Safely using eicosapentaenoic acid (fish oil) for schizophrenia

Fish oil, primarily eicosapentaenoic acid (EPA) is gaining popularity as a natural treatment for schizophrenia. (Before I continue, just want to say I have to be very careful with this post because I don't want to encourage anyone who needs to be on antipsychotics to read that I'm saying to discontinue them--I AM NOT!)

Because of this popularity, a prominent group of schizophrenia researchers in the UK decided to evaluate whether or not therapeutic doses of EPA produced any safety issues for its users. They divided 84 individuals with schizophrenia into two groups; one group received 2 grams EPA per day along with their antipsychotic, the other received a placebo along with their medication.

Those individuals receiving EPA experienced a trend toward decreased total cholesterol and HDL. Weight tended to increase. And their bleeding time increased, meaning it took longer for their blood to clot when they cut themselves.

Here are some thoughts to take away from this study.

1. 2 grams daily of EPA is a very high dose. Most over the counter capsules have about 10% of that amount. This was a very specific protocol unlikely to be randomly adopted by the average person.

2. If you have ever had any issues with blood clotting, or are on any type of medication that affects clotting time, such as Coumadin, it is very important to work with your prescribing physician in order to coordinate appropriate dosages of medications and supplements.

3. I'm not working with critically ill schizophrenics on an outpatient basis, so I have the liberty of starting low and upping doses to evaluate for tolerance. I tend to work with a mixture of dietary fats and fish oils and not use such a specific, directed protocol. I feel much safer with that. But I am always on the lookout for the kinds of reactions that this study produced.

4. What is not known is whether or not all the subjects were on the same antipsychotic, or for how long before starting this study. Each antipsychotic has a slightly different effect on lipids, weight, and hormones, and that information would likely affect the results that were reported.

Overall, I'd say the most important finding in this study was the effect of super-high doses of EPA on clotting time. Because EPA has been getting more attention for its potential in treating bipolar disorder and schizophrenia, it is showing up more and more as a single supplement rather than as a component of fish oil. There is a tendency to use the "more is better" approach and to assume that if it's natural, and it's over the counter, it's safe. That may or may not be true with EPA, and it should be used judiciously.

Emsley R, Niehaus DJ, Oosthuizen PP, Koen L, Ascott-Evans B, Chiliza B, van Rensburg SJ, Smit RM. Safety of the omega-3 fatty acid, eicosapentaenoic acid (EPA) in psychiatric patients: Results from a randomized, placebo-controlled trial. Psychiatry Res. 2008 Dec 15;161(3):284-91. Epub 2008 Oct 29.

There's something fishy about depression treatment...

Here's the study I've been looking for. There are plenty of studies showing the effectiveness of antidepressant medications. And there are plenty of studies showing the effectiveness of fish oil in treating depression. But no one had compared the two. Until now.

In Iran, researchers compared the separate relative effectiveness of eicosapentaenoic acid (EPA), one of the chemicals commonly referred to as fish oil, and fluoxetine (Prozac). What they found was that EPA was equally as effective as fluoxetine, in an 8 week trial, in reducing symptoms of depression. The most superior outcome was found in subjects who received both EPA and fluoxetine.

If you're wanting to try this at home, as always, discuss this with your physician. The risk of using fish oil in conjunction with antidepressants is almost always outweighed by the potential benefits--however, it is not advised that you discontinue any prescription medications you are on without consulting with the prescribing party.

A word about EPA. There is a lot of confusion about what it means to use fish oil. Most products available in the grocery store that are labeled as containing "omega-3 fatty acids" actually contain ALA, a great omega-3 but not the one that has been associated with improved mental health. If you're using omega-3 eggs, or vegan (marine algae-based) omega-3's, you're getting DHA, not EPA. That primarily comes from fish. Even though you will read that there are conversions to EPA from both ALA and DHA, the efficiency of these conversions is great and likely not enough to achieve results such as were seen in this study.

If your diet is high in pro-inflammatory oils (those "S" and "C" oils you see me routinely discuss in this blog), it will be harder to get effects described in this study. You're going to need to tweak your diet in order to get the most bang for your buck. And, realistically, that means you're going to have to get rid of most processed foods and salad dressings.

