Natural Herbal Supplements for Anxiety
For mild-to-moderate anxiety, melatonin, passiflora (passionflower), and lavender are the safest first-line herbal options with minimal drug interactions, while kava shows the strongest anxiolytic efficacy but carries significant safety concerns requiring careful consideration. 1
Highest Safety Profile Supplements (Recommended for Polytherapy Patients)
The American College of Cardiology identifies three herbal supplements with well-documented safety profiles and minimal pharmacological interactions: 1
- Melatonin: Reduces anxiety comparable to midazolam with excellent safety in patients taking multiple medications, can be continued without interruption 1
- Passiflora (Passionflower): Well-documented anxiolytic effects with favorable safety profile, safe for continuation in polytherapy 1
- Lavender: Effective for anxiety treatment including preoperative anxiety, no evidence of clinical interactions with sedatives or anesthetics 1
Moderate Safety Profile (Use with Caution)
- German Chamomile: Modest but significant anxiety reduction, no documented CNS interactions with other medications 1
- Valerian: Safe profile with potential cognitive protection, though evidence for anxiety is inconsistent 1, 2
- Hops: Improves sleep with no documented perioperative adverse effects 1
Strongest Efficacy Evidence (But Higher Risk)
Kava (Piper methysticum) has the most robust clinical trial evidence for anxiolytic activity, with independent replications demonstrating efficacy beyond reasonable doubt 3, 4. However, kava requires careful risk-benefit assessment: 1, 4
- Must be suspended 2 weeks before any surgical procedure due to additive/synergistic effects with anesthetics, benzodiazepines, and opioids causing excessive sedation 1
- Short-term use in mild-to-moderate anxiety shows greater potential benefit than harm 2, 4
- Not appropriate for patients on polytherapy or those requiring sedating medications 1
Additional Options with Clinical Evidence
- Bacopa monniera: Anxiolytic effects demonstrated, particularly in patients with cognitive decline 5, 3
- Ginkgo biloba: Some support for anxiety disorders in clinical trials 5
- Rhodiola rosea: Evidence for treating range of anxiety disorders 5
- Melissa officinalis (Lemon balm): Acute anxiolytic activity demonstrated, but must be suspended 2 weeks before procedures due to CNS depression risk with sedatives 1, 5
Supplements to Avoid
St. John's Wort should be suspended 2 weeks before any procedure and avoided in polytherapy due to cytochrome P450 3A4 induction, which reduces plasma concentrations of numerous medications 1. Current evidence does not support its use for anxiety disorders 5, 2.
L-tryptophan must be suspended 24 hours before procedures due to serotonin syndrome risk when combined with serotonergic medications 1.
Saffron carries serious safety concerns, with the World Health Organization warning of adverse hematological reactions in a large number of patients during treatment 6.
Critical Safety Considerations for All Herbal Supplements
The European Society of Cardiology and American Heart Association recommend: 1
- Monitor patients taking anticoagulants, antiplatelets, antidiabetics, or cardiovascular medications when adding natural products 1
- Start with low doses and gradually titrate 1
- Document all natural products in medical records as part of medication reconciliation 1
- More than 80% of severe adverse reactions are dose-dependent and predictable (Type A), therefore avoidable 1
Clinical Algorithm
For patients NOT on polytherapy with mild-to-moderate anxiety:
- First-line: Lavender, passiflora, or melatonin 1
- Second-line: Kava for short-term use (monitor closely) 3, 4
For patients ON polytherapy or multiple medications:
- Recommended: Melatonin, passiflora, or lavender only 1
- Avoid: Kava, St. John's Wort, lemon balm, L-tryptophan 1
For patients requiring surgical procedures: