Supplements in Psychiatry

[clozareal]

How often are you all using supplements in your psychiatric practice? I see many integrative practices in my area that are really thriving and I feel like I haven't gotten much of this education in my training.

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[WisNeuro]

Under most circumstances, this would be a quick way for a provider to be removed from my referral list.

 

[Sushirolls]

Because its snake oil.
People ride the high of placebo. That is the real intervention.
True deficiencies, Vitamin D, B, etc sure supplement.
Everything else, snake oil.

Sadly, its what an ever increasing portion of the population wants, seeks, desires. So, in some ways I do applaud the integrative psych folks for tapping into the history of America to be the snake oil salesman and fleece people of their money. In some ways its just a dance, a means to get patient buy in, build rapport, and establish the value for starting the real evidence based treatments. The ethical question beckons should we even be doing such thing with these "integrative" therapies as dessert to peoples main course?

The core of Naturopathy is this.

Perhaps I may be over expressing black bile, and need to release this humor.

 

[Merovinge]

NAC 500 or 600mg daily for a few days THEN BID for a few days THEN 1000-1200mg BID (different manufactures are either 500, 600, or 1000mg) for compulsive picking, hair pulling, or probably most importantly cannabis use disorder.

Vit D below 20 I would aggressively supplement, 20-30 usually still recommend but do not get excited to see improvement in psychiatric symptoms.

Light box therapy I definitely support in seasonal depression or even seasonal depression in bipolar patients (provided they have an antimanic agent on board). Needs to be high quality 10,000 + Lux, 18-24" from the face, 30-45 min in the morning for MDD, 30 min around 11-1 for Bipolar depression (don't ask me why).

Highly concentrated/pharmacutically based lavender has some research in Europe so if I had to recommend someone use a smell to pair with the experience of calming down it's a reasonable place to start.

I am wildly unconvinced about L-methylfolate from the research I have been presented but I wouldn't completely fault someone for giving this in MDD cases.

I think that's basically the whole of it, you didn't miss much in training...

 

[whopper]

Most Americans these days suffer from Vitamin D deficiencies and there's a growing body of evidence showing that this hormone is needed not just for healthy bones. E.g. cancer prevention, reduction in inflammation, and preventing infections. There is some data showing correlation with Vitamin D and depression but I rarely see depressed people feeling better once their Vitamin D is corrected.

There's data showing women with vitamin D deficiencies, if pregnant, the children have a higher chance of mental health problems.

There is evidenced based data that Silexan (found in lavender) can work well for anxiety. I've told patients to try it. So far about of 20 patients, 1/3 reported significant benefit (like they don't want to take a benzo anymore kind of improvement). Now while that benefit was significant this was below the majority so don't go there expecting this to work.

SAM-E has decent data showing that it can help depression.

L-Methylfolate I've seen worked great in patients with depression, more so if they had the double MTHFR mutation.

L-Theanine-I've seen this work well for anxiety and insomnia but it's effect is never a grand slam. Moderate at best. Usually subtle.

Tryptophan-5HTP: Can work well in PMDD.

The patients I've had who've tried Magnesium said they noticed a slight but noticeable reduction in anxiety when taking a supplement. This reduction again was slight only. I also tell patients not to take more than recommended on the bottle cause it is possible to get too much magnesium.

I've had patients try supplements, only if there's some evidenced-based data for it's use, if they've tried the several meds without much improvement. Except for the above I haven't seen much from several things such as Lion's Mane.

If a patient is showing treatment-resistance to depression it's a good idea to check their TSH and B12 levels.

 

[TheRightMedication]

We should do a review, rank the supplements in order of evidence base, and sell a supplement with the top ten in it. Call it Dr. Snake's Oil and put a picture of a shrugging anthropomorphic snake in a white coat on it. Would save a lot of conversation time with some patients. Just drink the Oil and call it a day.

 

[annoyedpsychiatrist]

Dr. APs magic pill for mildly depressed people going through a slightly rough time has been known to work wonders for referralls with PHQ scores of <4. $300 for 30 capsules.

 

[clausewitz2]

Examine.com is actually a great resource for this, entirely funded by subscribers with zero advertising or sponsorships.

