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St john's wort and panic disorder: adding an ssri to st john's wort ST JOHN'S WORT AND PANIC DISORDER: ADDING AN SSRI TO ST JOHN'S WORT
Vanessa is a scientist in her mid-forties who has suffered from recurrent depressions for as long as she can remember. During her depressed periods, which can last for months at a time, Vanessa withdraws from others, needs to sleep a great deal of the time, has difficulty concentrating and feels sad and worthless. Although a highly intelligent woman, she lacks confidence in her abilities and for many years worked in a job that was beneath her skills and qualifications. She was reluctant to ask her boss for a promotion, however, as she questioned whether she deserved it and feared that her request would be denied, which would confirm her sense of worthlessness.
In the past, Vanessa was treated with Lustral during the worst parts of her depression, requiring dosages of as much as 150 mg per day in order to obtain therapeutic effects. Although the medication removed the most painful aspects of her depressions, it also sedated her. In addition, she felt that it took away her range of feelings so that she was unable to respond fully to the events in her life, unable to muster great joy in response to good news or feel appropriately sad when bad things happened. As she described it, T felt zombified,' and for this reason she would discontinue the medication shortly after emerging from her depression.
Vanessa happened to be in one of her depressions when St John's Wort was becoming widely publicized in the US and she decided to try the herbal remedy at the dosage of 300 mg three times a day. After a few weeks she felt it was helping her - but now, instead of her feelings being flattened out, she felt greater swings in mood than before. Within the same day her mood would fluctuate several times from good humour to despair and discouragement. On the advice of a psychiatrist, Vanessa added Lustral to the mix, trying only 50 mg per day, one-third of the amount that she had previously required. For the first time in her life, she felt good in a sustained way without feeling medicated. As she put it, T feel like myself at my best all of the time. I get upset when things go wrong and happy when they go right, but they feel like normal feelings, not depression nor like being a dull zombie.'
Since feeling better, Vanessa has managed to travel and socialize much more freely and happily than had ever previously been possible. She has also plucked up the courage to ask her boss for a promotion, which he readily agreed she deserved and promptly took the necessary steps to make happen.
In another patient of mine, a combination of Prozac and St John's Wort appears promising. The young woman in question wanted to switch from Prozac 20 mg per day to St John's Wort because she had gained weight while on Prozac. Several weeks after the switch she began to feel depressed and we decided to restart her Prozac at a lower dosage of 10 mg per day in conjunction with the St John's Wort. This combination appeared to hold her depressive symptoms in check, but we have yet to see whether it helps her to lose the weight she gained on the higher dose of Prozac.
The lesson to be learned from this young woman and from Vanessa is that one does not have to choose between herbal and pharmaceutical anti-depressants. The best outcome may come from mixing the two. I would not, however, recommend trying such mixtures on your own, since medications can interact adversely as well as favourably and one is best off having a doctor involved to minimize the chance of that happening.
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