The Professional Counselor | Volume 12, Issue 2 107 can also exert antagonistic effects by blocking receptor sites and preventing the activation of receptors (Preston et al., 2021). The most important neurotransmitters in terms of mental health are serotonin, dopamine, GABA, norepinephrine, glutamate, and acetylcholine (Stahl, 2021). It is important to note that these neurotransmitters are involved in complex brain functions and often act in combination with other substances and neurotransmitters. Serotonin plays a role in anxiety disorders and depression. Dopamine has been implicated in psychotic disorders as well as bipolar disorder. GABA is considered to be inhibitory to the firing of neurons. Norepinephrine is involved in many functions including memory and mood. Glutamate is an excitatory neurotransmitter. Too much glutamate can lead to cell death. It has been implicated in bipolar disorder and Alzheimer’s disease. Acetylcholine is involved in memory and it has also been implicated in Alzheimer’s disease (Ingersoll & Rak, 2016). The therapeutic index or window describes the parameter between an effective dose and a toxic dose of a drug. Some drugs such as lithium (used for the treatment of bipolar disorder) have a narrow therapeutic window, meaning that the effective dose and the toxic dose are in close proximity to each other and care must be taken when prescribing these drugs (Preston et al., 2021). Drugs and herbal remedies may be additive (or synergistic). Additive effects are those in which a drug or herbal remedy may increase or improve the action of another drug or herbal remedy. Drugs or herbal remedies may also act antagonistically, which means the drug/herbal remedy renders another drug/herbal remedy less effective (Sharma et al., 2021). Drug interaction refers to how two or more drugs impact each other in terms of changes in absorption, distribution, metabolism, and excretion (Preston et al., 2021). Half-life refers to the time it takes the body to decrease the blood level of a drug by 50%. The half-life of drugs and herbal remedies can vary greatly, ranging from hours to days (Ingersoll & Rak, 2016). Many herbal remedies and drugs are metabolized through the cytochrome P450 enzymatic system located primarily in the liver and the gastrointestinal system (Stahl, 2021). Finally, serotonin syndrome can be a life-threatening, adverse reaction to the often unintentional overuse of drugs containing serotonin, or drugs that inhibit serotonin reuptake. Scotton et al. (2019) provided an overview of serotonin syndrome, noting that serotonin serves many functions in the brain and body, including regulating cognitive, emotional, and behavioral functions as well as regulating body temperature and digestion. Serotonin syndrome symptoms can range from mild to severe and can even lead to death. There are a host of symptoms caused by serotonin toxicity (too much serotonin) ranging from diarrhea, tachycardia, agitation, and experiencing tremors to life-threatening symptoms such as delirium, neuromuscular rigidity, hyperthermia, seizures, and coma. The main group of drugs implicated in serotonin syndrome are SSRIs in combination with other serotonergic substances, which also include herbal remedies and OTCs (Scotton et al., 2019). The following sections provide counselors with a detailed overview of herbal remedies and OTCs. Herbal Remedies It has been estimated that about 25%–35% of Americans use or have used herbal medicines (Rashrash et al., 2017; Wu et al., 2011). A National Institute of Health survey (Nahin et al., 2009) revealed that in the United States, consumers spent $33.9 billion on CAMs, with $14.8 billion going toward non-vitamin, non-mineral, and natural products (e.g., herbal remedies, melatonin, fish oil, glucosamine). This is roughly equivalent to one-third of the out-of-pocket expenditure for prescription drugs (Nahin et al., 2009). Ravven et al. (2011) found that 44.7% of those using psychiatric prescription drugs also used herbal remedies at the same time.
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