones or regularly work through the night, you know that it throws off your circadian rhythm, making it hard to get back into a regular sleep pattern. Expose yourself to sunlight, especially morning sunlight, when you can, which will help regulate your internal clock. A few specific tips…

• For jet lag, before your trip, wake up and go to sleep earlier several days before a trip heading east…go to sleep later for a westward trip…and when you get to your destination, make yourself get up in the morning and work out.

• For shift work, you’ll sleep better and be more awake on the job if you stick to the same sleep and wake schedule every day, even on days you’re not working.

If these approaches don’t work for you, consider…

Melatonin. “A lot of people think they should pop melatonin whenever they have trouble sleeping,” said Dr. Steelsmith, “but it’s really only best for resetting a body clock that has been thrown off by shifting time zones or shift work.” A typical dose is 3 mg under the tongue to be taken within one hour of when you want to fall asleep. “For jet lag, you can use it for a few nights to settle into a new time zone…or it can be used longer by people who have night shifts. It’s often used long term for men and women who change their day/night sleep cycle frequently—such as doctors and nurses.” Side effects can include headache, short-term depression, daytime sleepiness, dizziness, cramps and irritability. “Some people are very sensitive to melatonin, and even a typical 3-mg dose may be too much for them—I recommend patients start with a 1-mg dose and slowly increase to 3-mg if they tolerate it well. I would not prescribe it to children or to young women who want to get pregnant. Because melatonin levels tend to naturally drop as people get older, I am most apt to prescribe it to patients older than 50.”

NOURISH YOUR CALM

“All these strategies can help you feel rested and restored,” said Dr. Steelsmith, “but to truly improve sleep, I believe that you need to take stock of how your energies are being spent—and adjust your lifestyle so that you nourish a calm nervous system. This alone will do wonders for people who are having trouble sleeping.”

After all, you can’t expect to be mentally overstimulated all day and then have your mind turn off at night like a switch. Exercise is also key—it “discharges stress and tension, and encourages sound sleep.” She recommends getting regular physical exercise but avoiding exercising in the three hours before bedtime, when it could rev you up. For more tips on sleep, see Bottom Line’s “Guide to Better Sleep—No Sleeping Pills Needed.”

Finally…as a last resort, Dr. Steelsmith occasionally recommends prescription sleep aides. “I think there is a time and place for them. I have recommended them to patients who had intractable insomnia.” Some patients need these only occasionally, but others stay on these long term. She prefers drugs such as Benadryl, which allows a person to wake up, rather than others such as Ambien, “which could put a person into a trancelike state where they don’t remember what they’ve done if they get up in the middle of the night.”