A systematic review of St. John's wort for major depressive disorder

Antidepressant efficacy and side effect burden: an updated guide for clinicians

Antidepressant treatment has been evolving and changing since the 1950s following the discovery of the classic antidepressant treatments including tricyclic antidepressants and monoamine oxidase inhibitors. The heterogeneity of the disorder became apparent in the beginning when individuals remained symptomatic despite medication compliance. This spurred further research in order to understand the neurobiology underlying the disorder. Subsequently, newer medications were designed to target specific neurotransmitters and areas of the brain involved in symptom development and maintenance. Our original review article looked at both classic and modern antidepressant medications used in the treatment of major depressive disorder. This manuscript is an update to the original review and serves to provide clinicians with information about novel antidepressant medications, augmentation strategies with atypical antipsychotics, over-the-counter medications, as well as nonpharmaceutical treatments that should be considered when treating each individual patient who remains symptomatic despite treatment efforts.

Hypericum spp.: An Update on the Biological Activities and Metabolic Profiles

Plants from the genus Hypericum, one genus of the Hypericaceae family, have attracted a lot of attention for their potential pharmaceutical applications. Most of the studies in the literature focus on H. perforatum L. (common St. John's wort), whose complex spectrum of bioactive compounds makes this species one of the top herbal remedies and supplements in the world. It is also important to compare the studies on other Hypericum species, both from the phytochemical and biological point of view. The aim of this review was to provide an update of most recent studies about biological investigations of plants belonging to Hypericum genus. The metabolic profiles of Hypericum spp. were also discussed in order to present a spectrum of secondary metabolites not previously identified in this genus.

Crocus Sativus L. (saffron) versus sertraline on symptoms of depression among older people with major depressive disorders-a double-blind, randomized intervention study

BACKGROUND

While there is sufficient evidence that Crocus Sativus L. (saffron) improves symptoms of depression in young and middle-aged adults, research on older people are missing. The purpose of the double-blind, randomized intervention study was to compare the effect of saffron and sertraline on MDD among a sample of older people.

METHODS

A total of 50 older out-patients with MDD (mean age = =65 years; 70% males) were randomly assigned either to the saffron condition (60 mg/d) or to the sertraline condition (100 mg/day) for six consecutive weeks. Experts employed the Hamilton Depression Rating Scale (HDRS) to rate participants' degree of depression. Timepoints were baseline, week 2, week 4 and week 6, the end of the study.

RESULTS

Symptoms of depression decreased over time, with no advantages or disadvantages for the saffron or sertraline condition.

CONCLUSION

The pattern of results suggests that both saffron and sertraline have the potential to significantly decrease symptoms of depression. The results are clinically relevant, because major depressive disorders in older people is a health concern. The results are further relevant, because saffron appears to be a powerful antidepressant for older people, who might be more reluctant to the use of synthetic drugs.

Management of depressive symptoms in peri- and postmenopausal women: EMAS position statement

INTRODUCTION

Globally, the total number of people with depression exceeds 300 million, and the incidence rate is 70 % greater in women. The perimenopause is considered to be a time of increased risk for the development of depressive symptoms and major depressive episodes.

AIM

The aim of this position statement is to provide a comprehensive model of care for the management of depressive symptoms in perimenopausal and early menopausal women, including diagnosis, treatment and follow-up. The model integrates the care provided by all those involved in the management of mild or moderate depression in midlife women.

MATERIALS AND METHODS

Literature review and consensus of expert opinion.

SUMMARY RECOMMENDATIONS

Awareness of depressive symptoms, early detection, standardized diagnostic procedures, personalized treatment and a suitable follow-up schedule need to be integrated into healthcare systems worldwide. Recommended treatment comprises antidepressants, psychosocial therapies and lifestyle changes. Alternative and complementary therapies, although widely used, may help with depression, but a stronger evidence base is needed. Although not approved for this indication, menopausal hormone therapy may improve depressive symptoms in peri- but not in postmenopausal women, especially in those with vasomotor symptoms.

Omega-3-polyunsatured fatty acids (O3PUFAs), compared to placebo, reduced symptoms of occupational burnout and lowered morning cortisol secretion

BACKGROUND

Occupational burnout is both a serious health concern at both public and individual levels. Treatment options are psychopharmacological, psychological and physical activity-related interventions. Here, we tested whether, compared to placebo, omega-3-polyunsaturated fatty acids (O3PUFAs) have a positive impact on burnout and morning cortisol secretion.

METHOD

A total of 43 individuals (mean age: 38.4 years, 76.7% females) took part in the present double-blind and placebo-controlled intervention. Participants were randomly assigned either to the O3PUFA or to the placebo condition. At baseline and again eight weeks later, participants completed the Maslach Burnout Inventory and collected morning saliva samples for analysis of the cortisol awakening response (CAR).

