What Is It?
St. John’s wort (Hypericum perforatum), a common shrub-like perennial, bears bright yellow flowers that contain numerous therapeutic substances when dried. Europeans have used the herb for centuries to calm jangled nerves and heal wounds, among other ills. And so it’s not surprising that North Americans have recently embraced its use as a treatment for depression and conditions associated with it.
Not only is St. John’s wort effective and relatively free of side effects, it also costs under $20 for a month’s supply, about 75% less than the most popular antidepressant drugs. And because it doesn’t appear to interact with most conventional drugs (except for antidepressants), many older people on complex medication regimens may be able to benefit from it. In Germany, where doctors routinely prescribe herbal remedies, St. John’s wort is the most common form of antidepressant–more widely used than the drugs Prozac or Zoloft because it has far fewer side effects.
Although St. John’s wort has been the focus of a number of well-regarded studies, researchers still don’t know exactly how the herb works. A pigment called hypericin has long been identified as a key medicinal ingredient, although other compounds are now similarly believed to contribute to the herb’s therapeutic effects. In general, St. John’s wort appears to boost levels of the brain chemical serotonin, which affects the emotions. The herb seems so promising as a natural antidepressant that the National Institutes of Health (NIH) in Washington, D.C., began a major study in 1997 to investigate its effectiveness in this regard. Results are being eagerly awaited because the three-year study will track the herb over a much longer time than most trials have done so far.
A number of other uses for St. John’s wort have been proposed as well, many of them related to the herb’s antidepressive actions. The herb is even being investigated as a treatment for alcoholism, panic attacks, and general anxiety. Enthusiastic claims that it can promote weight loss when combined with the herb ephedra remain to be confirmed.
Specifically, St. John’s wort may help to:
Relieve mild to moderate depression. Careful analysis of 23 different studies of St. John’s wort concluded that the herb works as well as antidepressant drugs–and better than a placebo–in the treatment of mild to moderate depression. And because it helps promote sound sleep, St. John’s wort is particularly beneficial for those who suffer fatigue, low energy, or insomnia as a result of depression. Also under examination is the herb’s power to remedy more serious forms of depression. One study found St. John’s wort as effective as conventional antidepressants in relieving severe depression in 209 adults. Overall, however, there have been relatively few studies examining its usefulness for severe depression. The herb may also aid in treating depressive elements of chronic fatigue syndrome and seasonal affective disorder (also known as SAD or “wintertime blues”), a type of depression linked to the shortage of daylight in the fall and winter.
Control certain PMS and fibromylagia symptoms. Many women experience depression as their primary symptom of PMS (premenstrual syndrome). In such cases, St. John’s wort may be worth a try. Take the herb regularly for this purpose, but be patient; it may take one or two menstrual cycles for the active ingredients to reach therapeutic levels in your system and lessen emotional upset. European women have been turning to this herbal PMS cure for years. In the case of fibromylagia, St. John’s wort may not only ease depression but also improve tolerance to the widespread muscle pain associated with this chronic condition. In fact it’s used in much the same way that conventional antidepressants are prescribed for fibromyalgia.
Ease anxiety, stress, and chronic pain. The depression and tension often associated with these conditions may lessen with St. John’s wort.
Ward off infections. St. John’s wort has been shown to have antibacterial and antiviral properties. It’s particularly effective when applied topically (in the form of an ointment) for the treatment of burns, cuts, and scrapes. Some preliminary laboratory studies indicate that St. John’s wort might also be useful against herpes simplex, influenza, and the Epstein-Barr virus (the cause of mononucleosis). Clinical trials are still needed to confirm these findings, however.
Relieve hemorrhoids. St. John’s wort cream or ointment can soothe the pain of hemorrhoids. Burning and itching may lessen as well. The ointment may even help to shrink the inflamed and swollen tissue.
Note: St. John’s wort has also been found to be useful for a number of other disorders. For information on these additional ailments, see our Dosage Recommendations Chart for St. John’s wort.
Although most clinical studies have been done using an extract standardized for hypericin, there seems to be some doubt as to what aspect of the herb is truly responsible for its clinical efficacy. Recent findings indicate that a substance called hyperforin may even have more potent mood-enhancing properties than hypericin. For this reason, when treating depression, look for an extract standardized to contain 0.3% hypericin and hyperforin (3.0%).
For depression, PMS, and the majority of other ailments mentioned: Take 900 mg a day–either a 300 mg pill three times a day or a 450 mg pill twice a day. To avoid missing doses, you can also simplify the regimen by taking two 300 mg capsules in the morning and one in the evening (or vice versa). If using a tincture, follow the instructions on the bottle for dosage equivalence.
For fibromyalgia: Take 450 mg twice a day.
For skin infections and hemorrhoids: Apply St. John’s wort ointment three or four times a day. Use an ointment when treating hemorrhoids, applying it several times a day and, when possible, directly after bowel movements.
Be sure to check out our Dosage Recommendations Chart for St. John’s Wort, which lists therapeutic dosages for specific ailments at a glance.
Guidelines for Use
St. John’s wort takes some time to build up in the blood, so allow at least four weeks to see if it works for you. It can be used long term as needed.
Take St. John’s wort with meals to reduce the risk of stomach irritation.
No foods are off limits for those taking St. John’s wort, not even aged cheese and red wine, which are not recommended for those on MAO inhibitors.
To prevent the risk of adverse reactions to the herb, avoid making your own preparations of the plant. Stick to standardized supplements you can buy over the counter.
Although rare, serious adverse reactions have been reported from the combination of a conventional antidepressant, such as Prozac and Zoloft, with St. John’s wort. Don’t start taking St. John’s wort without consulting your doctor.