Re: lavender, Silexan has okay-ish evidence for anxiety.

Kava can be extremely effective but you need to make sure you have a legit preparation to avoid potential acute liver failure; also seems to impair hepatic metabolism of some other drugs, as evidenced by a former patient of mine who was using kava, took a single dose of Klonopin he had left over from a previous prescription, and ended up hospitalized medically floridly delirious for a couple of days. Ashwaganda has decent evidence, specifically Sensoril.

The downside to all of these supplements is quality control, of course, as they are almost entirely unregulated. Definitely would recommend doing your own research into which preparations in which brands seem to have good third-party testing to make sure what is in the bottle really is what is in the bottle.

 

[whopper]

Forgot the guy's name but he's the head researcher for Omega 3 and mental illness at Columbia U. Per his lectures fish oil can work as well as a prescribed antidepressant but we're talking at dosages about 15,000 mg a day. Aside from the patient smelling like fish, I'm suspecting it could cause a bleeding problem at that dosage.

 

[whopper]

There's emerging evidence that vitamin D levels are the reason why MS goes up in the more extreme lattitudes. As we know several neurological and psychiatric disorders, prevention is probably the best step. Better to not get MS at all since there's no cure. Same with schizophrenia. For this reason I'm pretty loose with recommending patients get Vitamin D levels, and consistent with recent data almost all my patients have Vitamin D deficiencies.

I'm suspecting Vitamin D could be a potential and exploitable factor in preventing Schizophrenia and Bipolar Disorder.

Vitamin D and schizophrenia: 20 years on - PMC

Many epidemiological studies have highlighted the link between vitamin D deficiency and schizophrenia. In particular, two prominent studies report an association between neonatal vitamin D deficiency and an increased risk of schizophrenia. In ...

www.ncbi.nlm.nih.gov

 

[clausewitz2]

There's emerging evidence that vitamin D levels are the reason why MS goes up in the more extreme lattitudes. As we know several neurological and psychiatric disorders, prevention is probably the best step. Better to not get MS at all since there's no cure. Same with schizophrenia. For this reason I'm pretty loose with recommending patients get Vitamin D levels, and consistent with recent data almost all my patients have Vitamin D deficiencies.

I'm suspecting Vitamin D could be a potential and exploitable factor in preventing Schizophrenia and Bipolar Disorder.

The problem is whenever we look at whether repleting Vit D actually alleviates most of the negative conditions it is associated with, the answer is usually "no." Repleting is probably protective for bone health and reduces thinning but the prevailing thinking seems to be that low vitamin D levels are a marker or correlate with ill health, rather than playing a causal role.

 

[clozareal]

How often are you all checking vitamin D, B12, folate, TSH levels? I don't get it unless there's something on the history on the ROS to make me suspicious enough of it. I'm not getting everyone with treatment resistant depression to get the labs, but I feel like this is more common practice. I just think the pretest probability would be low. In my area, it seems like everyone would be low on Vitamin D for half if not most of the year based on the amount of sun we get regardless of their depression status.

I feel like I keep getting asked by patients about magnesium, 5HTP, GABA, inositol, ashwagandha, theanine, fish oil, coenzyme q10, and all these other supplements that don't seem to have much evidence base, but I also haven't searched it myself for any RCTs or data on it for the most part. I have seen the RCT on Silexan but haven't used it in my practice. I also don't know how they interact with the meds I'm prescribing since most people don't tell me they are taking them, when they're starting or stopping them, and I'm not asking every appointment outside of the intake if they are.

 

[comp1]

Ugh, if the supplement industry ever gets regulated at all, I might be more inclined to be a part of it. As it is, you don't generally know what a patient is getting. In terms of labs, yeah those probably have low pretest probability outpatient, more in indigent inpatient populations, but they also aren't going to likely be chugging a bunch of supplements.

 

[FlowRate]

Lots of "integrative, holistic" clinics around here offering a urine neurotransmitter metabolite testing panel which is sold by the company that also sells the supplements to correct those levels to the "recommended" (rather than lab ref normal) value (as if there's any useful correlation or treatment function with either.) Nothing to see regarding kickbacks or conflicts of interest there...

