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St. John's Wort and Depression

Is St. John's wort a safe, effective alternative to medication for depression?

St. John's wort is a natural, herbal medicine that is reported to treat depression. The psychiatric history of this plant goes all the way back to ancient Greece where it was used to treat “nervous conditions”. Over the years it’s been reported to help PMS, menopause, anxiety, SAD and even OCD.

The mechanism of action for St. John's wort is not clear, but the therapeutic ingredients are thought to include hypericin, pseudohypericin and various xanthones. It is believed these chemicals elevate dopamine and serotonin levels in the brain, much the same as traditional antidepressants.

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St. John's wort is an invasive weed with yellow flowers found throughout the US. It rapidly grows and spreads, often overtaking other nearby plant life. Since its “natural” and an herb, if it works it must be all good. Right? Let's take a look:

Cochrane Researchers studied the results of 29 trials which involved 5,489 patients with major depression. In these studies, St. John's wort was compared to standard antidepressants. St. John's wort was found to be just as effective and participants were less likely to drop out because of adverse effects.

Researchers were quick to issue warnings, however, about the risk of adverse reactions when the herb was used other drugs and also stated, "using a St. Johns wort extract might be justified, but products on the market vary considerably, so these results only apply to the preparations tested."

The Cleveland Clinic reviewed over 30 clinical studies over the past 22 years and concluded that St. John's wort is effective in treating mild depression, but was no better than placebo for moderate or severe depression. Even the National Center for Complementary and Alternative Medicine (NCCAM) indicates St. John's wort is no better than placebo when treating major depression.

OK, so let’s say it works about as well as a standard antidepressant on mild depression. What about the downside?

The usual dosage of St. John's wort is 300 mg, three times a day. But, since herbal supplements are not regulated by the FDA, the actual dose and the amount of active ingredients can vary. Also, there are dozens of manufacturers and it can be steeped as a tea, taken as a pill or used as a liquid, which makes accurate dosing even more problematic.

Even worse, it’s not FDA approved for quality, safety or purity. It is very possible for St. John's wort or any other herbal supplement to be contaminated with other drugs or even toxic metals, so it should only be purchased from a reliable source. This supplement, produced under many brand names, is one of the top selling herbal supplements in the US and this begs the question what is a reliable source?

But, being “all natural” certainly must be better than a “man-made” drug, right? Clearly if something is “natural”, then it's good, pure, healthy and just plain better. When we think of natural herbs, we relate that to a natural balance, using Mother Earth to naturally treat ailments.

We consider herbal supplements to be free of toxins, pesticides and scary ingredients that no one knows how to pronounce. We think of the plant growing in its natural state, not a pharmaceutical-created pill. Natural. It sounds wholesome and pure, and the word spoken just sounds so positive.

That's not always the case. Consider cobra venom, puffer fish toxin, many types of mushrooms, oleander, crude oil, cyanide and arsenic. All are all highly toxic and may be fatal, and yet they occur naturally, in nature. Just because something is natural doesn't mean it's good or should be blindly swallowed.

G. E. Moore, a philosopher (1873-1958) said it was a mistake to define "good" in terms of "natural" properties. Claiming this was a fallacy, he coined the phrase naturalistic fallacy. Simply put, "good" cannot be defined simply. To attempt to define good based on the connotation of “natural” or any other word for that matter, is illogical.

Is a natural herb really safer than a pharmaceutical? The FDA is dedicated to regulating both medications and their manufacturers. They often are criticized for moving too slowly when approving new drugs, but safety is a major concern, and that takes time. When you take a medication, you know what you're getting and know it was extensively studied and researched before approval. The herbal supplement has no such regulation or extensive testing. It's take at your own risk.

In addition, St. John's wort has a host of interactions with other drugs. So much so, that France has banned the use of St. John's wort in all products and warnings of herb-drug interactions are listed in Japan, the UK and Canada, but not the US.

Many times, the bottom line relates to cost. Everything is becoming more expensive, and medication -- even generic -- is no exception. With the burden of rising health care costs, alternative treatments are being explored. Comparing the cost of a brand name med to the cost of St. John's wort is informative. No doubt newer, non-generic meds are much more expensive, some costing hundreds of dollars a month, while 180 pills of Nature's Way St. John's wort sells for $9.99. But, older generic antidepressants are filled at some national chains for under $10 per month, so price should not really be an issue.

OK, so assuming you have found a trusted supplier, have talked to your doctor about any herb-drug interactions and are suffering from mild depression. Then St. John's wort may be worth a try. But, and this is a big BUT, mild to moderate depression is the very depression that responds best to psychotherapy. And, if you really want to be “all natural” then psychotherapy is clearly superior to popping a pill.

Dale Archer, M.D., is a clinical psychiatrist and author of The New York Times bestseller, Better Than Normal: How What Makes You Different Can Make You Exceptional.

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