Common use of dietary supplements for bipolar disorder: a naturalistic, self-reported study
© Bauer et al.; licensee Springer. 2015
Received: 10 March 2015
Accepted: 12 May 2015
Published: 2 June 2015
Dietary supplements are taken by about half of Americans. Knowledge of dietary supplement use is important because they may interact with prescription drugs or other supplements, cause adverse reactions including psychiatric symptoms, or contain inherently toxic ingredients or contaminants. This study explores the use of dietary supplements by patients with bipolar disorder in the US.
Data were obtained from an ongoing, naturalistic study of patients with bipolar disorder who received pharmacological treatment as usual. The patients self-reported their daily mood, sleep, and medications taken, including all drugs prescribed for bipolar disorder or that the patient felt impacted their mood. These included other prescribed drugs, over-the-counter drugs and dietary supplements. Drugs that received premarketing approval from the FDA were not included as dietary supplements. Patient demographics and daily medication use were characterized.
Data were available from 348 patients in the US who returned a mean 249.5 days of data. In addition to prescribed psychiatric drugs, 101 of the 348 patients (29 %) used a dietary supplement for at least 7 days and 69 (20 %) used a supplement long term (for at least 50 % of days). Of the 101 supplement users, 72 (71.3 %) took one supplement daily. The 101 patients tried over 40 different supplements, and the long-term users took 19 different supplements. The most commonly taken supplements for both groups were fish oil, B vitamins, melatonin, and multivitamins. Patients using supplements were more likely to be white (p < 0.001), older (p = 0.009), and ill for more years (p = 0.025).
Many patients with bipolar disorder use dietary supplements in addition to prescribed drugs. Physicians should obtain detailed information about all dietary supplements taken by patients with bipolar disorder.
Dietary supplements, including vitamins, minerals, herbals and botanicals, amino acids, enzymes, and other products are used by about half the US population (Gahche et al. 2011). Sales of dietary supplements generated about US$32 billion in revenue in 2012 (Lariviere 2012; NIH 2011) or about one tenth of that generated by prescription drugs (Bartholow 2013). In 2008, the FDA estimated there were 55,600 distinct dietary supplement product labels manufactured by 1460 firms (Federal Register 2009). The most popular supplements are multivitamin/mineral products, taken by about one third of Americans (Bailey et al. 2011; NIH 2013). About three fourths of dietary supplements used by the general public are selected by personal choice rather than prescribed by a physician (Bailey et al. 2013). Less is known about the use of dietary supplements by people with mental illness, with studies reporting that 15–36 % take herbal and/or dietary supplements (Elkins et al. 2005; Knaudt et al. 1999; Matthews et al. 2003; Russinova et al. 2002; Wu et al. 2007).
Physician knowledge of patient use of dietary supplements is important because of the potential for interactions with prescription drugs or other supplements (Izzo and Ernst 2009), potential adverse reactions including psychiatric (Ernst 2003; Tsai et al. 2012), potential dangers to special populations such as pregnant women, and the inherent toxicity of some ingredients (Kroll 2004). Only about one third of patients, with and without mental illness, disclose the use of dietary supplements to their physician (Blendon et al. 2013; Elkins et al. 2005, Gardiner et al. 2006; Keaton et al. 2009; Kennedy 2005; Matthews et al. 2003; McCrea and Pritchard 2011; Mehta et al. 2008). Furthermore, the use of dietary supplements may not be documented in a patient’s electronic medical record (Staroselsky et al. 2008). This information may be particularly important for patients with bipolar disorder since most are prescribed polypharmacy (Bauer et al. 2013b; Lin et al. 2006), and the risk of drug interactions increases with the number of drugs taken (Goldberg et al. 1996; Köhler et al. 2000). This study explores the use of dietary supplements by patients with bipolar disorder who received pharmacologic treatment as usual, based on daily self-reported data.
