A systematic review evaluated the efficacy and safety of St. John's wort (SJW) in adults with major depressive disorder (MDD) compared to placebo and active comparator and whether the effects vary by severity of MDD.

A Systematic Review of St. John's Wort for Major Depressive Disorder

Published in: Systematic Reviews, v. 5, no. 1, 2016, p. 1–25

Posted on RAND.org on September 08, 2016

by Eric Apaydin, Alicia Ruelaz Maher, Roberta M. Shanman, Marika Booth, Jeremy N. V. Miles, Melony E. Sorbero, Susanne Hempel

Research Questions

  1. How effective and safe is the use of St. Johns Wort (SJW) for the treatment of Major Depressive Disorder (MDD)?
  2. Do the effects of SJW vary by the severity of MDD?

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; I2 79 %; 18 RCTs; N = 2922, moderate QoE; standardized mean differences [SMD] 0.49; CI 0.23, 0.74; 16 RCTs; I2 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, I2 52 %, moderate QoE; SMD −0.03; CI −0.21, 0.15; 14 RCTs; I2 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.

Key Findings

  • The existing evidence base suggests that the herb St. Johns Wort (SJW) is as effective as antidepressant medication in improving the symptoms of mild to moderate depression, with fewer adverse events.
  • Response to treatment did not differ significantly between participants receiving SJW and antidepressants.
  • The treatment response rate was significantly higher among those receiving SJW (56 percent) in comparison to those receiving placebo (35 percent).
  • There was insufficient evidence to evaluate the effect of SJW on severe depression.
  • Findings should be interpreted with caution, as differences were found in effects across studies.

Recommendation

Future studies should evaluate the effect of SJW on severe depression, the comparative effectiveness of specific extracts and dosages of SJW, the effect of concurrent use of SJW and psychotherapy, and the effect of SJW on quality of life. Additionally, systematic assessment of adverse events with SJW use is needed, especially for rare events.

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