Vitamin B-12 deficiency and psychiatric illness

5-Methyltetrahydrofolate level in the serum of depressed subjects and its relationship to the outcome of ECT

Serum 5-MeTHF levels are reported in 26 subjects, before and after completing a course of ECT, and compared to 21 healthy volunteers. 5-MeTHF levels of depressed subjects were significantly lower than controls before and after ECT. There was no difference in 5-MeTHF levels between ECT responders and non-responders but folate deficiency was related to severity of depression before ECT. Serum 5-MeTHF was not related to treatment response and values remained markedly low even after a good response to treatment.

Folate, vitamin B12 and cognitive impairment in patients with Alzheimer's disease

This study examines the relationship between folate, vitamin B12 and severity of cognitive impairment in patients with Alzheimer's disease (AD) as compared with other disorders associated with cognitive impairment. The patients were 97 consecutive referrals to an AD clinic. Forty patients had either possible or probable AD, 31 had other dementias (OD) and 26 had mild cognitive impairment (cognitively impaired, not demented; CIND). Patients had blood drawn for serum, red cell folate and B12, as well as other biochemical indicators of nutrition, within 24 h of the Mini-Mental State Examination (MMSE). In the AD group, only B12 was significantly correlated with MMSE. Using regression analysis, B12 contributed significantly to variance in MMSE. There was no correlation between MMSE and serum, red cell folate or B12 in the OD or CIND group and no significant correlation between MMSE and other nutritional indices in any group. These findings suggest the possibility of a specific relationship between B12 levels and severity of cognitive impairment in patients with AD.

Potentially reversible dementia: a review

Potentially reversible dementia is reviewed with reference to diagnosis, causes and outcome. Many disorders which cause cognitive impairment, such as drug toxicity and depression, fail to meet diagnostic criteria for dementia. These tend to have the best prognosis. Studies of the neuropsychiatric syndromes associated with disorders causing potentially reversible dementias suggest that dementia is an infrequent outcome and when it does occur, few cases recover. Factors predictive of improvement are short duration of symptoms and mild degree of cognitive impairment, usually subcortical in type. It is suggested that potentially reversible cognitive impairment would be a more accurate term as many cases are due to delirium and depression. While cases of well established dementia do not require extensive investigation, all cases should have a thorough clinical assessment as in many instances dual pathology exists and all require psychosocial management.

Dietary intake and clinical, anthropometric and biochemical indices of malnutrition in elderly demented patients and non-demented subjects

Anthropometric and biochemical indices of nutritional status and weighed dietary intake have been studied in hospitalized patients with senile dementia, demented patients living in the community and age-matched control subjects who were not cognitively impaired. Demented patients were lighter than control subjects, and had a lower body mass index, skinfold thickness, mid-arm circumference and arm muscle bulk. The hospitalized patients were more seriously affected than those living in the community, and body weight was significantly negatively correlated with duration of hospitalization. Over a 6-month period the hospitalized patients showed a further weight loss, while those living in the community did not. Both groups of demented patients had higher intakes of energy, protein, vitamins and minerals than the control subjects. The diet of the hospitalized patients was slightly, but not significantly, superior to that of the patients living in the community. Biochemical evidence of specific vitamin inadequacy was equally prevalent in all three groups of subjects, and there were no significant correlations between the degree of cognitive impairment or behavioural disorder and any of the indices of nutritional state. Clinical signs suggestive of malnutrition were not correlated with either biochemical evidence of deficiency or cognitive impairment and behavioural disturbance.

What are the psychiatric manifestations of vitamin B12 deficiency?

Psychiatric symptoms attributable to vitamin B12 deficiency have been described for decades. The earlier reports are for the most part in accord with more recent ones, despite being diagnostically less specific in psychiatric and hematologic terms. These symptoms seem to fall into several clinically separate categories: slow cerebration; confusion; memory changes; delirium, with or without hallucinations and/or delusions; depression; acute psychotic states; and (more rarely) reversible manic and schizophreniform states. While there still remain abundant hematologic, psychiatric, neurologic, or nutritional reasons for obtaining a serum vitamin B12 level, its use in the investigation of the etiology of a patient's dementia seems unjustified. However, acute or subacute changes in a demented patient's mental status, specifically a clouding of their consciousness, may make such testing advisable as part of the complete workup of their delirium regardless of a normal hematologic picture.

The biology of folate in depression: implications for nutritional hypotheses of the psychoses

Folate deficiency is a common occurrence in psychiatric disorders, whether organic or functional, particularly in depressive illness. We have shown that folate deficiency is a common association of depressive symptoms in a variety of settings including primary endogenous or non-endogenous depression, and in alcoholic, lithium-treated and anorexic patients. Possible pathogenetic mediating mechanisms for this association are methylation and hydroxylation and the implications for nutritional hypotheses of the psychoses are discussed. We suggest that folate deficiency, with or without deficiencies of other nutritional factors such as monoamine precursors, vitamins B6, B12 and C, may predispose to or aggravate psychiatric disturbances, particularly depression and a model for these interactions is proposed.

