Attention-Deficit Hyperactivity Disorder: A Concise Review

Attention-Deficit Hyperactivity Disorder: Epidemiology, Causes and Diagnosis

This is the first in a series of blog posts on ADHD. In it I concisely review the epidemiology, causes and diagnosis of this condition. Future blog posts will review the effectiveness and limitations of currently available mainstream treatments of ADHD, and research findings on a variety of complementary and alternative treatments being investigated.

Epidemiology of ADHD

Attention deficit hyperactivity disorder (ADHD) occurs in children and adults with roughly equal prevalence in all countries surveyed. Surveys suggest that 7 to 8 % of children and 4 to 5% of adults fulfill criteria for ADHD. The rate at which ADHD is diagnosed and treated in both children and adults has increased dramatically since the syndrome was first recognized as a specific disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in the 1970s. In the United States as many as 10% of males and 4% of females have been diagnosed with ADHD. An objective epidemiological or scientific basis for the rapidly increasing prevalence of ADHD in general and the higher incidence of the syndrome in boys compared to girls is highly controversial and may reflect social issues and changes in diagnostic criteria more than actual changes in prevalence rates.

ADHD has multiple causes

The causes of ADHD are multifactorial. Data from twin studies show that ADHD is a highly heritable disorder and the risk of developing this disorder is probably influenced by genes that affect CNS transport of dopamine and serotonin. ADHD is also associated with premature birth, birth trauma, childhood illness and environmental toxins. Increased risk of ADHD is associated with in-utero exposure to alcohol, tobacco smoke and lead. As many as 20% of ADHD cases may be caused by brain injury around the time of birth. While certain food preservatives exacerbate the symptoms of ADHD, they probably do not cause the disorder. Some cases of ADHD may be associated with delayed development of certain areas of the frontal and temporal lobes and relatively rapid maturation of motor areas of the brain. Neuroimaging studies suggest that these brain regions may have relatively decreased activation in individuals diagnosed with ADHD. Children diagnosed with ADHD frequently experience disturbed sleep including restlessness, sleep walking, night terrors and restless leg syndrome; however, a causal relationship between sleep disorders and ADHD has not been clearly established. Early childhood neglect or abuse may also increase the risk of developing ADHD. Most cases of ADHD probably result from multiple genetic, developmental, physiological, environmental and psychosocial factors.

Diagnosing ADHD

According to the DSM-5 a diagnosis of ADHD is considered to be a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. An ADHD diagnosis requires the presence of at least six symptoms (five for ages >17) of hyperactivity or inattention that begin before the age of 12, persist for at least 6 months, are maladaptive, inconsistent with the child’s development level, are present in tow or more settings, and are not better explained by a pre-existing medical or psychiatric disorder. Specific symptoms of inattention may include careless mistakes in schoolwork, difficulty sustaining attention in school-related tasks or play, failure to follow through with instructions, difficulty organizing tasks and activities, reluctance to engage in tasks requiring sustained attention, and being distracted easily by extraneous stimuli. Specific symptoms of hyperactivity or impulsivity may include fidgeting with hands or feet or squirming while sitting, frequently getting up in a classroom or other situation in which remaining seated is expected, running or moving in inappropriate or disruptive ways, or (in adults) subjective ‘feelings of restlessness’, difficulty engaging in quiet leisure activities and talking excessively.

Symptoms of inattention, impulsivity or hyperactivity must cause clinically significant impairment in at least two spheres including social, academic or occupational functioning. Neuropsychological testing is frequently employed to assess inattention, processing speed and neurocognitive deficits. A diagnosis of ADHD should be made in childhood only after other childhood disorders, including pervasive developmental disorders, learning disorders and anxiety disorders, have been ruled out. When evaluating adults a thorough medical history is important to rule out medical or psychiatric disorders that mimic symptoms or functional impairments that resemble ADHD. These include, for example, bipolar disorder, absence seizures, hypothyroidism, obsessive-compulsive disorder and chronic sleep deprivation.

The interested reader is referred to my ebook “Attention Deficit Hyperactivity Disorder: The Integrative Mental Health Solution” for a concise review of evidence-based non-pharmacologic approaches to this condition.

