Dr. Sanjeev Sharma joins our ambassador, Dr. Adrian Lopresti, for a discussion on supporting patients with Attention Deficit Hyperactivity Disorder (ADHD) and the potential for stimulant and natural medicine to support these patients.
Sanjeev shares with us the impact ADHD can have on the quality of life of an undiagnosed person with ADHD, in particular with academic studies and employment. With extensive experience in supporting ADHD patients, Sanjeev shares the challenges faced in obtaining a diagnosis, prescription medicines and the many opportunities a natural health practitioner has in suporting ADHD patients through integrative medicine, lifestyle, dietary and supplements while operating within their scope of practice.
Covered in this episode
[00:27] Welcoming Dr. Sanjeev Sharma
[01:25] The defining aspects of ADHD
[03:41] Adult ADHD diagnosis
[06:05] Is hyperactivity required for a ADHD diagnosis?
[07:39] DSM-5 and other diagnostic criteria for ADHD
[10:41] The importance of formal ADHD diagnosis
[14:10] Restrictions surrounding medications
[17:11] Neurotransmitters implicated in ADHD and the mechanisms of actions of ADHD medications
[20:46] Environmental and lifestyle factors that affect neurotransmitter levels
[26:43] Connections between inadequate detoxification, food intolerances and ADHD
[29:06] Beneficial integrative, functional and genetic testing
[32:11] Testing and dosing Vitamin D, DHEA and Omega 3 levels
[35:07] Safely prescribing nutrients in conjunction with stimulant medication
[39:00] Summarising key points of the episode
[40:31] Organic acid testing
[41:22] Beneficial herbs
[43:11] Thanking Sanjeev and closing remarks
- ADHD is often identified at an early age with hyperactivity and impulsivity indicating diagnosis. Inattentive behaviour associated with ADHD can lead to a delay in accurate diagnosis. Signs including the inability to sit still, fidgeting, easily aggravated or excited, deviation from topic of conversation or going on a tangent.
- If ADHD is not diagnosed, adults may find work and university challenging due to the lack of formal structure, impulsive behaviour, time management skills and sleep disturbances. ADHD may be closely associated with addiction.
- There are three types of ADHD listed in the DSM-5 including the following:
- Attention that is hyperactive disorder
- Inattentive type
- Mixed-type – both hyperactivity and inattentiveness present
- Any medication used for the management of ADHD, whether it is a SSRI, SNRI, tricyclic antidepressants, or multi-stabilizes, the medication will not make the neurotransmitter– it traps them. The medication will not influence the production of neurotransmitters, this provides an opportunity for the integrative practitioner to support the ADHD patient.
- Causes and exacerbaters of ADHD may include genetic predisposition, impulsion due to altered function of the frontal lobe often treated by blocking dopamine and noradrenaline uptake, dietary insufficiency, environmental exposure
- Detoxification pathways may be under increased pressure with ADHD increasing the risk of food intolerances and sensitivity, methylation, genetic SNPs and gut health should be considered.
- Practitioners need to take care when prescribing natural medicines by ensuring interactions are checked prior to prescribing natural medicines.
Resources discussed by Dr. Sharma in this episode
ADHD: Additional resources and articles
Supplementation for ADHD
Dr. Julia Rucklidge’s work on ADHD
Felice Jacka’s work on ADHD
|Research: The associations between maternal and child diet quality and child ADHD – findings from a large Norwegian pregnancy cohort study (Borge, et al., 2021)
Adrian: Hi, and welcome to FX Medicine, where we bring you the latest in evidence-based, integrative, functional, and complementary medicine. FX Medicine acknowledges the traditional custodians of country throughout Australia where we live and work, and their connections to land, sea, and community. We pay our respect to the elders, past and present, and extend that respect to all Aboriginal and Torres Strait Islander peoples today.
With us today is Dr. Sanjeev Sharma, consultant psychiatrist in private practice, where he practices in Perth, Western Australia. Dr. Sharma is an integrative psychiatrist with an interest in general adult psychiatry, where he specialises in the holistic treatment of affective disorders, psychotic disorders, addictions, and ADHD. His treatment combines both Eastern and Western medicine principles, where he believes that everyone is unique and should be treated as such. So welcome to FX Medicine, Sanjeev. Thanks for being with us today.
Sanjeev: Thank you.
Adrian: Today I wanted to talk... I mean, I wanted to talk about ADHD. So ADHD or Attention Deficit Hyperactivity Disorder is a disorder that is estimated to affect approximately 1 in 20 people, and more than three-quarters of children diagnosed with ADHD continue to experience symptoms into adulthood. And because it's such a prevalent condition and one that triggers a lot of debate, and because of your expertise in the area, I wanted to spend today's podcast talking about your views about ADHD and how you go about diagnosing and assessing it, and what effective treatment approaches you have identified. But before we get into that, can you tell us what is ADHD?
