Micronutrient considerations in mental health disorders

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By Kellie Blake, RDN, LD, IFNCP

With the often-conflicting information surrounding ketogenic, Paleo, low carbohydrate, and vegan diets, macronutrients are a hot topic. My patients are very curious about how much fat, carbohydrate, and protein to consume but seem less aware of micronutrients.

A micronutrient is a chemical element or substance such as a vitamin or mineral required by the body in small amounts for normal growth, development, and health. While macronutrients often take the spotlight, it’s important for integrative providers to bring micronutrients into the discussion, especially for patients experiencing mental health symptoms.

Global mental health statistics are striking, and I suspect the Western nutrient-poor diet as a significant contributor to the mental health disease burden in the United States. According to the National Institute of Mental Health, almost 20 percent of U.S. adults live with some type of mental illness. Whether patients are experiencing depression, anxiety, bipolar disorder, schizophrenia, or some other mental health diagnosis, suboptimal micronutrient intake or deficiency is common.

There is no one cause or cure when it comes to mental health disease but the nutritional landscape is an important consideration. After all, food affects neuroplasticity, the gut microbiota, and inflammation and micronutrients are intimately tied to cognitive function, behavior, and emotions.

As a dietitian in an acute-care psychiatric hospital, I have observed many patients with mental health symptoms have altered dietary habits. Skipping meals especially breakfast, high consumption of sugar, processed foods and caffeine, and the low consumption of fruits, vegetables, and lean protein seem to be common. This dietary pattern is deficient in both macro- and micronutrients and certainly exacerbates mental health symptoms but can also lead to the development of mental health disease.

On the other hand, an anti-inflammatory, whole-foods diet low in processed foods in combination with micronutrient optimization has been found to restore balance and help patients begin to heal. Quickly identifying and correcting nutritional deficiencies may possibly decrease medication usage, improve quality of life, and reduced the likelihood of suicide or hospitalization.

There is no single meal plan that’s appropriate for every mental health patient so it’s important to tailor the meal pattern and nutrient recommendations. But adjusting macronutrients is only the beginning, there are several common micronutrient deficiencies to address as well.  While I prefer food sources and often start with food, supplementation is almost always necessary. Addressing magnesium, zinc, selenium, B vitamin and vitamin D status can be important for patients with mental health symptoms.

Magnesium

Magnesium is a mineral vital for proper cell function and is involved in hundreds of enzymatic reactions in the body. Specific to mental health, magnesium is important for neurotransmitter regulation, and nerve and brain cell function and growth. In addition, magnesium can improve sleep, which is often suboptimal in those with mental health symptoms. Unfortunately, a large percentage of Americans do not consume adequate dietary magnesium, which could be one contributing factor to rising rates of depression. In one cross-sectional study reported in the Journal of the American Board of Family Medicine, very low dietary intake of magnesium was associated with depression, especially in younger people.

Adult males require a minimum of 320 milligrams and females need a minimum of 420 milligrams of magnesium daily. I encourage patients to consume a variety of magnesium-rich foods every day such as leafy greens, nuts, seeds, legumes, dark chocolate, and fish. When dietary intake is inadequate, supplementing with magnesium can be very helpful. In those with hypomagnesemia, supplementing with 500 milligrams of magnesium oxide has been found to improve depressive symptoms.

Zinc

Zinc is an element important for brain growth and development, but also acts as a neurotransmitter. Altered zinc status in the hippocampus and cerebral cortex can impact cognition, behavior, and emotional regulation. In addition, inadequate zinc levels can increase serum cortisol levels leading to depressive symptoms via dysregulation of the hypothalamus, pituitary, adrenal (HPA) axis.

Zinc supplementation has been shown to improve depressive symptoms via anti-inflammatory and antioxidant properties. For example, zinc can decrease C-reactive protein levels and also protect against lipid peroxidation, which have both been implicated in depressive symptoms. In addition, the antidepressant effect of zinc may be related to its function as an antagonist to the N-methyl-d-aspartate (NMDA) receptor and as a nitric oxide synthase (NOS) inhibitor.

Adult males require a minimum of 11 milligrams of zinc per day and females need 8 milligrams per day, however those with mental health symptoms often require up to 30 milligrams per day for symptom management. Zinc intake can be optimized by increasing dietary intake of oysters, beef, poultry, pork, beans and seeds. High dietary intake of zinc can affect copper status, so balancing with copper may be necessary. A general guideline is to provide 1 milligram of copper for every 15 milligrams of zinc.

Selenium

Selenium is a trace element and an important mood regulator. Altered thyroid function is a known contributor to mental health symptoms and selenium is required for proper thyroid function. In addition, selenium seems to help prevent the lipid peroxidation and oxidative stress that are implicated in the development of mental health symptoms. And finally, selenium functions to modulate a variety of neurotransmitter systems, which are all involved in the development of psychiatric symptoms. As reported in Biological Psychiatry, people fed a diet low in selenium experience more depressive and hostility symptoms when compared to people with a diet higher in selenium. In addition, supplementation with selenium for up to six weeks leads to significant improvement in mood.

