Mental Health Information - Suicidal Ideation

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Introduction

Welcome to the ISOM webpage for suicidal ideation and suicide prevention. The purpose of this resource is to provide information on potential causes and promoters of suicidal ideation that are related to nutrition, micronutrients, and metabolism. Understanding these factors can be an important and productive part of addressing suicidal ideation and preventing suicide.

The information provided is not intended to be a substitute for medical advice from a licensed physician or other qualified healthcare professional..

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Page Contents

What is suicidal ideation?

Suicidal ideation is a term to describe one’s thoughts of engaging in suicide-related behavior (Crosby et al., n.d.)

Symptoms of suicidal ideation include:

Threatening to harm or end their life
Seeking or access to means of suicide
Expressing ideation of suicide, or wish to die
Feeling of hopelessness, worthlessness
Acting reckless and impulsive
Talking about feeling trapped
Withdrawal from family/friends

Major risk factors of suicide include:

Prior suicide attempt(s)
Misuse of alcohol and/or drugs
Mental disorders (depression, mood disorders)
Chronic disease and disability
Lack of access to care

References

Crosby, A. E., Ortega, L., & Melanson, C. (n.d.). Self Directed Violence Surveillance. 96.

Resources

Suicide Prevention Resource Center
https://www.sprc.org/

American Psychiatric Association webpage
https://www.psychiatry.org/patients-families/suicide-prevention

Medical Standard of Care for Suicide prevention

Conventional treatment for suicide prevention mainly includes (Suicide and Suicidal Thoughts – Diagnosis and Treatment – Mayo Clinic, n.d.):

psychotherapy
medications such as antidepressants, antipsychotics, and anti-anxiety medications
treatment for drug and alcohol addiction (if relevant)
encouraging family support and education

Medications used in the context of suicide prevention typically work by acting on chemicals and neurotransmitters. Mechanisms include increasing the release, decreasing the uptake, and inhibiting the breakdown of molecules such as serotonin, epinephrine, and dopamine.

The medical approach to suicide prevention can potentially miss physiological and biological factors contributing to increased risk.

“Up to 50% of patients with psychiatric complaints have been found to harbor unrecognized medical illnesses that may have contributed to their mental deterioration” (Carrigan & Lynch, 2003).

References

Carrigan, C. G., & Lynch, D. J. (2003). Managing Suicide Attempts: Guidelines for the Primary Care Physician. Primary Care Companion to The Journal of Clinical Psychiatry, 5(4), 169–174. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419387/

Suicide and suicidal thoughts—Diagnosis and treatment—Mayo Clinic. (n.d.). Retrieved December 27, 2021, from https://www.mayoclinic.org/diseases-conditions/suicide/diagnosis-treatment/drc-20378054

Why consider the orthomolecular approach?

Numerous biological causes of, and contributors to, suicidal ideation have been identified through nutritional research and clinical practice. Each individual may experience suicidal ideation for different reasons.

An orthomolecular approach:

identifies the drivers and causes of suicidal ideation and focuses on understanding them
works WITH the body to restore balance and normal function, and considers the person with the suicidal ideation vs. just the suicidal ideation
addresses nutrient depletions that promote suicidal ideation whereas medications do not
can be done SAFELY in conjunction with most medical interventions

Depression and suicidal idealation

Addressing depression, if present, is an important aspect of addressing suicide risk. Refer to the Depression webpage for in-depth information on addressing depression with an orthomolecular approach.

Contributing factors for Suicidal ideation

Contributing factors are substances, contexts or conditions that have roles in promoting increased risk of suicide idealation and suicide.

Food/Diet

Eating an unhealthy diet is known to lead to nutrient deficiencies, which, in turn, can negatively affect brain function.

Foods that promote good brain health:

whole, fresh foods
eat sufficient good quality protein (w/fish 3x week) animal + plant-based
good-quality fats
minimal amounts of starches
antioxidant-rich vegetables and fruit

Substances that are bad for brain health:

sugar-containing foods and snacks
high glycemic foods (sugars and starches)
processed fats (processed plant oils, hydrogenated fats)
artificial ingredients (colours and preservatives)
fast food meals

Diet and suicide risk

A study with 6803 adults comparing food consumption of suicide attempters and non-attempters reported that fruits, vegetables and meat were significantly underconsumed in adults who had attempted suicide (Li et al., 2009).

Healthy diets for supporting addiction recovery

Mediterranean diet

The mediterranean diet is considered a good model for a healthy diet. It includes foods that are beneficial, and also reduces or eliminates foods that promote mental health issues.
General components of the mediterranean diet include:
- plenty of vegetables and fruit
- healthy fats including olive oil
- regular consumption of seafood
- poultry, beans, and small amounts of red meat
- small amounts of dairy as yogurt and cheeses.
- whole grains instead of refined grains

More information and menu plans:

https://www.healthline.com/nutrition/mediterranean-diet-meal-plan

(Mediterranean Diet 101, 2021)

Paleo diet

Foods to eat:

meat, fish, eggs
vegetables, fruits
nuts, seeds
healthy fats and oils
herbs, spices

Foods to avoid:

sugar, high-fructose corn syrup
grains
legumes and beans
dairy products
vegetable oils, and transfats
artificial sweeteners
processed foods

More information and menu plans:

https://www.healthline.com/nutrition/paleo-diet-meal-plan-and-menu

(The Paleo Diet — A Beginner’s Guide + Meal Plan, 2018)

References

Li, Y., Zhang, J., & McKeown, R. E. (2009). Cross-sectional assessment of diet quality in individuals with a lifetime history of attempted suicide. Psychiatry Research, 165(1–2), 111–119. https://doi.org/10.1016/j.psychres.2007.09.004

Mediterranean Diet 101: Meal Plan, Foods List, and Tips. (2021, October 25). Healthline. https://www.healthline.com/nutrition/mediterranean-diet-meal-plan

The Paleo Diet—A Beginner’s Guide + Meal Plan. (2018, August 1). Healthline. https://www.healthline.com/nutrition/paleo-diet-meal-plan-and-menu

Inflammation

Inflammation is a normal part of the body’s defense to injury or infection. However, inflammation is damaging when it occurs in healthy tissues or lasts too long (months or years).

