Natural weight loss supplements – Are they psychoactive?

To the Editor

Weight loss substitutes are advertised as quick solutions to the ever-expanding problem of obesity. However, the effect that these supplements have on mental health is under-recognised. We report the association of psychiatric symptoms following use of a natural weight loss supplement.

Ms S, a 33-year-old woman, presented to hospital with an acute onset of psychomotor retardation, flat affect, thought broadcasting, auditory hallucinations and persecutory delusions. There were no clinical features to suggest substance misuse, organic medical conditions or positive family history. Ms S had one previous admission 16 months earlier with similar symptoms associated with the consumption of Garcinia cambogia extract which resolved with risperidone 2 mg/day.

In the 8 weeks preceding this episode, Ms S commenced dietary supplements for weight loss. These included Graviola tablets and a spray containing levocarnitine, chromium, lipoic acid and extracts equivalent to dried Garcinia cambogia fruit (36 mg/mL), Gymnema sylvestre leaf (2160 mg/mL), Camellia sinensis leaf (1200 mg/mL equivalent to 20 mg caffeine) and Avena sativa seed (100 mg/mL). These supplements were ceased on admission. Within a few days, her psychotic symptoms abated, she became reactive and her neurovegetative functions normalised. Ms S was discharged a week later on risperidone 2 mg/day. Three weeks post discharge, she returned to her pre-morbid state and the risperidone was ceased.

Graviola and levocarnitine have been associated with adverse effects like movement disorders and weakness (Therapeutic Research Centre, 1999). Garcinia cambogia can cause headache and gastrointestinal symptoms, but no psychoactive effects are reported (Therapeutic Research Centre, 1999). Formulations containing Garcinia cambogia and Gymnema sylvestre have been implicated to cause psychiatric symptoms (Narasimha et al., 2013). It is unknown whether suppression of fatty acid synthesis by these agents contributes to CNS effects – or if the psychosis resulted from stimulants in the formulation.

In our case, there is temporal association of Garcinia cambogia with psychosis, on two separate occasions without other likely explanations. The Naranjo Probability Scale (Naranjo et al., 1981) score was 5 indicating a probable drug reaction. Garcinia cambogia is a condiment in subcontinental cooking. It could be a confounder or it is plausible that there exists a dose-related association with psychopathology. Our case illustrates a gap in knowledge about how such seemingly innocuous extracts can have psychoactive effects. Eliciting a history of natural supplement intake appears valuable when patients present with atypical psychiatric symptoms.