Abstract
There are two major types of medication available and they include over-the-counter (OTC) and prescriptions. Unlike the former, prescription drugs are strictly regulated by the FDA and can only be given with a prescriber’s approval. Furthermore, in regards to the chemical characteristics OTC drugs comprising herbal supplements contain a combination of several compounds whereas prescription drugs only contain a single active compound.
Nevertheless, they both have an effect on the body, hence, have distinct benefits and side effects. St. John’s Wort is a popular OTC drug used in the treatment of depression. Studies have shown its high efficacy in managing the illness, nevertheless, little is known about its potential adverse effects thought it is claimed to be minimal. Contrarily, Xanax, a popular prescription medication used for the treatment of anxiety is associated with several adverse side effects. It is challenging to determine which class of drugs supersede the other as there is minimal clinical evidence of the safety of OTC drugs.
Introduction
Even though the clinical evidence present might vary from conventional medicines, for most herbal regimens, there is now sound basis for evidence. The primary difference between these two substances is that the herbal medicines contains a combination of chemicals, while in the former, there is only a single active ingredient. Herbal medicines are often available as over-the-counter drugs for self-medication or after consulting with a pharmacist. Nevertheless, it is essential to note that both substances have strong effects on the body. This paper aims to compare and contrast the potential effects and side effects of over-the-counter and prescription drugs with regard to treating mental illness.
St. John’s Wort
History
St. John’s Wort is an over-the-counter herbal remedy. It is a perennial herb native to Europe and Asia; nevertheless, it is known for its modern and traditional applications. Its scientific name is Hypericum perforatum, while its other names in various oriental countries include Goat weed, Klamath Weed, Enola weed and Tipton weed (Shrivastava & Dwivedi, 2015). The common name St. John’s Wort originated from St. John the Baptist whose birthday is in June, the same month that the plan blooms (Apaydin et al., 2016).
Although it is regarded as a first-line antidepressant popular in several European countries, however, it has only recently gained popularity in the U.S. Its use is long-dated to the 19th century as it was utilized to treat mental illnesses that the ancient Greeks believed to be due to demonic possession (Forsdike & Pirotta, 2019). Furthermore, the Greek physicians also used it as a wound healer, diuretic, and menstrual disorders treatment.
Uses
St. John’s Wort is currently rated as one of the most popular herbal medicines in the U.S. for treating depression (Forsdike & Pirotta, 2019). The supplement is also used as a sedative herb to treat insomnia, sleep disturbances, and mood swings. It is believed to work similarly as antidepressants as it might help stabilize mood swings related to hormones, including those that occur during menopause and menstrual cycles. However, there lacks sufficient evidence to support its effectiveness (Forsdike & Pirotta, 2019).
Key Ingredients
St. John’s Wort is among the widely studied medicinal plants due to its chemical constituents and pharmacological properties. Some of the major bioactive compounds present comprise phloroglucinols, naphthodianthrones, and flavonoids, and they have been demonstrated to be effective in the treatment of mild to moderate depression (Forsdike & Pirotta, 2019). Hyperforin is one of the most abundant phloroglucinol compounds in H. perforatum; however, there are small amounts of adhyperforin. Hyperforin is the primary compound responsible for the herb’s antidepressant activity. There is also hypericin, the major naphtodianthrone in H. perforatum, and it possesses antidepressant properties.
Mechanism of Action
Some several mechanisms and theories have been associated with the antidepressant effects of St. John Wort. However, it has not been established whether one of the mechanisms affects the other and to what degree (Shrivastava & Dwivedi, 2015). As such, a conglomeration of the bioactive ingredients and mechanisms probably culminate in an antidepressant effect. One of the theories behind the pharmacology of H. perforatum is its inhibition of the uptake of dopamine, serotonin, and norepinephrine from the synaptic cleft of interconnecting neurons. Another mechanism is its capability of binding to the major gamma-aminobutyric acid (GABA-A and GABA-B) receptors, a neuro-inhibitory receptor to hinder the binding of GABA. The decrease in GABA ligand binding leads to a reduction in the central nervous system (CNS) depression. The third mechanism is the increase in the number of 5-hydroxytryptamine receptors in the brain’s frontal cortex, which holds potential benefits in treating depression. Nevertheless, the findings supporting this theory are primarily from rats (Shrivastava & Dwivedi, 2015).
