Proponents of herbal therapies frequently insist that traditional physicians must be made ready to accept so-called “alternative” or “complementary” treatments. In this month's issue of CNS Spectrums, two wonderful guest editors, Drs. Jonathan Davidson and Kathryn M. Connor, both of Duke University, help us turn that issue around. The real question for psychiatrists, neurologists, and neuroscientists is whether herbal treatments are ready for us.

Due in large part to recent Congressional mandates, dietary supplements, even when proposed to work for medical conditions like depression and generalized anxiety disorder, do not require approval in the United States by the Food and Drug Administration as pharmaceutical agents.

Recent literature regarding drug-drug, herb-drug, and food-drug interactions must not be ignored; nor can they always be taken at face value. Studies have shown that St. John's wort (SJW) (Hypericum perforatum) can reduce plasma levels of indinavir, cyclosporin, digoxin, and possibly other drugs as well. Current knowledge regarding the metabolism of these medications suggests that the cytochrome P450 (CYP) drug metabolizing enzyme systems cannot account for all these effects. It has been reported that the P-glycoprotein (Pgp) transmembrane pump is also induced by SJW. Medications that are substrates of both CYP 3A4 a Pgp are of particular concern and may pose special interaction risks when combined with certain foods or botanical products such as SJW.

Depression and anxiety are among the top 10 health problems for which complementary and alternative therapies (CATs) are most frequently used, and medicinal herbs are among the most popular of these treatments. St. Johns wort(Hypericum perforaturn) is a perennial herb that has become a widely used depression therapy. Extracts of hypericum have shown affinity for receptors within multiple neurochemical systems. The primary active substance responsible for the antidepressant effect is not well defined, but most work has concentrated specifically on the hypericin and hyperforin components. Although hypericum has demonstrated significant antidepressant and antianxiety effects in multiple studies, there are several recent studies that do not support the previous evidence. In all reported studies, hypericum extracts have been well tolerated. In addition, new psychiatric uses for hypericum in obsessive-compulsive disorder, generalized anxiety disorder, menopausal symptoms, and alcohol dependence have been reported. Because patients are choosing to pursue CAT as a first-line therapy, psychiatrists will need to have a better understanding of phytomedicines used for treating depression and anxiety, and thus be better prepared to serve as effective allies of their patients.

Valerian is a medicinal agent deriving from the plant Valeriana officinalis L. We reviewed the available literature on the use of valerian preparations in the treatment of neuropsychiatric disorders. Preclinical studies suggest that valerian has sedative and muscle-relaxant effects. Few clinical trials with valerian have been carried out in conditions other than insomnia. The insomnia studies have methodologic shortcomings but suggest that some preparations lead to significant subjective improvement in sleep complaints with remarkably few side effects. Furthermore, some evidence indicates that valerian preparations may have a mechanism of action and clinical characteristics that differ from the benzodiazepine-related sedative/hypnotics, making them more suitable for long-term use. If this safety profile and the plant's sedative/hypnotic efficacy are confirmed in double-blind, placebo-controlled trials with carefully and consistently prepared valerian compounds, then those compounds would fill an important and presently unfilled niche in the treatment of insomnia.

The use of alternative therapies has increased substantially over the last decade, particularly for more chronic conditions such as anxiety. Among the most widely used treatments are medicinal herbs, or phytomedicines, such as kava (Piper methysticum), which has demonstrated anxiolytic activity in both animal models and clinical samples. Kava has several advantages over conventional pharmacologic treatments for anxiety—in clinical settings it has been associated with better tolerability and lack of physiologic dependence and withdrawal. However, phytomedicines are not rigorously regulated in the United States and systematically collected safety data are very limited. These issues are a leading concern regarding the safety of medicinal herbs such as kava. In this report, the safety profile for kava is provided, including findings from a study of its use in generalized anxiety disorder. Safety parameters assessed include occurrence of adverse events, withdrawal symptoms, effect on heart rate, blood pressure, laboratory assessments, and sexual function. No differences were found between kava and placebo on any of the parameters evaluated. The data support the safety of kava in treating anxiety at 280 mg kava lactones/day for 4 weeks.

This report describes the psychometric properties of the Self-Assessment of Resilience and Anxiety (SARA) scale within the context of a study of kava for generalized anxiety. This eight-item, patient-rated scale includes questions designed to measure calmness, mental clarity, confidence, physical well being, sociability, and resilience. The SARA scale was administered during a clinical trial of kava versus placebo in 38 subjects diagnosed with generalized anxiety disorder (GAD). Validation of the SARA scale was assessed against the Hamilton Rating Scale for Anxiety, Hospital Anxiety and Depression Scale, Penn State Worry Questionnaire, Sheehan Disability Scale, Arizona Sexual Experience scale, and Clinical Global Impression of Illness Improvement scale. Good test-retest reliability, internal consistency, convergent validity, and sensitivity to treatment were identified, and factor analyses revealed a three-factor internal structure. The SARA scale was responsive to symptom change over time and correlated with comparable GAD symptom measures. The SARA scale demonstrates solid psychometric properties and may serve as a reliable and valid measure in the use of kava or related medicinal herbs.