Herbal and Dietary Supplements for Treatment of Anxiety Disorders SY ATEZAZ SAEED, MD, RICHARD M

COMPLEMENTARY AND ALTERNATIVE MEDICINE Herbal and Dietary Supplements for Treatment of Anxiety Disorders SY ATEZAZ SAEED, MD, RICHARD M. BLOCH, PhD, and DIANA J. ANTONACCI, MD East Carolina University, Greenville, North Carolina Use of complementary and alternative medicine has increased over the past decade. A variety of studies have suggested that this use is greater in persons with symptoms or diagnoses of anxiety and depression. Data support the effectiveness of some popular herbal remedies and dietary supplements; in some of these products, particularly kava, the potential for benefit seems greater than that for harm with short-term use in patients with mild to moderate anxiety. Inositol has been found to have modest effects in patients with panic disorder or obsessive-compulsive disorder. Physicians should not encourage the use of St. John’s wort, valerian, Sympathyl, or passionflower for the treatment of anxiety based on small or inconsistent effects in small studies. Although the evidence varies depending on the supplement and the anxiety disorder, physicians can collaborate with patients in developing dietary supplement strategies that minimize risks and maximize benefits. (Am Fam Physician 2007;76:549-56. Copyright © 2007 American Academy of Family Physicians.) se of complementary and alter- By doing so, they can avoid an overly dismis- native medicine in all of its sive attitude that discourages patients from varieties, such as herbal rem- disclosing their supplement use. At the same edies and dietary supplements, time, understanding the limits of avail- U increased from 34 percent of the overall U.S. able evidence allows physicians to collabo- population in 1990 to 42 percent in 1997.1 rate with interested patients in developing Use appears to be twice as great in persons dietary supplement strategies that minimize reporting anxiety and depression than in risks and maximize benefits. those reporting any other problem, except In this article, the supplements purported for back and neck pain.1 Based on results of to ameliorate anxiety disorders are divided two large-scale community surveys,2,3 inves- into three groups: herbal supplements, tigators have noted an association between nutritional supplements, and neurotrans- both panic disorder and major depression mitter and hormonal precursors. These divi- and the use of complementary and alterna- sions are somewhat arbitrary in that all of tive medicine. the products are taken orally, are available Currently, the preferred treatment for anx- over the counter, are marketed with a vari- iety disorders is cognitive behavior therapy ety of health claims on the Internet, and are and pharmacologic agents. Beta blockers or justified by their purported ultimate effects benzodiazepines are used for time-limited on the neurotransmitter systems that medi- and predictable anxiety disorders, whereas ate worry, stress, or fatigue symptoms in selective serotonin reuptake inhibitors patients with anxiety disorders. (SSRIs), selective serotonin-norepinephrine Information on supplements that claim reuptake inhibitors, tricyclic antidepres- to be useful or commonly used for anxiety sants, buspirone (Buspar), or monoamine disorders was obtained from several Inter- oxidase inhibitors are preferred for chronic net sites, particularly http://www.revolution or recurrent anxiety disorders. health.com/drugs-treatments, http://www. In recent years, studies using herbal rem- healthyplace.com/Communities/Anxiety/ edies and supplements to treat mild to mod- treatment/alternative_treatment.asp, and erate anxiety disorders have emerged. It is http:/www.naturaldatabase.com. Medline important for physicians to recognize that via Ovid was used to search for clinical supplements offer both benefits and risks. trials, guidelines, and meta-analyses that Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2007 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Herbs for Anxiety SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Comments Short-term use of kava is recommended for patients with A 4, 5 Cochrane systematic review of seven RCTs mild to moderate anxiety disorders who are not using (n = 380), with findings supported by five alcohol or taking other medicines metabolized by the lower-quality trials (n = 320); side effects liver, but who wish to use “natural” remedies. were rare and mild; same results with only extract WS1490 trials Use of inositol in a dosage of 12 to 18 g per day is a B 24, 25 Effectiveness