A Crash Course in Chinese Herbology for the Psychopharmocological Prescriber

Transcription

1 Experimental and Clinical Psychopharmacology 2009 American Psychological Association 2009, Vol. 17, No. 6, /09/$12.00 DOI: /a A Crash Course in Chinese Herbology for the Psychopharmocological Prescriber Kathryn P. White California School of Professional Psychology of Alliant International University and David Geffen School of Medicine at the University of California, Los Angeles Given the unparalleled popularity of botanicals in the United States, it is safe to say that almost every psychopharmacological prescriber will see some patients using Chinese herbs. Data show that between 36% and 42% of Americans use complementary and alternative medicine (CAM) each year and that persons suffering from depression and anxiety (67%) use CAM services significantly more than do their nonanxious and nondepressed counterparts (39%). This article gives an overview of several classical Chinese medical single herbs and herbal formulas commonly used for persons with psychiatric disorders and discusses some of the herbs that have the potential to interact with various pharmaceutical drugs. In addition, the article reviews scientific evidence and, at times, the lack thereof to validate the use of Chinese herbs and formulas in treating psychiatric conditions. Overall, the article seeks to prepare the pharmacological prescriber for working with patients concomitantly taking psychiatric medications and Chinese herbs. Keywords: Chinese medicine, herbs, botanicals, CAM Given the unparalleled popularity of botanicals in the United States, it is safe to say that almost every psychopharmacological prescriber will see some patients using Chinese herbs. Data show that between 36% and 42% of Americans use complementary and alternative medicine (CAM) each year (Austin, 1998; Barnes, Bloom, & Nahin, 2008; Barnes, Powell-Griner, McFann, & Nahin, 2004; Eisenberg et al., 1998; National Institutes of Health, 2004), a number that soars to 62% if prayer for health conditions is included in the definition. Topping the list of problems for which patients use CAM are conditions frequently treated by psychologists, including various pain disorders and depression and anxiety (Barnes et al., 2004; Eisenberg et al., 1998). In fact, persons suffering from depression and anxiety (67%) use CAM services significantly more than do their nonanxious and nondepressed counterparts (39%; Austin, 1998). A recent national survey indicated that over 38 million adults (18.6%) in the United States commonly used herbs to benefit their health in 2002 (Tindle, Davis, Phillips, & Eisenberg, 2005), up from 15% in 1997 (Eisenberg et al., 1998). A subset of these herbal consumers it is not known how many take Chinese herbs in tea, pill, tincture, Kathryn P. White, California School of Professional Psychology, Alliant International University, and David Geffen School of Medicine, University of California, Los Angeles. Dr. White is licensed as a clinical psychologist and as an acupuncturist, and board-certified in Chinese Herbology by the National Certification Commission for Acupuncture and Oriental Medicine. An earlier version of this article was presented to the American Psychological Association, Boston, Massachusetts, on August 16, Correspondence concerning this article should be addressed to Kathryn P. White, California School of Professional Psychology, Alliant International University, 1000 S. Fremont Ave., Unit 5, Alhambra, CA kwhitephd@earthlink.net capsule, or powdered forms. Chinese herbs are sold in health food stores, grocery stores, truck stops, convenience stores, specialty Chinese herb shops, on the worldwide web, and of course, in the offices of licensed acupuncturists, doctors of Oriental medicine, naturopaths, chiropractors, and some integrative physicians. This article is designed to prepare psychopharmacological prescribers to communicate with consumers of Chinese herbs and to be able to assess the primary issues associated with concomitant use of herbs and prescription drugs. History of Chinese Herbalism Chinese medical herbology originated long before recorded history. The earliest extant text in Chinese herbal medicine, The Divine Farmer s Materia Medica (Shen Nong s Ben Cao Jing), blended magic and herbs to address psychiatric disorders. It was reportedly composed and transmitted via oral traditions around 2800 B.C. and written down prior to the 3rd century A.D. (Yang, 1998). The most famous Chinese medical text, The Yellow Emperor s Inner Classic (Huang Di Nei Jing), which reflects centuries old oral traditions, finally compiled in writing between 25 and 220 A.D., dedicates half of its scrolls to the treatment of the mind and spirit, proclaiming that all diseases are rooted in spirit. Classical Chinese medicine comprises a vast number of schools and traditions, each featuring its own therapeutic approaches to the treatment of persons with psychological disorders. By the 14th century A.C.E., psychiatry was a well-known specialty, among the 22 medical specialties that existed at that time (Flaws & Lake, 2001; Unschuld, 1988). The post cultural revolution, communist-based traditional Chinese medicine (TCM), however, de-emphasized psychological aspects of the medicine along with facets 384

2 HERBS AND PHARMACEUTICALS 385 considered superstitious and religious. Committees of practitioners from various specialties and traditions, whose theories and techniques often diverged significantly from each other, developed TCM. They were brought together to develop a party-line medicine that could be taught to barefoot doctors in the villages as well as at the newly forming traditional Chinese medical schools. The assortment of traditions that became TCM is tantamount to what might occur if the U.S. government insisted we develop a party-line American psychology, blending dream interpretation from psychoanalysis, double-chair techniques from Gestalt, thought stopping and thought replacement from cognitive therapy, and classical conditioning. However, TCM still boasts a number of formulas for various psychiatric disorders and addresses major disturbances that would prevent people from performing in the factories and fields of the People s Republic of China. TCM is the most prevalent form of Chinese medicine practiced in the United States, but it is not the only form. Growing numbers of practitioners are learning the much-more psychologically sophisticated, pre- Cultural Revolution medicine, known as classical Chinese medicine (CCM), as well as traditions based on classical Chinese medicine that developed in Japan, Korea, England, Vietnam, and France (White, 2000). Chinese herbs currently are sold in the United States as supplements under the Dietary Supplement Health and Education Act (DSHEA), which allows structure and function claims to be made about herbs but excludes claims that herbs cure disease (U.S. Food & Drug Administration, 1994). Chinese Herbs and Formulas Chinese herbal materia medica comprises not only plant materials but also animal and mineral products, all of which are lumped under the term herbs (J. K. Chen & Chen, 2004). While analysis of Western medications focuses upon the chemical composition and resulting biochemical effects, Chinese medical herbalism bases its materia medica on the observed clinical effects of taking the herbs or herbal combinations over thousands of year of clinical experience without the benefit of biochemical analysis. In choosing herbs, practitioners of CCM synthesize multiple diagnostic findings within complex theoretical paradigms. Chinese herbal medical traditions diverge significantly from Western herbology in that the Chinese herbalism uses multiherb combinations; attends to the tastes, temperatures, and meridians that the herbs are said to enter; and boasts a millennia-old science as to which herbs potentiate, antidote, and are incompatible with others. In Chinese herbal formulas, certain herbs are designed to enhance the therapeutic effects of the principle herbs, while additional ones may be used to modulate particular qualities of other herbs (J. K. Chen & Chen, 2004). Chinese medical herbalism additionally uses its own diagnostic methods and ways of conceptualizing disorders, be they psychological or