St. John's Wort

The Natural Connection

During the Middle Ages, when life was much simpler than it is today, healers were often called upon to banish evil spirits. St. John's Wort (Hypericum perforatum), a weedy perennial that happily grows along ditches and roadsides, was a popular remedy for dispelling the demons of depression and melancholy. The fact that it’s bright yellow flowers could also help heal cuts and wounds from sword fights, frighten away witches, shrink hemorrhoids, soothe swollen feet, and protect crops from lightening made it that much more useful.

Although the medicinal properties of St. John’s Wort were recognized since Pagan times, the early Christians declared it as sacred to St. John, as it blooms and was harvested at the time of the summer solstice, near his birthday (June 24). Another theory holds that the reddish color produced when the buds and flowers are crushed was considered a symbol for the blood of John the Baptist. It's Latin genus name Hypericum is derived from the Greeks, and means “power over an apparition”.

Today, St. John’s Wort is one of the ten best selling dietary supplements in the United States, where millions of doses are sold to patients who are drawn by it’s reputation as a safe, mild, anti-depressant. In Germany, it is the most frequently utilized treatment for mild depression, and is prescribed by physicians twenty times more often than Prozac is in this country.

Despite it’s extreme popularity, controversy continues to exist over the usefulness of St. John’s Wort in the treatment of depression in the 21^st century. Most clinical studies have focused on its use in treating mild to moderate depression. In 1996, a review of 23 randomized trials of St. John’s Wort in a total of 1,757 patients with mild depression concluded that the herb was better than placebo, and as effective as some of the older anti-depressants such as Elavil and imipramine (Tofranil). The side effect profile was extremely low, and the herb was better tolerated, without the problems of dry mouth, constipation, and weight gain that often accompanied the use of the prescription medications.

More recently, a report in the Journal of the American Medical Association found that St. John’s Wort was not an effective treatment for severe depression. A study funded by the NIH and coordinated by Duke University is currently underway to determine if St. John’s Wort will be as effective as some of the newer treatments for depression, called SSRIs. These drugs, marketed under the names of Zoloft, Prozac, Paxil, Effexor, and others, are the most commonly prescribed medications for depression in the United States.

Although St. John’s Wort has been used safely for over 2400 years, its mechanism of action is not well understood. It appears to act by affecting the levels of central mood-altering neurotransmitters in the brain, called serotonin and norepinephrine. One interesting characteristic of the herb is its ability to alter the metabolism of many prescription medications.

Patients who are also taking HIV medications called protease inhibitors along with St. John’s Wort, were found to have markedly decreased levels of their HIV medications in their blood, causing enough concern among HIV experts to advise against these patients combining the medications.

St. John’s Wort has been shown affect the metabolism and availability of cardiac medications (Digoxin), birth control pills, anticoagulants (Coumadin), and some asthma medications (Theophyllin). Since the action of the herb is similar to prescription antidepressants, it is considered dangerous to combine St. John’s Wort with drugs such as Prozac or other SSRIs without physician supervision, as toxicity symptoms may result.

The quality of commercially available preparations of St. John’s Wort is extremely variable. A recent independent test of safety, purity and quality by Consumer Lab revealed that of twenty-one products tested, only fourteen met acceptable criteria. Some products contained as little as 21% of the active ingredient that was advertised. A number of other products were found to be contaminated with cadmium, a toxic metal that is accumulated from the environment by the plant in many areas of the country.

When a physician feels that a patient may safely try to use St. John’s Wort for mild depression, the usual starting dose recommended is 300 mg three times a day. A standardized extract is often suggested, and in the Consumer Lab testing mentioned above, products made with the flowers of the plant were more consistent in quality than those made with leaves or stems (often termed “aerial parts”). Because of the number of herb-drug interactions that can occur with St. John’s Wort, patients taking the herb should be sure to discuss their use with their physician.

For further information on St. John’s Wort, write to The Natural Connection, c/o Pauline Bellecci, MD, PO BOX 777, Waycross, GA 31501 or contact us on our web site www.swampdocs.com

5/14/01