James Lake, MD

 asked integrative psychiatrist James Lake, MD, for insights and advice for patients to reduce stress and take care of their mental health on a day to day basis, especially important now when life seems to be in upheaval for so many. It is of utmost importance to focus on improving lifestyle factors, which may then translate into improved general mental health, and more resilience in the face of stress. 

Dr Lake talks about 4 pillars of mental health and health: getting enough sleep, regular physical activity, healthy nutrition, and a practice addressed at stress management.

In order to optimize your mental well being, a healthy diet with the essential nutrients are vital to healthy brain function. Individuals who have healthy diets tend to function better, feel better, and manage better in the face of stress, whether that is day-to-day work stress, or in this case, the extraordinary unprecedented stress that we are all experiencing. Because of the COVID-19 pandemic a healthy diet that includes fresh fish, vegetables, and grains is essential. 

People who engage in regular physical activity tend to feel better and function better. This does not necessarily mean vigorous workouts every day today, but staying active is key. Moderate level of activity might include regular walks (up to 30 minutes or more per day); strength training; using weights; and hiking on the weekends. Nature is always a wonderful way to be active and refreshed, especially during these times of confinement. There is an enormous body of research showing the relationship between regular physical activity and good mental health. In fact, many studies show that individuals who have moderate depression or anxiety or who engage in regular physical activity, including patients who take antidepressants, derive benefit.

A consistent pattern of rest means a patient has enough time to get into deep sleep. This enables one to wake up the next day refreshed, ready go to work or school. Good sleep hygiene entails the things you do from the beginning of your day until the time you go to sleep that night. They will predispose you sleeping better. Try to turn off the television or any other electronics. Students should stop studying at least an hour before going to bed. Don't drink alcohol right before bed and try to avoid it the last few hours of the day. For patients with anxiety disorders, go into a very quiet, peaceful space using gentle yoga or simple mindfulness practice to take their minds off their worries before trying to fall asleep.

People who sleep tend to be more emotionally resilient. In the context of what we are dealing with now, sleep is fundamental to those who are struggling with depression

This can be simple or it can be elaborate, depending on your preferences, or religious or spiritual bearings. Listening to music with earbuds, while also engaged in very relaxing breathing practice can be very calming and can significantly lower your baseline anxiety.

Tools for reducing stress include mindfulness, such as meditation, simple yoga styles that are calming and relaxing, and breathing. Some yoga postures can promote improved sleep, and those should be done at night, an hour or so before bed.

During this time of extreme stress, spiritual practices can help relieve anxiety. Because we don't know what the future will bring, it is particularly important and valuable for people to engage in their spiritual work or to get closer to their religious community, whichever is more personally useful. It can provide enormous peace at to delve into, spiritual practice, which might be meditation and even Buddhist prayer, Christianity or Judaism.

There can be enormous power from thinking more deeply in one's spiritual life. and through affiliation with religious community or fellowship for support and for sharing faith with others. 

A Mental Health Pandemic: The Second Wave of COVID-19

 is a Psychiatrist in private practice in California. His most recent book is 

An Integrative Paradigm for Mental Health Care: Ideas and Methods Shaping the Future

Videos

Psychiatric Times asked integrative psychiatrist James Lake, MD, for insights and advice for patients to reduce stress and take care of their mental health on a day to day basis.

4 Pillars of Good Mental Health

The COVID-19 pandemic is causing suffering on a magnitude that is unprecedented in living memory. Millions have lost their livelihoods and are struggling financially. Tens of thousands have lost loved ones, and hundreds of thousands who have been infected with the virus face the very real prospect of serious illness or death. The health and financial costs of COVID-19 have resulted in widespread feelings of helplessness and overwhelming anxiety and despair in response to circumstances over which we have little or no control. Chronic exposure to severe stress in the absence of control among countless millions constitutes a perfect storm, with severe mental health consequences on a global scale, including increased rates of depressed mood, suicide, and posttraumatic stress disorder.

Individuals who were already struggling with mental illness before COVID-19 are now facing even greater challenges. After effective antivirals and vaccines have been developed and we have begun to contain the pandemic, the US and many other countries will be faced with a mental health pandemic that will probably continue for years to come. Historically, increases in rates of severe mental illnesses have often followed in the aftermath of national crises. For example, during the decade of the Great Depression from 1929 to 1939, the suicide rate rose from 13.9 to 17.4 per 100,000. Traumatic memories of surviving years of hardship during the Great Depression resulted in high rates of anxiety and depressed mood for generations. Although economic downturns disproportionately affected the health and well-being of the lower income segment of the population, all socioeconomic groups are negatively impacted.

