I remind you that that there are no magic bullets when it comes to mental health. The question, properly posed is not “Is St. John’s Wort effective for depression:” but rather “When is St. John’s Wort most likely to be effective for depression?”   

In Part I we examined the proposed cure, St. John’s Wort, and we will get back to it. But let’s look at the other side of the equation: the malady of depression. Depression is a major illness that severely disrupts the emotional, physical and behavioral health of those who it afflicts. There are several essential facts to consider about depression before you go about trying to treat it. There are different degrees or levels of depression and there are different kinds of depression. The severity of depression and the type of depression determine how it will respond to St. John’s Wort.

 

What many people think of as depression can simply be a case of recurrent melancholy. Everybody has variation in their mood, and everybody can get the blues. Technically, this is not a clinical depression, which must be more severe and must endure for at least two weeks to meet the diagnostic criteria for clinical depression.  

 

Still, when you’re bummed, it can be difficult to deal with it, so there may be some temptation to try St. John’s Wort to help. If you are going through a temporary emotional slump, if you are just  passing through a rough period during which you figure you’ll take some St. John’s Wort to lift your mood, well, forget it. Recall from Part I that you need to take St. John’s Wort for 3 to 4 weeks before you reach effective blood levels of the hypericum. If you take St. John’s Wort during a temporary down period, you might think the St. John’s Wort made you feel better when in fact you would have started to feel better anyway. 

 

This reminds me of a great cartoon I saw. There were two doctors talking to each other, and a patient was sitting on a table behind them. The caption read, “We better hurry up and operate. He’s getting better on his own”. The point here is that if you are having a short period of feeling blue, don’t bother taking St. John’s Wort briefly on an “as needed basis”. Work on your other coping skills to get yourself out of the low ebbs of your moods.      

 

A common form of depression is a chronic, low-grade, depression in which the symptoms are constantly present but relatively mild. They are disruptive but not disabling. This condition is call Dysthymia. Research suggests that Dysthymia is a form of depression that may be more responsive to St. John’s Wort.  

 

On the other hand, some people develop a form of depression that is more severe. In the worst cases it can even be accompanied with psychotic symptoms, such as delusions. Research has suggested that St. John’s Wort is far less effective in cases of moderately severe and severe depression. 

 

Some people develop a pattern where they are typically in a dysthymic state, and then have recurrent episodes of more severe depression. This condition has been called Double Depression.  I am unaware of research that demonstrates the effectiveness of St. John’s Wort in Double Depression. Just thinking logically about it, one might speculate that St. John’s Wort may help during dysthymic periods, may serve as a prophylactic against the recurrence of moderate depression, but may be less effective during the severe episodes.

 

But this is pure speculation. One of the down sides of St. John’s Wort not being classified as a drug is that the FDA doesn’t require the same standards of research, and drug companies are not directing their massive profits into efficacy research. So, in terms of the effectiveness of St. John’s Wort for Double Depression, the jury is out.

 

There are several different types of depression, and some forms of depression will be more responsive to St. John’s Wort. Some forms of depression may in fact be made worse by St. John’s Wort. 

 

A distinction must be made between Unipolar and Bipolar Depression.  In Unipolar Depression, a person will have episodes lasting anywhere from a few weeks to years where they show the symptoms of depression. These symptoms can include sadness, inability to experience pleasure, apathy, despair, sleep disturbance, irritability, chronic fatigue, loss of interest, loss of motivation, backaches, headaches, digestive disorders, thoughts about death, suicidal thoughts, social withdrawal, hopelessness, and feelings of worthlessness and inadequacy. Episodes of clinical depression come and go. In Unipolar Depression, when the person is not depressed these symptoms improve, and the person is more or less in the average range of moods, feelings, thoughts, affects and behaviors.     

 

A person with Bipolar Depression vacillates between depression and mania. The bipolar person has episodes of depression with symptoms that look just like Unipolar Depression. Also, just like the unipolor depressive, the bipolar person can have more “normal” periods of time where they are in the average range of moods, thoughts, feelings, behaviors, and so forth. However, the bipolar person also has episodes where they are manic. These episodes can last a few days to several months.

