♪ Bob and Brad ♪
♪ The two most famous physical therapists ♪
♪ On the internet ♪
- Welcome, my friends, to the "Bob and Brad" podcast,
produced by Bob and Brad,
the two most famous physical therapists on the internet,
in our opinion.
I'm Bob Schrupp.
I'm gonna be your host today.
I'm exactly one half of the Bob and Brad team.
I'm joined by Chris, the pharmacist,
who is, as I've said before,
one of the smartest guys I know.
And that's a compliment, Chris.
- Appreciate that. - So, today we're gonna talk
about should you use St. John's wort for depression.
And it's funny 'cause you brought this up to me a while back
and then I had a nurse practitioner mention to me
that, you know, if you are having trouble
with anxiety you maybe wanna try it.
I know you were kind of against.
- Yeah, you have to be careful.
I mean, St John's wort has a place in the role
of treating mild to moderate depression,
but the problem with St John's wort almost exclusively
is just the amount of drug-drug interactions
that it can cause and if somebody's already on a medication,
that would be very, very dangerous recommendation.
- Yeah, so it's, I mean, we're gonna name some of the drugs.
I looked up some and it can also affect
like, they're not sure how it affects pregnancy.
- With respect to pregnancy.
I mean, right now, I mean, St John's wort in and of itself,
I mean, there are, you know, most of the research
has been done by Germany and the German monograph E
is kind of the Bible for all of these types
of herbal remedies for any type of health condition.
But with pregnancy, there's just not enough data
that really supports safe use of it.
I mean, right now in the prescription world,
really the safest choice is probably sertraline,
but, and you know it's interesting pharmacologically
when you look at St John's wort,
it's kind of got the best of all the prescription worlds.
It's got year monoamine oxidase inhibition,
it raises serotonin, it raises norepinephrine,
and it raises dopamine.
So, when you take all those together,
I mean, you think on paper at least,
it would look really good,
but when you're looking at something as important
as being a pregnant woman,
the last thing we wanna do
is take any chance in causing any problems.
And right now I would- - The same holds true
for children?
I saw they really didn't have research
on that either. - They don't have a lot.
I found a couple of studies that suggest
that if they're over the age of 12
that maybe half the adult dose
which for an adult is 300 milligrams three times a day,
900 milligram total daily dose.
But, I would be reluctant to use it in children as well
because there's just I don't think enough data
that really- - Sure.
- Plus or minus at the end of the day though,
I mean, you know, children are pretty much small adults
as they start to age, but you know,
there's a point where with growth spurts in adolescents,
there's a lot of brain chemistry that's changing.
And even in the prescription world,
I mean it's becoming used more now with the pharmaceuticals.
Some kids with depression issues, anxiety issues,
that they will use a prescription,
but this is more of an unknown.
I would be really reluctant unless, and again,
just because of all the drug-drug interactions
which we'll certainly touch on.
- And you were saying in Germany,
it's actually a prescription drug.
- In Germany, it's specifically a prescription.
- And used quite a lot. - Used a lot.
Probably even more so than even some of the prescriptions.
- It's funny, I was looking at studies
and a lot of the German studies were positive towards it.
- Well, they are positive in certain circumstances
and I think when you take the Americanized studies,
which are based off of all the German studies,
they show that at least compared to,
and they use placebo and they use actually head-to-head,
they use pretty much what we would call moderate
or low doses of the other,
they call second generation antidepressants.
So, that's pretty much anything
that was invented after the 80s.
So, it's kind of everything that we use today.
So, you know, it stands up.
I mean, if you are going to take,
you know, St John's wort as a single agent
with nothing else in your system,
for mild or moderate depression,
I would say it's okay to try
as long as your doctor is on board.
And then, you know, you really have to touch on
with the doc, I mean,
you cannot use over the counter cough and cold preparations
that contain pseudoephedrine.
You have to stay away from cured meats,
aged cheeses, red wine, beers.
I mean, you know, alcohol. - Wow, so it's not
just other meds.
- No, it's everything.
And that's why I have
a hard time supporting it. - I haven't seen that list.
I saw- - It's intimidating.
Well, obviously, if you're gonna go on anti-depressants,
you shouldn't be doing that.
- Correct.
- But, I saw birth control pills.
- Birth control pills, blood thinners.
- Cyclospor- - HIV medication.
- Cyclosporine.
- Cyclosporine which would be used for organ transplant.
- Oxycodone.
Digoxin. - Digoxin for your heart
and other heart medications.
- Some HIV drugs. - Correct.
- Some cancer medication. - Absolutely.
So, you know, and that's the thing that makes it so...
It's metabolized in our livers.
So, cytochrome P450 system, and what it does,
it actually can influence either making
some drugs go higher in your system
or go lower in your system. - Sure.
- And that's why the danger exists.
And to the average person, unless you ask your pharmacist
or if you consult your physician or practitioner,
a lot of times, and even then,
look at the example with the practitioner you came up with
where a nurse practitioner, said,
"Well, why don't you use this?
