A meta-analysis on the efficacy and safety of St John's wort extract in depression therapy in comparison with selective serotonin reuptake inhibitors in adults

A review of the WHO strategy on traditional, complementary, and integrative medicine from the perspective of academic consortia for integrative medicine and health

Despite important progress in modern medicine, widely regarded as an indispensable foundation of healthcare in all highly advanced nations and regions, not all patients respond well to available treatments in biomedicine alone. Additionally, there are concerns about side effects of many medications and interventions, the unsustainable cost of healthcare and the low resolution of chronic non-communicable diseases and mental disorders whose incidence has risen in the last decades. Besides, the chronic stress and burnout of many healthcare professionals impairs the therapeutic relationship. These circumstances call for a change in the current paradigm and practices of biomedicine healthcare. Most of the world population (80%) uses some form of traditional, complementary, and integrative medicine (T&CM), usually alongside biomedicine. Patients seem equally satisfied with biomedicine and T&CM, but in the field of T&CM there are also many challenges, such as unsupported claims for safety and/or efficacy, contamination of herbal medicines and problems with regulation and quality standards. As biomedicine and T&CM seem to have different strengths and weaknesses, integration of both approaches may be beneficial. Indeed, WHO has repeatedly called upon member states to work on the integration of T&CM into healthcare systems. Integrative medicine (IM) is an approach that offers a paradigm for doing so. It combines the best of both worlds (biomedicine and T&CM), based on evidence for efficacy and safety, adopting a holistic personalized approach, focused on health. In the last decades academic health centers are increasingly supportive of IM, as evidenced by the foundation of national academic consortia for integrative medicine in Brazil (2017), the Netherlands (2018), and Germany (2024) besides the pioneering American consortium (1998). However, the integration process is slow and sometimes met with criticism and even hostility. The WHO T&CM strategies (2002-2005 and 2014-2023) have provided incipient guidance on the integration process, but several challenges are yet to be addressed. This policy review proposes several possible solutions, including the establishment of a global matrix of academic consortia for IM, to update and extend the WHO T&CM strategy, that is currently under review.

Effects of Geometric Sound on Brainwave Activity Patterns, Autonomic Nervous System Markers, Emotional Response, and Faraday Wave Pattern Morphology

This study introduces Geometric Sound as a subfield of spatial sound featuring audio stimuli which are sonic holograms of mathematically defined 3D shapes. The effects of Geometric Sound on human physiology were investigated through EEG, heart rate, blood pressure, and a combination of questionnaires monitoring 50 healthy participants in two separate experiments. The impact of Geometric Sound on Faraday wave pattern morphology was further studied. The shapes examined, pyramid, cube, and sphere, exhibited varying significant effects on autonomic nervous system markers, brainwave power amplitude, topology, and connectivity patterns, in comparison to both the control (traditional stereo), and recorded baseline where no sound was presented. Brain activity in the Alpha band exhibited the most significant results, additional noteworthy results were observed across analysis paradigms in all frequency bands. Geometric Sound was found to significantly reduce heart rate and blood pressure and enhance relaxation and general well-being. Changes in EEG, heart rate, and blood pressure were primarily shape-dependent, and to a lesser extent sex-dependent. Pyramid Geometric Sound yielded the most significant results in most analysis paradigms. Faraday Waves patterns morphology analysis indicated that identical frequencies result in patterns that correlate with the excitation Geometric Sound shape. We suggest that Geometric Sound shows promise as a noninvasive therapeutic approach for physical and psychological conditions, stress-related disorders, depression, anxiety, and neurotrauma. Further research is warranted to elucidate underlying mechanisms and expand its applications.

Pharmacokinetic and pharmacodynamic herb-drug interactions-part I. Herbal medicines of the central nervous system

Unlike conventional drug substances, herbal medicines are composed of a complex of biologically active compounds. Therefore, the potential occurrence of herb-drug interactions is even more probable than for drug-drug interactions. Interactions can occur on both the pharmacokinetic and pharmacodynamic level. Herbal medicines may affect the resulting efficacy of the concomitantly used (synthetic) drugs, mainly on the pharmacokinetic level, by changing their absorption, distribution, metabolism, and excretion. Studies on the pharmacodynamic interactions of herbal medicines and conventional drugs are still very limited. This interaction level is related to the mechanism of action of different plant constituents. Herb-drug interactions can cause changes in drug levels and activities and lead to therapeutic failure and/or side effects (sometimes toxicities, even fatal). This review aims to provide a summary of recent information on the potential drug interactions involving commonly used herbal medicines that affect the central nervous system (Camellia, Valeriana, Ginkgo, Hypericum, Humulus, Cannabis) and conventional drugs. The survey databases were used to identify primary scientific publications, case reports, and secondary databases on interactions were used later on as well. Search keywords were based on plant names (botanical genera), officinal herbal drugs, herbal drug preparations, herbal drug extracts.