All data were obtained from an ongoing, naturalistic, international study in which patients with bipolar disorder self-reported daily their mood, sleep, and medications taken (Bauer et al. 2009; Bauer et al. 2013a,b; Bauer et al. 2013c). Study participants must have a diagnosis of bipolar disorder by the DSM-IV criteria, be at least 18 years old, receive pharmacological treatment as usual, and be willing to use ChronoRecord self-reporting software daily on a home computer. The study has minimal inclusion criteria to better represent the heterogeneity of routine clinical practice. The diagnosis of bipolar disorder was made by the prescribing psychiatrist in a clinical interview, and all patients received treatment as usual. All participants were volunteers, primarily recruited by the prescribing psychiatrist, and were informed about the study prior to providing written informed consent. The study was approved by the Ethical Committee of the Medical Faculty of the Technische Universität Dresden, and is in compliance with the Helsinki Declaration. Patents received about a half hour of training, in person or by telephone, before entering data.
The ChronoRecord database includes patients who reside in several countries. However, because of international differences in the definition and regulation of dietary supplements (Getman 2015), only data from patients who reside in the US were included in this analysis.
The patients entered mood, sleep, medications, and significant life events daily and weight weekly into the ChronoRecord software. The daily self-ratings for mood in ChronoRecord were previously validated with clinician ratings on the Hamilton Depression Rating Scale (HAMD) and the Young Mania Rating Scale (YMRS) (Bauer et al., 2004, 2008). For rating mood, ChronoRecord uses a 100-unit visual analog scale between the extremes of mania and depression. Based upon the validation studies (Bauer et al., 2004, 2008), a mood entry less than 40 was considered depression, 40–60 euthymia, and greater than 60 hypomania/mania. The depression ratings varied from mild (entry of 20–39) to moderate-severe (entry of 0–19), and the mania ratings varied from hypomania (entry of 61–80) to moderate-severe (entry of 81–100).
During patient training, a medication list was created for each patient. The medication list includes all drugs prescribed for bipolar disorder and any other medications that the patient felt impacted their mood, including prescribed medications, over-the-counter (OTC) drugs, and dietary supplements. The prescribed psychotropic drugs were selected from a list in the software, displayed by brand and generic names, including some well-known supplements such as St. John’s wort. The patient could add a drug or dietary supplement not included in the software list and could modify the list of drugs taken throughout the study period as needed. For each selected drug, the pill strength was chosen from a list of available strengths. Every day, for each drug, the patient entered the total number of pills taken. Patients could enter partial pills (1/4, 1/2, or 3/4) for tablets but not capsules. If a drug was not taken, the patient entered 0 pills for that drug for that day. Data not entered on one day could be entered at a later date. The software includes many error checking steps such as to prevent entry for a future date.
The use of a dietary supplement was defined as taking one supplement for at least 7 consecutive or non-consecutive days during the study. Long-term use of a dietary supplement was defined as taking one supplement for at least 50 % of the study days. Drugs taken in this study that were approved by the FDA, such as the prescription drug Lovaza (omega-3-acid ethyl esters) or OTC drug Unisom (doxylamine), were not included as dietary supplements. The specific formulations or manufacturer of the dietary supplements were not obtained.
A minimum of 180 days of patient data was required for inclusion in the analysis. The characteristics of patients using and not using dietary supplements were compared. Distributions of categorical variables were compared using the Pearson’s two-sided asymptotic chi-squared test. Mean values of continuous variables were compared using the independent sample two-sided t test. Unequal variance was assumed for all t tests. A p value of less than 0.05 was considered statistically significant. SPSS version 22.0 was used for all calculations.
