ONLINE HERBALIST

St. John’s Wort: Snapshot


Saint John’s wort has been used for over one thousand years to treat depression. It is an official herb in the pharmacopoeias of Czechoslovakia, Poland, Romania, and Russia. Saint John’s wort restores the nerves, breaks up chi stagnation, and calms and lifts the spirit. It also promotes tissue repair, deters infection, and helps relieve pain. It can help heal damaged nerves when used internally or externally. It is thought that its action results in part from its ability to block the reabsorption of serotonin and that it might also enhance the body’s receptivity to light. One of its components, hypericin, increases serotonin and melatonin metabolism. Another component, hyperforin, inhibits the uptake of dopamine, serotonin, noradrenaline, gamma-aminobutyric acid (GABA), and L-glutamate, thereby allowing these neurotransmitters to persist longer in the body, which contributes to emotional stability.

Topically, Saint John’s wort can be prepared as a compress to treat mastitis and skin ulcers. Oil infused from the fresh plant is a beautiful shade of red and is used to treat back pain, bruises, burns, haemorrhoids, herpes, insect bites, nerve pain, perineal tears, stomach cramps, temporomandibular joint (TMJ), swellings, sunburn, tumours, ulcers, varicose veins, and wounds. The oil or a liniment prepared from the plant can be rubbed onto the spinal cord in treatments for arthritis, electric shock, hysteria, lumbago, neuralgia, paralysis, rheumatism, and sciatica.

Botanical Name

Hypericum perforatum

Part Used

Aerials

Common Names

Allheal; Herba John, John’s Wort, Fuga Daemonum; Goat Weed; Tipton Weed; Amber; Klamath Weed; Amber; Johannesort (Swedish); Hipericon (Spanish); Zwieroboij (Russian); Perforata, Iperico (Italian); Johanniskraut, Johannisblut, Blutkraut, Herrgottsblut, Lochkraut (German); Herba de Millepertuis, Herba de Saint Jean, Toutsaine (French); St. Jan’s Kraut, Sankt Hans Urt (Dutch); Qian Ceng Lou (Chinese); Dziurawiec Pospolity (Polish)

Brief History

Hypericum perforatum Flower

The plant takes its name from St. John the Baptist for it usually begins to bloom on his feast day, June 24th. It was reputed to bleed on the anniversary of the saint’s beheading. In Greek, hypericon means “over an apparition” since it was thought to protect one from evil. Later, the same attributes were transferred to Christianity, in which the herb became Herbal Sancti Ionnis. The word wort simply means herb.

It’s been used for centuries for depression, melancholy and hysteria. Paracelsus was one that prescribed it for these afflictions. One study by Dittmann, Hermann and Palleske showed that Hyperforat, a preparation based on a total extract, gave a well-reproducible specific inhibition of anaerobic glycolysis in secretions of brain tumours. An infusion of leaves and flowers in olive oil is excellent for skin burns. The herb/flowers are the parts used for lung problems, bladder complaints, diarrhoea, dysentery, depression, haemorrhages and jaundice. Steep two teaspoonsful of the herb per cup of water for twenty minute. Take one- half cup in the morning and one-half cup at bed time. Bedwetting is helped by a nightly cup of the tea or 5-10 drops of the tincture.

Constituents

Naphthodianthrones including hypericin and pseudohypericin. Flavonoids including hyperoside, rutin and quercetin, phenolic compound including hyperforin, procyanidins, essential oil and xanthones

Therapeutic Properties

Antidepressant, anti-inflammatory, antiseptic (topically), antiviral, anxiolytic, astringent, nervine tonic, relaxant, wound-healing

Vitalist Properties

Temperature: Cool

Moisture: Drying

Therapeutic Indications

Anxiety, depression including post natal and menopausal depression, irritability, nervousness, nervous excitability and nervous exhaustion, fibrositis, sciatica, neuralgia, premenstrual syndrome, wounds (topically)

Primary Uses

Burns and Skin Disorders

Studies in rats have shown that St. John’s wort is more effective for wound healing than placebo or calendula. Clinical studies have found that an ointment prepared by mixing fresh St. John’s Wort flowers with olive oil greatly accelerates the healing of burns. St. John’s wort lotions prevent skin infection with Staphylococcus aureus (staph infection). In one study, patients with subacute atopic dermatitis applied a topical cream made from hypericin extract for four weeks and their eczema healed better than the placebo group’s eczema. Hypericin-containing extracts may prove useful for the treatment of psoriasis, warts, and certain forms of skin cancer.