Sanjeev: Okay. Well, as we know, it is one of the disorders which has been in existence for a long time, because it is a well-known condition. But what has happened is that historically it contained a lot of taboos. And taboo was mainly in the '90s. And we started with the movement that like, we don't want to put people on medications and other things like that.
But if you see into the breakdown, into the symptomatology of these individual cases, it is a quality of life illness, it is not a life-threatening illness. Which means if an individual is not treated, are they going to die? Of course not. But can their quality of life be better? Which means that on a day-to-day basis, how their organisations are, their academics lost, also their professional pursuits.
So, usually, these individuals are picked up in their young age, especially if they are impulsive and hyperactive. But there's a third component of this illness, which is inattentive-type, which unfortunately can be misdiagnosed for several decades. And this is something I come across in my practice where they have reached into their 20s and 30s and in their professional setups they can see that they're struggling. And they may or may not have other key symptoms which I said earlier about impulsivity and also hyperactivity. So, it is a disorder in which these three key symptoms are there, and depending on the needs we plan their treatments after assessment is done.
Sanjeev: Yes. Yes. It's a very nice point which you have made. And this is something I come across. So, one of my subspecialty interest is addictions. And the place where I work, we specialise in dual diagnosis, which is mental health and addictions. Now, a substantial chunk of population, maybe more than 60% of people who have been using any addictive substances have associated undiagnosed ADHD.
Sanjeev: And these are the individuals who can start with sort of delinquent behaviour, followed by rebellion behaviour in the childhood, then conduct disorder, and then which gradually march onto antisocial personality. And then it can also have substance abuse. But usually, if you look at the trajectory of these individuals, you will find that if you go backwards, these individuals would have a lot of patients who would have sort of inattention problem. They cannot sit and they can be easily aggravated or excited and then mix up with their peers. So, there is a subgroup of patients which I come across, especially in this population that underlying ADHD is a common condition.
And there is also another category which we come across is when some of these individuals like, especially when they are coming out of a structured environment in the school, where there is a lot of like regimental approaches are there, but when they go to university or join the workforce or they join any apprenticeship, they find that this all, everything is loose and it all depends on them. And somehow they may be changing, a lot of degrees are changing their professions, and that's how and when they are picked up. So, there's a wide variations of adults which I come across when we see these individuals struggling. And depending on their nature and certain rules and regulations around prescriptions, we pick them up and treat them.
Adrian: Okay. Okay. So a lot of them would have comorbid conditions like you mentioned addictions, but then...
Adrian: ...when they change or transition from the school environment into a workplace where maybe it's not so much structure, then that's when some of these symptoms will become more apparent for them. And that's when they'll probably come and see someone like yourself?
Sanjeev: That's correct. That's correct.
Adrian: Wow. Okay. So, if we think about attention deficit hyperactivity disorder, now, does everybody with ADHD, do they have to have hyperactivity or can you have just the attentional/inattention side of things and not have the hyperactivity?
Sanjeev: Okay. It's a very good point. And as I mentioned earlier, in order for diagnosing ADHD, hyperactivity is not required. Okay. It can be. So, the way DSM-5 diagnosis is called as attention that's hyperactive disorder/inattentive type, or mixed-type, or when mixed-type is that when we see both hyperactivity and inattentiveness.
So, to answer your question, hyperactivity may not be there in everyone. And also, particularly in case of adults, what happens is that even people who have been diagnosed with ADHD when they were young, they may have a mixture of hyperactive and inattentive component, but hyperactive component tends to mellow down as they grow up. And is there in the late teens to early 20s.
But inattentive component can stay. So this is what it is mentioned that those like three out of four people will remain, have inattentive problem when they were diagnosed. So that's something that significantly impacts on their academic and professional pursuits. And this is where these people become quite dysfunctional. And I have seen remarkable changes once, certainly the medications, but also the integrative approaches are used in these individuals.
Adrian: Okay. Okay. So, I'll just for our listeners, I'll just kind of go through, I've got the DSM-5 criteria here. So with the inattention, some of the symptoms are that they often fail to give close attention to details or make careless mistakes, or they often have difficulties sustaining attention in task or play activities. They may not seem to listen when spoken to directly, they can have problems following through with instructions or fail to finish schoolwork, or chores, or tasks. They may have difficulty organising tasks and activities, and they often avoid or are reluctant to engage in tasks that require sustained mental effort, or they often lose things.
So, based upon the DSM-5, I think it's six of those symptoms need to...obviously, they don't need to have all of those, but around six of those symptoms need to be persistent for at least six months. And they need to kind of have a prevalence in childhood. Don't they?
