alternatives treatments for depression 2
light and st john’s wort
The universe is full of magical things patiently waiting for our wits to grow sharper.
Eden Phillpotts
This is the second in a series of three articles by James Hawkins on alternative treatments to
drugs and talking therapies for depression. The first article focused on exercise and ‘wake’
therapy. This article explores the value of light and St John’s wort. The third will look at food and
supplements, meditation, acupuncture, bibliotherapy, and the internet.
about the author:
I am a medical doctor, Chinese-trained acupuncturist and accredited cognitive therapist. I also
chair the clinical advisory group for Depression Alliance Scotland, the country’s main consumerled charity for depression sufferers. In 1983 I was one of the initial group of doctors who set up
the BHMA. Currently I work through ‘Good Medicine’ a small Edinburgh-based charity that
focuses on helping people with psychological difficulties. Good Medicine tries to use therapies
(conventional, complementary and self-help) with better research support before, if necessary,
adding in methods that are currently less evidence-based. Good Medicine is also clear that
knowledge evolves but the heart of medicine remains constant in the care and sensitivity with
which it is practised.
summary:
When all depressive subtypes are included, more than 1 in 3 of us is likely to have qualified for a
depression diagnosis by our mid 30’s [1]. All these depression subtypes are associated with
significant suffering as well as disturbance in work and social functioning. This is true too for the
even commoner subthreshold disorders [2, 3]. This article explores the value of light therapies
and St John’s wort for these widespread difficulties.
light:
A major paper entitled “The efficacy of light therapy in the treatment of mood disorders: a review
and meta-analysis of the evidence” was published in the American Journal of Psychiatry in April
2005 [4]. This recent study concluded “ … analysis of randomized, controlled trials suggests that
bright light treatment and dawn simulation for seasonal affective disorder and bright light for
nonseasonal depression are efficacious, with effect sizes equivalent to those in most
antidepressant pharmacotherapy trials.” A Cochrane Collaboration systematic review published
the year before [5] just looked at the value of bright light treatment for nonseasonal depression
and concluded “For patients suffering from non-seasonal depression, bright light therapy offers
modest though promising antidepressive efficacy, especially when administered during the first
week of treatment, in the morning, and as an adjunctive treatment to sleep deprivation
responders.” Mental health professionals are surprisingly unaware of these findings – as too are
many general practitioners and other therapists. Dr Norman Rosenthal, who has probably done
more than anyone to advance the use of light therapy for depression, commented on the 2005
review [6] saying “It is certainly an area in which clinicians need more education … when it comes
to pharmaceutical treatments of depression and other conditions, physicians are constantly being
educated by pharmaceutical representatives and at industry-sponsored dinners and symposia.
But when there is no money to be made, no such opportunities for education arise, and public
agencies would do well to step in and fill the vacuum.”
Rosenthal first described the value of light in the treatment of depression in a paper published
over 20 years ago [7]. The recent American Journal of Psychiatry meta-analysis initially identified
173 papers of potential relevance published up to July 2003 – most were excluded from their
subsequent analysis as they did not meet the systematic review’s strict inclusion criteria. 20
randomized controlled trials were finally studied in detail. 8 of these involved bright light and 5
dawn simulation for seasonal affective disorder (SAD). 3 studies involved bright light for
nonseasonal depression. A further 5 studies looked at the potential value of bright light as an
adjunct to antidepressant pharmacotherapy for nonseasonal depression. This last application of
bright light – as a support for antidepressants – was the only group of studies that the metaanalysis did not conclude showed effectiveness. A whole series of further papers have been
published since 2003, including some new evidence suggesting light might, after all, be of value in
boosting the effects of antidepressants for nonseasonal depression [8].
Increasing our exposure to light tends to improve our mood. This is true for many of us, and
especially so for a subgroup who suffer from subsyndromal or full syndrome seasonal affective
disorder (SAD). Interestingly it seems that most types of depression show some worsening in the
winter [9, 10], so what distinguishes SAD from other depression forms may be more a quantitative
rather than a qualitative difference in response to seasonal change. For example, a group of
Italian researchers noted that bipolar disorder patients exposed to morning sunlight in East-facing
rooms had an average 3.7 days shorter hospital stay than bipolar patients in West-facing rooms
[11]. In fact surveys in the general population suggest that, for women particularly, it is ‘normal’ to
suffer quite considerable worsening of general symptoms in the winter [12]. Thus seasonal
variation seems common for anxiety, irritability and hostility [13]. Panic disorder, as well,
frequently shows seasonal alterations in severity [14] as too may temporomandibular joint
syndrome and myofascial facial pain [15, 16], eating disorders [17], premenstrual syndrome [18,
19] and fatigue [20]. US surgeons have even found that surgery patients staying in rooms on the
sunnier side of their hospital reported less stress, less pain and had 21% lower medication costs
than patients on the less sunny side of the building [21]. No doubt, in the future, the severity of a
number of other disorders will be shown to be sensitive to the quantity of available light. For
those who do notice that they tend to feel worse in winter, it makes good sense to explore
whether getting more light would be helpful. Even healthy people suffering from no obvious
disorder may find their energy is boosted by increasing their light exposure [22].
