Initial Presentation

Sarah, a 33-year-old female, presented with symptoms of depression, anxiety and emotional eating. She reported feeling persistently sad, irritable, and was experiencing 1-2 panic attacks per week when we met for our first visit. She struggled with her weight and often resorted to emotional eating to cope with stress. While she had recently been offered an SSRI by her PCP, she preferred to “go the natural route,” which led her to scheduling a consultation with me.

Initial Relevant Labs

• Serum Vitamin B12, low normal at 273 pg/mL
• Ferritin, low normal at 18 ng/mL
• Multiple serum amino acids below optimal levels

Working Diagnoses

• Major Depressive Disorder
• Panic Disorder
• Emotional eating; did not meet full criteria for Binge Eating Disorder

Initial Treatment

• Vitamin B12 as methylcobalamin, 2,000 mcg/day sublingually
• Iron Bisglycinate, 27 mg/day
• NeuroPure, a combination of 5-hydroxytryptophan (5-HTP) and DL-phenylalanine with supporting nutrients, 2 caps twice daily
• Magnesium Glycinate, 240 mg twice daily
• Increase dietary protein and vegetables, reduce refined carbohydrates

Explanation

Adequate levels of Vitamin B12 are critical for neurologic and mental health via a number of mechanisms (Sahu et al., 2022). Current reference ranges for B12 are too wide, thus many patients with suboptimal levels of B12 are missed and untreated. B12 supplementation has been shown to improve symptoms of depression (Syed et al., 2013). With Sarah’s levels being on the low end of normal, vitamin B12 was indicated.

Low iron is a risk factor for psychiatric disorders including depression, anxiety, and insomnia (Lee et al., 2020). Similar to vitamin B12, normal lab ranges for ferritin in women are too low. Clinical trials have demonstrated that 50 ng/mL is likely a better cutoff, as symptoms of fatigue improve with supplementation when ferritin is below this level (Vaucher et al., 2012)

Magnesium is a critical mineral used in hundreds of biochemical processes in the body. Magnesium supplementation has been shown to benefit mental health and improve symptoms of depression (Tarleton et al., 2017).

As the building blocks for all proteins, enzymes and signaling molecules in the brain, amino acids are critical for the synthesis of neurotransmitters. They also support production of critical neuropeptides, which help to regulate hunger and satiety. 5-HTP, a precursor to the neurotransmitter serotonin, has been shown to positively affect eating behavior and mood (Ioannou & Williams, 2016). L-Phenylalanine is a precursor to dopamine. It’s also been shown to raise cholecystokinin (CCK), a peptide hormone that increases satiety (Steinert 2015). D-Phenylalanine may help to increase enkephalins in the brain (Ehrenpreis, 1985), potentially helping to decrease food cravings.

Follow-up Presentation

After three months of treatment with the recommended supplements and dietary modifications, Sarah showed significant improvement in her psychiatric symptoms. Specifically, she reported feeling less depressed and anxious, with near full resolution of panic attacks. She also demonstrated better control over her emotional eating habits, resulting in gradual weight loss. Her energy levels improved, and she reported better concentration and overall mood stability.

Follow-up Testing

• Vitamin B12 improved to 536 pg/mL
• Ferritin improved to 28 ng/mL
• Plasma amino acids normalized

Follow-up Treatment

Supplements were continued with the following modifications:

• Vitamin B12 was replaced with a comprehensive methylated B complex

Explanation

With her Vitamin B12 level now in normal range, it was prudent to switch over to a comprehensive methylated B complex. While Vitamin B12 is critical for brain function, other B vitamins play an instrumental role as well and are often deficient in individuals struggling with mental health symptoms (Calderon-Ospina & Nava-Mesa, 2020).

While there is no official consensus on optimal ferritin levels in the realm of mental health, many functional medicine providers aim for a target of 50-100 in women, thus we continued the iron supplement and I recommended ongoing attention to iron-rich foods in her diet.

Given the staggering rates of magnesium deficiency in the United States and the implications on psychiatric, neurologic, metabolic and cardiovascular health, magnesium is a foundational supplement in most, if not all, cases.

Case Summary

Sarah’s case highlights the importance of considering nutritional factors in the management of psychiatric disorders, particularly depression and anxiety. Sarah’s symptoms were significantly influenced by deficiencies in key micronutrients such as vitamin B12 and iron as well as suboptimal levels of amino acids. By addressing these deficiencies and supporting neurotransmitter synthesis with targeted supplements like NeuroPure, magnesium and iron, Sarah experienced notable improvement in her symptoms.

The functional psychiatry approach focuses on identifying and addressing the root causes of mental health issues, including biochemical imbalances and nutritional deficiencies. Integrating psychiatric care with nutritional interventions can enhance treatment outcomes and provide patients with a holistic approach to mental wellness. For nutritional interventions, regular monitoring of lab parameters and symptoms is crucial for optimizing treatment efficacy and ensuring patient well-being.