RESULTS

Emotional exhaustion and depersonalization decreased, and sense of personal accomplishment increased over time, but more so in the O3PUFA condition than in the placebo condition. Likewise, CAR decreased over time, but again more so in the O3PUFA condition than in the placebo condition.

CONCLUSIONS

The present pattern of results suggests that, compared to placebo, administration of daily omega-3-polyunsaturated fatty acids for eight consecutive weeks positively influences both psychological and physiological markers of occupational burnout.

Hypericum species: An analysis on the patent technologies

Hypericum (Hypericaceae) is a genus that comprises approximately 500 species around the world. The industrial relevance of these plants is based on the occurence of specialized metabolites that exhibit a range of pharmaceutical potential. Besides that, several species are relevant due to their ornamental value. Taking to account the vast market worth of products and processes involving Hypericum, the present study aims to provide a comprehensive overview of patents concerning this subject between 2007and 2017. For this purpose, a survey was performed in free databases (Espacenet®, PatentScope® and Google Patents®) using the keyword Hypericum in the patents title or title plus abstract. The documents were then organized by groups (medicinal and non-medicinal approaches), subgroups, type of applicants and countries. Espacenet® was chosen to data analysis, and a total of 174 patents were found. The majority of the applicants are from China and companies appear as the principal owners of patents. Several technologies are not intended for medicinal purposes, being mainly related to the development of new cultivars for ornamental uses. Concerning the medicinal approaches, the chief subject is related to extraction and incorporation into formulations. The main species cited in the documents is H. perforatum and the therapeutic use is for central nervous system diseases. In general, this study covers the patents published in recent years hoping to boost the scientists and companies that invest in Hypericum researches to visualize the state of art, opportunities and challenges for innovation in this area.

Establishing an Evidence Synthesis Capability For Psychological Health Topics in the Military Health System

BACKGROUND

To promote evidence-based health care, clinical providers and decision makers rely on scientific evidence to inform best practices. Evidence synthesis (ES) is a key component of this process that serves to inform health care decisions by integrating and contextualizing research findings across studies.

OBJECTIVE

This paper describes the process of establishing an ES capability in the Military Health System dedicated to psychological health topics.

RESEARCH DESIGNS

The goal of establishing the current ES capability was to facilitate evidence-based decision-making among clinicians, clinic managers, research funders, and policymakers, through the production and dissemination of trustworthy ES reports. We describe how we developed this capability, provide an overview of the types of evidence syntheses products we use to respond to different stakeholders, and detail the procedures established for selecting and prioritizing synthesis topics.

RESULTS

We report on the productivity, acceptability, and impact of our efforts. Our reports were used by a variety of stakeholders and working groups, briefed to major committees, included in official reports and policies, and cited in clinical practice guidelines and the peer-reviewed literature.

CONCLUSIONS

Our experiences thus far suggest that the current ES capability offers a needed service within our health system. Our framework may help inform other agencies interested in developing or sponsoring a similar capability.

Naturopathy as a Model of Prevention-Oriented, Patient-Centered Primary Care: A Disruptive Innovation in Health Care

Background and Objective: The concept of a "disruptive innovation," recently extended to health care, refers to an emerging technology that represents a new market force combined with a new value system, that eventually displaces some, or all, of the current leading "stakeholders, products and strategic alliances." Naturopathy is a distinct system of traditional and complementary medicine recognized by the World Health Organization (WHO), emerging as a model of primary care. The objective here is to describe Naturopathy in the context of the criteria for a disruptive innovation. Methods: An evidence synthesis was conducted to evaluate Naturopathy as a potentially disruptive technology according to the defining criteria established by leading economists and health technology experts: (1) The innovation must cure disease; (2) must transform the way medicine is practiced; or (3) have an impact that could be disruptive or sustaining, depending on how it is integrated into the current healthcare marketplace. Results: The fact that Naturopathy de-emphasizes prescription drug and surgical interventions in favor of nonpharmacological health promotion and self-care could disrupt the present economic model that fuels health care costs. The patient-centered orientation of Naturopathy, combined with an emphasis on preventive behaviors and popular complementary and integrative health services like natural products, mind and body therapies, and other therapies not widely represented in current primary care models increase the likelihood for disruption. Conclusions: Because of its patient-centered approach and emphasis on prevention, naturopathy may disrupt or remain a durable presence in healthcare delivery depending on policymaker decisions.

Complementary therapies for clinical depression: an overview of systematic reviews

OBJECTIVES

As clinical practice guidelines vary widely in their search strategies and recommendations of complementary and alternative medicine (CAM) for depression, this overview aimed at systematically summarising the level 1 evidence on CAM for patients with a clinical diagnosis of depression.