 

During manic episodes they show symptoms that can include great enthusiasm and excitement, dramatically reduced need for sleep, greatly accelerated thought, distractibility, boundless energy, and elation. Some people will have delusions of grandeur. They feel that they are much greater, more influential, more talented, or more powerful than they really are. They feel fearless and invincible, yet can suddenly feel persecuted and become irritable and hostile. Usually, the person who is in a manic episode feels like they are simply in peak form. They feel energetic, productive and effective. Mania creates problems for people because they become impulsive and engage in behavior that can be quite destructive, such as spending too much money, taking on vastly unrealistic endeavors, or falling prey to addictive behaviors. 

 

Now here is where there is a potentially serious problem with the use of St. John’s Wort. The use of an antidepressant alone during a depressive episode of bipolar depression can transform the bipolar depression into Rapid Cycling Bipolar Disorder, a significantly more severe, disruptive and difficult to treat form of Bipolar Depression. It is basically a variation of bipolar disorder in which the cycles between depression and mania are accelerated. Instead of happening intermittently every several months or years, the episodes cycle every couple of days or even several times per day. Obviously, this is something to be avoided.   

 

Another way to classify depressions is by whether they are endogenous or exogenous; that is to say, whether they are caused chiefly by internal, biochemical factors or by external events. If you lose your job, a loved one passes, you get a divorce, or some other significant, stressful event occurs it is quite natural to get depressed, to grieve. This is called a reactive or exogenous depression.

 

Medications can help in reactive depression, but they can’t solve all of life’s problems. If that were true, then we wouldn’t have wars. If only, huh? Maybe we could have solved the Middle-East conflict by air dropping crates of Prozac in Iraq and Afghanistan! 

 

Wishful thinking aside, while medications can help moderate the emotional impact that events have on us, there is no amount of medication that will numb us to the brute force of reality. When an exogenous depression hits, it is time to deploy your coping skills, get help and learn how to deal with whatever disaster has just struck this time. Score: Reality (1). St. John’s Wort (0). 

 

Finally, in addition to the types of depression described above, there are other types of depression including Seasonal Affective Disorder, Chronic Depression, Agitated Depression, Psychotic Depression, and Atypical Depression.

 

Atypical Depression is a subtype of Major Depression and Dysthymia. People with Atypical Depression have temporary improvement in their depression in response to positive events, and have at least two of the following symptoms: over sleeping, heavy feelings in legs and arms, a long standing pattern of extreme sensitivity to rejection and a significant increase in appetite or gain in weight. Atypical Depression is of particular interest because this type of depression seems to be responsive to MAOIs, and therefore will be more responsive to St. John’s Wort.

 

And Finally, a Summary and Conclusions Complete with Bullets

We’ve covered a LOT here. Let’s summarize and get to the answer of the rephrased question.

 

So, “When is St. John’s Wort most likely to be effective for depression?”

 

I still don’t have any magic bullets to offer. But for those of you who (1) were looking for a magic bullet, and (2) like to have a nice, visually arranged, simple answer, I at least have an answer for you with several regular, non-magical bullets. For those of you who skipped over most of the article looking for a brief summary of the entire thing in just a couple of lines, here it comes. For those of you who read every single little word, admit it, you learned some other stuff, and you are a better person for it. Anyway….

 

St. John’s Wort will more likely be effective when: 

Why is St. John’s Wort most likely to be effective under the bulleted conditions above? Basically, St. John’s Wort happens to be a certain kind of anti-depressant drug, a low dose MAO-inhibitor. Because it is a low dose medication, it seems to work more effectively for lower levels of depression and is less effective with moderately severe and severe depression. Some people with mild to moderate depression will not respond to it because the type of depression they have is not responsive to MAO inhibitors. Like any antidepressant St. John’s Wort may markedly worsen Bipolar Depression, transforming it into Rapid-Cycling Bipolar Disorder, an illness that is more debilitating and far more difficult to treat. Needless to say this is something you want to avoid.            

 

And now for some free advice. Depression is a serious illness. It messes with your mind, messes with your body and messes with your life. It should be taken seriously.  Look at those bulleted items. Can you diagnose those different conditions?  To paraphrase a well known quote about lawyers, it can be said that the doctor who treats himself has a fool for a patient. Well, the patient who thinks he’s a doctor, and then treats himself must be twice the fool. My final word of advice is this. If you have or think you have depression, seek help. Talk to your doctor. Talk to a shrink. Sure, when you’re talking with those guys, talk may not be cheap, but it can be helpful. 

 

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