Cancer.

St. John’s wort increases sensitivity to light. Photodynamic therapy is a type of treatment based on the ability of cancer cells to selectively take up a specific compound that makes the cancer cells more sensitive to specific wavelengths of light so that irradiation kills only the cancer cells. In experiments using mice, hypericin was shown to accumulate specifically in tumour tissue. When the hypericin-treated mice were irradiated, tumour growth was inhibited. Similar results have been found in human tumour cells. These results suggest that hypericin can be used as a photodynamic therapy in the treatment of cancer. The use of extracts containing hypericin may prove beneficial for certain types of skin cancer, such as cutaneous T-cell lymphoma, melanoma, and Kaposi’s sarcoma. Other studies were done in cell lines of human colon cancer, leukaemia, and gastrointestinal tumour cells, and hypericin showed the ability to kill cancer cells, but more work is needed before it can be recommended as a treatment for any type of cancer.

Depression

The most common use of St. John’s wort is in the treatment of depression. Although the exact way in which the herb works is not yet known, St. John’s wort is often described as a “natural Prozac.” Hypericin (or, more likely, a group of chemicals in this plant including hypericin) does, in fact, prevent the reuptake of serotonin by brain tissue, allowing this mood-controlling brain chemical to fight depression. However, St. John’s wort has also been described as a natural monoamine oxidase (MAO) inhibitor, acting in the same way as the antidepressant drugs commonly used before fluoxetine (Prozac). The whole herb does not seem to have this effect because it is not concentrated enough. There is also another possible explanation of how St. John’s wort works to counteract depression. Scientists at Humboldt University in Berlin have found that hypericin stops the production of cytokines, hormonal messengers that transmit sensations of pain and irritation. Small changes in cytokine balance apparently can make huge differences in brain function, affecting not only depression but also partial seizure disorders. In one study, blood samples were taken from a group of depressed patients and a group of healthy volunteers. Cells were bathed in an extract of hypericum. In both groups, there was a reduction in cytokines. It is thought that St. John’s wort lowered the number of cytokines, which leads to a decrease in corticotrophin releasing hormone, which triggers depressive moods.

However St. John’s wort acts against depression, its effects have been demonstrated in large-scale clinical tests against placebos and other antidepressant medications. A statistical review of twenty-three studies involving 1,757 outpatients with mild to moderate depression found that St. John’s wort was better than placebo and had an effect comparable to such antidepressants as amitriptyline (Elavil), maprotiline (Ludiomil), and imipramine (Tofranil). Typical doses of St. John’s wort ranged from 350 to 1,800 milligrams a day. Other double-blind studies found that St. John’s wort was more effective than fluoxetine (Prozac) and sertraline (Zoloft) and that it caused fewer and less severe side effects. In a meta-analysis of several studies, St. John’s wort was shown to be more effective than placebo and as effective as tricyclic antidepressants in treating moderate depression. In one study, 65 percent of the participants who took the herb got better. The participants took 300 milligrams of St. John’s wort three times a day to total 900 milligrams daily. Another study of this herb discounted its effects against depression, but that study did not discriminate between mild to moderate depression and severe depression. Other studies of St. John’s wort have focused on mild to moderate depression and have found the herb effective. In another study, using an extract of hypericum WS 5570, patients with acute episodes of moderate depression got better and had fewer depressive symptoms, according to the Hamilton Rating Scale for Depression, and also had fewer relapses than a placebo group. The German Commission E has approved the use of St. John’s wort for mild to moderate depression. In all probability, the herb does not have usefulness in treating severe depression. And if it is used in cases of severe depression, it should be used in combination with other therapies. In one study of patients with severe depression, hypericum WS 5570 was as effective as a commonly used selective

