A Cross-sectional Study on Utilization of Herbal Medications for Anxiety in the Lebanese Population: Usage Patterns and Implications for Harmonizing Mental Health

1.1. Aim of the Study

For all the mentioned issues, we have conducted this cross-sectional study to explore the pattern of using herbal medicine in treating anxiety and reducing its health consequences. On the other hand, the study is conducted to evaluate the user’s knowledge, attitude, and practice associated with herbal medicine and anxiety. Further- more, it is very essential to measure the importance of community pharmacist role in herbal medicine use, spreading knowledge, and warning herbal medicine users about special requirements, expected side effects, and dosage instructions.

1.2. Ethics approval

The study protocol was approved by the Institutional Review Board of the Lebanese International University (2023RC- 006-LIUSOP). The collection and processing of the data in this study complied with data protection and privacy. Written informed consent from the patients or their caregivers was obtained. This study is an obser- vational investigation and doesn’t have any physiologic, psychological, or social risks to the participants.

2.1. Study Design and Setting

It is performed between March and May 2023 to assess and measure the prevalence of anxiety and the use of herbal medicine as a primary therapy, adjunct to conventional therapy, or alternative to conventional treatment. The study data includes individuals aged 20 years and older who arrived at the community pharmacy and agreed to fill out the questionnaire with absolute confidentiality after they were informed that the aim of the questionnaire was for awareness and academic research. The investigators chose the pharmacies randomly, where they ensure that they are distributed all over the country. Participants who visited the pharmacy had an equal chance to fill out the questionnaire with the absence of any scale or specific measurement.

Medications, sociodemographic and clinical character- istics were collected from patients via Face-to-Face Interviews and a well-structured survey was offered to them to gather data via Online Google Platform Surveys. All collected data and the statistical calculations were performed and documented using SPSS (Statistical Package for Social Science). Descriptive statistics are used to describe independent variables. One-way ANOVA analysis followed by a T-test (binary logistic regression) was performed to capture information on herbal medications and plants’ usage, sources of recommendations, patient perspectives, and perceived efficacy and safety of herbal medications and plants for anxiety.

2.2. Study Participants

Study participants are Lebanese outpatients and currently have any medical condition or chronic disease, are taking one medication or any conventional treatment for a health condition, or have been taking herbal products or supplements during the last 12 months. The participants also answered if they take any medication for any acute or chronic illness and whether or not they have any idea about the probability of developing herbal-drug interactions or any potential to develop toxicities attributed to the combination of both. In this study, we didn’t prioritize patients who visit the pharmacy frequently over patients who rarely seek medical care at the pharmacy. This means that all participants had the same opportunity to fill out the questionnaire.

2.3. Data Collection Tool

The following sociodemographic information was answered by participants: age, gender, nationality, area and type of residence, educational level, work status, marital status, monthly income, and the availability of health insurance contracts [16]. The other section of the survey included the clinical and medical profile of the patient who had answered about the current medical condition, comorbidities, conventional treatment for current health condition, and adherence to lifestyle requirements based on the medical status of the patient [17]. A third section was related to anxiety information and the impact of this mental disorder on the sleeping pattern and hours of sleep. The last section included herbal substances used in the last 12 months, source of recommendation for herbal medication use, reporting any adverse event while consuming herbal medication, physician consultation and reaction about herbal product usage, herbal product advice, and patient’s general knowledge of herbal supplements and plants. The questionnaire included as well some information targeting the pharmacist's role in educating, managing, and avoiding drug-related problems associated with herbal medicine use.

2.4. Sample Size Calculation

Sampling statistics where a high prevalence of knowledge of Herb-Drug Interactions (HDIs) among Lebanese outpatients were reported to be around 50%. Estimating the Lebanese Population size in 2023 to be around 5,353,930 [7], with the power to provide a 95% confidence interval with a 5% confidence limit [9]. So, according to this information, we calculated a minimal sample size based on an application called Epi-info 7, and for the confidence interval 95%, it has shown that the recommended minimal sample size we should consider is 384.

