Rhodiola Rosea Therapy of Major Depressive Disorder

We will study the antidepressant action of R. rosea in patients with MDD. Depression affects more than a billion people world wide, and is now recognized as one of the most disabling medical conditions. It accounts for more than 11% of the total disease burden worldwide, and can result in devastating consequences and functional impairment exceeded only by that of cancer and cardiovascular disease. It results in substantial social, occupational, and personal disability and in increased medical co-morbidity and death by suicide. It is considered to be a multi-systemic disorder characterized by neurotransmitter, neuroendocrine, immunologic, and autonomic, and infectious disturbances. Although the development of antidepressant drug therapy has simplified the treatment of MDD, a substantial segment of the world's population remains untreated for economic, cultural, or personal reasons. As a result, many individuals seek CAM for relief of their symptoms. The identification of effective CAM therapies for MDD is of public health relevance. R. rosea belongs to the family Crassulaceae, and has a long history as a folk remedy for enhancing physical and emotional endurance. Its adaptogen, or preventive, properties have also led to its use in treating cancer, infection, depression, and other nervous system disorders. Several animal and human studies suggest that R. rosea may have antidepressant properties. For specific aim #1, we will ask: Is R. rosea a safe and effective short-term therapy (vs. sertraline and placebo) for patients with MDD?" To answer this question, patients meeting DSM IV criteria for mild to moderate MDD will be enrolled in a 12-week, randomized, double-blind, placebo-controlled, parallel group, dose-escalation study of R. rosea extract 340-1,360 mg daily vs. sertraline 50-200 mg daily. The primary outcome measure will be change over time in the 17-item Hamilton Depression Rating score. We hypothesize that R. rosea will have superior efficacy vs. placebo and comparable efficacy vs. sertraline. For specific aim #2, we will ask: Does R. rosea therapy result in a favorable tolerability and quality of life (QOL) profile vs. sertraline and placebo? To answer this question, we will obtain safety and QOL measures across treatment conditions that include: (i) frequency, duration, and severity of adverse events, (ii) frequency of serious adverse events, (iii) frequency of dosage reduction, (iv) frequency of treatment discontinuation, and (v) QOL and sexual performance measures. We hypothesize that R. rosea will have a superior tolerability profile vs. sertraline, and similar tolerability vs. placebo. We further hypothesize that R. rosea will have superior QOL and sexual performance ratings vs. sertraline and placebo. Results from this study will be used to inform future research hypotheses and to estimate the effect size necessary to power a future, large scale study.

• Herbal extract (Dietary supplement), also known as Golden root: 340-1,360 mg daily
• Sertraline (Drug), also known as Zoloft: 50-200 mg daily
• Lactose monohydrate (Other), also known as Milk powder: 1-4 capsules daily

Primary outcomes

• Depressive Symptoms as Measured by the Hamilton Depression Rating Scale (17-items) at Week 8 and Week 12. [12 weeks]: Hamilton Depression Rating Scale (HAM-D) is a validated, clinician-rated instrument for ascertaining the severity of MDD symptoms. The 28-item Hamilton Depression Rating Scale was used to determine the primary outcome of 17-item HAM-D score. The HAM-D will serves as the primary outcome measure. HAM-D17 score ranges from 0 to 68. Higher score indicates more depressed symptom.

Secondary outcomes

• The Clinical Global Impression (CGI) Severity and Change [12 weeks]: A clinician-rated measure of global symptom severity (CGI/S) and symptom change (CGI/C) of MDD. Severity was rated as "Not ill"; "Borderline ill"; "Mild"; "Moderate"; "Moderately severe"; "Severe" and "Extremely severe". Global change was rates as "Very much improved"; "Much improved"; "Minimally improved"; "Unchanged";"Minimally worse";"Much worse" and "Very much worse". Here in severity, we reported the N(%) of subjects who were not ill or borderline ill. In change, we reported N(%) of subjects who were "Very much improved" or "Much imp\[roved".Subjects started the study with mild to moderate MDD (moderate or above rating in the CGI-S). At WK12, the #/% of subjects in each treatment group who were not ill at WK12 (CGI-S) and who had much improved or very much improved at WK12 (CGI-C) was reported.
• Change in Depressive Symptoms as Measured by the Beck Depression Inventory [12 weeks]: All enrolled subjects were analyzed. Mean change in Beck Depression Inventory (BDI) total scores were reported. BDI is a self-reported outcome measuring the severity of depression. A negative # means a reduction in BDI score at the end of treatment compared to baseline which represents an improvement in depression symptoms. BDI total score ranges from 0-63. BDI score of 1-16 represents low level of depression;17-30 represents moderate level of depression; >=31 represents significant level of depression. A reduction in the BDI score represents improvement in the depression symptoms.
• Change in Sexual Function [12 weeks]: This is a patient completed rating of sexual function and satisfaction. It is used to assess current sexual health and changes in sexual health over time measured by the overall sexual satisfaction score. The reported score is the overall degree of sexual satisfaction attained. The score ranges from 0 to 100. Higher score indicates more sexual satisfaction.
• Number of Participants With Suicide Ideation as Determined by the Columbia Suicide Form [12 weeks]: Descriptive analysis of number of subjects in each treatment group who had suicidal ideation at baseline and WK12.
• Number of Participants With Treatment Emergent Side Effects [12 weeks]