Well, I'm already on something?"
And that, you know, when you take it
with other antidepressants,
increase risk for seizures, serotonin syndrome,
I mean, there's things that we have-
- Yeah, that's what I read,
it increases your body's serotonin levels
to possibly a dangerous life-threatening level.
- Correct. I mean, it's a rare interaction to begin with,
but to me, I mean, I am conservative by my nature
and my recommendations.
I mean, the only thing I care about is patient safety
and good results.
So, actually two things,
but I mean, the reality of it is,
is that we want to make sure
that if you're gonna choose to do something like this
that you are acutely aware that St John's wort
should be used with absolutely nothing else.
- Well, the other thing is that we don't wanna encourage you
to try to treat depression on your own.
- No. - And St. John's wort
could possibly do that.
- Yeah, well, it's available on any drug company
or any internet.
I mean, you go onto Amazon
and there's 100 different versions of it.
So, but I mean, the biggest thing is,
is you wanna see your doctor first, 'cause let's rule out,
maybe there's something else that's the cause of the issue.
And so, if we really don't, you know, and I mean
if you wanna have the discussion with a doctor,
"Well, I'd really like to try something more natural."
'Cause, I will tell you that St John's wort does tend
to have less side effects than the prescriptions.
So, that is an attractive advantage.
And again, I think that's why in Germany,
it's used so frequently is because it's when used in itself
as a singular agent with no other prescription medications
or over the counters,
you can have a relatively comfortable existence with it.
- I mean, when you started mentioning those foods
and you also mentioned alcohol
as far as there's three that you could.
- Yeah. Oddly enough bourbon, you can use vodka,
and you can have rum.
- I could get by.
- Nonetheless, not that we're gonna encourage you, you know,
because alcohol is a depressant, but I mean,
those are the three.
But yeah, you can't have dark beers.
You can't have red wines.
- How about white wines?
- White wines, actually there's some white wines
that you could like a Chardonnay.
- Oh really? - So, yeah.
- Some types.
- Really, you gotta watch yourself.
- You really have to be very, very careful.
And to me, the reason I give the thumbs-down on it
in many cases is because most of us, inadvertently,
you'll be taking the medication,
let's say things are going well,
12, 15 weeks down the road
and you kinda are, you know, not as, you know, post COVID.
Maybe everybody gets their vaccine you're out and about
and maybe you're out at a restaurant.
You know, what if you had like some sort of fancy,
protein-based meal and you wanted to have a glass of wine
and all the sudden you chose the wrong one.
Now, you're creating a tyramine reaction
which can be pretty severe.
So, we have to be super careful with its usage.
and that's why, you know, it's easy to just slip up once,
but it only takes one to create a real problem.
And all of a sudden what turns into a pleasant night
ends up in an ER.
- I did see some studies too
that showed it was not as effective,
you know which there almost always are.
- There are.
- They were saying it was not even as good
as a placebo in one study.
- Some of the older studies have said
that it really doesn't.
Some of the more modern ones do.
And I think it just comes down to, I mean,
we are constantly, when we're researching
these types of things and when doctors
and practitioner groups and university settings
are doing solid research on medications,
they're looking at the old studies and saying,
well, what if we approach this angle?
That's the unique thing about this field
in healthcare in general is that we're always looking
to find ways to improve.
Maybe we didn't look at the study appropriately
the last time, end points and things that they look at
for specific markers.
- It's very rare to find
that they give thumbs up
to a drug consistently in studies.
- Oh yeah.
And again, with St John's wort, I mean, realistically,
I mean, it has a place as long as it's a singular agent,
you're on nothing else.
I mean, I can't stress that enough.
- And that's rare.
- And you want your doctor involved
because like I said, there's other things
that we have to rule out
and I would hate to kinda go on this journey
and then haphazardly be taking something.
Or, let's say you were taking a thyroid medication
and maybe all you had to do is have the dose adjusted.
And also, now we take the St John's wort
and now we've really negatively inhibited
your thyroid production.
- And warfarin. - Yeah, warfarin,
blood thinner. - Very common.
A lot of people on warfarin.
- Lots of people.
We're going away from it because we have some
of the better newer anticoagulants.
- Oh, you do?
- But, warfarin still has a strong place in medicine
and we're gonna use it for years and years to come.
And again, that'd be something that all of a sudden
maybe you're a little low
and you're not really thinking about it.
And you're like, yeah, I've been on warfarin for five years
'cause I've got an issue with the heart
and I'm feeling a little low, it's COVID,
I'm isolated, you know, St. John's wort,
I read on the internet says it's good for depression.
Well, now you've created the bleed risk.
And now, you know, could you have had
a life-threatening bleed?
It's scary.
- Sure. - So, and that's the concern
that I have.
- So, we want you to go into this drug
with eyes wide open.
And, I think Chris has covered it very well
as far as what the downsides are possibly.
So, please proceed in that fashion.
- Absolutely.
- All right.
Thanks for watching.
- Thanks everyone.