St John’s Wort for endurance athletes

Is St John’s Wort a good mood-lifter for depressed endurance athletes?

You can find it everywhere – in most chemists and health-food shops, and staring brightly at you from the pages of your favourite ‘health’ magazine. St. John’s Wort is one of the hottest herbal supplements on the market right now.

Why are sales of St. John’s Wort skyrocketing? An oily salve concocted from extracts of St. John’s Wort may help heal burns, sores, and bruises, but St. John’s Wort’s popularity is primarily due to one of its chemical constituents – a unique compound called hypericin. Various clinical studies have shown that hypericin is a fairly effective anti-depressant, and there is also speculation that the compound might be somewhat effective against HIV-1, the virus that causes AIDS.

‘Saint John’s Wort’ is actually the common name for a family of plants called Hypericaceae. This family is actually in the order Theales, which includes the plants used to make various kinds of tea (that’s not surprising, since Saint John’s Wort itself is often sold in tea form). Members of the family Hypericaceae usually have five-petalled, yellow flowers with many stamens (male reproductive organs), which are often united in the form of bundles.

The ancients took it for internal worms
About 370 species of plants, both temperate and tropical, belong to a genus within the Hypericaceae family known as Hypericum, and the ‘St. John’s Wort’ found in shops is most often prepared from a common member of this genus known as Hypericum perforatum. Although Hypericum perforatum is regarded as a somewhat miraculous plant by depressed individuals who have benefited from taking it, it is much less than a miracle in southern Australia, where its rapid growth has led to its classification as a ‘nuisance weed’.

Someone unfamiliar with herbal medicine might well believe that St. John’s Wort is a rather new member of the herbal pharmacopoeia, but its first use as a healing compound dates back at least as far as the time of Pedanius Dioscorides, a Greek physician and pharmacologist who was born in about 40 A. D. Dioscorides’ great work, De Materia Medica, is probably the primary classical source of modern botanical terminology, and it was in fact the most important pharmacological text in the world for 16 centuries.

Dioscorides travelled as a surgeon with the armies of the Roman emperor Nero (it was common for the Romans to ‘import’ their medical specialists from Greece), and as the military forces were collecting cities, villages, and broad expanses of territory, Dioscorides collected a wide variety of plants and attempted to determine their medicinal properties. The Greek man of medicine studied almost 600 plants, including cannabis (marijuana), hemlock, peppermint, and Hypericum. Dioscorides might be considered the world’s first modern anaesthesiologist; he prepared a sleeping potion from opium and used it as an effective surgical anesthetic. He was also impressed by Hypericum (St. John’s Wort), which he recommended for killing internal worms – and also as a diuretic and emmenagogue (a compound which promotes menstrual flow).

St. John’s Wort was highly regarded by another great early physician – Galen of Pergamum (born 129 A. D., died circa 216), whose influence on the medical world was strongly felt into the 1600s. Galen studied medicine at Alexandria in Egypt, which was the greatest medical centre of the ancient world. Like Dioscorides, Galen eventually became a physician for a Roman emperor (in fact, he served four imperators – Marcus Aurelius, Verus, Commodus, and Septimius Severus). Galen was a keen student of anatomy; he managed to locate seven pairs of cranial nerves, meticulously described the valves of the heart, and noted the differences between arteries and veins. He was the first medical specialist to realize that arteries carried blood, not air, as had been previously believed. Galen prescribed St. John’s Wort to help maintain the ‘equilibrium’of what were thought to be the four main bodily fluids, or humours – blood, yellow bile, black bile, and phlegm. Like Dioscorides, he believed that St. John’s Wort was useful as a diuretic and emmenagogue.

Healing wounds and driving out devils
In mediaeval times, St. John’s Wort became very popular as a treatment for bloody wounds. This was probably the result of the popular medieval belief in the ‘doctrine of signatures,’ a medical hypothesis which maintained that the external form of a plant provided a clue to which diseased body organ could be cured by using a preparation made from the plant. Since St. John’s Wort forms juicy, bright-red seed capsules, many devotees of the doctrine of signatures came to believe that the plant was useful for treating bloody lacerations. This kind of thinking was very common in the Middle Ages; for example, another group of plants – the liverworts – were thought to cure liver disorders because of their lobed, liver-like leaves (the liverworts were also called the ‘hepatics’).