Bright light therapy has traditionally been used for seasonal affective disorder (SAD), a form of
depression that develops in the autumn and remits in the spring. SAD typically also involves
increased fatigue and sleep, increased appetite and weight, and decreased social activity. It has
been estimated that approximately 5% of the UK population suffer from SAD [23-25]. Probably at
least twice as many people suffer from milder subsyndromal SAD [26]. It has been argued that
SAD is a sort of attenuated hibernation response that had evolutionary advantage particularly for
women. The winter depression and associated springtime activation made it more likely that such
women would become pregnant in the summer and give birth the next spring thus giving their
babies a higher chance of survival [27]. Whatever the true explanation, increasing our exposure
to sunlight is an obvious way to improve symptoms in SAD and other light-sensitive disorders.
This can be achieved by encouraging sufferers to get out into daylight more – often this is usefully
combined with physical exercise. For those who can afford it, a winter holiday to somewhere with
good sunlight can also be a welcome boost. More extremely, some people will move house to a
latitude less far from the equator. In this latter case, it is worth knowing that there are also
seasonal disorders of too much heat characterised by symptoms like poor sleep, loss of appetite
and fatigue. In fact it may be that, in worldwide terms, summer seasonal disorders produce even
more difficulties than winter seasonal disorders [28].
Most research however has concentrated on ways of increasing light exposure by artificial means.
Bright light boxes and dawn simulation lights (light alarms) are the two ways of doing this that
have a good evidence base. Portable light visors have also been tried, but current visor models
may act more by a non-specific placebo effect than by the effects of light itself [29-31]. As is so
often the case in medicine generally, at times the placebo effect makes interpretation of studies
on light therapy more complicated to interpret. For bright light boxes, Golden et al in their metaanalysis [4] only included studies that provided a minimum of 4 days of at least 3,000 lux hours
(e.g. 1,500 lux for 2 hours or 3,000 lux for 1 hour). A ‘lux’ is a widely used unit of illumination
intensity. There are many useful websites providing good advice on how to use light boxes.
See for example the British Seasonal Affective Disorder Association (SADA) – www.sada.org.uk ,
the Society for Light Treatment & Biological Rhythms (SLTBR) – www.sltbr.org , Dr Lam’s site at
the University of British Columbia – www.psychiatry.ubc.ca/mood/sad , Dr Kripke’s site –
www.dankripke.org , and the fine Canadian Consensus Guidelines –
www.psychdirect.com/depression/d-treatmentguidelinesSAD.htm . The Canadian Guidelines,
published in 1999, give good research-based advice on how best to use bright light therapy. Key
points they make include:
 The fluorescent light box, with light intensities of greater than 2,500 lux, is the preferred device
for light therapy.
 Some patients may respond to other light devices, such as head mounted units and dawn
simulators.
 The starting “dose” for light therapy using a fluorescent light box is l0,000 lux for 30 minutes
per day. Alternatively, light boxes emitting 2,500 lux require two hours of exposure per day.
 Correct positioning is important (e.g. sitting close enough to the light box) to obtain the correct
illumination.
 Light boxes should use white, fluorescent light with the ultraviolet wavelengths filtered out.
 Light therapy should be started in the early morning, upon awakening, to maximize treatment
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response, but exposure at other times of the day may be helpful for some patients.
Response to light therapy often occurs within one week, but some patients require two to four
weeks to show a response.
Patients can be encouraged to become active participants in establishing an optimal light
protocol. Common side effects of light therapy include headache, eyestrain, nausea and
agitation, but these effects are generally mild and transient, or resolve with reducing the dose
of light.
There are no absolute contraindictions to light therapy and no evidence that light therapy is
associated with ocular or retinal damage.