#TreatmentResistantDepression: A qualitative content analysis of Tweets about difficult-to-treat depression

INTRODUCTION

Treatment-resistant depression (TRD) is depression unresponsive to antidepressants and affects 55% of British primary care users with depression. Current evidence is from secondary care, but long referral times mean general practitioners (GPs) manage TRD. Studies show that people with depression use Twitter to form community and document symptoms. However, Twitter remains a largely unexplored space of documented patient experience. Twitter data could provide valuable insights into learning about primary care experiences of TRD. In this study, we explored Twitter comments and conversations about TRD and produced patient-driven recommendations.

METHODS

Tweets from UK-based users were collected manually and using a browser extension in June 2021. Conventional content analysis was used to provide an overview of the Tweets, followed by interpretation to understand why Twitter may be important to people with TRD.

RESULTS

A total of 415 Tweets were organised into five clusters: self-diagnosis, symptoms, support, small wins and condition experts. These Tweets were interpreted as showing Twitter as a community for people with TRD. People had a collective sense of illness identity and were united in their experiences of TRD. However, users in the community also highlighted the absence of effective GP care, leading users to position themselves as condition experts. Users shared advice from a place of lived experience with the community but also shared potentially harmful information, including recommendations about nonevidence-based medications.

CONCLUSIONS

Findings illuminate the benefits of the TRD Twitter community and also highlight that the perception of a lack of knowledge and support from GPs may lead community members to advise nonevidenced-based medications.

PATIENT AND PUBLIC CONTRIBUTION

This study was led by a person with lived experience of TRD and bipolar. Two public contributors with mental health conditions gave feedback on our study protocol and results.

Exercise for Mental Well-Being: Exploring Neurobiological Advances and Intervention Effects in Depression

Depression is a common mental disorder in which patients often experience feelings of sadness, fatigue, loss of interest, and pleasure. Exercise is a widely used intervention for managing depression, but the specific molecular mechanisms underlying its antidepressant effect are unclear. In this narrative review, we aim to synthesize current knowledge on the molecular, neural, and physiological mechanisms through which exercise exerts its antidepressant effect and discuss the various exercise interventions used for managing depression. We conducted a narrative review of the literature on the topic of exercise and depression. Our review suggests that exercise impacts peripheral tryptophan metabolism, central inflammation, and brain-derived neurotrophic factors through the peroxisome proliferator-activated receptor γ activating factor 1α (PGC-1α) in skeletal muscles. The uncarboxylated osteocalcin facilitates "bone-brain crosstalk", and exercise corrects atypical expression of brain-gut peptides, modulates cytokine production and neurotransmitter release, and regulates inflammatory pathways and microRNA expression. Aerobic exercise is recommended at frequencies of 3 to 5 times per week with medium to high intensity. Here we highlight the significant potential of exercise therapy in managing depression, supported by the molecular, neural, and physiological mechanisms underlying its antidepressant effect. Understanding the molecular pathways and neural mechanisms involved in exercise's antidepressant effect opens new avenues for developing novel therapies for managing depression.

Immunological evaluation of herbal extracts commonly used for treatment of mental diseases during pregnancy

