Controversial study on St. John's wort

[Daniel E.]

Below is a report on the study by the BBC:

Herb 'as good as depression drug'
11 February, 2005
Source: BBC News

A German study has added weight to the argument that a herbal remedy is an effective treatment for depression.

Researchers compared the effectiveness of St John's wort to anti-depressant drug paroxetine in treating moderate and severe depression.

The team found half of those with the condition improved when given the herb, compared with a third using the drug, the British Medical Journal reported.

UK experts said the study of 244 people should be treated with caution.

The study also found patients on paroxetine - also known as Seroxat - suffered more side effects.

We would not advise anyone to use St John's wort without consulting their GP

Depression Alliance spokeswoman
In both cases the most common side effect was stomach upsets, the study by Karlsruhe-based Dr Willmar Schwabe Pharmaceuticals and the Institute for Medical Research Management and Biometrics in Nurnberg found.

Report co-author Dr Meinhard Kieser said: "Our results support the use of St John's wort as an alternative to standard anti-depressants in moderate to severe depression, especially as it is well tolerated."

The herb is not recommended for use by the UK's National Institute for Clinical Excellence (Nice) because of uncertainty about what constitutes an appropriate dose, and its potential side effects when mixed with other drugs.

However its guidelines do acknowledge there is some evidence to suggest St John's wort could benefit people with mild or moderate depression.

Folk medicine
Previous studies have produced mixed results about whether it is effective in treating more serious forms of depression.

The herb, which is extracted from bright yellow star-shaped flowers, has been used for centuries as a folk medicine for anxiety and stress.

In the UK it is often found on sale in health food shops, and people with depression are known to use it.

But Professor Philip Cowen, a member of the British Association of Psychopharmacology, said the German study should not alter professional thinking in the UK.

"I would not expect this to alter what doctors do in the UK - the problems highlighted in the Nice guidance still stand."

The problem with the herb was that it was difficult to get a standardised dose, he said. Until that was achieved he could not see it being accepted as a treatment for depression.

A spokeswoman for the Depression Alliance said: "There is evidence it can be used to treat mild to moderate depression but the problem with St John's wort is that it is not regulated. You just don't know what you are getting.

"We would not advise anyone to use St John's wort without consulting their GP."

But she added: "I think it would be good if Nice and the regulatory body had a look at this report."

 

[Daniel E.]

I have major doubts about this study, but it is interesting and controversial. For example, this study did not include a placebo control group, only a comparison to Paxil.

The full text of the study is online in the British Medical Journal. Most interesting are the letters to the editor that follow the article.

It seems the St. John's Wort extract used in the study may be most similar to a brand of St. John's wort called Perika. Perika is referred to as "WS 5572" by its German producer William Schwabe Pharmaceuticals, and the extract used in the study was called "WS 5570." (William Schwabe Pharmaceuticals funded the study.)

For some perspective, below are some of Dr. Baxter's comments from earlier this year on St. John's wort:

There's more information on this under "Alternative Medications".

Honestly, there were reports from European studies that it was effective for mild depression. However, I have never seen it do anything beneficial whatsoever. A more recent large-scale study in the US by NIMH found little or no benefits.

If ANY "natural" medication works, it's because it alters neurochemistry. But in most cases, it doesn't do so very efficiently (i.e., at best you're getting a weak effect). If you think you need this sort of medication, why not take the real deal? Why mess with something that may be largely a placebo? "Natural" does NOT mean safe, or free of side-effects, or effective.

At least with prescrioption medications, you can be confident about quality control...

http://www.psychlinks.ca/phpbb/viewtopic.php?t=1612

Also:

Clinical trials in the U.S. and Europe have shown St. John's wort to be as effective as Prozac, Tofranil and other antidepressants in treating mild and moderate depression. In recent years, a couple of American studies have suggested that St. John's wort is not effective in treating patients with major depression. But earlier this month, a well-designed German study published in the British Medical Journal showed that St. John's wort was as effective as Paxil — with less frequent side effects — in treating patients with moderate to severe depression. The researchers are now looking at how good the herb is at treating depression over the long term.

Evidence supports St. John's wort - LA Times (March 7, 2005)

From the NIH fact sheet on St. John's wort:

- St. John's wort is an herb that has been used for centuries for medicinal purposes, including to treat depression.

