09/16/2025
September is Su***de Prevention Awareness Month. It is a time for us to take a moment and remember those who have lost their lives to su***de and support the loved ones who are affected. It is a time to raise awareness about the millions who experience suicidal thoughts every day (Su***de and Su***de Behavior, 2023). Let us remind each other that each one of us matters, that we are not alone, and that it is okay to reach out for help or check in on those around us. We can all play a role in saving lives by learning more about su***de and helping to shift public perceptions through education and compassion.
A colleague who has experienced the profound loss of many loved ones to su***de once shared a powerful insight: even when we may not have the expertise to offer professional help, we can still make a difference by simply listening. When someone opens up, just being there to listen and acknowledge their feelings can be incredibly validating. Sometimes, this act of compassion can ease their pain, giving them the space to seek the professional help they need. We may not always have the answers, but showing we care can be the first step toward healing.
Mental health is something I care deeply about, both personally and professionally. My interest in writing this article was sparked at a natural health roundtable, where a company representative briefly mentioned the connection between folate deficiency and depressive symptoms. I had not heard of this link before, and I felt compelled to learn more. Over the years, many of my patients who’ve come to me for musculoskeletal issues have opened up about their own struggles with anxiety or depression, or those faced by someone they care about. It’s a reminder of how interconnected our mental and physical health truly are. That evening, I dove into research, and the result is this article, which explores one small but potentially important piece of the larger puzzle that is mental health and su***de.
Please note: this article is for informational purposes only and not intended as medical advice. If you or someone you know is in crisis, please call or text the Su***de & Crisis Lifeline at 988.
Mental Health Focus: The Role of Folate in Depression and Su***de Ideation
*This content is for informational purposes only and does not constitute medical advice.
Su***de is often the tragic result of a complex combination of social, psychological, and biological factors (World Health Organization, 2023). Among these, biological factors such as nutrient deficiencies can significantly affect nervous system function. One such deficiency is folate, a vitamin linked to worsened depression symptoms and increased suicidal thoughts and behaviors. In this discussion, we’ll explore key terms and statistics related to su***de and focus specifically on one often-overlooked factor: the relationship between depressive symptoms, folate deficiency, and suicidal thoughts.
Connection Between Depression, Su***de, and Su***de Ideation
Su***de is one of the leading causes of death in the United States and someone dies by su***de every 11 minutes (CDC, 2024). Su***de ideation refers to thoughts of ending one’s life or ruminating about it, while su***de behaviors include planning or attempting su***de. Su***de ideation is frequently associated with mental health disorders, though it can also be triggered by stressful situations (Harmer et al., 2024). It’s estimated that half to two-thirds of all su***des involve individuals with mental disorders, particularly depressive episodes (Isometsä, 2014).
A mental disorder is a clinically diagnosable condition that impacts a person’s thinking, mood, emotions, and behavior (American Psychiatric Association, 2013). About half of all people in the United States will be diagnosed with a mental health disorder at some point in their lives (CDC, 2019). For those with depression, the risk of su***de is significantly heightened (Depression, n.d.). Because of the strong link between depression and su***de, addressing mental health is a significant public health issue. Preventative measures, such as the establishment of Su***de Prevention Awareness Month in 2008 and the World Health Organization’s LIVE LIFE initiative, which offers evidence-based interventions for su***de prevention, have been implemented to combat this growing concern (WHO, 2019).
Antidepressant Treatment
Psychological treatments are typically the first-line therapy for depression, and antidepressants are generally not required for mild cases (WHO, 2023). For major depression, clinicians often prescribe antidepressants alongside psychotherapy, as su***de ideation is considered a symptom of this condition (Pompili, 2019). While antidepressants are generally considered safe, they all come with the strictest prescription warning, known as the black box warning, mandated by the Food and Drug Administration (FDA). The FDA’s warning highlights an increased risk of suicidal thoughts and behaviors in children, adolescents, and young adults aged 18-24 who are prescribed and take antidepressants (Fornaro et al., 2019; Spielmans et al., 2020).
The black box warning was issued after studies revealed that children and adolescents taking antidepressants were nearly twice as likely to experience suicidal thoughts and/or attempt su***de compared to the study subjects who were receiving placebos (Do Antidepressants Increase Su***de Attempts? Do They Have Other Risks?, 2018). However, doctors typically prescribe medications when they believe the potential benefits of the drug outweigh any possible risks. It is also important to recognize that as a multifaceted disease, depression is influenced by various factors. Biological, genetic, social, and psychological elements all play a role (Zielińska et al., 2023). Furthermore, combinations of mental illness, substance abuse, trauma, losses, and social isolation are often interconnected.
