Depression, Antidepressant Drugs and St. John's Wort: Myths, Lies and Manipulations

By Shahid Akbar

The book deals with the subject of depression and its causes and answers a number of questions that should be of interest to any and every patient regarding the health-care system and the society in general. Why has the diagnosis of depression increased over the past two decades? Are treatments offered to patients by their primary care physicians and psychiatrists justified and evidence based? Why do patients use nutritional and herbal supplements and are attracted to other complementary therapies? How do pharmaceutical companies exploit the health-care system and influence physicians to prescribe not the most effective but most expensive medicines? What is St. Johns wort, and who has been using this unassuming weed for health benefits? The effectiveness of antidepressant drugs, both typical and newer drug classes, like SSRIs and SNRIs, and their adverse effects have been presented. The author has made head-to-head comparisons of scientific studies of St. Johns wort with SSRIs, such as Prozac, Paxil, and Zoloft, for their effectiveness, adverse effects, and potentials for drug interactions in cogent and easily understood manner. The author leaves the reader with a take-home message as he concludes this book.

• Language: English
• Publisher: Trafford Publishing
• Release date: Feb 27, 2013
• ISBN: 9781466974616

Shahid Akbar

The author has both an MD and a PhD in pharmacology and is well conversant with both theoretical and practical aspects of treatment. His intentions are to allow readers to make up their own mind about the subject by providing scientific information in an easy-to-understand and objective manner.

Book preview

Depression, Antidepressant Drugs and St. John’s Wort

Myths, Lies and Manipulations

SHAHID AKBAR, M.D., Ph.D.

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© Copyright 2013 Shahid Akbar, M.D., Ph.D.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the written prior permission of the author.

The author has no conflicting interests with the companies or other entities involved in the manufacture, promotion or distribution of products based on St. John’s wort. Neither, this book is an endorsement of treatment of depression with St. John’s wort.

The author is not a psychiatrist and the information about depression presented in this book is from general medical sources and is not a substitute for professional help. Information for major depression is not exhaustive and is limited to what a common reader can easily comprehend. Readers must consult a licensed physician for diagnosis and treatment of depression.

Cover image taken from Wikipedia by Michael H. Lemmer on June 25, 2005.

ISBN: 978-1-4669-7460-9 (sc)

ISBN: 978-1-4669-7462-3 (hc)

ISBN: 978-1-4669-7461-6 (e)

Library of Congress Control Number: 2012924331

Trafford rev. 02/27/2013

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Contents

1.   Preface

2.   Introduction

3.   Depression

What is depression and who are the sufferers?

Percentage of Depressed Patients in a Population

What are the Causes of Depression?

Biochemical Changes in the Brains of Depressed Patients

Consequences of Untreated Depression

Available Treatments for Depression

4.   Medical Research and Pharmaceutical Industry

5.   St. John’s wort as an Antidepressant

Scientific Evidence, Comparative Studies St. John’s wort Vs Placebo

St. John’s wort Vs Standard Antidepressants

6.   Adverse Effects of Antidepressant Drugs

TCAs, SSRIs and SNRIs

Adverse Effects of St. John’s wort

Antidepressant Drugs and Suicide

7.   Drug-Drug (Herb) Interactions

Potential for Drug-Interactions

Potential for Drug-Interactions with Conventional Antidepressant Drugs

Potential for ‘Drug-Interactions’ with St. John’s wort

8.   Conclusion

9.   Bibliography

As for me, all I know is that

I know nothing.

(Socrates)

Knowledge and Wisdom, far from being one,

have oft-times no connexion.

Knowledge dwells in heads replete with thoughts of

other men,

Wisdom in minds attentive to their own.

(William Cowper)

Preface

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Preface

When I started writing this book several years ago, it was a time when depression and the use of SSRIs, the main contemporary antidepressant drugs, were in news because of their likelihood to increase suicidal thoughts and the FDA issuing a warning in this regard. A decade before that an acquaintance pharmacist, who suffered from bipolar disorder, had asked me a question about St. John’s wort, of which I knew nothing about at the time. In addition, in the early 2000s, I worked for some pharmaceutical companies who marketed drugs for depression and I gained first-hand knowledge about their tactics, tricks and how the healthcare establishment works hand-in-glove with them. In 2006, National Institute of Mental Health (NIMH) scientist (Psychiatrist), Pearson Trey Sunderland III (Chief of the Geriatric Psychiatry Branch), was found to have accepted $285,000 from Pfizer as consultant, and providing Pfizer spinal fluid samples of Alzheimer patients, that were collected for research at the National Institute of Health (NIH) at a cost of $6.4 million of taxpayers money. That was not only conflict of interest but a criminal act. Sunderland also received more than $600,000 in consulting and speaking fees from Pfizer from 1998 to 2004 without prior government disclosure or approval. A review by NIH’s Office of Management Assessment found that Sunderland engaged in serious misconduct, in violation of Department of Human Health and Services ethics rules and Federal law and regulation. Later, 43 other NIH researchers were found to have undisclosed relationship with pharmaceutical and biotech companies; administrative action was initiated against 34 and nine scientists were referred for criminal prosecution. Dr. Sutherland’s medical license was revoked by Maryland in 2009 and indefinitely suspended by New York in 2011.

