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St. John's Wort , Hypericum perforatum

Proposed Uses: Mild to Moderate Depression; Anxiety; Diabetic Neuropathy and Other Forms of Neuropathy; Eczema (Topical Cream); Insomnia; Menopause; Obsessive Compulsive Disorder; PMS; Seasonal Affective Disorder (SAD)

St. John's wort has a long history of use in treating emotional disorders. During the Middle Ages, St. John's wort was popular for "casting out demons." In the 1800s, the herb was classified as a "nervine," or a treatment for "nervous disorders." When pharmaceutical antidepressants were invented, German researchers began to look for similar properties in St. John's wort.

Today, St. John's wort is a widely used treatment for depression in Germany, other parts of Europe, and the United States. The evidence-base for its use approaches that of many modern prescription drugs at the time of their first approval.

Most studies of St. John's wort have evaluated individuals with major depression of mild to moderate intensity. This contradictory-sounding language indicates that the level of depression is more severe than simply feeling "blue." However, it is not as severe as the most severe forms of depression. Typical symptoms include depressed mood, lack of energy, sleep problems, anxiety, appetite disturbance, difficulty concentrating, and poor stress tolerance. Irritability can also be a sign of depression.

Taken as a whole, research suggests that St. John's wort is more effective than placebo and approximately as effective as standard drugs. Furthermore, St. John's wort appears to cause fewer side effects than many antidepressants. However, the herb does present one significant safety risk: it interacts harmfully with a great many standard medications (see Safety Issues for details).
Warning: St. John's wort should never be relied on for the treatment of severe depression. If you or a loved one feels suicidal, unable to cope with daily life, paralyzed by anxiety, incapable of getting out of bed, unable to sleep, or uninterested in eating, see a physician at once. Professional care may be lifesaving.

Besides depression, St. John’s wort has also been tried for many other conditions in which prescription antidepressants are thought useful, such as attention deficit disorder, anxiety, insomnia, menopausal symptoms, PMS, seasonal affective disorder (SAD) and social phobia. However, there is as yet no direct evidence that it offers any benefit for these conditions. One substantial double-blind study did find St. John's wort potentially helpful for somatoform disorders (commonly called "psychosomatic illnesses").

Standard antidepressants are also often used for diabetic neuropathy, and other forms of neuropathy (nerve pain). However, a small double-blind, placebo-controlled trial failed to find St. John's wort effective for this purpose. Another study failed to find St. John's wort helpful for obsessive-compulsive disorder.

St. John’s wort contains, among other ingredients, the substances hypericin and hyperforin. Early reports suggested that St. John's wort or synthetic hypericin might be useful against viruses such as HIV, but these haven't panned out. However, there is some evidence hyperforin may be able to fight certain bacteria, including some that are resistant to antibiotics. Note: this evidence is far too preliminary to count St. John's wort as an effective antibiotic.

Based on weak evidence that hypericin might have anti-inflammatory properties, St. John’s wort cream has been tried as a treatment for eczema, with some promising results.

One interesting double-blind study evaluated a combination therapy containing St. John's wort and black cohosh in 301 women with general menopausal symptoms as well as depression. The results showed that use of the combination treatment was significantly more effective than placebo for both problems.

Dosage
The typical dosage of St. John's wort is 300 mg 3 times a day of an extract standardized to contain 0.3% hypericin. Some products are standardized to hyperforin content (usually 2 to 3%) instead of hypericin. These are usually taken at the same dosage. Two studies found benefits with a single daily dose of 900mg.

Yet another form of St. John's wort has also passed double-blind studies. This form contains little hyperforin, and is taken at a dose of 250 mg twice daily. There is some evidence that this form of St. John's wort may be less likely to interact with medications. (See Drug Interactions)

If the herb bothers your stomach, take it with food. Remember that the full effect takes 4 weeks to develop. Don't give up too soon!

