Prescribing Supplements and Vitamins

[AD04]

How often do you prescribe supplements (e.g. methylfolate, ginkgo biloba, etc.) and vitamins for psychiatric disorders?

Where is the best place for patients to buy them?

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[nitemagi]

I don't. I let patients know about L-methylfolate if genetic testing indicates a deficiency, but caution them about my skepticism about its efficacy. I don't prescribe alternatives ever. If someone is asking "what else can I do," I might review alternatives. But I'm very transparent that most of the supplements have risks. Like ginkgo and blood thinning. They aren't benign, and should be weighed like any medication choice.

 

[tr]

L-methylfolate: If patient has depression resistant to standard treatments *and* either documented MTHFR mutation or elevated homocysteine
Vitamin D: If patient has depressive symptoms *and* serum 25-OH-D below 30
Melatonin: For short-term rebalancing of circadian dysrhythmia
N-acetylcysteine: For trichotillomania or skin picking

I usually put in a prescription unless the patients tells me the medication is easier/cheaper to find OTC. NAC in particular is not carried by many pharmacies but available cheaply on Amazon.

I have had patients come to me who request to take things like St John's Wort, Sam-E, ashwagandha, and various Chinese preparations that I know nothing about.
In general if they are already taking it and finding benefit I don't demand that they stop it, but I do ask them to please choose either an OTC supplement or a prescription, and not to take both together, since many of these may have overlapping mechanisms of action and could lead to serotonin syndrome or co-interference with drug metabolism.

Herbal preparations especially are almost totally unregulated and their content and potency can vary widely. There have been numerous publications documenting enormous discrepancies between the label claims and the actual content; for example this one, in which DNA from the source plant listed on the label was detected in only 4 out of 15 samples.
Authentication of Herbal Supplements Using Next-Generation Sequencing

 

[wolfvgang22]

I prescribe a lot of cholecalciferol after lab tests because vitamin D deficiency is common in my patient population. For patients with significant depression I aim for 50, because otherwise they seem to drop below 30 easily.

 

[LadyHalcyon]

Thoughts on high dose Omega-3 for mood lability?

 

[birchswing]

What does ginko biloba have evidence for? It's been a while since I read about it, but I can't remember seeing anything too impressive about ginko biloba.

I remember in my early high school (like around 1997) it was faddish for students to take it thinking it would help with academic performance. St. John's Wart was a thing with students then, too. I think it may have been because we lived near a Costco that pushed that stuff so much. At least that's where I got whatever the "new" supplement was back then. They also had the juice of some berry that was really big at the time I can't remember the name of now. Something like anona?

Anyhow, if you want supplements, Costco has them in spades. I mean most places do, but that seems to be a particularly big seller.

For l-methylfolate, I was once advised to buy from MethylPro but I have no reason to believe they're any better than any other source. They do seem to market to physicians which is probably why I was told about them. It's a non-prescription version of Deplin (and their marketing is about going head to head with Deplin), but pretty much every supplement manufacturer has l-methylfolate as an option now, either on its own or in a multivitamin (along with other methylated B vitamins) or in a prenatal vitamin with EPA and DHA.

 

[jettavr6]

I don't. I let patients know about L-methylfolate if genetic testing indicates a deficiency, but caution them about my skepticism about its efficacy. I don't prescribe alternatives ever. If someone is asking "what else can I do," I might review alternatives. But I'm very transparent that most of the supplements have risks. Like ginkgo and blood thinning. They aren't benign, and should be weighed like any medication choice.

Generally agree with you -- but for some reason, I've had a fair amount of success with Deplin. All anecdotal on my part.

 

[whopper]

I only recommend this stuff if there's data backing it. Most of this stuff doesn't require a prescription so I educate the patient on it, and tell them if they want to give it a try.

SAM-E, St. John's Wort, L-Methylfolate, and Vitamin D do have data backing their use. I don't, however recommend these first-line.

Gingko, to my knowledge, only helps patients of older age, based on a theory with a study backing it, that it helps with increased blood flow to the head. So if someone younger takes it, they usually don't suffer from any decreased blood flow and hence it didn't help in the study I saw. This study was years ago so if anyone has any newer data let me know.

L-Methylfolate 15 mg daily is now available for less than $20 a month if you go to the right websites.

 

[WisNeuro]

I only recommend this stuff if there's data backing it. Most of this stuff doesn't require a prescription so I educate the patient on it, and tell them if they want to give it a try.

SAM-E, St. John's Wort, L-Methylfolate, and Vitamin D do have data backing their use. I don't, however recommend these first-line.

Gingko, to my knowledge, only helps patients of older age, based on a theory with a study backing it, that it helps with increased blood flow to the head. So if someone younger takes it, they usually don't suffer from any decreased blood flow and hence it didn't help in the study I saw. This study was years ago so if anyone has any newer data let me know.

L-Methylfolate 15 mg daily is now available for less than $20 a month if you go to the right websites.

