Letter regarding the IDSA/AAN/ACR 2019 Draft Lyme Disease Guidelines

Lyme and Psychiatric Illness 7/28/2019

As a psychiatrist specializing in infection-associated psychiatric illness I have some concerns about the proposed 2019 draft of Lyme disease guidelines.

1.On the question of should all adult patients with psychiatric illness be tested for Lyme disease the guideline authors recommend against this testing.  It is interesting how the guideline authors selectively chose only literature to cite that supports their view of psychiatric symptoms being an independent factor, as if unconnected in an individual with Lyme disease. The literature supports there being an association between many bacterial infections and psychiatric symptoms even streptococcal pharyngitis, (PANDAS)   The draft states that  there is no systematic evidence supporting a causal relationship.   This is untrue.

I agree with the authors that routinely testing psychiatric patients is a questionable practice but that is only because the present recommended two-tier testing is so poor and only identifies a little over 50% of the cases (Stricker and Johnson BMJ 2007).  Dennis Parenti MD, a past group director of adult vaccines for SmithKline Beecham in a presentation of results from the Lyme Vaccine Trial that occurred between  Jan 1995-Nov 1996 and included over 11,000 patients found that the  rate of seroconversion (positive testing for BB) in the closely monitored study population was 90/142 or 64%  He concluded that “In this study had we relied only on seroconversion we would have missed one third of the cases.”  This flaw alone makes the reliance of serologic testing questionable (especially with the high number of false negatives) limiting the utility of routine testing for BB in psychiatric patients.

2.The authors appear to have overlooked multiple articles in the literature supporting the link between Lyme disease and psychiatric illness, including increased rates of depression and anxiety as well as suicidal and homicidal behavior.  This is a significant error that has major effects on patient’s diagnosis, treatment and prognosis.

Examples of relevant literature include:

1. Fallon BA, Nields JA,Parsons B,Liebowitz MR,Klein DF. Psychiatric manifestations of Lyme borreliosis; J Clin Psychiatry. 1993 Jul;54(7):263-8.
2. Fallon BA, Nields JA. Lyme disease:  a neuropsychiatric illness.; Am J Psycho Nov 1994.
3. Bransfield RC. Lyme disease, comorbid tick-borne diseases, and neuropsychiatric disorders. Psychiatric Times. 2007;24(14):59–6
4. Bransfield RC. Neuropsychiatric Lyme Borreliosis: An Overview with a Focus on a Specialty Psychiatrist’s Clinical Practice
5. Healthcare 2018, 6(3), 104;https://doi.org/10.3390/healthcare6030104
6. Greenberg R. Infections and Childhood Psychiatric Disorders: Tick-Borne

Illness and Bipolar Disorder in Youth. Bipolar Disorder 3:113. December

2016.DOI: 10.4172/2472-1077.1000113

3.Even though LD testing is of limited accuracy, it would be reasonable to recommend it be done in cases of psychiatric mood disorders, psychosis, and/or behavioral disturbances that appear treatment resistant to standard psychotropic medication. In these difficult atypical cases, it is important to keep neurologic, autoimmune and infectious diseases on the diagnostician’s radar.  In these situations, testing for

Borrelia species, just like testing for treponema pallidum infections is warranted.

I sincerely hope that the guideline authors will be receptive to this input.

Rosalie Greenberg MD FAPA DFAACAP

Board Certified in Child, Adolescent and Adult Psychiatry