Certain medications, such as tetracycline and fluoroquinolone antibiotics, can increase the skin’s sensitivity to the sun, so avoid taking St. John’s wort, which can also have this effect, at the same time. Consult your doctor for more information.
Because St. John’s wort and oral contraceptives are broken down and used by the body in the same way, the effectiveness of the oral contraceptives may be compromised. Consult your doctor.
A study conducted by The National Institutes of Health (NIH) showed a significant interaction between St. John’s wort and indinavir, a protease inhibitor drug used to treat HIV infection. It showed that taking St. John’s wort at the same time as indinavir greatly reduced the effectiveness of indinavir. St. John’s wort may also affect other protease inhibitors in a similar manner. Caution is advised.
Because the herb’s exact mechanism of action is still unclear, it’s probably not wise to combine it with MAO inhibitors, medications prescribed for depression and Parkinson’s disease.
Note: For information on interactions with specific generic drugs, see our WholeHealth Chicago Drug/Nutrient Interactions Chart.
Possible Side Effects
Side effects are uncommon but can include fatigue, dry mouth, dizziness, constipation, and upset stomach.
Some people experience increased sun sensitivity when taking St. John’s wort, especially if they are exposed to the sun for long periods of time. Skin reactions in AIDS patients taking high doses of St. John’s wort were so severe in one trial that many stopped participating. So while sun sensitivity is not a problem for most people at commonly recommended doses, be sure to contact your doctor if you develop an unexpected sunburn or rash after being in the sun.
Never stop taking prescription antidepressants (or even lower the dosage) without checking with your doctor first.
Serious allergic reactions to any food, herb or medication are always possible. Fortunately, such allergies to St. John’s wort are extremely rare. However, if you do develop hives or wheezing after taking the herb, get immediate medical help.
Though no adverse effects have been reported in pregnant or lactating women using the herb, there have been few studies on this group, so caution is advised.
Anxiety and Panic 300 mg 3 times a day or 450 mg twice a day
Chronic Fatigue Syndrome 450 mg twice a day or 300 mg 3 times a day
Chronic Pain 300 mg 3 times a day or 450 mg twice a day
Depression 300 mg 3 times a day (or 450 mg twice a day or 600 mg in the morning and 300 mg in the evening)
Fibromyalgia 450 mg twice a day or 300 mg 3 times a day
Hemorrhoids Apply oil or ointment 2 or 3 times a day, as needed.
High Cholesterol 450 mg twice a day for anxiety
Insomnia 450 mg twice a day for depression (or 300 mg 3 times a day)
Irritable Bowel Syndrome 450 mg twice a day or 300 mg 3 times a day
Memory Loss/Impairment 300 mg 3 times a day or 450 mg twice a day
Menopause 450 mg twice a day or 300 mg 3 times a day
Migraine 300 mg 3 times a day (or 450 mg twice a day or 600 mg in the morning and 300 mg in the evening)
Perimenopause 450 mg twice a day or 300 mg 3 times a day
PMS 300 mg 3 times a day (or 450 mg twice a day)
Stress 300 mg 3 times a day or 450 mg twice a day
Weight Loss 450 mg twice a day
David Edelberg, M.D.
Numerous studies have shown the benefits of St. John’s wort for mild to moderate depression. It’s still a bit of a mystery, however, exactly how this herb works. Originally, St. John’s wort was grouped with the MAO (monoamine oxidase) inhibitors, a class of antidepressant medications that have a number of irritating side effects, and many doctors actively discouraged their patients from trying it.
HOW IT HELPS DEPRESSION
In fact, St. John’s wort seems to combine a number of therapeutic properties. It does work like an MAO inhibitor, raising levels of the adrenal hormone norepinephrine. However, it has neither the MAO inhibitor side effects nor the stringent dietary restrictions necessary for users of this class of drug. But it also appears to increase levels of the neurochemical serotonin, making it more like the popular SSRI (selective serotonin reuptake inhibitors) antidepressants, including Prozac, Zoloft, and others. But again, without the usual side effects of excessive mental excitability, insomnia, or sexual dysfunction. Initially, these effects were thought to be due to the herb’s key ingredient, hypericin, but now studies have shown that other substances in the herb, particularly a compound called hyperforin, might be involved as well.
WHAT TO LOOK FOR
Herbalists will tell you to go for the freeze-dried form or the liquid extract, which capture all the chemical properties of the whole herb just as it’s harvested. They believe the herb has a number of active ingredients (some perhaps still unidentified) that work together to relieve depression. Scientists disagree, and will tell you to stick with the standardized extract, which conforms to formulations used in their research studies. This contains a reliable, specified amount (0.3%) of hypericin, which they believe is the substance completely responsible for mood effects. From my own clinical perspective, all these–the freeze-dried whole herb and the liquid extract, as well as the standardized extract–seem to work equally well. If you feel more attuned to St. John’s wort as it’s found in its natural state, get the freeze-dried or the liquid extract. On the other hand, if you want the same product used in the research studies, get a standardized extract.
On the other hand, I see a lot of cheap brands of St. John’s wort and wonder what’s really inside the capsule. Certainly, studies on various brands show that some are better than others. My advice is to stick with a reputable manufacturer–and remember that any St. John’s wort (even the most expensive) will be more reasonably priced than a similar amount of prescription antidepressants. If you’re on conventional antidepressants and want to try St. John’s wort instead, you must work with your physician. For some people with mild depression and on a low-maintenance antidepressant dose, the transition is fairly simple. On the other hand, St. John’s wort is not strong enough to make a suitable replacement for someone who really needs a conventional antidepressant, especially in the higher range.
Never make any changes in your antidepressant medications by yourself. Period.
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David Edelberg, MD