Nonpsychotic mental diseases (NMDs) affect approximately 15% of pregnant women in the US. Herbal preparations are perceived a safe alternative to placenta-crossing antidepressants or benzodiazepines in the treatment of nonpsychotic mental diseases. But are these drugs really safe for mother and foetus? This question is of great relevance to physicians and patients. Therefore, this study investigates the influence of St. John's wort, valerian, hops, lavender, and California poppy and their compounds hyperforin and hypericin, protopine, valerenic acid, and valtrate, as well as linalool, on immune modulating effects in vitro. For this purpose a variety of methods was applied to assess the effects on viability and function of human primary lymphocytes. Viability was assessed via spectrometric assessment, flow cytometric detection of cell death markers and comet assay for possible genotoxicity. Functional assessment was conducted via flow cytometric assessment of proliferation, cell cycle and immunophenotyping. For California poppy, lavender, hops, and the compounds protopine and linalool, and valerenic acid, no effect was found on the viability, proliferation, and function of primary human lymphocytes. However, St. John's wort and valerian inhibited the proliferation of primary human lymphocytes. Hyperforin, hypericin, and valtrate inhibited viability, induced apoptosis, and inhibited cell division. Calculated maximum concentration of compounds in the body fluid, as well as calculated concentrations based on pharmacokinetic data from the literature, were low and supported that the observed effects in vitro would probably have no relevance on patients. In-silico analyses comparing the structure of studied substances with the structure of relevant control substances and known immunosuppressants revealed structural similarities of hyperforin and valerenic acid to the glucocorticoids. Valtrate showed structural similarities to the T cells signaling modulating drugs.

Antidepressant effects of p-coumaric acid isolated from Vaccinium bracteatum leaves extract on chronic restraint stress mouse model and antagonism of serotonin 6 receptor in vitro

BACKGROUND

Vaccinium bracteatum Thunb. leaves (VBL) are used in traditional herbal medicines to treat various biological diseases. p-coumaric acid (CA), the main active component of VBL, has neuroprotective effects against corticosterone-induced damage in vitro. However, the effects of CA on immobility induced by chronic restraint stress (CRS) in a mouse model and 5-HT receptor activity have not been investigated.

HYPOTHESIS/PURPOSE

We investigated the antagonistic effects of VBL, NET-D1602, and the three components of Gαs protein-coupled 5-HT receptors. Additionally, we identified the effects and mechanism of action of CA, the active component of NET-D1602, in the CRS-exposed model.

METHODS

For in vitro analyses, we used 1321N1 cells stably expressing human 5-HT₆ receptors and CHO-K1 expressing human 5-HT₄ or 5-HT₇ receptors cell lines to study the mechanism of action. For in vivo analyses, CRS-exposed mice were orally administered CA (10, 50, or 100 mg/kg) daily for 21 consecutive days. The effects of CA were analyzed by assessing behavioral changes using a forced swim test (FST), measuring levels of hypothalamic-pituitary-adrenal (HPA) axis-related hormones in ntial therapeutic effects as 5-HT6 receptor antagonists for neurodegenerative diseases and depressioserum, and acetylcholinesterase (AChE), monoamines, including 5-HT, dopamine, and norepinephrine, using enzyme-linked immunosorbent assay kits. The underlying molecular mechanisms of the serotonin transporter (SERT), monoamine oxidase A (MAO-A), and extracellular signal-regulated kinase (ERK)/protein kinase B (Akt)/mTORC1 signaling were detected using western blotting.

RESULTS

CA was confirmed to be an active component in the antagonistic effects of NET-D1602 on 5-HT₆ receptor activity through decreases in cAMP and ERK1/2 phosphorylation. Moreover, CRS-exposed mice treated with CA showed a significantly reduced immobility time in the FST. CA also significantly decreased corticosterone, corticotropin-releasing hormone (CRH), and adrenocorticotropic hormone (ACTH) levels. CA enhanced 5-HT, dopamine, and norepinephrine levels in the hippocampus (HC) and prefrontal cortex (PFC) but decreased MAO-A and SERT protein levels. Similarly, CA significantly upregulated the ERK, Ca²⁺/calmodulin-dependent protein kinase II (CaMKII), Akt/mTOR/p70S6K/S6 signaling pathways in both HC and the PFC.

CONCLUSION

CA contained in NET-D1602 may play the antidepressant effects against CRS-induced depression-like mechanism and the selective antagonist effect of 5-HT₆ receptor.