physiological in nature, to discern which herbs and herbal formulas are indicated. While these methods vary somewhat from tradition to tradition or from specialty to specialty, the diagnostic methods and syndromes diverge significantly from those in the West. For example, a Western diagnosis of Major Depressive Disorder may present as any 1 of 10 commonly seen patterns of disharmony in TCM, each of which is addressed with different treatment strategies and representative herbal formulas, while a Chinese medical pattern known as blood stasis could underlie the clinical presentations of such diverse conditions as congestive heart disease, gynecological disorders, generalized anxiety disorders, major depression disorders, migraine headaches, and lower back pain. To conduct valid research in the way that Chinese herbalism is actually practiced, both Chinese and Western systems of diagnosis need to be used (White, 2000). Chinese herbalism considers the tastes, temperatures, and meridians that the herbs are said to enter, in creating formulas that balance these features to fit particular therapeutic strategies. Natural sweet-tasting herbs, typically containing amino acids and saccharides (Liu, Xu, & Wang, 2003; Yeung, 1996) are said to moisten, harmonize, tonify, and strengthen in moderation, although excessive amounts of sweet-tasting herbs (or foods) can lead to edema and phlegm physically (J. K. Chen & Chen, 2004) and to anxiety and confusion psychologically (Yuen, n.d.). Spicy and pungent herbs, typically featuring volatile oils, either disperse pathogenic factors on or to the exterior, or descend and activate peristaltic activity (Liu, Xu, & Wang, 2003; Yeung, 1996; Yuen, n.d.). Bitter-tasting herbs, usually containing alkaloids and glycosides (Liu, Xu, & Wang, 2003), promote exocrine secretions and contribute, with spicy herbs, to the stimulation of tubular muscles to induce peristalsis. Many bitter-tasting herbs contain cardiac glycosides that powerfully stimulate heart functioning, creating toxicity in high concentrations (Liu, Xu, & Wang, 2003; Yeung, 1996). However, some bitter-tasting herbs, according to Chinese medicine, can lower cholesterol and triglyceride levels and increase metabolism by fine-tuning the calibration of the transition times of digestion with digestive enzymes, stimulating gastric acid and bile production (Yeung, 1996; Yuen, n.d.). They are also said to purify and cleanse the blood and clear toxic inflammatory and infectious conditions. An old Chinese medical proverb states, Take bitter herbs to overcome the bitterness of life (Yuen, n.d.). Sour-tasting herbs, often containing organic acids and tannins (Liu, Xu, & Wang, 2003), astringe abnormal secretions, including excessive sweating, hemorrhages, seminal emissions, leucorrhea, and menorrhagia (J. K. Chen & Chen, 2004; Yeung, 1996). Salty herbs, comprising inorganic salts (Liu, Xu, & Wang, 2003), can lead the therapeutic action of herbs to the constitution and soften or break up tumors or fibroids (J. K. Chen & Chen, 2004; Yeung, 1996; Yuen, n.d.). Warm herbs generally promote metabolic activity, while cold herbs reduce it and cool off inflammatory processes (J. K. Chen & Chen, 2004; Liu, Xu, & Wang, 2003; Yeung, 1996; Yuen, n.d.). The acupuncture meridians or channels assigned to the herbs demonstrate CCM s bioenergetic approach to the use of plant medicines and help Chinese medical herbalists know which herbs affect various organs and parts of the body. In terms of psychological phenomena, herbs and treatments can be aimed at shifting

3 386 WHITE (a) our moods (Gan), which reflect our instinctive and reflexive responses to phenomena and how we posture ourselves in the world; (b) one or more associate herbs that enhance the effects and treat accompanying causes and symptoms; (b) (c) our emotions (Qing), which, to the Chinese, are always mediated by learning and cognition, even though the emotions may have been learned early in our lives without conscious memory of the events prompting the associations; or our temperaments (Xing), our in-born or inherited emotional dispositions (Yuen, n.d.). To affect the moods, CCM herbalists use plants assigned to the lung and liver primary channels; to influence emotions, they use herbs entering the heart, pericardium, and spleen pancreas channels; and to stimulate changes in temperaments, they use herbs addressing the kidney and tripleheater channels. The meridians assigned to herbs also are used to affect various body parts. For example, the herb Radix (Rx) Angelica Dahurica (Bai Zhi), assigned to the stomach and lung channels, opens the frontal zone of the head to treat sinus headaches. (The stomach primary channel goes to the nasal and forehead areas, and the lung primary channel is said to open to the nose.) By contrast, Rhizoma (Rz) and Rx Ligusticum sinensis (Gao Ben) treats headaches in the vertex and in the occipital lobe, areas traversed by its assigned meridian, the urinary bladder primary channel. Rx Bupleurum (Chai Hu) ameliorates headaches in the temporal region, navigated by one of its assigned meridians, the gall bladder primary channel (J. K. Chen & Chen, 2004; Liu, Xu, & Wang, 2003; Yeung, 1996; Yuen, n.d.). Composition of a Chinese Herbal Formula Chinese herbal formulas feature: (a) a principle or king herb that produces the primary effects, treating the chief causes and symptoms of the disorder; and (c) (d) one or more adjunctive herbs that (i) assist the principle and assistant herbs in enhancing their therapeutic effect, treat less important symptoms by themselves, or modulate the effects of other herbs, (ii) reduce the toxicity of the principle or assistant herbs to prevent side effects, or (iii) modulate the effects of the principle herb, often showing opposite properties. guiding or mediating herbs that lead the herbs to the affected areas or channels, or coordinate the effects of the various therapeutic strategies contained in the formula (J. K. Chen & Chen, 2004; Liu, Xu, & Wang, 2003; Yeung, 1995, 1996; Yuen, n.d.). Preparation of Chinese Herbs Consumers can find Chinese herbs prepared in numerous ways. Herbal preparations available in the United States include bulk herbs, teas, tinctures, fluid extracts, powdered extracts, pills, tablets, and capsules, to name a few. While Chinese herbs historically were almost always brewed from several minutes to up to an hour in decoction form and drunk as teas, or powdered and made into pills for ingestion or pastes for external applications, major improvements in the extraction and concentration processes and the ease of use of tinctures, pills, powders, and capsules have led to their popularity in the United States and elsewhere (J. K. Chen & Chen, 2004; Werbach, 2000; Liu, Xu, & Wang, 2003; Yeung, 1995, 1996). Table 1 provides definitions of terms for various forms of herbal preparations. In working with extracts, herbalists determine potencies in terms of either concentrations or content of active principles. Table 1 Types of Herbal Preparations Form Definition Extraction Concentrated form of herbs made by mixing crude herbs with solvents (such as alcohol & water). Decoction Liquid concentration made by brewing herbs in water for up to an hour. Water is the solvent. Infusion Liquid concentration obtained from steeping the herbs (or herbal tea bags) in hot water (Werbach, 2000). Tincture Liquid concentration obtained from soaking herbs in alcohol, typically rice wine or white wine, and water for hours to months (Yeung, 1996). Fluid extract Liquid concentration, more concentrated than tinctures, made by soaking the herbs in solvents such as vinegar, glycerin, or propylene, in addition to water and alcohol. Commercial fluid extract Liquid concentrations made by distilling off some of the alcohol by vacuum distillation and counter current filtration. Dry solid extract Powdered or granulated herbs achieved by grinding the extract (Werbach, 2000). Pills Pill or bolus made by mixing powdered herbs with wine, water, honey, vinegar, rice or flower pastes, or extracts from a decoction to form a small pill, which is typically easier to swallow, carry, or store than are herbs in some other forms (Yeung, 1996). Solid extract Herbs that have been diluted with alcohol and water to form a fluid extract or tincture (Werbach, 2000).

