A FEW IMPORTANT RECENT DEVELOPMENTS IN MEDICINE and psychiatry.

[NOT a vitamin] is a steroid hormone that is extremely important in many organ systems. We are all low in it.   Like all hormones, we make it. One step of making it is to expose skin to UV light from the sun.  Everyone is low in it b/o our lifestyle.  Adequate vitamin D is involved in many systems:  it reduces many cancers over 50%, including colon and breast.  The immune system uses it to reduce infections in the winter.  Virtually everyone who has osteoporois has it because of years of low D. Except for the first 6 months of life, vitamin D is essential to absorb sufficient calcium from food.  After that, if the baby is not provided with sufficient vitamin D he/she can develop rickets [deformed legs], which is why the government puts vitamin D in milk.   The first thing vitamin D is used for is to absorb calcium in the intestine—for which one needs a level of 30-32 ng/ml for maximum absorption and good bone density.   Only at higher levels does the body begin to use vitamin D for many other things –mostly preventative, such infections and cancers.  Levels of 50 to 80 ng/ml seem optimal for the other benefits.  The official maximum is 100 ng/ml, but it is safe to 200 ng/ml if someone is accidentally on too much.  Most adults should take at least 5000 I.U.’s (international units) per day (0.125 mg or 125mcg per day).  Someone over 75 y.o., because of slower liver metabolism, might need only 1000 or 2000 I.U. per day—so OBTAIN A LEVEL.  Go to Youtube and watch an entertaining lecture by Michael Holick, MD, PhD [who found the structure of D in ~1972], and you will never thereafter forget the significance of this steroid hormone.

Years ago a Chassidic Rabbi [Hershel Meisels] told me the daily dose should be approximately 1000 I.U. for every 25 lbs.  Later on, I found in the literature that he was right.   A 10 lb baby needs 400 I.U./day [or ~2800 I.U. once a week], 25 lbs child needs 1000 I.U./day , 50 lbs child needs 2000 I.U. and 100 lbs needs 4000 I.U.day.  The half-life is so long—6 weeks—that the whole dose can be taken once a week or once a month.  An adult weighing 125 lbs can take 3 pills of 50K I.U. once a month—for an average of 5K I.U. /day.      Someone who weighs 175 to 200 lbs would be better off on 4 pills of 50K I.U.’s once a month –for an average of 7000 I.U. /day.      50,000 I.U. sounds like a lot, but it is only 1.25mg.    They made up the units in ~1922 before they isolated the molecule.  If unsure, obtain a level.   Repeat the level 3 to 6 months after an increase or decrease in dose.    When in doubt, obtain a level.  After changing dose, repeat it in 3 and 6 months.

Multivitamins are a negative—they cause cancer.  They raise the risk of cancers slightly.   More important, if you do have a cancer, the multivitamin makes it much more aggressive.  Cancers are hyper metabolic. The combination of folic acid and B-12 is incendiary, as the cancer needs these to grow rapidly.   If one eats a varied diet, usually one does not need any extra vitamins or minerals.

The only two vitamins that we need be concerned about are vitamin B12 and  vitamin D [actually a hormone we make].  These should be measured periodically.

#1: B12 is frequently low, and is easy to replace. Much of it is obtained from meat, but sometimes it is not absorbed well.

#2: vitamin D: We make an insufficient amount of this steroid hormone because we are scarcely exposed to the sun.  Everyone in the developed world should be taking replacement vitamin D.

Women who are menstruating should probably take an iron pill once a week, or even every day.  Iron makes the blood red, so they are losing iron every month.    Men simply  recycle the iron from old red blood cells.  Therefore, women should periodically check their iron level (ferritin) as well as the vitamin D and B-12 levels.

The MTHFR gene should be tested—because 1/5 or more of us will have a significant anomalous MTHFR gene or genes:

For pregnant women:   they may indicate she should take L-methylfolate in pregnancy instead of folic acid —-as the folic acid will be ineffective in preventing neural tube defects in the baby. 

For patients with depression:  the results may indicate L-methylfolate will have a significant antidepressant effect—in a relatively high dose of 15mg/day.

