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Omega-3 fatty acid supplementation in patients with recurrent self-harm: Single-centre double-blind randomised controlled trial

  • Brian Hallahan (a1), Joseph R. Hibbeln (a2), John M. Davis (a3) and Malcolm R. Garland (a4)
Abstract
Background

Trials have demonstrated benefits of long-chain omega-3 essential fatty acid (n-3 EFA) supplementation in a variety of psychiatric disorders.

Aims

To assess the efficacy of n-3 EFAs in improving psychological well-being in patients with recurrent self-harm.

Method

Patients (n=49) presenting after an act of repeated self-harm were randomised to receive 1.2 g eicosapentaenoic acid plus 0.9 g decosahexaenoic acid (n=22) or placebo (n=27) for 12 weeks in addition to standard psychiatric care. Six psychological domains were measured at baseline and end point.

Results

At 12 weeks, the n-3 EFA group had significantly greater improvements in scores for depression, suicidality and daily stresses. Scores for impulsivity aggression and hostility did not differ.

Conclusions

Supplementation achieved substantial reductions in surrogate markers of suicidal behaviour and improvements in well-being. Larger studies are warranted to determine if insufficient dietary intake of n-3 EFAs is a reversible risk factor for self-harm.

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Copyright
Corresponding author
Dr Malcolm R. Garland, St Ita's Hospital, Portrane, County Dublin, Ireland. Email: mgarland@ireland.com
Footnotes
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See pp. 112-117, this issue.

Declaration of interest

Pronova (now Epax) AS, Lysaker, Norway provided the active preparation and placebo but were not otherwise involved in the study. Funding detailed in Acknowledgements.

Footnotes
References
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Omega-3 fatty acid supplementation in patients with recurrent self-harm: Single-centre double-blind randomised controlled trial

  • Brian Hallahan (a1), Joseph R. Hibbeln (a2), John M. Davis (a3) and Malcolm R. Garland (a4)
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eLetters

Omega-3 fatty acid for recurrent self-harm: unanswered questions

Debasish Basu, Consultant Psychiatrist
02 May 2007

The study by Hallahan et al. (2007) has clinically important implications. Before accepting the findings as valid, however, we wish to raise a few points regarding some of the methodological and analytic aspects of the study.

It is interesting to note that of the 392 patients initially assessedfor eligibility, only 39 patients (10%) completed the study, a large number (343) having been excluded for various reasons. While this rigorousselection procedure might have enhanced the internal validity of the findings, we are concerned that the generalisability of the findings in the real-world clinical situation (i.e., external validity) might have been compromised in the process.

Certain sample characteristics merit attention. Other than mentioningthat the subjects had had at least one lifetime self-harm episode apart from the index one, the report does not provide any data on self-harm in the two groups in terms of number, frequency, severity, and recency from the index episode. These data are important to characterize the sample andalso to ensure that the two groups did not differ on these. For example, the risk profile of a 60-year-old patient with two self-harm episodes spaced ten years apart would be very different from a 20-year-old with theprevious episode only ten days prior to the index one. Further, in patients with borderline and other personality disorders, suicidality and impulsivity can vary drastically over time, even in a single day. Instruments rated 4- or 6- weekly may not capture the ‘real’ picture. Finally, significantly more subjects in the placebo group were single or divorced compared to the active drug group. Thus, the placebo group in this study could be unstable compared to the active drug group; in any case, in view of this significant difference, marital status should have been taken into consideration in the logistic regression and other analyses.

In the analysis, while reporting on suicidality scores, the two groups were compared after categorically clubbing the values (zero for no suicidal ideation vs. presence of any suicidal ideation) to obtain a statistically significant difference. This seems to be a specific instanceof deviation from the usual pattern of analysis for all other variables ofinterest where the mean scores were compared. In fact, when the mean suicidality scores were compared like the others, the difference was not statistically significant. Indeed, it is interesting to note that the self-harm episodes were actually proportionally more in the patients of activegroup (7/22 = 38.2%) during the study period compared to placebo group (7/27 = 25.9%) though the difference was not statistically significant.

Finally, conceptually it is not clear what the findings really mean in terms of decrease in “surrogate markers of suicidal behaviour”. The authors discuss the findings in terms of improved mood and well-being, butthe logistic regression analysis showed that depression and other psychological measures did not have any effect on the suicidality score. Other surrogate markers such as impulsivity and aggression scores were notsignificantly different between the two groups.

Reference:

Hallahan, B., Hibbeln, J.R., Davis, J.M., & Garland, M.R. (2007) Omega-3 fatty acid supplementation in patients with recurrent self-harm. Single-centre double-blind randomised controlled trial. British Journal ofPsychiatry, 190, 118-122.
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Conflict of interest: None Declared

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essential fatty acids and mental health

Sara S Smith, consultant psychiatrist
15 February 2007

Sir

Re: essential fatty acids and mental health

It was refreshing to read the papers by Garland & Hallahan (January 2007) on the use of essential fatty acids in patients presenting with self-harm. Strategies to complement traditional prescribing are always welcome and my own experience echoes Hallahan’s findings.

Having prescribed high dose EFA supplements for a small number of patients with emotionally unstable personality disorder, I have been encouraged by the results.In some cases the addition of L-tryptophan has been helpful.EFA supplements have also been beneficial to several patients suffering with depression, schizophrenia and poor memory.

While I would not advocate routine supplementation for all patients, use of EFAs might be a suitable augmentation strategy for some. However the limited research base and high cost results in reluctance from GPs to continue the prescription.

With recent media campaigns to improve nutrition in schools and similar campaigns by mental health charities to look at the role of diet in mental health, this is timely research. It has long been recognised that many psychiatric patients have poor diets; patients with restricted diets (vegetarian or vegan for example) might also be at risk.It makes intuitive sense to enquire about this aspect of life as much as any other, although its relevance is generally overlooked despite our basic medical knowledge of nutrition, essential amino acids and neurochemistry.

Previously, support for a Royal College Special Interest Group in this area was insufficient. Perhaps now is the time to revisit this idea.

Yours faithfully,

Dr Sara Smith

Declaration of interest: none
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Conflict of interest: None Declared

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Augmentation or Supplementation?

Larry Rifkin, Consultant Psychiatrist
08 February 2007

This study adds to the emerging literature on mood and omega-3 Fatty Acids. Previous studies have been mainly augmentation studies or supplementation studies. This is a bit of both.

It would have been interesting to examine if there was any differencein outcome between those in the n-3 EFA group (59%) who were taking antidepressants at baseline (augmentation) and the 41% who were not takingpsychotropic medication (supplementation).

The authors also published a paper (1) examining lipid profiles in self -harming patients in the same issue of the BJP. Ideally the two studies could have been integrated to examine wether supplementation or augmentation effects are of relevance only if there is an established lipid deficiency.

Finally for those interested in the subject there is an excellent recent review article by Parker et al (2) which examines the current evidence in the area and suggests nine points to guide future research efforts.

1.Garland MR et al, Lipids and essential fatty acidsin patients presenting with self-harm, Br J Psychiatry, 190, 112-117, 2007.2. Parker G et al, Omega-3 Fatty Acids and Mood Disorders, Am J Psychiatry163:969-978, June 2006.
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Conflict of interest: None Declared

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