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Salm S, Rutz J, van den Akker M, Blaheta RA, Bachmeier BE. Current state of research on the clinical benefits of herbal medicines for non-life-threatening ailments. Front Pharmacol 2023; 14:1234701. [PMID: 37841934 PMCID: PMC10569491 DOI: 10.3389/fphar.2023.1234701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/08/2023] [Indexed: 10/17/2023] Open
Abstract
Herbal medicines are becoming increasingly popular among patients because they are well tolerated and do not exert severe side effects. Nevertheless, they receive little consideration in therapeutic settings. The present article reviews the current state of research on the clinical benefits of herbal medicines on five indication groups, psychosomatic disorders, gynecological complaints, gastrointestinal disorders, urinary and upper respiratory tract infections. The study search was based on the database PubMed and concentrated on herbal medicines legally approved in Europe. After applying defined inclusion and exclusion criteria, 141 articles were selected: 59 for psychosomatic disorders (100% randomized controlled trials; RCTs), 20 for gynecological complaints (56% RCTs), 19 for gastrointestinal disorders (68% RCTs), 16 for urinary tract infections (UTI, 63% RCTs) and 24 for upper respiratory tract infections (URTI) (79% RCTs). For the majority of the studies, therapeutic benefits were evaluated by patient reported outcome measures (PROs). For psychosomatic disorders, gynecological complaints and URTI more than 80% of the study outcomes were positive, whereas the clinical benefit of herbal medicines for the treatment of UTI and gastrointestinal disorders was lower with 55%. The critical appraisal of the articles shows that there is a lack of high-quality studies and, with regard to gastrointestinal disorders, the clinical benefits of herbal medicines as a stand-alone form of therapy are unclear. According to the current state of knowledge, scientific evidence has still to be improved to allow integration of herbal medicines into guidelines and standard treatment regimens for the indications reviewed here. In addition to clinical data, real world data and outcome measures can add significant value to pave the way for herbal medicines into future therapeutic applications.
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Affiliation(s)
- Sandra Salm
- Institute of Pharmaceutical Biology, Goethe University, Frankfurt, Germany
- Institute of General Practice, Goethe University, Frankfurt, Germany
| | - Jochen Rutz
- Department of Urology and Pediatric Urology, University Medical Center Mainz, Mainz, Germany
| | - Marjan van den Akker
- Institute of General Practice, Goethe University, Frankfurt, Germany
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
- Department of Public Health and Primary Care, Academic Centre of General Practice, KU Leuven, Leuven, Belgium
| | - Roman A. Blaheta
- Department of Urology and Pediatric Urology, University Medical Center Mainz, Mainz, Germany
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Zhou D, Lv Z, Shi L, Zhou X, Lin Q, Chen X, Wan L, Li Y, Ran L, Huang Y, Wang G, Li D, Wang W, Liu C, Kuang L. Effects of antidepressant medicines on preventing relapse of unipolar depression: a pooled analysis of parametric survival curves. Psychol Med 2022; 52:48-56. [PMID: 32501194 DOI: 10.1017/s0033291720001610] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Major depressive disorder is characterized by a high risk of relapse. We aimed to compare the prophylactic effects of different antidepressant medicines (ADMs). METHODS PubMed, Cochrane Central Register of Controlled Trials, Embase and the Web of Science were searched on 4 July 2019. A pooled analysis of parametric survival curves was performed using a Bayesian framework. The main outcomes were hazard ratios (HRs), relapse-free survival and mean relapse-free months. RESULTS Forty randomized controlled trials were included. The 1-year relapse-free survival for ADM (76%) was significantly better than that for placebo (56%). Most of the relapse difference (86.5%) occurred in the first 6 months. Most HRs were not constant over time. Proof of benefit after 6 months of follow-up was not established partially because of small differences between the drug and placebo after 6 months. Almost all studies used an 'enriched' randomized discontinuation design, which may explain the high relapse rates in the first 6 months after randomization. CONCLUSIONS The superiority of ADM v. placebo was mainly attributed to the difference in relapse rates that occurred in the first 6 months. Our analysis provided evidence that the prophylactic efficacy was not constant over time. A beneficial effect was observed, but the prevention of new episodes after 6 months was questionable. These findings may have implications for clinical practice.