2.5. Data Management and Statistical Analysis

Descriptive statistics were used to describe the demographic and clinical characteristics of Lebanese patients. Categorical variables were reported using numbers and percentages, whereas continuous variables were presented using means (M) and standard deviations (SD). The association of HIDs with each Lebanese patient’s demographic and clinical characteristics was tested using Tukey’s range test to find means that are significantly different from each other, Pearson’s test for categorical variables, and One-Way ANOVA analysis followed by a T-test for continuous variables. All variables in the bivariate analysis with a p-value <0.05 were included in the logistic regression model unless they were strongly correlated. Therefore, the binary logistic regression allowed the assessment of relationships between the binary dependent variable (consuming herbal medications use/not consuming herbal medications), the usage patterns of different types of herbal products or supplements, and the current usage of conventional treatment. Thus, it was possible to identify the significant contributing factors to HDIs.

2.6. Ethics Approval and Consent to Participate

The study protocol was approved by the Institutional Review Board of the Lebanese International University (2024ERC-029-LIUSOP). The collection and processing of the data in this study complied with data protection and privacy.

We confirmed that the research was done in accordance with the Ethical Principles for Medical Research Involving Human Subjects, outlined in the Helsinki Declaration, though the study posed no harm to the participants.

3.1. Patients’ Socio-demographics Characteristics and Medical Condition

The study comprised 501 Lebanese outpatients (General Population and Athletes) from 5 different governates (Beirut, Mount Lebanon, South, North, Beqaa) around Lebanon. Study participants had a mean age (± standard deviation (SD)) of 50.248 years with a range from 20 to 50 and above; 58.9% of patients were female and 41.1% of patients were men. 56.9% percent of Lebanese patients were single, 54.7% had difficulty sleeping and most of them (55.9%) were smokers and 70.5% didn’t consume alcohol and live in urban areas (72.5%), mostly in Beirut (35.5%). 61.7% of participants were classified as having a sedentary lifestyle, whereas 38.3% were categorized as having a healthy and active lifestyle (Table 1).

The respondents (46.7%) have consumed herbal medications during the last 12 months. Our study found that 54.7% percent of Lebanese patients have difficulty sleeping, and the most common medical conditions they are suffering from are anxiety (29.14%, n=146), menstrual symptoms (pain) (27.74%, n=139), insomnia, common cold symptoms (25.34%), gastric diseases (23.35%, n= 117), and hypertension (21.75%, n= 109) (Fig. 1).

The most frequently prescribed medications as (87.62%, n= 439) anti-inflammatory drugs for neuropathic pain, (84.23%, n=422) anxiolytics for anxiety and (61.077%, n=306) analgesics for relieving pain, (26.74%, n=134) for cold medications, (25.14%, n=126) PPIs for gastric diseases, (23.35%, n=117) ant-inflammatory medications, (20.95%, n=105) antihypertensive medications (Fig. 2).

Most of the Lebanese populations (27.34%, n=137) use herbal products or plants as pills for relaxation from insomnia and depression (24.75%, n=124), herbal products or plants in food for the treatment of insomnia and (21.35%, n=107) depression. Other uses of herbal products or plants in food as supportive for diarrhoea relief issues, so that the majority of Lebanese patients represented 28.94%, 26.74% of Lebanese patients using herbal products in food as protection from common cold and flu 26.34% of Lebanese patients use herbal products in food as a relief for constipation issues, and 5.94% use herbal products in food as supportive for weight loss and killing pain, as well as 25.54% use these herbal products in food as a treatment for gastric problems and bowel diseases, whereas (25.34%) use them as a treatment of diabetes (Table 2).