My last read of some of the newer stuff, at least as of last year-ish, was that Vitamin D actually does not have any data that supports its supplementation. We know that deficiencies are associated with mood and cognition changes, but supplementation does not show a reversal of those changes. Is there something newer in this area that goes against that?

 

[clausewitz2]

My last read of some of the newer stuff, at least as of last year-ish, was that Vitamin D actually does not have any data that supports its supplementation. We know that deficiencies are associated with mood and cognition changes, but supplementation does not show a reversal of those changes. Is there something newer in this area that goes against that?

I mean it's worth repleting for the skeletal effects alone and appears to reduce the risk of falls, so as physicians we psychiatrists certainly ought to prescribe it if our patients are deficient but my read of the evidence to date for improving mood and cognition is the same as yours.

 

[WisNeuro]

I mean it's worth repleting for the skeletal effects alone and appears to reduce the risk of falls, so as physicians we psychiatrists certainly ought to prescribe it if our patients are deficient but my read of the evidence to date for improving mood and cognition is the same as yours.

I mean, it's pretty benign, unless someone is really overdoing it, but yeah, I thought that the risk of falls and calcium absorption effects with supplementation data were equivocal as well?

 

[whopper]

, was that Vitamin D actually does not have any data that supports its supplementation.

Yeah one of those things where I have seen articles suggesting what you mentioned but don't have them in front of me. My vague memory was something to the effect of Vitamin D didn't help to reverse already existing depression or something like that.

I still recommend it for the following reasons. Vitamin D has been found to calm over-active immune systems and the immune-component to depression is established. It also may have benefits with seasonal depression. I get that myself and have a SAD lamp and when by Vitamin D was corrected I did notice some improvement (of course it could've been placebo) but that I needed to use my SAD lamp about 15-30 minutes a day instead of hours.

The link between SAD and Vitamin D is established but that link might not be causal or anything otherwise substantive.

But in reference to the specific data I recall reading I speculate perhaps it may have better utilization in preventing depression than actually treating it. I of course do inform patients of the limitations of the knowledge.

 

[Stagg737]

Has anyone seen data on Mg as an adjunct for mood stabilization? I'm not talking about for individuals who have measurably low levels. I'm talking about individuals with normal levels of Mg who take it and claim to have improved mood.

They also had the juice of some berry that was really big at the time I can't remember the name of now. Something like anona?

You're likely thinking of Acai berry, which supposedly has very high levels of antioxidants and was one of the earliest things labelled as a "super food". It's good for you, but as far as I know there's no data showing any actual health benefits beyond that of other berries.

 

[birchswing]

I mean, it's pretty benign, unless someone is really overdoing it, but yeah, I thought that the risk of falls and calcium absorption effects with supplementation data were equivocal as well?

The last I read about it, there was an interesting U shaped curve with Vitamin D levels as it related to cardiovascular health, with optimal health being in the middle (I don't remember the exact numbers, closer to 40-50 or so I think). High levels and low levels were both associated with worse cardiovascular outcomes. My lab now uses 30-100 as a normal reference range, but from my foggy memory I kind of recall starting to go over 75 was not good. It seems the lower end of normal has been increased over time without a lot of great evidence.

I also read a story recently that said it was actually time spent in the sun, which was correlated with Vitamin D levels, was the differentiator in health outcomes. The Vitamin D level was an incidental variable, and it was the sun exposure that improved health. I'm trying to find the article, but it's very hard to Google without getting a lot of results about how much time to spend in the sun to reach adequate Vitamin D levels.

You're likely thinking of Acai berry, which supposedly has very high levels of antioxidants and was one of the earliest things labelled as a "super food". It's good for you, but as far as I know there's no data showing any actual health benefits beyond that of other berries.

This was the 1990s before acai was trending. I googled a bunch and the name that looks the closest to me is Noni berry, of which juice is apparently made. I'm not positive it was Noni, but sounds familiar. It was one of those things I remember them sampling and my family buying for a while and then seemed to disappear. Doesn't look like it was too great: Noni juice - Wikipedia

Edit: I googled more and now I'm almost positive it was aronia berry juice: Aronia - Wikipedia

 

[WisNeuro]

The last I read about it, there was an interesting U shaped curve with Vitamin D levels as it related to cardiovascular health, with optimal health being in the middle (I don't remember the exact numbers, closer to 40-50 or so I think). High levels and low levels were both associated with worse cardiovascular outcomes. My lab now uses 30-100 as a normal reference range, but from my foggy memory I kind of recall starting to go over 75 was not good. It seems the lower end of normal has been increased over time without a lot of great evidence.

The issue isn't negative health outcomes associate with deficiency, that is well established. The issue is more and more research suggesting that supplementation when someone is already deficient does not reverse those negative outcomes.

 

[Merely]

L-methylfolate: If patient has depression resistant to standard treatments *and* either documented MTHFR mutation or elevated homocysteine
Vitamin D: If patient has depressive symptoms *and* serum 25-OH-D below 30
Melatonin: For short-term rebalancing of circadian dysrhythmia
N-acetylcysteine: For trichotillomania or skin picking

I usually put in a prescription unless the patients tells me the medication is easier/cheaper to find OTC. NAC in particular is not carried by many pharmacies but available cheaply on Amazon.