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Affiliation(s)
- Dongdong Zhou
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Zhen Lv
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Lei Shi
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoxin Zhou
- Medical Department, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Qingxia Lin
- Department of Psychiatry, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang Province, China
| | - Xiaorong Chen
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Liyang Wan
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Yao Li
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Liuyi Ran
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Yan Huang
- GCP Office, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Gaomao Wang
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Daqi Li
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Wo Wang
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Chuan Liu
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Li Kuang
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Trkulja V, Barić H. Current Research on Complementary and Alternative Medicine (CAM) in the Treatment of Major Depressive Disorder: An Evidence-Based Review. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1305:375-427. [PMID: 33834410 DOI: 10.1007/978-981-33-6044-0_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Complementary and alternative medicine (CAM) encompasses a wide range of different non-mainstream therapies that have been increasingly used for treatment or adjunctive treatment of various ailments with mood disorders and "depressive difficulties" being two of the commonly CAM (self-)medicated conditions. We focus specifically on clinically diagnosed (in line with the standard criteria) depressive disorders, primarily major depressive disorder (MDD), and overview evidence of efficacy/safety of a range of CAM modalities addressing exclusively randomized controlled trials (RCTs) and systematic reviews/meta-analyses of RCTs. The list of addressed CAM interventions is not exhaustive: due to space limitation, addressed are interventions with at least a few conducted RCTs in the specific clinical conditions. We try to provide numerical and meaningful data as much as it is possible and to (a) indicate situations in which the reported data/estimates might have been "too enthusiastic" and (b) warn about heterogeneity of results that, together with other possible limitations (various biases and imprecision), results in uncertainty about the effects.
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Affiliation(s)
- Vladimir Trkulja
- Department of Pharmacology, Zagreb University School of Medicine, Zagreb, Croatia.
| | - Hrvoje Barić
- Department of Neurosurgery, University Hospital Center Zagreb, Zagreb, Croatia
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Zirak N, Shafiee M, Soltani G, Mirzaei M, Sahebkar A. Hypericum perforatum in the treatment of psychiatric and neurodegenerative disorders: Current evidence and potential mechanisms of action. J Cell Physiol 2018; 234:8496-8508. [PMID: 30461013 DOI: 10.1002/jcp.27781] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 10/30/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Psychiatric disorders are substantially associated with reduced quality of life and increased mortality. Depression and anxiety are two of the most common psychiatric disorders that often co-occur with each other as well as with other mental health conditions. Because of the limitations of currently available antidepressant therapies, there is a need for agents with improved efficacy and less adverse effects. Hypericum perforatum, widely known as St. John's wort, is a perennial herbaceous plant most well known for its antidepressant properties. METHODS We reviewed the available in vitro, in vivo, and clinical evidence on the efficacy, safety, and mechanisms of action of St. John's wort and its active constituents in the treatment of psychiatric and neurodegenerative disorders. RESULTS Several interesting data have been reported about the antidepressant properties of H. perforatum in clinical trials with different designs. In particular, a number of antidepressant-controlled trials demonstrated that H. perforatum and its active ingredients, hypericin and hyperforin, possess antidepressant properties similar to those of tricyclic antidepressants and selective serotonin reuptake inhibitors but with fewer and milder side effects. CONCLUSION St. John's wort may exert potent antidepressant effects and represents an efficacious and safe treatment. However, the current clinical evidence regarding the efficacy of H. perforatum in other psychiatric and neurodegenerative disorders is not sufficient to draw a robust conclusion.
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Affiliation(s)
- Nahid Zirak
- Lung Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mojtaba Shafiee
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ghasem Soltani
- Lung Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Mirzaei
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhossein Sahebkar
- Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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Differing antidepressant maintenance methodologies. Contemp Clin Trials 2017; 61:87-95. [DOI: 10.1016/j.cct.2017.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 07/17/2017] [Accepted: 07/20/2017] [Indexed: 12/28/2022]
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Lee G, Bae H. Therapeutic Effects of Phytochemicals and Medicinal Herbs on Depression. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6596241. [PMID: 28503571 PMCID: PMC5414506 DOI: 10.1155/2017/6596241] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/22/2017] [Accepted: 04/04/2017] [Indexed: 01/21/2023]
Abstract
Background. Depression is a recurrent, common, and potentially life-threatening psychiatric disease related to multiple assignable causes. Although conventional antidepressant therapy can help relieve symptoms of depression and prevent relapse of the illness, complementary therapies are required due to disadvantage of the current therapy such as adverse effects. Moreover, a number of studies have researched adjunctive therapeutic approaches to improve outcomes for depression patients. Purpose. One potential complementary method with conventional antidepressants involves the use of medicinal herbs and phytochemicals that provide therapeutic benefits. Studies have revealed beneficial effects of medical herbs and phytochemicals on depression and their central nervous system mechanism. Here, we summarize the current knowledge of the therapeutic benefits of phytochemicals and medicinal herbs against depression and describe their detailed mechanisms. Sections. There are two sections, phytochemicals against depression and medical herbs against depression, in this review. Conclusion. Use of phytomedicine may be an alternative option for the treatment of depression in case conventional drugs are not applicable due to their side effects, low effectiveness, or inaccessibility. However, the efficacy and safety of these phytomedicine treatments for depression have to be supported by clinical studies.
