The antidepressant moclobemide is a reversible monoamine oxidase inhibitor. Once again, this is a drug that was frequently prescribed for a time, but has subsequently faded in popularity.
It was released in the late 80's; around 1990 many studies came out, comparing moclobemide with other antidepressants, including tricyclics and fluoxetine, showing that it worked just as well for treating depression. Many of these studies were published in Scandinavia. There have been very few clinical studies since then. Part of the reason may be that moclobemide was never approved in the U.S. (I do not understand why not).
Moclobemide has also been used effectively to treat social phobia.
In my opinion, it is a neglected option in treating depression. Because it has faded in popularity, it is usually tried as a third-line medication. For this reason, it is prescribed to patients who are more likely to have a more refractory depression. For this reason, it is less likely to be seen to help as much; this leads to clinicians pronouncing it ineffective, and not prescribing it. If it was prescribed as a first-line agent, I think we would see that it works pretty much as well as any other antidepressant.
Its advantages relate to the side-effect profile: its side effects in general are probably closest to placebo among all the antidepressants. And there are minimal or no sexual side effects with moclobemide, compared to the SSRI's. Here's a reference:
http://www.ncbi.nlm.nih.gov/pubmed/10974600
Other references:
http://www.ncbi.nlm.nih.gov/pubmed/17168253
{a 2006 meta-analysis showing that moclobemide works as well as SSRI's}
http://www.ncbi.nlm.nih.gov/pubmed/16702988
{a 2006 article from the British Journal of Pharmacology suggesting that moclobemide may have neuroprotective or even neurogenerative effects in the hippocampus}
http://www.ncbi.nlm.nih.gov/pubmed/12595913
{a 2003 review}
Addendum:
There was one case series study published in 2000 by Magder, Aleksic, and SH Kennedy, describing the successful use of very high-dose moclobemide in combination with lithium and/or trazodone for treatment-resistant depressed patients. The doses used were up to 1500-1650 mg/day, which is much higher than the usual maximum of 600 mg. They advocated using an MAOI diet at these doses. Moclobemide was well-tolerated, and the patients appeared to benefit over 1-2 years of follow-up. It's worth looking at this brief article in its entirety, here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/10831036
Tuesday, March 3, 2009
Volunteering Improves Mental Health
Altruistic volunteering is beneficial for mental health.
There are several mechanisms by which this could happen:
1) the experience of giving one's time and energy for another in need is an intrinsic life joy
2) there are opportunities to build new friendships, with others who also are "practicing altruists"
3) the experience may allow you to discover new aspects of yourself, in terms of skills, pleasures, ambitions, etc.
4) the structure of the volunteer experience may be a "benevolent structure" motivating action in your day, challenging depressive symptoms which might keep you inactive or alone
Here is some evidence from the literature:
http://www.ncbi.nlm.nih.gov/pubmed/18381833
{this 2008 study from a gerontology journal, shows that people in their 60's who volunteer moderately have higher levels of well-being, after controlling for variables such as educational level, physical health, etc. People who didn't volunteer, or people who volunteered "too much", had lower levels of well-being}
http://www.ncbi.nlm.nih.gov/pubmed/18321629
{a 2008 study from the London School of Economics, showing that there is a direct causal relationship between volunteering and happiness; weekly volunteering increases the likelihood of being "very happy" by 16%, independent of income level--the data also suggest that the effect is more pronounced for people who volunteer more frequently}
http://www.ncbi.nlm.nih.gov/pubmed/11467248
{a 2001 study looking at data from 2681 people, showing that volunteering is associated with increased well-being in numerous domains, including happiness, life satisfaction, self-esteem, sense of control over life, physical health, and depression}
http://www.ncbi.nlm.nih.gov/pubmed/9718488
{a 1998 study showing that volunteering bolsters well-being in elderly persons who volunteer; also the people who are helped by the volunteers had reduced amounts of depression}
I think there should be some more prospective, randomized studies of volunteering and other altruistic activity in the treatment of mental illnesses.
