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Evidence summaries

St John's Wort for Major Depression

Extracts of hypericum (St. John's wort) may be more effective than placebo and similarly effective as standard antidepressants for treating major depression. Level of evidence: "B"

A Cochrane review [Abstract] 1 included 29 trials (18 comparisons with placebo and 17 comparisons with synthetic standard antidepressants), with a total of 5 489 subjects. In trials restricted to patients with major depression, the combined response rate ratio (RR) for hypericum extracts compared with placebo from 9 larger trials was 1.28 (95% CI 1.10 to 1.49) and from 9 smaller trials 1.87 (95% CI 1.22 to 2.87). . Results of placebo-controlled trials showed marked heterogeneity. Compared with tri- or tetracyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs), respectively, RRs were 1.02 (95% CI 0.90 to 1.15; 5 trials) and 1.00 (95% CI 0.90 to 1.11; 12 trials). Results of trials comparing hypericum extracts and standard antidepressants were statistically homogeneous. Both in placebo-controlled trials and in comparisons with standard antidepressants, trials from German-speaking countries reported findings more favourable to hypericum. Patients given hypericum extracts dropped out of trials due to adverse effects less frequently than those given older antidepressants (OR 0.24; 95% CI 0.13 to 0.46) or SSRIs (OR 0.53, 95% CI 0.34 to 0.83).

Comment: The quality of evidence is downgraded by inconsistency (variability in results across studies) and by potential reporting bias (selective publication of overoptimistic results in small trials).

    References

    • Linde K, Berner MM, Kriston L. St John's wort for major depression. Cochrane Database Syst Rev 2008;(4):CD000448. [PubMed]

Primary/Secondary Keywords