St. John's Wort
(Hypericum perforatum)
Introduction
St. Johns Wort is an herb that has been widely promoted as a "natural" antidepressant. St. Johns Wort is prescribed in Germany for several psychiatric conditions, including anxiety and depression. Hypercin is believed to be the active ingredient although other components may have important biologic activity as well. 1
Does St. John's Wort Work?
Rigorous well designed studies that the FDA requires for antidepressant medications have not been done for St. Johns Wort. Comparing results of different studies is often difficult because of variations in medication dose as well as differing criteria used to define depression. 2, 3, 4, 7, 8
Some recent studies conclude that St. John's Wort is equally effective as other antidepressants when used for mild to moderate depression and has fewer side effects. 5, 6 Other in vitro ( "in a test tube") studies have shown St. John's wort to have similar effects on the brain neurotransmitters serotonin, dopamine, and norephinephrine as prescription antidepressants have. This would suggest that St. John's Wort has similar biologic effects as other antidepressants.
In the first large U.S. trial that was randomized and placebo controlled (well designed) St. John's Wort was found to be ineffective against moderate to major depression. This study is currently considered to be the best study to date with respect to overall design, number of patients involved (200), and length of time (8 weeks). Future studies comparing St. John's Wort to modern antidepressants are currently being considered.
What are the side effects?
When taken alone St. John's wort has few reported side effects.
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gastrointestinal upset (~5 %) is most common.
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Less commonly fatigue, dizziness, confusion and dry mouth are reported.
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Although rare, phototoxicity has also been reported. In this condition the offending medication sensitizes skin such that severe blistering and sloughing off of skin can occur with sun exposure.
Disturbing interactions have been reported in persons taking St. Johns Wort in combination with other antidepressants including severe lethargy, weakness and fatigue that can be seen if conventional antidepressants are taken at the same time as MAO (monoamine oxidase) inhibitors, another class of antidepressants. These interactions suggest that St. Johns Wort possesses MAO inhibitor properties and should not be taken with conventional antidepressants. 1
A very worrisome side effect that has recently been reported is that St. John's Wort may significantly lower the levels of Indinavir, a protease inhibitor used to treat HIV infection. 9
Bottom Line
Although St. John's Wort is probably effective for treating mild-moderate depression we do not believe anyone should self diagnose and treat themselves for true depression. St. John's wort has not been studied nearly as much as other FDA approved antidepressants.
Major depression severely alters and impairs a persons health, interpersonal relationships and outlook on every aspect of life. Diagnosing major depression requires that specific criteria be present. It is not the same as feeling down or having an a situational event that has caused a lot of stress- these are called adjustment disorders: most people get better on their own without medical treatment.
It is extremely important that you see your physician if you are experiencing major depression. Major depression is a serious and complex disorder that should not be self treated.
St. John's Wort may have a role in future treatment of depression; however, at the present time we recommend conventional antidepressants if your physician believes treatment with medication is indicated.
Notify your Physician if you are taking St. Johns Wort with other antidepressant medications!
1. American Family Physician March 1999 vol 59, no. 5: 1239-1244 "Herbal Remedies: Adverse Effects and Drug Interactions." Melanie Johns Cupp, PHARM.D.
Viewable online @ http://www.aafp.org/afp/990301ap/1239.html2. Ann Intern Med 2000 May 2; 132(9):743-56 "A systematic review of newer pharmacotherapies for depression in adults: evidence report summary." Williams JW Jr, Mulrow CD, Chiquette E, Noel PH, Aguilar C, Cornell J. South Texas Veterans Health Care System, Audie Murphy Division and the San Antonio Evidence-based Practice Center, Department of Medicine, University of Texas Health Science Center at San Antonio, 78229-3900, USA
3. BMJ 1996 Aug 3;313(7052):253-8 "St John's wort for depression--an overview and meta-analysis of randomised clinical trials. " Linde K, Ramirez G, Mulrow CD, Pauls A, Weidenhammer W, Melchart D Projekt Munchener Modell, Ludwig-Maximilians-Universitat, Munich, Germany.
4. Cochrane Database Syst Rev 2000; "St John's wort for depression." Linde K, Mulrow CD Munchener Modell - Centre for Complementary Medicine Research, Technical University/Ludwig-Maximilians-University, Kaiserstr. 9, Munich, GERMANY, 80801
5. Int Clin Psychopharmacol 2000 Mar;15(2):61-8 "Equivalence of St John's wort extract (Ze 117) and fluoxetine: a randomized, controlled study in mild-moderate depression." Schrader E Praxis Klinische Arzneimittelforschung, Pohlheim, Germany.
6. Int J Clin Pharmacol Ther 1999 Mar;37(3):111-9 "St. John's wort: a new alternative for depression?" Josey ES, Tackett RL Department of Clinical and Administrative Sciences, College of Pharmacy, University of Georgia, Athens 30602, USA.
7. J Affect Disord 1998 Dec;51(3):345-51 "The scientific, quasi-scientific and popular literature on the use of St. John's Wort in the treatment of depression." Deltito J, Beyer D Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
8. J Nerv Ment Dis 1999 Sep;187(9):532-8 "St. John's wort for depression: a meta-analysis of well-defined clinical trials." Kim HL, Streltzer J, Goebert D Department of Psychiatry, University of Hawaii, John A. Burns School of Medicine, Honolulu 96813, USA.
9. Lancet 2000 Feb 12;355(9203):547-8 "Indinavir concentrations and St John's wort." Piscitelli SC, Burstein AH, Chaitt D, Alfaro RM, Falloon J
10. In: Family Practice News May 15, 2001; vol. 31 no. 10 "St. John's Wort Ineffective Against Major Depression Compared with placebo, not active drug.
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