People want to know 'what is kava good for?' Plants don't come with instructions. We must learn from them what they're for.

-Steven Dentali, A.D., associate editor, Medical Herbalism

What Does Kava Do?

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What role can kava play in treating stress and anxiety? Here's what Kristen, a 29-year-old journalist from Arizona, had to say.

Background

"I've been taking kava off and on for years, as a sleep aid and nerve tonic. I am a fairly high-strung person. Throughout my life, I've been diagnosed with depression a bunch of times. Last year, I hit a very low period, and I finally found a doctor with some integrity, who took the time to find out what caused my depression. Then it all made sense. She told me I seemed to have anxiety-induced depression. I stress, I get irritable and stress even more, and that taxes my brain and produces some kind of chemical response, and bam! I'm hit with a nasty depression that I can't drag myself out of.

"Years ago, before this happened, I went through a phase (also right before a depressive period) where I was having regular panic attacks. These weren't just bouts of anxiety, but actual clinical panic attacks. I'd hyperventilate, become absolutely convinced that I was dying, having a stroke, or a having heart attack-you name it. I was the editor of the college newspaper then, and it was rather embarrassing, to say the least, when one of these attacks would hit me. I'd be sitting in my office wondering if I should (or could) go ask a reporter to take me to the hospital. Twice, I actually did ask someone, and he walked me outside. I would eventually calm down.

Using Kava

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"Right after that, I asked a friend who was training as an herbalist to recommend an herb for 'brain function.' She gave me kava, and I took it for about a month, three times a day. I don't know that it improved my brain function, exactly, but I noticed during that time that I was much easier to get along with. I slept better, I wasn't so high-strung, and everything came easier.

"I don't use it all the time anymore, but it's helped me when I couldn't sleep because I was simply too stressed, lying in bed trying to balance bills and paychecks. On those days when my mind is racing and I'm fretting needlessly about money, school, work, romance, or whatever, I take two dropperfuls of kava and boom-I'm relaxed.

"I'm amazed at how it has improved my life. I don't get that circular thinking, and it makes it easier for me to step back and look at everything calmly. So I've got only $10 in my bank account, and I don't know what I'm going to do with my life? Oh well! The sky is falling? just give me some kava so I can watch it happen, with no panic."

This is quite a Story! Kristen had a variety of problems over time: depression, panic attacks, insomnia, and a stressed, racing mind. The solution for all of them has been kava. She sounds like the kava poster childl Is this too good to be true?

According to a large body of scientific research, along with reports from other health practitioners and my own clinical experience, Kristen's case is not an isolated one.

European Use of Herbal Medicine

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Kava has a history of use in Europe-particularly France, Switzerland, and Germany. Most of the research has been done in Germany and some in Australia, because of its proximity to Oceania. Do you wonder why the United States has not been open to the practice of herbal medicine until recently? Despite a rich heritage of information, from both European and Native American sources, the legacy was lost in the early part of the 1900s. Phytomedicine (plant-bascd medicine) was removed from medical school curriculums, and replaced by technological medicine and pharmaceuticals. Meanwhile, in some European countries, natural medicine continued to be taught alongside Western medicine giving the Europeans a clear advantage in knowledge and research opportunities. It is only now that we have begun to revisit this cornucopia of healing resources.

In Germany, where doctors can prescribe herbal as well as synthetic products, they frequently choose the more benign, and often more effective, plant materials. Herbs containing chemical substances similar to our own, work as natural synergistic groups of compounds. Like food, these gifts of nature are available to nurture and heal us. Most of our pharmaceuticals are actually plant-based, just modified and refined for more specific actions and for patentability, since there is no return on their research investment otherwise. These changes are not always for the best, however, since concentrating a substance often removes its protective compounds and increases the possibility of side effects.

A good example of the drug/herb comparison is St. John's wort, which appears to work as well as the synthetic antidepressants for mild to moderate depression, but without their often intolerable side effects. In Germany, physicians prescribe it anywhere from 10 to 20 times more often than Prozac (see Chapter 5). Now that the American population is becoming more educated and is no longer willing to accept the shortcomings of conventional medicine, our medical community is finally beginning to catch on. The National Institutes of Health are funding a $4.3 million study at Duke University School of Medicine on the use of St. John's wort for severe depression. The movement toward complementary or integrated medicine has been well launched, with 63 medical schools currently teaching courses in alternative medicine. These projects are harbingers of things to come.

