Psychosis and Kratom: Rare but Real?

To the Editor: Kratom (Mitragyna speciosa) is a Southeast Asian tree whose leaves have traditionally been used to brew tea with stimulant and analgesic properties.¹ In the United States, kratom is commonly used for self-management of pain and opioid withdrawal, although regulators classify it as a “drug of concern.”¹ The plant’s effects are primarily attributed to the alkaloids mitragynine and 7-hydroxymitragynine (7-OH), which act as μ-opioid receptor agonists. Additionally, kratom influences adrenergic, serotonergic, and dopaminergic pathways; its interaction with D2 receptors may contribute to psychotic symptoms.¹

A recent case report described a patient who developed psychosis after using kratom, with symptoms resembling Fregoli syndrome.² This is a rare delusional misidentification disorder in which the patient believes that different people are actually a single person in disguise. This case aligns with findings from a meta analysis that identified a significant association between kratom use and the exacerbation of psychosis.³

Efforts to understand the prevalence of psychotic symptoms associated with kratom include a study from Malaysia involving a sample of 150 regular kratom users.⁴ This cross-sectional study estimated that 4% of the sample had mild psychotic symptoms. These symptoms were not significantly linked to kratom use frequency, amount, or duration. The authors concluded that the emergence of psychotic symptoms in kratom users is uncommon and not dose related. The generalizability of this study’s findings to the United States is limited, in part, by differences in kratom products.⁵

In Malaysia, kratom is typically consumed as tea or by chewing the leaves, resulting in relatively low concentrations of active alkaloids, especially 7-OH, which is present only in trace amounts.⁵ In comparison, US kratom products often contain variable and sometimes much higher concentrations of 7-OH due to potent extracts.⁵ Many users are unaware of these differences and are drawn to kratom’s “natural” image, viewing it as a safe, traditional remedy.^3,5

Product variability is substantial across countries and within the United States, where regulatory loopholes increase contamination and adulteration risks. In sum, pharmacologic complexity and inconsistent quality control underscore the need for caution when interpreting the kratom-psychosis link, particularly in the United States.

Article Information

Published Online: March 10, 2026. https://doi.org/10.4088/PCC.25lr04109
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2026;28(2):25lr04109
To Cite: Modesto-Lowe V, Patel T. Psychosis and kratom: rare but real? Prim Care Companion CNS Disord 2026; 28(2):25lr04109.
Author Affiliations: Quinnipiac University Health Sciences, Hamden, Connecticut (Modesto-Lowe); Quinnipiac University, Physician Assistant Studies, Hamden, Connecticut (Patel).
Corresponding Author: Vania Modesto-Lowe, MD,
Quinnipiac University Health Sciences, 275 Mount Carmel
Avenue, Hamden, CT 06518
([email protected]).
Financial Disclosure: None.
Funding/Support: None.
ORCID: Vania Modest-Lowe: https://orcid.org/0000-0003-3036-2566