St. John’s wort is a popular remedy for depression; however, it has many side effects and interactions. Get the latest facts and learn about alternatives.
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St. John’s wort is the most widely studied natural treatment for depression. (1)
Billions of dollars of St. John’s wort supplements are sold every year making it relatively mainstream for an alternative remedy.
But this popular herb is not without controversy.
In some parts of the world, it’s thought to be so potent that it’s available only by prescription.
But in others, it’s banned or restricted due to the number of unwanted side effects and interactions.
Before you take St. John’s wort you need to know two things: Is it safe? And is it effective?
Here’s an in-depth look at the benefits of St. John’s wort for depression as well as the potential risks.
What Is St. John’s Wort?
St. John’s wort (Hypericum perforatum) is a low-growing ground cover plant that is blanketed with cheerful yellow flowers around the time of St. John the Baptist’s birthday in late June.
Hypericum literally means “about spirits” as this plant was believed to contain magical properties that could ward off evil spirits. (2)
It has a 2,000-year-old history as a natural remedy and was mentioned in the works of Hippocrates and Pliny.
Traditionally, it was used both externally and internally to treat conditions as diverse as wounds, burns, snakebites, nervous disorders, ulcers, melancholy, tumors, and sciatica. (3)
Based on modern-day scientific theory and expert opinion, St. John’s wort is now used for alcoholism, athletic performance enhancement, benzodiazepine withdrawal, cancer, chronic ear infections, Epstein-Barr virus, substance abuse, and ulcers. (4)
But the most common use today by far is as an herbal remedy for depression.
In Germany, where St. John’s wort is available by prescription, doctors prescribe it 20 times more often than Prozac. (5)
Here in the United States it’s readily available as a supplement or an herbal tea.
An interesting aside is that in some western US states, St. John’s wort eradication programs are underway because it’s potentially deadly to livestock that graze on it. (6)
The Evidence for St. John’s Wort and Depression
In spite of its popularity, there is currently no consensus that St. John’s wort is a safe or effective natural antidepressant.
The evidence that St. John’s wort alleviates depression is mixed.
The most comprehensive and widely recognized meta-analysis of St. John’s wort studies is a prestigious Cochrane review conducted in 2008.
Their review of 29 international studies concluded that St. John’s wort may be as effective as standard prescription antidepressants for depression with fewer side effects than antidepressants.
Interestingly, studies conducted in German-speaking countries reported more positive results than those done elsewhere.
The reason for this is unclear.
It may be that better forms of St. John’s wort are used in these countries.
Or it could, in part, be a placebo effect since study participants in those countries were predisposed to believing in its effectiveness.
But more recent studies on St. John’s wort for depression have failed to produce the same results.
A US National Institute of Mental Health review of studies found the results on St. John’s wort to be mixed.
One study this organization sponsored found that neither St. John’s wort nor the prescription antidepressant it was being compared to worked better than a placebo! (7)
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What About St. John’s Wort for Anxiety?
You may have heard that St. John’s wort can be taken for anxiety, but there’s little evidence that it is helpful.
If anxiety is your main concern, it’s best to avoid St. John’s wort and try one of the many proven supplements for anxiety instead.
How St. John’s Wort Works to Alleviate Depression
St. John’s wort is the most widely studied herbal remedy for depression, yet it’s still not fully understood how it works.
It contains dozens of bioactive compounds, but the two most important ones are hypericin and hyperforin. (10)
Hyperforin boosts numerous mood-related brain chemicals including serotonin, dopamine, noradrenaline, GABA, and glutamate.
It helps serotonin, the neurotransmitter most commonly associated with depression, bind to serotonin receptors.
It also increases the number of serotonin receptors in the brain.
Flavonoids are another group of beneficial plant compounds found in St. John’s wort.
They may help to fend off depression by protecting the brain with their potent antioxidant and anti-inflammatory properties.
St. John’s Wort Risks: Side Effects, Cautions, and Interactions
Compared to many natural remedies, St. John’s wort is rife with side effects, cautions, and drug interactions.
Here is what you need to know to determine if St. John’s wort is safe for you and whether its downside outweighs its potential benefits.
St. John’s Wort Side Effects
One of the main reasons people want to try St. John’s wort instead of a prescription antidepressant is to avoid side effects.
But ironically, the list of St. John’s wort side effects is very similar to those of antidepressant medications — anxiety, panic attacks, dizziness, nausea, and spikes in blood pressure. (11)
A most concerning side effect is photosensitivity.
One of St. John’s wort main active ingredients, hypericin, is highly photoreactive.
This can create a rash similar to sunburn from even minimal sun exposure.
This property of hypericin can also endanger your eyes by leading to damage of the lens or retina. (15)
Caution: If you take St. John’s wort, it’s critical that you protect your eyes from sunlight.
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St. John’s Wort and Drug Interactions
Astoundingly, St. John’s wort is known to react badly with hundreds of medications. (16)
Sometimes, taking St. John’s wort along with a medication can cause side effects, while, at other times, it can cause your medication to stop working.
St. John’s wort can weaken the effects of many prescription medicines, including antidepressants, blood thinners, painkillers, and those that treat cancer, heart disease, and HIV. (17)
Ladies, be aware that St. John’s wort can cause your birth control pills to stop working!