The “F-value” of 200.69 and a very low “P-value” of 0.000) P<0.001) suggest that there are significant differences in means among the types of herbal product usage, there are significant differences in means among these groups (F=321.21, p < 0.001) are observed. Herbal plants or products used as food ingredients in cooking as a flavouring ingredient mostly by Lebanese patients are thyme (34.53%), Garlic (33.93%), Cinnamon (30.73%), Apple Cider Vinegar (30.73%), Curcumin or Turmeric (24.95%), Romarin or Rosemary (23.95%), while the herbal medications as oral pills used by Lebanese patients are Ginkgo biloba (26.94%), Panax Ginseng (24.15%), Garcina cambogia (22.15%), Valeriana officinalis root (21.55%), Echinacea (21.35%), Ashwagandha (21.15%) (Fig. 3).

Furthermore, 54.3% of Lebanese patients did not experience any adverse events or side effects when consuming herbal plants or medication alone, while (2.4%) admit that they experienced adverse events when consuming herbal plants or medication alone; on the other hand (1.8%) experienced adverse events when consuming it with their conventional medication (Fig. 4).

Finally, 38.52% of Lebanese patients agree that natural and herbal medicine have side effects, 35.12% of Lebanese patients neither agree nor disagree that natural medicine is more effective than conventional therapy. In comparison (33.93%) agree that natural medicine is more effective than conventional therapy. In addition, 46.10% of Lebanese patients agree that herbal medicines are beneficial in healthcare management, and (40.71%) of Lebanese patients agree that herbal supplements should be used as a substitute for medications after proper sports training, nutrition and recovery practices. About 37.32% of Lebanese patients agree and 30.73% neither agree nor disagree that herbal supplements can interact with other medications and supplements that you may be taking.

Furthermore, 44.51% of Lebanese patients agree that there is scientific research supporting the use of herbal supplements, 37.52% agree and 35.92% neither agree nor disagree that there are potential long-term health effects of consuming herbal supplements, 32.93% agree that the use of herbal supplements or herbal plants should be limited only to patients who have failed conventional therapy. In addition, 32.93% agree that herbal medicine is safer than conventional medicine, 39.32% of Lebanese patients agree that they are aware of the potential risks and side effects associated with herbal supplements or plants they use, 36.72% of Lebanese patients agree that they know the exact daily amount or dose of herbal supplement they should take for their condition, 40.51% of Lebanese patients agree that when taking any conventional medication along with the herbal supplement, the herbal supplement and conventional medication may interact together, 41.91% of Lebanese patients agree that herbal supplements should be regulated and controlled by the Ministry of Health and regulatory bodies to ensure safety and efficacy, 40.71% of Lebanese patients agree that there is a need for education about the risks and benefits of herbal supplements to be revealed to the population, 41.51% of Lebanese patients agree that herbal supplements have a health protective effect, 43.71% of Lebanese patients agree that herbal supplements have a disease curative effect, 38.32% of Lebanese patients agree that herbal supplements or herbal plants do not provide treatment but can only be supportive and therapy is provided only with conventional medicines.

Moreover, 29.34% agree that herbal supplements or herbal plants have no side effects, 38.72% of Lebanese patients agree that herbal supplements or herbal plants do not interact with drugs, and can be used at the same time, 38.12% of Lebanese patients agree that the use of herbal supplements or herbal plants can be dangerous, as they will affect the action of existing drug therapy, 37.12% of Lebanese patients agree that herbal supplements or herbal plants can be used as a last option to treat diseases, 33.53% of Lebanese patients agree that it is worth trying herbal supplements or herbal plants before visiting the physician, 37.32% agree that herbal supplements or herbal plants are not to be used in critical conditions. 41.71% of Lebanese patients agree that herbal supplements can be taken as a desire to boost energy and endurance, 31.73% agree that herbal supplements can help increase sports performance without being detected in blood tests, 42.51% of Lebanese patients agree that they should ask any pharmacist, or physician about any herbal supplement or herbal plant before using it alone or with conventional treatment, 41.12% of Lebanese patients agree that they should research the ingredients and dosage of herbal supplements on internet before taking them, 44.11% of Lebanese patients agree that they should purchase their herbal supplements from a source, like a certified sports coach or a pharmacy, 44.51% of Lebanese patients agree that they like to receive consultancy on herbal supplement or herbal plant to know more about how do they act and interact with the body, 35.52% of Lebanese patients neither agree nor disagree that they would purchase herbal supplements from an online source or herbalist (Table 3).

