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 36-year-old woman with two children visited a psychiatric outpatient clinic on an ambulatory basis. She had no history of endocrine or reproductive pathology or psychiatric problems. Although she had been receiving a conservative treatment for iron deficiency anemia and transient hematuria, there was no specific hematologic and nephrologic finding and she had not taken any dopamine antagonistic agents including gastrointestinal motility drugs and antipsychotic agents except ferrous sulfate. Her son had been diagnosed with pervasive development disorder and mental retardation. She had suffered symptoms of depressed mood, nihilistic ideation, decreased volition, decreased psychomotor activity, loss of appetite, and sleep disturbance, which occurred after her son's diagnosis 2 years ago. Diagnostic tests were performed to ascertain whether she had neurologic or any other systemic organic disease that could explain her symptoms. Following a detailed psychiatric examination with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), escitalopram 10 mg per day was prescribed to the patient with the diagnosis of major depressive disorder. She scored 26 on the Hamilton rating scale for depression (HRSD), and 25 on the Beck depression inventory (BDI)., After 2 weeks of medication, her complaints declined, her HRSD score was 18 and her BDI score further decreased to 20. However, she developed galactorrhea with breast pain (the nonpuerperal discharge of milk-containing fluid from the breast). She had no history of galactorrhea. She first noticed the discharge on treatment day 14 and described it as white-creamy and from both nipples. She did not notice any bloody, greenish, or foul-smelling discharge nor report sexual dysfunction. She consulted her gynecologist, who recommended mammography and breast ultrasonography. The results of these tests were normal. However, serum prolactin level on treatment day 14 was 200 ng/mL (reference range: 1.2-24.2 ng/mL). There were no abnormalities in blood chemistry, thyroid function tests, or electrocardiogram. She was recommended to undergo magnetic resonance imaging (MRI) of the hypothalamic/pituitary area to exclude mass lesions. However, she refused the test, which was not done. Because her galactorrhea developed after initiations of her medication with escitalopram, we stopped her medication. After cessation of the medication, the discharge abated and breast pain was relieved. Her serum prolactin level decreased to 2.38 ng/mL five days after discontinuing escitalopram.