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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 20 of 20. This is the beginning of the thread.
Posted by Alara on November 22, 2002, at 18:18:08
I just wanted anyone who is thinking about trying SJW to know that the herb works! After 6.5 weeks on Hypericum 1800 mg (3 times daily) I have stopped sleeping for 16 hours a day and am feeling a lot calmer and more confident about myself in general. I went out there last week and had a successful job interview. (Just waiting for confirmation that I have the job.) I have even managed to stay alcohol-free for 7 consecutive days, which was previously near impossible for me.:-) :-)
While I am not suggesting that anyone abandons their current AD medication to try St Johns Wort (which could be disasterous), I would definitely recommend it to anyone with anxiety and/or mild-moderate depression.
Just thought I'd share that.
Alara :-)
Posted by atxbelle2000 on November 23, 2002, at 12:22:24
In reply to St Johns Wort Works!, posted by Alara on November 22, 2002, at 18:18:08
A note of FYI!!!!!! if you're a female and taking birth control the SJW could interefere with the birth control!
Posted by Alara on November 23, 2002, at 19:04:15
In reply to Re: St Johns Wort Works!, posted by atxbelle2000 on November 23, 2002, at 12:22:24
> A note of FYI!!!!!! if you're a female and taking birth control the SJW could interefere with the birth control!
Yes, this is an issue. Recently I've been taking a break away from my boyfriend so I've temporarily discarded the pill. Still don't know what to do about this. Why can't men take on this responsibility?? Arghh!!
Posted by atxbelle2000 on November 23, 2002, at 20:04:02
In reply to Re: St Johns Wort Works!, posted by Alara on November 23, 2002, at 19:04:15
I don't know what to tell you. I'm glad that my boyfriend hasn't left me. We've been together for almost a year. Just recently I've been having anxiety attacks, depression, A.D.D. and partiel seizures, but they are getting worse every time. It's put so much stress on me and my family and him. I thank God that he hasn't left me.
Posted by atxbelle2000 on November 24, 2002, at 0:40:49
In reply to Re: St Johns Wort Works! » Alara, posted by atxbelle2000 on November 23, 2002, at 20:04:02
Also, it might help to continue taking the pill. There are so many benefits in taking the pill. I'm not sexually active but I'm on the pill because I had really bad cramps that would go on for what seemed like forever, I was also anemic which helped with that. You might want to go back on the pill because of these reasons, and IMHO hormones have a lot to do with the way we women feel.
> I don't know what to tell you. I'm glad that my boyfriend hasn't left me. We've been together for almost a year. Just recently I've been having anxiety attacks, depression, A.D.D. and partiel seizures, but they are getting worse every time. It's put so much stress on me and my family and him. I thank God that he hasn't left me.
Posted by Alara on November 25, 2002, at 3:26:26
In reply to Re: St Johns Wort Works! » Alara, posted by atxbelle2000 on November 23, 2002, at 20:04:02
Thanks, Axtabelle. My mood is actually a little brighter when I am off the pill, but everybody is different and I'm glad that it is helping you. At the end of the day I really don't mind taking the pill - as long as I know it's working!
Does anybody have links to studies supporting the claim that St John's Wort reduces the efficacy of the pill? So far I have found many vague statements such as "St John's Wort can reduce the efficacy of the pill by 50%." None of the claims that I have read have been backed up by evidence. Has anyone sighted a relevant study?
Posted by Larry Hoover on November 25, 2002, at 10:15:39
In reply to Re: St Johns Wort Works!, posted by Alara on November 25, 2002, at 3:26:26
> Thanks, Axtabelle. My mood is actually a little brighter when I am off the pill, but everybody is different and I'm glad that it is helping you. At the end of the day I really don't mind taking the pill - as long as I know it's working!
>
> Does anybody have links to studies supporting the claim that St John's Wort reduces the efficacy of the pill? So far I have found many vague statements such as "St John's Wort can reduce the efficacy of the pill by 50%." None of the claims that I have read have been backed up by evidence. Has anyone sighted a relevant study?SJW is believed to increase the activity of the enzyme known as CYP3A4. The evidence is pretty strong for that, although circumstantial. That's the same enzyme which the body uses to process the synthetic hormones in oral contraceptives.