If you are interested in volunteering in Vancouver, here is a place to start looking:
http://www.govolunteer.ca/cgi-bin/page.cgi?_id=16
There are several mechanisms by which this could happen:
1) the experience of giving one's time and energy for another in need is an intrinsic life joy
2) there are opportunities to build new friendships, with others who also are "practicing altruists"
3) the experience may allow you to discover new aspects of yourself, in terms of skills, pleasures, ambitions, etc.
4) the structure of the volunteer experience may be a "benevolent structure" motivating action in your day, challenging depressive symptoms which might keep you inactive or alone
Here is some evidence from the literature:
http://www.ncbi.nlm.nih.gov/pubmed/18381833
{this 2008 study from a gerontology journal, shows that people in their 60's who volunteer moderately have higher levels of well-being, after controlling for variables such as educational level, physical health, etc. People who didn't volunteer, or people who volunteered "too much", had lower levels of well-being}
http://www.ncbi.nlm.nih.gov/pubmed/18321629
{a 2008 study from the London School of Economics, showing that there is a direct causal relationship between volunteering and happiness; weekly volunteering increases the likelihood of being "very happy" by 16%, independent of income level--the data also suggest that the effect is more pronounced for people who volunteer more frequently}
http://www.ncbi.nlm.nih.gov/pubmed/11467248
{a 2001 study looking at data from 2681 people, showing that volunteering is associated with increased well-being in numerous domains, including happiness, life satisfaction, self-esteem, sense of control over life, physical health, and depression}
http://www.ncbi.nlm.nih.gov/pubmed/9718488
{a 1998 study showing that volunteering bolsters well-being in elderly persons who volunteer; also the people who are helped by the volunteers had reduced amounts of depression}
I think there should be some more prospective, randomized studies of volunteering and other altruistic activity in the treatment of mental illnesses.
If you are interested in volunteering in Vancouver, here is a place to start looking:
http://www.govolunteer.ca/cgi-bin/page.cgi?_id=16
Tuesday, February 24, 2009
Caffeine & Coffee : Health Benefits
So, is coffee good for you? Or is it bad for you?
How about decaf?
It seems that there are mixed messages out there, about health effects from things such as coffee or caffeine.
What does the evidence tell us?
The evidence base is extremely compelling --
Here is a link to a study by Lopez-Garcia et al. from Annals of Internal Medicine in 2008, involving over 100 000 people, over 18 years of follow-up. Such massive studies with long follow-up time are incredibly informative:
http://www.ncbi.nlm.nih.gov/pubmed/18559841
In the study, it shows clearly that coffee drinkers have lower overall mortality rates, mainly due to a reduction in rates of cardiovascular disease. It showed a modest reduction in mortality rates associated with decaffeinated coffee as well. The authors conclude that the potential health benefits from coffee are due to components in the coffee other than caffeine.
The graph on the top is copied from the paper, and summarizes the results from the study. You can click on the graph to expand it. Actually, the data as presented on the graph suggests that people are healthier who have 2-3 cups of coffee per day, compared to those who have just 1.
Perhaps the less desirable effects from just a single cup per day are due to the more pronounced "jolt" of caffeine that would happen in a person who is not used to drinking as much coffee. Perhaps this effect would offset the health benefit, at low doses. At higher doses, the body may become more tolerant to caffeine's anxiogenic effects.
Unfortunately, this study did not look at mental health effects from drinking coffee, or from caffeine intake.
In another large epidemiological study of over 1400 people followed over 21 years, it was found that those who consumed coffee in mid-life had a substantially lower risk of developing dementia. This association was true after adjustment for demographic differences, lifestyle, and vascular disease.
http://www.ncbi.nlm.nih.gov/pubmed/19158424
This case-control study from Archives of Neurology in 2007 showed an inverse association between coffee intake and development of Parkinson disease (i.e. this relationship suggests that coffee could protect the brain from disease such as Parkinson's). However, smaller case-control studies such as this one are much weaker than the large prospective studies cited above:
http://www.ncbi.nlm.nih.gov/pubmed/17420321
The following 2008 article from Sleep Medicine Reviews presents a more cautionary account of caffeine's effects, particularly with respect to causing a dependence phenomenon, and to disrupting sleep quality. However, a lot of the data cited in this article is absurd, such as showing that a dose of caffeine immediately before sleep causes sleep disruption! Bedtime doses of coffee are not a realistic reflection of most people's caffeine intake!
