The only studies of efficacy of St John’s Wort conducted to date have been done in Europe. These studies came to the attention of the US medical community initially when an issue of the Journal of Geriatric Psychiatry and Neurology was devoted to Hypericum in 1994 and later, when the highly regarded British Medical Journal published a meta-analysis of randomized clinical trials of the herbal remedy. In a meta-analysis, several small studies are combined together in order to determine whether certain general conclusions can be derived from the data obtained from them.
In their meta-analysis, Linde and colleagues addressed three simple questions: Is Hypericum more effective than placebo? Is it as effective as standard anti-depressant treatments? And does it have fewer side-effects than standard anti-depressant treatments ? In order to increase their chances of reaching valid conclusions, these researchers included in their meta-analysis only those studies that randomly assigned patients to different treatment conditions, which is generally regarded as a prerequisite for a valid clinical trial. It would not be valid, for example, to assign severely depressed patients one type of treatment and mildly depressed patients another. These researchers also used state-of-the art statistical methods to compare the treatment interventions.
Interestingly, when Linde and colleagues used only conventional computerized searches of the medical literature, they located fewer than a third of those clinical trials that they ultimately chose to include. This reflects the division separating herbal and conventional medicine which has been so prominent until recently and which persists to some extent even at the present time. Almost all studies were published in languages other than English, reflecting the fact that the recent development of herbal medicine has come predominantly from the German-speaking world. Finally, the authors had to go through many revisions before the prestigious mainstream British Medical Journal was willing to publish the review.
Altogether the authors analysed 23 randomized trials involving 1,757 patients suffering from mild to moderate depressions. In 13 trials of Hypericum versus placebo, Linde and colleagues found Hypericum to be clearly superior to placebo, yielding a response rate of 55 per cent as compared with 22 per cent for the control placebo treatment. In three trials of Hypericum versus standard anti-depressants, the two treatments were very similar, possibly favouring Hypericum. But when side-effects were compared, Hypericum emerged as the clear winner, with approximately 20 per cent of the Hypericum group reporting side-effects, as compared with about 53 per cent of those taking standard anti-depressants. Several studies reviewed by the researchers used combinations of St John’s Wort and valerian, an herbal sedative. I have excluded those studies from the present discussion, though their results were consistent with those which used St John’s Wort alone.
Linde and colleagues concluded rather persuasively that Hypericum is superior to placebo in the treatment of mild to moderate depression and that it has a very benign side-effect profile. Evidence is less persuasive when it comes to comparing the relative efficacy of St John’s Wort with other anti-depressants, mostly because adequate studies have not been performed. Studies comparing herbal and synthetic anti-depressants used dosages of the synthetic compounds that were lower than those often used in clinical practice.
Clearly there is room for more research on the efficacy of St John’s Wort, especially into questions of who would best benefit from Hypericum versus conventional anti-depressants, how best to regulate dosage and how to blend Hypericum with conventional anti-depressants. To date, there have been no head-to-head comparisons between St John’s Wort and the SSRIs. Such a comparison is part of the design of the multi-centre US study currently being planned under the aegis of the US National Institute of Mental Health. It is important to compare these two types of anti-depressant, since the SSRIs are the most commonly used anti-depressants at present and, in practice, both doctor and patient may often wish to choose between these and St John’s Wort in deciding how to initiate the treatment of a depression. There have also been no long-term studies of the anti-depressant effects of St John’s Wort but, in this regard, the herbal antidepressant is no different from many of the conventional anti-depressants for which long-term studies are lacking. While these questions have yet to be resolved to the satisfaction of scientists, for the person seeking relief from the painful symptoms of depression they are of much less importance than the fundamental question, ‘Does the herbal anti-depressant work?’ In my view this question has already been answered with a resounding ‘Yes.’
To date there has been only one study that has addressed the question of whether St John’s Wort works for more serious depression. The work of Daniel in the 1930s, mentioned in Chapter
6, suggests that the herbal remedy might be helpful in severe as well as in milder cases. In recent times, Vorbach and colleagues in Germany conducted a multi-centre study of 209 severely depressed patients, of whom 38 were hospitalized at the time of the study. They used a higher dosage of Hypericum than has been used in the studies of mild to moderate depressions (1,800 mg as opposed to 900 mg) and compared this with imipramine, an old standard anti-depressant. While the anti-depressant effects of these two treatments were very similar, far fewer side-effects were reported by those receiving Hypericum than by those receiving imipramine (23 per cent versus 41 per cent). This study suggests that there may indeed be a role for Hypericum in the treatment of severe depression, though more studies in such patients are clearly needed before St John’s Wort can be used with any confidence as a first-line treatment in those suffering from profound depressions.
As I have noted elsewhere, there is one study that suggests that Hypericum may be of value in seasonal affective disorder (SAD), though no one has properly researched how best to combine the herbal remedy with light therapy.
I should mention that most of the research on the St John’s Wort and depression has been conducted with the Kira™ brand of the herb. This preparation is extracted from the leaves and flowers of the plant by a special method and it is unclear whether the research findings with this type of extract can be generalized to other preparations.
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Ann is twenty-seven years old and was prescribed Ativan (3 mg) when she was told her baby was mentally handicapped. She coped well, but felt very down. After about four months, she felt increasingly anxious. Her doctor suggested she doubled the dose of Ativan. The anxiety lessened, but she had frequent headaches and lost her balance very easily. She thought she was run down due to increasingly heavy periods. Her husband complained that she was not the same person, and suggested a holiday.
