PSYCHIATRY ALTERNATIVES

L-Theanine is an amino acid in green tea that seems to increase levels of serotonin and GABA.  The form known as Suntheanine brand is popular and may have some benefits.  Theanine seems to induce relaxation without sedation.  This state is associated with increased brain alpha-waves. Theanine may decrease blood pressure and thus may interact with blood pressure medications to make blood pressure go too low.  It may decrease the effects of stimulants.    The Natural Medicines Comprehensive Database at www.naturaldatabase.com rates this supplement as having insufficient evidence for anxiety. Theanine is reviewed by James Lake M.D. in his book Complementary And Alternative Treatments in Mental Health Care and he speaks well of it in a very recent publication int the Psychiatric Times.  A calming effect is often achieved after a dose of 50 mg which may last 8 to 10 hours.  For anxiety the dose is often titrated with twice per day dosing.

 
Kava seems somewhat effective in treating anxiety.  The Natural Medicines Comprehensive Database at www.naturaldatabase.com rates Kava as possibly effective and the Natural Standard at www.naturalstandard.com gives it an A ranking (strong scientific evividence for this use).  It might increase the effects of GABA by increasing GABA binding.  While some people experience somewhat of an immediate sedating effect, the time of onset for treating anxiety disorders may take well over a week.  It may have some risks for addiction and possible liver injury (rare-per an FDA warning, also see www.fda.gov/medwatch/safety/2001/kava.htm) and should not be used without careful monitoring (sometimes including liver function tests), or for extended periods.  Kava is listed as being "very likely hazardous" by Consumer Reports in its "dirty dozen" list from May 2004.  Kava is contraindicated in pregnancy, it can be lethal in an overdose, it may worsen Parkinson's disease (and should not be taken with levodopa) and has many other potential adverse side effects including gastrointestinal upset, allergic skin reactions, dry scaley rash, pupil dilitation, problems focusing, photosensitivity, movement disorders, hematological disorders, renal dysfunction, pulmonary hypertension, increased depression/suicide risk.  Alcohol may somewhat increase the risk of sedation and liver toxicity.  For anxiety Kava is often used in a standardized form with 30% Kavalactones at 100 mg 1 to 3 times daily. 

 
5-Hydroxytryptophan (5-HTP) seems effective for depression, anxiety and insomnia.   The Natural Medicines Comprehensive Database at www.naturaldatabase.com rates 5-HTP as having insufficent evidence for anxiety and possibly effective for depression.  5-HTP is metabolized to Serotonin and is also a precursor to melatonin.  Onset of action may be somewhat delayed.  L-Tryptophan, a precursor to 5-HTP may have some advantages for cases where there is insomnia (see section for insomnia) because it may be more sedating.  Both 5-HTP and L-Tryptophan may be of some risk in causing eosinophilia-myalgia syndrome, though this may have been secondary to a contaminated batch of L-Tryptophan which had been manufactured in Japan.  5-HTP needs to be avoided with carcinoid syndrome and may adversely interact with antidepressants.  Side effects may include nausea, dry mouth, gastrointestinal irritation, and sedation.  Dosing may start a 50 mg once to three times per day.

Inositol is a naturally occurring isomer of glucose found in brain tissues.  It is involved in signaling brain cells that neurotransmitters such as serotonin, norepinephrine, and dopamine are occupying receptor sites on the cell membranes.  Inositol has demonstrated efficacy in treating disorders which may respond to the SSRIs.  There is a good review of Inositol by James Lake M.D. in his book Complementary And Alternative Treatments in Mental Health Care.  It is generally well tolerated, with potential side effects including flatuence along with other gastrointestinal problems.  It is contraindicated in pregnant women as it might induce uterine contractions.  It may also trigger manic reactions.  Dosing usually starts at 2 gm twice per day.

Saint John's Wort which is best known for its use in depression , also seems to demonstrate efficacy in anxiety disorders. It is rated by The Natural Medicines Comprehensive Database at www.naturaldatabase.com likely effective for depression and the Natural Standard at www.naturalstandard.com gives it an A rating for depression (strong scientific evidence for this use) but only a C rating (unclear scientific evidence) for anxiety and obsessive-compulsive disorder.  St. John's Wort seems to inhibit the reuptake of serotonin, norepinephrine, and dopamine.  It may also inhibit the uptake of GABA and glutamate, inhibit cotisol secretion, and blockade catabolic hormones.  It shares similarities with the SSRIs and also the MAOIs, but has a lot of their side effects as well.  Also like prescription antidepressants, the time until the onset of theraputic effects may be weeks and it may be over stimulating when first used for anxiety.  There are also multiple drug interactions, for example it can lower the levels of drugs like oral contraceptives, theophylline, and Coumadin.  Saint John's Wort may also inhibit medications used to prevent organ transplant rejection and which are used to treat HIV.  Side effects may include photosensitivity with possible increased risk of cataracts, mania, psychosis, allergic skin rashes, fatique, restlessness, constipation, and headaches.  Saint John's Wort can interact with other antidepressants and may cause a serotonin syndrome.  It also may cause a hypertensive crisis.  St. John's Wort is containdicated in pregnancy and should be stopped several days before surgery.  Typical dosing is 300 mg three times daily of a standardized extract with 0.3 to 0.5%hypericin and/or 3 to 5% hyperforin.

