People with recurrent depressions can be divided into unipolar and bipolar categories. Those with recurrent unipolar depressions suffer only from periods of low mood, separated from one another by normal periods. In contrast, those with bipolar depression experience periods of exaggerated energy and activation as well as depressions. During their activated periods, known as manic or hypomanic (less than manic) episodes, these individuals need less sleep, think and talk more quickly and are more sped-up than normal. Sometimes they are elated but at other times quite irritable and angry, especially when they feel blocked, frustrated or thwarted by those around them, who appear to them to be moving at a snail’s pace. The question here is whether a bipolar person can safely use St John’s Wort during a period of depression.
Unfortunately there are as yet no published studies on the use of St John’s Wort in the treatment of bipolar depressions. We do, however, know two important facts about the treatment of bipolar depression with other anti-depressants: (1) All anti-depressants that work in the treatment of unipolar depression also work for bipolar depression; and (2) All anti-depressants are capable of inducing hypomanic or manic episodes in patients with bipolar depression. Based on these observations, I would expect St John’s Wort to be an effective anti-depressant in bipolar depressions. I would also caution anyone with a tendency to develop hypomanic or manic symptoms to be sure to use the herbal antidepressant only under the close supervision of a doctor, and on no account to experiment with its use on your own. In addition, in most bipolar patients it is customary to use a mood stabilizer such as lithium carbonate or valproic acid before adding an antidepressant, to guard against the development of a hypomanic or manic episode. For those of you who are wondering why one should be so careful to prevent the development of a hypomanic or manic episode, I should mention that they can be extremely disruptive and destructive to a person’s life. Even though a mild hypomanic episode may not be harmful, when the process reaches its extremes it can cause the breakup of a marriage, the loss of a job, serious financial reversals and physical injury to the affected person.
I should emphasize that, to my knowledge, there has not been a single report to date of a manic episode induced by St John’s Wort and that there is no greater reason to be concerned about the herbal remedy in this regard than about any other effective anti-depressant. Even so, it is good to be aware of the potential risk, especially if you have a history of hypomania or mania. One of my patients who has experienced recurrent depressions and mild hypomanias in the past is on a maintenance dose of lithium carbonate to stabilize his moods. When he developed a mild depression I started him on 600 mg of St John’s Wort per day. A week later he rang me to say that he was feeling ‘too good’ and waking up in the early hours of the morning. I interpreted this as possible evidence of hypomania and suggested that he cut back to 300 mg a day, which turned out to be just the right amount for him. Once you are aware of the possibility that hypomania can develop with the use of any anti-depressant, you are forewarned
and better able to deal with the symptoms should they arise.
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