Taking the Edge Off Why Patients Choose St. John’s Wort

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.