Alternative Medical Therapies and Natural Remedies
The use of complementary and alternative medical therapies has been increasing in Americans. Other countries have a greater history in using these substances. Yet American medicine has been at the forefront of the scientific approach and is becoming more focused on Evidence-Based Treatments. Therefore we see a clear disparity with common patient practices and their physician's. 54% of patients reported using CAM therapies for their children but only 11% ever discussed them with their physicians. In this report I plan to inform about the theoretical basis for using complementary and alternative therapies in ADHD. There are very few scientific, controlled studies with these substances. In addition there are few studies that assessed the side affects as well as interactions with other medications and other substances.
Does Diet affect ADHD?
The use of foods and herbs has been used in traditional healing practices for thousands of years. These approaches have been specialized diets of detoxifying and the use of herb potions.
Choosing the right foods or cutting back on the wrong ones may be a proactive way to prevent ADHD symptoms from getting out of control.
Traditional medicine has used elimination diets based on the theory that some foods can cause physical and mental symptoms. There is research that some people are allergic to certain substances and can cause symptomology. One example of this is a gluten allergy. Gluten is in wheat, rye, barley and low level oats and some people are unable to process it, causing GI disturbances, diarrhea and gas. This may be Celiac Disease or Sprue. Children with this disorder can have psychiatric symptoms similar to ADHD or may worsen a patient's ADHD symptoms. Treatment usually entails a gluten-free diet. This can be a very difficult process for parents and their children.
There are some studies that have shown that some children are allergic to preservatives, food dyes, and additives. Children with food allergies have a higher incidence of ear infections and language learning disorders. Inflammatory mediators and neuropeptides increase after exposure to foods that a child is sensitive to. Recent studies have shown improvement in both school performance and behavior in children who eliminated junk food. Essential fatty acids also seem to have a beneficial effect on these problems.
Children love sweets but these can create havoc. Sugar has repeatedly been shown to increase a child's activity level and certainly in ADHD patients. ADHD patients should be careful about diets high in sugar content. Eating several servings of whole grains each day is advisable to prevent blood sugar levels from spiking and then plummeting.
Studies have also shown that people with ADD fare better on a protein-rich breakfast and lunch. Protein is important because it prevents surges in blood sugar that may increase hyperactivity. Parents and children are advised to think about their plates when preparing a meal. A balanced diet will help control mood swings caused by hunger or a shortfall of a particular nutrient.
Essential Fatty Acids
Docosahexaeroic Acid (DHA) and Omega 3 Fatty Acids
Did you know that we are all "fatheads"?! The nerves in our body, and therefore, the brain are made of fats. Without proper nutrition in infants and children, their brains will not develop fully and well.
Recent studies have shown that abnormalities of fat metabolism play a part in neurodevelopmental and psychiatric disorders, such as ADHD, depression, bipolar disorder, learning disorders and even autistic spectrum disorders.
For example, one study showed that a lack of Omega-3 fatty acids could occur in some ADHD children. These children had more temper tantrums, sleep problems, and learning problems such as dyslexia, auditory, linguistic, and motor problems. The body cannot make omega-3 fatty acids by itself nor are people consuming enough foods with omega-3 fatty acids (such as sardines, tuna, and salmon), so their supplements are becoming increasingly popular today.
Research also suggested that children fed with formula have a higher incidence of ADHD symptoms compared to those breastfed or who received milk with added polyunsaturated fatty acids. This second group had better problem solving and language learning skills. In 1995 the World Health Organization recommended baby formulas provide 40mg of DHA per kg of infant baby weight. Nutritionists recommend 100mg per day of Omega-3's to maintain DHA levels.
There are some ADHD children that show impaired metabolism of Omega-3 and impaired ability to synthesize DHA from vegetables. Diets high in trans-fats are associated with impaired brain development and interfere with conversion of vegetable derived Omega-3 and fatty acids into DHA.
Please consult a doctor before adding any omega-3 supplements to your or your child's diet. A doctor can recommend what ratio of DHA should be present to get a better response in ADHD symptoms.
Probiotics are substances that increase the gut flora of good bacteria such as bifidobacteria and lactobacilli.
Some studies have shown these preserve the mucosal barrier of the GI system. This prevents the gut from absorbing certain substances that pass into the blood stream. Children who have food allergies could then be adversely affected. This area needs research to clarify if it improves ADHD and the effect of Probiotics on children. We do know these Probiotics can cause GI distress in some individuals.
Vitamins and Minerals
Adequate minerals and vitamins are essential to normal brain development. Deficiencies in vitamin B & C cause abnormalities of functioning.
There are a few small studies that show blood levels of Zinc, Iron, Magnesium, and B vitamins to be lower in ADHD children. One ____ controlled study showed Zinc Sulfate (150mg/day) was associated with significant improvement in social skills and impulsivity. Zinc levels were also associated with a positive response to stimulant treatment. Zinc is necessary for metabolism of neurotrasmitter dopamine and fatty acids.