 

[Merovinge]

Lots of "integrative, holistic" clinics around here offering a urine neurotransmitter metabolite testing panel which is sold by the company that also sells the supplements to correct those levels to the "recommended" (rather than lab ref normal) value (as if there's any useful correlation or treatment function with either.) Nothing to see regarding kickbacks or conflicts of interest there...

Heh I just saw a patient who had this work done, shiesta city. I guess they sleep at night on their yachts because I don't otherwise know how you could be a physician, do that work, and sleep at night.

 

[clausewitz2]

Heh I just saw a patient who had this work done, shyster city. I guess they sleep at night on their yachts because I don't otherwise know how you could be a physician, do that work, and sleep at night.

FTFY

 

[whopper]

Repleting is probably protective for bone health and reduces thinning but the prevailing thinking seems to be that low vitamin D levels are a marker or correlate with ill health, rather than playing a causal role.

My theory is that being the evidence-body of inflammation increasing as an etiological factor for certain diseases that Vitamin D may play a protective role but once the person has the problem repleting it won't help much. E.g. COVID. Data showing repleting it didn't improve outcomes but more people with a Vitamin D deficiency had bad outcomes with COVID..

If this theory is correct, Vitamin D could play a good prevention role but not so much treatment role. Once you got schizophrenia or MS you got it for life. If Vitamin D could reduce the risk it could be worth it especially if you have a patient at high risk for it.

 

[G Sheb]

The shocking thing is that most of those "neutraceutical" practices are coming from graduates of top 5 programs.
Apparently this is what you get out of elite education in psychiatric residencies. How to sell snake oil, inc.
There are courses OP in "integrative" psychiatry and stuff if you want to get there.
You could also certify yourself in meditation or yoga or something and be the next bridge between "eastern and western" medicine.

 

[whopper]

Forgot to add...
I have had a lot of patients tried Ashwaghanda. About 50% cite some improvement being better sleep, improved sex drive.

NAC? There's a lot of good data showing it could help with mental health but I only see subtle improvement when I have patients try it. Only something to the effect of "I notice a little bit but it's barely anything." Also for years the only journal article showing anything that could reduce cannabis dependence was NAC and this study was done on children. When the study was done on adults no benefit was found.

(Edit-didn't mention this but I've tried over 50 patients on NAC. The overwhelming majority, seems like over 80% and I didn't keep count felt an improvement but none of them had significant improvement. Only something noticeable and better but never more. Described on the order of something like, "it's a hot day, 100 degrees, and the temperature it turned down a just a few degrees."

 

[Dantes]

ConsumerLab.com is a good resource for supplement testing, and as mentioned above Examine.com is good for gathering and summarizing the literature. A good chunk of the nootropics community are really self-medicating psychiatric symptoms with anything from OTC supplements to research chemicals. Some have evidence in humans but a lot don't. But I think being familiar with them is a good idea if patients are trying them.

 

[jbomba]

Isn't there somewhat reasonable evidence for Omega-3 fatty acids as well? I've seen some data in borderline personality, as well as depression.

 

[Stagg737]

Agree with most of the above. I generally don't prescribe supplements unless there's a medical issue directly correlated (ie, Wernicke's and thiamine/folate repletion) but I do educate patients about some supplements if they ask. I mostly do not recommend them, but am open to it if that's what patients want and it's reasonable.

I think it's worth understanding the recommendations and actual criteria for vitamin D deficiency (<12) vs insufficiency (>12 but <30) and have seen some patients have some improvements for depression. It's cheap and generally benign if taken appropriately, with that kind of risk vs benefit, why not?

NAC can help with augmentation as mentioned. I've never used it for cannabis dependence because the data good for those <21 yo and not for adults as well as patients being generally unwilling to quit. I've recommended it a couple of times, but no one has wanted to take it. Maybe if it had a more exotic or natural sounding name...