4 HERBS AND PHARMACEUTICALS 387 Tinctures generally features a 1:5 concentration of one part crude herbs to five parts solvent, while solid extracts generally use a 4:1 concentration of four parts crude herbs to make one part extract. With these proportions, the solid extract is 20 times (5 4) more potent than the tincture, provided that they both began with the same quality herbs. Concentrations of tinctures and solid extracts, however, can vary widely, with some tinctures using concentrations of up to 1:10 and some solid extracts using concentrations of up to 100:1. The potencies of extracts can also diverge significantly depending upon the particular raw herbs and the manufacturing techniques used. Herbalists must ascertain the concentrations used by their herb manufacturers and adjust dosages in herbal formulas accordingly. Analyzing known active principles is another way of determining strengths of herbal extracts. The standardized herbal preparations that are popular in Europe guarantee certain contents of active principles (Werbach, 2000). The process of preparing medicinal herbs begins when plants are collected in their natural habitats, which is called wild-crafting, or cultivated using farming practices. With wild-crafted herbs, it is especially important to use analytical techniques to make certain the right plants have been collected. With typical moisture contents of 60% to 80%, herbs have to be dried to moisture contents of less than 14% before they can be stored to prevent break down of compounds or infestation by microorganisms. Commercial dryers use mild temperatures of between 100 F and 140 F. If not performed during collection, portions of the plants used as herbs are next separated from other parts, dirt, and other matter, a process called garbling, which is usually accomplished by hand. The herbal parts of the plant are broken down into larger rough pieces or fine powders, a process called grinding. Raw Chinese herbs used in decoctions are ready for distribution at this point. Herbs used in extractions go through the extraction process after grinding, mostly with alcohol and water solutions as solvents but also with lipophilic solvents and hypercritical carbon dioxide. The resulting liquids typically are concentrated into solid or fluid extracts by evaporating the solvents. Some extracts are left as pure liquid extracts, while others are freeze-dried or spray-dried to make powders that can be placed in tablets or capsules. Solid extracts surpass tinctures and soft extracts in chemical stability because they are less subject to additional chemical reactions or contamination by microorganisms. A variety of means from simple observation of their sight, taste, touch, and smell called the organoleptic method to microscopic, physical, chemical, chromatographical, and nuclear resonance methods are used to examine herbs to ascertain their content. Microscopically, manufacturers may use stains or other media to study configurations of tissues and cell walls. Using physical methods, they may test for specific gravity, water content, or solubility. Chemically, they may evaluate proportions of active principles, proteins, alkaloids, flavonoids, vitamins, enzymes, fats, carbohydrates, ash, and essential oils. Nuclear magnetic resonance (NMR) and liquid chromatography can determine herbs unique chemical patterns. Standardized extracts approved by the European Economic Council (EEC) and the European Scientific Cooperative for Phytotherapy (ESCOP) go through 14 steps for quality control before they are registered, which in addition to most of the methods mentioned above include detailed pharmacological evaluation; studies on absorption, distribution, and elimination; assessment of toxicity; and clinical trials in humans (Werbach, 2000). Adverse Events With Chinese Herbs Chinese herbs are generally safe and effective, when prescribed by a knowledgeable practitioner according to the traditions in Chinese herbalism (Arnold, 2000). But adverse reactions to Chinese herbs can and do occur, attributed to myriad causes. People often take Chinese herbs without consulting a qualified herbalist and do so on a symptomatic basis, without understanding the underlying causes for their conditions from a Chinese medical perspective, thereby inviting difficulties. Patients treating themselves may exceed safe quantities, which can produce too strong a therapeutic effect and possible toxicity. Other adverse events occur from inadequate preparations of Chinese herbs by vendors or consumers not knowledgeable in the medicine. For example, raw Rz Pinellia is toxic if not heated, and raw Rx Aconite must be boiled for an hour to overcome its toxicity (J. K. Chen & Chen, 2004). Idiopathic adverse reactions also may occur, even when a well-trained herbalist prescribes mild herbs. Idiopathic adverse reactions are also known to occur with some drugs and some foods. Chan, Chan, Tomlinson, & Critchley (1994) reported two cases of generalized numbness after the patients ingested Rx Polygonum Multiflorum (He Shou Wu) and one case of angioedema from Chinese dates (Fructus Ziziphi Jujube; Da Zao). A few Chinese herbs are frankly toxic to the kidneys, to the liver, or to fetuses in utero although most of these herbs have been taken off the market in the West. Historically, for example, Cinnabaris (mercuric sulfide; Zhu Sha) and lead (Hei Xi) were used in special formulas. Prior to the discovery of penicillin, physicians in the West used mercury as well, to treat syphilis, for example. Between 1993 and 1998, more than 100 women suffered nephropathy when using Chinese herbs in a slimming regimen in Belgium, resulting in 30 deaths because of terminal renal failure (Vanhaelen, Vanhaelen-Fastre, But, & Vanherweghem, 1994; Vanherweghem, 1998). The toxicity was traced to the presence of aristolochic acid in the diuretic herb Rx Stephaniae Tetrandrae (Fang Ji), which has been removed from the market in Europe and the United States along with other herbs such as Caulis (Cs) Akebia (Mu Tong) and Rx Clematidis (Wei Ling Xian) containing aristolochic acid. The U.S. Food and Drug Administration released a statement in 2000 on its website citing aristolochic acid as a nephrotoxin and a potent carcinogen (U.S. Food & Drug Administration, 2000). The prepared formula, More Precious Than Gold (Jin Bu Huan), a popular remedy for insomnia and pain, was banned from the market in the United States and in the United Kingdom after some adults developed symptoms of hepatitis consistent with a drug reaction in (Jennes & Flaws, 2004). Some herbs processed into pill, powder, or

