A case of psychosis associated with Pai You Guo slimming capsules containing sibutramine.

To the Editor: Sibutramine is a potent serotonin-norepinephrine reuptake inhibitor that was approved by the US Food and Drug Administration (FDA) in 1997 for the treatment of obesity. 1,2 In 2010, the FDA issued a voluntary withdrawal of the drug due to concerns over adverse cardiovascular effects. 3,4 Despite this, sibutramine continues to be found in herbal slimming products sold over the Internet. 5–9 Pai You Guo is an over-the-counter herbal slimming product manufactured in China that is adulterated with sibutramine and phenolphthalein, a suspected carcinogen. 10 While the cardiovascular side effects of sibutramine have been well characterized, 1 there have been few reports of the neuropsychiatric sequelae of its use. We report a case of a woman who experienced an acute psychotic episode triggered by Pai You Guo slimming capsules. Case report. Ms A, a 27-year-old white woman with no significant medical history, was brought to the emergency department by her husband because of a depressed mood with bizarre, paranoid behavior for 6 days. She had no history of psychiatric illness, neurologic disturbance, or substance use before this admission. She was subsequently admitted to the psychiatric unit for manifesting bizarre behavior in the emergency department (disturbing other patients and attempting to lock herself in an imaging room). Laboratory test results (complete blood count, liver function tests, kidney function tests, blood glucose level, serum electrolyte test , thyroid function tests, urinalysis, urine toxicology screen, blood alcohol level, and pregnancy test) showed no significant abnormalities. Further history revealed that Ms A had been taking Pai You Guo slimming capsules daily for the past month for weight loss. She experienced depressed mood, insomnia, fatigue, and paranoid delusions that began 1 week before admission. There was no family history of psychiatric illness, and she took no other medications or herbal supplements before admission. Upon psychiatric assessment, Ms A was awake, alert, and oriented to person, place, and time but was irritable, isolative, paranoid, and suspicious of staff and displayed a blunted affect. She denied auditory or visual hallucinations and suicidal or homicidal ideations. She was started on treatment with risperidone 0.5 mg twice daily and subsequently showed a rapid improvement of psychotic symptoms. After 2 days, her paranoid delusions and bizarre behavior had improved. Because of her rapid response to therapy, risperidone was discontinued, and she was discharged with strong family support and the recommendation to stop taking her Pai You Guo diet …