Causes of chronic inflammation include (Inflammation, n.d.):

Environmental chemicals
Poor nutrition and nutritional deficiencies
Imbalanced microbiome (dysbiosis)
Sleep issues
Stress
Personal environment

Additional sources of Inflammation (Berk et al., 2013):

• consuming the Standard American diet
• environmental toxins
• low grade infections
• sedentary lifestyle
• allergies

Inflammation and Depression

Inflammation plays a mediating role in both the risk and progression of depression (Berk et al., 2013).

Depression is a symptom of inflammation. Symptoms include (Greenblatt, 2018):

lethargy/malaise/fatigue
decreased concentration
decreased appetite
decreased interest in pleasurable things
weakness

Cytokines and Depression

Depressed patients have been found to have (Huang & Lee, 2007):

Higher levels of pro-inflammatory cytokines (TNF- α & CRP) than healthy patients
Lower levels of anti-inflammatory cytokines than healthy patients

Pro-inflammatory cytokines are responsible for activating indoleamine 2,3-dioxygenase (IDO), a tryptophan and serotonin-degrading enzyme (Müller & Schwarz, 2007). Increased levels of IDO, and increased consumption of tryptophan and serotonin, results in a reduction in serotonergic neurotransmission (Müller & Schwarz, 2007) (Greenblatt, 2018).

Inflammation and suicide

- In psychiatric patients increased inflammation is associated with increased suicidal ideation (Greenblatt, 2018)
- Patients with depression and high suicidal ideation have been shown to have significantly higher markers of inflammation including TNF-α, IL-6, and C-reactive protein (O’Donovan et al., 2013).
- Pro-inflammatory marker levels in suicide attempters (Lindqvist et al., 2009):
- - IL-6 was higher in suicide attempters than controls
  - IL-6 was highest in violent suicide attempts
  - the higher the IL-6 the higher the depression severity
- In a study assessing inflammation, people with the highest inflammation were 4.2 times more likely to die by suicide than those with the lowest inflammation (Batty et al., 2016).

Sleep loss and inflammation

In a 12-day study a moderate reduction in sleep duration is associated with a significantly increased amount of inflammatory compounds (Vgontzas et al., 2004)

Trauma and inflammation (Danese et al., 2009):

immune function is affected in a pro-inflammatory way by childhood maltreatment, abuse, social isolation, and economic hardship
people who had strsss in childhood are twice as likely to suffer chronic inflammation

IDO, cytokines (inflammation mediators), and neurotransmission

The activity of Indoleamine 2,3-dioxygenase (IDO) – an important enzyme in tryptophan metabolism – is increased by pro-inflammatory cytokines (cell-signalling molecules)
IDO decreases levels of serotonin, and in turn, melatonin (important for mood and sleep)
IDO increases the production of quinolinic acid, which increases excitatory glutamate neurotransmission

References

Batty, G. D., Kivimäki, M., Bell, S., Gale, C. R., Shipley, M., Whitley, E., & Gunnell, D. (2018). Psychosocial characteristics as potential predictors of suicide in adults: An overview of the evidence with new results from prospective cohort studies. Translational Psychiatry, 8(1), 1–15. https://doi.org/10.1038/s41398-017-0072-8

Berk, M., Williams, L. J., Jacka, F. N., O’Neil, A., Pasco, J. A., Moylan, S., Allen, N. B., Stuart, A. L., Hayley, A. C., Byrne, M. L., & Maes, M. (2013). So depression is an inflammatory disease, but where does the inflammation come from? BMC Medicine, 11(1), 200. https://doi.org/10.1186/1741-7015-11-200

Danese, A., Moffitt, T. E., Harrington, H., Milne, B. J., Polanczyk, G., Pariante, C. M., Poulton, R., & Caspi, A. (2009). Adverse childhood experiences and adult risk factors for age-related disease: Depression, inflammation, and clustering of metabolic risk markers. Archives of Pediatrics & Adolescent Medicine, 163(12), 1135–1143. https://doi.org/10.1001/archpediatrics.2009.214

Greenblatt, J. (2018, May 24). Integrative therapies for schizophrenia and psychosis. https://isom.ca/schizophrenia-psychosis/.

Huang, T.-L., & Lee, C.-T. (2007). T-helper 1/T-helper 2 cytokine imbalance and clinical phenotypes of acute-phase major depression. Psychiatry and Clinical Neurosciences, 61(4), 415–420. https://doi.org/10.1111/j.1440-1819.2007.01686.x

Inflammation. (n.d.). National Institute of Environmental Health Sciences. Retrieved August 16, 2021, from https://www.niehs.nih.gov/health/topics/conditions/inflammation/index.cfm

Lindqvist, D., Janelidze, S., Hagell, P., Erhardt, S., Samuelsson, M., Minthon, L., Hansson, O., Björkqvist, M., Träskman-Bendz, L., & Brundin, L. (2009). Interleukin-6 is elevated in the cerebrospinal fluid of suicide attempters and related to symptom severity. Biological Psychiatry, 66(3), 287–292. https://doi.org/10.1016/j.biopsych.2009.01.030

Müller, N., & Schwarz, M. (2007). The immune-mediated alteration of serotonin and glutamate: Towards an integrated view of depression. Molecular Psychiatry, 12(11). https://doi.org/10.1038/sj.mp.4002006

O’Donovan, A., Rush, G., Hoatam, G., Hughes, B. M., McCrohan, A., Kelleher, C., O’Farrelly, C., & Malone, K. M. (2013). Suicidal ideation is associated with elevated inflammation in patients with major depressive disorder. Depression and Anxiety, 30(4), 307–314. https://doi.org/10.1002/da.22087

Vgontzas, A. N., Zoumakis, E., Bixler, E. O., Lin, H.-M., Follett, H., Kales, A., & Chrousos, G. P. (2004). Adverse effects of modest sleep restriction on sleepiness, performance, and inflammatory cytokines. The Journal of Clinical Endocrinology and Metabolism, 89(5), 2119–2126. https://doi.org/10.1210/jc.2003-031562

Lifestyle factors

Some modifiable lifestyle behaviors implicated in suicide risk (Berardelli et al., 2018):

• internet addiction

• nutrition, dietary patterns

• stressful occupation or work

• sedentary, lack of exercise

• substance and alcohol abuse

• tobacco smoking

• obesity, or being underweight

Sedentary activities and suicide

More than two hours a day playing video games or using a computer has been shown to significantly increase the likelihood of sadness, hopelessness and serious consideration of suicide. (Michael et al., 2020)

Suicidal thoughts and behaviours can be increased by feelings of isolation and loneliness that come from long periods of sedentary activities (Michael et al., 2020)

Sleep disturbances and suicide

A meta analysis that included 10 studies with over 100,000 participants showed that people with psychiatric diagnoses and sleeping disturbances were more likely to report suicidal behaviours (Malik et al., 2014).