The fourth and probably fifth contributing mechanism is H. perforatum capability to hamper catech-O-methyltransferase (COMT) enzymes and monoamine oxidase (MAO). When in action, the COMT and MAO enzymes metabolize dopamine precursors into their inactive form instead of facilitating dopamine metabolism to norepinephrine. As a result, inhibiting these enzymes in the CNS favors the synthesis of noradrenaline. As mentioned earlier, no single mechanism appears to predominate.
Thus, the overall antidepressant effect is probably an amalgamation of several mechanisms. It is essential to note that the dosage amount and form of the herb might affect its biological effect. This is because the concentration of every bioactive compound might be variable. Nevertheless, studies have revealed that St. John’s Wort is not as effective as other types of prescription antidepressants, for instance, selective serotonin reuptake inhibitors (Shrivastava & Dwivedi, 2015). On the contrary, others have noted that it is much more effective than placebo in treating severe depression, comparable to prescription antidepressants.
Potential Side Effects
Similar to other supplements and medication, it is associated with several side effects. In some people, it might increase anxiety and agitation as it possesses stimulant features. Furthermore, although it is utilized in treating insomnia, it can result in the symptom in some individuals. Also, psychosis is rare but possible. Antidepressants target serotonin in the brain; therefore, combining specific antidepressants and St. John’s wort can result in the possible life-threatening increase in serotonin levels, a condition known as serotonin syndrome. Lastly, other side effects, usually minor and uncommon, comprise stomach pain, diarrhea, sensitivity to sunlight, and low blood sugar levels. Therefore, it is important that people taking the herb consult with their doctors. Compared to SSRIs, St. John’s wort extract is associated with a lower incidence of adverse events (Cui & Zheng, 2016). Hence, it is more superior in safety management among depressed patients.
Potential for Abuse/Dependence/ Tolerance
Over-the-counter drugs are usually safe when used at recommended doses. Similar to prescription and illegal drugs, they can also be abused. Furthermore, even though they are less potent than other drugs, there is the risk of developing an addiction. There is limited evidence documenting the potential of St. John wort’s abuse or dependence. However, according to Cui and Zheng (2016), the probability of abuse or dependence is lower than that of traditional SSRIs.
Restrictions for Use
The applicability of St. John’s wort in the treatment of depression is a highly controversial topic. This is because the present evidence on the effectiveness of the herb is inconclusive. Furthermore, the Food and Drug Administration in the U.S. has not approved its use as a prescription or over-the-counter drug for depression. Therefore, the public needs to be educated regarding its safety; for instance, people should not use it before consulting with their healthcare providers.
Drug Interactions
Combining St. John’s wort with specific antidepressants can affect the safety and effectiveness of the latter. It has major interactions with prescribed medications, such as antidepressants, digoxin (a heart medication), warfarin (a blood thinner), birth control pills, oxycodone (pain medication), some HIV drugs (indinavir), cyclosporine, and some cancer medications (irinotecan). In most instances, H. perforatum reduced the effectiveness of other drugs by metabolizing them more rapidly. Furthermore, in combination with other antidepressants, specifically SSRIs, it might lead to increased serotonin-related side effects that are life-threatening.
Precautions
Since St. John’s wort is associated with several adverse events, individuals need to consider specific factors when taking the herb. For example, it should not be replaced with conventional care nor postponing a medical consultation. This is because if the depression is not sufficiently treated, the severity of the depression can increase. Second, such herbal supplements can cause medical problems if used incorrectly or used in large amounts. Third, there is limited safety information regarding its use in children, pregnant women, or nursing mothers. Therefore, it essential for this population to consult with health experts before taking it. Lastly, St. John Worts users must notify their health care providers regarding the integrative health approaches they use to facilitate the delivery of coordinated and safe care.
Symptoms of Overdose/Withdrawal
Empirical evidence on the withdrawal symptoms linked to St. John’s wort is predominantly anecdotal (Forsdike & Pirotta, 2019). Some individuals have reported dizziness, sickness, and anxiety after stopping to take the herb abruptly. Therefore, for safety, it is recommended to gradually reduce the dosage before discontinuing the use of St. John’s wort.
