Extra Vitamins E, C, and a Multivitamin Make Sense

Vitamin E is the vitamin best documented to be worth taking as a supplement. E has been shown to lessen fibrocystic mastophathy, lessen some heart ailments, especially atherosclerosis, delay the progression of the memory loss of Alzheimer’s disease, treat the movement disorder of Tardive Dyskinesia, help some skin ailments, and act as a broad antioxidant. The type of vitamin E matters little but like all fat soluble vitamins (A also) it is better absorbed taken with or after food. The adult supplement dose is 200 to 1000 IU (International Units) taken once a day. Higher doses have been used in Alzheimer’s and Tardive Dyskinesia but often causes gastrointestinal problems and bruising.

Vitamin C is the second best documented vitamin for taking as a supplement. Despite what Linus Pauling and others claim, its usefulness as a supplement is significantly weaker than E. C’s use is primarily as a general antioxidant and has not been proven to prevent or combat viral or other infections. Again, the type of vitamin C taken has not been shown to really matter. C is water soluble and thus can be taken anytime. The average antioxidant adult dosage is 500 to 1000 mg (1 gram) once daily.

Higher doses have not been convincingly shown to help more. Since C acidifies the urine, very high doses may promote the development of some types of kidney stones in some people.

A Multivitamin tablet containing 100% of the Recommended Daily Allowance (RDA) of each vitamin is a reasonable daily addition. No extra minerals are needed or advisable except in a few select situations. Extra Iron is advisable only for menstruating age females. Extra selenium, zinc, magnesium, chromium, etc., have not been convincingly shown to be beneficial, although selenium and zinc are the most promising. Extra calcium is desirable only in certain situations related to bone density if your doctor so advises.

Folic Acid beyond what is in a multivitamin is not generally needed but is valuable for some situations. A shortage of float or vitamin B12 can cause anemia characterized by large red blood cells while a shortage of iron will cause anemia with small red blood cells. Both levels of folic acid and B12, as well as iron, can be checked by blood test. Recently, intake of folic acid amounting to 2 or 3 times that advised in the RDA was shown to significantly decrease the rate of heart disease in a large study of nurses. This study shows that at least 400 mcg is best while the RDA is 180 and 225 for pregnancy. It is easy to get at least 400 mcg from increasing vegetables in your diet and it is also frequently present in a simple, inexpensive multivitamin. Read the label.

A few studies show that an extra 15 mg a day of 5-methyltetrahydrofolate may enhance the response of some depressed people to antidepressants. Extra folic acid taken by women of childbearing age appears to significantly lessen the risk of babies having spina bifida related disorders known as neural tube defects.

There is no real support, despite the popular notion that B12 gives energy, for giving vitamin B12 shots except for those very few with documented disorders of B12 absorption such as Schilling’s disease. Also be careful of certain very expensive B12 tests that too frequently show falsely low levels. Vegetarians may need a little extra B12, taken orally; usually the amount in a multivitamin is ample.

Vitamin B6 is occasionally given as a supplement to those taking birth control bills or Isoniazid due to some evidence they may deplete the body’s supply. B6 has been studies as a treatment for premenstrual syndrome (PMS) but has not panned out well in most studies. The same study of heart disease referred to above about folate showed at least 3 mg of B6 helped reduce the incidence of heart disease. Standard multivitamins often contain 2 mg while the RDA is 1.6 mg. B6 is also known as pyridoxine. Vitamin B1, also known as thiamin, is an important addition for problem drinkers. Niacin can help lower cholesterol levels.

Vitamin A is certainly an important fat soluble vitamin included in the group of carotenoids which are by far best obtained through eating carotenoid containing vegetables. Beta Carotene as a supplement has not been shown to have the benefits of simply eating the right foods.

Aspirin has been well documented to reduce the risk of heart attacks in persons who can safely take it. The dose is one baby aspirin a day. Check with your doctor. Alcohol amounting to one drink a day for women and two a day for men has repeatedly been shown to raise the level of good cholesterol (HDL). However, serious cautions are obvious as higher amounts often cause more harm than good.

Estrogen replacement, sometimes along with progesterone, for menopausal and some peri-menopausal women can have considerable cardia, bone, memory, skin, sexual, and emotional benefits. This must be balanced against the increased breast and uterine cancers risks of estrogen replacement therapy. For most women the balance is in favor of taking the estrogen. This is an important discussion for you and your doctor.

A Ginkgo Bilboa extract called Egb 761 has recently been shown in one study to very slightly slow the progression of Alzheimer’s dementia. Only 29% of the people who took this particular ginkgo improved an average of 4 points on only 2 of 3 tests while 13% of those in the placebo (sugar pill) did just as well.

I have discussed St. John’s Wort in detail in the September ’97 issue of Medical Memo; please see that article. In a nutshell, this herb shows promise for depression but good studies to determine its actual efficacy and mechanism of action are just beginning.

There are a number of other herbs such as garlic, ginseng, echinacea, saw palmetto and kava kava which have their proponents and may have some value. True consensus based on widely accepted quality studies proving their value are still lacking. Amino acids as supplements have not been shown to be generally worthwhile.