I have had patients come to me who request to take things like St John's Wort, Sam-E, ashwagandha, and various Chinese preparations that I know nothing about.
In general if they are already taking it and finding benefit I don't demand that they stop it, but I do ask them to please choose either an OTC supplement or a prescription, and not to take both together, since many of these may have overlapping mechanisms of action and could lead to serotonin syndrome or co-interference with drug metabolism.

Herbal preparations especially are almost totally unregulated and their content and potency can vary widely. There have been numerous publications documenting enormous discrepancies between the label claims and the actual content; for example this one, in which DNA from the source plant listed on the label was detected in only 4 out of 15 samples.
Authentication of Herbal Supplements Using Next-Generation Sequencing

R u md/PhD?

 

[birchswing]

The issue isn't negative health outcomes associate with deficiency, that is well established. The issue is more and more research suggesting that supplementation when someone is already deficient does not reverse those negative outcomes.

Hmm, yes. I saw something about that with type 2 diabetics:
Secret to health benefits of sunshine is more than vitamin D

So it could be that something in the body that causes poor health causes lower vitamin D levels.

And therefore augmenting the visible variable, vitamin D, has no effect on whatever the core issue is—maybe it's all part of metabolic syndrome.

 

[whopper]

Birchswing isn't an MD but patient with psych experience who (I figure) came to this forum seeking knowledge and has been a prominent member in the psychiatry forum.

N-aceytlcysteine has across-the-board benefits with psych problems especially with compulsive behaviors and addiction. I have recommended it several times but I've only seen it at best have a mild effect. Patients tell me they do notice a distinguishable difference with it but not much of one (vs other meds where they tell me they're not sure if they feel a difference or are convinced they don't feel a difference).

But despite the mild benefit, it is better than no benefit especially in areas where nothing else has been found to have been beneficial.
It is the only thing I've been able to tell a patient to take with pathological gambling (and not some other disorder like say Bipolar Disorder where patients might gamble while manic) where patients reported to me they felt something pharmacological impact their desire to gamble. I've never tried Naltrexone for it but I figure that might have an impact too.
It is the only substance I'm aware of that has been found to have an impact in reducing cannabis use.

L-theanine has been found to reduce anxiety but again-I see only mild benefits though again mild but discernible benefits reported where patient says they really do feel a difference, but small.

One more supplement-zinc I tell patients with low sex-drive to try it out and have found it to be beneficial for several patients, especially men starting their late 30s+.

 

[AD04]

Thoughts on high dose Omega-3 for mood lability?

Some studies shows positive studies for depression and bipolar disorder. It is worth a try because there is very minimal side effects, good to prevent blood vessel diseases, and isn't super expensive.

 

[Armadillos]

Don’t have the article in front of me, but recently saw something pretty promising for probiotics (think it was essentially culturelle) reducing risk of manic episode. Would align with general principle of another article I recently read where a substantial percent of patients admitted for mania had some sort of infection or antibiotics within the last month.

 

[tr]

The issue isn't negative health outcomes associate with deficiency, that is well established. The issue is more and more research suggesting that supplementation when someone is already deficient does not reverse those negative outcomes.

Last time I reviewed this literature was a while ago but my recollection is that the picture was muddied by a number of trials that supplemented vitamin D for depression, without first establishing deficiency. That led to predictably negative/mixed results. I believe at that time there were 2 trials that tested vitamin D supplementation for depression in people with established deficiency, and those both had positive results.

A quick swipe through PubMed just now reveals the following:

The effect of 2 different single injections of high dose of vitamin D on improving the depression in depressed patients with vitamin D deficiency: ... - PubMed - NCBI
A randomized controlled trial of vitamin D supplementation on perinatal depression: in Iranian pregnant mothers. - PubMed - NCBI
Vitamin D Supplementation Affects the Beck Depression Inventory, Insulin Resistance, and Biomarkers of Oxidative Stress in Patients with Major Depr... - PubMed - NCBI

 

[QofQuimica]

Herbal preparations especially are almost totally unregulated and their content and potency can vary widely. There have been numerous publications documenting enormous discrepancies between the label claims and the actual content; for example this one, in which DNA from the source plant listed on the label was detected in only 4 out of 15 samples.
Authentication of Herbal Supplements Using Next-Generation Sequencing

This. Just as when a person buys illicit drugs off the street, there is no one guaranteeing that what they think they're buying is what they're actually buying. As @tr suggested, there is also a significant body of literature suggesting that supplements often are adulterated (e.g., contain pharmaceuticals in them, and/or are contaminated with heavy metals and other concerning toxins - particularly imported Asian supplements). One famous historical example is eosinophilia myalgia syndrome thought to be caused by contamination of Trp supplements sold in the US by a Japanese manufacturer in 1989. The FDA can remove supplements from the market once they've been shown to be unsafe, but they're not doing pre-sale safety testing. Caveat emptor for sure.

