What supplements are effective for treating anxiety?

Supplements for Anxiety

Lavender, passionflower, and melatonin are the only supplements with sufficient evidence supporting their safe use for anxiety, while most other supplements should be avoided or used with extreme caution due to lack of efficacy data or significant safety concerns. 1

Evidence-Based Supplements That Can Be Recommended

Lavender

• Lavender supplementation has demonstrated efficacy and safety for treating anxiety, including in preoperative settings, with no clinical evidence suggesting it potentiates anesthetic effects or causes significant adverse events. 1
• Can be continued even in high-risk perioperative contexts, indicating a robust safety profile 1

Passionflower

• Primarily known for anxiolytic effects and has been studied in perioperative settings, demonstrating anxiety reduction with a good safety profile. 1
• Strong evidence exists for passionflower-containing herbal supplements as treatment for anxiety symptoms and disorders 2

Melatonin

• A Cochrane review concluded that preoperative melatonin reduces anxiety compared to placebo in adults and may be as effective as midazolam. 1
• Available evidence demonstrates melatonin is safe in the perioperative period and may decrease delirium in hospitalized elderly patients 1
• Can be continued without interruption even before surgery 1

Supplements With Limited or Insufficient Evidence

Kava

• May have short-term benefits for mild to moderate anxiety 3
• However, kava should be held 2 weeks before any surgical procedure due to concerns about additive or synergistic effects with anesthetics, benzodiazepines, and opiates causing excessive sedation. 1
• The risk-benefit profile limits its routine recommendation

Chamomile (German)

• An RCT found modest but significant reductions in anxiety with chamomile extract 1
• No data suggest CNS effects that would interfere with anesthesia, and it can be considered for continuation 1
• Evidence is weaker compared to lavender, passionflower, and melatonin

Inositol

• Has been found to have modest effects in patients with panic disorder or obsessive-compulsive disorder 3
• Insufficient evidence for generalized anxiety disorder 4

L-lysine and L-arginine Combinations

• Strong evidence exists for combinations of L-lysine and L-arginine as treatments for anxiety symptoms 2
• However, L-arginine alone should be held 24 hours before surgery due to increased nitric oxide production and potential intraoperative hypotension 1

Supplements That Should NOT Be Recommended

St. John's Wort

• Physicians should not encourage use of St. John's wort for anxiety treatment based on small or inconsistent effects in studies. 3
• St. John's wort monotherapy has insufficient evidence for use as an effective anxiolytic treatment 2

Valerian

• Should not be encouraged for anxiety treatment due to small or inconsistent effects. 3
• Insufficient evidence to support routine use 2

Lemon Balm

• Should be held 2 weeks before surgery due to evidence suggesting combination with sedatives or alcohol may result in additive CNS depression 1
• Insufficient evidence for routine anxiety treatment

Kola Nut and Guarana

• Should be held 2 weeks before any procedure 1
• Contain significant caffeine (2-3% in kola nut) and may interfere with diabetes control 1
• May inhibit platelet aggregation through caffeine-mediated processes 1

Kratom

• SPAQI does not recommend use of this supplement and advises discontinuation. 1
• Has opioid- and stimulant-like properties with withdrawal syndrome risk and potential neurologic effects including seizures 1
• The FDA warns against use 1

Critical Clinical Algorithm

For patients seeking supplement recommendations for anxiety:

1. First-line supplement options: Recommend lavender, passionflower, or melatonin based on patient preference and specific anxiety context 1, 2

2. If patient is already taking other supplements: Review the complete list and discontinue kratom immediately, hold kava/lemon balm/kola nut/guarana for 2 weeks if any procedures planned 1

3. Always emphasize: Supplements should complement, not replace, evidence-based first-line treatments (SSRIs/SNRIs and cognitive behavioral therapy) which have substantially stronger evidence 5, 6

4. For patients preferring "natural" approaches: Explain that cognitive behavioral therapy is non-pharmacological with large effect sizes (Hedges g = 1.01 for GAD) and should be prioritized over supplements 5, 6

Important Safety Considerations

• Most herbal supplements lack adequate safety and efficacy studies, and the FDA can only take action after products are marketed if found unsafe or making false claims. 4
• Any positive effects seen with supplements may be partially due to placebo effect, which can have significant psychological impact on participants with mental disorders 2
• Reported side effects with evidence-based supplements (lavender, passionflower, melatonin) are mild to moderate 2
• Patients should be counseled that dietary supplements are not intended to treat, diagnose, prevent, or cure disease per FDA regulations. 4

Common Pitfalls to Avoid

• Do not recommend supplements as monotherapy when evidence-based treatments (SSRIs/SNRIs, CBT) are available and appropriate 5, 6
• Do not assume "natural" means safe—many supplements have significant drug interactions and perioperative risks 1
• Do not fail to ask about supplement use preoperatively, as many require 2-week discontinuation 1
• Do not recommend magnesium-containing supplements or other herbal combinations for anxiety until more research establishes efficacy 2