3.2. Assessing the Role of Pharmacists in Harmonizing Patients’ Mental Health

These results show that 56.7% of Lebanese patients consider that the pharmacist should provide all the source of information about herbal plant or herbal supplement and its usage with conventional medication, while 20.8% of Lebanese patients consider the herbalist as the provider source of information about herbal plant or herbal supplement and its usage with conventional medication, 17% consider the physician and 0.4% consider the nurse, while 4.6% consider others (Fig. 5).

4.1. Anxiety Prevalence and Herbal Usage

The results of this study showed that 23.95% of the Lebanese population use Romarin or Rosemary as a flavouring ingredient in cooking.

Rosemary (Rosmarinus officinalis L.) is an evergreen shrub native to the Mediterranean region and naturalized throughout much of Europe [16]. The linear leaves resemble small, curved pine needles and are fragrant when crushed. Bluish flowers are borne in axillary clusters. Leaves are used to flavour baked potatoes or meat dishes [18]. Rosemary is used in folk medicine as a galactagogue or to treat renal colic and dysmenorrhea, mood and nervous system disorders, and physical and mental fatigue [19]. It is also used to relieve symptoms caused by respiratory disorders and to counteract hypercholesterolaemia [20]. This plant has been found to have several biological activities, such as antioxidant, anti-inflammatory, antimicrobial and anti-cancer properties, as well as being useful for anxiety, stress, and memory [21]. Rosemary extract is often used in aromatherapy to treat anxiety-related conditions and increase alertness [18]. The infusion of leaves (2 g into 100 mL of hot water) has been evaluated on adult male mice to test its effect on anxiety/fear, depression-like behaviour, memory/learning, and cerebral and liver cholinesterase [19]. Authors, using LC-MS analysis, identified 16 compounds in rosemary such as rosmarinic acid, caffeic acid, and 7-O-glucuronide as major components [18]. Data of behavioural tests revealed that daily oral administration of rosemary to adult mice significantly 24 reduced both the anxiety (p < 0.05), the depression-like behaviour (p < 0.05), and the cholinesterase isoforms activity (p < 0.05), while memory/learning was unaffected [19]. Noori Ahmad et al. (2016) evaluated the effect of the hydroalcoholic extract of R. officinalis L. on anxiety in 50 mice randomly divided into five groups (the control group received normal saline; the positive control group received 1 mg/kg diazepam; and the experimental groups received doses of 100, 200, and 400 mg/kg body weight of rosemary extract) [22]. Results of the elevated plus maze test showed that rosemary extract dose-dependently increases the mice spending time and the entries number of mice in plus maze open arms (indicating less stress) and that the dose of 400 mg/kg was similar to diazepam [22].

Authors investigated the effects of these non-volatile components of rosemary on CNS function, and they found that at doses 10–100 mg/kg, rosmanol, cirsimaritin, and salvigenin elicited anxiolytic effect on mice in both elevated plus maze and light/dark tests [23]. Moreover, since the anxiolytic activity was not ameliorated by flumazenil but was inhibited by pentylenetetrazol, authors suggested that a possible mechanism of action is likely to be mediated via GABAA receptors at a site other than the high-affinity benzodiazepine binding site [24].

In a clinical study, inhalation of rosemary and lavender essential oil sachets reduced anxiety, and, in particular, rosemary increased focus and concentration and promoted a sense of clarity [25]. Solhi et al. (2013) demonstrated the effectiveness of rosemary in the improvement of sleep and reduction of insomnia in a clinical trial of 81 patients with opium withdrawal syndrome divided into a control group (treated with methadone and placebo for 4 weeks) and a case group (treated with methadone and rosemary capsules filled with 300 mg of dried powdered leaves) [26].