http://www.ncbi.nlm.nih.gov/pubmed/17950009
Here's an interesting reference to an article showing that the tendency for caffeine to cause sleep disturbance is a heritable trait. That is, some people might be vulnerable to caffeine-induced insomnia, whereas others could sleep well regardless of their caffeine intake:
http://www.ncbi.nlm.nih.gov/pubmed/17969472
Here's a case report of a person with schizoaffective disorder improving upon discontinuing heavy caffeine intake:
http://www.ncbi.nlm.nih.gov/pubmed/18455857
In summary, it appears that coffee drinking is not harmful. In most cases, it may in fact be good for you. However, pregnant women should minimize their use of coffee. For some people, caffeine may cause or exacerbate anxiety or insomnia, especially at higher doses.
Buspirone
Buspirone is another of those medications that was introduced in the 80's, and was marketed for the treatment of anxiety. Most of the published studies on buspirone were done around 1990.
While many antidepressants simply increase the amount of serotonin or other neurotransmitters by blocking neurotransmitter re-uptake into neurons, buspirone works by directly stimulating one of the target receptors for serotonin, called the 5HT-1A receptor.
As with many new drugs, there was a wave of enthusiasm, which eventually faded. At this point buspirone is rarely prescribed.
In my opinion, it could be a useful and well-tolerated adjunct, to try in the following situations:
1) to treat generalized anxiety disorder
2) to augment antidepressants (i.e. to add to an antidepressant which isn't working well enough)
3) to treat antidepressant-induced jaw or tooth grinding (bruxism)
4) to treat aggressive or self-injurious behaviour; it may be particularly helpful in elderly patients with dementia, or in mentally handicapped patients
5) to treat migraine (a common comorbid problem among depressed or anxious patients)
6) to help with opiate withdrawal
7) to help quit smoking
Side effects are usually mild and subside with time; they include dizziness, nausea, sweating, or nervousness. About 10% of people in the clinical trials of buspirone discontinued the medication due to side effects.
Buspirone is metabolized through the cytochrome P450 3A4 system in the liver; because of this its levels in the body can be substantially increased by other medications or grapefruit juice, so these types of interactions have to be considered when choosing a dose.
I've been curious to revisit the evidence base for buspirone; here is my review of the literature:
1) Using buspirone as an augmentation to antidepressants, for treatment of depression:
http://www.ncbi.nlm.nih.gov/pubmed/17628435
{a good, important study from NEJM in 2006: 565 depressed patients who had not remitted despite receiving high-dose citalopram, were given augmentation therapy with either bupropion SR or buspirone. That is, the bupropion or buspirone was added onto their daily regimen of citalopram, and the patients were followed over at least 7 weeks. Both groups did similarly well, with about 30% of both groups having a remission. The bupropion group did slightly better in a few ways. Unfortunately there was no placebo augmentation group}
2) Treating generalized anxiety:
http://www.ncbi.nlm.nih.gov/pubmed/8666569
{a small study from 1996 showing that buspirone helps reduce anxiety symptoms in patients who also have mild depression; but the reduction in anxiety symptoms (about 50%) is only modestly different from placebo (about 35%) }
http://www.ncbi.nlm.nih.gov/pubmed/3320034
{this study from 1987 had a one-year follow-up of 700 patients. But it was open-label (no randomization, no placebo group). It did show that the patients taking buspirone for treatment of generalized anxiety showed sustained improvement, and tolerated the medication well}
http://www.ncbi.nlm.nih.gov/pubmed/17984162
{this 2007 study compares the effect sizes of numerous different medication treatments for generalized anxiety; buspirone fares particularly poorly, with a "non-significant" effect size of 0.17; SSRI's and venlafaxine do slightly better, and the novel anticonvulsant pregabalin actually does best. Complementary and alternative medications had a negative effect on symptoms, in this analysis. However, this meta-analysis is limited by the fact that most of the buspirone studies were done over 10 years ago and most of the results are from short-term treatment.}
