People have asked the question of what to do with their thoughts while working through issues in psychotherapy. There will be issues in therapy which need to be thought through and worked with, and they may cause anxiety and attacks. Again, it means walking a fine line. Be aware of why they have occurred and let them happen.

As our management skills increase we will begin to realise a subtle pattern emerging with our anxiety and attacks. When we are avoiding confronting particular personal issues, or in other words, not being honest with ourselves, we may find ourselves reacting with anxiety or an attack. We can use these subtle guides to get to know and understand ourselves on a deeper level.

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In some people the sexual side-effects of the SSRIs can be extremely marked. For example, they may cause impotence in men or complete inability to achieve orgasm in women. Depressed people generally have a diminished interest in sex to start with, and any anti-depressant may improve the level of interest and overall drive to connect with others sexually as well as socially by reversing7 the symptoms of depression. Initially people are so grateful to be free of their depression that any sexual side-effects they might experience might seem like a small price to pay for feeling better. After a while, though, the side-effects become less and less acceptable as they begin to take a toll on a person’s relationships and impair one’s quality of life.

Sexual side-effects of the SSRIs can involve decreases in sexual interest or arousal or subtle changes in the experience of sex. A colleague of mine, for example, who was previously on Lustral and is now taking St John’s Wort, described how on Lustral he had been able to function sexually but the orgasms just did not feel as good. ‘On Lustral’ he recalls, ‘I was still interested in sex and my erections were fine, but it took me longer to reach orgasm and, when I did, the arc of the orgasm was slower and more protracted and did not reach its previously satisfying level of intensity. I am glad to say that on St John’s Wort my orgasms are back to normal again.’

It would not surprise me, however, if in the course of time evidence emerges for alterations in sexual functioning on St John’s Wort as well, though perhaps only in a very small percentage of those who use the herb. This might be more likely to occur if people push the dosage of the herb above 900 mg per day, as I predict many will in their attempts to explore the full range of the herb’s efficacy. I have already encountered two people who claim some alteration in libido and sexual pleasure on St John’s Wort, albeit to a lesser degree than on the SSRIs. Given our best understanding, that St John’s Wort probably works at least in part by increasing the availability of serotonin, the biological mechanism believed to be responsible for the sexual side-effects of the SSRIs, some sexual side-effects might be expected to be reported as the herbal anti-depressant is more widely used.

It is important to remember that a slight decrease in sexual enjoyment may be an acceptable trade-off in exchange for being free of the painful symptoms of depression. One man whose depression had been successfully treated with Prozac for the previous two years switched to St John’s Wort after seeing a television programme about it. Two weeks after the switch he wrote to me that ‘the ol’ sex drive has come back with a vengeance … my wife is thrilled.’ Several months later, however, I checked up on how he was doing and learned that his depression had returned and that he had developed panic attacks, which resulted in his returning to conventional anti-depressants. It must be acknowledged that no medication, herbal or otherwise, is right for everyone. Nevertheless, St John’s Wort may actually turn out also to be of some value in panic disorder, as the following accounts suggest.

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