[First-episode mania with psychotic features induced by over-the-counter diet aids containing sibutramine].

Consumption of over-the-counter drugs or medicinal products in Turkey has been increasing following Turk-ish legislation on the classification of medicinal products in 2005, which regulates the marketing of over-the-counter drugs (Turkish Pharmacists' Association 2009). Moreover, many international pharmaceutical products are easily obtained via suppliers on the Internet (Mor-ris and Avorn 2003). Herbal medicines are marketed in drugstores and herbal stores, and via advertisements in the print media and on the Internet (De Smet 2004). In Turkey over-the-counter drugs and herbal medicines can be imported with the approval of the Ministry of Agriculture and Rural Affairs, bypassing the Ministry of Health (Turkish Pharmacists' Association 2009). Due to this approval and licensing process, products claimed to be herbal in origin and that potentially affect the central nervous system (CNS) can be obtained without adequate oversight. Some of these products are marketed as diet aids. Laboratory investigation of such products in many countries found that some contained pharmacological agents that affect the CNS and those particular products were confiscated (Müller et al. 2009). Three products marketed as diet aids were confiscated in Turkey in August 2010 following the probable association of one of those products with the death of an enteritis case in Kas-tamonu province (Ministry of Health 2010). Laboratory analysis showed that the three confiscated products contained sibutramine (Ministry of Health 2010). Sibutramine, which is indicated for the treatment of obesity (body mass index >30, or >27 in obesity cases with comorbid hypertension, hyperlipidemia, and diabetes mellitus), acts as a serotonin and noradrenalin re-uptake inhibitor in the synaptic cleft via its primary and secondary metabolites (Luque and Rey 1999). The effect of sibutramine on the CNS makes it relevant to psychiatric practice. While 10-15 mg per day of sibutramine is used for the treatment of obesity (Lu-que and Rey 1999), over-the-counter products illegally contain sibutramine in undisclosed concentrations. Various investigations reported that the concentration of sibutramine was 2-3-fold higher in products marketed as herbal medicines than in originally licensed medicines (Jung et al. 2006, Müller et al. 2009). Case reports on hypomania, mania, and psychotic episodes associated with sibutramine have increased along with the increase of its use in pharmaceutical products and as an undisclosed ingredient in quasi-herbal products (Taflinskially, there are case reports of mixed (Eker et al. 2003) and depressive mood episodes (Şengül and Balcı-Şengül 2007), as well as a psychotic episode (Dogangun et al. 2008) associated with use of …