1. St. John’s Wort An Alternative Treatment for Mild to Moderate Depression

2. Presentation Outline Alternate Names Alternate Names Description of Hypericum Description of Hypericum Forms of Hypericum Forms of Hypericum History and Naming of St. John’s Wort History and Naming of St. John’s Wort Treatment Treatment Dosage Dosage Side Effects Side Effects Drug Interactions Drug Interactions Cautions Cautions Advantages/Disadvantages Advantages/Disadvantages Evaluation Evaluation

3. Alternate Names  Hardhay  Amber  Guttiferae  Goat weed  Tipton weed  Klamath weed  Hypericum Perforatum  Most common  Latin

4. Hypericum Perforatum – The Plant Perennial plant Perennial plant Flower: bright yellow oval shaped leaves with black dots Flower: bright yellow oval shaped leaves with black dots Native to Northern Africa, Europe and Western Asia Native to Northern Africa, Europe and Western Asia Can be found in meadows, dry pastures, near railroad tracks and alongside roadbeds worldwide Can be found in meadows, dry pastures, near railroad tracks and alongside roadbeds worldwide

5. Forms of Hypericum Capsules Capsules Teas Teas Tablets Tablets Tinctures Tinctures Oil-based skin lotions (not to be ingested) Oil-based skin lotions (not to be ingested) Chopped/powered Chopped/powered

6. Hypericum Perforatum – History St. John’s Wort was first documented in the first century A.D. by Gaius Plinius Secundus (Pliny the Elder), a Roman philosopher, who discussed the herbs ability to treat diarrhea and bladder problems. St. John’s Wort was first documented in the first century A.D. by Gaius Plinius Secundus (Pliny the Elder), a Roman philosopher, who discussed the herbs ability to treat diarrhea and bladder problems. Following this, the ancient Greek physician Pedanius Dioscorides recommended it to expel “choleric excrements” (natural pharmacy, 2005) and to treat burns. Following this, the ancient Greek physician Pedanius Dioscorides recommended it to expel “choleric excrements” (natural pharmacy, 2005) and to treat burns. Philippus Theophrastus Aureolus Bombastus von Hohenheim (Paracelus) wrote about the use of St. John’s wort to treat wounds and psychotic symptoms (phatasmata) Philippus Theophrastus Aureolus Bombastus von Hohenheim (Paracelus) wrote about the use of St. John’s wort to treat wounds and psychotic symptoms (phatasmata)

7. Hypericum Perforatum – History In 1630AD Angelo Sala announced that St. John’s Wort had the ability to treat illnesses of the “imagination, melancholia, anxiety and disturbances of understanding” (natural pharmacy, 2005). In 1630AD Angelo Sala announced that St. John’s Wort had the ability to treat illnesses of the “imagination, melancholia, anxiety and disturbances of understanding” (natural pharmacy, 2005). The word continued to spread about St. John’s Wort through “wise women” and midwives. The word continued to spread about St. John’s Wort through “wise women” and midwives. It was brought to the Northeastern United States by European colonists and was used to treat breathing problems (tuberculosis), fever, nosebleeds, bladder and bowel problems, and for venereal diseases. It was brought to the Northeastern United States by European colonists and was used to treat breathing problems (tuberculosis), fever, nosebleeds, bladder and bowel problems, and for venereal diseases.

8. Naming St. John’s Wort St. John’s Wort is harvested and flowers by June 24 th, which is St. John’s (feast) day (John the Baptist) St. John’s Wort is harvested and flowers by June 24 th, which is St. John’s (feast) day (John the Baptist) When the petals are squeezed or rubbed, they leak red sap which is believed to be representative of the blood of the martyred saint (John the Baptist) When the petals are squeezed or rubbed, they leak red sap which is believed to be representative of the blood of the martyred saint (John the Baptist)