There are only case reports in the literature of breakthrough bleeding and unwanted pregnancy, usually in the form of letters to the editor of medical journals, rather than studies per se. Considering the widespread use of SJW and oral contraceptives, the risk appears to be small (or under-reported). The pill is not fool-proof to begin with, so you have to assess the risk in the context of your own life, i.e. how much risk of pregnancy are you willing to accept? If you can't risk pregnancy, use a back-up method.
Posted by ZeeZee on November 25, 2002, at 10:18:08
In reply to St Johns Wort Works!, posted by Alara on November 22, 2002, at 18:18:08
Hi Alara,
I've been on SJW for 8 weeks now. Around the 6th week I noticed a change in my thinking and subsequent feelings. It's taken the edge off of my panic disorder/agoraphobia. I'm in CBT and better able to practice what I've learned and am learning. Although this improvement is not dramatic enough for me to rule out trying another MAOI or a RIMA in the future, it will do for now. I am also taking a 2,500 mile round trip road trip this holiday season to visit family. I believe the SJW is what is allowing me to even consider doing this!
When I return from my trip I'm going to try the addition of Buspar. Didn't want to mess anything up right now before my trip.
Good Luck to you.
Posted by Bill L on November 25, 2002, at 12:01:17
In reply to St Johns Wort Works!, posted by Alara on November 22, 2002, at 18:18:08
Alara - just to be clear, I'm assuming that you are taking 600 mg three times a day for a total of 1800. Is that correct?
Years a go, docs recommended 300 mg 3x per day for a total of 900 mg. Then, a few years a go, people reported more success with double that dosage, or 1800 per day.
When a "big" SJW study was conducted about 2 years a go, the researchers concluded that it was largely ineffective for depression. And that's what the front page headlines on the news and magazines said. But they only used 900 mg and the study only lasted 8 weeks. Many people need more than 8 weeks to get a full effect. My feeling is that the researchers had a vested interest in downplaying the effectiveness of SJW in favor of prescription AD's (where there is a much greater profit margin).
I'm really glad that it works for you.
> I just wanted anyone who is thinking about trying SJW to know that the herb works! After 6.5 weeks on Hypericum 1800 mg (3 times daily) I have stopped sleeping for 16 hours a day and am feeling a lot calmer and more confident about myself in general. I went out there last week and had a successful job interview. (Just waiting for confirmation that I have the job.) I have even managed to stay alcohol-free for 7 consecutive days, which was previously near impossible for me.:-) :-)
>
> While I am not suggesting that anyone abandons their current AD medication to try St Johns Wort (which could be disasterous), I would definitely recommend it to anyone with anxiety and/or mild-moderate depression.
>
> Just thought I'd share that.
>
> Alara :-)
Posted by Larry Hoover on November 25, 2002, at 13:05:21
In reply to Re: St Johns Wort Works!, posted by Bill L on November 25, 2002, at 12:01:17
> Alara - just to be clear, I'm assuming that you are taking 600 mg three times a day for a total of 1800. Is that correct?
>
> Years a go, docs recommended 300 mg 3x per day for a total of 900 mg. Then, a few years a go, people reported more success with double that dosage, or 1800 per day.
>
> When a "big" SJW study was conducted about 2 years a go, the researchers concluded that it was largely ineffective for depression. And that's what the front page headlines on the news and magazines said. But they only used 900 mg and the study only lasted 8 weeks. Many people need more than 8 weeks to get a full effect. My feeling is that the researchers had a vested interest in downplaying the effectiveness of SJW in favor of prescription AD's (where there is a much greater profit margin).Do you think?
I'm employed to criticize scientific studies. It is my opinion that both studies reported in JAMA have significant limitations. I've edited down the abstracts a bit, to make my point.
JAMA 2001 Apr 18;285(15):1978-86
Effectiveness of St John's wort in major depression: a randomized controlled trial.
INTERVENTION: Participants completed a 1-week, single-blind run-in of placebo, then were randomly assigned to receive either St John's wort extract (n = 98; 900 mg/d for 4 weeks, increased to 1200 mg/d in the absence of an adequate response thereafter) or placebo (n = 102) for 8 weeks.
The number reaching remission of illness was significantly higher with St John's wort than with placebo (P =.02)
CONCLUSION: In this study, St John's wort was not effective for treatment of major depression.
