On May 4 of last year, I had a panic attack on the way back home from work. My commute from one end of London to another usually takes around 80 minutes and involves a mix of walking—underground and overground—and bus travel. This had never presented an issue before. After all, I was born and raised in London, and have rarely experienced claustrophobia. On that day though, something new and unpleasant kicked in, shortly after I passed the third metro station and was just settling in to another podcast episode of S-Town.
In an instant, a mood of heavy darkness overcame my mind and body. Like the moment when a regular dream turns nauseatingly Lynchian, I was suddenly aware that something was off-kilter. As I looked around at other passengers for some sort of validation of a shared experience, their bland disinterest gave way to a creeping sensation of paranoia. I felt that I couldn’t trust anyone. When I played a soothing classical piece to relax and distract my thoughts, the sounds became jumbled and dissonant. As I attempted the tried-and-tested technique of focusing on my breathing, I realized that I was taking deeper and sharper breaths. Debilitating fear gripped me for the whole journey until I finally tore through the front door of my home—a sweaty, disoriented mess—and burst into tears, certain I’d lost my mind.
Some of you will have also experienced panic attacks; most of you probably know someone who’s had one before. The National Institutes of Mental Health estimates that 2.7 percent of US adults experienced at least one panic attack in 2017 and that 4.7 percent of the adult population will experience a panic attack at some point in their lives. This places panic attacks in more or less the same ballpark as generalized anxiety disorder; when it comes to major depression, past year incidence makes the short jump to 6.7 percent.
If the fact that I had a panic attack is not particularly striking, perhaps the trigger for my experience is. Shortly before I left the office, I’d swallowed a capsule with what’s considered a small extract of St. John’s Wort—142 mg. At the time, my anxiety and depression was more prevalent than usual and—although I hadn’t experienced any major episodes—I was struggling with falling asleep, waking up, and batting away invasive, dark thoughts. I had recently attended a few sessions with a psychotherapist, but therapy can be a long-term and expensive game. Around one quarter of millennial Brits experience anxiety and depression, and like many in my peer group, I was looking for a quick and cheap respite. Thankfully, I’d never experienced a panic attack before—the prospect of it simply wasn’t on my mind as I looked into possible remedies.
The box ($17 for 50 capsules, versus around $50 per hour of therapy) stated that it’s a “traditional herbal medicinal product used to relieve the symptoms of slightly low mood and mild anxiety.” This matched my symptoms, plus the herbal aspect appealed to me against the available pharmacological alternatives. I’d also read up on the scientific evidence around it and it seemed pretty solid.
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A 2008 Cochrane review found that the plant extract was superior to placebos, while having similar efficacy and fewer side effects than standard antidepressants. An updated review from 2016 lent further support to those findings. Any adverse effects of St. John’s Wort appeared to arise from interactions with other drugs, such as prescribed antidepressants. I’d done my research and, alongside other complementary and alternative medicine users, was pretty sure that a natural remedy couldn’t be that dangerous—in the worst situation, I thought it would simply be ineffective.
As I collapsed on the staircase of my family home, a bundle of tears and confusion, St. John’s Wort was the last thing on my mind. Without really knowing what a panic attack was truly like, I was certain that I’d gone mad. It was only after my sister came out of her bedroom and gently calmed me down that we got talking about the herbal extract. She asked if I’d taken anything and as soon as I mentioned St John’s Wort, she told me that her doctor once advised that it can cause panic attacks. I re-read the leaflet inside my box of capsules and, sure enough, panic attacks were listed as both a symptom that the supplement alleviates and a potential side effect—almost as ironic as the apparent connection between antidepressants and suicidal feelings.
A lengthy Google search turned up a few similar stories. One man on a UK bodybuilding forum outlined how he experienced a panic attack at the movies a few days after first taking St. John’s Wort. “Blood was going through me [sic] arms and to me head, felt like I was going to explode, going crazy and was gonna die at the same time. Horrible, strange feeling.” Two Turkish psychiatrists also published a 2013 case study regarding an otherwise healthy 35-year-old man who was admitted to the hospital with “palpitations, sweating, chest discomfort, shortness of breath, nausea, blurred vision, and feelings of derealization” two hours after drinking a glass of St. John’s Wort extract to help with sleeping issues.
One of those psychiatrists, Fatih Canan—now based at the University of Texas Southwestern Medical Center—suggests that St. John’s Wort users who have panic attacks might be experiencing a so-called "activation syndrome." This can occur in the first days of antidepressant treatment. “Since the mechanism of action of St. John’s Wort is similar to classical antidepressants, it might be causing increased anxiety and agitation,” he tells me. The similarities between the plant extract and antidepressants don’t end there. “St. John’s Wort extracts are likely to be potent but nonspecific inhibitors of the reuptake of neurotransmitters such as serotonin, norepinephrine, and dopamine. This mechanism is very similar with that of many FDA-approved antidepressants.”
Consequently, it can achieve the same therapeutic outcomes—and side effects—as popular antidepressants like SSRIs and SNRIs. One study actually compared adverse drug reactions arising from St. John’s Wort and the SSRI fluoxetine (otherwise known as Prozac), and found that they share a large number of side effects.
In the US, the FDA doesn’t regulate herbal remedies, meaning that safety monitoring of these alternative medicines is mostly absent. Although the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK—where I bought the extract—is responsible for licensing traditional medicines, this is based on their long-standing use, rather than clinical trials. In both countries, St. John’s Wort is available over-the-counter and isn’t usually prescribed by doctors, meaning that the onus is on the individual to read the leaflet.
I appear to be in a minority of people who’ve had panic attacks on St John’s Wort. For the majority of those experiencing anxiety and depression, it appears to be incredibly useful. Nonetheless, my experience is a reminder that—just like in the S-Town episode I was listening to moments before my mind melted into paranoia—not everything is always as it seems, and herbal alternatives are no exception.
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