If one treats a large number of depressed patients, as I do, the use of anti-depressant combinations is standard operating procedure, as the anti-depressants frequently don’t work when administered individually. If one has to be depressed, the late 20th century is not such a bad time for it as there is an ever-increasing array of available medications that act on different elements of the neurones responsible for transmitting the signals that regulate our moods. The skilful clinician, working in collaboration with an observant patient, can mix and blend these medications in such a way as to maximize their benefits while minimizing their side-effects.
St John’s Wort appears to work very well in combination with all anti-depressants except for the MAOIs, such as Parnate or
Nardil, where adding them can be dangerous. This is not to say that medications should be mindlessly shaken into a cocktail in full dosage. After all, if these medications can interact with one another in positive ways that enhance their anti-depressant effects, they also have the potential to enhance one another’s side-effects. When mixing medications it is important therefore to move more cautiously with dosages and timing. Certainly, such medication combinations should not be tried on one’s own but rather under the supervision of a good doctor.
When properly handled, I have seen people manage to decrease the dosage of anti-depressants that were giving them unpleasant side-effects, and add in St John’s Wort instead. For example, Fred, a 52-year-old computer scientist, wrote to tell me that he had added St John’s Wort to the anti-depressants he was previously using, which had been helpful in removing his feelings of ‘doom and gloom’ but did not completely resolve his problems. According to Fred, St John’s Wort ‘takes the edge off feelings of anxiety and depression and flips the switch from negative to positive’. He was able to reduce his dosage of anti-depressant medication from 450 mg to 300 mg per day and, in addition, noticed that he did not need to be quite so precise as to when he took it. Before starting St John’s Wort he had observed that ‘If I missed a pill by one or two hours, I’d get very tired and the glass started looking half empty instead of half full. By taking 250 mg of St John’s Wort with 150 mg of my usual anti-depressant, I can delay taking the next dose by two to four hours.’
Besides helping Fred get by with less anti-depressant medication and space the pills out at wider intervals, the addition of St John’s Wort also gave him a more sustained feeling of well-being. As he put it, T feel like good things will happen – a feeling that I am OK – not perfect – but me. I sense life is going to get better.’
I have similarly observed in my own patients the highly beneficial interactions between St John’s Wort and other antidepressants, sometimes subtle, sometimes very robust. Although I have read of people who have experienced problems with such combinations, such as jitteriness or increased blood pressure, to date I have not observed them in my own patients, perhaps because of my practice of altering dosages of medications gradually, which enables one to detect potential problems early before they become too unpleasant.
Many of my patients are on complicated combinations of anti-depressants and I have been pleasantly surprised to find that the addition of St John’s Wort may nevertheless provide additional anti-depressant protection even in people with depressions that have been hard to reverse. Sometimes the addition of the herb has been so helpful that it has been possible to decrease the dose of some of the other medications or even to remove one or more of them, thereby simplifying the overall medication regimen. As always, the key to successfully combining medications – and St John’s Wort is no exception in this regard – is to change dosages slowly and observe carefully for any untoward effects.
Remember: If you are on a MAOI such as Parnate or Nardil, do not take St John’s Wort. Also, if you have discontinued an MAOI, wait at least two weeks before starting St John’s Wort.
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