The Sins of Our Mental Health Care System: Bang-Bang It’s Low B12—and Your Doctor Doesn’t Even Know It.

 The Sins of Our Mental Health Care System:  Bang-Bang It’s Low B12—and Your Doctor Doesn’t Even Know It

The Hippocratic oath, first do no harm, is being completely ignored every day in America’s mental health care system when it comes to diagnosing and treating vitamin B12 deficiency. The majority of mental illness patients are not being screened despite it being well-established that low B12 causes an array of psychiatric manifestations: (depression, mood disorders, anxiety, paranoia, suicidal ideations, hallucinations, dementia, psychosis, and violent behavior).

Consequences of this poor practice include injury, overcrowded emergency departments, and billions of misspent health care dollars.  Perhaps also crimes of violence and mass shootings.

Consider this, a 19-year-old employed male is brought to the ER for violent behavior.  He has a history of bipolar disorder and is taking prescribed anti-psychotic and anti-anxiety drugs.  Standard psychiatric medical clearance blood tests including alcohol and urine drug screen were normal.  He was referred for evaluation by the psychiatric team which determined him to be safe for discharge.  He was instructed to continue his current medications and outpatient therapy, and was discharged home.

One week later, he is brought back to the ER by police for suicidal and homicidal ideations.  He purchased a gun with the intent of killing his parents as well as himself.  All standard blood tests were repeated and were once again normal.  No evidence of illicit drugs or alcohol.  He is admitted to a psychiatric in-patient facility and the mental health team again takes over the responsibility of his care.

Could this patient have an underlying B12 deficiency causing his behavior?  Absolutely.  He was screened for low B12 on his second ER visit and found to be profoundly deficient.  When further questioned, the patient admitted to abusing nitrous oxide, well-known to cause B12 deficiency.  Nitrous oxide is easy to obtain and it is popularly abused by tweens, teens, and young adults.

The 2012 Sandy Hook Elementary School mass shooter, 20-year-old Adam Lanza, killed 26, plus his own mother and then himself.  Lanza was reported to have developmental issues in early childhood including socialization delays, sensory issues and repetitive behaviors.  Medical professionals treating Lanza toyed with diagnoses of anxiety, obsessive compulsive disorder, Asperger’s, and autism spectrum disorder.  Lanza was prescribed a psychotropic medication which was then discontinued because of confusion, disjointed speech, and immobility.  Lanza was later prescribed another psychotropic drug, and again began having severe side effects, reported by his mother before she discontinued it.  The mental health team erroneously interpreted this as being non-compliance by his mother instead of real adverse reactions.

Did Lanza have misdiagnosed B12 deficiency and did it cause or contribute to his violent actions?  The coroner determined him to be 6 feet tall and weighing only 112 pounds.  B12 deficiency is often found in anorexia and malnutrition.  Lanza was found not to have any drugs or alcohol in his system. “There is no chemical reason or apparent medical reason to explain [Lanza’s] actions,” former chief state’s medical examiner Dr. H. Wayne Carver II stated.  But was Lanza screened for B12 deficiency using serum B12, methylmalonic acid, homocysteine, and was he tested for methylenetetrahydrofolate reductase (MTHFR) gene mutations?

All children suspected or diagnosed on the autism spectrum need to have B12 deficiency ruled out, not only because pediatric B12 deficiency can cause permanent brain injury, but because they both present with neuropsychiatric manifestations and developmental delay.  It is dangerous to prescribe psychiatric drugs in patients with underlying B12 deficiency, and especially in those with MTHFR/MTRR gene mutations.

The incidence of low B12 is estimated to be around 25% of the U.S. population.(1)   Along with causing mental illness, it can result in a host of other adverse outcomes (neuropathy, myelopathy, demyelination, brain atrophy, dementia, anemia, vascular occlusions [e.g. strokes], and fall-related trauma). There are numerous reasons a person can become B12 deficient at any age:  1) diet [vegan/vegetarian]; 2) malabsorption; 3) autoimmune; 4) Helicobacter pylori; 5) nitrous oxide administration or abuse; 6) certain medications; 7) eating disorders; 8) maternal; 9) genetic mutations [MTHFR, MTRR, MTR]; 10) alcohol abuse; 11) chemotherapy/radiation; and 12) inborn errors of B12 metabolism.