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Affiliation(s)
- Gihyun Lee
- Department of Physiology, College of Korean Medicine, Kyung Hee University, 26 Kyunghee-daero, Dongdaemun-gu, Seoul 02447, Republic of Korea
- Department of Research and Development, National Development Institute of Korean Medicine, 94 Hwarang-ro, Gyeongsan-si, Gyeongsangbuk-do 38540, Republic of Korea
| | - Hyunsu Bae
- Department of Physiology, College of Korean Medicine, Kyung Hee University, 26 Kyunghee-daero, Dongdaemun-gu, Seoul 02447, Republic of Korea
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Apaydin EA, Maher AR, Shanman R, Booth MS, Miles JNV, Sorbero ME, Hempel S. A systematic review of St. John's wort for major depressive disorder. Syst Rev 2016; 5:148. [PMID: 27589952 PMCID: PMC5010734 DOI: 10.1186/s13643-016-0325-2] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 08/23/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This systematic review evaluated St. John's wort (SJW) for the treatment of Major Depressive Disorder (MDD). The objectives of this review are to (1) evaluate the efficacy and safety of SJW in adults with MDD compared to placebo and active comparator and (2) evaluate whether the effects vary by severity of MDD. METHODS We searched PubMed, CINAHL, PsycINFO, CENTRAL, Embase, AMED, MANTIS, Web of Science, and ICTRP and existing reviews to November 2014. Two independent reviewers screened the citations, abstracted the data, and assessed the risk of bias. We included randomized controlled trials (RCTs) examining the effect of at least a 4-week administration of SJW on depression outcomes against placebo or active comparator in adults with MDD. Risk of bias was assessed using the Cochrane Risk of Bias tool and USPSTF criteria. Quality of evidence (QoE) was assessed using the GRADE approach. RESULTS Thirty-five studies examining 6993 patients met inclusion criteria; eight studies evaluated a hypericum extract that combined 0.3 % hypericin and 1-4 % hyperforin. The herb SJW was associated with more treatment responders than placebo (relative risk [RR] 1.53; 95 % confidence interval [CI] 1.19, 1.97; I(2) 79 %; 18 RCTs; N = 2922, moderate QoE; standardized mean differences [SMD] 0.49; CI 0.23, 0.74; 16 RCTs; I(2) 89 %, N = 2888, moderate QoE). Compared to antidepressants, SJW participants were less likely to experience adverse events (OR 0.67; CI 0.56, 0.81; 11 RCTs; moderate QoE) with no difference in treatment effectiveness (RR 1.01; CI 0.90, 1.14; 17 RCTs, I(2) 52 %, moderate QoE; SMD -0.03; CI -0.21, 0.15; 14 RCTs; I(2) 74 %; N = 2248, moderate QoE) in mild and moderate depression. CONCLUSIONS SJW monotherapy for mild and moderate depression is superior to placebo in improving depression symptoms and not significantly different from antidepressant medication. However, evidence of heterogeneity and a lack of research on severe depression reduce the quality of the evidence. Adverse events reported in RCTs were comparable to placebo and fewer compared with antidepressants. However, assessments were limited due to poor reporting of adverse events and studies were not designed to assess rare events. Consequently, the findings should be interpreted with caution. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015016406 .
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Affiliation(s)
- Eric A Apaydin
- Pardee RAND Graduate School, RAND Corporation, 1776 Main St, PO Box 2138, Santa Monica, CA, 90407-2138, USA.
| | - Alicia R Maher
- Akasha Center for Integrative Medicine, Santa Monica, CA, USA
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Seifritz E, Hatzinger M, Holsboer-Trachsler E. Efficacy of Hypericum extract WS(®) 5570 compared with paroxetine in patients with a moderate major depressive episode - a subgroup analysis. Int J Psychiatry Clin Pract 2016; 20:126-32. [PMID: 27161105 PMCID: PMC4950448 DOI: 10.1080/13651501.2016.1179765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES efficacy and tolerability of WS(®) 5570 for the treatment of acute mild-to-moderate depression, has been demonstrated in various studies. Here, we present a subgroup analysis of a double blind, randomised trial to compare the therapeutic efficacy of WS(®) 5570 with paroxetine in patients suffering from a major depressive episode with moderate symptom intensity. METHODS moderate depression was defined by a baseline Hamilton Depression Rating Scale (HAM-D) total score between 22 and 25. Patients received, after a single blind placebo run-in phase of 3-7 d, either 3 × 300 mg/d WS(®) 5570 or 20 mg/d paroxetine for six weeks. The change of the HAM-D total score was used to describe the efficacy of WS(®) 5570 compared with paroxetine in the subgroup of patients with moderate depression. RESULTS the reductions of the HAM-D total score were significantly more pronounced in patients treated with 3 × 300 mg/d WS(®) 5570 compared to 20 mg/d paroxetine. CONCLUSIONS patients treated with WS(®) 5570 not only showed a reduction in depression severity score but also yielded greater response and remission rates compared with patients treated with paroxetine. Keypoints Various studies showed the efficacy and tolerability of WS(®) 5570 for the treatment of acute mild-to-moderate depression. Beneficial effects of WS(®) 5570 have been also shown in patients with moderate-to-severe depression. In this study reductions of the HAM-D total score were significantly more pronounced in patients with moderate depression treated with WS(®) 5570 compared with paroxetine. Patients treated with WS(®) 5570 not only showed a reduction in depression severity score but also yielded greater response and remission rates compared with patients treated with paroxetine.
