Peggy J. Wagner, PhD

Patient use of alternative medicine is increasing rapidly. The most common form of alternative treatment is self-medication with herbs (botanicals or phytomedicines), vitamins, or other pharmacologic or biologic substances.^1-3 Data from family practice patients reflect that 28% to 50% use some form of alternative medicine, and at least one third also take some form of alternative pharmacotherapy, usually herbs.^4,5 Alternative pharmacotherapy is now widely available in most supermarkets, drugstores, natural food shops, and from on-line stores. In early November 1999 we used a popular public Internet search engine to locate 505 Web sites for “alternative medicine,” 1100 sites for “herbs,” and more than 15,000 listings for individual herbs from 571 on-line stores.

Patients who self-medicate with herbs for preventive and therapeutic purposes may assume that these products are safe because they are natural; however, concerns about the safety of these products are well founded. Some herbal products can cause adverse side effects, such as nephropathy and hepatic toxicity, have the potential to interact with or potentiate prescription medications, and may contain high levels of contaminants, such as mercury, lead, and other toxic substances that can result in poisoning.^6-16 Chemical analysis has shown that some herbal preparations contain heavy metals or other toxins, and some do not contain some of the desired chemicals they advertise.¹⁷ Many herbal or other alternative preparations are considered dietary supplements, so their manufacture and contents are not monitored by the Food and Drug Administration (FDA) or other regulatory bodies.¹⁸ Of the more than 1400 herbs promoted and sold as medicine, the FDA has approved only 9.¹⁷ Although these products have shown promise as treatments for health concerns ranging from depression and cholesterol management to fertility enhancement and immune system stimulation, more clinical information is warranted.

Greater knowledge is needed about the use of alternative pharmacotherapies and particularly about the practice patterns of family physicians with regard to their patients who use them.^19-23 Although it is important for family physicians to be aware of and open to discussing their patients’ interest in these alternative approaches, it is also important to include documentation of their use in the medical history and record.^2,24-28 Our study illustrates the use of common alternative pharmacotherapies in a sample of family practice patients. It also expands our understanding of family physician response to the increasing use of these therapies by their patients.

Methods

Adult patients were recruited from an academic family medicine clinic in the Southeast United States from June 1999 to August 1999. A total of 204 patients were approached following their scheduled clinic visit, and 197 agreed to talk with the interviewer. Of these, 178 complete records of demographic data (age, race, sex) were obtained. Patients were then asked: “Do you use any type of medications, herbs, vitamins, or other substances other than what your physician tells you to use?” One hundred twenty-three (69%) indicated they did not, and 55 (31%) indicated that they did. The study was briefly explained to these 55 patients, and informed consent was obtained from those who agreed to participate. Of those reporting use of alternative pharmacotherapy, 44 patients (80%) agreed to participate, and 11 (20%) refused. The participants included 18 men and 37 women; 60% were white, and 40%, African American. One participant was younger than 19 years; 31% were aged 20 to 40 years; 49% were aged 41 to 59 years; and 18% were older than 60 years. Chi-square analysis was used to test for differences among the groups. The participants responded to a brief series of questions regarding the purpose of their clinic visit, the name of the physician seen, their history of self-medication with a list of commonly used vitamins and herbs (Table 1), the names of other substances they used that were not listed, the source of their information about vitamins and herbs, and their judgment about the helpfulness of the vitamins and herbs. To determine the extent of physician-patient discussion about alternative medication use, we assessed 3 levels of interaction: (1) we asked whether the physician had inquired about their use of vitamins and herbs during that day’s visit, or ever, during the course of any clinic visit; (2) after all interviews were completed, we reviewed each patient’s medical record to determine if the physician had documented anything about alternative medication use at any time in the relationship with the patient; and (3) we examined the medical record to determine the presence of more extensive recommendations for past, present, or future alternative medication use.

Results

Patterns of Patient Use. For the 31% of the patients who used alternative pharmacotherapies, a total of 42 different vitamins, herbs, or substances were taken representing 109 separate patient uses (Table 1). Forty-three percent of these alternative medications had been taken for the preceding 0 to 6 months, 12% for 7 to 12 months, 29% for 1 to 2 years, 12% for 3 to 5 years, 2% for 6 to 10 years, and 2% for 11 years or longer. The participants took 5% of the alternative pharmacotherapies 3 times daily, 14% twice daily, 76% once daily, 4% between one and 6 times per week, and 1% between one and 3 times per month. They reported getting most of their information about the alternative pharmacotherapies they take from the media or news (37%). Others received information from friends (24%), from a physician or nurse (14%), from family (12%), and from other sources (12%). In terms of therapeutic efficacy, 5% of the participants in this sample reported that the alternative medications they take are not helpful, 9% indicated that they are slightly helpful, 30% moderately helpful, 32% fairly helpful, 23% very helpful, and 2% were unsure about therapeutic effect. The 10 most frequently used alternative medications in order of frequency were: vitamin E, ginseng, ginkgo biloba, garlic, zinc, bilberry fruit extract, echinacea, vitamin C, chromium, and coenzyme Q10. The usage rates for these and other alternative medications are provided in Table 1. No significant differences in race, age, or sex were detected between those who reported using alternative medications and those who said they did not.

Patterns of Family Physician Practice. Eighty-four percent of the participants reported that they were not asked about their use of alternative pharmacotherapies on the day of their clinic visit and interview (Table 2). More than half (59%) indicated that the physician had never asked them about their use of alternative pharmacotherapies. Approximately two thirds (68%) of the participants’ medical records contained no entry (at any place in the record) reflecting a conversation or interchange between the physician and the patient about their use of alternative medications. Ninety-one percent of the medical records contained no physician documented recommendations about past, present, or future alternative medication use. Of the 7 participants reporting that they had been asked during that day’s visit about their alternative medication use, no notation of such use was found other than one notation of the use of vitamins. No significant differences in race, age, or sex were detected between those who reported their physician asking about their use of alternative medications (today or ever) and those who reported not being asked. Analysis also revealed no significant differences in terms of race, age, or sex between those patients whose records contained documentation of discussion or recommendation about alternative pharmacotherapy use and those whose records did not.

Discussion

We found that one third of the patients who participated in our study reported using alternative pharmacotherapies, and more than half of these had done so once daily for 1 year or less. The relatively recent use may reflect the impact of increasing media attention on alternative drugs. More than one third of these patients reported learning about the alternative drug they use from the news or media. These substances were more frequently used for prevention of conditions such as heart disease, dementia, memory loss, hypercholesterolemia, and cancer, and for treatment of menopausal symptoms and mood. The rate of physician inquiry about patient use of such alternative therapies does not match the increasing rate of use among patients. Documentation rates of physician inquiry or recommendation about alternative pharmacotherapy use were low regardless of the patient’s race, age, or sex. No physician biases appeared operative in terms of whether the physicians discussed or documented the alternative pharmacotherapy use of their patients. The limitations of our study include a small sample size and the use of only one clinical site.

Growing use of alternative pharmacotherapies as first-line treatment or for prevention may represent a substantial change in patients’ patterns of self-care and calls for a response on the part of physicians. To better address patients’ use of alternative pharmacotherapies, physicians will need to inform themselves about the alternative drugs being used and document their use in the medical record. We suggest that the current physician-patient policy of “don’t ask/don’t tell” be replaced with easy systemwide changes implemented to ensure that appropriate information is obtained and documented as follows:

1. Physicians should include questions about alternative medications and dosages on intake and history forms.
2. Nursing staff can routinely ask about herbs, vitamins, or natural remedy use. A question such as, “What are you doing to manage or improve your health?” could be incorporated into a general inquiry about health promotion and disease prevention activities.
3. Signs in examination rooms prompting conversation about alternative treatments may also be helpful, such as: “If you take any vitamins, herbs, plants, or minerals, please discuss this with your doctor—your doctor needs to know.”
4. Physicians should document all reported use of alternative treatments and physician recommendations. Documentation may remind the physician to inquire at each subsequent visit and to incorporate inquiry and documentation into standard practice. In doing so, physicians may notice local trends in the use of some alternative drugs for certain problems and can then direct more attention to that use in the population.
5. To better understand drug benefits, side effects, interactions, issues of contamination, and recommended dosages, use of a physician resource such as the Physicians Desk Reference for Herbal Medicines29 is suggested. Because an ever-expanding amount of information about alternative pharmacotherapies is available on the Internet, we suggest the physician become familiar with at least a few reputable Web sites.*
6. Patient education information covering benefits and risks associated with popular substances should be made available. Medical students or residents should also be encouraged to familiarize themselves with these materials and discuss a patient’s use of alternative medications with the attending physician.

Conclusions

Becoming more aware of their patients’ use of alternative pharmacotherapies will improve physicians’ understanding of their patients’ health care, will offer opportunities to give important warnings or advice about the use of alternative drugs or preparations, thereby reducing the chances of drug interaction, and will enhance physician-patient communication. Future studies should obtain data from larger samples and from multiple family practice sites in divergent geographic areas.

Acknowledgments

The authors would like to thank the Faculty Development Group of the Department of Family Medicine at the Medical College of Georgia for their review and suggestions regarding early versions of this manuscript.

Patient use of alternative medicine is increasing rapidly. The most common form of alternative treatment is self-medication with herbs (botanicals or phytomedicines), vitamins, or other pharmacologic or biologic substances.^1-3 Data from family practice patients reflect that 28% to 50% use some form of alternative medicine, and at least one third also take some form of alternative pharmacotherapy, usually herbs.^4,5 Alternative pharmacotherapy is now widely available in most supermarkets, drugstores, natural food shops, and from on-line stores. In early November 1999 we used a popular public Internet search engine to locate 505 Web sites for “alternative medicine,” 1100 sites for “herbs,” and more than 15,000 listings for individual herbs from 571 on-line stores.

Patients who self-medicate with herbs for preventive and therapeutic purposes may assume that these products are safe because they are natural; however, concerns about the safety of these products are well founded. Some herbal products can cause adverse side effects, such as nephropathy and hepatic toxicity, have the potential to interact with or potentiate prescription medications, and may contain high levels of contaminants, such as mercury, lead, and other toxic substances that can result in poisoning.^6-16 Chemical analysis has shown that some herbal preparations contain heavy metals or other toxins, and some do not contain some of the desired chemicals they advertise.¹⁷ Many herbal or other alternative preparations are considered dietary supplements, so their manufacture and contents are not monitored by the Food and Drug Administration (FDA) or other regulatory bodies.¹⁸ Of the more than 1400 herbs promoted and sold as medicine, the FDA has approved only 9.¹⁷ Although these products have shown promise as treatments for health concerns ranging from depression and cholesterol management to fertility enhancement and immune system stimulation, more clinical information is warranted.

Greater knowledge is needed about the use of alternative pharmacotherapies and particularly about the practice patterns of family physicians with regard to their patients who use them.^19-23 Although it is important for family physicians to be aware of and open to discussing their patients’ interest in these alternative approaches, it is also important to include documentation of their use in the medical history and record.^2,24-28 Our study illustrates the use of common alternative pharmacotherapies in a sample of family practice patients. It also expands our understanding of family physician response to the increasing use of these therapies by their patients.