Conclusion
St. John’s wort is a herbal remedy whose beneficial effects in the traditional medicinal system have been demonstrated in treating anxiety and depression. However, its effectiveness and safety are controversial as there are mixed research findings. Its mechanism of action is almost similar to those of conventional SSRIs, which are also used to treat depression. Furthermore, studies have found it to be a lower incidence of adverse events. Therefore, although not approved by the FDA, therapists can approve this herbal supplement; however, this should be under close supervision.
Xanax
History
Xanax, also known as alprazolam, is a benzodiazepine used as an anti-anxiety and antidepressant medication. It is frequently prescribed among the elderly (Tannenbaum, 2015). It was developed in the late 1960s by the Upjohn Laboratories of Kalamazoo in Michigan (now part of Pfizer) (Wick, 2013). During this period, the increase and popularity in psychiatric treatment led researchers to start identifying ways to help patients with insomnia, specifically those stemming from anxiety. Initially, it was created to be a superior sleep aid with muscle relaxant features; however, with ongoing research, Upjohn’s scientist recognized its effectiveness in treating panic, anxiety, and mood disorders.
Furthermore, during the late 1960s, the antidepressants present in the market were more harsh and toxic (Wick, 2013). Therefore, Upjohn attempted to create a benzodiazepine that was better and less toxic, and this was proven by the 50 double-blind studies conducted (Wick, 2013). In 1981, Xanax was approved by the United States FDA as the first benzodiazepine to treat panic disorder (Wick, 2013).
Uses
Xanax is primarily used in the treatment of anxiety and panic disorders. As a benzodiazepine, it acts on the central nervous system to generate a calming effect. It is also used in secondary treatment as a hypnotic, muscle relaxant, and anticonvulsant.
Key Ingredient
The active ingredient in Xanax is alprazolam, whose chemical name is 8-Chloro-1-methyl-6-phenyl-4H-s-triazolobenzodiazepine. It also has inactive ingredients, including corn starch, cellulose, magnesium stearate, lactose, docusate sodium, sodium benzoate, and silicon dioxide.
How it Works
Xanax pharmacodynamics is based on its ability to bind to the benzodiazepine receptors, BNZ1 and BNZ2. The binding causes the GABA (a) receptors to bind to their sub-receptors in the CNS readily. As a result, the formation of this complex results in the chloride ion channel gates opening, facilitating the entry of the chloride ions into the intracellular environment (Ingersol & Rak, 2016). This influx brings about the antidepressant effect. The binding on BNZ1 receptors induces sleep, while that on the BNZ2 receptors bring about motor coordination, muscle relaxation, and its anticonvulsant properties.
Potential Side Effects
With advancing age, older people are more sensitive to the potential side effects of Xanax due to altered pharmacokinetics and pharmacodynamics parameters (Tannenbaum, 2015). For instance, it has been linked with cognitive and intellectual impairment. The former is characterized by reduced short-term recall, anterograde amnesia, and increased forgetfulness. However, it is essential to note that cognitive impairment is a late complication of Xanax use. Alprazolam can also result in psychomotor impairment and is associated with an increase in the risk of falls and automobile accidents. This is because it slows down the reaction and decreases the accuracy and speed of motor tasks. Research indicates an increased risk of recurrent falls and hip fracture among elderly patients taking benzodiazepines (Singh & Sarkar, 2016).
Potential for Abuse/Dependence/Tolerance
Generally, long-term use of alprazolam is controversial and not recommended, even though it is commonly practiced. Intriguingly, tolerance is identified to develop more rapidly for the anticonvulsant and hypnotic functions. The risk of dependence increases with age and is more common among patients requiring multiple medications. In most cases, the elderly take benzodiazepines over an extended period. This is because they are more prone to problems, such as depression, chronic pain, and isolation that predispose them to Xanax use and dependence (Singh & Sarkar, 2016). Furthermore, the risk can increase as the tolerance to Xanax and alcohol decreases with age. Nevertheless, it is essential to note that not all individuals taking Xanax for prolonged durations experience dependency.
Restrictions for Use
Research indicates that tolerance to Xanax might occur without any signs of physical dependence (Ingersol & Rak, 2016). Therefore, prescribers need to recommend the appropriate dosage to be taken within a suitable amount of time. Furthermore, this also applies in the nature that elderly patients are more prone to the side effects.