Mixed Findings on Acupuncture for Smoking, Addiction and Insomnia

Acupuncture is not effective for smoking cessation

Acupuncture is widely used to treat individuals who wish to stop smoking however findings of most controlled trials on acupuncture for smoking cessation have been negative or equivocal. Three meta-analyses of sham-controlled studies on the efficacy of acupuncture for smoking cessation (2,000 total subjects) concluded that therapeutic acupuncture protocols and sham acupuncture have equivalent efficacy, suggesting a significant placebo effect. Longer sham-controlled studies are needed to determine whether more frequent acupuncture treatment following a specific protocol or a greater number of total treatments is effective for smoking cessation.

Acupuncture is not effective for reducing symptoms of nicotine withdrawal or cocaine addiction but may reduce cocaine craving after abstinence is achieved

Two systematic reviews of sham-controlled trials concluded that both conventional acupuncture and electro-acupuncture are equally ineffective in reducing symptoms of nicotine withdrawal and controlling cocaine addiction. A large study examining three auricular acupuncture protocols (i.e. a technique in which small needles or ‘seeds’ are applied to the ear) for relapse prevention in narcotics abusers concluded that all three protocols were associated with reductions in drug use over time. An 8-week randomized sham-controlled study (32 subjects) compared acupuncture with two prescription medications used for craving reduction versus placebo in cocaine addicts on methadone maintenance therapy. Half of the subjects dropped out however almost 90 percent of those who completed the study achieved abstinence by the end of the study. Patients who achieved abstinence reported diminished craving and significantly improved mood.

Acupuncture may be beneficial for insomnia in individuals with schizophrenia or anxiety disorders

The absence of standardized acupuncture treatment protocols for insomnia has interfered with efforts to design rigorously controlled double-blind studies. A systematic review of all studies on acupuncture for insomnia published in the English language through 2002 identified few studies for analysis because most studies had not employed randomized, double-blind procedures. Acupuncture may be beneficial for insomnia associated with generalized anxiety and schizophrenia. In a large-case series (500 subjects), schizophrenics reported significant improvements in sleep following acupuncture treatments. In a small sham-controlled trial (40 subjects), patients complaining of insomnia were diagnosed using Chinese medical assessment methods and randomized to an acupuncture protocol addressing the specific energetic “imbalance” underlying their sleep disturbance versus a sham acupuncture protocol. Significant and sustained improvements in the subjective quality of sleep and changes on EEG recordings during sleep reflecting normalization of sleep were found in the treatment group but not in the sham group.

Acupuncture is generally safe but there are rare reports of serious complications

Uncommon transient adverse effects associated with acupuncture include bruising, fatigue, and nausea. Infrequent cases of infection with human immunodeficiency virus (HIV), hepatitis B, and hepatitis C have been reported when non-sterilized needles are used. Rare cases of serious medical complications such as pneumothorax and cardiac tamponade have been reported as a result of accidental puncturing of the lungs or the pericardium.

Final words

Acupuncture is not effective for smoking cessation or reducing symptoms of nicotine or cocaine withdrawal but may reduce cocaine craving following withdrawal. Acupuncture is probably an effective treatment of insomnia in individuals diagnosed with schizophrenia or anxiety disorders, however studies need to be done in the general population to confirm general beneficial effects on insomnia.

Transcranial Direct Current Stimulation (tDCS) for Depressed Mood

Introduction

Transcranial direct current stimulation (tDCS) also called microcurrent electrical stimulation or cranioelectrotherapy stimulation (CES), is a technique that applies extremely weak electrical current to the head and neck to treat mental health problems. In a recent blog post I briefly reviewed the evidence for tDCS as a treatment of anxiety, substance abuse and insomnia. This entry is offered as a concise review of the evidence for tDCS for treating depressed mood

How (we think…) it works

Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that applies weak direct current (typically 1 to 2 milli-Amps) to the brain via electrodes placed on the scalp resulting in hyperpolarization or depolarization of underlying neural tissue causing beneficial changes in neurotransmitter receptor function or stimulating synaptic plasticity and neuronal remodeling. TDCS is being investigated as a treatment of depressed mood based on the theory that the application of very weak electrical currents to certain brain regions may have beneficial effects on brain circuits involved in attention, perception, learning and memory that affect mood. This hypothesis is consistent with findings of abnormal cognitive processing in major depressive disorder, bipolar disorder and other psychiatric disorders. Research findings suggest that problems in affective and cognitive processing are related to functional abnormalities in networks linking specific brain regions including the hippocampus, amygdala and prefrontal cortex. It has been suggested that changes in cortical excitability caused by tDCS may last longer than changes induced by transcranial magnetic stimulation, while offering the advantages of portability and fewer adverse effects.

