Transition from Pharmaceutical Antidepressants

In patients who were initially prescribed pharmaceutical antidepressants for mild to moderate depression, transition to herbal supplements can be tried if patient and physician determine that it is warranted. However, the optimum manner of arranging such transition is unclear. Some physicians who fear to overlap treatment on the basis of concerns over serotonergic syndrome recommend an adequate washout period prior to starting St. John’s wort. For drugs with long half-lives such as fluoxetine, many weeks may be necessary.

However, other physicians overlap treatments intentionally. Their purpose is to avoid the withdrawal reactions sometimes seen with all antidepressants and to minimize the period of no therapeutic benefit. A common, but not formally evaluated, approach is to simultaneously start St. John’s wort and cut the dose of pharmaceutical in half. After 1 to 2 weeks, the drug is stopped entirely. Clinically, this procedure is usually well tolerated, and no reports of serotonergic syndrome or any other significant adverse effects have been published (yet).

In patients who were initially prescribed medications on the basis of a severe clinical depression, St. John’s wort will likely be inadequate to prevent a relapse of symptoms. It should not be used as sole therapy in place of pharmaceutical treatment. The only exception is in patients who insist on stopping medication of their own volition anyway but who do not mind herbal treatment. St. John’s wort may be useful here on a better-than-nothing basis.

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