Depression and Its Phytopharmacotherapy-A Narrative Review

Depression is a mental health disorder that develops as a result of complex psycho-neuro-immuno-endocrinological disturbances. This disease presents with mood disturbances, persistent sadness, loss of interest and impaired cognition, which causes distress to the patient and significantly affects the ability to function and have a satisfying family, social and professional life. Depression requires comprehensive management, including pharmacological treatment. Because pharmacotherapy of depression is a long-term process associated with the risk of numerous adverse drug effects, much attention is paid to alternative therapy methods, including phytopharmacotherapy, especially in treating mild or moderate depression. Preclinical studies and previous clinical studies confirm the antidepressant activity of active compounds in plants, such as St. John's wort, saffron crocus, lemon balm and lavender, or less known in European ethnopharmacology, roseroot, ginkgo, Korean ginseng, borage, brahmi, mimosa tree and magnolia bark. The active compounds in these plants exert antidepressive effects in similar mechanisms to those found in synthetic antidepressants. The description of phytopharmacodynamics includes inhibiting monoamine reuptake and monoamine oxidase activity and complex, agonistic or antagonistic effects on multiple central nervous system (CNS) receptors. Moreover, it is noteworthy that the anti-inflammatory effect is also important to the antidepressant activity of the plants mentioned above in light of the hypothesis that immunological disorders of the CNS are a significant pathogenetic factor of depression. This narrative review results from a traditional, non-systematic literature review. It briefly discusses the pathophysiology, symptomatology and treatment of depression, with a particular focus on the role of phytopharmacology in its treatment. It provides the mechanisms of action revealed in experimental studies of active ingredients isolated from herbal antidepressants and presents the results of selected clinical studies confirming their antidepressant effectiveness.

Management of depression in patients with coronary artery disease: A systematic review

Depression is an independent risk factor for coronary artery disease (CAD). Both illnesses contribute significantly to the global burden of disease. This systematic literature review examines treatment interventions for CAD patients with comorbid depression. We systematically reviewed The Cochrane Library, MEDLINE, EMBASE, PsycINFO, PUBMED, CINAHL and the ISRCTN Registry for English language randomised control trials investigating treatment interventions for depression in adults with CAD and comorbid depression. Data extracted included author name(s), year published, number of participants, enrolment criteria, depression definition/measures (standardised interviews, rating scales), description of control arms and interventions (psychotherapy and/or medications), randomisation, blinding, follow-up duration, follow-up loss, depression scores and medical outcome. The database search revealed 4464 articles. The review yielded 19 trials. Antidepressant and/or psychotherapy did not significantly influence CAD outcomes in the overall population. There was no difference between antidepressant use and aerobic exercises. Psychological interventions and pharmacological interventions provide small effect on depression outcomes in CAD patients. Patient autonomy in choice of treatment is associated with greater depression treatment satisfaction, but the majority of studies are underpowered. More research is required to explore the role of neurostimulation treatment, complementary and alternative treatments.

Medicinal Plants for the Treatment of Mental Diseases in Pregnancy: An In Vitro Safety Assessment

Pregnancy is a critical period for medical care, during which the well-being of woman and fetus must be considered. This is particularly relevant in managing non-psychotic mental disorders since treatment with central nervous system-active drugs and untreated NMDs may have negative effects. Some well-known herbal preparations (phytopharmaceuticals), including St. John's wort, California poppy, valerian, lavender, and hops, possess antidepressant, sedative, anxiolytic, or antidepressant properties and could be used to treat mental diseases such as depression, restlessness, and anxiety in pregnancy. Our goal was to assess their safety in vitro, focusing on cytotoxicity, induction of apoptosis, genotoxicity, and effects on metabolic properties and differentiation in cells widely used as a placental cell model (BeWo b30 placenta choriocarcinoma cells). The lavender essential oil was inconspicuous in all experiments and showed no detrimental effects. At low-to-high concentrations, no extract markedly affected the chosen safety parameters. At an artificially high concentration of 100 µg/mL, extracts from St. John's wort, California poppy, valerian, and hops had minimal cytotoxic effects. None of the extracts resulted in genotoxic effects or altered glucose consumption or lactate production, nor did they induce or inhibit BeWo b30 cell differentiation. This study suggests that all tested preparations from St. John's wort, California poppy, valerian, lavender, and hops, in concentrations up to 30 µg/mL, do not possess any cytotoxic or genotoxic potential and do not compromise placental cell viability, metabolic activity, and differentiation. Empirical and clinical studies during pregnancy are needed to support these in vitro data.

Advantages and Disadvantages of Using St. John's Wort as a Treatment for Depression

Background and objectives: St. John's wort (SJW) extracts are currently being used to treat depression of various degrees of severity. While many studies have shown it to be superior to placebo, data regarding the effectiveness of using SJW as a stand-alone treatment compared with standard antidepressants has yet to be proven conclusively. This study aims to understand the advantages and disadvantages of SJW as a treatment modality for depression.