similar to SSRI and better than treatment option for panic disorder. placebo for reducing intensity and frequency of panic attacks; side-effect profile comparable to SSRI; supported by two RCTs, although both were small Inositol, 12 to 18 g per day, may be used to treat B 26, 27 In trials of patients with treatment-resistant obsessive-compulsive disorder but not in combination OCD, inositol by itself was better than with SSRIs. placebo in reducing OCD symptoms26 but not in reducing anxiety scale scores; when added to SSRIs, inositol had no additional effect27 Physicians should not encourage the use of St. John’s B 16-23 Small, unreplicated trials with design flaws wort, valerian, Sympathyl, or passionflower for anxiety suggest some limited effectiveness based on small or inconsistent effects in small studies. Side-effect profiles are benign. All other nutritional supplements have no research evidence C — No evidence beyond testimonials, effects suggesting a positive effect on anxiety disorders. on nonclinical groups, or hypothetical Physicians should recommend other treatments. mechanisms of action RCT = randomized controlled trial; SSRI = selective serotonin reuptake inhibitor; OCD = obsessive-compulsive disorder. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 483 or http://www.aafp.org/afpsort.xml. Table 1. Supplements with Clinical Trial Evidence of Effectiveness or Noneffectiveness for Treating Anxiety Neurotransmitter/ Type of evidence Herbal supplements Nutritional supplements hormonal precursors Effectiveness based on meta- Kava — — analysis or multiple RCTs Effectiveness based on St. John’s wort (for somatoform Inositol, 18 g (one RCT for 5-hydroxytryptophan a single double-blind, disorders), sympathyl (California poppy, panic disorder and one RCT (serotonin precursor; placebo-controlled RCT hawthorn, elemental magnesium) for OCD) for panic disorder) Weak effectiveness based Passionflower, St. John’s wort (for GAD), — — on clinical/open trials valerian Clinical trials demonstrating Cannabis Omega-3 fatty acids (as adjunct — noneffectiveness for treatment-resistant OCD) Note: The preparations are listed in order from the most evidence of effectiveness to the least evidence. RCT = randomized controlled trial; OCD = obsessive-compulsive disorder; GAD = generalized anxiety disorder. tested or asserted the effectiveness of these anxiety. Only therapies with evidence of preparations in the treatment of patients effectiveness are discussed in this review. with diagnosed anxiety disorders. Table 1 Patients often justify the use of certain includes suggested supplements that have preparations on the basis of irrelevant or some evidence of effectiveness for treating misleading evidence; to help physicians 550 American Family Physician www.aafp.org/afp Volume 76, Number 4 ◆ August 15, 2007 Herbs for Anxiety recognize such preparations, those supple- phobias. The only effective trial ments with no clinical evidence of effective- involved patients with somato- Although valerian has been ness in reducing anxiety are presented in form disorder, although the widely used to treat anxi- Table 2. Clearly, the vast majority of supple- relationship between somato- ety, there is no evidence of ments with purported anxiolytic effects have form disorder and anxiety is an anxiolytic effect. no evidence of clinical benefit. complex. Much stronger evidence is needed before St. Herbal Supplements John’s wort should be considered a treat- KAVA ment option for patients with diagnosable There is substantial evidence that kava has anxiety disorders. a positive effect on the symptoms of anxiety disorders. Table 3 summarizes the evidence HAWTHORN AND CALIFORNIA POPPY on the effectiveness and safety of kava in A single French study exists of a combination patients with anxiety disorders.4-12 product called Sympathyl,22 which contains 20 Kava dramatically inhibits the cytochrome mg California poppy, 75 mg hawthorn, and 75 P450 enzyme used by the liver to metabo- mg elemental magnesium. According to the lize many medications, potentially altering study, Sympathyl had a very small but posi- the potency of these other medications.13,14 tive effect on anxiety. No clinical trials suggest Thus, it is important to be aware of the risk that any of the individual components reduce of drug interactions with kava. Other side anxiety in patients with anxiety disorders. effects reported with long-term use include a reversible skin rash or lesion and a yellow VALERIAN tint to the skin, but these reports have not Although valerian is often cited as hav- been

Load more