Remission is important outcome

EDITOR—The authors of either of the two large trials of St John's wort for treating depression published in the BMJ have reported the proportion of patients entering full remission of symptoms after acute treatment. 1 2 This is unfortunate as remission of symptoms rather than response to treatment should be the key outcome objective. Partial remission is a common adverse outcome of depression after short term treatment and carries with it a high risk of relapse and continuing disability.3

There is now emerging evidence that although all antidepressants seem to be similarly efficacious in producing a short term response, there are differences in remission rates, particularly in severely ill patients.4 This shows the importance of reporting categorical as well as continuous outcomes in clinical trials of treatment with antidepressants.

Study design casts doubt on value of St John's wort in treating depression

EDITOR—Although it is impressive to see a study in which hypericum is equivalent to an antidepressant, suggesting efficacy, the design of this study by Woelk et al makes it difficult for us to know the value of St John's wort for the treatment of depression.1

Firstly, imipramine is an outdated antidepressant. The current batch of selective serotonin reuptake inhibitors and atypical antidepressants have far fewer side effects and can be tailored to the specific needs and responses of the patient. Will hypericum be coupled with activating herbs (such as Gingko biloba or Siberian ginseng) or sedating ones (such as kava or valerian root) to achieve the same effect? This study strikes me as an example of statistical interest (yes, hypericum may be at least as effective as imipramine), but it has minimal practical clinical relevance.

Secondly, the study ran for only six weeks. Most studies exploring the efficacy of an antidepressant run for a …