Janimine

"We have SAM-e," boast the signs in vitamin shops from Portland, Oregon, to Portland, Maine.

Eager for another blockbuster like St. John's wort or melatonin, the supplement industry has, in little more than a year, transformed SAM-e from a drug available by prescription in Europe into the over-the-counter dietary supplement du jour in the U.S.

What's all the hullabaloo about? If you believe its press, SAM-e lifts depression and relieves arthritis fast ... and with fewer side effects than prescription drugs.

And the evidence is certainly promising. But if you want to give SAM-e a shot, you may have to revise your household budget. At up to $20 a day for a therapeutic dose, it doesn't come cheap. What's more, your chances of buying a high-quality product are only 50-50.

SAM-e Says?

SAM-e (pronounced "sammy") is the user-friendly name for S-adenosylmethionine, a biochemical workhorse that's found in every cell of our bodies. SAM-e helps form vital compounds like DNA and the neurotransmitters that relay messages between nerve cells.

Healthy, well-nourished people seem to make all the SAM-e they need from the amino acid methionine, which is found in protein. There's no evidence that taking extra SAM-e does them any good (or harm). But the story may be different for people with depression or arthritis.

Depression

While testing SAM-e as a treatment for schizophrenia in the early 1970s, Italian researchers noted that it seemed to relieve depression in some patients (although it had no effect on schizophrenia).

Since then, at least 14 studies have compared SAM-e with look-alike (but SAM-e-free) placebos or with prescription antidepressants. "Most of these were done in Europe in severely depressed patients because SAM-e was being marketed as a prescription drug for these patients there," says Teodoro Bottiglieri of the Baylor Institute of Metabolic Disease in Dallas.

A 1994 meta-analysis pooled the results of the 13 studies then available into two larger studies, one comparing SAM-e with placebos, the other with antidepressant drugs.(1) The conclusion: SAM-e worked better than the placebos and about as well as the drugs. But lumping the studies together concealed some of their limitations:

* Short-term results. Nine of the 13 studies lasted three weeks or less. "That's too little time to draw solid conclusions," says Jerry Cott, formerly Chief of Adult Psychopharmacology at the National Institute of Mental Health in Rockville, Maryland. However, of the four studies that lasted more than three weeks, three found a benefit.

* Shots vs. pills. Eight of the 13 trials administered the SAM-e by intravenous drip or injection. "That was the popular form of SAM-e in Europe then, because a stable form in tablets became available only during the 1990s," says Bottiglieri. Of the five studies that used pills--the only kind of SAM-e that's available in the U.S.--three found some benefit. But they used 1,600 mg a day--four times the amount recommended on most labels.

In the most recent and ambitious test, SAM-e pills reportedly relieved the symptoms of moderate depression about as well as the prescription antidepressant imipramine (brand names: Tofranil, Janimine). (The study was sponsored by BASF Corporation, a major wholesale supplier of SAM-e, but it hasn't been published yet, so we can't evaluate it.)

What's more, SAM-e seemed to cause fewer side effects than the drug. "That's important," Bottiglieri points out, "because within the first six weeks, 40 percent of people typically will stop taking their antidepressant medication because they feel it's not working or because they can't tolerate the side effects."

The downside: As in the earlier successful studies with pills, researchers used 1,600 mg a day of SAM-e, which could cost up to $20 a day. Would smaller amounts work as well? It's not clear.

"The lowest oral dose tested in depressed patients was 800 mg a day," says Bottiglieri. SAM-e didn't help much, though the study was in severely depressed people. Bottiglieri and New York psychiatrist Richard Brown, who has treated hundreds of patients with SAM-e, wrote Stop Depression Now (Berkeley, 2000), a book about the supplement.

In it, the authors recommend that people "start off with 400 mg a day and then up the dosage if they don't see an effect within two weeks." Yet 400 mg a day hasn't been tested in any controlled study, Bottiglieri admits.

Because of SAM-e's high cost, some researchers believe that it should be tried only as a last resort. "It's so expensive that I think your back really has to be against the wall before you start spending that kind of money," says Jerry Cott. "This is especially true when there are alternatives, like St. John's wort, that may have comparable benefits at a much lower cost."

