It’s really annoying the way the pharmaceutical industry snookered US physicians over the herbal antidepressant St. John’s wort. If only the profession had been just a little skeptical of an article that appeared in the Journal of the American Medical Association (JAMA) a while back we might not be as up to our bellybuttons in antidepressants as we are now.
The JAMA piece was subsequently criticized by an article in the British Medical Journal (BMJ) for deliberately ignoring more than 100 previous studies showing SJW’s effectiveness and also challenging the project as tainted because researchers were on Pfizer’s payroll.
Here are the statistics that make the mess:
- 11% of Americans over 12 take one or more antidepressants every day. And more than half this group does so with no medical supervision (refills are automatic but visits with a mental health professional are not).
- Women take 2.5 times more antidepressants than men.
- Between ages 40 and 59, one woman in four (25%) takes an antidepressant.
- The warhorse antidepressants–Prozac, Paxil, Zoloft, Effexor, Celexa, Lexapro, Luvox, Wellbutrin, Cymbalta–are all generic and so inexpensive (Prozac costs about $30 a year) that primary care physicians with their ten-minute office visits have little incentive not to write an antidepressant prescription when a patient says, “I’m feeling sad these days.”
- And because these drugs are cheap and easily refillable, patients themselves have little incentive to get off them, except for the side effects. We’re awash in antidepressants (as is our drinking water, by the way).
Brain chemistry
All antidepressants, including SJW, work on brain chemistry by increasing the brain’s levels of feel-good serotonin, your factory-installed stress buffer. Your personal level of serotonin is genetically determined, although other factors including diet, sunlight exposure, and sex hormones also play a role in serotonin levels.
If you’re a woman, your serotonin level is significantly lower than that of most men you know. And since serotonin is linked to sex hormones, you may have noticed that you’re more vulnerable to stress just before your period, when estrogen plummets (as it does in menopause), or that you felt especially happy during pregnancy, when estrogen levels go through the roof.
When stress exceeds your serotonin buffer, you might feel depressed or anxious, start thinking obsessively, and/or experience a variety of physical symptoms like muscle aches or tiredness.
Virtually all antidepressants have side effects and, ironically, some of these (headache, depression, and fatigue) are quite similar to what they’re supposed to be treating. Other side effects are more subtle: weight gain, sexual dysfunction, jaw clenching, personality changes like feeling “numb.” Sadly, most prescribing doctors admit they don’t have the time to discuss side effects, and only a handful of patients or concerned family members actually bother to read the package inserts that come with the prescription.
Gentle St John’s wort unjustly maligned
Compared to big-gun antidepressants like Luvox or Effexor, SJW is very gentle. European physicians prescribe it to children.
When SJW first became available in the US, though, researchers on the payroll of Big Pharma classified it as an MAO inhibitor, a type of antidepressant rarely used because of its side effects and interactions with other drugs. In fact, because of this, physicians are extremely skittish about writing prescriptions for MAO inhibitors, and what better way to nip competition in the bud than by deliberately mis-classifying SJW.
When European researchers reported that SJW was in fact not an MAO-inhibitor, but simply a mild SSRI equivalent to a half-dose of Prozac or Zoloft, Big Pharma got worried about its revenues. The SSRIs were still under patent and extremely expensive, generic versions years in the future. They’d already seen how cholesterol-lowering red yeast rice had cut into statin sales and didn’t want that to happen again. Billions were at stake.
What mega-pharma Pfizer (maker of Zoloft) did was singularly devious. First, they purchased a small herbal company, one of whose products just happened to be SJW. Then, in the interest of “public safety” they funded a large study at several major medical centers, recruiting psychiatrists (an itchy-palmed specialty never averse to accepting pharmaceutical largesse) to recruit patients. The study would be double-blind and placebo-controlled, neither physician nor patient knowing if SJW or a dummy pill was being taken.
The only flaw (intentional or not) was a big one. The recruited patients all had serious major depression issues, exactly the sort of depression for which SJW is not effective. And, surprise, surprise, despite dozens of previous European studies showing effectiveness, this time SJW failed. No better than placebo, concluded the JAMA article, popular magazines echoing the refrain. And thus Big Pharma created a state of permanent disinformation among US physicians. As a result, you’re prescribed Zoloft and get a contemptuous snort or impatient look if you ask about SJW.
Two years and 40 pounds later, you wonder why no one told you about the weight issue.
A few months after the JAMA article, the BMJ, which had already published several articles recommending SJW, wrote an editorial commenting on the flaws in the JAMA study, urging physicians to continue recommending SJW to their patients for mild-to-moderate depression. Of course, very few American docs read the BMJ, so the misinformation stayed rooted in place.
Why is St. John’s wort my favorite herb?
Not only has it been proven effective for mild depression, but like all other SSRI antidepressants SJW will work its magic when a serotonin boost is called for. Doctors routinely prescribe SSRIs for such varied diagnoses as generalized anxiety disorder, panic attacks, obsessive thinking, compulsive behavior, various phobias, and for patients self-medicating emotional problems with alcohol or food. SSRIs are also part of the treatment for fibromyalgia, migraine headaches, seasonal affective disorder, premenstrual syndrome, postpartum depression, and even irritable bowel syndrome.
For any of these, there’s no harm in trying SJW first.
In my own practice, if a patient needs a dose increase on an SSRI she’s already taking, I’ll add SJW instead to avoid the side effects that might otherwise accompany the higher antidepressant dose. Do not, however, attempt this without physician guidance. Taking SJW and a prescription antidepressant, you could end up with too much serotonin in your brain. Let your doctor figure out the chemistry.
I also recommend SJW when a patient wants to discontinue her prescription antidepressant. Unlike prescription SSRIs, SJW is remarkable for its lack of side effects. No “numbing” of your personality, no weight gain, no sexual dysfunction, no heart arrhythmias.
Dosing St. John’s wort
- The minimum effective dose of SJW is 900 mg per day.
- Take 450 mg twice daily, with food.
- For patients with more severe symptoms, before resorting to a prescription antidepressant I’ll increase to 900 mg twice daily for a month.
- Like many herbs and prescription medications, drug interactions, although very rare, can occur with SJW. Check with your prescribing doctor or pharmacist if you have concerns about this
Just like all antidepressants, you need to be patient while you wait for SJW to work. The mood-enhancing effect won’t be felt for about three weeks, but then, to your pleasant surprise you’ll likely think “I’m feeling better.”
The SJW product I work with is HyperiMed by Integrative Therapeutics.
Be well,
David Edelberg, MD