Ms. Y is remorseful over her recent aggressive behavior, and fears that her boyfriend will leave her. She denies suicidal and homicidal ideation and does not require inpatient psychiatric hospitalization. We strongly advise her to discontinue carnitine supplements and energy drinks and to limit her caffeine intake. Because Ms. Y’s had continued to use carnitine supplements despite adverse consequences and against medical advice, we refer her for substance abuse treatment.
The authors’ observations
Although temporal coincidence does not necessarily imply causality, in Ms. Y’s case, the relationship between carnitine ingestion and psychiatric symptoms cannot be ignored. Individuals predisposed to mania or psychosis may be more likely to respond adversely after ingesting nutritional supplements or energy drinks.9 Ms. Y’s past psychotic episodes suggest that she could be vulnerable to future episodes. She also might have a biologic predisposition to psychosis because of her family history of schizophrenia.
The literature contains at least 1 other reported case of carnitine-induced psychosis. A patient with a history of bipolar disorder presented with auditory hallucinations, persecutory delusions, and verbally threatening and physically assaultive behavior 5 days after beginning nutritional supplements containing carnitine.1 There also are reports of patients who experienced acute changes in mental status after consuming other nutritional weight loss supplements (Table).9-17 Chelben et al9 describe 3 patients with known psychiatric illness who showed clinical deterioration leading to psychiatric hospitalization after ingesting nutraceutical preparations. This may be a common but unrecognized cause of decompensation in psychiatric patients who take supplements.
This case highlights the importance of being aware of patients’ use of alternative medications or nutritional supplements. Physicians should routinely inquire about the use of weight loss products, energy drinks, and supplements, and patients should be educated about the risks, including potential to exacerbate pre-existing psychiatric disorders.
Table
Psychiatric effects of common weight loss supplements
| Supplement | Psychiatric effects |
|---|---|
| Caffeine | Depression, anxiety, agitation, aggression, psychosis10-12 |
| Ephedra* | Psychosis, severe depression, mania or agitation, hallucinations, sleep disturbance, suicidal ideation13 |
| Panax (ginseng) | Euphoria, mania14 |
| Amino acid-containing drinks (taurine and inositol) | Euphoria, hypervigilance, insomnia, verbal and physical aggression, impulsive behavior9,15 |
| Hypericum (St. John’s wort) | Mania,16 psychosis17 |
| *FDA removed ephedra from the market in 2003 because of adverse events | |
Related Resources
- National Library of Medicine. Dietary supplements labels database. http://dietarysupplements.nlm.nih.gov/dietary.
- Grossberg G, Fox B. The essential herb-drug-vitamin interaction guide. New York, NY: Broadway Books; 2007.
Drug Brand Names
- Carbamazepine • Tegretol
- Haloperidol • Haldol
- Risperidone • Risperdal
- Valproic acid • Depakene
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.