MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

I have blogged about the herbal antidepressant before; for instance about the fact that it can cause potentially dangerous herb-drug interactions. When taken alone, however, it seems to be both safe and efficacious in reducing the symptoms of depression. This notion has just been confirmed yet again.

A new systematic review evaluated St. John’s wort (SJW) for the treatment of Major Depressive Disorder (MDD). The objectives of this review were to (1) evaluate the efficacy and safety of SJW in adults with MDD compared to placebo and active comparator and (2) evaluate whether the effects vary by severity of MDD.

The authors searched 9 electronic databases and existing reviews to November 2014. Two independent reviewers screened the citations, abstracted the data, and assessed the risk of bias. They included randomized controlled trials (RCTs) examining the effect of at least a 4-week administration of SJW on depression outcomes against placebo or active comparator in adults with MDD. Risk of bias was assessed using the Cochrane Risk of Bias tool and USPSTF criteria. Quality of evidence (QoE) was assessed using the GRADE approach.

Thirty-five studies examining 6993 patients met inclusion criteria; 8 studies evaluated a SJW extract that combined 0.3 % hypericin and 1-4 % hyperforin. SJW was associated with more treatment responders than placebo (relative risk [RR] 1.53; 95 % confidence interval [CI] 1.19, 1.97; I(2) 79 %; 18 RCTs; N = 2922, moderate QoE; standardized mean differences [SMD] 0.49; CI 0.23, 0.74; 16 RCTs; I(2) 89 %, N = 2888, moderate QoE). Compared to antidepressants, SJW participants were less likely to experience adverse events (OR 0.67; CI 0.56, 0.81; 11 RCTs; moderate QoE) with no difference in treatment effectiveness (RR 1.01; CI 0.90, 1.14; 17 RCTs, I(2) 52 %, moderate QoE; SMD -0.03; CI -0.21, 0.15; 14 RCTs; I(2) 74 %; N = 2248, moderate QoE) in mild and moderate depression.

The authors concluded that SJW monotherapy for mild and moderate depression is superior to placebo in improving depression symptoms and not significantly different from antidepressant medication. However, evidence of heterogeneity and a lack of research on severe depression reduce the quality of the evidence. Adverse events reported in RCTs were comparable to placebo and fewer compared with antidepressants. However, assessments were limited due to poor reporting of adverse events and studies were not designed to assess rare events. Consequently, the findings should be interpreted with caution.

This is an excellent review from a reputable and independent team. The findings are therefore trustworthy.

Does that mean that we can now recommend SJW for patients suffering from depression?

Perhaps – but we need to keep an eye on the interaction issue. As a sole treatment, SJW is much safer than conventional antidepressants. But if a patient takes other medicines, we ought to be very careful.

Other currently unresolved issues are the questions of which extract and which dose. At present, there is not enough evidence to provide conclusive answers to either of these, and therefore the enthusiasm of many doctors for prescribing SJW is understandably limited.

Irrespective of these problems, I have to say that SJW is without question one of the biggest ‘success stories’ from the realm of alternative medicine. Pity that there are not more of them!

16 Responses to St John’s Wort for depression: the biggest success story of alternative medicine

  • I got badly sunburnt after trying it.

  • However, if it works, then it becomes ‘science’. It seems to me not to be ‘altmed’, but a scientific fact that altmeds happened across randomly. Little else of what they claim turns out to be true. Vitamin C was discovered to cure scurvy in the British navy. What it doesn’t do, whatever the claims of the nuttier homeopaths, is cure cancer, and there seems to be little evidence that it does or will at some future point. The difference is that one hypothesis was tested scientifically, and proved to work. As far as St John’s Wort is concerned, that’s one hit among thousands of misses.
    Now-if those Indian homeopaths in the Himalayas manage to discover the plant that glows in the dark and can bring dead people back to life….

    • good point!
      I agree, if it works it becomes part of medicine.
      but has SJW done that?
      in Germany perhaps – but not in the UK, I think.

      • I agree, and if it works it should be standardized for consistency and all known side effects and drug/food interactions listed for informed consent. (like any legitimate pharmaceutical).

        • There are many, many St. John’s Wort products that contain 300 mg of St. John’s Wort per capsule/tablet that are standardized to 2 or 3% hyperforin. The reason many are standardized to 2-3% hyperforin is because THE St. John’s Wort which most of the published studies were done on a product known as St. John’s Wort WS 5570. This is made by a German company names Schwabe. This exact product is sold in the U.S. by Nature’s Way the name of Perika. Nature’s Way is owned by Schwabe and Perika is the same as the German product. If you look at the Cochrane reciew of St. John’s Wort most of the studies used the WS 5570. All of the other St. John’s Wort products on the market are copy cats of this material.

        • Drug interactions with SJW are so numerous that that I have to wonder how many “natural” products it may also interfere with. In addition to posing serious problems for those who may require medications, the marketplace is apparently rife with adulterated products. In a recent A HREF=”https://www.ncbi.nlm.nih.gov/pubmed/27343017″>survey of 37 commercial samples of SJW products (dry extracts, bulk raw herb, and finished products), 38% were found to be adulterated.

          The same survey notes that in the mainstream market of the US, SJW has fallen from 9th place among the most sold herbal products in 2011–2010 to the 31st in 2015. While the loss of interest in SJW could be due to its lack of effectiveness in those with serious depression, the role of adulteration must also be considered.

  • SJW is good value – I’ll take any tool in the tool kit so long as it is not produced by big pharma..
    I take it to reduce anxiety, but I tell you what, since I started learning to control my breathing, that has helped tenfold. I find that when someone/thing stresses me out, I hold my breath. Another thing is sleep. Having a cold shower before bed has taken me from sleeping 3.5 hrs per night to 7hrs and that is also with a 17 week old baby..

    • Gus- with respect, your ‘tool kit’/’big Pharma’ comment is so ludicrous as to suggest that you haven’t understood anything at all about the debate.

      • Hi Barrie, Apologies, what part have I misunderstood?

        • Gus- my point is that-whatever your thoughts on Big Pharma- ghastly cliche by the way- proper modern medicine works way more often than it doesn”t. Homeopathy doesn’t work, except by placebo. If anything in your metaphorical tool kit works, it’s already been accepted as Science. If it doesn’t, it hasn’t. The problem is that homeopaths want their ”treatments’ taken seriously just because they say so, and to have them judged by lower standards. If you avoid taking treatments simply on the basis that they’re produced by what you insist on calling ‘Big Pharma’, you may quite simply die There were one or two such cases mentioned on this blog recently. Your phrase ‘If it works’ can cover a multitude of lies, delusions, and made-up ‘evidence’.

  • What would be other success or potential success of alternative medicines?

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