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QUESTION: Why do people choose to self medicate with St John's Wort (SJW) instead of seeking conventional health care for symptoms of depression?
Qualitative design using open ended interviews to elicit information.
A city in southern Georgia, USA.
22 participants (mean age 45 y, 96% women) who were currently taking SJW for depression or had done so within the previous year were recruited through advertisements. 2 participants were excluded because of faulty session recordings.
2 initial open ended questions led participants to reflect on their decision making process, mood, and situation at the time of first use of SJW. Each open ended question was followed by a series of probes used to address specific topics if not already mentioned. Key factual questions about other treatments, seeking primary care physician or pharmacist advice, dosage, side effects, and recommendations to others were subsequently asked. Each session was audio taped. All interviews were transcribed, and quotes were extracted. Quotes were reviewed for each key question for similarities and contextual themes.
4 decision making themes emerged. The first was personal health care issues. Participants reported previous use of alternative remedies and concurrent use of other herbs, vitamins, and other supplements. Alternative medications were seen as appropriate treatments for all problems. Participants believed that herbal methods were purer and safer than prescriptions. There was also a belief in the need for personal control of health.
The second decision making theme to emerge was depressed mood. All SJW users reported a depressed mood and occasionally irritability, cognitive difficulties, social isolation, and hormonal mood changes.
The third theme was perception of seriousness of disease and risks of treatment. The participants reported a self diagnosis of “mild” depression, and they claimed that if depression had been more severe they would have sought medical attention. They also perceived SJW as being safer than prescription drugs and generally perceived prescription drugs as being dangerous.
The fourth decision making theme was accessibility to care. Participants had barriers to and lack of knowledge of traditional healthcare providers, and had an awareness of the ease of use and popularity of SJW.
Only 6 out of 20 participants had discussed taking SJW with their physicians. Most believed that SJW diminished symptoms but did not make them disappear. Half reported no side effects. Others mentioned minor side effects such as reflux and dry mouth.
St John's Wort users reported: a history of exposure to herbal remedies and a belief in their safety; depressed mood; and ease of access to alternative medicines.
Use of natural remedies is becoming increasingly common. Healthcare providers, therefore, must become well informed about their benefits, risks, drug interactions, and side effects. This study shows that clients often do not report use of SJW to their providers because they see them as unconcerned about natural remedies and the treatment of depression. Clinicians can help to change this perception by routinely asking clients about alternative therapies, just as we ask about prescription medications, alcohol, smoking, and illicit drugs.
Evidence suggests that SJW is safe.1 Nevertheless, failure to ask about its use may result in a missed opportunity to detect depression, anxiety, or life stresses in many individuals. Simply asking about use of SJW may open a window into a better understanding of clients, particularly those with less confidence in the healthcare system. It also allows clinicians to become involved in clients' treatment plans and to offer other therapies if needed.
Participants in this study preferred SJW because they made a self diagnosis of “mild” depression which they believed did not require standard therapy. They also believed that, unlike natural remedies, conventional medications were addictive and unsafe. It is the duty of clinicians to supply these individuals with timely information about all therapies without dismissing the role of SJW as a suitable therapy. Rather than threaten individuals' fundamental health beliefs, our goal should be to help them become “informed consumers” of any treatments they might choose, alternative or otherwise.
21 of 22 study participants were women. The authors attribute this to the higher prevalence of depression in women and the time commitment required for participation in the study. It is possible, however, that women are the primary consumers of SJW and other alternative remedies. Further research could illuminate such sex based differences.
Source of funding: Faculty Development in Family Medicine (grant received from Health Resources and Services Administration).
For correspondence: Dr P J Wagner, Department of Family Medicine, Medical College of Georgia, 1120 15th Street, HB-3041, Augusta GA 30912-3500, USA. Fax +1 706 721 7518.
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