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Ask the Doc: Patient seeks alternative to prescribed antidepressant

StaffMay 28, 2019

Dear Dr. Roach: I suffer from depression. It comes and goes, but I’ve been feeling sad, worried and angry at the world, as well as irritable, for the past four months or so. I force myself to function. My family doctor prescribed Effexor. He prescribed a 37.5 mg dose once a day to start and after one week, twice a day. I looked up the side effects and what I read scared me. Instead, I’ve been taking 1,000 mg of St. John’s wort daily. It will be three weeks on soonTo date, I have noticed no discernible effect.

I told my doctor I would take the Effexor after three weeks if the St. John’s wort hasn’t helped. Should I take his advice? Are there better alternatives? I am middle-age and take zero prescription drugs.

— S.M.

Dear S.M.: St. John’s wort, Hypericum perforatum, is a yellow flower that has been medicinally used for centuries. Initial studies suggested benefit in people with mild to moderate depression, and several substances in the flower have been shown to have pharmacologic effects on serotonin receptors, among other effects. However, other trials have shown St. John’s wort to be no better than placebo. It does have important drug interactions, fortunately not an issue for you (as long as you let the St. John’s wort wear off before starting Effexor), but for some people the potential interactions are dangerous. Side effects are not common, but include gastrointestinal upset, dizziness and confusion, fatigue, dry mouth and sexual side effects. It can make people more sensitive to sunlight, and may decrease fertility.

The studies that did show a benefit lasted four to 12 weeks. It is possible you might not have had benefit from it yet, and waiting a little longer, say another week, wouldn’t be unreasonable to really give the St. John’s wort a chance. However, I seldom recommend this herb due to lack of consistent benefit in trials, the potential for drug interactions and a concern about poor regulation of supplements in terms of amount and purity of the ingredients. For people who want to avoid prescription medicine, I have often recommended S-adenosyl methionine (SAMe). The evidence is better and the side effects and drug interactions fewer.

Effexor may be a good choice for you. Prescription antidepressants have been shown to be better than placebo, but they certainly do not work for everybody. If Effexor isn’t a good choice, there are several others. However, I would strongly recommend you consider non-pharmacologic treatment for depression whether or not you decide to take additional medication treatment, be it prescription or over-the-counter.

Dear Dr. Roach: A few years ago, I read that the herbal supplement feverfew may help with some migraines. Having suffered with severe migraine for over 50 years, I decided to try it. I take one capsule four times a day, and it has completely rid me of my migraines. Would you please mention it again?

— B.J.F.

Dear B.J.f.: Feverfew is a common herbal remedy to prevent migraine, and although not all trials have shown benefit, the majority of studies I have read showed that it is more effective than a placebo treatment and the side effect risk is very small. Other nonprescription treatments that have been shown in most studies to be beneficial include magnesium, riboflavin and coenzyme Q10. These treatments are generally safe and well-tolerated, and I hope other people may get the same relief you have found.

Readers may email questions to ToYourGoodHealth@med.cornell.edu

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