Treatments recommended by health shops for symptoms of depression

AIMS AND METHOD We assessed the appropriateness of treatments recommended by health shop staff for symptoms of mild-tomoderate depression using participant observation with ten members of staff from ten different health shops selling herbal medicinal preparations. RESULTS A wide range of treatment options were suggested by health shop staff when presented with common symptoms of depression.Themajority have no firm evidence base, with the exception of St John’s wort (Hypericum perforatum). CLINICAL IMPLICATIONS Most alternative treatments recommended by health shops for the treatment of depression have a poor evidence base. Implications for training and communication between agencies are discussed.

Treatments recommended by health shops for symptoms of depression

AIMS AND METHOD
We assessed the appropriateness of treatments recommended by health shop staff for symptoms of mild-tomoderate depression using participant observation with ten members of staff from ten different health shops selling herbal medicinal preparations.

RESULTS
A wide range of treatment options were suggested by health shop staff when presented with common symptoms of depression.The majority have no firm evidence base, with the exception of St John's wort (Hypericum perforatum).

CLINICAL IMPLICATIONS
Most alternative treatments recommended by health shops for the treatment of depression have a poor evidence base. Implications for training and communication between agencies are discussed.
Patients are becoming increasingly well informed about depression and its treatment, and often seek alternatives to traditional medical approaches. The herbal medicines industry has in recent years fallen under increasing scrutiny with regard to the safety of the many preparations on offer. Self-administration of St John's wort (Hypericum perforatum) for mild-to-moderate depression is a pertinent example. Studies have shown that a significant number of people with a psychiatric disorder turn to complementary and alternative medicine (Knaudt et al, 1999;Unutzer et al, 2000). In 2000 the Chief Medical Officer released an urgent communication to doctors about interactions between St John's wort and certain prescribed medications (Breckenridge, 2000) and in 2004 the European Community issued a directive on the use of traditional herbal medicinal products (European Community, 2004). In view of this we wanted to assess the appropriateness of treatments recommended by health shop staff for symptoms of mild-to-moderate depression.

Method
Members of staff from each of ten health shops offering herbal remedies within a 3-mile radius of Leeds city centre were included in the study. 'Health shop' is defined as a shop dedicated to selling complementary and alternative medicines and not a shop offering holistic therapies such as massage, acupuncture, etc.
Information was gathered using participant observation (by J.E.R.; Spradley, 1980). This ethnographic technique involves direct participation of the researcher (who may or may not reveal their reason for involvement) in the events being studied (Jones, 1995;Savage, 2000).
Members of staff were not aware that they were taking part. Health shop employees were presented with a customer (the researcher J.E.R.) complaining of a standard set of symptoms which commonly occur in mild-tomoderate depressive disorder (Box 1). Five of the shops (in the city centre) were visited by the researcher and the remaining five (within a 3-mile radius of the city centre) were telephoned by the researcher. In all ten interviews the same transcript was used (Box 1).
Health shop employees were then given an opportunity to ask questions to elicit further information about the condition presented. Additional symptoms described included: initial insomnia; weight loss; early morning wakening; not enjoying anything; weepiness; and sadness. The 'customer' had experienced symptoms for 2 months, had no recent life events, had not visited their general practitioner (GP) and was currently taking no over-the-counter preparations. Information given by health shop staff was recorded immediately after leaving Reed & Trigwell Treatments recommended by health shops for depression Box 1. Transcript of information given to health shop staff . 'I was wonderingif youcould give me some advice. I've not used herbal remedies before and was wondering if you could give me some information about things which may help me?' . 'I've not really been feeling myself lately. I've been a bit run down. I'm not sleeping as well as I used to and I'm just tired all the time. I can't be bothered doing anything, and I'm not concentrating very well. I've not really had much of an appetite either. Is there anything you could suggest?' the shop; only the names of the preparations suggested were recorded during the interview.

Questions asked by shop staff
A range of questions were asked by health shop staff, varying from none (n=3) to questions concerning recent stress and life events (n=3) and currently prescribed medication (n=4). Only two employees asked if a GP had been consulted about the symptoms and three specifically asked if there was depression of mood. Additional questions were asked about recent illness, presence of anaemia, duration of the symptoms, age, worsening symptoms in winter and current appetite. One employee explained that she was not medically trained and that it would be wise to see the GP first in order to rule out common causes of fatigue and lack of concentration, such as anaemia. Another employee also mentioned the possibility of anaemia but did not suggest consulting a GP. Staff made no response when the 'customer' explained that she was currently prescribed the oral contraceptive pill, despite evidence that St John's wort can decrease the efficacy of oral contraceptives (Barnes et al, 2001).

