1.0. CHAPTER 1: INTRODUCTION
1.1. Background
Mental wellbeing is among the major concerns in the recent years, especially with the changing dynamics of humanity. About 25% of women and 12% of men suffer from depression at least once in their lifetime (Kessler et al., 2015). From a more comprehensive perspective, depression and anxiety are a deeply rooted mental problem in the society than the magnitude reported in the official statistics.
Depression and anxiety are neuropsychiatric conditions with fluctuating remission states, recurrence, recovery, and relapse (Kanter et al., 2008). They affect an individual’s mental wellbeing, social interactions, and economic outcomes. Depression and anxiety are also known to be correlated with chronic diseases such as cardiovascular and immune disorders (Amsterdam et al., 2020). Due to this problem’s magnitude and effects, there is a need to seek alternative interventions to manage and possibly mitigate it.
Current pharmacological approaches to treating depression and anxiety disorder include the use of medications, psychotherapy, or a combination of both. Selective Serotonin Reuptake Inhibitor (SSRI’s) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s) such as citalopram, fluoxetine, venlafaxine, sertraline, and duloxetine are among the commonly used intervention in the field of pharmacology (Ballenger, 2000). Psychotherapy, which is subcategorized into psychodynamic therapy (PT) and cognitive behavioral therapy (CBT), are also effective forms of treatment for anxiety and depression (Mayo-Wilson et al., 2014).
Evidence shows that psychotherapy used in conjunction with pharmaceutical agents has more significant overall effects in treating mental health than stand-alone treatments (Cuijpers et al., 2014). These conventional treatments are often useful in treating the short-term effects of mental health disorders. However, the negative side effects that come along with these drugs prompt the medical profession and society, in general, to seek sustainable, effective, and friendly alternative solutions to mitigate the problem (Firoozeei et al., 2020)
.
1.1.1. Hypoglycemic, anxiety, and depression
Studies have confirmed that there is a bidirectional relationship between diabetes and depression. Chronic diabetic patients, particularly those with comorbid neuropathy, are likely to suffer from depression, anxiety, and other mental conditions due to hypoglycemia (Moncrieff, 2018). Both hypoglycemia and prolonged use of synthetic anti-depressants affect the kidneys; therefore, as hypoglycemic patients are likely to suffer from depression, a prolonged administration of synthetic anti-depressants is likely to worsen their condition. Such a situation presents a dilemma of compromising the patient’s health in the long run.
The bidirectional relationship is because depressed individuals are likely to suffer from various eating disorders associated with the intake of foods with a higher glycemic index, such as junk food, foods rich in carbohydrates, and starch (Gangwisch et al., 2015). A cross-sectional analysis found a correlation between depression and the intake of food rich in sugar. The study (statistically significant results, p<0.05) revealed a positive correlation between intake of refined foods and the risk of depression. The analyses showed that consuming fruits and vegetables with fiber, which lower the glycemic index was linked with lower rates of depression. Further studies also corroborated with the existing relationship between hyperglycemia and depression, the study revealed that healthy overweight respondents who regularly consumed high glycemic diets had negative mood scores, which is an indicator of anxiety and depression (Haghighatdoost et al., 2016). Another study evaluated the effects of high and low glycemic meals in adults with type 2 diabetes and children correspondingly (Cheatham et al., 2009). The researchers revealed that a diet with high glycemic was positively related to reduced cognitive function and well-being.
All this evidence points towards the fact that high glycemic is likely to lead to mental health issues such as depression and anxiety. The fact that synthetic anti-depressants affect the body’s vital organs when used for a long time exposes diabetic patients to adverse situations that jeopardize their quality of life and can lead to death in extreme cases. Such situations call for alternative interventions for depression and anxiety
1.1.2. Herbal Pharmacology
It is often a challenge to treat psychological disorders using conventional medication treatments as these disorders are often multifactorial. (Asher et al., 2017). Most pharmaceutical drugs are also known to have great impacts on mood, sleep, cause sexual dysfunction, and discontinuation reactions after its withdrawal which are intolerable for most patients (Asher et al., 2017). Serotonin syndrome which results from long term use of SSRI’s is characterized by agitation, high fever, sweating, confusion, tremors, restlessness, lack of coordination, and major changes in blood pressure and a rapid heart rate, can be life-threatening if not appropriately treated (Ravindran et al., 2015).