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Affiliation(s)
- Erich Seifritz
- a Department of Psychiatry, Psychotherapy, and Psychosomatics , Psychiatric Hospital, University of Zurich , Zurich , Switzerland
| | - Martin Hatzinger
- b Psychiatric Services Solothurner Spitäler & University of Basel , Basel , Switzerland
| | - Edith Holsboer-Trachsler
- c Psychiatric Clinics of the University of Basel , Center for Affective, Stress and Sleep Disorders (ZASS) , Basel , Switzerland
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Sim K, Lau WK, Sim J, Sum MY, Baldessarini RJ. Prevention of Relapse and Recurrence in Adults with Major Depressive Disorder: Systematic Review and Meta-Analyses of Controlled Trials. Int J Neuropsychopharmacol 2015; 19:pyv076. [PMID: 26152228 PMCID: PMC4772815 DOI: 10.1093/ijnp/pyv076] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/02/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Findings of substantial remaining morbidity in treated major depressive disorder (MDD) led us to review controlled trials of treatments aimed at preventing early relapses or later recurrences in adults diagnosed with MDD to summarize available data and to guide further research. METHODS Reports (n = 97) were identified through systematic, computerized literature searching up to February 2015. Treatment versus control outcomes were summarized by random-effects meta-analyses. RESULTS In 45 reports of 72 trials (n = 14 450 subjects) lasting 33.4 weeks, antidepressants were more effective than placebos in preventing relapses (response rates [RR] = 1.90, confidence interval [CI]: 1.73-2.08; NNT = 4.4; p < 0.0001). In 35 reports of 37 trials (n = 7253) lasting 27.0 months, antidepressants were effective in preventing recurrences (RR = 2.03, CI 1.80-2.28; NNT = 3.8; p < 0.0001), with minor differences among drug types. In 17 reports of 22 trials (n = 1 969) lasting 23.7 months, psychosocial interventions yielded inconsistent or inconclusive results. CONCLUSIONS Despite evidence of the efficacy of drug treatment compared to placebos or other controls, the findings further underscore the substantial, unresolved morbidity in treated MDD patients and strongly encourage further evaluations of specific, improved individual and combination therapies (pharmacological and psychological) conducted over longer times, as well as identifying clinical predictors of positive or unfavorable responses and of intolerability of long-term treatments in MDD.
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Affiliation(s)
- Kang Sim
- Yong Loo Lin School of Medicine, National University of Singapore (Drs K Sim, Lau, and J Sim); Research Department, Institute of Mental Health, Singapore (Dr K Sim and Ms Sum); Department of General Psychiatry, Institute of Mental Health, Singapore (Dr K Sim); Department of Psychiatry, Harvard Medical School, Boston, MA (Dr Baldessarini); International Consortium for Psychotic and Mood Disorders Research, McLean Hospital, Belmont, MA (Dr Baldessarini).
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Phytopharmaceutical treatment of anxiety, depression, and dementia in the elderly: evidence from randomized, controlled clinical trials. Wien Med Wochenschr 2015; 165:217-28. [PMID: 26092515 DOI: 10.1007/s10354-015-0360-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 05/10/2015] [Indexed: 12/13/2022]
Abstract
Based on subgroup analyses of randomized, controlled clinical trials, we review the efficacy of three phytopharmaceutical drugs, respectively of the corresponding active substances silexan® (WS® 1265, lavender oil) in anxiety disorders, WS® 5570 (Hypericum extract) in major depression, and EGb 761® (Ginkgo biloba extract) in Alzheimer, vascular, or mixed type dementia, in elderly patients aged ≥ 60 years. Four trials were eligible in each indication. Meta-analyses and analyses based on pooled raw data showed that the three drugs were significantly superior to placebo in the elderly subset, and that their treatment effects reflected in the main outcome measures (Hamilton Anxiety scale, Hamilton Depression scale, Neuropsychiatric Inventory) were comparable with those observed in the original trials without age restrictions. The results confirm the efficacy of the three herbal active substances in elderly patients of ≥ 60 years of age. In anxiety, depression, and dementia, they thus represent efficacious and well-tolerated alternatives to synthetic drugs.
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Bauer M, Severus E, Köhler S, Whybrow PC, Angst J, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders. part 2: maintenance treatment of major depressive disorder-update 2015. World J Biol Psychiatry 2015; 16:76-95. [PMID: 25677972 DOI: 10.3109/15622975.2014.1001786] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
These guidelines for the treatment of unipolar depressive disorders systematically review available evidence pertaining to the biological treatment of patients with major depression and produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians assessing and treating patients with these conditions. The relevant data have been extracted primarily from various treatment guidelines and panels for depressive disorders, as well as from meta-analyses/reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into five levels of evidence (CE A-F) and five levels of recommendation grades (RG 1-5). This second part of the WFSBP guidelines on depressive disorders covers the management of the maintenance phase treatment, and is primarily concerned with the biological treatment (including pharmacological and hormonal medications, electroconvulsive therapy and other brain stimulation treatments) of adults and also, albeit to a lesser extent, children, adolescents and older adults.