A second wave of the pandemic will be driven by intense feelings of anxiety and despair in a world that is no longer predictable and safe due to high rates of unemployment and homelessness coupled with traumatic memories of surviving one’s own brush with 

 or the death of a partner, parent, or loved one. The personal, social, and economic burden of human suffering, treatment costs, disability compensation, and productivity losses related to mental health problems in normal times have been major public health issues in the US and worldwide. This pandemic has served to amplify the personal, social, and economic costs of mental illness to a magnitude that is unprecedented. It is likely that the mental health consequences of COVID-19 will become the most urgent public health challenge worldwide for decades to come, impacting the well-being and productivity of billions. If left untreated, the psychiatric sequelae associated with the pandemic will have serious long-term social and financial consequences for all areas of human life, including personal relationships, family dynamics, academic performance, and work productivity. 

Developing and implementing programs aimed at enhancing resilience and treating individuals struggling with the mental health consequences of COVID-19 deserves the same urgent priority that is now being assigned to the development and testing of vaccines and antivirals. Large scale proactive measures are a key part of successfully preparing millions of people as they resume their day-to-day lives and livelihoods and is an essential step in re-starting stalled economies on a global scale. In the absence of such proactive measures, COVID-19’s long-term global impact on mental health could easily be as devastating and costly as the financial impact of the virus.

Such large-scale programs must be realistic from a cost perspective. Implementing resources that are both adequate and affordablecalls for a review of limitations of the existing model of mental health care. In the current model of care (so-called 

), individuals with medical problems are triaged and treated by family physicians while individuals with mental health complaints are seen in a different outpatient setting by psychiatrists and psychologists. The result is that individuals who have both medical and mental health problems typically receive care at different times, in different clinical settings, and from different clinicians who often do not have pertinent information about pre-existing health problems and treatment history. In outpatient medical clinics, the priority on efficient triage of medical problems may cause delays in the diagnosis and treatment of serious psychiatric disorders, including major depressive disorder and PTSD, due to the 

 spent screening patients for mental health problems.

Although usual care segregates medical care and mental health services, depressed mood, anxiety, and other common mental health problems are frequently comorbid with medical problems such as cardiovascular disease, lung disorders, chronic pain, and diabetes. In addition, usual care is associated with disparities in the delivery of mental health services to different socioeconomic classes.

In response to the limitations of usual care, innovative collaborative care models are being developed and implemented in outpatient clinic settings. In collaborative care, a team of family physicians (or other primary care providers) and behavioral health clinicians work together using systematic and cost-effective approaches aimed at providing patient-centered care that addresses both medical and mental health problems. Studies show that collaborative care models are more effective than usual care for treatment of mental health problems while simultaneously reducing health care disparities. Collaborative care has also been shown to be more effective for managing patients with chronic mental health problems who have comorbid medical disorders, and is more cost-effective than usual care.

Rethinking mainstream mental health approaches

In addition to improving the existing model of care, we need to rethink current mainstream approaches in mental health care in order to adequately address the mental health impacts of the pandemic. Although psychotropic medications are often effective treatments of depression, anxiety, and PTSD, such conventional treatments have limited effectiveness and safety problems, and they are unaffordable to large numbers of individuals who would otherwise benefit from them. Initiatives aimed at enhancing psychological resilience and treating mental health problems resulting from the pandemic should include non-medication (ie, complementary and alternative medicine [CAM]) interventions supported by research evidence. Examples include a regular mindfulness practice for anxiety, exercise for depression, and select natural supplements known to be safe and efficacious adjunctive treatments of specific mental health problems.

, the National Institutes of Mental Health, the 

, the American Psychological Association, and experts in complementary and alternative medicine to join forces and propose a national strategy for developing and implementing large-scale programs and resources needed to adequately address the growing COVID-19 mental health pandemic. Clinical resources should ideally be implemented following a collaborative care model placing equal emphasis on enhancing psychological resilience in healthy individuals and treating serious mental health problems. In order to be most effective and cost-effective, a COVID-19 mental health initiative should incorporate evidence-based conventional and alternative treatments, and should be made available at little or no cost to the millions of Americans who have lost their jobs and their health insurance.

Urgent need for improved mental health care and a more collaborative model of care, special report

Articles

The pandemic has brought about uneasy feelings that can exacerbate mental illness and cause further mental health issues. In its current state, our mental health system is not prepared to deal with what may become a global mental health pandemic, but there are ways to address it.

Millions of people have recently lost their jobs and health insurance benefits because of the 

 pandemic. The result is that many struggling with 

 cannot afford psychotherapy, medications, or other treatments. The economic fallout of the pandemic may continue for years resulting in prolonged unemployment and an increasing percentage of the population with untreated serious mental health problems.

