Vitamin B12 Supplementation in Psychiatric Practice.

PURPOSE OF REVIEW: Vitamin B12 (B12, cobalamin) deficiency has been associated with neuropsychiatric symptoms, suggesting a role for B12 supplementation both as a treatment for psychiatric symptoms due to B12 deficiency and as an augmentation strategy for pharmacological treatments of psychiatric disorders. This critical review discusses the major causes of B12 deficiency, the range of psychiatric and non-psychiatric manifestations of B12 deficiency, the indications for testing B12 levels, and the evidence for B12 supplementation for major psychiatric disorders. RECENT FINDINGS: We find that high-quality evidence shows no benefit to routine B12 supplementation for mild depressive symptoms or to prevent depression. There is very limited evidence on the role of B12 supplementation to augment antidepressants. No high-quality evidence to date suggests a role for routine B12 supplementation in any other major psychiatric disorder. No formal guidelines indicate when clinicians should test B12 levels for common psychiatric symptoms, in the absence of major risk factors for deficiency or cardinal symptoms of deficiency. No robust evidence currently supports routine B12 supplementation for major psychiatric disorders. However, psychiatrists should be aware of the important risk factors for B12 deficiency and should be able to identify symptoms of B12 deficiency, which requires prompt testing, medical workup, and treatment. Testing for B12 deficiency should be considered for atypical or severe psychiatric presentations.

Psychedelics, With a Focus on Psilocybin: Issues for the Clinician.

There has been a burgeoning interest in psychedelics among the public, state legislatures, psychiatrists and other clinical providers, and within the research community. Increasing numbers of studies evaluating psychedelics for depression, anxiety, posttraumatic stress disorder, and substance use disorders have been conducted or are underway. While discussing psychedelics in general, the focus of this paper is on psilocybin and its mechanism, how it exerts a psychedelic effect, dosing, and a review of the treatment studies of psilocybin, which were primarily for treatment-resistant depression and cancer-related anxiety. Future directions and potential limitations of studying and regulating psilocybin and other psychedelics are also discussed.

Selective Serotonin Reuptake Inhibitors: How Long Is Long Enough?

Selective serotonin reuptake inhibitors (SSRIs) are among the most commonly prescribed medications. They are among the first-line medications for several chronic or relapsing-remitting psychiatric conditions, including major depressive disorder and anxiety disorders. The advantages of SSRI use include ease of titration and their tolerability and safety profile. Guidelines for the short-term use of SSRIs are widely available, but there is no well-organized guidance on how and whether to maintain a patient on SSRIs for the long-term. In this article, we discuss the benefits and possible adverse consequences of long-term SSRI use, as well as clinical practice considerations when using SSRIs chronically. The major benefit of long-term SSRI use is relapse prevention. The current literature suggests that the general health risks of long-term SSRI use are low; however, further research, particularly in special populations including youth and the elderly, is needed. Long-term SSRI use increases the risk of tachyphylaxis and discontinuation syndrome. Recognizing that many patients may remain on SSRIs for many years, there are several factors that prescribers should consider if they choose to use an SSRI when initiating treatment and during long-term monitoring. The decision to continue or to discontinue an SSRI should be an active one, involving both the patient and prescriber, and should be revisited periodically. Patients who remain on SSRIs for the long-term should also have periodic monitoring to reassess the risk-benefit ratio of remaining on the SSRI, as well as to assess the safety, tolerability, and efficacy of the medication.

Detection of postpartum depression and anxiety in a large health plan.

To determine the prevalence of diagnosed and/or treated postpartum depression and anxiety, records were extracted for 1 year after delivery from databases of outpatient diagnoses and prescriptions, for women in a health maintenance organization who had delivered a child from July 1997 through June 1998. For comparison, telephone interviews were conducted 5 to 9 months after delivery with random samples of women who delivered at 2 facilities from June 1998 through January 1999. Of the women interviewed, 11% met criteria for major depression during the first 4 months postpartum, and an additional 13% met criteria for probable depression at 5 to 9 months postpartum. In contrast 7.0% of the large cohort had a visit or prescription for depression. The 1-year prevalence rate for diagnosed and/or treated anxiety without depression was 3.8%; the rate at time of interview was 14.7%. Overall, less than 33% of women with substantial depression or anxiety symptoms were detected.

The menopause and sexual functioning: a review of the population-based studies.

Sexual problems are among the most frequently presented health concerns of women attending menopause clinics. We examine rigorous observational studies of the menopausal transition to determine whether there are changes in sexual functioning associated with the menopausal transition and the relative roles of aging and hormonal factors. We detail the methodological limitations of menopause research. We then review studies documenting the effects of aging on women's sexual functioning prior to reviewing studies that document both aging and menopausal status. These latter studies are divided into both cross-sectional and longitudinal studies. In summary, there is an age-related decline in sexual functioning but an added incremental decline associated with the menopausal transition. There have been relatively few studies that have been prospective, population-based, utilised a validated measure of sexual functioning, and carried out concurrent hormonal sampling. The Melbourne Women's Midlife Health Project is a prospective, observational study of a community-based sample of Australian born women aged 45-55 at baseline. There were eight annual assessments using a self-report questionnaire based on the McCoy Female Sexuality Questionnaire and blood sampling for hormone levels. From early to late menopausal transition, the percentage of women with scores indicating sexual dysfunction rose from 42% to 88%. Decreasing scores correlated with decreasing estradiol but not with androgens. By the postmenopausal phase there was a significant decline in sexual arousal and interest, frequency of sexual activities, and the Total Score. There was a significant increase in vaginal dryness and dyspareunia and women's reports of their partner's problems in sexual performance. Women with low scores of sexual functioning were more likely to be distressed on the Female Sexual Distress Scale. In conclusion, there is a dramatic decline in female sexual functioning with the natural menopausal transition.

Testosterone and libido in surgically and naturally menopausal women.

The assessment and then treatment of a change in libido, or a change in the desire to partake in sexual activity, during the menopausal transition and beyond has been a challenging and elusive area of clinical research. This is partly due to the multidimensional nature of female sexuality, the difficulties of measuring testosterone in women in a reliable and accurate manner, and the complexity of the neurobiology and neurobehavior of female sexual desire. In addition, there is a lack of evidence for diagnostic specificity of low free testosterone levels for the symptom of low libido in women for whom there are no confounding interpersonal or psychological factors; although, in the symptomatic population of surgically or naturally menopausal women, a low level of free testosterone often accompanies a complaint of reduced desire/libido. The randomized clinical trial research on testosterone replacement for naturally and/or surgically menopausal women with sexual dysfunction has been criticized for a high placebo response rate, supraphysiological replacement levels of testosterone, the perception of modest clinical outcome when measuring objective data such as the frequency of sexual intercourse relative to placebo, and the unknown safety of long-term testosterone replacement in the estrogen-replete surgically or naturally menopausal woman. A careful review of current evidence from randomized, controlled trials lends support to the value of the replacement of testosterone in the estrogen-replete menopausal woman for whom libido and desire has declined. The issue of long-term safety remains to be answered.