A study of college students with a history of attempted suicide showed that (Bernert et al., 2017):

78% experienced frequent insomnia
36% had recurrent nightmares
sleep disturbances predicted suicide

References

Berardelli, I., Corigliano, V., Hawkins, M., Comparelli, A., Erbuto, D., & Pompili, M. (2018). Lifestyle Interventions and Prevention of Suicide. Frontiers in Psychiatry, 9, 567. https://doi.org/10.3389/fpsyt.2018.00567

Bernert, R. A., Hom, M. A., Iwata, N. G., & Joiner, T. E. (2017). Objectively Assessed Sleep Variability as an Acute Warning Sign of Suicidal Ideation in a Longitudinal Evaluation of Young Adults at High Suicide Risk. The Journal of Clinical Psychiatry, 78(6), e678–e687. https://doi.org/10.4088/JCP.16m11193

Michael, S. L., Lowry, R., Merlo, C., Cooper, A. C., Hyde, E. T., & McKeon, R. (2020). Physical activity, sedentary, and dietary behaviors associated with indicators of mental health and suicide risk. Preventive Medicine Reports, 19, 101153. https://doi.org/10.1016/j.pmedr.2020.101153

Malik, S., Kanwar, A., Sim, L. A., Prokop, L. J., Wang, Z., Benkhadra, K., & Murad, M. H. (2014). The association between sleep disturbances and suicidal behaviors in patients with psychiatric diagnoses: A systematic review and meta-analysis. Systematic Reviews, 3, 18. https://doi.org/10.1186/2046-4053-3-18

Medications

Standard treatments for suicide prevention include antidepressants, antipsychotics, and anti-anxiety medications. These medications typically only partially reduce symptoms and some can increase the risk of suicide.

Medications and Suicidality

Glucocorticoid medication increases risk of suicidal behaviour and neuropsychiatric disorders (Fardet et al., 2012).
Side effects of antidepressant and anti-anxiety medications include insomnia and increased risk of suicide (Huang et al., 2019; Eby et al., 2011)

The use of orthomolecular nutrients in conjunction with medications can reduce medication need, reduce side effects, and increase the potential for a full recovery.

References

Eby, G. A., Eby, K. L., & Murk, H. (2011). Magnesium and major depression. In R. Vink & M. Nechifor (Eds.), Magnesium in the Central Nervous System. University of Adelaide Press. http://www.ncbi.nlm.nih.gov/books/NBK507265/

Fardet, L., Petersen, I., & Nazareth, I. (2012). Suicidal behavior and severe neuropsychiatric disorders following glucocorticoid therapy in primary care. The American Journal of Psychiatry, 169(5), 491–497. https://doi.org/10.1176/appi.ajp.2011.11071009

Huang, Q., Liu, H., Suzuki, K., Ma, S., & Liu, C. (2019). Linking What We Eat to Our Mood: A Review of Diet, Dietary Antioxidants, and Depression. Antioxidants, 8(9), 376. https://doi.org/10.3390/antiox8090376

Orthomolecular interventions for Suicidal ideation

Orthomolecular interventions are substances like vitamins and minerals that have roles in promoting or addressing suicidal ideation, depending on the amount present in the body.

Vitamins

Vitamin D

Vitamin D, which is made from cholesterol in the skin and UVB radiation, is a neurosteroid hormone that has roles in brain development and normal brain function.

Vitamin D and mental health

Vitamin D regulates the transcription of genes involved in pathways for synaptic plasticity, neuronal development and protection against oxidative stress (Graham et al., 2015).
Vitamin D-deficient cells produce higher levels of the inflammatory cytokines TNF-α and IL-6, while cells treated with vitamin D release significantly less.
In the adrenal glands, vitamin D regulates tyrosine hydroxylase, which is the rate-limiting enzyme for the synthesis of dopamine, epinephrine, and norepinephrine.
In the brain, vitamin D regulates the synthesis, release, and function of serotonin. Serotonin modulates executive function, sensory gating, social behaviour, and impulsivity (Patrick & Ames, 2015).

Vitamin D and prevention of suicidal ideation

Roles of vitamin D in prevention of suicidal ideation include reduction of pro-inflammatory cytokines and oxidative stress, and neurotransmitter synthesis ans regulation in the brain and gut.

Vitamin D deficiency is common

70% of adults and 67% of children in the United States have inadequate vitamin D levels, even when supplementation is taken into consideration (Patrick & Ames, 2015)

Vitamin D, inflammation, and suicide risk

Inflammation is a risk factor for suicide.
Vitamin D-deficient cells have increased levels of the the pro-inflammatory compounds
TNF-a and IL-6 CRP (Greenblatt, 2018).
A study of vitamin D levels and inflammation in people who had attempted suicide found that 58% of the suicide attempters were vitamin D deficient. The study authors proposed that “routine clinical testing of vitamin D levels could be beneficial in patients with suicidal symptoms, with subsequent supplementation in patients found to be deficient” (Grudet et al., 2014).

