Tag: Anxiety

ADHD and useful Phytomedicines

On By philrasmIn Anxiety, Mental Health, Plant Medicine, StressLeave a comment

Introduction

ADHD (Attention deficit hyperactivity disorder) is a chronic neuro-behavioural condition characterised by a persistent pattern of inattention, hyperactivity and impulsiveness. It can disrupt education and social development of children and teenagers, and have a huge impact on a person’s life, yet is often undiagnosed.

The DSM (Diagnostic and Statistical Manual of Mental Disorders) describes three subtypes of ADHD. These include: ADHD-Inattentive type (ADHD-I), ADHD-Hyperactive/impulsive (ADHD-H), and ADHD-Combined type (ADHD-C). The presentation can change over time though, and a diagnosis provided at one specific time may differ from that provided at another time in a person’s life.

While reported rates of ADHD are higher than in the past, this is likely to be at least partially due to better recognition of the condition. It is a common condition among young children, and an estimated 50% of these retain ADHD symptoms for the rest of their lives. Research suggests around 5-8 percent of the population has ADHD but only 1-2 percent are diagnosed.  Diagnosis rates have historically been higher in boys than in girls, although rates are now thought to be similar for both genders.

Diagnosis of ADHD can be difficult and there is no diagnostic biological marker. Symptoms should have been present and persistent for a minimum of six months prior to the age of 12, are maladaptive, and cannot be explained by other psychiatric or medical disorders. However, often symptoms may not meet the criteria for a formal diagnosis of ADHD, despite causing significant issues in learning, social and family relationships.  

Symptoms

Impairing levels of inattention, disorganisazion, and/or hyperactivity-impulsivity, are key features of ADHD.  These symptoms are excessive for the age or development level.

In a classroom setting, children with ADHD will often tune out or appear to daydream. They can talk a lot, interrupt others and are unable to wait for their turn. Such children are frequently called out in class or a group or become known as the ‘class clown’, or the subject of bullying. These behaviours can exacerbate difficulties in ‘fitting in’ with peer groups or societal expectations.

While not an anxiety disorder as such, a large proportion of children with ADHD have coexisting psychiatric disorders, including but not limited to depression, bipolar disorder, autism spectrum disorders, eating disorders, and anxiety disorders (1). Adults with ADHD also often have an anxiety or substance use disorder, which can mask ADHD symptoms, sometimes for many years(2). Those with ADHD are also more likely to do dangerous and impulsive things.

Aetiology

Several potentially aetiological factors have been identified. ADHD has a significant familial and genetic predisposition, although the extent of the latter is somewhat contentious. Approximately 30% of children with epilepsy have ADHD .

Environmental contributions such as early childhood exposure to toxic heavy metals (especially lead) or phthalates, have received increased attention in recent years(3-7). Air pollution has also been associated with neurodevelopmental disorders including ADHD(8).

Other studies have associated ADHD with a higher prevalence of smoking, alcohol consumption, and excessive screen time among adolescents(9-11). Dysfunctions have been reported with BDNF (Brain derived neurotrophic factor) metabolism, dopaminergic neurotransmission, and with neurochemical parthways within the prefrontal cortex(12, 13).

However, these associations are complex, and to what extent they are aetiological versus outcome manifestations in those with ADHD, remains debatable.

Increasing greenness exposure or ‘nature medicine’, is likely to help protect against ADHD and other mental health conditions. A large New Zealand study has reported that children who always lived in a rural area after 2 years of age, were significantly less likely to develop ADHD(14 ).  Similar findings were reported in a German study, with residential greenness being protective, but air pollution being a risk factor(15).

Dietary factors may be contributory in some cases. Inattention was negatively correlated with fruit and vegetable consumption and a healthy dietary pattern, in a large population-based Swedish study (16). Some evidence suggests Vitamin D deficiency may be relevant to the pathogenesis of ADHD and autism, and supplementation with this as well as zinc and magnesium, both important cofactors in dopamine metabolism, may be useful(17, 18).

Treatments

The use of stimulant medications and particularly methylphenidate, is the usual treatment for ADHD. Methylphenidate is structurally similar to amphetamines, inhibits the reuptake of dopamine and noradrenaline, and leads to symptom improvement in around seventy percent of patients.  

