St John's Wort is also known as Hypericum perforatum.
St John's wort is a perennial plant which has bright yellow flowers that begin to bloom every year around 20 June. This date is the date of the feast of St John and hence the name of the plant. Wort means plant.
Hypericum was known to be an effective treatment for anxiety by Hippocrates. This ancient Greek physician used Hypericum as a treatment for "nervous unrest". Hypericum has been used for over 2400 years as a treatment for anxiety, worry and sleep disturbances.
Modern medical research has shown very clearly that Hypericum is as effective as prescription antidepressants such as fluoxetine for treating mild to moderate depression. However, unlike antidepressants prescribed by doctors, the side-effects from Hypericum are few and mild. In addition Hypericum is available without a prescription, making it a widely available and accessible herbal medicine.
In Germany Hypericum is now the most frequent antidepressant, synthetic or natural, prescribed by German doctors to treat depression. It is estimated by some that in Germany, Hypericum accounts for about 50% of the antidepressant market while fluoxetine (Prozac) only accounts for 2% of the antidepressant market. The German Commission E has not only approved Hypericum as a treatment for depression, but it has also approved Hypericum to treat anxiety and to treat sleep disturbances.
It is important to note that Hypericum cannot be taken as a tranquilliser to quickly relieve acute anxiety. This is because it's ability to treat anxiety relies on its antidepressant effect which like selective serotonin reuptake inhibitors (SSRI's) can take a few weeks to develop.
In clinical studies, Hypericum has demonstrated anti-anxiety effects which are similar to those of diazepam (Valium). But when Hypericum is used to treat anxiety it is not addictive and it does not impair cognitive functions.
How does Hypericum work to treat anxiety and depression?
It is known that Hypericum extract contains a number of active chemicals that together have antidepressant and anti-anxiety effects. Hypericum has been shown to enhance three important neurotransmitters: serotonin, norepinephrine (noradrenaline) and dopamine. Preliminary medical research also suggests that this remarkable herb also lowers levels of the stress hormone cortisol and in addition enhances the activity of gamma-aminobutyric acid (GABA). Hypericum is also a very mild and clinically insignificant monoamine oxidise inhibitor (MAOI).
Specialists in herbal medicine currently state that, contrary to the warnings in some outdated reports, it is no longer necessary when taking Hypericum to stick to the restrictive dietary guidelines that are necessary when taking monoamine oxidise inhibitor antidepressants. It is important to note that monoamine oxidise inhibitor (MAOI) antidepressants should not be combined with selective serotonin reuptake inhibitor (SSRI) antidepressants and should not be combined with Hypericum.
Examples of monoamine oxidise inhibitor antidepressants include phenelzine (Nardil) and tranylcypromine ( Parnate).
Combining MAOI antidepressants and Hypericum or SSRI antidepressants can result in a dangerous rise in blood pressure, along with severe anxiety, muscle tension, fever and confusion. After stopping a MAOI antidepressant it is very important to wait at least four weeks before taking any other antidepressants, including Hypericum.
If you are currently being treated for depression successfully with prescription antidepressants for anxiety or depression with few side effects, then there may be no need to switch to Hypericum. At present clinical research on switching from prescription antidepressants to Hypericum is limited. If you are taking prescription antidepressants and you wish to switch to Hypericum then it is very important that you discuss this with your doctor or psychiatrist.
Doctors and psychiatrists have experience of switching patients from a synthetic SSRI antidepressants to Hypericum, as this transition has been made frequently. This transition should always be made with your doctors advice. Generally it is best to gradually reduce the dosage of the prescription antidepressant, while slowly over 2 to 4 weeks increasing the dose of Hypericum extract up to 300 mg three times daily.
Your doctor will be aware of the medical condition known as the serotonin syndrome which is the result of having an excess of the serotonin neurotransmitter. The symptoms of the serotonin syndrome include sweating, anxiety, agitation, confusion, tremor, muscle spasms, lethargy and tiredness. Your doctor will need to monitor you for this syndrome. If you develop such symptoms then contact your doctor immediately. If the serotonin syndrome develops then either the dose of this synthetic SSRI or the Hypericum needs to be reduced until the symptoms resolve.
If after starting Hypericum and waiting a few weeks for the herb to have its antidepressant effect then you need to wait a few more weeks before gradually discontinuing the SSRI, again under careful medical supervision. It is important not to stop prescription antidepressants too quickly. After you have made the transition from synthetic antidepressant to Hypericum you should stay in close contact with your doctor. This is because the response to Hypericum varies and occasionally Hypericum does not work as well as a prescription antidepressant.
At present Hypericum should only be used to treat anxiety or depression that is mild-to-moderate. Hypericum should not be used to treat severe depression or an anxiety disorder. Also remember that other forms of treatment for anxiety and depression, such as cognitive behavioural therapy, deep muscular relaxation, meditation and mindfulness also have important role in the treatment of anxiety and depression.