Methods

Adult patients were recruited from an academic family medicine clinic in the Southeast United States from June 1999 to August 1999. A total of 204 patients were approached following their scheduled clinic visit, and 197 agreed to talk with the interviewer. Of these, 178 complete records of demographic data (age, race, sex) were obtained. Patients were then asked: “Do you use any type of medications, herbs, vitamins, or other substances other than what your physician tells you to use?” One hundred twenty-three (69%) indicated they did not, and 55 (31%) indicated that they did. The study was briefly explained to these 55 patients, and informed consent was obtained from those who agreed to participate. Of those reporting use of alternative pharmacotherapy, 44 patients (80%) agreed to participate, and 11 (20%) refused. The participants included 18 men and 37 women; 60% were white, and 40%, African American. One participant was younger than 19 years; 31% were aged 20 to 40 years; 49% were aged 41 to 59 years; and 18% were older than 60 years. Chi-square analysis was used to test for differences among the groups. The participants responded to a brief series of questions regarding the purpose of their clinic visit, the name of the physician seen, their history of self-medication with a list of commonly used vitamins and herbs (Table 1), the names of other substances they used that were not listed, the source of their information about vitamins and herbs, and their judgment about the helpfulness of the vitamins and herbs. To determine the extent of physician-patient discussion about alternative medication use, we assessed 3 levels of interaction: (1) we asked whether the physician had inquired about their use of vitamins and herbs during that day’s visit, or ever, during the course of any clinic visit; (2) after all interviews were completed, we reviewed each patient’s medical record to determine if the physician had documented anything about alternative medication use at any time in the relationship with the patient; and (3) we examined the medical record to determine the presence of more extensive recommendations for past, present, or future alternative medication use.

Results

Patterns of Patient Use. For the 31% of the patients who used alternative pharmacotherapies, a total of 42 different vitamins, herbs, or substances were taken representing 109 separate patient uses (Table 1). Forty-three percent of these alternative medications had been taken for the preceding 0 to 6 months, 12% for 7 to 12 months, 29% for 1 to 2 years, 12% for 3 to 5 years, 2% for 6 to 10 years, and 2% for 11 years or longer. The participants took 5% of the alternative pharmacotherapies 3 times daily, 14% twice daily, 76% once daily, 4% between one and 6 times per week, and 1% between one and 3 times per month. They reported getting most of their information about the alternative pharmacotherapies they take from the media or news (37%). Others received information from friends (24%), from a physician or nurse (14%), from family (12%), and from other sources (12%). In terms of therapeutic efficacy, 5% of the participants in this sample reported that the alternative medications they take are not helpful, 9% indicated that they are slightly helpful, 30% moderately helpful, 32% fairly helpful, 23% very helpful, and 2% were unsure about therapeutic effect. The 10 most frequently used alternative medications in order of frequency were: vitamin E, ginseng, ginkgo biloba, garlic, zinc, bilberry fruit extract, echinacea, vitamin C, chromium, and coenzyme Q10. The usage rates for these and other alternative medications are provided in Table 1. No significant differences in race, age, or sex were detected between those who reported using alternative medications and those who said they did not.

Patterns of Family Physician Practice. Eighty-four percent of the participants reported that they were not asked about their use of alternative pharmacotherapies on the day of their clinic visit and interview (Table 2). More than half (59%) indicated that the physician had never asked them about their use of alternative pharmacotherapies. Approximately two thirds (68%) of the participants’ medical records contained no entry (at any place in the record) reflecting a conversation or interchange between the physician and the patient about their use of alternative medications. Ninety-one percent of the medical records contained no physician documented recommendations about past, present, or future alternative medication use. Of the 7 participants reporting that they had been asked during that day’s visit about their alternative medication use, no notation of such use was found other than one notation of the use of vitamins. No significant differences in race, age, or sex were detected between those who reported their physician asking about their use of alternative medications (today or ever) and those who reported not being asked. Analysis also revealed no significant differences in terms of race, age, or sex between those patients whose records contained documentation of discussion or recommendation about alternative pharmacotherapy use and those whose records did not.

Discussion

We found that one third of the patients who participated in our study reported using alternative pharmacotherapies, and more than half of these had done so once daily for 1 year or less. The relatively recent use may reflect the impact of increasing media attention on alternative drugs. More than one third of these patients reported learning about the alternative drug they use from the news or media. These substances were more frequently used for prevention of conditions such as heart disease, dementia, memory loss, hypercholesterolemia, and cancer, and for treatment of menopausal symptoms and mood. The rate of physician inquiry about patient use of such alternative therapies does not match the increasing rate of use among patients. Documentation rates of physician inquiry or recommendation about alternative pharmacotherapy use were low regardless of the patient’s race, age, or sex. No physician biases appeared operative in terms of whether the physicians discussed or documented the alternative pharmacotherapy use of their patients. The limitations of our study include a small sample size and the use of only one clinical site.

Growing use of alternative pharmacotherapies as first-line treatment or for prevention may represent a substantial change in patients’ patterns of self-care and calls for a response on the part of physicians. To better address patients’ use of alternative pharmacotherapies, physicians will need to inform themselves about the alternative drugs being used and document their use in the medical record. We suggest that the current physician-patient policy of “don’t ask/don’t tell” be replaced with easy systemwide changes implemented to ensure that appropriate information is obtained and documented as follows:

1. Physicians should include questions about alternative medications and dosages on intake and history forms.
2. Nursing staff can routinely ask about herbs, vitamins, or natural remedy use. A question such as, “What are you doing to manage or improve your health?” could be incorporated into a general inquiry about health promotion and disease prevention activities.
3. Signs in examination rooms prompting conversation about alternative treatments may also be helpful, such as: “If you take any vitamins, herbs, plants, or minerals, please discuss this with your doctor—your doctor needs to know.”
4. Physicians should document all reported use of alternative treatments and physician recommendations. Documentation may remind the physician to inquire at each subsequent visit and to incorporate inquiry and documentation into standard practice. In doing so, physicians may notice local trends in the use of some alternative drugs for certain problems and can then direct more attention to that use in the population.
5. To better understand drug benefits, side effects, interactions, issues of contamination, and recommended dosages, use of a physician resource such as the Physicians Desk Reference for Herbal Medicines29 is suggested. Because an ever-expanding amount of information about alternative pharmacotherapies is available on the Internet, we suggest the physician become familiar with at least a few reputable Web sites.*
6. Patient education information covering benefits and risks associated with popular substances should be made available. Medical students or residents should also be encouraged to familiarize themselves with these materials and discuss a patient’s use of alternative medications with the attending physician.

Conclusions

Becoming more aware of their patients’ use of alternative pharmacotherapies will improve physicians’ understanding of their patients’ health care, will offer opportunities to give important warnings or advice about the use of alternative drugs or preparations, thereby reducing the chances of drug interaction, and will enhance physician-patient communication. Future studies should obtain data from larger samples and from multiple family practice sites in divergent geographic areas.

Acknowledgments

The authors would like to thank the Faculty Development Group of the Department of Family Medicine at the Medical College of Georgia for their review and suggestions regarding early versions of this manuscript.

Patient use of alternative medicine is increasing rapidly. The most common form of alternative treatment is self-medication with herbs (botanicals or phytomedicines), vitamins, or other pharmacologic or biologic substances.^1-3 Data from family practice patients reflect that 28% to 50% use some form of alternative medicine, and at least one third also take some form of alternative pharmacotherapy, usually herbs.^4,5 Alternative pharmacotherapy is now widely available in most supermarkets, drugstores, natural food shops, and from on-line stores. In early November 1999 we used a popular public Internet search engine to locate 505 Web sites for “alternative medicine,” 1100 sites for “herbs,” and more than 15,000 listings for individual herbs from 571 on-line stores.

Patients who self-medicate with herbs for preventive and therapeutic purposes may assume that these products are safe because they are natural; however, concerns about the safety of these products are well founded. Some herbal products can cause adverse side effects, such as nephropathy and hepatic toxicity, have the potential to interact with or potentiate prescription medications, and may contain high levels of contaminants, such as mercury, lead, and other toxic substances that can result in poisoning.^6-16 Chemical analysis has shown that some herbal preparations contain heavy metals or other toxins, and some do not contain some of the desired chemicals they advertise.¹⁷ Many herbal or other alternative preparations are considered dietary supplements, so their manufacture and contents are not monitored by the Food and Drug Administration (FDA) or other regulatory bodies.¹⁸ Of the more than 1400 herbs promoted and sold as medicine, the FDA has approved only 9.¹⁷ Although these products have shown promise as treatments for health concerns ranging from depression and cholesterol management to fertility enhancement and immune system stimulation, more clinical information is warranted.

Greater knowledge is needed about the use of alternative pharmacotherapies and particularly about the practice patterns of family physicians with regard to their patients who use them.^19-23 Although it is important for family physicians to be aware of and open to discussing their patients’ interest in these alternative approaches, it is also important to include documentation of their use in the medical history and record.^2,24-28 Our study illustrates the use of common alternative pharmacotherapies in a sample of family practice patients. It also expands our understanding of family physician response to the increasing use of these therapies by their patients.

Methods

Adult patients were recruited from an academic family medicine clinic in the Southeast United States from June 1999 to August 1999. A total of 204 patients were approached following their scheduled clinic visit, and 197 agreed to talk with the interviewer. Of these, 178 complete records of demographic data (age, race, sex) were obtained. Patients were then asked: “Do you use any type of medications, herbs, vitamins, or other substances other than what your physician tells you to use?” One hundred twenty-three (69%) indicated they did not, and 55 (31%) indicated that they did. The study was briefly explained to these 55 patients, and informed consent was obtained from those who agreed to participate. Of those reporting use of alternative pharmacotherapy, 44 patients (80%) agreed to participate, and 11 (20%) refused. The participants included 18 men and 37 women; 60% were white, and 40%, African American. One participant was younger than 19 years; 31% were aged 20 to 40 years; 49% were aged 41 to 59 years; and 18% were older than 60 years. Chi-square analysis was used to test for differences among the groups. The participants responded to a brief series of questions regarding the purpose of their clinic visit, the name of the physician seen, their history of self-medication with a list of commonly used vitamins and herbs (Table 1), the names of other substances they used that were not listed, the source of their information about vitamins and herbs, and their judgment about the helpfulness of the vitamins and herbs. To determine the extent of physician-patient discussion about alternative medication use, we assessed 3 levels of interaction: (1) we asked whether the physician had inquired about their use of vitamins and herbs during that day’s visit, or ever, during the course of any clinic visit; (2) after all interviews were completed, we reviewed each patient’s medical record to determine if the physician had documented anything about alternative medication use at any time in the relationship with the patient; and (3) we examined the medical record to determine the presence of more extensive recommendations for past, present, or future alternative medication use.

Results

Patterns of Patient Use. For the 31% of the patients who used alternative pharmacotherapies, a total of 42 different vitamins, herbs, or substances were taken representing 109 separate patient uses (Table 1). Forty-three percent of these alternative medications had been taken for the preceding 0 to 6 months, 12% for 7 to 12 months, 29% for 1 to 2 years, 12% for 3 to 5 years, 2% for 6 to 10 years, and 2% for 11 years or longer. The participants took 5% of the alternative pharmacotherapies 3 times daily, 14% twice daily, 76% once daily, 4% between one and 6 times per week, and 1% between one and 3 times per month. They reported getting most of their information about the alternative pharmacotherapies they take from the media or news (37%). Others received information from friends (24%), from a physician or nurse (14%), from family (12%), and from other sources (12%). In terms of therapeutic efficacy, 5% of the participants in this sample reported that the alternative medications they take are not helpful, 9% indicated that they are slightly helpful, 30% moderately helpful, 32% fairly helpful, 23% very helpful, and 2% were unsure about therapeutic effect. The 10 most frequently used alternative medications in order of frequency were: vitamin E, ginseng, ginkgo biloba, garlic, zinc, bilberry fruit extract, echinacea, vitamin C, chromium, and coenzyme Q10. The usage rates for these and other alternative medications are provided in Table 1. No significant differences in race, age, or sex were detected between those who reported using alternative medications and those who said they did not.

Patterns of Family Physician Practice. Eighty-four percent of the participants reported that they were not asked about their use of alternative pharmacotherapies on the day of their clinic visit and interview (Table 2). More than half (59%) indicated that the physician had never asked them about their use of alternative pharmacotherapies. Approximately two thirds (68%) of the participants’ medical records contained no entry (at any place in the record) reflecting a conversation or interchange between the physician and the patient about their use of alternative medications. Ninety-one percent of the medical records contained no physician documented recommendations about past, present, or future alternative medication use. Of the 7 participants reporting that they had been asked during that day’s visit about their alternative medication use, no notation of such use was found other than one notation of the use of vitamins. No significant differences in race, age, or sex were detected between those who reported their physician asking about their use of alternative medications (today or ever) and those who reported not being asked. Analysis also revealed no significant differences in terms of race, age, or sex between those patients whose records contained documentation of discussion or recommendation about alternative pharmacotherapy use and those whose records did not.

