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 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.