Acute psychosis in a patient with vitamin B(12) deficiency and coincident cervical stenosis

Hallucinations and Vitamin B12 Deficiency: A Systematic Review

INTRODUCTION

Vitamin B12 deficiency is primarily associated with pernicious anaemia, polyneuropathy, and spinal-cord disease, but publications on its association with hallucinations are on the rise.

METHODS

I carried out a systematic literature search on these hallucinations in PubMed, PsycINFO, and Google Scholar, up until July 1, 2023.

RESULTS

The search yielded 50 case studies published between 1960 and 2023. The hallucinations described therein are predominantly visual and/or auditory in nature, with 20% being specified as complex, compound, or panoramic. They are often described in the context of vitamin B12-related neuropsychiatric conditions such as dementia, delirium, epilepsy, psychotic disorder, schizoaffective disorder, bipolar disorder, depressive disorder, catatonia, or obsessive-compulsive disorder. In the context of such disorders, they tend to appear first and also often appear to be the first to disappear with cobalamin treatment. Within an average of 2 months, full amelioration was thus obtained in 75% of the cases and partial amelioration in the remaining 25%. Remarkably, a quarter of the cases involved therapy-resistant hallucinations that fully resolved under cobalamin monotherapy, while other neuropsychiatric manifestations of vitamin B12 deficiency disappeared in 60% of the treated cases. Only 32% of the cases involved comorbid pernicious anaemia. This suggests that two separate or diverging pathways exist for perceptual and haematological symptoms of vitamin B12 deficiency.

CONCLUSION

In the light of the high prevalence rate of vitamin B12 deficiency in the general population, the findings here presented should be interpreted with great caution. Nonetheless, they offer cues for further research and experimental application in clinical practice. This may be especially relevant in light of the recent increase in the popularity of vegetarianism and the recreational use of nitrous oxide (laughing gas), which are both risk factors for vitamin B12 deficiency.

Vitamin B12 Supplementation in Psychiatric Practice

PURPOSE OF REVIEW

Vitamin B12 (B12, cobalamin) deficiency has been associated with neuropsychiatric symptoms, suggesting a role for B12 supplementation both as a treatment for psychiatric symptoms due to B12 deficiency and as an augmentation strategy for pharmacological treatments of psychiatric disorders. This critical review discusses the major causes of B12 deficiency, the range of psychiatric and non-psychiatric manifestations of B12 deficiency, the indications for testing B12 levels, and the evidence for B12 supplementation for major psychiatric disorders.

RECENT FINDINGS

We find that high-quality evidence shows no benefit to routine B12 supplementation for mild depressive symptoms or to prevent depression. There is very limited evidence on the role of B12 supplementation to augment antidepressants. No high-quality evidence to date suggests a role for routine B12 supplementation in any other major psychiatric disorder. No formal guidelines indicate when clinicians should test B12 levels for common psychiatric symptoms, in the absence of major risk factors for deficiency or cardinal symptoms of deficiency. No robust evidence currently supports routine B12 supplementation for major psychiatric disorders. However, psychiatrists should be aware of the important risk factors for B12 deficiency and should be able to identify symptoms of B12 deficiency, which requires prompt testing, medical workup, and treatment. Testing for B12 deficiency should be considered for atypical or severe psychiatric presentations.

Low serum vitamin B12 levels among psychiatric patients admitted in Butabika mental hospital in Uganda

Background

Psychiatric manifestations have been noted in patients with low serum vitamin B₁₂ levels even in the absence of other neurologic and/or haematologic abnormalities. There is no literature on low serum B₁₂ prevalence among Ugandans with psychiatric illnesses. The aim of this study was to establish the prevalence, risk factors, and clinical manifestations of low serum vitamin B₁₂ among psychiatric patients admitted in a Mental Health Hospital in Uganda.

Method

Using a cross sectional descriptive study design, 280 in-patients selected by systematic sampling were studied using a standardized protocol. Low serum vitamin B12 was defined as a level < 240 pg /mL.

Results

We found a prevalence of low serum B₁₂ in 28.6% of the participants. Absent vibration sense which was significantly associated (58.3% Vs. 26.7%: OR = 3.84 (95% C.I. 1.18, 12.49); p-value = 0.025) with low vitamin B₁₂ was observed among 12 participants. Macro-ovalocytes present among 23 participants on peripheral film were significantly associated with low serum levels (73.9% Vs. 26.2%: OR = 7.99 (95% C.I. 3.01, 21.19) p-value < 0.0001). Factors significantly associated with low serum B₁₂ levels included psychiatric diagnosis of schizophrenia (AOR 1.74 (95% C.I. 1.00, 3.02); p-value = 0.049), duration of psychiatric illness > or = 3 years (AOR 2.27 (95% C.I. 1.29, 3.98); p-value = 0.004), and hospitalization < 3 weeks (AOR 4.01 (95% C.I. 1.02, 15.79); p-value = 0.047). Female participants were associated with protection from low serum levels (AOR 0.4 (95% C.I. 0.22, 0.73); p-value = 0.003).

Conclusion

Low serum B₁₂ is common among hospitalized psychiatric patients with the majority having no haematological findings. Associated risk factors included having a psychiatric diagnosis of schizophrenia, a shorter duration of hospitalization and longer duration of psychiatric illness. Female participants were less likely to have low serum vitamin B₁₂ levels. Routine screening for serum vitamin B₁₂ levels should be adopted by all hospitals for admitted psychiatric patients.

Schizophrenia-like psychotic episode precipitated by cobalamin deficiency

Although cobalamin deficiency is widely known and usually presents with hematologic and neuropsychiatric manifestations, the psychiatric symptoms are not usually the predominant manifestation. We describe a young single male vegetarian who developed a cobalamin-induced psychotic episode without preceding neurologic manifestations and without any hematologic symptoms. He recovered after a short course of antipsychotics and oral cobalamin supplementation and remained asymptomatic and functionally independent at 1 year of follow-up.