Gradually, the number of uses to which St. John’s Wort was put expanded. In mediaeval Europe, it was believed that St. John’s Wort could be used to ‘drive devils out of possessed persons’, and the plant was employed in the treatment of hypochondriacs and the mentally ill – and as a charm against witchcraft and evil spirits. The somewhat unusual name ‘St. John’s Wort’ was given to the plant because it usually begins to flower on approximately Saint John’s Day (June 24) each year (the word ‘wort’ may come from the Gothic word waurts, which means roots). European peasants believed strongly that St. John’s Wort had powerful healing properties and would gather the plant on St. John’s Day in hopes of curing some of their most serious medical problems.

John Gerard, the renowned English herbalist (born 1545, died 1612) who published The Herball, or Generall Historie of Plantes, was a strong proponent of Hypericum. Gerard wrote that ‘St. John’s Wort, with his (sic) flowers and seed boyled and drunken, provoketh urine, and is right good against stone in the bladder.’ The Herball described the habitats, flowering times, and practical uses of over 1000 species of plants and became an extremely popular source book, thus increasing the fame of St. John’s Wort.

Yet despite such spirited support, the little plant gradually began to fall out of favour as the years rolled by. In fact, in the United States the FDA included St. John’s Wort on its ‘unsafe herb list’ in 1977, and even the widely read ‘pro-herbal’ book, Herbs That Heal: Prescription for Herbal Healing (Quantum Books, 1994) lists St. John’s Wort as being ‘not recommended for internal use.’

So what’s the real story?
Is St. John’s Wort safe to take, or are you running the risk of killing yourself? And does St. John’s Wort actually work? Can it really help heal skin lesions, and does it alleviate mild forms of depression (for now, we won’t worry about whether it can drive out devils)?

As far as skin problems are concerned, there are strong indications that St. John’s Wort is indeed effective. In one published study, German scientists found that second- and third-degree burns healed three times faster when treated with an ointment containing St. John’s Wort, compared to conventional treatments. In Russia, scientists have noted that two widely used St. John’s Wort remedies – Imanine and Novoimanine – are quite effective against skin infections caused by a rather feared bacterial species – Staphylococcus aureus.

If Sports Performance Bulletin happened to be a German publication, we wouldn’t be debating the effectiveness of St. John’s Wort as a mood-lifter. German doctors are prescribing Hypericum extract preparations for their depressed patients with increasing frequency. In fact, tablets manufactured from dried extracts of St. John’s Wort make up more than 25 per cent of all prescriptions filled out in Germany for antidepressants. In 1994, German physicians prescribed 66 million daily doses of St. John’s Wort extract, with an estimated monetary value of 40 million U. S. dollars, and the leading brand of Hypericum extract – Jarsin 300 – is currently the most widely prescribed antidepressant in all of Germany.

Why is St. John’s Wort so popular in Germany? The German medical establishment keeps an open mind regarding herbal therapies, and scientific research exploring the properties and effects of herbal compounds is better funded, conducted, and respected in Germany than in other parts of the world. In the case of Hypericum, the German research has shown that an extract of the plant can indeed be clinically effective as an antidepressant, that it may work via biochemical mechanisms which are not too dissimilar from the widely prescribed non-herbal antidepressant drugs, and that it is also much safer to take than the ‘synthetic’ antidepressants such as Elavil and Prozac (ie, there are fewer unpleasant side effects with St. John’s Wort).

In a recent review paper, H.-P. Volz of the University of Jena in Germany analyzed 12 placebo-controlled Hypericum investigations to determine whether the plant had a positive effect on depression – and also looked at three investigations in which St. John’s Wort and the more traditional synthetic antidepressants went ‘head to head’ (‘Controlled Clinical Trials of Hypericum Extracts in Depressed Patients – An Overview,’ Pharmacopsychiatry, vol. 30 (Supplement), pp. 72-76, 1997).

All 15 studies were ‘double-blind’ (neither the researchers nor subjects initially knew who was getting St. John’s Wort).

How SJW did
In one study analyzed by Volz in which some outpatients with the blues took three 300-mg tablets of St. John’s Wort per day while others ingested only a placebo, SJW-takers felt better within two weeks after starting their treatment, while placebo persons remained in the dumps. Reductions in depression were even more pronounced for the SJW people after four weeks, while placebo individuals remained down.

At that point in the study, the placebo participants shifted over to St. John’s Wort for two weeks, and their depressive states began to abate within that short time frame.

