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Case History: Kathy

Diagnosis: ADHD

“She felt like she’d found her self-esteem again.”

Kathy was a 30-year-old female with a diagnosis of ADHD since high school. She initially presented to our clinic with depression, suicidal ideation, ongoing attention problems, sex addiction and poor dietary habits.

Her medical history was remarkable for multiple skin rashes and chronic seasonal allergies. She was attending sex addicts anonymous and weekly psychotherapy. At the time of her first visit, she was taking Wellbutrin and had previously tried multiple medications including numerous SSRI’s, Vyvanse, Ritalin, and Buspar with little benefit.

Her family history included significant anxiety disorders on her mother’s side and addiction on her father’s side.

Testing and evaluation uncovered the following:

  • MTHFR 677 variant homozygous for TT
  • Low RBC Magnesium
  • Essential fatty acid deficiency with low levels of both omega-3s, EPA and DHA
  • Low magnesium and undetectable lithium on trace mineral hair analysis
  • Low 25-hydroxy Vitamin D at 20 ng/mL

Without changing her current medication, Kathy started on nutritional supplements based on her testing:

  • Vitamin D, 5,000 iu once per day
  • Fish oil, 2 capsules per day
  • Folate, 5 mg per day
  • Magnesium glycinate, 360 mg per day

At her next follow-up four weeks later, Kathy noted some initial improvements. Upon questioning, she was able to articulate that her mood had improved some and she was more interactive with friends and family. However, she still had significant symptoms, especially around impulse control. Due to the residual symptoms, lithium was added, starting at 2 mg per day with a recommendation to increase to 5 mg after two weeks.

Six weeks later upon her next return visit, Kathy was able to describe marked improvement in her symptoms. Her depression was significantly better and she felt more impulse control around both food and sex.

At six months, things had continued to improve. She was doing well at work and her interpersonal relationships had stabilized. Most importantly, she felt like she’d found her self-esteem again. She continued with the Wellbutrin and supplements, quite satisfied with the results.

Want to learn nutritional and functional medicine interventions like these to help your patients? Enroll in our comprehensive Fellowship for mental health providers! Book a private phone call with Dr. James Greenblatt to learn more today.

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