But, for those individuals motivated to make these changes, the results can be profound. I see it routinely in my private counseling. It is certainly my first recommended item of action when someone is trying to reduce the number of medications they are on.

Finally, for physicians who prescribe antidepressants, this study suggests that if you do so without strong nutritional guidance as well, you're not as helpful to your patients as you have the potential to be. It's not just about pills. Your patients did not become depressed because they were antidepressant-deficient!

Jazayeri S, Tehrani-Doost M, Keshavarz SA, Hosseini M, Djazayery A, Amini H, Jalali M, Peet M. Comparison of therapeutic effects of omega-3 fatty acid eicosapentaenoic acid and fluoxetine, separately and in combination, in major depressive disorder. Aust N Z J Psychiatry. 2008 Mar;42(3):192-8.

Mania and free fatty acids

Plasma free fatty acids (primarily omega-3's) have gained much attention for their therapeutic potential in many psychiatric diagnoses--including depression, anxiety, obsessive-compulsive disorder, attention-deficit hyperactivity disorder, schizophrenia, post-traumatic stress disorder, and bipolar disorder. Now researchers are discovering that the level of these fatty acids in the blood may actually influence the symptom severity of these illnesses.

In this particular study, done in patients with bipolar disorder, medication-free patients who were seeking help for a manic episode had their blood tested for free fatty acid levels. These levels were compared to those in individuals who did not have bipolar disorder. In the manic individuals, the lower the levels of arachidonic acid (AA) or eicosapentaenoic acid (EPA), the worse the manic symptoms were. The greater the AA/EPA ratio, the worse the manic symptoms were.

In plain English? While the diets of these individuals were not analyzed, it is well-established that a diet high in fish and omega-3's promotes good EPA levels. A diet high in meat and pro-inflammatory oils (those "S" and "C" oils I like to refer to), the higher the AA levels.

So...eat a lot of meat and processed foods with the wrong kinds of fat, and your bipolar disorder stability might pay the price. Focus on fish, flax, and nuts...and you might not need as many emergency room visits.

It's kind of a catch-22. In working with bipolar disorder, it seems that the very foods that cause trouble are the very foods these individuals seem to crave. It can take a concerted effort to stay on track with nutrition. However...what I do notice is that if these individuals DO stick with the plan and pull their nervous systems back into balance, the cravings eventually lessen and appetites for healthier food begin to surface.

I've been in the presence of a client in the middle of her mania. At least from my shoes, on the outside looking in, knowing what danger her state put her in, I'd highly recommend making the effort and minimizing the manic episodes.


Sublette ME, Bosetti F, DeMar JC, Ma K, Bell JM, Fagin-Jones S, Russ MJ, Rapoport SI. Plasma free polyunsaturated fatty acid levels are associated with symptom severity in acute mania.Bipolar Disord. 2007 Nov;9(7):759-65.

Fish oil, anxiety, and anger

I am noticing in my most recent medication reviews, that more and more psychotropic medications are being tested as treatments for aggressive behavior. I've worked in treatment centers and I know that the kind of aggression seen in substance users is more than just being "a little pushy"...and that this behavior, if it can be intervened on, can help a person with this problem to have more productive relationships and overall life successes.

A recent study found that substance abusers have dietary habits that promote poor omega-3 balance. (Anyone reading this who has attended a 12 Step meeting will attest to the donuts and sugared coffee these meetings are known for!)

In this study, 3 months of using 3 grams per day of fish oil (containing both EPA and DHA), anger and anxiety on test scores decreased significantly.

Interestingly, EPA and anxiety were most closely associated, and DHA and anger were most closely associated. For anyone using fish oil as a supplement, this distinction is likely moot. However, for anyone who is vegetarian and using marine algae or marine algae-supplemented foods as their omega-3 source, they may not see the reduction in anger that a fish-eating person may eat.

I just love it when nature shows us ways to feel better that don't always have to involve medication!

Buydens-Branchey L, Branchey M, Hibbeln JR. Associations between increases in plasma n-3 polyunsaturated fatty acids following supplementation and decreases in anger and anxiety in substance abusers. Prog Neuropsychopharmacol Biol Psychiatry. 2007 Nov 1 [Epub ahead of print]