The authors proved that rosemary can be used to boost prospective and retrospective memory, reduce anxiety and depression, and improve sleep quality [27]. A very recent study investigated the effect of rosemary tea consumption on the plasma levels of anxiety and depression biomarkers in twenty-two healthy volunteers aged between 20 and 50 years old [27]. The tea was prepared from 5 g of dried 25 rosemary in 100 mL boiled water, and the main polyphenols were found to be rosmarinic acid, caffeic acid derivatives, luteolin -30- O-(2”-O-acetyl)-b-D-glucuronide, luteolin3- O- glucuronide, rosmarinic acid-3-O-glucoside, nepitrin, syringic acid, feruloylnepitrin, luteolin- 7-O-rutinoside, caffeic acid, vanillic acid, and luteolin. The tea was administered once a day for ten days, and results indicated the anxiolytic and/or antidepressant effects of rosemary tea consumption since it increases the level of the most reliable depression biomarker, including brain-derived neurotrophic factor and TNF-a [23].

Another herbal product or plant used as an oral pill by the Lebanese population is Valeriana officinalis root (21.55%). Valerian (Valeriana officinalis L.) is a perennial herbaceous plant native to Europe and Asia [28, 29]. In traditional phytotherapy, valerian is also used to treat cramps, tachycardia, headache, colitis, toothache, and hypertension [30]. Over 150 chemical constituents have been identified in valerian extract, and many of them are physiologically active, such as alkaloids, terpenes, free amino acids, organic acids, valepotriates, and flavones [29, 31]. The main alkaloids (0.01–0.05% of root dry weight) found in valerian’s root are actinidine, chatinine, valerianine, valerine, alpha -methylpyrryl ketone, and naphthyridin methyl ketone [29, 32]. Terpenes and organic acids represent 0.2–2.8% of root dry weight, and they are mainly composed of valeric, isovaleric, valerenic, isovalerenic, and acetoxyvalerenic acids; bornyl acetate; bornyl isovalerenate; 1-pinene; 1-comphene; 1-borneol; terpineol; valeranone; and cryptofauronol [29, 32]. Other important active compounds are valepotriates (iridoid molecules), which are exclusively found in valerian extracts [29, 33].

Valerian is a mild sedative and sleep-promoting agent, often used as complementary or alternative medicine in the treatment of anxiety-induced sleep disturbance [29, 34]. Constituents of V. officinalis roots, such as vale- potriates and valerenic acid, activate GABAergic system and, to a lesser extent, the serotonergic system, which is both involved in sleep promotion and regulation [31]. It was demonstrated, using the elevated plus maze method, that a significant reduction occurred in 26 anxious behaviour of rats when valerian-extract- (3 mL/kg) or valerenic-acid (75 µg/kg) exposed subjects were compared to the ethanol control group (1 mL/kg) [34]. In a randomized, controlled trial conducted by Aliakbari and Rafieian (2018) on eighty patients, it was shown that Valeriana officinalis improves the quality of sleep in patients with chronic heart failure [28]. However, five meta-analysis reviews published in 2000, 2006, 2007, 2010, and 2020 revealed that the effect of V. officinalis in treating sleep problems and associated disorders might vary, and in some cases, the outcomes do not support its use in treating insomnia [35-37]. Stevinson and Ernst (2000) analyzed nine randomized, placebo-controlled, double-blind trials measuring the effect of valerian on sleep in human participants [38].

The meta-analysis of 18 randomized placebo-controlled trials published by the author [39] showed that Valeriana spp. interventions reduced sleep latency over placebo by only 0.70 min. The authors [40] performed a meta-analysis on sixty studies to evaluate the effectiveness of Valeriana spp. (V. officinalis and Vedulis) to improve sleep quality and reduce anxiety. Results produced inconsistent outcomes, most probably due to the quality of herbal extracts; therefore, authors suggest that it may be necessary to revise the quality control processes, including standardization methods and shelf life of valerian extracts [41].