Discussion

We found that one third of the patients who participated in our study reported using alternative pharmacotherapies, and more than half of these had done so once daily for 1 year or less. The relatively recent use may reflect the impact of increasing media attention on alternative drugs. More than one third of these patients reported learning about the alternative drug they use from the news or media. These substances were more frequently used for prevention of conditions such as heart disease, dementia, memory loss, hypercholesterolemia, and cancer, and for treatment of menopausal symptoms and mood. The rate of physician inquiry about patient use of such alternative therapies does not match the increasing rate of use among patients. Documentation rates of physician inquiry or recommendation about alternative pharmacotherapy use were low regardless of the patient’s race, age, or sex. No physician biases appeared operative in terms of whether the physicians discussed or documented the alternative pharmacotherapy use of their patients. The limitations of our study include a small sample size and the use of only one clinical site.

Growing use of alternative pharmacotherapies as first-line treatment or for prevention may represent a substantial change in patients’ patterns of self-care and calls for a response on the part of physicians. To better address patients’ use of alternative pharmacotherapies, physicians will need to inform themselves about the alternative drugs being used and document their use in the medical record. We suggest that the current physician-patient policy of “don’t ask/don’t tell” be replaced with easy systemwide changes implemented to ensure that appropriate information is obtained and documented as follows:

1. Physicians should include questions about alternative medications and dosages on intake and history forms.
2. Nursing staff can routinely ask about herbs, vitamins, or natural remedy use. A question such as, “What are you doing to manage or improve your health?” could be incorporated into a general inquiry about health promotion and disease prevention activities.
3. Signs in examination rooms prompting conversation about alternative treatments may also be helpful, such as: “If you take any vitamins, herbs, plants, or minerals, please discuss this with your doctor—your doctor needs to know.”
4. Physicians should document all reported use of alternative treatments and physician recommendations. Documentation may remind the physician to inquire at each subsequent visit and to incorporate inquiry and documentation into standard practice. In doing so, physicians may notice local trends in the use of some alternative drugs for certain problems and can then direct more attention to that use in the population.
5. To better understand drug benefits, side effects, interactions, issues of contamination, and recommended dosages, use of a physician resource such as the Physicians Desk Reference for Herbal Medicines29 is suggested. Because an ever-expanding amount of information about alternative pharmacotherapies is available on the Internet, we suggest the physician become familiar with at least a few reputable Web sites.*
6. Patient education information covering benefits and risks associated with popular substances should be made available. Medical students or residents should also be encouraged to familiarize themselves with these materials and discuss a patient’s use of alternative medications with the attending physician.

Conclusions

Becoming more aware of their patients’ use of alternative pharmacotherapies will improve physicians’ understanding of their patients’ health care, will offer opportunities to give important warnings or advice about the use of alternative drugs or preparations, thereby reducing the chances of drug interaction, and will enhance physician-patient communication. Future studies should obtain data from larger samples and from multiple family practice sites in divergent geographic areas.

Acknowledgments

The authors would like to thank the Faculty Development Group of the Department of Family Medicine at the Medical College of Georgia for their review and suggestions regarding early versions of this manuscript.

As health maintenance organizations (HMOs) and physicians increasingly become medical partners, the HMO formularies and prescribing recommendations will be more evident in physicians’ practices. Upper-respiratory infections and low back pain are so common and often so difficult to treat that they are prime targets for HMO intervention.

A recent study showed that HMO physicians, perform less diagnostic testing, but may prescribe more antibiotics for viral illnesses than other physicians.¹ Often the physician believes the patient expects antibiotics when that is not the case.^2-5 In turn, patients may feel they need treatment for self-limited conditions because they have received them in the past.⁶

Physicians may believe that patients will be dissatisfied when expectations are not met. Dissatisfied patients are less likely to comply with physicians’ treatment recommendations.⁷ Patients may continue to call or visit the physician until expectations are met.⁸ Sometimes physicians think that patients will go elsewhere to get treatment. We asked patients for their opinions on the need for prescriptive medications and compared prepaid and fee-for-service (FFS) patients.

Methods

A total of 244 consecutive patients or parents of patients in an urban family medicine clinic completed survey forms in October 1997. This was an undifferentiated patient population seeking care for any reason. No attempt was made to screen for the reason for the visit. Parents completed the questionnaire for any child in the consecutive grouping. The questionnaire addressed perceptions of appropriateness of the frequency of medication prescription in general, reassurance or prescriptions as treatments related to 3 specific problems (virus, muscle straining, diarrhea), and preferred timing of treatment modification. No one refused to complete the questionnaire.

Men made up 37% of the sample (n=91) and women 63% (n=153). Patients were mostly white (n=191, 78%), with a substantial African American minority group (n=50, 21%), and 1% were of other ethnicities. Eighteen percent of the sample were single (n=44); 66%, married (n=160); 7%, widowed (n=16); and 9%, divorced or separated (n=23). Most of the patients were aged 30 to 59 years, with 17% 60 years or older and 20% 29 years or younger.

Sixty-seven percent of the sample were HMO members and 30% were fee-for-service patients. Most of the HMO members were charged a flat fee for medications (63%). White patients were more likely to be enrolled in an HMO than African Americans (72% vs 59%, respectively; c2= 2.937; P <087).

Analyses were largely descriptive with chi-squares conducted for group comparisons of categorical variables. Respondents were excluded from analyses if any item was missing. We conducted 2-way analysis of variance on continuous treatment change questions to compare race and HMO status.

Results

Medication Questions

Most respondents indicated that they did not believe physicians prescribed too many medications (75%). Eighty-four percent of the patients would want an expensive medicine if the physician recommended it. In a comparison of patients who had a set fee for medicine with those who did not, 88% with the set fee said they would want the more expensive medications as opposed to 77% in the group without a set fee (c2= 3.39, P <.066). African Americans were less likely to want the more costly medicine than were whites (79.6% vs 92%, respectively; c2= 6.471; P <.011).

Reassurance and Prescription Questions

We asked several questions regarding personal preferences about receiving prescriptions, reassurance, or antibiotics for virus, muscle strains, and diarrhea. Reassurance and over-the-counter treatments were seen as sufficient care for viruses (84%), muscle strain (72%), and diarrhea (56%). In contrast, when asked if they would want an antibiotic or pain medication “just to be sure,” 43% said yes in the case of a virus, 37% for a muscle strain, and 92% for diarrhea.

For viruses, we found a significant difference in preferences (P <.001) by race, with white patients more likely to accept reassurance as sufficient care (76%) than African Americans (51%). African Americans were also less likely than whites to see reassurance as sufficient for muscle strain (P <001) and diarrhea (P <.06). Table 1 shows the percentages of patients accepting reassurance. When asked about prescriptions, “just to be sure,” race and HMO membership influenced the outcome, with more African Americans than whites likely to want an antibiotic for a virus (P <001) as were more FFS members than HMO members (P <.001). For a muscle strain, FFS members and African Americans were again more likely to want painkillers “just to be sure.” For diarrhea, FFS respondents were more likely than HMO respondents to want an antibiotic (P <.03), and there was a similar trend for African Americans to prefer the medication (P <.06). Table 2 shows the percentage of patients wanting medication “just to be sure.”

Eighty-four percent of the sample said that reassurance and cold medicine would be enough care for a virus that antibiotics would not help. A significant difference was found by race, with white patients more likely to accept reassurance (76%) than African Americans (51%, X²=11.176, P <.001).

Forty-three percent of the sample would want an antibiotic “just to be sure” if they had a virus (even though 84% said reassurance was sufficient). Sex, race, and HMO membership all influenced this finding with women, African Americans, and patients not in an HMO more likely to want the antibiotic (56% women vs 39% of men, X²=6.020, P <.014; 71% of African-Americans vs 39% of whites, c2= 15.348, P <000; 63% of patients not in an HMO vs 38% of HMO members, X²=11.712, P <.001).

Similar questions were asked in reference to muscle strain: would reassurance be enough? Again, African Americans were less likely to see reassurance as sufficient (55% vs 81%, X²=14.003, P <.000). Seventy-two percent of those responding felt this would be sufficient care. However, 37% stated that they would like muscle relaxers or pain medication just to be sure. Patients who were in an HMO and African Americans were more likely to prefer the medication than those not in an HMO (55% HMO vs 36% non-HMO, X²=6.014, P<.014; 63% African Americans vs 37% whites, X²=9.59, P<.002).

Finally, the same questions were asked about diarrhea, which was most likely caused by a virus. Reassurance was again less apt to be perceived as sufficient by African Americans (50% vs 65%, X²= 3.442, P<.064), and they were more likely to want an antibiotic “just to be sure” (37% vs 23%, X²=3.759, P<.053). The patients not in an HMO were also more likely to want an antibiotic just to be sure (35% vs 21%, X²=4.669, P<.031).

Treatment Change Questions

Two questions were asked about the timing of requests for different treatments. The first had to do with the timing of a change in medicine (assuming the patient was not getting sicker) and the second with the number of medication changes that would be acceptable before requesting a referral to a specialist. Overall, 14% of the respondents would call for new medicine within 24 hours; 22% would call within 48 hours; 31% would call within 72 hours; and 33% would wait longer. In terms of requesting a specialist, 8% of the respondents would accept one medicine change before calling a specialist; 43% would accept 2 changes; 36% would accept 3 changes; and 13% would accept more changes. African Americans and FFS patients would wait for a shorter amount of time before calling for a medication change (F=14.66, P <017; F=6.34, P <013, respectively). No differences were observed by sex, race, or HMO membership status in number of medication changes before going to a specialist.

Discussion

We addressed patient preferences concerning 3 main topics: (1) influence of cost of medicine, (2) use of reassurance as a valid treatment, and (3) timing of treatment changes. Results indicate that patients want expensive medicine if there is a reason to believe it will work better. This finding is particularly true of HMO enrollees who have a set charge for medicine, suggesting that such plans and provisions may change patient preferences in a more costly manner or that patients self-select for membership. The acceptance of reassurance as a valid treatment by many patients belies the stereotype of patients always wanting prescriptions. However, variation in the wording of that question (the switch to whether they would want medication “just to be sure”) significantly reduced the percentage of those who simply accepted over-the-counter treatments and reassurance as adequate treatments. Substantial variation was observed by race, with African Americans consistently not as accepting of reassurance and more desirous of “just to be sure” medication. Although the small sample size precludes the drawing of conclusions, this may be suggestive of cultural differences in health-seeking behavior and also reduced exposure to managed care plans. One possibility is that African Americans may have a higher threshold for consulting a physician and may have tried symptomatic treatment for a longer period of time than whites. Because FFS patients were more likely to be African American, observed differences by race may be because of the covariation of race with insurer type. Future studies should explore these possible explanations.

We also found that patients are willing to accept multiple changes in medicines before seeking specialist care and to wait several days before calling physicians about medication ineffectiveness. African Americans and FFS members were less willing to wait. Perhaps there is a self-selection factor to enrollment in HMOs, or perhaps HMO members change their expectations after enrollment. In any case, these data show that understanding the role of patient preferences and expectations about the care they receive may have some potential for cost saving through the use of reassurance and corresponding patient satisfaction with care that does not always deliver a prescription.

Acknowledgements

The authors wish to thank Pam Stovall and Tracey Barton for their typing of the manuscript.

As health maintenance organizations (HMOs) and physicians increasingly become medical partners, the HMO formularies and prescribing recommendations will be more evident in physicians’ practices. Upper-respiratory infections and low back pain are so common and often so difficult to treat that they are prime targets for HMO intervention.

