What nutritional deficiencies can cause psychosis?

Nutritional Deficiencies That Can Cause Psychosis

Vitamin B12 deficiency, folate deficiency, and vitamin D deficiency are the primary nutritional deficiencies associated with psychotic symptoms, with B12 deficiency having the strongest evidence for causing psychosis even in the absence of anemia or neurological symptoms. 1, 2

Vitamin B12 Deficiency

• Vitamin B12 deficiency can present with psychiatric manifestations including organic brain syndrome, paranoia, violence, and depression that may precede anemia or neurological symptoms 1, 2
• Psychotic symptoms can be the first manifestation of B12 deficiency, even in patients with normal hematological parameters and no spinal cord symptoms 2
• Studies have found that 10% of psychiatric inpatients had vitamin B12 levels in the deficient range (<160 pg/ml) and 20% had low levels (<200 pg/ml) 3
• Psychotic symptoms due to B12 deficiency can be reversed with vitamin B12 supplementation, highlighting the importance of early detection 4
• B12 deficiency can cause psychosis even in patients with adequate nutritional intake, suggesting that absorption issues may be involved 3

Folate Deficiency

• Folate deficiency can cause neuropsychiatric manifestations including depression, irritability, insomnia, cognitive impairment, and psychosis 5
• Symptoms of folate deficiency often overlap with B12 deficiency, making it important to test for both when evaluating psychotic symptoms 5
• Treating folate deficiency without checking B12 status can be dangerous, as folate supplementation may improve blood parameters while worsening neurological manifestations of B12 deficiency 5
• Serum folate levels should be at least 10 nmol/L and red blood cell folate at least 340 nmol/L to prevent neuropsychiatric symptoms 5

Vitamin D Deficiency

• Vitamin D deficiency is significantly more common in patients with first-episode psychosis compared to matched controls 6
• The odds of being vitamin D deficient are nearly three times higher in first-episode psychosis patients compared to matched controls 6
• Vitamin D has neuroprotective properties, and developmental vitamin D deficiency may be a risk factor for psychosis 6
• Vitamin D deficiency is highly prevalent among patients with established psychotic disorders 6

Other Nutritional Factors Associated with Psychosis

• Omega-3 fatty acid deficiency may contribute to psychiatric symptoms, including depression with psychotic features 5
• Inadequate sleep, poor social participation, and excessive alcohol consumption can exacerbate psychotic symptoms and are common in people with severe mental disorders 5
• Thiamine deficiency can lead to Wernicke's encephalopathy and Korsakoff psychosis, particularly in patients with alcohol use disorders 5

Clinical Approach to Nutritional Deficiencies in Psychosis

• Serum B12 determinations should be performed in all patients presenting with organic mental symptoms or psychosis 2
• Testing for folate deficiency should accompany B12 testing due to overlapping symptoms and potential interactions 5
• Vitamin D levels should be checked in patients with first-episode psychosis or established psychotic disorders 6
• When evaluating psychotic symptoms, clinicians should consider secondary causes including nutritional deficiencies before diagnosing primary psychotic disorders 7, 8
• Patients with unbalanced diets are particularly at risk for nutritional deficiency-induced psychosis and warrant thorough nutritional evaluation 4

Treatment Considerations

• Prompt supplementation of deficient nutrients can lead to resolution of psychotic symptoms in cases of nutritional deficiency 4
• For B12 deficiency, supplementation can reverse EEG abnormalities and organic mental changes 2
• When treating folate deficiency, always rule out concomitant B12 deficiency to avoid worsening neurological symptoms 5
• Treatment of the underlying nutritional deficiency should be the primary approach for secondary psychotic disorders, rather than antipsychotic medications 8

Monitoring and Follow-up

• After supplementation for B12 or folate deficiency, levels should be rechecked within 3 months to verify normalization 5
• In diseases known to increase folate needs, folate status should be measured every 3 months until stabilization, then annually 5
• Ongoing monitoring for nutritional deficiencies is important in patients with chronic psychotic disorders, even when nutritional intake appears adequate 3