A note of caution: I have seen unpredictable negative interactions when patients take 3 or more “herbs”, amino acids, or “supplements” containing multiple ingredients, along with prescription or over the counter medicines. I have not seen this occur while taking only vitamins. There should not be any interaction with a true homeopathic remedy marked as 4X or greater as these preparations are so diluted the ingredient is not typically measurable.

This is a very important questions. The answer varies with the situation and must be tailored to each person’s needs and wishes. There are, nonetheless, guiding principles we can discuss. Before I go further, it is important to remember that, depending on what is being treated, medicine may be: Crucial, optional, accompanied by other treatments such as psychotherapy, or not advised at all. What follows is a summary of the advice I give when possible and appropriate.

First, the medicine must work or we’re not going to keep it anyway. By this I mean the medicine must substantially help the target symptoms and condition we are treating; the good effects must significantly outweigh the bad effects experienced, if any. If not, we are going to stop or change the medicine.

Once we have found a medicine that helps a lot and we have fine tuned it for you, we can then decide better how long to keep it. I rarely need to say “for the rest of your life.” This is especially true for children, adolescents and young adults.

If this is the first episode of a moderate to serious depression or anxiety disorder, the answer is typically 7 to 9 months from the time the medicine started helping. Generally, the longer you stay on the medicine the less chance of relapse when you stop it. this is true up to about 7 to 9 months for most episodes. In many cases we will then try tapering it off; if symptoms return we will resume the medicine for a while longer and then try to taper it off again. If symptoms do not resume we will likely say goodbye to at least this part of our work together and I or another doctor will be available should you need or want medicine or other help again.

The advice changes if this is a recurrent severe depression or anxiety disorder. Research and clinical experience indicates that if this is the third, and maybe if this is the second, serious episode in the last five years it is likely advisable to stay on the medicine indefinitely. This is called “maintenance treatment” and often means keeping the medicine at or near the same dose that helped originally. This will tend to prevent recurrences or at least lessen the severity of any recurrences.

Notice that “indefinitely” is not necessarily the same as “for the rest of your life”. Over the years to come, knowledge will continue to increase and may thus change our advice. We are also likely to develop new medicine and non-medicine treatments.

Some people have experienced many years of depression or anxiety of at least moderate levels that may or may not vary somewhat in intensity over time. These are often described as chronic or persistent illnesses. In these situations, keeping the medicine indefinitely is often advisable. Additionally, certain conditions such as Bipolar Disorder (previously known as manic-depression) and Schizophrenia are often lifelong and thus are often treated throughout life, or at least recurrently, often with medication as least a key part of the treatment.

Conditions that typically begin in childhood or adolescence such as Attention Deficit Hyperactivity Disorder (ADHD), Tourette’s Syndrome, Autism, Asperger’s Syndrome, Eating Disorders, and enuresis (bedwetting) may or may not persist into adulthood.

Some conditions can begin in either youth or adulthood. These include, for example, Post Traumatic Stress Disorder, Obsessive Compulsive Disorder, Depression, Anxiety and Panic disorders, Bipolar Disorder, Schizophrenia, and Substance Abuse.

When medicine is advised and proven helpful for a child or adolescent, I generally follow the same guidelines as I described above for adults, with certain exceptions. For kids, I advise reconsidering the wisdom of continuing medicine at least yearly. sometimes this is an easy decision to try off the medicine, sometimes it is more complex. One of the fun things about working with kids is that often development is on your side so that with time and maturing we can often remove all or some treatments including medicine. The same is true, but to a lesser degree, with adults.

A recent study in the JAMA (Journal of the American Medical Association) showed that women taking Zoloft, Paxil, or Luvox had no increased risk of birth defects, miscarriages, or any complications of pregnancy. This combined with a prior study showing no problems with Prozac in pregnancy is very reassuring. I still advise, if at all possible, to avoid any medication in pregnancy, especially in the first trimester. However, the medications in this group would be good choices, depending on other factors, when medication for depression, anxiety , or obsessive compulsive disorder are needed in pregnancy. They are also a good choice for women who may become pregnant while being treated for these conditions.

Psychopharmacology literally means the study of chemicals, medications, and drugs affecting the mind and brain and thus our feelings, thoughts and behavior. The focus is particularly on medications but can include substances of abuse, vitamins, nutrients, herbs, toxins or any chemical directly or indirectly affecting the central nervous system.

Almost all psychopharmacologists are Psychiatrists (see the June 1997 Medical Memo for details about what a psychiatrist is) who develop expertise in the skillful use of medications to treat psychiatric and mental health disorders. All psychiatrists, being MD’s or DO’s, are licensed to prescribe medications. Each psychiatrist prescribes medication to varying degrees based on their training, experience, the type of practice setting they work in, and the needs of the patients they see. Thus psychopharmacology may be best seen as a part of the medical specialty of psychiatry that some psychiatrists develop as a special interest and expertise.

The ideal art and science of psychopharmacology is customizing the medication, its type, its dose, its frequency, its beneficial effects, its possible side effects, and its possible interactions, fine tuned to fit the particular needs, wants, health situation, and target symptoms of the individual. This is a lofty goal and obviously cannot be reliably achieved without a good working relationship between the patient and doctor.

While my own practice certainly includes other areas of psychiatry such as psychotherapy, a substantial emphasis is on doing evaluations, consultations, second opinions, and psychopharmacology (prescribing, monitoring, adjusting and fine tuning medications.)