Vitamin D and serotonin

Two enzymes that are key for serotonin production are tryptophan hydroxylase 1 and 2 (TPH1 and TPH2):

- TPH1 produces most of the serotonin found in the body
- TPH2 produces all of the serotonin in the brain
Deficiency of vitamin D suppresses TPH2 and activates TPH1 which results in reduced serotonin synthesis and increased inflammation in the body
Low serotonin is associated with increased anxiety, depression, and affective dysregulation (Greenblatt, 2018)

Causes of vitamin D deficiency

limited sun exposure
strict vegan diet (most sources of vitamin D are animal-based)
darker skin (the pigment melanin reduces the vitamin D production by the skin)
digestive tract and kidney issues
obesity (vitamin D is sequestered by fat cells)

Measuring vitamin D

The best indicator of vitamin D status is serum 25(OH)D, also known as 25-hydroxyvitamin D. 25(OH)D reflects the amount of vitamin D in the body that is produced by the skin and obtained from food and supplements.

Vitamin D levels and health status

Institute of Medicine, Food and Nutrition Board. (2010)

Serum (ng/ml) and Health status

<20 deficient 20–39 generally considered adequate 40–50 adequate >50–60 proposed optimum health level

>200 potentially toxic

Top sources of vitamin D based on serving size (Office of Dietary Supplements – Vitamin D, 2020)

cod liver oil
trout
pink salmon
sardines
fortified cereal, milk, and orange juice
fortified almond, soy, and oat milks
egg yolk

Comprehensive food list

Table 3: Vitamin D Content of Selected Foods https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

Referenced Dietary Intakes

RDAs for vitamin D (IU/day)

Adolescents (14-18 years): 600 (M) 600 (F)

Adults (19-50 years): 600 (M) 600 (F)

Adults (51 years and older): 800 (M) 800 (F)

Tolerable Upper Intake: 4000 IU/day

(Office of dietary supplements, 2020)

Vitamin D supplementation

Amounts of vitamin D used in practice and research range from 400-14,000 IU/day. (Vitamin D, 2014)

SAFETY, SIDE EFFECTS (Vitamin D, 2014)

“Research suggests that vitamin D toxicity is very unlikely in healthy people at intake levels lower than 10,000 IU/day”
Vitamin D can increase risk of hypercalcemia with calcium-related medical conditions – including primary hyperparathyroidism, sarcoidosis, tuberculosis, and lymphoma
Certain medical conditions can increase the risk of hypercalcemia in response to vitamin D, including primary hyperparathyroidism, sarcoidosis, tuberculosis, and lymphoma

Some drugs that affect vitamin D absorption or metabolism include (Vitamin D, 2014):

cholestyramine
colestipol
orlistat
mineral oil
phenytoin
fosphenytoin
phenobarbital
carbamazepine
rifampin
cimetidine
ketoconazole
glucocorticoids
HIV treatment drugs

References

Graham, K. A., Keefe, R. S., Lieberman, J. A., Calikoglu, A. S., Lansing, K. M., & Perkins, D. O. (2015). Relationship of low vitamin D status with positive, negative and cognitive symptom domains in people with first‐episode schizophrenia. Early Intervention in Psychiatry, 9(5), 397-405.

Greenblatt, J. (2018, May 24). Integrative therapies for schizophrenia and psychosis. https://isom.ca/schizophrenia-psychosis/.

Grudet, C., Malm, J., Westrin, A., & Brundin, L. (2014). Suicidal patients are deficient in vitamin D, associated with a pro-inflammatory status in the blood. Psychoneuroendocrinology, 50, 210–219. https://doi.org/10.1016/j.psyneuen.2014.08.016

Institute of Medicine, Food and Nutrition Board. (2010). Dietary reference intakes for calcium and vitamin D. Washington, DC: National Academy Press.

Office of Dietary Supplements—Vitamin D. (2020). https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

Patrick, R. P., & Ames, B. N. (2015). Vitamin D and the omega-3 fatty acids control serotonin synthesis and action, part 2: relevance for ADHD, bipolar disorder, schizophrenia, and impulsive behavior. The FASEB Journal, 29(6), 2207- 2222.

Vitamin D. (2014, April 22). Linus Pauling Institute. https://lpi.oregonstate.edu/mic/vitamins/vitamin-D

Minerals

Lithium

Lithium and mental health

Lithium (Greenblatt, 2018):

protects neurons from damage
stimulates growth of new neurons
has anti-inflammatory properties
inhibits glutamate synthesis and release
modulates dopamine by decreasing its release
stimulates production of GABA and GABA receptors
increases levels of brain serotonin

Lithium and suicide

Higher amounts of lithium in drinking water are related to lower amounts of suicide (Ohgami et al., 2009; Schrauzer & Shrestha, 1990).
An examination of 31 studies with patients with major affective disorders showed lithium treatment was associated with an 80% decreased risk of completed or attempted suicide (Baldessarini et al., 2006).

Nutritional lithium

Lithium orotate (Kling et al., 1978):

has been used to treat stress, manic depression, alcoholism, ADD, ADHD, PTSD, and Alzhiemer’s disease
can be used at much lower doses than medical lithium
has fewer side effects

Nutritional lithium supplementation

Medical lithium is a mood stabilizer used in the context of manic episode of bipolar disorder. Medical dosing for lithium prescriptions is typically between 900 and 1800 mg a day (Lithium, n.d.).
Nutritional lithium as lithium orotate and lithium aspartate have been shown to be beneficial. Dosing ranges from 2–30 mg a day. (Greenblatt, 2015)
Important: medical lithium should not be reduced or eliminated without the supervision of a medical health professional.

References

Greenblatt, J. (2018, May 24). Integrative therapies for schizophrenia and psychosis. https://isom.ca/schizophrenia-psychosis/.

Greenblatt, J. (2015, April 26). Low dose lithium for the treatment of mood, behavioural, and cognitive disorders. Orthomolecular Medicine Today Conference, Toronto, Canada.