Although there are a number of adverse effects that stem from SSRI use, these pharmaceutical agents remain popular due to the convenience of administering them and the fact that the first dose is similar to the therapeutic dose, which renders careful, slow dosage administration (Ravindran et al., 2015). Apart from the fact that they have shown to be efficient in managing anxiety and depression by targeting the medulla part of the brain, their side effects can range from nausea, indigestion, and constipation, to weight loss, dizziness, and blurred vision (Ravindran et al., 2015).
There have also been recent concerns of SSRI-induced indifference which is largely under-recognized with insidious and delayed onset, which is most likely related to dosing (Puri & Treasaden, 2010). Contrary herbal therapies use various mechanisms to help address the challenges of mental health disorder treatments, such as up-regulation of 5-hydroxytryptamine (5-HT), norepinephrine (NE) and dopamine (DA)
via the suppression of the reuptake of these neurotransmitters in the brain and sensitization of serotonin receptors or inhibition of monoamine oxidases (Liu et al., 2015).
1.1.3. Herbal antidepressants
Depression is a common psychological disorder that affects an individual’s body fitness and wellbeing. Most synthetic anti-depressants usually have adverse side effects that affect the patients’ mental wellbeing.
The drugs are also costly, and thus, some consumers might not end up affording them in the long run, which also compromises the patient adherence rate to the intervention (Kasper et al., 2016). Contrary, herbal anti-depressants are more efficient since they target multiple psychological implications, are pocket-friendly to acquire and have low toxicity levels (Kharasch et al., 2019). Most patients may prefer natural remedies to manage depression and anxiety because they have organic elements that multi-target mental disorders and other underlying conditions in an individual’s body.
Lavender is among the most commonly used natural remedies by various civilizations to enhance an individual’s moods, which led to multiple researchers exploring it to assess the efficacy of the herb in reducing depressive symptoms (Farahani et al., 2015). An experimental study in rats revealed that Lavender has sedative, neuroprotective, analgesic, anxiolytic, and anticonvulsive properties capable of reducing depressive symptoms (Hritcu et al., 2012).
The study also revealed that Lavender had an anti-conflict impact on mice (Hritcu et al., 2012). Persistent exposure to lavender oils for a week, limited anxiety and depressive behaviors in the sample (Hritcu et al., 2012).
As much as the survey used elevated plus-maze and forced swimming tests only, the results were viable and proved to be statistically significant. In other studies, lavender oils proved efficient in treating antianxiety effect; this study used Geller and Vogel conflict tests to confirm the hypothesis (Hritcu et al., 2012). Linalool is an extract from lavender oil that was shown to have anti-conflict properties in the Vogel and Geller tests (Hritcu et al., 2012).
Further analysis compared the efficiency of chlordiazepoxide with lavender oils by evaluating the effects of anxiolytics on mice’s behavior (Linck et al., 2010).
The study revealed that Lavender had similar efficacy as chlordiazepoxide in reducing depressive symptoms (Linck et al., 2010). In comparing Lavender’s anxiolytic impacts with diazepam using the plus-maze tests on the Mongolian gerbil rats, the study revealed that exposure to Lavender resulted to similar anxiolytic characteristics to those of diazepam (Bradley et al., 2007).
These studies confirmed that lavender oil has the potential of reducing aggressive behaviors and increase social interactions, which are desirable effects when mitigating depression and anxiety (Bradley et al., 2007). The reported study is indicative of the fact that lavender may be a much safer alternative than its pharmaceutical counterparts such as diazepam and chlordiazepoxide in terms of human consumption, addiction rate, and long-term effects (Bradley et al., 2007).
Most herbal therapies also suppress corticosteroid elevation in humans, which reduces the effects of stress and anxiety (Firoozeei et al., 2020). Herbal medicine exerts anti-depressant activity in the brain and restores the body’s normal functioning (Firoozeei et al., 2020).
Adaptogens are a category of herbal medicine that contain constituents that can help alleviate stress and fatigue, boosting a patient’s immune functioning (Firoozeei et al., 2020). Adaptogens are also essential since they protect the central nervous systems and cardiovascular systems of patients who suffer from depressive disorders (Firoozeei et al., 2020).