Various degrees of dementia in a selected group of gastrectomized patients with low serum B12

Forty-two gastrectomized patients (mean age 56 years) with a serum B12 level less than 200 pg/ml were studied by psychological testing and electroencephalography. A total of 50 per cent exhibited mild to moderate or more severe intellectual impairment, judging by the history and psychological testing. EEG abnormalities were found, mainly in the form of reduced dominant activity, in 48 per cent. The results of psychological testing were in accurate conformity with the findings of dementia due to other reasons. The characteristic findings were depression and lability of affect, with a high frequency of suicidal attempts (20 per cent). We interpret the cerebral abnormalities as a result of vitamin B12 deficiency.

Hepatic morphology in Huntington's chorea

Liver biopsy specimens from six patients with Huntington's chorea were examined locally and referred with clinical information to three colleagues abroad experienced in the interpretation of liver biopsy specimens. The minor and inconsistent abnormalities reported upon were of non-specific character. The suggested interrelation between damage to cerebral neurones and hepatocytes in Huntington's chorea was not substantiated by this study.

The present status of vitamin B 12 and folic acid deficiency in psychiatric illness

Vitamin B12 Deficiency

Among the many causes of organic psychoses are a number of processes which may be cured or arrested by the right treatment and by early recognition. This includes deficiency of vitamin B12. There is, therefore, a temptation to carry out sophisticated tests for vitamin B12 deficiency in all psychiatric patients. However, until cheaper and fully-automated techniques become available, routine vitamin B12 assays cannot be justified in psychiatric patients. At the present time a hemoglobin estimation and a careful inspection of the peripheral blood film by an experienced hematologist appear to be the most economic primary screening test for vitamin B12 deficiency. Nevertheless, psychiatrists should be alert to the possibility of vitamin B12 deficiency in patients with unexplained fatigue and in those with confusional states or dementia of unknown origin. Another presentation may be impotence which sometimes precedes other neurological manifestations of the disease. Even in patients who are not anemic or have no blood film abnormalities (which is uncommon) the possibility of missing cases of hypovitamin B12 deficiency can be further diminished by doing serum B12 assays in patients who are clinically at risk. For example, this includes post-gastrectomy patients, those with a familial history of pernicious anemia and those with an associated auto-immune disorder, such as thyroid disease.

Folic Acid Deficiency

The available evidence linking folate deficiency with psychiatric disorders is inconclusive. It is probable that the observed excess of folic acid deficiency in psychiatric patients can be explained on the basis of malnutrition, chronic physical illness, alcoholism or other drug usage. An important exception is brain damage and mental retardation in infants with inborn errors of folic acid metabolism. Further evaluation of folate deficiency is indicated, particularly in the affective disorders and in ambulatory, non-institutionalized, epileptic patients receiving anticonvulsant medication.

Psychiatry in a postgraduate teaching hospital

A study is presented of 217 adults referred for psychiatric assessment from the wards of a postgraduate teaching hospital.

The pattern of referral and the disproportionate importance of disturbed behaviour amongst referrals from non-medical wards are discussed. The main diagnostic groups, namely, affective disorders, organic states, psychogenic somatic symptoms and attempted suicide, are tabulated and discussed. Complex problems of diagnosis and management were common and are considered under five headings: multiple pathology; the effects of intensive treatment procedures; language and cultural differences, and difficulties in follow-up.

It is concluded that the problems met in this specialized setting are likely to become general as intensive treatment and diagnostic procedures become more widespread.

The importance of organic reactions is stressed and their relative neglect by both psychiatrists and physicians commented on. The frequency of social precipitants of affective disorders and attempted suicide, however, is considered to emphasize the range of activities required of the psychiatrist in even the most technologically advanced centres.

Serum vitamin B 12 levels in Indian psychiatric patients

It is known that pernicious anaemia is sometimes associated with mental symptoms which improve following vitamin B12 therapy (Eilenberg, 1960; Holmes, 1956; Smith, 1960). Further, it has been pointed out that such mental symptoms can occur years before the development of anaemia and no definite relationship exists between them and the severity of anaemia (Smith, 1960). Cases have been described with a variety of psychiatric symptoms and low serum vitamin B12 levels without any neurological manifestation or abnormality of peripheral blood and bone marrow. Since pernicious anaemia is due to vitamin B12 deficiency it is suspected that B12 deficiency is responsible for the mental symptoms, and serum B12 assays have been advocated routinely in psychiatric patients (Strachan and Henderson, 1965; Hunter and Matthews, 1965).

Clinical trial of the effect of vitamin B12 in elderly subjects with low serum B12 levels

A clinical trial of the effect of vitamin B(12) therapy was conducted in 39 elderly subjects who had been found, in a community screening survey, to have low levels of serum B(12) without a macrocytic anaemia or neuropathy. The study produced no evidence which suggests that in such subjects B(12) is superior to placebo in effecting an improvement in psychiatric state or general well-being. There was a clear tendency for all the subjects to show an improvement during the trial, but this probably represents the therapeutic effect of involvement in a research exercise of this kind.

Serum folate and vitamin B12 in epileptics with and without mental illness

Considerable interest is at present focused on the possibility of an association between mental illness in epileptics and metabolic abnormalities resulting from the anticonvulsant drugs they have been taking; in fact it has been suggested that these drug-induced abnormalities may be actually causative of the psychiatric disorders. For a good summary of this literature the interested reader is referred to Reynolds (1968).