Lithium: Drug Uses, Dosage and Side Effects. (n.d.). Drugs.Com. Retrieved December 27, 2021, from https://www.drugs.com/lithium.html

Ohgami, H., Terao, T., Shiotsuki, I., Ishii, N., & Iwata, N. (2009). Lithium levels in drinking water and risk of suicide. The British Journal of Psychiatry: The Journal of Mental Science, 194(5), 464–465; discussion 446. https://doi.org/10.1192/bjp.bp.108.055798

Schrauzer, G. N., & Shrestha, K. P. (1990). Lithium in drinking water and the incidences of crimes, suicides, and arrests related to drug addictions. Biological Trace Element Research, 25(2), 105–113. https://doi.org/10.1007/BF02990271

Magnesium

Magnesium and mental health

Magnesium in the context of mental health (Kirkland, Sarlo, & Holton, 2018)

calms neurotransmission by regulating glutamate and GABA
modulates the HPA axis
has roles in the synthesis of serotonin and dopamine
regulates cortisol levels
increases brain-derived neurotrophic factor (BDNF)
is required for enzyme systems that use thiamine (vitamin B1) and pyridoxine (vitamin B6) – these vitamins are cofactors in the production of serotonin, GABA, and melatonin (Kanofsky, & Sandyk, 1991)
decreases activation of the NMDA receptor which in turn, decreases excitatory neurotransmission (Bartlik, Bijlani, & Music, 2014)

Magnesium and suicide risk

Magnesium deficiency is associated with major and suicidal depression (Eby & Eby, 2006).

Causes of magnesium deficiencies include:

loss of soil magnesium due to farming practices
following the standard American diet pattern, as it is high in processed and nutrient-deficient foods,
decreased magnesium levels in foods, especially cereal grains (Guo, Nazim, Liang, & Yang, 2016)
low dietary protein (needed for magnesium absorption)
gastrointestinal disorders (e.g. Crohn’s disease, malabsorption syndromes, and prolonged diarrhea)
stress, which causes magnesium to be lost through urine (Deans, 2011), and
chronically elevated cortisol, which depletes magnesium (Cuciureanu, & Vink, 2011).
high doses of supplemental zinc (competes for absorption)
alcoholism
certain diuretic medications
lower dietary intake, absorption, and increased loss of magnesium (common in the elderly)

Top sources of magnesium based on serving size

Brazil nuts
oat bran
brown rice (whole grain)
mackerel

Comprehensive food list:

Table 2. Some Food Sources of Magnesium (Magnesium, 2014)

https://lpi.oregonstate.edu/mic/minerals/magnesium

Referenced Dietary Intakes

RDAs for magnesium (mg/day)

Adolescents (14-18 years): 410 (M) 360 (F)

Adults (19-30 years): 400 (M) 310 (F)

Adults (31 years and older): 420 (M) 320 (F)

Supplementing magnesium

Amounts of magnesium used in practice and research range from 100–750 mg a day in divided doses (elemental magnesium dose).
Correction of magnesium deficiency with magnesium supplementation has resulted in significant improvement in psychiatric symptoms (Kanofsky & Sandyk, 1991).

Magnesium supplementation – beneficial forms and dosing (Greenblatt, 2018)

Magnesium glycinate supplementation of 120-240 mg per meal and at bedtime has been shown to benefit mood
Magnesium glycinate or citrate supplementation of 240-360 mg before bed supports sleep onset and sleeping through the night
Some beneficial forms of magnesium include magnesium aspartate, magnesium glycinate, magnesium threonate
The magnesium oxide form is less beneficial

SAFETY, SIDE EFFECTS

Side effects of magnesium supplementation are rare, but can include a laxative effect, dizziness or faintness, sluggishness, cognitive impairment, and depression.
An effective strategy for dosing magnesium is to gradually increase the amount to bowel tolerance, then reduce slightly.
Magnesium is best taken in divided doses throughout the day. Caution is required for high doses of magnesium with existing kidney disease.

References

Bartlik, B., Bijlani, V., & Music, D. (2014, July 22). Magnesium: An essential supplement for psychiatric patients—Psychiatry Advisor. Psychiatry Advisor. https://www.psychiatryadvisor.com/home/therapies/magnesium-an-essential-supplement-for-psychiatric-patients/

Cuciureanu, M. D., & Vink, R. (2011). Magnesium and stress. In R. Vink & M. Nechifor (Eds.), Magnesium in the Central Nervous System. University of Adelaide Press. http://www.ncbi.nlm.nih.gov/books/NBK507250/

Deans, E. (2011, June 12). Magnesium and the brain: The original chill pill. Psychology Today.
http://www.psychologytoday.com/blog/evolutionary-psychiatry/201106/magnesium-and-the-brain-the-original-chill-pill

Eby, G. A., & Eby, K. L. (2006). Rapid recovery from major depression using magnesium treatment. Medical Hypotheses, 67(2), 362–370. https://doi.org/10.1016/j.mehy.2006.01.047

Greenblatt, J. (2018). Orthomolecular Applications in Integrative Psychiatry, Depression [Pdf].

Guo, W., Nazim, H., Liang, Z., & Yang, D. (2016). Magnesium deficiency in plants: An urgent problem. The Crop Journal, 4(2), 83–91. https://doi.org/10.1016/j.cj.2015.11.003

Kanofsky, J. D., & Sandyk, R. (1991). Magnesium Deficiency in Chronic Schizophrenia. International Journal of Neuroscience, 61(1–2), 87–90. https://doi.org/10.3109/00207459108986275

Kirkland, A. E., Sarlo, G. L., & Holton, K. F. (2018). The Role of Magnesium in Neurological Disorders. Nutrients, 10(6). https://doi.org/10.3390/nu10060730

Magnesium. (2014, April 23). Linus Pauling Institute. https://lpi.oregonstate.edu/mic/minerals/magnesium

Fatty acids and lipids

Cholesterol

Cholesterol is a lipid molecule. Approximately 80% made by the body and the rest comes from food.

Cholesterol and mental health:

Cholesterol (Greenblatt, 2018):

is required for the production of bile, vitamin D, and all steroid hormones
activates serotonin and oxytocin receptors
is an important component of brain-cell membranes

Low Cholesterol is associated with (Greenblatt, 2018).

increased incidence of stroke
increased violent behavior and aggression
increased difficulty recovering from drug addiction
anxiety, depression, and suicide

Cholesterol and Serotonin

Low cholesterol levels decrease serotonin affect the function of serotonin receptors. Serotonin receptors regulate (Chattopadhyay et al., 2007):

sleep
aggression
anxiety
eating behavior

Cholesterol and suicide

A 15-year study of over 4000 American veterans found (Boscarino et al., 2009):
- men with low total cholesterol and depression were seven times more likely to die from suicide and accidents
- with major depressive disorder, there was a significant correlation between low plasma cholesterol and suicidal behaviour
In a study of males with PTSD, higher serum total cholesterol was associated with decreased risk of suicidal ideation (Vilibić et al., 2014).
Over 500 inpatient records showed that patients who had attempted suicide had significantly lower serum cholesterol than non-suicidal patients (Modai et al., 1994).