While many individuals experience relief from depressive symptoms through antidepressant use, research indicates that a substantial portion do not see meaningful improvement. One study found that 20 out of 100 participants did not improve, and approximately one in three failed to achieve remission from their depressive episodes (Institute for Quality and Efficiency in Healthcare, 2020).
At the onset of the widespread and routine prescription of antidepressants in the late 1980s, the most compelling evidence supporting their efficacy in treating depression among youth came from clinician-rated depression scales (Cohen, 1988). Later, studies using self-reported measures such as perceived depressive symptoms, quality of life, global mental health, and autonomy have shown no significant advantage of antidepressants over placebo (Spielmans & Gerwig, 2014). More recent findings suggest that even in cases of severe depression, antidepressants may offer only a slight reduction in symptoms compared to placebo (Meyerson et al., 2023).
Folate Deficiency Contributes to Depression
For individuals who do not respond to antidepressants, nutritional deficiencies affecting the neuro-endocrine system have been suggested as potential contributors to the development of depressive disorders. One such deficiency is folate. The link between folate deficiency and depression has been studied and known as early as the 1960s (Young, 2007). Folate, or vitamin B-9, is a water-soluble B-complex vitamin necessary for protein metabolism, red blood cell formation, and the healthy growth and function of cells (Mayo Clinic, 2021). People with depression often show low levels of folate, which can significantly affect central nervous system function (Liwinski & Lang, 2023; Bender et al., 2017). The reverse can also occur, where a folate deficiency or malabsorption can result in a poor response to antidepressant medications (Folate Deficiency - Disorders of Nutrition, n.d.; Stein, 2013).
Antidepressants and Folate Deficiency
Further confounding the connection between antidepressants and folate deficiency, certain medications can deplete blood folate levels. Selective serotonin reuptake inhibitors (SSRIs) are typically the first-line treatment due to their safety and fewer side effects compared to other medications like tricyclic antidepressants, bupropion, venlafaxine, and mirtazapine (Grover et al., 2019). A pilot study from 1988 found a significant association between antidepressant use and folic acid deficiency (Farrell et al., 1998), with subsequent studies confirming similar results (Coppen & Bolander-Gouaille, 2005). The key concern, however, is not whether folate deficiency or depression came first, but how to address the suicidal ideation that often accompanies these conditions.
Folic Acid Supplementation
A large-scale study found that folic acid, the synthetic form of folate, was associated with lower rates of su***de attempts (Gibbons et al., 2022). Another study found that adjunct therapy with folic acid improved depression scale scores, patient responses, and remission rates (Altaf et al., 2021). Given these promising results, which form of folate is most effective when prescribed for depression?
L-methylfolate, which helps with neurotransmitter synthesis and can cross the blood-brain barrier, is the recommended form of folate supplementation, typically at a dosage of 15 mg per day. In studies where participants did not respond fully to SSRIs, L-methylfolate was shown to be both safe and effective (Papakostas, 2012). It is also widely accessible and affordable.
While 15 mg of L-methylfolate may be safe when prescribed for individuals with a documented folate deficiency, it is significantly higher than the daily requirement for most people and may not be appropriate for general use without medical supervision. The Recommended Dietary Allowance (RDA) for folate in healthy adults is approximately 400 micrograms of Dietary Folate Equivalents (DFE) (Program, n.d.). It is important to consult a healthcare provider if folate deficiency is suspected.
Given the close connection between mental health and poverty, access to appropriate treatment can be especially difficult for uninsured or low-income individuals (Ridley et al., 2020). For those living in Texas at or below 300% of the Federal Poverty Level, St. Vincent de Paul of North Texas operates a free pharmacy that provides medications at no cost, including free shipping for those who qualify (Pharmacy Main | St. Vincent de Paul of North Texas, 2024).
Conclusion
Research indicates that folic acid, the synthetic form of folate, is linked to lower rates of su***de attempts (Gibbons et al., 2022) and folic acid may be recommended as a safe, cost-effective, and widely accessible adjunct treatment for suicidal ideation. While supplementing with folic acid may offer some benefits, it is just one small piece of the complex puzzle that contributes to depression and suicidal thoughts. For individuals experiencing depression and suicidal ideation, it's crucial to understand that supplementation alone may not resolve these mental health challenges.