Hypericum has an exceptional safety record over many hundreds of years. There have been no reports of Hypericum related deaths, in contrast to numerous deaths due to overdose of synthetic prescription antidepressants. Twenty seven double-blind research studies and drug monitoring studies on more than 7000 patients confirm the safety of Hypericum. The widespread use of Hypericum by millions of people has not resulted in reports of serious side-effects even when Hypericum has been taken in overdose.
There is one important side-effect to mention and that is photo-toxicity. Photo toxicity is hypersensitivity to sunlight. This is a potential side-effect with Hypericum and it is particularly important to take note of this potential side-effect if you have fair skin. Generally it is recommended that people with fair skin should use added sun protection whilst they are taking Hypericum. Severe sun hypersensitivity reactions have not been well documented in humans. There have, however been reports of sun hypersensitivity reactions in sheep that have been eating very large amounts of St. John's wort and also been exposed to the sun!
There have been numerous medical studies looking at the effectiveness of Hypericum in treating depression. A meta-analysis and review of randomised clinical studies of the use of Hypericum in depression was published in the British Medical Journal by Dr Klaus Linde and colleagues in 1996. They looked at 23 trials involving 1757 outpatients. Their conclusion was that: " There is evidence that extracts of Hypericum are more effective than placebo for the treatment of mild to moderately severe depressive disorders". The incidence of side effects was lower in the patients treated with Hypericum. In addition, six comparative studies showed that Hypericum is as effective as synthetic antidepressants when used to treat depression but Hypericum has less side effects. It was found in these studies that about 10% of patients had side-effects with Hypericum. These side-effects were mild and included: gastrointestinal irritation, dizziness, dry mouth and a few mild allergic reactions. Synthetic antidepressants were found to have side-effects in about 35% of patients. The British Medical Journal report emphasised that the side-effects experienced with Hypericum were "rare and mild". It has been noted by herbal medicine specialists that less than 5% of patients discontinue Hypericum because of side-effects.
There was a major study in the Journal of Geriatric Psychiatry and Urology published in 1994 by Drs. Woelk et al.,in in which 3250 patients were treated with Hypericum extract 300 mg three times a day by 633 doctors. The patients were treated for depression and these patients described eight typical complaints which were: depression, restlessness, difficulty falling asleep, headaches, gastrointestinal symptoms, mild cardiac symptoms and sweating. It was reported that about 80% of the patients felt improved after just four weeks, as assessed by medical and patient evaluations. Only about 2 to 3% of patients in this study develops side-effects with Hypericum.
The typical dose of Hypericum, based on a majority of medical studies, is 300 mg of Hypericum extract standardised to 0.3 percent hypericin three times a day. It is recommended that if nausea or gastrointestinal upset, such as indigestion, is a problem then the dose of Hypericum should be taken with each meal - breakfast, lunch and dinner. It is important to mention though, that it is not known to what extent food affects absorption of St John's wort. Sometimes herbal specialists advise a reduction of the dosage to 300 mg once or twice daily, if side-effects are experienced and some time is required for the body to adjust.
Hypericum cannot as yet be recommended for use during pregnancy because of insufficient research data.
Hypericum has also been studied as a treatment for severe recurrent depression. In a study published in Pharmacopsychiatry, in 1997, in a randomised double-blind controlled trial, by Dr Vorbach and colleagues, 209 patients with severe recurrent depression (but no delusional or psychotic symptoms) were treated for six weeks with Hypericum extract 600 mg three times daily. This high-dose treatment (1800mg - double the usual dose) was shown to be equally effective as treatment with a full dose of imipramine (Tofranil) 50 mg three times daily. It was noted that even at this higher dose, Hypericum come had significantly fewer side effects than imipramine. It is important to note that you should not consider taking up to 1800 mg daily of Hypericum without medical supervision.More studies on treating severe depression with Hypericum are needed.
Hypericum takes time to work when it is used to treat anxiety or to treat depression. The effectiveness of Hypericum in treating anxiety or depression should not be evaluated until 4 to 6 weeks have passed. As with prescription antidepressants, such as amitriptyline, clomipramine, dothiepin, imipramine and selective serotonin reuptake inhibitors (SSRI's), the effect of Hypericum in treating anxiety and depression takes place gradually over a number of weeks. It is very important to give Hypericum a chance to work.
Animal studies using Hypericum have shown that its antidepressant effects accumulate gradually in the brain. To stop taking treatment with Hypericum after one or two weeks thinking that: "This is not working to treat my anxiety or depression" is not sensible. If a satisfactory treatment effect is not achieved after six weeks, then it is important to take medical advice and consult with the doctor and consider taking a prescription antidepressant instead.
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