By David S Baldwin; Jon Birtwistle

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There are many other compounds present in H. perforatum extract, including naphtodianthrons, flavenoids, xanthones and bioflavenoids, which probably exert their effects via different mechanisms56. Extracts are standardized to only one component, resulting in heterogeneity between brands; to minimize this, many treatment studies use the LI160 extract. The mode of action of St John’s Wort is poorly understood, but may depend on alterations in neurotransmitter concentrations and receptor density at postsynaptic neurones57.

An emerging amount of literature supports the use of SSRIs in the treatment of children and adolescents with OCD, as well as in adults70. OCD is usually a chronic disorder, waxing and waning in severity over time, and the magnitude of change during acute treatment studies can therefore be rather disappointing. The relative efficacy and tolerability of clomipramine and the SSRIs in the management of patients with OCD has been discussed extensively70. Although there are occasional studies indicating that an SSRI is more efficacious than clomipramine, systematic reviews and meta-analyses have shown that treatment with clomipramine is marginally, but significantly, more effective than treatment with SSRIs71–73.

In addition there must have been adequate trials of a standard drug treatment, and it can be used only as an adjunct to other antidepressant medication. Patients’ eosinophil levels must be closely monitored for signs and symptoms of EMS. The patient and prescriber must be registered with the Optimax Information and Clinical Support (OPTICS) Unit, with progress reported at 3 and 6 months, then 6-monthly. Other potential unwanted effects include sedation, myoclonus and serotonergic syndrome when combined with SSRIs.

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