Studies on tDCS in depressed mood

Findings of small sham-controlled studies suggest that antidepressant effects of tDCS are related to changes in affective processing. Limited research findings support that tDCS may have beneficial synergistic effects when combined with antidepressants and that combined treatment might be more effective than medications or tDCS alone. TDCS should be viewed as a promising emerging treatment of depressed mood pending confirmation by large sham-controlled studies. It is important to comment that findings of studies on tDCS for depressed mood are limited by small study size, heterogeneity in outcomes measures and reporting bias resulting in underreporting of non-significant findings.

Few safety problems

Few mild transient adverse effects of tDCS have been reported including burning, itching and tingling sensations at the site of electrode placement.

Acupuncture in Mental Health Care: A Concise Review

Challenges in acupuncture research

Acupuncture is widely used in Asian and Western countries to treat diverse mental health problems. Evaluating the clinical efficacy of acupuncture in depressed mood and other mental health problems poses many methodological challenges because of differences in the severity and comorbidity of mental, emotional, and physical symptoms in study populations; concurrent use of other conventional or CAM treatments; conceptual differences between Chinese medicine and biomedical diagnoses; and the use of individualized acupuncture treatment protocols reflecting the patient’s “energetic” balance. This post concisely reviews the evidence for acupuncture as a treatment of depressed mood, anxiety, post-traumatic stress disorder (PTSD) and alcohol abuse. A subsequent post will review the evidence base for acupuncture for smoking cessation, narcotic abuse and insomnia.

Electroacupuncture may have superior efficacy compared to conventional acupunture

Sham-controlled studies suggest that conventional needle acupuncture, electroacupuncture, and computer-controlled electroacupuncture (CCEA) have consistent beneficial effects on depressed mood. Findings of a double-blind, sham-controlled study support that traditional manual acupuncture (i.e., needles in the absence of electrical current) is an effective treatment of severe depressed mood. By the end of the 8-week study, 68 percent of 33 female outpatients being treated with a specialized acupuncture protocol directed at depressed mood had achieved full remission. However, matched depressed women in a wait-list group showed equivalent improvement. In a large 6-week, multicenter study (241 subjects) depressed inpatients randomized to receive electroacupuncture plus placebo versus electroacupuncture plus the antidepressant amitriptyline experienced equivalent improvements in mood. Electroacupuncture was superior to amitriptyline in patients who did not report comorbid anxiety. Patients treated with electroacupuncture had significantly elevated plasma norepinephrine concentrations following a 6-week course of treatment, suggesting that the mechanism of action of electroacupuncture involves stimulation of norepinephrine release.

Findings inconclusive pending confirmation by improved study designs

CCEA uses computer-guided modulation of the frequency and waveform of electrical current delivered through acupuncture needles. Preliminary findings suggest that high frequencies (up to 1,000 Hz) yield responses in depressed patients that may be superior to both conventional acupuncture and electroacupuncture. A narrative review of controlled studies, outcomes studies, and published case reports on acupuncture as a treatment of anxiety and depressed mood supported that sham-controlled studies yielded consistent improvements in anxiety using both regular acupuncture and electroacupuncture. Research findings on acupuncture in depressed mood and anxiety should be regarded as inconclusive because of methodological flaws including the absence of standardized symptom rating scales in most studies, limited follow-up, and poorly defined differences between protocols used in different studies.

A review of prospective trials on acupuncture as a treatment of post-traumatic stress disorder (PTSD) identified four quality sham-controlled studies and two quality uncontrolled trials that met inclusion criteria. One high-quality trial included in the review showed statistically significant differences between the acupuncture and wait-list group but non-significant differences between the acupuncture and individuals receiving cognitive-behavioral therapy (CBT). Patients receiving acupuncture or CBT continued to report clinical improvements in PTSD symptoms 3 months after study endpoint. These findings are limited by the small number of trials that met inclusion criteria (only one study reviewed was included in the analysis), the absence of sham-controlled studies, the use of different study designs across trials examined, and poor methodological quality of many studies.