Politicians and state legislatures are debating on how to fill the gap in health care that is a direct result of the pandemic and programs that will provide adequate mental health care for growing numbers of uninsured may take months or longer to implement. The result will be that many people-in the US and other countries-who would receive conventional treatments such as psychotherapy and medications for mental health problems during normal times will not be able to afford treatment, their symptoms may become worse, affecting overall quality of life, relationships, and academic and work performance.

Even when conventional treatment is unavailable or unaffordable for millions of individuals who are struggling with depressed mood, anxiety and insomnia, simple lifestyle choices can make a significant difference. This article is offered as a concise review of the mental health benefits of changes in diet, physical activity, and a regular mindfulness or mind-body practice for depressed mood, anxiety, and insomnia.


	The relationship between diet and risk of developing depressed mood is multifactorial. Findings from epidemiologic studies suggest that individuals who consume whole foods (as opposed to processed foods and fast food diets) are at reduced risk for depression. For example, individuals who closely adhere to a Mediterranean diet, as well as traditional diets in Norway, Japan, and China, which are rich in vegetables and fish, have a 30% lower risk for depressed mood than those with the lowest rate of adherence to a 

 identified 12 essential nutrients that met criteria for antidepressant efficacy: folate, iron, long-chain omega-3 fatty acids (EPA, DHA), magnesium, potassium, selenium, thiamine, vitamin A, vitamin B6, vitamin B12, vitamin C, and zinc.

 Foods with the highest antidepressant food scores (AFS) included oysters and mussels as well as other seafood, organ meats, leafy greens, lettuces, peppers, and cruciferous vegetables such as broccoli, cauliflower, cabbage, kale, and Brussels sprouts.

Deficiencies of select nutrients are associated with increased risk of depressed mood, including certain B vitamins, omega-3 fatty acids, vitamin D, zinc, and magnesium. The B vitamins function as enzyme co-factors that facilitate the synthesis of neurotransmitters implicated in mood regulation such as serotonin, dopamine, and norepinephrine. Foods rich in B-vitamins especially folate, pyridoxine (B-6), and methyl-cobalamin (B-12) may be especially effective against depressed mood. These include whole grains and dark green leafy vegetables. Omega-3s and some B vitamins also have general anti-inflammatory and neuroprotective benefits in the body and brain, which may contribute to their antidepressant effects. Zinc, magnesium and omega-3 fatty acids promote increased synthesis of brain-derived neurotropic factor, which enhances neuroplasticity, resulting in greater resilience of the brain in the face of chronic stress. Increased neuroplasticity may also reduce risk of depressed mood.

 67 individuals with depressed mood symptoms ranging from mild to severe were randomized to a diet support group versus a social support group.

 Individuals in the diet support group received seven individual one-hour sessions and were encouraged to follow diets rich in whole grains, vegetables, fruits, legumes, and low-fat dairy foods. They ate more raw unsalted nuts, fish, lean red meats, eggs, and olive oil while reducing intake of sweets, refined cereals, fried foods, processed foods, and sugary drinks. Individuals in the social support group received the same number of sessions, during which they discussed neutral topics of interest, but did not receive psychotherapy, lifestyle advice, or other interventions. At study end, individuals in the diet support group demonstrated significantly greater improvement in depressed mood scores based on standardized outcome measures compared with those in the social support group.

Dietary preferences also play important roles in anxiety. Generalized anxiety is often associated with reactive hypoglycemia, in which blood sugar drops to an abnormally low level following a meal or drink that contains a large amount of sugar resulting in acute anxiety symptoms that can mimic a panic attack. 

 indicate that individuals who experience heightened anxiety related to reactive hypoglycemia benefit from simple dietary changes including reducing refined sugar and carbohydrate intake, increasing protein intake, and reducing or eliminating caffeine or alcohol.

Caffeine use is also associated with an increased risk of anxiety. Caffeine consumption increases the levels of epinephrine, norepinephrine, and cortisol in the blood, resulting in feelings of “nervousness” in adults who have no mental health history, feelings of increased generalized anxiety, and in some cases, panic attacks in individuals who are predisposed to anxiety or panic. Many individuals with chronic generalized anxiety report a significant reduction in the severity of anxiety symptoms when they abstain from caffeine. Chronic alcohol abuse can also manifest as hypoglycemia and malnutrition resulting in generalized anxiety and depressed mood.

Finally, on a general level, the microbiome-which consists of microorganisms that naturally populate the large and small intestines-may contribute to both physical and mental health through a variety of mechanisms, including beneficial changes in CNS levels of serotonin and other neurotransmitters implicated in mood regulation. The general health of the digestive system modulates immune functioning and brain activity through the microbiome-gut-brain axis. Recent 

 point to a link between imbalances in bowel microflora, increased inflammation of the mucosal lining of the intestines, and systemic immune dysregulation resulting in increased risk of depressed mood.


