Experience with St John's Wort (Hypericum perforatum) in children under 12 years with symptoms of depression and psychovegetative disturbances.

The value of an extract of Hypericum perforatum (St John's wort) for children with mild to moderate depressive symptoms was investigated for the first time in a multi-centre post-marketing surveillance study. One hundred and one children under 12 years were treated for a minimum of 4 weeks with an extension to 6 weeks with parental consent and medical practitioner recommendation. the dosage used ranged from 300 to 1800 mg per day. Compliance, tolerability and efficacy were assessed every 2 weeks by physicians and parents. Based on the data available for analysis, the number of physicians rating effectiveness as 'good' or 'excellent' was 72% after 2 weeks, 97% after 4 weeks and 100% after 6 weeks. The ratings by parents were very similar. There was, however, an increasing amount of missing data at each assessment point with the final evaluation including only 76% of the initial sample. Tolerability was good and no adverse events were reported. The results of this study suggest that Hypericum is a potentially safe and effective treatment for children with symptoms of depression.

The quantitative EEG as a screening instrument to identify sedative effects of single doses of plant extracts in comparison with diazepam.

Two multiple crossover studies, each involving 12 adult female subjects, were performed to screen for acute sedative effects of eight different plant extracts (Valeriana off., Lavandula off., Passiflora incarnata, Kava-kava, Melissa off., Eschscholzia californica, Hypericum perforatum and Ginkgo biloba). Both studies were placebo-controlled, and a single dose of 10 mg diazepam was used as an active reference drug. All drugs were administered as a single dose. Prior to administration, as well as 2 h and 3 h after administration the EEG was recorded from two leads (F(z)-C(z) and O(z)-T(6)) under vigilance-controlled and resting conditions, for five minutes each. The extend of tiredness was rated by the subjects on a visual analogue scale. The EEG was digitized and stored for later analysis of the absolute and relative power of seven factorially defined frequency bands. Under diazepam the power in the theta frequency band decreased while it increased in the beta band. In contrast, some plant extracts showed an increase of power in the theta frequency band, but no increase in the beta frequency range. Valerian extract, which was administered in both studies, displayed an increase of power in the delta and theta band and a decrease in the beta band. Self-rated tiredness increased under diazepam and under some of the plant extracts but not with placebo. The results show that sedating effects of plant extracts can be identified by quantitative EEG analysis and by self-assessment instruments.

Efficacy and tolerability of St. John's wort extract LI 160 versus imipramine in patients with severe depressive episodes according to ICD-10.

The special extract of St. John's wort, LI 160, exhibited a superior antidepressant efficacy compared to placebo in several controlled trials. Two further trials demonstrated a similar reduction of depressive symptomatology under LI 160 compared to tricyclics. All these trials were performed in mildly to moderately depressed patients. The present investigation was a randomized, controlled, multicentre, 6-week trial comparing 1800 mg LI 160/die to 150 mg imipramine/die in severely depressed patients according to ICD-10. The main efficacy parameter, a reduction of the total score of the Hamilton Depression Scale, proved both treatment regimens very effective at the end of the 6 week treatment period (mean values 25.3 to 14.5 in the LI 160 group and 26.1 to 13.6 in the imipramine group), but not statistically equivalent within a a-priori defined 25% interval of deviation. The analysis of subgroups with more than a 33% and 50% reduction of the HAMD total score justified the assumption of equivalence within a 25% deviation interval. This view was also supported by the global efficacy ratings from patients and investigators. Regarding adverse events, the nonrejection of the nonequivalence hypothesis denotes a superiority of the herbal antidepressant. These main result indicate that LI 160 might be a treatment alternative to the synthetic tricyclic antidepressant imipramine in the majority of severe forms of depressions. However, more studies of this type must be performed before a stronger recommendation can be made.

The effect of hypericum extract on cardiac conduction as seen in the electrocardiogram compared to that of imipramine.

The electrocardiographic effects of high-dose hypericum extract were compared to the effects of imipramine hydrochloride on ECG recordings in a randomized, double-blind, multicenter treatment study of 209 patients suffering from depression. ECGs were recorded before and after a six-week treatment period with either hypericum extract or imipramine. At the end of the study ECGs of 84 patients treated with hypericum extract and 76 patients treated with imipramine were suitable for an analysis of conduction intervals and pathological findings. In the first ECG analysis comparing high dose hypericum extract with imipramine, a prolongation of the conduction intervals PR, QRS and QTc was found for imipramine. In contrast, a small acceleration of conduction was seen for the high-dose hypericum extract. The comparison of ECGs at the beginning and after six weeks of treatment showed a significant increase in first degree AV-blocks and abnormalities of repolarization under imipramine but a significant reduction of such pathological findings under treatment with hypericum extract. It should be emphasized that this favorable feature of safe cardiac activity was achieved with 1800 mg of hypericum extract. The reduction in pathological ECG features after treatment with hypericum extract may have resulted mainly from the change of medication, probably tricyclics, to hypericum extract. Our results indicate that for the treatment of patients with a pre-existing conductive dysfunction or elderly patients, high-dose hypericum extract is safer with regard to cardiac function than tricyclic antidepressants.