Inconsistent findings for acupuncture in relapse prevention

Research findings on acupuncture for relapse prevention in alcohol abuse are inconsistent, reflecting differences in the selection of acupuncture points, the treatment protocol used (i.e., conventional vs. electroacupuncture), frequency of treatments, the duration of total treatment, and the relative skill or specialized training of practitioners. Positive findings of two controlled trials supported the hypothesis that specific acupuncture protocols significantly reduced alcohol craving and reduced relapse rate in recovering alcoholics. However, a subsequent randomized controlled trial found no significant differences in craving or relapse rates between an acupuncture protocol traditionally used to treat addiction, sham transdermal stimulation on random points, and a wait-listed group.

Energetic Therapies in Mental Health Care

Energetic Therapies in Mental Health Care: A Short Introduction

This blog post is intended as a short introduction to diverse ‘energetic’ therapies and their uses in mental health care. Future posts will review the evidence for individual energetic therapies in more depth.

Traditional healing methods based on postulated forms of ‘subtle’ energy include acupuncture, homeopathic remedies, Healing Touch, qigong, Reiki, and energy psychology. Beneficial effects of these modalities rest on the assumption that energetic fields or directed human intention that are challenging to investigate using contemporary scientific research methods and, in fact, may not be explainable by current science. Chinese medicine, Ayurveda, and Tibetan medicine posit the existence of a subtle “energy” body and a gross physical body. All of the Asian healing traditions use a combination of physical, psychological, and spiritual approaches to treat energetic imbalances and restore optimal health. In Chinese medicine, “qi” is regarded as a fundamental kind of energy that cannot be explained by contemporary science but may have properties consistent with quantum mechanics. Ayurveda posits an analogous energetic principal called “prana.” In both healing traditions, a central goal of treatment is to restore “balance” in the energetic and physical body, thus enhancing the body’s capacity for self-healing.

Like Asian healing traditions, homeopathy posits that physical and emotional symptoms of distress result from imbalances in a fundamental vital force. Current science cannot explain the postulated curative mechanism of homeopathic remedies, which are typically diluted beyond the limit of possible biological action. Healing Touch is an “energy healing” method used to treat both physical and mental illness. Specific energetic techniques include “chakra spreading,” “magnetic unruffling,” “mind clearing,” and “stopping.” Healing Touch practitioners claim that “energetic” contact between the practitioner and the patient results in alleviation of symptoms. In Healing Touch, the practitioner positions his or her hands over specific areas of the body but does not physically touch the patient’s body.

Therapeutic Touch is similar to Healing Touch but uses gentle physical contact to promote healing. Reiki holds that a fundamental energetic principle, “ki,” promotes healing when guided by a skilled practitioner. Direct physical contact between the practitioner and the patient is not believed to be necessary for beneficial effects to take place. In contrast to Healing Touch and Therapeutic Touch, the Reiki practitioner does not consciously direct healing intention to specific regions of the body but serves as a “conduit” for ki to flow into the patient to restore healthy energetic functioning.

Somatoemotional release is an energy therapy in which the practitioner “releases” pathological energetic states that accumulate in the body following physical injury. The technique involves gentle touch while guiding the patient to assume positions that stimulate body memories of past trauma. Energy psychology is an eclectic combination of Western psychological theory and Chinese medical theory that posits that energetic imbalances in the meridians (i.e., pathways through which qi flows) are associated with different physical, emotional, and mental symptoms. Thought field therapy (TFT) and emotional freedom technique (EFT) are specific energy psychology approaches used to treat anxiety and depression. In TFT, the patient is asked to invoke a “thought field” associated with depressed mood, a traumatic memory, or other principal symptom pattern. The TFT practitioner then reattunes energetic imbalances associated with the target symptom by tapping on specific acupuncture points in a specified manner in an effort to alleviate symptoms. EFT is a simplified version of TFT that involves only one routine for stimulating acupuncture points.

Positive research findings

12 of 18 studies examined in a systematic review of sham-controlled trials included of non-contact biofield therapies including Reiki, Healing Touch, Johrei and Therapeutic Touch reported statistically significant positive outcomes; however, findings were limited by the small sample size of most studies and methodological problems.

