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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One of the commonest symptoms of anxiety is the abnormal awareness of the action of our heart. Palpitation is a normal accompaniment of a response to danger. In this case the increased action of our heart serves to prepare us to meet the threat. However, as soon as the danger passes the action of our heart returns to normal and we cease to be aware of it. But when we suffer from anxiety, the unpleasant awareness of the action of our heart is often constantly with us.

Besides the persistence of the palpitation there is another factor. In our normal response to real danger our heart does in fact beat more strongly. But in the palpitation of anxiety there may be little actual overactivity of the heart, and the unpleasant awareness is due to our hypersensitivity to the normal beating of our heart rather than to overactivity of the organ.

The feeling of palpitation focuses our attention on our heart. We are all familiar with the dangers of heart attacks from coronary thrombosis. We soon come to feel that something is wrong with our heart. To reassure us our doctor takes an electrocardiogram and tells us that it shows our heart to be quite normal and that the palpitation is only due to our nervous condition. But we are not reassured. A lurking feeling remains that there is something wrong. In fact, it is hard to be reassured so long as our anxiety is still with. us.

A few years ago I saw an industrial tycoon, a man of strikingly pleasant personality and such exceptional ability that in a matter of a decade he had amassed a great fortune. But over the previous two and a half years he had suffered from pain over his heart and quite violent palpitation; and as a result was unable to enjoy the material success he had achieved.

In the manner of the real tycoon he was determined at all costs to get himself fixed up. He was not sure whether it was ten or twelve cardiologists that he had consulted in the various capital cities of Australia. He had gone to America to the most famous cardiological clinic in that country. He had been treated by a psychiatrist in America and by three psychiatrists in Australia.

“You can tell when there is something wrong with your heart, you can feel it,” he asserted.

There was obviously no point in having a head-on collision with such a man, so I merely said, “Anyway, you would be more comfortable if you were more relaxed.” And we went on from there.

One day about eighteenth months later I was driving home, when I caught sight of him in his car. In typical style he shouted, “Never better in my life.”

I must also tell you something of the other side. Last week I saw a healthy, athletic student who was becoming crippled by pain over his heart. Two leading cardiologists had assured him that his heart was perfectly normal. He was really brought to me against his wishes, by his father. He is convinced there is something wrong with his heart. He will not listen to me. He refuses to come back. Yet I am sure that if he would only do what I suggest he would soon be free of the pain.

Rejection by the patient like this does not happen often, but it is the most common cause of failure.

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Jake is a 29 year-old freelance writer and health food shop owner, who is currently trying to write and sell screenplays. He has suffered from feelings of sadness, fatigue and anxiety off and on since the age of three when his parents got divorced. He remembers being sick a lot as a child and getting into many fights at school. He was the class clown and was often in trouble with teachers.

Jake’s depressions went undiagnosed until age 22, by which point he felt extremely sad and dejected. He had recently completed his university course but didn’t know what he wanted to do with his life. He was working as a fund-raiser for disadvantaged children, but was tired much of the time and had a hard time performing his tasks. When he consulted me that autumn, he had quit work and was home sleeping for most of the time.

Jake had previously been treated with Prozac, but it didn’t help his lack of energy, which was one of his main symptoms, and made him feel ‘spacey’. I then treated him with another SSRI in high dosages. Although the drug made him feel more energetic and less down-in-the-dumps, it also made him angry and irritable and he developed a nasty edge in his dealings with other people that was quite uncharacteristic for him. To combat these unwelcome effects, I added a second mood-regulating drug, lithium carbonate. In addition, he also received psychotherapy and light therapy. This combination of treatments was quite effective and by the new year Jake had enough energy to acquire two part-time jobs and felt about as good as he could remember ever feeling. He was bothered, however, by medication side-effects such as sleep disturbance and continued aggressive feelings despite the placating effects of lithium.

