Friday, 23 January 2015

Herbs And Mental Health

This title is a bit broad and clearly I won't be covering the entire topic of mental health and herbs in one fell swoop.  Nonetheless this was an issue which sometimes arises regarding clients.  Some quasi-sceptical people might in fact argue that a mental health problem is a sine qua non of going to see a herbalist as it would betray a flawed understanding of reality and a delusional perception of the efficacy of herbal remedies.  Cognitive dissonance of course assures that I do not share this opinion.

Even so, it is the case that a lot of my patients present having been diagnosed (see why this blog would be better in Latin?  Diagnosatae  says "having been diagnosed" in one word and indicates that they are plural and all female - obviously not all subsets of my patients are exclusively female) with mental health conditions and like many other patients are also taking medication prescribed by their GPs with which I don't interfere.  Sometimes they may be diagnosed during the time they're seeing me, obviously not by me but by someone else, and start taking, for example, anti-psychotics or anti-depressants.

For now I want to leave aside the thorny question of the nature of mental illness and just temporarily settle with the idea that there are people who are on medication which will change their behaviour, for instance make it less likely that they will kill themselves while not sedating them out of waking consciousness.  In particular with monoamine oxidase inhibitors (MAOIs), a class of antidepressant, there has been an issue that if someone takes something else at the same time, such as St John's Wort, there is a widely-perceived risk of danger to life from physically-based pathological processes.  This could also be turned round of course, and the insistence could be made that the risk is from the MAOIs rather than the Hypericum perforatum,

 so there is a bit of an issue there about what counts as the default, unmarked state and what counts as outside the norm, so to speak.  Another issue is like the one you find with this stuff:

Grapefruit juice of whatever colour, along with some other Citrus fruits and pomegranates, inhibits the activity of a liver enzyme called CYP3A4, which is part of what's known as the cytochrome P450 system, responsible for oxidising substances so that their properties change and they can be excreted more easily and safely.  The liver does a lot of this, and CYP3A4 is just one example.

"Trifolium pratense 0522" by 池田正樹 (talk)masaki ikeda - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons -

Trifolium pratense is substantially broken down by it, although since it's a herb rather than a purified drug that probably wouldn't apply to everything in it.  I am currently using this very fact to reduce the breakdown of trifoliol, an oestrogen from that plant, in my own body. It does have a lot of drug interactions, including some used for psychiatric conditions.  It will generally lead to an increase in the plasma levels of the compound concerned, so it is potentially risky, and this is the kind of possible interaction we should all be wary of, so it is sensible to take care.

A dead white male - Hippocrates in this instance

It is indeed.  It now gets rather complicated because of the following quote attributed to the Father of Medicine, Hippocrates:  "Let food be your medicine and medicine your food".  Food is also medicine.  It gets absorbed and processed, and its constituent parts broken down by the liver and eliminated just like medicine does, and so there can, as grapefruit indicates, be drug interactions just as much with food as there can between herbal remedies and purified drugs.  Two examples are the anticoagulant drug warfarin, which works because it looks to the body a bit like vitamin K but doesn't work like it, and antifolates, which are drugs used against cancer, malaria and some other conditions which again work by being mistaken for a vitamin but not being able to perform the same function in the body, this time folic acid.  Incidentally, it's not hugely surprising that the same drug can be used against cancer cells and malaria since malaria is an animal-like single-celled organism, so these are "cytotoxic" drugs.  If you have to attack cells, which with malaria you do because that's all it is, you can sometimes target part of the cell which doesn't exist in human cells but if it's more general, that attack might well also kill cancer cells.  That's a digression though.