Patient demographics by using or not using dietary supplements (N = 348)
Using (N = 101)
Not using (N = 247)
Gender N (%)
Diagnosis N (%)
Employment N (%)
Education N (%)
Marital status N (%)
Ethnicity N (%)
Age mean age (SD)
Dietary supplements taken by supplement users (N = 101)
Vitamin B (folate, B6, B12, niacin, and combination products)
Herbs and nutritional products
Glucosamine (with/without chondrotin)
St. John’s wort
Thyroid support products
Weight loss products
Clinical characteristics by using or not using dietary supplements (N = 348)
Using dietary supplements (N = 101)
Not using dietary supplements (N = 247)
Taking mood stabilizer N (%)a
Taking antidepressant N (%)a
Taking antipsychotic N (%)a
Taking benzodiazepine N (%)a
Percentage of days depressed, mean (SD)
Percentage of days euthymic, mean (SD)
Percentage of days manic, mean (SD)
Percentage of days severely depressed, mean (SD)
Percentage of days severely manic, mean (SD)
Hospitalizations, mean number (SD)
Age of onset, mean age (SD)
Years of illness, mean years (SD)
Thirty percent of patients with bipolar disorder in this study used dietary supplements in addition to prescribed medications, with one in five patients using supplements for the long term. Since this study did not include dietary supplements used for other diseases or general health, the results are likely to underestimate the total number of patients using dietary supplements and the total supplements taken. Nevertheless, these findings remain consistent with prior research. About 13–52 % of adults in the general population use dietary supplements and prescription medications concurrently (Farina et al. 2014; Gardiner et al. 2006; McCrea and Pritchard 2011; Qato et al. 2008), increasing when including vitamins and minerals. The finding that dietary supplement use was highest among older, white individuals was also consistent with prior research (Bailey et al. 2011; Gahche et al. 2011; Schaffer et al. 2003), although some studies also report higher use in women than men (Gahche et al. 2011; Gardiner et al. 2006; Schaffer et al. 2003).
In this study, patients using both dietary supplements and mood stabilizers skipped taking the supplements nearly three times more often than the mood stabilizers. Similarly, in prior research, complementary and alternative medicines did not decrease adherence to medications prescribed for psychiatric disorders (Ennis 2014) or general medical disorders (Cherniack 2011). The long-term use of supplements had no impact on self-reported mood symptoms, although individual supplements were not analyzed. While the efficacy of dietary supplements in the treatment of bipolar disorder is outside the scope of this analysis, most review articles do not recommend routine use of dietary supplements yet recognize that some products have potential adjunctive benefit (Andreescu et al. 2008; Rakofsky and Dunlop 2014; Sagduyu et al. 2005; Sarris et al. 2011). However, adverse effects of some supplements may destabilize mood (Ernst 2003; Werneke et al. 2006). For example, St. John’s wort, S-adenosylmethionine, and ginseng may induce mania (Andreescu et al. 2008; Norelli and Xu 2014), supplements containing serotonergic agents and stimulants may induce anxiety (McCarthy et al. 2014), and melatonin may increase daytime sleepiness (Werneke et al. 2006).
The findings of this study highlight the need to ask all patients with bipolar disorder about their use of dietary supplements. While the vast majority of dietary supplements are taken safely by millions daily, many issues remain relating to the formulations of commercial dietary supplements. Analytical testing of many commonly taken dietary supplement products has found a wide deviation between the ingredient amount stated on the label and the measured amount (Lockwood 2011). For example, testing of products purchased in US retail outlets have reported potency between 62–184 % for fish oil EPA and DHA (Kleiner et al. 2014) and between 9–146 % for vitamin D (cholecalciferol) (LeBlanc et al. 2013). A recent investigation of top-selling store brands of herbal supplements at four national retailers found that 80 % of the products did not contain the herbs stated on their labels (O’Connor 2015). Differences in the purity and integrity of melatonin products may contribute to the observed variations in effective doses and serum concentrations (de Rooij et al. 2014). Other quality concerns with dietary supplements include adulterants not declared on the labels such as prescription drugs, prohibited stimulants, prohormones, anabolic steroids, chemical toxins or other chemical ingredients (Geyer et al. 2008; Vaclavik et al. 2014), and microbial contamination (Tournas 2009). Clinically relevant amounts of T3 and/or T4 were present in nine out of ten dietary or “thyroid support” supplements purchased online (Kang et al. 2013). The supplements most frequently adulterated are those advertised for the support of chronic illnesses, obesity, and for athletes (Vaclavik et al. 2014).
