Study 7

Hypericum in the treatment of seasonal affective disorders

Martinez, S. Kasper, S. Ruhrmann, and H.4. Möller

SO: J Geriatr Psychiatry Neurol 1994; (supl1) PP 29-33

Definitions

Seasonal affective disorder

Seasonal affective disorder (SAD) represents a subgroup of major depression with a regular occurrence of symptoms in autumn/winter and full remission in spring/summer.

A. There is a regular, time-related connection between the onset of an episode of bipolar disturbance (including nonspecified bipolar disturbances) or a major depression (including nonspecified bipolar disturbances) during a certain 60-day period during 1 year (e.g., regular onset of depression between the beginning of October and the end of November).

B. Complete remission (or a change from depression to mania or hypomania) also occurs during a 60-day period in 1 year (e.g., between mid-February and mid-April).

C. At least three episodes of affective disorder have occurred within the last 3 years that exhibit a seasonally dependent relationship as in (A) and (8); in at least 2 successive years.

D. Seasonally dependent episodes of an affective disorder as described above were more frequent than nonseasonal affective disorders (ratio at least 3 to 1).

Light therapy

Light therapy (LT) has become the standard treatment of this type of depression. Light therapy is generally practiced as follows: the light intensity is measured in lux. A standard intensity of 2500 to 3000 lux has proven valuable. This corresponds approximately to the amount of light registered when looking out of a window on a spring day, and is about five times brighter than normal room lighting. The ultraviolet and infrared rays of the very bright, white light emitted are filtered to protect the patient's eyes. The flicker frequency of the lamps is raised electronically to ensure as few adverse effects as possible. This type of phototherapy is applied for 2 hours. The patient is instructed to maintain a distance of around 90 cm from the light, mounted at eye level, and to look into the lamps once a minute. During the treatment session, the patient can perform any sitting tasks, such as paperwork. The time of day at which light is applied does not appear to be essential, although there are indications that the morning is more beneficial. As a rule, phototherapy must he applied without interruption during the critical season, because premature discontinuation results in remanifestation of symptoms. Apart from this, pharmacotherapy with antidepressants also seems to provide an improvement of SAD symptoms. The aim of this study was to check whether hypericum has any effect on SAD.

Description

Twenty SAD patients (13 women and 7 men) who fulfilled DSM-III-R criteria for major depression with seasonal pattern were randomized in a 4-week treatment study and were given 900 mg of Jarsin 300 (2.7 mg hypericin) per day combined with either bright (3000 lux, n 10) or dim (<300 lux, n 10) light. Light therapy was applied for 2 hours daily. The length of the study was 4 weeks.

The clinical efficacy was evaluated on the basis of the following parameters: Hamilton Depression Scale, 21-item version (HAMD), Supplementary HAMD scale, Hypomania scale (HY), Expectation Scale (ES), Profile of Mood States (POMS), the von Zerssen Self-Rating Scale (Bf-S), von Zerssen´s Depression Scale (D-S), and Visual Analog scales.

Results

• At the onset of treatment, all patients reported that they were extremely tired, and 92% had depressive moods. Anxiety occurred in 81% of the patients, 55% had noticed that they were less active, and 46% had an increased appetite. Similarly, libido was weaker in 46%, and 71% stated that they slept longer.
• The seasonal fluctuations in mood were recorded quantitatively using the Seasonal Pattern Assessment Questionnaire. The 20 patients in our trial felt they were worse in November, December, and January (90% to 95%) and at their best during the months of May, June, July, and August (70% to 100%).
• The sum score of the Hamilton Depression Scale (HAMD) was comparable for both groups (hypericum + bright light and hypericum + dim light) before treatment (Figure 16). During the 4-week treatment period, the group with hypericum + bright light showed a drop in the HAMD sum score of 72% (21.9 to 6.1), and the group with hypericum + dim light a drop in score of 60% (20.6 to 8.2).
• There was a statistically significant effect of treatment in both groups (p = 0.001)
• There was no significant difference in treatment effect between the two groups.
• Analysis of the self-rating scales (POMS; Bf-S; D-S) showed no significant difference between the two groups.
• A significant decrease in symptomatology was recorded for the whole group during the 4 weeks of treatment for all the POMS factors: despondency (p = .0001); fatigue ( p = .0001); desire for action (p =.0001); and bad temper ( p = .0001).
• None of the patients in either treatment group reported any adverse drug reactions.

Researchers' comments

These results, which were gained from a relatively small sample, show that hypericum also has antidepressive actions in SAD patients. This is important insofar as this was the first trial ever to investigate the effectiveness of hypericum in SAD patients.

Nevertheless, the results support the assumption that the antidepressant effect of hypericum might be increased by the additional application of phototherapy. Equally, there were no indications that combined therapy takes effect more quickly. However, since a smaller number of patients were enrolled in this trial, it is conceivable that the absence of a difference is attributable to the small sample size. Thus, in order to provide conclusive answers to this question as well as the question of efficacy, trials on larger subject groups, including a placebo group, are necessary. Still, if these preliminary results are confirmed, namely that hypericum also has antidepressive effects in SAD patients, this would represent an alternative form of treatment to phototherapy, regarded by some patients as too time consuming.

Our comments

• This study seems to confirm the possibility that hypericum has a light sensitizing mechanism, as referred to in the study, "Nocturnal Melatonin and Cortisol Secretions Before and After Subchronic Administration of Hyperforat."