St. John’s Wort for Depression

The herbal antidepressant St. John’s wort is the most widely prescribed antidepressant in the world, and it is highly effective in treating depression. The botanical name is Hypericum perforatum. Its standard uses are for mild-to-moderate depression, but St. John's wort has been used for major depression as well. When researchers have compared St. John’s wort to Zoloft and Paxil, St. John’s wort was as effective as medications and patients reported fewer side effects. One of its constituients, hyperforin, has also been shown to be highly anti-inflammatory, and this likely contributes to its effectiveness in treating depression.


Used by itself, St. John’s wort has an excellent safety record. But there are two important cautions. First, it does interact with several classes of medications, so should not be combined with antidepressants, birth control pills, cyclosporins, and several other classes of medications. If you decide to take St. John’s wort, be sure to tell your doctor or other health care provider. Second, brands of herbal products vary widely in quality, and it’s not always possible to tell which product is good quality. Seek the advice of a naturopath or licensed herbalist to find a good product. Or for a small fee, ConsumerLabs.com provides information on specific brands. Below are some resources and recommendations regarding use of St. John's wort.

Dosage: 300 mg, three times a day

Standardized to 0.3% hypericin or 2% to 4% hyperforin

The Complete German Commission E Monographs available online and for purchase from the American Botanical Council, www.herbalgram.org

Exercise Can Treat Major Depression

Health care providers often believe that alternative treatments for depression are only appropriate for mild depression. For more serious depressions, the patient needs DRUGS. But is that true? As I mentioned in a previous post, there are a number of non-drug treatments for depression. For this posting, I’d like to focus on exercise.

Two recent studies at the Duke University Medical Center tested exercise as a treatment for depression by putting it head-to-head with Zoloft in two randomized clinical trials. The patients were older adults with major depression. In both studies, exercise was as effective Zoloft.

Other studies have found that exercise prevents or treats depression with a wide range of people. The strongest effects are for aerobic exercise, but weight lifting and stretching/yoga are also helpful. If you exercise at a moderate level, exercise is safe during pregnancy or breastfeeding. The guidelines for treating mild-to-moderate and major depression with exercise are listed below.

The recommended exercise regimen for treating major depression requires more effort than the regimen for mild-to-moderate depression. But it is a viable alternative to medications and many women find that it is worth the effort. In the second Duke study, the researchers found that the group that came to the lab to exercise had a lower rate of depression than the group that followed a home-exercise program. The fact that they needed to come to the laboratory probably meant that they also received social support from study staff and fellow participants in addition to benefits of exercise. The participants were also probably more likely to exercise regularly when they knew that they were expected to show up some place. You might find that exercise in a group setting works well for you too.

How much exercise do you need to do? Here are some guidelines summarized from several recent studies.

For mild-to-moderate depression
• Frequency: 2 to 3 times a week
• Intensity: moderate
• Duration: 20 to 30 minutes

For major depression
• Frequency: 3 to 5 times a week
• Intensity: 60% to 85% maximum capacity
• Duration: 45 to 60 minutes

Exercise is another thing you can do for yourself to increase your physical and mental well-being. Get off that couch and just do it! You’ll be happy you did.

Can Fats Make You Happy?: Omega-3 Fatty Acids and Depression

Is all the discussion about Omega-3 fatty acids in health just a bunch of hype? The short answer is “no.”

Our best evidence on the effectiveness of Omega-3s is in the prevention of heart disease. They are particularly good at lowering triglycerides. And as I described in a previous blog, heart disease and depression and not only related, but likely share a similar underlying mechanism.So the fact that Omega-3s are helpful for both makes sense.

The long-chain Omega-3 fatty acids, EPA and DHA, have been used successfully to both prevent and treat depression. Both of these are found in fatty fish. EPA is the Omega-3 that actually treats depression because it specifically lowers inflammation and lowers the stress response. It has been used by itself or has been combined with medications. When it is used with medications, it makes medications work more effectively. The American Psychiatric Association recently recognized EPA as a promising treatment for mood disorders.

DHA helps prevent depression, but does not treat it by itself. It is usually combined with EPA. There is a vegetarian source of DHA, but no vegetarian source of EPA; fish oil is still the best source. Sources and dosages are listed on the side bar. Even in relatively large doses, EPA and DHA are safe for children, pregnant and breastfeeding women, and other populations. In addition, they provide a number of other health benefits for men and women, including lower their risk of heart disease and making them less vulnerable to stress.

For vegetarians, the bad news is that ALA, the Omega-3 in flax seed and other plant sources, such as walnuts and canola oil, does not prevent or treat depression. ALA is not harmful and can be helpful in other ways. But it is metabolically too far removed from EPA to aid in lessening depression.

What I like is that there really is no downside to using Omega-3s. And there is considerable upside. Even if they doesn’t lessen depression by themselves, they increase overall health. And that is a good thing.

Alternative Treatments for Depression in Pregnant Women

There has recently been a lot of discussion in the news about the potential hazards of taking antidepressants while pregnant. Some are concerned that they increase the risk of birth defects. Proponents of antidepressants point out, correctly, that depression during pregnancy is also risky and can lead to premature delivery and other complications.

Health care providers often make treatment decisions by balancing the risks and benefits of a medication. Is the risk of using the medication less than the risk of the mother getting depressed again? In most cases, the risk of using the medication is less than the risk of possible depression, so clinicians will prescribe it. But are antidepressants the only choice?