One of my addictions attendings in residency liked using Silexan with their patients as they could tell patients that there was data showing it was as effective as ativan. I only prescribed it 3 or 4 times, but recall 2 of the patients saying they loved it. I haven't used it since, but have discussed it with a few people. I'd love to see more studies done on it as I have lots of patients who say "I don't want an anti-depressant for anxiety" and a non-benzo option for that would be great.

I've had a few patients do well with Mg, including an extended family member (not a patient) who is noticeably irritable/anxious when she doesn't take it. Some data there, worth discussing if patients are super into "natural" stuff.

There are other "natural" options with some evidence like SJW, Kava, or Ashwaganda, but they all have the same issues (unregulated, side effects, interactions with other meds/substances). I always discuss side effects and polypharm interactions of supplements and natural/alternative substances with patients just like with other meds, and after that they're usually a lot more open to discussing meds knowing that I'm not just bashing natural medicine as BS (even when it is).

How often are you all checking vitamin D, B12, folate, TSH levels? I don't get it unless there's something on the history on the ROS to make me suspicious enough of it. I'm not getting everyone with treatment resistant depression to get the labs, but I feel like this is more common practice. I just think the pretest probability would be low. In my area, it seems like everyone would be low on Vitamin D for half if not most of the year based on the amount of sun we get regardless of their depression status.

I feel like I keep getting asked by patients about magnesium, 5HTP, GABA, inositol, ashwagandha, theanine, fish oil, coenzyme q10, and all these other supplements that don't seem to have much evidence base, but I also haven't searched it myself for any RCTs or data on it for the most part. I have seen the RCT on Silexan but haven't used it in my practice. I also don't know how they interact with the meds I'm prescribing since most people don't tell me they are taking them, when they're starting or stopping them, and I'm not asking every appointment outside of the intake if they are.

I always ask for TSH labs if they've been done and will ask for them if there's associated physical symptoms with the depression or anxiety to suggest an abnormality. I haven't had too many patients whose mood symptoms resolved or dramatically improved with treatment, but I have had quite a few patients who needed adjustments to their meds who may not have gotten them otherwise who did feel better when it was addressed. I don't regularly order Vitamin D on an outpatient basis, but may throw it on if they're getting other labs drawn, especially if it's been low previously and they're not on a supplement.

 

[VA Hopeful Dr]

The problem is whenever we look at whether repleting Vit D actually alleviates most of the negative conditions it is associated with, the answer is usually "no." Repleting is probably protective for bone health and reduces thinning but the prevailing thinking seems to be that low vitamin D levels are a marker or correlate with ill health, rather than playing a causal role.

This is the right answer. Us primary care types went through the same thing with HDL and niacin.

 

[clausewitz2]

It turns out when you survey the nootropics community about what the most effective nootropics are, generally what wins are stimulants of various kinds, various enantiomers of modafinil that are pharmaceuticals in Europe and are in a legal gray area in the States, tianeptine, racetams of various kinds that are used more often in thee former Soviet bloc countries, phenibut and theanine+caffeine.

Only one of those should you be using liberally without very careful thought, and I would argue some of them no one should be using.

 

[whopper]

I have only one NAC success case that went beyond the usual "I feel only slightly better," even while on high dosages of it.
It was a pathological gambling case. There is evidenced-based data where it helps. Patient was screened for the big stuff like Bipolar Disorder, ADHD, etc, and it was just Pathological Gambling. Patient told me she didn't have the urge to gamble while taking it. Success held for years.

 

[clozareal]

NAC is interesting because it wasn't initially supplement as it was first authorized/patented as a "new drug" for use for medical conditions: acetaminophen overdose and as a mucolytic for cystic fibrosis. This is why the FDA pulled it from the OTC market two years ago and then now it's allowed again.

I haven't found much success with using NAC for anxiety, OCD, cannabis dependence in teens, trichotillomania, excoriation disorder, or anything else psychiatric. Maybe a mild benefit at the most, but at the cost of delaying more effective treatment (higher doses of SSRI).

 

[clozareal]

There is evidenced based data that Silexan (found in lavender) can work well for anxiety. I've told patients to try it. So far about of 20 patients, 1/3 reported significant benefit (like they don't want to take a benzo anymore kind of improvement). Now while that benefit was significant this was below the majority so don't go there expecting this to work.

