St. John’s WortSt. John’s Wort

An Alternative Treatment for Mild to An Alternative Treatment for Mild to Moderate DepressionModerate Depression

Presentation OutlinePresentation Outline Alternate NamesAlternate Names Description of HypericumDescription of Hypericum Forms of HypericumForms of Hypericum History and Naming of St. John’s WortHistory and Naming of St. John’s Wort TreatmentTreatment DosageDosage Side EffectsSide Effects Drug InteractionsDrug Interactions CautionsCautions Advantages/DisadvantagesAdvantages/Disadvantages EvaluationEvaluation

Alternate NamesAlternate Names

Hardhay Hardhay Amber Amber Guttiferae Guttiferae Goat weed Goat weed Tipton weed Tipton weed Klamath weed Klamath weed Hypericum PerforatumHypericum Perforatum

Most commonMost common LatinLatin

Hypericum Perforatum – The PlantHypericum Perforatum – The Plant

Perennial plantPerennial plant Flower: bright yellow oval Flower: bright yellow oval

shaped leaves with black shaped leaves with black dotsdots

Native to Northern Africa, Native to Northern Africa, Europe and Western AsiaEurope and Western Asia

Can be found in meadows, Can be found in meadows, dry pastures, near railroad dry pastures, near railroad tracks and alongside tracks and alongside roadbeds worldwideroadbeds worldwide

Forms of HypericumForms of Hypericum

CapsulesCapsules TeasTeas TabletsTablets TincturesTinctures Oil-based skin lotions Oil-based skin lotions

(not to be ingested)(not to be ingested) Chopped/powered Chopped/powered

Hypericum Perforatum – HistoryHypericum Perforatum – History St. John’s Wort was first documented in the first St. John’s Wort was first documented in the first

century A.D. by Gaius Plinius Secundus (Pliny the century A.D. by Gaius Plinius Secundus (Pliny the Elder), a Roman philosopher, who discussed the Elder), a Roman philosopher, who discussed the herbs ability to treat diarrhea and bladder problems.herbs ability to treat diarrhea and bladder problems.

Following this, the ancient Greek physician Pedanius Following this, the ancient Greek physician Pedanius Dioscorides recommended it to expel “choleric Dioscorides recommended it to expel “choleric excrements” (natural pharmacy, 2005) and to treat excrements” (natural pharmacy, 2005) and to treat burns.burns.

Philippus Theophrastus Aureolus Bombastus von Philippus Theophrastus Aureolus Bombastus von Hohenheim (Paracelus) wrote about the use of St. Hohenheim (Paracelus) wrote about the use of St. John’s wort to treat wounds and psychotic symptoms John’s wort to treat wounds and psychotic symptoms (phatasmata)(phatasmata)

Hypericum Perforatum – HistoryHypericum Perforatum – History

In 1630AD Angelo Sala announced that St. John’s In 1630AD Angelo Sala announced that St. John’s Wort had the ability to treat illnesses of the Wort had the ability to treat illnesses of the “imagination, melancholia, anxiety and disturbances “imagination, melancholia, anxiety and disturbances of understanding” (natural pharmacy, 2005).of understanding” (natural pharmacy, 2005).

The word continued to spread about St. John’s Wort The word continued to spread about St. John’s Wort through “wise women” and midwives.through “wise women” and midwives.

It was brought to the Northeastern United States by It was brought to the Northeastern United States by European colonists and was used to treat breathing European colonists and was used to treat breathing problems (tuberculosis), fever, nosebleeds, bladder problems (tuberculosis), fever, nosebleeds, bladder and bowel problems, and for venereal diseases.and bowel problems, and for venereal diseases.

