Furious Seasons

February 17, 2009

Wall St. Journal Dubs St. John's Wort As Effective As Anti-Depressants

Yesterday, the Wall Street Journal published an article on a European meta-study showing that St. John's Wort was as effective as standard anti-depressants. It focused on a study published in the Cochrane Collaboration last October, which I wrote about last October. I'm not sure why the paper is just getting around to writing about the study now--the news hook was what in February?--but it's interesting that they paid attention to it at all. As far as I know, no one else in the major media has touched the study.

Some of the commentary was interesting.

"[A] review published late last year by the Cochrane Collaboration concluded that St. John's Wort is better than a placebo for major depression and 'similarly effective' to standard antidepressants, with fewer side effects.
"While St. John's Wort flopped in the two U.S. trials, "the overall evidence looks a little different," says the Cochrane review's lead author Klaus Linde, a physician at the Center for Complementary Medicine Research at the Technical University of Munich. The Cochrane Review looked at 29 trials with 5,489 patients, mostly from non-U.S. countries. Side effects of the extract were generally not worse than placebo, Dr. Linde says."

The article also noted that some researchers were skeptical of the study because, in it, Zoloft failed to outperform placebo, making them suspect methodological errors. (I've still not seen the study or a published abstract and am working to remedy that.) Of course, American doctors aren't exactly fans of St. John's Wort, for reasons that escape me since there's enough evidence at this point showing the wildflower extract is somewhat effective for mild to moderate depression.

"Many physicians remain skeptical of St. John's Wort, even for minor depression, because many positive studies on it come from German-speaking countries, such as Germany, Austria and Switzerland. The reasons for the more positive results in those countries aren't known, says Dr. Linde. He says the German patient populations may be different, perhaps depressed for less time than U.S. patients. Most of the trials in German-speaking countries also were funded by makers of St. John's Wort products, while the two major U.S. trials weren't, Dr. Linde says.
"'It's hard to totally discount the evidence out of Europe, but it's a bit puzzling that we haven't been able to replicate the results here,' says Sheila G. Jowsey, assistant professor of psychiatry at the Mayo Clinic in Rochester, Minn."

What Jowsey means is that US studies of the extract have been complete failures for St. John's Wort. Personally, I've never given St. John's Wort much of a try, so I have no personal opinion of its effectiveness. But I should note that it's generally regarded as side effect free, which ought to increase researchers' interest in studying the extract, given how nasty anti-depressants have turned out to be.

Here's a 1998 Linde paper in which he found St. John's Wort outperformed placebo in treating major depression. Here's a 1996 BMJ paper where similar results were found for mild to moderate depression. Here's a slideshow presentation Linde gave recently on various St. John's Wort studies.

Posted by Philip Dawdy at February 17, 2009 12:01 AM

del.icio.us Digg it reddit

Comments

While there may be fewer side effects with St. John's Wort, there are potential drug interactions which anyone taking it should be aware of. So if you are going to try it, make sure it doesn't interact with any other medications you take.

Posted by: Tony at February 17, 2009 09:48 AM

Hi Philip,

Having worked in the botanical supplement industry, I can tell you it is very loosely regulated. Supplements often come with bonus lead or other heavy metals. In fact, Consumer Lab, a private for-profit independent- testing lab, routinely finds manufacturers adulterating products and not just the weight loss supplements either. It looks like the industry is taking steps to self-regulate- see American Herbal Products Association- www. ahpa.com. But you really are on your own in the "Wild West" of the herbal supplement industry. But as we are unfortunately learning with drug manufacturers, buyer beware: do your homework. Also, due to Serotonin Syndrome, don't take SJW if you're taking an anti-depressant. That being said I'm a strong believer in the placebo effect, and since they certainly have a better side-effect profile, I believe it's worth a try for those with very mild depression. Also, I can't help but wonder if Germany's better test results have more to do with doctors in Germany looking at herbal supplements in a more favorable light.

Posted by: Melissa at February 17, 2009 10:24 AM

I tried taking St. John's Wort out of desperation a couple of years back after reading something about its purported benefits.. Memory being what it is(n't), soon forgot to keep taking it.. Also don't remember the effect it had, although feel safe in saying there was nothing negative that stands out *in my particular case*..

Posted by: Cindy Sue Causey at February 18, 2009 06:45 AM

I have read a fair amount on SJW. This is yet another topic where big Pharma can play loose with the rules. One way to "fix" the results to your favor is to fail to use a recognized herbal remedy the correct way. In a trial to establish efficay of some hopefully patentable pharmaceutical, let's say some injection drug needed to be refridgerated until used. Would a pharmaceutical company ever leave it unrefridgerated for weeks before use? No. Let's say it needed to be injected into muscle (intramuscular "IM") , not fat (subcutaneous "SubQ"), and not vein (intravenous, hnce the familiar term "IV"). Would they inject it into fat? No. Would they inject it IV? No.

