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This article is a transcribed edited summary of a video Bob and Brad recorded in January of 2021. For the original video go to https://www.youtube.com/watch?v=hIg0lN8Poxg
Bob: Welcome, my friends. I’m joined by Chris, the pharmacist, who is, as I’ve said before, one of the smartest guys I know. And that’s a compliment, Chris.
Chris: I appreciate that.
Bob: So, today we’re going to talk about should you use St John’s wort for depression. It’s funny because you brought this up to me a while back and then I had a nurse practitioner mention to me that if you are having trouble with anxiety, you maybe want to try it. I know you were kind of against it.
Chris: Yeah, you have to be careful. St John’s wort has a place in the role of treating mild to moderate depression but the problem with St John’s wort almost exclusively is just the amount of drug to drug interactions that it can cause. If somebody’s already on a medication, that would be very dangerous recommendation.
Bob: So, we’re going to name some of the drugs. I looked up some and they’re not sure how it affects pregnancy.
Chris: With respect to pregnancy, right now, most of the research has been done by Germany. The German monograph E is kind of the Bible for all these types of herbal remedies for any type of health condition. With pregnancy, there’s just not enough data that really supports the safe use of it. Right now, in the prescription world, really the safest choice is probably sertraline. You know, it’s interesting pharmacologically when you look at St John’s wort, it’s kind of got the best of all the prescription worlds. It’s got your monoamine oxidase inhibition, it raises serotonin, it raises norepinephrine, and it raises dopamine. When you take all those together, you think on paper at least, it would look really good. When you’re looking at something as important as being a pregnant woman, the last thing we want to do is take any chance to causing problems.
Bob: The same holds true for children? I saw that they don’t have a lot of research on that either.
Chris: I found a couple of studies that suggest that if they’re over the age of 12 that maybe half the adult dose, which for an adult is 300 milligrams three times a day, 900 milligram total daily dose. I would be reluctant to use it in children as well because there’s just, I don’t think enough data. Plus or minus at the end of the day though, children are pretty much small adults as they start to age but there’s a point where with growth spurts in adolescents, there’s a lot of brain chemistry that’s changing. Even in the prescription world, it’s becoming used more now with the pharmaceuticals. Some kids with depression issues, anxiety issues, that they will use a prescription, but this is more of an unknown. I would be really reluctant just because of all the drug-drug interactions which we’ll certainly touch on.
Bob: You were saying in Germany, it’s actually a prescription drug.
Chris: In Germany, it’s specifically a prescription.
Bob: And used quite a lot.
Chris: Probably even more so than even some of the prescriptions.
Bob: It’s funny, I was looking at studies and a lot of German studies were positive towards it.
Chris: They are positive in certain circumstances, and I think when you take the Americanized studies, which are based off of all the German studies. They show that at least compared to and they use placebo, and they use actually head-to-head, pretty much what we would call moderate or low doses of the other, what they call second generation antidepressants. That’s pretty much anything that was invented after the 80s, so, it’s kind of everything that we use today. So, you know, it stands up. If you’re going to take St John’s wort as a single agent, with nothing else in your system, for mild or moderate depression, I would say it’s okay to try as long as your doctor is on board. And then, you really have to touch on with the doctor. You cannot use over the count cough and cold preparations that contain pseudoephedrine. You have to stay away from cured meats, aged cheeses, red wine, beers.
Bob: Wow, so it’s not just other meds.
Chris: No, it’s everything. That’s why I have a hard time supporting it.
Bob: I haven’t seen that list. It’s intimidating. Obviously, if you’re going to go on anti-depressants, you shouldn’t be doing that. But I saw birth control pills.
Chris: Birth control pills, blood thinners or HIV medication.
Bob: Cyclosporine.
Chris: Cyclosporine which would be used for organ transplant.
Bob: Oxycodone. Digoxin.
Chris: Digoxin for your heart and other heart medications.
Bob: Some HIV drugs.
Chris: Correct.
Bob: Some cancer medications.
Chris: Absolutely. So, you know, that’s the thing that makes it so intimating. It metabolized in our livers, so, cytochrome P450 system, and what it does is it can actually influence either making some drugs go higher in your system or go lower in your system. And that’s why the danger exists. To the average person, unless you ask your pharmacist or if you consult your physician or practitioner, a lot of times and even then, look at the example with the practitioner you came up with where: a nurse practitioner said, “Well, why don’t you use this?” “Well, I’m already on something.” And that, you now, when you take it with other antidepressants, increase risk for seizures, serotonin syndrome.
