Lyme borreliosis, commonly known as Lyme disease, is a tick-borne illness caused by the Borrelia burgdorferi bacterium. While its most notable symptom is the characteristic "bull's-eye" skin rash, the disease can also have profound neurological and psychiatric implications. Recent studies have shed light on the potential links between Lyme disease and mental health disorders, but the connection remains a subject of ongoing research.
This is such an important consideration in the Upper Midwest, where our clinic is located and where I am licensed (in Minnesota, Wisconsin, and Iowa). Learning about Lyme disease was never on my radar in my psychiatry residency training but I felt compelled to complete more training once I started realizing that a subset of my patients didn't seem to getting better within the realms of my integrative diagnostic assessment and treatment approaches.
So let's explore the connection between Lyme disease and mental health. (Side note: other tickborne diseases like Bartonella and Babesia are frequent co-infections with Lyme borreliosis and also may have mental health manifestations).
Understanding the Lyme Disease and Psychiatry Connection
Psychiatric Manifestations: Lyme borreliosis has been associated with various psychiatric manifestations. Patients have been observed with symptoms like depression, suicidal ideation, obsessive-compulsive disorder, mania, psychosis, and cognitive impairments like brain fog, poor memory, and slower speeds of thinking. These symptoms were not only observed in individuals with untreated acute infection but were also reported months to years post-antibiotic therapy.
Research on the Link: The connection between Lyme borreliosis and psychiatric symptoms remains controversial. Some studies noted higher rates of depression in individuals post-Lyme infection, while others found no significant elevated rates. For instance, a retrospective study without a control comparison group found that nearly 43.5% of the 253 patients reported suicidal thoughts. However, several other studies were plagued by various limitations, such as small sample size, ascertainment bias, and lack of control for confounding variables, making it challenging to draw definitive conclusions.
More Recent Evidence from the American Journal of Psychiatry: A recent study from the American Journal of Psychiatry tackled many previous limitations by conducting a nationwide, population-based cohort study. This extensive study aimed to compare the rate of new-onset mental disorders in individuals diagnosed with Lyme borreliosis with those without the diagnosis. The results from this study were significant (and leaves me wondering why this isn't talked about more in psychiatry):
Mental Disorders: Individuals with Lyme borreliosis had a 28% higher rate of new mental disorder diagnoses compared to those without the disease. This incidence was particularly higher during the first 6 months post-diagnosis.
Affective Disorders: A 42% increased rate of affective (mood) disorders was observed among Lyme patients, with the highest rates seen 6-12 months post-diagnosis.
Suicide Attempts: Individuals with Lyme borreliosis had a significantly higher rate of suicide attempts, with an incidence rate ratio (IRR) of 2.01. The risk was especially heightened 3 years post-diagnosis.
Death by Suicide: Lyme patients had a 75% higher rate of death by suicide, with the risk peaking within 3 years of the initial diagnosis.
Holistic Care Emphasized
It's imperative to consider these findings in the context of the broader medical literature and understand that correlation doesn't always imply causation. The exact mechanisms underlying the connection between Lyme disease and psychiatric disorders remain elusive. However, this research emphasizes the importance of holistic care for Lyme patients, recognizing not just the physical but also the mental health implications of the disease.
Furthermore, while these findings underscore the need for more research and awareness, they also emphasize the importance of early diagnosis and comprehensive treatment for Lyme disease. Both healthcare professionals (including psychiatrists) and patients should be cognizant of the potential mental health ramifications, ensuring timely interventions to manage and mitigate the risks.
Red Flags for Tickborne Diseases: A Psychiatrist's Perspective
In my profession as a psychiatrist, beyond the realm of emotional and cognitive concerns, I often find myself playing the role of a detective. Over the years, I've learned to look out for certain patterns and symptoms in my patients that may indicate underlying health conditions, particularly tickborne diseases. As someone practicing in Lyme-endemic areas—across all three states where I'm licensed—it's become crucial for me to recognize these red flags.
Here are some of the critical signs that prompt me to delve deeper:
Past History: If a patient mentions they have had Lyme disease in the past, it raises an immediate red flag. Lyme can have lingering effects, and past infections can sometimes become reactivated or present residual symptoms.