The German Commission E has approved the use of St. John’s wort for mild to moderate depression. In all probability, the herb does not have usefulness in treating severe depression. And if it is used in cases of severe depression, it should be used in combination with other therapies. In one study of patients with severe depression, hypericum WS 5570 was as effective as a commonly used selective serotonin reuptake inhibitor (SSRI) drug. However, the authors cautioned against using St. John’s wort in this way because it has numerous interactions with other medications. The focus has now shifted from efficacy to the potentially harmful aspects of the herb.

Clinical Research

  • Meta-analysis and systematic reviews, including the Cochrane review, published from 1996 to 2000 concluded that St. John’s wort extracts are more efficacious than placebo for treating mild to moderate depression. More data is required to assess its efficacy compared with other antidepressant medication. Fewer side effects were, however, reported for St. John’s wort extracts compared with standard antidepressants. For the trials considered in one of the previously listed reviews 20 and based on recent formulation specifications, the most common daily dose of extract prescribed corresponded to approximately 5 g of dried herb, containing 2.7 mg of TH. One trial investigated the efficacy of a high daily dose (twice this dose).
  • Since the publication of these reviews, further trials have been published. Two randomized, double-blind, multicenter studies found St. John’s wort extract to be more efficacious than placebo and at least as beneficial as imipramine (a tricyclic antidepressant) in treating mild to moderate depression. St. John’s wort extract (equivalent to 6 g/day of dried herb and containing 2.6 mg/day of TH and 26 mg of hyperforin) was compared to 100 mg/day imipramine or placebo for 8 weeks. The other trial compared the effects of St. John’s wort extract containing 1 mg per day hypericin with 150 mg per day of imipramine over a 6-week period. Side effects were less common in patients taking the St. John’s wort extract in both studies. The design of these studies has been questioned, notably the use of imipramine as a comparison instead of a more modern antidepressant, the short duration of treatment, and the absence of a placebo group (in the case of one trial).
  • A number of trials found that standardized St. John’s wort extracts compared favourably with the SSRI fluoxetine, particularly for treating depressed patients with anxiety symptoms. The dose of St. John’s wort used was equivalent to 4.8 g per day of dried herb in one of these trials and was standardized to contain 1 mg per day hypericin in two others. 28, 29 Duration of treatment was typically 6 weeks. A review of controlled trials found St. John’s wort as efficacious as fluoxetine for mild depression. St. John’s wort compared favourably with the SSRI sertraline for treating mild to moderate depression in a randomized, placebo-controlled pilot trial involving a small group of outpatients.
  • A randomized, double-blind, placebo-controlled, multicenter trial published in 2001 concluded that standardized St. John’s Wort extract administered for 8 weeks was not an effective treatment for severe depression compared with placebo. Although St. John’s wort was found to be safe and well tolerated, no significant benefits above placebo were observed for the Hamilton Depression Scale (HAMD) or other measures of anxiety or depression. However, the number of patients reaching remission of their illness was significantly higher in the St. John’s wort group compared with placebo (based on intention- to treat analysis). This effect was not regarded as clinically significant by the authors. The daily doses corresponded to approximately 5 to 7 g of original dried herb. A number of letters were published criticizing the design of this trial (see letters published in JAMA 286(1):42, 2001). Of relevance is that a trial included in one of the systematic reviews found similar efficacy for St. John’s wort compared with imipramine (150 mg/day) in treating severe depression. The response rates were low for both groups, but fewer side effects were recorded in the herbal treatment group. The daily dose of St. John’s wort extract corresponded to approximately 8 g of original dried herb and provided 5.4 mg of TH.
  • The results of a postmarketing surveillance study suggest that St. John’s wort is beneficial for treating mild to moderate depression in children under 12 years of age. The 76 children who completed the study were treated with a St. John’s wort extract, the majority of patients receiving daily doses corresponding to approximately 1.7 to 3.3 g of original dried herb (containing 0.9 to 1.8 mg of TH) for 4 to 6 weeks. No adverse events were reported.