Osteoarthritis

Since 1985, at least six good studies have tested SAM-e pills in about 300 people with osteoarthritis of the knees, hips, or other joints. In five of the six, SAM-e helped about as well as anti-inflammatory drugs like ibuprofen (Advil), indomethacin (Indocin), or piroxicam (Feldane), and better than a placebo. "SAM-e does seem to offer pain relief," concludes physician William Arnold, chief medical editor of The Arthritis Foundation's Guide to Alternative Therapies.

But four of the successful studies--all done in Italy--used 1,200 mg a day. And the only U.S. study had mixed results. For five days, John Bradley and his colleagues at the Indiana University School of Medicine gave SAM-e intravenously to 40 volunteers with arthritis. For the three weeks afterwards, they used 600 mg a day of SAM-e in pill form.(2)

"Those who were younger and who had milder osteoarthritis experienced significantly greater reduction in overall pain when on the SAM-e than when on the placebo," says Bradley. Those who were older or who had more severe osteoarthritis didn't do any better when taking SAM-e. Bradley's bottom line: "For milder osteoarthritis symptoms, SAM-e may be useful, but it needs more study."

THE BOTTOM LINE

* High doses of SAM-e (1,200 to 1,600 mg a day) may lessen symptoms of osteoarthritis and depression. There isn't enough research to show whether lower doses are as effective.

* SAM-e's side effects--typically nausea or mild stomach upset--are infrequent. Researchers don't have safety studies on people taking large amounts of SAM-e for years, but it has been used as a prescription drug in Europe for two decades with no major side effects reported.

* SAM-e supplements are expensive ... and as many as half of them contain less SAM-e than their labels indicate. Three out of 23 SAM-e brands tested last year contained no SAM-e at all.

SAM-e STRIKES OUT

If a dietary supplement is going to cost as much as $20 a day, consumers have a right to get everything they pay for. Unfortunately, the chances of wasting your money on an inferior brand of SAM-e are about 50-50.

Three organizations have tested a total of 23 different SAM-e products during the past year or so. Eleven brands contained the amounts of SAM-e listed on their labels. Twelve (including the most expensive brand, Nature's Plus) contained less.

Here's a summary of the results from the three tests--carried out for Consumer Reports magazine; the Web site Consumerlab.com; and Pharmavite, the company that makes Nature Made supplements (its test was conducted by an independent laboratory). The list price of a 1,200-mg dose for brands that passed at least two of the tests is in parentheses following each name. (That's the dose used in the arthritis studies. The depression studies used 1,600 mg a day.)

Keep in mind that not all brands were tested in each of the three surveys, and Consumerlab.com doesn't release the names of the brands that fail its tests. So if a brand passed or failed one or two of the three tests, it may also have failed--or not been included in--the Consumerlab.com test. To pass, a brand had to contain at least 90 percent of the SAM-e listed on the label. Here are the brands that:

* Passed all three tests: GNC ($8), Natrol ($10), Nature Made ($6), TwinLab ($7).

* Passed two of the tests: Puritan's Pride ($4), Solgar ($13), Source Naturals ($7), Vitamin Shoppe ($4).

* Passed one of the tests: MotherNature.com, NutraLife, Smart Nutrition.

* Failed one of the tests: Healthy Associates, Jarrow, Life Source, Natural Treasures, Nature's Life, Nature's Rx, Nature's Vision, Olympian Labs, Oregon Health, Whole Foods.

* Failed two of the tests: FoodScience, Nature's Plus.

* Contained less than 10% of the amount listed on the label in at least one test: Oregon Health.

* Contained no SAM-e in at least one test: Healthy Associates, Life Source, Nature's Rx.

See www.consumerlab.com for the details of their analysis. Bear in mind that Consumerlab and Pharmavite tested only one sample of each brand and Consumerlab doesn't release the names of brands that fail its tests. The Consumer Reports results were published in the December 2000 issue.

(1) Acta Neurol. Scand. Suppl. 154: 7, 1994.

(2) J. Rheumatol. 21: 905, 1994.

COPYRIGHT 2001 Center for Science in the Public Interest
COPYRIGHT 2001 Gale Group