Update and critique of natural remedies as antidepressant treatments.

Natural medications such as St. John's Wort, SAMe, and omega-3 fatty acids eventually may prove to be valuable additions to the psychiatrist's pharmacologic armamentarium, both as monotherapy and as adjunctive therapy for mood disorders. Current research data are compelling, from a standpoint of both efficacy and safety, but before clinicians can recommend these as first-line treatments, more well-designed controlled studies in large patient populations are needed. During the past decade, the National Institutes of Health, the National Institute for Mental Health, and the National Center for Complementary and Alternative Medicine have widened their support for research on the efficacy and safety of alternative treatments, and increasing numbers of academic institutions are undertaking large-scale, multicenter studies on the natural medications reviewed here, as well as others. These studies should help answer some of the yet-unsettled questions about natural medications. Psychiatrists who are considering recommending natural antidepressants to their patients should emphasize that these treatments are relatively unproven and that it remains to be seen whether they would be appropriate or preferable to the conventional psychotropic agents. in the absence of more conclusive data, the best candidates for alternative treatments may be patients for whom a delay in adequate treatment would not be devastating(eg, the mildly symptomatic patient who has a strong interest in natural remedies). Other good candidates may include patients who have been unresponsive to conventional antidepressants or particularly intolerant of side effects; these patients, however, often are the most difficult to treat, and alternative agents seem best suited for the mildly ill. Care should be taken with patients who are taking multiple medications, in view of adverse drug-drug interactions that have emerged with increased use of alternative treatments. Finally, as with all psychotropic agents, natural medications should be used preferably under the supervision of a physician.