In this paper, I have chosen to specify the discussion of herbal supplements to their use for depression and anxiety. I consider recent research and briefly cover four topics related to herbal usage in psychotherapy. First, I examine the use of herbs for depression and anxiety. Second, I discuss the efficacy of using herbs to treat depression and anxiety. Third, I highlight concerns that should be addressed when using herbs. Fourth, I conclude by sharing  my beliefs on incorporating herbs into the therapeutic environment.

The Use of Herbs for Depression and Anxiety

The herbal market is estimated to be over $100 billion worldwide, resulting from 80% of the world’s population using herbal supplements, often without medical oversight (Zhang, 2015). There are varied reasons why people select herbs for treatment, including: the desire for natural remedies, no access to medical treatment (requiring self-treatment), aversion to synthetic drugs, aggressive marketing efforts, and no requirements to obtain prescriptions for herbs (Liu et al., 2015; Preston, O’Neal, & Talaga, 2017). However, most people do not understand that natural does not necessarily mean safe and that 25% of modern synthetic medications were originally derived from plants (Zhang, 2015)

Depression affects 17% of people worldwide (Farahani et al., 2015). As a result, there is a considerable need for effective therapies, including medications when clinically warranted. Herbal supplements with documented valid and reliable research, demonstrating efficacy in treating depression include the following: St. John’s wort, SAMe, 5-HTP, omega 3 fatty acids, and folic acid (Liu et al., 2015; Preston, O’Neal, & Talaga, 2017; Rojas-Carvajal, 2017).

Regarding anxiety, there are numerous herbs that have been shown effective in treating anxiety, including: abies pindrow, acatia spicata, albizzia lebbeck, brassica oleracea, cecorpia glazioui, citrus paradisi, colocassia esculenta, drypetes roxburghis, hebenaria intermedia, mellissa paraflora, moringa oleifera, ginseng, etc (Singh, 2017). However, Kava has been shown to be the most effective and well tolerated (Preston, O’Neal, & Talaga, 2017).

Efficacy of Herbal Supplements on Depression and Anxiety

Advancements in genomics, metabolic pathways, pharmacogenomics, and neuropsychology are furthering scientific knowledge about the effectiveness of herbs, resulting in increased medical community acceptance (Swati Sahoo, 2019). 

Studies have found herbal remedies to positively impact molecular mechanisms, leading to anti-depressive traits (Farahani, 2015).  The elevation of 5-HT levels, including reuptake inhibition of neurotransmitters, is the most popular mechanism by which herbs alleviate depressive and anxiety symptoms in animal and human subjects (Farahani, 2015). Additionally, monoamine oxidase (MAO) is a key enzyme in the degradation process of the monoamine neurotransmitters, so the inhibition of MAO or reduction of MAO results in an accumulated level of monoamine neurotransmitters. Finally, serum corticosterone level is also altered by some herbal therapies, which modulates the HPA axis (Farahani, 2015). 

Specific Herbal Efficacy

St. John’s wort (hypericum) shows normalizing effects on brain serotonin levels and is a promising alternative treatment for mood disorders (Farahani, 2015). It has been shown to have wider safe dosing ranges and is without the side effects associated with benzodiazepines and SSRI’s (Rojas-Carvajal et al., 2017). In a well-cited study, Van der Watt reviewed a meta-analysis with five trials, involving 2231 patients that compared St John’s wort with antidepressants and found it to be equally effective (2008). Also, van der Watt found St John’s wort effective when compared with placebo in 25 trials, involving 2129 patients (2008).  Additional meta-analyses by Ravindran (2016) confirmed the comparable efficacy of St. John’s wort to antidepressants and placebo and found them superior for mild to moderate major depressive disorder (MDD).  In MDD of greater severity, research has found St. John’s wort equally effective to SSRI’s with a lower rate of adverse events (Ravindran, 2016). 

Suggested mechanisms of antidepressant action of St. John’s word include: direct effect on serotonin receptors, monoamine oxidase inhibition, and neuroendocrine and ion channel modulation (Ravidran, 2016).

Two meta-analyses found SAM-e effective as a monotherapy versus placebo in mild to severe MDD or versus antidepressants in mild to moderate MDD (Ravidram, 2016). There is also evidence supporting adjunctive SAM-e with antidepressants in mild to moderate MDD (Ravidram, 2016). Overall, SAM-e is relatively well tolerated, with the most common side effects being gastrointestinal upset, insomnia, sweating, headache, irritability, restlessness, anxiety, tachycardia, and fatigue (Ravindram, 2016). 

Van der Watt found that Kava was the most researched remedy for anxiety and that there was strong evidence for its anxiolytic effect and favorable comparison to placebo and benzodiazepines with far less side effects (2008).  These findings have been replicated (Ravindran, 2016). 

Concerns with Herbal Supplements

There are numerous concerns when using herbs, ranging from minor to fatal. At a minimum, these concerns include the following: drug interactions, side effects, and effects of the unregulated herbal industry. 

First, drug interactions are an important consideration for any pharmacologic agent, herbal or synthetic. To evaluate drug interactions, medical providers must be aware that herbs are being used. Many patients do not notify their medical providers that they are using herbs (Zhang, 2015). Interactions among herbs and with medications is serious (Zhang, 2015). As an example, St John’s wort when combined with SSRIs has been known to cause psychosis in patients (Preston, O’Neal, & Talaga, 2017; van der Watt, 2008).  