Now, how did they come to ignore the major finding of the study, that there was a significantly higher remission rate with SJW over placebo? They employed a very conservative analytical process called intention-to-treat analysis. I'll spare you the details, but I've never seen such analysis applied to pharmaceutical company antidepressants. Never. (But I don't read them all.....that's my limitation.)
Then, there's this study, which compared SJW to both placebo and sertraline:
JAMA 2002 Apr 10;287(14):1807-14
Effect of Hypericum perforatum (St John's wort) in major depressive disorder: a randomized controlled trial.
INTERVENTIONS: Patients were randomly assigned to receive H perforatum, placebo, or sertraline (as an active comparator) for 8 weeks. RESULTS: On the 2 primary outcome measures, neither sertraline nor H perforatum was significantly different from placebo. Full response occurred in 31.9% of the placebo-treated patients vs 23.9% of the H perforatum-treated patients (P =.21) and 24.8% of sertraline-treated patients (P =.26).
CONCLUSION: This study fails to support the efficacy of H perforatum in moderately severe major depression. The result may be due to low assay sensitivity of the trial, but the complete absence of trends suggestive of efficacy for H perforatum is noteworthy.
Pardon me? Notice the complete absence of any mention to the effect that sertraline (Zoloft) failed the experiment? Note any mention of the fact that the SJW product was tested, and shown to contain only a minimum of 0.12% hypericin, rather than the generally accepted minimum of 0.3%? Simple math: 0.12% hypericin times 1500 mg (the highest SJW dose in the trial) equals dosage of 18.0 mg hypericin. Standard dose of 900 mg of 0.30% hypericin gives dosage of 27.0 mg hypericin. And that's the recommended dose for mild to moderate depression, not the serious depression experienced by these subjects.
It is standard medical practice to give an antidepressant a full trial before withdrawing it. You gradually ramp up the dose until one of two things occurs: a) remission of symptoms; b) intolerable side-effects. The same thing goes for SJW; dose should be adjusted to symptoms. There has never been a reported case of SJW overdose in the literature (that I've ever seen, anyway, and I look). There is no reason to restrict SJW dosage to that given for mild to moderate depression if one is attempting to treat serious depression.
What is amazing, to my mind, is that these two studies didn't get the same press.
Can Fam Physician 2002 May;48:905-12
St John's wort or sertraline? Randomized controlled trial in primary care.
van Gurp G, Meterissian GB, Haiek LN, McCusker J, Bellavance F.
Emergency Department, St Mary's Hospital Centre, 3830 Lacombe Ave, Montreal, QC. gerald.vangurp@mcgill.ca
OBJECTIVE: To compare the change in severity of depressive symptoms and occurrence of side effects in primary care patients treated with St John's wort (SJW) and sertraline. DESIGN: Double-blind, randomized 12-week trial. SETTING: Community-based offices of 12 family physicians practising in greater Montreal, Que. PARTICIPANTS: Eighty-seven men and women with major depression and an initial score of > or = 16 on the Hamilton Rating Scale for Depression (Ham-D). INTERVENTIONS: Patients were randomized to treatment with either sertraline (50 to 100 mg/d) or SJW (900 to 1800 mg/d) in a double-blind fashion. Assessment of depression was done at entry and at 2, 4, 8, and 12 weeks using the Ham-D, the Beck Depression Inventory (BDI), and a questionnaire asking about compliance and side effects. MAIN OUTCOME MEASURES: Changes from baseline in Ham-D and BDI scores and self-reported side effects. RESULTS: There were no important differences in changes in mean Ham-D and BDI scores (using intention-to-treat analysis), with and without adjustment for baseline demographic characteristics, between the two groups at 12 weeks. Significantly more side effects were reported in the sertraline group than in the SJW group at 2 and 4 weeks' follow up. CONCLUSION: The more benign side effects of SJW make it a good first choice for this patient population.
Here's one about severely depressed subjects successfully treated with SJW:
Pharmacopsychiatry 1997 Sep;30 Suppl 2:81-5
Efficacy and tolerability of St. John's wort extract LI 160 versus imipramine in patients with severe depressive episodes according to ICD-10.
Vorbach EU, Arnoldt KH, Hubner WD.
Department of Psychiatry and Psychotherapy, Ev. Krankenhaus Elisabethenstift, Darmstadt, Germany.