Safety Issues
St. John's wort taken alone usually does not cause immediate side effects. In a study designed to look for side effects,250 people took St. John's wort for 4 weeks. Overall, about 2.4% reported problems. The most common complaints were mild stomach discomfort (0.6%), allergic reactions—primarily rash—(0.5%), tiredness (0.4%), and restlessness (0.3%). Another study followed 313 individuals treated with St. John's wort for 1 year. The results showed a similarly low incidence of adverse effects.

In the extensive German experience with St. John's wort as a treatment for depression, there have been no published reports of serious adverse consequences from taking the herb alone. Animal studies involving enormous doses of St. John's wort extracts for 26 weeks have not shown any serious effects.

However, there are a number of potential safety risks with St. John's wort that should be considered. These are outlined in the following sections.

Photosensitivity
Cows and sheep grazing on St. John's wort have sometimes developed severe and even fatal sensitivity to the sun. In one study, highly sun-sensitive people were given twice the normal dose of the herb. The results showed a mild but measurable increase in reaction to ultraviolet radiation. Another trial found that a one-time dose of St. John’s wort containing 2 or 6 times the normal daily dose did not cause an increased tendency to burn; nor did seven days of treatment at the normal dose. However, there is a case report of severe and unexpected burning in an individual who used St. John's wort and then received ultraviolet therapy for psoriasis. In addition, two individuals using topical St. John's wort experienced severe reactions to sun exposure.

The morals of the story are as follows: if you are especially sensitive to the sun, don't exceed the recommended dose of St. John's wort, and continue to take your usual precautions against burning; if you are receiving UV treatment, do not use St. John’s wort at all; and if you apply St. John’s wort to your skin, keep that part of your body away from the sun.

In addition, you might get into problems if you combine St. John's wort with other medications that cause increased sun sensitivity, such as sulfa drugs and the anti-inflammatory medication Feldene (piroxicam). The medications Prilosec (omeprazole) and Prevacid (lansoprazole) may also increase the tendency of St. John's wort to cause photosensitivity.

Finally, a report suggests that regular use of St. John's wort might also increase the risk of sun-induced cataracts.50 While this is preliminary information, it may make sense to wear sunglasses when outdoors if you are taking this herb on a long-term basis.

Drug Interactions
Herbal experts have warned for some time that combining St. John's wort with drugs in the Prozac family (SSRIs) might raise serotonin too much and cause a number of serious problems. Recently, case reports of such events have begun to trickle in. This is a potentially serious risk. Do not combine St. John's wort with prescription antidepressants except on the specific advice of a physician. Since some antidepressants, such as Prozac, linger in the blood for quite some time, you also need to exercise caution when switching from a drug to St. John's wort.
Antimigraine drugs in the triptan family (such as sumatriptan, or Imitrex) and the pain-killing drug tramadol also raise serotonin levels and might interact similarly with St. John's wort.

However, perhaps the biggest concern with St. John's wort is that it appears to decrease the effectiveness of numerous medications, including protease inhibitors and reverse transcriptase inhibitors (for HIV infection), cyclosporine and tacrolimus (for organ transplants), digoxin (for heart disease), statin drugs (used for high cholesterol) warfarin (a blood thinner), chemotherapy drugs, oral contraceptives, tricyclic antidepressants, protein pump inhibitors (like Prilosec), atypical antipsychotics like olanzapine or clozapine (for schizophrenia), anesthetics, and the new heart disease drug ivabradine.

Transitioning from Medications to St. John's Wort
If you are taking a prescription drug for mild to moderate depression, switching to St. John's wort may be a reasonable idea if you would prefer taking an herb. To avoid overlapping treatments, the safest approach is to stop taking the drug and allow it to wash out of your system before starting St. John's wort. Consult with your doctor on how much time is necessary.

However, if you are taking medication for severe depression, switching over to St. John's wort is not a good idea. The herb probably won't work well enough, and you may sink into a dangerous depression.

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