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.”

High-density negative ions for seasonal affective disorder (SAD)

Regular exposure to high density negative ions may be as effective as bright light therapy for seasonal depressed mood

I recently posted a blog on the health benefits of light. In addition to bright full-spectrum light and (to a lesser extent) dim blue or red light, emerging evidence suggests that regular daily exposure to high-density negative ions may be an effective treatment of seasonal depressed mood and may have comparable efficacy to bright light exposure for this condition.

Twenty-five depressed patients with seasonal depressed mood were randomized to high-density negative ions (2.7 × 106 ions/cm3) versus low-density negative ions (1 × 104 ions/ cm3) using in-home ion generators 30 minutes daily for 3 weeks. Fifty-eight percent of patients exposed to high-density negative ions experienced significant improvements in mood on standardized rating scales, compared to 15 percent of patients exposed to low-density negative ions. In a 2-week randomized-controlled trial (158 subjects), patients with seasonal depressed mood were randomly assigned to bright light exposure (10,000 lux) versus high-density or low-density negative ions. Patients exposed to high-density negative ions or bright light experienced significant and equivalent improvements in mood. In another controlled trial (128 subjects), bright light exposure, a pleasing auditory stimulus, and high-density negative ions resulted in equivalent and rapid improvements in mood and alertness in mildly depressed and non-depressed adults.

No adverse effects

Adverse effects have not been reported with regular daily exposure to negative ions following the approaches used in published studies.

Integrative mental health care

To learn more about non-pharmacologic therapies of depressed mood and other mental health problems read my e-books on integrative mental health care.

Urgent Need for Transforming Mental Health Care

Existing models of care and conventional therapies are limited

Existing models of care and available conventional treatment approaches fail to adequately address the global crisis of mental health care. Mental illness accounts for about one-third of the world’s disability caused by all adult health problems, resulting in enormous personal suffering and socioeconomic costs. Severe mental health problems including major depressive disorder, bipolar disorder, schizophrenia, and substance use disorders affect all age groups and occur in all countries, including the US, Canada, the European Union countries, and other developed and developing countries. Mental illness is the pandemic of the 21st century and will be the next major global health challenge. There is a large and growing gap between mental health care needs of the population and available resources.

Weak evidence and safety problems affect many psychotropic medications

Many individuals diagnosed with bipolar disorder, major depressive disorder, and schizophrenia depend on medications to function and be productive members of society. However, after decades of research and billions of dollars of industry funding, the evidence supporting pharmacologic treatments of major depressive disorder, bipolar disorder, and other psychiatric disorders is not compelling. Many commonly prescribed psychotropic medications including antidepressants and antipsychotics are associated with serious adverse effects, including weight gain, increased risk of diabetes and heart disease, neurologic disorders, and sudden cardiac death. Metabolic syndrome associated with weight gain and increased risk of diabetes and coronary artery disease is a well-documented adverse effect of antipsychotics and other psychotropic agents. Poor treatment outcomes owing to limited efficacy of antidepressants, mood stabilizers, antipsychotics, and other psychotropic medications result in long-term impaired functioning, work absenteeism, and losses in productivity.

CAM therapies can help improve outcomes

In the context of the limitations of available conventional biomedical treatments, accumulating research findings are providing evidence for both safety and efficacy of select complementary and alternative (CAM) treatments of depressed mood, anxiety, and other mental health problems, including select pharmaceutical-grade natural products, lifestyle modifications (Lifestyle Medicine), mind-body approaches, and nonallopathic whole-system approaches such as traditional Chinese medicine and Ayurveda. Examples of natural supplements being investigated as nonpharmacologic therapies include S-adenosyl methionine for depressed mood; the adjunctive use of nutraceuticals (ie, botanicals and other natural product supplements) as stand-alone therapies or in combination with psychotropics such as omega-3 fatty acids, folic acid (especially its active form l-methyl-folinic acid), 5-hydroxytryptophan, and n-acetyl cysteine for mood disorders; a standardized extract of the herbal kava; and the amino acid l-theanine.

To read more click here.

Light therapy for depressed mood and insomnia

How light therapy works

Light of different intensities and colors is used in conventional biomedicine and many nonconventional systems of medicine to treat both medical and psychiatric disorders. Diverse mechanisms of action are probably involved, including regulation of melatonin and neurotransmitters. Entrainment of sleep–wake cycles by external bright light cues and the associated suppression of melatonin production by the pineal gland is the established mechanism of action underlying the therapeutic benefits of light exposure on sleep and daytime fatigue.

Bright light therapy for depressed mood

Exposure to natural sunlight, especially in the early morning, has significant antidepressant benefits and may reduce the length of hospital stays in severely depressed patients who are hospitalized. A systematic review of controlled studies confirmed an antidepressant effect of bright light (10,000 lux) exposure therapy in seasonal depressed mood but provided only limited evidence supporting bright light as a treatment of nonseasonal depressed mood. A more recent meta-analysis of controlled studies concluded that bright light exposure or dawn simulation for seasonal depressed mood and bright light exposure (but not dawn simulation) for nonseasonal depression had comparable efficacy to antidepressants. Findings of a small randomized controlled trial suggested that bright light therapy may be an effective alternative to antidepressants in pregnant depressed women.