The special extract of St. John's wort, LI 160, exhibited a superior antidepressant efficacy compared to placebo in several controlled trials. Two further trials demonstrated a similar reduction of depressive symptomatology under LI 160 compared to tricyclics. All these trials were performed in mildly to moderately depressed patients. The present investigation was a randomized, controlled, multicentre, 6-week trial comparing 1800 mg LI 160/die to 150 mg imipramine/die in severely depressed patients according to ICD-10. The main efficacy parameter, a reduction of the total score of the Hamilton Depression Scale, proved both treatment regimens very effective at the end of the 6 week treatment period (mean values 25.3 to 14.5 in the LI 160 group and 26.1 to 13.6 in the imipramine group), but not statistically equivalent within a a-priori defined 25% interval of deviation. The analysis of subgroups with more than a 33% and 50% reduction of the HAMD total score justified the assumption of equivalence within a 25% deviation interval. This view was also supported by the global efficacy ratings from patients and investigators. Regarding adverse events, the nonrejection of the nonequivalence hypothesis denotes a superiority of the herbal antidepressant. These main result indicate that LI 160 might be a treatment alternative to the synthetic tricyclic antidepressant imipramine in the majority of severe forms of depressions. However, more studies of this type must be performed before a stronger recommendation can be made.
Tricyclics like imipramine are often recommended for the most severe forms of depression because they work. It's the side effect profile that limits them (anticholinergic effects, praticularly).
IMHO, there are two major problems with people trying SJW and getting no response. One is the rampant fraud in the herbal industry. Because the herbal supplement suppliers are not bound by legislation which requires them to assure the contents of their supplements actually contains what the label says, you don't know what you're buying. Independent analyses of commercial SJW products show that up to 1/3 of all products contain no or negligible amounts of the active ingredients, 1/3 contain substantial amounts, but appreciably less than the label states, and 1/3 meet (or exceed) the label amounts. I want to ask you, what major industrial concern stands to profit from this state of affairs? Pharmaceutical companies. Destroy peoples' confidence in herbal products, and they're the only players. Germany was able to quickly and efficiently bring in pharmaceutical-type standards for herbal products. Surely America can do the same.
The second issue, as I mentioned, is that people seldom give the same sort of trial for SJW that they give for a prescribed med, i.e. increase the dose until either remission or side-effects occur.
I'm skeptical of the JAMA reports. And I think, for good reason.
Lar
Posted by ZeeZee on November 25, 2002, at 14:44:03
In reply to Re: St Johns Wort Works!, posted by Larry Hoover on November 25, 2002, at 13:05:21
Since you seem to be very knowledgeable are you aware of any U.S. manufacturers of herbal supplements like SJW that do in fact adhere to recommended guidelines and safety standards?
Posted by Larry Hoover on November 25, 2002, at 15:17:39
In reply to Re: St Johns Wort Works! » Larry Hoover, posted by ZeeZee on November 25, 2002, at 14:44:03
> Since you seem to be very knowledgeable are you aware of any U.S. manufacturers of herbal supplements like SJW that do in fact adhere to recommended guidelines and safety standards?
The only one I know of that has a long-term reliability of content is Nature's Way. I'm not familiar with all the products that you might choose from.
Posted by ZeeZee on November 25, 2002, at 17:39:37
In reply to Re: St Johns Wort Works!, posted by Larry Hoover on November 25, 2002, at 15:17:39
Posted by Alara on November 26, 2002, at 5:09:22
In reply to Re: St Johns Wort Works!, posted by Larry Hoover on November 25, 2002, at 10:15:39
> > >
> >
> There are only case reports in the literature of breakthrough bleeding and unwanted pregnancy, usually in the form of letters to the editor of medical journals, rather than studies per se. Considering the widespread use of SJW and oral contraceptives, the risk appears to be small (or under-reported). The pill is not fool-proof to begin with, so you have to assess the risk in the context of your own life, i.e. how much risk of pregnancy are you willing to accept? If you can't risk pregnancy, use a back-up method.
>Thank you, Larry. I am thinking that there would have been more widely publicised case reports and follow-up experiments by now if the risk of pregnancy were truly great. I think I will continue on the pill while taking St John's Wort, using the rhythm method for backup.
Posted by Alara on November 26, 2002, at 5:27:33
In reply to Re: St Johns Wort Works!, posted by Bill L on November 25, 2002, at 12:01:17
> Alara - just to be clear, I'm assuming that you are taking 600 mg three times a day for a total of 1800. Is that correct?