Pharmaceutical anti-depressants may lose its effectiveness in the human body after prolonged use because the body tends to develop resistance and becomes less responsive to the drug itself (Firoozeei et al., 2020). Such cases call for the patient to increase the drug’s dosage, which might adversely affect the patient’s body, unlike natural medicine, which may have little or no side effects in the long run (Firoozeei et al., 2020).
1.1.4. Herbal Anxiolytics
Anxiety disorders are known to affect both genders. Women are well known to experience anxiety disorders more than men in their various life stages, including during the postpartum period, pregnancy, menopause, and the premenstrual period (Lopresti et al., 2019). Steroid hormones, such as progesterone, estrogen, and testosterone hormones, influence the human body’s anxiety and emotions and are abundant in women (Firoozeei et al., 2020). These hormones have various effects on an individual’s brain, such as regulating emotions, and any slight hormonal imbalance might lead to anxiety and depression (Firoozeei et al., 2020).
Anxiety and depression may be presented in various forms such as phobic disorders, panic, and generalized disorders. The mechanism of anxiety disorders is unknown; most scientific evidence suggests that anxiety mechanisms are related to serotonergic, glutamatergic, and GABA transmissions (Lopresti et al., 2019).
Some of the side effects caused by the long-term use of pharmaceutical anti-depressants and anxiolytics include elevated blood pressure, suicidal thoughts, hallucinations, migraines, insomnia, and loss of motor coordination (Lopresti et al., 2019). In contrast, natural medicines work by altering the neurotransmitters and the HPA axis (Lopresti et al., 2019), and therefore they do not present any deadly side effects.
The Gamma-aminobutyric acid, known as the GABA, is a well-known inhibitory neurotransmitter in the human nervous system, which plays a significant role in anxiety (Ng et al., 2017).
When the GABA levels are low in the body, it increases hyperactivity levels linked to psychological disorders such as anxiety. Most of the herbal medicines have anxiolytic effects; this means that it aids in elevating the GABA levels to manage anxiety disorders. Medicinal extracts of herbal medications, such as the Lemon Balm, have been found to contain high levels of GABA (Kessler et al., 2001). An added advantage of these natural medicines is that it includes essential medicinal components containing an anti-inflammatory, antioxidant, and a detoxifier effect.
The natural treatments that have the GABA also help relieve increased anxiety levels by increasing brain waves, necessary for activating relaxing systems and ‘feel good’ hormones in the human body (Kessler et al., 2001).
Over the past decades, there has been a significant rise in individuals using natural herbal medicines to treat underlying anxiety disorders. For example, natural therapies such as the Gardenia Fructus have anxiolytic effects, efficiently improving depression and anxiety issues.
(Palette et al., 2017). Ginkgo biloba is a great example of an herb that has shown promise in managing mental health disorders in the elderly. Apart from relieving and managing depression and anxiety symptoms, Biloba leaves contain compounds that have anti-dementia effects and may be of great aid to the elderly individuals who suffer from these types of mental disorders (Kessler et al., 2001).
Some herbal medicines have effectively treated underlying psychological disorders, such as St John’s Wort, a natural anti-depressant mostly found in North and South American regions (Rajizadeh et al., 2017). The St. John wort is a known drug that effectively treats anxiety disorders because its mode of action entails restoring the HPA axis by reducing both the inflammatory and oxidative stress levels in an individual’s body
. As per the meta-analysis conducted by the Cochrane review on 64 different Randomized Controlled Trials, St. John’s Wart demonstrated moderate-quality evidence that it could significantly reduce anxiety and depression symptoms (Linde et al., 2005). Compared to modern pharmaceutical anti-depressants, St. John’s Wort competed relatively well.
The wart proved that it could reduce the severity levels of depression, remission, and relapse rates (Linde et al., 2005).
Such natural extracts have proven to reduce anxiety (Rajizadeh et al., 2017) by activating the GABA pathways and reducing the patient’s anxiety levels. The Ashwagandha is an anti-inflammatory herb that effectively alleviates different forms of anxiety and offers an efficient alternative.
Theanine, an amino acid found in green tea, has a calming effect on an individual’s brain, thus effectively lowering any form of stress. Extensive studies based on green tea’s efficacy in reducing depressive symptoms among humans have shown positive outcomes (Niu et al., 2019). The study targeted elderly patients with depressive symptoms and other underlying conditions. The results revealed that green tea could limit depressive symptoms among these patients.
