Herbs for mental illness: Effectiveness and interaction with conventional medicines

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Applied Evidence

Herbs for mental illness: Effectiveness and interaction with conventional medicines

J Fam Pract. 2005 September;54(9):789-800

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References

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Mechanisms of action. The key active components of Panax ginseng are ginsenosides, a group of steroidal saponins that target a multitude of tissues to produce pharmacologic responses. The overall pharmacology of ginseng is complex due to the ability of ginsenosides to initiate multiple actions in the same tissue. Attele and colleagues³¹ provide an in-depth review of these mechanisms.

Herb-drug interactions. Ginseng may potentiate the effect of MAO inhibitors,³² stimulants (including caffeine), and haloperidol.³³ In addition, a case study suggests a probable interaction with warfarin.³⁴

Adverse effects. Reported side effects include insomnia, hypertension, diarrhea, restlessness, anxiety, and euphoria.³⁵ There is at least 1 report of ginseng-induced mania, which occurred within 4 to 10 days of a patient’s interrupting a lithium and amitriptyline treatment.²⁶

Evening primrose

Evening primrose (Oenothera biennis L) is a plant native to North America. The oil pressed from its seed is marketed as a nutritional supplement, and it has been used to treat many disorders, including premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD), both which are marked by affective disturbances.^36,37

Efficacy. A systematic review³⁸ of the efficacy of evening primrose oil in the treatment of PMS revealed few clinical trials of adequate methodology. The authors found only 2 well-controlled studies, both which failed to show beneficial effects for the herb. Thus, at best, SOR=C for the evidence in support of evening primrose.

Methods used for this review

Literature searches were conducted using Medline, PsycInfo, and the Cochrane Library electronic databases, and by consulting bibliographies of pertinent publications. We focused primarily on meta-analyses and large-scale case report tabulations at an evidence level of 1b. Additionally, articles selected included those that discussed the use of herbal treatments for mental illness, as well as those that addressed drug-herb interactions between herbal and traditional psychiatric drug treatments.

Mechanisms of action. Gamma linolenic acid, a precursor of prostaglandin E and several other active substances, is the main constituent responsible for the therapeutic effects of evening primrose.³⁷

Herb-drug interactions. This herb has the potential to interact with phenothiazines, nonsteroidal anti-inflammatory drugs, corticosteroids, beta-blockers, and anticoagulants.⁹

Adverse effects. Although it is generally safe, evening primrose oil has occasionally exacerbated the symptoms of epilepsy.³⁹ Other adverse effects are nausea, softening of the stool, and headache.³⁷

Ephedra

Ephedra (Ephedra sinica) is an evergreen shrub native to Asia used in traditional Chinese medicine for thousands of years. In recent decades, ma-huang, the extract derived from this herb, has been a common ingredient in many natural supplements that promote increased energy, mood enhancement, and weight loss.^40,41 In early 2004, the FDA banned the sale of dietary products containing ephedra due to concerns over its adverse effects.⁴²

FAST TRACK

Support for evening primrose is primarily anecdotal

Efficacy. Research on ephedra’s efficacy is largely focused on its role in weight loss, and there is little evidence that evaluates it as a mood enhancer. A comprehensive meta-analysis⁴³ assessed 20 controlled trials with a treatment duration of at least 8 weeks and concluded that ephedra, when administered alone or with caffeine, promotes modest short-term weight loss (0.9 kg/month more than placebo). However, not all of the included studies were randomized or double-blind, and no data were available on long-term effects. A smaller systematic review⁴⁴ of 5 double-blind studies also found the combination of ephedra and caffeine stimulated weight loss, but it was unclear whether 2 of the trials were randomized. Thus, SOR=A for the evidence in support of weight loss in the short term. There is no evidence in support of it as a mood-enhancing treatment.

Mechanisms of action. The primary constituents of ephedra are ephedrine-type alkaloids. As a sympathomimetic agonist at both α- and β-adrenergic receptors, ephedrine enhances cardiac rate and contractibility, peripheral vasoconstriction, bronchodilation, and central nervous system stimulation.⁴¹

Herb-drug interactions. Ephedra should not be used with anesthetic agents,⁴⁵ MAO inhibitors,^46,47 antihypertensives, or antidepressants.⁴¹

FAST TRACK

The risk of serious side effects with kava far outweighs its mild anxiolytic effect

Adverse effects. The relative risk of adverse reactions to ephedra is more than 100 times greater than that of all other herbs.⁴⁰ As noted by Jacobs and Hirsch,⁴⁸ between 1993 and 1997 the FDA had received 34 notices of death and reports of approximately 800 medical and psychiatric complications all directly linked to ephedra. A more recent review⁴⁹ indicated that hypertension, palpitations, tachycardia, stroke, seizures, and death are related to ephedra use. The herb has also been noted to induce symptoms of psychosis and affective disturbances.^50,51

Anxiety

Kava-kava

Kava-kava is derived from the dried rhizome of the oceanic kava plant (Piper methysticum), and it has been cultivated for thousands of years throughout the South Pacific, where it is consumed as a psychotropic drink for recreational and medicinal purposes.⁵² Kava has been shown to alleviate anxiety symptoms,⁵³ and it has euphoric and muscle relaxant properties, although its effect on arousal and alertness appears to be minimal.⁹ It is commonly used in Europe and North America for its anxiolytic effects.