LETTERS

TO THE

EDITOR

and their medications.

patients

of this

very

useful

group

of antidepressant

who received fluoxetine, alopecia was listed as a side effect in less than 1 % of the patients, but a causal relationship was not determined (personal communication, Dista Phammaceutical Co., November 1990). Severe hair loss may be an uncommon but potentially distressing side effect of fluoxetine.

REFERENCES 1. Haft JI, Litterer WE: Chewing nifedipine to rapidly treat hypertension. Arch Intern Med 1984; 144:2357-2359 2. Clary C, Schweitzer E: Treatment of MAOI hypertensive crisis with sublingual nifedipine. J Clin Psychiatry 1987; 48:249-250 MORTON FIER, Hackensack,

Severe SIR:

Hair I would

Loss

Associated like

to report

With the

Fluoxetine following

M.D. N.J.

Use case.

Ms. A, a 53-year-old unemployed woman, reported having had severe obsessions and compulsions since her early 20s. She feared touching items in her house because of possible contamination and had extensive ordering and checking rituals. Much of her day was spent repeating activities until they “felt right.” If she resisted her rituals, she became severely anxious and did not feel well until she eventually gave in to them. Ms. A felt that she could not eat unless “everything had been done exactly correct and in order,” and as a consequence she weighed 75 lb, which was 30 lb under hen ideal body weight. Her score on the Yale-Brown Obsessive-Compulsive Scale was 26, and her Maudsley Obsessional-Compulsive Inventory score was 22. Both of these scores indicated severe disability 5ccondany to her obsessions and compulsions. Her Beck Dcpression Inventory scone was 21, indicating moderate depression. Previous treatments for her obsessive-compulsive disorden had included more than two decades of psychodynamic psychotherapy and trials of medications such as diazepam, alpnazolam, imipramine, and nortmiptyline. Findings from a medical work-up were normal, and the patient was started on a regimen of fluoxetine, 20 mg each morning (1-3). The dose was raised oven the next S weeks to 40 mg twice daily, and after 2 months she began behavior therapy with exposure and response prevention. Over the next S months, she lost 3 lb but complained of no side effects of the fluoxetine except for mild “shaky hands.” After about S more months, Ms. A reported that “huge clumps of hair” were coming from her head whenever she brushed her hair. Examination showed a general thinning of her hair, and in a number of areas, the skin of hen scalp could be clearly seen through the remaining fine hairs. A complete medical work-up, including thyroid function tests, CBC, and chemistries revealed no other cause for the hair loss. She was not taking any other mcdication concomitantly. She took great pride in her shoulden-length hair and was very distressed, so she discontinued the fluoxetine despite feeling that it had helped her somewhat. Ms. A noted some minimal hair loss even 2 months after discontinuing fluoxetine. At 4-month follow-up, hair loss had stopped, and hair was growing back. After 6 months, hem hair had returned to normal. A computerized Paper Chase literature search revealed no previously reported cases of hair loss or alopecia related to use of fluoxetine. In a multicenter trial of about 600 patients

392

REFERENCES 1. Turner SM, Jacob RG, Beidel DC, et al: Fluoxetine treatment of obsessive-compulsive disorder. J Clin Psychopharmacol 1985; 5:207-212 2. Fontaine R, Chouinard G: An open clinical trial of fluoxetine in the treatment of obsessive-compulsive disorder. J Clin Psychopharmacol 1986; 6:98-101 3. Jenike MA, Buttolph L, Baer L, et al: Open trial of fluoxetine in obsessive-compulsive disorder. Am J Psychiatry 1989; 146: 909-911 MICHAEL

Clozapine Induced

as an Alternative Gynecomastia

SIR: Commonly other psychotropic secretion (1), which lactorrhea in some served 3.2-fold and schizophrenic men initiating neuroleptic patient who developed neunoleptics recovered clozapine.

