We are immersed these days in the erroneous idea that only randomized placebo-controlled studies (RCTs) constitute scientific data. We will discuss the origins of the over-reliance on RCTs in a future column. For now, we shall simply assume that many of our readers understand that a well-documented case study can provide information relevant to many.
And so, we would like to tell you about a Calgary-based child who we refer to as ‘Andrew’ (not his real name). Andrew is the middle child of three boys in an intact family, with two parents with professional careers. His two brothers seemed to have a normal developmental course, but Andrew did not. He displayed various learning and developmental problems from an early age, and because it was so atypical in his family, he was evaluated in the local genetics clinic (which found no evidence of any known syndrome). By age 8, after a diagnosis of pervasive developmental disorder was ruled out, he was diagnosed with an anxiety disorder. When he was 10, his anxiety symptoms became quite significant, associated with insomnia, difficulties with activities of daily living, inattention, distractibility, and self-injurious behaviour. He subsequently developed auditory and visual hallucinations, with voices telling him to harm himself. These hallucinations were followed by delusions in which he believed someone was poisoning his food, and that he had committed both murder and adultery. He engaged in obsessive prayer out of guilt for his acts.
Andrew became so ill that he was admitted to a tertiary inpatient pediatric hospital (Alberta Children’s Hospital) where he was evaluated for everything from neurological problems (CT, MRI) to PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections). Everything was ruled out, but he continued to be the sickest case of childhood psychosis ever seen on this inpatient unit even after many trials of psychiatric medication alone and in combination, including quetiapine, risperidone, fluoxetine, fluvoxamine and clonazepam. Andrew was discharged after six months on a regimen of risperidone and fluvoxamine. He returned home, and his care was transferred to the outpatient Mood and Anxiety Disorders Clinic.
Two important notes: 1) At the time of his hospital admission, his Children’s Global Assessment Scale score was 35 out of 100 (indicating very low function); at discharge his CGAS score was still exactly 35. 2) A health economist extracted provincial health care costs of much of his 6 months of hospital care, which conservatively was $158,829.53.
What happened next was remarkable. His parents approached his outpatient psychiatrist Dr. Megan Rodway and asked for her opinion about trying Andrew on a broad spectrum nutrient formula which at that time was called EMPowerplus (EMP), since he had not responded to any medications. Dr. Rodway reports that her response was “It is snake oil, but I don’t have anything better to offer.” And so beginning in September 2008, Andrew transitioned onto EMP while gradually reducing his two medications to zero. Here is the parent report data on his symptoms of anxiety (if you are interested in seeing the graphs of OCD and psychosis, as well as Andrew’s self-report of auditory and visual hallucinations, the reference is provided below):
The long-term result was impressive: all symptoms of psychosis and OCD had remitted in a few months. By the next summer, Andrew was able to attend sleep-away camp.
Here are some important questions to ask:
- Has he remained well? The Calgary people have kept in touch with the family for over 4 years now, and Andrew has remained well. At one point after about 3 years, Andrew became tired of taking the capsules and began to fight them. His parents let him cut back, and then were terribly frightened when some of his symptoms returned. They quickly put him back on the full dose (12-15 capsules/day for him), and insisted that no further reversals be tried. There are no data from this reversal; only parent report.
- What is in the formula? It is a broad spectrum formula consisting of mostly vitamins and minerals. In keeping with one of our previous blogs on ‘magic bullets,’ we would like to mention that it seems highly unlikely that a single nutrient could have resulted in Andrew’s recovery.
- Are vitamins and minerals safe? He had repeated blood tests for about two years, and all results were normal. These results are consistent with others that we have published on the safety of this complex formula (see Simpson et al. reference below).
- Could Andrew’s improvement be attributed to a placebo/expectancy effect? Psychosis is a challenge to treat and complete remission is difficult to achieve. Without a placebo-controlled trial, one can never be sure, but there are several factors which argue against this interpretation: a) there is 4 ½ years of follow-up information indicating sustained improvement (unlikely for an expectancy effect), b) the parent report of an informal reversal suggests on-off control of symptoms with the nutrient formula, c) Andrew was given the best state of the art care with the inpatient admission and medications, and still there was no observed benefit, indicating that it is unlikely that expectancy effects could remove psychosis.
- What about the cost? The health economist compared the first 6 months of inpatient care to the next 6 months of outpatient care. As mentioned above, inpatient costs exceeded$158,000. Outpatient costs to the health care system were <$2,000. The roughly $1000 that the nutrients cost could not be recovered from health care; the family must pay for them.
- What is Andrew like now? Andrew is a boy with a tendency toward anxiety, who has some significant learning disabilities requiring special education. He continues to take a therapeutic dose of the micronutrient formula, sometimes with a broad spectrum amino acid formula (whey protein).
- What is the significance of this case? There does not appear to be anything unique about Andrew, which suggests to us that broad spectrum nutrient treatment should be considered for virtually all first-episode psychoses. In fact, this case illustrates what might be called a new world view: for some people, nutrients can be the primary treatment, and medication might be a supplement. (It is for this reason that we tend to avoid the word ‘supplement’ when referring to nutrient treatments.)
This is our 6th post on nutrition and mental health, and we are attempting to write about many aspects of the broad emerging field of Nutritional Psychiatry. Some of this field includes data on successful nutrient treatments (like Andrew), but other aspects include correlational data from epidemiological surveys, understanding mechanisms by which nutrients affect brain function, diet and fetal development, elimination diets, improved resistance to environmental toxicants and stress with nutrition, etc! Future posts will continue to talk about some of these more ‘academic’ topics, with occasional treatment stories like Andrew interspersed to keep us reminded about the enormous potential of this field.
To read more
- Rodway M, Vance A, Watters A, Lee H, Bos E, Kaplan BJ (2012 Nov 9), Efficacy and cost of micronutrient treatment of childhood psychosis. BMJ Case Reports. doi: 10.1136/bcr-2012-007213
- Simpson, JSA, Crawford, SG, Goldstein, ET, Field, C, Burgess, E, Kaplan, BJ (18 April 2011). Systematic review of safety and tolerability of a complex micronutrient formula used in mental health. BMC Psychiatry, 11:62. doi: 10.1186/1471-244X-11-62.