5 388 WHITE tincture forms in mainland China called patent formulas in Chinese herbalism have been found to include contaminants such as lead or even Western pharmaceuticals (Fratkin, 1998). However, most Chinese herbal manufacturers in the United States voluntarily test their herbs for contaminants, toxicity, pesticides, heavy metals, and microbial loads. Herb Drug Interactions Interactions occur when one or more herbs or drugs modify the bioavailability and clinical effectiveness of other substances, generally when they are taken concurrently. Herbs can and sometimes do interact with psychiatric drugs, displaying the same mechanisms that govern drug drug interactions. The interactions can either be pharmacokinetic in nature interfering with the absorption, distribution, metabolism, or excretion of the herbs or drugs or pharmacodynamic in nature, potentiating or antidoting the involved herbs or drugs. Absorption Absorption generally takes place in the intestines, where the herbs or drugs travel through the intestinal walls to reach the bloodstream. Herbs or drugs that increase intestinal motility such as Rz and Rz Rhubarb (Da Huang) and Cortex (Cx) Magnoliae Officinalis (magnolia bark; Hou Po) decrease the absorption of other herbs and drugs, whereas herbs that reduce intestinal motility Fructus (Fr) Corni (Shan Zhu Yu) or Fr Schizandra (Wu Wei Zi) boost the absorption of other herbs and drugs. Drugs or herbs that alter the ph of the stomach such as antacids, antipsychotics, or mineral herbs such as Concha Ostrae (oyster shell; Mu Li) or Os Draconis (Dragon Bone; Long Gu) generally reduce absorption. Chinese medical herbalists recommend that patients taking these kinds of drugs consume their herbs 2 3 hours later to allow their bodies to regain the gastric acidity for normal absorption. Distribution Distribution is the process by which drugs and herbs are transported, generally through the circulatory system, to different parts of the body, by being bound to a plasma protein and remaining inert while so bound and then released at specific sites. Most herbs and drugs do not appear to have significant interactions in terms of distribution, unless they have a narrow range of safety (J. K. Chen & Chen, 2004). The drug warfarin (Coumadin) interacts with various drugs, vitamins, herbs, and foods via different mechanisms either by enhancing its effectiveness and leading to prolonged bleeding or by decreasing its effectiveness and increasing risks of blood clots in the vessels, both of which may be quite dangerous to the patient. Patients taking warfarin need to be exceedingly cautious when taking herbs concurrently. It is extremely difficult to predict whether an individual herb will interact with warfarin because very few tests or experiments have documented such interactions, but herbalists generally avoid prescribing herbs or use them with great caution when patients are taking warfarin. Metabolism The liver metabolizes most herbs and drugs into inactive derivatives. The rate of metabolism establishes the time frame in which the substances remain active in the body. When Chinese medical herbalists learn that patients are taking drugs that speed up liver metabolism for example, anticonvulsants (Dilantin and Tegretol), some antibiotics (Rifadin), and phenobarbitals they generally increase the dosage of the herbs to maintain the same effectiveness. By contrast, when patients are using drugs that reduce the speed of liver metabolism such as alcohol, antifungals (e.g., Difucan, Sporonos, and Nizoral), antibiotics (e.g., Erythromycin and Tagamet), herbalists generally decrease the dosages to prevent adverse effects. An extract of the Chinese herb Angelica Dahurica (Bai Zhi), used in Chinese medicine to treat frontal headaches and early signs of colds and flus, has been found to interact pharmacokinetically with diazapam, inhibiting metabolism and delaying metabolism (Ishihara et al., 2000). Herbs that speed up metabolism, such as Rx Paeoniae Alba (white peony; Bai Shao Yao), can weaken the effectiveness of medications, and herbs that slow down metabolism, such as Fr Schizandra (Wu Zhu Yu), can boost the effectiveness, possibly leading to adverse effects. Elimination Elimination involves Phase 1 and Phase 2 detoxification processes of the liver and elimination through the kidneys. Herbs and drugs affecting elimination through the liver were discussed under the heading Metabolism. Drugs that damage the kidneys such as gentimicin and amphotericin B require that herbalists lower the dosages of the herbs to avoid unwanted side effects. Meanwhile herbs promoting diuresis such as Herba (Hb) Ephadrae (Ma Huang) or Sclerotium (Scl.) Poriae Cocos (Fu Ling) may speed up elimination, reducing the effectiveness of other herb and drugs. Pharmacodynamic interactions are much harder to predict than are pharmacokinetic interactions, and most are documented through actual case histories. J. K. Chen and Chen (2004) recommended that patients be monitored closely in terms of signs and symptoms and any abnormal reactions to prevent pharmacodynamic interactions, which may be additive or antagonistic. With the exception of documented cases, most herbalists speculate theoretically about possible pharmacodynamic interactions between herbs and drugs and choose their herbs and dosages accordingly. For example, patients taking herbs containing the element potassium are theorized to be subject to hyperkalemia if they are concurrently taking potassium-sparing diuretics. Often herbalists recommend that patients take medications and herbs 2 or 3 hours apart to avoid any possible interactions.