 

[birchswing]

This. Just as when a person buys illicit drugs off the street, there is no one guaranteeing that what they think they're buying is what they're actually buying. As @tr suggested, there is also a significant body of literature suggesting that supplements often are adulterated (e.g., contain pharmaceuticals in them, and/or are contaminated with heavy metals and other concerning toxins - particularly imported Asian supplements). One famous historical example is eosinophilia myalgia syndrome thought to be caused by contamination of Trp supplements sold in the US by a Japanese manufacturer in 1989. The FDA can remove supplements from the market once they've been shown to be unsafe, but they're not doing pre-sale safety testing. Caveat emptor for sure.

Except for being approved initially for bio-efficacy, that's largely how generic drugs are regulated as well. The FDA requires companies to self-police themselves and can look into how they are self-policing themselves, but until recently the FDA itself has not tested finished products, and even now testing limited products is extremely limited. I read some of the observation letters the FDA writes to companies and they're toothless. I read one recently where pigeons were living in a factory and were pooping into containers that were supposed to be sterile, and the FDA basically just writes a nice letter saying, "We see pigeons pooping in sterile containers, it would be nice if you had a plan for that to stop."

It took over 5 years from initial reports about problems with Teva generic Wellbutrin XL for it to be pulled from the market. The first to sound the alarm was People's Pharmacy, a web-site that takes letters from consumers. Then ConsumerLab.com, which usually tests supplements, tested Wellbutrin XL generics, and it was only after those results became public that the FDA asked for Teva Wellbutrin XL generics from the market (and later others did as well).

It turned out the FDA had never required the original generic manufacturer, Teva, to do bioequivalence studies on their 300 mg formulation, only on the 150 mg formulation. The FDA finally did their own studies (which is extremely rare) and found the same as ConsumerLab.com that it was acting like an immediate release formula. They then asked the other manufacturers to test their tablets—which they should have to begin with—and Watson found that its formula also did not meet bioequivalence standards and was pulled from the market.

The impetus for all this came from a private lab that tests supplements for purity and potency, not from the FDA.

I'm not saying I trust all supplement manufacturers. But I don't trust the FDA much either or the commodities market we've embraced for drug manufacturing where nearly all the APIs are made in China and then sent to factories around the world. This is not labor intensive type of work, and there's no reason more of it couldn't be done in the US. Elizabeth Warren has proposed that the US government manufacture generic drugs, an idea that I support. It makes more sense than us spending tax money to send inspectors to the ends of the Earth to write down a note about pigeon poop in some filthy factory, write a milquetoast letter, and sit back and do absolutely nothing.

 

[whopper]

This. Just as when a person buys illicit drugs off the street, there is no one guaranteeing that what they think they're buying is what they're actually buying.

Consumer Reports every few years does a study where they get several OTCs from various manufacturers to see if it is what is claimed. I haven't read their last report but have read 3 prior ones. In the ones I read they mentioned the overwhelming majority of those studied were in fact what they claimed to be and found pretty much every brand name supplement to be trustworthy. They also mentioned 3rd party/private organizations that did testing and some of the supplements had stamps of those organizations approval.

But, I haven't read the latest report.

Another factor, despite the FDA approval and regulation of various meds, I've seen several patients get bad reactions to one brand and not another. Given the FDA regulation I can only conclude that it's likely the excipients that are differing in the different brands given that the active ingredient medication is supposed to be the same.

 

[nighthawk2551]

Thoughts on high dose Omega-3 for mood lability?

There are several studies of it slightly improving impulsivity and mood in borderline. There are pretty much zero side effects (besides taste) and there are documented CV benefits, so I don't see why not.

 

[VA Hopeful Dr]

Consumer Reports every few years does a study where they get several OTCs from various manufacturers to see if it is what is claimed. I haven't read their last report but have read 3 prior ones. In the ones I read they mentioned the overwhelming majority of those studied were in fact what they claimed to be and found pretty much every brand name supplement to be trustworthy. They also mentioned 3rd party/private organizations that did testing and some of the supplements had stamps of those organizations approval.

But, I haven't read the latest report.

Another factor, despite the FDA approval and regulation of various meds, I've seen several patients get bad reactions to one brand and not another. Given the FDA regulation I can only conclude that it's likely the excipients that are differing in the different brands given that the active ingredient medication is supposed to be the same.

I recommend the brands that do that (NatureMade being the most prominent).

 

[WisNeuro]

Last time I reviewed this literature was a while ago but my recollection is that the picture was muddied by a number of trials that supplemented vitamin D for depression, without first establishing deficiency. That led to predictably negative/mixed results. I believe at that time there were 2 trials that tested vitamin D supplementation for depression in people with established deficiency, and those both had positive results.

A quick swipe through PubMed just now reveals the following:

The effect of 2 different single injections of high dose of vitamin D on improving the depression in depressed patients with vitamin D deficiency: ... - PubMed - NCBI
A randomized controlled trial of vitamin D supplementation on perinatal depression: in Iranian pregnant mothers. - PubMed - NCBI
Vitamin D Supplementation Affects the Beck Depression Inventory, Insulin Resistance, and Biomarkers of Oxidative Stress in Patients with Major Depr... - PubMed - NCBI

I appreciate the links, I thought I had read some meta-analyses in the last few years that showed minimal effects, but those may have been in general, not necessarily individuals who were deficient. I'll take another look when I get a free chunk of time, slammed with inpatient consults this past week.

