I looked up St. John's Wort on the Net. My gawd, what a weed!
There are indications that it acts as an MAOI, as an SSRI, an inhibitor of norepinephrine reuptake, and has a high affinity for GABA receptors. It also may raise estrogen levels. Imagine bringing a pharmaceutical to market that has the combined effects of nortriptylene, lorazepam, and phenylzene. Further imagine doing so for a lower price than fluoxetine and getting it to the consumer without going by a physician's pen. (1)
My feelings are mixed. First, I've gone toe-to-toe with some mothers over the past 3 years about green algae as a natural treatment for ADHD. It isn't. On the other hand, DHEA helps me heal after running. Gingko is gaining credibility for people with Alzheimers.
However, I'm leery because of what happens to children and adults with manufactured SSRIs. Restless people are sometimes miserable when they encounter consequences and limits to their demands. Their mates or mothers could well suggest SJW. Many of these same restless people, however, have too much self-esteem rather than too little. Mom (and the psychologist) seek happiness for them but may discover grandiosity on the same path.
Grandiosity can be obvious. Some people feel themselves mentored by the Almighty and sent on a mission to save us all. (The guy up on the corner, a fundamentalist preacher, seems a bit like this.) The Comet Leader who recently led his followers to early deaths was also blatant. He had a history of bipolar disorder but none of his sheep understood the full meaning of that label. (And manics rarely admit their full nature to anyone.) (2) Sometimes a kid makes the local news for threatening his family with a rifle. He's almost guaranteed to make it if he's been taking Prozac. And he should make the news along with his doctors because there are usually more than a few suggestions of bipolar disorder in the relatives.
Grandiosity can also be a subtle thing. I know Chuck, a gangling 13 yo heartache. He's sliding through Catholic school, missing his assignments, and daydreaming in class. He was pretty avoidant a year ago, dreading school because the other children snickered at his grades. He became more sociable at school, less intimidated by making mistakes at school. He also spent less time retreating to the basement when home. The nice changes were at 5 mgs; he became silly on 10.
We stopped the 5 mgs Prozac three weeks ago. Chuck "no longer cared," not in a depressed sense, but with a bland indifference to parental and scholastic sanctions. He's more responsive this week, a bit more guilt when he makes significant mistakes. However, he wants a wallet for Christmas but it has to be a leather one. His group at school grouses about "child labor" and requirements that they empty the trash. After all, his parents paid for everything and he should not have to help. He also feels that adults need children to "continue civilization because the world needs civilization." His father recently found crumpled cigarette packs in Chuck's closet. Chuck hates smoking and dislikes smokers but was smuggling 2 or 3 cigarettes per day into school in an M&M wrapper and peddling them to the other students. (3)
"Manic Switching" is clinically blatant and may occur every few days. It may also occur as often as 30% of the time when an ADHD child is started on a tricyclic. However, there are more subtle types, that likely do not meet clinical standards for diagnosis, but still transform, as they did for Chuck, the child's operating characteristics for loyalty, compliance, guilt, and honesty. You have to talk to the child, to know him pretty well, to notice these changes in him because of their slowly evolving shifts.
It's not uncommon for a child or adolescent to start with a baseline of blues, tears, social isolation, and lots of physical complaints. Although mania can occur at any age, it seems more likely in the teens when shy children graduate to terrorism. There will likely be some tales of sad children given SJW, switching later (either because of SJW or because it was time anyhow) into subtle or blatant forms of grandiosity. (4)
I think we will all have to deal with these phenomena. SJW is out there, it works for common complaints, it's inexpensive, and you don't have to tell your physician or see a head doctor. School guidance counselors may well be recommending SJW, sotto voce, to anxious mothers.
For example, Joey is 12, with a long history of tears and social avoidance. He's in a new school, experiences panic during the day and has 20-60 minute crying tantrums in the evenings because his folks won't sell their new house and put him back in his old school district. Dad had similar fears and inhibitions in school. It all sounds biological and a likely target for an SSRI in addition to some behavior mod. However, his parents don't believe in medicines and started him on SJW some 4 weeks before bringing him to me. He's had some benefit but is still miserable too often for their comfort.
I called my favorite and brightest and most energetic pediatrician who had no information on SJW or its pharmacology. I called several pharmacists who also knew nothing about SJW mechanisms or possible interactions with SSRIs.
I hit the Net and found SJW to be a lively topic. One report noted SJW to be 56% effective for mild or moderate depression, twice the placebo response rate (which was unusually low for a depression study) and some speculations about monoamine oxidase inhibition, serotonin uptake blockage, norepinephrine uptake blockage, and some inhibition of GABA binding. None of these things were surprising given our apparatus for rejection sensitivity, for achievement and arousal, and for anxiety appear to involve serotonin, NE, and GABA. Any substance affecting those emotional experiences is apt to involve their correlated juices. An antidepressant that operates independently of serotonin would be surprising.