Sanjeev: Yeah. So, what happens is that like sometimes we do standardised questionnaires but we do a small checklist of questionnaires are there. And there is a detailed one, it is called a DIVA. And in which there are some questions related to their childhood. And also depends on their cultural environment. So a lot of times people, if their parents have been migrants or the parents themselves have their own challenges, they may not even recognise that these children have problems, you know? But when they look back and ask these specific questions, some of them have these symptoms lifelong but it was never brought to their attention. So, and this is where these individuals miss out a lot. Okay.
Adrian: Yeah. Okay.
Sanjeev: If they would've been picked up earlier, then chances are they could have done much better.
Sanjeev: At least some of them.
Adrian: And what was the questionnaire you mentioned that you use?
Sanjeev: Yeah. It is called a DIVA. And this is basically a diagnostic tool based on DSM-5 questionnaire. So it's basically, each individual symptoms have been broken down into like a checklist of questions. And usually, they tick them whether they had this in a mild, moderate, and severe category. And then based on that, you do a calculation. But certainly, in some cases, particularly in case of children, they go through some kind of a standardised diagnostic checklist. So, one is the Conners speech rating scale, which both is done by the caregivers for that like parents and also the teacher's version. And then based on that they are checked up.
So, they can be formally assessed as well, but especially in case of adulthood, I primarily rely on the free-flow interview in which we can listen to their struggle. And once we have gone through the individual categories which are related to their academics, their time management, their organisations, their finances, their impulsive behaviours, or lifestyle challenges, or sleep disturbances, you will come to know that yes, most of the areas within the symptoms are covered. And hopefully, then we can proceed with the treatment options.
Adrian: Yeah. Okay. So most of it, so you obviously do your interview, your standard interview, you ask questions to identify symptoms, you may or may not use questionnaires or checklist or things like that, and that helps you identify the diagnosis.
Now, is the diagnosis important? Is that something that you think is important when it comes to ADHD, is actually coming up with the formal diagnosis?
Sanjeev: That's correct. Because otherwise what happens is that we are trying to, because that's a primary category, especially if we are using certain medications. So, if you want I can talk now, but we can talk it later. But there are certain medications which are longer-acting preparations, which are not covered by PBS if you are diagnosed after the age of 18.
Sanjeev: So, there are... So, yes, that's where we have to be assured that we are making a diagnosis at an appropriate age. And especially there are some subgroup of people who come, who were seen by their doctors, or by paediatricians, or psychologists, but they were never initiated the treatment. And that's okay. As long as there's a diagnosis there and I've got documentary evidence, certainly then they can be eligible for PBS rebate. Otherwise, they may have to pay like a private script for medications, longer-acting preparations of methylphenidate like Ritalin LA and Concerta.
Adrian: Okay. Yeah.
Sanjeev: Whereas in case of Xaggitin, since last one year, even the adults are eligible. Initially they were not. So, that's an advantage which some of the individuals have if they were diagnosed earlier.
Adrian: When do you go, "Okay, this is ADHD. This is not just your normal inattention, forgetfulness, a bit of hyperactive." When do you kind of go, "Yep. Definitely, I think diagnosis is warranted here."
Sanjeev: Usually, the best way to look into, like I would say for like general practitioners because a lot of times I come across that. And yesterday, I can give you example, I saw a lady and she was told by her general practitioner that, "Well, I don't think you have ADHD because you have been sitting for one-hour." Okay. And she didn't move. Okay. So, and that's the biggest myth, you know. So, let them flow, but what these people will do is that if you allow them to flow and sit in the talk, if they're hyperactive, first, they will be very fidgety. Okay. They will be constantly tapping their legs, they will be moving their hands, they will be moving their body. And they sometimes want to stand up. Some of them do stand up and they find it very difficult to sit at one place.
So these are some people we come across. And they will preferably want jobs which requires movement. Like anywhere they are a tradesman or a warehouse. But if they're given an office job, they hate it. So, that's sometimes we see that those things when they require a lot of attentions to details, and especially if it is administrative worker which requires like invoicing and data entry, they just cannot do it.
Now, there are other subgroups of people in which if you allow them to speak at length, you will see that they are just like a wanderer.. They will just deviate from the topic. And sometimes they will ask “What was the question?” because they themselves know that they have deviated. So, we call it like going on a tangent. But it is not a tangent if it is a primary psychiatric illness, then you have to rule out that it is not a part of hypomania, or a mania, or a psychosis.
So, we have to keep a very fine line of other comorbid psychiatric disorders, because the rules regarding prescriptions of certain medications, like there are restrictions. If we have a primary psychiatric illness, like a bipolar affective disorder and schizophrenia, then individual in Australia are not eligible, at least in the beginning for stimulants, and that's where the difficulties comes in. And also in cases of people who have been using, substance abuse disorder.