Dexamphetamine is also occasionally used, as is its prodrug lisdexamfetamine. The selective noradrenaline reuptake inhibitors atomoxetine and viloxazine, are sometimes prescribed. These and alpha-2 adrenergic agonists guanfacine and clonidine, which stimulate noradrenergic neurotransmission in the prefrontal cortex, are occasionally used when stimulants or these drugs are not suitable or tolerated.

Reduced appetite, sleeping difficulties, nausea and abdominal pain are the most common adverse events to stimulant medication. Rare but serious adverse events can include cardiac problems, weight loss, mood fluctuations and psychotic disorders. These can cause concern as treatment can continue from childhood into adolescence and beyond.

Official guidelines discourage the use of medication in children under the age of six, although these are sometimes prescribed by a specialist in severe cases. ‘Off-label’ use of medicines in this age group, is increasingly common. However, few studies have taken place involving the use of ADHD drugs in very young children, and safety and efficacy data is generally lacking. 

Treatment programmes should also include psychological interventions such as counselling or psychotherapy, with patients’ and parents’ preferences and need for such treatment, always considered(19).  It is also often beneficial to not only treat a child, teenager or adult with ADHD, but also offer phytotherapy or other treatment support to their parents, partners or other family members. Adjunctive phytomedicines and sometimes lifestyle and dietary changes, can be very helpful.

Of note is that there are several disparities  in treatment guidelines and the selection and sequencing of various medications  in different countries. Danish guidelines for instance, do not recommend methylphenidate, lisdexamfetamine or atomoxetine as first line treatment options, while German guidelines provide specific drug recommendations tailored to individual comorbidities (1). A greater emphasis on psychotherapy, school and parental support systems and a higher bar before methylphenidate medication is trialed, is applied in some jurisdictions, particularly those where health care expenditure per capita is higher.

Some Useful Phytomedicines

An individualised treatment protocol incorporating plant medicines can offer much to ADHD patients. They can also help children who are resistant to stimulant medications, or those who wish to not take these medicines, or to keep drug dosage needs as low as possible.

Treatment selection depends on the particular type of ADHD, its symptomatology, and of course individual patient needs and wishes.  Given the diverse presentation of ADHD, a range of phytomedicines should be considered. An individualised but ‘trial and error’ approach is recommended, but desirable actions can include neuroprotection, cognition enhancement, anxiolytic and stimulant properties. Any use of other medications or presence of other health conditions should be taken into account.  Addressing other co –existing mental or physical health issues, can in itself often produce significant benefits, and sometimes avoid the need for additional drug-based interventions.

Where restlessness or accompanying anxiety are part of the symptomatology, anxiolytic and relaxant phytomedicines can be useful.  They include Bacopa, Chamomile, Holy basil, Kava, Lavender, Lemon balm, Skullcap, Passionflower, Skullcap, Valerian, Withania and more(20).  Many of these (Ginkgo, Bacopa, Lemon Balm, Valerian, Withania) also have neuroprotective activities and when used appropriately, can help improve cognition and learning outcomes.

Leaves of the Indian plant Bacopa (Bacopa monniera) have been used for anxiolytic and memory enhancing purposes for centuries. As with Ginkgo and Lemon Balm, it is neuroprotective and may help with cognition and attention deficit disorders. It is frequently used in the management of ADHD and autism in children and teenagers.

A recent 14 week Australian clinical trial into Bacopa’s effects in boys with ADHD aged 6-14, found no significant behavioural improvement. However, improvements occurred in their sleep routine and in cognitive flexibility and interpersonal problems(21).  Reduced symptoms of restlessness and improvement in self control, were reported in a smaller open label study in children with ADHD(22).  It is safe in children, although as a liquid its bitter taste can be an issue, particularly as dosage needs tend to be quite high.

Ginkgo (Ginkgo biloba) can be helpful in ADHD or for cognitive deficits in children, and combines very well with other psychoactive phytomedicines such as St Johns wort and anxiolytics. It is also hepatoprotective, and can be helpful when concomitant drug medications which can cause liver or kidney damage, are being taken.

Lemon balm (Melissa officinalis) is another generally safe anxiolytic, and like chamomile is indicated particularly where gastrointestinal upsets or eating disorders are associated with feelings of anxiety(23).  It can also help with cognition in teenagers, though large doses are generally required.

The Chinese medicinal herb Rehmannia (Rehmannia glutinosa) was reported to reduce impulsive and spontaneous behaviour and ameliorate hippocampal neurodevelopmental abnormalities an a rat model of ADHD(24).