A recent study showed that HMO physicians, perform less diagnostic testing, but may prescribe more antibiotics for viral illnesses than other physicians.¹ Often the physician believes the patient expects antibiotics when that is not the case.^2-5 In turn, patients may feel they need treatment for self-limited conditions because they have received them in the past.⁶

Physicians may believe that patients will be dissatisfied when expectations are not met. Dissatisfied patients are less likely to comply with physicians’ treatment recommendations.⁷ Patients may continue to call or visit the physician until expectations are met.⁸ Sometimes physicians think that patients will go elsewhere to get treatment. We asked patients for their opinions on the need for prescriptive medications and compared prepaid and fee-for-service (FFS) patients.

Methods

A total of 244 consecutive patients or parents of patients in an urban family medicine clinic completed survey forms in October 1997. This was an undifferentiated patient population seeking care for any reason. No attempt was made to screen for the reason for the visit. Parents completed the questionnaire for any child in the consecutive grouping. The questionnaire addressed perceptions of appropriateness of the frequency of medication prescription in general, reassurance or prescriptions as treatments related to 3 specific problems (virus, muscle straining, diarrhea), and preferred timing of treatment modification. No one refused to complete the questionnaire.

Men made up 37% of the sample (n=91) and women 63% (n=153). Patients were mostly white (n=191, 78%), with a substantial African American minority group (n=50, 21%), and 1% were of other ethnicities. Eighteen percent of the sample were single (n=44); 66%, married (n=160); 7%, widowed (n=16); and 9%, divorced or separated (n=23). Most of the patients were aged 30 to 59 years, with 17% 60 years or older and 20% 29 years or younger.

Sixty-seven percent of the sample were HMO members and 30% were fee-for-service patients. Most of the HMO members were charged a flat fee for medications (63%). White patients were more likely to be enrolled in an HMO than African Americans (72% vs 59%, respectively; c2= 2.937; P <087).

Analyses were largely descriptive with chi-squares conducted for group comparisons of categorical variables. Respondents were excluded from analyses if any item was missing. We conducted 2-way analysis of variance on continuous treatment change questions to compare race and HMO status.

Results

Medication Questions

Most respondents indicated that they did not believe physicians prescribed too many medications (75%). Eighty-four percent of the patients would want an expensive medicine if the physician recommended it. In a comparison of patients who had a set fee for medicine with those who did not, 88% with the set fee said they would want the more expensive medications as opposed to 77% in the group without a set fee (c2= 3.39, P <.066). African Americans were less likely to want the more costly medicine than were whites (79.6% vs 92%, respectively; c2= 6.471; P <.011).

Reassurance and Prescription Questions

We asked several questions regarding personal preferences about receiving prescriptions, reassurance, or antibiotics for virus, muscle strains, and diarrhea. Reassurance and over-the-counter treatments were seen as sufficient care for viruses (84%), muscle strain (72%), and diarrhea (56%). In contrast, when asked if they would want an antibiotic or pain medication “just to be sure,” 43% said yes in the case of a virus, 37% for a muscle strain, and 92% for diarrhea.

For viruses, we found a significant difference in preferences (P <.001) by race, with white patients more likely to accept reassurance as sufficient care (76%) than African Americans (51%). African Americans were also less likely than whites to see reassurance as sufficient for muscle strain (P <001) and diarrhea (P <.06). Table 1 shows the percentages of patients accepting reassurance. When asked about prescriptions, “just to be sure,” race and HMO membership influenced the outcome, with more African Americans than whites likely to want an antibiotic for a virus (P <001) as were more FFS members than HMO members (P <.001). For a muscle strain, FFS members and African Americans were again more likely to want painkillers “just to be sure.” For diarrhea, FFS respondents were more likely than HMO respondents to want an antibiotic (P <.03), and there was a similar trend for African Americans to prefer the medication (P <.06). Table 2 shows the percentage of patients wanting medication “just to be sure.”

Eighty-four percent of the sample said that reassurance and cold medicine would be enough care for a virus that antibiotics would not help. A significant difference was found by race, with white patients more likely to accept reassurance (76%) than African Americans (51%, X²=11.176, P <.001).

Forty-three percent of the sample would want an antibiotic “just to be sure” if they had a virus (even though 84% said reassurance was sufficient). Sex, race, and HMO membership all influenced this finding with women, African Americans, and patients not in an HMO more likely to want the antibiotic (56% women vs 39% of men, X²=6.020, P <.014; 71% of African-Americans vs 39% of whites, c2= 15.348, P <000; 63% of patients not in an HMO vs 38% of HMO members, X²=11.712, P <.001).

Similar questions were asked in reference to muscle strain: would reassurance be enough? Again, African Americans were less likely to see reassurance as sufficient (55% vs 81%, X²=14.003, P <.000). Seventy-two percent of those responding felt this would be sufficient care. However, 37% stated that they would like muscle relaxers or pain medication just to be sure. Patients who were in an HMO and African Americans were more likely to prefer the medication than those not in an HMO (55% HMO vs 36% non-HMO, X²=6.014, P<.014; 63% African Americans vs 37% whites, X²=9.59, P<.002).

Finally, the same questions were asked about diarrhea, which was most likely caused by a virus. Reassurance was again less apt to be perceived as sufficient by African Americans (50% vs 65%, X²= 3.442, P<.064), and they were more likely to want an antibiotic “just to be sure” (37% vs 23%, X²=3.759, P<.053). The patients not in an HMO were also more likely to want an antibiotic just to be sure (35% vs 21%, X²=4.669, P<.031).

Treatment Change Questions

Two questions were asked about the timing of requests for different treatments. The first had to do with the timing of a change in medicine (assuming the patient was not getting sicker) and the second with the number of medication changes that would be acceptable before requesting a referral to a specialist. Overall, 14% of the respondents would call for new medicine within 24 hours; 22% would call within 48 hours; 31% would call within 72 hours; and 33% would wait longer. In terms of requesting a specialist, 8% of the respondents would accept one medicine change before calling a specialist; 43% would accept 2 changes; 36% would accept 3 changes; and 13% would accept more changes. African Americans and FFS patients would wait for a shorter amount of time before calling for a medication change (F=14.66, P <017; F=6.34, P <013, respectively). No differences were observed by sex, race, or HMO membership status in number of medication changes before going to a specialist.

Discussion

We addressed patient preferences concerning 3 main topics: (1) influence of cost of medicine, (2) use of reassurance as a valid treatment, and (3) timing of treatment changes. Results indicate that patients want expensive medicine if there is a reason to believe it will work better. This finding is particularly true of HMO enrollees who have a set charge for medicine, suggesting that such plans and provisions may change patient preferences in a more costly manner or that patients self-select for membership. The acceptance of reassurance as a valid treatment by many patients belies the stereotype of patients always wanting prescriptions. However, variation in the wording of that question (the switch to whether they would want medication “just to be sure”) significantly reduced the percentage of those who simply accepted over-the-counter treatments and reassurance as adequate treatments. Substantial variation was observed by race, with African Americans consistently not as accepting of reassurance and more desirous of “just to be sure” medication. Although the small sample size precludes the drawing of conclusions, this may be suggestive of cultural differences in health-seeking behavior and also reduced exposure to managed care plans. One possibility is that African Americans may have a higher threshold for consulting a physician and may have tried symptomatic treatment for a longer period of time than whites. Because FFS patients were more likely to be African American, observed differences by race may be because of the covariation of race with insurer type. Future studies should explore these possible explanations.

We also found that patients are willing to accept multiple changes in medicines before seeking specialist care and to wait several days before calling physicians about medication ineffectiveness. African Americans and FFS members were less willing to wait. Perhaps there is a self-selection factor to enrollment in HMOs, or perhaps HMO members change their expectations after enrollment. In any case, these data show that understanding the role of patient preferences and expectations about the care they receive may have some potential for cost saving through the use of reassurance and corresponding patient satisfaction with care that does not always deliver a prescription.

Acknowledgements

The authors wish to thank Pam Stovall and Tracey Barton for their typing of the manuscript.

As health maintenance organizations (HMOs) and physicians increasingly become medical partners, the HMO formularies and prescribing recommendations will be more evident in physicians’ practices. Upper-respiratory infections and low back pain are so common and often so difficult to treat that they are prime targets for HMO intervention.

A recent study showed that HMO physicians, perform less diagnostic testing, but may prescribe more antibiotics for viral illnesses than other physicians.¹ Often the physician believes the patient expects antibiotics when that is not the case.^2-5 In turn, patients may feel they need treatment for self-limited conditions because they have received them in the past.⁶

Physicians may believe that patients will be dissatisfied when expectations are not met. Dissatisfied patients are less likely to comply with physicians’ treatment recommendations.⁷ Patients may continue to call or visit the physician until expectations are met.⁸ Sometimes physicians think that patients will go elsewhere to get treatment. We asked patients for their opinions on the need for prescriptive medications and compared prepaid and fee-for-service (FFS) patients.

Methods

A total of 244 consecutive patients or parents of patients in an urban family medicine clinic completed survey forms in October 1997. This was an undifferentiated patient population seeking care for any reason. No attempt was made to screen for the reason for the visit. Parents completed the questionnaire for any child in the consecutive grouping. The questionnaire addressed perceptions of appropriateness of the frequency of medication prescription in general, reassurance or prescriptions as treatments related to 3 specific problems (virus, muscle straining, diarrhea), and preferred timing of treatment modification. No one refused to complete the questionnaire.

Men made up 37% of the sample (n=91) and women 63% (n=153). Patients were mostly white (n=191, 78%), with a substantial African American minority group (n=50, 21%), and 1% were of other ethnicities. Eighteen percent of the sample were single (n=44); 66%, married (n=160); 7%, widowed (n=16); and 9%, divorced or separated (n=23). Most of the patients were aged 30 to 59 years, with 17% 60 years or older and 20% 29 years or younger.

Sixty-seven percent of the sample were HMO members and 30% were fee-for-service patients. Most of the HMO members were charged a flat fee for medications (63%). White patients were more likely to be enrolled in an HMO than African Americans (72% vs 59%, respectively; c2= 2.937; P <087).

Analyses were largely descriptive with chi-squares conducted for group comparisons of categorical variables. Respondents were excluded from analyses if any item was missing. We conducted 2-way analysis of variance on continuous treatment change questions to compare race and HMO status.

Results

Medication Questions

Most respondents indicated that they did not believe physicians prescribed too many medications (75%). Eighty-four percent of the patients would want an expensive medicine if the physician recommended it. In a comparison of patients who had a set fee for medicine with those who did not, 88% with the set fee said they would want the more expensive medications as opposed to 77% in the group without a set fee (c2= 3.39, P <.066). African Americans were less likely to want the more costly medicine than were whites (79.6% vs 92%, respectively; c2= 6.471; P <.011).

Reassurance and Prescription Questions

We asked several questions regarding personal preferences about receiving prescriptions, reassurance, or antibiotics for virus, muscle strains, and diarrhea. Reassurance and over-the-counter treatments were seen as sufficient care for viruses (84%), muscle strain (72%), and diarrhea (56%). In contrast, when asked if they would want an antibiotic or pain medication “just to be sure,” 43% said yes in the case of a virus, 37% for a muscle strain, and 92% for diarrhea.

For viruses, we found a significant difference in preferences (P <.001) by race, with white patients more likely to accept reassurance as sufficient care (76%) than African Americans (51%). African Americans were also less likely than whites to see reassurance as sufficient for muscle strain (P <001) and diarrhea (P <.06). Table 1 shows the percentages of patients accepting reassurance. When asked about prescriptions, “just to be sure,” race and HMO membership influenced the outcome, with more African Americans than whites likely to want an antibiotic for a virus (P <001) as were more FFS members than HMO members (P <.001). For a muscle strain, FFS members and African Americans were again more likely to want painkillers “just to be sure.” For diarrhea, FFS respondents were more likely than HMO respondents to want an antibiotic (P <.03), and there was a similar trend for African Americans to prefer the medication (P <.06). Table 2 shows the percentage of patients wanting medication “just to be sure.”