Sanjeev: So there are very strict regulations, particularly in WA, where we are today recording this interview, that each states have their own regulations about. So, in WA, one of the requirement is that the stimulant panel can audit your records. And in those and other cases there, there are some restrictions, we have to apply like a special access, and until is approved by the stimulant panel we cannot alter the dose. And again, there are certain requirements that can you please do few times random urine for drug screen. And again, it's a supervised collection which means chain of custody and no other alteration is done and it's a clean sample.
Adrian: So there's a lot of restrictions. There's a lot of…obviously the diagnosis and then the prescription of the stimulant medications. There's a whole bunch of processes that you need to stick to as a psychiatrist.
Sanjeev: That's correct. Because it's a schedule 8 drug. So, it's a schedule 8 drug prescription, which means that very strict dispensing guidelines have to be maintained. So, whenever we have done a prescription, usually the dose interval has to be mentioned, and chemist has to follow that. And also, in some cases we have to also monitor that people are not misusing their privileges. And those subgroup of individuals who are at high risk, we have to be even more cautious, because not only the side effect of medications can be a risk, but also if misused people can have relapse of psychosis. And this is something I often see in a small percentage of people in my practice where they have misused it. But once they have misused, if there's a stimulant-induced, primary psychiatric illness exacerbations like a bipolar or schizophrenia, then there is a, what do we call, mandatory reporting of that incident to the health department.
Adrian: Wow. And does that happen very often?
Sanjeev: Well, it does happen. Not very often, but does happen. So usually, if you are...it depends on where a clinician is. If they're in the emergency department they will see more often. But certainly, it should not be ignored. So, what happens is that on the department of health WA website, there's a form there, you just download it, you tick the boxes and say what you saw. And then what happens is that the stimulant panel contacts the prescriber to suggest that, "Please do not prescribe this anymore because this is a side effect has been notified."
Adrian: Wow. Okay. So, I mean, obviously, then there's regulations in place and it sounds like for good reasons that's the case. Now, obviously, the mainstream treatment for ADHD is your stimulant medication.
Adrian: Now, I'm interested in your approach, but before we kind of get into that, just in terms of the ADHD and what the causes behind it, I mean, what causes ADHD?
Sanjeev: Okay. Good question. Well, certainly there's a genetic component. So, I will have seen that either of the parents have an ADHD then the chances are that the prevalence can go up. But in general, as you mentioned in the introduction that 1 in 20 are diagnosed, have ADHD in Australia.
Sanjeev: And out of that 1 in 10 are treated. So, which means there's a substantial gap in between.
Adrian: And so with ADHD, obviously, you mentioned there's a genetic component to it.
Adrian: There's some neurotransmitters that are kind of implicated with it too like, is it dopamine and noradrenaline, is that kind of one of the theories behind it?
Sanjeev: Yes. So, that's why... Yeah. Yeah, yeah. That's where the medications work. So, what happens is that if you do the functional imaging scans of these individuals, like SPECT scan or PET scan, you will see that there's a, like a low attenuation in the frontal lobes of these individuals. So, frontal lobe is not coordinating well. And as a result, there's a lot of noise in the system. When I say noise, it doesn't mean that they're hearing something. It is that they tend to have sub-particle structures override, and as a result, they become more impulsive. So it's like more primitive brain is there. So that's why the impulsive behaviours are quite common in these individuals.
So the primary aim of the treatment, doesn't matter whether it is a stimulant or non-stimulant choices are. The role is to block the uptake of dopamine and norepinephrine. So, when dopamine and norepinephrine uptake is blocked, as a result of that the neurotransmitter which has been like a pool which is created, percolates through the front part of the brain. And as a result of that you see a substantial improvement in reduction in the impulsive and inattentive behaviour. And you can see that there is an improvement.
But when we use an integrated approach, we can talk in detail later, but what we are doing is that... And this is something I want very clear to the listeners, that any medication you use, it doesn't matter, any psychotropics you're using, whether it is an SSRI, or an SNRI, or tricyclic antidepressants, or multi-stabilises, including stimulants, they do not make neurotransmitter. They only trap the neurotransmitter. So they have no control on the production line. And this is where the integrated approach can help as well. That once we start addressing the other aspects of their wellbeing, then the chances are the need for the medication will be less, which means less side effects, which means better quality of life.
Adrian: Okay. So the medications that you're referring to, they either stop the breakdown of the neurotransmitter, or they affect the receptor sensitivity to the neurotransmitter, but they don't actually help make more of the neurotransmitter?
Sanjeev: That's correct. That's correct.
Adrian: Okay. And that's where the integrative approach, and that's where obviously, what we'll talk a bit more about, comes into play where that may look at how we can actually increase neurotransmitter production.
Sanjeev: That's correct.
Adrian: Now, if we just kind of go back to the…let's say, obviously, you mentioned that there's some dysregulation in the frontal cortex, maybe there's some dopamine or noradrenaline issues or norepinephrine issues going on. Are there environmental factors or lifestyle factors that might be the cause of those, or contributed to those changes in the brain?
