Sleep Disorders and Insomnia
One of St. John's wort's major advantages over prescription antidepressant medications is its ability to promote a better quality of sleep. Unlike St. John's wort, most antidepressants lengthen the time it takes to enter the REM (rapid eye movement) sleep phase, reducing or even eliminating REM sleep. Far from inactive during sleep, the subconscious mind is busy analyzing the day's events and processing feelings during the dreaming or REM phase. This is essential for mental health.

Pete is an example of someone whose sleep disorder was relieved by a combination of St. John's wort and sedating herbs.

Pete, a 40-year-old businessman, blamed his inability to sleep on his stressful job. He would toss and turn, worrying about his work problems and about being too tired to handle them the next day. He was always exhausted from lack of sleep.

Dreading the thought of another tormented night, Pete asked his family doctor for a sleeping pill prescription. Fortunately for him, his doctor was aware of natural alternatives, and suggested an herbal approach to the problem. For the insomnia, he recommended an herbal combination of valerian and kava, both excellent sedating herbs, and for the underlying depression, St. John's wort. Pete was then able both to get to sleep and to remain asleep through the night. Just having sufficient rest was enough to help his mood. Then, after a few weeks, the St. John's wort began to work more noticeably, and he could feel his mood lift further, and he had less need for the other herbs.

Had Pete gone the standard medical route, the requested sleeping pill prescription would have handled the symptom-temporarily. The downside would have been habituation, in which he would have needed increasing doses for the same result, in addition to the lack of REM sleep.

St. John's wort is also helpful for insomnia in general, not just that associated with depression. Prescription sedatives often produce grogginess or a hangover effect the next morning, and can also be addictive. St. John's wort, on the other hand, works with the body's own sleep-promoting mechanism to bring on restful sleep. It harmoniously enhances the natural actions of the brain, instead of drugging it into submission. Consequently, one awakens feeling more relaxed and refreshed. Since it can take a week or so for this effect to begin, St. John's wort is recommended mainly for recurring insomnia, and not just an occasional night of tossing and turning.

Seasonal Affective Disorder (SAD)
St. John's wort can also be used to treat SAD. As we saw in Chapter 2, persons with SAD, a form of major depression, are profoundly affected by the lack of sunlight that occurs in autumn and winter. This triggers biochemical changes in the brain, directed by the brain chemicals melatonin and serotonin, and leads to such symptoms as depression, impaired concentration, anxiety, marked decrease in energy and libido, and carbohydrate cravings. Also, like bears preparing to hibernate, these people eat more, gain weight, and need more sleep.

Scientists have found light therapy to be effective in treating SAD. Light therapy consists of exposing the individual to a set of full-spectrum fluorescent lights during the early morning and evening hours. Alternatively, lighted visors can be worn that shine light through the eyes and into the pineal gland. This stimulates the production of melatonin, a hormone associated with cyclic bodily processes. St. John's wort can be combined with light therapy for greater effect. In the view of herbalist Terry Willard, the herb "brings light into dark places." He finds it extremely effective in treating the rampant SAD that occurs during the long, dark winters of northern Canada, where he lives and works.

Premenstrual Syndrome (PMS)
PMS is a common complaint that produces both physical and mental symptoms. Since some of its mental symptoms are similar to those experienced during depression, including irritability, tension, and restlessness, it should come as no surprise that St. John's wort can help. For centuries, herbalists have recognized the herb's value in treating discomforts associated with the menstrual cycle, and it remains a most widely utilized natural treatment for PMS, as well as menstrual cramps. The latter is likely due to the herb's ability to reduce uterine levels of prostaglandins, substances that can promote inflammation. You will often find women's tonics that contain St. John's wort in combination with other ingredients that function in a similar manner.

What to Expect and When to Expect It
As with most antidepressants, it may take three or four weeks before you notice a significant effect. Larger dosages are unlikely to reduce this time lag. On the other hand, positive results often occur sooner. For example, within a week to ten days, many people notice improved sleep: better quality, fewer interruptions, and even more dreaming. After one to two weeks, there may be improvements in appetite, energy levels, and physical well-being. By the second or third week, there is a reduction in emotional symptoms, with less anxiety, a more positive mood, and a greater sense of peace.

Many of my patients report positive effects almost immediately, with a sensation in their brains of "a weight being lifted," decreased anxiety, and an enhanced ability to concentrate. We don't know if this is a "real" response, or simply a placebo effect brought on by positive expectations. It is also important to remember that as with any remedy, natural or synthetic, St. John's wort affects different people in different ways. Some people experience changes sooner or later than average, and some don't experience changes at all.

