Cases That Test Your Skills

Malnourished and psychotic, and found incompetent to stand trial

Current Psychiatry. 2015 October;14(10):41-43,54-55

References

1. Dogan M, Ozdemir O, Sal EA, et al. Psychotic disorder and extrapyramidal symptoms associated with vitamin B12 and folate deficiency. J Trop Pediatr. 2009;55(3):205-207.
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3. Jauhar S, Blackett A, Srireddy P, et al. Pernicious anaemia presenting as catatonia without signs of anaemia or macrocytosis. Br J Psychiatry. 2010;197(3):244-245.
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5. Berry N, Sagar R, Tripathi BM. Catatonia and other psychiatric symptoms with vitamin B12 deficiency. Acta Psychiatr Scand. 2003;108(2):156-159.
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The forensic examiner sees Mr. N after 3 months of continued therapy. His thought pattern is more organized and he is able to comprehend the criminal charges against him and to work with his attorney. He is determined competent by the forensic examiner; in a court hearing, the judge finds Mr. N competent to stand trial.

The authors’ observations
Based on our experience treating Mr. N, we think that it is important to establish an association between vitamin B12 deficiency and psychosis. Vitamin B₁₂ deficiency is uncommon; however, serum levels do not need to be significantly low to produce severe neuropsychiatric morbidity, which has been reported with serum levels ≤457 pg/mL.^2-5,24,25 It is more frequent than the other organic causes of psychosis^5,10,24 and Mr. N’s improvement further strengthened the correlation.

Parenteral vitamin B₁₂ therapy is the first-line treatment for a deficiency, but oral or sublingual vitamin B₁₂ can be given to patients who are disabled, geriatric, or refuse parenteral administration.²¹ Only approximately 1% of oral vitamin B₁₂ is absorbed in patients who do not have intrinsic factor. The daily requirement of vitamin B₁₂ is 1.0 to 2.5 μg/d; large oral dosages of 1,000 to 5,000 μg/d therefore seem to be effective in correcting deficiency, even in the presence of intrinsic factor deficiency.^15,20,21 Large oral dosages also benefit other hematological abnormalities, such as a low white blood cell count and neutropenia.

How vitamin B12 deficiency affects neuropsychiatric illness
Vitamin B₁₂ is essential for methylation, a process crucial for the formation of neurotransmitters such as serotonin, dopamine, and epinephrine. A low level of vitamin B₁₂ can interrupt methylation and cause accumulation of homocysteine and impaired metabolism of serotonin, dopamine, and epinephrine. Hyperhomocysteinemia can contribute to cerebral dysfunction by causing vascular injury.²⁶

Vitamin B₁₂ also is involved in tetrahydrobiopterin synthesis in the brain, which is pivotal for synthesis of monoamine neurotransmitters. Vitamin B₁₂ deficiency can lead to accumulation of methyltetrahydrofolate, an excitatory neurotoxin. All of these can contribute to development of psychosis. Therefore, a defect in the methylation process could be responsible for the neuropsychiatric manifestations of vitamin B₁₂ deficiency.

What did we learn from Mr. N?
In most people, vitamin B₁₂ levels are normal, however, we recommend that clinicians consider vitamin B₁₂ deficiency when a patient has new-onset or unresponsive psychosis,²⁷ particularly in a homeless person or one who has a restricted diet.²⁸ It is important to rule out vitamin B₁₂ deficiency in a patient with a low serum folate level because folic acid therapy could exacerbate neurologic manifestations of underlying vitamin B₁₂ deficiency and increase the risk of permanent nerve damage and cognitive decline.

We were intrigued to see improvement in Mr. N after we added vitamin B₁₂ to his ongoing treatment with an antipsychotic. We did not believe that vitamin B₁₂supplementation was the sole reason his mental status improved enough to be found competent to stand trial, although we believe that initiating oral vitamin B₁₂ was beneficial for Mr. N.

Last, this case supports the need for research to further explore the role of vitamin B₁₂ in refractory psychosis, depression, and mania.

Bottom Line
Vitamin B₁₂ deficiency can contribute to psychosis and other psychiatric disorders, especially in patients with a restricted diet, such as those who are homeless. Parenteral vitamin B₁₂ therapy is the first-line treatment, but oral supplementation can be used if the patient refuses therapy. Large oral dosages of 1,000 to 5,000 μg/d seem to be effective in correcting vitamin B₁₂ deficiency.

Related Resources
• Ramsey D, Muskin PR. Vitamin deficiencies and mental health: How are they linked? Current Psychiatry. 2013;12(1):37-43.
• Lindenbaum J, Healton EB, Savage DG, et al. Neuropsychiatric disorders caused by cobalamin deficiency in the absence of anemia or macrocytosis. N Engl J Med. 1988;318(26):1720-1728.

Drug Brand Names
Amitriptyline • Elavil
Chlorpromazine • Thorazine
Divalproex sodium • Depakote
Methylphenidate • Ritalin
Paroxetine • Paxil
Risperidone • Risperdal
Thioridazine • Mellaril

Acknowledgements
The authors thank Jan Jill-Jordan, PhD, for her help preparing the manuscript of this article.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

References

CBT improves depression but not self-care in heart failure patients

Malnourished and psychotic, and found incompetent to stand trial

References

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