After several years on this combination, Jake stopped his medications because he wanted to see how he would do without them. He felt fine until he moved to a new city with his girlfriend. He had always had difficulties with transitions and he felt the old familiar fatigue and anxiety coming back to him and consulted a GP, who restarted Jake on anti-depressants. Once again, he began to feel unpleasantly edgy. At Jake’s request, the GP prescribed a different anti-depressant, Lustral, which helped his mood somewhat but decreased his sex drive a great deal. Not only was he less interested in sex, but also had difficulty with erections and orgasms. He began to avoid sex because it was uncomfortable for him not to be able to perform and affected his self-esteem.

Jake read about St John’s Wort in the popular press and coinci-dentally, I had just begun to treat his mother with the herbal extract with excellent results. Since he is interested in alternative medicines, he put himself on St John’s Wort, 300 mg three times a day, and gradually phased out the Lustral. His sex drive, mood and energy improved markedly following the introduction of St John’s Wort. The only side-effect was mild indigestion, which responded readily to antacids and was in any case short-lived.

Jake’s mood and energy levels are as good as they have ever been and he finally feels ‘like a normal person’. He is grateful to the herbal remedy for helping him so much, even though he recognizes that he has also worked very hard to feel better about himself and his life. This work has involved therapy and self-reflection, regular exercise and actively avoiding toxic influences and negative attitudes. He plans to move to Los Angeles where he is more likely to succeed as a screenwriter, and feels optimistic even though his chosen course is a difficult and risky one and he has recently broken up with his girlfriend, with whom he was deeply in love.

Although Jake shifted from Lustral to St John’s Wort on his own, it is certainly better to make such changes under a doctor’s supervision. But Jake had clearly learned some of the key principles of anti-depressant management during his years of psychiatric care and did a good job with juggling his own medications. He recalled, for example, that you should try not to stop an antidepressant abruptly if at all possible. To do so is to court withdrawal side-effects, such as dizziness, sleep disruption and flu-like symptoms, to name just a few. Also there can be a rapid decline back into depression again. So Jake was wise to taper his Lustral gradually. In addition, Jake recognized that finding the right antidepressant is only one aspect of the treatment of depression. He is combining the herbal remedy with other healthy activities, such as therapy, self-reflection, exercise and the avoidance of negative influences. His move to Los Angeles also promises to be a healthy choice for him as it is more likely to offer him the career opportunities he needs in order to feel professionally fulfilled.

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The conditions present while going to sleep are called “sleep associations” They are the things, events, people, and anything else that might surround induce sleep.

We all tend to look forward to, and even depend on, the same, or a a similar set of sleep conditions being there for us each time we want l asleep. These are different and personal for each of us. They usually ir things like a dark room, a favorite side of the bed, or that special pillow.

Sleep associations help us get to sleep. Routines and rituals ã important part of most people’s lives—but nowhere are they more common, and more important, than when they center around sleep. They seem to help bridge the gap between day and night, wakeful activity and the unknowns of sleep. Even as adults—logical, rational, and usually wanting more sleep—we go through certain steps to be sure everything is “right” for sleep.

I can’t go to sleep without reading for a while.

I set a glass of water on the nightstand, plump up my pillow, check the alarm twice, and then relax.

Children learn to go to sleep in the conditions that their parents set up.

They learn to expect that old blanket, the night light, the music box, or their special pillow.

Kevin was always rocked to sleep. We made sure that he was fast asleep when we laid him down; otherwise he would cry. If he woke up later, he would cry until we rocked him again.

Since adults are generally in charge of their own lives, they are, theoretically, also in charge of their own sleeping conditions. Imagine what would happen if they were not. Suppose that the parent noted above, when awakened by a windstorm, was all out of water—or, worse yet, discovered someone had hidden her alarm clock. How could she possibly get back to sleep worrying that she might not wake up on time?

Children often find themselves in such frustrating situations. They wake during the night to find that the conditions they went to sleep with somehow changed during the night.