>
>
Bill, I am actually taking 3 tablets a day, each of which contains:St John's Wort (Hypericum perforatum) extract equivalent to dry flowering herb top...1800mg
Hyperforin..............................15mg
Hypericin...............................990mcgThis preparation is made by Herron Pharmaceuticals. Indication: Take one tablet three times daily with food or as professionally directed. (Equals 5400mg Hypericum daily.)
Judging from the case studies cited by Larry, I am taking more than the recommended dose. Is this too much?
I am also wondering about the safety of eating matured cheese etc on my current dose as St John's Wort acts like a MAO inhibitor. There is information on the net suggesting that the original fears about SJW and food interactions have now been abandoned. Larry???
Posted by ZeeZee on November 26, 2002, at 8:18:34
In reply to Re: St Johns Wort Works! » Bill L , posted by Alara on November 26, 2002, at 5:27:33
You do not have to adhere to an "MAOI diet". I was on SJW for 4 years and ate whatever I wanted and I am SUPER sensitive to all medications. The original thinking that it acted like an MAOI has been corrected. There is only a slight association between SJW and the action of a MAOI.
Posted by Bill L on November 26, 2002, at 9:03:06
In reply to Re: St Johns Wort Works! » Bill L , posted by Alara on November 26, 2002, at 5:27:33
Alara - Unfortunately I can't answer your question about dosage. Maybe Larry can. I'm not sure about the dry flower part or the other things on the label.
Posted by Larry Hoover on November 26, 2002, at 9:32:18
In reply to Re: St Johns Wort Works! » Bill L , posted by Alara on November 26, 2002, at 5:27:33
> > Alara - just to be clear, I'm assuming that you are taking 600 mg three times a day for a total of 1800. Is that correct?
> >
> >
> Bill, I am actually taking 3 tablets a day, each of which contains:
>
> St John's Wort (Hypericum perforatum) extract equivalent to dry flowering herb top...1800mg
> Hyperforin..............................15mg
> Hypericin...............................990mcgThis is a non-standard format. They're comparing their tablets to raw herb mass.
> This preparation is made by Herron Pharmaceuticals. Indication: Take one tablet three times daily with food or as professionally directed. (Equals 5400mg Hypericum daily.)
>
> Judging from the case studies cited by Larry, I am taking more than the recommended dose. Is this too much?Let's do some math. SJW products standardized on both hyperforin and hypericin typically contain 4% hyperforin and 0.3% hypericin, in a 300 mg capsule/tablet. With t.i.d. dosing, you get:
Hyperforin: 0.04 times 300 mg times 3 = 36 mg
Hypericin: 0.003 times 300 mg times 3 = 2.7 mgHere's what you're getting:
Hyperforin: 15 mg times 3 = 45 mg
Hypericin: 990 mcg = 0.99 mg times 3 = 2.97 mgYou're getting 10-20% more than the recommended dose for mild to moderate depression. You can quite safely adjust the dose upwards (or downwards) according to your symptoms. If you get intolerable side effects, that will affect your personal upper dose limit.
> I am also wondering about the safety of eating matured cheese etc on my current dose as St John's Wort acts like a MAO inhibitor. There is information on the net suggesting that the original fears about SJW and food interactions have now been abandoned. Larry???There is a mild and possibly reversible MAOI activity with certain extracts of SJW. The original report of this activity used concentrations 180 times the typical physiological concentration, and achieved only 60% inhibition (still safe, by the way). Only if you have a genetic trait which causes malformation of both the MAO enzymes might you be conceivably at risk. The risk is theoretical, not practical.
I just wish the nefazadone (Serzone) inhibition of the liver enzyme CYP3A4 got nearly as much press as the MAOI activity of SJW. Serzone nearly killed me.
Lar
Posted by bluedog on November 26, 2002, at 10:14:53
In reply to St Johns Wort Works!, posted by Alara on November 22, 2002, at 18:18:08
Can you take SJW and SAM-e together?
If yes do they augment eachother?
Does SJW or SAM-e taken either alone or together help with social anxiety?
Thanks
bluedog
Posted by Alara on November 28, 2002, at 1:00:35
In reply to Re: St Johns Wort Works! » Alara, posted by Larry Hoover on November 26, 2002, at 9:32:18
This is the end of the thread.
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