METHODS

PubMed, PsycInfo and Central were searched for meta-analyses of randomised controlled clinical trials (RCTs) until 30 June 2018. Outcomes included depression severity, response, remission, relapse and adverse events. The quality of evidence was assessed according to Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) considering the methodological quality of the RCTs and meta-analyses, inconsistency, indirectness, imprecision of the evidence and the potential risk of publication bias.

RESULTS

The literature search revealed 26 meta-analyses conducted between 2002 and 2018 on 1-49 RCTs in major, minor and seasonal depression. In patients with mild to moderate major depression, moderate quality evidence suggested the efficacy of St. John's wort towards placebo and its comparative effectiveness towards standard antidepressants for the treatment for depression severity and response rates, while St. John's wort caused significant less adverse events. In patients with recurrent major depression, moderate quality evidence showed that mindfulness-based cognitive therapy was superior to standard antidepressant drug treatment for the prevention of depression relapse. Other CAM evidence was considered as having low or very low quality.

CONCLUSIONS

The effects of all but two CAM treatments found in studies on clinical depressed patients based on low to very low quality of evidence. The evidence has to be downgraded mostly due to avoidable methodological flaws of both the original RCTs and meta-analyses not following the Consolidated Standards of Reporting Trials and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Further research is needed.

Opportunities in Novel Psychotropic Drug Design from Natural Compounds

Multiple initiatives at the national and international level support natural drug discovery. Psychiatrists and patients are not well informed about natural psychotropics in general. Existing antidepressant and antipsychotic drugs were developed from atropine, a natural product. Subsequent drug developments were largely based on extension and modification of earlier molecular scaffolds. This limits their mechanisms of action to similar neuropathways. Natural psychotropic substances, particularly those with hallucinogenic and psychedelic properties and different chemical structures, may serve as new paths to novel psychotropic drug development.

Antidepressant-like activity of hyperforin and changes in BDNF and zinc levels in mice exposed to chronic unpredictable mild stress

Chronic unpredictable mild stress (CUMS) - a rodent model of depression mimics a variety of neurochemical and behavioral alterations similar to those seen in human depression. This study evaluated the antidepressant activity of hyperforin in the CUMS model using fluoxetine (FLX) as a reference drug. The antidepressant-like effects of hyperforin and FLX were evaluated in the tail suspension test (TST), forced swim test (FST), and splash test (SPT). CUMS induced an increase in immobility time in mice (pro-depressive effects) in the FST and TST. CUMS-induced changes were reversed by chronic treatment with hyperforin (2.5 and 5 mg/kg), as well as FLX (10 mg/kg). SPT results revealed a decrease in the frequency and duration of grooming in stressed mice. These effects were normalized by hyperforin (5 mg/kg) and FLX treatment. Hyperforin (2.5 mg/kg) only reversed the CUMS-induced deficits related to the frequency of grooming. CUMS also caused a decrease in zinc concentration in the frontal cortex (FC) and hippocampus (Hp) of mice; hyperforin (2.5 mg/kg) increased zinc concentration in the Hp of control rats. CUMS also induced a decrease in BDNF protein levels in the FC and Hp, while decreasing the pCREB/CREB ratio only in the Hp. Hyperforin (2.5 and 5 mg/kg) reversed the CUMS-induced reduction of BDNF only in the Hp. Our results demonstrate the antidepressant-like activity of hyperforin in the CUMS model in mice and the possible involvement of hippocampal BDNF/zinc alterations in this activity.

The antidepressant-like effects of sinomenine in mice: a behavioral and neurobiological characterization

Sinomenine is a bioactive alkaloid extracted from Sinomenium acutum. Here, we investigated the antidepressant effects of sinomenine in mice. The antidepressant actions of sinomenine were first examined in the forced-swim test and the tail-suspension test, and then assessed in the chronic social defeat stress (CSDS) model of depression. Changes in the brain-derived neurotrophic factor (BDNF) signaling pathway after CSDS and sinomenine treatment were also investigated. A tryptophan hydroxylase inhibitor and a BDNF signaling inhibitor were also used to determine the pharmacological mechanisms of sinomenine. It was found that sinomenine induced antidepressant-like effects in the forced-swim test and tail-suspension test without affecting the locomotor activity of mice. Sinomenine also prevented the CSDS-induced depressive-like symptoms. Moreover, sinomenine fully restored the CSDS-induced decrease in the hippocampal BDNF signaling pathway, whereas a BDNF signaling inhibitor, but not a tryptophan hydroxylase inhibitor, blocked the antidepressant effects of sinomenine. In conclusion, sinomenine exerts antidepressant effects in mice by promoting the hippocampal BDNF signaling pathway.