Cranioelectrotherapy Stimulation (CES): An Emerging Therapy in Mental Health Care

How cranioelectrotherapy stimulation works

Cranioelectrotherapy stimulation (CES) also called transcranial direct current stimulation (tDCS) or microcurrent electrical stimulation, is based on the application of extremely weak electrical current to the head and neck to treat anxiety, depressed mood, insomnia, and substance abuse. The mechanism of action may involve stimulation of endorphin release and induction of frequency changes in the frequency of brain waves that, in turn, reduce the severity of emotional and cognitive symptoms. This blog briefly reviews findings for anxiety, dementia, substance abuse and insomnia. A future blog post will review the evidence for microcurrent electrical stimulation for treating depressed mood.

CES for treating anxiety

A meta-analysis of controlled trials comparing CES with a sham treatment found that generalized anxiety improved in seven of eight studies, and the magnitude of improvement reached statistical significance in four of these. A review of 34 sham-controlled trials concluded that regular CES treatments resulted in short-term symptomatic relief of generalized anxiety through direct effects on autonomic brain centers. Individuals diagnosed with one or more phobias reported significant reductions in the level of anxiety when exposure to the phobic stimulus was followed by 30 minutes of CES treatment.

CES for treating dementia

Daily application of weak electrical current to the neck or the head may stimulate global brain activity, resulting in beneficial changes in the activity of neurotransmitters implicated in dementia. A meta-analysis of three studies on CES in patients with dementia found evidence of significant but transient improvements in word recall, face recognition, and motivation immediately following treatment that were not sustained at 6-week follow-up.

CES for alcohol and drug abuse

CES is used to lessen symptoms of alcohol and drug withdrawal. The postulated mechanism of action involves stimulation of release of endorphins, enkephalins, and other endogenous opioid peptides and may prove to be similar to the mechanism underlying electroacupuncture. In a 4-week RCT (20 subjects), depressed alcoholics were randomized to receive 20 CES treatments at 70 to 80 Hz, 4 to 7 milli-amps, versus sham treatments. Patients who received CES treatments experienced significantly reduced anxiety by the end of the study. Findings of a sham-controlled study (60 subjects) on hospitalized alcohol or polysubstance abusers suggested that daily 30-minute CES treatments significantly improved cognitive functioning and reduced measures of stress and anxiety during the acute phases of withdrawal in this population. In a 7-year prospective study of CES in the treatment of alcohol, drug, and nicotine addiction, acute and chronic withdrawal symptoms were diminished, normal sleep patterns were restored more rapidly, and more patients remained addiction-free following regular CES treatments compared to conventional psychopharmacological management. The discrepancy between largely positive outcomes from studies on CES and frequent negative findings on electroacupuncture in detoxification may be partly attributable to sub-optimal current or frequency settings in electroacupuncture protocols investigated for this clinical application.

CES for insomnia

CES is widely used to treat insomnia. However, findings of sham-controlled studies are inconsistent. Whereas some studies showed no beneficial effects of CES in insomnia, others reported sustained improvements in the timing of sleep onset and total sleep duration. Disparate findings on the therapeutic benefits of CES in insomnia may be related to differences in equipment, protocols, and duration and timing of treatment.

Safety issues

Transient mild adverse effects of microcurrent electrical brain stimulation are sometimes reported.

Regular exercise is beneficial for depressed mood and anxiety and reduces risk of dementia

How exercise works to improve depressed mood

Many studies show that infrequent physical activity increases the risk of developing depressed mood. Physical exercise increases the levels of brain-derived neurotrophic factor (BDNF) and may enhance neural plasticity and new synapse formation. Regular exercise is associated with increases in the relative size of the frontotemporal and parietal lobes, which are important centers for learning, memory, and executive functioning. Brain levels of endorphins, dopamine, norepinephrine, and serotonin are increased following sustained exercise.

Regular exercise is as effective as antidepressants

Two meta-analyses of controlled trials confirmed consistent positive effects of regular exercise on depressed mood. Aerobic conditioning and strengthening exercise are equally effective against depressed mood. The optimum duration and frequency of exercise for depression have not been determined but are probably related to age and fitness level. In a 16-week study (156 subjects), depressed patients older than 50 years randomized to aerobic exercise three times a week versus sertraline (Zoloft) (up to 200 mg per day) versus exercise plus sertraline experienced equivalent improvements in standardized measures of mood, self-esteem, and negative thoughts. Patients in the antidepressant-only group initially improved faster. However, patients in the exercise-only group had a lower 6-month relapse rate.