Passion Flower seems to bind to the GABA receptor.  It may have an effect like benzodiazepines with a relatively rapid onset of action, but it may interact with other sedatives and it may also cause cognitive impairment as well. It is rated by The Natural Medicines Comprehensive Database at www.naturaldatabase.com as possibly affective for anxiety.  It is given a C rating (unclear scientific evidence) for Sedation (agitation,anxiety,insomnia) by the Natural Standard at www.naturalstandard.com. There may be risks with bleeding disorders and with people on anticoagulants.  For anxiety a typical dose is about 100 mg 2-3 times daily with a standardized 3.5% isovitexin extract.

Skullcap seems to bind to benzodiazepine receptors and have an anxiolytic and sedative effect.  It may cause cognitive impairment and hepatotoxicity among its side effects, and may react with alcohol in a manner similar to Antabuse.  Skullcap is listed as being "likely hazardous" by Consumer Reports in its "dirty dozen" list from May 2004.  While there may be a relatively rapid onset of action, the effect is limited in duration.  Little is actually known about the use of this supplement in humans.   The Natural Medicines Comprehensive Database at www.naturaldatabase.com rates this supplement as having insufficient evidence for anxiety.  Caution should be used in individuals taking anticoagulants.  A typical dose may be 1 gm of dried herb 3 times daily.

Valerian which seems to inhibit the metabolism of GABA is better known for its use as a sedative, but may also have some benefit for treating anxiety.  The Natural Medicines Comprehensive Database at www.naturaldatabase.com rates this supplement as having insufficient evidence for anxiety but possibly effective for insomnia.  The  Natural Standard at www.naturalstandard.com gives Valerian a C rating for anxiety (unclear scientific evidence for this use) and a B rating (good scientific evidence for this use) for insomnia.  There are multiple potential drug interactions and side effects.  The onset of action may take weeks.  Valerian may cause day time sedation, cognitive and motor impairment, contact allergy, headache, restlessness, paradoxical insomnia, cardiac dysfunction, gastrointestinal upset and liver toxicity.  Long term use with discontiuation may lead to a withdrawal syndrome.  For anxiety a typical dose is 200 mg 1-4 times per day of a standardized extract containing 0.8 to 1% valerenic acids is often used.

Geriforte is an Ayurvedic herb preperation from India.  It is sold in the United States as StressCare.  It has some efficacy supported by research.  Geriforte is reviewed by James Lake M.D. in his book Complementary And Alternative Treatments in Mental Health Care.  While it does not seem to have a lot of side effects, it contains multiple herbs which may increase the risk of drug-drug interactions and may pose danger in pregnancy along with other conditons, as well the potential for unforseen problems.  SressCare may need to be taken several weeks to appreciate benefits.

Bacopa is an single Ayurvedic herb.  It has shown possible efficacy for lowering anxiety and also may also have cognitive benefits in the elderly and the Natural Medicines Comprehensive Database at www.naturaldatabase.com rates this supplement (also called Brahmi) as being possibly effective for cognitive function.  It seems to be generally well tolerated but side effects include dry mouth, nausea, and fatigue.  There may be several drug interactions.  There is less research on Bacopa than several of the other supplements and it may take several weeks to appreciate benefits.  James Lake in his book Complementary And Alternative Treatments in Mental Health Care reviews the benifits of Bacopa as being favorable.  Typical dosing is 100 mg 3 times per day standardized to contain 20% bacosides A and B.

Gotu Kola (Centella) is a single Ayurvedic herb that may help with anxiety and has also been under investigation for some possible neuroprotective effects.  While generally well tolerated, there is some risk of liver toxicity, hypoglycemia, and central nervous system sedation.  Gotu Kola is containdicated in pregnancy.  There are some mixed research results and it might take several weeks  to help for anxiety, though in one study Gotu Kola seemed to reduce the acoustic startle response 30 to 60 minutes after a one time dose.   James Lake M.D.  in his book Complementary And Alternative Treatments in Mental Health Care reviews the benifits of Centella. Typical dosing is 50-100 mg 2-3 times per day of a standardized form with 10-30% asiaticosides and 2-4% triterpenes.

Ashwagandha (Withania somniferum) is a single Ayurvedic herb that has been used for anxiety, insomnia, and also in combination with Mucuna for depression.  This herb is reviewed by James Lake M.D. in his book Complementary And Alternative Treatments in Mental Health Care.  It has antioxidant properties and has been associated with cholinesterase inhibition.  It has a high iron content and also contains the amino acids arginine and ornithine.  Large doses may cause stomach upset, diarrhea, and vomiting.  It should not be used if pregnant or breast-feeding, with stomach ulcers, hemachromatosis, or with immune system disease.  It may effect thyroid function and thus interact with thyroid medications and acetylcholineserase inhibitors.  Ashwagandha may cause sedation and caution should be taken with other sedatives.  450 mg 1-2 times daily of an extract containing 1.5% withanolides is a typical dose.