Journal of Steroid Biochemistry & Molecular Biology 121 (2010) 467470

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Journal of Steroid Biochemistry and Molecular Biology

journal homepage: www.elsevier.com/locate/jsbmb

Low serum levels of 25-hydroxyvitamin D (25-OHD) among psychiatric

out-patients in Sweden: Relations with season, age, ethnic origin
and psychiatric diagnosis
Mats B. Humble a, , Sven Gustafsson b , Susanne Bejerot a
a
b

Department of Clinical Neuroscience, Division of Psychiatry, St. Gran, Karolinska Institutet, Stockholm, Sweden
Department of Laboratory Medicine, Section for Clinical Chemistry, Karolinska Institutet, Stockholm, Sweden

a r t i c l e

i n f o

Article history:
Received 10 November 2009
Received in revised form 25 January 2010
Accepted 1 March 2010
Keywords:
Vitamin D
Calcidiol
Parathyroid hormone
Blood levels
Out-patients
Chart review
Autism
Schizophrenia
Bipolar disorder
Depressive disorder
ADHD
Ethnic groups
Immigrants

a b s t r a c t
In a chart review at a psychiatric out-patient department, latitude 59.3 N, a sample of patients with
tests of serum 25-hydroxy-vitamin D (25-OHD) and plasma intact parathyroid hormone (iPTH) was
collected, together with demographic data and psychiatric diagnoses. During 19 months, 117 patients
were included. Their median 25-OHD was 45 nmol/l; considerably lower than published reports on
Swedish healthy populations. Only 14.5% had recommended levels (over 75). In 56.4%, 25-OHD was under
50 nmol/l, which is related to several unfavourable health outcomes. Seasonal variation of 25-OHD was
blunted. Patients with ADHD had unexpectedly low iPTH levels. Middle East, South-East Asian or African
ethnic origin, being a young male and having a diagnosis of autism spectrum disorder or schizophrenia
predicted low 25-OHD levels. Hence, the diagnoses that have been hypothetically linked to developmental (prenatal) vitamin D deciency, schizophrenia and autism, had the lowest 25-OHD levels in this adult
sample, supporting the notion that vitamin D deciency may not only be a predisposing developmental
factor but also relate to the adult patients psychiatric state. This is further supported by the considerable psychiatric improvement that coincided with vitamin D treatment in some of the patients whose
deciency was treated.
2010 Elsevier Ltd. All rights reserved.

1. Introduction
In the eld of psychiatry, interest in vitamin D is of relatively
recent origin. The discovery that the brain possesses vitamin D
receptors was decisive and rst inspired the suggestion that mood
and depressive disorders may be related to vitamin D deciency
or insufciency [1,2]. Also, hypotheses suggesting that prenatal
vitamin D deciency impairs fetal neural development, thereby
contributing to adult schizophrenia [3] or childhood autism [4]
have been put forward. In the case of schizophrenia, ample evidence from epidemiology and preclinical research supports this
hypothesis [5,6]. A small study of in-patients with schizophrenia showed decreased levels of 25-hydroxy-vitamin D (25-OHD)
[7]. In an epidemiological case-control study, however, individuals

Special issue selected article from the 14th Vitamin D Workshop held at Brugge,
Belgium on October 48, 2009.
Corresponding author at: Psychiatric Services for the Elderly, Uppsala University
Hospital, SE-750 17, Uppsala, Sweden. Tel.: +46 18 611 23 11.
E-mail address: mats.humble@gmail.com (M.B. Humble).
0960-0760/$ see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jsbmb.2010.03.013

with psychosis did not differ from controls [8]. Concerning depressive disorders, two population based studies support a relation
between lower 25-OHD levels and depressed mood [9,10]. Four
randomized trials, none of them focussing on Major depression,
nevertheless support the possible causality of vitamin D deciency
[1114]. The few previous studies on 25-OHD levels in psychiatric
patients have presented data from in-patients [7,15]. In psychiatric
research, hyperparathyroidism has been related to depressive disorder [16,10], however, many cases of hyperparathyroidism are
secondary to vitamin D deciency [17], and in most psychiatric
studies, this has been disregarded. According to Jorde et al. [9]
depressed mood is more related to low 25-OHD than to elevated
intact parathyroid hormone (iPTH).
In view of this background and in order to improve the quality of care for psychiatric out-patients, we considered it relevant
to include measurements of 25-OHD and iPTH in our standard
procedure for evaluating the physical health of our patients. The
aim of the present chart review was to describe results on these
measurements from a sizeable group of patients with various psychiatric diagnoses, and search for possible predictors of vitamin D
deciency requiring treatment.

