Treatment
Nutrition
Two laboratory values are checked at the first visit for nearly every patient here, because they are common, cheap to measure, and easy to miss: vitamin D and ferritin. Both are involved in how the brain makes and uses dopamine, and low levels can look like, or worsen, the very conditions people come in for.
Vitamin D3 and dopamine
Vitamin D is not only a bone vitamin. Its active form acts on receptors throughout the brain, and one of the things it regulates is tyrosine hydroxylase, the enzyme that carries out the rate-limiting step in making dopamine. Dopamine underlies attention, motivation, reward, movement, and the sleep–wake rhythm, so a persistent vitamin D deficiency can flatten the same systems that ADHD, depression, and restless sleep already strain. Deficiency is common in the northeastern United States, in people with darker skin, in those who spend the day indoors, and in winter, which is to say in most of the people who walk through the door.
In practice: the 25-hydroxyvitamin D level is checked at the first visit. When it is low in a symptomatic patient, vitamin D3 (cholecalciferol) is replaced to a target in the sufficient range and rechecked, usually after about three months. This is not a treatment for ADHD or depression on its own; it removes a deficit that would otherwise blunt the response to treatment. The NIH Office of Dietary Supplements summarizes the evidence and reference ranges.
Ferritin, iron, and the symptomatic patient
Ferritin measures the body’s iron stores. Iron is a required cofactor for tyrosine hydroxylase as well, and low brain iron is one of the best-established biological findings in restless legs syndrome, periodic limb movements in sleep, and, in children, a contributor to ADHD symptoms and disrupted sleep. A laboratory will report ferritin as “normal” once it is above roughly 12 to 30 ng/mL, because that is the threshold for anemia. The brain needs more than that.
Ferritin targets
In a symptomatic patient, this practice treats ferritin below 75 ng/mL in adults and below 50 ng/mL in children and adolescents as low, and works to bring it above those levels before concluding that restlessness, poor sleep, fatigue, or inattention have a purely psychiatric cause.
These are the thresholds used in the American Academy of Sleep Medicine and international restless legs guidelines for iron supplementation, applied here to the wider group of patients whose symptoms overlap with low brain iron.
“Symptomatic” matters. A ferritin of 40 in a well adult who sleeps soundly needs no treatment. The same value in a teenager who cannot fall asleep, kicks through the night, and cannot sit still in class is a finding to act on, alongside, not instead of, the psychiatric evaluation. Iron is replaced by mouth in most cases, with the dose and timing adjusted for absorption, and ferritin is rechecked after about three months; intravenous iron is considered with the patient’s physician when oral iron fails or is not tolerated. Because ferritin also rises with inflammation, it is interpreted together with a complete blood count and, where needed, an inflammatory marker.
Why a psychiatrist checks these
- Low vitamin D and low iron stores are among the most common reversible contributors to fatigue, poor sleep, restlessness, and poor concentration, and are routinely overlooked when a laboratory flags the value as “normal.”
- Correcting them often makes psychiatric treatment work better and at lower doses, and sometimes removes the need for a stimulant or a sleep medication that was treating an iron problem.
- Both are especially relevant to the groups this practice serves: adolescents, women of reproductive age (menstruation is the most common cause of low ferritin), people in early recovery from alcohol or opioids, and anyone whose sleep is disrupted.
- Results are shared with your primary care physician or pediatrician, and replacement is coordinated with them.
What is also considered
Depending on history, the first-visit laboratory panel may include vitamin B12 and folate, thyroid function, a complete blood count, and, for patients on certain medications, a metabolic panel. Omega-3 fatty acids, magnesium, and dietary pattern are discussed where the evidence supports it. None of this replaces a thorough psychiatric evaluation; it makes sure the evaluation is not chasing a deficiency.