LETTERS TO TH E E D IT O R

question for which there is inadequate information and doingboth the children and the field a disservice.

Gabrielle A. Carlson. M.D.Division of Child and Adolescent Psychiatry

School of MedicineState University of New York

Stony Brook

Biederman J. Klein RG , Pine DS, Klein DF ( 1998). Resolved: mania is mis­taken for AD HD in prepuberta l childre n . ] Am Acad Child AdolescPsychiatry37:1091-10 99

Capl an R (1998), Co mmunication deficits in children: is thought disorderspecific to schizophrenia? Presented at Annual Meeting of the AmericanAcadem y of C hild and Adolescent Psychiatry. Anaheim, CA. Oc tober 28

Carlson GA. Brome t EJ (1998) Youth vs adu lt onset man ia: comorbidity orcon fusion? Present ed at Ann ual Meeting of the Amer ican Academy ofChild and Adolescent Psychiat ry, Anahe im, CA. O ctober 28

Ca rlson GA, Kelly KK (1998) , Man ic sympto ms in psychiatrically hospital­ized children: what do they mean ?] Affiet Disord 51:123-1J5

Cloninger R (1987), A systematic meth od for clinical description and classi­fication of personality variants. Arch Gen Psychiatry44:573-588

McElroy SL, Soutullo CA, Beckm an DA, Taylor P. j r, Keck PE. Jr (1998),DSM -IVi ntermillent explosive disor der: a repo rt of 27 csses.] Clin Psy­chiatry 59:20 3- 210

Tannock R, Schachar R (1996), Executuve dysfunction as an underlying mech­anism of behavior and language pro blems in attention deficit hyper­ac t ivity disorder. In: Language, Learning and Behavior Disorders:Developmental. Biological and Clinical Perspectives. Beirch man JH, CohenN, Konstanrareas MM , Tanock R. eds. New York: Ca mbridge UniversityPress. pp 128-1 55

MORE ON VALPROATE AND POLYCYSTIC OVARIES

To the Editor:

In this Journal. Dr. Eberle (1998) recently commented ondata linking valproate to polycystic ovaries (PCO). We wouldlike to add our comments to the dialogue.

We have been keenly interested in the issue of gynecologi­cal effects of valproate (and divalproex) in young girls andhave advocated th at thi s drug be considered a second-lineagent (johnston er al., 1997) for the treatment of bipolar dis­order in girl s. Our recommendation is based largely onIsojarvi and colleagues' (1993) finding of extraordinarily highrates of obesity, menstrual disturb ance, and PCO in womentaking valproat c for epilepsy. It is also based on the productlabeling for divalproex (Depakote'"), which stat es that it isindicated for acute treatment of mania. Currently. lithium isthe only medication approved for prophylaxis of mania.

We disagree with Dr. Eberle's assertion that "there is no evi­den ce that valproate directly causes PCO." It appears that100% of th e wome n in th e Isojar vi et al. stu dy who hadstarted valproate before age 20 and who were obese had PCO.While it is true that PCO are associated with obesity (Pasqualiand Casimirri, 1993), and with epilepsy (Bilo cr aI., 1988), itis improbable that these factors could account for such a strik­ing finding. Indeed, in Isojarvi and colleagues' study popula-

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tion, the rate of PCO in obese epileptic women not taking val­proate was far less. We do not believe Isojarvi and colleagues'data conclus ively establishes valproate as the culprit. but hisdata strongly suggest that caut ion is warranted! We agree withDr. Eberle that withholding valproate from seriously ill girls isnot sensible. Indeed. valproate can be strikingly effectivewhenall else has failed. However, we feel that other mood -stabiliz­ing medi cations should be considered first, part icularly forlonger-term prophylactic treatm ent.

We are surpr ised and dismayed that the manufacturer ofdivalproex, Abbott Laboratories, is not conducting prospec­tive studies that would shed light on this extremely importantquestion . We are also con cerned that the Food and DrugAdministration has not taken a leadership role by requiringsuch studies be done. This is part icularly troubling given thatwe are now in an enlightened era in which issues specific towomen's health are (supposedly) receiving mu ch-neededemphasis.

Hugh E Johnston, M.D.Child Psychopharmacology Information Service

University of Wisconsin Medical SchoolMadison

Bilo L. Meo R. Nappi C et al. (1988) , Reproductive endocrine disorder s inwomen with primary generalized epilepsy. Epilepsia29:612-6 19

Eberle AJ (1998), Valproate and polycyst ic ovaries (lener).] Am ACM ChildAdolesc Psychiatry 37:1009

lsojarvi JIT, Laatikainen TJ, Pakarinen AJ et al. (1993), Polycystic ovaries andhyperand rogenism in women taking valproate for epilepsy. N Eng ] Med329 :1383-1 388

Johnsron IF. W itkovsky MT, Fruehling JJ (199 7), Valproare, ovaries andteenage girls. Just the Facts 4(1):1-2

Pasquali R. Cas imirri F (1993), T he impac t of obesi ty 0 0 hyperaodrogeoismand polycystic ovary syndrome in ptemenopausal wome n. Clin Endocrinol(Oxf) 39: 1-1 6

SSRIs AND MOVEMENT DISORDERS

To the Editor:

