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.
A 34-year-old female patient was admitted to our clinic with complaints of anhedonia, decreased appetite, loss of sexual desire, irritability and passive suicidal thoughts. These complaints had lasted about two months. The patient was considered to have major depressive disorder, so we initiated venlafaxine, 75 mg/day. Six months after this initiation, we increased the dose of venlafaxine to 150 mg, because the patient was not admitted to the clinic regularly.\nThree months later (the ninth month of treatment), we increased the venlafaxine dose to 225 mg/day. The patient started to experience galactorrhea while she was taking 150 mg/day, but she did not inform us about this side effect during our examination, so we increased the dose of venlafaxine. Ten days after taking venlafaxine at a dose of 225 mg/day, the patient was admitted to our clinic again for galactorrhea that was so severe she could not endure it anymore. Brain magnetic resonance imaging was performed for her pituitary tumor, but the result was normal. We checked her hormone levels: FSH, LH, T3, T4 and TSH were within the normal range; however, her prolactin level was 156 ng/ml. We considered the galactorrhea and the increased prolactin levels were a result of venlafaxine the patient had been taking. Consequently, we decreased the venlafaxine dose to 150 mg/day.\nOne month later, although her prolactin level had decreased to 9 ng/ml, the galactorrhea persisted. So we decreased the venlafaxine dose to 75 mg/day. At the patient’s next visit, she stated that while she was taking 75 mg/day, the galactorrhea symptoms had been significantly relieved, but she felt worse, so she started to take 150 mg/day again, which once more caused a severe case of galactorrhea. We decreased the dose of venlafaxine to 75 mg/day; afterwards, we switched the patient to escitalopram 10 mg/day, and lorazepam 2 mg/day. One month later, we increased the escitalopram dose to 20 mg/day, and over the course of the following four weeks, we tapered the lorazepam dose. With a treatment of escitalopram 20 mg/day, the patient has reported that she is feeling very well; she was experiencing only minimal galactorrhea, but she chose to continue with escitalopram.