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Jurnal Asam Folat
www.elsevier.com/locate/psychres
PII: S0165-1781(16)31441-X
DOI: http://dx.doi.org/10.1016/j.psychres.2017.04.032
Reference: PSY10458
To appear in: Psychiatry Research
Received date: 25 August 2016
Revised date: 14 April 2017
Accepted date: 20 April 2017
Cite this article as: Erman Esnafoğlu and Elif Yaman, Vitamin B12, folic acid,
homocysteine and vitamin D levels in children and adolescents with obsessive
compulsive disorder, Psychiatry Research,
http://dx.doi.org/10.1016/j.psychres.2017.04.032
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Vitamin B12, folic acid, homocysteine and vitamin D levels in children and
a
Department of Child and Adolescent Psychiatry, Training and Research
b
Department of Pediatry, Training and Research Hospital, Faculty of Medicine,
Abstract
folic acid and homocysteine has been investigated in many psychiatric disorders like
OCD. In recent years, vitamin D has also been considered to contribute to many of
homocysteine and vitamin D play a role in the aetiology of paediatric OCD. With this
aim we compared 52 children and adolescent OCD patients with 30 healthy controls.
The participants were tested for vitamin B12, folic acid, homocysteine and vitamin D
levels and were evaluated with a sociodemographic form, state-trait anxiety inventory
(Y-BOCS). As a result we found significantly lower levels of vitamin B12 and vitamin
D and higher levels of homocysteine in the patient group compared to control group
(p values for all three scores were <0.001), whereas there was no significant
difference between groups in terms of folate levels (p=0.083). This demonstrates that
one carbon metabolism and vitamin D deficiency can play a role in the aetiology of
OCD.
vitamin D, aetiopathogenesis,
1. Introduction
by obsessions (all kinds of images and impulses that are involuntary and persistent)
and compulsions (repetitive involuntary behaviours that are performed to clear the
mind of the obsessive thoughts and to eliminate the stress caused by them)
(Douglass et al., 1995; Flament, 1990; Heyman et al., 2001; Jaisoorya et al.,
2015; Zohar et al., 1992). Adolescents with OCD have greater psychological distress
and poorer academic performance together with higher rates of suicidal thoughts,
suicide attempts, attention deficit and hyperactivity, sexual abuse and tobacco use
(Jaisoorya et al., 2015). OCD is a complex psychiatric disorder that may occur due
Vitamin B12, folic acid and homocysteine levels were shown to be associated
with certain neuropsychiatric disorders and vitamin B12, folate deficiency and high
levels of homocysteine were shown to have an impact on brain functions and cause
non-specific psychiatric symptoms. Many studies found high levels of homocysteine,
low levels of vitamin B12 and/ or folic acid in patients with schizophrenia
(Haidemenos et al., 2007; Kim and Moon 2010; Mabrouk et al., 2011;
Muntjewerff et al., 2006, Zhang et al., 2016), autism (Al-Farsi et al., 2013; Ali et
al., 2011; Puig-Alcaraz et al., 2015; Tu et al., 2013; Zhang et al., 2016) and
with schizophrenia and mood disorders (Kevere et al., 2012). In a few studies on
adult patients with OCD, there is some evidence of increased homocysteine, deficient
levels of folic acid and vitamin B12 in adult patients with OCD (Atmaca et al., 2005;
Türksoy et al., 2014). Also cases of OCD that are due to a vitamin B12 deficiency
have been reported (Sharma and Biswas, 2012; Valizadeh and Valizadeh, 2011).
and vitamin B12 (Folstein et al., 2007; Klee, 2000; Nilsson et al., 1999).
role in the aetiology of schizophrenia and autism (Crews et al., 2013; Feng et al.,
2016; McGrath et al., 2010; Saad et al., 2015; Valipour et al., 2014; Wang et al.,
anxiety disorders (Anglin et al., 2013; Berk et al., 2007; Bertone-Johnson, 2009;
Bicikova et al., 2015; Milaneschi et al., 2013). In the last few years, many reports
demonstrating an important role for vitamin D in brain development and functions and
deficiency in children and adolescents with OCD has not yet been investigated. For
this reason we aimed to investigate serum vitamin B12, folic acid homocysteine and
All subjects were patients who attended the outpatient clinic for children and
Participants in the patient group were diagnosed according to DSM V criteria. Healthy
control subjects were chosen from patients with minor issues that were admitted to
psychologists blind to the study. Besides routine laboratory tests (thyroid function
tests, hemogram, routine biochemistry), vitamin B12, folic acid, homocysteine and
vitamin D levels were measured. Blood samples were collected from all participants
between 08:00 and 11:00 in the morning under sterile conditions. To obtain more
accurate results those participants who had used a nutritional support product in the
last year and who were vegetarians were not included in the study. Additionally,
those with infection, psychotic disorders, and subjects with diagnosis of mental
retardation and developmental disorder were excluded from the study. This study
Informed consent was obtained from all participants and their families.
