It's been said that taking drugs to fight depression has the opposite effect to drinking alcohol. With alcohol you get the good bits first and the hangover later. With antidepressants you get the unpleasant side effects first and it can take up to six weeks to feel the benefits. It's no wonder that many people get fed up and stop taking them, leaving depression as not only one of the most common medical problems around, but one of the most under treated.
So it's handy that a paper in last week's British Medical Journal suggests that there may be an alternative pill for treating depression. Hypericum perforatum (St John's wort), a herb used in ancient Greece to cure demonic possession, may be as effective as routine antidepressants in relieving depression. In a German study of 324 patients with mild to moderate depression, those who took St John's wort for six weeks reported nearly half as many side effects as those on routine antidepressants and only 3% stopped taking the herb. About 16% of those taking antidepressants stopped because of side effects.
"We've known for a while that St John's wort works for depression," says Patricia White, spokeswoman for the Depression Alliance. "In Germany it has been prescribed for 20 to 30 years. Patients don't seem to be told about it in the UK, which is a shame because some people may feel it's more acceptable to take a herbal remedy before trying antidepressants."
National surveys show that people are reluctant to take medication for depression, according to Dr Paul Bebbington, professor of social and community psychiatry at University College, London. "People often think they should be able to deal with it without taking tablets - that they should just pull their socks up. When you are depressed you have a low tolerance for side effects anyway. People particularly dislike having a dry mouth and feeling woozy." Other common side effects include blurred vision, headaches, constipation and nausea. "But some symptoms that people attribute to the antidepressants, like tiredness, are actually due to the depression," says Bebbington. Stephen Harrison, a 42-year-old teacher, now retired on medical grounds, has been taking St John's wort for depression for two years, after being on antidepressants for six years. It took him over a decade to be diagnosed and given any treatment at all. "I probably had my first major depressive episode in my early 20s," he says. "It seems pretty obvious that was what it was now but then my doctor called it burn out. I was on a graduate trainee banking scheme and I just felt this unhappiness creep over me. I went to bed for a week - I couldn't face getting up."
He left banking and became a teacher, moved to Gloucestershire and got married. He was well until his 30s when the symptoms of depression started creeping back. "They were classic symptoms - although I didn't realise - I didn't want to get up in the mornings, I was sad and tearful, in my worst moments I felt suicidal. I went off my food, I lost weight. But I was still in denial about my depression." His new GP was direct with him. "He immediately said, 'Come on, this is depression,'" says Harrison, "My reaction was relief that someone had put a name to it."
Prozac didn't help but other antidepressants did. "I wouldn't run them down but I reached the stage where I didn't want to fill up my system with these drugs. They made me feel drowsy and I got a little confused at times. My short-term memory seemed to go a bit. I heard about St John's wort and knew people who were taking it so I thought I would give it a try. I didn't tell my GP until afterwards and he said, 'Fine if it works for you.' I got the right dose by trial and error, taking different brands and different strengths. I don't get any side effects with it. I get the odd day when I feel a bit depressed again but that's all it is. I have found it to be incredibly effective for me." With his depression under control Harrison feels obliged to be open with people about his ill ness. "Everyone who knows me knows what I have suffered from. There is still a stigma around depression, especially for men. It's unfortunate we use the word depression to cover such a range of feeling. We say a film is depressing but it's not in the true sense of the word."
The Depression Alliance estimates that one in four people will suffer from depression sufficiently badly to benefit from taking antidepressants of some sort. Many don't even see their doctors. "Depression can be a relapsing condition and it is bad news to suffer from it without treatment, says Bebbington. The causes are not clear; genetics and circumstances both play a part: "It's probably due to a range of factors. I tend to think a lot of it is down to adversity and social circumstances."
"We find lots of people with depression have had an adverse life event, such as bereavement or redundancy," says Patricia White. Why these things work on the brain to reduce levels of serotonin [a neurotransmitter - a chemical messenger between nerve cells] in the brain is unknown. But antidepressants work for over 75% of people. They generally block off receptors in the brain so that people with depression can reuptake serotonin at the same speed as everyone else. It's a biochemical disorder. Some people don't like the idea of taking drugs that interfere with chemicals in the brain."
It's not clear how St John's wort works - it has at least 10 compounds that may contribute to its pharmacological effects such as flavinoids and xanthones. Its side effects, such as confusion and stomach upsets are generally mild, although it can react dangerously with other drugs such as warfarin (a blood thinning drug) and tetracycline (an antibiotic). Despite its pharmacological activity it is sold as a food supplement and not registered as a drug in the UK - so preparations are not standardised or available on the NHS. "In Germany it is registered drug with standardised preparations," says Edward Ernst, professor of complementary medicine at the university of Exeter. "In the UK the amount of St John's wort in a preparation can vary from 100% to zero. Doctors know very little about how to use it and what doses are needed."
If the Medicines Control Agency was to consider registering St John's wort as a medicine, the herb may never make it. "It is difficult to register any herbal drug," says Ernst. "There are toxicology problems; each herb has many compounds, not a single clean one. How can you know which compound you have to supply toxicity data for? A third category may be needed that falls between registered medicines and food supplements."
Even without registered medicine status, doctors may feel it's appropriate to suggest St John's wort as a first line drug for mild and moderate depression. "But you would have to treat it like a new drug and be rather careful, especially as it is not subject to the normal surveillance system for drug side effects," says Bebbington. "There are side effects that only emerge when the drug is used in clinical practice as opposed to trials."
"We think the most important thing is that people have an informed choice about which medication they take," says White. "We would also suggest they have a talking therapy as well such as psychotherapy or counselling. Antidepressants lift your mood but they don't cure depression. It's important that people develop their support networks. Depression is a very treatable condition, especially if it's caught early."
The difference between sadness and depression
Sadness
You cry when you watch Casablanca.
You go to bed for an afternoon mope.
You're too lethargic to go clubbing.
You phone round your friends. asking for three of your good points.
It takes a good episode of the Simpsons to make you smile.
You eat a box of peppermint Matchsticks for comfort and enjoy them.
You go off sex, but only because you think no one wants to do it with a misery guts.
Depression
You cry at nothing, sometimes for ages and afterwards you don't feel any better.
You go to bed for a week at a time.
You are so lethargic you don't have the energy to see your GP.
You feel useless, helpless and hopeless.
You find it hard to make simple decisions.
You wake up earlier than usual.
You have difficulty sleeping
You lose appetite or weight (or do the reverse).
You go off sex.
You avoid other people.
You think of suicide.
For more information go to: www.depressionalliance.org or www.bmj.com
