Bromine and Bromism: What’s Old Is New Again

“The dangerous ChatGPT advice that landed a 60-year-old man in the hospital with hallucinations,” said the New York Post headlines, sensationalizing a less dramatic medical journal article from the Annals of Internal Medicine: Clinical Cases in 2025.¹ Variations of this case report have since appeared on online medical forums (eg, Doximity), and sparked lively discussions on Reddit and Facebook. Related reports appeared in Huff Post, The Guardian, NBC News, Fox News, The Economic Times, People, USA Today, and more. In other words, the story about this obscure and ordinarily outdated condition did not go unnoticed, largely because articles highlighted its relationship to erroneous advice given by AI, which is a very contemporary concern.

As expected, the Post and other sources inveigh against the evils of AI, which in this case was consulted by a health-conscious man who aspired to avoid table salt. AI recommended substituting sodium bromide for sodium chloride (table salt), which he did for 3 months. Although the case report states that the patient had no prior psychiatric history, the mere fact that the man distilled his own water because he feared its contamination would make any psychiatrist ask about preexisting, albeit undiagnosed, paranoid tendencies or at least orthorexia. However, premorbid psychiatric conditions are not prerequisites for developing symptoms of bromism.

The man described in the medical report developed confusing perplexing and out-of-the ordinary neuropsychiatric symptoms. He also showed signs of bromoderma, the acneiform skin eruptions that can accompany bromism. Importantly, he had telltale laboratory findings of elevated bromine, lowered chlorine levels, and a negative ion gap—but those lab results did not signal bromism until his protracted exposure to bromine became known.

The differential diagnosis of his new onset psychiatric symptoms—which included visual and auditory hallucinations and paranoia—sent house staff scurrying in search of explanations and prompted consultations with poison control centers. His behavior led to his involuntary hold in a psychiatric ward. The backstory about bromines and bromism that followed this seemingly simple switch is hidden in the tabloid’s text but reported in detail in the Annals of Internal Medicine case report. For those of us in psychiatry, the hallucinosis of bromism is arguably more compelling, or at least more relevant, than the artificial intelligence innovations that stole the stage.

Arguments aside, the condition the newspaper touts as “new” news is nothing more than old news, for it was reported over a decade ago by Psychiatric Times, and other case reports can be found in emergency medicine and toxicology journals and in poison control center logs.¹

Bromism was a common contributor to psychiatric hospitalization in the early 20^th century, when potassium bromide and lithium bromide were often used as sedatives.² It was connected to 1 to 10% of psychiatric admissions in those years (exact data with adequate documentation is difficult to access). The names of some medicinal sources of bromine may still be recognizable today. For instance, Bromo-Seltzer, introduced in 1888, was touted as a hangover helper and used as a headache remedy. Earlier still, Dr Miles Medical Company synthesized bromine-rich Miles Nervine Pills in 1884. Those pills became remarkably popular for so-called nerves. The term bromides came to describe comforting clichés that recollected the superficial relief provided by these easily available bromide-based anti-anxiety agents.

For example, the 2014 Psychiatric Times article “The Clue in the Blue Bottle” (by this author, involved in the case) concerned an older diabetic man who downed bottle after bottle of Bromo-Seltzer to quell his upset stomach—until the brain syndrome that resulted from bromism likewise landed him in the hospital, in this case, on an endocrinology ward, which became his home away from home because his diabetes demanded so much medical attention. His compromised kidney functions, related to his diabetes, interfered with excretion of ingested bromine, and thereby compounded his susceptibility to bromide toxicity. His impaired vision, related to his diabetic retinopathy, may have accentuated his hallucinatory symptoms, making the ghosts and alien invaders which he perceived appear even more real.

The gravity of this patient’s confusing clinical condition peaked after he assaulted an intern, under the belief that the portable X-ray machine wheeled into the room was the prelude of an impending alien invasion orchestrated by the intern. The chest X-ray was clear, and did not show signs of pneumonia, which is a common cause of behavioral disturbances in geriatrics, and which was high on the differential diagnosis. His urinalysis showed no signs of a urinary tract infection, another cause for confusion in someone his age.