Shared Decision-Making With Choosing Wisely

Choosing Wisely is a national health care improvement campaign promoting conversations between women and their health care professionals about selecting high-value health care practices. It disseminates lists of recommendations and downloadable educational materials from professional societies on its website. In November 2018, we searched for and categorized Choosing Wisely recommendations pertinent to women's health care. Of 78 recommendations, 28 (36%) were related to perinatal care, 22 (28%) were related to gynecologic care, and 28 (36%) were related to women's health and general care. Twelve recommendations (17.6%) were related to antenatal care, 10 (14.7%) to intrapartum and postpartum care, and 10 (14.7%) to cervical cancer screening. These free resources can help frame the shared decision-making process in clinical practice.

St. John's Wort (Hypericum perforatum) Products - How Variable Is the Primary Material?

Background: Saint John's wort (Hypericum perforatum L., HP) is commonly registered in Europe under the THR scheme (Traditional Herbal Registration) or licensed as a medicine. Nonetheless unregulated medical products and food supplements are accessible through the internet which are often of poor quality. The species' natural distribution stretches through large regions of Europe to China and four subspecies have been distinguished. When compared to the European Pharmacopoeia reference, the presence of additional compounds was linked to so-called Chinese HP. Aim: In order to obtain an integrated picture of the entire chemoprofile, the chemical composition of HP materia prima was studied using a combination of techniques well-established in the relevant industries. The impact of phytogeographic factors on the materia prima can shed light on whether the variability of the final products is strongly influenced by these factors of whether they relate to poor processing, adulteration, or other factors linked to the processing of the material. Methods: Eighty-six Hypericum samples (77 H. perforatum) were collected from 14 countries. Most were authenticated and harvested in the wild; others came as roughly ground material from commercial cultivations, markets and pharmacies. The samples were analyzed using HPTLC and 1H-NMR-based principal component analysis (PCA). Results and Discussion: Limited chemical variability was found. Nonetheless, the typical fingerprint of Chinese HP was observed in each specimen from China. Additional compounds were also detected in some samples collected in Spain. Rutin is not necessarily present in the crude material. The variability previously found in the marketed products can be ascribed only partially to the geographical origin of harvested material, but mainly to the plant part harvested, closely related to harvesting techniques, processing and probably time of harvest. Conclusion: HP can be sourced in a consistent composition (and thus quality) from different geographical sources. However, chemical variability needs to be accounted for when evaluating what is considered authentic good material. Therefore, the processing and good practice are all stages of primary importance, calling for a better (self-)regulation and quality assurance along the value chain of an herbal medical product or botanical.

Effects of Xingpi Kaiyu Fang on ATP, Na/K-ATPase, and Respiratory Chain Complexes of Hippocampus and Gastrocnemius Muscle in Depressed Rats

Objective

To clarify the effectiveness and mechanism of the Chinese herbal formula Xingpi Kaiyu Fang (XPKYF) which is composed of American ginseng (Xi-Yang-shen), Radix curcumae (Yu-Jin), Acori tatarinowii rhizoma (Shi-Chang-pu), and Hypericum perforatum (Guan-Ye-lian-qiao) in depressed rats.

Methods

The rat model of depression was established by chronic unpredictable mild stress (CUMS) method for 6 weeks. Rats were randomly divided into six groups: control group, CUMS group, CUMS+XPKYF (3.6g/kg/d, 7.2g/kg/d, 14.4g/kg/d) groups, and CUMS+sertraline (4.5mg/kg/d) group. The sucrose preference test and the forced swimming test were performed to assess the rats' depression behavior. Mitochondrial ultrastructure was observed by transmission electron microscope and adenosine triphosphate (ATP) content, sodium potassium ATPase (Na/K-ATPase) activity, and mitochondrial respiratory chain complexes activities in hippocampus and gastrocnemius muscle were measured at the 14^th and 42^nd day.

Results

Rats subjected to six weeks of CUMS exhibited decreased sucrose preference ratio and prolonged immobility time. CUMS reduced ATP content in hippocampus, decreased Na/K-ATPase activity and respiratory chain complex I, III, and IV activities in hippocampus and gastrocnemius muscle, and damaged mitochondrial ultrastructure of hippocampus and gastrocnemius muscle. XPKYF at 14.4g/kg, the efficacy trend of which was better than the other drug groups, could prevent the stress-induced depressed behavior changes, inhibit the decrease of Na/K-ATPase activity in hippocampus, inhibit the decrease of respiratory chain complex III activities in hippocampus and gastrocnemius muscle, and protect mitochondria from ultrastructural damage.

