BACKGROUND: The number of visits to alternative medicine practitioners in this country is estimated at 425 million, which is more than the number of visits to allopathic primary care physicians in 1990. Patients’ use of St. John’s Wort (SJW) has followed this sweeping trend. The purpose of our study was to examine the reasons people choose to self-medicate with SJW instead of seeking care from a conventional health care provider.
METHODS: We used open-ended interviews with key questions to elicit information. Twenty-two current users of SJW (21 women; 20 white; mean age = 45 years) in a Southern city participated. All interviews were transcribed, and descriptive participant quotes were extracted by a research assistant. Quotes were reviewed for each key question for similarities and contextual themes.
RESULTS: Four dominant decision-making themes were consistently noted. These were: (1) Personal Health Care Values: subjects had a history of alternative medicine use and a belief in the need for personal control of health; (2) Mood: all SJW users reported a depressed mood and occasionally irritability, cognitive difficulties, social isolation, and hormonal mood changes; (3) Perceptions of Seriousness of Disease and Risks of Treatment: SJW users reported the self-diagnosis of “minor” depression, high risks of prescription drugs, and a perception of safety with herbal remedies; and (4) Accessibility Issues: subjects had barriers to and lack of knowledge of traditional health care providers and awareness of the ease of use and popularity of SJW. Also of note was the fact that some SJW users did not inform their primary care providers that they were taking the herb (6 of 22). Users reported moderate effectiveness and few side effects of SJW.
CONCLUSIONS: SJW users report depression, ease of access to alternative medicines, and a history of exposure to and belief in the safety of herbal remedies. Users saw little benefit to providing information about SJW to primary care physicians.
In the recent replication of his 1990 survey of trends in the use of alternative medicine, Eisenberg1,2 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.