Other Common Healing Approaches 601(Wheatley, 1997), yielding a slightly better side effect pro“le.
Meta-analyses evaluating theses studies have found SJW to
be between 1.5 to 3 times more likely to produce an antide-
pressant response as compared to placebo, and to be equiva-
lent in ef“cacy to tricyclic antidepressants, (see H. L. Kim,
Streltzer, & Goebert, 1999; Linde et al., 1996).
Research on the biological mechanisms through which
SJW may exert its antidepressant effects suggests that similar
to popular pharmaceutical antidepressants, SJW in”uences
amine levels. The main dif“culty in studying the biological
mechanism of SJW pertains to the fact that several active
constituents have been identi“ed from H. perforatum
(Nahrstedt & Butterweck, 1997) including hypericin (Muller,
Rolli, Schafer, & Hafner, 1997), and hyperforin (Chatterjee,
Bhattacharya, Wonnemann, Singer, & Muller, 1998;
Laakmann, Schule, Baghai, & Kieser, 1998; Muller et al.,
1997, 1998; Schellenberg, Sauer, & Dimpfel, 1998). Overall,
research indicates that SJW may inhibit the synaptosomal re-
uptake of serotonin, dopamine, and norepinephrine (Muller
et al., 1997, 1998; Muller & Rossol, 1994; Neary & Bu,
1999); upregulate postsynaptic serotonin receptors (Teufel-
Mayer & Gleitz, 1997); and interfere with the central
dopaminergic system (Butterweck, Wall, Lie”ander -Wulf,
Winterhoff, & Nahrstedt, 1997; Franklin et al., 1999).
Studies demonstrate that the main advantage to SJW is its
more preferable side effect pro“le and tolerability to syn-
thetic antidepressants. The most common adverse side effects
included gastrointestinal symptoms (0.6%), allergic reactions
(0.5%), tiredness (0.4%), and restlessness (0.3%) (Woelk,
Burkard, & Grunwald, 1994). In addition, hypericum has
been found to be safer with regard to cardiac function than
tricyclic antidepressants (Czekalla, Gastpar, Hubner, & Jager,
1997). While SJW appears to be a safe herbal remedy for de-
pression when taken alone, the major danger with SJW seems
to lie in its potential for drug interactions.
Current limitations in the research include lack of •well
characterized populationsŽ (Cott, 1997); translation bias
(Gaster & Holroyd, 2000); limited research on long-term ef-
“cacy, safety, and tolerance at various doses (Volz & Kieser,
1997); ef“cacy for severe depression (Gaster & Holroyd,
2000); and ef“cacy as compared to serotonin reuptake
inhibitors.
Summary of Herbal Treatment Research
In addition to the herbal remedies highlighted, more than
20,000 herbs are available to the public over the counter. For
a good review of herbal remedies frequently used in psychi-
atric practice, refer to Wong, Smith, and Boon (1998). Cur-
rently, the Dietary Supplement Health and Education Act
(DSHEA) does not require manufacturers to provide data on
the safety, purity, and ef“cacy of their products (Wagner,
Wagner, & Hening, 1998). Moreover, the Food and Drug Ad-
ministration (FDA) does not regulate their use or standardize
their purity or content (Lantz, Buchalter, & Giambanco,
1999). Therefore, individuals are able to self-prescribe herbs
without the guidance of a physician, which may lead to ad-
verse side effects and drug interactions. For instance, Lantz
et al. (1999) discussed several case studies of elderly patients
who developed serotonin syndrome (e.g., central and periph-
eral serotonergic hyperstimulation) from taking SJW in con-
junction with their prescribed antidepressant. It is important
that clinicians appreciate the strength of these herbs and ask
their patients about herbal use and educate them on the dan-
gers of herbal and drug interactions. Lantz et al. also recom-
mends that herbal remedies provide warning labels and that
ef“cacy studies be subjected to •the same vigorous stan-
dardsŽ as prescription medications as related to ef“cacy and
safety.
While the research suggests ef“cacy of a variety of herbal
remedies, further research in required. There is a need for
studies with (a) larger sample sizes, (b) data assessing partic-
ipants• ability to distinguish placebo from the herb, (c) better
characterization of the active constituents and mechanisms of
action, and (d) results on the effects of chronic dosing, side
effects, and standardization of preparation.Dietary, Nutrition, and Lifestyle ModificationDietary modi“cation has recently become a way for individ-
uals to take an active role in their well-being and a way
to prevent the onset of illness or reduce the negative conse-
quences of disease. Medical practitioners commonly recom-
mend dietary modi“cation and lifestyle changes as a
complement to traditional treatment, rather than as a sole al-
ternative cure.Very Low Fat DietsIn 1988, the National Cholesterol Education Program
(NCEP) published guidelines for the treatment of high cho-
lesterol in adults. The guidelines recommend dietary therapy
for the lowering of LDL cholesterol (LDL-C). Speci“cally,
they recommend an initial diet that includes an intake of total
fat less than 30% of calories (National Cholesterol Education
Program Expert Panel, 1998). Lichtenstein and Van Horn
(1998) conducted a review of the literature on the ef“cacy of
a very low fat diet, and reported that while there is •over-
whelming evidenceŽ that reductions in saturated fat, dietary
cholesterol, and weight are effective in reducing total