It is important to discuss not only folate levels with your healthcare provider but also consider a full nutrition panel as deficiencies in nutrients such as protein, B vitamins, vitamin D, magnesium, zinc, selenium, iron, calcium, and omega-3 fatty acids can impact the brain and nervous system function, potentially contributing to depressive symptoms (Zielińska et al., 2023). Mental health issues, including suicidal ideation, require a holistic approach: a comprehensive treatment plan may include professional therapy, medication (when appropriate), and lifestyle changes, under the guidance of a qualified healthcare provider.
Lifestyle factors such as stress management, adequate sleep, a balanced diet, regular exercise, and a strong support network all play key roles in reducing depression and suicidal ideation risk. Seeking professional help is often necessary for anyone experiencing suicidal thoughts. Reaching out to loved ones can be the first step and often makes a huge difference on the path to recovery.
In upcoming Mental Health Awareness Months, we’ll take a closer look at integrative and complementary therapies—including acupuncture and herbal medicine—as part of a holistic approach to managing depression and supporting mental well-being.
This September, let’s come together to listen and support one another, sharing the message that healing is possible and hope is within reach. If you or someone you know is experiencing emotional distress or a suicidal crisis, call the National Su***de & Crisis Lifeline at 988 for free, confidential support. Maybe you haven’t been told this recently… or maybe you’ve heard it before. Either way, you need to hear it again:
We see you.
We value you.
You are loved and irreplaceable.
—------------------------------------------------------------------------
Dr. LS Collings is a National Board-Certified Acupuncturist, Certified Childbirth Educator, and the owner of Aspen Leaf Wellness in Keller, TX. With a strong commitment to mental health, she gained valuable experience integrating acupuncture into psychiatric care during her internship at Cross Creek Hospital in Austin, TX. At the heart of her practice is a simple philosophy: to offer the kind of care she would want for herself and her loved ones—thorough, respectful, and truly healing.
To learn more or get in touch, you can reach her at DrLSCollings@gmail.com.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Pearson.
Bender, A., Hagan, K. E., & Kingston, N. (2017). The association of folate and depression: A meta-analysis. Journal of psychiatric research, 95, 9–18. https://doi.org/10.1016/j.jpsychires.2017.07.019
CDC. (2019). Data and Publications - Mental Health - CDC. CDC.
https://www.cdc.gov/mentalhealth/data_publications/index.htm
Centers for Disease Control and Prevention. (2024, May 13). Su***de Data and Statistics. Su***de Prevention. https://www.cdc.gov/su***de/facts/data.html
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Lawrence Erlbaum Associates.
Coppen, A., & Bolander-Gouaille, C. (2005). Treatment of depression: time to consider folic acid and vitamin B12. Journal of psychopharmacology (Oxford, England), 19(1), 59–65.
https://doi.org/10.1177/0269881105048899
Depression. (n.d.). Www.who.int. https://www.who.int/health-topics/depression/ =tab_2
Do Antidepressants Increase Su***de Attempts? Do They Have Other Risks? (2018, October 31). National Center for Health Research. https://www.center4research.org/antidepressants-increase.../
Farrell, K. A., Jamjoom, S., Donaldson, D., & Dickerson, J. W. (1988). Do antidepressants cause folic acid depletion? A pilot study. The Journal of the Royal College of General
Practitioners, 38(306), 17–19.
Folate Deficiency - Disorders of Nutrition. (n.d.). Merck Manuals Consumer Version.
https://www.merckmanuals.com/.../vitamins/folate-deficiency
Fornaro, M., Anastasia, A., Valchera, A., Carano, A., Orsolini, L., Vellante, F., Rapini, G., Olivieri, L., Di Natale, S., Perna, G., Martinotti, G., Di Giannantonio, M., & De Berardis, D. (2019). The FDA "Black Box" Warning on Antidepressant Su***de Risk in Young Adults: More Harm Than Benefits?. Frontiers in psychiatry, 10, 294.
https://doi.org/10.3389/fpsyt.2019.00294
Gibbons, R. D., Hur, K., Lavigne, J. E., & Mann, J. J. (2022). Association Between Folic Acid Prescription Fills and Su***de Attempts and Intentional Self-harm Among Privately
Insured US Adults. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2022.2990
Grover, S., Gautam, S., Jain, A., Gautam, M., & Vahia, V. (2019). Clinical Practice Guidelines for the Management of Depression. Indian Journal of Psychiatry, 59(5), 34.