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M.B. Humble et al. / Journal of Steroid Biochemistry & Molecular Biology 121 (2010) 467470

Table 1
Demographic data, psychiatric diagnoses, serum 25-OH-vitamin D levels and plasma intact PTH levels of 117 psychiatric out-patients from Vrmd municipality, Sweden,
latitude 59.3 N.
Diagnostic group

Age years
(means)

Sex
(% females)

Origin
(% Southern)

25-OHD nmol/l
median (25th and
75th percentiles)

iPTH pg/l
median (25th and
75th percentiles)

Autism
Schizophrenia
Bipolar
Depressive
Anxiety
ADHD
Substance
Others
All groups

10
20
22
36
13
8
3
5
117

36.5
47.4
53.4
41.5
40.3
34.2
42.0
42.4
43.7

40
60
55
53
69
50
33
60
54.7

0
20
9
17
0
0
0
0
10.3

31.5 (23, 39)

35 (23.5, 52.5)
48 (33, 57)
47.5 (33, 72)
62 (44, 81)
45 (31, 67.5)
40 (37, 43)
61 (45, 80)
45 (31, 60)

56 (39, 72)
52 (36, 63)
53 (46, 63)
42 (37, 66)
47 (39, 58)
26 (23, 41)
43 (27, 48)
33 (22, 53)
47 (37, 62)

For 25-OHD, a level between 75 and 250 nmol/l is recommended. Reference values of iPTH are 2065 pg/l, however, in the absence of vitamin D deciency iPTH should be
under 43 pg/l.

2. Materials and methods

2.4. Blood sampling

2.1. Setting

Blood samples (most of them fasting before 10 a.m.) were taken

at a primary care sampling unit and sent to the laboratory as part
of usual clinical routine, together with other samples, and analyzed
consecutively. Results were communicated to the psychiatric unit
consecutively.

The rst author worked as clinical psychiatrist in the psychiatric out-patient department of Gustavsberg, latitude 59.3 N,
in Stockholm County. This department is the main psychiatric facility serving the catchment area of Vrmd municipality with 37,376 inhabitants (2008). Data were collected
between March 2008 and September 2009, a time span of
19 months.

2.2. Patients
The patients were unselected consecutive cases, with a clinical
indication for blood sampling not related to the study (approximately 75% of all patients seen). For instance, some patients
with regular controls related to lithium or clozapine therapy
were included. In other cases, the reason for blood sampling was
assessment of possible organic causes of depression (e.g. hypothyroidism or cobalamin deciency) or screening for metabolic
disturbance in patients on antipsychotic treatment. Patients
regularly taking vitamin D supplements (10 g/day) were
excluded.

2.3. Demographic data and psychiatric diagnoses

All patients were seen and assessed by the rst author in his
routine clinical praxis. Most of the patients had been in treatment
for several years at the unit, and previous medical records were
available in order to care for the patients. Demographic data and
psychiatric diagnoses were assessed by the rst author on this
basis. In cases of comorbidity, the clinically most relevant main
diagnose was used. Diagnoses were grouped according to ICD-10
[18] as follows: Autism spectrum disorders, including Aspergers
syndrome (F94), Schizophrenia, including Schizoaffective disorders
(F20, F25), Bipolar disorders (F31), Depressive disorders, including
Dysthymia (F32, F33, F34.1), Anxiety disorders, including Personality disorders, if not depressed (F40F42, F60.3), Attention decit
hyperactivity disorders (ADHD) (F90), Substance use disorders
(F10F19), and Others, including Organic mental disorders and
Delusional disorders (F05F09, F22). Ethnic origin was based on
the patients personal assertion and mother tongue. Ethnicity of
adopted children was based on biological parents. Ethnicities were
categorized as Northern (Scandinavian, Finnish or Slavonic origin)
or Southern (Middle East, South-East Asian, African or Mediterranean origin).

