Ashwagandha for Stress Relief and Sleep Improvement
Ashwagandha (Withania somnifera) appears safe for short-term use and shows modest efficacy for improving sleep and reducing anxiety, but it is not recommended as a first-line treatment for chronic insomnia according to established sleep medicine guidelines.
Guideline-Based Treatment Hierarchy
Current clinical practice guidelines do not recommend herbal supplements, including ashwagandha, as first-line therapy for insomnia:
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia in adults, demonstrating superior long-term efficacy compared to pharmacological options 1, 2.
Herbal supplements are explicitly not recommended for chronic insomnia due to limited efficacy and safety data. The American Academy of Sleep Medicine states that "over-the-counter antihistamines or herbal supplements, such as valerian and melatonin, are not recommended for chronic insomnia" 1, 3.
Long-term use of non-prescription treatments is not recommended, as efficacy and safety data for most over-the-counter insomnia medications is limited to short-term studies 4.
Evidence for Ashwagandha's Effects
Despite guideline recommendations against herbal supplements, recent research has examined ashwagandha specifically:
Sleep Improvement
- A 2021 meta-analysis of 5 randomized controlled trials (n=400) found ashwagandha extract showed a small but significant effect on overall sleep (Standardized Mean Difference -0.59) 5.
- Effects were more prominent in adults diagnosed with insomnia, at dosages ≥600 mg/day, and with treatment duration ≥8 weeks 5.
- A 2019 double-blind RCT (n=60) found 300 mg twice daily for 10 weeks significantly improved sleep onset latency (p<0.019), sleep efficiency, and sleep quality (p<0.002) compared to placebo 6.
Stress and Anxiety Reduction
- Clinical trials demonstrated reasonable efficacy in chronic stress (2 studies), anxiety (1 study), and as an adaptogenic agent (3 studies) 7.
- The 2021 meta-analysis found ashwagandha improved mental alertness on rising and anxiety levels 5.
Safety Profile
General Safety
- No serious adverse events or changes in hematological, biochemical, or vital parameters were reported in 30 human clinical trials reviewed 7.
- Most common adverse events (>5%) were mild and transient: somnolence, epigastric pain/discomfort, and loose stools 7.
- Less common adverse events included giddiness, drowsiness, vertigo, nasal congestion, decreased appetite, nausea, constipation, and skin rash 7.
Drug Interaction Risk
- Ashwagandha has sedative properties independent of anesthesia and can potentially enhance sedative effects of prescribed medications 4.
- A 2025 study found no reversible inhibition of major cytochrome P450 enzymes (CYP1A2, CYP2A6, CYP2C8, CYP2C9, CYP2D6, CYP3A4/5, CYP2B6) at concentrations up to 100 μg/mL, suggesting low risk for pharmacokinetic drug interactions 8.
Perioperative Considerations
- The Society for Perioperative Assessment and Quality Improvement does not provide specific recommendations for ashwagandha cessation before surgery, though sedative herbs are generally held perioperatively 4.
- Given its sedative properties, caution is warranted when combining ashwagandha with CNS depressants, alcohol, or other sedatives 4.
Clinical Recommendations
When Ashwagandha May Be Considered
- Only after CBT-I has been attempted or deemed inappropriate 1, 2.
- For short-term use (8-10 weeks maximum based on available trial data) 6, 5.
- At dosages of 300-600 mg daily, preferably divided into twice-daily dosing 6, 5.
- In patients seeking alternatives to prescription medications who understand the limited evidence base.
Important Caveats
- Data on long-term safety are limited, and more safety data are needed to assess whether ashwagandha is safe for extended use 5.
- Ashwagandha should not replace evidence-based treatments (CBT-I or FDA-approved medications when appropriate) 1, 2.
- Patients should be counseled about the modest effect size compared to established treatments 5.
- Avoid during pregnancy or nursing, as safety has not been established 4.
- Use caution in patients with depression, compromised respiratory function, or hepatic/cardiac conditions 4.
- Discontinue if combining with prescription sedatives, hypnotics, or undergoing surgery 4.