Exercise is as effective as cognitive behavioral therapy

The antidepressant effects of running or fast walking may be equivalent to those of CBT and conventional antidepressants for moderate depressed mood. Depressed individuals who exercise in a brightly lit (2,500 to 4,000 lux) indoor environment reported greater improvements in mood and vitality than depressed individuals who exercised indoors in ordinary room light (400 to 600 lux).

Regular moderate exercise reduces the risk of dementia

Routine physical activity is associated with reduced risk of all categories of dementia. More than 2,000 physically nonimpaired men aged 71 to 93 years were followed with routine neurological assessments at 2-year intervals starting in 1991. At the end of the study period, men who walked less than 1/4 mile daily had an almost twofold greater probability of being diagnosed with any category of dementia than men who walked at least 2 miles daily. Findings of the Nurses’ Health Study based on biannual mailed surveys over 10 years showed that women aged 70 to 81 years who engaged in regular vigorous physical activity were significantly less likely to have been diagnosed with dementia than women with more sedentary lifestyles.

Exercise does not slow the rate of cognitive decline after onset of dementia

A small randomized study found that regular daily exercise in individuals with moderate dementia receiving in-home care reduced depressed mood but did not improve cognitive functioning, suggesting that regular exercise does not slow the rate of cognitive decline once dementia has begun.

Regular exercise reduces anxiety symptoms

A period of 20 to 30 minutes of regular daily exercise significantly reduced symptoms of generalized anxiety. A prospective 10-week study on exercise in individuals diagnosed with panic disorder found that regular walking or jogging (4 miles three times a week) reduced the severity and frequency of panic attacks.

Alcoholics report improved well-being with regular exercise

In a small open study of alcoholics who exercised regularly while hospitalized for acute detoxification reported significant improvements in mood and general well-being. Abstinent alcoholics enrolled in outpatient recovery programs reported improved mood with regular strength training or aerobic exercise.

Regular exercise improves overall quality of sleep in the elderly

A systematic review of studies on the relationship between exercise and sleep in the elderly concluded that exercise probably enhanced sleep quality and improved overall quality of life.

To learn more about non-pharma ways to improve your mental health check out my series of e-books

DHEA improves depressed mood but not symptoms of cognitive impairment or schizophrenia

What it is and how it works in the brain

Dehydroepiandrosterone (DHEA) is a precursor of testosterone and other hormones. The sulfated form of DHEA—DHEA-S—is the most abundant steroid in the body. DHEA is an important neuroactive steroid and modulates neuronal excitability by acting as an antagonist at the GABA receptor complex. Preclinical animal studies suggest that mood-enhancing effects of DHEA are mediated through androgen receptors, estrogen receptors, serotonin, GABA, NMDA, and possibly norepinephrine. DHEA’s antipsychotic effects may involve increased dopamine release in the frontal cortex and increased activity of NMDA and sigma receptors.

DHEA for depressed mood

In a small six-week study (22 subjects), depressed patients were randomized to DHEA in an escalating dose (30 mg per day for two weeks, followed by 30 mg twice daily for two weeks and 30 mg thrice daily for two weeks) versus placebo. Half of the patients in the DHEA group improved by 50 percent or more on standardized rating scales. In a six-week placebo-controlled trial (46 subjects), moderately depressed adults off antidepressants were randomized to 90 mg per day of DHEA for three weeks, followed by 450 mg per day of DHEA (150 mg thrice daily) for three weeks versus placebo. The majority taking DHEA reported a 50 percent or greater reduction in depressive symptoms and improved sexual functioning. Most patients who responded to DHEA remained asymptomatic at the 12 months follow-up. More studies are needed to replicate these findings, evaluate DHEA for severe depressed mood, and clarify the mechanism for a putative synergistic or independent antidepressant effect. In a small placebo-controlled trial (30 subjects), inpatients with schizophrenia treated with 100 mg per day of DHEA in addition to their conventional antipsychotic medications experienced significant improvements in depressed mood, anxiety, and negative psychotic symptoms. Women improved more than men, and serum cortisol levels did not change during treatment.

DHEA for cognitive decline in normal aging

DHEA is used in Europe and North America to self-treat decline in cognitive functioning associated with normal aging, however, limited research findings support this use. Small pilot studies suggest that DHEA (25 to 50 mg per day) improves memory and enhances general cognitive functioning in healthy adults. However, most findings are inconsistent, and negative findings have been reported at doses less than 90 mg per day. A systematic review of studies on DHEA or DHEA-S in healthy older adults found no evidence of improved memory or cognitive functioning. Large studies of at least one year or longer are needed to fully explore claims of long-term beneficial effects of DHEA.

