Psychosomatics 48:350-351, July-August
doi: 10.1176/appi.psy.48.4.350
© 2007 Academy of Psychosomatic Medicine
Normalization of Prolactin With Aripiprazole in a Patient With Psychotic Depression and a Comorbid Pituitary Microadenoma
Christine K. Steinhagen, M.D.
Received April 11, 2006; revised April 23, 2006; accepted May 5, 2006. From the Dept. of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA. Send correspondence and reprint requests to Dr. Steinhagen. e-mail: steinhck{at}evms.edu
© 2007 The Academy of Psychosomatic Medicine
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INTRODUCTION
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Antipsychotic medications are thought to exert their benefit on psychosis by the mechanism of dopamine D2 receptor antagonism in the mesolimbic pathway. Antipsychotic medications also indiscriminately cause dopamine-receptor blockade in the tuberoinfundibular pathway, which can lead to elevated prolactin levels.1 Hyperprolactinemia can lead to clinical presentations that include galactorrhea.2 Pituitary adenomas, which secrete prolactin, can cause hyperprolactinemia, and, by virtue of the pituitary’s location, enlargement of this gland can also cause symptoms such as headaches and visual disturbances. Treatment includes dopamine agonists.3 Aripiprazole is an antipsychotic medication that is a dopamine D2-receptor partial agonist. It has been shown to effectively treat psychosis and decrease serum prolactin levels.4 This case report illustrates the use of aripiprazole to effectively treat a patient with psychotic depression, hyperprolactinemia, and a pituitary microadenoma.
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Case Report
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A review of earlier records showed that "Ms. SW" had initially presented in 2002. She was a 40-year-old African-American woman with a first-break psychotic episode, with auditory hallucinations of voices threatening her family and trying to control her mind. The psychotic symptoms had been preceded by a 6-month history of worsening depressed mood, crying spells, poor appetite, hypersomnia, poor functioning in activities of daily living, and difficulty making decisions. She denied any previous history of psychotropic medication and also denied alcohol and substance abuse. She denied medical problems and was considered physically healthy. She was treated with risperidone 0.75 mg po tid and citalopram 20 mg po daily. After she had gained 20 pounds in 3 months, topiramate 25 mg po bid was added for its potential appetite-suppression and mood-stabilization effects.
Six months after risperidone and citalopram were started, she presented to this writer. She complained of galactorrhea, visual hallucinations of amorphous red- and green-colored shapes, and frequent headaches. She endorsed depressive symptoms, but reported that the auditory hallucinations had resolved. She reported regular menstrual cycles throughout treatment. Lab testing was obtained, and she was found to have an elevated prolactin level, at 72.1 (normal range: 2.8 to 29.2 ng/ml). Complete blood count and liver- and kidney-function tests were within normal limits. TSH was slightly low, at 0.02 (normal range: 0.35 to 5.50 mcu/mL), with normal free T3 and T4 levels. An MRI of the brain revealed a lesion measuring 0.8 x 0.6 x 0.6 cm in the superior aspect of the pituitary gland, thought to be consistent with a pituitary microadenoma. Risperidone, citalopram, and topiramate were discontinued. She was started on aripiprazole 15 mg po daily for 1 week; the dosage was then increased to 30 mg po daily. After 2 weeks on aripiprazole, the patient reported that galactorrhea had resolved. Recheck of prolactin revealed a normal level, at 1.8 ng/mL after 1 month of treatment with aripiprazole. Endocrinology consultation recommended no further treatment of the pituitary microadenoma other than close follow-up to observe for any increase in prolactin level or tumor size that might indicate a dopamine agonist should be utilized. After 3 months’ compliance with aripiprazole, she reported resolution of her significant depressive symptoms, headaches, and visual hallucinations. She subsequently was lost to follow-up because she relocated out of the area.
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Discussion
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After treatment with risperidone, the patient reported development of galactorrhea and was found to have an elevated prolactin level and a pituitary microadenoma. It is unclear whether the pituitary microadenoma was a prolactin-secreting lesion or represented an incidental finding of a nonsecretory lesion. The elevated prolactin level and galactorrhea could have been solely due to the treatment with risperidone. It is unclear whether the hyperprolactinemia and galactorrhea resolved because of the discontinuation of risperidone or the possible benefit of decreased serum prolactin level by aripiprazole. Further study is needed to determine whether aripiprazole is effective in maintaining a normal prolactin level when there is a known prolactin-secreting pituitary adenoma.
Of note, the headaches and visual hallucinations resolved after treatment with aripiprazole. Treatment with a dopamine agonist will often shrink a prolactin-secreting pituitary adenoma.3 Unfortunately, this patient was lost to follow-up because of geographic relocation, but further investigation by reimaging the pituitary microadenoma would have been interesting to see whether there was any change in the size of the lesion after an extended period of time on aripiprazole. Future study is warranted to determine whether aripiprazole may be a good choice to treat a psychotic disorder when there is a comorbid pituitary microadenoma.
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FOOTNOTES
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Department of Psychiatry, and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA
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REFERENCES
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- Stahl SM: Psychopharmacology of Antipsychotics. London, UK, Martin Dunitz, Ltd., 1999
- Misra M, Papakostas GI, Klibanski A: Effects of psychiatric disorders and psychotropic medications on prolactin and bone metabolism. J Clin Psychiatry 2004; 65:1607–1618[Medline]
- Endocrine and Metabolic Diseases Information Service: Prolactinoma. http://www.endocrine.niddk.nih.gov/pubs/prolact/prolact.htm; accessed Feb 25, 2006
- Potkin SG, Saha AR, Kujawa MJ, et al: Aripiprazole, an antipsychotic with a novel mechanism of action, and risperidone vs. placebo in patients with schizophrenia and schizoaffective disorder. Arch Gen Psychiatry 2003; 60:681–690[Abstract/Free Full Text]
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INTRODUCTION
Case Report
