ST JOHN’S WORT AT WORK: FIRED BY A CHEMIST’S ASSISTANT
'This letter is to cancel my appointment,' wrote Malcolm, who worked as an assistant at a chemist's. 'I suppose I could come in and "show myself to the priest" ... but I had only mild to moderate depressions, not leprosy ... I have never been a danger to myself or others, only a danger to my chequebook. And in the interests of protecting my current account, I would like to cancel further appointments.
'I am relatively happy with my current "prescription" of St John's Wort. It is working as well as, or better than, any of the anti-depressants I have tried so far. So I'll keep with it for now, and see how well it does as the days get longer. If I feel the need to try more prescriptions, I will feel free to call.'
Well, I have always encouraged my patients to express themselves freely to me - and apparently Malcolm took me at my word. But his letter captured my attention more for its substance than its style. Malcolm's depression had been very difficult to treat. It was not that his symptoms were so severe. He was correct in describing them as 'mild to moderate' and he had never felt suicidal, but it was long-standing and seemed to sap his life of all joy. His energy level was very low and he withdrew from others in order to conserve his meagre energy reserves for his job. His only pleasure came from buying things, such as compact discs. 'Music seemed to fill my emptiness,' he said. Two women he had dated over the previous 10 years had remarked that his main problem was that he wasn't happy, though he was barely aware of this unhappiness himself.
I had treated Malcolm's symptoms with a comprehensive list of anti-depressant medications, trying each one diligently for the right amount of time, calibrating dosages, using novel and unusual combinations and integrating the medications with all sorts of health-enhancing recommendations. While these interventions were quite helpful, we were always brought up short by side-effects, especially problems with his sinuses, dryness of the mouth and feelings of spaciness. Of all medications we had used, Lustral seemed best but he still felt unhappy and 'out of touch' emotionally. He decided to stop Lustral after finding out about St John's Wort on the World Wide Web and concluded that he felt he had enough information on which to base an intelligent decision.
Malcolm followed his earlier communication to me with a second letter, to reassure me that T was in no way displeased with your "psychiatric care" (I guess the term is) 'and to report on' "my current herbal concoction".' He was now on Hypericum 900 mg per day, which appeared both to reduce his anxiety and to energize him. He was 'more positive and upbeat, more apt to say things instead of sitting around and being quiet'. He was amazed to find himself more outgoing and confident, even among strangers. He felt a qualitative difference between the effects of Lustral and those of St John's Wort. While the Lustral had helped his mood, it had not allowed him to communicate that improved mood to others and to engage with them as freely as was now possible.
Over the next six months, while taking St John's Wort, Malcolm made certain changes in his life. He made sure to get enough sleep, which helped his energy level, and kept his time awake constant, even at weekends, which he believed had a marked stabilizing effect on his mood. He left the chemist's, where he had felt isolated, and took up a job in a home for mentally disabled adults, where he had more daily contact with people. He involved himself in religious activities, which added a spiritual dimension to his life. Finally, he plucked up the courage to approach a young woman whom he had met at church and whom he is now dating.
My experience with Malcolm was my first direct encounter with the new herbal anti-depressant, and to say that I was amazed would be an understatement. After treating him with so many potent anti-depressants both individually and in combination and observing his responses to them, I discounted a placebo explanation for his improvement. In his case, I was convinced that the herb had exerted a specific anti-depressant effect. His story reminded me once again, however, how important it is to add healthy activities to any anti-depressant intervention - though again I realized how little these activities help unless the disturbance in brain chemistry has been turned round. I now wonder whether the tendency for St John's Wort to make Malcolm more outgoing might have been related to its effects on the neurotransmitter dopamine, which is important in modulating social behaviour in animals, while the mood-enhancing effects that he experienced on both Lustral and St John's Wort might have been related to the effects of both of these substances on serotonin.
The lessons I learned from Malcolm encouraged me to try St John's Wort in my own practice. The first patient I treated was Adele, whose story I describe below.
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