 

[whopper]

Fish oil allegedly does start becoming efficacious on the order of prescribed antidepressants but on a dosage of about 15,000 mg a day, and at this dosage there could be higher risk of bleeding, not to mention smelling like a fish.

 

[Seb345]

I personally feel like supplements are important. I have been recommending them to most of my patients. I am currently looking for a good vitamin complex for myself too. Of course it's important to keep in mind that not everyone needs the supplements but I still think that a lot of people might benefit from it. I have been taking supplements for many years now and honestly I never experienced any side effects. I have been using many different brand throughout the years and there are a few brands of over the counter supplements that I really like but recently I have been looking for something new, I was browsing online and I came across this really interesting brand called Nordic Naturals. I ordered a few packs of supplements from their page (I am trying to keep myself self-isolated as much as I can) and I only recently got the package. I really like the overall effect that they have. and I feel a lot better and a lot ore full of energy. So yes I think that vitamins an be useful for boosting the overall feeling.

 

[WisNeuro]

I personally feel like supplements are important. I have been recommending them to most of my patients. I am currently looking for a good vitamin complex for myself too.

Even in people not deficient in them? And, what particular supplements? And is this based on empirical research, or a gut feeling?

 

[sloh]

Even in people not deficient in them? And, what particular supplements? And is this based on empirical research, or a gut feeling?

Resist the grifting. You guys are physicians. No need to grift.

 

[WisNeuro]

Resist the grifting. You guys are physicians. No need to grift.

At least in terms of supplements, I am very familiar with the cognitive literature and supplements. And, in general, there is no evidence to support supplementation unless someone is deficient in a certain vitamin or mineral. Just wondering what evidence is being used to prescribe or recommend in certain circumstances.

 

[whopper]

Emerging data is showing that Vitamin D could prevent and be protective against COVID-19, so in addition to the potential psych benefits I've been telling all patients to get a Vitamin D level and if deficient to supplement.

I have seen some patients significantly psychologically improve if deficient on Vitamin D and corrected but this is in a very small minority to the degree where I don't know if it's placebo. Most patients tell me they feel no specific difference, although it's still a good idea to get them to an optimal level. I have seen some patients with fibromyalgia improve with optimized Vitamin D levels. No improvement was complete remission of symptoms but more on the order of "I have slightly more energy that I can tell is from the Vitamin D, and my pain is about 5-10% less."

Several patients I have with autoimmune problems told me their symptoms were also somewhat improved with Vitamin D levels. Usually nothing of huge significance but a noticeable improvement.


I've had some patients try SAM-E if they tried a few prescribed antidepressants and failed and in some the SAM-E worked well.

A problem with multivitamins is the overwhelming majority of people are not deficient on any of them. The complaint of it's really only making expensive urine is valid. That said, some people may need them (but these are the exception).

I'd rather have patients try an OTC supplement such as L-Theanine, Melatonin, Magnesium, or Tryptophan for sleep before an prescribed sleep med is given.

 

[WisNeuro]

Emerging data is showing that Vitamin D could prevent and be protective against COVID-19, so in addition to the potential psych benefits I've been telling all patients to get a Vitamin D level and if deficient to supplement.

I have seen some patients significantly psychologically improve if deficient on Vitamin D and corrected but this is in a very small minority to the degree where I don't know if it's placebo. Most patients tell me they feel no specific difference, although it's still a good idea to get them to an optimal level. I have seen some patients with fibromyalgia improve with optimized Vitamin D levels. No improvement was complete remission of symptoms but more on the order of "I have slightly more energy that I can tell is from the Vitamin D, and my pain is about 5-10% less."

Just have to be careful with some people, as many do not understand the difference between water and fat soluble substances. It's rare, but I've had a couple of people in the past couple of years cresting into the toxicity levels from taking mega dose D pills multiple times a day. Also, isn't there potential for interaction with certain statins and BP drugs at high doses?

 

[whopper]

Yes. In general I've noticed about 5000 IU a day raises Vitamin D levels by about 20 pg/ml, but I've seen in it some only raise it by 5, and in others over 50.
I take Vitamin D 15,000 IU a day 6 days a week. My level was a 13, I took 5000 daily, redid a Vitamin D test 3 months later and it was in the 20s. Raised to 10,000 IU daily and redid the test 3 months later and it was in the mid 30s. I raised to 15,000 daily and redid the test later and the level was in the 70s. So I took 15,000 6 days a week instead of 7, and 3 months later yet another Vitamin D test showed it to be 63.

My results are not the norm, they are the extreme exception.

I learned this later on but the ability to absorb vitamin D is genetic and with some people, like me (and I had a test to verify this) being a very poor absorber . I have one patient whose Vitamin D level was 5 and only after taking 150,000 IU weekly did it get to above the 40s. This is after several several tests and verifications.

