Patient Case Study

Initial Presentation

Luann was a 41-year-old office worker with a history of depression. While she’d always struggled with her weight and binging, after being prescribed paroxetine, she felt like she had even less self control. She often binged carbohydrates and had gained 55 pounds in the last three years. Even after her doctor added bupropion, she continued to gain weight and struggle with binging episodes.

Due to her poor response, she had been trying to wean off the paroxetine with the help of her doctor. However, the withdrawal effects were severe and she was stuck at 10 mg per day, down from 30 mg. Even at that dose she was having occasional electric shock sensations, insomnia and increased anxiety.

Initial Relevant Labs

• Highly sensitive C-reactive protein elevated at 12 mg/L
• Homocysteine elevated at 17 µmol/L
• IgG high-reactivity to dairy and eggs
• Urinary Kryptopyrrole elevated at 37 µg/dL

Working Diagnosis:

• Binge eating disorder (BED), major depressive disorder and paroxetine withdrawal

Initial Treatment

• Curcumin 500 mg with BioPerine, 3 caps per day
• Zinc picolinate, 30 mg and vitamin B6 50 mg twice daily
• Active B-complex, 1 cap per day
• 5-HTP, 50 mg for one week then increase to 50 mg twice daily
• Eliminate dairy and eggs

Explanation

Inflammation is a common component of numerous mental health conditions. Research has even found associations between binge eating disorder, depression and elevated C-reactive protein (CRP), a common marker of inflammation (do Rosário Caldas 2022). Curcumin is a polyphenol found in the kitchen spice turmeric that has anti-inflammatory effects and can lower CRP levels (Gorabi 2022). It may also help to decrease appetite in overweight patients and improve mood (Jazayeri-Tehrani 2018, Fusar-Poli 2021).

In 1958, a compound that was labeled as kryptopyrrole was originally discovered in the urine of patients with psychosis (Irvine 1969). Initial estimates suggested that between 30 and 60% of patients struggling with psychosis had elevated values. Further work discovered that the compound appeared to deplete zinc and vitamin B6 and that supplementation of these two nutrients improved psychotic symptoms (Pfeiffer 1974). Since its discovery, other mental health conditions have been found to correlate with elevations in kryptopyrrole (McGinnis 2008). While eating disorders have not historically been associated with elevated kryptopyrrole, other co-occurring conditions that are common in eating disorders, like depression and anxiety, may respond to kryptopyrrole treatment utilizing zinc and vitamin B6 when kryptopyrrole is elevated.

Homocysteine is a neurotoxic metabolite that is commonly elevated in a number of different mental health conditions, from depression to eating disorders (Moradi 2021, Levine 2007). Elevated levels of homocysteine typically respond to supplementation of an active B complex containing vitamin B12 and methylfolate.

Immunoglobulin G (IgG) antibody tests for food sensitivities are controversial. Yet studies continue to accumulate showing the potential utility of food elimination diets based around IgG-food-antibody-testing results. Eosinophilic esophagitis has clearly been tied to elevated levels of IgG4 antibodies to foods (Clayton 2014). Migraine headaches and irritable bowel syndrome also both appear to benefit from diets based around IgG antibody test results (Geiselman 2019). Other evidence suggests that elevated IgG antibodies to foods are present in cases of depression (Karakula-Juchnowicz 2018). IgG food reactions may also contribute to the low-grade chronic inflammation typically present in obese patients (Wilders-Truschnig 2008).

5-Hydroxytryptophan (5-HTP) is a precursor to serotonin. Serotonin levels are critical for regulating appetite and food intake. Clinical studies have found 5-HTP to be effective for reducing food intake and helping with weight loss (Cangiano 1991) along with benefiting depression (Javelle 2020).

Follow-up Presentation

Two months after Luann started her initial treatment regimen she was already noticing significant improvements. Her mood was better and her anxiety levels had decreased. But most importantly to her, the binging episodes were mostly under control. As such, her weight had started to decrease. The side effects from the reduced dose of paroxetine had also stopped and she was ready to continue the paroxetine taper.

Follow-up Treatment

• Continue supplements
• Continue the paroxetine taper at a pace that minimizes withdrawal symptoms

Case Summary

Patients struggling with mental health concerns are often complex, frequently presenting with comorbid conditions that can be due to an intricate web of different underlying factors. In cases where antidepressants need to be tapered, withdrawal symptoms can further add to the complexity, exacerbating symptoms during the withdrawal process.

By identifying common triggers, including nutrient deficiencies, elevated kryptopyrroles and homocysteine, symptoms can often be reduced or eliminated. This biochemical individuality, unique to each patient, is often a critical piece that can effectively improve treatment outcomes.