Unlike drugs with a single active ingredient, supplements are often complex mixtures of ingredients, often of biological origin, and have multiple pharmacological properties (Foster et al. 2005). As reviewed in detail elsewhere, many dietary supplements used by patients with bipolar disorder have the potential for pharmacokinetic and pharmacodynamic interactions with prescribed drugs or other supplements (Izzo and Ernst 2009; Gardiner et al. 2008). Pharmacokinetic interactions occur when one drug impacts the absorption, distribution, metabolism, or excretion of another drug, causing the blood level to increase or decrease (Sandson et al. 2005). For example, St. John’s wort may reduce effectiveness of benzodiazepines and methadone due to induction of cytochrome P450 3A4 enzyme (Izzo and Ernst 2009). Pharmacodynamic interactions occur when drugs act upon the same or related receptors, causing additive or oppositional effects (Sandson et al. 2005). For example, St. John’s wort may interact with serotonergic agents such as SSRI antidepressants to produce serotonin syndrome (Izzo and Ernst 2009; Gardiner et al. 2008). In a literature review of 1491 drug-dietary supplement interactions, prescription drugs that affect the central nervous system or cardiovascular system were involved in the most interactions with dietary supplements, and the most frequently involved supplements were products containing St. John’s wort, magnesium, calcium, iron, and ginkgo (Tsai et al. 2012). Adverse events with dietary supplements are underreported for several reasons including the expectation that consumers will recognize and report these to the FDA (GAO 2013). Furthermore, many dietary supplements may not be included in software that checks for drug interactions. The use of herbal products may also result in abnormal laboratory test results (Dasgupta 2003).
Given their frequent use in bipolar disorder, it is also important to recognize that the general public has many misconceptions about dietary supplements. Many incorrectly assume that the FDA evaluates dietary supplement products for safety and efficacy and approves product advertisements (Ashar et al. 2008; Dodge et al. 2011; Keaton et al. 2009; Pillitteri et al. 2008). Dietary supplements and products labeled “natural” are often perceived as being safer than OTC or prescription drugs (Dennehy et al. 2005; Nichter and Thompson 2006). In a survey of the general public (n = 1027), 29 % felt it was not necessary to follow the recommended dosages for dietary supplements, as compared with only 9 % for prescription drugs (Gibson and Taylor 2005). Additionally, warning labels on dietary supplement products intended to decrease consumer perceptions of safety may have unintended consequences and increase some consumer perceptions of efficacy (Mason et al. 2007). Only one fourth of users would stop using a supplement if the regulators said it is ineffective (Blendon et al. 2013).
It is also difficult for patients to find high-quality information about dietary supplements. Many pharmacists do not have sufficient knowledge of dietary supplements to provide counselling (Boon et al. 2009). Dietary supplements are often purchased on the Internet, and many of these web sites provide inadequate information to the consumer (Monteith et al. 2013). In a survey of 1179 web sites for 13 common herbal products, only 8 % of retail sites contained any safety information, and only 10.5 % recommended consultation with a health-care professional (Owens et al. 2014).
There are limitations to this study. All data in the study were self-reported, and daily access to a home computer was required. The study included more females than males and did not include patients with bipolar disorder who were not receiving treatment. However, the demographic profile of the patients who use ChronoRecord is similar to that in other studies of bipolar disorder (Bauer et al. 2009; Bauer et al. 2012). Patient reluctance to report dietary supplement use may also contribute to underestimation of usage. We assume that most physicians do not routinely ask patients about supplement use. It is not known if use of the dietary supplement in this study was initiated by the patient or recommended by the physician. This database does not include medications taken for diseases other than bipolar disorder, so the potential for interactions with dietary supplements could not be accurately determined. Only US data were included in this analysis, although dietary supplements are commonly used worldwide. There are not enough study participants to analyze for ethnic differences in the use of dietary supplements, which have been noted in prior research (Albright et al. 2012).
Patients with bipolar disorder commonly take dietary supplements in addition to prescription medications. About three out of ten patients used dietary supplements, with two in ten of these taking supplements for the long-term. The patients tried about 40 different supplements, with fish oil, vitamin B preparations, multivitamins, and melatonin taken most frequently. Dietary supplements have the potential to interact with prescription drugs and other supplements and to cause adverse reactions. Many quality issues remain with formulations of commercial dietary supplements. The physician should obtain detailed information about all dietary supplements taken by patients with bipolar disorder.