Ann thought she might have more energy if she reduced her pills to half the dose. Two days later she felt very ill. She had diarrhoea, vomiting, nasal congestion, and a sore throat. The doctor diagnosed a virus. Ann had not slept so she resumed her full dose of Ativan. The symptoms dramatically disappeared. She recognized the same symptoms nine months later when she forgot to pack her pills when she stayed with an aunt. She thought it could have something to do with the pills, but her doctor assured her they were safe and non-addictive.
The heavy bleeding persisted and she was admitted to hospital for investigations. The ward sister kept the pills. Her skin burned, she felt sick, and the world looked strange again. She was sure it was the pills this time. Her doctor was kind, but said that this was unlikely.
A phone call to a friend, a Community Psychiatric Nurse, gave her some hope. He advised her to cut down slowly. Three months through withdrawal she noticed her periods were not so heavy and the sinus pains that had plagued her for the two years on Ativan had gone. There were times during withdrawal when she felt unwell, but she felt her old self returning. Her husband remarked how different she looked. It is now nine months since she completed withdrawal. Getting off to sleep, and palpitations, are still a problem, but apart from these, she feels well and is delighted to be drug-free. She is also delighted that the hair she lost during withdrawal has grown in again.
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Changes in Body Temperature
Some people complain they are ‘on fire’. Others say they feel icy cold, or cold one minute and hot the next. Feeling hot, with or without profuse sweating is often a feature of drug withdrawal. If you are very cold perhaps moving more or massaging the affected parts would improve circulation.
Sore Mouth
There are frequent reports of painful/cracked/glossy/ swollen tongues; mouth ulcers; gum boils; cracks at the corners of the mouth and sore lips. These symptoms may be a reflection of the nutritional state of the body, particularly in the long-term user. Even if the diet seems adequate there is often so much disturbance in the digestive system that absorption of essential minerals and vitamins could be impaired.
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Depression Following Tension
How often have you heard people say that they were depressed when the examination finished, or after an unwelcome visitor had left. The depression does not arrive whilst the strain is still there, but comes when you have a chance to relax. Perhaps this is nature’s way of forcing you to slow down. Physical exercise and a conscious effort to relax during stress could prevent this type of depression.
How Does A Depressed Person Look?
If he is very depressed, he could look round-shouldered, head bowed, slow moving with a shuffling walk, and mask-like expression, or he could be the joke-a-minute person who tries hard to cover up his inner misery by being the life and soul of the party.
What do Depressed People Say?
‘My body is so heavy; life, relationships, work, have no meaning; I feel far away and isolated, even in a room full of people; I know I love my family but I cannot feel it; I have no interest in anything; I won’t read the papers or watch the news in case there is anything that makes me sadder; the smallest physical task seems beyond me; washing and dressing is such an effort; everyone else looks so normal; I dread a visitor in case they can see how abnormal I feel; my relatives would be better off without me; I see everything through a grey mist’.
How Can I Heal Myself?
If your doctor has ruled out physical illness, he may want you to have a course of anti-depressant drugs. These help some people dramatically, but cannot erase bad memories, or the way you feel about yourself. Acknowledge that by positive thinking, you can stop the past, or the present, circumstances hurting you.
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Repetitive thoughts form an important part of an anxiety neurosis. These are often provoked by awareness of autonomic over-activity; e.g. a patient who feels his heart beating fast may worry about having a heart attack. Thoughts of this kind probably prolong the condition.
The appearance of a person with an anxiety neurosis is characteristic. His or her face looks strained, with a furrowed brow; the posture is tense; he or she is restless and often tremulous. The skin looks pale, and sweating is common especially from the hands, feet and axillae (armpits).
Readiness to tears, which may at first suggest depression, reflects a generally apprehensive state.
The physical symptoms and signs of an anxiety neurosis result from either over-activity in the sympathetic nervous system or increased tension in skeletal muscles.
The list of symptoms is long, and is conveniently grouped by systems of the body. Symptoms related to the gastrointestinal tract include dry mouth, difficulty in swallowing, epigastric discomfort (under breastbone), excessive wind caused by aerophagy (air swallowing), borborygmi (rumbling of intestinal gases), and frequent or loose motions.
Common respiratory symptoms, include a feeling of constriction in the chest, difficulty in inhaling (which contrasts with the expiratory difficulty in asthma), and over-breathing and its consequences (which are described later).
Cardiovascular symptoms include palpitations, a feeling of discomfort or pain over the heart, awareness of missed beats, and throbbing in the neck.
Common genito-urinary symptoms are increased frequency and urgency of micturition (act of passing urine), failure of erection, and lack of libido.
Women may complain of increased menstrual discomfort and sometimes amenorrhoea (absence of menstruation).
Complaints related to the functions of the central nervous system include tinnitus, blurring of vision, prickling sensations, and dizziness (which is not rotational).
Other symptoms may be related to muscular tension. In the scalp this may be experienced as aching or stiffness, especially in the back and shoulders. The hands may tremble so that delicate movements are impaired.
In anxiety neuroses sleep is disturbed in a characteristic way. On going to bed, the patient lies awake worrying; when at last he falls asleep, he wakes intermittently. He often reports unpleasant dreams.
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