Hypericin and pseudohypericin: pharmacokinetics and effects on photosensitivity in humans.

Extracts of St. John's wort (Hypericum perforatum) are used in treatment of depression. They contain various substances with the naphthodianthrones hypericin and pseudohypericin as characteristic ingredients. These compounds were shown to cause phototoxicity in cell culture and in animals. A placebo-controlled randomized clinical trial with monitoring of hypericin and pseudohypericin plasma concentration was performed to evaluate the increase in dermal photosensitivity in humans after application of high dose hypericum extracts. The study was divided into a single dose and a multiple dose part. In the single dose period, each of 13 volunteers received in a double blind fourfold complete crossover design, either placebo, or 900, 1800 or 3600 mg of a standardized hypericum extract (LI 160) containing zero, 2.81, 5.62 and 11.25 mg of total hypericin (total hypericin is the sum of hypericin and pseudohypericin). Maximum total hypericin plasma concentrations were observed about 4 h after dosage and were 0, 0.028, 0.061 and 0.159 mg/L, respectively. Before and 4 h after drug intake, the subjects were exposed at small areas of their back to increasing doses of solar simulated irradiation (SSI, with combined ultraviolet A, UV-A, and UV-B light) and another part was exposed to selective UV-A light irradiation. Minimal erythema dose was determined 5, 20 and 68 h after irradiation. Comparison of SSI sensitivity without and with hypericum extract did not show and difference and there was no dose-related trend in light sensitivity. Sensitivity to selective UV-A light was increased only after the highest dose from a minimal tanning dose of 10.8 J/ cm2 (mean) after placebo to 8.7 J/cm2 after 3600 mg extract with marginal statistical significance (p = 0.03 by one sided paired t-test). There was no correlation between total hypericin plasma concentrations and photosensitivity. In the multiple dose part, 50 volunteers received 600 mg hypericum extract t.i.d. with a daily dose of 5.6 mg of total hypericin. Comparison of UV light sensitivity before dosing with day 15 of treatment showed a slightly increased SSI sensitivity expressed by decrease of the MED from 0.17 to 0.16 J/cm2 (p = 0.005 by Wilcoxon test), and similarly, sensitivity to UV-A light increased (the mean tanning dose decreased from 9.9 to 7.8 J/cm2, p < 0.0001). This increase in cutaneous light sensitivity could be compensated by reducing irradiation time by 21%. Doses used in this study were higher than typical doses in current commercial preparations. In spite of these high doses in the double blind single dose part, frequency of side effects was equal to placebo medication and UV light sensitivity was not or only marginally increased. The study does not, however, exclude phototoxic reactions with doses above 11.25 mg of total hypericin and plasma levels above 100 micrograms/L. Furthermore, phototoxicity may be different after application of pure hypericin, since some constituents in the plant extract may exhibit protective effects.

Clinical trials with Phyto-Psychopharmacological agents.

Phyto-psychopharmacological agents are extracts of plants with stimulating or calming effects on the central nervous system. Phyto-psycho-pharmacological agents are among the most commonly prescribed herbal medicines in Germany. The efficacy and harmlessness of some of the preparations have been established by high quality clinical trials. Between 1975 and 1992, a total of 34 clinical studies involving some 2326 patients were published on the effects of Ginkgo special extract EGb 761 and LI 1370; to date, 28 clinical trials in 2120 patients have been under-taken with alcoholic extracts of St. John's Wort. The therapeutic efficacy of kava and valerian extracts has been investigated in six and four controlled studies, respectively. In general, a high placebo effect is likely, which is why it is essential to include control groups in these studies. A considerable advantage over synthetic psychopharmacological agents is the low incidence of side effects, which in safety assessment studies is below 3%. The sharp increase in quality standards for clinical trials has meant that only a few preparations have undergone large scale testing programs in accordance with international guidelines. For other phyto-psychopharmacological agents, there is the danger that no further clinical trials will be undertaken due to the excessively high standards now demanded.

Hypericum treatment of mild depressions with somatic symptoms.

In a randomized, placebo-controlled, double-blind study, 39 patients with depression with somatic symptoms were treated with hypericum extract LI 160. The therapy lasted for 4 weeks; the dosage was 300 mg three times daily. At the onset of the study as well as after 2 and 4 weeks, the following criteria were analyzed: HAMD, B-L, CGI, and vegetative symptoms. The results show a significant improvement in the active treatment group at the 5% level as compared to placebo. Seventy percent of the patients treated with LI 160 were free of symptoms after 4 weeks. Typical symptoms of the depression such as lack of activity, tiredness, fatigue, and disturbed sleep, were especially responsive. In no case were any undesirable side effects observed.