2.5. Laboratory analyses

Serum 25-OHD was measured by radioimmunoassay, DiaSorin,
Stillwater, USA. Plasma levels of iPTH were analyzed by an electrochemiluminescent immunoassay, Roche Diagnostics, Germany.
2.6. Statistical analysis
When distributions were non-normal, values are reported as
medians with 25th and 75th percentiles in parentheses, and nonparametric tests (MannWhitney U-test, KruskalWallis ANOVA
and Spearman Rank Order Correlation) were used. A general regression model with data log transformed was used for multiple
correlations. Statistica v. 7.1 from StatSoft Inc. was used. Diagnostic
groups with 5 or less cases were not included in the comparisons
between diagnoses. Because of the presumed seasonal variation of
25-OHD, a seasonal adjustment was done by multiplying individual values with the quotient between the mean of the year and the
mean of the season. Probabilities < 5% were assumed as signicant.
2.7. Ethics
This was a clinical quality assurance project. Neither randomization, nor placebo treatment was implemented. Blood samples were
taken on clinical grounds, and the charts were reviewed in order
to improve clinical care. Accordingly, no research ethics committee was involved and written informed consent was not obtained.
However, all patients were orally informed about the vitamin D
sampling and about their results, and treated with vitamin D when
appropriate.
3. Results
Serum levels of 25-OHD was tested in 121 and iPTH in 97
patients. Due to holidays and other factors, the samples were
unevenly distributed over the year with few samples taken in January, July and November. Four users of vitamin-D supplements
(10 g/day) with signicantly higher 25-OHD (median 93.5 (79.5,
100.5) compared to 45 (31, 60) nmol/l, MW-U = 27.5; p = 0.003)
were excluded, leaving 117 patients for this analysis (93 with iPTH

M.B. Humble et al. / Journal of Steroid Biochemistry & Molecular Biology 121 (2010) 467470

469

Fig. 1. Serum 25-OH-vitamin D levels among 117 psychiatric out-patients differed

between sexes (MW-U = 1226.5; p = 0.010) and between age categories (KWH(2;117) = 7.30; p = 0.026), however, the age difference was entirely driven by the
younger males (males only: KW-H(2;53) = 8.18; p = 0.017, females N.S.).

Fig. 2. Serum levels of 25-OH-vitamin D among psychiatric out-patients in different

diagnostic groups (KW-H(5;109) = 15.86; p = 0.0073). For delineation of diagnostic
groups, see Section 2.3. In post hoc comparisons, the difference between Autism
and Anxiety/Personality Disorder was signicant (p = 0.014). Schizophrenia vs. Anxiety/PersD attained p = 0.053.

sample). Demographic data and median levels of 25-OHD and iPTH

are summarized in Table 1.
Both 25-OHD and iPTH were non-normally distributed. The distribution of 25-OHD was: 25, 15.4%; 2550: 41.0%; 5075: 29.1%;
and >75: 14.5%, with the highest value, 115 nmol/l, attained by
one Scandinavian male with personality disorder in September.
Three patients had 25-OHD under 12.5 nmol/l: two Scandinavian
males with post-stroke depression and schizophrenia, respectively, and one Mediterranean female with schizophrenia. Of 93
patients with iPTH samples, 19% had pathologically elevated levels (>65 pg/l according to reference values). Only 41% had optimal
levels (<43 pg/l). There was a negative correlation between 25OHD and iPTH (R = 0.32; p = 0.002). iPTH correlated linearly with
age (R = 0.21; p = 0.04) whereas 25-OHD did not. On the other
hand, when age was categorized, a signicant difference between
those under 34 years and the two older categories was found
(KW-H(2;117) = 7.30; p = 0.026), which was entirely driven by the
males (Fig. 1). Females had higher 25-OHD than males; 52.5
(34.5, 63) vs. 39 (25, 52) nmol/l (MW-U(1;117) = 1226.5; p = 0.010),
while iPTH did not differ between sexes. Southern (Middle East,
Mediterranean, South-East Asian or African) ethnic origin was
a strong predictor of low 25-OHD; 26.5 (14.5, 34) vs. 47 (32,
61) nmol/l among those with Northern origin (MW-U(1;117) = 224;
p = 0.00027), but not of iPTH. In a general regression, there was
an interaction between sex and ethnic origin (Wald 2 (1) = 8.04,
p = 0.005), females of Southern origin having more reduced 25-OHD
compared to the Northern group than the Southern males. Interestingly, among the subgroups, those of Finnish origin had the highest
25-OHD levels: 71 (53, 79) nmol/l, signicantly higher than Scandinavians in pair-wise comparison; while those from the Middle East
had the lowest levels, 25 (13, 34) nmol/l. Seasonal variation of 25OHD was small: winter 40.5 (32, 56); spring 40 (28, 53); summer
46 (25, 67); and autumn 58 (42, 73). Autumn levels were higher
in pair-wise comparisons, but this failed to reach signicance in a
multiple comparison. With seasonal adjustment of 25-OHD values,
only minor numerical changes appeared, and the statistical signicance of all other tests and comparisons were unchanged (data not
given).
The psychiatric diagnostic groups differed in 25-OHD levels
(KW-H(5;109) = 15.86; p = 0.0073). This was mainly related to the
markedly low levels of patients with autism spectrum disorder
and schizophrenia see Fig. 2. Also the iPTH levels differed between