4.2. Herbal Drug Interactions (HDIs) related Knowledge

Patients at high risk for HDIs who also take drugs with narrow therapeutic indexes should be monitored more closely for herb-drug interactions, especially when a new drug is added or discontinued [42]. The overall prevalence of HDIs among Lebanese patients can be when using herbal products either in food such as Thyme-Anticoagulants/ Antiplatelet Drugs, which slow blood clotting and causes a risk of bruising and bleeding, Garlic-Anticoagulant/ Antiplatelet (warfarin/ aspirin) developed platelet disorders and/or haemorrhage (Fig. 2 and Fig. 3). So, patients using warfarin should be cautioned regarding the possible risk of increased bleeding with ingestion of garlic [43], garlic- analgesics (paracetamol), which causes changes in paracetamol pharmacokinetics [43], cinnamon-antihypertensive which increase the effects of antihypertensive drug and causes hypotension [44], another HDI is Cinnamon- Analgesics/Dyslipidaemia drugs can increase the risk of liver damage [45], Cinnamon- Antidiabetics can cause hypoglycaemia [44], Apple cider vinegar- Antihypertensive (Furosemide) which increases the effect of Furosemide causing a decrease in potassium levels [45], Curcumin/turmeric-Anticoagulant (Fluindione), which increases the risk of bleeding [45], Romarin/ Rosemary-Antihypertensives (Hydrochlorothiazide/ furo- semide), which increases hydrochlorothiazide and furosemide clearance [44], or when using herbal products as herbal oral pills medications such as Ginkgo biloba - PPIs (Omeprazole) which decreased omeprazole blood concentration [45], Ginkgo biloba - Ibuprofen causes death due to cerebral haemorrhage (Inhibition of platelet aggregation) [45], Ginkgo biloba - Anticoagulant (warfarin) which increases warfarin levels [45], Ginseng-Anticoagulant (warfarin) which increases anticoagulant effect [44], Ginseng- Insulin which has a synergistic action that increases insulin effects [44] Ginseng- anxiolytic (Midazolam) which reduces the effect of midazolam, Garcinia Cambogia -Antidiabetics which causes hypoglycaemia [44] Garcinia Cambogia- Anticoagulants/ Antiplatelet drugs which slows blood clotting that increases the risk of bruising and bleeding [44], Valeriana root- Alprazolam/Benzodiazepines/Narcotics which incr- eases sedative effects of Alprazolam, benzodiazepines and narcotics [34], Echinacea- Caffeine and anxiolytic (Midazolam), which increases systemic clearance of oral caffeine and IV Midazola [44], Ashwagandha-Benzo- diazepines/Anticonvulsants/Barbiturates which increase sedative effects of benzodiazepines and narcotics [46], Ashwagandha-Warfarin, clopidogrel which increases the risk of bleeding or when using herbal products as a drink such as Caffeine/Green tea- Folic acid which decreases folate blood concentration [46], Green tea-warfarin which 28 increases the risk of bleeding [46], Ginger root- antihypertensives (Nifedipine), which potentiates antiplatelet effects of nifedipine [46], Sage- anticoagulant/ antiplatelet (Warfarin/ Clopidogrel), which increases anticoagulant effect of warfarin and reduces plasma levels of clopidogrel [45], Sage-dyslipidaemia drugs (Rosuva- statin) in which plasma clearance of rosuvastatin is reduced by >57% [46].