Methods: The authors searched PubMed, JAMA network, Springer Link, Elsevier, Google Scholar, and Scientific Progress databases, from 2011 through August 2021, using the following keywords: St John’s wort, Hypericum perforatum, depression, antidepressant, complementary alternative medicine, economic evaluation depression St. wort, St John’s wort and depression, antidepressant interactions. This yielded a total of 27 papers following a thorough removal of irrelevant content and dissemination in languages other than English.

Results: In patients with mild and moderate depression, SJW proved superior to placebo. Certain studies comparing the efficacy of SJW versus selective serotonin reuptake inhibitors (SSRIs), especially fluoxetine, reported SJW to be more efficacious, while the majority reported no significant difference. Tricyclic antidepressants were also found to have similar efficacy as SJW. Moreover, treatment with SJW was also found to reduce postmenopausal depression. Regarding the safety profile, although SJW is better tolerated with fewer adverse effects when compared to standardized antidepressants, its predisposition to causing fatal serotonin syndrome, when used in conjunction with other serotonergic agents and drug interactions noted with CYP 450 drugs, raises a question in the safety profile.

Conclusion: It is essential to acknowledge that SJW has been used as a treatment measure in Germany. Despite being only listed as a dietary supplement by the FDA and not a drug, SJW has shown to be comparable, if not more efficacious, than most standard treatment options for depression. SJW does prove to be an exciting piece of pharmacotherapy in the realm of mental health and post-menopausal treatment. More prospective studies will help us better understand its efficacy in mild and moderate depression and its ability to serve as a long-term agent. Considering its mechanism of action, its role in relieving patients suffering from an anxiety disorder is also worth considering.

Potential Mechanisms of Shu Gan Jie Yu Capsule in the Treatment of Mild to Moderate Depression Based on Systemic Pharmacology and Current Evidence

Background

Shu Gan Jie Yu (SGJY) capsule has a good effect on relieving depressive symptoms in China. However, the mechanism of action is still unclear. Therefore, systemic pharmacology and molecular docking approaches were used to clarify its corresponding antidepressant mechanisms.

Methods

Traditional Chinese Medicine Database and Analysis Platform (TCMSP), the Encyclopedia of Traditional Chinese Medicine (ETCM), and Swiss Target Prediction servers were used to screen and predict the bioactive components of the SGJY capsule and their antidepressive targets. Mild to moderate depression (MMD) related genes were obtained from GeneCards and DisGeNET databases. A network of bioactive components-therapeutic targets of the SGJY capsule was established by STRING 11.5 and Cytoscape 3.9.0 software. Gene function and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were performed by utilizing Database for Annotation, Visualization, and Integrated Discovery (DAVID) platform. Active components were taken to dock with the hypothetical proteins by iGEMDOCK and SwissDock, and the docking details were visually displayed by UCSF Chimera software. Then, the related research literature of the SGJY capsule was reviewed, summarized, sorted, and analyzed, including experimental evidence and clinical experience.

Results

Seven active components and 45 intersection targets were included in the study. PPI network had genuinely uncovered the potential therapeutic targets, such as AKT1, HSP90AA1, ESR1, EGFR, and PTGS2. KEGG pathway analysis showed that the mechanism of the SGJY capsule on MMD was mainly involved in the PI3K-Akt signaling pathway.

Conclusions

In this study, we have successfully predicted the biochemically active constituents, potential therapeutic targets, and comprehensively predicted the related drug-gene interaction of the SGJY capsule for treating MMD and provided a basis for subsequent experiments.

Advanced in Vitro Safety Assessment of Herbal Medicines for the Treatment of Non-Psychotic Mental Disorders in Pregnancy

