Our study presents an interesting case of a seventeen-year-old girl who was referred to the child psychiatry clinic with symptoms of depression and suicide attempt by taking medical pills. The patient was transferred to institutionalized care owing to intra-familial events. She had consistent problems of adaptation to the institutional surroundings and could not get along well with other children. As a result, she did not attend the school and displayed aggressive behaviours. At the initial psychiatric evaluation, she looked tired and sad with untidy hair and unkempt clothes. Her mood was clearly depressive and consistent with her affect. During the interview, she was reluctant, had minimal eye contact and answered with a subdued voice. She explained the reason for her suicidal behaviour that she blamed her loneliness and stated that she could not stand living anymore. During interview, no active suicidal ideations, delusions or hallucinations was observed. During the first interview, Beck Depression score was 44, State-Trait Anxiety Inventory (STAI)-1 score was 40 and STAI-2 score was 38. Based on Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) criteria, she was diagnosed with Major Depressive Disorder and treatment with fluoxetine (20 mg/day), and aripiprazole (5 mg/day) was started. Two months after the initiation of the treatment, fluoxetine was doubled (40 mg/day) and this treatment regime was continued for subsequent four months, with aripiprazole (5 mg/day). This resulted in regression of depressive symptoms. During the next follow-up interview, she reported not having menstrual cycles for the past four months. Therefore, she was referred to an obstetrician immediately. She had no reports of menstrual irregularity, hirsutism, drug use or history of any related medical disorder prior to the treatment. There, she underwent pelvic ultrasonography examination which showed normal ovaries and endometrium. Analysis of blood test reports showed normal functions of thyroid, liver and kidney. Her pregnancy test was also negative. No pathology was detected in cranial magnetic resonance imaging. Finally, the pathology was reasoned to very high prolactin level in blood serum, which was shown to be 74 ng/ml, while the normal range being 4–20 ng/ml. After ruling out other possible causes of hyperprolactinemia, aripiprazole treatment was thought to be responsible for the observed symptoms. As an immediate change in therapy, aripiprazole was replaced with quetiapine (200 mg/day). Aripiprazole replacement successfully resulted in reduction of blood prolactin levels to 17 ng/ml and menstrual cycle returned to normal after two months of quetiapine treatment.
A 15-year-old girl was diagnosed with adjustment disorder with depressive symptoms and trichotillomania. Family reported that the presenting symptoms have emerged after a perantal relationship problem. Her psychiatric history revealed that she had been diagnosed with ADHD combined type when she was 9 years old and she was on osmotic-release oral system (OROS) MPH 54 mg/day for 2 years. She had a Children’s Depression Inventory (CDI) total score of 24 at admission. Her body weight was 62 kg. To target the depressive and trichotillomania symptoms, sertraline was firstly initiated in the dose of 50 mg/day, and was gradually increased to 100 mg/day. Depressive symptoms greatly resolved however, tricotillomania was largely unchanged. As an addition to the sertraline treatment, risperidone 1mg/day was inititated. After 2 weeks, since risperidone induced increased appettite, risperidone was switched to haloperidol in the dose of 0.5 mg/day (5 drops). Haloperidol was used nightly since trichotillomania was evident only in the night time. During these treatments, OROS MPH treatment was kept unchanged. After 8 weeks of sertraline and haloperidol treatment, tricotillomania symptoms also greatly reduced. At the 12-week-follow-up, family reported that the patient had significant inattentiveness symptoms at school, especially in the early hours. OROS MPH was firstly increased to 72 mg/day; however, the patient could not tolerate this dose due to severe head ache. Thereafter, OROS MPH was switched to MPH-modifed release, beginning with the dose of 30 mg/day. Patient tolerated the initial doses well and, in 2 weeks, MPH dose was planned to increase to 50 mg/day. Three days after MPH was increased to 50 mg/day, family communicated that the patient had spontaneous flow of milk from both of her breasts. For the evaluation of galactorrhea, the patient was consulted to obstetrics and pediatric endoncrinology clinics. Her physical examination and laboratory workup including liver, thyroid, and renal function tests; electrolytes; blood cell count; testosterone; estrogen; luteinizing hormone; follicle-stimulating hormone; and cortisol levels were all within normal range, while her prolactin level was found as 67.7 ng/ml (normal value, 6–29.9 ng/ml). No medical or surgical condition was detected to explain the galactorrhea. The evaluation of the Naranjo adverse drug reaction (ADR) probability scale was 7 (which indicates a probable ADR). Due to the suspect of an ADR, modified-release MPH and haleperidole was discontinued while continuing sertraline in the dose of 50 mg/day. One week later, galactorrhea symptoms resolved completely. Fifteen days after discontinuation, prolactin level of the patient was found as 19.4 ng/ml.