Causes of low cholesterol

Risk factors for low cholesterol include (Elmehdawi, 2008):

malabsorption
chronic inflammation
acute or chronic infection
hyperthyroid
chronic liver disease
statin medications

References

Boscarino, J., Erlich, P., & Hoffman, S. (2009). Low serum cholesterol and external-cause mortality: Potential implications for research and surveillance. Journal of Psychiatric Research, 43, 848–854. https://doi.org/10.1016/j.jpsychires.2008.11.007

Chattopadhyay, A., Paila, Y., Jafurulla, M., Chaudhuri, A., Singh, P., Murty, M., & Vairamani, M. (2007). Differential effects of cholesterol and 7-dehydrocholesterol on ligand binding of solubilized hippocampal serotonin1A receptors: Implications in SLOS. Biochemical and Biophysical Research Communications, 363, 800–805. https://doi.org/10.1016/j.bbrc.2007.09.040

Elmehdawi, R. (2008). Hypolipidemia: A Word of Caution. The Libyan Journal of Medicine, 3(2), 84–90. https://doi.org/10.4176/071221

Greenblatt, J. (2018, May 24). Integrative therapies for schizophrenia and psychosis. https://isom.ca/schizophrenia-psychosis/.

Modai, I., Valevski, A., Dror, S., & Weizman, A. (1994). Serum cholesterol levels and suicidal tendencies in psychiatric inpatients. The Journal of Clinical Psychiatry, 55(6), 252–254.

Vilibić, M., Jukić, V., Pandžić-Sakoman, M., Bilić, P., & Milošević, M. (2014). Association between total serum cholesterol and depression, aggression, and suicidal ideations in war veterans with posttraumatic stress disorder: A cross-sectional study. Croatian Medical Journal, 55(5), 520–529. https://doi.org/10.3325/cmj.2014.55.520

EPA and DHA

Essential fatty acids and mental health

Polyunsaturated fatty acids (PUFAs) (omega 3 and 6 fatty acids) are necessary for normal development and function of the brain.
Omega 3 fatty acids and their metabolites have roles in regulating inflammation, neuroinflammation, and neurotransmission (Larrieu, & Layé, 2018).

Omega 3 and 6 fatty acids and suicide risk

Deficiencies in omega-3s can result in a 50% reduction of serotonin and dopamine in the frontal cortex and nucleus accumbens of animal brains (Brunner et al., 2002)

A study of depressed people who were medication free for 2 years found that low amounts of the omega 3 fatty acid DHA, and a high amounts omega 6 to 3 fatty acids predicted suicide attempts (Sublette et al., 2006).

Deficiency of Omega-3 fatty acids have been correlated with (Hibbeln & Gow, 2014):

a 25 percent increased risk of suicide
2.6 times increased risk of depression
1.5 times increased risk of suicidal ideations

Deficiency of essential fatty acids is associated with (Greenblatt, 2018)

• digestive tract problems

• inflammation

• anxiety

• depression

• aggression

• distorted perceptions

• increased risk of suicide

Reasons for EFA deficiencies

Inadequate dietary intake
Poor absorption
Deficiencies of nutrients required for EFA metabolism
Issues with metabolism that cause decreased incorporation of, or increased removal of, fatty acids from cell membranes

Top EPA and DHA (omega 3) food sources by serving size

herring, pacific
salmon, chinook
sardines, pacific
salmon, atlantic
oysters, pacific

Comprehensive food list:

Table 4. Food Sources of EPA (20:5n-3) and DHA (22:6n-3) (Office of Dietary Supplements, n.d.)

https://lpi.oregonstate.edu/mic/other-nutrients/essential-fatty-acids

Top α-Linolenic Acid (omega 3) food sources by serving size

flax seed oil
chia seeds
walnuts
flax seeds ground

Comprehensive food list:

Table 3. Food Sources of α-Linolenic Acid (18:3n-3) (Office of Dietary Supplements, n.d.)

https://lpi.oregonstate.edu/mic/other-nutrients/essential-fatty-acids

Top Linoleic Acid (omega-6) sources by serving size

safflower oil
sunflower seeds
pine nuts
sunflower oil

Comprehensive food list: Table 2. Food Sources of Linoleic Acid (18:2n-6)

(Office of Dietary Supplements, n.d.)

Commonly suggested amounts for dietary fatty acid consumption:

cold water fish – 2 to 3 times a week, or
flaxseed oil – 2 to 6 tbsp daily, or
ground flax seed – 2 tbsp daily

Flaxseed oil may have negative effects in about 3% people, including: hypomania, mania, behaviour changes. (Prousky, 2015)

Referenced Dietary Intakes

Adequate Intakes for Alpha linolenic acid (Omega 3) (g/day) (Institute of Medicine, 2002)

Adolescents (14–18 years): 1.6 (M) 1.1 (F)

Adults (19 years and older): 1.6 (M) 1.1 (F)

Recommendations for long-chain omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) (mg/day) (European Food Safety Authority, 2009)

Adults: 250 mg/day (M+F)

Supplementing omega 3 fatty acids

Supplementation of omega 3 fatty acids seems beneficial for addressing depression (Bruinsma & Taren, 2000).
Amounts of omega 3 fatty acids used in practice and research range from 1–4 g/day of combined EPA and DHA, in divided doses.
Fish oil and E-EPA are generally well tolerated, but may cause gastrointestinal side effects in some individuals (Gaby)
Long-term supplementation with EPA and DHA should be accompanied by a vitamin E supplement (Gaby), as polyunsaturated fatty acids increase vitamin E requirements in the body.