The flip-side however, is some people take 5000 IU daily and now they're toxic and Vitamin D toxicity can be dangerous. Definitely get a Vitamin D follow-up test if recommending supplements. Dosing definitely is not 1-size fits all although I'd save the 5000 IU raises it by about 20 lbs has been true for over 50%. I have done this on literally hundreds of patients.

All those FDA recommendations recommending 400 IU a day? Were written decades ago long before the late 80s trend of staying in all day to avoid skin cancer. 400 a day raises it about 5 points.

 

[Merovinge]

I personally feel like supplements are important. I have been recommending them to most of my patients. I am currently looking for a good vitamin complex for myself too.

This is the scariest post I've read on SDN lately. You're giving me flashbacks of listening to a M2 classmate back in the day who "didn't like the idea of so many vaccines given near birth" as someone planning on going into peds. Supplements have a surprising amount of data on their use, if you want to discuss that, this is a great place to do so. If you "personally feel" like spreading that to your patients, please have the data or professional guidelines to back that up.

 

[whopper]

There is no "feel" in science. There's hard data. There's gestalt extrapolation if you have a good foundation of data and are faced with a novel situation. There is no "feel," but in the latter you accept this is the best you can do in that novel situation and when the hard data comes out then you go with the hard data.

Psychiatrists are like chiropractors in that there is no shortage of people in our field who think they know more than what they know having read a total of maybe 3 pages of Freudian theory thinking this makes them an expert in Freudian psychoanalysis, who think they can use "feelings" without evidence to treat people. Said this before, I knew a psychiatrist that picked out Seroquel for a patient cause of it's red-pink packaging saying "it's warm and she needs that cause she's blue."

 

[calvnandhobbs68]

Emerging data is showing that Vitamin D could prevent and be protective against COVID-19, so in addition to the potential psych benefits I've been telling all patients to get a Vitamin D level and if deficient to supplement.

I have seen some patients significantly psychologically improve if deficient on Vitamin D and corrected but this is in a very small minority to the degree where I don't know if it's placebo. Most patients tell me they feel no specific difference, although it's still a good idea to get them to an optimal level. I have seen some patients with fibromyalgia improve with optimized Vitamin D levels. No improvement was complete remission of symptoms but more on the order of "I have slightly more energy that I can tell is from the Vitamin D, and my pain is about 5-10% less."

Several patients I have with autoimmune problems told me their symptoms were also somewhat improved with Vitamin D levels. Usually nothing of huge significance but a noticeable improvement.


I've had some patients try SAM-E if they tried a few prescribed antidepressants and failed and in some the SAM-E worked well.

A problem with multivitamins is the overwhelming majority of people are not deficient on any of them. The complaint of it's really only making expensive urine is valid. That said, some people may need them (but these are the exception).

I'd rather have patients try an OTC supplement such as L-Theanine, Melatonin, Magnesium, or Tryptophan for sleep before an prescribed sleep med is given.

Yeah and honestly the vast majority of us who live anywhere where the sun goes down at 7PM half the year are likely pretty Vit D deficient. I don't think people realize exactly how much Vit D production you lose from not being in the sun frequently (esp when during the fall/winter most of us probably don't see the sun at all some days between work and then by the time you get home its already dark).

"When an adult wearing a bathing suit is exposed to one minimal erythemal dose of UV radiation (a slight pinkness to the skin 24 h after exposure), the amount of vitamin D produced is equivalent to ingesting between 10,000 and 25,000 IU"

Vitamin D: The “sunshine” vitamin

Vitamin D insufficiency affects almost 50% of the population worldwide. An estimated 1 billion people worldwide, across all ethnicities and age groups, have a vitamin D deficiency (VDD). This pandemic of hypovitaminosis D can mainly be attributed to lifestyle ...

www.ncbi.nlm.nih.gov

I also take Vit D supplementation and as long as you don't go wild with the dosing, generally doesn't approach toxic levels.

 

[WisNeuro]

I also take Vit D supplementation and as long as you don't go wild with the dosing, generally doesn't approach toxic levels.

This one I don't mind as much, it's cheap, and as long as no one is overdoing it (but it does rarely happen), isn't deleterious. My biggest headache is Prevagen. That one is pretty costly, especially as many of my patients are on fixed incomes. I'd say half ask about it, and unfortunately there is a PCP in our system that recommends it to all of his over 65 patients

 

[adaptation1]

Do people even find vitamin-d levels to be reliable? There is within day variation and within person variation.

 

[WisNeuro]

Is there a high quality study examining intraday Vitamin D variability?

 

[adaptation1]

These are not conclusive studies by any stretch. But they do suggest more research needs to be done to account for possible intraday variability. Coupled with the fact that there is known seasonal variation, assay variation, without any established levels of vitamin d deficiency, I question the usefulness of obtaining a level. Just take it at a safe dosage, if the patient is so inclined.

