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The Herbal Phamacy by Dr. John Heinerman

ST. JOHNSWORT HERB

The rhizome of this last herb is strongly phototoxic to Candida albicans, Escherichia coli and Saccharomyces cerevisiae. (2) The same light activating compounds that kill the aforementioned bacteria, also reversed heavy gastric acid secretion in male Wistar-King strain rats and Hartley strain guinea pigs suffering from aspirin-induced stomach ulcers. (3) Such atractylodes substances have also helped to heal gastric ulcers caused by stress and anxiety, especially when accompanied with adequate exposure to light. (4) St. Johns  Wort is  also used  as  an anti-depressent.

Physicians in Germany routinely prescribe herbal medicines and in 1994 prescribed 66 million daily doses of Hypericum perforatum (St.-John's-wort), approved there for use in the treatment of depression (de Smet and Nolen 1996). German researchers (with a colleague from San Antonio) recently published their metaanalysis of 23 randomized trials of St.-John's-wort in a total of 1,757 outpatients with mild to moderately severe depressive isorders. They concluded that the herb was significantly superior to placebo, and appeared comparably effective to standard antidepressants while producing fewer side effects (Linde 1996).

Breakthroughs in psychotherapeutic medication development may be more likely to occur through exploitation of traditional folk medicine and naturally occurring products than in the incremental steps of conventional research and development, according to Jerry Cott, Ph.D., chief of the pharmacologic treatment research program, division of clinical and treatment research, National Institute of Mental Health (NIMH). "Reuptake inhibition (and therapeutic efficacy) has really not improved since the accidental discovery of imipramine," Cott has written (parentheses his). "How many more 'potent and selective' uptake inhibitors do we really need?"

(Cott 1995). Cott indicates that the opportunities to scrutinize potential medicinal properties of natural products through controlled scientific investigations have markedly increased in recent years. In the United States, research with natural products has been spurred by the 1992 establishment of the National Institutes of Health Office of Alternative Medicine; the Dietary Supplement Health and Education Act of 1994; and increased funding by the National Cancer Institute for natural products research directed toward AIDS and chemotherapy. The psychotherapeutic potential of naturally occurring compounds is specifically being sought through functional bioassay screening in an NIMH initiative.

The yellow flowering tops of St.-John's-wort have been consumed for centuries in a tea or olive oil extract for a variety of "nervous conditions," and it is being assessed in the United States for antiviral activity in AIDS research. Cott reported at the 1993 American College of Neuropsychopharmacology annual meeting that the NIMH screening revealed the crude extract exerts relatively potent affinity for gamma-aminobutryic acid receptors (GABAa) (PT April, 1995). He has subsequently determined that pure hypericin has neither strong ffinity for common neuroreceptors nor does it inhibit monoamine oxidase (MAO), and posits that any psychopharmacological activity is caused by the herb flavinoid components (Cott, personal communication,Aug. 1996).

Outside the United States, many developed countries with more extensive use of natural medicaments are well along in clinically testing their traditional applications. These efforts abroad, as well as in the United States, have been furthered by World Health Organization (WHO) Guidelines for the Assessment of Herbal Medicines (Akerele 1992), which standardize methods for developed countries to incorporate traditional medicines into their modern pharmacopeias. Cott, a member of the WHO Unit on Neurosciences, for the Collaborative Study of the "Early Diagnosis, Prevention and Treatment of Alzheimer's Disease," which is currently considering a multinational study of ginkgo biloba, explained that these guidelines essentially enable the historical use of a substance to serve as valid safety and efficacy information in the absence of scientific evidence to the contrary.

The controlled studies of St.-John's-wort efficacy in depression included in the metaanalysis were randomized, or "quasi-randomized" through alternation, comparisons of the herb alone or in combination with other plant extracts to placebo and/or a standard antidepressant. Twenty of the 23 trials were double-blind, one was single-blind, and two were open-label; most were four to eight weeks in duration. The methodological quality of each study was assessed by at least two reviewers to ascertain eligibility for inclusion in the metaanalysis. The metaanalysis report did not indicate whether the studies involving standard antidepressants had been screened for adequacy of antidepressant dose.

In each study, improvement in depressive symptoms had been evaluated with depression scales with interrater reliability, most commonly the Hamilton Depression Rating Scale and the Clinical Global Impressions Scale. The daily dose of either hypericin, the reference substance for pharmaceutical standardization, or of total extract varied considerably between studies, from 0.4 to 2.7 mg and 300 to 1000 mg, respectively.

In 13 studies comparing a single Hypericum preparation with placebo, 55.1% (225) of patients receiving the herb were improved, compared to 22.3% (94) responding to placebo. In the comparisons to standard antidepressants in three trials with single preparations and two with combinations, 63.9% (101) of patients responded to single preparations compared to 58.5% (93) with standard antidepressants; and 67.7% (88) responded to combination extract products compared to 50% (66) with standard antidepressants.

The researchers acknowledged the problems in drawing valid conclusions from the pooled data of quite heterogeneous studies. These problems are compounded by the different amounts and preparations of the herb used across the studies, and the possibility that the "standardized" hypericin extract is not the only active component.

These limitations notwithstanding, Linde and colleagues find sufficient evidence to conclude that St.-John's-wort is better than placebo in treating some depressive disorders. The data were inadequate, however, to yet judge whether it is as effective as standard antidepressants, although it appears to cause fewer side effects. They consider that these initial indications of efficacy warrant the undertaking of longer controlled trials comparing specific amounts of different Hypericum preparations to standard antidepressants.

In separate commentary accompanying the metaanalysis, Netherlands clinicians Peter de Smet and Willen Nolen agreed that the data are promising, but not yet sufficient to accept St.-John's-wort as an effective antidepressant preparation (de Smet and Nolen 1996). In addition to the need for dose standardization and adequate trial lengths, they call for studies in severely depressed patients and long-term studies to assess the risk of relapse and emergence of late side effects.

References

1.Akerele O. WHO guidelines for the assessment of herbal medicines. Fitoterapia. 1992;62:99-110. Summarized in Herbalgram. 1993;28:13-20.

2.Cott J. Natural product formulations available in Europe for psychotropic indications. Psychopharmacol Bull. 1995;31:745-751.

3.De Smet PA, Nolen WA. St. John's wort as an antidepressant. BMJ. 1996;313:241-247. Editorial.

4.Linde K, Ramirez G, Mulrow CD, et al. St. John's wort for depression: an overview and meta-analysis of randomized clinical trials. BMJ. 1996;313:253-258.