Bob: That’s what I read. It increases your body’s serotonin levels to possibly a dangerous life-threatening level.
Chris: Correct. I mean, it’s a rare interaction to begin with but to me I am conservative by my nature and my recommendations. The only thing I care about is patient safety and good results. So, actually two things, but the reality of it is that we want to make sure that if you’re going to choose to do something like this that you are acutely aware that St John’s wort should be used with absolutely nothing else.
Bob: The other thing is that we don’t want to encourage you to try to treat depression on your own. And St Johns wort could possibly do that.
Chris: Well, it’s available on any drug counter or the internet. Go onto Amazon and there’s 100 different versions of it. The biggest thing is, you want to see your doctor first because let’s rule out maybe there’s something else that’s the cause of the issue. If you want to have the discussion with your doctor "well I really like to try something more natural," I will tell you that St Johns wort does tend to have less side effects than the prescriptions. That is an attractive advantage. Again, I think that’s why in Germany it’s used so frequently is because when it’s used in itself as a singular agent with no other prescription medications or over the counters, you can have a relatively comfortable existence with it.
Bob: When you started mentioning those foods and you also mentioned alcohol as far as there’s three that you could.
Chris: Yeah. Oddly enough bourbon, you can use vodka and you can have rum.
Bob: So, I could get by.
Chris: LOL. Nonetheless, not that we’re going to encourage you because alcohol is a depressant, but I mean those are the three. You can’t have dark beers; you can’t have red wines.
Bob: How about white wines?
Chris: There’s actually some white wines that you could like a Chardonnay. You really have to be very careful. To me, the reason I give the thumbs down on it in many cases is because most of us, inadvertently, you’ll be taking the medication, let’s say things are going well 12-15 weeks down the road and your kind of post COVID, maybe everybody gets their vaccine and you’re out and about, maybe at a restaurant. What if you had some sort of fancy protein-based meal and you wanted to have a glass of wine and all of a sudden you chose the wrong one. Now you’re creating a tyramine reaction which can be pretty severe. So, we have to be super careful with its usage. That’s why it’s easy to just slip up once but it only takes one to create a real problem. All of a sudden what turns into a pleasant night ends up in an ER.
Bob: I did see some studies that showed it was not as effective, which there almost always are. They were saying it was not even as good as a placebo in one study.
Chris: Some of the older studies have said that it really doesn’t. Some of the more modern ones do. When we are researching these types of things and when doctors and practitioner groups and university settings are doing solid research on medications, they’re looking at the old studies and saying, “well, what if we approach this angle?” That’s the unique thing about this field in healthcare in general is that we’re always looking to find ways to improve. Maybe we didn’t look at the study appropriately the last time, end points and things that they look at for specific markers.
Bob: It’s very rare to find that they give thumbs up to a drug consistently in studies.
Chris: Oh yes, and again, with St Johns wort, realistically, it has a place as long as it’s a singular agent, you’re on nothing else. I can’t stress that enough.
Bob: And that’s rare.
Chris: You want your doctor involved because there’s other things that we have to rule out and I would hate to go on this journey and then haphazardly be taking something. Or let’s say you were taking a thyroid medication and maybe all you had to do is have the dose adjusted. Also, now we take the St John’s wort and now we’ve really negatively inhibited your thyroid production.
Bob: And warfarin. Very common. A lot of people are on warfarin.
Chris: Yes, lots of people. We’re going away from it because we have some of the better newer anticoagulants. Warfarin still has a strong place in medicine and we’re going to use it for years and years to come. Again, that’d be something that all of a sudden, maybe you’re a little low and you’re not really thinking about it. You’re like, yeah, I’ve been on warfarin for five years because I’ve got an issue with the heart and I’m feeling a little low, it’s COVID, I’m isolate, you know, St John’s wort, I read on the internet says it’s good for depression. Well, now you’ve created the bleed risk. Now could you have had a life-threatening bleed? It’s scary. So that’s the concern I have.
Bob: So, we want you to go into this drug with eyes wide open. I think Chris has covered it very well as far as what the downsides are possibly. So, please proceed in that fashion.
Chris: Absolutely.
Bob: Thanks for watching.
Patient Resources:
National Alliance on Mental Illness www.nami.org 1-800-950-NAMI
Anxiety and Depression Association of America www.adaa.org
National Institute of Mental Health www.ninh.nih.gov
Help Finding a Therapist 1-800-THERAPIST
National Suicide Prevention Lifeline 1-800-273-TALK
American Psychological Association Crisis Text Line Text HOME to 741741
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