Drug Interactions
Drug interactions might alter the pharmacodynamics of various medications or heighten the risk of major side effects. Some of the products that might interact with Xanax comprise kava and sodium oxybate. There is also medication that can influence the elimination of the drug from the body, hence, having a consequential impact on the way it works (Chakradhar & Mondal, 2019). Examples are certain antidepressants (fluvoxamine, nefazodone, fluoxetine), azole antifungals (itraconazole and ketoconazole), delavirdine, HIV drugs (indinavir), St. John’s wort, alcohol, macrolide antibiotics, and rifamycins (rifabutin). The various drug interactions might augment the risk of serious adverse events, such as severe drowsiness and shallow breathing.
Precautions
The effectiveness of Xanax is greatly influenced by alcohol intake, which also has a trickle-down effect on tolerance. Additionally, the interaction of Xanax with other drugs might lead to serious side effects. Therefore, it is recommended that elderly patients inform their doctors on alcohol consumption and any medications they are taking, including herbal and dietary supplements. Furthermore, until older adults experience the side effects of Xanax, they should not operate heavy or dangerous machinery such as cars. Lastly, individuals should not increase dosage without the doctors’ approval as they might develop tolerance and dependence.
Symptoms of Overdose/Withdrawal
When a person stops taking Xanax abruptly after using it for an extended period, they might experience withdrawal symptoms. These include anxiety, agitation, perceptual disturbances, dysphoria, delirium, increased awareness of sensory stimuli, seizures, and depersonalization. However, as compared to other benzodiazepine withdrawal syndromes, those associated with Xanax are more severe, even in cases when it is discontinued according to the manufacturer’s guidelines (Tannenbaum, 2015). Symptoms among the elderly might differ from those experienced by younger patients. According to Singh and Sarkar (2016), disorientation with or without hallucinations and confusion were identified as the most common symptoms elicited by the elderly. They did not develop perceptual changes, anxiety, and insomnia, common in the younger generation.
Conclusion
Alprazolam is often prescribed for elderly patients, and is this is because it is rapidly cleared from the circulation and has greater dosage flexibility. However, it has a greater potential for tolerance and abuse among the elderly, and this is bases on altered pharmacokinetics and pharmacodynamics. Furthermore, this generation is highly susceptible to potential side effects. Therefore, therapists must take extreme caution when prescribing Xanax for this age group. Lastly, tailored discontinuation guidelines should be embraced when tapering the medication; therapists should not explicitly rely on the manufacturer’s guidelines.
References
Apaydin, E. A., Maher, A. R., Shanman, R., Booth, M. S., Miles, J. N., Sorbero, M., & Hempel, S. (2016). A systematic review of St. John’s wort for major depressive disorder. Systematic Reviews, 5(148), 2-25. Web.
Chakradhar, T., & Mondal, S. (2019). Review on drug interactions of alprazolam on pharmacodynamic and pharmacokinetic actions. European Journal of Medical and Pharamaceutical Sicences, 6(1), 657-662. Web.
Cui, Y. H., & Zheng, Y. (2016). A meta-analysis on the efficacy and safety of St John’s wort extract in depression therapy in comparison with selective serotonin reuptake inhibitors in adults. Neuropsychiatric disease and treatment, 12, 1715–1723. Web.
Forsdike, K., & Pirotta, M. (2019). St John’s wort for depression: Scoping review about perceptions and use by general practitioners in clinical practice. Journal of Pharmacy and Pharmacology, 71, 117-128. Web.
Ingersol, R. E., & Rak, C. F. (2016). Psychopharmacology for mental health professionals (2nd ed.). Cengage Publishing. Web.
Shrivastava, M., & Dwivedi, L. K. (2015). Therapeutic potential of Hypericum Perforatum: A review. International Journal of Pharmaceutical Sciences and Research, 6(12), 4982-88. Web.
Singh, S., & Sarkar, S. (2016). Benzodiazepine abuse among the elderly. Journal of Geriatric Mental Health, 3(2), 123-130. Web.
Tannenbaum C. (2015). Inappropriate benzodiazepine use in elderly patients and its reduction. Journal of psychiatry & Neuroscience, 40(3), 27–28. Web.
Wick, J. (2013). The history of benzodiazepines. Journal of American Society of Consultant Pharmacists, 28(9), 538-548. Web.