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Affiliation(s)
- Michael Bauer
- Department of Psychiatry and Psychotherapy , TU Dresden , Germany
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Bet PM, Hugtenburg JG, Penninx BWJH, Hoogendijk WJG. Side effects of antidepressants during long-term use in a naturalistic setting. Eur Neuropsychopharmacol 2013; 23:1443-51. [PMID: 23726508 DOI: 10.1016/j.euroneuro.2013.05.001] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 03/11/2013] [Accepted: 05/04/2013] [Indexed: 11/18/2022]
Abstract
Side effects of antidepressants are usually underreported in clinical trials and large scale naturalistic studies are restricted to six months of use. We examined the prevalence and nature of patient-perceived side effects and their determinants during long-term antidepressant use in a naturalistic setting. Subjects, aged 19 to 67 years, in the Netherlands Study of Depression and Anxiety were recruited from primary care and specialized mental health care covered 927 cases of single antidepressant use. In 64% of cases, on average, 2.9 side effects were reported. The number of side effects was higher when subjects had higher depression severity (OR=1.28; p=0.002), three or more psychiatric diagnoses (OR=1.97; p=0.02), higher dose (OR=1.44; p=0.006) and was lower when subjects were older (OR=0.83; p=0.02) and had longer duration of use (OR=0.94; p=0.04). Tricyclic antidepressants were associated with more side effects (OR=2.52; p=0.003) and, particularly, more anticholinergic effects, like dry mouth and constipation, as compared to selective serotonin reuptake inhibitors. Venlafaxine showed more profuse sweating (OR=1.79; p=0.007), whereas mirtazapine showed more weight gain and less sexual dysfunction (OR=0.36; p=0.03), as compared to selective serotonin reuptake inhibitors. Weight gain was associated with female gender (OR=1.76; p=0.004) and duration of use (OR=1.06; p=0.03). We show that antidepressant side effect, known from short-term studies, persist during long-term use and are associated with depression severity and antidepressant dose. A novel finding was that venlafaxine is associated with more profuse sweating and that weight gain appeared more specific in female users. Clinicians should be aware that, during long-term antidepressant use, side effects are common and persistent.
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Affiliation(s)
- Pierre M Bet
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands; Neuroscience Campus Amsterdam, VU University, Amsterdam, the Netherlands.
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Abstract
OBJECTIVE WS(®) 5570 is a Hypericum (St. John's wort) dry extract that is available as a medicinal product in coated tablets and has a marketing authorisation for the acute treatment of mild to moderate major depression in Germany. METHODS This article summarizes the current state of knowledge regarding the clinical efficacy and safety of WS(®) 5570. RESULTS In randomised, double-blind, controlled clinical trials the antidepressant effect of the drug was superior to that of the placebo and at least comparable to that of paroxetine. The beneficial effect of WS(®) 5570 is particularly pronounced with respect to the core symptoms of depression. There is evidence that the drug may also be effective in moderate to severe depression and in prophylactic continuation treatment after recovery from an acute episode. CONCLUSIONS WS(®) 5570 has a very favourable safety profile, with adverse event rates on one level with placebo and lower than that of synthetic antidepressants in randomised, controlled clinical trials. It may therefore also be an option for patients who do not tolerate other antidepressant drugs. Patients with polydrug treatment should nevertheless use the drug with caution, due to its potential for interactions.
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Russo E, Scicchitano F, Whalley BJ, Mazzitello C, Ciriaco M, Esposito S, Patanè M, Upton R, Pugliese M, Chimirri S, Mammì M, Palleria C, De Sarro G. Hypericum perforatum: pharmacokinetic, mechanism of action, tolerability, and clinical drug-drug interactions. Phytother Res 2013; 28:643-55. [PMID: 23897801 DOI: 10.1002/ptr.5050] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 07/03/2013] [Accepted: 07/05/2013] [Indexed: 11/06/2022]
Abstract
Hypericum perforatum (HP) belongs to the Hypericaceae family and is one of the oldest used and most extensively investigated medicinal herbs. The medicinal form comprises the leaves and flowering tops of which the primary ingredients of interest are naphthodianthrones, xanthones, flavonoids, phloroglucinols (e.g. hyperforin), and hypericin. Although several constituents elicit pharmacological effects that are consistent with HP's antidepressant activity, no single mechanism of action underlying these effects has thus far been found. Various clinical trials have shown that HP has a comparable antidepressant efficacy as some currently used antidepressant drugs in the treatment of mild/moderate depression. Interestingly, low-hyperforin-content preparations are effective in the treatment of depression. Moreover, HP is also used to treat certain forms of anxiety. However, HP can induce various cytochrome P450s isozymes and/or P-glycoprotein, of which many drugs are substrates and which are the main origin of HP-drug interactions. Here, we analyse the existing evidence describing the clinical consequence of HP-drug interactions. Although some of the reported interactions are based on findings from in vitro studies, the clinical importance of which remain to be demonstrated, others are based on case reports where causality can, in some cases, be determined to reveal clinically significant interactions that suggest caution, consideration, and disclosure of potential interactions prior to informed use of HP.