Diurnal rhythms of vitamin D binding protein and total and free vitamin D metabolites

Vitamin D binding protein (DBP) concentration is known to influence the availability and bioactivity of vitamin D metabolites but its diurnal rhythm (DR), its inter-relationships with the DRs of vitamin D metabolites and its influence on free vitamin ...

www.ncbi.nlm.nih.gov

Circadian rhythm of serum 25 (OH) vitamin D, calcium and phosphorus levels in the treatment and management of type-2 diabetic patients - PubMed

The circadian time structure of serum 25 (OH) vitamin D (25-OHD), calcium (Ca) and phosphorus (P) may prove to be helpful in prevention, efficacy and management of diabetes mellitus. Ten newly diagnosed patients with type-2 diabetes mellitus (6 men and 4 women), 30-65 years of age, and 10...

pubmed.ncbi.nlm.nih.gov

25-Hydroxyvitamin D variability within-person due to diurnal rhythm and illness: a case report

Vitamin D nutrition research requires accurate measures of circulating 25-hydroxyvitamin D. Our objectives were to test whether a diurnal fluctuation in blood-spot concentrations of 25-hydroxyvitamin D can be demonstrated statistically in a single individual, ...

www.ncbi.nlm.nih.gov

 

[WisNeuro]

Yikes, that study is a mess. Also, these people clearly need to hire a statistician. While I agree with you that nutrition research does not have a good foundation, and needs a LOT more research, this very poor study is nothing to draw any conclusions from. From the very low n's, to the inappropriate statistical anlsyses for n and analysis type, it's hard to find anything redeeming about it.

For reference, this concerns the middle citation, still looking at the others

Regarding the first study, these aren't huge swings, it likely wouldn't change anyone's categorization unless they were generally sitting on a threshold to begin with. So, like I said, let's research it more, but there does not seem to be much here to suggest significant intraday changes. Surely nothing even approaching the magnitude of say, cortisol variability.

 

[tr]

Yeah I don't think a 20% variability would change my clinical decisions much at all. So you're saying someone with serum D of 25 could have been as low as 20 or as high as 30 if I had measured at a different time? I don't find that particularly impressive, either way I'm still going to suggest they supplement.

 

[hebel]

The Big Vitamin D Mistake

Since 2006, type 1 diabetes in Finland has plateaued and then decreased after the authorities’ decision to fortify dietary milk products with cholecalciferol. The role of vitamin D in innate and adaptive immunity is critical. A statistical error ...

www.ncbi.nlm.nih.gov

You guys ever see this study? Talks about how above certain latitudes, people have vastly underestimated how much vitamin D supplementation people often need.

 

[clozareal]

Here's a smattering of my thoughts:

1. Vitamin D: The association between Vitamin D and depression is pretty convincing to me from cohort studies and systematic reviews.
   
   The question therefore is: Does low vitamin D lead to being depressed or does being depressed cause low vitamin D, presumably because people who are depressed are less likely to be outdoors? I don't know the answer to this question and would love to hear what other people think.
   
   There's only one RCT that's not flawed that I've found that has some credible positive data on the treatment of MDD that compares vitamin D to placebo but only as an adjunct to fluoxetine.
   
   There was an RCT published in JAMA last month. N=~18k. Showed that Vitamin D supplementation over 5 years doesn't change the risk of depression in those with no history of depression or those with depression more than 2 years ago. Doesn't say anything about the treatment of major depressive disorder. I'm now going to recommend against using Vitamin D to prevent depression in those who are not currently depressed.
   
   Vitamin D supplementation is not entirely benign. There's a risk of hypercalcemia and kidney stones that I always counsel patients about if they want to use Vitamin D supplements. Because of the low quality of evidence for benefit for major depressive disorder, I typically don't recommend supplementation but am not opposed to it only as an adjunct, if the patient has documented Vitamin D deficiency, and if s/he understands the risks of adverse effects. I recommend against it as supplementation for those with normal Vitamin D levels.
   
   
2. For folate (and L-methylfolate), there's decent evidence that it works as an adjunct to SSRIs for treatment-resistant MDD, but the studies I've seen didn't genotype patients for MTHFR mutations so I don't think getting one is necessary. Probably benign—the last time I looked there was possibly an association with colon polyps but it's been a while since I last looked this up.
   
   
3. N-acetylcystine seems like it has okay evidence trichotillomania/skin picking as well as for cannabis use disorder in adolescents but not adults.
   
   
4. I don't typically use melatonin for insomnia, only for delayed sleep phase disorder. Patients will commonly ask about this though. If I do use it, I recommend melatonin only at doses of 0.1-0.3mg as those mimic physiologic doses, 4 hours before bedtime as that is when it is released, as this is how it was used in the studies. Maybe 3mg is okay because it's 10-50% bioavailable, but I don't recommend doses above 6mg. The adverse effect would be supraphysiologic doses that stick around until the next day, which then delays sleep onset the next day and can actually disrupt future sleep patterns.
   
   
5. Patients have been asking me about magnesium for anxiety or sleep. I don't know what to tell them as I haven't looked into this, but I recommend against it in those with chronic kidney disease.
   