Preparations suggested
A list of the preparations recommended and the information given about each is shown in Table 1. Information varied from none to advice about administration and beneficial effects. Twelve different preparations (not including Chinese tea) were suggested; the most popular were multivitamins (n=4) and Bio-Strath tonic (n=4) (Fig. 1). These were recommended for symptoms of tiredness and lack of concentration (Table 1). The employees who directly asked about depression of mood were also those who recommended St John's wort (n=3). The other seven recommended treatments for specific symptoms, for example, low energy, feeling run down, reduced appetite, and poor concentration. In conjunction with this, St John's wort was recommended purely for low mood rather than the biological symptoms of depression described in the interview.
Two out of ten employees stated that the following remedies had no side-effects: ginseng; Gingko biloba; guarana; and B-complex. It was also suggested that these could be taken together with no harmful effects. Importantly, one employee also added that Chinese medicines, for example ginseng, have no interactions with other medications.
Other suggestions A number of suggestions for changes in diet and lifestyle were made (Fig. 2). Three employees stated that a healthy, balanced diet would be beneficial. It was suggested that increased exercise and fluid intake would increase energy and vitality, as would decreased consumption of caffeinated drinks, wheat and dairy produce. Two employees disclosed beneficial personal experience in the discussions.

Discussion
This study has shown that on approaching health shop staff with symptoms of mild-to-moderate depression, the general public are presented with a number of complementary and alternative medicines. Only 1 of the 13 preparations suggested, St John's wort, is supported by an evidence base (Linde et al, 1996(Linde et al, , 2006. There is evidence for a putative role in the treatment of depression for a further two: ginseng (Panax ginseng) (Wiklund et al, 1999) and B-complex vitamins (Bell et al, 1991). Furthermore, staff are unlikely to warn customers about potential interactions and adverse side-effects.
This study raises concerns about the virtually complete separation and independence of complementary and alternative medicine services from the National Health Service and pharmaceutical agencies. Many herbal remedies may have beneficial properties which could be used to great advantage if an adequate evidence base was developed. However, owing to the lack of overlap between the two sectors little is understood about each in either area. A more integrated approach would allow patients to benefit from herbal preparations, such as St John's wort, with optimum safety.
The majority of staff did ask additional questions prior to giving recommendations. This appeared to be in order to rule out a medically treatable physical condition (e.g. anaemia) or to decide upon appropriate preparations. Although the elements of a holistic and safe approach seem to be present, they were not consistently employed throughout all shops.
The choice of preparations offered appeared to be influenced by the amount of additional information elicited by staff. Results suggested that treatments were recommended according to individual symptoms rather than on the basis of a syndromal approach. The specific mood-lifting treatment, St John's wort, was only recommended when depression of mood was suspected. It appeared that the biological symptoms were not considered to be part of the same condition. However, patients rarely present with their own diagnosis; they more often Reed & Trigwell Treatments recommended by health shops for depression original papers Fig. 1 Preparations recommended by health shop staff complain of a collection of typical physical symptoms. It is also worrying that patients who have already been prescribed an antidepressant may seek additional help from herbal remedies (Knaudt et al, 1999;Unutzer et al, 2000) when evidence suggests the possibility of interactions and increased side-effects (Mills et al, 2004), including serotonin syndrome (Johne et al, 1999). It is important that both health shops and medical practitioners are aware of this and make this clear to patients.

Potential influencing factors
The public nature of shops may lead employees to avoid asking personal questions, resulting in the suggestion Reed & Trigwell Treatments recommended by health shops for depression original papers  of less-appropriate remedies for the treatment of depression. Many of the remedies were offered for a general 'boost' or 'pick-me-up' (e.g. multivitamins), but with little evidence base. It is also worth noting that a large proportion of people may purchase the medicine without consulting shop staff.
More information specific to the interactions and side-effects of particular preparations may have been obtained from the product packaging if purchases had been made.
Although our research method precluded the collection of more detailed background information about the participants, participant observation enabled us to experience what members of the public are likely to encounter when searching for treatments for mild-tomoderate depression in health shops.

Conclusions
This study has identified a wide range of treatment options which are suggested by health shop staff when presented with common symptoms of depression. The majority of these, with the exception of St John's wort, have no firm evidence base, and have potentially serious drug interactions. There is a clear need for better communication between patient, medical practitioner and herbal agencies to ensure optimal patient choice, safety and therapeutic benefit in the treatment of depression. It may be possible to address some of these concerns during the training of doctors, allied health professionals and health shop staff.

Declaration of interest
None.
Reed & Trigwell Treatments recommended by health shops for depression original papers