https://doi.org/10.4103/0019-5545.196973
Harmer, B., Lee, S., Duong, T. vi H., & Saadabadi, A. (2024, April 20). Suicidal ideation. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK565877/
Institute for Quality and Efficiency in Health Care. (2020, June 18). Depression: How Effective Are Antidepressants? National Library of Medicine; Institute for Quality and Efficiency in Health Care (IQWiG). https://www.ncbi.nlm.nih.gov/books/NBK361016/
Isometsä E. (2014). Suicidal behaviour in mood disorders--who, when, and why?. Canadian journal of psychiatry. R***e canadienne de psychiatrie, 59(3), 120–130. https://doi.org/10.1177/070674371405900303
Liwinski, T., & Lang, U. E. (2023). Folate and Its Significance in Depressive Disorders and Suicidality: A Comprehensive Narrative Review. Nutrients, 15(17), 3859.
https://doi.org/10.3390/nu15173859
Mayo Clinic. (2021, February 23). Folate (folic acid). Mayo Clinic.
https://www.mayoclinic.org/drugs-supplements-folate/art-20364625
Meyerson, W. U., Pieper, C. F., & Hoyle, R. H. (2023). Use of Quantile Treatment Effects Analysis to Describe Antidepressant Response in Randomized Clinical Trials Submitted to the US Food and Drug Administration. 6(6), e2317714–e2317714.
https://doi.org/10.1001/jamanetworkopen.2023.17714
Papakostas, G. I., Shelton, R. C., Zajecka, J. M., Etemad, B., Rickels, K., Clain, A., Baer, L., Dalton, E. D., Sacco, G. R., Schoenfeld, D., Pencina, M., Meisner, A., Bottiglieri, T., Nelson, E., Mischoulon, D., Alpert, J. E., Barbee, J. G., Zisook, S., & Fava, M. (2012). L-methylfolate as adjunctive therapy for SSRI-resistant major depression: results of two randomized, double-blind, parallel-sequential trials. The American journal of psychiatry, 169(12), 1267–1274. https://doi.org/10.1176/appi.ajp.2012.11071114
Pharmacy Main | St. Vincent de Paul of North Texas. (2024). Svdpdallas.org. https://svdpdallas.org/pharmacy/
Pompili M. (2019). Critical appraisal of major depression with suicidal ideation. Annals of general psychiatry, 18, 7. https://doi.org/10.1186/s12991-019-0232-8
Program, H. F. (n.d.). Folate and folic acid on the nutrition and Supplement Facts Labels. U.S. Food and Drug Administration. https://www.fda.gov/food/nutrition-facts-label/folate-and-folic-acid-nutrition-and-supplement-facts-labels
Ridley, M., Rao, G., Schilbach, F., & Patel, V. (2020). Poverty, depression, and anxiety: Causal evidence and mechanisms. Science (New York, N.Y.), 370(6522), eaay0214. https://doi.org/10.1126/science.aay0214
Spielmans, G. I., & Gerwig, K. (2014). The Efficacy of Antidepressants on Overall Well-Being and Self-Reported Depression Symptom Severity in Youth: A Meta-Analysis. Psychotherapy and Psychosomatics, 83(3), 158–164. https://doi.org/10.1159/000356191
Spielmans, G. I., Spence-Sing, T., & Parry, P. (2020). Duty to Warn: Antidepressant Black Box Suicidality Warning Is Empirically Justified. Frontiers in psychiatry, 11, 18. https://doi.org/10.3389/fpsyt.2020.00018
Stein, T. (2013). Depression Won’t Go Away? Folate Could Be the Answer | Psychology Today. www.psychologytoday.com.
https://www.psychologytoday.com/.../depression-wont-go...
Su***de and Suicidal Behavior. (2023). Samhsa.gov.
https://www.samhsa.gov/mental-health/su***de
World Health Organization: WHO. (2019, July 😎. Su***de. Who.int; World Health Organization: WHO. https://www.who.int/health-topics/su***de =tab_3
World Health Organization. (2023, March 31). Depressive disorder (depression). World Health Organization; World Health Organization. https://www.who.int/news-room/fact-sheets/detail/depression
Young, S. N. (2007) Folate and depression–a neglected problem. Journal of psychiatry & neuroscience : JPN, 32(2), 80–82.
Zielińska, M., Łuszczki, E., & Dereń, K. (2023). Dietary Nutrient Deficiencies and Risk of Depression (Review Article 2018-2023). Nutrients, 15(11), 2433. https://doi.org/10.3390/nu15112433
