Saturday 20 January 2018

Herbal antidepressant St John's Wort returns

Mental Health... mind and meaning

Research into St John's Wort has shown it to be effective in the condition that is referred to as 'major depression'
Research into St John's Wort has shown it to be effective in the condition that is referred to as 'major depression'

Patricia Casey

In 2000, there was a big fuss when St John's Wort, the popular herbal remedy for depression, was removed from over-the-counter sales in health-food shops. People asked, what is the problem with a natural remedy? Surely something so harmless, but so good, should continue to be available. It is widely assumed that naturally occurring remedies are entirely safe and free from any risks.

The reality is that every substance we imbibe - whether it be tea or digitalis (a naturally occurring substance from the lovely foxglove plant that grows along our hedgerows and used to treat heart disease) - act on various organs in the body.

St John's Wort (hypericum perforatum) has a significant action on the brain. It is no different from the synthetic antidepressants in this regard. It is a yellow flowering, perennial herb and its active ingredient, hypericum, is thought to work by preventing the uptake of the neurotransmitters noradrenaline, serotonin and dopamine, which are associated with depression, into the nerve endings.

Like all antidepressants, there is evidence that it could interact with other commonly used medications. The list is long but the possibility of an interaction with other antidepressants is real. In particular, there was concern that it might cause an excess of serotonin due to the simultaneous use of two treatments both affecting this neurochemical. Serotonin syndrome, as it is called, is potentially lethal.

St John's Wort also interacts with some antibiotics, antihypertensives, warfarin and the oral contraceptive pill to name just a few. These reservations require it to be medically supervised.

A further concern about its availability over the counter, was that depression is potentially a serious illness which can be life-threatening, and so, its treatment should be properly supervised. The danger of self-medicating might be to underestimate the gravity of the symptoms and to delay seeking medical attention.

Research into St John's Wort has shown it to be effective in the condition that is referred to as 'major depression'. A study, which combined the results of 29 trials involving almost 5,500 patients and published by the Cochrane Review Group in England, found that it was superior to placebo and as good as standard antidepressants, but better tolerated.

So if somebody thinks they have clinical depression, they should attend their GP. The problem is deciding when "depression" is an illness needing treatment, and/or when is it simply sadness. The definition of depressive illness in the major classifications of psychiatric disorders, published by the World Health Organization and the American Psychiatric Association, do not help very much as they are very broad and overlap with sadness and the emotions of everyday life.

Depressive illness is a pervasive and overwhelming sense of sadness, flatness and lack of pleasure or joy from normal activities. People will speak of not having feelings for their loved ones, of not being cheered even by good news and of feeling hopeless. Some are physically slowed up. Some describe a change in mood with the time of day, being worst in the morning and much better in the evening.

Sleep, appetite and concentration are affected, but these physical features may also occur in those who are simply experiencing distressing life events, such as losing a job or ending a relationship - these are referred to as stress reactions since they occur as a direct consequence of events. Thus, deciding what depressive illness (now called major depression) is, has generated much controversy within and outside the profession.

Distinguishing between depression as a stress reaction and depression as an illness is of more than theoretical interest since antidepressants are usually required for depressive illness, while they are not helpful in stress reactions.

Some talking therapies may be beneficial in conjunction with medication in depressive illness, although when an individual is so despondent that the act of getting up is a mountain to be climbed, engaging with the psychological treatments for the illness may be just too difficult and burdensome. Unlike depressive illness, stress reactions usually resolve spontaneously or with brief psychological support.

Among those who are correctly diagnosed with depressive illness and are likely to benefit from antidepressants, there is reluctance to take medication, citing fear of "dependence" or of stigmatisation. If after a period of "watchful waiting", or after a trial of an evidence-based talking treatment, the symptoms are still present, the availability of natural remedies such as St John's Wort on prescription now provides a non-stigmatising alternative to traditional antidepressants for this group.

Depressive illness is unpleasant and disabling. It does not resolve spontaneously, so discussing it with a GP is the first step towards healing.

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