When confronted with non-psychotic mental disorders, pregnant women often refrain from using synthetic drugs and resort to herbal medicines such as St. John’s wort, California poppy, valerian, lavender, and hops. Nevertheless, these herbal medicines have not yet been officially approved in pregnancy due to lack of safety data. Using a variety of in vitro methods (determination of cytotoxicity, apoptosis induction, genotoxicity, effects on metabolic properties, and inhibition/induction of differentiation) in a commonly used placental cell line (BeWo b30), we were previously able to show that extracts from these plants are likely to be safe at the usual clinical doses. In the present work, we wanted to extend our safety assessment of these herbal medicines by 1) looking for possible effects on gene expression and 2) using the same in vitro methods to characterize effects of selected phytochemicals that might conceivably lead to safety issues. Proteomics results were promising, as none of the five extracts significantly affected protein expression by up- or down-regulation. Protopine (contained in California poppy), valerenic acid (in valerian), and linalool (in lavender) were inconspicuous in all experiments and showed no adverse effects. Hyperforin and hypericin (two constituents of St. John’s wort) and valtrate (typical for valerian) were the most obvious phytochemicals with respect to cytotoxic and apoptotic effects. A decrease in cell viability was evident with hypericin (≥1 µM) and valtrate (≥10 µM), whereas hyperforin (≥3 µM), hypericin (30 µM) and valtrate (≥10 µM) induced cell apoptosis. None of the tested phytochemicals resulted in genotoxic effects at concentrations of 0.1 and 1 µM and thus are not DNA damaging. No decrease in glucose consumption or lactate production was observed under the influence of the phytochemicals, except for valtrate (at all concentrations). No compound affected cell differentiation, except for hyperforin (≥1 µM), which had an inhibitory effect. This study suggests that extracts from St. John’s wort, California poppy, valerian, lavender, and hops are likely to be safe during pregnancy. High plasma concentrations of some relevant compounds—hyperforin and hypericin from St. John’s wort and valtrate from valerian—deserve special attention, however.

St. John's wort (Hypericum perforatum) and depression: what happens to the neurotransmitter systems?

St. John's wort (Hypericum perforatum) is a herbaceous plant containing many bioactive molecules including naphthodianthrones, phloroglucinol derivatives, flavonoids, bioflavonoids, proanthocyanidins, and chlorogenic acid. Evidence has shown the therapeutic effects of St. John's wort and especially its two major active components, hyperforin and hypericin, on different psychiatric and mood disorders such as posttraumatic stress disorder (PTSD), attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), and anxiety disorders. St. John's wort also induces antidepressant effects. In this review study, we aimed to discuss the role of St. John's wort in modulating depression, with respect to the role of different neurotransmitter systems in the brain. We discussed changes in the neurotransmitter levels in depression, and following use of St. John's wort. It was concluded that changes in the function and level of neurotransmitters in depression are complex. Also, St. John's wort can induce inconsistent effects on neurotransmitter levels. We also found that glutamate and acetylcholine may be the most important neurotransmitters to study in future works, because the function of both neurotransmitters in depression is unclear. In addition, St. John's wort induces a dualistic modulation on the activity of cholinergic signaling, which can be an interesting topic for future studies.

Phytotherapy in Integrative Oncology-An Update of Promising Treatment Options

Modern phytotherapy is part of today's conventional evidence-based medicine and the use of phytopharmaceuticals in integrative oncology is becoming increasingly popular. Approximately 40% of users of such phytopharmaceuticals are tumour patients. The present review provides an overview of the most important plants and nature-based compounds used in integrative oncology and illustrates their pharmacological potential in preclinical and clinical settings. A selection of promising anti-tumour plants and ingredients was made on the basis of scientific evidence and therapeutic practical relevance and included Boswellia, gingko, ginseng, ginger, and curcumin. In addition to these nominees, there is a large number of other interesting plants and plant ingredients that can be considered for the treatment of cancer diseases or for the treatment of tumour or tumour therapy-associated symptoms. Side effects and interactions are included in the discussion. However, with the regular and intended use of phytopharmaceuticals, the occurrence of adverse side effects is rather rare. Overall, the use of defined phytopharmaceuticals is recommended in the context of a rational integrative oncology approach.

St. John's Wort-Induced Supraventricular Tachycardia

St. John’s wort, a non-FDA-approved over-the-counter (OTC) herbal supplement with antidepressant activity known as Hypericum perforatum, has been found to induce supraventricular tachycardia (SVT) in the absence of any underlying structural cardiac abnormality or known medical history via currently unclear pathophysiology. In this case presentation, the authors present a case of a 33-year-old female who presented with recurrent episodes of palpitations one month after initiating St. John’s wort for the treatment of depression, which ultimately resolved upon cessation of the herbal supplement. Therefore, the postulated insinuating event is suspected to be the ingestion of St. John’s wort. This will be the first documented case of St. John’s wort-induced SVT. This case study brings into question the safety of the use of this agent as an OTC supplement for the management of depression. Further investigation is required to aid in the knowledge and understanding of the causative mechanism and to identify those patients who are at potentially heightened risks of such manifestations.