Remember that arousals are a normal part of sleep cycles—a time when we check to be sure everything is as it should be before we fall back to sleep. How lonely a child who has fallen asleep at the breast must feel to discover that it is no longer nearby! The bed must certainly feel less comfortable than Daddy’s arms or the rocking chair. Certainly calling out or crying is a logical, understandable, reaction—an attempt to regain the conditions favorable to sleep.

Difficulty falling asleep and frequent waking are common sleep problems. They may be connected. When a child cannot get to sleep, he will also not be able to get back to sleep. His sleep associations can be the root of it all. Even if you do not suspect this to be your child’s problem, it is important to look at it. Developing independent sleep associations is also a preventive measure.

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As I have noted, insomnia is one of the most commonly reported disturbances in behaviour. As the above table indicates, as many as one in three people reports that in the previous month there has been some problem related to sleep patterns. Many people have written to tell me that they have taken St John’s Wort to treat their insomnia and to good effect. For example, a 52-year-old woman began to take St John’s Wort ‘because I was not sleeping when it was possible to do so’. Since starting St John’s Wort T don’t stay awake if I wake up during the night unless there is an emergency. It also reinforces my positive outlook during the day’

Although there are no studies of the effects of St John’s Wort for insomnia, it is important to remember that sleep difficulties are a cardinal symptom of depression. These difficulties may take the form of having trouble falling asleep, tossing and turning or sleeping fitfully during the night, or waking up too early in the morning. So distressing are such symptoms that they may overwhelm the clinical picture and the depressed person may misdiagnose the condition as insomnia.

All types of anti-depressants may be helpful in reversing insomnia when it is part of the overall picture of depression. St John’s Wort is no exception in this regard. People with insomnia might benefit from reading over the symptoms of depression to determine whether they are suffering from other symptoms of depression as well. If they are, then the herbal remedy is more likely to help resolve their sleep difficulties.

A 56-year-old woman writes to tell me how her sleep difficulties, which were the most troublesome symptoms of her depression, were helped by St John’s Wort: ‘I can sleep again!‘ she exclaims. ‘Getting rest at night has helped everything else; gloom has lifted and I am in good spirits, energetic and positive. I feel a heavy weight off me. Immediately (the first night) I began to have dreams. I used to dream lots until about five to six years ago when the menopause kicked in. I did not dream as usual, if at all. I really hadn’t thought about it until I took St John’s Wort and began to dream again. Maybe the increased dreams are also related to my increased sense of well-being.’

If there are no other symptoms of depression, however, the insomnia may well be due to some other condition. It is worth paying a visit to your GP to have the problem checked out, as some causes of insomnia are potentially dangerous and eminently treatable. One such cause is sleep apnoea, a condition in which people stop breathing for brief spells frequently during the night, which wakes them up repeatedly. This leaves people drowsy and feeling ‘hung over’ during the day, and puts them at risk when driving or operating machinery. The resulting lack of oxygen to the tissues can also be medically harmful. Sleep apnoea is unlikely to respond to St John’s Wort, but can readily be treated by other means, such as a special machine that pumps air into the lungs when the person stops breathing.

Simple but important factors worth considering in identifying possible causes of insomnia include commonly used drugs, such as caffeine, nicotine and alcohol. Often cutting down the number of cups of coffee, tea or caffeinated sodas, particularly in the latter part of the day, can work wonders in bringing insomnia under control. Some people may not realize that nicotine is a stimulant and that smoking in the latter part of the night may be preventing them from falling asleep. Even though alcohol has immediate sedative properties, its effects wear off after a few hours. So too much alcohol at night may appear to promote sleep but may actually disrupt it when blood alcohol levels begin to fall. Removing these drugs from the latter part of the day or, at times, altogether, can be very helpful in promoting restful sleep. In addition, sleep experts emphasize the importance of what they call sleep hygiene – a quiet peaceful bedroom with dim lights and low noise levels. They recommend keeping arguments and conflicts out of the bedroom and engaging in peaceful rituals to wind oneself down before bedtime. If such simple remedies don’t help overcome sleep difficulties in the absence of depressive symptoms, it is worth seeking out the help of an appropriate doctor. If insomnia is part of a depression, however, it may resolve when treated with St John’s Wort or an anti-depressant.