Treatment

for

A. JENIKE, M.D. Boston, Mass.

Neuroleptic-

used neuroleptics, in contrast to most drugs, are known to stimulate prolactin may lead to gynecomastia and even gapatients (2). Meltzer and Fang (3) ob3.8-fold increases of prolactin in 27 and women, respectively, 72 hours after treatment. We report a case in which a gynecomastia after receiving classical from this side effect after switching to

Mn. A was a 55-year-old patient suffering from schizophrenia, residual type. As an outpatient, during one winter he needed considerable neuroleptic medication: 15 mg of halopenidol, 175 mg of levomepromazine, and 200 mg of thionidazine daily, as well as bipeniden. At the end of February, during a physical examination, the treating physician observed bilateral gynecomastia without galactorrhea. The patient’s prolactin level was 23.4 ng/ml (normal values in men2-10 ng/ml), and his plasma halopenidol concentration was 4.4 ng/ml. Because of these findings and because his clinical picture had worsened during the last 6 months, it was decided to decrease the neuroleptic mcdication. Thionidazine and halopenidol were stopped in the middle of April, bipeniden on April 28, and levomepromazine on May 2. Clozapine was slowly introduced in mid-April, and a final daily dose of400 mg was reached on April 29. On May 3 Mr. A’s prolactin level (2.2 ng/ml) was within the normal range. However, he was hospitalized 2 weeks later because of an increase in several symptoms: loss of appetite and weight, psychomotor agitation, incoherence in speech and behavior, anxiety, and neglect of grooming and work. On July 5, all symptoms of gynecomastia had disappeared in parallel with the return to normal of the prolactin level. In the next few weeks, the global clinical picture of the patient improved, as did his sleep, weight (gain of 6 kg), and anxiety. However, he still presented logorrhea and increased motor activity. His hematological measures,

Am

J

Psychiatry

148:3,

March

1991

LETTERS

checked weekly within the normal This

case

during range.

demonstrates,

clozapine

treatment,

remained

as previously

for

criteria

for seasonal

affective

disorder

mined by a structured interview in which Affective Disorders and Schizophrenia-Lifetime shown,

that

prolac-

tin levels rapidly return to normal after neuroleptics are stopped. Indeed, Meltzer and Fang (3) observed that after patients stopped neuroleptic treatment, their prolactin levels were normal within 48-96 hours. The search for neuroleptics that arc devoid of extnapyramidal side effects and that do not induce tardive dyskinesia has gained much interest. Clozapine is such an atypical neumoleptic, and it is known to have no effect (4) or only a small, transient effect (5) on prolactin levels. As demonstrated in this case, clozapine can be used as a substitute stimulators of prolactin

DSM-III-R

TO THE EDITOR

other neumoleptics secretion, especially

where the patient presents side monal change and consequently veloping breast cancer.

effects incurs

that are potent in a situation

related to this hora greater risk of de-

free says and

1550-1555 CLAUDE

UEHLINGER, M.D. Perreux, Switzerland PIERRE BAUMANN, PH.D. Prilly-Lausanne, Switzerland

product of the T4 and T3 resin uptake measures. There was no significant difference between light treatment and baseline in mean±SD serum (1 17.8

±21.4

nmol/liten

mal=S1-142);

versus

T3 (2.3±0.5

1 13.5

±22.5

nmol/liter

liter; nonmal= 1.1-3.2); T3 resin uptake 0.30±0.02; normalO.25-0.35); TSH versus 3.6±2.9 mU/liter; nonmal=O.S-4.S);

Function

and

Phototherapy

SIR: Theme is a well-known dysfunction and abnormalities

most

consistently

affective

disorder

in Seasonal

association of mood

observed

findings

is that

a variety

(1,

in patients of

with

treat-

ments cause limited but substantial decrements in thyroid function (1, 2). In particular, treatment with tricyclic antidepressants, ECT, carbamazepinc, stantial decreases in measures

and of T4 and

lithium causes subT3 with or without

changes in thynotropin (TSH). Phototherapy has been documented as an effective treatment for seasonal affective disorder (3). We were therefore interested in determining whether light treatment for winter depression would be associated with alterations in thyroid function. Although light does not specifically affect the thymoid, phototherapy, roid function. Fourteen subjects,

by alleviating six

male

depression, and

eight

may female,

alter

thywhose

mean±SD age was 42.4± 12.2 years, consented to panticipate in a treatment program. All received 2 weeks of light treatment administered for 1 hour between 6:00 and 7:00 a.m. at an intensity of 5000 lax. All subjects fulfilled the