- Albright CL, Schembre SM, Steffen AD, Wilkens LR, Monroe KR, Yonemori KM, et al. Differences by race/ethnicity in older adults’ beliefs about the relative importance of dietary supplements vs prescription medications: results from the SURE study. J Acad Nutr Diet. 2012;112:1223–9.View ArticlePubMed CentralPubMedGoogle Scholar
- Andreescu C, Mulsant BH, Emanuel JE. Complementary and alternative medicine in the treatment of bipolar disorder—a review of the evidence. J Affect Disord. 2008;110:16–26.View ArticlePubMedGoogle Scholar
- Ashar BH, Miller RG, Pichard CP, Levine R, Wright SM. Patients’ understanding of the regulation of dietary supplements. J Community Health. 2008;33:22–30.View ArticlePubMedGoogle Scholar
- Bailey RL, Gahche JJ, Lentino CV, Dwyer JT, Engel JS, Thomas PR, et al. Dietary supplement use in the United States: 2003–2006. J Nutr. 2011;141:261–6.View ArticlePubMed CentralPubMedGoogle Scholar
- Bailey RL, Gahche JJ, Miller PE, Thomas PR, Dwyer JT. Why US adults use dietary supplements. JAMA Intern Med. 2013;173:355–61.View ArticlePubMedGoogle Scholar
- Bartholow M. Top 200 drugs of 2012. Pharmacy Times. Wednesday, July 17, 2013 http://www.pharmacytimes.com/publications/issue/2013/July2013/Top-200-Drugs-of-2012. Accessed February 17, 2015.
- Bauer M, Grof P, Gyulai L, Rasgon N, Glenn T, Whybrow PC. Using technology to improve longitudinal studies: self-reporting with chronorecord in bipolar disorder. Bipolar Disord. 2004;6:67–74.View ArticlePubMedGoogle Scholar
- Bauer M, Wilson T, Neuhaus K, Sasse J, Pfennig A, Lewitzka U, et al. Self-reporting software for bipolar disorder: validation of ChronoRecord by patients with mania. Psychiatry Res. 2008;159:359–66.View ArticlePubMedGoogle Scholar
- Bauer M, Glenn T, Grof P, Rasgon NL, Marsh W, Sagduyu K, et al. Frequency of subsyndromal symptoms and employment status in patients with bipolar disorder. Soc Psychiatry Psychiatr Epidemiol. 2009;44:515–22.View ArticlePubMedGoogle Scholar
- Bauer M, Glenn T, Keil M, Bauer R, Marsh W, Grof P, et al. Brief depressive symptoms in patients with bipolar disorder: analysis of long-term self-reported data. Aust N Z J Psychiatry. 2012;46:1068–78.View ArticlePubMedGoogle Scholar
- Bauer M, Glenn T, Alda M, Sagduyu K, Marsh W, Grof P, et al. Regularity in daily mood stabilizer dosage taken by patients with bipolar disorder. Pharmacopsychiatry. 2013a;46:163–8.View ArticlePubMedGoogle Scholar
- Bauer M, Glenn T, Alda M, Sagduyu K, Marsh W, Grof P, et al. Drug treatment patterns in bipolar disorder: analysis of long-term self-reported data. Int J Bipolar Disord. 2013b;1:5.View ArticlePubMed CentralPubMedGoogle Scholar
- Bauer R, Glenn T, Alda M, Sagduyu K, Marsh W, Grof P, et al. Antidepressant dosage taken by patients with bipolar disorder: factors associated with irregularity. Int J Bipolar Disord. 2013c;1:26.View ArticlePubMed CentralPubMedGoogle Scholar
- Blendon RJ, Benson JM, Botta MD, Weldon KJ. Users’ views of dietary supplements. JAMA Intern Med. 2013;173:74–6.View ArticlePubMedGoogle Scholar
- Boon H, Hirschkorn K, Griener G, Cali M. The ethics of dietary supplements and natural health products in pharmacy practice: a systematic documentary analysis. Int J Pharm Pract. 2009;17:31–8.PubMed CentralPubMedGoogle Scholar
