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My Favorite Herb: St. John’s Wort

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


Posted in Blog, Knowledge Base, M, S Tagged with: , , , , ,
19 comments on “My Favorite Herb: St. John’s Wort
  1. Maria says:

    Does this natural supplement interact with prescription medication?

  2. Dr E says:

    All herbs and prescription meds are capable of interactions but most of these are harmless. You’d need to ask your doctor although much of the information about these interactions is available online

  3. Mary says:

    Interesting article. Thanks, DR. Edelberg!

  4. Jennifer says:

    Is it okay to stay on SJW indefinitely, or could it compromise liver function, etc.?

  5. Dr E says:

    I have patients who have been using it continuously for as long as 15 years without any problems. I am sure your primary care doctor is checking routine blood tests during your check-ups and these would include liver tests

  6. Carina Gibson says:

    Thank you for the post. I myself was diagnosed with severe Depression round 17 (the teen years where we are going through many hormonal and emotional changes) and took Zoloft for a year. I had a rather severe case, so I assume Zoloft might have helped a bit, but I can never be quite sure. I begged to be taken off as I started to feel “numb” as you mentioned, and it almost felt as if it was doing more harm then good I managed to easily stop taking it in a year(thank goodness!). A couple years later I was having troubles again, and started doing consistent courses of STW and Fish oil. They helped subtly, but tremendously. The only side not was that SJW gave me rather intense skin pain when I was in the sun. While I was taking it, every time I had been in the sun, when I walked into the shade it felt as if my skin was icy cold and prickly, so I had to stop taking it…

  7. Roma says:

    What about the ‘hyperforin’ angle? I am currently trying SJW after a bad/good experience with an SSRI. While the SSRI undoubtedly made me feel better and eased my anxiety (the latter being the main reason I was taking it), I had debilitating fatigue, felt unmotivated and… gained 15 pounds within six months. So I’ve recently switched to SJW. I chose a German brand standardized to contain hyperforin, which is supposed to be more effective, and/or more certain to be effective. Or is it? I need to order this brand online and it’s very expensive compared to others. It would be nice if I could just pick up some SJW at my local health store instead. So I would like to know your opinion on this. Thx.

  8. Dr. R says:

    To Roma. Probably best to try a pharmaceutical grade brand of SJW (such as Integrative Therapeutics) and see how you do.

  9. Susan says:

    I don’t take any other meds except the St. John’s wort herb in dried leave and flower form. I make myself a tea everyday, and since I have done this, I have noticed increase in weight. I don’t understand this. I have been a lifetime member on a weightloss program since 2003 and know all about how to maintain a healhty weight, but this is throwing me for a loop. Are there any chances whatsoever that the tea is causing this gain?

  10. Susan says:

    And I should add that I stopped the tea for the last two days, and I am down 1.5lbs. Now I’m really scratching my head. How can an herb have this kind of effect?

  11. Dr E says:

    Hi Susan
    Although I have never seen weight gain with St John’s wort, it is theoretically possible because it is an SSRI and this whole family of meds is associated with weight gain. This very rapid loss of weight suggests more that the herb causes some fluid retention and by stopping it you are flushing the excess fluid out through your kidneys

  12. Dana says:

    I have been taking SJW for 20+ years. I started for seasonal affective symptoms one winter and was amazed it made all the difference for me. Then 10 years later I began to take fish oil. Lastly I added walking for exercise and have made a few lifestyle changes so I do not have to deal with depression. I taper it down it the spring. I have discontinued it in the summer. Yet when fall start creeping around the corner that is the most telltale indicator for me, I need my SJW!

    My concern is I have also put on 50 lbs. My doctor says Prozac would be a better choice, it can decrease my appetite and I will feel amazing. I have never been on a prescription antidepressant. 3 years ago I lost 10 lbs. walking 4000 steps a day, monitoring my food intake, making better choices and I cut my cal down to 2500. When I moved I stopped walking but I continue to eat the same new meal plan. I do believe the SJW has caused the weight gain for me. I was 120lbs before I tried SJW. I have had many very physical jobs so I burned up plenty of cal. I don’t know much about Prozac and its side effects.

  13. Dr E says:

    Hi Dana
    Officially SJW is not supposed to cause weight gain but every person is biochemically unique. You might discuss with your doctor either of two meds: Wellbutrin and Brintellix. Both are used for depression and FDA studies have shown no weight gain. Prozac is associated with weight gain. Just type Prozac weight gain in your Google bar and read what pops up

  14. Celine Ralph says:

    Will St.Johns Worst help with Fibromylgia pain

  15. Dr. R says:

    To Celine. It may help but taking it with certain medications is often contraindicated. It is best to use all herbs under a physicians direction.

  16. Joseph says:

    I have transitioned from taking Prozac to St. Johns Wort. Is it likely to gain weight while on this medication? I am a 25 year old male nurse weighing a solid 175 at 5’8.

    Thank you!

  17. cliffmaurer says:

    Hi Joseph – I’ve encountered patients who say they’ve gained a bit of weight on St John’s Wort, though their weight gain, as we later discovered, may have been due to several different and unrelated factors (change in diet, activity level, other medications, etc.). If you’ve experienced unexplained weight gain, it would be a good idea to make an appointment with your primary care physician.
    Dr M

  18. Girlie says:

    Hi. After being on Prozac for 11 years for depression and anxiety I weaned off over a two month period. Two weeks after stopping the Prozac I started to experience some uncomfortable withdrawal symptoms. I preserved with this for 10 weeks before I had to go back on the Prozac. I would really like to try St Johns Wort but am extremely scared that I would end up back in that dark place again if I stop the Prozac. I am taking 20mg daily and was wanting to know if I could take St Johns Wort with this dosage as I wean off. You advice would be really appreciated as my GP seems to think that there is nothing wrong with me taking Prozac for the rest of my life.

  19. Dr E says:

    Hi Girlie
    Your GP has a point. Some people do just fine on a lifetime of Prozac and by staying on it, avoid the dark place you are referring to. If you’ve had no problems with the Prozac except relief of symptoms, I’d just stay on it

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