Use and Misuse of St. John’s Wort
Use and Misuse of St. John’s Wort
ABSTRACT & COMMENTARY
Source: Beckman SE, et al. Consumer use of St. John’s wort: A survey on effectiveness, safety, and tolerability. Pharmacotherapy 2000;20:568-574.
While not classified as a drug, st. john’s wort (SJW) has gained popularity among consumers throughout the world as a treatment for depression. This is largely due to some reports of its efficacy, its reputation as being somewhat free of side effects, its relatively low cost, and the trend toward the use of alternative or herbal remedies. However, there are sparse data on the overall safety and efficacy of SJW in the treatment of depression. As such, there is uncertainty about whether consumers are adequately informed of the proper use of SJW.
In the current study, Beckman and associates investigated the factors related to consumer use of SJW. They conducted a telephone survey of 43 subjects who had taken SJW to assess demographics, psychiatric and medical conditions, dosage, duration of use, reason for use, side effects, concomitant drugs, professional consultation, effectiveness, relapse, and withdrawal effects. The subjects were recruited via local newspaper ads as well as flyers distributed to local area psychiatric treatment facilities. After eligibility was determined, subjects were interviewed via a one-time 15-minute, confidential survey designed to assess the following: demographics, SJW dosage, duration of use, reason for use, adverse effects, withdrawal effects during nonadherence, diet, overall efficacy, psychiatric and medical diagnoses, consultation with a health professional, consumer’s source of information, and recurrence of depressive symptoms after a switch to a prescription antidepressant. All questions were open ended with the exception of a series of yes/no questions designed to capture those side effects commonly reported in the literature such as photosensitivity or sunburn, gastrointestinal upset, allergic reactions, sleep difficulties, fatigue, and restlessness or nervousness. Additional open-ended questions on side effects were asked and listed separately.
The study discovered an alarming rate of inappropriate use of SJW among consumers. Regarding product knowledge, 67% of the consumers were unaware of SJW’s side effect profile while 88% were unconcerned about drug interactions. The majority of subjects (70%) reported taking SJW to alleviate depressive symptoms. Other reported reasons for use were insomnia, bipolar disease, memory impairment, mood swings, attention deficit disorder, immune system enhancement, anxiety, and stress. Roughly half of the sample reported at least one adverse effect while approximately 25% reported more than one adverse effect. The most commonly reported adverse event was sleep disturbance (insomnia or vivid dreams).
The reported efficacy was somewhat impressive, with 84% of the sample reporting minimal improvement or much improvement. Of the six subjects (14%) who reported no change, four were taking subtherapeutic doses (< 900 mg/d) of SJW. Withdrawal symptoms were reported in roughly half of the sample, consistent with many prescription antidepressants. Two of the five subjects who had taken SJW in combination with prescription antidepressants or other serotonergic agents experienced symptoms consistent with serotonin toxicity, including nausea, headache, increased anxiety, diaphoresis, nervousness, hyperactivity, weakness, muscle cramping, tachycardia, and increased blood pressure. One such patient sought emergency treatment for this toxicity. Two patients had reported beginning SJW at 300 mg/d after deciding to stop their prescription antidepressants due to adverse effects; both experienced a relapse of depression within two weeks.
Comment by Michael F. Barber, PharmD
As with many illnesses, there is an obvious risk assumed by patients who treat themselves with alternative therapies for depression. These risks include the lack of efficacy resulting in worsening of symptoms (potentially leading to increased risk of suicidal behavior), serious adverse effects of the alternative therapy caused directly or indirectly via drug interactions, and mismanagement due to the patient’s inability to diagnose and/or monitor their symptoms. While theoretical, the current study supports that a significant number of consumers engage in risky behaviors associated with the treatment of depression. Clearly, the subjects were not well informed of the appropriate use of SJW or the adverse effects of the drug that require monitoring. While it is clear that education of consumers is necessary, clinicians also must take some initiative by inquiring as to which of their patients are taking or considering taking SJW. Less than half of the current sample reported taking SJW to their doctor or pharmacist; this is consistent with other published surveys. While clinicians are becoming more aware of drug interactions involving SJW and such drugs as protease inhibitors and digoxin, there is also concern that patients who are prescribed antidepressants for depression may decide to add or switch to SJW. Thus, it would be prudent to inform all depressed patients of SJW’s risks—even those who are prescribed antidepressants.
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