- Cherniack EP. Complementary medicine use is not associated with non-adherence to conventional medication in the elderly: a retrospective study. Complement Ther Clin Pract. 2011;17:206–8.View ArticlePubMedGoogle Scholar
- Dasgupta A. Review of abnormal laboratory test results and toxic effects due to use of herbal medicines. Am J Clin Pathol. 2003;120:127–37.View ArticlePubMedGoogle Scholar
- de Rooij SE, van Munster BC, de Jonghe A. Melatonin prophylaxis in delirium: panacea or paradigm shift? JAMA Psychiatry. 2014;71:364–5.View ArticlePubMedGoogle Scholar
- Dennehy CE, Tsourounis C, Horn AJ. Dietary supplement-related adverse events reported to the California Poison Control System. Am J Health Syst Pharm. 2005;62:1476–82.View ArticlePubMedGoogle Scholar
- Dodge T, Litt D, Kaufman A. Influence of the dietary supplement health and education act on consumer beliefs about the safety and effectiveness of dietary supplements. J Health Commun. 2011;16:230–44.View ArticlePubMedGoogle Scholar
- Elkins G, Rajab MH, Marcus J. Complementary and alternative medicine use by psychiatric inpatients. Psychol Rep. 2005;96:163–6.View ArticlePubMedGoogle Scholar
- Ennis E. Complementary and alternative medicines (CAMs) and adherence to mental health medications. BMC Complement Altern Med. 2014;14:93.View ArticlePubMed CentralPubMedGoogle Scholar
- Ernst E. Serious psychiatric and neurological adverse effects of herbal medicines—a systematic review. Acta Psychiatr Scand. 2003;108:83–91.View ArticlePubMedGoogle Scholar
- Farina EK, Austin KG, Lieberman HR. Concomitant dietary supplement and prescription medication use is prevalent among US adults with doctor-informed medical conditions. J Acad Nutr Diet. 2014;114:1784–90.View ArticlePubMedGoogle Scholar
- Federal Register. FDA agency information collection activities. Comment request. Dietary supplement labeling requirements and recommendations under the DSNDCPA. 74, Fed Reg, 8263, (February 24, 2009) http://www.fda.gov/OHRMS/DOCKETS/98fr/E9-3916.pdf. Accessed February 17, 2015.
- Foster BC, Arnason JT, Briggs CJ. Natural health products and drug disposition. Annu Rev Pharmacol Toxicol. 2005;45:203–26.View ArticlePubMedGoogle Scholar
- Gahche J, Bailey R, Burt V, Hughes J, Yetley E, Dwyer J, et al. Dietary supplement use among U.S. adults has increased since NHANES III (1988–1994), NCHS data brief, no 61. Hyattsville, MD: National Center for Health Statistics; 2011. http://www.cdc.gov/nchs/data/databriefs/db61.htm#citation Accessed February 17, 2015.Google Scholar
- GAO. Dietary supplements. In: FDA may have opportunities to expand its use of reported health problems to oversee. 2013. http://www.gao.gov/assets/660/653113.pdf Accessed February 17, 2015.Google Scholar
- Gardiner P, Graham RE, Legedza AT, Eisenberg DM, Phillips RS. Factors associated with dietary supplement use among prescription medication users. Arch Intern Med. 2006;166:1968–74.View ArticlePubMedGoogle Scholar
- Gardiner P, Phillips R, Shaughnessy AF. Herbal and dietary supplement-drug interactions in patients with chronic illnesses. Am Fam Physician. 2008;77:73–8.PubMedGoogle Scholar
- Getman S. EU regulations on food supplements, health foods, herbal medicines. US Department of Commerce. 2011. http://export.gov/europeanunion/static/MR162-%20FoodSuppsIMIupdate2011_Latest_eg_eu_032796.pdf Accessed 17 February 2015.