Sanjeev: Yes. Very important point. And I think this is where the traditional approach missed the boat. Okay. Although we do talk about in general about diet and wellbeing, but be as an integrated practitioner plays a very important role. And now just to give an example, if you look at the production line of manufacturing of dopamine. First, dopamine is a neurotransmitter, which means neurotransmitter is an outcome of amino acid, which means it is an outcome of proteins. So, if people have suboptimal levels of proteins in the diet, and then certain cofactors. So cofactors are basically, B group of vitamins, it could be a pH in the system. Then we create that environment that facilitates the production of that neurotransmitter.
But when it comes down to the environmental factors. So like, brain is very vulnerable organ when it comes down to the oxidative stress because it has very small amount of mitochondria given to its disposal as compared to the other organs. Like for example, if a heart, and a liver, and a kidney is given few thousands of mitochondria each cell, brain has got hardly 300 to 500. Which means if there is an insult to the brain, there is less workforce to combat. Now, when we talk about mitochondria, mitochondria has series of chain reactions which goes across before we produce ATP, which is our powerhouse or energy. So, certain environmental factors, for example, it could be in the form of heavy metal exposure, it could be in the form of PCBs, it could be in the form of environmental chemicals, or it could be in the form of infections, could be a barrier in the production line of these individual neurotransmitters.
So the classic example which we commonly see in the brain health is that those patients who have not been responding, or those who have been struggling, could have either low levels of proteins, which means they're not able to detoxify these toxins, and that's what is needed, or they are quite acidic in their pH, which means that there's no environment where it will facilitate the clearance through the lymphatics channels. And the third thing is that the essential cofactors which are required for the production is fighting another battle to deal with that toxin. For just example, one molecule of mercury will keep 1000 molecules of zinc busy. One molecule of cadmium will keep hundred molecules of zinc busy. So, zinc is also required to produce dopamine and other serotonin and GABA. But if it is busy elsewhere doing the job, then what happens is that bioavailability of that zinc for produce is not there and it is busy somewhere. So as a result of that we see blockages in these individuals' performances. And you'll see not only the mental health challenges would be there, but also there could be wide variety of physical health problems, which obviously autoimmunes and GI disturbances are...
Sanjeev: ...commonly seen in these people. So, to answer your question in a nutshell, yes, environmental factors do play a very big role in these.
Adrian: All right. So we've got then just kind of recap of what you're saying. So, could be then through our diets, so we're not either not, we're not consuming enough proteins, or essential nutrients that are important for co-factors. So that could come from there. Or there could be environmental exposures that then mean our body needs to work towards detoxifying or dealing with that exposure. And then say, for example, zinc is then used to kind of fight that exposure or to deal with that exposure, but then it can't be used to help make dopamine or noradrenaline. Wow.
Adrian: So it's not necessarily that somebody maybe low in zinc through dietary zinc. It could be that they're using it up fighting something else.
Sanjeev: That's correct.. So usually, you will see that either their diet is poor and that's where from the integrated approach… so one thing which I will tell to the listener that first of all, if the iron level is low in any individual, until proven otherwise it's associated cousins zinc and magnesium will be low.
Adrian: Yep. Okay.
Sanjeev: And you don't have to check it, because certain testing like for example, magnesium. Magnesium is a type II nutrient. It is inside the cell. Okay. So if you're going to check for serum levels of magnesium, it is not an appropriate marker, until unless you have a tissue sample, which is like red blood cell magnesium, or 24-hour urinary excretion of magnesium. So, how you are testing that mineral is also very important, and there are wide varieties about where we can test it. And also looking into associated patterns, because there's a concept called a type II nutrient. So people can do a scholarly search of these nutrients, which include specifically zinc, potassium, sulphur amino acid. Okay. And so, which are required for optimal functioning of all the neurotransmitter production. And they all work on alkaline pH of 6.8 to 7.2.
So, first, we need a raw material, we need a cofactor, and then we need an adequate environment to cook it. You know. But if any of the barriers are there, then chances are we will not. So, some of these individuals, there's a likely possibility that would have an insight since conception. So, if the neurodevelopmental challenges have been there, then that's where the challenges comes in. And it can be part of the broad range of associated PTSD spectrum or autism could be also there in these individuals.
Adrian: So, I know that, when you talk about the insults, I know there's some good body of literature with specifically with ADHD, with lead. That's one thing that's come across in the literature. Smoking is often increases the risk of ADHD. And then you're mentioning obviously, that there's potentially some nutrient deficiencies. And there's also research around food intolerances and ADHD, isn't there?
Sanjeev: And that is something that has to be checked as well.