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From the dark realms of cyberspace a 19-year-old girl who calls herself Dream wrote to me as follows:

I began taking St John’s Wort for depression – severe mood swings, excessive anger, guilt, feelings of worthlessness and irritability. It helped me function at work. My job requires good customer relations, and I was too easily irritated and hacked off. On St John’s Wort 1 could smile and interact just fine. It caused me a problem only once when I took it on an empty stomach and suffered severe stomach cramps for the rest of the day. I’ve stopped taking St John’s Wort because I feel better now. I was extremely grateful for it because it enabled me to function at work and subsequently keep my job (I recently got promoted, too). I can’t afford a therapist or any expensive medications. I only wish St John’s Wort worked as well for everyone as it did for me.

Work stress is a common source of frustration in modern times. Perhaps it always has been. But nowadays, corporate downsizing is making many workers increasingly insecure about their jobs. International competition has led to companies trying to get as much from their workers as possible for as little as possible. People shoved into tiny cubicles feel unappreciated and depersonalized. Chronic stress results in both physical and behavioural changes. Physically, there is evidence of increased blood pressure and pulse rate. More stress hormones, such as Cortisol, are produced by the adrenal gland, which can reduce appetite and disrupt sleep. After time, individuals can feel burned out and, like the young woman in the above example, can become irritable in ways that can get them into trouble with their supervisors. If stress continues for long enough it can turn into clinical depression and a person would do well to head off such a development at the pass. There are, of course, many things one can do to reduce stress and avoid depression. But one easy solution, which should certainly be considered, is the use of St John’s Wort. As in Dream’s experience, the need for the herb may be temporary, to tide a person over a particularly stressful time, but the benefits may be permanent. For example, in Dream’s case she was promoted, perhaps as a result of her improved mood and better control of her temper while on the herbal remedy.

Although work-related problems are stressful, being made redundant, laid off, downsized or whatever it is called nowadays can be even more so. A 48-year-old man from Germany who has treated himself with St John’s Wort for the past year writes, T lost my job a year ago. I was finished with the world. Now after a month in a new job, I am fine. With all the problems I was having, I could no longer see light at the end of the tunnel. Now everything is normal again.’ There are all sorts of adjustments that need to be made following a job loss and specific actions that need to be taken to determine how best to find new employment or get on with one’s career. But putting your brain chemicals in order may be a first step to developing the best mind-set to enable you to make these changes; for this man, St John’s Wort appears to have done just that.

Another source of chronic stress is the aftermath of losing a loved one. Grieving is an extremely painful process and probably a valuable and necessary one. Nevertheless, in some people the degree of suffering is so great that some form of medication may be warranted. In one recent study of widows and widowers, researchers found that almost one in four of the bereaved individuals had enough symptoms to be given the diagnosis of full-blown clinical depression. The decision as to whether to alleviate such painful symptoms is obviously a personal one. For many people, the idea of a natural substance, an herbal anti-depressant that they can buy and administer themselves, may prove to be appealing. A 45-year-old woman describes how she has taken St John’s Wort three times a day to deal with her feelings of grief following the death of her husband six months ago. She feels that St John’s Wort has helped her enormously so that now she is more at peace with herself and can sleep properly again.

The chronic illness of a close relative or friend and the unremitting care and attention this may require is another stress that can wear down those who love the ailing person. One 64-year-old woman felt very stressed as a result of her husband’s depression. Taking St John’s Wort has helped her enormously without causing any side-effects. Now she feels better and can sleep again.