6 HERBS AND PHARMACEUTICALS 389 Five Representative Chinese Herbs Used for Psychiatric Disorders Chinese medical herbalists typically tailor-make herbal formulas to fit specific diagnostic parameters and address idiosyncratic combinations of features in their patients. Historically, most classical formulas were developed for teaching purposes to demonstrate various treatment principles and strategies (Yuen, n.d.). Thus, if 12 persons suffered from a major depressive disorder or a generalized anxiety disorder, each would receive a unique and personalized herbal prescription. Nonetheless, Chinese medical herbalism features a number of common herbs and classical combinations for various clinical presentations of psychiatric disorders. In this section, five single herbs commonly used in prescriptions for psychiatric patients are presented, and in the next section, five psychiatric formulas are explicated. The herbs presented here include two seeds, two roots, and a mineral. Left out of the discussion of Thorowax Root single herbs is Hypericum perforatum (Guan Ye Lian Qiao), also known as St. John s wort, the primary antidepressant herb in European and Western herbal traditions, but one that has not traditionally been used for treating psychiatric disturbances in Chinese herbal medicine. Chinese herbalists historically prescribed Hypericum perforatum, in combination with other herbs, to treat toxic infections, to stop bleeding, and to relieve muscle aches and pains, although in modern times, some practitioners have combined it with Chinese herbal formulas such as Free and Easy Rambler (Xiao Yao Wan), discussed below, to treat certain types of depressions marked by depressed mood, anger, frustration, and intercostal pain (J. K. Chen & Chen, 2004). For more information regarding the efficacy of Hypericum perforatum, readers are referred to the summary of findings on the Natural Medicines Comprehensive Database and website (Therapeutic Research Faculty, 2008), the Herb Research Foundation (2008) website, and the National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine (NCCAM) website (National Center for Complementary and Alternative Medicine, 2008b). Semen (Sm) Ziziphi Spinosae (Sour Jujube or Spiny Date; Suan Zao Ren) One of the best-known herbs for treating anxiety and insomnia marked by palpitations and irritability is the dried ripe seed of the sour jujube or spiny date. Pharmacological studies have shown that it has sedative and hypnotic effects in a variety of mammals, inhibits excitation provoked by caffeine, lengthens sleep time induced by barbiturates, and shows marked analgesic effects (J. K. Chen & Chen, 2004; Z. W. Li, 1993). While its exact biochemical actions are unknown, it appears to work on 5HT 1a, 5HT 2, and GABA receptors (Liao et al., 1995). The chemical composition for Sm Ziziphi Spinozae includes jujuboside, butolin, betulic acid, ebelinlactone, jujubogenin, zivulgarin, swertisin, ceanothic acid, alphitolic acid, and saponosin. As a sedative, it can potentiate the effects of barbiturates and many other categories of drugs that produce sedation, such as narcotic analgesics, antihistamines, and benzodiazepines. A relatively safe herb, up to 70 g have been used clinically without toxic reactions (J. K. Chen & Chen, 2004). Sm Ziziphi Spinosae is a common herb used in classical Chinese herbal formulas that treat anxiety, insomnia, nervousness, and palpitation, such as the herbal formula bearing its name, sour jujube decoction (Suan Zao Ren Tang), available in many patent and powdered herb forms in the United States. Sm Biota Orientalis or Sm Platycodis Orientalis (Biota Seeds; Bai Zi Ren) This dried kernel of a ripe seed from Biota orientalis frequents formulas designed to treat anxiety, insomnia, palpitations, and night sweats, often accompanying Rx Zizphi Spinosae. Containing glucosides, steroids, saponins, lipids, and vitamin A, it has demonstrated hypnotic effects in rats (Wing, 2001) and mild lubricating effects in the bowels (J. K. Chen & Chen, 2004). Historically, biota seeds have been contraindicated in patients with loose stools or phlegm, but it is considered a safe, nontoxic herb. Rx Bupleurum Chinense (Thorowax Root; Chai Hu) An herb featured in many formulas addressing major depressive disorders is the dried root of Bupleurum Chinense. A literal translation of the Chinese name, Chai Hu, means kindling of the barbarians (J. K. Chen & Chen, 2004, p. 84). While it is also used in Chinese medicine to ameliorate fever and a variety of liver disorders, its use in formulas that treat depressive disorders stem from the Chinese medical perspective that depression often is the result of bound-up energy in the liver, called liver qi stagnation. Chemically, the herb contains triterpenoids (saikosaponia A, B, C, D, E; saikogenin F, G, E; saikoside), carbohydrates, flavone, coumarin, and organic acids. Water extracts of the herb demonstrate an affinity to dopamine D 2, GABA, and 5HT 1a receptors (Liao et al., 1995). Pharmacological studies indicate that Rx Bupleurum has analgesic, antipyretic, sedative, hepatoprotective, cholagogic, antihyperlipidemic, anti-inflammatory, immunostimulant, and antibiotic effects, with very low toxic potential (J. K. Chen & Chen, 2004). The herb serves as the principle herb in a number of formulas treating major depressive disorders, including Free and Easy Wanderer (Xiao Yao San) and Powder to Disperse Vital Energy in the Liver (Chai Hu Shu Gan San). These formulas are widely available in the United States in decoction, tinctures, powders, pills, and patent form. Rx Ligustici Wallichi (Chinese Lovage Root; Chuan Xiong) This dried root, first discussed in the Divine Husbandman s Classic of Materia Medica (Shen Nong Ben Cao), written down in the 2nd century A.C.E., is featured in many classical Chinese medical formulas that treat certain types of depression related to issues with blood viscosity, rheumatic pains, headaches, and pains in general. Containing

7 390 WHITE butylidenephthalide, butylphthalide, tetramethylpyrazine, and indole, among other constituents, the herb s water extracts have shown an affinity to GABA and 5HT 1a receptors (Liao et al., 1995). Pharmacologically, Rx Ligustici Wallichi has demonstrated sedative effects on the central nervous system, while boosting blood profusion to the brain, dilating coronary arteries, improving microcirculation, exerting antiplatelet activities, inhibiting the immune system to treat allergies or hyperactivity of the immune system, reducing the growth of cancer cells in vitro, and slowing the growth of bacteria (J. K. Chen & Chen, 2004). Though not documented, because of its known pharmacology, it is speculated that the herb may show additive effects with anticoagulant drugs such as warfarin (Coumaden). Rx Ligustici Wallichi is included in some formulas for anxiety and insomnia such as the sour jujube decoction (Suan Zao Ren Tang), as well as a number of formulas that treat depressive disorders, such as Powder to Disperse Vital Energy in the Liver (Chai Hu Shu Gan Wan) above, and Drive the Blood out of the Blood Mansion Formula (Xue Fu Zhu Yu Tang), described below. Cinnabaris (Cinnabar; Zhu Sha) A mineral from the sulfide class, Cinnabar is used as a tranquilizer for sudden disruptions to the heart from terrifying experiences that produce severe anxiety, restlessness, insomnia, uncontrolled and unconscious emotions, and tremors. In Chinese alchemical traditions, it was said to instigate an alchemical process for change, possibly a metaphor for the strong immune response the body mounts to reject this toxic herb (Yuen, n.d.). Minerals are used in Chinese herbology principally to settle and ground persons out of control psychologically or with out-of-control pathology such as hypertension. Chemically, Cinnabar is composed of mercuric sulfide and other trace elements. In some states, it is still legal and may be taken in very small amounts (0.3 to 1.0 g) for short periods in pill form only, because the toxicity of the mineral jumps significantly when processed with heat in decoctions. An herb that treats schizophrenia, severe delirium, intense anxiety, and certain