Adrian: Okay. And what do you think is going on there? Is that just the food tolerances are causing some type of inflammatory exposure and then the body is then kind of dealing with that immune response and therefore not able to be used to produce neurotransmitters? Is that one mechanism that you think is going on there?
Sanjeev: Yes. So like for example, first of all, if there are any adulterants or pesticides added to the production line of that food, you know. So that is one factor. So which means that if there's a heavy pesticide exposure on that food, then chances are that you are consuming that. Now, food intolerances mainly happens is that if your detoxifying enzymes are also overwhelmed and they cannot.... So they're working to their maximum capacity. So, detoxify enzymes are nothing but they are protein.
Sanjeev: So, if you do not have robust mechanisms for clearance, then the chances are that these individuals will become intolerant or sensitive to certain foods. So, you can get a broad range of food sensitivity panel testing. I personally do not do those things because of cost prohibitiveness, but certainly integrated GP colleagues who work with me do help in looking into those aspects. And then people tend to avoid those foods temporarily. That doesn't mean some of them are good food, but they're not tolerating them. Like for example amines, okay? So, they're not bad foods. But if you start improving their phase II metabolism, like, glucuronidation, methylation, okay, glaciation, Sulfonation, pathways improved. And then you see where the challenge are, then you can specifically target intervention and gradually you can start tolerating some of these foods, which you are intolerant to. But some individuals may be having like gluten intolerance or Coeliac, that's these are the ones who has to be very careful. Particularly when it comes down to ASD spectrum.
Adrian: So you mentioned, you know, you obviously you do your interview and checklists and things like that. You don't do the food intolerance testing. But if you are suspecting ADHD, are there particular assessments that you are looking at that you may kind of do from an integrated point of view?
Sanjeev: Okay. Good question. So, I usually do a broad range of metabolic screen in any individual. And majority... There are two sets. Like some of them are covered by Medicare, which means that it could be cost-neutral. So, certainly, looking into their liver functions will tell us that how liver is performing, so that also tells us about the status of their proteins. Then pH balance can be tested through the anion gap. Okay. And again, through that could be done.
Now, iron studies will give us to lead status of their iron load. Thyroid functioning will tell us that how T3, T4 balances are. Vitamin D again, very important, again covered the Medicare will be a big immune modulator. It's a hormone, it's not a vitamin. Okay. It's a psychosteroid. So, it has a broad range of roles. And then you can check for certainly certain parameters like B12, folate, and zinc.
So, some of these testings when you broadly do it, you get some kind of an idea that yes, where this individual stands. So my approach is always to be conservative side, because if you spend a lot of money on investigations, then treatment may not be possible. Sometimes people get overwhelmed. But the main role comes up is that once that these testings are done, the whole session is dedicated in educating them. So, I give evidence about how the neurotransmitters are manufactured. So as I mentioned to you earlier, I share that slide with them, then I tell them that how neurons work, what kind of diets would be helpful. So, like for example, low carbohydrate, sort of a keto principles diet would be helpful, healthy fats including like medium chain triglycerides are also helpful. And then we can look for some supplementations along with that.
Now, in some individuals, those who are not responding, or sometimes they have a poor associated gut health. Okay. Then these are the ones where you have to look for more advanced panels. Where you are looking for their methylation profiling, including their genetic studies. Because if they have certain SNPs like MTHFR, MAO, COMT, GAD or RGST, these are the individuals who will have vulnerability in detoxification, and may have a potential side effect. And once you have created the environment in which these genes operate, then chances are that even the spare tire will optimally perform, maybe not at that speed what you want, but at least a decent one where you are not reacting to those foods. Okay. So, in these perspective, individual is supported with their diet first, plus then some supplements, nutrients, plus then adding a medication, I have seen good response.
Adrian: Okay. So it's dietary changes, medications, and then some supplements. So the supplements are they... Obviously, you are giving vitamin D. Vitamin D's low. Is that what you're doing based using the blood work to...
Sanjeev: Yes. That's correct. So, what I tend to do is that again, you know, the range of the nutrients are important. So, if you could see that the range is very broad in certain nutrients. Let's say classically give an example of vitamin D.
So, in Australian labs we measure them in nanomoles per litre, and the range given is 50 to 150. That doesn't mean 49 is indirect to it and 50 they are okay. So, our target is particularly in brain health is that we are around 70th to 80th percentile of the top range. So, if you're targeting vitamin D somewhere around 125 nanomoles, which is equal to 50 nanograms, when there's a conversion factor is there, that's where you will see optimal performance of the brain neurotransmitter. And usually, at that level it creates an environment where there's an uptake of serotonin there and in conjunction with good quality fish oil, like particularly DHA component will help. So, it's like a synergistic effect which you'll see once we provide the need for some of these nutrients.
Adrian: Okay. And you mentioned it's more of a DHEA when you use omega-3, a higher DHEA version?
Adrian: Is that what you use?