Passionflower (Passiflora incarnata), has been shown to help control anxiety in several studies involving adult patients(25) . A combination with St Johns wort and Valerian was reported to reduce nervous agitation in children aged between 6 and 12 years(26)  .  Potential benefits in ADHD and autism, have been reported(27, 28), although larger and better controlled clinical trials are needed.

Kava (Piper methysticum) also has a place in the management of ADHD in some children and adults. Its effectiveness in treating anxiety has been affirmed through several clinical trials and meta-analyses. It may also exhibit a mild antipsychotic effect and be helpful for children with OCD or autism.

Withania (Withania somnifera) is a useful allrounder when it comes to anxiety and stress-associated conditions. As with all adaptogens, it acts on multiple relevant sites of action, neurotransmitter and hormonal systems(29), and is often an effective component of the treatment of ADHD in both young and older people.

St Johns wort (Hypericum perforatum) is our best known clinically effective antidepressant, and I have used it successfully in many hundreds of patients, over the past thirty years. While beyond the scope of this article, concerns about its safety and interactions with other medications, are also often unjustified, this depending on the type of St Johns wort used, and its phytochemical profile(30).

ADHD is now recognised as a common neurodivergent condition, which if not well managed and treated can cause enormous emotional and mental suffering in children, teenagers, adults and their friends and families.

Summary

As with most chronic health conditions, early diagnosis and interventions which are natural and affordable and incorporate a selfcare approach, can produce huge benefits and avoid the need for more serious treatments later on.  While not denying the usefulness of drug medications such as methylphenidate and atomoxetine, it is concerning given the frequency at which these can cause adverse events, that they are being so widely prescribed and relied upon.

If the need for a long term drug prescription can be avoided or drug dosage requirements kept to a minimum through the concomitant use of more natural interventions, then this is a preferred approach. While there is a need for further and larger clinical trials involving phytomedicines in the treatment of ADHD, many medicinal plants exhibit pharmacological actions of benefit to those dealing with this condition, and treatment targeted for each person’s individual clinical presentation, can produce huge benefits.

References:

  1. Van Vyve L, Dierckx B, Lim CG, Danckaerts M, Koch BCP, Häge A, Banaschewski T. Pharmacotherapy for ADHD in children and adolescents: A summary and overview of different European guidelines. Eur J Pediatr. 2024 Mar;183(3):1047-1056. 
  2. Neurodivergence and substance use. Te Puna Whakaiti Pamamae Kai Whakapiri, New Zealand Drug Foundation, Sept 2024.https://drugfoundation.org.nz/articles/neurodivergence-and-substance-use
  3. Farmani R,. Exploring the link between toxic metal exposure and ADHD: a systematic review of lead and mercury. J Neurodev Disord. 2024;16(1):44. 
  4. Moore S, Paalanen L, Melymuk L, Katsonouri A, Kolossa-Gehring M, Tolonen H. The Association between ADHD and Environmental Chemicals-A Scoping Review. Int J Environ Res Public Health. 2022 Mar 1;19(5):2849.
  5. Oh J, Kim K, Kannan K, Parsons PJ, Mlodnicka A, Schmidt RJ, Schweitzer JB, Hertz-Picciotto I, Bennett DH. Early childhood exposure to environmental phenols and parabens, phthalates, organophosphate pesticides, and trace elements in association with attention deficit hyperactivity disorder (ADHD) symptoms in the CHARGE study. Environ Health. 2024 Mar 14;23(1):27. 
  6. Robinson DM, Edwards KL, Willoughby MT, Hamilton KR, Blair CB, Granger DA, Thomas EA. Increased risk of attention-deficit/hyperactivity disorder in adolescents with high salivary levels of copper, manganese, and zinc. Eur Child Adolesc Psychiatry. 2024 Sep;33(9):3091-3099
  7. Symeonides C, Aromataris E, Mulders Y, Dizon J, Stern C, Barker TH, Whitehorn A, Pollock D, Marin T, Dunlop S. An Umbrella Review of Meta-Analyses Evaluating Associations between Human Health and Exposure to Major Classes of Plastic-Associated Chemicals. Ann Glob Health. 2024 Aug 19;90(1):52.
  8. Compa M, Baumbach C, Kaczmarek-Majer K, Buczyłowska D, Gradys GO, Skotak K, Degórska A, Bratkowski J, Wierzba-Łukaszyk M, Mysak Y, Sitnik-Warchulska K, Lipowska M, Izydorczyk B, Grellier J, Asanowicz D, Markevych I, Szwed M. Air pollution and attention in Polish schoolchildren with and without ADHD. Sci Total Environ. 2023 Sep 20;892:164759.
  9. Meng Z, Ao B, Wang W, Niu T, Chen Y, Ma X, Huang Y. Relationships between screen time and childhood attention deficit hyperactivity disorder: a Mendelian randomization study. Front Psychiatry. 2024 Sep 23;15:1441191
  10. Namimi-Halevi C, Dor C, Dichtiar R, Bromberg M, Sinai T. Attention-deficit hyperactivity disorder is associated with risky and unhealthy behaviours among adolescents. Public Health. 2024 Sep 25;237:51-56.
  11. Thorell LB, Burén J, Ström Wiman J, Sandberg D, Nutley SB. Longitudinal associations between digital media use and ADHD symptoms in children and adolescents: a systematic literature review. Eur Child Adolesc Psychiatry. 2024 Aug;33(8):2503-2526.
  12. Ijomone OK et al. Dopaminergic Perturbation in the Aetiology of Neurodevelopmental Disorders. Mol Neurobiol. Published online August 7, 2024.
  13. Liu DY, Shen XM, Yuan FF, Guo OY, Zhong Y, Chen JG, Zhu LQ, Wu J. The Physiology of BDNF and Its Relationship with ADHD. Mol Neurobiol. 2015 Dec;52(3):1467-1476. 
  14. Donovan GH et al, Association between exposure to the natural environment, rurality, and attention-deficit hyperactivity disorder in children in New Zealand: a linkage study. The Lancet Planetary Health, 2019; 3 (5): e226-e234
  15. Markevych I, Tesch F, Datzmann T, Romanos M, Schmitt J,  Heinrich J. Outdoor air pollution, greenspace, and incidence of ADHD: a semi-individual study. Sci Total Environ, 2018; 642:1362-1368
  16. Li HH, Yue XJ, Wang CX, Feng JY, Wang B, Jia FY. Serum Levels of Vitamin A and Vitamin D and Their Association With Symptoms in Children With Attention Deficit Hyperactivity Disorder. Front Psychiatry. 2020 Nov 23;11:599958
  17. Hemamy M, Pahlavani N, Amanollahi A, Islam SMS, McVicar J, Askari G, Malekahmadi M. The effect of vitamin D and magnesium supplementation on the mental health status of attention-deficit hyperactive children: a randomized controlled trial. BMC Pediatr. 2021 Apr 17;21(1):178
  18. Lange KW, Lange KM, Nakamura Y, Reissmann A. Nutrition in the Management of ADHD: A Review of Recent Research. Curr Nutr Rep. 2023 Sep;12(3):383-394.
  19. Schatz NK, Fabiano GA, Cunningham CE, dosReis S, Waschbusch DA, Jerome S, Lupas K, Morris KL. Systematic Review of Patients’ and Parents’ Preferences for ADHD Treatment Options and Processes of Care. Patient. 2015 Dec;8(6):483-97.
  20. https://herbblurb.com/2017/02/03/why-herbs-should-be-the-first-choice-of-treatment-for-acute-anxiety/
  21. Kean JD, Downey LA, Sarris J, Kaufman J, Zangara A, Stough C. Effects of Bacopa monnieri (CDRI 08®) in a population of males exhibiting inattention and hyperactivity aged 6 to 14 years: A randomized, double-blind, placebo-controlled trial. Phytother Res. 2022;36(2):996-1012.
  22. Dave UP, Dingankar SR, Saxena VS, et al. An open-label study to elucidate the effects of standardized Bacopa monnieri extract in the management of symptoms of attention-deficit hyperactivity disorder in children. Adv Mind Body Med. 2014;28(2):10-15.
  23. https://herbblurb.com/2021/01/29/lemon-balm-a-true-tonic-for-stress/
  24. Sun R, Yuan H, Wang J, Zhu K, Xiong Y, Zheng Y, Ni X, Huang M. Rehmanniae Radix Preparata ameliorates behavioral deficits and hippocampal neurodevelopmental abnormalities in ADHD rat model. Front Neurosci. 2024 May 30;18:1402056.
  25. Janda K, Wojtkowska K, Jakubczyk K, Antoniewicz J, Skonieczna-Żydecka K. Passiflora incarnata in Neuropsychiatric Disorders-A Systematic Review. Nutrients. 2020;12(12):3894. 
  26. Trompetter I, Krick B, Weiss G. Herbal triplet in treatment of nervous agitation in children. Wien Med Wochenschr. 2013;163(3-4):52-57. 
  27. Amini F, Amini-Khoei H, Haratizadeh S, et al. Hydroalcoholic extract of Passiflora incarnata improves the autistic-like behavior and neuronal damage in a valproic acid-induced rat model of autism. J Tradit Complement Med. 2023;13(4):315-324.
  28. Golsorkhi H, Qorbani M, Sabbaghzadegan S, Dadmehr M. Herbal medicines in the treatment of children and adolescents with attention-deficit/hyperactivity disorder (ADHD): An updated systematic review of clinical trials. Avicenna J Phytomed. 2023;13(4):338-353.
  29. https://herbblurb.com/2017/02/03/why-herbs-should-be-the-first-choice-of-treatment-for-acute-anxiety/
  30. Rasmussen PL, St Johns Wort – Safety in Clinical Practice. Phytomed Webinar, available from Phytomed Medicinal Herbs Ltd, Auckland, New Zealand, February 2015

