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Nutritional and Herbal Supplements in the Treatment of Obsessive Compulsive Disorder

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Nutritional and Herbal Supplements in the Treatment of Obsessive Compulsive Disorder Open access Review Gen Psych: first published as 10.1136/gpsych-2019-100159 on 11 March 2020. Downloaded from Nutritional and herbal supplements in the treatment of obsessive compulsive disorder Canan Kuygun Karcı ,1 Gonca Gül Celik2 To cite: Kuygun Karcı C, Gül ABSTRACT pharmacotherapy with selective serotonin Celik G. Nutritional and herbal Obsessive- compulsive disorder (OCD) is a neuropsychiatric reuptake inhibitors (SSRI), the tricyclic supplements in the treatment disorder that is characterised by obsessions and antidepressant clomipramine, or serotonin of obsessive compulsive compulsions. The recommended treatments for OCD disorder. General Psychiatry noradrenaline reuptake inhibitors such as are cognitive– behavioural therapy using exposure and 8 9 2020;33:e100159. doi:10.1136/ venlafaxine or duloxetine. response prevention and/or pharmacotherapy. On the other gpsych-2019-100159 Limited effectiveness and possible side hand, some nutritional and herbal supplements may be effects of present treatments have lead to the Received 03 October 2019 effective in the treatment of OCD. Nutritional and herbal Revised 02 December 2019 supplements in OCD treatment will be reviewed in this search for alternative strategies. It is known Accepted 19 December 2019 paper. PubMed (Medline), Cochrane Library and Google that various nutritional deficiencies can Scholar databases were reviewed for the topic. There are be detected in patients with mental disor- some supplements that have been researched in OCD ders. Therefore, nutritional supplements treatment studies such as vitamin D, vitamin B12, folic are thought to be effective in treatment. acid, homocysteine, trace elements, N- acetyl cysteine, In this paper, use of nutritional and herbal glycine, myoinositol, St John’s wort, milk thistle, valerian supplements in the treatment of OCD will be root, curcumin and borage. The effectiveness of herbal and reviewed. nutritional supplements in the treatment of OCD should be supported with more conclusive evidence. METHODS INTRODUCTION This review is focused on herbal and nutri- tional treatments for OCD. Therefore, http://gpsych.bmj.com/ Obsessive- compulsive disorder (OCD) is a PubMed (Medline), Cochrane and Google neuropsychiatric disorder that is character- Scholar databases were searched using the ised by obsessions and compulsions. OCD terms ‘Obsessive- Compulsive Disorder’ OR usually begins in childhood or adolescence ‘OCD’ in combination with ‘herbal’ OR and comorbid disorders such as mood, ‘plant’ OR ‘nutrition’ OR ‘nutraceuticals’ OR anxiety, psychotic and somatoform disorders 1 ‘supplement’ OR ‘minerals’ OR ‘vitamin’. are common in patients with OCD. Papers written in English and conducted with Structural, neurochemical, genetic and on September 29, 2021 by guest. Protected copyright. humans were reviewed. immunological factors play a role in the aetiology and pathophysiology of OCD.2 Alterations in certain neurotransmitters are involved in OCD symptoms. Serotonin defi- RESULTS © Author(s) (or their ciency and the dysfunction in the availability Vitamin D employer(s)) 2020. Re- use permitted under CC BY-NC. No of serotonin transporter (5- HTT) have been Vitamin D has important functions in immu- 3 commercial re- use. See rights implicated in OCD symptomatology. In nity modulation, inflammatory response and and permissions. Published by addition, elevated glutamate, glutamine and antioxidant processes.10 It is also essential for BMJ. gamma aminobutyric acid (GABA) levels in normal brain development and functioning, 1 Child and Adolescent the caudate nucleus4 and increased gluta- and plays key roles nervous system processes Psychiatry, Dr. Ekrem Tok mate levels in the cerebrospinal fluid have such as neurotransmission, neuroprotection, Psychiatry Hospital, Adana, 5 11 12 Turkey been found in patients with OCD. Also, the proliferation and differentiation. 2Child and Adolescent glutamatergic ionotropic N- methyl D- aspar- Vitamin D is synthesised in the epidermis Psychiatry, Cukurova University tate (NMDA) receptor has been associated as vitamin D3 (cholecalciferol) and then it is Medical Faculty, Adana, Turkey 6 with OCD. converted to 25- OH D3 in the liver by hydrox- Correspondence to The recommended treatments for OCD ylation. After rehydroxylation in the kidney, Dr Canan Kuygun Karcı; are cognitive–behavioural therapy using 25- OH D3 becomes 1,25- dihydroxy- vitamin 7 11 c_ kuy@ hotmail. com exposure and response prevention and/or D3, the active form of vitamin D. Kuygun Karcı C, Gül Celik G. General Psychiatry 2020;33:e100159. doi:10.1136/gpsych-2019-100159 1 General Psychiatry Gen Psych: first published as 