Reader seeks alternative to prescription antidepressant

DEAR DR. ROACH: I suffer from depression. It comes and goes, but I’ve been feeling sad, worried and angry at the world, as well as irritable, for the past four months or so. I force myself to function.

My family doctor prescribed Effexor. He prescribed a 37.5 mg dose once a day to start and after one week, twice a day. I looked up the side effects and what I read scared me. Instead, I’ve been taking 1,000 mg of St. John’s wort daily. It’s approaching three weeks. To date, I have noticed no discernible effect.

I told my doctor I would take the Effexor after three weeks if the St. John’s wort hasn’t helped. Should I take his advice? Are there better alternatives? I am middle-age and take zero prescription drugs. — S.M.

ANSWER: St. John’s wort, Hypericum perforatum, is a yellow flower that has been medicinally used for centuries. Initial studies suggested benefit in people with mild to moderate depression, and several substances in the flower have been shown to have pharmacologic effects on serotonin receptors, among other effects.

However, other trials have shown St. John’s wort to be no better than placebo. It does have important drug interactions, fortunately not an issue for you (as long as you let the St. John’s wort wear off before starting Effexor), but for some people the potential interactions are dangerous.

Side effects are not common, but include gastrointestinal upset, dizziness and confusion, fatigue, dry mouth and sexual side effects. It can make people more sensitive to sunlight, and may decrease fertility.

The studies that did show a benefit lasted four to 12 weeks. It is possible you might not have had benefit from it yet, and waiting a little longer, say another week, wouldn’t be unreasonable to really give the St. John’s wort a chance.

However, I seldom recommend this herb due to lack of consistent benefit in trials, the potential for drug interactions and a concern about poor regulation of supplements in terms of amount and purity of the ingredients.

For people who want to avoid prescription medicine, I often recommend S-adenosyl methionine (SAMe). The evidence is better and the side effects and drug interactions fewer.

Effexor may be a good choice for you. Prescription antidepressants have been shown to be better than placebo, but they do not work for everybody. If Effexor isn’t a good choice, there are several others.

However, I would strongly recommend you consider nonpharmacologic treatment for depression whether or not you decide to take additional medication treatment, be it prescription or over-the-counter.

DEAR DR. ROACH: A few years ago, I read that the herbal supplement feverfew may help with some migraines. Having suffered with migraines for over 50 years, I decided to try it. I take one capsule four times a day, and it has rid me of my migraines. Would you please mention it again?

ANSWER: Feverfew is a common herbal remedy to prevent migraine, and although not all trials have shown benefit, the majority of studies I have read showed that it is more effective than a placebo treatment and the side effect risk is very small.

Other nonprescription treatments that have been shown to be beneficial include magnesium, riboflavin and coenzyme Q10.

These treatments are generally safe and well-tolerated.

DEAR DR. ROACH: In 2008, I had a partial sigmoid colectomy. Since then, I have had no recurrence of diverticulitis. The surgeon recommended I not use laxatives but take fibre gummies to keep things moving easily in addition to drinking lots of fluids.

I am doing that, but my flatulence could power all the homes in a small city. It is difficult to control outbursts. Is there any other way to avoid hard stools, and other unhealthy gastrointestinal situations?

ANSWER: I agree with the surgeon that getting fibre and plenty of water is the safest and best way to prevent problems. However, maybe it isn’t just the fibre, but your diet that is at least partially responsible for the increased gas. You could try reducing your intake of foods in the cabbage family, onions, beans, corn and other gas producers. Avoid carbonated beverages and any beverage containing artificial sweeteners. In some people, changing the bacteria that live in your gut (your microbiome) through probiotic supplements and a change of diet can reduce the amount of gas produced.

There are other types of fibre supplements that might be better tolerated.