Choline 450mg/ day during last six months of pregnancy apparently reduces the risk of the baby developing schizophrenia – and maybe other brain disorders. The baby’s brain grows rapidly the last 6 months, and choline helps this process.  THIS IS NOT FIRMLY ESTABLISHED YET. [if anyone finds good papers on choline and fetal development, send them to me].

Vitamin D during the entire pregnancy seems to also reduce the risk of some mental illnesses.   E.g., schizophrenia is rarer the closer one is to the equator—i.e., in areas where there is more sunlight and higher vitamin D levels.

 

THE FOLLOWING ARE OFTEN EXTREMELY EFFECTIVE FOR DEPRESSION—and for prophylaxis against depression. 

A TSH (thyroid stimulating hormone) level greater than 2.5 mIU/L* indicates that the addition of the thyroid hormone Cytomel/T3/liothyronine [~25mcg] is likely to help depression. For a few years ago, Joseph Goldberg has emphasized that research indicated that the biggest predictor of poor response to antidepressant medication was a TSH greater than 2.5.  Frye and others found that patients who had the fastest, best antidepressant effect had a TSH of <1.7.   Both the American Thyroid Society and The American Society of Clinical Biochemists say the upper limit of normal of TSH should be 2.5 mIU/L [Garber et al, 2012].   [*mIU/L = milli-international units per liter.]   In the following book, the chapter on thyroid explains this complex problem extremely well, with all the relevant references:  A Spectrum Approach to Mood Disorders: Not Fully Bipolar but Not Unipolar – Practical Management, by James Phelps, M.D.  [Norton, 2016] His website– www.psycheducation.org– is a good resource for patients.

Very low dose lithium –150 mg per day—can have enormous benefit for depression—if not within two weeks, then as the months and years pass.   Lithium 300-600mg/day is often better, but anyone with a mood disorder should at least stay on 150 mg indefinitely. The other obvious reason is that every psychiatric disorder increases the risk of Alzheimer’s and lithium significantly decreases this risk.

Unless it is an acute problem, many of us start at 150mg, and watch and wait.   For manic depression the dose is more like 1200mg—to stabilize large mood swings.    For depression, however, low doses work better than high doses.

A combination of Lamictal/ lamotrigine and low dose lithium is the ideal maintenance medication for many depressions—e.g., the medication one should stay on indefinitely after the depression is in remission. Other medications—as well as TMS (Transcranial Magnetic Stimulation), CBT, et al—might initially be needed to help bring about remission.  This combination is especially effective in “bipolar spectrum” depression–often characterized by:  sudden, rapid mood swings secondary to events; swings between different variations of depression [including anger and irritability]; and “atypical symptoms” of oversleeping, overeating/ carbohydrate craving, and rejection sensitivity.   In A Spectrum Approach to Mood Disorders, Phelps points out that frequently this combination works alone, does not poop out, has virtually no side effects, and is safe in pregnancy. In 1996, I was floored by how well Lamictal/ lamotrigine worked in treatment resistant atypical depression and have given it to some 1000 patients. As the years passed I more and more frequently added low dose lithium to it.  Of course, this combination is usually not sufficient for an acute, severe depression.    The combination is a goal to strive for ultimately and is often the lynchpin when the patient has been stable a long time.

TMS (Transcranial Magnetic Stimulation) has excellent benefit for depression, even for TRD (treatment resistant depression). The benefit is often extraordinarily long lasting—even years.  .  [It is covered by Medicare!]   The patient needs should stay on prophylactic medication (my favorite is low dose lithium and Lamictal/ lamotrigine 200mg, of course).   TMS works well for bipolar depression—maybe better than for unipolar– as well as other conditions such as chronic pain, OCD, and Parkinson’s.   The usual course is 30 treatments—5 days per week for 6 weeks.  Each treatment is 30 minutes, with minimal discomfort. It is becoming more and more effective as new parameters are discovered.  Remission rate is increased, of course, if one can do many more than #30 treatments.    It is not essential that the treatments be 5 days a week. It seems the total number of treatments is most important.  We had two very treatment resistant women come completely to normal in 23 to 25 treatments—stretched over 11 months!   Because of logistics, they could only make it to two treatments per month.

—Robert D. McMullen, MD

https://www.youtube.com/watch?v=lIDrqjzsk5g