	Findings from animal and human studies suggest that both the immediate and long-term beneficial effects of exercise on mood are mediated by multiple factors that increase brain levels of mood-elevating endorphins, dopamine, norepinephrine, and serotonin, promote neurogenesis, reduce oxidative stress, and enhance immune functioning.

 Moreover, regular exercise may promote increased neuroplasticity in certain brain regions, resulting in improved mood.

Regular exercise including aerobic and non-aerobic strengthening exercise has 

. Individuals who are less sedentary have a reduced risk of both depressed mood and cardiovascular disease.

 Regular aerobic exercise may also improve cognitive functioning in chronically depressed individuals who often experience difficulties with thinking and memory.

 The results from a meta-analysis of controlled studies (N = 977) of exercise used as a single intervention or in combination with antidepressants support that regular exercise has consistent beneficial effects on depressed mood.

 of studies on exercise as an add-on therapy in individuals with MDD showed that depressed individuals who exercise regularly respond consistently better than individuals who take an antidepressant but do not exercise.

Following a regular exercise program while taking an antidepressant and doing cognitive therapy was found to improve 

 Moderately depressed individuals who exercise in addition to receiving regular CBT are less depressed and report fewer suicidal thoughts compared with individuals engaged in CBT only.

 Antidepressants and exercise probably have equivalent effects on moderate depressed mood.

 The therapeutic benefits of regular exercise may also be comparable to select 

complementary and alternative (CAM) treatments

 of depressed mood such as St John’s Wort (Hypericum perforatum).

Findings of open studies suggest that both aerobic exercise and strength training improve anxiety when done on a regular basis.

 The beneficial effects of exercise on anxiety are similar to those of meditation and regular relaxation. A workout program consisting of at least 20 to 30 minutes of daily exercise can significantly reduce symptoms of generalized anxiety. Findings of a prospective 10-week study of exercise in individuals prone to panic attacks support that regular walking or jogging (4 miles three times a week) reduces the severity and frequency of panic attacks.

In addition to its mood enhancing and anxiety reducing effects, regular exercise enhances self-sufficiency and ensures positive social interactions with other people. Regular exercise has also been shown to improve sleep quality in depressed individuals who do not respond to antidepressants.

 This may be a significant benefit of exercise for general resilience and day-to-day functioning in view of the high prevalence of insomnia in patients who are chronically depressed.

Relaxation, mindfulness, and mind-body practices


	Relaxation techniques include sustained deep breathing, listening to calming music, and progressive muscle relaxation. Examples of mindfulness training include different styles of meditation and guided imagery. Mind-body practices involve both body and mind and include taijiquan, qigong, yoga, and other approaches that involve both the mind and the body. Improved capacity for focused attention and reflection have been proposed as important nonspecific psychological benefits of meditation and mind-body practices. The regular practice of meditation or mind-body techniques such as yoga and taijiquan, may be as effective as CBT or antidepressants for moderately severe depressed mood.

Simple relaxation techniques and mind-body practices also have beneficial effects on insomnia. Mind-body approaches that have been looked at in controlled trials of insomnia include progressive muscle relaxation, massage, meditation, desensitization, guided imagery, autogenic training, and hypnosis. Progressive muscle relaxation and sustained deep breathing are especially effective at reducing sleep latency in individuals with chronic insomnia. Listening to relaxing music soon before bedtime can help individuals with insomnia fall asleep quicker. Many individuals who have problems falling asleep because of chronic worrying report improved sleep with guided imagery.

Meditation and guided imagery are probably more effective than progressive muscle relaxation for situational insomnia but are of little benefit for severe insomnia. Individuals with chronic insomnia who use a cognitive-behavioral technique alone or in combination with a benzodiazepine or other sedative-hypnotic drug report that non-pharmacologic or combined approaches are more effective than medications alone. Improved sleep is sustained longer in individuals who use non-pharmacologic or integrative approaches compared with those who take sleep aids only.

 found that non-pharmacologic treatments of chronic insomnia are initially more expensive and require more time compared with medication management but lead to sustained benefits and are more cost-effective than drugs alone in the long run.


	Finally, I want to emphasize the importance of relationships. In addition to engaging in healthy lifestyle choices, supportive relationships with friends and family members can provide important buffers to day to day stresses and uncertainties that we will continue to face in these uncertain times. Video calls or phone calls can be very heartening and encouraging even when shelter-in-place orders restrict us from direct contact with family and loved ones.

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The economic fallout of the pandemic may continue for years resulting in prolonged unemployment and an increasing percentage of the population with untreated serious mental health problems.

Self-Care for Mental Health Problems in the Time of COVID-19

As scientists and politicians debate how and when to 

, there remains enormous uncertainty over the future and a realization that the pandemic is far from over. Some believe that the pandemic may be ushering in a new normal characterized by widespread economic privation, rolling waves of illness and death, and pervasive feelings of loss of control on a global scale. Individuals struggling with mental health problems are especially affected by this pervasive awareness of uncertainty.