That's pretty huge if you could use a supplement to the point where around 6 of your patients no longer want a benzo. I'll use it for every patient with an anxiety disorder who wants a benzo if that's the case if I can even reduce a % of them, even if it isn't the majority. I feel like SSRIs also don't help completely resolve depression/anxiety in a majority of patients anyways. Are there any risks to using Silexan?

 

[whopper]

I'm not trying to endorse a product but there's only one Silexan I've seen where the mgs are shown and it's in 80 mg capsules. I bet the study that was done showing it worked likely used the same supplement because it too was used in 80 mg capsules. If I mention the name this post will likely get struck down.

Also bear in mind that my private practice already weeds out people where I have good evidence of drug-seeking behavior so these were people that knew to get off of a benzo, and their dosage wasn't high. Back in my Medicaid office days too many patients wanted benzos cause even the ones that didn't want to take them knew they could sell them.

Adding to this, the evidenced-based data for Silexan is decent. You're not endorsing snake-oil. You have a good evidence base to say it's worth a try. Like I said, don't give it out, however, expecting it to work. I've had good successes with it but more failures.

Lavender oil preparation Silexan is effective in generalized anxiety disorder – a randomized, double-blind comparison to placebo and paroxetine

Abstract. The anxiolytic efficacy of the orally administered lavender oil preparation Silexan was investigated in generalized anxiety disorder (GAD) in com

academic.oup.com

 

[clausewitz2]

That's pretty huge if you could use a supplement to the point where around 6 of your patients no longer want a benzo. I'll use it for every patient with an anxiety disorder who wants a benzo if that's the case if I can even reduce a % of them, even if it isn't the majority. I feel like SSRIs also don't help completely resolve depression/anxiety in a majority of patients anyways. Are there any risks to using Silexan?

The most common one is the delightfully named 'lavender burps'.

 

[annoyedpsychiatrist]

Has anyone else noticed that basically everyone who has vitamin D levels drawn are somehow deficient in vitamin D?

 

[WisNeuro]

Has anyone else noticed that basically everyone who has vitamin D levels drawn are somehow deficient in vitamin D?

Definitely varied by age and location. Wasn't as much of a problem when my pts were younger and in the south when I was at a VA. But, in the north, working with 65+ clinically, yep.

 

[Merovinge]

Has anyone else noticed that basically everyone who has vitamin D levels drawn are somehow deficient in vitamin D?

This is a feature of moderity not a problem with the lab draws. When we were hunting/gathering/farming outside as a species it would not be a problem. Many people aspire to avoid time outside these days...

 

[hamstergang]

If I mention the name this post will likely get struck down.

Seems a bit paranoid to me. What could possibly be the motivation fot SDN to remove a post mentioning a brand of this stuff? This forum is meant for us to collaborate and share knowledge, even if that's suggesting one drug or brand over another.

 

[Stagg737]

Seems a bit paranoid to me. What could possibly be the motivation fot SDN to remove a post mentioning a brand of this stuff? This forum is meant for us to collaborate and share knowledge, even if that's suggesting one drug or brand over another.

If this violates TOS, then may the mod gods strike me down. The product is CalmAid by Nature's Way. You can get a pack of 60 tabs in 80mg doses for $30 on Amazon. Study showed best efficacy taking 80mg BID, but 80mg daily was still as effective as Paxil. Apparently Lasea is also available via Amazon, but idk about that brand/supplement.

That's pretty huge if you could use a supplement to the point where around 6 of your patients no longer want a benzo. I'll use it for every patient with an anxiety disorder who wants a benzo if that's the case if I can even reduce a % of them, even if it isn't the majority. I feel like SSRIs also don't help completely resolve depression/anxiety in a majority of patients anyways. Are there any risks to using Silexan?

Risks seem to be largely some GI distress or headaches. Link the the study below with an excerpt on safety profile:

"Safety of silexan​

In the analyzed 5 studies, adverse events, attributable to silexan use, consisted mainly of gastrointestinal problems such as nausea, eructation or breath odour, and diarrhea. A number of patients also reported having headaches in the 2015 study by Kasper et al.41 Nevertheless, the number of patients that experienced these mild adverse events comprised of a small percentage of the sample size. No serious adverse event was found to be linked to the use of silexan.