You might be tempted to use St. John’s wort to taper off your antidepressant, but you should never mix the two.
Together, they can cause a rare but serious condition called serotonin syndrome.
It may seem odd that a natural substance can interact with so many medications, but you’re probably familiar with a similar scenario.
It’s well-known that many medications should not be taken along with grapefruit or grapefruit juice. (18)
St. John’s wort, much like grapefruit, interferes with drugs by affecting the activity of certain enzymes.
St. John’s wort should also be avoided by women who are pregnant or breastfeeding.
Lastly, do not take it if you have schizophrenia or bipolar disorder as it can trigger episodes of mania. (19)
Caution: If you take any medications, you should not take St. John’s wort until you’ve discussed it with your doctor or pharmacist.
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St. John’s Wort and Food Reactions
Some people experience reactions with St. John’s wort when eating foods high in the amino acid tyramine.
Foods that have been pickled, aged, smoked, or fermented are highest in tyramine.
This includes beer and wine, many kinds of cheese, aged or cured meat, sauerkraut, fermented soy products, and chocolate. (20)
The combination of tyramine-rich foods and St. John’s wort is especially dangerous for anyone with high blood pressure.
It’s also advised that you avoid alcohol and minimize caffeine intake when supplementing with St. John’s wort. (21)
Unless you are willing to forgo tyramine-rich foods, caffeine, and alcohol, you should take a pass on St. John’s wort supplements.
St. John’s Wort’s Interactions With Supplements
St. John’s wort does not safely mix with many other natural supplements either.
St. John’s wort should not be taken with 5-HTP, another popular supplement for depression, anxiety, and insomnia.
When taken together, there’s a risk of serotonin syndrome.
Worryingly, many multi-ingredient mood-enhancing supplements contain both St. John’s wort and 5-HTP.
You should avoid these.
St. John’s wort works synergistically with many other herbs to enhance their beneficial actions.
But this property cuts both ways since it also increases the risk for and severity of side effects should they occur.
Here’s a list of some of the most popular herbs that can interact with St. John’s wort: (22)
- German chamomile
- gotu kola
- lemon balm
- Siberian ginseng
- stinging nettle
- yerba mansa
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What to Look For in a St. John’s Wort Supplement
If you decide to give St. John’s wort a try, you’ll find a wide array of tablets, capsules, liquid extracts, dried herbs, oils, and teas available.
Most will be standardized to contain 0.3% hypericin. (23)
Others will contain dried flowers and leaves of the St. John’s wort plant.
Here’s a typical St. John’s wort supplement label:
The first ingredient is the standardized hypericin extract.
The second ingredient is the whole dried leaves and flowers.
The term aerials simply means the above-ground parts of the plant (not the roots).
The Best St. John’s Wort Supplement
The standardization of hypericin has lead to the erroneous belief that it is St. John’s wort’s main active ingredient.
Actually, there is no strong evidence that hypericin is responsible for St. John’s wort antidepressant properties. (25)
It seems that most of St. John’s wort’s pharmacological properties come from hyperforin rather than hypericin.
Yet almost all supplements contain a standardized extract of hypericin, not hyperforin.
This is because hypericin was discovered first and has been studied longer and is a more stable compound than hyperforin.
However, there is one patented brand of hyperforin that uses a stabilizing technology — Perika (WS 5570).
This is the same form used in Germany where St. John’s wort is considered to have substantial medicinal value. (26)
The only readily available supplement I’ve found that contains this is Nature’s Way Perika St. John’s Wort.
Whatever form you decide to take, be sure to buy a reputable brand.
Sixty percent of the St. John’s wort supplements tested by the independent watchdog group ConsumerLab.com did not contain what was stated on the label. (27)
You can’t expect to reap any of St. John’s wort’s benefits with an inferior product.
St. John’s Wort Dosage
The accepted dose of St. John’s wort is 300 mg of standardized extract (0.3% of hypericin) taken 3 times per day. (28)
Clinical studies have used doses of up to 1,800 mg per day for moderate to severe depression. (29)
If you are taking the whole dried herb, you can take 2 to 4 grams per day. (30)
Be patient when trying St. John’s wort.
It can take a few weeks to notice any improvement in depression symptoms.
However, if you don’t experience any positive effects in 4 to 6 weeks, it’s advised that you stop taking it. (31)
Safer, More Effective Alternatives to St. John’s Wort
You may now understandably be leery of taking a St. John’s wort supplement.
If you are currently taking it with success, then stick with it.
But if you are one of the millions of people for whom St. John’s wort is not a viable option, rest assured that there are many alternatives.
You can also use proven antidepressant activities such as yoga, breathing exercises, neurofeedback, or mindfulness meditation.
Benefits of St. John’s Wort: Take the Next Step
St. John’s wort is a very popular herbal remedy for depression, but it’s not our top choice.
Its efficacy is in doubt, but its side effects and large number of negative interactions are not.
It should not be mixed with hundreds of medications, certain herbal remedies, and even some foods.
Its side effects can be similar to those of antidepressant medications.
Why take these risks when there are many other natural remedies for depression with better records of effectiveness and safety?
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