A 30-Year-Old Woman Comes to the Office for Evaluation and Treatment

A 30-year-old woman comes to the office for evaluation and treatment of depression.  The patient says, "I have been feeling down for the past 3 months.  Sometimes I cry for no reason.  My energy is low all day at work.  On weekends, all I want to do is stay in bed, and I make excuses for avoiding my friends and family.  My sleep and appetite are poor, and the only things I eat are unhealthy snacks."  The patient has a demanding job as a restaurant manager and is worried that she has become less productive at work.  She is not interested in dating and says, "Who would want to be with me when I feel so down?"  The patient has no medical problems.  Her medications include combination estrogen-progestin contraceptives.  Physical examination is normal.  On mental status examination, the patient has a depressed mood and sad affect.  She has no suicidal ideation or psychotic features.  She says, "I have heard good things about St. John's wort and wonder if it would help me.  I have read positive reviews for it on the Internet, and my sister takes it and is doing well."  Which of the following would be the most appropriate response to this patient?

A) I am glad your sister is doing well, but you should not trust Internet claims that are not substantiated by research.
B) St. John's wort can be helpful, but I recommend it as an adjunct to a selective serotonin reuptake inhibitor.
C) St. John's wort is effective and much safer now due to product standardization.
D) St. John's wort is safe, but there is little to no evidence for its efficacy.
E) Standardized extracts of St. Johns wort help mild depression but may make your oral contraceptive less effective.