Naming St. John’s WortNaming St. John’s Wort

St. John’s Wort is harvested and flowers by June 24St. John’s Wort is harvested and flowers by June 24 thth, , which is St. John’s (feast) day (John the Baptist) which is St. John’s (feast) day (John the Baptist)

When the petals are squeezed or rubbed, they leak red When the petals are squeezed or rubbed, they leak red sap which is believed to be representative of the sap which is believed to be representative of the blood of the martyred saint (John the Baptist)blood of the martyred saint (John the Baptist)

Hypericum PerforatumHypericum Perforatum

It is believed that the combination of It is believed that the combination of Hypericum’s constituents is what allows it to Hypericum’s constituents is what allows it to have an antidepressant effect rather than just have an antidepressant effect rather than just one compoundone compound

These constituents include:These constituents include: Napthodianthrones hypericin Napthodianthrones hypericin Pseudohypericin Pseudohypericin HyperforinHyperforin

TreatmentTreatment

Researchers are unsure how St. John’s Wort Researchers are unsure how St. John’s Wort actually works to treat depressionactually works to treat depression

St. John’s Wort was originally though to work St. John’s Wort was originally though to work somewhat like MAOI’S do, however recent somewhat like MAOI’S do, however recent clinical tests (Dr. Muller and Colleagues) clinical tests (Dr. Muller and Colleagues) show that St. John’s wort is able to also inhibit show that St. John’s wort is able to also inhibit serotonin, norepinephrine and dopamine serotonin, norepinephrine and dopamine without the added complications of MAOI’s without the added complications of MAOI’s and side effects of SSRI’s and TCA’sand side effects of SSRI’s and TCA’s

St. John’s Wort versus SSRI’s, St. John’s Wort versus SSRI’s, MAOI’s and TCA’SMAOI’s and TCA’S

St. John’s WortSt. John’s Wort Affects Serotonin, Affects Serotonin,

Norepinephrine and dopamineNorepinephrine and dopamine Mild side effectsMild side effects Rare side effectsRare side effects Non-competitive inhibitorNon-competitive inhibitor

SSRI’SSSRI’S SerotoninSerotonin Side effectsSide effects

MAOI’sMAOI’s Negative interaction with Negative interaction with

other medicationsother medications Requires a strict dietRequires a strict diet Affects tyramine (linked to Affects tyramine (linked to

blood pressure)blood pressure)

TCA’sTCA’s Side effectsSide effects Can be fatalCan be fatal

DosageDosage

Dosage depends on the hypericin contentDosage depends on the hypericin content Usually advised that the St. John’s wort extract Usually advised that the St. John’s wort extract

be standardized to contain 0.3% hypericin at a be standardized to contain 0.3% hypericin at a dosage of 300mg, three times a daydosage of 300mg, three times a day

Takes about 6 weeks to notice a differenceTakes about 6 weeks to notice a difference Generally takes longer to reach full Generally takes longer to reach full

effectiveness than prescription antidepressantseffectiveness than prescription antidepressants

Side EffectsSide Effects

Generally few side effects and quite mildGenerally few side effects and quite mild Not a single recorded hypericum-related death Not a single recorded hypericum-related death

in 2,400 years in 2,400 years All side effects are reversible (stops when the All side effects are reversible (stops when the

herb is no longer being used)herb is no longer being used) Photosensitivity (sensitive to sunlight)Photosensitivity (sensitive to sunlight)

Fair skinned people should avoid, if possible, Fair skinned people should avoid, if possible, prolonged sunlight exposureprolonged sunlight exposure

Side EffectsSide Effects

Less Commonly:Less Commonly: ConstipationConstipation Gastrointestinal problems (nausea, vomiting, diarrhea)Gastrointestinal problems (nausea, vomiting, diarrhea) FatigueFatigue Dry mouthDry mouth DizzinessDizziness Allergic reactionsAllergic reactions ConfusionConfusion To help combat these side effects it is suggested that St. To help combat these side effects it is suggested that St.

John’s wort be taken with food.John’s wort be taken with food.

Drug InteractionsDrug Interactions

It is advised to be cautious when taking other It is advised to be cautious when taking other medications with St. John’s Wort as it has shown to medications with St. John’s Wort as it has shown to decrease their effectivenessdecrease their effectiveness

This includes:This includes: AntidepressantsAntidepressants Immunosuppressive medicationsImmunosuppressive medications

Especially in those with heart or kidney Especially in those with heart or kidney transplants as it can cause the body to reject the transplants as it can cause the body to reject the transplanted organstransplanted organs

Indinavir and other protease inhibitors (treats HIV)Indinavir and other protease inhibitors (treats HIV)

Drug Interactions cont’dDrug Interactions cont’d

Loperamide (diarrhea medication)Loperamide (diarrhea medication) Can lead to deliriumCan lead to delirium

