Researcher examines Saint John’s wort

by Kelly Field, Public Relations

Dr. Naresh Emmannuel is one of six MUSC researchers currently studying the effect of St. John's wort on depression.

It’s called Saint John’s wort, and if popularity is any predictor, it may someday replace Prozac as the most commonly prescribed treatment for depression.

Little, yellow, and different (from Prozac, that is), Saint John’s wort (Hypericum Perforatum) has long been studied in Europe, where patient demand has made it a near-standard supplement to traditional treatments. But it was not until recently that it attracted the attention of researchers here at MUSC and research centers nationwide. Their response came from a finding that many prospective test subjects were self-medicating with the herb.

“We found in our entrance interviews that a lot of people were using herbs and not telling us,” said Naresh P. Emmannuel, M.D., assistant professor of psychiatry, whose screening of 227 subjects for an anxiety and mood disorder study revealed that one-third had used herbal treatments in the past three months, 29 percent (37) of them Saint John’s wort. “They were just assuming that since it was natural it was benign.”

While an overview and meta-analysis of 23 randomized clinical trials in Europe published by the British Medical Journal (Volume 313 pages 253-258), suggested that this assumption might be correct, researchers in the United States were dissatisfied with the limited evidence. Too many problems existed with the continental research, and scientists decided to replicate the trials here, this time with a uniform definition, a standardized extract, and a longer observation period.

Their goal was to determine whether the herb was as innocuous as the studies suggested, and whether it was indeed more effective than a placebo in treating depression. They also planned to extend the research by comparing hypericum, the presumed active ingredient in Saint John’s wort, with other market antidepressants.

“There were a lot of holes in the research,” said Emmanuel, one of six MUSC members currently participating in a nationwide trial organized by Vanderbilt University. “And there was a need to evaluate the efficacy and safety of hypericum as compared with other treatments.”

The MUSC study, which Emmanuel characterizes as “double-blind,” “placebo-controlled,” is a part of one of three resultant studies. Currently slated to run until the year 2000, it pits hypericum against a placebo, administering 600 to 1,200 ml of hypericum to half the subjects and placebo to the rest. If it and other tests of the drug (including one comparing hypericum with sertraline prove successful, Saint John’s wort might eventually come to supplement, or even supplant, the present pharmaceutical preference, Prozac.

“It could go either way,” said Emmanuel, explaining the process by which an herb would theoretically obtain “drug” status. “The findings will in part dictate this.”

If shown to be safe and significantly better than the current standard, hypericum could potentially be approved by the Food and Drug Administration, the national organization responsible for approving manufactured drugs. Finding enough funding for the requisite research could prove problematic, however. The National Institute of Mental Health (NIMH) has limited funding, and pharmaceutical companies, the primary sponsors of drug research, are reluctant to underwrite treatments they can’t potentially copyright.

“You can’t really say Saint John’s wort is `mine, mine, mine,’” joked Emmanuel, evoking scenes of drug companies calling their stock brokers to announce the good news. “It's found in nature, so you can’t really say you invented it. And you can’t own it, either.”

And even assuming sufficient funding, Saint John’s wort will probably not become mainstream tomorrow. The FDA has not been traditionally receptive to unsponsored treatments, and St. John’s wort will probably spend several more years as an alternative treatment before being “recognized” with the “drug” label. If this re-classification comes, it will probably come out of necessity, as unchecked markets proliferate and quality assurance becomes essential.

Still, there are some indications that alternative medicines are becoming tolerated, if not wholeheartedly embraced. Herbal remedies are currently being used for conditions ranging from irritable bowel syndrome, to carpal tunnel syndrome, to Premenstrual Syndrome and the Physician Desk Reference, the “gold standard” in drug prescriptions has recently produced a book on alternative treatments.

“We are seeing an increased interest in alternative medicine,” said Emmanuel, justifying a replication of the suspect European studies. “There is no question that people take these herbs. It’s a $4 billion business. The question we’re trying to find the answer to now is “do they work?”

For further information on this study or to participate call the Department of Psychiatry and Behavioral Sciences at 792-5900.

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