Patients with ocular risk factors should have a baseline ophthalmologic consultation prior to
starting light therapy, and periodic monitoring. Risk factors for retinal toxicity to bright light
exposure are: pre-existing retinal or eye disease (e.g., retinal detachments, retinitis
pigmentosa, glaucoma); systemic illnesses that affect the retina (e.g., diabetes mellitus);
previous cataract surgery and lens removal; older age, because of greater risk of age-related
degeneration; and taking medications that have photosensitizing effects in humans e.g.
lithium, phenothiazines such as thioridazine (antipsychotics, antiemetics), chloroquine
(antimalarial), hematoporphyrins (used in photodynamic therapy for cancer), 8methoxypsoralens (used in ultraviolet treatment for psoriasis), melatonin, and hypericum (St.
John’s Wort).
It is sensible to also add a caution about the possible risk of light-induced mania. Probably all
treatments for depression occasionally cause a switch from depression to mania in vulnerable
individuals. Especially if someone has any history of mania or hypomania, they should use light
therapy very cautiously and consider possible pre-treatment with a mood stabilizing agent if they
are not already taking such medication. Fascinatingly ‘dark therapy’ – staying in a darkened room
away from all light – seems to have some value in the treatment of mania [32].
For further detailed information about diagnosis, assessment, prevalence, possible use of
standard antidepressants and other details, the Canadian guidelines site is well worth visiting (see
address given above). Dr Lam’s University of British Columbia site (see above) is also hugely
useful with a free 45 page health professional download that contains handouts and
questionnaires that are formatted to be easily printed. Also of considerable interest is the freely
downloadable 35 page PDF from Dr Kripke’s site. If you decide you want to explore the use of
light further, there are numerous manufacturers of light boxes and light alarms. Unfortunately
these devices are not usually available on the NHS and have to be bought from specialist
retailers. Typically light boxes can be bought free of VAT and prices range from approximately
£100 to £300. The more expensive units usually provide more intense light allowing shorter
duration treatments and the convenience of not having to sit so close to the light box. Light
alarms are cheaper, ranging from about £60 to £100. Besides the price differential, light alarms
do not take time out of your day as the treatment occurs while you are waking up. Alarms are
also very unlikely to interact with photosensitizing medications like St John’s Wort and so are
safer if you are taking such substances. However there is less research on light alarms than light
boxes so, even if a light alarm fails to help, it is well worth trying a light box as well. Since the two
forms of therapy probably act by different mechanisms, it may be that their benefits are additive. I
know of no research that has tested this possibility so far. Several companies offer a home trial
or hire scheme and the British Seasonal Affective Disorder Association (SADA) also has a
number of boxes for short-term hire. An internet search will bring up a number of suppliers. In
alphabetical order, examples include:
National Light Hire Company - www.sad-lighthire.co.uk/index.html - free phone 0800 074 1105.
Outside In - www.outsidein.co.uk/index.htm - phone 01954 780500.
The S.A.D. Lightbox Company - www.sad.uk.com/home.php - phone 01494 484852.
St John’s Wort & other herbs:
This section of the article will almost entirely be devoted to St John’s Wort. This is because there
is so little good research supporting the value of other herbs in the treatment of depression.
There is some work, for example on crocus [33, 34], but it is very limited and there currently
seems no good evidence-based reason to recommend any other herbal preparation besides St
John’s Wort for depression treatment. In contrast, the literature on St John’s Wort is confusing,
not because of lack, but because of its quantity and its mixed conclusions. The most recent
major Cochrane review of St John’s Wort’s effectiveness in treating depression[35] was updated
in February 2005. It covers 37 rigorously selected randomized controlled trials - 26 include
comparisons with placebo and 14 include comparisons with standard synthetic antidepressants.
There were half a dozen earlier systematic reviews published between 1995 and 2000 [35]. In
general these reviews painted a rather positive picture of St John’s Wort suggesting it was more
effective than placebo, as effective as synthetic antidepressants (at least for mild to moderate
depression), and better tolerated than synthetic antidepressants in the treatment of adult
depression. A recent systematic review of large-scale observational studies also suggests
worthwhile benefit and few side effects from St John’s Wort treatment of mild to moderate
depressive disorder [36]. The National Institute for Clinical Excellence (NICE) guideline on
depression treatment – see www.nice.org.uk – was published at the end of 2004 based on
literature searches that were updated over most of 2003. This guideline included a systematic
review of St John’s Wort research and recommendations about its use that are discussed further
below. The Cochrane review is slightly more recent than the NICE guideline as it covers research
published up till April/May of 2004. Since then several other interesting studies have come out
[37-40] including a further systematic review [41].