Am

J

Psychiatry

148:3,

March

1991

nmol/

(0.30±0.02 versus (3.4±2.7 mU/liter on FF1 (33.6±

Reanalysis

of the data

response

excluding

data

on the

alter the findings. on thyroid func-

tion in our group of patients with seasonal affective disorder. It may be that more than 2 weeks is required before changes in thyroid function with light treatment can be observed in these tests. The change in thyroid function with other antidepressants occurred after 4-fl weeks of treatment (2).

REFERENCES 1

. Bauer

MS, Whybrow PC: Thyroid hormones and the central nervous system in affective illness: interactions that may have clinical significance. Integrative Psychiatry 1988; 6:75-100 2. Joffe RT: A perspective on the thyroid and depression. Can J Psychiatry (in press) 3. Terman M, Terman JS, Quitkin FM, et al: Light therapy for seasonal affective disorder: a review of efficacy. Neuropsycho. pharmacology 1989; 2:1-22 4. Spitter RL, Endicott J: Schedule for Affective Disorders and Schizophrenia-Lifetime Version, 3rd ed. New York, New York State Psychiatric Institute, Biometrics Research, 1979

T. JOFFE,

Toronto,

primary

antidepressant

non-

2.1±0.4

4.6 versus 33.2±4.9; normal= 13-SO). Eleven of the 14 patients had an antidepressant

Affective

between thyroid 2). One of the

the end of levels of T4

nmol/liter;

versus

RUSSELL Thyroid Disorder

for (4)

for the duration of the trial. Standard radioimmunoaswere used for measurement of T4, T3, T3 resin uptake, TSH. The free T4 index (FF1) was calculated as the

three nonnesponders did not substantially Phototherapy had no significant effects

1. Gnuen PH, Sachar EJ, Langer G, et al: Prolactin responses to neuroleptics in normal and schizophrenic subjects. Arch Gen Psychiatry 1978; 35:108-116 2. Shader RI, Di Mascio A: Psychotropic Drug Side Effects. Baltimore, Williams & Wilkins, 1970 3. Meltzer HY, Fang VS: The effect of neuroleptics on serum prolactin in schizophrenic patients. Arch Gen Psychiatry 1976; 33: 279-286 4. Sachar EJ, Gruen PH, Altman N, et al: Use of neuroendocrine techniques in psychopharmacological research, in Hormones, Behavior, and Psychopathology. Edited by Sachar EJ. New York, Raven Press, 1976 S. Meltzer HY, Goode DJ, Schyve PM, et al: Effect of clozapine on human serum prolactin levels. Am J Psychiatry 1979; 136:

as deter-

Schedule Version

was used. Blood was drawn just before and at the completion of 2 weeks of light treatment. All subjects were medication

to phototherapy. REFERENCES

the

A Patient’s SIR:

We

Psychotic would

like

neuroleptic-induced external forces were psychotic

Interpretation to

report

akathisia controlling

interpretation

of a Drug the

case

Ont.,

M.D. Canada

Side Effect

of a patient

with

who developed a delusion that his legs, which represented a

of this

side

effect.

Mr. A, a 34-year-old man with a 6-year history of paranoid schizophrenia and poor compliance with regimens of oral medications, was admitted to the hospital with an acute paranoid psychosis after missing two fluphenazine decanoate injections. As on previous admissions, he had delusions

focused

ual behavior. clipped graphic

on

his

“evil”

On the evening

all the magazine

photographs and set

brother’s

before

“immoral”

admission,

from his brother’s them on fire in his

sex-

Mr.

A had

pornobedroom

wastebasket. On admission Mr. A was started on fluphenazine, 10 mg/day p.o., and his psychosis initially improved. However, after several weeks he complained of restlessness and showed psychomotor agitation consistent with akathisia.

393

Severe hair loss associated with fluoxetine use.

LETTERS TO THE EDITOR and their medications. patients of this very useful group of antidepressant who received fluoxetine, alopecia was list...
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