Vitamin B12 Deficiency: An Important Reversible Co-Morbidity in Neuropsychiatric Manifestations

Abstract

Background:Vitamin B12 deficiency is a common condition causing neurologic, cognitive, psychiatric, and mood symptoms. With varied religious, ethnic, and socioeconomic heterogeneity among the people in India greatly influencing their dietary habits and with the high prevalence of Helicobacter pylori infection, Vitamin B12 deficiency is not uncommon, but is often under recognized due to the lack of classical symptomatic presentation.Materials and Methods:Retrospective study on Vitamin B12 deficiency with neuropsychiatric symptoms in patients who attended neurology, psychiatry, and geriatric OPDs for a period of 1 year in a specialized neuropsychiatric institute in South India.Results:Out of 259 patients who had Vitamin B12 deficiency (<220 pmol/L), 60 had neuropsychiatric symptoms. Among them the Vitamin B12 levels were <150 (severe), 150-200 (moderate), and 201-220 pmol/L (mild) in 19, 24, 17 patients, respectively. Twenty one were diagnosed with Posterior dementias, 20 with frontotemporal dementia, 7 with Schizophrenia, 4 each with Parkinson's disease and alcohol-dependent syndromes (ADS), 3 with bipolar affective disorder, and 1 with Creutzfeldt-Jakob disease. Eight patients also had hypothyroidism. First symptom of presentation was behavioral disturbances in 30 (50%), memory loss in 20 (33.9%), and sensorimotor and movement disorders in 9 (15.3%), and 56.7% were vegetarians while 43.3% were nonvegetarians. In our study, Vitamin B12 deficiency was more prevalent in elderly males (56.67%) and was associated with increased severity of behavioral disturbances (P = 0.043) which was the most common presentation. Memory loss was present in 16 (84.2%) patients of severe Vitamin B12 deficiency. Hindi mental status examination (HMSE) score was graded as <20, 20-24, 24-31 in 37 (61.7%), 10 (16.7%), and 13 (21.7%) patients, respectively. Cognitive decline in Vitamin B12 deficiency was significantly associated with increased serum cholesterol (P = 0.019) and was significantly prevalent in neurological disorders when compared with primary psychiatric illnesses (P = 0.001). Mean folate and mean homocysteine in our study was 11.7 ± 6.44 ng/ml and 17.77 ± 5.45 μmol/L, respectively. Eighty percent of the population had normal folate levels whereas mean homocysteine values were much higher than that of the western population (10-12 μmol/L).Conclusion:Vitamin B12 deficiency though common in India is often overlooked. It increases the load of cognitive decline and accentuates vascular risk factors in neuropsychiatric illnesses. Vitamin B12 deficiency also increases homocysteine levels contributing to the vascular comorbidity in cerebro and cardiovascular illnesses. So prevention, early detection, and management of this reversible Vitamin B12 deficiency state is of profound importance.

Déficit de vitamina B12 en la práctica psiquiátrica

“…Falta evidencia que pueda apoyar esta hipótesis, pero algunos autores recomiendan hacer tamizaje en el primer episodio de manía, y con mayor indicación si no hay historia familiar de trastornos afectivos (63,64). Se han informado en algunos estudios niveles séricos bajos de vitamina B12, pero en otros no se ha encontrado diferencia o han sido altos (60)(61)(62).…”

“…El diagnóstico de hipovitaminosis B12 por medición de los niveles séricos permite la siguiente clasificación: 1) "bajos" cuando son menores de 150-200 pg/ mL (75); 2) "normales" cuando están por encima de 350 pg/mL; en este último caso es improbable que los síntomas neuropsiquiátricos se expliquen por hipovitaminosis (9,35,63); 3) un rango llamado "normal bajo" entre 150-200 pg/mL y 350 pg/mL, en el que la mayoría de los estudios recomiendan medir el ácido metilmalónico para poder definir si existe o no una hipovitaminosis real (9,35,63,76). Ante las dificultades para medir dicho ácido, algunos autores recomiendan la reposición vitamínica cuando los niveles son inferiores a 350 pg/mL (2).…”

Acid Folic Supplementation in Major Depressive Disorder Treatment: A Double-Blind Randomized Clinical Trial

“…Previous studies have investigated the role of nutritional factors in treating neuropsychiatric disorders (9)(10)(11). These studies have shown that a considerable portion of patients with psychiatric disorders, including MDD, have been reported as having low levels of different vitamins, especially folate (12,13).…”

Helicobacter Pylori-Related Vitamin B12 Deficiency: A Potential Contributor in Neuropsychiatric Disorders

“…concluded that Vitamin B12 deficiency, common in India, increases the load of cognitive decline and accentuates vascular risk factors in neuropsychiatric illnesses; it also increases homocysteine (Hcy) levels contributing to the vascular comorbidity in cerebro-and cardio-vascular disorders, thereby correcting this reversible Vitamin B12 deficiency state is of profound importance. [ 1 ]…”

“…In this regard, Helicobacter pylori infection (Hp-I), also very common in India, is a potential environmental risk factor contributing to the pathophysiology of several neuropsychiatric diseases. Based on the histologic analysis of gastric mucosa biopsy for the documentation of Hp-I, a higher prevalence of Hp-I in Alzheimer's disease (AD) and mild cognitive impairment (MCI) patients in a Greek cohort has been found accompanied with increased Hcy concentration, an independent risk factor for dementia and AD,[ 2 3 4 ] also mentioned by the authors;[ 1 ] increased cerebrospinal fluid anti-Hp IgG antibody levels in AD patients may reflect the disease severity, and Hp eradication may positively influence AD manifestations at 2- and 5-year clinical endpoints. [ 2 3 4 ] Consistent associations with the Greek data were shown in subsequent studies from France, USA, and China, supporting Hp-I role in AD pathobiology.…”