In another study, St. John’s Wort squared off against maprotiline, a powerful synthetic antidepressant which is sold under the trade name Ludiomil. Reduction of depression in the two initially moderately depressed groups was equivalent, but patients tolerated the ‘phytopharmacon’ (St. John’s Wort) significantly better, with about half as many reported ‘side effects’. Tiredness, an often-reported adverse effect which is associated with many anti-depressants, occurred just 20 per cent as often with St. John’s Wort, compared to Ludiomil.

Overall, Jena determined that about 55 per cent of mildly depressed individuals who took St. John’s Wort experienced an improvement in mood, compared with 22 per cent of placebo takers. You might wonder why 22 percent of individuals with depression would feel better after taking sugar (placebo) tablets, but that of course is due to the aptly named ‘placebo effect’.

In an investigation not examined by Jena (but scrutinized by Sports Performance Bulletin), St. John’s Wort ‘fought it out’ with amitriptyline, another widely prescribed synthetic antidepressant medication which is sold under the various trade names Elavil, Endep, Enden, Domical, Lentizol, and Trytizol.

In this double-blind study, which lasted for six weeks and was carried out with 156 depressed individuals, improvement in depression was about the same in the St. John’s Wort and Elavil groups. However, the St. John’s Wort takers had far fewer side effects (37 per cent of SJW ingesters reported problems, against 64 per cent of those on Elavil): the key difference was that few SJW users experienced dry mouths, drowsiness, or dizziness, problems which occurred at a high rate when Elavil was taken.

In a study carried out with severely rather than mildly depressed patients, SJW was found to be approximately as effective as yet another synthetic antidepressant called imipramine, which is sold under the brand names Melipramine, Tofranil, and Janimine. Again, SJW had far fewer adverse effects. And in another extremely interesting study carried out at the University of Vienna, SJW was found to be as effective as bright-light therapy in alleviating the mental disturbances associated with SAD (seasonal affective disorder).

Will it work for you?
Overall, the available research provides pretty strong support for the notion that St. John’s Wort is an effective antidepressant. Should you give this well-known herb a try? Well, are you depressed? You’ll have to admit that it’s a bit odd that the general public has basically gone hook, line, and sinker for SJW. Does this imply that most Americans and Europeans are mildly depressed? And if people really are depressed, is the correct response to squirt a little hypericin into their systems – or should they try to find out why they are feeling so out of sorts?

If you do decide to have a go with SJW, the dose which has been shown to be effective in clinical trials is about 300 mg of Saint John’s Wort extract, taken three times a day (each 300-mg dose is supposed to contain about 900 micrograms of the allegedly active antidepressant, hypericin). A smaller quantity of daily SJW might be equally effective, but no one knows for sure, since the dose-response relationship has not been carefully studied.

SJW itself doesn’t appear to be toxic, although it can produce some side effects, including dry mouth, vertigo/dizziness, gastrointestinal problems (nausea and diarrhoea), and dermatitis (if Saint John’s Wort ingestion is combined with heavy sun exposure). The widespread use of SJW in Germany is an indication that these problems tend to occur with low frequencies; in fact, one recent study indicated that gastrointestinal problems occurred in only 6 out of every 1000 SJW ingesters, while fatigue was present in just 4 out of 1000 individuals.

However, this research spanned just a four-week period, and one key caution concerning SJW ingestion is that most Saint John’s Wort studies have lasted for no more than six weeks; no research has examined the effects of SJW ingestion over a one-year period, for example, or even for time periods as short as three months. And don’t forget that deciding to use Saint John’s Wort immediately brings you face to face with the usual problems associated with herbal preparations Their production and sale are not well regulated, so you might end up getting milk sugar, ephedrine, ginseng, or a variety of other strange ingredients instead of Saint John’s Wort and its beloved hypericin – unless you buy from a totally reliable supplier (and who’s to say that any supplier is totally reliable?).

What hypericin does (we think)
How does hypericin actually work in the brain to relieve depression? No one is certain, but there is speculation that its action is similar to several of the widely used synthetic antidepressants. Antidepressants themselves generally belong to three types – the tricyclic antidepressants (so named because their molecules have three ring-like structures), the monoamine oxidase (MAO) inhibitors, and the serotonin re-uptake inhibitors.

