Hydroxycut – Dietary supplements for weight loss: Can they induce mania?

To the Editor

The use of dietary supplements has been steadily increasing in developing countries (Gahche et al., 2011). An Indian study (Malik and Malik, 2010) reported that gym goers using dietary supplements to increase muscle mass and decrease body fats were unaware of their possible side effects. Hydroxycut is a herbal preparation marketed as an aid for weight loss. It contains caffeine (63 mg per capsule), Paullinia cupana (guarana) (95 mg per capsule), Garcinia cambogia, Gymnema sylvestre, glucomannan, green tea and willow bark (Willis et al., 2006). Hydroxycitric acid is the active ingredient of Garcinia cambogia and it suppresses fatty acid synthesis as do the active principles of Gymnema sylvestre and glucomannan. Guarana extract is said to contain stimulant properties (De Oliveira Campos et al., 2011). The United States Food and Drug Administration (FDA) has issued warnings to consumers on the usage of Hydroxycut products. Various case studies have shown serious side effects of this dietary supplement such as hepatotoxicity, seizures and rhabdomyolysis (Cvetanovich et al., 2011). We present a case of mania induced by Hydroxycut.

Mr P, a 23-year-old male, presented to the outpatient services of the National Institute of Mental Health and Neuro Sciences, Bangalore, India with acute onset of symptoms including extreme irritability, aggression, hallucinatory behaviour and decreased sleep commencing 2 weeks previously. He gave a history of taking the dietary supplement Hydroxycut (one to two capsules/day) for 1 month. The initial symptoms noticed were unprovoked angry outbursts and defiant behaviour, followed by over-familiarity, over-talkativeness and increased psychomotor activity. A mental status examination showed an increased rate and volume of speech with paranoid and grandiose ideas in thought content. There was no history of substance abuse, co-morbid medical or psychiatric conditions or history of similar symptoms in the past. His physical examination and biochemical parameters were normal, and his urine drug screen was negative.

He was admitted for observation and initiated on risperidone 4 mg and clonazepam 2 mg for symptomatic management. However, these medicines were stopped within 4 days as his symptoms reduced dramatically. He reached pre-morbid levels within a week and remained asymptomatic.

Given the absence of pre-disposing factors, such as significant family, past or personal history, any precipitating stressful events, the rapid resolution of symptoms on stopping the offending drug, and with the patient not requiring any further treatment interventions, it can be safely assumed that the mania was related to the use of Hydroxycut, which contains stimulants such as caffeine and guarana.

Clinicians need to be aware that susceptible individuals are at risk of physical and psychiatric complications. It is therefore imperative to include a history of use of dietary or herbal supplements during psychiatric assessment. The licensing practices and marketing regulations for such products need to be monitored, as neither patients nor health care professionals are aware of their potential adverse effects.