Another famous and rightly described as the most influential psychiatrist of Emory University, Dr. Charles B. Nemeroff, who at one time consulted 21 drug and device companies, also received a total of $2.8 million as consultation fee from pharmaceutical companies, between the years of 2000 and 2007. He conducted clinical trials for some of their drugs as reported by Gardiner Harris of New York Times. A Congressional inquiry conducted by Senator Charles Grassley discovered a number of scientists accepting huge amounts of money from pharmaceutical companies, such as Dr. Melissa Del Bello of University of Cincinnati receiving $238,000 from AstraZeneca alone between 2005 and 2007. Similarly, Drs. Joseph Biederman and Timothy Wilens of Harvard Medical School each received at least $1.6 million as ‘consulting fee’ from drug companies between 2000 and 2007. In 2006, former FDA Director Lester Crawford was charged with lying about and not disclosing his ownership of stocks of companies that were being examined in a study by the FDA in which he was involved to make recommendations, a clear conflict of interest. Many others in the FDA hierarchy are known to consider pharmaceutical companies as their customers or clients and thus worthy of utmost care. These are just a few examples exposed otherwise countless contacts and associations of drug companies with government agencies and important University faculties serving their interests remain in place. Therefore, how can one expect an unbiased and objective oversight by the FDA and impartial assessment of many pharmaceutical drugs by those conspiring with pharmaceutical companies?

We live in an age of practice of evidence-based medicine. A small number of scientists/physicians generally collect the evidence and the rest trust it and follow it. Thus, the impartiality and objectivity of evidence collectors is crucial because any bias could prejudice the collected ‘evidence.’ Therefore, after the FDA issued warning about potential for increased risk of suicidal tendency by SSRIs, it occurred to me that I should go back and reevaluate efficacy reports of St. John’s wort, about which I had done some literature search earlier but this time in a more critical manner. I constructed a list of questions for myself, for which I would look for answers (evidence) in published scientific literature in an objective and as much as possible unbiased manner. If I were reasonably satisfied, then I would give it the shape of the book that was put on the back burner a while ago. This is meant to help common people understand depression, its causes, its effects on life, available choices and pitfalls associated with its treatment, and the scientific evidence in favor or against the use of St. John’s wort for depression.

Following were the questions I set out to answer:

What is depression and who are the likely sufferers? What percentage of population is affected from depression? What are the supposed causes of depression or how does it develop? What types of biochemical changes in brain are purportedly responsible for depression? What happens to these people if they are not treated? What types of treatments are available and how much they are availed by a common Bob and Mary, and if not, then why? How effective these treatments are and what kind of adverse effects they produce? What are the chances for ‘drug-drug interactions’ when patients are treated with ‘antidepressant drugs’ along with other drugs? What is St. John’s wort and how does it stack against FDA-approved conventional antidepressant drugs in terms of effectiveness and safety in light of scientific evidence? What is the adverse effects profile of St. John’s wort compared to conventional antidepressant drugs? What, if any, drug-drug interactions are likely to occur with St. John’s wort? Should a person even indulge in self-treatment of depression, and what are the potential ill consequences from doing so?

This book is an attempt to answer these questions. My intention is not to defend or condemn St. John’s wort but to present collective facts as published in professional and general forums over the years that form professional and public opinions about a product. Despite my concerted efforts to avoid unnecessary details about clinical trials, some had to be included to help reader understand the context of information, and to present an apple-to-apple comparison. There were different SJW extracts used in various studies, with some expected qualitative and quantitative differences in their chemical contents, as there were no established standards for these extracts ten years ago. Therefore, results obtained in different clinical trials may not be equally comparable. In the past few years, active chemical constituent primarily responsible for antidepressant effects of SJW has been redefined. However, with natural products it is not just one active constituent rather the collective actions of various chemical components that ultimately produce a particular effect.

The book describes depression from a general perspective, and raises questions in a logical manner anticipating what could pop up in the minds of readers after reading its description and the causes. As a common person and not as a pharmacologist, I have raised some questions that may sound absurd but these questions beg answers. Readers may find some passages that are outside the realm of commonly accepted concepts and theories. As described later, depression in the general sense is a multi-factorial and multi-faceted disease when it appears as a disease. While, most psychiatrists would like to label as many patients depressed as they can and treat them with antidepressant drugs, we as a society (the common John and Jane) must review our priorities, our personal issues, the state our families, and their effects on our physical and mental health.