These natural medicines contain psychoactive components that can bind to both the GABA and dopamine receptors, which act on the human muscles by reducing its impulses; thus, it is used as a mild anxiety relaxant (Rajizadeh et al., 2017). Like in the Kava kava plant, patients who received this medication showed positive results since their anxiety levels reduced.
1.2. Challenges of Using Conventional Medicine
1.2.1. Complications with drug treatment and management
Anxiety and depression are commonly diagnosed concurrently and undertreated in primary care settings (Ballenger, 2000). Treatment and management of these two comorbid conditions can be quite challenging to medical practitioners, as many patients often present with somatic symptoms instead of the typical psychiatric complaints that clinicians treat (Ballenger, 2000).
Most of the drugs in the categories mentioned above are often used in combination with anticonvulsants, benzodiazepines, tricyclic anti-depressants, and atypical anti-depressants to provide optimal benefits, which can be expensive, complicated, and cause greater side effects than the use of mono drug therapy (Ballenger, 2000). Patients that present comorbid conditions with anxiety and depression tend to be more resistant to pharmacologic treatments and have poorer outcomes than if they occurred alone (Ballenger, 2000).
Because of the difficulties in treating comorbid anxiety and depression, physicians must be more diligent when administering pharmacological agents through frequent dosing adjustments, interchanging medications, and regular follow-up appointments to assess progress (Dunlop, Scheinberg, & Dunlop, 2013).
1.2.2. Mechanism of Action is Not Visible
Antipsychotic drugs help relieve depressive symptoms by altering neurotransmitters’ functionality, such as dopamine and norepinephrine (Amsterdam et al., 2020). Conventional drugs only work on neurotransmitters; thus, their desired effect in treating psychological disorders may be short of what is expected by the users (Ravindran et al., 2015). Venlafaxine has also revealed greater efficiency as compared to SSRI, particularly in cases of chronic depression. In cases of severe depression, an increase in the dosage of the drug is recommended.
The increment exposes the patient to dose-related hypertension, which affects about 10% of all patients treated using a high dose of this drug (Ali et al., 2018). Another example of a drug with better outcomes is Mirtazapine. The drug works by constraining presynaptic noradrenergic systems, which enhances the noradrenergic functionality and serotoninergic functions. With such benefits, its typical side effects include sedation and weight gain (Douros & Renoux, 2018). Such side effects could lead to increased depression.
1.2.3. Side Effects
Most of these conventional drugs are effective but have proven to have more side effects than benefits. One example is the Serotonin Selective Reuptake Inhibitors (SSRI), which has been used over the past years as an effective anti-depressant in managing psychological disorders (Amsterdam et al., 2020). These drugs may impose a mild to severe side effects on an individual with the prolonged years of use (Amsterdam et al., 2020).
These side effects include sedation and sexual issues, such as decreased libido (Amsterdam et al., 2020). These drug also affects other medications’ efficacy, when consumed concurrently. Bupropion is one example; the drug affects norepinephrine and dopamine and has no serotoninergic impacts (Kharasch et al., 2019). It functions by stimulating the patient, while its side effects include insomnia, headache, and anxiety, among others.
Bupropion has some advantages, especially for younger patients who do not experience any loss of sexual drive and weight gain (Kharasch et al., 2019). Even so, for the same age group, the drug has the potential of causing seizures, and it is contraindicated in subjects with eating abnormalities like anorexia nervosa and bulimia nervosa.
1.2.4. Increased Risks
Antidepressants, together with the anxiolytic drugs used by most pharmacological companies to manage depression and anxiety, have more risks and side effects than benefits. Most of the patients who use pharmacological drugs are exposed to a higher risk of developing drug abuse, tolerance, and even drug addiction (Asher et al., 2017).
Medications such as the tricyclic anti-depressants, which has been used over the past years as an anti-depressant due to its high potency and low costs, have been found to exhibit many side effects, such as increased levels of toxicity in the human body since one has to increase the drug dose to achieve its full effect after a prolonged period of use (Asher et al., 2017).
1.2.5. Switching of Drugs
To efficiently treat most psychological disorders, one needs to switch pharmaceutic anti-depressants and anxiolytics or combine them (Asher et al., 2017).