- Geyer H, Parr MK, Koehler K, Mareck U, Schänzer W, Thevis M. Nutritional supplements cross-contaminated and faked with doping substances. J Mass Spectrom. 2008;43:892–902.View ArticlePubMedGoogle Scholar
- Gibson JE, Taylor DA. Can claims, misleading information, and manufacturing issues regarding dietary supplements be improved in the United States? J Pharmacol Exp Ther. 2005;314:939–44.View ArticlePubMedGoogle Scholar
- Goldberg RM, Mabee J, Chan L, Wong S. Drug-drug and drug-disease interactions in the ED: analysis of a high-risk population. Am J Emerg Med. 1996;14:447–50.View ArticlePubMedGoogle Scholar
- Izzo AA, Ernst E. Interactions between herbal medicines and prescribed drugs: an updated systematic review. Drugs. 2009;69:1777–98.View ArticlePubMedGoogle Scholar
- Kang GY, Parks JR, Fileta B, Chang A, Abdel-Rahim MM, Burch HB, et al. Thyroxine and triiodothyronine content in commercially available thyroid health supplements. Thyroid. 2013;23:1233–7.View ArticlePubMedGoogle Scholar
- Keaton D, Lamkin N, Cassidy KA, Meyer WJ, Ignacio RV, Aulakh L, et al. Utilization of herbal and nutritional compounds among older adults with bipolar disorder and with major depression. Int J Geriatr Psychiatry. 2009;24:1087–93.View ArticlePubMedGoogle Scholar
- Kennedy J. Herb and supplement use in the US adult population. Clin Ther. 2005;27:1847–58.View ArticlePubMedGoogle Scholar
- Kleiner AC, Cladis DP, Santerre CR. A comparison of actual versus stated label amounts of EPA and DHA in commercial omega-3 dietary supplements in the United States. J Sci Food Agric. 2014;95:1260–7.View ArticlePubMedGoogle Scholar
- Knaudt PR, Connor KM, Weisler RH, Churchill LE, Davidson JR. Alternative therapy use by psychiatric outpatients. J Nerv Ment Dis. 1999;187:692–5.View ArticlePubMedGoogle Scholar
- Köhler GI, Bode-Böger SM, Busse R, Hoopmann M, Welte T, Böger RH. Drug-drug interactions in medical patients: effects of in-hospital treatment and relation to multiple drug use. Int J Clin Pharmacol Ther. 2000;38:504–13.View ArticlePubMedGoogle Scholar
- Kroll DJ. ASHP statement on the use of dietary supplements. Am J Health Syst Pharm. 2004;61:1707–11.PubMedGoogle Scholar
- Lariviere D. Nutritional supplements flexing muscles as growth industry. Forbes. 4/18/2013. http://www.forbes.com/sites/davidlariviere/2013/04/18/nutritional-supplements-flexing-their-muscles-as-growth-industry/ Accessed 17 February 2015.
- LeBlanc ES, Perrin N, Johnson Jr JD, Ballatore A, Hillier T. Over-the-counter and compounded vitamin D: is potency what we expect? JAMA Intern Med. 2013;173:585–6.View ArticlePubMedGoogle Scholar
- Lin D, Mok H, Yatham LN. Polytherapy in bipolar disorder. CNS Drugs. 2006;20:29–42.View ArticlePubMedGoogle Scholar
- Lockwood GB. The quality of commercially available nutraceutical supplements and food sources. J Pharm Pharmacol. 2011;63:3–10.View ArticlePubMedGoogle Scholar
- Mason MJ, Scammon DL, Fang X. The impact of warnings, disclaimers, and product experience on consumers’ perceptions of dietary supplements. J Consum Aff. 2007;41:74–99.View ArticleGoogle Scholar
- Matthews SC, Camacho A, Lawson K, Dimsdale JE. Use of herbal medications among 200 psychiatric outpatients: prevalence, patterns of use, and potential dangers. Gen Hosp Psychiatry. 2003;25:24–6.View ArticlePubMedGoogle Scholar
- McCarthy CE, Candelario DM, Liu MT. Anxiety-inducing dietary supplements: a review of herbs and other supplements with anxiogenic properties. Pharmacol Pharm. 2014;5:966–81.View ArticleGoogle Scholar
- McCrea CE, Pritchard ME. Concurrent herb-prescription medication use and health care provider disclosure among university students. Complement Ther Med. 2011;19:32–6.View ArticlePubMedGoogle Scholar
- Mehta DH, Gardiner PM, Phillips RS, McCarthy EP. Herbal and dietary supplement disclosure to health care providers by individuals with chronic conditions. J Altern Complement Med. 2008;14:1263–9.View ArticlePubMed CentralPubMedGoogle Scholar
- Monteith S, Glenn T, Bauer M. Searching the internet for health information about bipolar disorder: some cautionary issues. Int J Bipolar Disord. 2013;1:22.View ArticlePubMed CentralPubMedGoogle Scholar
- Nichter M, Thompson JJ. For my wellness, not just my illness: North Americans’ use of dietary supplements. Cult Med Psychiatry. 2006;30:175–222.View ArticlePubMedGoogle Scholar
- NIH. Dietary supplements: what you need to know. 2011. http://ods.od.nih.gov/HealthInformation/DS_WhatYouNeedToKnow.aspx Accessed 17 February 2015.Google Scholar
- NIH. Multivitamin/mineral supplements. In: Fact sheet for health professionals. 2013. http://ods.od.nih.gov/factsheets/MVMS-HealthProfessional/ Accessed 17 February 2015.Google Scholar
- Norelli LJ, Xu C. Manic psychosis associated with ginseng: a report of two cases and discussion of the literature. J Diet Suppl. 2014;1:7.Google Scholar
- O’Connor A. New York attorney general targets supplements at major retailers. New York Times. http://well.blogs.nytimes.com/2015/02/03/new-york-attorney-general-targets-supplements-at-major-retailers/?_r=0 Accessed 17 February 2015.