9. Hypericum Perforatum It is believed that the combination of Hypericum’s constituents is what allows it to have an antidepressant effect rather than just one compound It is believed that the combination of Hypericum’s constituents is what allows it to have an antidepressant effect rather than just one compound These constituents include: These constituents include: Napthodianthrones hypericin Napthodianthrones hypericin Pseudohypericin Pseudohypericin Hyperforin Hyperforin

10. Treatment Researchers are unsure how St. John’s Wort actually works to treat depression Researchers are unsure how St. John’s Wort actually works to treat depression St. John’s Wort was originally though to work somewhat like MAOI’S do, however recent clinical tests (Dr. Muller and Colleagues) show that St. John’s wort is able to also inhibit serotonin, norepinephrine and dopamine without the added complications of MAOI’s and side effects of SSRI’s and TCA’s St. John’s Wort was originally though to work somewhat like MAOI’S do, however recent clinical tests (Dr. Muller and Colleagues) show that St. John’s wort is able to also inhibit serotonin, norepinephrine and dopamine without the added complications of MAOI’s and side effects of SSRI’s and TCA’s

11. St. John’s Wort versus SSRI’s, MAOI’s and TCA’S St. John’s Wort St. John’s Wort Affects Serotonin, Norepinephrine and dopamine Affects Serotonin, Norepinephrine and dopamine Mild side effects Mild side effects Rare side effects Rare side effects Non-competitive inhibitor Non-competitive inhibitor SSRI’S SSRI’S Serotonin Side effects MAOI’s MAOI’s Negative interaction with other medications Requires a strict diet Affects tyramine (linked to blood pressure) TCA’s TCA’s Side effects Can be fatal

12. Dosage Dosage depends on the hypericin content Dosage depends on the hypericin content Usually advised that the St. John’s wort extract be standardized to contain 0.3% hypericin at a dosage of 300mg, three times a day Usually advised that the St. John’s wort extract be standardized to contain 0.3% hypericin at a dosage of 300mg, three times a day Takes about 6 weeks to notice a difference Takes about 6 weeks to notice a difference Generally takes longer to reach full effectiveness than prescription antidepressants Generally takes longer to reach full effectiveness than prescription antidepressants

13. Side Effects Generally few side effects and quite mild Generally few side effects and quite mild Not a single recorded hypericum-related death in 2,400 years Not a single recorded hypericum-related death in 2,400 years All side effects are reversible (stops when the herb is no longer being used) All side effects are reversible (stops when the herb is no longer being used) Photosensitivity (sensitive to sunlight) Photosensitivity (sensitive to sunlight) Fair skinned people should avoid, if possible, prolonged sunlight exposure Fair skinned people should avoid, if possible, prolonged sunlight exposure

14. Side Effects Less Commonly: Less Commonly: Constipation Constipation Gastrointestinal problems (nausea, vomiting, diarrhea) Gastrointestinal problems (nausea, vomiting, diarrhea) Fatigue Fatigue Dry mouth Dry mouth Dizziness Dizziness Allergic reactions Allergic reactions Confusion Confusion  To help combat these side effects it is suggested that St. John’s wort be taken with food.

15. Drug Interactions It is advised to be cautious when taking other medications with St. John’s Wort as it has shown to decrease their effectiveness It is advised to be cautious when taking other medications with St. John’s Wort as it has shown to decrease their effectiveness This includes: This includes: Antidepressants Antidepressants Immunosuppressive medications Immunosuppressive medications Especially in those with heart or kidney transplants as it can cause the body to reject the transplanted organs Especially in those with heart or kidney transplants as it can cause the body to reject the transplanted organs Indinavir and other protease inhibitors (treats HIV) Indinavir and other protease inhibitors (treats HIV)

16. Drug Interactions cont’d Loperamide (diarrhea medication) Loperamide (diarrhea medication) Can lead to delirium Can lead to delirium Oral contraceptives Oral contraceptives Can cause bleeding Can cause bleeding Reserpine (treats high blood pressure) Reserpine (treats high blood pressure) Theophylline (treats asthma, emphysema, or chronic bronchitis) Theophylline (treats asthma, emphysema, or chronic bronchitis) Warfarin (anticoagulant) Warfarin (anticoagulant) Digoxin Digoxin