Many researchers believe that depression itself is often caused by reduced concentrations or activities of the neurotransmitters serotonin and norepinephrine within the brain (neurotransmitters are simply chemicals which carry messages from one nerve cell to another). Antidepressants seem to work by inhibiting the reabsorption or inactivation of these key neurotransmitters, so that they may remain in contact with brain cells and ‘mellow out’ the individual taking the antidepressant medication.

The so-called tricyclic antidepressants (including imipramine and amitriptyline, the ones which were compared with SJW in the studies described above) stop the inactivation of norepinephrine and serotonin within the brain. Although researchers believe that the tricyclics can lift the moods of more than 70 per cent of depressed patients so treated, the side effects can be troubling, ranging from blurred vision, dry mouth, dizziness, and difficulty in urination to actual cerebral and cardiac toxicity.

Meanwhile, the second class of antidepressants – the MAOs – achieve their anti-depressive effect by hashing up the action of monoamine oxidase, a key enzyme which breaks down norepinephrine and serotonin within nerve cells. Again, since this leads to increased concentrations of those neurotrans-mitters within the brain, the patient’s mood tends to lift, although side effects are unfortunately common and unpredictable. Generally, the MAOs aren’t prescribed unless treatment with the tricyclics has proven to be ineffective.

The third kind of antidepressant – the serotonin re-uptake inhibitor – first appeared on the antidepression stage with a flourish in the 1980s. This kind of compound prevents serotonin from being absorbed by nerve cells, thus letting the neurotransmitter languish in the spaces between nerve cells, where it can ‘mellow’ an individual’s mood state. The most popular serotonin re-uptake inhibitor is fluoxetine (sold under the brand name Prozac), a drug which has had the reputation of relieving depression in patients for whom the tricylics and MAOs were ineffective. Many believe that Prozac produces fewer – and less serious – side effects than the tricylics and MAOs, and it has become the single most widely used antidepressant in the world (except in Germany, where Hypericum is king).

AIDS and cancer
Research carried out in Sweden suggests that the hypericin in Hypericum may behave similarly to both the MAOs and Prozac, preventing both the breakdown and absorption of serotonin (this new Swedish research also claims that St. John’s Wort improves the mood of about 75 per cent of individuals who ingest the stuff). A ‘phytotherapeutic monograph’ published in Germany in 1984 based on research funded by the German government claimed that hypericin was in fact a MAO and indicated that the daily therapeutic quantity of hypericin – .2 to 1 mg – was useful for the treatment of ‘psychogenic disturbances, depressive states, anxiety, and nervous excitement’.

Can hypericin also help individuals with AIDS? That possibility is much less certain, compared to the known effect of SJW on depression, but researchers at New York University and the Weizmann Institute of Science in Israel have noted that hypericin does possess strong anti-viral properties, particularly against HIV-1. Hypericin seems to be able to prevent viruses from adhering to – and penetrating into – cells, thus controlling infection. Preliminary reports have indicated that hypericin may work synergistically with another AIDS drug, AZT, and research concerning the full effects of hypericin on HIV-1 is currently underway. To date, however, there have been no clinical studies carried out with humans. Cancer researchers have also been quite interested in hypericin, because there are indications that if large quantities of the chemical are injected into a tumour site, ‘programmed cell death’ may occur (ie. the cancer cells may in effect commit suicide).

The bottom line? St. John’s Wort can help lift the moods of mildly depressed endurance athletes – and many individuals in the population at large. Since SJW has a calming effect, it’s also possible that it may reduce mental fatigue and thus enhance endurance performance.

If you are surprised that SJW works against depression, bear in mind that the plant world is the source of approximately 25 per cent of all prescription drugs, and that many other herbal compounds offer relief for various maladies. Camomile tea can induce sleep, mint tea can calm a jittery stomach, senna leaves can cure constipation, Echinacea is a mild immune-system booster, and extracts of the plant Ephedra can relieve sinus congestion. The fact that St. John’s Wort contains a health-promoting chemical should not be a cause of astonishment.

However, caution is the word when it comes to herbal products. Ephedra, for example, can increase fat metabolism and reduce respiratory congestion, but it has also been linked with nervous-system and cardiovascular disorders, and many other herbal supplements have been linked with a variety of health problems. Before you begin using any herbal product, check out the actual scientific research first, not just the claims made by the people who are attempting to sell you their supplements, and make sure you buy your herbal preparations only from totally reliable suppliers.

Jim Bledsoe

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