Conclusions

Energy deficiency and damaged mitochondrial ultrastructure were found in hippocampus and gastrocnemius muscle of depressed rats established by CUMS. XPKYF could partly reverse alterations in ATP, Na/K-ATPase, and respiratory chain complexes of hippocampus and gastrocnemius muscle and protect mitochondria from ultrastructural damage. This provides another experimental evidence for the clinical application of XPKYF in the treatment of depression.

Structural diversity and biological activities of phloroglucinol derivatives from Hypericum species

Plants of the genus Hypericum (Hypericaceae) are used in folk medicine all over the world, H. perforatum being the most well-known species. Standardized extracts of this plant are commercially-available to treat mild to moderate depression cases. The present review summarizes the literature published up to 2016 concerning the phloroglucinol derivatives isolated from Hypericum species, together with their structural features and biological activities. These phytochemical studies led to the isolation of 101 prenylated phloroglucinols, chromanes and chromenes, 35 dimeric acylphloroglucinols, 235 polycyclic polyprenylated acylphloroglucinols, 25 simple benzophenones and 33 phloroglucinol-terpene adducts. These compounds show a diverse range of biological activities, such as antimicrobial, cytotoxic, antinociceptive and antidepressant-like effects.

[Herbal medicines for psychiatric disorders]

BACKGROUND

In Germany herbal medicines are traditionally frequently used. They represent an important therapeutic option, especially in self-medication.

METHODS

Current systematic review articles and meta-analyses were evaluated and summarized with respect to the evidence of phytotherapeutic drugs for selected psychiatric indications.

RESULTS

Apart from the use of St. John's wort for depression, no other herb has so far shown convincing evidence.

CONCLUSION

Due to the promising effects and the low side effect potential within the existing studies, further randomized controlled trials (e. g. for Passiflora incarnata, Rhodiola rosea and Lavendula officinalis) are definitely indicated.

Depression and glioblastoma, complicated concomitant diseases: a systemic review of published literature

Glioblastoma multiforme (GBM) is the most common primary brain cancer. Depression is a common co-morbidity of this condition. Despite this common interaction, relatively little research has been performed on the development of GBM-associated depression. We performed a literary search of the PubMed database for articles published relating to GBM and depression. A total of 85 articles were identified with 46 meeting inclusion criteria. Depression significantly impacts care, decreasing medication compliance, and patient survival. Diagnostically, because depression and GBM share intricate neuro-connectivity in a way that effect functionality, these diseases can be mistaken for alternative psychological or pathological disorders, complicating care. Therapeutically, anti-depressants have anti-tumor properties; yet, some have been shown to interfere with GBM treatment. One reason for this is that the pathophysiological development of depression and GBM share several pathways including altered regulation of the 5-HT receptor, norepinephrine, and 3':5'-cyclic monophosphate. Over time, depression can persist after GBM treatment, affecting patient quality of life. Together, depression and GBM are complicated concomitant diseases. Clinicians must be aware of their co-existence. Because of overlapping molecular pathways involved in both diseases, careful medication selection is imperative to avoid potential adverse interactions. Since GBMs are the most common primary brain cancer, physicians dealing with this disease should be prepared for the development of depression as a potential sequela of this condition, given the related pathophysiology and the known poor outcomes.

Hypericum perforatum chronic treatment affects cognitive parameters and brain neurotrophic factor levels

Objective:

To evaluate the effects of Hypericum perforatum (hypericum) on cognitive behavior and neurotrophic factor levels in the brain of male and female rats.

Methods:

Male and female Wistar rats were treated with hypericum or water during 28 days by gavage. The animals were then subjected to the open-field test, novel object recognition and step-down inhibitory avoidance test. Nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and glial cell-line derived neurotrophic factor (GDNF) levels were evaluated in the hippocampus and frontal cortex.

Results:

Hypericum impaired the acquisition of short- and long-term aversive memory in male rats, evaluated in the inhibitory avoidance test. Female rats had no immediate memory acquisition and decreased short-term memory acquisition in the inhibitory avoidance test. Hypericum also decreased the recognition index of male rats in the object recognition test. Female rats did not recognize the new object in either the short-term or the long-term memory tasks. Hypericum decreased BDNF in the hippocampus of male and female rats. Hypericum also decreased NGF in the hippocampus of female rats.

Conclusions:

The long-term administration of hypericum appears to cause significant cognitive impairment in rats, possibly through a reduction in the levels of neurotrophic factors. This effect was more expressive in females than in males.

