A 36-year-old married female was presented to the psychiatry outpatient services with 2 years of delusion of infidelity and significant sociooccupational dysfunction in the absence of any impairment in sleep or appetite. Vitals were stable, body mass index (BMI) was calculated to be 26 and systemic examinations revealed no abnormality. Baseline prolactin level was 14 ng/ml.\nIn view of the high BMI and poor insight, she was started on aripiprazole. It was expected that the favorable side effect profile of aripiprazole with relatively less weight gain and extrapyramidal symptoms would ensure compliance. Aripiprazole was started at an initial dose of 5 mg at night and was increased to 10 mg and later 15 mg after 4 days each and 15 mg was continued as maintenance. However, 3 weeks later, she was presented with galactorrhea and a missed menstrual period. Her psychotic symptoms had subsided. There was no weight gain or extrapyramidal symptoms. A urine pregnancy test was done to rule out pregnancy. Serum prolactin level was found to be 96 ng/ml. Neuroimaging was done to rule out a prolactinoma. The possibility of aripiprazole-induced hyperprolactinemia was considered and aripiprazole was stopped. As she was otherwise asymptomatic, no other medication was started and she was sent home. At follow-up, 1-month later, galactorrhea had subsided, she had menstruated, and repeat prolactin levels were 18 ng/ml. Her psychotic symptoms continued to be in remission, and she returned home medication-free.\nThree months later, she presented with the relapse of psychotic symptoms. Aripiprazole was restarted as previously, but was maintained at 10 mg owing to the previous history of hyperprolactinemia. She reported back within a month with the complaints of galactorrhea and amenorrhea at which time her psychotic symptoms were in complete remission. Serum prolactin levels were repeated and found to be elevated (84 ng/ml). Again, aripiprazole was stopped and patient returned home. Serum prolactin levels were normalized (19 ng/ml) and hyperprolactinemia symptoms were subsided within 1-month.\nThe patient and her spouse have provided consent for publishing this case report.
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.