Curiously, while people debate about antidepressant use in both research studies and the popular media, non-drug treatments for depression are largely absent from the discussion. Fortunately, antidepressants are not the only choice for treating depression and may offer a safe “third choice” for treating depression during pregnancy. Physicians and other health care providers may not consider these non-drug treatments, assuming that they cannot address more severe depression.

But recent research paints a very different picture. There are a number of non-drug treatments that are effective for even major depression. Non-drug treatments include Omega-3s, exercise, bright light therapy, psychotherapy, and St. John’s wort. Many of these can be combined with each other, and are sometimes used in addition to antidepressants (only St. John’s wort cannot be combined with medications). What all these treatments have in common is that they are all specifically anti-inflammatory. In the next few installments, I’ll explain that in more detail. But it’s important to know that there are alternatives, and these are especially important to consider during vulnerable times, like pregnancy.

Depression and Inflammation: The Surprising Link

Depression is risk factor for depression. Researchers have known that for many years but couldn't really explain why—until now.

In the past 10 years, researchers have firmly established that a lot of common diseases--such as diabetes, cancer, Alzheimer’s, and yes, even heart disease--are due to inflammation. For example, physicians have noted that elevated levels of an inflammatory marked called C-reactive protein is an early harbinger of heart disease.

But here’s where the plot really thickens. Depression is also caused by inflammation, and specifically by elevated levels of molecules called proinflammatory cytokines. In fact, by specifically treating people with cytokines, as they do for conditions such as MS, doctors have actually caused depression. The more cytokines patients received, the more depressed they got. When the patients started to taper off of the cytokines, the depression got better too.

Depressed people have significantly higher levels of the cytokines in their plasma than non-depressed people. And this is where the disease-depression link comes from. High levels of proinflammatory cytokines damage blood vessels, and elevate other factors in the blood that increases the risk of clots.

And in another interesting twist, we now know that most of the effective treatments for depression have one thing in common: they are also anti-inflammatory. In fact, that knowledge has fueled some very interesting discoveries. For example, antidepressants lower inflammation levels in cardiac patients. And they’ve been added to steroids for treating asthma, leading to the use of fewer steroids in these patients.

This discovery has also led to some novel ways of treating depression. For example, anti-inflammatory medications, such as ibuprofen, which is not an antidepressant, have been added to antidepressants to make them more effective. Adding Omega-3 fatty acids to a treatment regimen helps with depression for the same reason.

Knowing about the anti-inflammatory connection also gives us a framework for understanding why non-medication treatments for depression would also work.

Inflammation: The Key to the Link between Stress and Disease

Human beings are wired to respond to physical threat in some predetermined ways. This is our body’s way of preserving our lives. The problem is that our normal stress response is meant to be acute, not chronic. But the types of stressors modern humans encounter are often chronic, and so our stress response is out of sync with the realities of our world. When stressors are chronic, our stress response malfunctions and actually increases our risk of disease.

There are three main components of the stress response. When you understand these, you will understand the basic concepts underlying mind-body medicine.

Simply put, the human stress response has three basic components.

The first is the catecholamine, or fight-or-flight response, and it kicks in as soon as we are threatened.

The second is the response of the HPA axis. HPA stands for hypothalamic-pituitary-adrenal axis. When faced with a threat, the HPA axis responds with a cascade of chemicals, the final one being the stress hormone cortisol.

The third component is the immune system’s response. When faced with danger, the immune system increases inflammation by releasing molecules known as proinflammatory cytokines. Cytokines are basically messenger molecules of the immune system. Inflammation has a very important role in protecting your health. These molecules protect you against infection and heal wounds. But when levels of these cytokines continue to be high, they can actually damage your body.

A key finding in mind-body research is that psychological stress can trigger the inflammatory response.

You’ll notice that I’ve drawn this three-component response with arrows connecting each component. In a normally functioning system, these three components serve as checks and balances to each other. When one part gets too high, the others activate to lower it. The problem is that when this system is overloaded, as it is in stress and depression, the components no longer serve as checks and balances. Instead, they start actually enhancing the negative effects.

Fortunately, there are some steps you can take to lower your response to stress. And that is what we will talk about in the next few posts.

What’s Stress Got to Do With It?: The Many Ways That Stress Impacts Our Health

Health care providers often tell me that they came to my lectures to learn about something for their patients, but they ended up finding something useful for themselves. They could be suffering from chronic pain, or heart disease, or metabolic syndrome. But they didn’t know that psychological stress was often a key part of why they were sick--and could even kill them.

In one of the first major studies in this field, researchers noted that people who were taking care of spouses with Alzheimer’s were dying at higher than rates than their non-caregiving peers. They were developing heart disease and cancer and other fatal diseases. I often think of Christopher Reeves' wife. Had caring for her severely disabled husband contributed to her own early death?

Researchers have also studied the link between depression and heart disease. Did you know that depression is a well-known risk factor for heart disease? Or that depression, hostility and other negative mental states increases your risk of developing diabetes?

Along these same lines, researchers have discovered that depression, stress or anxiety during pregnancy dramatically increases the risk of preterm birth. We are now beginning to understand why that would be so.

Sleep problems are another fascinating area of study. A lot of people know that sleep problems increase this risk of heart disease and diabetes. But what you might not realize is why they do.

The answer to these questions has to do with how humans respond to stress. And that is the focus of our installment. Stay tuned!