A Case of Panic Attack Induced by St John's Wort.

St. John’s wort (SJW)(Hypericum perforatum L) is one of the oldest medicinal herbs. Hypericum extracts have been shown to be significantly effective in treating mild to moderate depression. To our knowledge, this is the first case report about panic attack in a man induced by a single dose of SJW extract. A 35-year-old male was admitted for gradually increased trembling and fear of dying. He stated that 2 hours after he received a glass of SJW extract (because of difficulty falling asleep), he became restless, and agitated. He also reported palpitations, sweating, chest pain, shortness of breath, nausea, blurred vision, and feelings of derealization. He denied hallucinations or delusions. An ECG showed tachycardia. Vital signs were remarkable for pulse 110/min, and respiratory rate 22/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 one or two days a week) current stressors, and use of alcohol. Family history was noncontributory. He reported a similar episode after taking a glass of St. John’s wort extract approximately 2 months ago. The patient met the DSM-IV criteria for panic attack. According to Naranjo Probability Scale, there was a probable association between SJW and panic attack. After being discharged, the patient denied any further panic attacks during his visits at 1 and 3 month. Although exact mechanism of action is not known in vivo studies have shown that Hypericum extracts lead to a downregulation of beta-adrenergic receptors and an upregulation of 5-HT2 receptors. The most important risk associated with SJW extracts is reported to be an interaction with other drugs. However, as reported here, a single dose of St. John’s wort extract can induce a panic attack. It is crucial to investigate herbal drugs use in patients presenting with psychiatric complaints.