  • St. John’s wort extract reduced depressive symptoms in patients addicted to alcohol and was well tolerated in a randomized, double-blind, placebo-controlled trial involving 119 male and female patients. The daily dose corresponded to 2.7 mg of TH.
  • St. John’s wort extract for 4 weeks (containing 2.7 mg/day TH) significantly reduced HAM-D scores in patients with seasonal affective disorder (SAD) when combined with either bright or dim light therapy in a single-blind trial. In an uncontrolled trial, survey results showed a significant improvement from baseline values for anxiety, loss of libido and insomnia in patients with SAD treated with St. John’s wort alone and in those treated with both St. John’s wort and light therapy. No significant between-group differences were observed, except that improvement in sleep was greater in the combined treatment group. New findings suggest that the photodynamic impact of St. John’s wort increases the effect of normal light as if the patient were subject to continuous light therapy.
  • In an open, pilot trial, administering St. John’s wort extract (standardized to 2.7 mg/day hypericin for 12 weeks) produced promising results in treating obsessive-compulsive disorder.
  • Oral treatment with St. John’s wort extract reduced the number of patients experiencing herpetic episodes and the total symptom score compared with placebo in two double-blind, randomized trials lasting 90 days. The trials included 94 patients with recurrent orofacial herpes and 110 patients with genital herpes.
  • In a randomized, double-blind trial, St. John’s wort extract (0.9 mg/day TH) did not demonstrate a significant effect over placebo for treating painful polyneuropathy. However, a tendency to improvement was observed, which did not achieve statistical significance, possibly because of the low patient numbers involved.
  • In an open, observational study, improvement in symptoms was observed in premenopausal and postmenopausal women after 12 weeks of treatment with St. John’s wort (standardized to 0.9 mg/day TH). Climacteric complaints such as irritability and outbreaks of sweating decreased or disappeared in the majority of women. Sexual well being also improved. A St. John’s wort and black cohosh combination significantly reduced menopausal symptoms compared with placebo in a randomized, double-blind trial involving 179 women. The daily dose of herbal treatment corresponded to 0.5 mg of TH and 2 mg of 27-deoxyactein (a marker compound in black cohosh).
  • An uncontrolled, pilot study with St. John’s wort found improvement in PMS scores and a decrease in symptom severity when the herb was administered for two menstrual cycles. The daily dose of extract contained 0.9 mg TH.
  • In an uncontrolled trial, St. John’s wort extract (standardized to deliver 0.5 mg/day TH) for 3 weeks produced a significant increase in nocturnal melatonin plasma concentration in healthy volunteers.
  • A placebo-controlled, crossover study found that 6 weeks of treatment with St. John’s wort extract (equivalent to 2 g/day of dried herb) significantly improved vigour while reducing anger, fatigue, confusion, and mood disturbance in athletes. In a double-blind, placebo-controlled trial, athletes were randomized into three groups: St. John’s wort plus vitamin E, vitamin E, and placebo. The St. John’s wort plus vitamin E group demonstrated a significantly better aerobic endurance capacity compared with the other groups. The daily dose of St. John’s wort used was approximately 170 mg of standardized extract, probably corresponding to approximately 1 g of dried herb.
  • In Germany, the Commission E supports using St. John’s wort internally to treat anxiety-related symptoms and depressive moods, as well as anxiety, nervous unrest, or both. Oily St. John’s wort preparations are recommended internally for dyspeptic complaints and externally for treatment and post-therapy of acute and contused injuries, myalgia, and first-degree burns.

Dosage (Divided Daily)

Dried Aerials: 6,000 – 12,000mg (as an infused tea)

• Standardised Extract: 2 – 3mg Hypericin (Active Ingredient)

• Tincture: 2 – 6 mL (1:2)

Contraindications

  • Not suited to treating serious depression with psychotic symptoms or suicidal risk.
  • St. John’s wort is not advisable in cases of known photosensitivity. Patients taking higher doses should avoid excessive exposure to sunlight and UV radiation.