Once those possibilities were ruled out, the gentleman was then presumed to be hypoglycemic, which can precipitate aggressive behavior, and which is a medical emergency that demands immediate treatment to offset further consequences. The putative hypoglycemia was supposedly corrected with IV glucose infusions, but when the lab tests returned, it became clear that he had was not hypoglycemic after all: he had become hyperglycemic from the supplemental glucose, and was approaching ketoacidosis, which was yet another potential medical emergency. This new laboratory data quelled the latest hypothesis.

At a loss as to what else to do, we simply observed, as is traditional in medicine. And I observed (and heard) the patient’s recurrent belching. The belching was loud enough to be audible despite the commotion outside his hospital room. So, I inquired with his wife about the burping. She looked understandably distraught, but assured me that he always burped a lot, long before this episode. She pulled out a blue bottle from her purse, intending to show me how she relieved her husband’s distress. The blue bottle was Bromo-Seltzer. She said that she always kept it handy whenever she accompanied her husband, because he used the blue bottle so often.

“How much does he use?” I queried, falling back on the standard medical dictum of asking about quantities and qualifiers. When she said, “six or seven bottles a day,” I gasped. I was no expert on Bromo-Seltzer (at least not yet), but that sounded excessive, especially considering that his compromised kidney function limited excretion of substances such as bromine. The good news is that the IV fluid treatment instituted for the hyperglycemia or impending ketoacidosis also flushed the bromine out of his system, without his needing hemodialysis as we feared.

In hindsight, we realized that the chlorine levels on the laboratory reports were spurious, because kidneys preferentially reabsorb bromide over chloride and labs can misread bromine as chloride, leading to inaccurate results. The high chloride levels seen on the admission labs, which were initially attributed to lab error, were suggestive of bromism, had we known more about bromine from the start. However, bromine levels are not ordinarily ordered, unless there is reason for suspicion, or unless someone spots “the clue in the blue bottle,” as occurred here.

It is worth rereading that Psychiatric Times article on this case, along with more recent medical reports, to better understand the unfortunate events that befell the man who took ChatGPT at its word, and to remind us that ordinary human acts, even innocent or inadvertent ones, can cause equally adverse—albeit less click-worthy—consequences than AI.

Even though Bromo-Seltzer removed its eponymous bromine content in 1975, it is noteworthy that various sources for ingestible or absorbable bromine remain. For instance, a common cough remedy (Robitussin, Waltussin, and related house brands) include dextromethorphan-bromide. As reported in an emergency medicine journal, an intentional overdose on the bromine-based cough suppressant precipitated bromism. It has also impacted regular “Robo-trippers” (named for Robitussin) who abuse dextromethorphan (DXM). These recreational DXM users intentionally seek out changes in consciousness and alternations in perception, making it possible that their disorientation and hallucinosis may result from undiagnosed bromine toxicity via DXM-bromide, although such symptoms are typically attributed to the DXM content of their cough syrup, exclusively.

Other emergency medical journals include intriguing case reports of bromism. The NYC Poison Control Center even identified a case of infantile bromism, secondary to the potassium bromide in Cordial de Monell, which is an illegal (yet readily available) compound imported from the Dominican Republic and marketed to treat colic and teething discomfort in infants.^3,4 The small size of infants make them susceptible to very small doses of bromides. Dead Sea Salt, a natural relaxation remedy that is sold without a prescription and that is more commonly used for bathing than for ingesting, also includes high concentrations of bromine, and has been implicated in inducing bromine toxicity when used orally—contrary to warnings on the label.⁵ Bromide can also be found naturally in some well water, and brominated vegetable oil that is used in some soft drinks contributed to a case of cola-related bromism in a person who drank between 2 to 4 liters a day.⁶

Availability of other unregulated sources of bromine has increased through the Internet.⁷ Rising interest in supposedly natural treatments that bypass commercial pharmaceuticals has made these potentially hazardous approaches more appealing. It is especially worrisome that attacks against psychotropic prescriptions, articulated by certain members of new government administration, may be sufficient to steer users toward these and other off-label and unregulated products. Distinct from such natural health seekers are chemical plant workers who experience environmental or occupational exposure though skin absorption of bromine used in industrial settings, such as those related to deep drilling, or the manufacture of flame retardants.