It is true that we cannot control the difficult circumstances we are facing-as individuals or as nations-and even near-term predictions by pundits and politicians are modified almost daily. However, we do have the capacity to lessen the intensity of our anxiety and despair in face of the 

 pandemic by changing our internal narratives.

 argues that the degree to which people believe they are in control significantly influences their attitudes toward difficult circumstances, affects resilience, and determines choices of coping strategies. According to the theory, personality styles exist on a continuum with 

 at the other. Individuals with a strong internal locus of control believe that events that happen to them are a consequence of their own choices and actions, whether or not they choose to have control over them (

). On the other end of the spectrum, individuals with a strong external locus of control interpret events as influenced not by their actions or abilities but by circumstances beyond their control. In other words, individuals with a strong external locus of control rely on beliefs in ideas like luck and fate to interpret their experiences. Because individuals with a strong internal locus of control interpret circumstances as being within their ability to control, they are more confident in their ability to influence their future and, hence, more resilient in the face of extreme circumstances. In fact, numerous research studies have established that a strongly held internal locus of control correlates to improved physical and mental health as well as better quality of life.

Interestingly, it turns out that there are regional differences in locus of control; geographic differences significantly influence how populations in different regions deal with natural disasters and other crises. For example, 

 found that a greater loss of life caused by tornadoes in Alabama as compared to that in Illinois was due to more prevalent external personality styles among Alabama residents, who took fewer precautions in face of an impending tornado.

Broad differences in locus of control may also exist between different cultures. For example, ethnic Japanese people and African-Americans tend to be more external. Meanwhile, Whites in North America and Europe tend to be more internal; and findings on locus of control in people of Hispanic origin are ambiguous. All of these differences have important implications for how individuals residing in different geographic regions and in different cultures might be responding to the pandemic and its related hardships. On a large scale, these differences have implications for public health policies, as they may translate into significant regional and cultural differences in numbers of individuals who are directly and adversely impacted by the pandemic (ie, become infected). 

Locus of control theory is a valuable model with important practical implications for understanding how individual responses to the pandemic result in very different outcomes. Those with a strong internal locus of control make choices reflecting their beliefs that their actions play an important role in determining how the pandemic will affect their health and their future well-being, such as maintaining safe social distancing, wearing a face mask, and frequent handwashing. In contrast, those with a strong external locus of control do not believe they have control over their future health in face of the pandemic and are less likely to embrace recommendations aimed at mitigating risk of infection. In other words, a strongly held internal locus of control will expectably result in beliefs and behaviors that could significantly lessen the risk of becoming infected, spreading the virus, or dying as well as abiding by government and medical recommendations.

Although we cannot control the dire circumstances that we are facing, we do have the capacity to lessen the intensity of our anxiety and despair by changing our internal narratives in a world that continues to spin out of control. As we take first steps to re-start the economy, resume our day-to-day lives, and renew normal social contact beyond video calls, we will continue to face unknown risks of infection, and we will continue to share a deep sense of anxiety and despair over economic hardship that will probably last for years to come. In this new normal, choosing to embrace a different narrative-one of internal control-can make a real difference as we continue to face uncertainties.

is a Psychiatrist in private practice in California. His most recent book is 

An Integrative Paradigm for Mental Health Care: Ideas and Methods Shaping the Future.

Personality, Individual Differences and Intelligence

 (1st ed.). Harlow: Pearson Prentice Hall. 2007.

The tornado threat: coping styles of the north and South

Shifting the internal narrative can enhance resilience.

Resilience and Locus of Control in the Time of Pandemic

This activity offers CE credits for:
	1. Physicians (CME)
	2. Other

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

The goal of this activity is to provide an understanding of the evidence for the use of complementary and alternative (CAM) treatments for ADHD.

At the end of this CE activity, participants should be able to:

• Discuss the limitations of conventional treatment and how CAM therapies are used as adjuncts to stimulants;

• Describe the effects of certain food products and how they might affect ADHD symptoms as well as the evidence for the use of the oligoantigenic diet;

• Explain EEG biofeedback protocols and the strategies to address various symptoms of ADHD;

• Identify which nutritional and herbal supplements have the best evidence for treating symptoms of ADHD.

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

 This activity has been planned and implemented in accordance with the Essential Areas and policies of the
	Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

CME Outfitters designates this enduring material for a maximum of 

. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note to Nurse Practitioners and Physician Assistants:

 AANPCP and AAPA accept certificates of participation for educational activities certified for 

It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.

The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.

James Lake, MD, has received received travel support from Blackmores Institute Visiting Fellowship and royalty payments from Norton, American Psychiatric Publishing, Thieme Medical, and Blue Poppy Press.

