Justin, a 29-year-old man, presented seeking a functional psychiatry consultation after experiencing significant challenges with psychiatric treatment over several years. His previous psychiatrist had recently relocated, and he was looking for a clinician who could incorporate a functional medicine approach into his care.

Clinical History

Justin carried a diagnosis of Bipolar Disorder with manic episodes and psychotic features. Over time, he had experienced significant difficulty tolerating and responding to psychiatric medications. By the time of the consultation, his symptoms had progressed to the point that he was on medical leave from work.

Justin’s family described a striking personality change. Previously a motivated, high-performing professional, Justin had become withdrawn, with low motivation, impaired cognition, and decreased functioning. At one point, the severity of his cognitive and behavioral decline raised concerns about a possible schizophrenia-spectrum disorder.

At the time of evaluation, he was taking multiple psychiatric medications. One of the first goals of treatment was to simplify and stabilize his medication regimen while also exploring possible biological contributors to his symptoms.

Functional Assessment

A comprehensive functional psychiatry evaluation was performed, including targeted laboratory testing to identify potential metabolic and nutritional contributors.

One finding that stood out was an elevated kryptopyrrole (HPL) level:
Kryptopyrrole (HPL): 23.03 mcg/dL

Reference ranges:

• Optimal: 0–10 mcg/dL
• Borderline: 11–15 mcg/dL
• Elevated: ≥16 mcg/dL

A level above 16 mcg/dL is considered elevated and may suggest pyroluria, a metabolic condition associated with increased excretion of pyrroles that bind and deplete key nutrients—particularly zinc and vitamin B6. These nutrient deficiencies have been associated with mood instability, anxiety, impaired stress tolerance, and cognitive symptoms in some individuals.

Additional laboratory findings included elevated prolactin levels and low testosterone. Because these abnormalities remained persistently elevated, additional hormone testing was performed, including luteinizing hormone (LH). These findings ultimately prompted a pituitary MRI, which revealed a pituitary adenoma, providing an important additional layer of understanding for the patient’s endocrine abnormalities.

Treatment Approach

Treatment focused on both psychiatric stabilization and targeted nutritional support. Justin’s medication regimen was simplified and stabilized with continuation of:

• Lithium carbonate
• Olanzapine (Zyprexa)

Given the elevated kryptopyrrole level, the clinician initiated targeted nutritional therapy aimed at correcting the nutrient losses associated with pyroluria. Treatment included gradual titration of zinc picolinate along with vitamin B6 and pyridoxal-5-phosphate (P5P).

Clinical Outcome

Over the following two to three months, Justin experienced marked improvement. His energy, motivation, and cognitive functioning returned. He was able to return to work, and shortly after resuming his job, he received both a promotion and a raise—a reflection of the restoration of his previous level of functioning.

His family noticed the difference as well. As his parents shared during follow-up: “We have our child back.”

At the time of reporting, Justin remains stable on lithium carbonate and olanzapine, along with the nutritional interventions. While gradual medication reduction may be considered in the future, his current stability has led the treatment team to maintain the existing regimen.

Clinical Takeaway

This case illustrates the importance of looking beyond symptom management to identify underlying biochemical and physiological contributors in complex psychiatric presentations.

Screening for kryptopyrroles may be particularly helpful in patients with treatment-resistant mood symptoms, cognitive decline, or unexplained functional deterioration. In addition, careful evaluation of abnormal laboratory findings—such as persistent hyperprolactinemia and low testosterone—may uncover additional medical conditions that influence psychiatric health.

In this case, combining functional laboratory testing, targeted nutritional therapy, and careful endocrine evaluation contributed to a dramatic recovery in functioning and quality of life.