DHEA for dementia

DHEA may improve memory in elderly patients who have low DHEA serum levels more than in healthy adults with normal serum levels. However, no correlations were found between serum DHEA-S levels and severity of cognitive impairment or cumulative mortality in a large cohort of individuals newly diagnosed with Alzheimer disease. Preliminary findings suggest that 200 mg per day of DHEA may improve symptoms of cognitive impairment in multi-infarct dementia. However, no controlled trials on DHEA in Alzheimer disease have been completed. In a six-month placebo-controlled trial (47 subjects), men with mild dementia and healthy men aged 50 years and older were randomized to receive 75 mg of testosterone (in the form of a dermal gel) versus placebo together with their usual medications. Quality-of-life measures improved in men with mild dementia and healthy men taking testosterone, and fewer men with mild dementia who received testosterone experienced declines in overall functioning and visuospatial abilities.

DHEA for schizophrenia

In a six-week placebo-controlled trial (30 subjects), inpatients diagnosed with schizophrenia randomized to DHEA at 100 mg per day in addition to their regular antipsychotic medications experienced significant improvements in negative psychotic symptoms, including reduced apathy and social withdrawal. However, there were no significant changes in positive psychotic symptoms, including auditory hallucinations and delusions. Findings of another small study (30 subjects) suggest that augmentation of antipsychotics with DHEA (100 mg day for six weeks) may significantly reduce negative symptoms and may be especially effective in women. However, a systematic review of three small placebo-controlled studies (126 total subjects) on DHEA or testosterone as adjunctive therapies to antipsychotics found equivocal evidence for an augmentation effect on measures of positive and negative symptoms, global functioning, and quality of life.

Huperzine: A Chinese Herbal for Mild Cognitive Impairment (MCI) and Dementia

What it is and how it works

Huperzine-A is an alkaloid compound derived from the herb Huperzia serrata and is an ingredient of herbal formulas used in Chinese medicine to treat Alzheimer disease and age-related cognitive decline. Animal studies show that huperzine-A reversibly inhibits acetylcholinesterase (the brain enzyme that breaks down the neurotransmitter acetylcholine), slows age-related neurotoxicity, regulates the secretion of nerve growth factor, and protects against oxidative stress and neuronal cell death associated with β-amyloid formation. All of these mechanisms probably contribute to the beneficial effects of huperzine-A on cognition and memory.

Summary of research evidence

Findings from preclinical animal studies suggest that huperzine-A may have a longer duration of action, better penetration of the blood–brain barrier, and be a more potent and more specific inhibitor of acetylcholinesterase than available prescription cholinesterase inhibitors–the principal treatments of dementia in Western countries. Placebo-controlled human trials report consistent beneficial effects of huperzine-A in age-related memory loss, Alzheimer disease, and vascular dementia at very small doses–between 200 and 400 micrograms per day. A meta-analysis of eight placebo-controlled randomized controlled trials (733 total subjects) on huperzine-A in Alzheimer disease and two placebo-controlled randomized controlled trials on huperzine A in vascular dementia reported improved global mental functioning as measured by changes in mini-mental status exam (MMSE) and improvements in daily activities. The significance of these findings is limited by small study size and poor methodological quality of some studies included in the meta-analysis.

Safety issues

Infrequent adverse effects include transient dizziness, nausea, and diarrhea. To learn more about huperzine-A and other complementary and alternative approaches for treating mild cognitive impairment (MCI) or dementia read my e-book “Dementia and mild cognitive decline: The Integrative Mental Health Solution.”

Virtual Reality Graded Exposure Therapy (VRGET) for PTSD and Phobias

Virtual Reality Graded Exposure Therapy (VRGET)–What it is and how it works

VRGET is a technology-based exposure therapy with important implications for the management of post-traumatic stress disorder (PTSD) as well as severe phobias that are difficult to treat using conventional psychological therapies and medications. VRGET combines advanced computer graphics, three-dimensional visual displays, and body-tracking technologies to create realistic virtual environments with the goal of simulating feared situations or objects. Virtual environments have been designed to provide visual, auditory, tactile, vibratory, vestibular, and olfactory stimuli to patients in highly controlled settings. During a virtual exposure session, the therapist closely tracks the patient’s state of arousal by monitoring physiological indicators of stress, including heart rate and respirations. Many individuals are readty to take the next step and engage in real life (i.e., in vivo) exposure to the feared object or situation after they have been desensitized to a virtual environment.