Second, adverse events must be anticipated. All medical remedies have side effects to varying degrees. Many people who use herbs think that they are natural and not different than foods; however, herbs are complicated biochemical structures and must be treated as medicines and not food. (Zhang, 2015). Marketing efforts are one of the prime culprits in leading to people’s beliefs that herbs are natural, safe, and can be taken for long periods of time (Zhang, 2015). Marketers for herbal supplements are unregulated and are free to make any claim they desire. Most herbs do have lower risk profiles than synthetic medications, but they are not free from adverse effects that marketing materials may claim (Zhang, 2015). 

As an example, Ravindran (2016) discussed that although St. John’s wort is significantly better tolerated than many antidepressants, side effects include: gastrointestinal upset, headaches, skin irritation, photosensitivity, and dry mouth. Another consideration pertains to higher potency extracts, which can interfere with the metabolism of other medications (Ravindran, 2016). Additionally, serotonin syndrome and hypomania have been reported when St. John’s wort is used concurrently with antidepressants (Ravindran, 2016). Finally, self-dosing or incorrect disease identification can lead to significant problems (Preston, O’Neal, & Talaga, 2017). For example, using St. John’s wort for depression when the patient is actually bipolar will potentially lead to severe manic attacks (Preston, O’Neal, & Talaga, 2017). 

Third, the herbal industry is entirely unregulated, and until recently, has been supported by a lack of empirically-based science free from industry support and conflicts. With no FDA oversight, there is no standardization of doses, ingredients, purity, or potency of herbal supplements (Preston, O’Neal, & Talaga, 2017). Additionally, adverse effects can occur from contaminated products or products that have unknown ingredients, which is frequent in herbal samples (Zhang, 2015). 

Conclusion

In this brief paper, I summarized recent research related to the therapeutic incorporation of herbs in the treatments of depression and anxiety. I discussed the use of herbs for depression and anxiety, the efficacy of using herbs, and selected concerns that should be considered when using herbs. 

To finalize, given the increasing amount of non-biased empirical research that is being generated about herbal biochemical and neurobiological affects and treatment efficacies, I believe that herbal pharmacologic additions to the therapeutic courses of action are well established and efficacious. Due to the frequent patient use of herbs, psychotherapists have ethical requirements to be knowledgeable and competent in the use of herbs. APA Ethics Codes Principle A: Beneficence and Non-Maleficence,  Standards 2.01 Boundaries of Competence and 2.03 Maintaining Competence, and Standard 10.01 Informed Consent to Therapy (APA, 2017) must be considered. 

Psychotherapists should work with patients and their physicians to include herbal remedies in treatment if each party is in agreement with the therapeutic benefits in light of possible adverse effects and drug interactions. It is imperative to ensure that the ingredients and purity of the selected herbs are validated, the psychological disorder is accurately assessed, drug interactions are considered, and the herbs selected are dosed correctly by a medical professional (Preston, O’Neal, & Talaga, 2017; Zhang, 2015). 

References

American Psychological Association.  (2017).  Ethical principles of psychologists and code of conduct.  Washington, D.C.:  American Psychological Association.

Farahani, M.S., Bahramsoltani, R., Farzaei, M.H., Abdollahi, M., & Rahimi, R. (2015). Plant-derived natural medicines for the management of depression: an overview of mechanisms of action. Review of Neuroscience, 26, 305-321.

Liu, L., Liu, C., Wang, Y., Li, Y., & Li, B. (2015). Herbal medicine for anxiety, depression, and insomnia. Current Neuropharmacology, 13, 481-493.

Preston, J.D., O’Neal, J.H, & Talaga, M.C. (2017). Handbook of clinical psychopharmacology for therapists (8th ed.). Oakland, CA: New Harbinger Publications.

Ravindran, A.V. (2016). Canadian Network for Mood and Anxiety Treatments 2016 clinical guidelines for the management of adults with major depressive disorder: Complementary and alternative medicine treatments. The Canadian Journal of Psychiatry, 6, 576-587. 

Rojas-Carvajal, M. Fornaguera, J., Badilla, S., Brenes, J., & Calvo, M.F. (2017). Sub-chronic administration of St. John’s wort reverses anxiety and depressive-like behaviors induced by two different protocols of chronic stress.Neurociencia, 18, 2-10. 

Singh, G.P., Sharma, S., Chawla, R., & Mukhtar, H. (2017). Herbal drugs in treatment of anxiety disorders. World Journal of Pharmaceutical Research, 7, 302-311.

Swati Sahoo, B. (2019). Pharmacogenomic assessment of herbal drugs in affective disorders. Biomedicine and Pharmacotherapy, 109, 1148-1162. 

Van der Watt, G., Laugharne, J., & Janca, A. (2008). Complementary and alternative medicine in the treatment of anxiety and depression. Current Opinions in Psychiatry, 21, 37-42. 

Zhang, J., Onakpoya, I.J., Posadzki, P., & Eddouks, M. (2015). The safety of herbal medicine: From prejudice to evidence. Evidence-Based Complementary and Alternative Medicine, 1-3. http://dx.doi.org/10.1155/2015/316706 

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