This scale was developed to evaluate the degree of severity of the OCD,
1989). On this scale, 10 parameters are scored between 0 (no symptoms) and 4
(extreme symptoms). Turkish validity and reliability studies of the scale, which is
accepted as a reliable and valid tool for evaluating the severity of OCD, were
indicate mild disease, scores from 16 to 23 indicate moderate disease, and scores
This inventory was developed by M. Kovacs with the hypothesis that ‘child
adult depression (Kovacs, 1985). The validity of this questionnaire for Turkish
speaking children and adolescents aged 6-17 was demonstrated by Öy et al. in 1991
(Öy, 1991). The depression scale for children can be applied to children aged 6-17
years. It consists of 27 items in total. The cut off value was determined as 19. The
scale is completed by the child himself/herself or it is read to the child. The child is
asked to choose the most representative option from three available sentences
considering his/her situation in the last 2 weeks. Given answers were scored
between 0 and 2 points. The highest possible total score is 54. The total score
The Turkish validation study of this form was performed by Öner and Le in 1985
(Öner, 1985). The questionnaire has 2 sub-domains each of which has 20 items:
Situational Anxiety Scale and Continuous Anxiety Scale. The Situational Anxiety
Scale determines how a subject feels under a certain condition at a certain time and
it is scored by choosing either ‘nothing’, ’a little bit’, ‘a lot’ or ‘completely’ to reflect the
severity of the feeling, thought or behaviour. The Continuous Anxiety Scale evaluates
questionnaire contains direct or inverted statements. The total score obtained from 2
subscales changes between 20 and 80. A higher score shows a higher level of
anxiety. The cut off value for each sub domain is 45.
(BD Vacutainer Blood Collection Tube) after overnight fasting. Serum was isolated by
centrifugation at 3000 rpm for 10 min at room temperature (NF 1200R, Nuve®). Then
25-OH Vitamin D levels were measured using the chemiluminescent micro particle
analyser (Abbott Laboratories, Abbot Park, Illinois, USA). Vitamin B12 was measured
According to the completed power analysis, with type 1 error rate 0.05 and
0.80 power ratio, for a 50 pg/ml difference in vitamin B12 values to be significant, the
minimum subject number in each group was calculated as 65. Data analysis was
performed using SPSS 22.0 software. Descriptive statistics were stated as mean ±
standard deviation (SD) for continuous variables and as percentage (%) for
between the groups, the Student’s t-test and the Mann Whitney U-test were applied.
The normal distribution of the data was checked using Shapiro-Wilk test. Direct
Spearman correlation tests. Categorical data comparisons were made using the Chi-
3. Results
This study involves 52 OCD patients and 30 healthy controls. Fifty percent of
patient group were boys (n=26) and 50% were girls (n=26). The mean age was
14.7±2.3 SD years. Fifty-three percent of the control group were girls (n=16) and
46.7% were boys (n=14). The mean age of the control group was 14.2±2.6 years
(Table 1). None of the subjects were taking nutritional support like any medication or
neuro-nutraceuticals.
There was no significant difference between patient and control groups in
terms of age and gender distribution (p: 0.821 and 0.364, respectively). There was a
significant difference in Y-BOCS, Kovacs CDI and STAI-2 scores (p values for all
three scores were <0.001). There was no significant difference between STAI-1
scores of the groups (p: 0.057). For all subjects there was a positive correlation
identified between Y-BOCS points and Kovacs CDI, STAI-1 and STAI-2 values
homocysteine and Vitamin D levels of the groups (p values for all three scores were
<0.001). There was no significant difference between the groups in terms of folic acid
Y-BOCS: Yale-Brown Obsessive Compulsive Scale; CDI: Children’s Depression Inventory; STAI-1
and 2: State-Trait Anxiety Inventory 1 and 2
Figure 1: Distribution of vitamin B12, folic acid, homocysteine and vitamin D between
the groups The upper and lower edges of the boxes show the 25th and 75th
percentile values, horizontal lines in the box are median value, asterix (*) are extreme
values and circle (o) are outliers. The vertical lines extending from the boxes extend
to larger and smaller values that are not outliers.
The correlation analysis between groups demonstrated a statistically
significant positive correlation between age and homocysteine levels (r: 0.320, p:
0.003). Yale-Brown score and depression scale score, STAI-1 and STAI-2 scores
were positively correlated (r: 0.550, p<0.001; r: 0.322, p: 0.003; r: 0.499, p< 0.001,
respectively) when all subjects were evaluated. There was no correlation between
folic acid, homocysteine levels and Y-BCOS score (r:-0.141, p: 0.207 and r: 0.093, p:
B12, vitamin D levels and Y-BOCS score (r:-0.260, p: 0.018 and r:-0.545, p<0.001
respectively) (Figure 2). When the patient group is investigated, there was no
p:0.086), but there was a significant correlation identified with vitamin B12, folic acid
and homocysteine levels (r:0.314; p:0.023; r:0.278; p:0.046 and r:-0.599; p<0.001,
identified between vitamin B12 and folic acid and homocysteine (r:-0.401; p<0.001
and r:-0.315; p:0.023, respectively). When the healthy control group is assessed,
there was no significant correlation found between Y-BOCS and all vitamin values.
