St. John's Wort Versus Prozac - All A Matter Of Perspective
February 2000
by Peter Golden, Publisher

Dietary 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.

Supplement 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.

The 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."

Similar to Prozac and Zoloft

The 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.

While 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.

Subsequently, 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.

Regarding 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 reference product.

While 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 depressed individuals?

Over-prescribing powerful pharmaceuticals

In 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 pharmaceuticals.

In 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).

In 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.

Excessive dosage levels

In 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.

Notably, 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.

Whatever 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:

If 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?

Put 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? Think again.

Insolvent!

Ever 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 medicines.

What 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.

With 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.

The choice we face

Whatever 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?

Is 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.