John's Wort Versus Prozac - All A Matter Of Perspective
by Peter Golden, Publisher
supplements are hot! A joint survey undertaken in the spring of
1999 by Harvard's Kennedy School and National Public Radio revealed
that over 50% of adult Americans view supplements favorably and
would continue to take them, even if their doctor recommended otherwise.
popularity notwithstanding, several critical issues must be addressed
if they are to enter the mainstream currently occupied by prescription
medicines. Example: A special report covering the entire lead page
in the Health/Science section of the January 10, 2000 edition of
The Boston Globe focused on dietary supplement testing.
article, entitled "St. John's wort: Less than meets the eye," was
accompanied by a subhead carrying the additional information that
"Globe analysis shows popular herbal antidepressant varies widely
in content, quality."
to Prozac and Zoloft
real story in the Globe special, however, lay not in the
articles on testing methods and a call for FDA oversight. Clearly
visible on the first page of the article, but otherwise presented
without comment, was graphical information long known to users of
dietary supplements: Both chemical analyses and biological testing
show that St. John's wort possesses properties similar to Prozac
and Zoloft - two pharmaceutical drugs widely prescribed for depression.
this information comes as no surprise to many consumers of dietary
supplements, its presence in the pages of a nationally recognized
newspaper published in one of the world's leading medical centers
is noteworthy in and of itself.
an article appeared in The New York Times, parent paper of
the Globe, surveying federally supported research on dietary
supplements. In contrast to past Times coverage, the article
was straightforward and unbiased, at times even hopeful that the
combination of federal money and hospital-based, scientific research
might prove the efficacy of certain widely-used supplements.
the Globe study, of seven leading St. John's wort brands,
two (Quanterra and Naturemade) came close to or exceeded the levels
of seratonin and dopamine reuptake inhibitors present in a "test
reference product" of St. John's wort (Perika) shown to be effective
in clinical trials. Corresponding levels of these reuptake inhibitors
present in Prozac and Zoloft varied from 97% to 254% of the test
both Prozac and Zoloft packed more "punch" than all tested samples
of St. John's wort, their enhanced strength begged a question: at
what financial cost when compared to the needs of mildly or moderately
part, the answer to this question comes from a different, and somewhat
unexpected quarter: the December 6, 1999 edition of Newsweek.
There, Dr. Jay S. Cohen MD, a clinical professor at the University
of California, San Diego and author of Make Your Medicine Safe,
highlights the often deleterious effects of over-prescribing powerful
an article entitled "The One-Size Dose Does Not Fit All," Cohen
raises the idea that scores of prescription drugs (at least 150
by his count) are often just as effective when administered in significantly
lower doses than is currently the practice (5 and 10 mg doses vs.
typical 20 and 50 mg amounts).
support of his thesis, Cohen faxed an article to SupplementQuality.com
entitled "Free Communications: Depression" from the Volume 24, No.
1, 1988 edition of Psychopharmacology Bulletin. This study
of low-dose administration of fluoxetine (the generic name for Prozac),
suggests that patients who are mildly to moderately depressed (About
50% of all depressed patients!) will benefit from lower doses of
fluoxetine - and that increases in dosage provide only modest gains
in the number who benefit.
his Newsweek article, Cohen cites many instances in which
the recommended dosage levels of medications for high blood pressure,
cholesterol and depression - levels recommended by manufacturers
and the Physicians' Desk Reference - actually have a deleterious
effect on patient health.
Eli Lilly, the developer of Prozac and the sponsor of the research
published in the Psychopharmacology Bulletin, appears to
have omitted the study referenced by Cohen from the Physicians
Desk Reference. Just as notably, the Physicians Desk Reference,
while widely viewed as "authoritative" and "objective," is actually
a "paid insertion" marketing tool distributed free to physicians
throughout the US.
Lilly's reasons for omitting a self-sponsored study that runs counter
to the notion of administering higher dosage levels of anti-depressants
to patients than might otherwise be needed, the combination of the
Globe's test findings and Cohen's previously published article
in Newsweek lead to an interesting question:
manufacturers of St. John's wort can achieve consistent test results
for quality (of bottle content vs. label statements), what's to
stop individuals from buying this common herb with the reasonable
assurance that in the case of mild or even moderate depression,
it is useful?
another way, what's to stop physicians from recommending it, or
for that matter, individuals from growing, distributing and using
it themselves? Think the issue is trivial, or borders on the fringes
of "feel good" alternative medicine or self-prescription run amuck?
increasing numbers of health maintenance organizations are going
bankrupt. Harvard Pilgrim Health, a Massachusetts insurer of more
than 1 million patients, recently announced it was insolvent to
the tune of over $180 million dollars. (Creditor hospitals estimate
the figure is closer to $300 million.) As expected, a large but
unspecified component of the health plan's debt is for prescription
are the cost implications if a large number of mildly depressed
individuals start using St. John's wort as an alternative to prescription
medicines? Answer: No one knows for sure, but consumers aren't waiting
for a cost analysis.
a physician's guidance, significant savings are possible. Without
a physician's intervention, but perhaps the guidance of a nurse
practitioner, alternative health provider or clinically sanctioned
Web site, even greater savings are possible. All approaches are
worth examining, both by health care consumers and providers.
choice we face
approach one takes, and free markets typically represent a variety
of them, the crisis in health care costs is real. As a society,
do we want to spend more money on expensive pharmaceuticals, or
do we want to establish uniform quality standards for dietary supplements
like St. John's wort that are both effective and cost efficient?
St. John's wort worth endorsing as a mainstream solution for mild
or moderate depression? If it is, do we regulate it to the point
that medicinal benefits are overcome by cost? Or do we allow it
the widest access possible in the marketplace? The answer seems
obvious, but it's all a matter of perspective.