In a study patients who took omega 3 supplements with antidepressant medication, 44% patients achieved full remission versus 18% of the placebo group (Gertsik et al., 2012).
It takes at least 10 weeks to restore brain levels of EPA and DHA after chronic deficiency (Bourre et al., 1993).

SAFETY, SIDE EFFECTS

Common side effects of high dose EPA and DHA supplementation include heartburn, nausea, gastrointestinal discomfort, diarrhea, headache, and odoriferous sweat
The European Food Safety Authority considers long-term consumption of EPA and DHA supplements at combined doses of up to about 5 g/day to be safe.
The FDA recommends not exceeding 3 g/day EPA and DHA combined, with up to 2 g/day from dietary supplements (Office of Dietary Supplements, n.d.).

OMEGA 3 FATTY ACIDS AND MEDICATIONS

Use caution when supplementing omega 3 fatty acids while taking blood-thinning medications, or blood-sugar issues (Essential fatty acids, 2014).

References

Bruinsma, K. A., & Taren, D. L. (2000). Dieting, Essential Fatty Acid Intake, and Depression. Nutrition Reviews, 58(4), 98–108. https://doi.org/10.1111/j.1753-4887.2000.tb07539.x

Brunner, J., Parhofer, K. G., Schwandt, P., & Bronisch, T. (2002). Cholesterol, essential fatty acids, and suicide. Pharmacopsychiatry, 35(1), 1–5. https://doi.org/10.1055/s-2002-19834

Essential Fatty Acids. (2014, April 28). Linus Pauling Institute. https://lpi.oregonstate.edu/mic/other-nutrients/essential-fatty-acids

European Food Safety Authority. Labelling reference intake values for n-3 and n-6 polyunsaturated fatty acids. (2009, July 10). https://www.efsa.europa.eu/en/efsajournal/pub/1176

Institute of Medicine. (2002). Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. https://doi.org/10.17226/10490

Gaby, A. R. (2011). Nutritional Medicine (VitalBook file).

Larrieu, T., & Layé, S. (2018). Food for Mood: Relevance of Nutritional Omega-3 Fatty Acids for Depression and Anxiety. Frontiers in Physiology, 9. https://doi.org/10.3389/fphys.2018.01047

Greenblatt, J. (2018, May 24). Integrative therapies for schizophrenia and psychosis. https://isom.ca/schizophrenia-psychosis/.

Hibbeln, J. R., & Gow, R. V. (2014). The Potential for Military Diets to Reduce Depression, Suicide, and Impulsive Aggression: A Review of Current Evidence for Omega-3 and Omega-6 Fatty Acids. Military Medicine, 179(11S), 117–128. https://doi.org/10.7205/MILMED-D-14-00153

Office of Dietary Supplements—Omega-3 Fatty Acids. (n.d.). Retrieved October 29, 2020, from https://ods.od.nih.gov/factsheets/Omega3FattyAcids-HealthProfessional/

Prousky J, (2015) Anxiety: Orthomolecular diagnosis and treatment, Kindle Edition. CCNM Press.

Sublette, M. E., Hibbeln, J. R., Galfalvy, H., Oquendo, M. A., & Mann, J. J. (2006). Omega-3 polyunsaturated essential fatty acid status as a predictor of future suicide risk. The American Journal of Psychiatry, 163(6), 1100–1102. https://doi.org/10.1176/ajp.2006.163.6.1100

Amino acids

Tryptophan/5-HTP

Tryptophan and 5-HTP and mental health

Serotonin, regarded as the happy, feel good neurotransmitter, is synthesized from the amino acid tryptophan. Tryptophan is converted in the body to 5-HTP, which is then converted into the neurotransmitter serotonin.

Serotonin and suicide

low levels of serotonin can contribute to general lack of sensitivity to consequences which can trigger risky, impulsive and aggressive behaviours, that may culminate in suicide (Rao et al., 2008).

Food sources of tryptophan

Common sources of tryptophan (Richard et al. 2009):

turkey
chicken
tuna
oats
peanuts

Referenced Dietary Intakes

The recommended daily allowance for tryptophan for adults is estimated to be between 250 mg/day and 425 mg/day (Richard et al. 2009).

1. Supplementing tryptophan

Amounts of tryptophan used in practice and research range from 50–6000 mg/day in divided doses.
Carbohydrate consumption increases the amount of TRP that crosses the Blood Brain Barrier (BBB) (Richard et al., 2009). Therefore tryptophan is best taken away from meals, but with a small amount of carbohydrate to facilitate absorption. 5-HTP transport across the Blood-Brain Barrier (BBB) is not affected by dietary protein consumption and can be taken with meals (Werbach, 1997).
The optimal dose of tryptophan has been found in practice to be 2 g/day, taken with vitamin B6 (Prousky, 2015).

L-tryptophan increases serotonin levels, suggesting that it is most likely to be effective in serotonin-deficient patients. This includes patients with a history of a positive response to SSRIs or other serotonergic drugs (Gaby).
A dosage of 6 g/day or less is recommended when L-tryptophan is used by itself, and 4 g/day or less is recommended when given in combination with 2 g/day of niacinamide. These should be given in two separate doses per day to minimize fluctuation of tryptophan concentration (Chouinard et al., 1977) (Chouinard et al., n.d.).
The dose required can be reduced by administering L-tryptophan and niacinamide on an empty stomach along with carbohydrates. (Gaby)
L-tryptophan may cause fatigue. When this is experienced, the addition of 500 mg of L-tyrosine twice a day in addition to the L-tryptophan dose can prevent the fatigue and potentially increase the antidepressant effect of L-tryptophan. (Gaby)
For tryptophan-deficent individuals, L-tryptophan supplementation can provide a larger range of benefits than supplementation with 5-HTP.

SAFETY, SIDE EFFECTS – Tryptophan

Side effects of L-tryptophan supplementation can include heartburn, stomach pain, belching and gas, nausea, vomiting, diarrhea, and loss of appetite, headache, lightheadedness, drowsiness, dry mouth, visual blurring, muscle weakness, and sexual problems in some people (L-Tryptophan: Uses, Side Effects, n.d.).
High doses of tryptophan can promote bronchial asthma aggravation and nausea.
Tryptophan should not be used during pregnancy, with lupus, or with adrenal insufficiency (Prousky, 2015).
Co-administering L-tryptophan and antidepressants that increase serotonergic activity (SSRIs, amitriptyline, monoamine oxidase inhibitors) may increase the efficacy and toxicity of the drugs (Gaby).