SA

California

December 2012

Introduction

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Introduction

Nature (God) bestows upon each one of us some unique personal qualities that are not usually common with other people. Nonetheless, all of us share to varying degrees two most useful characteristics of human self, forgetfulness and adaptation. Both of these qualities are blessings to humans as they are not only helpful for our effective survival but are essential for living a near-normal productive life. If we could not forget or adapt to the changing life conditions and the environment around us we would be stuck in a time warp and all progress human race has made in its existence would not have been possible. Just imagine if we could not forget the loss of a loved one or memories of disastrous and painful events in our life, it would make living a normal fruitful life to be almost impossible and a living hell.

Nevertheless, this forgetfulness is very selective by nature in all of us; sometimes it is complete when we lose all recollections of an event or incident, or a partial one. Most of our everyday events are lost and are not stored in our long-term memory; for instance, we cannot recall what we ate for dinner on Tuesday of last week, unless of course if it was a special occasion. In case of a partial forgetfulness, memory of an event is stored in the long-term memory but is slowly buried under the pile of more recent happenings. It is only after a little effort and some dusting that we can recall some or most of the details of an issue or incident long forgotten.

However, certain events of our lives are very strongly etched in our memory. These events are so easily accessible that a very small, trivial stimulus brings back memory of a whole episode in a matter of nanoseconds. Sometimes these often painful memories stay alive and become part of our, what I call the Random Access Memory, as the term is used in computer language. This memory is so strong that it is almost impossible to bury it under any layers of reasoning and logic, and it starts affecting our normal daily functioning. We become so engrossed in the painful event(s) that they just seem to become unwanted parts of our lives; some of us are burdened with such painful memories. Post-Traumatic Stress Disorder (PTSD) is one such condition that has lingering effects of a traumatic experience and very adversely affects everyday life of those suffering from it and results in physical symptoms that could sometimes be debilitating. Almost all soldiers returning from wars with memories of horrendous events witnessed during deployments do likely suffer from PTSD to some degree.

Adaptation is another natural human quality that has helped human race survive under various trying conditions and made it thrive and progress over the past several millennia. Normally we adapt without making any conscious efforts and sometimes we need to make some conscious adjustments. We easily adapt to alternating seasons, family situations, changing weather and driving conditions and the ever-changing work environments. Our body also adapts to the demands placed on it on an hour-to-hour and minute-to-minute basis, both physically and mentally. Internal environment of our body is maintained by a process called homeostasis. Body changes to maintain homeostasis are usually imperceptible and we feel ‘disturbance’ in our biological clock only when these changes are outside the normal functioning bandwidth of our body, such as jetlag.

We are all gifted by nature with this quality of adaptation, but our capability to adapt varies from person to person. This quality is tied to some extent with our age, gender, environment and the circumstances in which we are raised. Also as we grow older, our adaptation capacity becomes more limited and then comes a time (old age) when we start complaining about everything we have to adjust to… again. Adaptability also partially depends on our ability to forget and vice versa. Therefore, these two qualities are not mutually exclusive but inter-dependent and complementary to each other. If one of these qualities is somehow impaired, the other is also affected. Adaptation is also influenced by our prior experiences and the degree of sensitivity. Some people are very adaptable regardless of the circumstances, their age and the degree of adaptation, while many others are not so malleable. Most of us have a feeling of satisfaction and a sense of achievement after successfully adapting to a new, sometimes a challenging situation.

There are, however, instances when we are not comfortable with a new situation and do not approve of it but we have no control over it. In cases when we fail to reconcile with a new situation, we unwillingly and grudgingly go along while resisting it from inside, creating a constant struggle and conflict within ourselves. We feel helpless and frustrated when we do not have an alternative or the ability to change the circumstances; this situation is more critical when it involves our employment or family members because both are integral parts of our lives and indispensable. If this kind of situation persists for long it could result in some psychological problems that are mostly transient. Have not we experienced situations when a family, social, health or job problem is so serious that the seemingly unremitting situation puts us into a seriously depressed state? However, fortunately most of the times and with most of us when the situation is resolved we regain our normalcy without any residual behavioral or psychological effects, as if nothing bad or wrong happened.

Another aspect of human psychology and instinct is that we like, wish and prefer to see everyone around us to be in our own image, doing things like we do, think like us, act like us, like what we like and dislike what we dislike, etc. an unrealistic but still could be a strong desire in some of us. That’s why we like to befriend those people who closely resemble us in their mannerism, activities, hobbies, and share our views, and those that are ‘different’ from us we have ‘problems’ with them. That is how we create conflicts with those ‘unlike us’ in our family, circle of friends and co-workers. It is also an inherent human nature that everyone wants and longs to be