WITHANIA: A USEFUL ADJUNCT WITH ANTIPSYCHOTIC MEDICATIONS

On By HerbBlurbIn Anxiety, Herbal Medicine, insomnia, Plant Medicine, Stress, withania1 Comment

Antipsychotic drugs are strong medicines, and while they can successfully alleviate symptoms of psychosis and prevent relapse of schizophrenia and related conditions, like all drugs they are not without side effects.

There are two types of antipsychotics, older generation ones such as chlorpromazine or haloperidol developed in the 1960s, and so called ‘atypical’ antipsychotics such as olanzapine, clozapine and quetiapine developed in the 1990s, with a different side effect profile. While atypical newer generation antipsychotics are less likely than older generation ones to produce the extrapyramidal or Parkinson’s disease-like side effects, they can cause weight gain and precipitate or worsen metabolic syndrome or diabetes, and both types increase the risk of sudden cardiac death. Over-use and mis-use of antipsychotics is also of growing concern in the elderly(1).

Despite these risks, in a world in which the incidence and predominance of mental health conditions is rising, prescribing rates for antipsychotic drugs are increasing. Nearly seven million Americans take antipsychotic medications, and a recent study revealed a 49% rise in the use of anti-psychotic drugs by New Zealanders between 2008 and 2015. New Zealanders are now 60% more likely to be prescribed such drugs than Australians, with one in 36 New Zealand adults, or 2.81% of the population, being prescribed antipsychotic medication in 2015(2).

This recent New Zealand study also suggests that in a significant and probably increasing number of cases, these strong prescription-only drugs are being used to help with stress and associated sleep problems, rather than for their primary indication for conditions such as schizophrenia and bipolar disorders. Such ‘off label’ uses for prescription-only antipsychotics such as olanzapine, is something that has landed pharmaceutical companies in court in the U.S., in a number of prominent cases.

Herbal medicine offers an array of potential treatments for insomnia and stress-related conditions(3). One of the most suitable of these is Withania somnifera (Withania), known as Ashwagandha in India. The roots of Withania have a subtle but powerful nervous system and adrenal tonic action which insulates the nervous system from stress, enabling it to be better prepared to respond appropriately to the ‘fight or flight’ response. Many studies now support its applications for stress-associated anxiety conditions, including several human clinical trials(3).

Another possible application for Withania became apparent recently, through an American clinical trial where it was used as an adjunctive treatment alongside antipsychotic drug treatment in patients with schizophrenia(4). A total of 66 patients who had recently experienced an exacerbation of their schizophrenia symptoms, were given Withania or placebo alongside their usual antipsychotic drug medications, for a 12 week period. Outcomes were change from baseline to end of treatment on the “Positive and Negative Syndrome Scale” (PANSS), which measures total, positive, negative, and general symptoms of schizophrenia, and indices of stress and inflammation.