Additionally when the presence and degree of insight among OCD patients
Figure 2: Scattergram of Y-COBS score with vitamin B12 and vitamin D distribution
4. Discussion
In this study the OCD group were found to have higher points on anxiety and
occurs with other psychiatric disorders. It is proposed that 80% of OCD children have
another axis I disorder (Friedlander and Desrocher, 2006; Pinto et al., 2006). Of
these the most common appear to be other anxiety disorders at rates of 50% and
depressive disorders at rates of 40% (Pinto et al., 2006; Shafran, 2001). In this
study in accordance with the data, OCD patients obtained clearly high points on the
CDI depression scale and the STAI-2 showing continuous anxiety and there was a
Although vitamin B12, folic acid and homocysteine levels in adults with OCD
have been studied, no such research on children and adolescents with OCD has
been performed up to now. To the best of our knowledge vitamin D levels have never
been investigated in any patients with OCD. The findings of this study demonstrated
that vitamin B12 and vitamin D levels were significantly lower in patients compared to
healthy controls, whereas homocysteine was higher in the patient group. There was
no significant difference between groups in terms of folic acid levels. These findings
are in line with similar studies conducted in adults. In the study of Atmaca et al.
(2005), folic acid levels in OCD patients were low whereas homocysteine levels were
high. Türksoy et al. (2014) found low vitamin B12 levels, high homocysteine levels
and indifferent folic acid levels in patients with OCD. Hermesh et al. (1988) reported
more frequent vitamin B12 deficiency in patients with OCD. There are studies in the
literature reporting OCD symptoms in patients with vitamin B12 deficiency (Sharma
and Biswas, 2012; Valizadeh and Valizadeh, 2011). When evaluated together all
these findings suggest that one carbon metabolism, which involves vitamin B12, folic
acid and homocysteine, may contribute to the aetiology of OCD. One carbon
2005). These metabolic pathways may play a central role in the occurrence of
neuropsychiatric symptoms (Coşar at al., 2014). Folic acid and vitamin B12
endoplasmic reticulum and also increases influx of calcium into the cell by activating
NMDA receptors. Apoptotic signals are activated and intracellular oxidative stress
increases (Bhatia and Singh , 2015; Bottiglieri, 2005; Coşar at al., 2014; Ho at al.,
neuron protection and neuroplasticity. Besides this, it also has functions such as DNA
protection and protection against oxidative stress (Cannell, 2013a, 2013b; Kinney at
al., 2011). For this reason it has been argued that vitamin D can play a role in normal
functioning of central nervous system and it’s diseases (Eyles at al., 2012; Harms at
psychiatric disorders like OCD (Kaneko at al., 2015; Patrick and Ames, 2014;
Patrick and Ames, 2015). Therefore vitamin D may contribute to OCD development
via the serotonin system. Closest to OCD, vitamin D has been investigated in anxiety
disorders and it was found to be significantly lower in patients with anxiety disorders
compared to control subjects (Bicikova at al., 2015). As a result of this study vitamin
D levels were found to be lower in OCD patients with a negative correlation to the
There are some limitations to this study. Firstly increasing the number of
subjects may allow the opportunity to make a more accurate assessment. The
subject number in our study is low compared to the results of power analysis.
Additionally the dietetic situation of subjects and seasonal effects on vitamin values
should be noted. Additionally, due to reasons such as OCD patients making changes
to their eating habits linked to symptoms and reduced exposure to ultraviolet sunlight
required for vitamin D synthesis, these factors should be taken into consideration
5. Conclusion
adolescents with OCD. Vitamin D deficiency may be a risk factor for development of
OCD. Clinicians should be vigilant about one carbon metabolism and vitamin D levels
in patients with OCD. The role of one carbon metabolism and vitamin D in the
limitations should be researched with more subjects. Further research on the benefits
Conflict of interest
The authors declare no conflict of interest. The authors declare that this study
Acknowledgments
We wish to thank all children and adolescents and their families who
participated in the study and Prof.Dr. Suna Taneli for guidance and inspiration.
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Highlights
understood aetiopathogenesis
One carbon metabolism that includes vitamin B12, folic acid and
It has been suggested that Vitamin D can play a role in the aetiopathogenesis
Findings of this study demonstrated lower levels of vitamin B12 and higher
levels of homocysteine in OCD patients which suggests that they can play a
aetiopathogenesis.