WHAT TYPES OF DEPRESSIONS RESPOND BEST TO ST JOHN’S WORT?
St John’s wort should be considered as a first-line treatment for:
mild depression
short-term stress associated with depression and anxiety
moderate depression
depression in those who are very sensitive to, or concerned about, side-effects
winter depression (seasonal affective disorder or SAD)
depression in the elderly
dysthymia (chronic low-grade unhappiness)
St John’s wort should be considered, but probably not as a first-line treatment, for:
depression in children and adolescents
severe depression
St John’s wort should not be considered for:
depression in pregnancy
As I discussed in the chapter on research on St John’s Wort, the beneficial effects of the herb have been most convincingly demonstrated for mild and moderate depressions. There is one study in which it was used in more severely depressed individuals and proved as effective as a standard anti-depressant, imipramine. More research will be needed, however, before the herbal remedy can be recommended for more severe depressions.
A severely depressed man presented to me recently. He had legal actions pending against him and was in danger of being put in gaol. His business was in disarray and he was struggling to manage his day-to-day affairs. His desk was covered in papers that he was unable to muster the will or concentration to deal with. He could hardly sleep at all and it was an effort to fight his way through his exhaustion and get through each day. Yet it was critical that he be as functional as possible in order to co-operate with his solicitor in reaching the best possible deal with his creditors and the prosecutor’s office. He also needed to be alert and active in keeping his business afloat and avoiding bankruptcy if at all possible. He needed my help urgently. Given the seriousness of my patient’s depression, he was not someone in whom I wanted to try something that had not been fully researched for severe depression. I therefore chose a more established anti-depressant, nortriptyline, to which my patient responded well within a few weeks. Nortriptyline is one of a family of potent older antidepressants, which may have a number of undesirable side-effects, such as dry mouth, constipation and blurred vision. These side-effects seemed like reasonable trade-offs given the seriousness of this patient’s predicament. If the situation had been less urgent, however, I would have been more inclined to St John’s Wort with its much lower likelihood to produce unpleasant side-effects.
As more research studies are performed on the use of St John’s Wort for serious depression, clinical reasoning might change and the herbal anti-depressant might emerge as a first-line treatment even for severe depressions. In my experience, severely depressed people often end up on more than one anti-depressant, and there is no reason why St John’s Wort should not be used as one of a combination of anti-depressants if more than one is required.
There is at least one study suggesting that St John’s Wort might be useful in the treatment of SAD. Patients with SAD also benefit from light therapy and these treatments can be used together to good effect. St John’s Wort should also be considered as a prime anti-depressant candidate for treating depression in the elderly because of its mild side-effect profile. Depression in the elderly is becoming a particularly pervasive problem, given our ageing population.
It is only relatively recently that clinicians and the public at large have become aware of how common depression is in children and adolescents. There has been a rapid increase in the prescription of anti-depressants for young patients in recent years. Because there have not as yet been any studies on the use of St John’s Wort in young people, the herbal remedy should not be considered as a first-line treatment for these individuals. Nevertheless, I know of some cases where the herb has been used effectively in adolescents and have described one such case in an earlier chapter. In depressed children and adolescents, St John’s Wort should be regarded as a second-line treatment, to be used if conventional anti-depressants prove unsuitable for any reason.
Treating pregnant women with medications is something always undertaken with hesitancy and only after very careful deliberation, given the possibility that any medication may affect the growth and development of the baby. Yet some pregnant women are so depressed that it seems wrong not to provide them with relief of their symptoms because of some theoretical risk to the baby. In such cases I try to use medications with the longest track record, particularly if there is a published literature on their safe use in pregnancy. No such literature exists for the use of St John’s Wort in pregnant women, whereas there is some reassuring evidence that the older anti-depressants and Prozac might be relatively safe for the developing foetus. I would therefore prefer to use these drugs rather than St John’s Wort for the treatment of depression in pregnancy.
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