Most of the interviewees believe that SJW diminishes symptoms but does not make them disappear. Specific comments about the effectiveness of SJW reflected its reduction of the emotional symptoms that the person described having before taking SJW. The benefits of taking SJW included: maintaining the status quo, increased energy, feeling more normal and more in control, feeling more relaxed, less severe depression, lower sense of pressure, better sleep, less hopelessness, increased ability to focus, and feeling less overwhelmed. Two of the 20 respondents were not sure of the success of the supplement, finding it hard to pinpoint or describe.
Half of the interviewees reported no side effects. Others mentioned minor side effects and specifically expressed the minimal nature of such. These included reflux, jitteriness, insomnia, sleepiness, dry mouth, acne, decreased libido, nausea, change in bowel habits, and headaches. The known side effect of photo sensitivity was not mentioned.
Discussion
In 1993, Eisenberg2 implored physicians to begin asking their patients about alternative treatments, when he reported that 1 in 3 persons use them. Today the incidence of use of alternative treatments is approximately 42%.7 Some physicians believe that unorthodox care is sought only where traditional care has not been successful.9 The successful treatment of depression is difficult to measure because of its few biologic parameters and its reliance of self-report to indicate presence or absence. SJW is therefore a prime example of an alternative medicine that may become widely accepted.
Our study found that a pattern of previous beliefs and openness to alternative treatments sets the stage for use of SJW in the self-treatment of depression. The potential for selecting a nontraditional solution increases when this openness is combined with a distrust of the contemporary medical system and a value in personal control. Perceptions about the remedy itself, its safety and lack of side effects, along with a stigmatized perception of prescription antidepressants, increases the likelihood of use of SJW. Finally, SJW has been effectively presented in the media, and awareness and availability of it are high. There are few barriers against use, it is inexpensive, and a person does not have to risk the embarrassment of self-disclosure to try it. Using the Health Belief Model10 as an explanatory model, we see that perceived decreased seriousness of the disorder, increased perceived benefits, and reduced barriers to use of SJW work together to make it the easy choice for patients having an acute emotional crisis.
Other researchers have found similar themes. Astin11 found that a holistic health orientation, a transforming health experience, anxiety, presence of chronic problems, and membership in a cultural group with positive feelings toward alternative medicine led to its use. In a sample of arthritis patients, use of alternative therapies was related to the belief that the disease was uncurable by conventional or unconventional methods and chronic pain. However, this sample of patients did discuss their use of alternative therapies with their provider.12 Patients with inflammatory bowel disease who used alternative treatments reported more concern about surgical options, a greater feeling that their problem and treatment was out of their control, and increased disease duration.13 Thus, the pattern of use of SJW in our study appears to be consistent with previous research that suggests that alternative medicine use could be predicted from dissatisfaction with the traditional medical care, need for personal control, and a philosophical acceptance of natural health and illness.
Limitations
Participants were required to take time to attend a medical university setting, and such a constraint may have reduced the likelihood of participation by some demographic groups (eg, men). Our methods produced a sample with a female majority. However, rates of depression are higher in women, and women are stereotypically more willing to discuss these personal issues. Our themes may reflect these limitations.
Conclusions
The rising popularity of alternative treatments and SJW suggests that many patients may be choosing this therapy. We found in a local random sample phone survey that 57% of people are aware of and can correctly identify the indication for SJW.14 Further, 7% currently report using SJW. Because of this popularity, family physicians should become familiar with the effectiveness and side effects of SJW, as well as the risks of concurrent use with other medications. Given that most SJW users fail to tell their health care providers about the use of alternative treatments, and because of the potentially serious consequences of misdiagnosis and inappropriate medication of mental illness, it is imperative that family physicians become more effective at eliciting this information from patients. Although some efficacy of SJW has been found in treating “mild” depression,3-6 the subtleties of diagnosis for a potentially life-threatening condition suggest that some herbal therapies should be monitored by licensed health care providers. Understanding the reasons behind a patient’s therapeutic choice may help physicians legitimize and become involved in their treatment and maximize the potential for recovery.