I get numerous questions each week regarding the use of the herb St. John’s Wort. The reason for this increase in questions is directly related to this supplement having been in the news recently. The questions themselves relate to issues of safety and the effectiveness of this supplement.

When surveying my patients I have found that the medical community tends to commonly comment that their patients should stop using this supplement. The rationale given for this recommendation is typically two-fold. The first is that studies have shown St. John's Wort to be ineffective and the second is that the safety of using this product is in question.

My belief is that it is too easy for medical professionals to simply dismiss the use of alternative products due, in part, to getting incomplete information or not getting good information at all. The problem is that you are rarely exposed to what Paul Harvey likes to call “The Rest of the Story.” My goal in this issue is to give you the “other side” empowering you to make more informed decisions when it comes to taking St. John's Wort.

St. John’s Wort (Hypericum perforatum)

One of the best examples of misconceptions about a natural remedy concerns the use of the herb St. John’s Wort (SJW) for depression. A number of medical professionals have told me that they do not recommend this herb because studies show that it does not work. In fact, the study most commonly quoted was an April 2001 JAMA study.¹ So, let’s evaluate this study and look at other recent studies to see if this basis for not recommending this herb is supported.

The JAMA 2001 article concluded that, “St. John’s wort was not effective for treatment of major depression.” This was picked up by the AP and it released the headline, “Study: St. John’s Wort Ineffective in Treating Major Depression.” The major media then reprinted this headline but left out the very important word “Major” in most cases. Common headlines were “St. John’s Wort Fails Test on Depression” and “St. John’s Wort Ineffective, Study Says”, while Time Magazine titled their article “St. John’s What? The ‘natural’ antidepressant may not work. Bummer.”

The problem was that most medical professionals read and heard these same headlines. They filed the negative results in their heads without being given the chance to look at the specifics of the study. I would venture to say that the vast majority did not read the study. The common conclusion was that SJW has not been shown to be effective for depression (in general). The recommendation to not use SJW due to the lack of study support ensued.

So, let’s dissect this JAMA study and look at others to get a better picture. The authors of the JAMA study simply dismissed the 30+ previous studies that had been done on SJW. They stated, “...most have significant flaws in design and do not enable meaningful interpretation.” One of those previous studies in severe depression concluded that patients improved significantly on SJW, compared to placebo and the antidepressant drug imipramine only on the higher dose of 1,800 mg/day of SJW.² The JAMA study started with 900 mg/day and only increased the dose to 1,200 mg/day. There was no explanation why they decided to only use 1,200 mg/day instead of 1,800 mg/day. Which study had the inadequate design? Also, almost no one knew that this JAMA study was funded by Pfizer, the manufacturer of the antidepressant Zoloft. I am sure that Pfizer was hoping for a good result from this study so that their sales of Zoloft would go down.

Additionally, in this same JAMA article the researchers noted, “The number reaching remission of illness was significantly higher with St. John’s Wort than with placebo (P=.02)” but they were quick to add, “...but the rates were very low in the full intention-to-treat analysis (14/98 [14.3%] vs. 5/102 [4.9%], respectively.” In other words, SJW did show some significant benefit, but this was immediately downplayed as “very low”. The bottom line is that this is not a study for any clinician to hang their hat on.

What other studies are out there that support the use of SJW? Space will not allow me to list all of them. So, I will go over a couple of recent studies that I bet you have not seen.

The first is a study published in October 2005. The conclusion stated, “SJW was significantly more effective than fluoxetine (Prozac) and showed a trend toward superiority over placebo.” This study was completed on patients with major depression.³

A study in March 2005 concluded, “The results indicate that hypericum extract STW 3 is not inferior to sertraline (Zoloft) and that it is a well-tolerated drug for the treatment of moderate depression. These favorable effects were achieved with a once-daily dose of 612 mg of hypericum extract given for up to 24 weeks.” ⁴

In April of 2005 another study concluded, “In the treatment of moderate to severe major depression, hypericum extract WS 5570 is at least as effective as paroxetine (Paxil) and is better tolerated.” ⁵

This same extract was studied in August of 2002 with the conclusion, “H. perforatum extract WS 5570 was found to be safe and more effective than placebo for the treatment of mild to moderate depression.” ⁶

A review study published in January of 2005 concluded, “The available studies show that hypericum extract are well tolerated and seem to be effective in routine treatment of mild to moderate depressive disorders.” ⁷

The point to be taken from my examples is that not any one study proves or disproves the benefits of any treatment. The facts, which somehow are very well suppressed, show that SJW is effective and safe when compared to other commonly prescribed antidepressants or placebo in many studies. My hope is that you will realize that the “it isn’t studied” or “studies do not support” excuses do not hold water when it comes to SJW.

Now, the consideration to use SJW should not be governed solely by studies showing its effectiveness. SJW is one of the herbs that can interact with a number of other pharmaceuticals. The potential for other drug interactions is a real concern when using SJW.

In vitro studies suggest that SJW causes induction of the cytochrome P450 isoenzyme CYP3A4.^8,9 Thus, SJW may reduce the serum levels of the following drugs: indinavir, cyclosporine, theophylline, digoxin, warfarin, and oral birth control pills.^10-18 Although we view these interactions as potentially harmful, the fact is that up-regulation of cytochrome P450 enzymes may help the body detoxify certain toxins and may be of benefit.

Since the true drug interactions of SJW are not known, my recommendation to patients is that SJW not be utilized if they are taking one of the mentioned prescriptions. This includes any other antidepressants. In fact, I tend to not suggest SJW if they are taking any prescription drugs just to stay on the safe side.

The clinically important point to be made from the information supplied in this article is that you can use this herb with the confidence that there is published support for SJW in the peer-reviewed literature. My recommendation is that you do not use it if you are taking any number of other prescriptions. We simply do not know with any confidence whether there will be drug-herb interactions. If you decide to use of SJW, make sure that you buy SJW from ZN.com.  Taking a quality product is of great importance.

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