A Balanced Risk-Benefit Analysis to Determine Human Risks Associated with Pyrrolizidine Alkaloids (PA)-The Case of Herbal Medicinal Products Containing St. John's Wort Extracts (SJW)

OBJECTIVES

Pyrrolizidine alkaloids (PA) exist ubiquitously in our environment. More than 6000 plants, about 3% of the world’s flowering plants, are known to synthesize PA. As a consequence, many herbal ingredients, including St. John’s wort (SJW), are contaminated with PA that can possess acute and subchronic toxic effects as well as mutagenic and genotoxic properties. Therefore, the possible benefits of SJW as an herbal remedy against depression need to be weighed against the possible risks of unwanted PA intake.

METHODS

We searched the literature regarding the current knowledge on PA and evaluated the evidence on the antidepressant effects of quantified SJW extract based on a Cochrane Review and the current practice guidelines on depression. Risks are depicted in form of a risk ladder and benefits in form of an icon array.

RESULTS

Evidence from clinical studies indicates that quantified SJW extract is an effective treatment option for mild to moderate depression with fewer side effects than conventional antidepressants. Health statistics from different countries do not quantify cases of death caused by PA intake. However, deaths due to suicide, often triggered by depression, are common (11 in 1000 in Germany in 2015) and rank between fatalities due to liver diseases (16 in 1000) and household accidents (10 in 1000).

CONCLUSIONS

Quantified SJW extract is a safe and effective treatment option, and its potential of treating depression outweighs the (hypothetical) risk of unwanted PA intake.

Health consumer and health provider preferences for an integrative healthcare service delivery model: A national cross-sectional study

BACKGROUND

Although global interest in integrative healthcare (IHC) has escalated over the past few decades, stakeholder perspectives and preferences in relation to IHC remain poorly understood. Our study aimed to address this knowledge gap by exploring Australian health consumer (HC) and healthcare provider (HCP) understanding, attitudes and preferences for an IHC service delivery model, and to translate these views into an operational framework for IHC.

METHOD

The research used a cross-sectional study design. Eligible persons were informed of the study using a multi-modal recruitment approach. Adult HCs and HCPs from any medical, nursing, allied and traditional and complementary medicine discipline, who had internet access and resided in Australia, were eligible to complete the 55-item online questionnaire.

RESULTS

Four hundred and nine participants completed the survey. HCs and HCPs shared a common understanding of, and positive attitude towards, IHC. When asked about the IHC service delivery model, participants advocated the provision of diverse healthcare and support services across multiple centres, to individuals mainly presenting with chronic/terminal conditions. The preference was for these services to be charged as fee-for-service, paid using a split payment system, and managed by a customised team of clinicians following triage by a non-medical staff member. These findings were subsequently translated into an operational framework for IHC.

CONCLUSIONS

This is first known study to translate HC and HCP attitudes and preferences into an operational framework for IHC. A logical next step of this work will be to ascertain the feasibility of this model in primary care.

Herbal supplements: Research findings and safety

Herbal supplements are used extensively worldwide without much awareness regarding their safety and efficacy. Extensive research to determine the safety, utility, and level of research support for commonly used herbs has culminated in an easily accessible summary chart for NP providers.

A regulatory science viewpoint on botanical-drug interactions

There is a continued predisposition of concurrent use of drugs and botanical products. Consumers often self-administer botanical products without informing their health care providers. The perceived safety of botanical products with lack of knowledge of the interaction potential poses a challenge for providers and both efficacy and safety concerns for patients. Botanical–drug combinations can produce untoward effects when botanical constituents modulate drug metabolizing enzymes and/or transporters impacting the systemic or tissue exposure of concomitant drugs. Examples of pertinent scientific literature evaluating the interaction potential of commonly used botanicals in the US are discussed. Current methodologies that can be applied to advance our efforts in predicting drug interaction liability is presented. This review also highlights the regulatory science viewpoint on botanical–drug interactions and labeling implications.

Understanding drug interactions with St John's wort (Hypericum perforatum L.): impact of hyperforin content

Objective

The aim of this study was to review herb–drug interaction studies with St John's wort (Hypericum perforatum L.) with a focus on the hyperforin content of the extracts used in these studies.

Methods

PUBMED was systematically searched to identify studies describing pharmacokinetic interactions involving St John's wort. Data on study design and the St John's wort extract or product were gathered to extract hyperforin content and daily dose used in interaction studies.

Key findings

This analysis demonstrates that significant herb–drug interactions (resulting in a substantial change in systemic exposure) with St John's wort products were associated with hyperforin daily dosage. Products that had a daily dose of <1 mg hyperforin were less likely to be associated with major interaction for drugs that were CYP3A4 or p-glycoprotein substrates. Although a risk of interactions cannot be excluded even for low-dose hyperforin St. John's wort extracts, the use of products that result in a dose of not more than 1 mg hyperforin per day is recommended to minimise the risk of interactions.