VRGET is more effective than conventional exposure therapy

VRGET is more effective than conventional imaginal exposure therapy and has comparable efficacy to in vivo exposure therapy for the treatment of specific phobias, agoraphobia, panic disorder, and PTSD. Like in vivo and imaginal exposure therapy, VRGET desensitizes the patient to a situation or object that would normally cause anxiety or panic. In a randomized controlled trial, VRGET and conventional cognitive behavioral therapy (CBT) were equally effective treatments of panic disorder with agoraphobia, and patients who underwent VRGET required 33 percent fewer sessions to achieve similar results. Studies also confirm that VRGET is an effective treatment of fear of flying, fear of heights, fear of small animals, fear of driving, and other phobias. VRGET is as effective as and more cost-effective than conventional exposure therapy for fear of flying because patient and therapist avoid the cost and inconvenience of airplanes. A virtual environment simulating the devastation of the September 11, 2001, attacks on the World Trade Towers has been successfully used to treat individuals diagnosed with severe PTSD following the attacks.

VRGET reduced PTSD symptoms in combatants who do not respond to conventional exposure therapy

Findings of a study on combined multisensory exposure and VRGET reported significant reductions in severity of PTSD symptoms in active duty combatants who had failed to respond to other forms of exposure therapy. Several subjects reported significant improvement following only five VRGET sessions; however, there was considerable variability in the number of VRGET sessions needed to reduce symptom severity to the same level.

VRGET is being used to screen individuals at high risk of developing PTSD

Research studies are being aimed at developing virtual reality tools for assessing and preventing combat-related PTSD. STRIVE (Stress resilience in virtual environments) is a highly integrative “stress resilience training” program aimed at enhancing emotional coping strategies prior to active deployment. STRIVE employs an immersive VR environment to simulate combat situations that includes a “virtual mentor” who guides the combatant through a virtual experience while coaching him or her in relaxation and emotion self-regulation skills. The intensity of the virtual stimulus used is determined by the individual’s habituation based on HRV and other measures of autonomic arousal. Physiological biomarkers of stress response are measured before and after VRGET sessions. The STRIVE system permits users to be immersed in stressful combat scenarios and interact with virtual characters for training in a variety of coping strategies that may enhance resilience in the face of extreme stress. The STRIVE protocol may provide a useful tool for predicting the risk of developing PTSD or other psychiatric disorders in new recruits prior to actual combat exposure. Recruits who display high resilience and thus presumably at relatively lower risk of developing PTSD might be more suitable for direct combat roles while individuals who display low resilience might preferentially be assigned to noncombat roles.

Future innovations will integrate VRGET with biofeedback and broadband internet connections permitting in-home therapy

Future integrative approaches to phobias, panic attacks, and other severe anxiety disorders will combine VRGET with biofeedback in outpatient settings or in the patient’s home via broadband Internet connections, with CBT, relaxation, mind–body practices, and appropriate medications. Combining VR environments with real-time feedback based on neurophysiological responses to stress may permit each unique patient to optimize the level and type of VR exposure to enhance resiliency training and speed the rate of recovery from PTSD. Human–computer interface (HCI) systems based on CBT and biofeedback are being developed for resilience training in individuals at risk of developing PTSD following exposure to trauma. Larger studies on patient populations diagnosed with PTSD using headmounted displays and other technologies that create more immersive virtual environments are needed to determine whether combining VRET and EEG biofeedback is practical in clinical settings and yields superior outcomes compared to either approach alone.

Few safety problems

Infrequent cases of disorientation, nausea, dizziness, headache, and blurred vision have been reported following VRGET. Intense sensory stimulation during VRGET can trigger migraine headaches, seizures, or gait abnormalities in individuals who have these disorders. Patients with schizophrenia should not use VRGET because immersion in a virtual environment can exacerbate delusions.

To learn more about VRGET and other non-pharmacologic treatments of PTSD check out my e-book “Post-traumatic stress disorder: the integrative solution.”