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PSYCHIATRY | CASE REPORT

ST.JOHN’S WORT ( PERFORATUM) - INDUCED PSYCHOTIC EPISODE: CASE REPORT

Can Sait Sevindik∗,1 ∗Edremit State Hospital Psychiatry Clinic Balıkesir/TURKEY, ORCID Id 0000-0003-0898-502X.

ABSTRACT Introduction: It is known that St John’s wort is widely used for treating depression symptoms. This report is a presentation of the case induced by this herbal drug. Case report: A 29-year-old male who had a psychotic episode induced by St.John’s wort (). In this case, the patient did not get diagnosed with a mental disorder before but had a positive family history including psychotic depression. Conclusion: It should be noted that there is several potential safety risks with St John’s wort.

KEYWORDS St John’s wort, psychosis, herbal medicine, adverse effect

There have been studies comparing St.John’s wort to a placebo that is found that St John’s wort can significantly re- duce Hamilton Depression Index (HAM-D) scores as compared Introduction to placebo [12,13] and studies comparing it to St John’s wort is a perennial herb that grows wildly. During the like fluoxetine, , or . [14,15,16] In Middle Ages, St john’s wort had popularity, and in the 1800s, most of these studies, it is proved as effective as the drug. it had a use in treating nervous disorders. Today it is widely In the study that looks its side effects mild stomach discom- used for depression in Germany, other parts of Europa and the fort, allergic reactions, tiredness, and restlessness are found. [17] United States. And besides depression, it is used for conditions It might raise if it is combined with SSRI. [18] Triptan like anxiety, insomnia [1], attention deficit disorder [2], seasonal family drugs and interact similarly with St.john’s wort. affective disorder [3], social phobia [4], menopausal symptoms [19] St John’s wort can induce psychosis. [20] [5] and premenstrual syndrome [6] that antidepressants are pre- scribed. Also, it has used for diabetic neuropathy and atopic Case Report: dermatitis. [7] A 29-year old male was admitted to our psychiatric unit due to St.John’s wort is thought to raise levels of his psychotic symptoms. He was single, living with his family like serotonin, and in the brain. [8] and working as private security. When he was working night Also, there are affect on the functioning of GABA, glutamate period his sleeping difficulty started. After loss of interest in and NMDA receptors. [9] The active ingredient of St.John’s daily activities, decrease social activities, loss of appetite and Wort is not well known. It contains (which have anti- loss his ability to feel joy in life began; he started using St Johns inflammatory properties) and hyperforin among other ingredi- wort tea when he found some information on the internet. His ents. There are studies that mainly hyperforin raises the levels of sleep problem and motivation in life got better. However, after neurotransmitters. [10] However, trials are using low hyperforin one month of usage delusions of reference -his first symptom of form that found it effective. [11] More research is necessary to psychosis occurred. His family reported suspiciousness, trou- understand how it works for depression. ble sleeping, drop in job performance and hostility towards the family. He did not get diagnosed with a mental disorder before Copyright © 2020 by the Bulgarian Association of Young Surgeons DOI:10.5455/IJMRCR.St-John-wort-Hypericum-Perforatum but had a positive family history of psychotic depression. After First Received: February 04, 2020 examinations, St.John’s wort was stopped and 10 Accepted: February 13, 2020 mg/day and 25 mg/day was started. However, after Manuscript Associate Editor: Ivan Inkov (BG) 15 days, he was brought again because of unchanging symptoms.

1Can Sait Sevindik, M.D.: Edremit State Hospital Psychiatry Clinic Balıkesir/Turkey, His family reported irregular usage of drugs prescribed. So he Phone: +90(0266) 3731313, e-mail: [email protected] was hospitalized and after haloperidol 10 mg/IM and biperiden

Can Sait Sevindik / International Journal of Medical Reviews and Case Reports (2020) 4(4):114-115 5 mg /IM for three days usage, it was changed to 8. Muller WE, Rossol R. Effects of hypericum extract on the ex- 2 mg/day and 10 mg/day. The patient was dis- pression of serotonin receptors. J Geriatr Psychiatry Neurol. charged after the acute episode disappearance with risperidone 1994;7(suppl 1): S63-S64. 1 mg/day and olanzapine 5 mg/day prescription. The 3-month follow-up of the patient revealed no psychotic symptoms. 9. Butterweck V. Mechanism of action of St John’s wort in depression: what is known? CNS Drugs. 2003;17:539-62.

Discussion 10. Ghattacharya SK, Chakrabareti A, Chatterjee SS. Ac- Our belief about the acute psychotic episode of the patient we tivity profiles of two hyperforin-containing hypericum presented is induced with St.john’s wort. He was not diagnosed extracts in behavioural models. Pharmacopsychiatry. with mental disorders and was not prescribed psychiatric drugs 1998;31(suppl):22-29. before. He has a known genetic predisposition. Similar case 11. Schrader E. Equivalence of St John’s wort extract (Ze reports are defined in the literature. (20,21) Induced episode 117) and fluoxetine: a randomized, controlled study in symptoms did not change even if the patient stopped using St mild-moderate depression. Int Clin Psychopharmacol. Johns wort because of the irregular usage of prescribed drugs. 2000;15:61-68. With effective treatment, no psychiatric symptom was revealed. 12. Uebelhack R, Gruenwald J, Graubaum HJ, Busch R. Efficacy Conclusion and tolerability of Hypericum extract STW 3-VI in patients with moderate depression: a double-blind, randomized, St.John’s wort induced psychosis is known as a rare side-effect. placebo-controlled . Adv Ther. 2004;21:265-75. The increasing use of herbal products emphasises the impor- tance of screening the patient’s herbal product intake while 13. Kasper S, Anghelescu I, Szegedi A, Dienel A, Kieser M. Su- treatment and follow-up. Side effects and drug interactions of perior efficacy of St Johns wort extract WS® 5570 compared herbal products stand out as an area of interest for clinicians. to placebo in patients with major depression: a randomized, double-blind, placebo-controlled, multi-center trial. BMC Conflict of interests Med. 2006 Jun 23. [Epub ahead of print] No any potential conflicts of interest. 14. Gastpar M, Singer A, Zeller K. Comparative efficacy and safety of a once-daily dosage of hypericum extract STW3- Funding VI and citalopram in patients with moderate depression: a double-blind, randomised, multicentre, placebo-controlled Self-funding study. Pharmacopsychiatry. 2006;39:66-75.

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Can Sait Sevindik / International Journal of Medical Reviews and Case Reports (2020) 4(4):114-115