10.1136/gpsych-2019-100159 on 11 March 2020. Downloaded from 23 Previous studies have demonstrated that vitamin D decrease due to deficiency of vitamin B12 and folic acid. deficiency is associated with numerous neuropsychiatric Increased plasma homocysteine levels are accepted as a 24 diseases that include autism, major depressive disorder, sensitive marker of folic acid and vitamin B12 deficiency. schizophrenia and OCD.13–15 There are several possible Increased homocysteine levels may cause DNA damage, relationships between vitamin D and OCD pathophysi- mitochondrial dysfunction, activation of apoptotic signals ology. One of these is the association between the active and increased oxidative stress.25 All these findings suggest form of vitamin D3 (1,25- dihydroxy- vitamin D3) and tyro- that vitamin B12, folic acid and homocysteine may be sine/tryptophan hydroxylase. While tyrosine hydroxylase related with the aetiology of OCD. is the rate- limiting enzyme in dopamine, epinephrine In the literature, there are case reports of patients 26 27 and norepinephrine synthesis, tryptophan hydroxylase is with OCD having vitamin B12 deficiency. Also, some the rate- limiting enzyme in serotonin synthesis. Levels of studies have investigated the association between OCD these two enzymes are regulated by 1,25- dihydroxy- vitamin and vitamin B12, folic acid, and homocysteine levels both 16 17 D3. Therefore, vitamin D deficiency may contribute to in adult and child- adolescent patients. Hermesh et al OCD aetiology by affecting the pathway of serotonin and have compared 30 patients with OCD, 30 patients with catecholamines synthesis. chronic schizophrenia and 30 healthy controls. They have The other relationship between vitamin D and OCD has reported that vitamin B12 deficiency was more frequent in to do with the neuroprotective effect of vitamin D. In some patients with OCD compared with controls, but there was studies, the role of free radicals, especially increased levels no significant difference between vitamin B12 and folate of nitric oxide, is shown in OCD.18 Vitamin D has antiox- levels among the three groups.28 Atmaca et al found lower idant effects and inhibits an essential enzyme (inducible folate and higher homocysteine levels in patients with nitric oxide synthase) for nitric oxide synthesis.19 Thus, OCD (n=23) compared with controls (n=23) and those vitamin D deficiency may play a role in OCD by causing levels were significantly correlated with the symptom the deterioration of neuroprotection. severity of OCD.29 Türksoy et al showed that vitamin In the literature, all available papers on OCD and vitamin B12 deficiency was significantly higher in patients with D are studied with child and adolescent patients. There is OCD (n=35) compared with control (n=22).30 But folate no adult study on this topic. Esnafoğlu and Yaman have deficiency was not found in either group. Additionally, compared vitamin D, vitamin B12, homocysteine and folic homocysteine levels were significantly higher in the OCD acid levels between 52 patients with OCD and 30 healthy group, and highest in the OCD group with major depres- controls. They found that there was a negative correla- sive disorder. Similarly, Esnafoğlu and Yaman found lower tion between severity of OCD and the level of vitamin vitamin B12 and higher homocysteine levels in the group D and also vitamin D levels were lower in patients with of children and adolescents with OCD compared with OCD.20 On the other hand, Yazici et al showed no signif- healthy controls. However there was no significant differ- icant difference in vitamin D, calcium, phosphate and ence in the folic acid levels of both groups.20 A double- http://gpsych.bmj.com/ alkaline phosphatase levels between patients with OCD blind, 12- weeks study was conducted in 36 patients with and healthy controls. But the level of vitamin D was nega- OCD who were randomly assigned to folic acid+fluoxe- tively correlated with symptom severity in patients with tine or placebo+fluoxetine group. They have reported no OCD.21 This study has compared 60 patients with OCD significant difference in Yale- Brown Obsessive Compul- and 60 healthy controls. Similarly, Celik et al found lower sive Scale (Y- BOCS) scores between folic acid and placebo vitamin D levels in paediatric autoimmune neuropsychi- groups. Also, all baseline folate levels of patients with 31 atric disorders were associated with streptococcal infec- OCD were not lower than the normal range. on September 29, 2021 by guest. Protected copyright. tion (PANDAS)- in patients with OCD (n=33) compared Folate and vitamin B12 levels might be influenced by to healthy controls (n=20), but the difference was not dietary habits. So the results of studies can vary in samples statistically significant.22 PANDAS is a neuropsychiatric from different societies. disorder that OCD symptoms manifest in
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