Case study – possible interaction of anxiolytic drugs and a herbal sleep remedy containing Lavender essential oil

This was a story related to me in August 2018, by an aromatherapist friend and her partner who have been using essential oils for many years for many different purposes. The man is in his 60s, and generally a fit and strong man, an ex-Vietnam veteran, who has been taking anxiolytic medication to help him manage his Post Traumatic Stress Disorder.
They decided to trial a herbal sleep remedy with Lavender oil in it that was supposed to help promote restful sleep, and added a couple of capsules to his medication one evening, as he was not sleeping well.
The morning after taking the herbal sleep capsules this is how the man described his experience:
 
After waking up following voiding of my bowels in bed:
 (1) I tried to get out of bed as I felt unclean.
 (2) I could not stand up properly and crashed to the floor. I lay on the floor for several minutes, until I could gather my strength and stand up. By this time my partner helped me up and gave me directions to the shower.
 (3) When I was wobbly before I crashed to the floor, I vaguely remember vision problems as I could not orientate myself between the bed and the side dresser and I was quite dizzy. I had to confirm where I was by touch. I took a few wobbly steps and crashed to the floor at the end of the bed. I lost all strength to my knees and collapsed. [This is all very embarrassing to me as I consider myself a Rock and a strong man].
 I cannot recall my state the next morning, as from memory, I felt quite crook and stayed in bed until early pm that day.
 
His usual medication regime, most of which are S4 prescription medications, with extensive warnings, is as follows:
Escitalopram; Seroquel; Imovane; Apo-risperidone (full details of dosage in attached PDF, see below).

The capsules contained the following:  Lavender essential oil and L-Theanine along with lemon balm, passionflower, and chamomile (dosage not given; preparation not stated for the last three ingredients, whether herbal powder or essential oil).
The list of reference papers given by the capsule company supporting the use of these ingredients is also in the attached PDF, and I’ve found out what the dosage was in each of the papers, so the dosage in the capsules was probably something similar.

The suggested dose for the herbal sleep capsules was 2 capsules a night, which would “deliver the recommended dose” of Lavender essential oil, presumably either 80 mg or 160 mg. This dosage was found to be equivalent to Lorazepam in reducing anxiety if taken over 8 weeks (Woelk & Schläfke, 2010). Linalool, the main constituent in Lavender oil (about 42%) has been shown to potentiate GABAA receptors, producing a similar effect to benzodiazepines in vitro (Milanos, Elsharif, Janzen, Buettner, & Villmann, 2017).

These two papers were what alerted me to the possibility that perhaps the Lavender oil in the capsules may have interacted with the mixture of drugs already in the man’s system, to exacerbate the dizziness side-effects.  I don’t know what would have caused the nocturnal voiding of the bowels while he was asleep, however.
​
I think the event was a drug interaction between the components of the herbal sleeping capsules and the man’s existing medication, and that people taking S4 drugs should take care when taking oral dosages of Lavender essential oil, as there may well be unexpected drug interactions such as the ones reported here.
References
Bradley, B. F., Brown, S. L., Chu, S., & Lea, R. W. (2009). Effects of orally administered lavender essential oil on responses to anxiety-provoking film clips. Hum Psychopharmacol, 24(4), 319-330. doi:10.1002/hup.1016
Chang, S. M., & Chen, C. H. (2016). Effects of an intervention with drinking chamomile tea on sleep quality and depression in sleep disturbed postnatal women: a randomized controlled trial. J Adv Nurs, 72(2), 306-315. doi:10.1111/jan.12836
Fißler, M., & Quante, A. (2014). A case series on the use of lavendula oil capsules in patients suffering from major depressive disorder and symptoms of psychomotor agitation, insomnia and anxiety. Complement Ther Med, 22(1), 63-69. doi:10.1016/j.ctim.2013.11.008
Higashiyama, A., Htay, H. H., Ozeki, M., Juneja, L. R., & Kapoor, M. P. (2011). Effects of l-theanine on attention and reaction time response. Journal of Functional Foods, 3(3), 171-178. doi:https://doi.org/10.1016/j.jff.2011.03.009
Juneja, L. R., Chu, D.-C., Okubo, T., Nagato, Y., & Yokogoshi, H. (1999). L-theanine—a unique amino acid of green tea and its relaxation effect in humans. Trends in Food Science & Technology, 10(6), 199-204. doi:https://doi.org/10.1016/S0924-2244(99)00044-8
Kakuda, T. (2011). Neuroprotective effects of theanine and its preventive effects on cognitive dysfunction. Pharmacol Res, 64(2), 162-168. doi:10.1016/j.phrs.2011.03.010
Kennedy, D. O., Scholey, A. B., Tildesley, N. T. J., Perry, E. K., & Wesnes, K. A. (2002). Modulation of mood and cognitive performance following acute administration of Melissa officinalis (lemon balm). Pharmacology Biochemistry and Behavior, 72(4), 953-964.
Kimura, K., Ozeki, M., Juneja, L. R., & Ohira, H. (2007). l-Theanine reduces psychological and physiological stress responses. Biological Psychology, 74(1), 39-45. doi:https://doi.org/10.1016/j.biopsycho.2006.06.006
Milanos, S., Elsharif, S. A., Janzen, D., Buettner, A., & Villmann, C. (2017). Metabolic Products of Linalool and Modulation of GABAA Receptors. Front Chem, 5, 46. doi:10.3389/fchem.2017.00046
MIMS/myDoctor. (2017). Medicine Finder.   Retrieved from https://www.nps.org.au/medical-info/medicine-finder/
Ngan, A., & Conduit, R. (2011). A double-blind, placebo-controlled investigation of the effects of Passiflora incarnata (passionflower) herbal tea on subjective sleep quality. Phytother Res, 25(8), 1153-1159. doi:10.1002/ptr.3400
Nobre, A. C., Rao, A., & Owen, G. N. (2008). L-theanine, a natural constituent in tea, and its effect on mental state. Asia Pac J Clin Nutr, 17 Suppl 1, 167-168.
Scholey, A., Gibbs, A., Neale, C., Perry, N., Ossoukhova, A., Bilog, V., . . . Buchwald-Werner, S. (2014). Anti-stress effects of lemon balm-containing foods. Nutrients, 6(11), 4805-4821. doi:10.3390/nu6114805
Woelk, H., & Schläfke, S. (2010). A multi-center, double-blind, randomised study of the Lavender oil preparation Silexan in comparison to Lorazepam for generalized anxiety disorder. Phytomedicine, 17(2), 94-99. doi:http://dx.doi.org/10.1016/j.phymed.2009.10.006

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