Learn about five natural supplements to combat stress, anxiety and depression.
MOTHER raised the subject of natural supplements to combat stress, anxiety and depression recently with Dr. Richard Firshein, an expert in nutritional research and medicine. He agreed to give us the lowdown on five of the more talked about natural mood boosters: St. John's wort, ginkgo, kava, tyrosine and SAM-e.
St. John's wort was among the first herbal supplements to break into the mainstream market, and it remains the leading natural antidepressant. But do we know yet if and how it works?
We are still not sure of how St John's wort works. Several mechanisms have been proposed. The most likely is that it works as a selective serotonin reuptake inhibitor [SSRI], similar to Prozac. But originally it was thought to work as a monoamine oxidase inhibitor [MAOI]. [For more on SSRIs and MAOIs, see Natural Remedies: Antidepressants and How They Work in this issue.] It was also thought that the active ingredient in St. John's wort was hypericin, but some more recent research indicates that there may be a whole slew of compounds at work.
So how this herb works is still very much under investigation, but do we know that it works?
Well, I think there is some good research going on. There have been some excellent [foreign] studies done over the last several years showing that it does improve mild to moderate depression. And there is a study that is currently being done in the U.S., which should be out within the year.
You mean the $4 million National Institutes ofHealth-sponsored study? Is this our government's first serious look at a natural antidepressant?
It's been a long time in coming, but this is our first real look into whether or not there are natural approaches to treating depression.
Are there any precautions associated with using St. John's wort?
I would be careful about using it with other antidepressants. Anytime a patient is thinking of using St. John's wort, it is a good idea to talk it over with his or her physician, particularly if someone is taking another medication and either wants to switch to or add St. John's wort. That should be discussed very carefully. Some other concerns are that St. John's wort may cause sun sensitivity, and it may interfere with anesthetics. If patients are taking antidepressants, and particularly MAO inhibitors, we generally ask them to stop before surgery.
Let's move onto ginkgo, which has been shown in studies to relieve mild to moderate depression. Is this related to ginkgo's widely reported ability to improve blood flow to the brain?
There are probably several mechanisms at work. One is the increased blood flow. Ginkgo works as a platelet activating factor inhibitor and what that means is that it thins the blood. But at the same time it also increases the amount of oxygen that can be transported [in the blood]. It also works as an antioxidant . . . and that is very important to brain chemistry as well.
When do you suggest taking ginkgo?
If someone comes to me and says they are depressed and are also feeling sluggish and have mental clouding or are not thinking clearly, that is when I start to think about ginkgo.
I've heard that people taking blood thinners should be wary of ginkgo.
Certainly if you have hypertension, a history of stroke or are on more serious blood thinners like Coumadin, you want to be very careful with ginkgo. Also, if there are risk factors for bleeding — a dental procedure or a surgery — you want to be very careful about the use of too many blood thinners.
Next on our list is kava, an herb you call "the key to calm". How does kava work to relieve anxiety?
It appears to work in much the same way that other similar drugs, like Valium and Halcyon, work, by inhibiting the enzyme that is involved in producing anxiety or the anxious state.
Anxiety and depression are often linked in patients. How do you decide when to prescribe St. John's wort, kava or both?
Many times I will recommend both. Anxiety and depression often go together, partly because if you are feeling stuck in a situation and you become anxious about it and can't figure a way out, you become depressed. And the reverse can also be true too. But there are some situations where people really are just depressed and we'll use St. John's wort alone, because we don't want to add to the person's somnolence.
Kava can make people sleepier?
Yes, in fact I'll recommend it to people who are having trouble sleeping. But you have to be careful; you don't want to take a lot of it and drive a car, for example.
Kava has stood its own against Valium-type drugs in laboratory comparisons. Is it a viable alternative for people with not just mild or moderate, but even severe anxiety?
I think in serious anxiety situations, you run the risk if you don't use a medication of creating an ongoing problem. Sometimes you just have to break the cycle. So in severe anxiety situations I think it is a good idea to use medications, but in mild situations, particularly ones that are short-term — perhaps there is a particular event in a person's life that is causing the anxiety — I think kava is an excellent first choice.
There can be some fairly serious side effects to using kava, including, in extremely high doses, ataxia and paralysis, and it may even be addictive. Is this an herb that is better taken under the supervision of a health care professional?
It's a good idea to talk over using any supplement or medication with your physician. For an occasional use situation, I think kava is fine. But the idea that something can be either psychologically or physiologically addictive is important. If someone is taking kava every day and would have been taking a medication every day, I'd say that is a reasonable substitute. But it's when a drug or a supplement becomes a crutch that it becomes a problem.
Moving now to tyrosine, you call this amino acid the "stress buster. " I understand it acts as a precursor to three important neurotransmitters?
Tyrosine is a very important building block for neurotransmitters, including dopamine, norepinephrine and epinephrine, or adrenaline. Tyrosine can be depleted during periods of stress. [Taking tyrosine supplements] builds up a person's reserves of this amino acid, which allows the neurotransmitters to be produced. We can't make dopamine or norepinephrine without tyrosine.
And rebuilding these neurotransmitters somehow helps people to perform better under stress?
Yes. Initial studies were done with the military during repetitive stress situations. Tyrosine was found to be helpful in those situations, and it works just as well with other kinds of repetitive stress, the kind you'd find with day-to-day work or in difficult situations where you have to be on guard or keep performance up. Sometimes people find that they just get so exhausted, they've been working and working and they get this sense of fatigue depression, where they say, "I just can't do anymore." And they start to become anxious and depressed. Tyrosine can help alleviate that kind of problem.
So is it really more energy booster than antidepressant? Does it simply give people the energy to respond to stress?
It gives them the neurotransmitters, which allows them to deal with the challenges.
Is there anyone that should avoid tyrosine?
Anyone who is on a number of different medications, including antidepressants or antihypertensives, again should be cautious.
Finally on our list is SAM-e, a chemical compound that occurs naturally, though apparently not always at the proper levels, in our brains. This newcomer to the scene is being called the "miracle" mood booster. Is it as good as its hype?
When things get hyped it's usually because people get excited about the latest product or the newest drug, and it may or may not live up to its press. SAM-e definitely has its place in the treatment of depression. It's crucial for the manufacture of neurotransmitters, and when depressed patients are given SAM-e, they show increased levels of important brain chemicals like dopamine and serotonin. In treating my patients, I have not, however, found that SAM-e is necessarily better or works in more patients than does St. John's wort. I can say that St. John's wort still holds its own and does quite well in comparison, and it's much cheaper.
So I gather — I've seen SAM-e prices listed as high as $50 or $60 for a week's worth. Is there truth to the rumor that you can raise your body's natural level of SAM-e by eating certain high protein foods, avoiding the cost of the supplement.?
I really don't think you can get adequate amounts of SAM-e from foods. I've read that, too, but I think that I would be very careful about recommending it. The problem with getting SAM-e from foods is that, to get the most benefit, you really need to take it before meals.
SAM-e seems to have the side benefit of helping with arthritis pain. I imagine it would be particularly helpful for people suffering from depression and arthritis, or perhaps depression triggered by arthritis pain?
Absolutely, in such cases it would be the treatment of choice. It can be a very elegant solution. But all of these supplements have their niche: For people suffering with both memory loss and depression, ginkgo is a great solution because it works on multiple levels. The same is true for kava if you have someone who has depression or anxiety and insomnia. So each one seems to have a niche that it has carved out for itself.
SAM-e has been used for more than 20 years in Europe, yet it remains a prescription drug there. Here it is being sold as an over-the-counter dietary supplement. Do you think it should be more closely regulated.
I think that most supplements should come with more information for the consumer. But I think that regulation would probably reduce the number of people who would receive the supplement and so I am not for overregulation, but rather for increased education.
Any final thoughts?
Just that I think it's important that people know that they have options, that they can take these supplements. They should also know that these supplements are not a free ride, that they may have side effects all their own, but that their safety profile is generally much better than that of a drug. The bottom line is. that people should do as much research as possible . . . they may find that their depression and anxiety is treatable through other natural approaches, diet changes or biofeedback or stress management or yoga or exercise. And those may be better treatments. Or maybe the answer is short-term therapy. It's important to look at the big picture.
Dr. Firshein is president of Nutraceutical Research Inc., a corporation dedicated to researching natural therapies. He hosts HouseCalls, a call-in radio program, is a contributing editor, for Psychology Today magazine and has devoted considerable research to the topic of drug alternatives. His latest book is The Nutraceutical Revolution: 20 Cutting-Edge Nutrients to Help You Design Your Own Perfect Whole-Life Program (Riverhead Books, 1998).
St. John's wort:
Ginkgo: An ornamental tree native to eastern China, with fan-shaped leaves and yellow fruit, ginkgo now grows in many countries worldwide, including the United States. Ginkgo's earliest known medicinal use dates back to 2800 B.C., when members of the royal court were reportedly instructed to eat the leaves to combat senility.
Kava: An Australian shrubby pepper whose roots possess intoxicating properties, kava was used centuries ago in Polynesia to ease social interaction at weddings and other traditional ceremonies. Captain James Cook was the first Westerner to encounter the herb, on a voyage to the Pacific Islands in 1768.
Tyrosine: One of 20 amino acids that are the building blocks of all bodily proteins, tyrosine is found in dairy products such as cheese and milk and in meats like chicken and turkey. It is also one of the key amino acids for proper brain functioning, enabling the production of three neurotransmitters essential for mental balance: dopamine, norepinephrine and epinephrine.
SAM-e: S-adenosylmethionine, or SAM-e, is a chemical compound formed from the amino acid methionine and present in protein-rich foods, as well as in our bodies and brains. Low levels of SAM-e have been associated with depression, fibromyalgia, osteoarthritis and liver disorders. SAM-e has been prescribed in Europe for more than 20 years to treat depression and arthritis pain. It was approved as an over-the-counter dietary supplement in the U.S. last March.
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