Megavitamin use is dangerous for children and no studies suggest this intervention in ADHD. Indeed, the two controlled studies did not show any benefit to megadoses of Vitamin C, Pyridoxine, and niacin. This may be due to the filtering of the vitamins in the GI system and again by the "Blood Brain Barrier". This filtering system protects the brain from danger. There are some people who have defects in their brains ability to break down folic acid into L-methylfolate, which is allowed to cross the "Blood Brain Barrier". These people do not respond adequately to antidepressants until they are given methylfolate directly. Are there other problems like this that affects ADHD? More research is needed.
L-methyl folate in the brain aids in the synthesis and normalization of the neurotransmitter levels associated with mood enabling an anitdepressant to be more effective.2, 3, 4 The modulation and release of neurtransmitters has been associated with L-methyl folate binding to mood receptors (glutamate receptors). 1 L-methylfolate improves depressive symptoms over 6 months in one study. 11 No adverse events were reported with the use of methyl folate. 5, 6-11 Why is L-methyl folate effective? 7 out of 10 depressed patients have an impaired ability to metabolize folic acid to L-methyl folate. 12 Research is being conducted to see if L-methyl folate can help autism.
The popularity of herbal remedies and "natural" medications has increased dramatically in the United States over the past few years. More patients are asking their physicians whether they may benefit from natural treatments, and many already employ the services of herbalists, naturopaths, and other healers. Many patients choose to self-medicate with herbal remedies that are available over the counter. The National Institutes of Health (NIH) has recognized that as many as 25% of people in the U.S. seek and obtain nontraditional treatments. Unfortunately medical schools and residency training programs have largely ignored the topic of natural remedies; thus leaving physicians poorly equipped to advise their patients regarding these treatment options. Furthermore, medical research has, until recently (I am aware of several federal and foundation funded clinical trials of omega 3 fatty acids), overlooked this area, and pharmaceutical companies do not typically fund studies on these substances because they are not patentable.
A common public misperception is that because something is "natural," it is automatically safe. Don't forget that mercury, opium, and arsenic are "natural". The US Food and Drug Administration (FDA) does not regulate herbal remedies, though recently it has begun looking into claims made by various herbal manufacturers in an effort to limit unsubstantiated claims of efficacy. Unfortunately, the FDA does not regulate the manufacturing or potential substitution of ingredient contents in herbal remedies. Due to the lack of federal regulation and lagging medical research, mainly anecdotal data are available regarding safety, efficacy and appropriate indications for natural treatments, and little to no data are available regarding potential drug interactions. The commonly used herbal products include St. John's Wart, Gingko biloba, Ginseng, and Kava Kava. There is no scientific study that shows efficacy in ADHD or ADD with any herbs, vitamins, dietary supplements, or any combinations of these.
Pycnogenol is derived from the bark of the European coastal pine. It consists of a mixture of bioflavonoids that are felt to be free radical scavengers, and thus helpful in protecting blood vessels, improving circulation, reducing inflammation, and protecting collagen from natural degradation. There is no indication that pycnogenol affects catecholamines, which are the neurotransmitters most consistently implicated in ADHD. To date there are no controlled studies of this compound in ADHD, though anecdotal reports abound. The only reference I was able to find in the scientific literature regarding pycnogenol use in ADHD were two letters written to the editors of the Journal of the American Academy of Child and Adolescent Psychiatry.
St. John's Wort received much media attention years ago as a potential treatment for depression. Hypericum is the extract of the flower of St. John's Wort that is believed to provide its therapeutic effects. It is believed to either cause inhibition of serotonin reuptake by presynaptic receptors, and/or to inhibit the enzyme monoamine oxidase (MAO), which are known mechanisms of action for current pharmaceutical antidepressants. To date St. John's Wort has been shown to be effective in controlled trials of mild to moderate depression; however, a meta-analysis suggested that it might not be effective for the acute treatment of severely depressed patients. The suggested dosage is 300mg taken three times daily, with possible side effects of gastrointestinal symptoms and fatigue. Of concern is the potential for drug interactions with other antidepressants, in particular selective serotonin reuptake inhibitors (SSRI's). There are no published trials comparing St. John's Wort to SSRI's though the NIH has sponsored a multi-center, randomized, controlled study comparing 50-150mg/day of sertraline (Zoloft), 900-1800mg/day of St. John's Wort, and placebo in over 300 patients. I am not aware of any systematic research into the possible uses of St. John's Wort for ADHD.