http://www.ncbi.nlm.nih.gov/pubmed/2211567
{one of the small randomized studies comparing buspirone with a benzodiazepine for treatment of anxiety; the study shows similar effectiveness. Given that buspirone is non-addictive, it makes buspirone a more attractive option}
3) Treating other anxiety conditions:
http://www.ncbi.nlm.nih.gov/pubmed/2407755
{one of the studies showing that buspirone is NOT effective for treating panic disorder}
4) Improving cognitive function in schizophrenia:
http://www.ncbi.nlm.nih.gov/pubmed/17628435
{this 2007 study had a good randomized design, and 6 months of follow-up; it claimed in the abstract that buspirone had a beneficial effect on cognition when added to antipsychotics in schizophrenia -- but if you take a look at the actual data in the article, the differences in buspirone vs. placebo groups are very small. So I'm not impressed.}
5) Treating migraine:
http://www.ncbi.nlm.nih.gov/pubmed/16109114
{a small 2005 study in a headache journal looking at a group of 74 patients with migraine over 6 weeks of treatment; it showed that low-dose buspirone (10 mg) reduces migraine frequency by about 40%, and reduced anxiety scores by about 20%, both of which a substantial difference compared to placebo. The improvement in anxiety did not depend on the improvement in headache, they appeared to be separate, independent effects.}
6) Treating acute heroin withdrawal:
http://www.ncbi.nlm.nih.gov/pubmed/15876901
{an interesting 2005 study showing that 45 mg per day of buspirone can reduce symptoms of heroin withdrawal over a 2-week period; looking at the results directly, it appears that the effect is very substantial, that the buspirone almost eliminated withdrawal symptoms}
7) Helping quit smoking:
http://www.ncbi.nlm.nih.gov/pubmed/1739365
{a small 1992 study from Archives of Internal Medicine showing that buspirone helps with nicotine withdrawal, and may help people quit smoking}
8) Treating ataxia:
http://www.ncbi.nlm.nih.gov/pubmed/8806320
{another interesting study from Lancet in 1996, showing that buspirone helps improve symptoms of cerebellar ataxia, a type of brain disease which causes impaired balance & coordination}
9) Treating aggressive behaviours:
http://www.ncbi.nlm.nih.gov/pubmed/2016248
{a small study suggesting that buspirone can help reduce aggression and anxiety in mentally handicapped adults, without causing sedation or cognitive side-effects}
10) Treating bruxism:
http://www.ncbi.nlm.nih.gov/pubmed/10665633
{a 1999 study of 4 cases of SSRI-induced bruxism improving with buspirone}
11) Treating tardive dyskinesia:
http://www.ncbi.nlm.nih.gov/pubmed/8102622
{a 1993 study showing some improvement in tardive dyskinesia (a movement disorder) after treatment with buspirone for 12 weeks. However there are a few other case reports in the literature of buspirone causing worsened symptoms of various movement disorders, such as dystonias or myoclonus (twitching); but the incidence of such side effects appears to be very low}
12) Animal studies:
http://www.ncbi.nlm.nih.gov/pubmed/17312776
{in this study a badger in a zoo (!) was suffering agitation and engaging in self mutilation; "environmental enrichment" initially helped, but the behavioural problems still recurred. Buspirone ended up helping substantially, over an 18 month period, with no side-effects}
http://www.ncbi.nlm.nih.gov/pubmed/15766212
{in another animal study, buspirone helped reduce self-injurious behaviour in a group of rhesus macaques, and it seemed to help more than fluoxetine, with fewer side-effects}
While many antidepressants simply increase the amount of serotonin or other neurotransmitters by blocking neurotransmitter re-uptake into neurons, buspirone works by directly stimulating one of the target receptors for serotonin, called the 5HT-1A receptor.
As with many new drugs, there was a wave of enthusiasm, which eventually faded. At this point buspirone is rarely prescribed.