Dim red or blue light for seasonal depressed mood

Recent studies suggested that regular exposure to dim red or blue light might be as efficacious as bright light, especially in the management of seasonal depressed mood. In a 4-week single-blind study (57 subjects), patients diagnosed with seasonal affective disorder (SAD) were randomized to daily bright light versus dim red light exposure. Both groups experienced an equivalent and significant (40 percent) reduction in symptoms. Preliminary findings suggest that antidepressant effects of early-morning exposure to narrow spectrum blue or green light may be equivalent to benefits obtained from full-spectrum bright light exposure. Exposing depressed patients to low-intensity artificial light approximately 2 hours before they would naturally be exposed to early-morning daylight increased the speed of response to conventional antidepressants. Thirty depressed inpatients treated with citalopram at 40 mg per day were randomized to early-morning dim green light, 400 lux, versus a sham, non–light-emitting device during the first 2 weeks of drug treatment. Patients in the combined citalopram–light exposure group reported significantly greater and more rapid improvements in mood compared to the citalopram only group. No adverse effects have been reported with regular exposure to dim light.

Light therapy for sleep disorders

An expert consensus report on light treatment for sleep disorders concluded that there is compelling evidence for the efficacy of bright light exposure in the management of circadian rhythm sleep problems but not for other types of insomnia. Most protocols recommend 30 to 40 minutes of bright light exposure daily for beneficial effects in shifting circadian rhythms and changing sleep–wake cycles. Beneficial effects of bright light exposure therapy are usually noticeable within a few days, and an appropriate treatment plan often resynchronizes the patient’s sleep–wake cycle with his or her time zone in 2 to 3 weeks. Correct timing of light exposure is essential for successful treatment of circadian sleep problems, and bright light exposure between the hours of late morning and late afternoon probably has no effect on circadian rhythm phase. Preliminary findings suggest that melatonin used in conjunction with bright light exposure may achieve more rapid normalization of the sleep–wake cycle.

Safety issues

Individuals interested in trying light therapy for depressed mood or a sleep disorder should avoid using sun lamps (which emit harmful ultraviolet rays) and keep the eyes open while viewing the light fixture at an oblique (approximately 45 degrees) angle to avoid excessive eye strain. Some individuals exposed to bright morning light at 10,000 lux on a regular basis report transient side effects, including mild jitteriness or headaches (10 percent) and mild nausea (16 percent). Sporadic cases of hypomania have been reported, especially in winter depressives or bipolar patients exposed to early-morning bright light. Almost two-thirds of patients who use bright light exposure therapy in the evening report insomnia.

Ginkgo for cognitive decline and dementia: the verdict is still out

How Ginkgo works

Ginkgo (Ginkgo biloba) extract is used in Europe and North America to treat dementia and other neurodegenerative diseases. Most commercially available preparations are standardized to two active ingredients: flavone glycosides and terpenoids. The flavonoid constituent is a strong antioxidant and is believed to have a general neuroprotective benefits. The terpenoid fraction interferes with platelets and helps individuals recover following a stroke by decreasing the risk of blood clots in the brain and reducing nerve cell death associated with stroke. Constituents of Ginkgo may also inhibit neurotoxicity and nerve cell death caused by nitric oxide.

Ginkgo may improve cognitive functioning in both healthy and cognitively impaired non-demented adults

Two placebo-controlled trials found that a compound herbal product containing both Ginkgo biloba (160 or 320 mg) and Panax ginseng (400 mg) resulted in transient improvement in recall performance in healthy adults. Enhanced cognitive functioning appears to reach its peak approximately 6 hours after the herbal preparation is taken. Preliminary findings suggest that combining Ginkgo with another traditional Chinese herbal, dangshen (Codonopsis pilosula), may improve cognitive performance in healthy adults more than either herbal alone. A meta-analysis of 11 clinical trials on standardized ginkgo extracts in elderly cognitively impaired individuals who did not meet full criteria for dementia suggested consistent cognitive enhancing effects.

Inconsistent findings for Ginkgo as a treatment of dementia

Early systematic reviews of randomized controlled trials on ginkgo in dementia concluded that ginkgo preparations in doses between 120 and 600 mg per day taken over several weeks to 1 year result in modest improvements in memory, general cognitive functioning, and activities of daily living in mild to moderate Alzheimer dementia and multi-infarct dementia. However, a systematic review of all randomized controlled trials published up to 2006 on ginkgo in the treatment of dementia and other types of acquired cognitive impairment found inconsistent evidence, noting that early trials were generally small or methodologically flawed, including the absence of standardized preparations and the use of different dementia rating scales across studies. In a 24-week, double-blind placebo-controlled trial, patients with mild to moderate dementia were randomized to a standardized ginkgo extract (160 mg per day) versus the cholinesterase inhibitor donepezil (5 mg per day) or placebo. At 24 weeks, patients taking ginkgo and donepezil experienced equivalent improvements in cognitive performance and global functioning. The findings of one study suggest that the rate of overall cognitive decline is moderately slowed in severe dementia.