Combining these drugs or switching from one to the other, is likely to cause multiple side effects on the patient. Each set of pharmaceutical anti-depressants has different side effects that could lead to adverse outcomes among the users
. Therefore, switching from one drug to another exposes an individual to various side effects that could affect their vital organs. These drugs’ ability to change the human metabolism via the P450 structures – a cluster of hepatic enzymes that metabolize food, medicines, and any other toxic element in the body (Stahl & Stahl, 2013) – renders their side effects dire.
1.2.6. Somatic Disease
Somatic diseases’ re-occurrence may increase individuals’ chances of developing depressive disorders (Firoozeei et al., 2020). Therefore, when one uses anti-depressants without treating somatic conditions, it is implausible that patients are likely to achieve any long-term solution.
Patients with co-current somatic conditions are likely to be depressed, which increases their probability to rely om anti-depressants (Firoozeei et al., 2020). Managing depression and failing to control the somatic condition can never be sustainable in the long run.
Contrarily, the underlying condition can also hinder the administration of some anti-depressive drugs, especially in cases where sensitive organs like the kidney or liver are involved (which is the case in most diabetic patients, yet they have a higher risk of suffering from depression).
Some synthetic drugs can have dire effects on patients with other underlying conditions and can expose them to life-threatening situations (Collard et al., 2015). For example, administering venlafaxine to a hypertensive patient would lead to dire consequences.
In cases where depressive patients have underlying conditions, they are supposed to be carefully monitored through regular checkups, including assessing the drug concentration in the patient’s blood (Collard et al., 2015). Unfortunately, most patients that abuse pharmaceutical depression drugs avoid such checkups because they fear being exposed. At the same time, non-compliant depressive patients are also likely not to adhere to routine checkups, which eventually jeopardizes their health.
1.3. Research Rationale
Anxiety and depression are quickly becoming a public health crisis and have even been identified as a major healthcare priority amongst many U.S. organizations (McLaughlin, 2011). Due to the high incidence of Americans with comorbid anxiety and depression, medical services in primary care settings are often over-utilized, and primary care doctors are overwhelmed trying to manage and treat people with these disorders (Devane et al., 2005).
The economic burden of the two mental health disorders highlighted are also cause for concern. The annual health care cost for anxiety is about $42.3- $42.6 billion (Devane et al., 2005), while the yearly health care cost of depression are about $83.1 billion (McLaughlin, 2011). Another aspect of the U.S economy’s burden is the loss of productivity caused by these disorders (McLaughlin, 2011).
On average, two hundred twenty-five million workdays were lost due to depression, which is equivalent to $36.6 billion of salary per year (McLaughlin, 2011). There is also a higher rate of physiological manifestations that directly or indirectly complicate existing chronic illnesses with depression and anxiety (Dimatteo et al., 2000). Given the negative impacts of anxiety and depression, there is a great need to find solutions that help eliminate their burdens.
Depression may manifest itself in various ways, which include Generalized Anxiety Disorders (GAD), which affects a total number of 6.8 million individuals worldwide, panic Disorders, which affect a maximum of 2.7 million individuals, Social Anxiety Disorders (SAD), which involves a total number of 15 million adults and the Posttraumatic Stress Disorders (PTSD) affects a total number of 7.7 million adults (Dimatteo et al., 2000; McLaughlin, 2011).
Research conducted over the past decades proves that depression and anxiety affects maximum of 25% of children below 15 and 13 years old (Firoozeei et al., 2020). When anxiety is left untreated among children, it affects their school performance and how they interact with others socially (Lopresti et al., 2019). In older individuals, it presents itself through Generalized Anxiety Disorders, which are usually triggered by traumatic experiences like when an individual develops an acute illness.
“Evidence of strong covariation of depression and medical noncompliance suggests the importance of recognizing depression as a risk factor for poor outcomes among patients who might not be adhering to medical advice” (Dimatteo et al., 2000, p.1).
Lack of adherence to treatment recommendations not only endangers patient health and causes exacerbations of illness, but puts a strain on the doctor-patient relationship due to the frustrations from both parties (Dimatteo et al., 2000).
Many patients also report being unaware of their medications’ nature, the expected side effects harboring their administration’s negative feelings (Haslam, 2004). New interventions that can reduce mental health disorders’ health care burden are continuously sought after for the sake of sustainability, lessening the side effects of the current pharmaceutical drugs and improving patient compliance (Pratte et al., 2014).
