The supplement aisle is full of anxiolytics, antidepressants, and sleep aids. Some work, and some are risky.
STUDY: Căuș MN et al, Pharmaceuticals 2026;19:399
STUDY TYPE: Narrative review
FUNDING: Independent
Background
There are two types of supplements. Nutraceuticals are natural to the body — vitamins, minerals, and antioxdiants that are essential to health. Then there are phytochemicals — extracts of herbs and plants that aren’t natural to the body. Some of these have a reassuring track record as part of the diet, like ginger and saffron, but on the whole these are riskier than nutraceuticals and are more in league with medications. Indeed, many psych meds were derived from herbs, like bupropion (Wellbutrin), valproate (Depakote), and varenicline (Chantix).
This review looked at safety signals with popular herbal supplements like St. John’s Wort, ashwagandha, valerian, kava, passionflower, saffron, and turmeric (curcumin).
Results
Several supplements have solid evidence to work. St. John’s Wort matched fluoxetine and citalopram for mild-to-moderate depression in randomized trials — with better tolerability than paroxetine. Passionflower performed comparably to oxazepam for generalized anxiety and preoperative anxiety, with less work impairment. Valerian matched oxazepam for insomnia. Ashwagandha reduced stress and improved sleep in a 90-day double-blind trial. Saffron outperformed placebo for both depression and anxiety.
But the risks are real. St. John’s Wort is a potent CYP3A4 inducer — it lowers plasma levels of benzodiazepines, antidepressants, and antipsychotics, and can trigger serotonin syndrome when combined with SSRIs. Kava can damage the skin and carries a well-documented hepatotoxicity risk, including cases requiring liver transplant. Ashwagandha has been linked to cholestatic liver injury. Passionflower has caused QT prolongation. Valerian overdose has caused encephalopathy.
Adulteration adds another layer of risk. The FDA identified undeclared pharmacologically active substances — including benzodiazepines, fluoxetine, and stimulants — in nearly two-thirds of flagged supplement products.
Practice Implications
- Herbs are like medications. The US should follow other countries in demanding proof of safety and efficacy as they do with meds.
- Short of that, we can benefit from herbs that are approved in other countries, like lavender (Silexan) for anxiety.
- Herbs contain many chemicals, and finding a research-grade supplement is difficult. Look for products certified by independent groups like Consumer Lab, United States Pharmacopeia (USP), NSF International, and Lab Door. I’ve lab-tested products here.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
What’s Your Take? Share in Comments
- Are there herbs you’d stay away from because of risks?
- Have you seen benefits with particular herbs?