The point is that they can "fix" the results by inappropriately delivering the "herbal" remedy.

As with MANY pharmaceuticals, including such an everyday staple as aspirin, moisture from the air can make the "active ingredient" break down. This is the exact same process of why bread goes "stale" when you leave it out of the wrapper - chemical processes happen to it as it sits out, usually due to atmosheric oxygen or water or both. Why do bread and aspirin both have expiration dates? Coffee and tea absorb moisture, decreasing the quality of that coffee or tea. This is why better tea bags come in their own, airtight foil wrappers. This is why coffee is vacuum-sealed. This is just the way it is for some things, including tea, coffee, bread, herbs, and some drugs including aspirin.

So, if you want to prove your coffee is superior to "Seattle's Finest," leave the Seattle's Finest out for a few months before you brew it and taste-test it against your fresh Dunkened Donuts coffee.

Likewise, if you want to prove your new headache remedy is superior to aspirin, use aspirin that has been sitting out for a few months.

Here is one example of Big Pharma-supported study with unfair, unreaonable study design to handicap a botanical / herbal / whatever you want to call SJW:

Weber et al (including Biederman) in JAMA 2008 published their head-to-head study of SJW "Hypericum" (technical name) versus placebo for ADHD.

Now, keep in mind: this is a federally-funded study.

If Biederman's name is on the author list, you can pretty much guess the results.

SJW was not superior to placebo.

Frankly, I am not a believer in SJW myself personally. Maybe I need to look at this recent Germany evidence.

Nonetheless -

These authors actually TELL you how they ran the study, including TELLING you how they let the SJW spoil, IF you have your head screwed on right and think for yourself, and have common sense, and read the article beyond the headline and abstract all the way through to the discussion. Most of us stop at the headline. Some of us will persist up to the p value.

Here is a direct quote from their conclusion/discussion regarding the lack of a significant finding:

"The product used in this trial was tested for hypericin and hyperforin content [two suspected active ingredients of SJW] at the end of the trial and contained only 0.13% hypericin and 0.14% hyperforin. Hyperforin is a very unstable constituent that quickly oxidizes and then becomes inactive, which is likely what happened to the product used in this clinical trial."

In other words, they tested placebo against an inactive ingredient (the spoiled SJW), and found that neither was superior for ADHD symptoms. They know the SJW was spoiled because they tested it.

Now, when I was reading about SJW a couple years ago, some writers made a big deal about how it needs to be harvested, processed, etc. One view was that the active ingredients are in the correct part of the plant in a certain season. If you harvest SJW at other seasons, it is worthless. Kind of like trying to get maple syrup fron a maple tree in the wrong season. The sap is not rising, so you will get nothing.

This is an empirical question that can be answered with decent science. Like: test for seasonal variation of concentration of these 2 suspected active ingredients. Then, if they truly vary by season, test high-concentration and low-concentration for depression, ADHD, whatever.

Establish decent methods, doses, etc.

Answer these basic questions, then move on, scientifically. The NIH-funded study was a waste of taxpayer money, a waste of researcher time, and a waste of space in JAMA. It was a fundamentally flawed study from the beginning.

Unless the REAL aim was NOT truly to test SJW for ADHD.

Posted by: MedsVsTherapy at February 18, 2009 07:21 AM

I am even more leery of SJW than other antidepressants. The lack of regulation, as Melissa, mentioned is a big problem. I remember seeing an investigative news report where herbals were tested - the ingredients sometimes varied wildly between bottles (SJW was not one that they tested, however). If the person taking it is getting a different dose each time that could be quite dangerous.

Also, I have concerns about it being similar in action to a MAOI. Are the people taking it going to be aware of the need to be careful with foods containing tyramine? The med interactions? Just because it's natural doesn't mean it's safer.

Posted by: Lisa at February 18, 2009 01:00 PM

Hi Lisa

Actually, St. Johns Wort is considered to be a very weak MAOI inhibitor:

http://www.holistic-online.com/herbal-med/_Herbs/h20.htm

Personally, I took it for 3 years and never had to worry about interactions with foods like cheese and wine.

You are correct about the quality of the ingredients varying, particularly hypericin which also greatly varied in weight depending on the brand. After reading an LA Times article from 98 in 2001 about how the top brands varied, I chose a local grocery store SJW brand that was rated very highly. It worked well for quite a while and was one of the most effective ADs I was on. A therapist I was seeing at the time agreed.

While it certainly isn't side effect effect free, as long as you take a high quality brand, I would chose it over any AD in a heartbeat, I easily lost all the weight I had gained on the SSRIs I was previously on.

Posted by: AA at February 18, 2009 05:50 PM