In my opinion, it could be a useful and well-tolerated adjunct, to try in the following situations:
1) to treat generalized anxiety disorder
2) to augment antidepressants (i.e. to add to an antidepressant which isn't working well enough)
3) to treat antidepressant-induced jaw or tooth grinding (bruxism)
4) to treat aggressive or self-injurious behaviour; it may be particularly helpful in elderly patients with dementia, or in mentally handicapped patients
5) to treat migraine (a common comorbid problem among depressed or anxious patients)
6) to help with opiate withdrawal
7) to help quit smoking
Side effects are usually mild and subside with time; they include dizziness, nausea, sweating, or nervousness. About 10% of people in the clinical trials of buspirone discontinued the medication due to side effects.
Buspirone is metabolized through the cytochrome P450 3A4 system in the liver; because of this its levels in the body can be substantially increased by other medications or grapefruit juice, so these types of interactions have to be considered when choosing a dose.
I've been curious to revisit the evidence base for buspirone; here is my review of the literature:
1) Using buspirone as an augmentation to antidepressants, for treatment of depression:
http://www.ncbi.nlm.nih.gov/pubmed/17628435
{a good, important study from NEJM in 2006: 565 depressed patients who had not remitted despite receiving high-dose citalopram, were given augmentation therapy with either bupropion SR or buspirone. That is, the bupropion or buspirone was added onto their daily regimen of citalopram, and the patients were followed over at least 7 weeks. Both groups did similarly well, with about 30% of both groups having a remission. The bupropion group did slightly better in a few ways. Unfortunately there was no placebo augmentation group}
2) Treating generalized anxiety:
http://www.ncbi.nlm.nih.gov/pubmed/8666569
{a small study from 1996 showing that buspirone helps reduce anxiety symptoms in patients who also have mild depression; but the reduction in anxiety symptoms (about 50%) is only modestly different from placebo (about 35%) }
http://www.ncbi.nlm.nih.gov/pubmed/3320034
{this study from 1987 had a one-year follow-up of 700 patients. But it was open-label (no randomization, no placebo group). It did show that the patients taking buspirone for treatment of generalized anxiety showed sustained improvement, and tolerated the medication well}
http://www.ncbi.nlm.nih.gov/pubmed/17984162
{this 2007 study compares the effect sizes of numerous different medication treatments for generalized anxiety; buspirone fares particularly poorly, with a "non-significant" effect size of 0.17; SSRI's and venlafaxine do slightly better, and the novel anticonvulsant pregabalin actually does best. Complementary and alternative medications had a negative effect on symptoms, in this analysis. However, this meta-analysis is limited by the fact that most of the buspirone studies were done over 10 years ago and most of the results are from short-term treatment.}
http://www.ncbi.nlm.nih.gov/pubmed/2211567
{one of the small randomized studies comparing buspirone with a benzodiazepine for treatment of anxiety; the study shows similar effectiveness. Given that buspirone is non-addictive, it makes buspirone a more attractive option}
3) Treating other anxiety conditions:
http://www.ncbi.nlm.nih.gov/pubmed/2407755
{one of the studies showing that buspirone is NOT effective for treating panic disorder}
4) Improving cognitive function in schizophrenia:
http://www.ncbi.nlm.nih.gov/pubmed/17628435
{this 2007 study had a good randomized design, and 6 months of follow-up; it claimed in the abstract that buspirone had a beneficial effect on cognition when added to antipsychotics in schizophrenia -- but if you take a look at the actual data in the article, the differences in buspirone vs. placebo groups are very small. So I'm not impressed.}
5) Treating migraine:
http://www.ncbi.nlm.nih.gov/pubmed/16109114
{a small 2005 study in a headache journal looking at a group of 74 patients with migraine over 6 weeks of treatment; it showed that low-dose buspirone (10 mg) reduces migraine frequency by about 40%, and reduced anxiety scores by about 20%, both of which a substantial difference compared to placebo. The improvement in anxiety did not depend on the improvement in headache, they appeared to be separate, independent effects.}
6) Treating acute heroin withdrawal:
http://www.ncbi.nlm.nih.gov/pubmed/15876901
