Psychiatric Bulletin (2001) 25: 254-256. doi: 10.1192/pb.25.7.254
© 2001 The Royal College of Psychiatrists
Psychiatric Bulletin (2001) 25: 254-256
© 2001 The Royal College of Psychiatrists
How many patients self-medicate with St John's wort?
Amanda Redvers, Senior House Officer,
Richard Laugharne, Consultant Psychiatrist,
Gunam Kanagaratnam, Associate Specialist and
Guru Srinivasan, Senior House Officer
Department of Mental Health, University of Exeter, Wonford House
Hospital, Dryden Road, Exeter EX2 5AF
 |
Abstract
|
|---|
AIMS AND METHOD
St John's wort is popularly taken as a herbal remedy, but it interacts with
prescribed drugs. The aim of this survey was to estimate the prevalence of
patients self-medicating with St John's wort. All new referrals to a community
mental health team over 5 months were asked about any use of St John's
wort.
RESULTS
Fifteen patients, of 101, had taken St John's wort at some time and of
those seven were currently taking it. Patients who used St John's wort tended
to be younger and female. Only nine of the 15 patients took it for depressive
symptoms and none had received medical advice. One patient was taking an
interacting medication.
CLINICAL IMPLICATIONS
A significant number of patients are taking St John's wort. In order to
prevent drug interactions, doctors should ask all patients whether they use
it, especially young women who may be on the contraceptive pill. Patients need
better education about its risks and benefits and it should be taken with
medical advice.
|
|
Introduction
|
|---|
St John's wort (Hypericum perforatum) is a common herb that has
been used medicinally since the times of Hippocrates and Galen, who used it as
a cure for intestinal worms. The active compound is hypericin and the herb is
commonly taken for depression. It is commonly believed that herbal remedies
are ‘safer’ than synthetic medicines, but we should not assume
that the herb is harmless. Two cases of organ rejection have been attributed
to a reduction of plasma ciclosporin levels, possibly owing to an effect of St
John's wort on cytochrome p450 in the liver
(Ruschitzka et al,
2000), and a recent warning by the chief medical officer advised
against taking St John's wort with a number of drugs, including theophylline,
digoxin, warfarin, ciclosporin, indinavir and the oral contraceptive pill
(Department of Health, 2000). The same report also suggested that it is inadvisable for patients to take St
John's wort with selective serotonin reuptake inhibitor (SSRI)
anti-depressants, as the herb may increase serotonin levels. Other
side-effects and drug interactions have also been described
(Ernst, 1999). We carried out a
survey to measure the proportion of new mental health referrals who were
self-medicating with St John's wort.
|
|
Methods
|
|---|
The study was conducted by an inner-London general adult community mental
health team. All new referrals over a 5-month period were included. The
interview took place during the initial assessment and was always performed by
a doctor. We asked the patients if they had ever taken St John's wort and if
they had taken it in the past 3 months, the dose they had taken, and any other
comments. The age and gender of the patients were recorded along with the
clinical diagnosis made by the assessing doctor.
|
|
Results
|
|---|
A total of 114 patients were seen and data were obtained for 101 (89%). We
found that 15 had taken St John's wort at some time for psychiatric symptoms.
These patients were younger (mean age 31.6 v. 42.7 for the whole
group, independent T test P=0.01) and included more female
patients (73% compared with 57%, 
2 test not significant).
Eleven had taken the herb in the past 3 months and seven were taking it at the
time of presentation. Of the 15 patients that had used St John's wort, nine
had depressive symptoms either in isolation or together with anxiety disorders
or dysthymia. Six patients self-medicating did not have depressive
symptoms.
Most (12) patients had heard of it through family/friends, one via the
media and one from a healthfood shop. None had sought professional advice
beforehand and only six were aware of the dose they had taken. One patient
suffered a photosensitivity reaction after taking St John's wort for 2 weeks,
which resolved when discontinued, a side-effect previously reported
(Bove, 1998). Of the seven
patients taking St John's wort, one was taking an interacting medication.
|
|
Discussion
|
|---|
A significant number of patients self-medicate with St John's wort before
they present to the psychiatric services. Although St John's wort has been
used for over 2400 years and is considered to have relatively few
side-effects, its clinical profile is changing through interactions with
modern medicines.
The two important implications of this survey are the need to educate
clinicians and patients. Clinicians need to be aware when prescribing that
many patients will already be taking St John's wort. Clinical trials have
established the use of hypericum as an antidepressant only and it is as
effective as conventional antidepressants in treating mild to moderate
depression (Linde et al,
1996). It is a psychotropic drug but we do not routinely ask about
its use. It is important we do so because it has interactions with medical
drugs and SSRI antidepressants that psychiatrists may wish to prescribe.
This study highlights the need to improve patient education about which
illnesses benefit most from hypericum and in what doses. Patients tended not
to discuss starting on St John's wort with their doctor, a finding also found
in the US (Wagner et al,
1999). The public need to be aware of potential side-effects and
drug interactions, as they can perceive St John's wort to be safer than
conventional prescription drugs (Wagner
et al, 1999). This survey suggested younger women are
more likely to use St John's wort. The risk of pregnancy when using the oral
contraceptive may not be known by the user.
While these problems might suggest that St John's wort should be prescribed
by physicians, it should be noted that some foods also potentiate sub-enzymes
of the P450 system, such as cabbage and sprouts
(Jobst et al, 2000).
St John's wort may be a useful addition to therapeutic options and if the
public are educated about its uses and risks then self-medication may be a
useful and acceptable choice. However, the risk of drug interactions and
side-effects suggests a need either to regulate its use or provide clear
information and warnings when purchasing St John's wort.
|
|
Declaration of interest
|
|---|
R.L. has been principal investigator in a trial sponsored by Lilly
Pharmaceuticals.
|
|
References
|
|---|
BOVE, G. (1998) Acute neuropathy after exposure to sun
in a patient treated with St. John's wort. Lancet,
52,
1121-1122.[CrossRef]
DEPARTMENT OF HEALTH (2000) Important
Interactions between St John's wort (Hypericum perforatum). Preparations and
Prescribed Medicines. Public Health Link/CMO's Urgent
Communication. CEM/CMO/2000/04. London: Department of Health.
ERNST, E. (1999) Second thoughts about St. John's
wort. Lancet, 354,
2014-2015.[CrossRef][Medline]
JOBST, K. A., McINTYRE, M., ST GEORGE, D., et al.
(2000) Safety of St John's wort. Lancet,
355, 575.
LINDE, K., RAMIREZ, G., MULROW, C., et al
(1996) St John's wort for depression — an overview and
meta-analysis of randomised clinical trials. British Medical
Journal, 313,
253-257.[Abstract/Free Full Text]
RUSCHITZKA, F., MEIER, P., TURINA, M., et al
(2000) Acute heart transplant rejection due to St. John's wort.
Lancet, 355,
548-549.[CrossRef][Medline]
WAGNER, P. J., JESTER, D., LECLAIR, B., et al
(1999) Taking the edge off: why patients choose St. John's wort.
Journal Family Practice
48,
625-619.
This article has been cited by other articles:
|
|
|
|
 
T. L. Charrois, C. Sadler, and S. Vohra
Complementary, Holistic, and Integrative Medicine: St. John's Wort
Pediatr. Rev.,
February 1, 2007;
28(2):
69 - 72.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
