Initial Presentation

Tammy came to my clinic with a history of “spacey” behavior and a predilection to imitate those around her. During the visit, Judy—Tammy’s mother—shared her concerns about Tammy’s recent weight gain and eating habits. She mentioned finding hidden candy wrappers throughout her bedroom. Over the course of the summer, Tammy had gained 25-pounds.

Another odd behavior was Tammy’s tendency to wear long-sleeved clothing even in warm, sunny weather. When confronted by her parents, Tammy revealed that she had been cutting her arms as a way to relieve stress. This prompted her parents to schedule an appointment with me.

During our conversation, Tammy expressed feelings of depression. Her previous doctor had prescribed antidepressant medications, including Prozac and Lexapro. Unfortunately, Prozac had increased thoughts of suicide and Lexapro had caused severe nausea, leading Tammy to discontinue their use.

Upon a review of systems, it was noted that Tammy had two skin conditions, eczema and keratosis pilaris—a bumpy skin condition on her upper arms and neck. These conditions can often indicate a need for essential fatty acids, including eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and gamma linolenic acid (GLA). She also didn’t meet criteria for binge eating disorder, but was clearly struggling with binging on sweets.

Based on her history and physical exam, testing was ordered to further identify underlying factors that could be contributing to her symptoms.

Initial Relevant Labs

• RBC magnesium was low at 3.6 mg/dL
• EPA, DHA and GLA red blood cell levels were all very low

Working Diagnosis:

Major depressive disorder, eating disorder not otherwise specified, magnesium deficiency and essential fatty acid deficiency

Initial Treatment

• Magnesium glycinate 240 mg twice daily
• EPA/DHA/GLA combination 2 grams twice daily

Explanation

Magnesium deficiency is known to have mental health consequences (Botturi 2020). In the brain, magnesium blocks the excitatory neurotransmitter glutamate through its actions on NMDA receptors. It also acts to modulate serotonergic activity. Beyond neurotransmitters, magnesium is also critical for helping to maintain an appropriate hypothalamic-pituitary-adrenal axis, being a key factor in helping to reduce an overactive stress response. Studies have found magnesium useful for treating depression and anxiety symptoms (Wang 2023).

Omega-3 fatty acids are also known to be critical for normal brain function, playing roles in neurogenesis, neurotransmitter function and modulating inflammation (Lange 2020). A recent meta-analysis concluded that there is compelling evidence that omega-3s are useful for treating depression in children (Lam 2024). While not as well studied, data also suggests that GLA levels are low in people at risk for depression, potentially indicating an increased need (Yary 2017).

Follow-up Presentation

Four weeks later when Tammy returned, her parents described some small improvements in Tammy’s behavior. Tammy had noticed that her mood had improved, and she hadn’t been cutting to deal with stress.

During the visit, Tammy’s parents remembered a previous diagnosis that they had failed to mention in the initial visit: attention-deficit/hyperactivity disorder (ADHD). When Tammy had been eight, she had been diagnosed with ADHD by her pediatrician, but treatment had not been prescribed. Upon further questioning, Tammy also confessed to struggling to focus on activities at home or at school and was often reprimanded for not paying attention. Based on the additional information, treatment was expanded to help address all of Tammy’s symptoms.

Follow-up Treatment

• Lisdexamfetamine 30 mg
• Referral for Tammy and her family for psychotherapy

Follow-up Presentation

Four months later, Tammy was markedly improved. Her school performance had caught the attention of her teachers and she was no longer being reprimanded. Family dynamics at home were also more stable with Tammy’s parents feeling like they’d gained significant insights through psychotherapy.

Upon testing, her EPA, DHA and GLA levels had all normalized and Tammy was able to slowly taper the stimulant medication over the next few months without any loss of benefits.

Case Summary

The case demonstrates the importance of utilizing all of the tools available to help in a patient’s recovery. While Tammy had significant nutritional deficiencies, the judicious, short-term use of medication and counseling was also helpful for improving symptoms. Short-term symptom relief with medication, when appropriate, can help to win the trust of patients, giving them the motivation to continue treatment.