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<p class="ltrs-br-ltr-br-title"><span class="bold">A Case of Panic Attack Induced by St John’s Wort</span></p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold">To the Editor:</span> St John’s wort (<span class="italic">Hypericum perforatum</span> L) is one of the oldest and best investigated medicinal herbs.<span class="htm-cite"><a href="#ref1">1</a></span> <span class="italic">Hypericum</span> extracts have been shown to be significantly effective in treating mild-to-moderate depression.<span class="htm-cite"><a href="#ref2">2</a></span></p>
<p class="ltrs-br-ltr-br-body-text">To the best of our knowledge, we report the first case of panic attack induced by a single dose of St John’s wort extract.</p>
<p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Case report.</span> Mr A, an otherwise healthy 35-year-old man, was admitted to the hospital for gradually increased trembling and fear of dying. He stated that, 2 hours after he drank a glass of St John’s wort extract (because of difficulty falling asleep), he became restless, anxious, and agitated. He also reported palpitations, sweating, chest discomfort, shortness of breath, nausea, blurred vision, and feelings of derealization. The patient denied hallucinations or delusions. An electrocardiogram showed tachycardia. Vital signs were remarkable for a pulse of 110 bpm and respiratory rate of 22 breaths/min. Improvement was seen in the panic state, and vital signs returned to normal within 25 minutes after oral alprazolam 1 mg was administered. He denied any psychiatric history (apart from difficulty falling asleep 1 or 2 days a week), current stressors, or use of alcohol. Family history was noncontributory. When questioned, Mr A reported a similar episode after drinking a glass of St John’s wort extract approximately 2 months previously. </p>
<p class="ltrs-br-ltr-br-body-text">The patient met the <span class="italic">Diagnostic and Statistical Manual of Mental Disorders</span>, Fourth Edition, diagnostic criteria for panic attack. According to the Naranjo Adverse Drug Reaction Probability Scale,<span class="htm-cite"><a href="#ref3">3</a></span> there was a probable association between St John’s wort and panic attack. After being discharged, Mr A denied any further panic attacks at his 1- and 3-month visits.</p>
<p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
<p class="ltrs-br-ltr-br-body-text">Although the exact mechanism of action is not known, there is good evidence from in vitro experiments that St John’s wort extracts are potent but nonspecific inhibitors of the synaptosomal reuptake of serotonin, norepinephrine, and dopamine.<span class="htm-cite"><a href="#ref4">4</a></span> In vivo studies have shown that <span class="italic">Hypericum</span> extracts lead to a down-regulation of β-adrenergic receptors and an up-regulation of 5-HT<span class="subscript">2</span> receptors.<span class="htm-cite"><a href="#ref4">4</a></span></p>
<p class="ltrs-br-ltr-br-body-text">The most important risk associated with <span class="italic">Hypericum</span> extracts is reported to be the interactions with other drugs.<span class="htm-cite"><a href="#ref5">5</a></span> However, as reported here, a single dose of St John’s wort extract can induce a panic attack. It is crucial to investigate herbal drug use in patients presenting with psychiatric complaints. It is important that clinicians become aware of the potential psychiatric adverse effects associated with St John’s wort, which is a widely used medicinal herb, and explain these effects to their patients.</p>
<p class="ltrs-br-ltr-br-references-head"><span class="smallcaps">References</span></p>
<p class="references-references-text-1-9"><a name="ref1"></a>1. Lawvere S, Mahoney MC. St John’s wort. <span class="italic">Am Fam Physician</span>. 2005;72(11):2249–2254.<span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16342849&dopt=Abstract"> PubMed</a></span></p>
<p class="references-references-text-1-9"><a name="ref2"></a>2. Kasper S, Caraci F, Forti B, et al. Efficacy and tolerability of Hypericum extract for the treatment of mild to moderate depression. <span class="italic">Eur Neuropsychopharmacol</span>. 2010;20(11):747–765. <span class="pubmed-crossref"><a href="http://dx.doi.org/10.1016/j.euroneuro.2010.07.005">doi:10.1016/j.euroneuro.2010.07.005</a><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=20708905&dopt=Abstract"> PubMed</a></span></p>
<p class="references-references-text-1-9"><a name="ref3"></a>3. Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. <span class="italic">Clin Pharmacol Ther</span>. 1981;30(2):239–245. <span class="pubmed-crossref"><a href="http://dx.doi.org/10.1038/clpt.1981.154">doi:10.1038/clpt.1981.154</a><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7249508&dopt=Abstract"> PubMed</a></span></p>
<p class="references-references-text-1-9"><a name="ref4"></a>4. Butterweck V. Mechanism of action of St John’s wort in depression: what is known? <span class="italic">CNS Drugs</span>. 2003;17(8):539–562. <span class="pubmed-crossref"><a href="http://dx.doi.org/10.2165/00023210-200317080-00001">doi:10.2165/00023210-200317080-00001</a><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12775192&dopt=Abstract"> PubMed</a></span></p>
<p class="references-references-text-1-9"><a name="ref5"></a>5. Linde K. St John’s wort—an overview. <span class="italic">Forsch Komplement Med</span>. 2009;16(3):146–155.<span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=19657198&dopt=Abstract"> PubMed</a></span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Osman Yildirim, MD</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Fatih Canan, MD</span></p>
<p class="ltrs-br-ltr-br-author"><a href="mailto:fatihcanan@gmail.com">fatihcanan@gmail.com</a></p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Author affiliations:</span> Department of Psychiatry, Abant Izzet Baysal University, School of Medicine (Dr Yildirim); and Bolu Izzet Baysal Mental Health Hospital (Dr Canan), Bolu, Turkey.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Potential conflicts of interest:</span> None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Funding/support:</span> None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Published online:</span> January 24, 2013<span class="italic">.</span></p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">Prim Care Companion CNS Disord 2013;15(1):</span><span class="doi">doi:10.4088/PCC.12l01453</span></p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">© Copyright 2013 Physicians Postgraduate Press, Inc.</span></p>
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