Adrian: Okay. Is there a dosage that you would use for omega-3s?
Sanjeev: Yeah. Omega-3s are used, so you can use omega-3 index, can be a like some clinicians wants to do it, you can do omega-3 index. It's about $120 to do it. And particularly more so for those who are like autoimmune, so you want to make sure that you want to maintain the best levels of their omega-3s because omega-3:omega-6 ratio is very important, especially when it is, what is going to be inflammatory. But these DHA will not only have a D series of resolvins, but also they have protectins. And the protectins are particularly required for neurons.
Sanjeev: So, you want to downregulate that inflammation and also helps to improve the outer layer of mitochondria and health of that phospholipid layer. That's why we want healthy DHA levels.
Adrian: And how much do you generally give, from a dose point of view?
Sanjeev: Yeah. So, my target is around 2.5 to 3 grams of EPA, DHA combination.
Adrian: Okay. Yes.
Sanjeev: And then see how they are going. Now, usually, if it is taken in a concentrated oil form, then usually you require about 5 mls to 10 mils. But if sometimes taste is an issue then capsules is the only choice. So, between 2.5 to 3 grams is a reasonable dose. And then where you can start seeing the response in few months. But I'm aware of that, if people have autoimmune and cardiac things, then you can even go up higher at 5 to 6 grams.
Adrian: So if, let's say a naturopath sees someone who's on stimulant medication and that client of theirs, or that patient of theirs is seeing a mainstream psychiatrist, are they able to prescribe these nutrients? Are they safe to prescribe in conjunction with stimulant medication?
Sanjeev: Yes. Good question. And I think most of the naturopaths have got their interaction software.
Sanjeev: So, one thing which they can always look for is that I would recommend that if you are prescribing certain supplements, then you should look for any potential interactions. For example, if somebody's on warfarin or blood thinners, you have to be careful that their INR doesn't deranges. And the reason is not that fish oil is bad, but the main thing is that the dose of the anticoagulants have to be adjusted, you know? So, that is to be important. If you're giving some for example, garlic, that also affects the coagulation. Okay.
Now, other things comes up is certainly certain herbal nutraceuticals, like for example, St. John Wort. Okay. Now, St. Johns Wort is a MAO inhibitor. So, what it means is that if you're going to give someone St. John’s Wort, and they are on a stimulant, let's say, for example, then it's a very, not a good cocktail. You know? Because you are blocking the breakdown of that neurotransmitter, then you can have the serotonergic symptoms are there. And if they have got a genetic vulnerability, okay, on the top of it, so they have a MAO SNP, or a COMT SNP, where they cannot break it down, it is very vital that when the supplements are given, first, they should be aware of their potential interaction, number one. And there are methods available. I think if I'm not wrong, there is a platform that you can actually check potential interactions. And again, when you are giving it always start low and slow. Do not be aggressive, okay, in anything, because you never know.
Now, a barrier could come up is then the psychiatrist on the other end may or may not like it. Because that something is not part of their training. This is where I think collaborative approach will be helpful rather than taking a defensive view of naturopaths over stimulant. And I would say on the other end to the psychiatrist, is that how you can resolve it is by sharing literature. So, I think one of the researchers from our part of the world is Professor Julia Rucklidge. Okay. I'm sure. A well-known name. She has done a lifetime of work in this area and has done a lot of work in the area of ADHD. Felice Jaka, as you know, from Melbourne has also done a lot of work in this area.
So there are very eminent researchers in these areas and they have published their work in mainstream journals, including psychiatry journals. And if you start creating library of some of these papers, and in case there's any doubt, you share those research papers with them. Because, rather than a defensive view, you should have a collaborative view. And there is a book which I would recommend to all of my listeners. And it is written by Dr. James Greenblatt, who's a child psychiatrist who has been practising integrated approaches in mental health, particularly ADHD and ASD. And he's written this book, Finally Focused.
Adrian: Finally Focused.
Sanjeev: It's a masterpiece. If you do a search it'll come up. And it is well written. First, written by a psychiatrist, which means that author is practising mental health clinician and who has been working. And he has given a lot of strategies of nutrients approaches which can be used in conjunction. Some of it I've already highlighted in our discussion.
Adrian: Yeah. Okay. All right. Sounds like a great resource. We'll certainly put that link to that in the show notes for people to refer to.
Adrian: I mean, obviously we briefly talking about ADHD and it sounds like, you know, you've got lots of wisdom and information that you can definitely give us to help us really understand how to firstly, assess for and then treat ADHD. And we touched on along some of those, but it sounds like certainly assessment sounds like it's really important from your perspective, not just asking about symptoms but also doing some good blood work. And a lot of the blood work that you mentioned previously that were Medicare rebatable, which is great. And then you start off there and then treat accordingly, basically, if there's low vitamin D, you treat accordingly, if there's low iron. And an interesting thing that you mentioned was, I'll just recap on it. You said, "If there's low iron, you can pretty much assume there's low zinc."