There are studies investigating the awareness and knowledge of herbal products by patients, athletes, and pharmacists in various medical branches and health problems [47]. However, there is no study in Lebanon evaluating the use of herbal products by Lebanese patients and athletes in terms of the examination of Pharmacokinetic and Pharmacodynamics HDIs. In addition, this study will contribute to the development of effective strategies for patient education and healthcare professionals to enable healthcare providers to deliver better guidance and advice regarding HDIs for their patients. According to Lebanese patients’ attitudes towards herbal medications or products, 33.93% agree that natural medicine is more effective than conventional treatment, while only 9.18% of them disagree, and 32.93% of Lebanese patients agree that herbal medicine is safer than conventional medicine, while 7.98% disagree. Also, 29.34% of Lebanese patients agree that herbal supplements or herbal plants have no side effects, whereas 12.37% disagree. This can negatively affect the treatment process of the patients, as well as lead to dangerous consequences in terms of drug interactions and side effects. Considering herbal products completely safe and using them without the advice of a doctor or pharmacist may cause negative consequences [48]. Because some plants may have toxic components and many herbal products also interact with drugs [49]. The most famous Herb-drug interaction is garlic and green tea with warfarin, which is used as an anticoagulant and has serious interactions that can alter blood haemostasis and anticoagulation by interacting with these herbal products [45]. This interaction can be obviously observed with Lebanese patients since 33.33% of Lebanese patients consume caffeine/ green tea and, 33.93% consume garlic as the herbal product in food, in which 16.76% use anticoagulant or platelet as a conventional treatment.

For this reason, it is necessary to raise awareness of Lebanese patients, athletes, physicians and pharmacists in order to provide the best treatment conditions and to prevent possible damages [50]. It is extremely important for healthcare professionals to have comprehensive training in phytotherapy and to have sufficient knowledge and skills in terms of increasing effectiveness in treatment and preventing unwanted results [51]. One of the important issues regarding the use of herbal products is from which sources patients learn about these products [44]. In general, it is observed that 29.1% of Lebanese patients do not consult their doctors about this issue. In our study, when the Lebanese patients were asked if they did any research before using herbal products, 41.12% of the patients stated that they did research.

In our study, 28.14% of Lebanese patients agree with the view that herbal supplements or herbal plants do not interact with drugs and can be used at the same time, but 11.57% of the remaining patients disagreed with this view and 38.72% of them remained undecided or don’t know.

These results actually suggest that patients do not have enough information about toxic plants or their toxicity in inappropriate use.

Similarly, in the present study, 32.93% of the Lebanese patients agreed with the opinion that the use of herbal supplements or herbal plants should be limited only to patients who have failed conventional therapy, while 12.17% of them disagreed and 33.93%of them don’t know. These results suggest that some patients consider herbal products quite safe and ignore possible side effects. However, the use of complementary therapies and herbal products in patients taking conventional medications for long term or chronic diseases should be used under the supervision of a doctor. Considering Lebanese patients' positive attitudes towards the knowledge of pharma- cokinetics and pharmacodynamics of herbal products, most of the Lebanese patients expressed a good knowledge about this issue.

The results of our study show that 39.32% of Lebanese patients are aware of the potential risks and side effects associated with herbal supplements or plants they use, 36.72% of Lebanese patients know which exact daily amount or dose of herbal plant or herbal supplement I should take for their condition, 40.51% of Lebanese patients know that there is an interaction when taking any conventional medication along with the herbal supple- ment, 41.91% of Lebanese patients agree that herbal supplements should be regulated and controlled by the Ministry of Public Health (MOPH) and regulatory bodies to ensure safety and efficacy, 38.32% of Lebanese patients agree that herbal supplements or herbal plants do not provide treatment but can only be supportive and treatment is provided only with conventional medicines, 38.12% of Lebanese patients agree that the use of herbal supplements or herbal plants can be dangerous, as they will affect the action of existing drug therapy; 37.32% of Lebanese patients agree that herbal supplements or herbal plants should not be used in the treatment of serious diseases.