Stress and Anxiety

If we are looking for analogies with conventional drugs, and consider St. John's wort to be "Nature's Prozac," then kava is "Nature's Valium." But unlike users of Valium and other antianxiety drugs, the mind of the kava user remains clear, with many even reporting a sharpening of physical coordination and mental clarity. Research bears out these findings, as does clinical experience.

German Commission E Monograph

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The German Commission E is an expert advisory panel to the German equivalent of the U.S. Food and Drug Administration (FDA). They review the available literature on various herbs, to determine their suitability as non-prescription medicines. Commission E has published nearly 400 monographs evaluating herbal medicines as to their effectiveness, side effects, dosage, interactions with conventional mcdicines, and contraindications. An English translation by an elite team of herbal specialists, headed by Mark Blumenthal and Joerg Gruenwald, is newly available through the American Botanical Council. With translation and commentary, it will be one of the most reliable sources of information on the use of herbal products, especially for health professionals (see Appendix B).

Commission E Monograph Summary for Kava

The Commission E kava monograph is summarized below:

Uses: Conditions of nervous anxiety, stress, and restlessness (translated by Gruenwald), or nervous anxiety, tension, and agitation (translated by Schulz, 1997). Author's Note: The subtle differences in meaning-,'stress" versus "tension" and "agitation" versus "restlessness" have implications, since almost all research to date is in German, and our knowledge is based on the translator's interpretation. There are also significant cultural differences between the United States and Germany. We need U.S.-based research in order to really understand the spectrum of use and the effects of a substance, especially when the measures are as subjective as emotional states and responses.

Contraindications: Pregnancy, nursing, and endogenous depression.

Side Effects: Extended intake can cause a temporary yellow discoloration of the skin, hair, and nails. In this case, further applications of this drug must be discontinued. In rare cases, allergic skin reactions can occur. Accommodative disturbances, such as enlargement of the pupils and disturbances of oculomotor equilibrium, have also been described (see Chapter 11).

Interactions with Other Drugs: Potentiation of effectiveness is possible for substances acting on the central nervous system, such as alcohol, barbiturates, and psychopharmacological agents (see Chapter 11).

Dosage: Equivalent of 60 to 120 mg kava pyrones (kavalactones).

Mode of Administration: Comminuted rhizome and other galenic preparations for oral use. This means that the root and extract can be taken in oral preparations.

Duration of Application: Not more than three months without medical advice.

Author's Note: Even when administered within its prescribed dosages, this herb may adversely affect motor reflexes and judgment for driving and/or operating heavy machinery.

Action: Antianxiety. In animal experiments, a potentiation of narcosis (sedation), anticonvulsive, antispasmodic, and central muscular relaxant effects were described.

How Kava Helps Anxiety

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A screenwriter patient of mine took a dose of kava (40 drops of tincture) to calm his nerves before an initial meeting with a group of studio executives. By his report, not only did his anxiety disappear, but he was able to present his material and think on his feet more clearly than ever.

Forty-seven-year-old Jessica uses kava when she is overwhelmed with work schedules and deadlines. She states, "Kava doesn't overpower you. It relaxes your muscles and calms your emotions without changing your personality. You're still yourselfjust not as tense or anxious."

Jessica's observation is echoed by Wayne Silverman of the American Botanical Council, "People are interested in the subtlety of kava. That makes kava more palatable than many of the conventional medications."

Clinical Studies

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What does the research show about the effectiveness of kava in reducing anxiety~ There have been six double-blind studies of kava in patients with anxiety. "Double blind" means that neither the participants nor the doctors know who is getting the active compound, in this case, kava, or an inactive "dummy" pill.

Kava vs. Placebo

Volz's 1997 double-blind placebo-controlled study represents a major step forward in kava research. It lasted 25 weeks and had 101 participants, making it a longer and larger study than any previous study on the effects of kava on anxiety disorder. The dose was one capsule of WS1490 extract (Schwabe), containing 70 mg kavalactones, taken three times daily.