Patients given Withania were significantly more likely to achieve at least 20% improvements in PANSS negative, general, and total symptom scores, but not positive symptom scores, compared to those assigned to placebo. They also showed a significant improvement in stress scores compared to placebo. Additionally, only two of the Withania-treated subjects required an increase in their antipsychotic drug dosage, whereas nine of the placebo-assigned subjects either had their antipsychotic drug dosage increased or had a second antipsychotic drug added. These improvements were first noted at 4 weeks, and continued through the 12-week study period.

This is not the first time that Withania has been shown to be useful when taken alongside antipsychotic drugs. A one month clinical trial involving 30 schizophrenia patients with metabolic syndrome who had taken second generation antipsychotics for more than 6 months, found that adding Withania to their normal antipsychotic medication reduced serum triglycerides and fasting blood glucose, thus improving these metabolic syndrome symptoms(5).

Apart from Withania, clinical trials have shown appropriate doses of other high quality herbal medicines to benefit patients receiving antipsychotic drugs. Ginkgo was found to both increase the response rate to haloperidol when taken alongside it for 12 weeks(6), and to reduce the incidence of extrapyramidal side effects(7, 8). Similar effects have also been reported using Ginkgo alongside olanzapine(9).

Another U.S. study has shown American Ginseng (Panax quinquefolium) to have positive effects on memory function in individuals with schizophrenia, and to reduce the occurrence of extrapyramidal symptoms in patients on antipsychotic medications(10).

While underlying reasons for the high and increasing level of antipsychotic drug use in New Zealand and other countries should be further examined and addressed, clinical trials suggest that adjunctive herbal medicines such as Withania, Ginkgo and American ginseng, can play a role to help reduce some of the adverse events, and improve their response rates. Larger and longer term trials, are warranted.

References:
1. Bjerre LE; Canadian Fam Physician 2018; 64(1):17-27
2. Wilkinson S, Mulder RT. NZ Med J 2018 Aug 17; 131(1480):61-67.
3. Rasmussen PL, Feb 2017; Why Herbs should be the first choice of treatment for acute    anxiety. http://www.herbblurb.com
4. Chengappa KNR et al, J Clin Psychiatry 2018 Jul 10;79(5).
5. Agnihotri AP et al, Indian J Pharmacol 2013; Jul-Aug;45(4):417-8
6. Zhang XY et al, Psychopharmacology 2006; 188(1):12-17.
7. Zhang XY et al, J Clin Psychiatry 2001; 62(11):878-883.
8. Chen X et al, Psychiatry Res 2015; 228(1):121-127.
9. Atmaca M et al, Psychiatry Clin Neurosci 2005; 59(6):652- 656.
10. Chen EY et al, Phytother Res. 2012 Aug;26(8):1166-72

Why Herbs Should Be the First Choice of Treatment for Acute Anxiety

On By HerbBlurbIn Anxiety, Herbal Medicine, insomnia, Stress1 Comment

Anxiety can manifest in a wide range of ways. Apart from the internal emotional fearfulness, symptoms can include irritability, agitation, muscle tension, palpitations, sweating, insomnia, breathlessness, poor concentration, reduced socialisation and ability to undertake everyday activities. It is the most prevalent mental health disorder affecting children and adults, but many more people are dealing with problematic anxiety symptoms without any diagnosis.

In our increasingly changing world, where our daily exposure to stressful stimuli and life challenges can produce a rising barometer of worries, anxiety is often a major impediment to leading a fulfilling and happy life. Like most other health woes, humans have long pursued various practices to help overcome anxiety, the most popular of which is alcohol. Then there are drug medications, which have long been used to relieve anxiety, and remain widely prescribed.

Barbiturates were the first of these, sedative and anticonvulsant drugs which became popular particularly with sleep-deprived young mothers in the middle of last century, but which lead to the overdose deaths of thousands of people, including Elvis Presley and Marilyn Monroe. The next day ‘hangover effect’ from barbiturates was also always a problem, and development of a new chemical group of anxiolytic (anti-anxiety) and sedative drugs known as the benzodiazepines, lead to these superceding the barbiturates for the treatment of anxiety and insomnia. Benzodiazepines seem to act predominantly through stimulating GABA (gamma amino butyric acid) receptors in the central nervous system, and the commercialisation of Valium® (diazepam) by Roche in 1963 marked the start of a period during which this and other benzodiazepine drugs such as lorazepam, alprazolam and clonazepam began to be widely prescribed by GP’s and psychiatrists for anxiety and sleep difficulties. Between 1969 and 1982 Valium® was the most prescribed drug in the U.S., during which time Roche’s share price soared.