Eighty-four percent of the sample said that reassurance and cold medicine would be enough care for a virus that antibiotics would not help. A significant difference was found by race, with white patients more likely to accept reassurance (76%) than African Americans (51%, X²=11.176, P <.001).

Forty-three percent of the sample would want an antibiotic “just to be sure” if they had a virus (even though 84% said reassurance was sufficient). Sex, race, and HMO membership all influenced this finding with women, African Americans, and patients not in an HMO more likely to want the antibiotic (56% women vs 39% of men, X²=6.020, P <.014; 71% of African-Americans vs 39% of whites, c2= 15.348, P <000; 63% of patients not in an HMO vs 38% of HMO members, X²=11.712, P <.001).

Similar questions were asked in reference to muscle strain: would reassurance be enough? Again, African Americans were less likely to see reassurance as sufficient (55% vs 81%, X²=14.003, P <.000). Seventy-two percent of those responding felt this would be sufficient care. However, 37% stated that they would like muscle relaxers or pain medication just to be sure. Patients who were in an HMO and African Americans were more likely to prefer the medication than those not in an HMO (55% HMO vs 36% non-HMO, X²=6.014, P<.014; 63% African Americans vs 37% whites, X²=9.59, P<.002).

Finally, the same questions were asked about diarrhea, which was most likely caused by a virus. Reassurance was again less apt to be perceived as sufficient by African Americans (50% vs 65%, X²= 3.442, P<.064), and they were more likely to want an antibiotic “just to be sure” (37% vs 23%, X²=3.759, P<.053). The patients not in an HMO were also more likely to want an antibiotic just to be sure (35% vs 21%, X²=4.669, P<.031).

Treatment Change Questions

Two questions were asked about the timing of requests for different treatments. The first had to do with the timing of a change in medicine (assuming the patient was not getting sicker) and the second with the number of medication changes that would be acceptable before requesting a referral to a specialist. Overall, 14% of the respondents would call for new medicine within 24 hours; 22% would call within 48 hours; 31% would call within 72 hours; and 33% would wait longer. In terms of requesting a specialist, 8% of the respondents would accept one medicine change before calling a specialist; 43% would accept 2 changes; 36% would accept 3 changes; and 13% would accept more changes. African Americans and FFS patients would wait for a shorter amount of time before calling for a medication change (F=14.66, P <017; F=6.34, P <013, respectively). No differences were observed by sex, race, or HMO membership status in number of medication changes before going to a specialist.

Discussion

We addressed patient preferences concerning 3 main topics: (1) influence of cost of medicine, (2) use of reassurance as a valid treatment, and (3) timing of treatment changes. Results indicate that patients want expensive medicine if there is a reason to believe it will work better. This finding is particularly true of HMO enrollees who have a set charge for medicine, suggesting that such plans and provisions may change patient preferences in a more costly manner or that patients self-select for membership. The acceptance of reassurance as a valid treatment by many patients belies the stereotype of patients always wanting prescriptions. However, variation in the wording of that question (the switch to whether they would want medication “just to be sure”) significantly reduced the percentage of those who simply accepted over-the-counter treatments and reassurance as adequate treatments. Substantial variation was observed by race, with African Americans consistently not as accepting of reassurance and more desirous of “just to be sure” medication. Although the small sample size precludes the drawing of conclusions, this may be suggestive of cultural differences in health-seeking behavior and also reduced exposure to managed care plans. One possibility is that African Americans may have a higher threshold for consulting a physician and may have tried symptomatic treatment for a longer period of time than whites. Because FFS patients were more likely to be African American, observed differences by race may be because of the covariation of race with insurer type. Future studies should explore these possible explanations.

We also found that patients are willing to accept multiple changes in medicines before seeking specialist care and to wait several days before calling physicians about medication ineffectiveness. African Americans and FFS members were less willing to wait. Perhaps there is a self-selection factor to enrollment in HMOs, or perhaps HMO members change their expectations after enrollment. In any case, these data show that understanding the role of patient preferences and expectations about the care they receive may have some potential for cost saving through the use of reassurance and corresponding patient satisfaction with care that does not always deliver a prescription.

Acknowledgements

The authors wish to thank Pam Stovall and Tracey Barton for their typing of the manuscript.

In the recent replication of his 1990 survey of trends in the use of alternative medicine, Eisenberg^1,2 reported an overall increase for many treatments and conservatively estimated out-of-pocket expenditures in 1997 at $27 billion. A significant increase was reported in the use of herbal medicines in the 12 months before each survey (from 2.5% in 1990 to 12.1% in 1997). Also of note, of the 44% of adults taking prescription medications, approximately 1 in 5 reported concurrent use of at least 1 herbal product or a high-dose vitamin. It is no longer prudent to ignore the reality of self-medication and the implications it suggests for physician care.

Recent media attention has focused on the herbal plant Hypericum perforatum for its natural antidepressant qualities. Known to the public as St. John’s Wort (SJW), it has quickly gained popularity as an over-the-counter herbal antidepressant. It is commercially available at nominal cost without prescription and is marketed as safe to use and with fewer side effects than prescription antidepressants.^3-5 A recent meta-analysis reported that Hypericum extracts were superior to placebo (odds ratio = 2.65; 95% confidence interval, 1.78 - 4.01).⁶ Sixty-six million daily doses of SJW were prescribed in Germany in 1994, and today it is Germany’s most prescribed antidepressant.⁴ Studies have claimed that SJW helps a variety of other maladies in addition to depression: wounds, inflammation, viruses, microbial infections, menstrual cramps, and even cancer.⁷

Although many complementary therapies for depression are also used⁸ (eg, exercise, relaxation), the use of SJW is the one most likely to conflict with the pharmaceutical treatments usually used by family physicians. This is because of the potential risks of herb/drug interactions and the reduced efficacy of herb versus drug treatment. The mechanisms of action for SJW are complex, and to date the exact process has not been identified. With apparently similar efficacy and an emphasis on fewer side effects by the advertising world, self-treatment with SJW may be easier than seeing a physician to obtain a prescription. The purpose of our study was to examine the reasons people choose to self-medicate with an herbal remedy instead of visiting a conventional health care clinician. Secondary purposes were to understand their perceptions of its effectiveness, and the degree to which they coordinate this alternative treatment into their conventional medical care.

Methods

We recruited subjects by placing an advertisement in the local newspapers from May to August 1998. Additionally, a 1-page flyer was distributed to local pharmacies, health food stores, and on the campuses of 2 southeastern universities.

A total of 49 interested people called the contact number and were screened for eligibility over the phone. Inclusion criteria included people aged 18 years and older who were currently taking SJW for depression or had done so within the past year. Twelve callers were not available for or canceled their phone interview, 4 were calling for information about SJW, 4 had not taken SJW, and 7 chose not to schedule an appointment. Individual interview sessions with 1 or 2 investigators were conducted and averaged 40 minutes in length. After obtaining consent, 13 open-ended questions were asked that related to the subject’s use of St. John’s Wort for depression to allow the interviewee to tell his or her story.

Twenty-two subjects were enrolled in the study during the 4-month period: 21 women and 1 man aged 24 to 77 years (mean age = 45 years). Twenty subjects were white; 2 were African American.

The interview questions were developed by investigators who brainstormed about important topics that would relate to the decision to use SJW. Two initial open-ended questions led people to reflect on their decision-making process, mood, and situation at the time of first use. Each open-ended question was followed by a series of probes used to address specific topics if these topics were not already mentioned by the participant. Key factual questions about other treatments, seeking primary care physician or pharmacist advice, dosage, side effects, and recommendations to others were subsequently asked.

Each session was audio-recorded. Two subjects were excluded because of faulty recordings (2 white women). The remaining 20 sessions were transcribed verbatim, reviewed by 2 independent analysts who extracted substantive quotes from the responses to each interview question. Extracted quotes were discussed in 3 group meetings by at least 4 investigators who reviewed each interview and aggregated categories and frequencies of responses. Theme categories evolved from the data and were agreed on by the investigators as interviews were discussed.

Transcription and quotation extraction was performed concurrent with subsequent interviews to permit better recall of interview nuances of importance. After the transcription was complete themes were developed and derived for each interview question and later combined into overall interview themes in the following areas: aspects of decision making, characteristics of the acute emotional crisis, previous history and perceptions of treatments for depression, previous history and perceptions of the use of alternative medicine in general, perceptions of conventional providers, views about alternative treatments, and effectiveness and side effects of SJW.

Results

Themes

Interviewees reported many reasons for choosing SJW. Four decision-making themes emerged: personal health, depressed mood, perceptions of disease seriousness, and accessibility to care issues.

Personal Health Care Values. This theme included the interviewee’s history of use of medical services and alternative treatments. Respondents reported prior use of alternative remedies, and concurrent use of other herbs, vitamins, and other supplements. The reports of prior use were positive and were often presented in a zealous fashion. Often the subjects’ parents were proponents of alternative therapies, and they were likely to express a belief in such type of care, sometimes even reflecting a faith in divine healing through natural treatments.

Alternative medications were seen as appropriate treatments for all problems. Respondents believed that herbal methods were purer and safer than prescriptions and reported a corresponding mistrust of modern medicines because of their increased potency, increased side effects, and the fear that medicine can cause more harm than good or be addictive in nature. They expressed a willingness to experiment and try new things, almost a sense of adventure in the herbal arena and the belief that it is “cool” to take herbal medicines. One study subject explained, “I’m into the natural stuff anyway. I’m Christian, and I believe God supplied in nature what we need for the most part. I felt like if I could help myself by taking a natural product…also, we had done some research on Prozac, and I didn’t really want to go that route because of the side effects and the dangers there. I felt better about taking something natural.”

The belief that a person should be in control of his or her own treatment was evident in this group. Borrowing from the concept of health locus of control, these are people who believe that they are responsible for their health and their health care. This belief came from a history of failed attempts with medical providers and also from a family or cultural idea that “you are to take care of yourself,” especially your emotional problems. A great advantage to SJW is that a prescription is not necessary; the patients could experiment with SJW on their own.

Mood. All patients in this sample reported depressed mood, sometimes characterized by agitation and sometimes by lethargy. All participants recognized depression as the reason for their use of SJW, and most reported an acute crisis in their lives that led to the decision to self-treat.

The primary emotional descriptors were sadness or depressed mood, hopelessness, suicidal ideation, and lack of energy. Some interviewees reported confused thinking, the inability to make decisions, and an increasing desire to be alone. Others reported feeling irritable or overwhelmed and stressed out. Finally, a small but consistent theme connected depressed mood to menstrual or menopausal changes.

One subject described her mood in the following way: “Waking up in the morning tired, like you don’t want to get up in the morning. Basically, you dread waking up, and you dread the day. Depression also has done this to me: feeling all the negative feelings and not feeling any positive feelings. Not feeling any sense of hope, not caring whether—I don’t want to sound dramatic—but sometimes you get these periods where you just don’t care if you live or die.”

Perceptions of Seriousness of Disease and Risks of Treatment. Our group of SJW users distinguished their moods as mild depression. The differentiation of subthreshold depression by persons without medical training is important. Participants often stated that although they felt depressed, they were not “clinically depressed” or “seriously depressed.” If they had been “really” depressed they would have sought help; instead they chose SJW. In the words of one subject, “I think if someone was really depressed or severely depressed, I would rather them seek medical help than SJW, but pretty ordinary able-to-function people who are depressed for one reason or another, I think it’s good.” Participants also reported a belief that people should have a “joie de vivre,” an essence of joy that was required to really “live.” Many had lost that feeling and were using SJW to reclaim that joy.

The study subjects saw SJW as a safe treatment because it did not cause side effects as do prescription antidepressant medications and would not cause addiction. This safety was often attributed to its “naturalness,” but there were also some general misconceptions about how herbals and controlled medicines are regulated.