These alternative treatments do not necessarily have to replace existing conventional treatments, but supplement the existing intervention (Martinsen, 2008).
Most of the evidence-based alternatives which are used in the treatment of psychological disorders are usually limited. Pharmacological therapy is the most recognized and currently used in most cases to treat and allay anxiety and depression disorders.
Although most pharmacological drugs have been used for years to treat these conditions, they have proved ineffective in managing patients (Lopresti et al., 2019). The patients may experience adverse side effects from using the drugs and sometimes develop tolerance or become intolerant to the dosage.
As a result, most patients can use natural medicines in managing these psychological disorders and experience a prompt positive reaction that is well-tolerated and highly efficient (Lopresti et al., 2019). Alternative medication has proven to be worthy since it has more benefits and fewer side effects (Ng et al., 2017); therefore, it can improve the patient’s compliance in adhering to interventions that manage and curb mental disorders.
Natural interventions are beneficial because they reduce the patients’ risk of developing other disorders such as autoimmune disorders and cardiovascular diseases popular with conventional medications (Muszyńska et al., 2015). Since most natural medicines contain neuroprotective effects, they are likely to reduce anxiety and depression among patients.
1.4. Research Purpose
Mental health disorders such as anxiety and depression is a major public health threats and significantly contributes to the amount of sick leaves and disability in America, carrying considerable weight in the U.S economy (Martinsen, 2008). Scientific evidence attests to the clinical efficacy of psychological and pharmacological therapies, but the ever-increasing incidence of anxiety and depression diagnoses make it difficult for the healthcare system to meet the demand for effective and sustainable treatments (Martinsen, 2008).
Natural interventions can help fill in the gaps left by current pharmaceutical and conventional psychotherapy treatments and serve as valuable resources for both patients and clinicians.
These psychological disorders can affect any individual irrespective of their age and are known to cause severe distress in society and can disrupt everyday life, and when these disorders are left untreated, it can be fatal (Kessler et al., 2001). Pharmacological drugs have effectively managed anxiety and depression for years (palette et al., 2017); however, these conventional medications have extreme side effects that expose the patient to adverse outcomes, unlike natural medications.
Synthetic anti-depressants can also lead to resistance and developing withdrawal symptoms over time, cancer, or even dementia in extreme cases (Kessler et al., 2001).
This research analyzes the clinical effects of natural interventions in treating anxiety and depression and how they are useful in clinical settings. This paper will highlight some of the most studied natural interventions and assess their effectiveness in anxiety and depression management. Furthermore, this research seeks to prove that alternative health care options are equal to or better than that of the existing pharmaceutical options.
From the previous evidence, natural medicines have proven to be effective manage the effects of depression and anxiety (Parletta et al., 2017). These interventions offer more similar or better outcomes, including fewer side effects, correcting sleeping disorders, and rectifying any underlying impacts of anxiety and depression disorders.
This research aims to assess how natural medicine interventions are beneficial for treating anxiety and depression disorders, unlike the standard conventional drugs that harm the patient than benefits. It will provide a spotlight and in-depth information on how natural interventions are more effective than the common pharmacological drugs used to manage these psychological disorders.
The research also offers the necessary insights to depression treatment recommendations and alleviating the social burden facing patients diagnosed with anxiety and depression disorders.
Ultimately, the alternative therapies discussed in this literature review can potentially persuade more healthcare practitioners to utilize these interventions in mental health patients. The evidence provided in this research paper leads to a deeper understanding of alternative and complementary medicine modalities.
This paper serves as an opportunity to deliver treatment recommendations and alleviate the public health burden of anxiety and depression.
The evidence will benefit scientific society since it will help scientists identify environmental, genetic, and psychological factors that increase the risk of developing mental disorders.
It will also allow scientists to determine the structural and abnormal brain functioning that can be corrected using natural medicines. The main research question would be on “How natural medicine interventions can be used in treating and managing patients who have been diagnosed with anxiety and depression disorders and the additional advantages that come with using natural medicines?”
1.5. Research Questions
Follow up questions that are to be addressed in this paper entails the following:
1. How can natural depression remedies benefit the public?
2. How will natural medicines be of great aid in managing psychological disorders such as anxiety and depression?
3. What are the clinical outcomes of using natural medicines that are used to manage anxiety and depression?