- The composition of St. John's wort and how it might work are not well understood.

- There is some scientific evidence that St. John's wort is useful for treating mild to moderate depression. However, recent studies suggest that St. John's wort is of no benefit in treating major depression of moderate severity. More research is required to help us know whether St. John's wort has value in treating other forms of depression.

- St. John's wort interacts with certain drugs, and these interactions can be dangerous.

- It is important to inform all of your health care providers about any therapy that you are currently using or considering, including any dietary supplements. This is to help ensure a safe and coordinated course of care.

St. John’s Wort

 

[David Baxter PhD]

I have doubts about it too, Daniel. For one thing, as you note in the quoted comment from me earlier, I have NEVER seen any client who took St. John's Wort and showed any improvement whatsoever. That's not a controlled study, either, of course. But it does mean it will take some pretty good evidence to counter those observations.

One of the concerns I have about research on St. John's Wort is that the studies claiming it works are from people who have a vested (read: financial) interest in having people believe it works. That's one of the reasons (but certainly not the only one) why I'm more impressed by the NIMH negative result.

Another major concern is the number of medications that produce adverse interactions when taken in combination with St. John's Wort, including birth control pills.

So from where I sit I see a "natural" drug of dubious benefits and well-documented risks. It just doesn't sound like a good bet to me.

 

[Daniel E.]

More reasons to have doubts:

The extract used in the German trial is marketed in European countries under the brand name Neuroplant VO, said Dr. Jochen Muehlhoff, marketing information manager for the company. It is sold in the United States as a dietary supplement by Nature's Way products under the brand name Perika, "for promoting a positive mood, rather than a drug for the treatment of depression," he said.

...

Dr. Carol Kleinman, a spokeswoman for the American Psychiatric Association, said the brevity of the German study was a matter of concern.

"I noticed that it was only for six weeks," she said. "Paroxetine [the generic name for Paxil] usually is not completely effective in that period. If the study went out in time a little further, the effects of the treatments might distinguish themselves. Paroxetine needs eight weeks to be fully effective."

Nevertheless, Kleinman said, "I think I would be comfortable in prescribing St. John's wort for mild depression, if it was for someone I could follow closely. Some people prefer what they call natural substances. But for moderate to severe depression, it does not work as well."

Kleinman said she is not currently prescribing St. John's wort for any of her patients.

However, Dr. Uriel Halbreich, a professor of psychiatry at the State University of New York at Buffalo, who took part in an earlier U.S. trial of St. John's wort, said he "definitely would not prescribe St. John's wort."

While he called the results of the German trial "quite impressive," Halbreich said there are practical difficulties in the use of St. John's wort, particularly for persons who take an extract on their own.

"If you go to a drug store or vitamin or supplement store, you find a lot of brands, and they are different from each other," he said. "Even with a very reputable German manufacturer, there are differences in activity."

Another problem is the potential for adverse reactions with other medications, Halbreich said. "I would not recommend it to a patient because of the inability to control for drug-drug interactions. Many people who would get the medication without a prescription are taking many other medications. I would advise any patient to be careful of what they take."

excerpted from:
Herbal Treatment Outdoes Paxil, HealthDay News (2/11/05)

 

[David Baxter PhD]

"I noticed that it was only for six weeks," she said. "Paroxetine [the generic name for Paxil] usually is not completely effective in that period. If the study went out in time a little further, the effects of the treatments might distinguish themselves. Paroxetine needs eight weeks to be fully effective."

Sheesh. It amazes me that this study is getting so much publicity -- this is just an incredibly biased and flawed study. Unfortunately, it's also not atypical for studies of "natural remedies", one among several reasons for my skepticism. If the makers of Paxil had tried to publish this study, the outcry would have been loud and long.

It's not just that it takes 4-6 weeks to see sizeable benefits from SSRIs but (1) during that time the dose is usually started at a subtherapeutic dose and increased every 2 weeks or so, and (2) even after that time frame, the benefits usually continue to accumulate for several months. Thos two points alone mean that over the longer term one would expect the SSRI to vastly outperform St. John's Wort.

 

[free]

i used to take st. johns (to wean off anti-depressants). just as good as paxil, prozac, zoloft, klonopin, etc.