types of manic episodes, its toxicity from overdose can be addressed by the herbal formula, Coptis Decoction to Relieve Toxicity (Huang Lian Jia Du Tang) or the twice-daily ingestion of 9gofblack or green tea (J. K. Chen & Chen, 2004). While Cinnabar is rarely used in medicinal products today, it may still be found in a number of patent remedies such as Cinnabar Pill to Calm the Spirit (Zhu Sha An Shen Wan). Five Representative Chinese Herbal Formulas for Psychiatric Disorders Sour Jujube Decoction (Suan Zao Ren Tang) Sour jujube decoction (Suan Zao Ren Tang) treats persons with certain types of anxiety, nervous exhaustion, and insomnia marked by agitation, fidgetiness, heart palpitations, nightmares, impaired memory, night sweats, spontaneous perspiration, thirst, and dry mouth. Its ingredients are listed in Table 2. Two double-blind, experimental studies have supported this formula s effectiveness in treating patients with anxiety and insomnia. Chen (1986) found that this formula provided the same anxiolytic effect in patients with anxiety, weakness, irritability, and insomnia as did diazepam, but unlike diazepam, the herbs improved psychomotor performance during the daytime and showed no side effects. Hsieh and Chen (1986) demonstrated that this formula had significant anxiolytic effects, in comparison with placebo, in 60 cardiac patients with symptoms of anxiety including palpitations, chest pain, and shortness of breath. The herbs also reduced elevated plasma norepinephrine and blood lactic acid levels. While the formula, given in the traditional dosages, has no contraindications and no known toxicities or potential interactions, prescribers should know that it is speculated that Sm Ziziphi Spinosae may potentiate barbiturates and other sedative hypnotic drugs. Scl Poriae Cocos is contraindicated in patients with frequent, copius urination and contains potassium with the potential for creating hyperkalemia if used with potassium-sparing diuretics. Rz Ligusticum Wallichi should be used with caution with pregnant women, women with menorrhagia, anyone with abnormal bleeding, and anyone taking anticoagulant and antiplatelet drugs. Rz Anemarrhenae Aspheloidis is contraindicated in patients with diarrhea and digestive enzyme deficiencies and should be used with caution in combination with insulin, sulfonylurea, and other anti-diabetic medications; and Rx Glycrrhizae, in higher doses, used chronically, may cause edema, elevated blood pressure, sodium retention, and potassium loss (Jemes & Flaws, 2004). Table 2 Ingredients in Sour Jujube Decoction (Suan Zao Ren Tang) Pharmaceutical name Common name Chinese name (Pinyin) Common dosage (grams in typical decoction form) Sm Zizyphi Spinosae Sour jujube Suan Zao Ren 9 15 Scl Poriae Cocos Hoelen Fu Ling 9 12 Rz Ligusticum Wallichi Chinese lovage root Chuan Xiong 6 9 Rz Anemarrhenae Aspheloidis Anemarrrhena Zhi Mu 6 9 Rx Glycyrrhizae Licorice root Gan Cao 3 Note. Sm Semen; Scl Sclerotium; Rz Rhizoma; Rx Radix.

8 HERBS AND PHARMACEUTICALS 391 Free and Easy Wanderer Powder (Xiao Yao San) Originating in the Song Dynasty ( A.C.E.), this formula is one of the most important for treating moodrelated disorders. A literal translation of its Chinese name is promotion of a free and relaxed spirit (Wing, 2001). The specific type of major depressive disorders and premenstrual syndrome disorders treated by Free and Easy Wandering Powder are those marked by depressed mood; chronic frustration and irritability; chest, breast, abdominal, or costal rib-side distention and pain; headaches; fatigue; reduced appetite; anemia or subclinical anemia; breast distention; and irregular menstruation. Free and Easy Wanderer Powder includes the herbs listed in Table 3. In a double-blind, randomized, placebo-controlled study of 24 bipolar depressed and 111 manic patients, Z. J. Zhang et al. (2007) found that administering this formula with carbamazepine (CBZ) produced significantly greater reduction in symptomatology in depressed patients (84.8% vs. 63.8%, p.032), in comparison with CBZ alone but showed no difference for manic subjects. Participants taking this formula also obtained a lower incidence of dizziness and fatigue. L. T. Li et al. (2008) compared the efficacy of this formula to that of fluoxetine in treating 150 patients suffering from poststroke depression. While there was no difference in the effectiveness of Free and Easy Wanderer formula and fluoxetine in alleviating depression at the end of the 8-week study and while both significantly surpassed the response rates of the placebo group, Free and Easy Wanderer resulted in significantly greater amelioration of depression at Week 2, in comparison with Fluoxetine, as was measured by the Hamilton Depression Scale and the Barthel Index; it also resulted in significantly greater recovery in the activities of daily life at the end of the study, in comparison with the medication. Although this herbal combination generally is considered to be relatively safe and to have no formula toxicities and interactions when used appropriately with standard dosages, some constituent herbs possess the potential for herb drug interactions or toxicity in certain circumstances. The herb Rx Angelicae Sinensis (Dang Gui) should be used with caution in pregnancy and contains potassium, with the theoretical concerns indicated above. Dang Gui could exacerbate the anticoagulant effects of warfarin (Coumadin). Rx Albus Paeoniae Lactiflorae (white peony root; Bai Shao Yao) could possibly reduce the effect of most antibiotics, cause digitalis intoxication and heart arrhythmias, and reduce the absorption and therapeutic effect of levadopa, chlorpromazine, calcium carbonate and gluconate, atropine, ephedrine, quinine, reserpine, vitamin B, trypsine, amylase, and pepsin, among others. Hb Menthae (Peppermint; Bo He) may inhibit lactation in nursing mothers. Potential interactions of Rx Glycyrrhizae Uralensis (licorice root; Gan Cao) and Poria Cocos (Hoelen; Fu Ling) have been discussed above. Powder to Disperse Vital Energy in the Liver (Chai Hu Shu Gan San) This formula is considered to be excellent in Chinese medicine for treating major depressive disorders associated with depressed mood; chronic frustration and irritability; chest, breast, abdominal, or costal rib-side fullness, distention, and pain; headaches; and muscle tension, especially of the neck and shoulders. Featured ingredients and standard dosages are presented in Table 4. Kim et al. (2005) explored the antidepressant effects of an extract of this formula in rat models of depression, in which the rodents were required to engage in forced swimming tests and underwent chronic mild stress. The researchers concluded that the herbal combination was as effective as imipramine in these experimental animal models. Considered safe when indicated, the individual herbs have the same potentials for toxicities or interactions as is indicated above in previous discussions. Because Fr Citri Aurantii contains potassium, it has the additional concern of potentiating this element when used with potassium-sparing diuretics. Drive the Blood Out of the Blood Mansion Formula (Xue Fu Zhu Yu Tang) A Qing Dynasty ( ) formula, Drive the Blood Out of the Blood Mansion is the classical prescription for treating stagnant emotions suppressed or trapped in the body, theoretically giving rise to increased blood viscosity in Chinese medicine. Symptomatically, the formula is used for severe major depressive disorders when persons suffer from suicidal thoughts or behavior, impaired concentration, irritability, agitation, psychomotor retardation, slowness in thinking and re- Table 3 Ingredients in Free and Easy Wanderer Powder (Xiao Yao San) Pharmaceutical name Common name Chinese name (Pinyin) Common dosage (grams in typical decoction form) Rx Bupleuri Bupleurum Chai Hu 9 Rx Angelicae Sinensis Tang Kwei Dang Gui 6 9 Rz Atractylodis Macrocephalae White Atractylodes Bai Zhu 6 9 Scl Poriae Cocos Hoelen Fu Ling 6 9 Hb Menthae Peppermint Bo He 3 Rz Zingiberis Officinalis Fresh ginger root Sheng Jiang 3 Rx Glycyrrhizae Licorice root Gan Cao 3 6 Note. Rx Radix; Rz Rhizoma; Scl Sclerotium; Hb Herba.