The Cochrane review acknowledged several major criticisms of St John’s Wort’s value in more
recently published research – both suggesting that, with some forms of depression, it might be no
more effective than placebo [42-44] and that it’s interactions with other widely used standard
medications could be a very real source of harm [45-47]. However, when all good research
results were combined, the review concluded that overall St John’s Wort appears as effective as
standard antidepressants and is associated with lower drop out rates due to adverse effects. In a
similar vein, the NICE guideline found very little difference between the effectiveness of St John’s
Wort and standard antidepressants. In fact the NICE review concluded (p.230) that “In moderate
depression there is some evidence suggesting that there is a clinically significant difference
favouring St John’s Wort over antidepressants on achieving the likelihood of a 50% reduction in
depression symptoms ... “, and even the NICE review’s proposition that standard antidepressants
may sometimes be more effective than St John’s Wort for severe depression is highly qualified as
it makes this statement in relation to low dose (not standard or high dose) tricyclics (not SSRI’s) –
an observation which is largely irrelevant to standard medical treatment of depression.
The 2004 NICE guideline “Depression: management of depression in primary and secondary
care” is probably the key source of evidence-based advice on how UK doctors should currently
treat depression. The guideline’s comments on St John’s Wort are challenging and to some
extent puzzling. In their clinical summary (p. 231) the herb is acknowledged to be “... more
effective than placebo on achieving response in both moderate and severe depression ... “.
Further commendation comes with the conclusion that “There appears to be no difference
between St John’s Wort and other antidepressants, other than in moderate depression where it is
better at achieving response ... “ and the encouraging finding that “... St John’s Wort appears as
acceptable as placebo, and more acceptable than antidepressants, particularly TCA’s, with fewer
people leaving treatment early due to side-effects and reporting adverse events.” One might
understandably conclude that St John’s Wort is now going to be recommended over synthetic
antidepressants as the preferred first line treatment for depression. Far from it – the guideline (p.
234) states “... healthcare professionals should not prescribe or advise its use by patients
because of uncertainty about appropriate doses, variation in the nature of preparations and
potential serious interactions with other drugs ... “. At least they have the honesty to acknowledge
this recommendation as only level “C” – just supported by “level IV” evidence – the lowest
evidence grade cited by the guideline (p.46). Level IV evidence is based on “... expert committee
reports or opinions and/or clinical experiences of respected authorities.” In other words there is
no level I evidence (randomized controlled trials or meta-analyses), level II evidence (well
conducted non-randomized trials), or even level III evidence (well designed descriptive work such
as comparative, correlation and case studies) to back up the guideline’s recommendations on St
John’s Wort. St John’s Wort is a newcomer on the block as far as the medical establishment is
concerned. To be blunt, doctors have been wined and dined by the drug industry for far too long.
We know from level I evidence (p.179 of the guideline) that “Most studies of the effects of drugs
are sponsored by the drug industry, and these have been shown to be more than 4 times as likely
to demonstrate positive effects of the sponsor’s drug as independent studies.[48]” There has
been a blizzard of further solid reports and research studies showing that bias is a huge problem
in the drug literature [49-53]. Level I evidence meta-analysis even throws serious doubts on just
how effective synthetic antidepressants really are [54]. If the medical establishment is going to
make an evidence-based statement that keeps the outsider St John’s Wort from ‘joining the
party’, it seems to me that we need better data for taking that recommendation particularly
seriously than level IV “opinions and/or clinical experiences of respected authorities.” As has
frequently been noted “The plural of anecdote is not data”.
To give the NICE guideline its due, it notes (p.8) that “Guidelines are not a substitute for
professional knowledge and clinical judgement”. So when might one consider using St John’s
Wort for depression? I can see several possible reasons why an informed practitioner or
depression-sufferer might well think seriously about this option. These include:
 Negative attitudes to synthetic antidepressants. A large scale survey [55] of general public
attitudes to depression in the UK published in 1996 found that 85% “believed counselling to be
effective but were against antidepressants” with 78% “regarding antidepressants as addictive.”
More recent publicity on the increased suicidal thoughts many people may face early in
treatment, problems with side-effects during treatment, and difficulties when trying to come off
these medications, combines with the stigma many people feel taking these drugs to produce
very understandable problems with acceptance and compliance. This may well mean that
many depression-sufferers who would benefit from treatment, are not prepared to accept the
offer of a synthetic antidepressant. Clinical experience suggests that quite a high proportion of
these people would be prepared to try St John’s Wort. It would be fascinating to check this
impression in a clinical trial.