Sex: All, ages: 18 Years to 80 Years

Inclusion Criteria:

* Men and women (all races and ethnicity) ≥ 18 years old
* DSM IV Axis I diagnosis of mild to moderate Major Depressive Disorder
* Baseline CGI/S rating of 3 ('mild') or 4 ('moderate')
* Baseline Hamilton Depression Rating score ≥ 10
* Not receiving other antidepressant therapy
* Able to provide signed informed consent

Exclusion Criteria:

* Patients < 18 years old
* Current primary DSM IV Axis I diagnosis other than Major Depressive Disorder
* CGI/S rating of 5 ('marked'), 6 ('severe') or 7 ('very severe')
* Actively suicidal or requiring hospitalization
* Uncontrolled medical condition
* Pregnant or nursing women
* Women of child-bearing potential not using a medically acceptable form of contraception
* Concurrent use of herbal remedies or mineral supplements \[Note: Use of mineral supplements prescribed for medical purposes (e.g., osteoporosis) will not be excluded\]
* Current use of chemotherapy or other medication (e.g., interferon) known to produce fatigue or mood changes
* Known sensitivity to R. rosea or sertraline
* History of non-response to sertraline in the current depressive episode

Participant flow

Outcome results

• Depressive Symptoms as Measured by the Hamilton Depression Rating Scale (17-items) at Week 8 and Week 12. (Primary), Mean, units on a scale: Rhodiola Rosea 8 +/- 5.4; Sertraline 8.3 +/- 4.5; Sugar Pill 8.9 +/- 6.5
• The Clinical Global Impression (CGI) Severity and Change (Secondary), Count of participants, Participants: Rhodiola Rosea 9; Sertraline 6; Sugar Pill 7
• Change in Depressive Symptoms as Measured by the Beck Depression Inventory (Secondary), Mean, scores on a scale: Rhodiola Rosea -14.0 +/- 10.0; Sertraline -13.7 +/- 5.1; Sugar Pill -7.5 +/- 12.2
• Change in Sexual Function (Secondary), Median, scores on a scale: Rhodiola Rosea 48 (10 to 83); Sertraline 36 (5 to 62); Sugar Pill 17 (5 to 31)
• Number of Participants With Suicide Ideation as Determined by the Columbia Suicide Form (Secondary), Count of participants, Participants: Rhodiola Rosea 6; Sertraline 6; Sugar Pill 9
• Number of Participants With Treatment Emergent Side Effects (Secondary), Count of participants, Participants: Rhodiola Rosea 6; Sertraline 12; Sugar Pill 3

Adverse events

Other adverse events by term

Limitations and caveats: Subjects refuse to answer measures such as the RUSH sexual inventory and the CSSR. Therefore, no statistical analysis was performed on these. In addition, suicidal ideation (measured by CSSR) was captured in the AE form during the study peiod.

• Results publication: Mao JJ, Xie SX, Zee J, Soeller I, Li QS, Rockwell K, Amsterdam JD. Rhodiola rosea versus sertraline for major depressive disorder: A randomized placebo-controlled trial. Phytomedicine. 2015 Mar 15;22(3):394-9. doi: 10.1016/j.phymed.2015.01.010. Epub 2015 Feb 23. PMID 25837277

• Jun J. Mao, MD, Principal investigator, University of Pennsylvania

NIH grants: R21AT005230