Hypomania induced by a Garcinia cambogia supplement

To the Editor

Garcinia cambogia, a tropical fruit traditionally used in India and Southeast Asia for culinary and therapeutic purposes, recently became a popular ingredient in weight-loss over-the-counter supplements. Hydroxycitric acid, considered its main active ingredient, has serotoninergic effects and has been implicated in cases of severe serotoninergic syndrome. Such effects have been proposed to underlie the occurrence of mania associated with consumption of supplements containing Garcinia (Hendrickson et al., 2016; Narasimha et al., 2013).

Here, we present the case of a 51-year-old woman with a 12-year history of type 1 bipolar disorder. Written informed consent was obtained from the patient for publication of patient information. After introduction of mood stabilizers, the patient remained stable, with only occasional episodes of hypomania or mild depression. After 2 years of full stability, under treatment with valproic acid 1250 mg/day and paroxetine 20 mg/day, the patient started consumption of a weight-loss dietary supplement containing Garcinia cambogia, calcium, chromium and potassium. After 2 weeks, irritability, agitation, increased energy and decreased need for sleep were noticed, that were sustained until the next routine visit with the psychiatrist, which was 2 weeks later. Given the assessment of a hypomanic episode temporally related to consumption of the dietary supplement, and considering the available literature (Hendrickson et al., 2016; Narasimha et al., 2013), the patient was advised to discontinue the supplement, while maintaining other medication. She returned 2 weeks later and reported that approximately 1 week after ceasing the supplement, while maintaining treatment with valproic acid and paroxetine at the same doses, her mood had stabilized with full remission of all symptoms of hypomania.

We believe this case supports and extends prior reports of Garcinia-associated mania. Critically, prior reports either omitted full supplement composition (Hendrickson et al., 2016) or reported on mania after consumption of a supplement containing also other active stimulants, such as caffeine and guarana (Narasimha et al., 2013), rather than only Garcinia and inert ingredients, as reported here. Furthermore, in previous cases, treatment included introduction of mood stabilizers, neuroleptics and/or benzodiazepines, such that improvement could not be attributed specifically to withdrawal of the supplement (Hendrickson et al., 2016; Narasimha et al., 2013). Here, improvement of manic symptoms resulted only from withdrawal of Garcinia, meriting an assessment of a probable/likely causal association between consumption of the Garcinia supplement and occurrence of hypomania (Edwards and Aronson, 2000). This case thus underscores the need to explore and record use of dietary supplements in patients with bipolar disorder, while reinforcing the adequacy of recommending against the use of Garcinia supplement in this patient population.