17. Cautions Should not be used during pregnancy or while breast feeding as there is no information on it's safety under these conditions Should not be used during pregnancy or while breast feeding as there is no information on it's safety under these conditions Should not be used for severe depression or bipolar disorder as not enough research is yet available to show effectiveness in these circumstances Should not be used for severe depression or bipolar disorder as not enough research is yet available to show effectiveness in these circumstances Do not take St. John’s wort in combination with MAOI’s Do not take St. John’s wort in combination with MAOI’s Can produce a dangerous rise in blood pressure Can produce a dangerous rise in blood pressure Should not be taken in combination with prescription SSRI’s as this can lead to serotonin syndrome – too much serotonin. Should not be taken in combination with prescription SSRI’s as this can lead to serotonin syndrome – too much serotonin.

18. Advantages Few side effects Few side effects Mild side effects Mild side effects Reversible side effects Reversible side effects Do not need a prescription Do not need a prescription Sexual dysfunction (as a side effect) has never been reported, whereas this is a common problem with other antidepressants and the reason many people choose to discontinue using them Sexual dysfunction (as a side effect) has never been reported, whereas this is a common problem with other antidepressants and the reason many people choose to discontinue using them Clinical studies have proven St. John’s Wort to be for mild to moderate depression (a significant difference was found between the placebo group and the group receiving St. John’s Wort) Clinical studies have proven St. John’s Wort to be for mild to moderate depression (a significant difference was found between the placebo group and the group receiving St. John’s Wort)

19. Disadvantages Is not recommended for Severe Depression or Bipolar disorder Is not recommended for Severe Depression or Bipolar disorder Although St. John’s Wort is widely used and accepted in Europe, specifically Germany, it is not FDA approved in the United States for medical purposes Although St. John’s Wort is widely used and accepted in Europe, specifically Germany, it is not FDA approved in the United States for medical purposes Since it is not regulated in the U.S., there is no regulatory oversight of the manufacturing, distributing and labeling of St. John’s Wort, therefore the contents and potency of the herb cannot be guaranteed Since it is not regulated in the U.S., there is no regulatory oversight of the manufacturing, distributing and labeling of St. John’s Wort, therefore the contents and potency of the herb cannot be guaranteed There have been cases in the past where herbal products (not necessarily St. John’s wort) were analyzed and sometimes found to contain dangerous toxic compounds. There have been cases in the past where herbal products (not necessarily St. John’s wort) were analyzed and sometimes found to contain dangerous toxic compounds.

20. Evaluation St John’s Wort seems to be an effective alternative to more popular antidepressants St John’s Wort seems to be an effective alternative to more popular antidepressants The side effects are few and quite mild in comparison with MAOI’s and TCA’s The side effects are few and quite mild in comparison with MAOI’s and TCA’s While it is not as acceptable of a treatment for depression as other antidepressants, it is widely used in Europe, specifically Germany, where it has been, and continues to be, widely researched. The research shows significant effectiveness when compared to placebos and other antidepressants While it is not as acceptable of a treatment for depression as other antidepressants, it is widely used in Europe, specifically Germany, where it has been, and continues to be, widely researched. The research shows significant effectiveness when compared to placebos and other antidepressants

21. Evaluation There is some concern over Hypericum’s interaction with other medication. There is some concern over Hypericum’s interaction with other medication. For example, Women more commonly suffer from depression than men do, yet this herb reduces the effectiveness of oral contraceptives. For example, Women more commonly suffer from depression than men do, yet this herb reduces the effectiveness of oral contraceptives. In the future, it would be beneficial to see more sound research on how it works in the brain and long term effects In the future, it would be beneficial to see more sound research on how it works in the brain and long term effects