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Affiliation(s)
- Emilio Russo
- Science of Health Department, School of Medicine, University of Catanzaro, Catanzaro, Italy; Pharmacovigilance's Center Region Calabria, University Hospital Mater Domini, Catanzaro, Italy
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15
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Crispin MC, Hur M, Park T, Kim YH, Wurtele ES. Identification and biosynthesis of acylphloroglucinols in Hypericum gentianoides. PHYSIOLOGIA PLANTARUM 2013; 148:354-70. [PMID: 23600727 PMCID: PMC3687794 DOI: 10.1111/ppl.12063] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 04/05/2013] [Accepted: 04/10/2013] [Indexed: 05/18/2023]
Abstract
Species of the genus Hypericum contain a rich array of unusual polyketides, however, only a small proportion of the over 450 Hypericum species, other than the popular medicinal supplement St. John's Wort (Hypericum perforatum), have even been chemically characterized. Hypericum gentianoides, a small annual used medicinally by Cherokee Americans, contains bioactive acylphloroglucinols. Here, we identify acylphloroglucinol constituents of H. gentianoides and determine a potential pathway to their synthesis. Liquid chromatography/electrospray ionization-mass spectrometry (LC/ESI-MS) and HPLC-UV indicate that the level of accumulation and profile of acylphloroglucinols in H. gentianoides vary little seasonally when grown in a greenhouse, but do vary with development and are highly dependent on the accession, highlighting the importance of the selection of plant material for study. We identify the chemical structures of the nine prevalent polyketides, based on LC/ESI-MS and hybrid quadrupole orthogonal time-of-flight (Q-TOF) mass spectrometry; these metabolites include one monomeric phlorisobutyrophenone (PIB) derivative and eight dimeric acylphloroglucinols. Q-TOF spectrometry was used to identify eight additional PIB derivatives that were not detected by LC/ESI-MS. These data lead us to propose that diacylphloroglucinols are synthesized via modification of PIB to yield diverse phloroglucinol and filicinic acids moieties, followed by dimerization of a phloroglucinol and a filicinic acid monomer to yield the observed complement of diacylphloroglucinols. The metabolomics data from H. gentianoides are accessible in plant metabolomics resource (PMR) (http://www.metnetdb.org/pmr), a public metabolomics database with analysis software for plants and microbial organisms.
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Affiliation(s)
- Matthew C. Crispin
- Department of Genetics, Developmental, and Cell Biology, Iowa State University USA
| | - Manhoi Hur
- Department of Genetics, Developmental, and Cell Biology, Iowa State University USA
| | - Taeseong Park
- Division of Mass Spectrometry Research, Korea Basic Science Institute, Ochang 863-883, Korea
| | - Young Hwan Kim
- Division of Mass Spectrometry Research, Korea Basic Science Institute, Ochang 863-883, Korea
- Graduate School of Analytical Science and Technology, Chungnam National University, Daejeon 305-764, Korea
| | - Eve Syrkin Wurtele
- Department of Genetics, Developmental, and Cell Biology, Iowa State University USA
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Economic evaluation of St. John's wort (Hypericum perforatum) for the treatment of mild to moderate depression. J Affect Disord 2013; 148:228-34. [PMID: 23291009 DOI: 10.1016/j.jad.2012.11.064] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 09/20/2012] [Accepted: 11/29/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND The burden of rising health care expenditures has created a demand for information regarding the clinical and economic outcomes associated with Complementary and Alternative Medicines. Clinical controlled trials have found St. John's wort to be as effective as antidepressants in the treatment of mild to moderate depression. The objective of this study was to develop a model to assess the cost-effectiveness of St. John's wort based on this evidence. METHODS A Markov model was constructed to estimate health and economic impacts of St. John's wort versus antidepressants. Outcomes were treatment costs, quality-adjusted life years (QALYs) and Net Monetary Benefits (NMB). Probabilistic analyses were conducted on key model parameters. RESULTS The average NMB across 5000 simulations identified St. John's wort as the strategy with the highest net benefit. The total cost savings for SJW were $359.66 and $202.56 per individual for venlafaxine and sertraline respectively, with a gain of 0.08 to 0.12 QALYs over the 72 weeks of the model. LIMITATIONS A lack of direct comparative clinical trial data comparing SJW to venlafaxine and limited data with sertraline as a comparator was a major limitation. CONCLUSIONS In this model, St. John's wort was shown to be a cost-effective alternative to generic antidepressants. Patients are more likely to receive treatment for a duration consistent with professional guidelines for treatment of major depression due to reduced incidence of adverse effects, improving outcomes. This represents an important option in the treatment of Major Depressive Disorder.