Effectiveness and tolerance of the hypericum extract LI 160 in comparison with imipramine: randomized double-blind study with 135 outpatients.

In a double-blind comparative study, 135 depressed patients were treated in 20 centers. Inclusion diagnoses were typical depressions with single episode (296.2), several episodes (296.3), depressive neurosis (300.4), and adjustment disorder with depressed mood (309.0) in accordance with DSM-III-R. The dosage was 3 x 300 mg hypericum extract LI 160 or 3 x 25 mg imipramine daily. The treatment lasted for 6 weeks. Main assessment criteria were the Hamilton Depression Scale (HAMD), the Depression Scale according to von Zerssen (D-S) and the Clinical Global Impressions (CGI). In both treatment groups, a parallel reduction of the Hamilton score from 20.2 to 8.8 (LI 160, n = 67) or from 19.4 to 10.7 (imipramine, n = 68), and the transformed D-S point values from 39.6 to 27.2 (LI 160) and 39.0 to 29.2 (imipramine) were found. The analysis of CGI revealed comparable results in both treatment groups. Clinically relevant changes of the safety parameters were not found. In the LI 160 group fewer and milder side effects were found as compared to imipramine.

Effectiveness and tolerance of the hypericum extract LI 160 compared to maprotiline: a multicenter double-blind study.

A randomized, double-blind study examining the effectiveness and tolerance of a standardized hypericum preparation when compared to maprotiline was performed in a group of 102 patients with depression, in accordance with ICD-10, F 32.1. The study was conducted in the offices of neurology and psychiatry specialists. The patients received, over a period of 4 weeks, either 3 x 300 mg of the hypericum extract or 3 x 25 mg maprotiline pills of identical appearance. Effectiveness was determined using the Hamilton Depression Scale (HAMD), the Depression Scale according to von Zerssen (D-S), and the Clinical Global Impression Scale (CGI). The total score of the HAMD scale dropped during the 4 weeks of therapy in both treatment groups by about 50%. The mean values of the D-S scale and the CGI scale showed similar results, and after 4 weeks of therapy, no significant differences in either treatment group were noticed. The onset of the effects occurred up to the second week of treatment, but were observed earlier with maprotiline than with the hypericum extract. On the other hand, maprotiline treatment resulted in more cases of tiredness, mouth dryness, and heart complaints.

Efficacy of the Hawthorn (Crataegus) preparation LI 132 in 78 patients with chronic congestive heart failure defined as NYHA functional class II.

Seventy-eight male and female patients between the ages of 45 and 73, who were affected by chronic heart failure defined as NYHA functional class II, were treated either with Crataegus extract or with a placebo preparation. The extract LI 132 was administered to the patients in the form of 3 dragées a day (verum preparation) corresponding to a daily dose of 600 mg. Treatment was continued over a period of 8 weeks, with a wash-out phase of one week. The confirmatory parameter used to asses the efficacy of the preparation was the patients' working capacity which was measured using an ergometer bicycle. Before the start of the study, an increase in the patients' working capacity of at least half an exercise step on the ergometer bicycle (12.5 watt) was determined to be clinically relevant. Apart from the compatibility of the preparation, a score system was used to assess the severity level of the typical symptoms. From day 0 to day 56 of the trial, the median values obtained for the working capacity of the patients treated with the verum preparation were found to have increased by 28 watt, while the increase in the working capacity of the placebo patients was as little as 5 watt. The difference was statistically significant (p < 0.001). Apart from that, a significant reduction of the systolic blood pressure, of the heart rate and of the pressure/rate product was observed for the patients treated with the verum preparation, compared to the patients treated with the placebo preparation. Also, the clinical symptoms (score system) were found to have improved significantly. There were no severe side effects observed.

[Ointment treatment of 1st degree hemorrhoids. Comparison of the effectiveness of a phytogenic preparation with two new ointments containing synthetic drugs]. / Salbenbehandlung von Hämorrhoiden ersten Grades. Wirksamkeitsvergleich eines Präparats auf pflanzlicher Grundlage mit zwei nur synthetische Wirkstoffe enthaltenden Salben.

OBJECTIVES: Investigation of the usefulness of a vegetable-based hemorrhoid ointment in comparison with two other ointments containing synthetic substances, one of which additionally contained corticoid. STUDY DESIGN: Treatment of 90 patients with first-degree hemorrhoids in the surgical department of a University Polyclinic, within the framework of a double-blind three-limb study of 21 days duration. Follow-up examinations on the third, seventh, fourteenth and twenty-first day of treatment. TARGET CRITERIA: Four typical symptoms--pruritus, bleeding, burning sensation, sore sensation--graded by both physician and patient. RESULTS: All three ointments proved highly effective. Both during the course of treatment and at the final examination carried out on the 21st day, no major differences were to be found between the three treatment groups. In the case of some of the test parameters, a positive tendency in favor of the herbal ointment was observed.