Part of my mission as an herbalist and natural health expert is to expand bridges that link not only people and plants, but also clinicians and herbalists. I firmly believe we all must work together to find the balance between modalities to support natural health. In my school, I teach ways to use herbs safely and effectively, ensuring that there is balance and proper methodology alongside common sense.

It’s important to know that herbs are not magic bullets and that while they can be safe and very useful, they can also be harmful when not used correctly. This is the message herbalists have shared to the general public for years: use herbs, and be sure to use them properly.

This is why articles such as one I came across today gall me. This one, titled “The one supplement doctors say may be useless and unsafe for heart health: St. John’s wort” published on the “SheFinds” online site is one of the worst. It’s a misleading headline that promotes fear-based behavior with no facts and fewer benefits.

First, the article’s author is not an herbalist nor a health care practitioner, but she readily skews the content to fit an agenda likely supported by advertisers. She starts with “Many people use supplements to improve their health and address nutritional gaps, but not all supplements are as beneficial as they seem. Sometimes, especially when taken in large doses or without proper guidance, these supplements can cause harmful side effects.” Later she repeats, “Ultimately, while supplements like St. John's wort seem beneficial at first glance, they can pose significant health risks if not used correctly.”

And she quotes a doctor whose name is hyperlinked not to a biography of himself or to a clinic where he practices, but to an online store selling mushroom supplements. The author hyperlinks to another SheFinds article discussing herbs that might cause high blood pressure, and not only does she duplicate her wording in both articles, but she even writes “Yikes!” as if to highlight a great danger.

Folks, this drama is meant as click-bait for internet surfers… not to educate the public on how herbs work. Of course herbs are supposed to be taken in the proper dosages. Of course people aren’t supposed to take too much or use them clinically without proper guidance.

Let’s get some facts straight about herbs in general, and especially about St. John’s wort (Hypericum perforatum). This will be a comprehensive article about St. John’s wort especially geared toward how clinicians can use SJW safely and reliably, and I’ll share a number of contraindications as well as benefits that have been scientifically presented. If you want a basic introduction to St. John’s wort instead, check out this blog.

Modern Scientific Studies of St. John’s Wort

First, herbs are plants that are made up of dozens of potent chemicals and herbalism has long held that they must be used responsibly. Second, centuries of traditional use and modern scientific evaluations prove that herbs can be very beneficial… again, when used responsibly and in the proper context. Third, many current medical journals and studies show that St. John’s wort is effective at addressing mild to moderate depression and it is widely regarded as a strong and effective antidepressant.

Here are some studies, reviews and meta-analyses about St. John’s wort from the past 20 years:

Systematic Review and Meta-Analysis (1996): This comprehensive analysis reviewed 23 randomized trials involving 1,757 outpatients with mild to moderate depression. It found that St. John's wort extracts were significantly more effective than placebo and similarly effective as standard antidepressants, with fewer side effects. BMJ

Double-Blind, Placebo-Controlled Clinical Trial (2008): Conducted in Pakistan, this study evaluated the efficacy of St. John's wort extract in patients with mild to moderate depression. It showed that the extract was more effective than placebo in reducing depressive symptoms, with a comparable safety and tolerability profile. ResearchGate

Comparison with Imipramine (2000): This randomized, multicenter, double-blind trial compared the efficacy and tolerability of St. John's wort extract with imipramine, an antidepressant, in patients with mild to moderate depression. The study showed that St. John's wort was as effective as imipramine in treating depression and also had a better safety profile. BMJ

Systematic Review (2005): Published in The British Journal of Psychiatry, this review analyzed studies on St. John's wort for depression and found that St. John's wort was more effective than placebo and comparable to standard antidepressants in treating mild to moderate depression, with fewer adverse effects. Cambridge University Press

These are among many studies that suggest St. John's wort may be a viable option for individuals with mild to moderate depression, with results comparable to conventional antidepressants and with fewer side effects.

Second, the claim that SJW raises blood pressure is only partially accurate and does not deserve the fear-mongering claimed by that misleading online article. St. John’s wort does not directly raise blood pressure but in certain cases it can have this effect due to its influence on biological pathways (i.e., decreasing the action of blood pressure meds). Specifically, it can reduce the work of antihypertensive drugs by accelerating their breakdown, potentially leading to hypertension. See contraindications below.

And, because individuals react differently to herbs, there are cases where a person experiences restlessness or increased anxiety rather than the opposite, which can elevate blood pressure. But St. John’s wort is not inherently a hypertensive herb.

However, let’s be clear: St. John’s wort is powerful. No one lists it as completely safe. It is well-known to interact with or potentiate (strengthen or alter) the action of quite a number of pharmaceutical medications and is regarded as one of the key potentiators of serotonin syndrome (for details about this condition, enroll in the online course Herbs for the Brain).

Because it is so powerful, St. John’s wort has a long list of contraindications and this is the exact reason herbalists, acupuncturists, nurses, physicians, and therapists MUST educate themselves about the drawbacks as well as the benefits so they can accurately describe this to their patients to co-manage their health. 