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Abstract
St. John's wort (Hypericum perforatum) has been extensively studied and reviewed for its use in depression; however, there is less salient discussion on its clinical application for a range of other psychiatric disorders. This article outlines the current evidence of the efficacy of St John's wort in common psychiatric disorders, including major depression, bipolar depression, attention-deficit hyperactivity disorder, obsessive-compulsive disorder, social phobia, and somatization disorder. Mechanisms of action, including emerging pharmacogenetic data, safety, and clinical considerations are also detailed.
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Affiliation(s)
- Jerome Sarris
- Department of Psychiatry, The Melbourne Clinic, The University of Melbourne, 2 Salisbury Street, Richmond, Victoria 3121, Australia.
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18
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Stein AC, Viana AF, Müller LG, Nunes JM, Stolz ED, Do Rego JC, Costentin J, von Poser GL, Rates SMK. Uliginosin B, a phloroglucinol derivative from Hypericum polyanthemum: a promising new molecular pattern for the development of antidepressant drugs. Behav Brain Res 2011; 228:66-73. [PMID: 22155486 DOI: 10.1016/j.bbr.2011.11.031] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 11/23/2011] [Indexed: 11/28/2022]
Abstract
In this study we have demonstrated that cyclohexane extract of Hypericum polyanthemum (POL) and its main phloroglucinol derivative uliginosin B (ULI) present antidepressant-like activity in rodent forced swimming test (FST). The involvement of monoaminergic neurotransmission on the antidepressant-like activity of ULI was evaluated in vivo and in vitro. POL 90 mg/kg (p.o.) and ULI 10 mg/kg (p.o.) reduced the immobility time in the mice FST without altering locomotion activity in the open-field test. The combination of sub-effective doses of POL (45 mg/kg, p.o.) and ULI (5 mg/kg, p.o.) with sub-effective doses of imipramine (10 mg/kg, p.o.), bupropion (3 mg/kg, p.o.) and fluoxetine (15 mg/kg, p.o.) induced a significant reduction on immobility time in FST. The pretreatment with SCH 23390 (15 μg/kg, s.c., dopamine D1 receptor antagonist), sulpiride (50 mg/kg, i.p., dopamine D2 receptor antagonist), prazosin (1mg/kg, i.p., α1-adrenoceptor antagonist), yohimbine (1mg/kg, i.p., α2-adrenoceptor antagonist) and pCPA (100 mg/kg/day, i.p., p-chlorophenilalanine methyl ester, inhibitor of serotonin synthesis, for four consecutive days) before ULI administration (10 mg/kg, p.o.) significantly prevented the anti-immobility effect in FST. ULI was able to inhibit synaptosomal uptake of dopamine (IC50 = 90 ± 38 nM), serotonin (IC50 = 252 ± 13 nM) and noradrenaline (280 ± 48 nM), but it did not bind to any of the monoamine transporters. These data firstly demonstrated the antidepressant-like effect of POL and ULI, which depends on the activation of the monoaminergic neurotransmission in a different manner from the most antidepressants.
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Affiliation(s)
- Ana C Stein
- Graduate Studies Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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19
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Herbal medicine for depression, anxiety and insomnia: a review of psychopharmacology and clinical evidence. Eur Neuropsychopharmacol 2011; 21:841-60. [PMID: 21601431 DOI: 10.1016/j.euroneuro.2011.04.002] [Citation(s) in RCA: 226] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 03/09/2011] [Accepted: 04/06/2011] [Indexed: 11/22/2022]
Abstract
Research in the area of herbal psychopharmacology has increased markedly over the past decades. To date however, a comprehensive review of herbal antidepressant, anxiolytic and hypnotic psychopharmacology and applications in depression, anxiety and insomnia has been absent. A search of MEDLINE (PubMed), CINAHL, PsycINFO, and the Cochrane Library databases was conducted (up to February 21st 2011) on commonly used psychotropic herbal medicines. A review of the literature was conducted to ascertain mechanisms of action of these botanicals, in addition to a systematic review of controlled clinical trials for treatment of mood, anxiety and sleep disorders, which are common comorbid psychiatric disorders. Specific emphasis was given to emerging phytomedicines. Analysis of evidence levels was conducted, as were effect sizes (Cohen's d) where data were available. Results provided evidence of a range of neurochemical, endocrinological, and epigenetic effects for 21 individual phytomedicines, which are detailed in this paper. Sixty six controlled studies were located involving eleven phytomedicines. Several of these provide a high level of evidence, such as Hypericum perforatum for major depression, and Piper methysticum for anxiety disorders. Several human clinical trials provide preliminary positive evidence of antidepressant effects (Echium amoenum, Crocus sativus, and Rhodiola rosea) and anxiolytic activity (Matricaria recutita, Ginkgo biloba, Passiflora incanata, E. amoenum, and Scutellaria lateriflora). Caution should however be taken when interpreting the results as many studies have not been replicated. Several herbal medicines with in vitro and in vivo evidence are currently unexplored in human studies, and along with use of emerging genetic technologies "herbomics", are areas of potential future research.