TRYPTOPHAN AND MEDICATIONS

Supplementing tryptophan or 5-HTP while on SSRI or MAOI medications is not generally recommended as it may promote an excessive buildup of serotonin (Birdsall, 1998).
Do not supplement tryptophan if taking morphine (Prousky, 2015)
Avoid taking tryptophan or 5-HTP (or limit to very low doses) if receiving electroconvulsive therapy (Gaby)

2. Supplementing 5-HTP

Referenced Dietary Intakes

RDAs/Upper intakes for 5-HTP

None established.

Amounts of 5-HTP used in practice and research range from 100–900 mg/day in divided doses (Prousky, 2015; Rakel, 2012).
5-HTP can be taken with meals, as opposed to tryptophan, which needs to be taken away from meals.
Common amounts of 5-HTP used for addressing anxiety range from 100 to 900 mg daily in divided doses (Prousky, 2015; Rakel, 2012).

SAFETY, SIDE EFFECTS – 5-HTP

Side effects of 5-HTP supplementation are typically minimal and can include heartburn, flatulence, rumbling sensations, feeling of fullness, mild, nausea, vomiting, and hypomania (Werbach 1999: Murray & Pizzorno, 1998, p. 391-93)
Other possible side effects include, stomach pain, diarrhea, drowsiness, sexual problems, and muscle problems (5-Htp: Uses, Side Effects, n.d.).
High-dose supplementation – from 6-10 grams daily – have been linked to severe stomach problems and muscle spasms (5-HTP: Uses, Side Effects, n.d.).

5-HTP AND MEDICATIONS

Supplementing tryptophan or 5-HTP while on SSRI or MAOI medications is not generally recommended as it may cause an excessive buildup of serotonin (Birdsall, 1998).
Avoid taking tryptophan or 5-HTP (or limit to very low doses) if receiving electroconvulsive therapy (Gaby)

References

5-HTP: Uses, Side Effects, Interactions, Dosage, and Warning. (n.d.). Retrieved October 29, 2020, from https://www.webmd.com/vitamins/ai/ingredientmono-794/5-htp

Birdsall, T. C. (1998). 5-Hydroxytryptophan: A clinically-effective serotonin precursor. Alternative Medicine Review: A Journal of Clinical Therapeutic, 3(4), 271–280.

Chouinard, G., Young, S. N., Annable, L., & Sourkes, T. L. (1977). Tryptophan-nicotinamide combination in depression. Lancet (London, England), 1(8005), 249. https://doi.org/10.1016/s0140-6736(77)91036-4

Chouinard, G., Young, S. N., Annable, L., & Sourkes, T. L. (n.d.). Tryptophan-nicotinamide, imipramine and their combination in depression. Acta Psychiatrica Scandinavica, 59(4), 395–414. Retrieved August 26, 2021, from https://www.academia.edu/24627244/Tryptophan_nicotinamide_imipramine_and_their_combination_in_depression

Gaby, A. R. (2011). Nutritional Medicine (VitalBook file).

L-Tryptophan: Uses, Side Effects, Interactions, Dosage, and Warning. (n.d.). Retrieved October 29, 2020, from https://www.webmd.com/vitamins/ai/ingredientmono-326/l-tryptophan

Murray, M., & Pizzorno J. (1998). Encyclopedia of Natural Medicine. Revised 2nd ed. Rocklin, CA: Prima Publishing.

Prousky J, (2015) Anxiety: Orthomolecular diagnosis and treatment. CCNM Press.

Rakel, D., (2012). Integrative Medicine (3rd ed.). Elsiver.

Rao, T. S. S., Asha, M. R., Ramesh, B. N., & Rao, K. S. J. (2008). Understanding nutrition, depression and mental illnesses. Indian Journal of Psychiatry, 50(2), 77–82. https://doi.org/10.4103/0019-5545.42391

Richard, D. M., Dawes, M. A., Mathias, C. W., Acheson, A., Hill-Kapturczak, N., & Dougherty, D. M. (2009). L-Tryptophan: Basic Metabolic Functions, Behavioral Research and Therapeutic Indications. International Journal of Tryptophan Research : IJTR, 2, 45–60.

Werbach, M. R. (1997). Adverse effects of nutritional supplements. Foundations of Nutritional Medicine. Tarzanna, CA: Third Line Press, Inc,.

Resources

This section contains useful information and tools for exploring the orthomolecular approach to addressing suicidal ideation.

Basic first steps

BASIC FIRST STEPS

1. Supplement nutrients for prevention of suicidal ideation:

Vitamin D
Reason: regulates serotonin production, protects against neuronal oxidative stress
Typical dosing: 1000–5000 IU

Magnesium
Reason: calms neurotransmission, anti-stress, serotonin and dopamine production
Typical dosing: 100–750 mg/day

Lithium orotate or lithium aspartate
Reason: mood stabilizer, anti-inflammatory, increases serotonin and GABA
IMPORTANT: work with a medical professional if currently taking lithium medication

Fish oil
Reason: anti-inflammatory, brain supportive
Typical dosing: 1000–4000 mg (of fish oil)

Tryptophan/5-HTP
Reason: addresses serotonin deficiencies
Typical dosing:
Tryptophan 500–2000 mg/day,
5-HTP 100-300 mg/ 3x day
Important: use with caution if taking SSRI medications

2. Supplement basic supporting nutrients for mental health:

Vitamin C
Reason: antioxidant, anti-inflammatory, supports neurotransmitter production
Typical dosing: 1000–6000 mg/day

Multivitamin
Reason: broad spectrum nutrient support
Typical dosing: 1–2x day

AND/OR

B-complex
Reason: full spectrum of B-vitamins, supports brain function, blood sugar control
Typical dosing: B50 2–4/day

3. Eat a healthy diet