Oral contraceptivesOral contraceptives Can cause bleedingCan cause bleeding

Reserpine (treats high blood pressure)Reserpine (treats high blood pressure) Theophylline (treats asthma, emphysema, or Theophylline (treats asthma, emphysema, or

chronic bronchitis)chronic bronchitis) Warfarin (anticoagulant)Warfarin (anticoagulant) DigoxinDigoxin

CautionsCautions Should not be used during pregnancy or while breast Should not be used during pregnancy or while breast

feeding as there is no information on it's safety under feeding as there is no information on it's safety under these conditionsthese conditions

Should not be used for severe depression or bipolar Should not be used for severe depression or bipolar disorder as not enough research is yet available to disorder as not enough research is yet available to show effectiveness in these circumstancesshow effectiveness in these circumstances

Do not take St. John’s wort in combination with Do not take St. John’s wort in combination with MAOI’s MAOI’s Can produce a dangerous rise in blood pressureCan produce a dangerous rise in blood pressure

Should not be taken in combination with prescription Should not be taken in combination with prescription SSRI’s as this can lead to serotonin syndrome – too SSRI’s as this can lead to serotonin syndrome – too much serotonin. much serotonin.

AdvantagesAdvantages Few side effectsFew side effects Mild side effectsMild side effects Reversible side effectsReversible side effects Do not need a prescriptionDo not need a prescription Sexual dysfunction (as a side effect) has never been reported, Sexual dysfunction (as a side effect) has never been reported,

whereas this is a common problem with other antidepressants whereas this is a common problem with other antidepressants and the reason many people choose to discontinue using themand the reason many people choose to discontinue using them

Clinical studies have proven St. John’s Wort to be for mild to Clinical studies have proven St. John’s Wort to be for mild to moderate depression (a significant difference was found moderate depression (a significant difference was found between the placebo group and the group receiving St. John’s between the placebo group and the group receiving St. John’s Wort)Wort)

DisadvantagesDisadvantages Is not recommended for Severe Depression or Bipolar disorderIs not recommended for Severe Depression or Bipolar disorder Although St. John’s Wort is widely used and accepted in Although St. John’s Wort is widely used and accepted in

Europe, specifically Germany, it is not FDA approved in the Europe, specifically Germany, it is not FDA approved in the United States for medical purposesUnited States for medical purposes

Since it is not regulated in the U.S., there is no regulatory Since it is not regulated in the U.S., there is no regulatory oversight of the manufacturing, distributing and labeling of St. oversight of the manufacturing, distributing and labeling of St. John’s Wort, therefore the contents and potency of the herb John’s Wort, therefore the contents and potency of the herb cannot be guaranteedcannot be guaranteed

There have been cases in the past where herbal products (not There have been cases in the past where herbal products (not necessarily St. John’s wort) were analyzed and sometimes necessarily St. John’s wort) were analyzed and sometimes found to contain dangerous toxic compounds. found to contain dangerous toxic compounds.

EvaluationEvaluation

St John’s Wort seems to be an effective alternative to St John’s Wort seems to be an effective alternative to more popular antidepressantsmore popular antidepressants

The side effects are few and quite mild in comparison The side effects are few and quite mild in comparison with MAOI’s and TCA’swith MAOI’s and TCA’s

While it is not as acceptable of a treatment for While it is not as acceptable of a treatment for depression as other antidepressants, it is widely used depression as other antidepressants, it is widely used in Europe, specifically Germany, where it has been, in Europe, specifically Germany, where it has been, and continues to be, widely researched. The research and continues to be, widely researched. The research shows significant effectiveness when compared to shows significant effectiveness when compared to placebos and other antidepressantsplacebos and other antidepressants

EvaluationEvaluation

There is some concern over Hypericum’s There is some concern over Hypericum’s interaction with other medication. interaction with other medication. For example, Women more commonly suffer from For example, Women more commonly suffer from

depression than men do, yet this herb reduces the depression than men do, yet this herb reduces the effectiveness of oral contraceptives.effectiveness of oral contraceptives.

In the future, it would be beneficial to see In the future, it would be beneficial to see more sound research on how it works in the more sound research on how it works in the brain and long term effectsbrain and long term effects