Ginkgo has safety issues related to interference with normal blood clotting

Ginkgo is generally well tolerated. Mild transient adverse effects include upset stomach, dizziness, and headaches. Cases of spontaneous bleeding have been reported. Ginkgo should be avoided in individuals taking aspirin, or anticoagulants like warfarin, or heparin. G. biloba preparations should be discontinued at least 2 weeks prior to surgery. G. biloba may cause elevation of hepatic enzymes, and there are case reports of possible serotonin syndrome when taken with SSRIs.

Omega-3s in Mental Health Care: Part 2

Part 1 reviewed the evidence for omega-3 supplementation in the treatment of depressed mood. This post concisely reviews the evidence for omega-3s in treating schizopohrenia, dementia, ADHD, PTSD and borderline personality disorder.

Omega-3s for symptoms of schizophrenia and other psychotic disorders

Augmentation with the omega-3 fatty acid EPA may be an effective preventive strategy in individuals at high risk for developing schizophrenia or in the early phase of psychotic illness but not as a treatment of established cases of schizophrenia. The neuroprotective role of omega-3s during the early so-called prodromal phase of schizophrenia may be related to general effects on the brain’s antioxidative intracellular defense mechanisms or direct interactions between EPA and the glutamate receptor system. EPA augmentation may be especially appropriate for younger or antipsychotic naïve individuals in the early phase of illness or cases in which metabolic or sexual adverse effects may result in poor medication adherence and symptomatic worsening. Limited findings suggest that a combination of EPA and DHA may reduce the rate of progression to full-blown schizophrenia in high-risk populations including individuals who chronically abuse substances or already have impairments in neuropsychological functioning. In contrast to positive findings of studies on EPA augmentation in the prodromal phase of schizophrenia, a meta-analysis of placebo controlled studies on EPA augmentation on symptom severity in patients with chronic schizophrenia or other psychotic disorders found no evidence for greater benefit of EPA augmentation over antipsychotic medications alone. All studies included in the meta-analysis lasted 12 weeks and used EPA doses between 2 and 3 g per day. Possible explanations of reported negative findings include small study size, absence of clinical efficacy of EPA supplementation in chronic schizophrenia, a “ceiling effect” on response to EPA augmentation associated with concurrent treatment with antipsychotics, combinations of different fatty acids may be more effective than EPA alone, and dietary differences and other socio-demographic factors that may have confounded findings.

DHA supplementation for treatment of cognitive decline and dementia

Systematic reviews and meta-analysis of studies on the effects of omega-3 supplementation on cognitive development, function, and decline throughout the life span concluded that omega-3 supplementation—especially DHA—may significantly improve cognitive development in infants but not in children, adolescents, adults, or the elderly. Omega-3 supplementation was not associated with a reduced rate of cognitive decline in healthy elderly adults or with a slowing in the rate of progression of Alzheimer disease.

Inconclusive evidence for omega-3s in ADHD

Although individual studies on omega-3s in ADHD report positive findings, a systematic review and meta-analysis of placebo-controlled trials on omega-3s in the treatment of ADHD in children and adolescents reported inconclusive findings due to methodological problems including small sample sizes, variability of selection criteria, and type and dosage of supplements and short-term follow-ups.

Recent studies have investigated the role of omega-3s in PTSD. These studies are based on the observation of increased rates of neuronal regeneration in the hippocampus soon following trauma. It is hypothesized that increased neuronal regeneration following trauma may result in more rapid clearance of fear memories and prevent immediate post-trauma memories from becoming long-term memories, reducing the risk of developing PTSD. In fact, animal studies support that omega-3 fatty acids increase hippocampal neurogenesis. Studies done in Japan following the 2011 tsunami investigated the effectiveness of pre-treatment with omega-3s in preventing the development of PTSD following exposure to trauma in first medical responders.

Symptoms of borderline personality disorder may improve with omega-3 supplementation

In a small, 8-week controlled trial (N = 30), women diagnosed with moderately severe borderline personality disorder randomized to ethyl-EPA (1 g per day) versus placebo reported less severe symptoms of aggression and depressed mood compared to the placebo group.

Omega-3s have few mild safety issues

Omega-3 fatty acids are generally well tolerated and pose few safety issues. Transient mild gastrointestinal distress is sometimes reported by patients who take omega-3 fatty acids. There is one case report of possible hypomania induced by omega-3 fatty acids. Rare cases of increased bleeding times have been reported in patients who take aspirin or anticoagulants together with omega-3s.