Correspondingly, the view emerged that prescribed drugs are dangerous. Interviewees stated that such drugs have major side effects, a person could easily get addicted or might easily overdose. In addition, interviewees believed that if they took antidepressants they would be “different” people with new personalities, but if they took SJW they would just be less sad. “I knew that if I had gone to a doctor and explained it, I would have probably been put on some kind of prescription, and I don’t have any desire to be on a prescription drug,” explained one participant. “I guess you can get addicted to antidepressants, but I guess I felt like there was less risk involved in SJW versus prescriptive antidepressants. I also figured that SJW was a good place to start. If SJW didn’t work, then I could go the next step, but if I jumped into the fast lane and got put on prescription drugs, I would have never given anything simple a chance.”

Accessibility Issues. Interviewees reported that sources of traditional care were not helpful in obtaining relief from depression. Many did not think to ask physicians for help (“Why would a physician know about depression?”), had experienced negative or useless counseling or psychiatric care, had tried antidepressants and found them unhelpful or burdensome, and expressed overall dissatisfaction with traditional medicines and the health care system. “There’s no possible way [physicians] can know everything. There’s no possible way you can know everything. And so, you know, you tend to study and to home in on what’s important to you and what you find interesting.”

Additionally, SJW is easy to obtain. A person does not need to “get permission” from a physician or psychiatrist; it can be bought at the supermarket or drug store. Thus embarrassment, financial cost, time to obtain—all the typical barriers—are waived, and SJW becomes almost immediately available. Further, increased promotion of SJW in the media puts it in patients’ minds when they are looking for relief.

Other Findings. The interviewees reported currently using a number of additional “helps” in their self-treatment programs, including social support, professional counseling, faith, activities such as volunteering and crafts, relaxation, modifications in diet and exercise, and an assortment of other things such as eating chocolate, smoking, and having pets. Generally, counseling was viewed as having limited use or value by the 12 participants (60%) who had counseling experience. Nine of the 20 persons in our study had no previous experience with antidepressants, 6 had tried multiple antidepressants in the past, and 5 had tried 1 antidepressant. The drug most commonly previously used was fluoxetine (Prozac) followed by sertraline (Zoloft). There was a general impression of ineffectiveness of prescription remedies (in contrast to the perception of effectiveness of SJW).

Conventional health care providers were not informed about SJW use: Only 6 of the 20 subjects had discussed taking SJW with their physicians. This was not seen as an area in which physicians would have expertise, and patients believed their physicians would discourage them from taking SJW. It didn’t occur to some subjects to consult their physicians about alternative medicine. Others did not think they were “sick,” so they did not need to address this issue with their physician. Many would tell their physician, but since they had no other need for an office visit, they thought it unnecessary to schedule a visit to discuss SJW. It was even less likely that they had discussed SJW with a pharmacist at any time.

Most of the interviewees believe that SJW diminishes symptoms but does not make them disappear. Specific comments about the effectiveness of SJW reflected its reduction of the emotional symptoms that the person described having before taking SJW. The benefits of taking SJW included: maintaining the status quo, increased energy, feeling more normal and more in control, feeling more relaxed, less severe depression, lower sense of pressure, better sleep, less hopelessness, increased ability to focus, and feeling less overwhelmed. Two of the 20 respondents were not sure of the success of the supplement, finding it hard to pinpoint or describe.

Half of the interviewees reported no side effects. Others mentioned minor side effects and specifically expressed the minimal nature of such. These included reflux, jitteriness, insomnia, sleepiness, dry mouth, acne, decreased libido, nausea, change in bowel habits, and headaches. The known side effect of photo sensitivity was not mentioned.

Discussion

In 1993, Eisenberg² implored physicians to begin asking their patients about alternative treatments, when he reported that 1 in 3 persons use them. Today the incidence of use of alternative treatments is approximately 42%.⁷ Some physicians believe that unorthodox care is sought only where traditional care has not been successful.⁹ The successful treatment of depression is difficult to measure because of its few biologic parameters and its reliance of self-report to indicate presence or absence. SJW is therefore a prime example of an alternative medicine that may become widely accepted.

Our study found that a pattern of previous beliefs and openness to alternative treatments sets the stage for use of SJW in the self-treatment of depression. The potential for selecting a nontraditional solution increases when this openness is combined with a distrust of the contemporary medical system and a value in personal control. Perceptions about the remedy itself, its safety and lack of side effects, along with a stigmatized perception of prescription antidepressants, increases the likelihood of use of SJW. Finally, SJW has been effectively presented in the media, and awareness and availability of it are high. There are few barriers against use, it is inexpensive, and a person does not have to risk the embarrassment of self-disclosure to try it. Using the Health Belief Model¹⁰ as an explanatory model, we see that perceived decreased seriousness of the disorder, increased perceived benefits, and reduced barriers to use of SJW work together to make it the easy choice for patients having an acute emotional crisis.

Other researchers have found similar themes. Astin¹¹ found that a holistic health orientation, a transforming health experience, anxiety, presence of chronic problems, and membership in a cultural group with positive feelings toward alternative medicine led to its use. In a sample of arthritis patients, use of alternative therapies was related to the belief that the disease was uncurable by conventional or unconventional methods and chronic pain. However, this sample of patients did discuss their use of alternative therapies with their provider.¹² Patients with inflammatory bowel disease who used alternative treatments reported more concern about surgical options, a greater feeling that their problem and treatment was out of their control, and increased disease duration.¹³ Thus, the pattern of use of SJW in our study appears to be consistent with previous research that suggests that alternative medicine use could be predicted from dissatisfaction with the traditional medical care, need for personal control, and a philosophical acceptance of natural health and illness.

Limitations

Participants were required to take time to attend a medical university setting, and such a constraint may have reduced the likelihood of participation by some demographic groups (eg, men). Our methods produced a sample with a female majority. However, rates of depression are higher in women, and women are stereotypically more willing to discuss these personal issues. Our themes may reflect these limitations.

Conclusions

The rising popularity of alternative treatments and SJW suggests that many patients may be choosing this therapy. We found in a local random sample phone survey that 57% of people are aware of and can correctly identify the indication for SJW.¹⁴ Further, 7% currently report using SJW. Because of this popularity, family physicians should become familiar with the effectiveness and side effects of SJW, as well as the risks of concurrent use with other medications. Given that most SJW users fail to tell their health care providers about the use of alternative treatments, and because of the potentially serious consequences of misdiagnosis and inappropriate medication of mental illness, it is imperative that family physicians become more effective at eliciting this information from patients. Although some efficacy of SJW has been found in treating “mild” depression,^3-6 the subtleties of diagnosis for a potentially life-threatening condition suggest that some herbal therapies should be monitored by licensed health care providers. Understanding the reasons behind a patient’s therapeutic choice may help physicians legitimize and become involved in their treatment and maximize the potential for recovery.

Acknowledgements

The authors thank Jennifer Kenrick and Tracey Barton for their assistance in the preparation of the manuscript, and Lanier Adams, DO, for his involvement in the early stages of question analysis.

In the recent replication of his 1990 survey of trends in the use of alternative medicine, Eisenberg^1,2 reported an overall increase for many treatments and conservatively estimated out-of-pocket expenditures in 1997 at $27 billion. A significant increase was reported in the use of herbal medicines in the 12 months before each survey (from 2.5% in 1990 to 12.1% in 1997). Also of note, of the 44% of adults taking prescription medications, approximately 1 in 5 reported concurrent use of at least 1 herbal product or a high-dose vitamin. It is no longer prudent to ignore the reality of self-medication and the implications it suggests for physician care.

Recent media attention has focused on the herbal plant Hypericum perforatum for its natural antidepressant qualities. Known to the public as St. John’s Wort (SJW), it has quickly gained popularity as an over-the-counter herbal antidepressant. It is commercially available at nominal cost without prescription and is marketed as safe to use and with fewer side effects than prescription antidepressants.^3-5 A recent meta-analysis reported that Hypericum extracts were superior to placebo (odds ratio = 2.65; 95% confidence interval, 1.78 - 4.01).⁶ Sixty-six million daily doses of SJW were prescribed in Germany in 1994, and today it is Germany’s most prescribed antidepressant.⁴ Studies have claimed that SJW helps a variety of other maladies in addition to depression: wounds, inflammation, viruses, microbial infections, menstrual cramps, and even cancer.⁷

Although many complementary therapies for depression are also used⁸ (eg, exercise, relaxation), the use of SJW is the one most likely to conflict with the pharmaceutical treatments usually used by family physicians. This is because of the potential risks of herb/drug interactions and the reduced efficacy of herb versus drug treatment. The mechanisms of action for SJW are complex, and to date the exact process has not been identified. With apparently similar efficacy and an emphasis on fewer side effects by the advertising world, self-treatment with SJW may be easier than seeing a physician to obtain a prescription. The purpose of our study was to examine the reasons people choose to self-medicate with an herbal remedy instead of visiting a conventional health care clinician. Secondary purposes were to understand their perceptions of its effectiveness, and the degree to which they coordinate this alternative treatment into their conventional medical care.

Methods

We recruited subjects by placing an advertisement in the local newspapers from May to August 1998. Additionally, a 1-page flyer was distributed to local pharmacies, health food stores, and on the campuses of 2 southeastern universities.

A total of 49 interested people called the contact number and were screened for eligibility over the phone. Inclusion criteria included people aged 18 years and older who were currently taking SJW for depression or had done so within the past year. Twelve callers were not available for or canceled their phone interview, 4 were calling for information about SJW, 4 had not taken SJW, and 7 chose not to schedule an appointment. Individual interview sessions with 1 or 2 investigators were conducted and averaged 40 minutes in length. After obtaining consent, 13 open-ended questions were asked that related to the subject’s use of St. John’s Wort for depression to allow the interviewee to tell his or her story.

Twenty-two subjects were enrolled in the study during the 4-month period: 21 women and 1 man aged 24 to 77 years (mean age = 45 years). Twenty subjects were white; 2 were African American.

The interview questions were developed by investigators who brainstormed about important topics that would relate to the decision to use SJW. Two initial open-ended questions led people to reflect on their decision-making process, mood, and situation at the time of first use. Each open-ended question was followed by a series of probes used to address specific topics if these topics were not already mentioned by the participant. Key factual questions about other treatments, seeking primary care physician or pharmacist advice, dosage, side effects, and recommendations to others were subsequently asked.

Each session was audio-recorded. Two subjects were excluded because of faulty recordings (2 white women). The remaining 20 sessions were transcribed verbatim, reviewed by 2 independent analysts who extracted substantive quotes from the responses to each interview question. Extracted quotes were discussed in 3 group meetings by at least 4 investigators who reviewed each interview and aggregated categories and frequencies of responses. Theme categories evolved from the data and were agreed on by the investigators as interviews were discussed.

Transcription and quotation extraction was performed concurrent with subsequent interviews to permit better recall of interview nuances of importance. After the transcription was complete themes were developed and derived for each interview question and later combined into overall interview themes in the following areas: aspects of decision making, characteristics of the acute emotional crisis, previous history and perceptions of treatments for depression, previous history and perceptions of the use of alternative medicine in general, perceptions of conventional providers, views about alternative treatments, and effectiveness and side effects of SJW.

Results

Themes

Interviewees reported many reasons for choosing SJW. Four decision-making themes emerged: personal health, depressed mood, perceptions of disease seriousness, and accessibility to care issues.

Personal Health Care Values. This theme included the interviewee’s history of use of medical services and alternative treatments. Respondents reported prior use of alternative remedies, and concurrent use of other herbs, vitamins, and other supplements. The reports of prior use were positive and were often presented in a zealous fashion. Often the subjects’ parents were proponents of alternative therapies, and they were likely to express a belief in such type of care, sometimes even reflecting a faith in divine healing through natural treatments.

Alternative medications were seen as appropriate treatments for all problems. Respondents believed that herbal methods were purer and safer than prescriptions and reported a corresponding mistrust of modern medicines because of their increased potency, increased side effects, and the fear that medicine can cause more harm than good or be addictive in nature. They expressed a willingness to experiment and try new things, almost a sense of adventure in the herbal arena and the belief that it is “cool” to take herbal medicines. One study subject explained, “I’m into the natural stuff anyway. I’m Christian, and I believe God supplied in nature what we need for the most part. I felt like if I could help myself by taking a natural product…also, we had done some research on Prozac, and I didn’t really want to go that route because of the side effects and the dangers there. I felt better about taking something natural.”