Subjects had to have at least one of the following diagnoses by DSM-IlI-R criteria: agoraphobia, social phobia, generalized anxiety disorder, or adaptation disorder. The criteria for inclusion were consistent with U.S. standards, since the DSM-111-R is the official diagnostic manual used by the American Psychiatric Association. The Hamilton Anxiety Scale (HAMA) was used by the examining physicians to measure the severity of symptoms, with a score over 18-indicating moderate to severe anxiety-necessary for inclusion in the study. A 90-item Self-Report Symptom Inventory was also used so that the participants could rate their subjective experience.

After eight weeks, and continuing through the rest of the study, the kava group showed a significant improvement compared to the placebo group, on both physician-rated and self-rated scales. They also showed fewer side effects. In fact, the inert "placebo" pill produced more side effects than the real one. While placebo treatment almost always causes side effects, these extra side effects were most likely the results of their already-existing and untreated anxiety. Side effects in the kava group were few and minor, and laboratory tests showed no abnormal changes.

In summary, Volz's study showed that anxiety and depression significantly decreased, as did physical symptoms, including headaches, breathlessness, heart palpitations, chest or stomach pains, and faintness.¹ Interestingly, a similar 1996 study with 58 subjects using the same product showed that, unlike the previous study, kava worked better than the placebo from the outset. A majority of the kava users improved markedly after one week, with the improvement continuing through week four, which was the end of the survey period. The placebo group showed little change in their anxiety levels.²

Possible explanations for this difference in the onset of the effects of kava (week one vs. week eight) compared to placebo are as follows:

1. The Volz group were more seriously ill to start with, having an average illness duration of 6.5 months, and many had more than one diagnosis, including depression, making them more difficult to treat.

2. The placebo effect in the Volz group was particularly high, thereby decreasing the gap in results between the two groups.

Similarly rapid results were seen in two other randomized, placebo-controlled double-blind studies that followed 40 women with menopause-related anxiety symptoms. Subjects had improvement in symptoms after one week, reaching optimal levels at four weeks, and maintaining this comparative benefit for the full eight weeks of the study.^{3, 4}

A 1989 study determined that an extract of kavain produced emotional and muscular relaxation while simultaneously stimulating the thinking process and activity. This study shows that an isolated compound, kavain, extract of kava, can also have a positive result. In general, though, research indicates that the whole extract is superior to the isolated compounds.⁵ (See Chapter 7.)

Kava vs. Benzodiazepines

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In several studies, we've seen that kava produces positive effects when compared to a placebo. That tells us it's better than nothing. But the question remains: How does it compare to the most widely prescribed pharmaceuticals-the benzodiazepines (see Chapter 5)?  The following studies attempted to provide answers in terms of both efficacy and safety. As you already know, medications such as Valium, Xanax, and Klonopin have the potential to relieve anxiety and insomnia, but with potent side effects, including dependency and addiction.

A 1993 study of 12 volunteers compared the effects on mental function of a standardized kava extract (WS 1490, 70 mg, three times a day) versus oxazepam (Serax). The 12 volunteers were tested on word recognition, measured in terms of accuracy, reaction time, and EEG responses. First, the oxazepam group "showed significant changes toward a less active, more introverted and drowsy behavior," while the kava group showed no such tendency. More importantly, oxazepam decreased both the speed of reaction time and the quality of recognition responses. Kava, on the other hand, improved reaction time and enhanced recognition. The researchers concluded that these results indicate "enhanced memory performance under kava ... and a greatly impaired performance [with] oxazepam." This seems to confirm the claim that kava, as opposed to benzodiazepines, does not sedate. Moreover, nather than impairing mental sharpness, it actually improves it. This study was only comparing mental function and physical reaction time. What about relaxation? In two other studies, kava compares very favor-ably to two popular benzodiazepines in terms of relieving anxiety-but without the drugs' side effects.⁶

Another 1993 double-blind study followed 174 patients with anxiety symptoms for a period of six weeks. Patients received either 15 mg of oxazepam (Serax), 9 mg of bromazepam (a European benzodiazepine), or 300 mg of a 70% kavalactone extract daily. Kava matched both drug groups in improving anxiety scores as measured by the Hamilton Anxiety Scale (HAMA).⁷