{an interesting 2005 study showing that 45 mg per day of buspirone can reduce symptoms of heroin withdrawal over a 2-week period; looking at the results directly, it appears that the effect is very substantial, that the buspirone almost eliminated withdrawal symptoms}
7) Helping quit smoking:
http://www.ncbi.nlm.nih.gov/pubmed/1739365
{a small 1992 study from Archives of Internal Medicine showing that buspirone helps with nicotine withdrawal, and may help people quit smoking}
8) Treating ataxia:
http://www.ncbi.nlm.nih.gov/pubmed/8806320
{another interesting study from Lancet in 1996, showing that buspirone helps improve symptoms of cerebellar ataxia, a type of brain disease which causes impaired balance & coordination}
9) Treating aggressive behaviours:
http://www.ncbi.nlm.nih.gov/pubmed/2016248
{a small study suggesting that buspirone can help reduce aggression and anxiety in mentally handicapped adults, without causing sedation or cognitive side-effects}
10) Treating bruxism:
http://www.ncbi.nlm.nih.gov/pubmed/10665633
{a 1999 study of 4 cases of SSRI-induced bruxism improving with buspirone}
11) Treating tardive dyskinesia:
http://www.ncbi.nlm.nih.gov/pubmed/8102622
{a 1993 study showing some improvement in tardive dyskinesia (a movement disorder) after treatment with buspirone for 12 weeks. However there are a few other case reports in the literature of buspirone causing worsened symptoms of various movement disorders, such as dystonias or myoclonus (twitching); but the incidence of such side effects appears to be very low}
12) Animal studies:
http://www.ncbi.nlm.nih.gov/pubmed/17312776
{in this study a badger in a zoo (!) was suffering agitation and engaging in self mutilation; "environmental enrichment" initially helped, but the behavioural problems still recurred. Buspirone ended up helping substantially, over an 18 month period, with no side-effects}
http://www.ncbi.nlm.nih.gov/pubmed/15766212
{in another animal study, buspirone helped reduce self-injurious behaviour in a group of rhesus macaques, and it seemed to help more than fluoxetine, with fewer side-effects}
Monday, February 23, 2009
Ferritin & Iron
Ferritin levels in the blood correlate well with the amount of iron available in the body's "reservoir". If ferritin levels are low, the body has very low reserves of iron. (the converse may NOT be true -- if ferritin levels are high, the body may still have low iron reserves, because there are a variety of conditions, such as inflammatory states, that can cause ferritin levels to rise)
Anemia is a condition in which the body does not have enough iron-containing red blood cells, therefore the body cannot deliver oxygen to the tissues (including the muscles, heart, and brain) as efficiently. One of the most common symptoms of anemia, not surprisingly, is fatigue.
Sometimes, iron reserves can be low, without actually causing anemia. It is like a low water reservoir: water may still be flowing into people's homes despite the water levels being low.
Here is a 2003 study from the major journal, BMJ, which shows that iron supplementation improves fatigue in non-anemic women with low ferritin:
http://www.ncbi.nlm.nih.gov/pubmed/12763985
This study, from the major medical journal Lancet in 1996, shows that iron supplementation given to non-anemic girls with low ferritin improved their verbal learning and memory:
http://www.ncbi.nlm.nih.gov/pubmed/8855856
Low ferritin levels are associated with a disease called "restless legs syndrome" (RLS), which causes discomfort and insomnia at night, and which can often give rise to a substantial reduction in quality of life. I suspect there are many milder cases of RLS which could be contributing to insomnia, and therefore contributing to resulting anxiety and mood problems. Here are some studies showing the association, and demonstrating that iron supplementation can improve RLS:
http://www.ncbi.nlm.nih.gov/pubmed/15854860
http://www.ncbi.nlm.nih.gov/pubmed/8085504
http://www.ncbi.nlm.nih.gov/pubmed/19200780
In this recent study from the Journal of Pediatric Neurology, children with ADHD and low ferritin levels showed improvement in their ADHD symptoms after receiving iron supplements:
http://www.ncbi.nlm.nih.gov/pubmed/18054688
In conclusion, I believe it is very important to evaluate ferritin levels, particularly in women, since the levels are frequently low; low ferritin is associated with fatigue, restless legs, ADHD, and reduced cognitive function. It could be a contributing factor to mood disorders and other psychiatric problems.