Professor Sarris has received either presentation honoraria, travel support, clinical trial grants, book royalties, or independent consultancy payments from Integria Healthcare & MediHerb, Pfizer, Scius Health, Key Pharmaceuticals, Taki Mai, FIT-BioCeuticals, Blackmores, Soho-Flordis, Healthworld, HealthEd, HealthMasters, Grunbiotics, Australian Natural Therapies Group, Kantar Consulting, Research Reviews, Elsevier, Chaminade University, International Society for Affective Disorders, Complementary Medicines Australia, SPRIM, Terry White Chemists, ANS, Society for Medicinal Plant and Natural Product Research, Sanofi-Aventis, Omega-3 Centre, the National Health and Medical Research Council, CR Roper Fellowship. He also receives support from a NHMRC Clinical Research Fellowship (APP1125000).

Patricia Gerbarg, MD, (peer/content reviewer) has no disclosures to report.

 staff and CME Outfitters staff have no disclosures to report.

Faculty of this CME/CE activity may include discussion of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices. CME Outfitters, LLC, and the faculty do not endorse the use of any product outside of the FDA-labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.

; for CME credit questions call 877.CME.PROS (

Recent surveys suggest that 7% to 8% of children and 4% to 5% of adults meet ADHD criteria.

 The rate at which ADHD is diagnosed and treated has increased dramatically since the syndrome was recognized by DSM as a specific disorder in the 1970s. It is estimated that fewer than 20% of adults with ADHD have had a correct diagnosis and have thus incurred significant social and occupational risk. Almost half of those who have ADHD never graduate from high school and fewer than 5% complete a 4-year university degree program.

A diagnosis of ADHD has been associated with 35 days of lost work on average per year, which suggests US$19 billion in lost productivity and 120 million lost work days annually.

Because stimulants are usually classified as scheduled or restricted medications (depending on the country), prescriptions are often limited to a small supply, which results in treatment interruptions and transient worsening of when refills are not obtained on timely basis. Adverse effects of stimulants include insomnia, decreased appetite, abdominal pain as well as occasional stimulant-induced psychosis; chronic use can increase the risk for slow growth. Moreover, stimulants and other pharmacologic treatments for adult ADHD may be only half as effective as they are in children.

Controlled-release stimulants, bupropion, and the SSRI antidepressants are being increasingly used in the adult ADHD population, however these medications may not be as efficacious as stimulants. Although atomoxetine is FDA-approved for the treatment of childhood ADHD, there are growing concerns about its adverse effects, including hypertension, tachycardia, nausea and vomiting, liver toxicity, and possibly increased risk of suicide.

CAM therapies are widely used to treat ADHD

Growing concerns about inappropriate prescribing or over-prescribing of stimulant medications and the incomplete understanding of risks associated with their long-term use have led to increasing acceptance of complementary or alternative medicine (CAM) therapies. CAM therapies in children with ADHD are used largely out of parental concerns over prescription drug safety. CAM therapies, including vitamins/minerals, dietary changes, and expressive therapies, are used although parents rarely disclose this to the child’s doctor. Although there is limited evidence to support most CAM therapies for treating ADHD, it is highly regarded by many patients’ parents.

Early studies suggested that artificial food colors were associated with ADHD; however, a meta-analysis of studies spanning a 35-year period failed to confirm this relationship.

One such diet, the oligoantigenic diet (OAD), is a highly restrictive multiple elimination diet that excludes food colors and additives, in addition to dairy products, sugar, wheat, corn, citrus, eggs, soy, yeast, nuts, and chocolate. The diet permits a limited number of hypo­allergenic foods like lamb, chicken, potatoes, rice, bananas, apples, cabbages, broccoli, brussels sprouts, carrots, peas, pears, and cucumber, as well as salt, pepper, calcium, and some vitamins. Reductions in hyperactivity were seen in children who were on the OAD regimen when specific food items were eliminated from the diet.

Behavioral symptoms improved during the elimination and placebo phases and recurred when children were subsequently challenged with the eliminated food item.

Roughly one-third of hyperactive children may benefit from some form of an elimination diet.

Although these findings are promising, they cannot be used to develop general ADHD treatment protocols because of study design flaws, including heterogeneity of patient populations, absence of standardized outcome measures, high dropout rates and, in some studies, non-blinded researchers.

 does not endorse elimination diets because of inconsistent efficacy findings as well as concerns that highly restrictive diets do not provide balanced 

. Parents who are considering restrictive diets should consult with a qualified nutritionist. Highly restrictive diets should not be continued for longer than two weeks in the absence of noticeable improvements in ADHD symptoms.