Ginkgo Biloba is believed to have cognitive enhancing effects and has been studied in Alzheimer's and vascular dementia. Ginkgo biloba is produced from the seed of the ginkgo tree and consist of various amino acids and bioflavonoids. Its mechanism of action may involve membrane stabilization, inhibition of platelet-activating factor, and free radical scavenging. A recent double-blind placebo-controlled study (1997) of ginkgo for dementia revealed 27% of patients on ginkgo versus 14% on placebo improved. The changes were modest but objectively measurable. Currently there are no published trials comparing ginkgo to pharmacological agents such as tacrine or donepezil. The suggested dose range is 120-240mg per day, divided in two to three dosages, with potential side effects including gastrointestinal symptoms, headaches, dizziness, and irritability. No adequate studies in ADHD.
Ginseng is commonly advertised to improve mood, enhance energy, and reduce stress. The active component of ginseng is believed to consist of ginsenosides, which are steroid like compounds. A number of small and poorly designed studies have reported a variety of beneficial effects such as reducing plasma glucose levels and increasing the level of high-density cholesterol. No adequate studies in ADHD.
Kava Kava is the dried rhizome and roots of Pioer methysticum, a large shrub commonly found in Polyneisian islands. It is believed to be helpful in treating anxiety, which may be secondary to mild muscle relaxant effects of kavapyrones. Several placebo-controlled studies have shown it to be effective in reducing symptoms in patients with various anxiety diagnoses including agoraphobia, generalized anxiety disorder, specific phobia and insomnia. The suggested dosage range is 60-120mg/day with potential side effects including gastrointestinal symptoms, headaches, allergic skin reaction, dizziness, and abnormal liver enzymes. To date there are no controlled trails comparing kava to anxiolytics such as benzodiazepines, buspirone, and SSRI's.
It is clear that herbal remedies and natural medications represent a growing field in the pharmacology of mental disorders. Some of the agents above may in fact have a very useful role in the treatment of various patients. However, the questions remain for which patients and for which conditions. Fortunately academic scientists have begun large, multi-center studies to answer some of these important questions. In the interim these compounds remain unproven both with regards to their efficacy and safety, let alone the potential for drug interactions. At the same time they are easily available and can appear quite attractive based on anecdotal reports and popular press articles. In the absence of more conclusive data, these agents should be used cautiously and should not be combined with prescribed medications without informing your physician. In recommended that they pursue them as "trials." Namely, one should have a list of target symptoms that one hopes to improve and a timeline (usually –12 weeks) in which to look for change. Rating scales are available to measure symptom changes. These should be filled out by multiple observers especially those who are not aware that a substance is being tried. This is called a "blind study". If no improvement occurs then terminating the trial is prudent.
A problem with vitamins and nutritional supplements is their absorption in adequate quantities because the body limits absorption. The body tries to maintain homeostasis-equilibrium. So deficiencies of vitamins would allow absorption but mega doses are eliminated. The brain also limits the type and amount of substances that can cross the blood brain barrier. The body protects the brain by only allowing certain substances and amounts that can cross over into the brain.
- Alpert M: Prediction of treatment response in geriatric depression from baseline folate level: interaction with an SSRI or a tricyclic antidepressant. Journal Clin Pharmacology 2003
- Bottiglieri T, Homocysteine and folate metabolism in depression; Progress in Neuro-Psychopharmacology & Bilogical Psychiatry, 2005
- Popakostas G., Serum Folate, Vitamin B12, and Homocysteine in Major Depressive Disorder, Part 1: Predictors of Clinical Response in Fluoxetine-Resistant Depression, J. Clinical Psychiatry; 2004, 1090-1095
- Mischoulon D, Role of S-adenosyl-l-methionine in the treatment of depression: a review of the evidence; Am J Clin Nutr, 2002
- Coppen A., Enhancement of the Antidepressant Action of Fluoxetine by Folic Acid: A Randomized, Placebo Controlled Trial; J Affective Disorders; 2000. 121-130
- Alpert J, Folinic Acid (Leucovorin) as an Adjunctive Treatment for SSRI-Refractory Depression; Annals of Clin Psychiatry, 2002
- Guaraldi G, An Open Trial of Methyltetrahydrofolate in Elderly Depressed Patients; Annals of Clin. Psychiatry, 1993, 101-105
- DiPalma C., Is Methylfolate Effective in Relieving Major Depression in Chronic Alcoholics? Therapeutic Research, 1994
- Passeri M., Oral 5-MTHF Acid in Senile Organic Mental Disorders With Depression: Results of a Double-blind Multicenter Study; Aging, 1993, 63-71
- Coppen A., Folic Acid Enhances Lithium Prophylaxis; Journal of Affective Disorders, 1986, 9-13
- Godfrey P.S.A., Enhancement of Recovery From Psychiatric Illness by Methylfolate; The Lancet, 1990: 392-395
- Kelly B, Journal of Psychopharmacology, 18(4) (2004) 567-571