Utilisation of self-care products and practices and its associated factors among stroke survivors

This study explored the characteristics associated with the use of self-care products and practices by people rehabilitating from stroke. A cross-sectional sub-study of the Sax Institute's 45 and Up Study in which 1300 participants who had indicated a doctor had diagnosed them as having had a stroke were mailed a sub-study survey. The survey instrument included questionnaire items on demographics, self-care products and practices, health status and stroke status. The survey was completed by 576 (44.3%) of those eligible. At least one self-care product or practice was used by 39.9% of participants. Female participants were more likely than males to use self-care products (P ≤ .001) and self-care practices (P = .021). Self-care product use was higher amongst those with higher levels of fatigue (OR = 1.07) and/or those reporting slight (OR = 2.05) or moderate disability (OR = 2.28), compared with those who had no symptoms at all. As the burden of stroke survivorship increases because of improved acute stroke care in an ageing population, a stronger focus is needed by researchers, clinicians and policy makers on the self-care strategies used by stroke survivors and the ability for health professionals to appropriately support stroke survivors' in their rehabilitation and long-term management.

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.

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.

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.

Hypericum perforatum in the treatment of psychiatric and neurodegenerative disorders: Current evidence and potential mechanisms of action

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.

Vaccinium bracteatum Leaf Extract Reverses Chronic Restraint Stress-Induced Depression-Like Behavior in Mice: Regulation of Hypothalamic-Pituitary-Adrenal Axis, Serotonin Turnover Systems, and ERK/Akt Phosphorylation

The leaves of Vaccinium bracteatum Thunb. are a source of traditional herbal medicines found in East Asia. The present study aimed to evaluate the mechanisms underlying the antidepressant-like effects of water extract of V. bracteatum Thunb. leaves (VBLW) in a mouse model of chronic restraint stress (CRS) and to identify the possible molecular in vitro mechanisms of the neuroprotective effects. The CRS-exposed mice were orally administered VBLW (100 and 200 mg/kg) daily for 21 days consecutively. The behavioral effects of VBLW were assessed through the forced swim test (FST) and the open field test (OFT). The levels of serum corticosterone (CORT), corticotropin releasing hormone (CRH), and adrenocorticotropin hormone (ACTH), brain monoamines, such as serotonin, dopamine, and norepinephrine, and serotonin turnover by tryptophan hydroxylase 2 (TPH2), serotonin reuptake (SERT), and monoamine oxidase A (MAO-A) were evaluated, in addition to the extracellular signal-regulated kinases (ERKs)/protein kinase B (Akt) signaling pathway. CRS-exposed mice treated with VBLW (100 and 200 mg/kg) showed significantly reduced immobility time and increased swimming and climbing times in the FST, and increased locomotor activity in the OFT. Moreover, CRS mice treated with VBLW exhibited significantly decreased CORT and ACTH, but enhanced brain monoamine neurotransmitters. In addition, CRS mice treated with VBLW had dramatically decreased protein levels of MAO-A and SERT, but increased TPH2 protein levels in the hippocampus and the PFC. Similarly, VBLW significantly upregulated the ERKs/Akt signaling pathway in the hippocampus and the PFC. Furthermore, VBLW showed neuroprotective effects via increased CREB phosphorylation in CORT-induced cell injury that were mediated through the ERK/Akt/mTOR signaling pathways. These results suggested that the antidepressant-like effects of VBLW might be mediated by the regulation of the HPA axis, glucocorticoids, and serotonin turnover, such as TPH2, SERT, and MAO-A, as well as the concentration of monoamine neurotransmitters, and the activities of ERK and Akt phosphorylation, which were possibly associated with neuroprotective effects.

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.

Nutritional psychiatry: the present state of the evidence

Mental illness, including depression, anxiety and bipolar disorder, accounts for a significant proportion of global disability and poses a substantial social, economic and heath burden. Treatment is presently dominated by pharmacotherapy, such as antidepressants, and psychotherapy, such as cognitive behavioural therapy; however, such treatments avert less than half of the disease burden, suggesting that additional strategies are needed to prevent and treat mental disorders. There are now consistent mechanistic, observational and interventional data to suggest diet quality may be a modifiable risk factor for mental illness. This review provides an overview of the nutritional psychiatry field. It includes a discussion of the neurobiological mechanisms likely modulated by diet, the use of dietary and nutraceutical interventions in mental disorders, and recommendations for further research. Potential biological pathways related to mental disorders include inflammation, oxidative stress, the gut microbiome, epigenetic modifications and neuroplasticity. Consistent epidemiological evidence, particularly for depression, suggests an association between measures of diet quality and mental health, across multiple populations and age groups; these do not appear to be explained by other demographic, lifestyle factors or reverse causality. Our recently published intervention trial provides preliminary clinical evidence that dietary interventions in clinically diagnosed populations are feasible and can provide significant clinical benefit. Furthermore, nutraceuticals including n-3 fatty acids, folate, S-adenosylmethionine, N-acetyl cysteine and probiotics, among others, are promising avenues for future research. Continued research is now required to investigate the efficacy of intervention studies in large cohorts and within clinically relevant populations, particularly in patients with schizophrenia, bipolar and anxiety disorders.