Many individuals with ADHD have abnormal patterns of brain electrical activity, including under-arousal in the frontal and midline cortical regions. Electroencephalogram (EEG) biofeedback is aimed at normalizing EEG activity to correct the brain’s state of relative under-arousal and improve cognitive and behavioral functioning. Two EEG biofeedback protocols have been extensively evaluated as treatments of ADHD.

Sensorimotor rhythm (SMR) training reinforces EEG activity in the faster beta frequency range (16-20 Hz) in the midline cortical regions, with the goal of reducing symptoms of impulsivity and hyperactivity. Theta suppression reduces EEG activity in the slower theta frequency range (4 to 8 Hz) and is primarily used to treat symptoms of inattention. An EEG biofeedback protocol directed at suppressing theta activity (4 to 8 Hz) over the midline regions is probably the most effective strategy when treating primarily symptoms of distractibility and inattention.

Controlled studies that compared EEG biofeedback with a stimulant medication versus a waitlist showed positive clinical effects and EEG normalization; however, it is not yet established whether improved alertness is associated with increased or decreased alpha activity (12 to 18 Hz).

 A review of 14 randomized neurofeedback trials in children with ADHD consistently showed beneficial outcomes.

 Findings of neurofeedback research are limited by small study sizes, heterogeneous populations, absence of a control group, inconsistent outcome measures, and limited or absent follow-up. The potential benefits of neurofeedback are limited by expensive treatments that are seldom covered by insurance.

 have lower plasma concentrations of certain essential fatty acids (EFAs). However, findings from controlled trials of supplemented EFAs in ADHD are inconsistent. One study found no differential benefit of EFAs compared with stimulants.

In another study, parents of children in the EFA-treatment group (n = 104) reported more improvement than parents of children who received a palm oil placebo.

This study has been criticized because a high dropout rate confounds findings in a positive direction. A meta-analysis (including studies from 1965 to 2010) confirmed positive effects of adjunctive EFAs in childhood ADHD; however, therapeutic benefits were significantly less compared with conventional pharmacological treatments.

The use of olive oil as a placebo in certain studies may mask the beneficial clinical effects of EFAs because an active constituent of olive oil is converted into oleamide, which is known to affect brain function. Furthermore, the short durations and low doses of EFAs used in most studies may not be adequate to result in the long-term changes in neuronal membrane structure required for clinical improvement.

Some children with ADHD have abnormally low plasma zinc levels, which may interfere with optimal information processing and thereby result in difficulties maintaining attention. However, findings on zinc supplementation are inconsistent. In a large 12-week prospective controlled trial, children and adolescents randomized to zinc (150 mg/d) experienced significant improvements in hyperactivity and impulsivity over placebo but not inattention.

However, a high dropout rate limited the significance of these findings. In contrast to these findings a more recent placebo-controlled study failed to show efficacy.

Abnormally low serum ferritin levels may be associated with hyperactivity in children with non-anemic ADHD, but not with deficits in cognitive performance. A 2012 systematic review of studies on iron in children with ADHD found mixed results in the relationship between serum iron levels and symptom severity as well as inconsistent responses of ADHD symptoms to iron supplementation.

The amino acid acetyl-L-carnitine (ALC) is required for energy metabolism and synthesis of fatty acids. L-carnitine may significantly reduce the severity of ADHD symptoms; however, inconsistent findings and design flaws limit the significance of these findings. In a multisite 16-week pilot study, 112 children with ADHD were randomized to placebo versus ALC (500 to 1500 mg bid). Children in the ALC group with predominantly inattentive-type ADHD experienced greater improvement over placebo, but there was no differential benefit in children with combined-type ADHD.

In a six-week placebo-controlled trial, children and adolescents were randomized to ALC (doses ranged from 500 to 1500 mg/d depending on weight) plus methylphenidate (20 to 30 mg/d) versus placebo plus methylphenidate. At the end of the study no differences were observed between the groups.

The bioactive constituents of saffron may increase reuptake inhibition of dopamine and norepinephrine and may function as both N-methyl-D-aspartic acid (NMDA) receptor antagonists and gamma-aminobutyric acid (GABA)-a agonists.

In a six-week randomized double-blind study children and adolescents aged 6 to 17 years were randomized to methylphenidate (20 to 30 mg/d) or saffron capsules (20 to 30 mg/d). Participants who received saffron capsules 

 on both parent and teacher symptom rating scales.

Both treatments were well tolerated. Large long-term placebo-controlled studies are needed to confirm these findings and to investigate the efficacy of saffron in individuals with comorbid mood and anxiety disorders.

In a four-week open label study, an herbal preparation containing Ginkgo biloba and Panax quinquefolium was added to existing ADHD medication.

Beneficial effects were observed in 18 children (53%) taking the herbal combination after four weeks. However, the absence of a control group and the small size of the study limit the significance of these findings.