diagnoses (KW-H(5;87) = 11.97; p = 0.035), see Table 1. According

to post hoc comparisons, this was due to the relatively low levels
of patients with ADHD. Treatment with neither lithium (N = 17) nor
clozapine (N = 6) had any effect on 25-OHD or iPTH.
4. Discussion and conclusion
The 25-OHD levels in our sample indicate a high prevalence of
vitamin D deciency/insufciency among Swedish psychiatric outpatients. In contrast, previously published samples from healthy
Swedish populations [1923] (mainly based on postmenopausal
women) have found 25-OHD means between 69 and 99 nmol/l, i.e.
unexpectedly high in international comparisons [20]. The considerably lower levels in the present study may be related to our sample
being younger and including males, but may also be associated with
our patients diagnoses. The usual seasonal pattern was blunted in
this sample, indicating life styles with reduced sun exposure. Also,
the expected decrease with age was absent; on the contrary, signicantly lower levels were seen in the younger male patients. In
line with other European studies, immigrants (particularly females)
with darker skin or diminished sun exposure (e.g. covered clothing)
had markedly lower 25-OHD levels.
Interestingly, the two diagnoses that have been hypothesized as
possibly related to developmental (prenatal) vitamin D deciency,
schizophrenia [3] and autism [4], had the lowest 25-OHD levels
in this adult sample. Indeed, this may be related to diet or indoor
life-style, but unknown biological factors may also contribute. This
nding supports the notion that vitamin D deciency may not only
be a predisposing developmental factor, but also bear on these
patients present psychiatric state [24]. This is further supported by
the considerable improvement of psychosis or depression, which
coincided in several patients with effective treatment of their
vitamin D deciency, even if other treatments were unchanged.
Vitamin D was given as cholecalciferol 16004000 IU daily or ergocalciferol 35,00070,000 IU once weekly. In the absence of a control
group, these improvements could have been due to the natural
course or a placebo effect, but the possibility remains that vitamin D deciency or secondary hyperparathyroidism was related to
their present psychiatric symptomatology.
The relatively low iPTH levels among patients with ADHD are
of interest, since they were not related to higher 25-OHD levels.
We were unable to nd any previous study on PTH in ADHD. How-

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M.B. Humble et al. / Journal of Steroid Biochemistry & Molecular Biology 121 (2010) 467470

ever, blunted PTH response to vitamin D deciency is an established

feature of magnesium deciency [25], and magnesium deciency
has repeatedly been described in ADHD [26,27]. Our nding is
based on only 8 individuals with ADHD and may be spurious. In
our view, however, it indicates that further investigations of the
PTH-magnesium relations in ADHD are warranted.
There are several limitations of this study. There may have been
a selection bias. Patients in seemingly perfect somatic health were
sometimes excluded; however, such patients were rare among the
rst authors clientele. The diagnoses were not ascertained with
structured diagnostic rating scales. Arguably, diagnoses based on a
lengthy clinical treatment history may be at least as valid as those
based on one cross-sectional rating. Finally, there was no healthy
control group of similar age and sex distribution. The different diagnostic groups may to some extent serve as substitute for this.
The clinical relevance of hypovitaminosis D in our sample may
be underscored by the increased somatic morbidity, especially
cardiovascular disorders and diabetes, among psychiatric patients
[28]. To what extent vitamin D deciency contributes to this, is at
present unknown. Furthermore, two common treatments in psychiatric clinical praxis have been reported to negatively affect bone
mineral density (BMD): Several antipsychotic agents may lead to
hyperprolactinemia, which in the long-term may cause osteoporosis [29,30]. Secondly, long-term use of selective serotonin reuptake
inhibitors has been found to decrease BMD and increase the risk
of fractures [31,32]. Since vitamin D deciency may further challenge the psychiatric patients bone health, this remediable factor
deserves increased interest. Our ndings also call for focussed
observance of vitamin D status in immigrant patients. In Sweden,
as in other sun deprived countries, increased rates of psychoses
and autism among dark skinned immigrants have been reported
[3335,24]. While controlled studies of the effect of vitamin D
replenishment on the psychiatric symptoms are still wanting, the
somatic risks of continued deciency should alert clinicians to meet
the specic needs of this population.
In conclusion, the previous optimistic view on vitamin D status in Sweden, mainly derived from healthy elderly females, is not
supported by this younger sample including both sexes and immigrants. Considering the high proportion of low 25-OHD levels in the
present sample, a substantial number of psychiatric patients are at
risk for unfavourable health outcomes related to vitamin D deciency, and may benet from detection and treatment of vitamin D
deciency.
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