A 31-year-old unmarried woman, without significant family/personal history or medical comorbidity, presented with complaints of fear from dirt, excessive checking and washing behaviors and repeated intrusive thoughts, gradually deteriorating for 2 years. She acknowledged the thoughts to be her own, and that they were unnecessary and baseless; but also expressed her inability to resist them at all. The thoughts did cause her severe anxiety. Because of an increase in severity, she had discontinued her job for last 3 months and was having difficulty in sleeping at night. At presentation, she was restlessness with psychomotor agitation, and had anxious, irritable affect. Enquiries regarding thought possession revealed severe obsessions and compulsion. She was diagnosed as obsessive-compulsive disorder according to ICD 10. Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score was 30 which showed ‘extreme’ symptoms severity. Her physical examination and laboratory tests including blood biochemistry, electrocardiogram, and radiological examinations were within normal limits. Her treatment was started with FXT (20 mg/day) according to available treatment guidelines, and it was decided to keep a watch for further deterioration of anxiety symptoms due to activating side-effects of FXT. The treating team decided to use short-term clonazepam cover for anxiety symptoms, but the patient did not require this rescue regimen. After two weeks of initiation, FXT was hiked to 40 mg/day. After 3 weeks of increasing FXT to 40 mg/day, there was significant improvement in Y-BOCS score (Y-BOCS=19), and she was advised to continue the drug at this dose. We used an immediate-release formulation of FXT in our patient.\nAfter 8 months, the patient came with 3-months’ amenorrhea and 15-days’ history of milky, non-hemorrhagic bilateral breast discharge on 40 mg/day FXT. The discharge had begun after 7 and a half month of hiking FXT to 40 mg/day, and was first noted by the patient who brought this to clinician’s notice. Her serum prolactin level was investigated for and found to be 122 ng/ml. Her physical manifestations were highly suggestive of hyperprolactinemia associated with amenorrhea and GLH. Her urea, creatinine, thyroid-stimulating hormone, free-T4 and beta human chorionic gonadotropin were all normal; and thus we excluded underlying kidney disease, hypothyroidism or pregnancy as possible causes of GLH.\nTreatment was first modified by discontinuing FXT over one week and adding clonazapam 0.5 mg/day to decrease anxiety. Sertraline was started after allowing for 7 days’ washout time after last dose of FXT, and slowly built up-to 200 mg/day over next 2 weeks. Two months after initiation of Sertraline, and one and a half month after a dose of sertraline 200 mg/day was reached, her serum prolactin level normalized (12 ng/ml) and menstrual abnormalities were resolved. Over next 10 months, the patient remained on same therapeutic regimen and continued to be mentally stable with regular menstrual cycles and no GLH.
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.