Sanjeev: And magnesium.
Adrian: And what was the other... And magnesium.
Adrian: Wow. So you automatically low iron then that's it. You automatically assume that zinc and magnesium is low.
Sanjeev: Until proven otherwise they are low.
Adrian: Okay. All right. Yeah. All right. So then you do that and then you obviously, you treat either through dietary changes, there's supplementation that's more targeted looking at increasing detoxification, improving liver detoxification, also, helping with neurotransmitter production. And then if you're still not getting full remission in symptoms or great improvement in symptoms, then you might look at doing other assessments and you mentioned the guts and doing certain genetic testing.
Sanjeev: That's correct. That's correct. So, organic acid testing gives us a snapshot of biochemical availability of that nutrient which we are prescribing. So, consumption doesn't mean absorption. Because... and absorption depends on several cofactors and the mechanism. So that's where the organic acid testing can be a benchmark for a lot of these individuals. Particularly when we are dealing with complex cases like ASD, autism-like spectrums, and also mental health where ADHD can be an associated part. You know?
Sanjeev: And often I get, when I go through those results, patient has to be educated. It's not that doing a testing and taking a supplement, until and unless they do not change their lifestyle, it's not going to work.
Adrian: Yeah. The other thing I suppose from my clinical experience is sometimes there's certain herbs that can be beneficial, and some of those that have had some positive effects, things like Bacopa, Ginko seems to be some beneficial with some people. And even phosphatidylserine, there's some nice research showing that that may be beneficial too. So, we've got a whole range of different options that we can choose from. It's not just giving them stimulant medication then. Is that right?
Sanjeev: Yes. And I think you have, like, your work has been on turmeric and saffron, so, you know very well that's how it has. So, I remember one of the seminars Professor Kerry Bone saying about Saffron, it is a mother nature's ketamine. So, and it's a calming formula. You know. It's a GABA enhancing, it's a neuromodulator. Again, a neuromodulator.
Adrian: Absolutely. Yeah.
Sanjeev: So, certainly, we should be looking into some of these mother nature nutrients given like turmeric. Okay?
Adrian: Yeah. Absolutely.
Sanjeev: It has more than a hundred actions, you know? So, you can see that like once you incorporate some of these things in the part of their diet. And another thing which I often collaborate is that like if, depending on the individuals who are listening, but let's say you can form up a team of nutritionist, dietician, chef, where person can go and learn how to cook a dish. No, a lot of them don't know how to do it. Okay. And I see in my practice, I've actually created certain recipes to cook, how to do it. So, I share with them that this is how you do it. Like, so, and do not hesitate in involving other clinicians who may be expertise in that area, and then it becomes like a collaborative effort. And I'm sure patients will be beneficially at the end of it.
Sanjeev: Thank you.
Adrian: ...provide some great information about ADHD and just your integrative approach in general, not just that can be applied with ADHD, but any mental health condition. I know that you're doing some great work and great education. You're educating a lot of practitioners about this integrative approach, and I thank you very much. I think you're doing some great work, so keep it up.
Sanjeev: Thank you. Thank you very much. Thank you.
Adrian: So thank you everyone for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the FX Medicine website. I'm Dr. Adrian Lopresti, and thanks for joining us. We'll see you next time.
About Dr. Sanjeev Sharma
Dr Sanjeev Sharma MBBS, MD(Psychiatry), Fellow Royal Australian and New Zealand College of Psychiatrist (FRANZCP), Fellow Australian College of Nutritional and Environmental Medicine (FACNEM), Master’s in Clinical Nutrition (SAHAMM, Malaysia)
He works as Consultant Psychiatrist in Perth, Australia with interest in treating substance use disorder. He has been in Perth since 2002 and now in Private practice in Abbotsford Private and Marian Centre.
He completed his post-graduate training from Northern India and before moving to Australia, he worked in National Institute of Mental Health and Neurosciences, (NIMHANS) Bangalore which is one of the premier Indian institute in the field of neurosciences.
He has interest in incorporating nutritional strategies in management of Psychiatric disorders and completed Fellowship of Australian College of Nutrition and Environmental Medicine (ACNEM) 2022. In addition, he is in final stages of completing Fellowship in Addiction Medicine through Royal Australian College of Physician.
With a treatment philosophy that combine both eastern and western medicine, Dr Sharma offers a holistic approach to healing and believes everyone is unique and should be treated as such. He places great emphasis on lifestyle and dietary choices. As part of the treatment interventions, he carries out advanced pathology to create treatment plans tailored for each patient in conjunction with pharmaceuticals and psychological approach. He has interest in meditation and is active member trainer of Heartfulness Meditation, an organisation with worldwide presence.