Other findings suggest that a standardized extract of 

 (pycnogenol) bark may be beneficial for ADHD; however, only one controlled study has been published.

Children and adolescents who received pycnogenol for one month experienced non-significant improvements in inattention, improved visual-motor coordination; however, no improvements were seen in symptoms of hyperactivity. Symptoms returned to pretreatment baseline levels after a one-month wash-out. Only one case of mild gastric discomfort was reported. These findings should be regarded as preliminary pending replication by large prospective studies.

In addition to singular vitamins or herbal medicines, various proprietary herbal and nutrient formulas have been used to treat ADHD; however, little research evidence supports their use. A four-month randomized double-blind placebo-controlled trial 

the efficacy of a patented, compound herbal preparation (Nurture and Clarity) in improving attention, cognition and impulse control in children (n = 120) with newly diagnosed ADHD.

At study end those who received the herbal formula showed statistically significant improvement in symptoms of inattention, impulse control and cognition in all four subscales of the test of variables of attention (TOVA) compared with no improvement in the control group. The herbal formula was well tolerated. These findings should be regarded as preliminary pending confirmation by large prospective placebo-controlled studies.

A 2010 meta-analysis of acupuncture for ADHD revealed three studies that met inclusion criteria for sufficient methodological rigor and sample size.

Positive results were seen with electroacupuncture given concurrently to behavioral therapy. A meta-analysis of two other studies of somatic acupuncture or auricular acupuncture combined with drug therapy showed significant differential effects of combined treatment.

The findings, however, were inconclusive because of the small study size, its short duration (less than one month), the absence of blinding, and the absence of an intention-to-treat analysis.

In a systematic review of studies on meditation and mind-body practices (eg, yoga, Tai chi, Qi gong) to treat ADHD, only four studies (83 participants total) met inclusion criteria for methodological rigor and sample size.

Two studies evaluated mantra meditation and two studies compared yoga with conventional drugs, relaxation training, non-specific exercise, or treatment as usual. However, design problems resulted in a high risk of bias in all studies and identified only one study that met criteria for formal analysis. In that small study (n = 15) the teacher rating ADHD scale failed to show significant outcome differences between the meditation group and the drug therapy group.

In a small pilot study (n = 19), children in a yoga group experienced greater improvement in symptoms over time compared with children who exercised. Children who continued on stimulants while practicing yoga experienced the greatest improvements.

Two small controlled studies suggest that yoga and regular massage therapy may reduce the severity of ADHD symptoms.

When stimulants fail to result in significant reductions in symptom severity or when adverse effects, toxicities, or comorbid substance abuse preclude their use, EEG biofeedback and select evidence-based CAM treatments may be considered. Restrictive diets are reasonable interventions in cases where impulsivity and distractibility may be related to sugar intake or food allergies. Parents of children with ADHD should first consult their child’s pediatrician before initiating a strict dietary regimen, and ideally with a qualified nutritionist who can provide them with expert guidance should be consulted.

When therapeutic doses of stimulants cannot be achieved with acceptable tolerance, the adjunctive use of EFAs and select herbals including 

Ginkgo biloba, Panax quinquefolium, Pinus pinaster, 

 may improve response. The adjunctive use of acetyl-L-carnitine, zinc, and iron may be beneficial in some cases; however, these treatments are not substantiated by strong research findings. Regular yoga and massage therapy may help improve attention and hyperactivity in some cases. When a person diagnosed with ADHD fails to respond to pharmacological and CAM treatments it is prudent to rule out confounding psychiatric disorders, including learning disorders, depressed mood, and anxiety disorders, which are frequently comorbid with the syndrome and may interfere with treatment outcomes.

Post-tests, credit request forms, and activity evaluations must be completed online at 

 (requires free account activation), and participants can print their certificate or statement of credit immediately (80% pass rate required). This Web site supports all browsers except Internet Explorer for Mac. For complete technical requirements and privacy policy, visit 

PLEASE NOTE THAT THE POST-TEST IS AVAILABLE ONLINE ONLY ON THE 20TH OF THE MONTH OF ACTIVITY ISSUE AND FOR 18 MONTHS AFTER.

Dr Lake is a Psychiatrist in private practice in California; he is the author of An Integrative Paradigm for Mental Health Care: Ideas and Methods Shaping the Future. Professor Sarris is Deputy and Research Director, NICM Health Research Institute, Westmead, New South Wales and an honorary Principle Research Fellow, Professorial Unit, The Melbourne Clinic, Department of Psychiatry, Melbourne University, Richmond, VIC, Australia.

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Recent surveys suggest that 7% to 8% of children and 4% to 5% of adults meet ADHD criteria. This CME article provide an understanding of the evidence for the use of complementary and alternative (CAM) treatments for ADHD.

Author | James Lake, MD

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