Interestingly, a relatively new, rapid-acting antidepressant medication that hit the market in 2022, Auvelity, combines DXM-bromide with bupropion.⁸ It is too soon to observe side effects from long-term use of this pharmaceutical, which contains only 45 mg of DXM, a small amount compared to the quantities consumed by recreational DXM users or by someone seeking to overdose. However, depressive symptoms often linger long past the acute stage, for which this medication is marketed. Given that many patients remain on their antidepressants for protracted time periods, it is conceivable that some may continue to use an agent that was initially intended to jump-start antidepressant action. Hopefully, raising awareness of the hazards of chronic bromine use will circumvent such hypothetical concerns. There is yet another caveat to consider. Because this branded medication is not ordinarily covered by commercial insurance, some doctors recommend combining OTC DXM 45 mg with generic bupropion, to replicate this pricey combination, and to make it more affordable—but this tactic complicates tracking side effects secondary to long-term use of DXM-bromide.

Other prescription medications that are bromine-based include vercuronium bromide, which is prescribed to relax muscles prior to general anesthesia, and which is used as a one-off rather than as a maintenance medication. Alternatively, brompheniramine is an antihistamine that combines DXM-bromide with pseudoephedrine; this combination became available as of 2023. It is used to relieve allergies, which are commonly persistent and may lead to longer term use, although the regulations related to pseudoephedrine (because it is used in the manufacture of illicit methamphetamine) may dampen risks of overuse that can cause bromism. In short, even though bromine-based Bromo-Seltzer and Miles Nervine Pills are relics of the past, new bromine-based pharmaceuticals still come to market, and it is too soon to close this book on bromism.

What does this tell us about the hazards inherent in AI, which spearheaded this current discussion, as compared to the hazards of human actions and the hypothetical consequences of newer bromine-based pharmaceuticals? Human behavior may be difficult to regulate, and new medications constantly come to market, but regulatory actions of the past succeeded in quelling the once-common condition of bromism. There is every reason to believe that dissemination of the information about the risks of this chemical, coupled with attention to prevention, will succeed in the future, and push this condition back into the history books, rather than into more case reports. In the interim, it is wise to remember that human intelligence is not invariably better than artificial intelligence, and that both need outside input.

Dr Packer is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai in New York, New York.

References

1. Eichenberger A, Thielke A, Van Buskirk A. A case of bromism influenced by use of artificial intelligence. Annals of Inter Med: Clin Cases. 2025;4:8.

2. Rudy M. ChatGPT dietary advice sends man to hospital with dangerous chemical poisoning. Fox News. August 13, 2025. Accessed November 24, 2025. https://www.foxnews.com/health/chatgpt-dietary-advice-sends-man-hospital-dangerous-chemical-poisoning

3. Walrath-Holdridge M. Man took diet advice from ChatGPT, ended up hospitalized with hallucinations. USA Today. August 13, 2025. Accessed November 24, 2025. https://www.usatoday.com/story/news/health/2025/08/13/man-hospitalized-chat-gpt-diet-advice/85646650007/

4. Schultz CL. Man went to ChatGPT for health advice. What he did next led to poisoning and psychosis. People.com. August 13, 2025. Accessed November 24, 2025. https://people.com/man-chatgpt-health-advice-led-to-poisoning-psychosis-11789649 

5. Packer S. Altered mental state: the clue in the blue bottle. Psychiatric Times. February 24, 2014. https://www.psychiatrictimes.com/view/altered-mental-state-clue-blue-bottle

6. S Rayamajhi, S Sharma S, H Iftikhar. Unexplained bromide toxicity presenting as hyperchloremia and a negative anion gap. Cureus. 2023;15:e36218.

7. Lugassy DM, Nelson LS. Case files of the medical toxicology fellowship at the New York City Poison Control: bromism: forgotten, but not gone. J Med Toxicol. 2009;5:151-7.

8. Keep illegal teething products away from children, says NY health dept. Pediatrics.com. https://www.pediatrics.com/dangerous-teeting-product. Accessed November 24, 2025.

9. Taylor BR, Sosa I, Stone WJ. Bromide toxicity from consumption of dead sea salt.Am J Med. 2010;123(3):e11-12.

10. Horowitz BZ. Bromism from excessive cola consumption. J Toxicol Clin Toxicol. 1997;35(3):315-320.

11. Friedman NA, Cantrell FL. Mind the Gap: Bromism Secondary to Internet-Purchased Supplements. Am J Emerg Med. 2022;60:229.e5-229.e6.

12. Auvelity label. US Food and Drug Administration. Accessed November 24, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/215430s000lblCorrect3.pdf