4.3. Role of Pharmacists in Harmonizing Patients’ Mental Health

Mental Health Lebanese patients are willing to be more educated about herbal products use since 40.71% of Lebanese patients agree that there is a need for education about the risks and benefits of herbal supplements, and 42.51% of Lebanese patients ask any pharmacists, or physicians about any herbal supplement or herbal plant before using it alone or with conventional treatment, 41.12% of Lebanese patients research the ingredients and dosage of herbal supplements on internet before taking them, 44.51% of Lebanese patients like to receive consultancy on herbal supplement or herbal plant to know more about how do they act and interact in their body. Another study concerning the knowledge of athletes about herbal products shows that 17% of collegiate female athletes have used herbal supplements such as “Guarana”, “Ashwagandha”, “Caffeine”, “Purple Willow Bark”, “Cayenne”, “Pepper”, and “Ginger root”, which are believed to increase mental vigilance, stimulate fat-burning metabolism, and improve muscle performance [14].

Other plants such as Tribulus terrestris, Ginkgo biloba, Rhodiola rosea, Cordyceps sinensis have demonstrated benefits on muscle growth and strength in active men, while others have shown no effect on muscle performances [15]. Whereas in this study, 28.94% of Lebanese patients and, especially the athletes, use these herbal supplements mostly the Ashwagandha (21.15%), ginger root (16.96%), caffeine/green tea (33.33%) as energy booster in order to increase energy and endurance, and 28.34% for relaxation from muscle spasms after sport exercises and 41.71% of them agree that herbal supplements can be taken as a desire to boost energy and endurance, also 31.73% agree that herbal supplements can help increase sports performance without being detected in blood tests. Moreover, Ashwagandha can cause false positive results in benzodiazepine, thyroxine, and digoxin drug tests, which can trigger false positive results that may affect certain lab test results [52]. Moreover, in the literature, we discuss the pharmacists’ knowledge, their experience of customer-reporting adverse reactions and their awareness of these reactions could play a vital role in identifying and reporting these reactions [53]. Almost an enormous number of patients have failed to mention correctly the known adverse events of each herbal anxiolytic, and this would be adjusted and improved by pharmacist training workshops and community campaigns to spread knowledge and education.

Our study agrees with the literature part that more than half of the pharmacists were not aware of potential herb-drug interactions, and an even larger majority did not receive complaints from the customers about herbal medicines. So, in our study, we recommend strategies to prevent HIDs among Athletes and the Lebanese Population that can be taken by the Lebanese Ministry of Public Health (MOPH), Lebanese Hospitals, and Lebanese Pharmaceutical Companies. In contrast to the literature, 56.7% of Lebanese patients get their source of information about herbal plants or supplements and their usage with conventional medication, while only 20.7% 32 of Lebanese patients refer to the herbalist. Moreover, in this study, the patients’ first choice to purchase herbal supplements from the pharmacy or certified sports coach was 44.11%, while purchasing from an online source or herbalist was 29.54% as the 2nd choice, which is the opposite to the literature. This reflects the trustworthy of Lebanese patients in their pharmacists, so pharmacists need enhanced education on pharmacokinetic and pharmacodynamics mechanisms, drug metabolizing enzymes and transporters playing significant roles in herb-drug mechanisms in order to provide objective and evidence-based information on the benefits and risks of herbal medicines which might affect the general knowledge and awareness of the targeted population for better patient care and benefit in the future [54]. Patient education and healthcare professionals play a crucial role in raising awareness and providing guidance on herb-drug interactions. The study also highlights the high prevalence of anxiety among the Lebanese population and herbal product use in Lebanon, driven by factors such as the unaffordability of synthetic medications and the economic crisis. Tens of articles assess the association between external, governmental, and financial threats and the widespread incidence of anxiety along with the use of herbal products as anxiolytics. These studies have confirmed that such events have influenced society to need anxiolytics as a therapy, and they aimed for herbal products as a first-line choice. On the other hand, several related articles have highlighted the adverse events accompanied by herbal medicine use as anxiolytics but this issue was weekly addressed in our study, and the participants have shown a very weak knowledge about the adverse events since they missed almost all of the correct information while answering this part.