   
6. High dose caffeine (300mg/day) is a pretty benign treatment for those with treatment-resistant OCD that can have a quick response within a week. Also sometimes use IV caffeine as pretreatment in ECT to lower seizure threshold and lengthen the seizure duration.
   
   
7. Lots of patients ask me about THC/CBD for all kinds of things. At this time, I haven't been recommending it for any psychiatric disorder as there is not enough convincing evidence of benefit except for the causes of pain/muscle spasms from MS or anorexia/cachexia/nausea/vomiting with cancer/AIDS. I definitely recommend against cannabis for insomnia as it can lead to cannabis use disorder as insomnia is the hallmark of cannabis withdrawal, which can negatively impact attempts to stop cannabis use. There's strong evidence that it disrupts slow wave sleep (decreases total amount of time in NREM). Interestingly, the studies of cannabidiol showed improvement in sleep in those with fibromyalgia (Nabilone) and those with non-sleep related conditions.
   
   
8. SAM-e has been shown to be effective for depression as an adjunct but not for OCD or anxiety symptoms
   
   
9. Valerian seems to be an okay supplemental option for insomnia, but not anxiety.
   
   
10. I've tried gingko biloba as add-on treatment along with Vitamin E and B6 for TD with no benefit. Seems like there is at least one positive RCT in GAD. Maybe it could be helpful in antidepressant-induced sexual dysfunction. Not effective for cognitive impairment in dementia but maybe neuropsychiatric symptoms?.

 

[whopper]

At least the last time I checked gingko's theorized mechanism was vasodilation. In demographics outside the elderly there isn't enough atherosclerosis for the vasodilation to be of any real benefit. E.g. if you vasodilate an older person's carotids and other brain arteries where they're already somewhat blocked, okay great, and hence the effects, but do it in a younger person with no significant blockage don't expect any benefits and if anything a headache.

 

[whopper]

You guys ever see this study? Talks about how above certain latitudes, people have vastly underestimated how much vitamin D supplementation people often need.

Not surprised. In fact it makes sense although I'm taking a leap and fully admitting it. I've theorized that the increased incidence of Multiple Sclerosis as you go further from the equator may be directly in correlation to Vitamin D, especially since there is data showing there's a Vitamin D correlation with autoimmune diseases. So if my fully admitted hypothesis is correct if you adjusted Vitamin D accordingly in groups so everyone had about the same Vitamin D level no matter their location one should see a consistent incidence of MS instead of an increasing incidence of MS as you go further away from the equator. So anyone care to take my hypothesis and do a study? I don't even care if you don't put me as an author so long as you buy me a drink. (I also figure I'm not the first idiot who came up with this idea).

Also correspondingly this may have implications as to a precipitating factor for first-onset psychosis since a theorized mechanism is inflammation. Just as a study was done years ago showing that EPA may be a protective factor against developing schizophrenia in high risk groups so too may Vitamin D.
Again this is only a hypothesis.

Someone I knew did fellowship in Hawaii and I remember him telling me "funny but no one who was born or raised here seems to get Fibromyalgia."

 

[WisNeuro]

Not surprised. In fact it makes sense although I'm taking a leap and fully admitting it. I've theorized that the increased incidence of Multiple Sclerosis as you go further from the equator may be directly in correlation to Vitamin D, especially since there is data showing there's a Vitamin D correlation with autoimmune diseases. So if my fully admitted hypothesis is correct if you adjusted Vitamin D accordingly in groups so everyone had about the same Vitamin D level no matter their location one should see a consistent incidence of MS instead of an increasing incidence of MS as you go further away from the equator. So anyone care to take my hypothesis and do a study? I don't even care if you don't put me as an author so long as you buy me a drink. (I also figure I'm not the first idiot who came up with this idea).

Also correspondingly this may have implications as to a precipitating factor for first-onset psychosis since a theorized mechanism is inflammation. Just as a study was done years ago showing that EPA may be a protective factor against developing schizophrenia in high risk groups so too may Vitamin D.
Again this is only a hypothesis.

Someone I knew did fellowship in Hawaii and I remember him telling me "funny but no one who was born or raised here seems to get Fibromyalgia."

This has been around since at least the early 90's. Hundreds, if not thousands of studies on it. The association between lower levels and MS is pretty robust and reproducible, but they just don't know the mechanism of action yet. There's been a lot of newer work on Vitamin D supplementation and whether or not is can reduce the risk of relapse in certain forms, or if it reduces lesion load, but it's been somewhat equivocal, maybe with some decent evidence to support it.

 

[tr]

1. High dose caffeine (300mg/day) is a pretty benign treatment for those with treatment-resistant OCD that can have a quick response within a week. Also sometimes use IV caffeine as pretreatment in ECT to lower seizure threshold and lengthen the seizure duration.

COME ON!!! Equivalent response between active placebo control and test drug, and conclusion is wow, they both work great, let's recommend for patient care?? Really, the scientific thinking on this one left a lot to be desired. How is it still being bandied about.

If you feel good about the clinical response you've seen on with caffeine that's great (personally I haven't been impressed), but this particular study should be buried.