Michael Jenike, MD, editor,

Journal of Geriatric Psychiatry and Neurology, 1994

One result of the success of modern medicine in conquering the diseases of childhood and middle life is the ageing of our population and the progressive increase in those of us who can be regarded as elderly, regardless of how we define that term. Depression is very common among the elderly and major depression has been estimated to affect approximately one in seven individuals over age 65 in community settings, and as many as one in four individuals in nursing homes. An index of the severity of this problem is the fact that the highest suicide rates occur among our elderly citizens. The elderly have many reasons to be depressed, including physical ailments, isolation from family, the loss of friends, and financial difficulties, to name just a few. This leads to the common misconception even among healthcare workers that depression may be a natural and justifiable response to an elderly person’s life circumstances. Regardless of how adverse a person’s life circumstances may be, wherever depression is encountered, including among the elderly, it is certainly worth treating. This will often result in a markedly improved quality of life even though it will not necessarily change the realistic basis for a person’s sorrows.

Because St John’s Wort has only recently come to the attention of clinicians, doctors have very little experience with its use in older patients with depression. Yet, as Michael Jenike points out in the editorial quoted above, St John’s Wort would seem like a very reasonable anti-depressant for those elderly patients who are depressed. As our population ages, medications that are suited to older people will surely become increasingly important and, considering the widespread prevalence of depression in the elderly, it is a particular blessing that Nature’s own apothecary appears to have yielded so excellent a remedy for this group of people in the form of St John’s Wort.

Perhaps the person with the most experience in treating elderly patients with St John’s Wort is Dr Hans-Peter Volz, Chief of the Department of Psychiatry in Jena, Germany. He estimates that he has treated approximately 70 depressed patients over age 65 with St John’s Wort in dosages of up to 900 mg per day. He is comfortable with recommending it as a first-line treatment in mildly depressed elderly patients, though he is still inclined to use conventional anti-depressants for those who are moderately or severely depressed. He acknowledges, however, that his practice of not using St John’s Wort as a first-line treatment in more seriously depressed cases is not based on any direct experience of its ineffectiveness for such people, but rather on the absence of sufficient controlled study data on St John’s Wort in severely affected individuals.

Volz reports excellent anti-depressant effects in the elderly people he has treated with St John’s Wort, with very few side-effects. In addition, he has noted no adverse interactions between St John’s Wort and the many drugs that elderly people often need to take for ailments accumulated over a lifetime. He emphasizes the need to wait six to eight weeks before passing judgement as to whether the herbal remedy is working or not. Here are two cases from Professor Volz’s clinical files.

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Does being ill bring more care and attention from others or protect you from issues you are unwilling to face? Are you avoiding rejection/going out into the world/being an adult/admitting you are with the wrong partner? Because of the illness are you able to avoid responsibility/ risks/social interaction/a sexual relationship/failure or physical effort?

If you are not doing any of these, are you hanging on to sadness or hurtful feelings from the past in order to justify the way you are?

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Tie something around your wrist to remind you to be aware of your breathing patterns.

1. Do two 1\2 hour breathing exercise sessions per day and note your breathing rate every hour.

2. Loosen anything tight around your waist and preferably lie on the bed or floor.

3. Allow your lungs to inflate fully by gently lifting your tummy out as you breathe in (it could make you a little light-headed or tingly at first) and allow it to fall as you breathe out.

4. Try to keep the breaths equal and aim to gradually train yourself to breathe between 8 to 12 breaths per minute.

5. Don’t exhaust yourself by doing this too vigorously. Once you have mastered this, you will be able to do it anywhere—standing at the bus stop; whilst ironing; whilst washing up.

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The Open University course called ‘Anxiety and Benzodiazepines (Tranquillizers)’ recommends a dose reduction of 1\8 th of the daily dose per 2-4 weeks. Some people feel that this regime prolongs the agony and prefer to tolerate symptoms of a more rapid withdrawal. The course also recommends that where a short-acting drug (e.g. Ativan) is being taken, a long-acting drug (e.g. Valium) be substituted. This can be done when the lowest possible dose of the short-acting drug is reached. Alternatively the recommendation for Diazepam (Valium) substitution from the Drugs Newsletter, No. 31, April, 1985, of the Regional Drug Information Service, Newcastle upon Tyne, can be used.

The benzodiazepine in use should be replaced in increments of one dose per day by the equivalent dose of diazepam [see Appendix]. This substitution can usually be accomplished within a week, although the duration of this period should be varied to suit individual patients. For example, a regime for a patient taking Lorazepam lmg morning, midday and evening is to replace the evening dose with l0 mg Diazepam for two days, then add replacement of the midday dose for two days, and finally replace the morning dose. The patient is then taking a daily dose of 30 mg Diazepam, which is approximately equivalent to 3 mg Lorazepam. Some patients feel better when Lorazepam or other relatively short-acting benzodiazepines are replaced by Diazepam in this manner. Some, however, require slightly more than the approximately equivalent dose of Diazepam given in the table to replace the benzodiazepine they are used to. A minority of patients experience real difficulties in changing from one benzodiazepine to another. In these cases, the changeover needs to be carried out more gradually.

It is generally agreed that the short-acting drugs cause most problems during withdrawal.

Many people have found the short-term or intermittent use of Propranolol (Inderal) useful. It helps the panic attacks, palpitations, sweating, and is a mild sedative.

It is extremely important to check with your doctor before you reduce any drugs.

Do not compare the numbers of milligrammes—1 mg of one drug cannot be substituted for 1 mg of another drug. 5 mg of Ativan does not equal 5 mg of Valium or 5 mg of Mogadon.

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