How does St. John's wort work? At this point, it is hard to give a definitive answer. While initially thought to be an MAO inhibitor, St. John's wort is more likely similar in its action to the SSRIs such as Prozac (see Prozac and Beyond-The Synthetic Antidepressants). These reduce the rate at which the brain cells reabsorb serotonin, leaving more of the neurotransmitter molecules in the synapses, thereby enhancing receptor-site activity. And, as I've said before, in people who are depressed, the brain's receptor sites are often less sensitive than normal, and it is possible that the herb enhances the sensitivity of these sites. It has also been suggested that St. John's wort inhibits interlukin-6, a chemical messenger that mediates the stress response. This gives St. John's wort an antistress effect.

In any case, do not expect instant results, like Rob did.

Rob, an artist acquaintance of mine, was a moody, impulsive guy who, for example, would go from being excited about a project to forgetting about it entirely. He heard about St. John's wort, and thought it might smooth out his moods. He asked my opinion, and I agreed that it was worth a try. He began that very day. When he didn't feel any different an hour after his first capsule, he took another. And another. By the end of the day, he had taken four. Then he called me, asking why it wasn't working! I explained that St. John's wort was not a stimulant, nor was it rapid in its action. Rather, the antidepressant effects accumulate over time, and that he had to take it regularly for a few weeks before he would begin to notice a difference. Rob was disappointed.

Rob seemed to be caught up in the "take a pill for fast, fast relief" mentality.

Some depressions may not respond at all to St. John's wort, depending on the source of the depression. Take Gretchen, for example.

Gretchen, a bright, creative hairstylist and artist, had been depressed for a couple of weeks. "I was going home at night and crashing, not wanting to see anyone. I just wanted to sleep when I wasn't working. I had read about St. John's wort, and decided to try it for two weeks. Nothing changed. Then I remembered that I have a tendency to be anemic." When her iron was low, Gretchen would feel tired and depressed. "I went off to the health food store, bought some iron, took it daily, and within a week, was feeling normal."

Was this a St. John's wort failure? I don't think so. Rather, Gretchen is a great example of someone who understands her own body, looks for a recognizable pattern, and feels confident enough to take charge of her own health when necessary. Before assuming that the source of a depression is a neurotransmitter imbalance, you should look for a nutritional deficiency or other physical disorder. We will look at this in more detail in Nutritional Approaches to Mental Health.

When there is a neurotransmitter imbalance, my preference is to start with St. John's wort, unless in one of the exception major depression or bipolar disorder. This herb still has many advantages over the synthetic antidepressants.

St. John's Wort's Effects on Other Disorders
Though current attention focuses on St. John's wort's role in the treatment of depression, the herb has been shown to have many other valuable medical uses as well. Studies have shown that St. John's wort has broad antiviral and antibacterial properties, and relieves inflammation. This confirms its traditional usage as an excellent treatment for wounds and burns. Also, St. John's wort may be useful in cancer treatment.

How can one herb produce so many different benefits? St. John's wort is a complex mixture of at least ten groups of active ingredients (see chart), each with its own effects. It works with our bodies to achieve healing in multiple ways. A manufactured drug, in contrast, is aimed at one specific target, and often produces negative side effects when its action expands beyond that target. The opposite is true of herbs such as St. John's wort, which contain compounds that work together to accomplish more than any one component could do on its own. Rather than unwanted side effects, you receive bonus healing effects.

It is also important to remember that the holistic view of medicine does not separate illness into two neat stacks, physical ailments and mental ailments. To begin with, many physical disorders can lead to depression, and depression in turn can lead to physical illness. In addition, the mind-body continuum has common influences, and imbalances can be bodywide in nature. Therefore, the use of St. John's wort, by relieving your physical problems, may very well help lift your mood.

Antiviral Actions
St. John's wort has been shown to have dramatic antiviral activity, although in dosages much higher than those required to treat depression. Experiments, both in test tubes and in animals, have indicated that two of the active chemicals in the plant, hypericin and pseudohypericin, are clearly effective against a number of retroviruses, including the herpes and hepatitis C viruses. The herbs show significant activity against influenza types A and B; the vesicular stomatitis virus, which causes inflammation of the mouth; and even the Epstein-Barr virus, which is associated with infectious mononucleosis and chronic fatigue syndrome.

Hypericin and pseudohypericin show great promise for several reasons. They inactivate or interfere with the ability of viruses to reproduce. They are also able to cross the blood-brain barrier, an organic safety mechanism that prevents many substances from reaching the brain. Intended to filter out toxic substances, this barrier also denies entry to many beneficial ones. The ability to cross this barrier is particularly meaningful in dealing with viruses that target the brain.

In several cases, the two chemicals have proven effective in preventing disease after a single oral or intravenous dose. This is highly unusual, since viruses are normally much more resistant than that to treatment. Compared with other antiviral medications, St. John's wort has very few side effects, although there can be some phototoxicity, or extreme sensitivity to light, when it is administered in very high doses. Researchers are now studying the potential of hypericin against other viruses.