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Depressing News About St. John's Wort

For patients with major depression who consider herbal preparations to be safer or more "natural" than prescribed pharmaceuticals, St. John's wort (SJW) seems an obvious choice to treat depression. SJW is available in a wide variety of formulations and has enjoyed official acceptance for the treatment of depression in Germany. However, previous studies that have found SJW to be safe and effective for treating depression have been poorly designed. Therefore, these U.S. authors performed a multicenter, double-blind, placebo-controlled, manufacturer-supported study to assess the efficacy of a standard preparation of SJW for treating major depression. Because of the placebo control, suicidal patients were excluded and subjects were carefully followed for exacerbation of symptoms.

The subjects, 200 adult outpatients (85.9 percent white; 67 percent women) with baseline Hamilton Depression Ratings of 20 or higher (i.e., major depression), were randomized to receive either placebo or SJW at a dosage of 900 mg/day; the dosage was increased to 1200 mg/day if the patient had not improved after 4 weeks. Study length was 8 weeks. Outcomes were assessed using standardized diagnostic criteria and measurement instruments.

More patients receiving SJW experienced a remission from depression than did patients receiving placebo (P=0.02); however, an intention-to-treat analysis revealed remission rates of only 14.3 percent and 4.9 percent, respectively. Severity of the depression did not affect response. The only adverse effect of SJW was a slightly higher incidence of headache than occurred with placebo (41 percent vs. 25 percent).

Comment: Depression is a serious and potentially life-threatening disease that merits treatment with agents of demonstrated efficacy. As the authors note, we cannot be certain that these findings can be generalized to all populations with depression. Patients with strong negative feelings about prescribed antidepressants may enjoy a greater placebo effect from a so-called "natural" preparation, and clinician openness to such treatment may increase the likelihood of maintaining the clinician-patient relationship and the opportunity to intervene if necessary. Clinicians should, however, caution patients that SJW has been shown to interact with other medications. Of note, this article also includes a meta-analysis of previous publications on SJW.

— NL Stotland

Published in Journal Watch Women's Health July 3, 2001

Citation(s):

Shelton RC et al. Effectiveness of St. John's wort in major depression: A randomized controlled trial. JAMA 2001 Apr 18 285 1978-1986.

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