What natural products can help with anxiety?

Natural Products for Anxiety

Based on the strongest guideline evidence, lavender supplementation and passionflower are the most well-supported natural products for anxiety, with melatonin showing efficacy specifically for preoperative anxiety. 1

Recommended Natural Products

Lavender (Silexan)

• Lavender supplementation has demonstrated efficacy and safety for treating anxiety, including in preoperative settings 1
• The 2021 Mayo Clinic/SPAQI guidelines recommend continuing lavender perioperatively with no clinical evidence suggesting it potentiates anesthetic effects 1
• Lavender essential oil inhalation may be offered during cancer-related diagnostic and treatment procedures, though evidence quality is low 1
• A 2022 network meta-analysis found Silexan (lavender oil) showed significant anxiety reduction (mean difference: -3.84) and may also benefit depression and insomnia 2

Passionflower

• Primarily known for anxiolytic effects with a good safety profile 1
• Has been studied in the perioperative setting and demonstrated anxiety reduction 1
• The SPAQI consensus recommends continuing passionflower through surgery 1

Melatonin

• A Cochrane review concluded preoperative melatonin reduces anxiety compared to placebo and may be as effective as midazolam 1
• Available evidence demonstrates melatonin is safe in the perioperative period 1
• However, evidence is inconclusive for anxiety in cancer patients, with trials showing no impact when anxiety was a secondary outcome 1

Provisionally Recommended Natural Products

Ashwagandha (Withania somnifera)

• Modestly supported for anxiety disorders (++) in the 2022 WFSBP/CANMAT guidelines 3
• A 2022 network meta-analysis found it efficacious (mean difference: -4.90) but noted small sample sizes as a limitation 2

Saffron

• Provisionally recommended (++) for unipolar depression in the 2022 WFSBP/CANMAT guidelines 3
• Showed promise in separate network analyses despite not reaching significance in summary networks 2
• One positive low-risk-of-bias trial using 30 mg saffron for anxiety in cancer patients 1

Galphimia glauca

• Weakly recommended (+) for anxiety disorders 3
• Exhibited same anxiolytic effect as standard treatments but lacks high-quality trials 2

Not Currently Recommended

Kava

• Should be held 2 weeks before surgery as it may act additively or synergistically with anesthetics, benzodiazepines, and opiates causing excessive sedation 1
• Found effective as an anxiolytic (mean difference: -2.46) but possibly ineffective specifically in generalized anxiety disorder 2
• Not recommended (-) for generalized anxiety disorder in the 2022 WFSBP/CANMAT guidelines 3

Chamomile

• Not currently recommended (+/-) for generalized anxiety disorder 3
• Insufficient evidence to confirm effectiveness, with one negative trial of chamomile tea in cancer patients 1
• Network meta-analysis showed no significant benefit compared to placebo (mean difference: 0.54) 2

Valerian

• Not supported for any anxiety disorder based on current evidence 4
• Insufficient evidence to confirm effectiveness (mean difference: 0.95) 2

St. John's Wort

• Physicians should not encourage use for anxiety treatment based on small or inconsistent effects 5
• Not supported for anxiety disorders despite efficacy in depression 4

L-theanine

• Did not outperform placebo for anxiety treatment (mean difference: -0.49) 2

Important Safety Considerations

Lemon Balm

• Hold 2 weeks before surgery 1
• Evidence suggests combination with sedatives or alcohol may result in additive CNS depression 1

Panax Ginseng

• Hold 2 weeks before surgery 1
• Potential for hypoglycemia when combined with diabetic medications 1
• Concern for increased bleeding 1
• One positive trial of fermented red Panax ginseng extract but one negative trial of white P. ginseng extract with significant dose variation 1

Kratom

• Discontinue - SPAQI does not recommend use 1
• Opioid- and stimulant-like properties with withdrawal syndrome if taking >5-15 g per day 1
• Chronic use may lead to neurologic effects including seizures 1
• FDA warns against use 1

Clinical Pitfalls

• Quality and standardization of phytoceuticals is a key limiting issue - ensure products are from reputable sources with standardized extracts 3
• Most evidence comes from studies with small sample sizes and brief intervention durations - temper expectations accordingly 1, 2
• Nutraceuticals and phytoceuticals should be used adjunctively within standard medical care, especially in severe mental illness 3
• Many natural products have potential drug interactions - particularly those metabolized through CYP3A4 and CYP2D6 systems 1
• Perioperative management requires specific timing - most supplements with sedative properties should be held 2 weeks before surgery to avoid excessive sedation 1