In a 1990 study of 38 outpatients, half were treated with oxazepam, and half with kavain (a single kavalactone). Kavain relieved anxiety just as well as the pharmaceutical, and with no adverse cffects.⁸

Conclusions

Since German diagnostic criteria differ, some of these studies have been criticized for not using more precise criteria. We may also lose something in language and cultural translation. However, in the largest, longest-running study to date, Volz used the DSM-111-R (American-based) diagnostic categories. All the studies described here show that the participants gained some relief from their suffering and that kava compared well to benzodiazepines, without the latter's adverse effects. In studies where it was measured, kava actually enhanced mental functioning. These results look quite promising. Does kava lose its touch when it crosses the Atlantic? Only American research will tell.

References

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1. Volz, H.P. et al., "Kava-Kava Extract WS 1490 versus Placebo in Anxiety Disor ders-A Randomized Placebo-Controlled 25 Week Outpatient Trial" Pharmacopsychiatry (1997): 30 (1): 1-5.

2. Lehmann, E., Kinzler, E., and Friedemann, J., "Efficacy of a Special Kava Extract in Patients with States of Anxiety, Tension and Excitedness of Non-Mental Origin-A Double Blind Placebo Controlled Study of Four Weeks of Treatment." Phytomedicine Vol. 111 (1996): 113-119.

3. Warnecke, G., "Psychosomatic Dysfunctions in the Female Climacteric: Clinical Effectiveness and Tolerance of Kava Extract WS 1490" Fortschr Med (1991): 109 (4): 119-122.

4. Warnecke G. et al., "Wirksamkeit von Kawa-Kawa-Extract beim klimakter ischen Syndrom." Z Phytother (1990): 11: 81-86.

5. Lehmann, E., Klieser, R., Klimke, H. et al., "The Effects of Kavain on Patients Suffering from Anxiety" Pharmacopsychiatry (1989): 22: 258-262.

6. Munte, IF., Heinze, HJ., Matzke, M., and Steitz, J., "Effects of Oxazeparn and an Extract of Kava Root (Piper methysticum) on Event-Related Potentials in a Word-Recognition Task" Neuropsychobiology (1993): 27 (1): 46-53.

7. Woelk H., et al., "Double-Blind Study: Kava Extract versus Benzodiazepines in Treatment of Patients Suffering from Anxiety" ZAlIgMed (1993): 69: 271-277.

8. Lindenberg, D. et al., "Kavain in Comparison with Oxazeparn in Anxiety Disorders: A Double-Blind Study of Clinical Effectiveness" Fortschr Med (1990): 108: 49-50.

9. Singh, Y.N., "Effects of Kava on Neuromuscular Transmission and Muscle Contractility" Journal of Ethnopharmacology (1983): 7: 267-276.

10. Bruggenmann, F, et al., "Die analgetische Wirkung der Kawa-Inhaltsstoffe Di hydrokawain und Dilrydromethysticin" Armneim-Forsch (1963): 13: 407-409.

11. Morrison, J., The Journal of James Morrison. London: Golden Cockerel Press, (1935): 151.

12. Carper, J., Miracle Cures. New York, NY. HarperCollins (1997): 160-161.

13. See note 3 above.

14. See note 4 above.

15. Balch, D., "Sulle Propierta Farmacologische Del I Piper Methysticum" Terapia Moderna (1980): 4: 359-364.

16. Lebot, Vincent, Merlin, Mark, and Lindstrom, Lamont, Kava: The Pacific Elixir. Rochester, VT: Healing Arts Press, (1997).

17. Hansel, R. et al., "Characterization and Physiological Activities of Some Kava Constituents" Pacific Science (1966): 22: 293.

18. Hansel, R. et al., "Fungistatic Effects of Kava" Planta Med (1966): 14: 1-9.

19. Duffield, A.M. et al., Journal of Chromatography (1989): 475, 273.

20. Rasmussen, A.K. et al., "Metabolism of Some Kava Pyrones in the Rat" Xenobiotica (1979): 9:1-16.