Fatigue is a known side effect of lorazepam. In the study conducted by Woelk & Schlafke38, 16.2% of patients receiving treatment with lorazepam had fatigue whereas none in the silexan group experienced fatigue. However, 10.0% in the silexan group had nausea whereas only 2.7% had nausea in the lorazepam group.

The actual number and type of total adverse events experienced by the participants in the study conducted by Kasper et al.36,37 were not reported in details. Nonetheless, it was noted by Kasper et al.37 that the participants receiving treatment with silexan experienced a 3% increase in risk of gastrointestinal problems compared to those in the placebo group. Further details on adverse events reported in the studies can be found in Table 5."

Efficacy and safety of lavender essential oil (Silexan) capsules among patients suffering from anxiety disorders: A network meta-analysis - Scientific Reports

A systematic review and network-meta analysis (NMA) were performed to estimate significance of the anxiolytic effect of lavender essential oil taken as silexan capsules versus other comparators (i.e., placebo/paroxetine/lorazepam). The outcome of interest was Hamilton Anxiety Scale (HAMA)...

www.nature.com

 

[allantois]

I use "supplement" Zoloft and Abilify and... lol

 

[JKinSC]

Isn't there somewhat reasonable evidence for Omega-3 fatty acids as well? I've seen some data in borderline personality, as well as depression.

I think Carlat has covered this fairly extensively. Reportedly, in the right ratio (EPA > DHA), the effect size is pretty remarkable with regard to mood lability in borderline.

 

[forchinet121]

There’s evidence for omega 3 in schizophrenia and the APA has even recommended all psychotic people be on omega 3s

 

[clausewitz2]

There’s evidence for omega 3 in schizophrenia and the APA has even recommended all psychotic people be on omega 3s

There was a time when omega-3s looked like they made a big difference in first episode psychosis, but the big international multi-center trial was a total bust, with the caveat that the control condition was also receiving CSC-style care. This would be unremarkable in a FEP program but doesn't really happen outside of them.

 

[forchinet121]

There was a time when omega-3s looked like they made a big difference in first episode psychosis, but the big international multi-center trial was a total bust, with the caveat that the control condition was also receiving CSC-style care. This would be unremarkable in a FEP program but doesn't really happen outside of them.

But doesn’t the APA recommend them for all psychotic patients?

 

[splik]

But doesn’t the APA recommend them for all psychotic patients?

No, definitely not. The practice guidelines don't mention anything about omega-3s. Years ago, there was an APA omega-3 subcommittee that said there was evidence supporting the use of omega-3s for mood disorders but said the evidence was less clear for psychosis. In addition, the committee was formed with several integrative psychiatrists and one now known sex offender. But the APA never recommend omega-3s for all patients- psychotic or otherwise.

 

[forchinet121]

No, definitely not. The practice guidelines don't mention anything about omega-3s. Years ago, there was an APA omega-3 subcommittee that said there was evidence supporting the use of omega-3s for mood disorders but said the evidence was less clear for psychosis. In addition, the committee was formed with several integrative psychiatrists and one now known sex offender. But the APA never recommend omega-3s for all patients- psychotic or otherwise.

It seems like there was a recommendation at one point in time I guess it’s been revised

Trim the fat: the role of omega-3 fatty acids in psychopharmacology - PMC

The American Psychiatric Association (APA) currently recommends the use of omega-3 fatty acid supplementation for depressive disorders, impulse-control disorders, and psychotic disorders in treatment guidelines. This review examines the evidence for ...

www.ncbi.nlm.nih.gov

 

[splik]

It seems like there was a recommendation at one point in time I guess it’s been revised

Trim the fat: the role of omega-3 fatty acids in psychopharmacology - PMC

The American Psychiatric Association (APA) currently recommends the use of omega-3 fatty acid supplementation for depressive disorders, impulse-control disorders, and psychotic disorders in treatment guidelines. This review examines the evidence for ...

www.ncbi.nlm.nih.gov

This article is inaccurate