Current data suggest that Ginkgo biloba ginkgo , and Hypercium perforatum St.
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E-mail address: jsarris unimelb. All rights reserved. Promising candidates for future research include Bacopa monniera brahmi and Piper methysticum kava , providing potential efficacy in improv- ing attentional and hyperkinetic disorders via a combination of cognitive enhancing and sedative effects.
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Contents Introduction Intervention search terms Sarris et al. Quality assessment of the papers anorexia, weight loss, abdominal pains, sleep disturbances, was independently rated to assess inter-rater reliability. Was the study described as randomised? CAMs alone or adjunctively with conventional pharmaco- 2. Was the randomisation protocol detailed and appropri- logical treatments, with one study of children with ate? Was the study described as double-blind? Was the blinding process detailed and appropriate? ADHD, evidence is required to support claims of efficacy, 5. Did the study have a control group?
Previous publications 6. Was the control detailed and appropriate? Was there an adequate exclusion criterion? Was the intervention used at a therapeutic dose? Was there a description of withdrawals and dropouts? Thus, the purpose of this paper is to present a sys- Were the data clearly and adequately reported? Two hundred and nation with specific CAMs herbal and nutritional medicine seventeen of these were eliminated, commonly due to irrel- interventions see Appendix 1 for intervention search term evance, methodological weakness e.
Papers that met the inclusion criteria were human ran- controlled, or randomised , or the study not having a pri- domised controlled trials RCTs of sufficient methodological mary focus on attentional, behavioural or hyperactivity rigor. This left 16 clinical trials for inclusion. Five nutritional interventions met criteria for 1 Sample consisting of children or adolescents aged inclusion: zinc, iron, omega-3, vitamin C, and acetyl- 5—17 or adults aged 18—65 L-carnitine, while four herbal medicines were included: 2 Primary diagnosis of ADHD, or marked level of attention Ginkgo biloba ginkgo , Hypericum perforatum St.
The average sample size and duration of the stud- ies were 92 range 23— , and The intervention with the most research was excluded. Each paper was analysed for methodological qual- found to be omega-3 fish oil, DHA, or flaxseed oil. In ity using a purpose-designed scale based on the Jadad our systematic review of the literature, four omega-3 RCTs scale25 as first used in Sarris and Byrne,26 and in subsequent were located that met inclusion criteria, with only one reviews e. Pase et al. The Jadad scale uses three pri- producing significant positive results on the main primary mary quality factors — randomisation, blinding and reported ADHD outcome measures.
Two of the omega-3 studies, withdrawals. The modified augmented version also assesses Stevens et al. This may have potentially contributed of the previous zinc studies. Zinc glycinate was randomly to the better outcomes on the placebo groups. EPA as a predominantly adjunctive intervention to psychos- Results revealed on ADHD outcome scales that no signifi- timulants, found no differential benefit of the supplement cant improvements occurred with zinc supplementation in compared to controls.
Strict dren with predominantly inattentive type ADHD experienced exclusion criteria ensured no participants in the study were greater improvement over placebo but there was no dif- on stimulant medication or any additional omega-3 supple- ferential benefit on primary outcomes in children with ments within the previous 3 months.
Young population. No Inatt: 0. Average sample size The data provided did multiple cross-overs. A recent study by Salehi et al. Dosage in this study was also much higher than in previous studies. The study also treatment cross-over showed the herbal formula to be safe and tolerable for ADHD Duration periods weeks children as monitored by the blood, urine, and stool analysis and liver and renal function.
The strength of this review is that a rigorous systematic search criteria and quality analysis Van Ouheusden was conducted. As discussed in the introduction, this is First author the first systematic review to our knowledge on natural products in the treatment of ADHD.
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We however acknowledge a couple of potential weaknesses with this review. Firstly, we only reviewed studies in English, thereby some non-English RCTs Intervention were excluded involving three Chinese papers three herbal L-Carnitine medicine studies 47—49 and one Russian paper magnesium plus B vitamin combination. Sinn and Bryan33 were need to be strongly considered especially regarding the able to find significance with a large population of ADHD potential effect on the liver. The high drop-out rate from This may be achieved via cholinesterase inhibition and this study poses an issue when looking to validate such antioxidant effects.
Antioxidant effects may potentially a design, but it should be noted that the drop-out rate be beneficial in ADHD as evidence by the beneficial was evenly spread between active and non-active groups effects of pine bark, which due to the oligomeric and that the drop-out rate was more often due to non- proanthocynadin compounds provides a strong antioxidant compliance than to adverse events. Raz et al. A CPT significance was not reached. As well as the issue of is an objective neurophysiological measure of attention, dosage, vitamin C was used for placebo which has signifi- impulsivity and inhibition that removes the subjectivity cant antioxidant properties and may have also play a role found in behavioural measures.
Stevens et al. The specificity of the population may found no significant effects of the tested CAM product over not be generalisable to a broad ADHD population, and so placebo. These results could indicate that CPTs are sensi- may have acted as a confounding variable in this case. These techniques are valuable to observe durations and low doses of essential fatty acids used in effects of substances on brain waves electroencephalog- some studies may not be adequate to result in long-term raphy: EEG , cerebral blood flow fMRI , and activation of changes in neuronal membrane structure required for clin- brain function PET.
Most children were rated by a blinded psychiatrist as having In respect to the results of our systematic review inform- significant improvements in both inattention and hyperac- ing clinical practice, currently there is no clear picture about tivity that correlated with reductions in the AA:EPA ratio which, if any, CAMs can be recommended for use in treat- at the end of 8-week treatment period.
Marinus van Reymerswaele
Large prospec- ing ADHD. The CAM natural products reviewed provide a tive trials are needed to replicate these findings. Voigt mixture of results, with the most promising concerning min- et al. The oil maritime pine bark. While future studies should focus on its use only in deficient the current omega-3 data are not supportive of its use in samples. ADHD, future studies using higher dose preparations may The minerals studied iron and zinc displayed mainly reveal better effects, and regardless, can still be advised in positive evidence of effect on reducing ADHD symptoms. Herbal medicines while presently under- This beneficial effect could be potentially occurring due to researched in this area may yet provide novel treatments of addressing deficiency, as mineral deficiency is common is ADHD.
Interventions involving combinations of herbal and Western child and adolescent populations. While the herbal medicines St. Future potential Conflict of interest statement studies could involve kava Piper methysticum or brahmi Bacopa monniera. Kava has demonstrated positive effects None declared. Lancet 1.
EM, Knight JR, et al. American Psychiatric Association.
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Saint Jerome Oil on panel Wearing a red habit, Saint Jerome sits at a table, pointing to his customary attribute, the skull that illustrates his meditations on the vanity of life. Clic para ampliar.