Stress inhibits tryptophan hydroxylase expression in a rat model of depression

Serotonin (5-hydroxytryptamine, 5-HT) dysfunction is associated with the pathophysiology of depression. Tryptophan hydroxylase (TPH), the rate-limiting enzyme in 5-HT biosynthesis, is believed to have essential role in many mental disorders, including depression. In the present study, we generated a rat model of depression by exposing the animals to stress, and the rats were then treated with paroxetine. The results indicated that the concentration of 5-HT in the brain and liver tissues were significantly lower in the rat model of depression than in healthy or treated rats. Immunohistochemical analyses of TPH1/2 showed less TPH1 and TPH2 expression, specifically TPH2, in the brain, liver and kidney of the depressive rats than in the healthy rats; In addition, the two TPH isoforms, TPH1 and TPH2, had different spatial distributions,the mRNAs of the TPH1/2 genes were significantly decreased and TPH1/2 were highly methylated in the depressive model rat, but treatment with paroxetine ameliorated the expression and methylation of TPH1/2. All together, stress was able to inhibit expression of TPH1/2 in brain tissue and decrease concentration of 5-HT, the mechanism maybe involve in increasing the methylation of TPH2 genes promoter; Paroxetine has a role in confronting the effect of stress in depressive rat model.

Changes in prevalence of psychotropic drug use and alcohol consumption among the elderly in Germany: results of two National Health Interview and Examination Surveys 1997-99 and 2008-11

BACKGROUND

Psychotropic drug use and alcohol consumption among older adults need to be monitored over time as their use or combined use bears risks of harms. Representative data on changes in prevalence, patterns and co-relates of substance use are lacking in Germany.

METHODS

Participants were older adults (60-79 years) from two German National Health Surveys: 1997-99 (GNHIES98, N = 1,606) and 2008-11 (DEGS1, N = 2,501). Included were drugs acting on the nervous system used during the last 7 days. Alcohol consumption was measured by frequency (daily drinking) and quantity (risky drinking: ≥20/10 g/day alcohol for men/women). Changes in prevalence adjusted for potential socio-economic and health-related confounders were calculated by logistic regression models approximated by the SAS LSMEANS statement.

RESULTS

The prevalence of overall psychotropic drug use (20.5% vs. 21.4%) remained constant between the two surveys. Significant changes were observed in the use of some psychotropics (all GNHIES98 vs. DEGS1): Synthetic antidepressants (3.9% vs. 6.9%), St. John's wort (2.9% vs. 1.1%), benzodiazepines (3.7% vs. 2.5%), benzodiazepine related drugs (0.2% vs. 0.8%), narcotic analgesics (3.0% vs. 4.1%), anti-dementia drugs (2.2% vs. 4.2%) and anti-epileptics (1.0% vs. 2.3%). Significant changes were also observed in long-term use of synthetic anti-depressants (3.2% vs. 5.9%), St. John's wort (2.0% vs. 0.6%) and opioid analgesics (1.0% vs. 2.2%). Further, we found significant changes in benzodiazepines use (3.3% vs. 1.4%) among men, opioids use (2.9% vs. 7.3%) among people with a lower social status, and overall psychotropics (26.8% vs. 32.5%) as well as opioids use (4.4% vs. 8.1%) among those with a worse health status. Moderate alcohol consumption increased significantly (58.0% vs. 66.9%). Risky drinking remained unchanged (16.6% vs. 17.0%). In spite of significant increases in daily alcohol drinking (13.2% vs. 18.4%) psychotropic drug use combined with daily drinking remained unchanged (1.8% vs. 2.7%).

CONCLUSIONS

Although prevalence of overall psychotropic drug use remained stable, changes in the use of some psychotropic drug groups and alcohol consumption patterns have been observed. Further studies are required to investigate resulting health consequences and public health relevance of those outcomes.