While SJW and SAM-e products appear to be
safe and at least as well-tolerated as conventional
antidepressants such as the SSRIs,154 it has become
increasingly clear that herbal or “natural” does not
always mean safer.155 Questionable adherence to
good manufacturing processes and quality control
measures in the supplement industry has led to
undisclosed product adulterations and to preparations
that can vary substantially in content from
batch to batch, potentially putting consumers at
risk.149 While recent legislative actions are clearly a
step in the right direction, as long as manufacturers
of these products are not required to prove that
their products are relatively effective, consumer
safety will continue to be impacted.156
Consumers have a right to know which dietary
supplement products may provide real health
benefits, which may be associated with side effects,
and which may be essentially nothing more than
placebos. !ey will often turn to the internet to
seek information related to dietary supplements;
however, studies have shown that the quality of
the content on internet sites and in the media
about herbal products is generally poor.157,158 A
sizable portion of the dietary supplements purchased
in the United States are sold in pharmacies.
Pharmacists therefore, given their training in
pharmacology, therapeutics, and drug interactions
are well-suited to serve as a primary point of
contact for consumers searching for reliable
information regarding these products. Pharmacists
can also play a needed role as the first line of
defense against the indiscriminate use of these
products. Relying on product labeling will not be
particularly helpful, however, as studies have
shown that the vast majority of dietary supplement
labeling fails to adequately address key
clinically relevant issues.159 To best assist consumers
regarding these products, pharmacists, physician
prescribers, psychologists, and other health
professionals should have an adequate understanding
of relevant pharmacology and be reasonably
familiar with the key evidenced-based findings
from the clinical literature. !is can present a
challenge, given the relatively scarce reliable
literature and often inconclusive findings published
for many of these products. Clinicians also
need to be aware that consumers who inquire
about natural antidepressant products are likely to
already be taking one or more alternative products,
even though this may not be reflected in their
chart/profile. !ese patients therefore might be at
a greater risk for adverse drug-nutrient/herb
interactions. Useful strategies for approaching
patient consultations regarding the use of alternative/herbal
therapies have been proposed.160
It is important that these two products, as well
as other potentially useful alternative agents for
mood disorders such as omega-3 fatty acids,
continue to undergo rigorous, well-controlled trials.
Further data from randomized, double-blind,
placebo-controlled (and ideally also active-controlled),
well-powered clinical trials would clearly
be most useful.