- Mr. J’s cognitive symptoms are more severe than those caused by kava intoxication
- his psychotic symptoms occur only when he is delirious
- his disturbed consciousness, cognitive, and perceptual disturbances and the temporal relationship between symptom onset and massive kava use match DSM-IV-TR criteria for substance-induced delirium.4
Being aware of cultural customs and beliefs in your practice area can alert you to herbal substance use in various populations, such as kava by patients from the South Pacific or echinacea, goldenseal, and burdock by some Native Americans (see Related resources).
Medicinal use. Patients often use kava and other herbal supplements—including fatty acids, ginkgo biloba, ginseng, St. John’s wort, valerian, and others—with or instead of prescription drugs to alleviate psychiatric symptoms. Complementary and alternative medicine practitioners use kava to treat anxiety, for example (Box).
Anxiety and depression are among the most common reasons persons seek complementary or alternative treatment. In a national survey, 57% of respondents who suffered “anxiety attacks” and 54% of those with “severe depression” reported using such therapies.8 Nearly 1 in 5 persons who take prescription drugs also take herbs and/or high-dose vitamin supplements.9
Herbal products have been shown to cause adverse effects (Table 1).10 Kava, for example, has been associated with hepatotoxicity, dermopathy, movement disorders, GI disturbance, and weight loss. Standardized extracts such as capsules and tinctures appear more likely to cause adverse effects than traditional extractions, such as a beverage made by infusing kava root.5
Kava toxicity has been reported among heavy users. Although the dosage at which kava becomes dangerous is unknown, the FDA recommends that users not exceed typical dosages (50 to 280 mg/d) and use kava only under a physician’s supervision.11
Also, interactions between herbal products and allopathic medications can cause substantial morbidity (Table 2). St. John’s wort, for example, can lead to serotonin syndrome when combined with selective serotonin reuptake inhibitors (SSRIs)12 and can reduce blood levels of psychotropics metabolized by the cytochrome P-450 3A4 isoenzyme, such as alprazolam and carbamazepine.
Mr. J combined kava with clonazepam. Both substances affect gamma-aminobutyric (GABA) receptors, increasing the risk of sedation by depressing the CNS.
Table 1
Possible adverse effects of herbal supplements
used for psychiatric symptoms
| Medication | Psychiatric uses | Adverse effects |
|---|---|---|
| Fatty acids | Depression, mania | GI upset |
| 5-HTP (5-hydroxytryptophan) | Depression, anxiety | Agitation, ataxia, blurred vision, bradycardia, dyspnea, eosinophilia, headache, hypotension, insomnia, mania, psychosis, tremulousness |
| Ginkgo (Ginkgo biloba) | Cognitive enhancement | Bleeding, dizziness, GI upset, headache, palpitations, Stevens-Johnson syndrome |
| Ginseng (Panax ginseng) | Cognitive enhancement | Estrogenic effects, insomnia, mania |
| Kava (Piper methysticum) | Anxiety | Dermopathy, drowsiness, dry mouth, GI disturbance, hepatotoxicity, weight loss, movement disorders |
| SAM-e (S-adenosyl-L-methionine) | Depression, fibromyalgia | Constipation, diarrhea, increased salivation, headache, nausea, urinary frequency, mania in patients with bipolar disorder |
| St. John’s wort (Hypericum perforatum) | Depression | Anorexia, anorgasmia, anxiety, constipation, dizziness, dry mouth, fatigue, GI upset, mania, photosensitivity, pruritis, restlessness, urinary frequency |
| Valerian (Valeriana officinalis) | Insomnia | Drowsiness, GI upset, headache, hepatotoxicity |
| Source: Reference 10 | ||
Potential adverse interactions between psychotropics and complementary/alternative medications
| Herb | Interacts with… | Interaction can cause… |
|---|---|---|
| 5-HTP | carbidopa, MAOIs, SSRIs | delirium, serotonin syndrome |
| Ginseng | MAOIs | mania |
| Kava | first- and second-generation antipsychotics, benzodiazepines, MAOIs | sedation |
| SAM-E | TCAs | serotonin syndrome |
| St. John’s wort | benzodiazepines, beta blockers, buspirone, carbamazepine, clozapine, MAOIs, SSRIs, TCAs, trazodone | serotonin syndrome (w/SSRIs) |
| reduced plasma levels of cytochrome P-450 3A4 substrates, diminishing their effectiveness | ||
| Valerian | benzodiazepines | sedation |
| MAOIs: Monoamine oxidase inhibitors | ||
| SSRIs: Selective serotonin reuptake inhibitors | ||
| TCAs: Tricyclic antidepressants | ||
Kava: A popular alternative to prescription anxiolytics
Kava, extracted from the roots of Piper methysticum, acts as a muscle relaxant, anesthetic, and anxiolytic.5 It is among the most commonly used alternative treatments for psychiatric symptoms, with sales estimated at $17 million in the United States in 2004.6
Kava lactones, the pharmacologically active components of kava, might act via several pathways, including GABA-A receptor binding and dopaminergic antagonism.7 This GABAergic CNS activity affects similar receptors as do benzodiazepines and produces kava’s anxiolytic effects.
Kava is available in health food stores as capsules, tinctures, and fluid extracts and can be obtained without a prescription. The amount of active ingredient varies greatly from preparation to preparation.
Ask about alternative medicine use
According to a national survey,13 many patients do not tell allopathic physicians they are using complementary or alternative medications because:
- “It wasn’t important for the doctor to know.”
- “The doctor never asked.”
- “It was none of the doctor’s business.”
- “The doctor would not understand.”
- or “The doctor would disapprove or discourage CAM use.”
- routinely question patients about use of alternative therapies
- discuss safety and efficacy of commonly used alternative treatments
- discuss merits of alternative treatments
- provide information on the effectiveness and risks of various treatments
- learn about alternative therapies by consulting the Physicians’ Desk Reference (PDR) for Herbal Medicines or similar references
- help patients make decisions about alternative treatments, such as finding a qualified, licensed alternative provider.