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Singer A, Schmidt M, Hauke W, Stade K. Duration of response after treatment of mild to moderate depression with Hypericum extract STW 3-VI, citalopram and placebo: a reanalysis of data from a controlled clinical trial. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2011; 18:739-742. [PMID: 21514125 DOI: 10.1016/j.phymed.2011.02.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 01/14/2011] [Accepted: 02/27/2011] [Indexed: 05/30/2023]
Abstract
St. John's Wort (Hypericum perforatum L.) is a useful medication in the treatment of mild to moderate depression. By reanalysis of the data obtained from a total of 154 patients, who responded in a randomised, multicentric, double-blind, placebo-controlled study, to 6 weeks of treatment for an episode of moderate depression with either 20 mg citalopram or 900 mg Hypericum extract STW 3-VI, the duration of response and occurrence of relapse/recurrence were evaluated. Duration of response and occurrence of relapse/recurrence was measured by re-evaluating the responders in a controlled-clinical trial (final score of ≤10 according to HAMD at the end of the clinical trial) according to the Hamilton Rating Scale for Depression (HAMD). In total, 30 (19.5%) of the 154 responders were diagnosed with a relapse. The numbers of patients with relapses were highest in the citalopram group (14 of 54), whereas patients who were treated with Hypericum extract STW 3-VI showed the lowest relapse rate (8/54); patients from the placebo group showed a relapse rate of 8/46. No difference in the severity of relapse could be observed. The duration of response was longest for the Hypericum group (1817 days), intermediate for the citalopram group (1755 days) and shortest for the placebo group (802 days). Hypericum extract STW 3-VI is more efficient in lowering the relapse and recurrence rates of responders, when compared to citalopram and placebo. In addition, duration of response was increased in the group treated with Hypericum extract STW 3-VI.
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Affiliation(s)
- A Singer
- Pierrel Research Onco-Immunology GmbH, Wiesbaden, Germany.
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Klemow K, Bartlow A, Crawford J, Kocher N, Shah J, Ritsick M. Medical Attributes of St. John's Wort (Hypericum perforatum). OXIDATIVE STRESS AND DISEASE 2011. [DOI: 10.1201/b10787-12] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Solomon D, Ford E, Adams J, Graves N. Potential of St John's Wort for the treatment of depression: the economic perspective. Aust N Z J Psychiatry 2011; 45:123-30. [PMID: 20977305 DOI: 10.3109/00048674.2010.526094] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The burden of rising health care expenditures has created a demand for information regarding the clinical and economic outcomes associated with complementary and alternative medicines. Meta-analyses of randomized controlled trials have found Hypericum perforatum preparations to be superior to placebo and similarly effective as standard antidepressants in the acute treatment of mild to moderate depression. A clear advantage over antidepressants has been demonstrated in terms of the reduced frequency of adverse effects and lower treatment withdrawal rates, low rates of side effects and good compliance, key variables affecting the cost-effectiveness of a given form of therapy. The most important risk associated with use is potential interactions with other drugs, but this may be mitigated by using extracts with low hyperforin content. As the indirect costs of depression are greater than five times direct treatment costs, given the rising cost of pharmaceutical antidepressants, the comparatively low cost of Hypericum perforatum extract makes it worthy of consideration in the economic evaluation of mild to moderate depression treatments.
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Affiliation(s)
- Daniela Solomon
- School of Population Health, University of Queensland, Brisbane, Herston, Queensland, Australia.
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Better tolerability of St. John's wort extract WS 5570 compared to treatment with SSRIs: a reanalysis of data from controlled clinical trials in acute major depression. Int Clin Psychopharmacol 2010; 25:204-13. [PMID: 20568656 DOI: 10.1097/yic.0b013e328335dc1a] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Selective serotonin reuptake inhibitors (SSRIs) like paroxetine have replaced older antidepressants mainly because of a more favorable safety profile, but they are still associated with burdensome side effects. We investigate the tolerability of St. John's wort extract WS 5570, a herbal antidepressant with proven efficacy, in comparison to paroxetine and other SSRIs and placebo. A reanalysis was performed based on the original data from four controlled clinical trials during which 1661 outpatients with major depression (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria) received between 600 and 1800 mg/day WS 5570 (n=1264), 20 or 40 mg/day paroxetine (n=126), or placebo (n=271) for 6 weeks. For single and grouped adverse events, the risk ratios for treatment group comparisons were determined along with their 95% confidence intervals, including comparisons with published data for SSRIs. Across the four trials, the percentage of patients with any adverse events under WS 5570 exposition was comparable with placebo [risk ratio (95% confidence interval): 1.1 (0.9-1.3) in favor of WS 5570] and significantly lower than for paroxetine [2.4 (2.1-2.8)]. Compared with the herbal extract adverse event rates under paroxetine were between 10 and 38-fold higher (point estimates) in five out of seven symptom clusters inspected. WS 5570 was devoid of effects of sedation, anticholinergic reactions, gastrointestinal disturbances, and sexual dysfunction often found during treatment with SSRIs and other synthetic antidepressants. In conclusion, WS 5570 exhibits substantially lower incidence rates of adverse events than paroxetine and other SSRIs.
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