 A preferable side-effect profile. Meta-analysis has repeatedly shown that St John’s Wort is
better tolerated than synthetic antidepressants. Besides the probems already mentioned,
synthetic antidepressants are often plagued by their aggravation of sexual difficulties [56, 57]
weight gain [58], nausea, diarrhoea, headache and other problematic effects including, of
course, the danger of fatal overdose [59]. The most commonly reported side-effects with St
John’s Wort are gastrointestinal symptoms such as nausea, dermatological symptoms such as
itching and increased light sensitivity, and occasionally fatigue, sleep disorders, and
headache. It is well worth noting though that, in randomized controlled trials, St John’s Wort
only produces side-effect rates that are similar to those produced by inactive placebos [45].
 Increased effectiveness with certain types of depression. Much more research is needed
here, but there is preliminary data suggesting St John’s Wort may be a good treatment choice
with atypical symptoms such as increased appetite and increased sleep [39], where there are
multiple unexplained physical (somatoform) symptoms [40], in juvenile depression [60], and in
agitated depression [61].
Key issues to note if someone is taking or considering taking St John’s Wort are the potential for
drug (and light) interactions, the variability of different types of St John’s Wort, and the obvious
need to review treatment if, after about four weeks, there is inadequate treatment response. Drug
interactions are common with many medications. For example the NICE guideline notes (p.199)
that the SSRI’s “Fluvoxamine, fluoxetine and paroxetine are potent inhibitors of various hepatic
cytochrome metabolising enzymes precipitating many significant drug interactions.” In this kind of
situation care, but not a blanket veto on use, is needed. To quote a recent authoritative
systematic review of adverse effects due to St John’s Wort [45] “A wide range of drug interactions
has been described in the recent past [46], but the clinical relevance of these interactions is not
clear, as many of these interactions as actual side effects in patients have not been observed or
reported. The lowering of plasma cyclosporine concentration in transplant patients is obviously of
great importance ... Hypericum extracts should also not be used in HIV-infected patients receiving
antiretroviral treatment. In patients receiving anticoagulants of the coumarin type, the use of
hypericum is only acceptable if coagulation parameters are regularly monitored. Simultaneous
use of hypericum extracts and other antidepressants, particularly SSRI’s, is inadequate and can
be harmful. The question whether hypericum extracts interact with oral contraceptives is of major
relevance but has been difficult to answer up to now. A recent randomized trial [62] in a limited
number of healthy females taking low-dose oral contraceptives found no evidence of ovulation in
subjects taking a hypericum extract, but intracyclic bleeding episodes increased. Patients should
be informed that an interaction cannot be ruled out with certainty. Finally hypericum extracts
should be avoided in patients with a known allergy or hypersensitivity to such products.” The
March 2005 edition of the British National Formulary[63] (BNF) gives a longer list of possible
problematic interactions between St John’s Wort and other medications, including some
antiepileptics, digoxin, simvastatin, theophylline, and other drugs. Generally what happens is that
St John’s Wort lowers blood levels of these agents. It is therefore important, if you are
considering taking St John’s Wort with any other medication, that you check on the safety of the
combination. Strength of interaction is likely also to vary with the brand of St John’s Wort [64]. It
is well worth noting though that the list of cautions for St John’s Wort is considerably shorter than
the list of possible drug interactions given by the BNF for SSRI antidepressants, for tricyclic
antidepressants or even for antihistamines.
The sensible and very informed Knuppel and Linde review went on to report research showing
that available St John’s Wort preparations can vary considerably in quality and even batch to
batch composition [65-67]. The authors suggest that ideally one should use products that have
been tested in clinical trials – the most widely researched is the Kira brand produced by Jarsin
and quite easily available in the UK. They go on to suggest that one should avoid products that
do not give important content information such as the amount of total extract, the extraction fluid,
and the raw material to extract ratio. One economic option would be for an individual to start with
the relatively expensive Kira brand and, if there is an adequate response, then later see whether
a reputable but cheaper alternative product is as effective. I will leave the final coment on St
John’s Wort to Klaus Linde whose meta-analysis[35] has been so helpful in clarifying the value of
this herb: “In conclusion, the available evidence suggests that hypericum extracts are well
tolerated and safe if taken under the control of a physician who is aware of potential risks in
specific circumstances. Self-medication might be acceptable in patients who have very mild
depressive symptoms and who are not taking any other medication.”[45]
conclusion:
This article began by emphasising how very common depression is. The potential values of light
and St John’s Wort were then described in some detail. Both interventions have much to
recommend them and are well worth considering as alternatives or complements to more widely
used therapies.
a note for depression sufferers:
Information in this article is not a substitute for seeking expert help. If you feel you may be
depressed, please see your family doctor or other qualified health professional. You can always
show them this article and discuss these treatments with them.
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