St. John’s wort is contraindicated with many pharmaceutical medicines because it alters drug metabolism. It induces (or triggers) certain enzymes and transport proteins in the body that break down pharmaceutical meds and renders them less effective. Specifically, St. John’s wort induces the cytochrome P450 (CYP450) enzyme system and P-glycoprotein (P-gp), both of which process and transport meds throughout the body. In other words, Hypericum stimulates the metabolism of drugs so quickly they either break down or quickly become less effective.

How St. John’s wort Works in the Body

Basically, St. John’s wort leads to the over-metabolizing of other medications and renders them weak.

• CYP450 Enzyme Induction
  John’s wort induces several enzymes, particularly CYP3A4, which is responsible for metabolizing many pharma drugs. By increasing the activity of this enzyme, SJW accelerates the breakdown of drugs and reduces their effectiveness.
• P-glycoprotein Activation
  SJW also induces P-glycoprotein, a transporter protein that pumps pharma drugs out of the cells where they are working and sends them back into the bloodstream or digestive tract. This is not what we want. This will decrease a drug’s absorption and effectiveness.

Common St. John's Wort Drug Interactions

Due to these effects, St. John’s wort can interact with a wide range of medications and is contraindicated for many people on a variety of prescriptions. If your patients or clients are on any of the following, avoid St. John’s wort in your protocols:

•  St. John’s wort will increase the risk of serotonin syndrome when it is combined with selective serotonin reuptake inhibitors (SSRIs) or other antidepressants. This can be a fatal condition. St. John’s wort also reduces the efficacy of tricyclic antidepressants (TCAs) and other drugs by increasing their metabolism.
• Contraceptives. St. John’s wort reduces the effectiveness of hormonal contraceptives, increasing the risk of unplanned pregnancy. Don’t mix St. John’s wort with oral birth control pills, cervical rings, or slow-release implants.
• Blood Thinners. It decreases the effectiveness of anticoagulants like warfarin, increasing the risk of blood clots.
• Immunosuppressants. St. John’s wort reduces blood levels of drugs like cyclosporine, potentially leading to organ rejection in transplant patients.
• Antiretroviral Drugs (HIV Medications). It reduces the effectiveness of HIV medications like protease inhibitors.
• Cancer Medications. Ditto.
• Antiepileptics. Ditto.
• Sedatives. Ditto. This likely includes herbal sedatives.
• Photosensitivity: High doses can cause increased sensitivity to sunlight, leading to skin reactions​.

These are straightforward contraindications that every herbalist and healing arts practitioner should know. But it’s complicated because many clients and patients drink tea that includes St. John’s wort or they take it without realizing how potent it can be, and they don’t share this with their care team.

This is why my Herbs for the Brain course and my Clinician’s Toolkit include Patient Intake templates help you ask the right questions regarding herbs and are targeted for brain and mental health.

So, if St. John’s wort is this potent, why use it? In fact, this herb is widely shown to be incredibly beneficial as long as it is used correctly, i.e., in the right dosage and in people who are not taking any of the medications listed above, or who are not pregnant or breastfeeding. Rather than being scared away from using this valuable botanical medicine, learn to use it properly and with the ideal client, and teach your clients about its importance.

How St. John’s wort Works in the Brain

St. John’s wort is known for its ability to help with mild to moderate depression, ease anxiety, and support overall mental health in a wide range of situations from generalized anxiety disorder to premenstrual syndrome to acute stress. Hundreds of studies around the world demonstrate its efficacy for easing mild to moderate depression. It works in the following ways to protect the brain and improve mental clarity and emotional well-being:

1. Enhances Neurotransmitter Activity. St. John’s wort contains hypericin, hyperforin, and flavonoids. Hyperforin and hypericin decrease the reuptake of key neurotransmitters, including serotonin, dopamine, norepinephrine, and gamma-aminobutyric acid (GABA). Inhibiting reuptake means these neurotransmitters remain active in the brain longer, improving mood and emotional stability. In this way, St. John’s wort appears to act like an SSRI, a selective serotonin reuptake inhibitor, preventing the “reuptake” of the neurotransmitter into the pre-synaptic neuron and allowing it to continue its work and movement across the synapse toward the post-synaptic neuron. Hence, the serotonin does its job.
2. Protects Brain Cells. St. John’s wort’s flavonoids quercetin and rutin have antioxidant properties that can reduce oxidative stress and inflammation in the brain. This helps protect neurons from damage caused by chronic stress or aging, leading to better cognitive health and more mental clarity.
3. Eases Depression and Anxiety. Because of its influence on neurotransmitter, St. John’s wort improves the regulation of mood and reduces overactivation of stress-related pathways. This results in fewer symptoms of depression, such as sadness and fatigue, and helps alleviate anxiety by promoting a sense of calm. (See below regarding cortisol.)
4. Regulates the Stress Response. St. John’s wort influences the hypothalamic-pituitary-adrenal (HPA) axis, the body’s central stress-response system… but probably not in the way you think. Rather than modulating this system, St. John’s wort appears to actually increase cortisol in the body within 30–90 minutes after ingestion of a 600 mg dose. This suggests that the herb may temporarily stimulate the HPA axis, possibly helping the body respond to acute stress, danger, or panic attacks. However, both animal and human studies seeking to answer the question of whether St. John’s wort balances or modulates cortisol levels have been inconclusive.