All out selenium deficiency is common across the globe, but is rare in the United States. However, the selenium content of foods is dependent on soil concentrations, which vary and may be inadequate in many instances. Adults need a minimum of 55 micrograms of selenium daily and Brazil nuts, seafood, and organ meats are particularly rich sources. However, selenium is also found in meat, cereal, grains and dairy products. According to the National Institutes of Health, plasma or serum selenium concentrations of eight micrograms per deciliter are adequate for healthy people.

Caution should be used with selenium supplementation as high doses can be toxic. In addition, when selenium is supplemented at high doses, tissue saturation occurs and the excess selenium metabolites can increase the production of reactive oxygen species potentially worsening mental health symptoms.

B Vitamins

There are eight B vitamins including thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), biotin (B7), folate (B9), and cobalamin (B12). While each B vitamin has a distinct function, they all act as cofactors in a variety of cellular processes. Deficiencies of these micronutrients have been associated with an increased risk of mood disorders and other mental health symptoms.

Specific to mental health, B vitamins are important for the DNA methylation and offloading of homocysteine. When B vitamins are in short-supply, the resulting elevated homocysteine levels may contribute to mood disturbances. In addition, B vitamins are cofactors in the formation and management of neurotransmitters, which are important mood regulators. While the adequate intake of all B vitamins is important, special attention to optimizing pyridoxine, folate, and cobalamin may be helpful for the prevention and treatment of depression and other mental health disorders.

B vitamins are found in a wide variety of foods and I encourage patients to focus on whole foods with emphasis on leafy green vegetables, nuts, seeds, starchy vegetables, and high-quality seafood, poultry, beef, and eggs. While it may be necessary to correct a deficiency with a single B vitamin, the mental health benefits may be a result of the combined action of all B vitamins. So, a B-complex supplement may be more effective for those with mental health symptoms.

Vitamin D

Vitamin D is a fat-soluble vitamin and along with hundreds of other functions, it acts as a neuroactive steroid in the brain. Many psychiatric illnesses involve the dysregulation of neurotrophic agents. Since vitamin D can modulate nerve growth factor, brain-derived neurotrophic factor, and neurotrophin, it can potentially improve mental health symptoms. When vitamin D is in short supply however, neurotransmitter levels are altered and inflammatory markers increase, which can initiate or exacerbate mental health symptoms.  

There are very few food sources of vitamin D. Fatty fish, fish oil, fortified foods and mushrooms have some vitamin D, but not an adequate amount to maintain optimal vitamin D levels. The best source of vitamin D is the sun, but for those living in the northern U.S., sun exposure is not adequate to maintain optimal vitamin D levels for much of the year.

Vitamin D deficiency is defined as a serum 25 hydroxyvitamin D level of less than 20 ng/mL and insufficiency is defined as less than 30 ng/mL. While vitamin D levels of greater than 20ng/mL are necessary for preventing bone disease, levels of greater than 30ng/mL can impart a myriad of health benefits. The National Institutes of Health recommend adults consume 600 to 800 international units of vitamin D3 per day, however this is likely not adequate to maintain vitamin D levels above 30ng/mL. I personalize vitamin D recommendations based on serum levels but also consider sun exposure and diet. Vitamin D is rarely toxic, but serum vitamin D levels of greater than 150 ng/mL are associated with hypercalcemia, hypercalciuria and hyperphosphatemia.

References

Bodnar, L. M., & Wisner, K. L. (2005) Nutrition and depression: implications for improving mental health among childbearing-aged women. Biological psychiatry. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4288963/

Geng, C. (2019) Vitamin D and depression: mechanisms, determination and application. Asia Pacific journal of clinical nutrition. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/31826364/

LaChance, L. R., & Ramsey, D. (2018) Antidepressant foods: An evidence-based nutrient profiling system for depression. World journal of psychiatry. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6147775/

Mental Illness. National Institute of Mental Health. Retrieved from: NIMH » Mental Illness (nih.gov)

Selenium. National Institute of Health. Retrieved from: https://ods.od.nih.gov/factsheets/Selenium-HealthProfessional/

Tarleton, E. K., & Littenberg, B. (2015) Magnesium intake and depression in adults. Journal of the American Board of Family Medicine. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/25748766/

Vitamin D. National Institute of Health. Retrieved from: https://ods.od.nih.gov/factsheets/vitamind-healthprofessional/

Wang, J., Um, P., Dickerman, B. A., & Liu, J. (2018) Zinc, Magnesium, Selenium and Depression: A Review of the Evidence, Potential Mechanisms and Implications. Nutrients. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5986464/

Young, L. M. (2019) A Systematic Review and Meta-Analysis of B Vitamin Supplementation on Depressive Symptoms, Anxiety, and Stress: Effects on Healthy and ‘At-Risk’ Individuals. Nutrients. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6770181/