Discovered more than 50 years ago and long prescribed by doctors in Europe, SAM-e (Sadenosylmethionine) has received much attention in the United States over the past few years regarding its ability to effectively treat depression and osteoarthritis. SAM-e is not an herb or a supplement. It is a synthetic form of a chemical produced naturally in the body from methionine?an amino acid found in protein-rich food?as well as in adenosine triphosphate?an energy-producing compound found in all the body's cells.
SAM-e is essential to a number of the body's biochemical processes, including maintaining cell membranes and helping to produce and break down serotonin, melatonin, and dopamine. SAM-e also helps the body produce DNA and cartilage.
A 2002 report by the US Department of Health and Human Services (HHS), which reviewed published studies on SAM-e's effects on depression, osteoarthritis, and liver disease, showed that SAM-e is more effective than placebo for relief of symptoms of depression, pain of osteoarthritis, and pruritus in cholestasis of pregnancy and in intrahepatic cholestasis. The HHS report did reveal, however, that the majority of the studies reviewed were flawed. Many enrolled small numbers of patients, and the quality of the studies varied greatly.
"Studies have not been large, and they have been poorly controlled, but SAM-e does seem to have an effect, and it is something worth trying for many patients," said James Dillard, MD, assistant clinical professor at Columbia University College of Physicians and Surgeons and director of Columbia's Rosenthal Center for Complementary and Alternative Medicine.
Small studies have been conducted to determine SAM-e's effectiveness in treating hepatitis and other liver disorders, chronic fatigue syndrome, fibromyalgia, and Alzheimer's disease. Dr. Dillard said, however, that he has not seen enough research to support the claims. The HHS review of literature did not look at the use of SAM-e for those indications.
Despite thin research, for many patients SAM-e is an attractive alternative to traditional therapies that have undesirable side effects. For example, it does not cause the weight gain or sexual dysfunction associated with prescription antidepressants.
Perhaps even more significant, SAMe also appears to work more quickly, often within 1 week. It can take up to several weeks before the effects of standard antidepressants become apparent. SAM-e also is attractive to patients with osteoarthritis, because the product does not pose the risk of stomach bleeding or kidney damage associated with long-term use of nonsteroidal anti-inflammatory drugs.
For patients with arthritis, Dr. Dillard said that SAM-e is his second line of treatment. "I've seen better results with glucosamine and condroitin and omega-3 fish oils, but for people who are allergic to shellfish, or patients who aren't responding to those therapies, SAM-e can be a very useful supplement," he said. "Often, patients with chronic pain can have an element of depression as well, so using SAM-e can give you a little extra bang for the buck, so to speak."
Dr. Dillard added that the data are stronger in favor of the use of SAM-e as an antidepressant. "Since SAM-e is a naturally occurring compound found in every cell in the body, it is reasonable to supplement if your body isn't making enough of it," he said.
Patients with severe depression should be carefully monitored on SAM-e, and patients with bipolar disorder rarely are good candidates for SAMe therapy. "SAM-e in high doses can make bipolar patients manic," said Dr. Dillard. SAM-e also can interact with antidepressants, so experts are divided over whether it is safe for use in combination with pharmaceutical antidepressants.
One study, published in Psychiatry Research, comparing 40 depression patients taking imipramine, found that the half given 400 mg of SAM-e as well as imipramine showed significant improvement over the group given imipramine alone. Other experts believe that combining SAM-e with pharmaceutical antidepressants poses risks.
Although SAM-e is available without a prescription, patients should seek medical advice before trying it. Experts say that SAM-e therapy is far from an exact science.
"We do everything in trials," Dr. Dillard explained. "You never know how someone will respond. Knowing if SAM-e will work is like knowing what will happen with the stock market. We just can't say for sure at this stage."
Dr. Dillard recommends between 400 mg and 600 mg of SAM-e per day. "It's best to break it up into 200-mg doses taken with meals to decrease any side effects," he said. Side effects include nausea, diarrhea, stomach upset, and rashes. "I usually start with 200 mg a day, then push it up to 600 mg if side effects are limited and the patient is experiencing relief," he said.
"Sometimes, you don't know whether the side effects are caused by the SAM-e or something else in the supplement," Dr. Dillard pointed out. "[Using] enteric-coated SAM-e or taking the product with meals seems to reduce side effects."
Most people report a mild boost of energy with SAM-e. Therefore it is best not to take the product late in the day, because SAM-e can cause insomnia in some patients.
SAM-e can be expensive and normally is not covered by insurance. Thus there can be a cost aspect to therapy with this product. "If this stuff works at 600 mg a day, you have to be prepared for the cost, which is not inconsequential," said Dr. Dillard.
There also has been concern that all SAM-e products are not created equal, so it is difficult for consumers to know what they are getting. ConsumerLab.com, which provides consumer information and independent evaluations of health and nutrition products, found that the quality of products with SAM-e has improved in the last few years. Reviews of SAM-e products in the year 2000 had found that nearly half of the products tested contained less of the ingredient than the label claimed.
More recent tests by ConsumerLab.com showed that only 1 in 8 products failed to meet label claims. ConsumerLab.com cautioned consumers, however, that products with high prices do not necessarily mean high quality when it comes to SAM-e.
Dr. Dillard advised that patients should be educated consumers. "This is a very expensive product, so patients have to be careful about what they are purchasing," he said.
Ms. Sax is a freelance writer based in Ridgewood, NJ.
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