We started him on 6 mgs (normally a silly amount) of Zoloft and graduated him to 12. He has done markedly better since. He still wants to go back to his old district but he's participating in the new one, his grades have come up, and he's joining some teams. I still worry and will do so until there's some more information about enzyme kinetics in his liver.
Pete, also 12, was inattentive in class but not hyperactive. He failed his CPT but had a marginal response to 5 mgs of methylphenidate. In addition, he became more picky and critical. He knew nothing of his math or spelling lessons but his Psych Adaptations that inventoried his teacher's annoying quirks worked at peak efficiency. He began SJW without information to the teacher. Her reports after a week included the words "focused, pleasant, cooperative, accepting of help, and asking good questions" (She was still annoyed by his calling out more, but she seemed to had her own difficulties with activity level and auditory distractibility.)
The evolutionary relevance?
The Adapted Mind (1992) describes Psychological Adaptations as highly efficient systems for processing information and solving problems. We are thought to have adaptations for avoiding poison and for recognizing edible fruits and vegetables. This could be a basis for the ease with which many mothers opt to purchase green things (or white things made from green things) at a health store and give them to their children. This same group of mothers can be strongly critical and avoidant of medication, citing Pete Breggin or the most recent "Prozac Tale" from the news.(5)
Parents also rescue complaining children. One of my most uncomfortable jobs is periodically, with parental consent, giving Time Out to a 4-8 yo in my office, in his parents' presence. The child's adaptive tools (crying, sobbing, calling mommy) routinely elicit parental fidgeting. Getting the child out of direct eye contact with the parents makes it easier for him/her to meet a 3 minute criterion for silence in TO. These reactions may someday qualify for status as a Psychological Adaptation; meanwhile, I suspect they will tip many mothers towards the option of making their child happy even if less productive and purchasing SJW even if he calls out more in class. (7, 8, 9)
1) SJW, by Net resources, is estimated to be mildly to moderately effective for anxiety and depression. Like the SSRIs, it will apparently cause some nausea and GI difficulties in some adults. If it's really an effective and irreversible MAO inhibitor, people should not be eating tyramine-containing foods because such may cause lethal reactions in combination with a synthetic MAOI. Still, there don't seem to be stories emerging about autonomic emergencies after a dinner of SJW and Stilton. The English surely would have noticed these phenomena. I once got in trouble for remarking to a group of school administrators that the willingness to stand in lines more than a few people in length was correlated positively with depression. The high school principal was English and objected that long lines are tolerated just fine in the UK. He may have proved my point.
2) See related postings on mania and alpha traits.
3) I reminded him that the world does not "need" civilization and that children have traditionally been sought for labor, whether on farms in this country or in Asia to manufacture sneakers. I probably could have skipped the lecture and been just as far ahead as Prozac continues to clear his system. His grandfather on his mother's side believes in UFOs, aliens, and spirits. The old man has been in trouble for one irresponsible thing or another for much of his life.
4) This danger is not confined to SJW; it has been a traditional risk with TCAs and the SSRIs. I knew one gentleman in various social embarrassments who was given on Prozac by his diabetes specialist. The client promptly sold his foundering business and left town to sell antiques at a resort. He's bright. He may have made it and his decisions to leave could have been good sense. His wife and children were certainly puzzled by the change. In theory, one could argue that Prozac lowered his worry about making social mistakes; however, his ADHD-impulsiveness was still fully operative. Prozac has been noted to make a significant percentage of children more restless and to do so quickly. Are they sprouting manics or disinhibited ADHDs?
5) SJW may also be used in combination with stimulants at some point in order to reduce severity of some of the "ADHD comorbidities" such as anxiety or dysthymia. Again, this group of children may be at some risk, although probably less than with the more potent TCAs and SSRIs, for manic patterns, including grandiosity.
6) There may be some age-related changes on this point. Sometime around third grade, the child is at a larger risk for ADHD diagnosis and beginning stimulants even if they don't make him happy. Parents could be making a trade of some (hopefully) short term complaints from their budding manics in exchange for better marks and more choices in the remote future.
7) The marked inconsistency in these situations is perhaps another clue to the power of Psychological Adaptations. The effect is enhanced by avoiding physicians and costs and by parents' forming alliances with health foods staff and other parents. This is not a good time for managed care to switch to an 8 minute standard to assess a child or adult. It is also not a good time because the subtlety of many effects requires more than 8 minutes to uncover.
8) Things may not go that badly because the Europeans appear to be doing fairly well. Some protective mechanisms might be that parents become less consistent with medication when the child becomes happier. Thus, a negative feedback loop could exist between the child's mood and the chances of his being given pills or weeds. Also, as the cost of SJW climbs (said to have tripled in the past few months), people will be reluctant to continue it. Even a mild manic episode could have its positive aspects. Many manics are reluctant to be "taking" anything, that "anything" could include SJW. If so, then any resulting mania could raise the probability of the child's refusing to take it because he "doesn't need it."