Conclusions

This review highlights that the significance of herb–drug interactions with St John's wort is influenced by the nature of the herbal medicines product, particularly the hyperforin content.

Exodermis and endodermis are the sites of xanthone biosynthesis in Hypericum perforatum roots

Xanthones are specialized metabolites with antimicrobial properties, which accumulate in roots of Hypericum perforatum. This medicinal plant provides widely taken remedies for depressive episodes and skin disorders. Owing to the array of pharmacological activities, xanthone derivatives attract attention for drug design. Little is known about the sites of biosynthesis and accumulation of xanthones in roots. Xanthone biosynthesis is localized at the transcript, protein, and product levels using in situ mRNA hybridization, indirect immunofluorescence detection, and high lateral and mass resolution mass spectrometry imaging (AP-SMALDI-FT-Orbitrap MSI), respectively. The carbon skeleton of xanthones is formed by benzophenone synthase (BPS), for which a cDNA was cloned from root cultures of H. perforatum var. angustifolium. Both the BPS protein and the BPS transcripts are localized to the exodermis and the endodermis of roots. The xanthone compounds as the BPS products are detected in the same tissues. The exodermis and the endodermis, which are the outermost and innermost cell layers of the root cortex, respectively, are not only highly specialized barriers for controlling the passage of water and solutes but also preformed lines of defence against soilborne pathogens and predators.

Advances in the Preclinical Study of Some Flavonoids as Potential Antidepressant Agents

Flavonoids are phenolic compounds found commonly in plants that protect them against the negative effects of environmental insults. These secondary metabolites have been widely studied in preclinical research because of their biological effects, particularly as antioxidant agents. Diverse flavonoids have been studied to explore their potential therapeutic effects in the treatment of disorders of the central nervous system, including anxiety and depression. The present review discusses advances in the study of some flavonoids as potential antidepressant agents. We describe their behavioral, physiological, and neurochemical effects and the apparent mechanism of action of their preclinical antidepressant-like effects. Natural flavonoids produce antidepressant-like effects in validated behavioral models of depression. The mechanism of action of these effects includes the activation of serotonergic, dopaminergic, noradrenergic, and γ-aminobutyric acid-ergic neurotransmitter systems and an increase in the production of neural factors, including brain-derived neurotrophic factor and nerve growth factor. Additionally, alterations in the function of tropomyosin receptor kinase B and activity of the enzyme monoamine oxidase A have been reported. In conclusion, preclinical research supports the potential antidepressant effects of some natural flavonoids, which opens new possibilities of evaluating these substances to develop complementary therapeutic alternatives that could ameliorate symptoms of depressive disorders in humans.

Popular Herbal and Natural Remedies Used in Psychiatry

Natural and herbal remedies, also known as "alternative" or "complementary" medicines, have grown tremendously in popularity over the past two decades, becoming a major component of health care and general wellness in the United States and worldwide. The ready availability of these remedies over the counter and their generally good tolerability and safety contribute to this popularity, and many people have benefited from them, often in cases when conventional treatments have failed or caused intolerable side effects. Despite many Food and Drug Administration (FDA)-approved psychotropic medications on the market, efficacy has been inconsistent for some, and many treatment responders will eventually relapse. Continued research on the efficacy and safety of these alternative therapies is, therefore, important. This article reviews six of the most commonly used natural remedies for psychiatric conditions, including the antidepressants St. John's wort, omega-3 fatty acids, and S-adenosyl methionine (SAMe); the sedative-hypnotics valerian and melatonin; and the nootropic ginkgo biloba. We outline the general indications for use, suggested doses, possible mechanisms, and adverse effects to give clinicians a good summary of the benefits and liabilities of each. Although there is growing evidence of efficacy and safety to support the use of these remedies, clinicians must be aware of the limitations of the evidence base and take that into account with all the other factors that contribute to clinical decision making.

Current Role of Herbal and Natural Preparations

Depression remains difficult to manage, despite the many registered treatments available. For many depressed individuals, particularly those who have not responded to and/or had adverse effects from standard therapies, herbal and natural medications represent a potentially valuable alternative. This chapter will review several natural remedies used in the treatment of depression. Specific remedies covered include St. John's wort (SJW), S-adenosyl-L-methionine (SAMe), omega-3 fatty acids, rhodiola, and others. We will begin by providing some historical and social context about these remedies. Then we will review efficacy and safety data, as well as biological mechanisms of action of these therapies. Finally, we will discuss the limitations of the current state of knowledge and provide suggestions for a productive research agenda focused on natural remedies. While many questions about these treatments remain unanswered and much work needs to be done before we determine their place in the psychiatric armamentarium, we believe that this chapter will give psychiatrists a good perspective on the pros and cons of herbal and natural antidepressants as part of the pharmacological armamentarium and sensible guidelines on how and when they should be used.

