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Combining st john's wort with stimulant medications COMBINING ST JOHN'S WORT WITH STIMULANT MEDICATIONS
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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