The belief that a person should be in control of his or her own treatment was evident in this group. Borrowing from the concept of health locus of control, these are people who believe that they are responsible for their health and their health care. This belief came from a history of failed attempts with medical providers and also from a family or cultural idea that “you are to take care of yourself,” especially your emotional problems. A great advantage to SJW is that a prescription is not necessary; the patients could experiment with SJW on their own.

Mood. All patients in this sample reported depressed mood, sometimes characterized by agitation and sometimes by lethargy. All participants recognized depression as the reason for their use of SJW, and most reported an acute crisis in their lives that led to the decision to self-treat.

The primary emotional descriptors were sadness or depressed mood, hopelessness, suicidal ideation, and lack of energy. Some interviewees reported confused thinking, the inability to make decisions, and an increasing desire to be alone. Others reported feeling irritable or overwhelmed and stressed out. Finally, a small but consistent theme connected depressed mood to menstrual or menopausal changes.

One subject described her mood in the following way: “Waking up in the morning tired, like you don’t want to get up in the morning. Basically, you dread waking up, and you dread the day. Depression also has done this to me: feeling all the negative feelings and not feeling any positive feelings. Not feeling any sense of hope, not caring whether—I don’t want to sound dramatic—but sometimes you get these periods where you just don’t care if you live or die.”

Perceptions of Seriousness of Disease and Risks of Treatment. Our group of SJW users distinguished their moods as mild depression. The differentiation of subthreshold depression by persons without medical training is important. Participants often stated that although they felt depressed, they were not “clinically depressed” or “seriously depressed.” If they had been “really” depressed they would have sought help; instead they chose SJW. In the words of one subject, “I think if someone was really depressed or severely depressed, I would rather them seek medical help than SJW, but pretty ordinary able-to-function people who are depressed for one reason or another, I think it’s good.” Participants also reported a belief that people should have a “joie de vivre,” an essence of joy that was required to really “live.” Many had lost that feeling and were using SJW to reclaim that joy.

The study subjects saw SJW as a safe treatment because it did not cause side effects as do prescription antidepressant medications and would not cause addiction. This safety was often attributed to its “naturalness,” but there were also some general misconceptions about how herbals and controlled medicines are regulated.

Correspondingly, the view emerged that prescribed drugs are dangerous. Interviewees stated that such drugs have major side effects, a person could easily get addicted or might easily overdose. In addition, interviewees believed that if they took antidepressants they would be “different” people with new personalities, but if they took SJW they would just be less sad. “I knew that if I had gone to a doctor and explained it, I would have probably been put on some kind of prescription, and I don’t have any desire to be on a prescription drug,” explained one participant. “I guess you can get addicted to antidepressants, but I guess I felt like there was less risk involved in SJW versus prescriptive antidepressants. I also figured that SJW was a good place to start. If SJW didn’t work, then I could go the next step, but if I jumped into the fast lane and got put on prescription drugs, I would have never given anything simple a chance.”

Accessibility Issues. Interviewees reported that sources of traditional care were not helpful in obtaining relief from depression. Many did not think to ask physicians for help (“Why would a physician know about depression?”), had experienced negative or useless counseling or psychiatric care, had tried antidepressants and found them unhelpful or burdensome, and expressed overall dissatisfaction with traditional medicines and the health care system. “There’s no possible way [physicians] can know everything. There’s no possible way you can know everything. And so, you know, you tend to study and to home in on what’s important to you and what you find interesting.”

Additionally, SJW is easy to obtain. A person does not need to “get permission” from a physician or psychiatrist; it can be bought at the supermarket or drug store. Thus embarrassment, financial cost, time to obtain—all the typical barriers—are waived, and SJW becomes almost immediately available. Further, increased promotion of SJW in the media puts it in patients’ minds when they are looking for relief.

Other Findings. The interviewees reported currently using a number of additional “helps” in their self-treatment programs, including social support, professional counseling, faith, activities such as volunteering and crafts, relaxation, modifications in diet and exercise, and an assortment of other things such as eating chocolate, smoking, and having pets. Generally, counseling was viewed as having limited use or value by the 12 participants (60%) who had counseling experience. Nine of the 20 persons in our study had no previous experience with antidepressants, 6 had tried multiple antidepressants in the past, and 5 had tried 1 antidepressant. The drug most commonly previously used was fluoxetine (Prozac) followed by sertraline (Zoloft). There was a general impression of ineffectiveness of prescription remedies (in contrast to the perception of effectiveness of SJW).

Conventional health care providers were not informed about SJW use: Only 6 of the 20 subjects had discussed taking SJW with their physicians. This was not seen as an area in which physicians would have expertise, and patients believed their physicians would discourage them from taking SJW. It didn’t occur to some subjects to consult their physicians about alternative medicine. Others did not think they were “sick,” so they did not need to address this issue with their physician. Many would tell their physician, but since they had no other need for an office visit, they thought it unnecessary to schedule a visit to discuss SJW. It was even less likely that they had discussed SJW with a pharmacist at any time.

Most of the interviewees believe that SJW diminishes symptoms but does not make them disappear. Specific comments about the effectiveness of SJW reflected its reduction of the emotional symptoms that the person described having before taking SJW. The benefits of taking SJW included: maintaining the status quo, increased energy, feeling more normal and more in control, feeling more relaxed, less severe depression, lower sense of pressure, better sleep, less hopelessness, increased ability to focus, and feeling less overwhelmed. Two of the 20 respondents were not sure of the success of the supplement, finding it hard to pinpoint or describe.

Half of the interviewees reported no side effects. Others mentioned minor side effects and specifically expressed the minimal nature of such. These included reflux, jitteriness, insomnia, sleepiness, dry mouth, acne, decreased libido, nausea, change in bowel habits, and headaches. The known side effect of photo sensitivity was not mentioned.

Discussion

In 1993, Eisenberg² implored physicians to begin asking their patients about alternative treatments, when he reported that 1 in 3 persons use them. Today the incidence of use of alternative treatments is approximately 42%.⁷ Some physicians believe that unorthodox care is sought only where traditional care has not been successful.⁹ The successful treatment of depression is difficult to measure because of its few biologic parameters and its reliance of self-report to indicate presence or absence. SJW is therefore a prime example of an alternative medicine that may become widely accepted.

Our study found that a pattern of previous beliefs and openness to alternative treatments sets the stage for use of SJW in the self-treatment of depression. The potential for selecting a nontraditional solution increases when this openness is combined with a distrust of the contemporary medical system and a value in personal control. Perceptions about the remedy itself, its safety and lack of side effects, along with a stigmatized perception of prescription antidepressants, increases the likelihood of use of SJW. Finally, SJW has been effectively presented in the media, and awareness and availability of it are high. There are few barriers against use, it is inexpensive, and a person does not have to risk the embarrassment of self-disclosure to try it. Using the Health Belief Model¹⁰ as an explanatory model, we see that perceived decreased seriousness of the disorder, increased perceived benefits, and reduced barriers to use of SJW work together to make it the easy choice for patients having an acute emotional crisis.

Other researchers have found similar themes. Astin¹¹ found that a holistic health orientation, a transforming health experience, anxiety, presence of chronic problems, and membership in a cultural group with positive feelings toward alternative medicine led to its use. In a sample of arthritis patients, use of alternative therapies was related to the belief that the disease was uncurable by conventional or unconventional methods and chronic pain. However, this sample of patients did discuss their use of alternative therapies with their provider.¹² Patients with inflammatory bowel disease who used alternative treatments reported more concern about surgical options, a greater feeling that their problem and treatment was out of their control, and increased disease duration.¹³ Thus, the pattern of use of SJW in our study appears to be consistent with previous research that suggests that alternative medicine use could be predicted from dissatisfaction with the traditional medical care, need for personal control, and a philosophical acceptance of natural health and illness.

Limitations

Participants were required to take time to attend a medical university setting, and such a constraint may have reduced the likelihood of participation by some demographic groups (eg, men). Our methods produced a sample with a female majority. However, rates of depression are higher in women, and women are stereotypically more willing to discuss these personal issues. Our themes may reflect these limitations.

Conclusions

The rising popularity of alternative treatments and SJW suggests that many patients may be choosing this therapy. We found in a local random sample phone survey that 57% of people are aware of and can correctly identify the indication for SJW.¹⁴ Further, 7% currently report using SJW. Because of this popularity, family physicians should become familiar with the effectiveness and side effects of SJW, as well as the risks of concurrent use with other medications. Given that most SJW users fail to tell their health care providers about the use of alternative treatments, and because of the potentially serious consequences of misdiagnosis and inappropriate medication of mental illness, it is imperative that family physicians become more effective at eliciting this information from patients. Although some efficacy of SJW has been found in treating “mild” depression,^3-6 the subtleties of diagnosis for a potentially life-threatening condition suggest that some herbal therapies should be monitored by licensed health care providers. Understanding the reasons behind a patient’s therapeutic choice may help physicians legitimize and become involved in their treatment and maximize the potential for recovery.

Acknowledgements

The authors thank Jennifer Kenrick and Tracey Barton for their assistance in the preparation of the manuscript, and Lanier Adams, DO, for his involvement in the early stages of question analysis.

In the recent replication of his 1990 survey of trends in the use of alternative medicine, Eisenberg^1,2 reported an overall increase for many treatments and conservatively estimated out-of-pocket expenditures in 1997 at $27 billion. A significant increase was reported in the use of herbal medicines in the 12 months before each survey (from 2.5% in 1990 to 12.1% in 1997). Also of note, of the 44% of adults taking prescription medications, approximately 1 in 5 reported concurrent use of at least 1 herbal product or a high-dose vitamin. It is no longer prudent to ignore the reality of self-medication and the implications it suggests for physician care.

Recent media attention has focused on the herbal plant Hypericum perforatum for its natural antidepressant qualities. Known to the public as St. John’s Wort (SJW), it has quickly gained popularity as an over-the-counter herbal antidepressant. It is commercially available at nominal cost without prescription and is marketed as safe to use and with fewer side effects than prescription antidepressants.^3-5 A recent meta-analysis reported that Hypericum extracts were superior to placebo (odds ratio = 2.65; 95% confidence interval, 1.78 - 4.01).⁶ Sixty-six million daily doses of SJW were prescribed in Germany in 1994, and today it is Germany’s most prescribed antidepressant.⁴ Studies have claimed that SJW helps a variety of other maladies in addition to depression: wounds, inflammation, viruses, microbial infections, menstrual cramps, and even cancer.⁷

Although many complementary therapies for depression are also used⁸ (eg, exercise, relaxation), the use of SJW is the one most likely to conflict with the pharmaceutical treatments usually used by family physicians. This is because of the potential risks of herb/drug interactions and the reduced efficacy of herb versus drug treatment. The mechanisms of action for SJW are complex, and to date the exact process has not been identified. With apparently similar efficacy and an emphasis on fewer side effects by the advertising world, self-treatment with SJW may be easier than seeing a physician to obtain a prescription. The purpose of our study was to examine the reasons people choose to self-medicate with an herbal remedy instead of visiting a conventional health care clinician. Secondary purposes were to understand their perceptions of its effectiveness, and the degree to which they coordinate this alternative treatment into their conventional medical care.

Methods

We recruited subjects by placing an advertisement in the local newspapers from May to August 1998. Additionally, a 1-page flyer was distributed to local pharmacies, health food stores, and on the campuses of 2 southeastern universities.

A total of 49 interested people called the contact number and were screened for eligibility over the phone. Inclusion criteria included people aged 18 years and older who were currently taking SJW for depression or had done so within the past year. Twelve callers were not available for or canceled their phone interview, 4 were calling for information about SJW, 4 had not taken SJW, and 7 chose not to schedule an appointment. Individual interview sessions with 1 or 2 investigators were conducted and averaged 40 minutes in length. After obtaining consent, 13 open-ended questions were asked that related to the subject’s use of St. John’s Wort for depression to allow the interviewee to tell his or her story.