The latest shooter at You Tube headquarters was a 38-year-old practicing vegan.  She shot three people and then killed herself. Vegans are well known to be B12 deficient because the vegan diet is devoid of B12.  Was B12 deficiency involved in her mental illness causing her to do the unthinkable?

B12 deficiency can make one feel and act “crazy.”  When patients develop psychiatric symptoms, doctors typically don’t consider the possibility that B12 deficiency might be the cause.  They generally go no further than applying labels such a depression, anxiety, or psychosis and prescribing expensive medications.  This is inappropriate and dangerous treatment if low B12 is the real cause. How will we know if patients are B12 deficient if they are not being tested?  No guidelines exist to ensure this testing takes place.

Emergency departments are the gateway to medical clearance for psychiatric evaluations and admissions.  We have identified many patients who were suicidal and found to be B12 deficient when B12 screening was performed.  Interestingly, most were already on psychotropic drugs, indicating that their primary care physician and/or psychiatrist failed to include B12 deficiency in the differential diagnosis of the cause of their mental symptoms.

The increased incidence of youth practicing veganism, vegetarianism, the increase abuse of nitrous oxide, and the fact that clinicians and mental health institutions do not screen their patients for B12 deficiency, creates the perfect storm for people being misdiagnosed as having mental illness, potentially leading to more crimes of violence with deadly outcomes.

B12 deficiency is the most unrecognized medical disorder causing mental illness.  Oversight? Incompetence? Health care malpractice? Poor protocols?  Where are the American College of Psychiatrists and the American Medical Association?  How do they not know about B12 deficiency? It appears our health care leaders, physician and nursing organizations, and elected officials are either oblivious or complacent to this negligent practice.  No wonder we are in a major mental health care crisis and our psychiatric facilities are bursting at the seams.  We don’t even rule out treatable conditions?  B12 deficiency has a treatment, which is inexpensive and easy to provide.   And therein may lie the answer, it is too cheap to treat, and there is no big money to be made.

One has to ask, is Big Pharma at the root of persuading mental health leaders and medical academia to ignore B12 deficiency and not include it in their differential diagnosis?  Why has there been such a severe oversight for decades?  When misdiagnosed B12 deficiency has been brought to the attention of health care leaders, institutions, governmental officials, and elected politicians to investigate, why has it fallen on deaf ears?

There are some clinicians who do screen their patients, but why aren’t the majority?  How many more people will have to die before someone in power changes this oversight in our mental health care system?

Who is the watchdog?  Why hasn’t the Centers for Medicare & Medicaid Services made undiagnosed B12 deficiency a Never Event?  Untreated B12 deficiency causing mental illness, fall-related trauma, neurologic injury, developmental disabilities, vascular occlusions, and severe anemia are serious, preventable, and costly medical problems.   Does the Joint Commission who accredits and certifies more than 20,000 health care organizations and programs in the U.S. know that our system is failing the public by misdiagnosing B12 deficiency?  Physicians can’t treat what they don’t know.

There is no excuse for anyone from any country to suffer from mental illness caused by B12 deficiency, or to die from killing themselves or someone else. Our mental health care system has failed to understand a fundamental medical disorder, a discovery for which three Americans won the Nobel prize in medicine & physiology in 1934.  We can win the war on B12 deficiency through education and advocacy.  This can be accomplished by initiating a multimedia campaign and enlisting help from the government, insurance industry, and health care organizations.  We need to start a conversation about B12 deficiency and that conversation needs to begin today.

1.   T.S. Dharmarajan and E.P. Norkus.  Approaches to vitamin B12 deficiency.  Early treatment may prevent devastating complications.  Postgrad Med. 2001 Jul;110(1):99-105.

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