Geographical Residency: Living in a Lyme-endemic area—even if it's an urban setting—substantially raises the risk. Many individuals mistakenly believe that they're immune to tickborne diseases because they reside in cities, but ticks are ubiquitous and don't exclusively inhabit rural places.
Physical Symptoms alongside Mental Health Issues: While mental health symptoms are expected in my practice, when these are paired with significant fatigue, executive function challenges, concentration difficulties, brain fog, recurrent headaches, migratory joint pain, and transient numbness or burning sensations, it warrants further investigation.
History of Autoimmune Disorders: Some patients come to me with prior diagnoses of autoimmune diseases like lupus, fibromyalgia, chronic fatigue syndrome, or multiple sclerosis. These conditions can sometimes overlap with or be misdiagnoses for tickborne diseases.
Limited Response to Conventional/Integrative Treatments: When a patient is taking supplements or pharmacological treatments for their mental health symptoms—such as modafinil for enhanced focus and reduced fatigue—and find limited to no relief from their symptoms, it makes me question the root cause. If standard interventions aren't making a dent in their symptoms, it often leads me to wonder about what might be occurring upstream, triggering these manifestations.
It's essential to view the human body as an interconnected system, where physical symptoms can impact mental health and vice versa. We are not just fragmented body parts that are siloed from each other. By staying curious and recognizing these red flags, I believe we can offer more holistic and effective care to our patients, addressing not just the symptoms, but the root causes. As we dive deeper into these cases, we often uncover the hidden culprits that have been influencing their health, allowing for targeted and more effective interventions.
If you're interested in becoming a patient at Driftless Integrative Psychiatry and working with Dr. Burger for a personalized, holistic, and root-cause approach to mental health including the assessment for and treatment of tickborne diseases, you can learn more here.
This blog post is designed as a general guide. This is not a substitute for personalized medical advice, nor is a patient-physician relationship established in this blog post.
References
Bratton, R. L., Whiteside, J. W., Hovan, M. J., Engle, R. L., & Edwards, F. D. (2008). Diagnosis and treatment of Lyme disease. Mayo Clinic Proceedings, 83(5), 566-571.
Fallon, B. A., Madsen, T., Erlangsen, A., & Benros, M. E. (2021). Lyme Borreliosis and Associations With Mental Disorders and Suicidal Behavior: A Nationwide Danish Cohort Study. American Journal of Psychiatry. https://doi.org/10.1176/appi.ajp.2021.20091347
Hassett, A. L., Radvanski, D. C., Buyske, S., Savage, S. V., & Sigal, L. H. (2009). Psychiatric comorbidity and other psychological factors in patients with “chronic Lyme disease”. American Journal of Medicine, 122(9), 843-850.
Stricker, R. B., & Johnson, L. (2008). Lyme disease: the next decade. Infection and Drug Resistance, 4, 1-9.
Further Reading
Clinicians who want to learn more about tickborne diseases and how to best assess for and treat patients, consider joining ILADS.
Bransfield, R. C. (2017). Neuropsychiatric Lyme Borreliosis: An Overview with a Focus on a Specialty Psychiatrist’s Clinical Practice. Healthcare, 5(3), 76.
Marques, A. R. (2008). Lyme disease: a review. Current allergy and asthma reports, 8(1), 7-13.
Gocmen, A. Y., Guler, E., & Hanagasi, H. A. (2016). Psychiatric disorders and characteristics of patients with Lyme borreliosis. Journal of Clinical Neuroscience, 33, 48-51.
Greenberg, R. (2013). Chronic Lyme Disease: A Review. Infectious Disease Clinics of North America, 27(2), 317-323.
Murthy, J. M., Yangala, R., & Meena, A. K. (2000). Lyme neuroborreliosis: A case report. Journal of the Association of Physicians of India, 48(11), 1090-1091.
Bransfield, R. C. (2012). The psychoimmunology of Lyme/tick-borne diseases and its association with neuropsychiatric symptoms. The Open Neurology Journal, 6, 88.
Fallon, B. A., Levin, E. S., Schweitzer, P. J., & Hardesty, D. (2010). Inflammation and central nervous system Lyme disease. Neurobiology of Disease, 37(3), 534-541.