Twenty-two subjects were enrolled in the study during the 4-month period: 21 women and 1 man aged 24 to 77 years (mean age = 45 years). Twenty subjects were white; 2 were African American.

The interview questions were developed by investigators who brainstormed about important topics that would relate to the decision to use SJW. Two initial open-ended questions led people to reflect on their decision-making process, mood, and situation at the time of first use. Each open-ended question was followed by a series of probes used to address specific topics if these topics were not already mentioned by the participant. Key factual questions about other treatments, seeking primary care physician or pharmacist advice, dosage, side effects, and recommendations to others were subsequently asked.

Each session was audio-recorded. Two subjects were excluded because of faulty recordings (2 white women). The remaining 20 sessions were transcribed verbatim, reviewed by 2 independent analysts who extracted substantive quotes from the responses to each interview question. Extracted quotes were discussed in 3 group meetings by at least 4 investigators who reviewed each interview and aggregated categories and frequencies of responses. Theme categories evolved from the data and were agreed on by the investigators as interviews were discussed.

Transcription and quotation extraction was performed concurrent with subsequent interviews to permit better recall of interview nuances of importance. After the transcription was complete themes were developed and derived for each interview question and later combined into overall interview themes in the following areas: aspects of decision making, characteristics of the acute emotional crisis, previous history and perceptions of treatments for depression, previous history and perceptions of the use of alternative medicine in general, perceptions of conventional providers, views about alternative treatments, and effectiveness and side effects of SJW.

Results

Themes

Interviewees reported many reasons for choosing SJW. Four decision-making themes emerged: personal health, depressed mood, perceptions of disease seriousness, and accessibility to care issues.

Personal Health Care Values. This theme included the interviewee’s history of use of medical services and alternative treatments. Respondents reported prior use of alternative remedies, and concurrent use of other herbs, vitamins, and other supplements. The reports of prior use were positive and were often presented in a zealous fashion. Often the subjects’ parents were proponents of alternative therapies, and they were likely to express a belief in such type of care, sometimes even reflecting a faith in divine healing through natural treatments.

Alternative medications were seen as appropriate treatments for all problems. Respondents believed that herbal methods were purer and safer than prescriptions and reported a corresponding mistrust of modern medicines because of their increased potency, increased side effects, and the fear that medicine can cause more harm than good or be addictive in nature. They expressed a willingness to experiment and try new things, almost a sense of adventure in the herbal arena and the belief that it is “cool” to take herbal medicines. One study subject explained, “I’m into the natural stuff anyway. I’m Christian, and I believe God supplied in nature what we need for the most part. I felt like if I could help myself by taking a natural product…also, we had done some research on Prozac, and I didn’t really want to go that route because of the side effects and the dangers there. I felt better about taking something natural.”

The belief that a person should be in control of his or her own treatment was evident in this group. Borrowing from the concept of health locus of control, these are people who believe that they are responsible for their health and their health care. This belief came from a history of failed attempts with medical providers and also from a family or cultural idea that “you are to take care of yourself,” especially your emotional problems. A great advantage to SJW is that a prescription is not necessary; the patients could experiment with SJW on their own.

Mood. All patients in this sample reported depressed mood, sometimes characterized by agitation and sometimes by lethargy. All participants recognized depression as the reason for their use of SJW, and most reported an acute crisis in their lives that led to the decision to self-treat.

The primary emotional descriptors were sadness or depressed mood, hopelessness, suicidal ideation, and lack of energy. Some interviewees reported confused thinking, the inability to make decisions, and an increasing desire to be alone. Others reported feeling irritable or overwhelmed and stressed out. Finally, a small but consistent theme connected depressed mood to menstrual or menopausal changes.

One subject described her mood in the following way: “Waking up in the morning tired, like you don’t want to get up in the morning. Basically, you dread waking up, and you dread the day. Depression also has done this to me: feeling all the negative feelings and not feeling any positive feelings. Not feeling any sense of hope, not caring whether—I don’t want to sound dramatic—but sometimes you get these periods where you just don’t care if you live or die.”

Perceptions of Seriousness of Disease and Risks of Treatment. Our group of SJW users distinguished their moods as mild depression. The differentiation of subthreshold depression by persons without medical training is important. Participants often stated that although they felt depressed, they were not “clinically depressed” or “seriously depressed.” If they had been “really” depressed they would have sought help; instead they chose SJW. In the words of one subject, “I think if someone was really depressed or severely depressed, I would rather them seek medical help than SJW, but pretty ordinary able-to-function people who are depressed for one reason or another, I think it’s good.” Participants also reported a belief that people should have a “joie de vivre,” an essence of joy that was required to really “live.” Many had lost that feeling and were using SJW to reclaim that joy.

The study subjects saw SJW as a safe treatment because it did not cause side effects as do prescription antidepressant medications and would not cause addiction. This safety was often attributed to its “naturalness,” but there were also some general misconceptions about how herbals and controlled medicines are regulated.

Correspondingly, the view emerged that prescribed drugs are dangerous. Interviewees stated that such drugs have major side effects, a person could easily get addicted or might easily overdose. In addition, interviewees believed that if they took antidepressants they would be “different” people with new personalities, but if they took SJW they would just be less sad. “I knew that if I had gone to a doctor and explained it, I would have probably been put on some kind of prescription, and I don’t have any desire to be on a prescription drug,” explained one participant. “I guess you can get addicted to antidepressants, but I guess I felt like there was less risk involved in SJW versus prescriptive antidepressants. I also figured that SJW was a good place to start. If SJW didn’t work, then I could go the next step, but if I jumped into the fast lane and got put on prescription drugs, I would have never given anything simple a chance.”

Accessibility Issues. Interviewees reported that sources of traditional care were not helpful in obtaining relief from depression. Many did not think to ask physicians for help (“Why would a physician know about depression?”), had experienced negative or useless counseling or psychiatric care, had tried antidepressants and found them unhelpful or burdensome, and expressed overall dissatisfaction with traditional medicines and the health care system. “There’s no possible way [physicians] can know everything. There’s no possible way you can know everything. And so, you know, you tend to study and to home in on what’s important to you and what you find interesting.”

Additionally, SJW is easy to obtain. A person does not need to “get permission” from a physician or psychiatrist; it can be bought at the supermarket or drug store. Thus embarrassment, financial cost, time to obtain—all the typical barriers—are waived, and SJW becomes almost immediately available. Further, increased promotion of SJW in the media puts it in patients’ minds when they are looking for relief.

Other Findings. The interviewees reported currently using a number of additional “helps” in their self-treatment programs, including social support, professional counseling, faith, activities such as volunteering and crafts, relaxation, modifications in diet and exercise, and an assortment of other things such as eating chocolate, smoking, and having pets. Generally, counseling was viewed as having limited use or value by the 12 participants (60%) who had counseling experience. Nine of the 20 persons in our study had no previous experience with antidepressants, 6 had tried multiple antidepressants in the past, and 5 had tried 1 antidepressant. The drug most commonly previously used was fluoxetine (Prozac) followed by sertraline (Zoloft). There was a general impression of ineffectiveness of prescription remedies (in contrast to the perception of effectiveness of SJW).

Conventional health care providers were not informed about SJW use: Only 6 of the 20 subjects had discussed taking SJW with their physicians. This was not seen as an area in which physicians would have expertise, and patients believed their physicians would discourage them from taking SJW. It didn’t occur to some subjects to consult their physicians about alternative medicine. Others did not think they were “sick,” so they did not need to address this issue with their physician. Many would tell their physician, but since they had no other need for an office visit, they thought it unnecessary to schedule a visit to discuss SJW. It was even less likely that they had discussed SJW with a pharmacist at any time.

Most of the interviewees believe that SJW diminishes symptoms but does not make them disappear. Specific comments about the effectiveness of SJW reflected its reduction of the emotional symptoms that the person described having before taking SJW. The benefits of taking SJW included: maintaining the status quo, increased energy, feeling more normal and more in control, feeling more relaxed, less severe depression, lower sense of pressure, better sleep, less hopelessness, increased ability to focus, and feeling less overwhelmed. Two of the 20 respondents were not sure of the success of the supplement, finding it hard to pinpoint or describe.

Half of the interviewees reported no side effects. Others mentioned minor side effects and specifically expressed the minimal nature of such. These included reflux, jitteriness, insomnia, sleepiness, dry mouth, acne, decreased libido, nausea, change in bowel habits, and headaches. The known side effect of photo sensitivity was not mentioned.

Discussion

In 1993, Eisenberg² implored physicians to begin asking their patients about alternative treatments, when he reported that 1 in 3 persons use them. Today the incidence of use of alternative treatments is approximately 42%.⁷ Some physicians believe that unorthodox care is sought only where traditional care has not been successful.⁹ The successful treatment of depression is difficult to measure because of its few biologic parameters and its reliance of self-report to indicate presence or absence. SJW is therefore a prime example of an alternative medicine that may become widely accepted.

Our study found that a pattern of previous beliefs and openness to alternative treatments sets the stage for use of SJW in the self-treatment of depression. The potential for selecting a nontraditional solution increases when this openness is combined with a distrust of the contemporary medical system and a value in personal control. Perceptions about the remedy itself, its safety and lack of side effects, along with a stigmatized perception of prescription antidepressants, increases the likelihood of use of SJW. Finally, SJW has been effectively presented in the media, and awareness and availability of it are high. There are few barriers against use, it is inexpensive, and a person does not have to risk the embarrassment of self-disclosure to try it. Using the Health Belief Model¹⁰ as an explanatory model, we see that perceived decreased seriousness of the disorder, increased perceived benefits, and reduced barriers to use of SJW work together to make it the easy choice for patients having an acute emotional crisis.

Other researchers have found similar themes. Astin¹¹ found that a holistic health orientation, a transforming health experience, anxiety, presence of chronic problems, and membership in a cultural group with positive feelings toward alternative medicine led to its use. In a sample of arthritis patients, use of alternative therapies was related to the belief that the disease was uncurable by conventional or unconventional methods and chronic pain. However, this sample of patients did discuss their use of alternative therapies with their provider.¹² Patients with inflammatory bowel disease who used alternative treatments reported more concern about surgical options, a greater feeling that their problem and treatment was out of their control, and increased disease duration.¹³ Thus, the pattern of use of SJW in our study appears to be consistent with previous research that suggests that alternative medicine use could be predicted from dissatisfaction with the traditional medical care, need for personal control, and a philosophical acceptance of natural health and illness.

Limitations

Participants were required to take time to attend a medical university setting, and such a constraint may have reduced the likelihood of participation by some demographic groups (eg, men). Our methods produced a sample with a female majority. However, rates of depression are higher in women, and women are stereotypically more willing to discuss these personal issues. Our themes may reflect these limitations.

Conclusions

The rising popularity of alternative treatments and SJW suggests that many patients may be choosing this therapy. We found in a local random sample phone survey that 57% of people are aware of and can correctly identify the indication for SJW.¹⁴ Further, 7% currently report using SJW. Because of this popularity, family physicians should become familiar with the effectiveness and side effects of SJW, as well as the risks of concurrent use with other medications. Given that most SJW users fail to tell their health care providers about the use of alternative treatments, and because of the potentially serious consequences of misdiagnosis and inappropriate medication of mental illness, it is imperative that family physicians become more effective at eliciting this information from patients. Although some efficacy of SJW has been found in treating “mild” depression,^3-6 the subtleties of diagnosis for a potentially life-threatening condition suggest that some herbal therapies should be monitored by licensed health care providers. Understanding the reasons behind a patient’s therapeutic choice may help physicians legitimize and become involved in their treatment and maximize the potential for recovery.

Acknowledgements

The authors thank Jennifer Kenrick and Tracey Barton for their assistance in the preparation of the manuscript, and Lanier Adams, DO, for his involvement in the early stages of question analysis.