Although there are no research studies on the use of St John’s Wort for the treatment of stress, it is commonplace to recommend conventional anti-depressants for such uses, often to very good effect. Already there are thousands of people using St John’s Wort for chronic stress. I predict that its use in this regard will greatly increase over the coming decade.

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There has been a resurgence in the use of stimulant medications, such as Ritalin and Dexedrine, with the increased awareness and recognition of the problem of adult attention deficit disorder (ADD). Since it is not uncommon to find both depression and

ADD in the same person, the question will arise as to the safety of combining stimulants with St John’s Wort. There is no reason not to do so under a doctor’s supervision, using the usual rules of starting low and going slow, as the following two case studies will indicate.

Dick, an economist in his early fifties, was referred to a sleep clinic by his wife, who suspected him of having sleep apnoea because of his snoring. After sleep studies were performed, sleep apnoea was ruled out and instead, he was diagnosed as suffering from narcolepsy, a condition characterized by waking during the night and severe drowsiness during the day. The drowsiness can reach dangerous levels as patients may doze off at the wheel or fall asleep at other inopportune times. Other curious features of this disorder are a tendency to have hallucinations just as one is falling asleep and to collapse while awake, often as part of an emotional response such as laughing. It has been suggested that the dormouse in Alice in Wonderland might have been suffering from narcolepsy, as he was always falling asleep and collapsing into the teapot!

Dick’s symptoms of narcolepsy were effectively treated with the stimulant Ritalin, but after his drowsiness cleared he realized that he was left with aspects of his personality that he was not happy with, particularly shyness and excessive cautiousness. He would hesitate to initiate conversations, to offer his opinions in group meetings or to assert himself in the workplace. In addition, he continued to overeat and gain weight and his sleep disturbances persisted to some degree. Even though he was not actually depressed and was able to experience pleasure in aspects of his life, his psychiatrist thought he might be suffering from a type of depression and prescribed St John’s Wort.

The very day after starting the herb, Dick felt buoyant, which was very surprising to him as he had read that it takes weeks for the herb to exert its effects. He knew that something unusual was going on because he had bicycled into work every day for months and had never before initiated a conversation with one of his fellow bikers. That day he did – and he has been less shy ever since, as well as less self-effacing and more inclined to speak up. Even confrontations which he would have assiduously avoided in the past now no longer seem so daunting. He is contributing more in meetings, feels more engaged and others have noted these changes even more than he has and have pointed them out to him. His psychiatrist has pushed the dosage of St John’s Wort higher in an attempt to get the maximum benefit from it. Best of all, Dick has not noticed any side-effects of the herb whatsoever.

I had occasion to combine St John’s Wort and stimulants in treating Zack, a 17-year-old boy with a long-standing history of both depression and ADD. When he first came to see me he was on one of the older anti-depressants, nortriptyline. Even though he was on a relatively low dosage of the anti-depressant, he noted a distinct decrease in his interest in girls after starting the medication. “I am still interested in them up here,’ he remarked, pointing in the vicinity of his brain, ‘but it doesn’t seem to be connected with down there.’ This was clearly a case for St John’s Wort. In my usual fashion, I gradually added in the herbal anti-depressant while tapering the conventional anti-depressant. On St John’s Wort alone, Zack felt too giddy, impulsive and unconstrained, so I reduced the dosage of St John’s Wort and reintroduced the nortriptyline at an even lower dosage than before. He declared the mix to be perfect. He no longer felt depressed, was no longer impulsive and experienced a welcome return of his interest in girls both emotionally and physically.

Now it was time for Zack to go off to university, and concentration and focus became major problems, as they invariably are for people with ADD. I introduced Dexedrine 5 mg twice a day to the mix, which helped him with his attention and his studies. He reported no problematic side-effects of the combination and is now enjoying university both socially and intellectually.

While this chapter has portrayed the value of St John’s Wort in a variety of conditions that are severe enough to warrant medical attention, the herbal remedy is also being used by countless numbers of people for less major, yet quite disruptive problems of everyday life.

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