9 392 WHITE Table 4 Ingredients in Powder to Disperse Vital Energy in the Liver (Chai Hu Shu Gan San) Pharmaceutical name Common name Chinese name (Pinyin) Common dosage (grams in typical decoction form) Rx Bupleuri Bupleurum Chai Hu 9 12 Rx Albus Paeoniae Lactiflorae White Peony Root Bai Shao Yao 6 9 Fr Citri Aurantii Bitter Orange Zhi Ke 6 9 Pc Citri Reticulatae Orange Peel Chen Pi 6 Rz Liguistici Wallichi Chinese Lovage Root Chuan Xiong 3 6 Rz Cyperi Rotundi Cyperus Xiang Fu 6 9 Rx Glycyrrhizae Licorice Root Gan Cao 3 Note. Rx Radix; Fr Fructus; Pc Pericarpium; Rz Rhizoma. sponding, and bilateral costal rib pain, and display a dark, dusky facial complexion and a purplish tongue. Ingredients and standard dosages are presented in Table 5. Controlled clinical trials have not yet been conducted using this formula for depression; however, two outcome studies have reported positive outcomes and provide evidence for the need of such trials. Liang (1996) evaluated this formula in one outcome study in its ability to treat one of six patterns of premenstrual dysphonic depression in 60 cases, finding that 65 (93%) were ameliorated by the appropriate formula. D. Y. Zhang (1994) used this formula to treat one of three patterns of perimenopausal syndrome in 557 women aged 45 55, in which 90% of participants reported insomnia and 88% reported profuse dreams, tenseness, agitation, easy anger, and restlessness. A total of 543 (97.3%) experienced moderate to complete amelioration of symptoms with this formula. Drive the Blood Out of the Blood Mansion Decoction is contraindicated for bleeding of any sort, its use with blood thinners such as warfarin (Coumaden), and use during pregnancy, as it may cause miscarriage. In addition, a number of individual herbs may be toxic in certain circumstances. Sm Pruni Persicae (peach kernel; Tao Ren) is contraindicated during pregnancy and contains potassium and glycosides. Consumed with codeine, morphine, or other opiates, it is possible that hydrocyanic acid may form, which could lead to respiratory failure and death. Because many of the toxins in this herb are located in the skin and tip, the tip is removed, and the herb is often blanched to make it less toxic. Flos Carthami (safflower flowers; Hong Hua) also is contraindicated during pregnancy and with hemorrhagic diseases or peptic ulcer. As with Sm Pruni Persica, it contains potassium and glycosides, with the same possible interactions. Rx Rubrus Paeoniae Lactiflorae (red peony root; Chi Shao) possesses tannic acid, potassium, and glycosides, which could potentially diminish the absorption and biological effects of most antibiotics, isoniazid, chlorpromazine, calcium carbonate and gluconate, atropine, ephedrine, quinine, reserpine, digitalis, vitamin B 1, trypsine, amylase, and pepsin. Rx Cyathulae (Chuan Niu Xi) is contraindicated during pregnancy and in menorrhagia. It contains alkaloids, potassium, and glycosides, giving it the same potentials for interactions as Rx Rubrus and Rx Ligusticum Wallichi. Rx Platycodi Grandiflori (Jie Geng) is contraindicated in hemoptysis and should be used with caution in bleeding peptic ulcer. Containing calcium and glycosides, Rx Platycodi Grandiflori potentially could diminish the effects of most antibiotics and cause digitalis intoxication and heart arrhythmias. Uncooked Rx Rehmanniae Glutinosae (Sheng Di Huang) is contraindicated in patients with lack of appetite or diarrhea. With potassium as part of its chemical composition, it could possibly cause hyperkalemia when used with potassium-sparing diuretics. The contraindications and potential toxicity of the other herbs have been discussed above. Table 5 Ingredients in Drive the Blood Out of the Blood Mansion Formula (Xue Fu Zhu Yu Tang) Pharmaceutical name Common name Chinese name (Pinyin) Common dosage (grams in typical decoction form) Sm Pruni Persicae Peach kernel Tao Ren 9 12 Flos Carthami Tinetori Safflower flowers Hong Hua 6 9 Rx Angelica Sinensis Tang Kwei Dang Gui 6 9 Raw Rx Rehmanniae Raw Rehmannia Sheng Di Huang 6 9 Rz Liguistici Wallichi Chinese lovage root Chuan Xiong 3 6 Rx Rubrus Paeoniae Lactiflorae Red peony root Chi Shao Yao 6 9 Rx Platycodi Platycodi Jie Geng 3 6 Rx Cyathulae Cyathula root Chuan Niu Xi 6 9 Rx Bupleuri Chinese lovage root Chai Hu 3 6 Fr Citri Aurantii Bitter orange Zhi Ke 6 9 Rx Glycyrrhizae Licorice root Gan Cao 3 6 Note. Sm Semen; Flos ;Rx Radix; Rz Rhizoma; Fr Fructus.