Suppose a patient has been sectioned and is now in a mental health ward.  Certain aspects of their life and environment will of course be fairly tightly controlled.  For example, they probably won't be drinking alcoholic beverages.  That particular drug is out of the picture for them.  However, some of them will undoubtedly be consuming, for example, caffeine, a drug which has obvious effects on mental health, for instance generalised anxiety disorder and panic attacks, among other things.  Nicotine is another one.  Tobacco use has been seen as a form of self-medication.  It's no longer clear to me whether psychiatric in-patients are permitted to smoke, but as a former cleaner of mental hospital ceilings it's entirely clear to me that they used to do it in droves, and a common request of patients at that time (the mid-'80s) was for a cigarette.  Tobacco smoke contains MAOIs, so that raises some interest for a start.

Suppose, further, that this patient has a cough, possibly linked with their self-medication from tobacco.  I might offer them Glycyrrhiza glabra and Althaea officinalis, which are licorice and marsh mallow, both soothing expectorants, both used as sweets.  A member of staff might object to the use of these herbs because they perceive there to have been insufficient research on them, although that is not in fact so - I don't want to go into that here.  Having said that, I would be prepared to bet that at some point a patient on antidepressants, anxiolytics or antipsychotics has eaten copious quantities of licorice and marsh mallow without ill-effects.  Marsh mallow is less likely because of the perverse tendency of confectioners to use gelatin instead of marsh mallow itself to make it nowadays, but it has very probably taken place at some point.

(Thanks for the mug Emma).

There will also be psychoactive components in patients' diets, often in very large amounts, such as gluten.  This like other compounds will vary in psychoactivity according to the patient, often unpredictably.  It's inconsistent not to allow the use of prescribed herbal remedies of particular species - not all of course - and yet to allow the use of coffee, tea, tobacco, garlic, licorice and ginger, which I strongly suspect does take place.

The question also arises of how well the categories of psychoactive and physical even work for herbs.  Some herbs clearly do have a direct and very clear effect on the mind, such as Nicotiana (tobacco), Coffea (coffee) and Cannabis.  However, consider some other herbs.  Suppose you have an emotional element premenstrually and you use an oestrogenic herb such as Trifolium pratense (again!) to address that.  That will change your mood.  Suppose there is an element of iron-deficiency anaemia contributing to your depression.  In that case, herbs rich in iron such as Urtica (nettle) or Petroselinum (parsley) would be psychoactive because they will provide iron and might address anaemia and therefore depression.  Suppose I then bung a bitter in like Erythraea  and more of the iron is absorbed.  That would possibly address the depression more effectively.  Or, someone with an underactive thyroid due to iodine deficiency might also be depressed and Fucus, being high in iodine, could address that too. On the other hand, a particular herb might not suit someone or there might be no thyroid or iron-deficiency connection to the patient's depression.  More abstractly, someone who once took LSD once took Xanthoxylum from me, and the oddness of the experience of tasting it (it makes the tongue tingle) triggered an acid flashback.  Similar associations might exist between the taste of culinary herbs and spices and past experience - they could for instance induce a sense of well-being due to nostalgia about the time you had that curry your dad always used to make you when you were a child, or it might bring less happy memories.  In certain circumstances, almost any herbal remedy could be psychoactive.

The remedies I mentioned above for a sectioned patient with a cough are expectorants although licorice in particular has other marked actions.  They may or may not have interacted with the patient's medication, but that interaction is not confined to something which happens to be deliberately prescribed by a herbalist as a herbal remedy.  It also applies to other substances which even a sectioned patient will be exposed to.  Scores of such substances are ingested every day in such circumstances.  Moreover, everyone is an individual and has her own personal history.  Maybe she would remember that curry with fondness and that would improve her mood.  Given that, asking for remedies to be controlled in this way makes little sense.  It is of course sensible to be cautious about what something does to the liver.  Karela, also a popular South Asian vegetable, is bound to have a major effect there and will be found in some curries because of its bitterness, for example.  I am finding my own body exhibiting the bitter reaction while I am typing this, which is another factor as it means the trifoliol will now be declining more rapidly than previously.  Sectioned patients are at least as subject to this kind of process as I am and often probably more so.  Therefore it makes no sense to restrict the intake of certain herbal remedies in those circumstances unless there is a similar restriction of food and other ingredients, and that doesn't, on the whole, seem to happen.