Pharmacological and non-pharmacological treatments for major depressive disorder: review of systematic reviews

OBJECTIVES

This study aims to summarise the evidence on more than 140 pharmacological and non-pharmacological treatment options for major depressive disorder (MDD) and to evaluate the confidence that patients and clinicians can have in the underlying science about their effects.

DESIGN

This is a review of systematic reviews.

DATA SOURCES

This study used MEDLINE, Embase, Cochrane Library, PsycINFO and Epistemonikos from 2011 up to February 2017 for systematic reviews of randomised controlled trials in adult patients with acute-phase MDD.

METHODS

We dually reviewed abstracts and full-text articles, rated the risk of bias of eligible systematic reviews and graded the strength of evidence.

RESULTS

Nineteen systematic reviews provided data on 28 comparisons of interest. For general efficacy, only second-generation antidepressants were supported with high strength evidence, presenting small beneficial treatment effects (standardised mean difference: -0.35; 95% CI -0.31 to -0.38), and a statistically significantly higher rate of discontinuation because of adverse events than patients on placebo (relative risk (RR) 1.88; 95% CI 1.0 to 3.28).Only cognitive behavioural therapy is supported by reliable evidence (moderate strength of evidence) to produce responses to treatment similar to those of second-generation antidepressants (45.5% vs 44.2%; RR 1.10; 95% CI 0.93 to 1.30). All remaining comparisons of non-pharmacological treatments with second-generation antidepressants either led to inconclusive results or had substantial methodological shortcomings (low or insufficient strength of evidence).

CONCLUSIONS

In contrast to pharmacological treatments, the majority of non-pharmacological interventions for treating patients with MDD are not evidence based. For patients with strong preferences against pharmacological treatments, clinicians should focus on therapies that have been compared directly with antidepressants.

TRIAL REGISTRATION NUMBER

International Prospective Register of Systematic Reviews (PROSPERO) registration number: 42016035580.

St John's wort (Hypericum perforatum)-induced psychosis: a case report

BACKGROUND

St John's wort (Hypericum perforatum) has been known for centuries for its therapeutic properties and its efficacy as an antidepressant has been confirmed by a growing body of evidence. During the last two decades it has also come to prominence with a wider public, due to advertising efforts across Europe and United States of America. However, its availability without prescription, as an over-the-counter medication, raises some concern regarding its clinical management and unsupervised administration to individuals with psychopathological risks. To date, the evidence available regarding the administration of Hypericum in people with severe mental health problems is still meager and refers mainly to affective disorder spectrum or psychotic relapse in people with established diagnoses. To the best of our knowledge, this is the first report regarding the onset of psychotic features in a patient presenting with psychotic diathesis.

CASE PRESENTATION

The case discussed in this report is a 25-year-old white man, not known to the psychiatric services, with a history of brief and self-remitting drug-induced psychosis and a positive family history of psychotic depression. He was admitted to hospital due to the onset of florid psychotic symptoms concomitant with self-administration of Hypericum perforatum.

CONCLUSIONS

The aim of this report is to promote further systematic research, draw the attention of clinicians to the potential risks of Hypericum precipitating psychosis, and raise awareness among health professionals to investigate and caution their patients on the haphazard use of phytotherapeutics such as Hypericum.

Biotechnological production of hyperforin for pharmaceutical formulation

Hyperforin is a major active constituent of Hypericum perforatum (St. John's wort). It has amazing pharmacological activities, such as antidepressant properties, but it is labile and difficult to synthesize. Its sensitivity and lipophilicity are challenges for processing and formulation. Its chemical complexity provokes approaches of biotechnological production and modification. Dedifferentiated H. perforatum cell cultures lack appropriate storage sites and hence appreciable hyperforin levels. Shoot cultures are capable of forming hyperforin but less suitable for biomass up-scaling in bioreactors. Roots commonly lack hyperforin but a recently established adventitious root line has been demonstrated to produce hyperforin and derivatives at promising levels. The roots also contained lupulones, the typical constituents of hop (Humulus lupulus). Although shear-sensitive, these root cultures provide a potential production platform for both individual compounds and extracts with novel combinations of constituents and pharmacological activities. Besides in vitro cultivation techniques, the reconstruction of hyperforin biosynthesis in microorganisms is a promising alternative for biotechnological production. The biosynthetic pathway is under study, with omics-technologies being increasingly implemented. These biotechnological approaches may not only yield hyperforin at reasonable productivity but also allow for modifications of its chemical structure and pharmacological profile.