10 HERBS AND PHARMACEUTICALS 393 Cinnabar Pill to Quiet the Spirit (Zhu Sha an Shen Wan) First documented in the Ming Dynasty ( A.C.E.), this classical formula is used for its tranquilizing effects in treating patients with schizophrenia, schizoaffective or delusional disorders, or bipolar disorders with manic episodes marked by sudden, violent anger and agitation, restlessness, physically violent behavior, foul speech, severe insomnia, red facial complexions, and red eyes. The ingredients composing the formula are presented in Table 6. In placebo-controlled trials with cats, the formula has been documented to reduce time awake, lengthen duration of sleep, improve slow-wave sleep, and reduce sleep latency (Z. W. Li, 1993; Wing, 2001). The principle ingredient, the mineral Cinnabaris, is highly toxic, should not be used in large amounts or long term because its effects are cumulative, and should not be decocted or heated in any way, which enhances its toxicity. Cinnabaris is rarely used in medicinal products today. Most practitioners substitute other minerals such as Concha Ostrae (oyster shell; Mu Li), Os Draconis (bone; Long Gu), hematite (Dai Zhe Shi), or magnetite (Ci Shi) for Cinnabaris. Rz Coptis Chinensis (Huang Lian) which contains berberine, alkaloids, quercetin and potassium is known to antagonize a number of other Chinese herbs and counteract others. It is theorized to possibly reduce the absorption and therapeutic effect of potassium; sodium iodides; sodium bicarbonate; calcium gluconate, carbonate, and lactate; aluminum hydroxide; magnesium; ferrous sulfates; and bismuth subcarbonate (Jenne & Flaws, 2004). The possible interactions of Rx Angelicae Sinensis, uncooked Rx Rehmanniae Glutinosae, and Rx Glycyrrhizae Uralensis have been discussed above and will not be repeated here. In reviewing the empirical evidence for the efficacy of these formulas, it can be seen that two formulas Sour Jujube Decoction and Free and Easy Wanderer Formula are supported by randomized, double-blind, placebo-controlled studies in humans, and two more Powder to Disperse Vital Energy in the Liver and Cinnabar Pill to Quiet the Spirit are backed by randomized, double-blind, placebo-controlled studies in animal models. The fifth formula Drive the Blood Out of the Blood Mansion Formula was supported among several other formulas in two outcome studies that did not use placebos. Clearly, additional research needs to be conducted to assess the formulas in randomized, double-blind, placebo-controlled studies in humans, and I recommend that this research be conducted using a combination of Western diagnosis and Chinese patterns of differentiations, so that the research actually evaluates the formulas in the ways that they are traditionally used by Chinese medical herbalists. However, it must be acknowledged that the lack of fully sufficient evidence for efficacy of these formulas in terms of the gold standard of randomized, double-blind, placebo-controlled research in humans does not mean these formulas are ineffective. Millions of Chinese and, currently, Americans have found these formulas helpful in treating their psychological problems. Conclusions Chinese herbal traditions present unique concerns for the prescribing psychologist and psychiatrists. As with other plant-based products in the United States, Chinese herbs are regulated only under the Dietary Supplement Health and Education Act (DSHEA), and as such, they may vary widely in quality and either may not contain active ingredients or may, on occasion, contain unidentified contaminants or even toxic substances. Many consumers take Chinese herbs without the supervision of a qualified herbalist, purchasing them in health food stores, truck stops, convenience stores, grocery stores, and on various websites. The products they buy may misuse Chinese herbs or contain improperly prepared ingredients, both of which can lead to deadly consequences. For example, the wrong application of Hb Ephedrae (Ma Huang) in weight loss products led to the death of some people with ephedra-related hypertension (National Center for Complementary and Alternative Medicine, 2008a). A board-certified herbalist would never recommend use of this herb for more than 2 weeks and then for only a small subset of persons with acute asthma or the common cold, avoiding its use altogether in persons with hypertension. Even if Chinese herbal products contain highquality ingredients and have been formulated by qualified Chinese herbalists, consumers may take herbal combinations not indicated for their conditions, leading to deleterious effects. The guidance of a professional Chinese herbalist is necessary for optimal therapeutic benefit. Because Chinese medical herbology typically uses multiherb combinations, determining their active principles, clinical effectiveness, and possible herb drug interactions are much more complicated than with single herbs, and additional research needs to be conducted on Chinese herbal formulas for psychological conditions. Table 6 Ingredients in Cinnabar Pill to Quiet the Spirit (Zhu Sha An Shen Wan) Pharmaceutical name Common name Chinese name (Pinyin) Common dosage (grams in typical decoction form) Cinnabaris Cinnabar Zhu Sha 3 Rz Coptis Chinensis Coptis Huang Lian 9 Rx Angelica Sinensis Tang Kwei Dang Gui 9 Raw Rx Rehmannia Glutinosae Raw Rehmannia Sheng Di Huang 9 Rx Glycyrrhizae Licorice root Gan Cao 3 Note. Rz Rhizoma; Rx Radix.

11 394 WHITE Despite these problems, Chinese medical herbs prescribed by qualified professional herbalists appear to be relatively safe and in many cases, relatively effective in addressing psychological concerns. The Herbal Research Foundation a nonprofit organization staffed by some of the leading experts on pharmacognosy, pharmacology, and toxicology, which routinely conducts extensive reviews on herbal safety has found that the general incidence of serious toxicity of herbs is relatively low (Werbach, 2000). Compare these results to articles published in medical journals about the safety of medications. For example, Davies, Green, Mottram, and Pirmohamed (2007) listed adverse drug reactions (ADRs) as between the fourth and sixth leading causes of death in the United States, with fatal ADRs occurring in 0.32% of patients. In my own experience as a California-licensed clinical psychologist (for 25 years), who was also licensed as an acupuncturist and was board certified in Chinese herbology and acupuncture 14 years ago, I have found that Chinese herbs successfully resolve numerous cases of anxiety, depression, insomnia, headaches, dysmenorrhea, and other pain disorders, among many other health problems, and only once have I encountered an herb drug interaction. The interaction occurred with a highly agitated, angry patient presenting with severe insomnia, to whom I gave a formula containing Concha Ostrae (oyster shell), a sedative and tranquilizing mineral. The patient had failed to disclose his use of a calcium channel blocking medication and as a result, suffered even more extreme insomnia when he ingested the formula. The following guidelines are recommended to pharmacological prescribers talking to their patients about herbs: 1. Take an herb history (Arnold, 2000). Be sure to ask patients directly if they are taking herbs or nutritional supplements before prescribing medications, or patients may not tell you about their supplement use (Eisenberg et al., 1998). Patients are more likely to disclose CAM use when they view their prescribers as open-minded about their choice to use CAM and positive about their efforts to improve their own health. 2. Ask patients whether they are taking herbs under the supervision of a qualified herbalist. Standards in the United States require that practitioners complete a 4-year master s degree program in Chinese herbology or traditional Oriental medicine and be licensed as acupuncturists or doctors of Oriental medicine. Board certification in Chinese herbology by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) further ensures that practitioners have undergone relatively extensive training and mastered a certain level of expertise in Chinese herbology. 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