Usually, low ferritin levels are easily remedied by iron supplementation. Most daily multivitamins contain iron, but the amount of iron in these is usually enough only to maintain your iron stores, not to build them up. Similarly, increasing iron-rich foods in the diet will help to maintain or build iron stores, but this could take a very long time. In order to build up your iron stores more quickly, higher doses of iron salts, such as ferrous sulphate, need to be taken daily for several months.
I recommend aiming for a serum level of at least 50 micrograms / litre (50 ug/L). Many labs give a normal range starting at 20 ug/L, and therefore you may not hear from your physician if the level comes back at 25. It is important to know that the average for women is at least 50, and the average for men is about 100. Exceptions include children, whose ferritin levels are a little lower, and women in advanced stages of pregnancy, who have average ferritin levels of only about 20.
If you do have low ferritin, then further investigation could be warranted, to assess for other causes of iron deficiency (e.g. chronic blood loss from the digestive tract, from heavy menstrual flow, or from the kidneys). So your decisions on this matter should be discussed and followed-up with a primary care physician.
Anemia is a condition in which the body does not have enough iron-containing red blood cells, therefore the body cannot deliver oxygen to the tissues (including the muscles, heart, and brain) as efficiently. One of the most common symptoms of anemia, not surprisingly, is fatigue.
Sometimes, iron reserves can be low, without actually causing anemia. It is like a low water reservoir: water may still be flowing into people's homes despite the water levels being low.
Here is a 2003 study from the major journal, BMJ, which shows that iron supplementation improves fatigue in non-anemic women with low ferritin:
http://www.ncbi.nlm.nih.gov/pubmed/12763985
This study, from the major medical journal Lancet in 1996, shows that iron supplementation given to non-anemic girls with low ferritin improved their verbal learning and memory:
http://www.ncbi.nlm.nih.gov/pubmed/8855856
Low ferritin levels are associated with a disease called "restless legs syndrome" (RLS), which causes discomfort and insomnia at night, and which can often give rise to a substantial reduction in quality of life. I suspect there are many milder cases of RLS which could be contributing to insomnia, and therefore contributing to resulting anxiety and mood problems. Here are some studies showing the association, and demonstrating that iron supplementation can improve RLS:
http://www.ncbi.nlm.nih.gov/pubmed/15854860
http://www.ncbi.nlm.nih.gov/pubmed/8085504
http://www.ncbi.nlm.nih.gov/pubmed/19200780
In this recent study from the Journal of Pediatric Neurology, children with ADHD and low ferritin levels showed improvement in their ADHD symptoms after receiving iron supplements:
http://www.ncbi.nlm.nih.gov/pubmed/18054688
In conclusion, I believe it is very important to evaluate ferritin levels, particularly in women, since the levels are frequently low; low ferritin is associated with fatigue, restless legs, ADHD, and reduced cognitive function. It could be a contributing factor to mood disorders and other psychiatric problems.
Usually, low ferritin levels are easily remedied by iron supplementation. Most daily multivitamins contain iron, but the amount of iron in these is usually enough only to maintain your iron stores, not to build them up. Similarly, increasing iron-rich foods in the diet will help to maintain or build iron stores, but this could take a very long time. In order to build up your iron stores more quickly, higher doses of iron salts, such as ferrous sulphate, need to be taken daily for several months.
I recommend aiming for a serum level of at least 50 micrograms / litre (50 ug/L). Many labs give a normal range starting at 20 ug/L, and therefore you may not hear from your physician if the level comes back at 25. It is important to know that the average for women is at least 50, and the average for men is about 100. Exceptions include children, whose ferritin levels are a little lower, and women in advanced stages of pregnancy, who have average ferritin levels of only about 20.
If you do have low ferritin, then further investigation could be warranted, to assess for other causes of iron deficiency (e.g. chronic blood loss from the digestive tract, from heavy menstrual flow, or from the kidneys). So your decisions on this matter should be discussed and followed-up with a primary care physician.
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