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 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.