Side effects

  • In patients who are HIV-positive receiving oral St. John’s wort, mild, reversible elevations of serum liver enzymes were observed.
  • A postmarketing surveillance study of 3250 depressed patients reported that 2.4% experienced side effects that were mainly mild gastrointestinal complaints and allergic reactions, such as pruritis.
  • No reliable evidence of phototoxicity in humans has been found. Investigations involving volunteers found that the threshold daily dose for a mild increase in photosensitization was approximately 2 to 4 g of commercial extract (containing 5 to 10 mg of hypericin). Reversible photosensitivity has been observed in patients receiving oral doses of isolated hypericin (0.05 to 0.10 mg/kg of body weight/day). Avoiding excessive exposure to sunlight or artificial UVA light is advisable for patients taking high doses, and St. John’s wort should be used cautiously in patients with known photosensitivity.
  • Several cases of hypomania were reported for individuals with no history of bipolar disorder after taking St. John’s wort. Episodes of mania were also reported for two people with a history of bipolar depression and in one depressed patient concurrently taking sertraline. In the last case, the adverse reaction may have been the result of the drug alone. A psychotic episode associated with using St. John’s wort was reported for a woman who was later diagnosed as having Alzheimer’s disease.

Interactions with other drugs

  • Concurrent administration of high doses of St. John’s wort is contraindicated with the following drugs: warfarin, digoxin, and cyclosporine, as well as indinavir and related anti-HIV drugs.
  • St. John’s wort may interact with a number of drugs, possibly via cytochrome P-450 induction.
  • Practitioners should avoid prescribing St. John’s wort if patients are taking immune suppressants (cyclosporine) cardiac glycosides (digoxin), HIV nonnucleoside reverse transcriptase inhibitors (nevirapine) 1 and other HIV protease inhibitors (indinavir), the chemotherapeutic drug irinotecan (Camptosar) 2, and the anticoagulants warfarin and phenprocoumon.
  • Caution should be exercised when prescribing St. John’s wort to patients taking selective serotonin reuptake inhibitors (SSRIs) because of potential effects on serotonin levels and the risk of subsequent serotonin syndrome (confusion, fever, shivering, sweating, diarrhoea, and muscle spasm).
  • Several reports indicate breakthrough bleeding occurring in women taking St. John’s Wort while on the oral contraceptive pill (OCP) and recent reports from Sweden and Britain of unwanted pregnancies. Practitioners should exercise caution with women who are taking a very low dose OCP.
  • Concerns have also been raised about the concurrent administration of St. John’s wort with theophylline (a broncho-relaxant) and phenytoin (an anticonvulsant). A case was reported in which St. John’s wort reduced serum levels of theophylline. However, no clinical adverse effects have been reported for phenytoin or any other anticonvulsant drugs. In fact, an open trial demonstrated that St. John’s wort extract had no effect on carbamazepine pharmacokinetics in eight healthy volunteers.


 Bibliography
  1. Balch, P. A., & Bell, S. J. (2012). Prescription for Herbal Healing (2nd ed.). New York, N.Y.: Avery.

  2. Bone, K. (2003). A clinical guide to blending liquid herbs: herbal formulations for the individual patient. St. Louis, MI: Churchill Livingstone.
  3. Herbalpedia (2013)
  4. Mars, B. (2007). The desktop guide to herbal medicine: the ultimate multidisciplinary reference to the amazing realm of healing plants, in a quick-study, one-stop guide. Laguna Beach, CA: Basic Health Pub.
  5. Mills, S., & Bone, K. (2000). Principles and practice of phytotherapy: modern herbal medicine. Edinburgh; London: Churchill Livingstone. 

All material on this website is provided for your information only and may not be construed as medical advice or instruction. No action or inaction should be taken based solely on the contents of this information; instead, readers should consult appropriate health professionals on any matter relating to their health and well-being.

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