- Owens C, Baergen R, Puckett D. Online sources of herbal product information. Am J Med. 2014;127:109–15.View ArticlePubMedGoogle Scholar
- Pillitteri JL, Shiffman S, Rohay JM, Harkins AM, Burton SL, Wadden TA. Use of dietary supplements for weight loss in the United States: results of a national survey. Obesity (Silver Spring). 2008;16:790–6.View ArticleGoogle Scholar
- Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA. 2008;300:2867–78.View ArticlePubMed CentralPubMedGoogle Scholar
- Rakofsky JJ, Dunlop BW. Review of nutritional supplements for the treatment of bipolar depression. Depress Anxiety. 2014;31:379–90.View ArticlePubMedGoogle Scholar
- Russinova Z, Wewiorski NJ, Cash D. Use of alternative health care practices by persons with serious mental illness: perceived benefits. Am J Public Health. 2002;92:1600–3.View ArticlePubMed CentralPubMedGoogle Scholar
- Sagduyu K, Dokucu ME, Eddy BA, Craigen G, Baldassano CF, Yildiz A. Omega-3 fatty acids decreased irritability of patients with bipolar disorder in an add-on, open label study. Nutr J. 2005;4:6.View ArticlePubMed CentralPubMedGoogle Scholar
- Sandson NB, Armstrong SC, Cozza KL. An overview of psychotropic drug-drug interactions. Psychosomatics. 2005;46:464–94.View ArticlePubMedGoogle Scholar
- Sarris J, Mischoulon D, Schweitzer I. Adjunctive nutraceuticals with standard pharmacotherapies in bipolar disorder: a systematic review of clinical trials. Bipolar Disord. 2011;13:454–65.View ArticlePubMedGoogle Scholar
- Schaffer DM, Gordon NP, Jensen CD, Avins AL. Nonvitamin, nonmineral supplement use over a 12-month period by adult members of a large health maintenance organization. J Am Diet Assoc. 2003;103:1500–5.View ArticlePubMedGoogle Scholar
- Staroselsky M, Volk LA, Tsurikova R, Newmark LP, Lippincott M, Litvak I, et al. An effort to improve electronic health record medication list accuracy between visits: patients’ and physicians’ response. Int J Med Inform. 2008;77:153–60.View ArticlePubMedGoogle Scholar
- Tournas VH. Microbial contamination of select dietary supplements. J Food Saf. 2009;29:430–42.View ArticleGoogle Scholar
- Tsai HH, Lin HW, Simon Pickard A, Tsai HY, Mahady GB. Evaluation of documented drug interactions and contraindications associated with herbs and dietary supplements: a systematic literature review. Int J Clin Pract. 2012;66:1056–78.View ArticlePubMedGoogle Scholar
- Vaclavik L, Krynitsky AJ, Rader JI. Mass spectrometric analysis of pharmaceutical adulterants in products labeled as botanical dietary supplements or herbal remedies: a review. Anal Bioanal Chem. 2014;406:6767–90.View ArticlePubMedGoogle Scholar
- Werneke U, Turner T, Priebe S. Complementary medicines in psychiatry: review of effectiveness and safety. Br J Psychiatry. 2006;188:109–21.View ArticlePubMedGoogle Scholar
- Wu P, Fuller C, Liu X, Lee HC, Fan B, Hoven CW, et al. Use of complementary and alternative medicine among women with depression: results of a national survey. Psychiatr Serv. 2007;58:349–56.View ArticlePubMedGoogle Scholar
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.