While safer than barbiturates, and effective as a ‘quick fix’ for anxious feelings or insomnia, safety concerns for benzodiazepines soon emerged. Feelings of fatigue, or a hangover the following day when taken as sleeping tablets, and a wide range of other side effects are all too common experiences. Most significant of these is the development of tolerance when they are used for more than a short period of time. As anyone who has been through it will testify, withdrawing from long term benzodiazepine use is a hugely stressful, unpleasant and often very protracted experience.

Feelings of depression can both contribute to or arise from excessive anxiety, and it is not uncommon for feelings of low mood and a low tolerance to stress, to be experienced together with anxiety. Apart from GABA, neurotransmitters such as serotonin, adrenaline and dopamine are intrinsically involved in influencing our emotions and mood, interacting together in complex ways that scientists still have little understanding of. It is therefore not surprising that many SSRI’s (selective serotonin reuptake inhibitor) drugs, used primarily as antidepressants, can have an anxiolytic effect in some people, and in many countries, these are often prescribed instead of or together with benzodiazepines, for anxiety conditions.

While sometimes effective as anxiolytics and less likely to produce adverse effects than most older generation tricyclic antidepressants, some find that SSRI’s can cause or increase anxiety feelings, or experience any one or more of a wide range of unpleasant side effects including insomnia, weight gain, emotional numbing or sexual dysfunction.

Another class of non-benzodiazepine sleeping tablets, the so-called  ‘Z-drugs’ such as zopiclone and zolpidem, have become popular in recent years, and while initially thought to be less habit-forming than benzodiazepines, they can also be very difficult to withdraw from after more than short-term use.

A large number of herbs have been traditionally used for nervous conditions and their anxiolytic effects, several of which have been shown in clinical trials to be beneficial as anxiety treatments. These include Chamomile, Skullcap, Passionflower, Valerian, Kava, Lemon balm and Withania.  Despite the number of well-designed trials undertaken to date being relatively low, and results sometimes variable depending on the particular herbal product(s) and dosages used, results are encouraging and in all cases show a better safety profile than for comparable anxiolytic drugs.

Of these, Kava (Piper methysticum), is the most studied, and is a non-addictive anxiolytic with great potential to treat anxiety. Its effectiveness in treating anxiety has been affirmed through several clinical trials and meta-analysis(1-3). While case reports of liver toxicity associated with kava usage lead to its restriction in some countries at the end of last century, use of the wrong plant part as raw material, or use in combination with alcohol or various drugs, were likely contributory factors. Also the frequency of such adverse events reports was substantially less than that for paracetamol, a commonly used analgesic.

Aerial parts of the herb Passionflower (Passiflora incarnata), have also been taken for anxiety for many centuries, and in a trial involving 36 outpatients with generalized anxiety disorder, it was as effective as the benzodiazepine drug oxazepam, but unlike oxazepam caused no impairment of job performance(4).

Roots of the herb Withania (Withania somnifera, Ashwagandha), have a subtle but powerful nervous system and adrenal tonic action, which insulates the nervous system from stress, and enables the adrenal glands to be better prepared to respond appropriately to stressful stimuli. A large number of scientific papers now support its applications for stress-associated anxiety conditions, including several recent human clinical trials(5,6).

While further studies involving greater participant numbers and longer term treatment are needed to identify optimal dosages and phytochemical makeup of the treatments involved, the fact that most herbal anxiolytic agents are safe and have the same or only a slightly higher incidence of adverse effects to placebo, is clear. It is therefore logical that before reverting to drug medications, more likely to produce unwanted adverse effects and in some cases long term dependency, herbal anxiolytics should be tried, in anxiety conditions.

Refs:

  1. Sarris J, Aust NZ J Psychiatry 2011; 45(1):27-35.
  2. Sarris J, J Clin Psychopharmacol 2013; 33(5):643-648.
  3. Savage K et al, Trials 2015; 16:493.
  4. Akhondzadeh S et al, J Clin Pharm Ther 2001; 26(5):363-367.
  5. Chandrasekhar K et al, Indian J Psychol Med 2012; 34(3):255-262.
  6. Pratte MA et al, J Altern Complement Med 2014; 20(12):901-908