Ideal Candidate for St. John’s wort Use

Because it’s such a powerful herb, clinicians may rightly be concerned about placing their patients onto a regimen that includes Hypericum perforatum, but using it properly and in the right situations can lead to positive outcomes.

In my experience, the ideal patient is someone who:

• Communicates clearly with the clinician and discloses all herbs he or she takes, and is trustworthy regarding full compliance
• Needs support for mild-to-moderate depression, PMS, PMDD, perimenopause, anxiety, GAD, or panic attacks
• Is of any age, though I discourage use in children younger than about 13 (click here to see my article on teenage anxiety)
• Is not taking antidepressants OR wishes to wean off the pharma meds to exclusively herbal remedies with their health care team’s support
• Is not scheduled for surgery
• Is not taking any of the following:
  • Antidepressants including SSRIs or MAOIs
  • Birth control pills or other contraceptives such as a cervical ring or slow-release estrogen implants
  • Blood thinners/anticoagulants such as warfarin
  • Blood pressure medications
  • Immunosuppressants
  • Antiretroviral drugs (HIV medications)
  • Cancer medications or completing chemotherapy or radiation
  • Antiepileptics or anti-seizure medications
  • Sedative medications or other sedative herbs

When you’re working with this type of ideal client, you can readily integrate St. John’s wort into a safe and effective protocol.

Personal and Professional Observances Using St. John's Wort

I’ve used St. John’s wort personally and with my clients over many years and these are some of my observations:

• SJW eases episodes of panic, grief, anxiety, overstress, and depressive states reliably
• SJW seldom causes side effects that are typical in over-the-counter or prescription medications, such as sleep disturbances, sexual ineptitude, nausea, vomiting, rashes, or bloating. It can, however, cause photosensitivity with sun exposure.
• SJW is best taken as a strong tincture in a menstruum of grain alcohol at a 1:4 or 1:5 solvency ratio
• Homemade remedies, esp. tinctures, tend to be less potent than commercially prepared tinctures. Teas tend to be less effective than tinctures. Capsules of dried powder should be standardized.
• Dosages: 300 mg of standardized extract, containing 0.3% hypericin or 2–5% hyperforin, taken 3 times daily. This totals 900–1,200 mg per day, which is the most commonly studied and effective range for treating mild to moderate depression. Alternatively, some people opt for a single daily dose of 900–1,200 mg for convenience, with the same standardization (0.3% hypericin or 2–5% hyperforin). Alert your clients to the fact that herbs often need more time to become effective, such as 2-6 weeks, so they don’t give up.
• A client can, in many cases, wean themselves off fluoxetine and other antidepressants slowly and with the ongoing support of a health care team, while slowly adding a Hypericum protocol in the last few days of medication.

Herbs to Combine with St. John’s Wort for Brain and Mental Health

I find St. John’s wort supports general emotional relief and is best combined with:

• Passionflower (Passiflora incarnata) especially for mild-to-moderate depression
• Ginkgo (Ginkgo biloba) especially for mild headaches, general brain health
• Roses (Rosa rugosa) especially for grief and chronic sadness
• Lemon balm (Melissa officinalis)
• Oats (Avena sativa)
• Mimosa (Albizia julibrissin)
• Holy basil (Tulsi spp.)
• Hawthorn (Cretagus spp.) especially for high blood pressure
• Linden (Tilia Europa) especially for high blood pressure
• Gotu kola (Centella Asiatica)
• Eleuthero (Eleuthero senticoccus) for fatigue, malaise, loss of ambition
• Turmeric (Curcuma longa) especially for general brain health, depression leading to loss of ambition
• Licorice (Glycyrrhiza glabra) especially for mood swings, PMS, PMDD, and hormonal fluctuations

To recap: Be wary of what you read in online magazines as they are suited to advertisers and have provocative agendas that may be counter to true understanding of scientific subjects. Be open to using herbs in your clinical protocols and make yourself aware of both the pros and cons of a particular herb and its effects.

Develop clinical relationships with clients in which the client feels comfortable openly disclosing all herbs and nutrients taken and recognizes the importance of long-term patient compliance. Educate yourself about brain and mental health processes and keep up-to-date on recent research into herbs. Finally, teach others that using herbs is a serious endeavor for better health and it must be done with due diligence.

To learn more, enroll in the Herbs for the Brain: Nootropic, Herbal and Natural Support for Mental Health certificate course.

Nothing in this article is meant to serve as medical advice. These statements have not been evaluated by the FDA. This information is for educational purposes only and you are encouraged to work with your trusted health care team for health matters. This information is not intended to treat, diagnose, cure or prevent any disease.