Movement disorders have been associated with selectiveserotonin reup take inh ibitors (SSRIs) (Bates et al., 1998; Gillet aI., 1997; Jones-Fearing , 1996 ; Leo, 1996; Leonard et al.,199 7). H owever, although akathisia and extrapyramidalsymptoms (EPS) have been widely reported in adults (Bateset al., 1998; Gill et aI., 1997; Jones-Fearing, 1996; Leo, 1996;Leonard et aI. , 1997) extensive review of the literature identifiesonly 2 case repo rtS of children or adolescents without pre­vious exposure to neurolepti cs who have developed similarsymptoms possibly attributable to SSRIs. A 12-year-old girldeveloped acute dystonia on her third day of Huoxetine treat­ment; th is patient had recentl y discontinued nortriptylineand illicit ampheta mine use that may have contributed to hersymptoms (Jones-Fearing, 1996). Another case describes anl l-year-old girl with a left-sided dystonia which evolved into

J. AM . ACAlJ . CHIl.D ADOLES C. PSYC HI ATRY. _' 8: 4 . AP RI L 19 9 9

an extensive movement disorder, beginning on day 22 of Huox­etine treatment. The authors reported a mixed picture of dys­tonia, akarhisia, and tardive dyskinesia; they reserved judgmenton the outcome of th is case because of the possible obfuscat­ing factors of beh avior and secondary gains (Bates et al., 1998).

Presented here is a case of an adolescent with an acute dys­tonic reaction after 2 do ses of Huoxetine, She had no previousneuroleptic exposure and no known illicit substance use, andshe was tak ing no co ncur rent medications. In addition. this

patient had had previous trials of paroxetine and sertralinewithout similar symptoms.

M.e., a 16-year-old Hispanic female , was admitted to theinpatient adolescent unit with two superficial cuts on her left

forearm and intermittent suicidal ideation with a plan to hangherself. She had a history of 2 previous psychiatric admissionsin the 10 months pr ior to this admission, and she had pre­viously had trials of paroxetine and sertraline without ill effect.She had been noncompliant with sertraline for 3 months beforethis admission. All laboratory tests obtained at the time ofadmission, including complete blood cell count, liver functiontests , electrolytes, thyroxine, urine toxicology screen , humanimmunodeficiency virus, and human chorionic gonadotropin,were unremarkable. On the third hospital day, Huoxetine 20mg/day was begun. The patient was taking no concurrent med ­ications. Approximately 10 hours after the second do se, the

patient began to complain of neck "twitching." Physical exam­ination revealed the patient to be anxious, with myoclonic-like

contractions of her neck resulting in right-sided dev iation,concurrent eye movements to the right, sternocleidomastoidstiffness, and slight cogwheel rigidity of the upper extremities.

There was full range of motion of the neck without pain, vitalsigns were stable, and there was no change in mental status.

The patient was prescribed benztropine mesylate 1 mg p.o.The first dose resulted in a significant decrease in sympto ms,and sym ptoms resolved completely with a second dose approx­imately 1 hour later. There were no additional symptoms until24 hours later, at which time the patient became restless andcomplained of blurry vision and pain when trying to fixate onobjects. Results of ph ysical examination at this time were nor­

mal except for mild intentional dysmetria on cerebell ar testingand some saccadic eye movements when following , but nonystagmus. Benztropine rnesylate 1 mg p.o. was again admin­istered twice and the symptoms decreased. The next day thepatient again complained of blurry vision and her eyes "feel­ing funny." There were no subsequent complaints, and thepatient was started on bupropion 3 days after the last dose (i.e.,second dose) of Huoxctine: she was discharged 3 days later andcontinued to do well on this medication for 1 year of knownfollow -up.

M.e. experienced an acute dystonic reaction to fluoxetinewhile receiving no other medications, with no prior history ofexposure to neuroleptic medications. Symptoms recurred

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LETTERS T O T HE ED IT O R

with decreasing intensity over a period of 3 days , as would beconsistent with the extended half-life of fluoxetine, As the

dystonia resolved , the patient also complained of restlessness .It has been documented that an "akath isia-likc syndrome"

may have a preval ence as high as 30% in patients treated withfluoxetine (Jones-Fearing, 1996). As there are few documented

reports of EPS in children and adolescents treated with anSSRI , and these few case reports are complicated by other psy­chotropic medications or illicit substance use, little is known

about the incidence of this side effect in this population .However, it is important for clinicians to be attuned to the

potential for EPS-like symptoms to occur, especi ally in lightof the impact thi s uncomfortable and frightening symptommay have on com pliance in a population that is notoriouslynoncompliant.

Sarah F. Boyle, M.D.Butler HospitalProvidence, RI

Bates G D L. Khin-M aung -Zaw F (1998). Movement disorder with Huoxerine(lcttcr).] Am Acad Child Adolesc Psychiatry 37: 14-15

G ill HS. DcVanc C L, Risch SC (1997), Extrapyramidal, symptoms asso­ciared with cyclic anridepressanr treatm ent : a review of the literature andconsolidating hypotheses.] Clin PsychopharmacoI17:377-389

Jones-Fearing KB (1996). SSRI and EPS with Auoxetine (lette r).] Am AcadChild Adolesc Psychiatry 35:1107-1108

Leo RJ (1996). Movement disorders associated with the sero toni n selectivereuptake inhibitors.] Clin Psychiatry 57:449-454

Leonard HL , Mar ch J, RickJer KC, Allen AJ (1997). Pharm acology of theselective serotonin reupr ake inhibito rs in child ren and ado lescents. ] AmAcad Child Adolesc Psychiatry 36:725- 736

METHADONE-INDUCED HALLUCINATIONS

To the Editor:

Hallucinations are a rarel y reported complication associ­

ated with the use of methadone (Jellema, 1987; Lewinson

et aI., 1995) . Lewin son et aI., in a retrospective chart review.

identified 4 cases in 3,000 adult patients admitted to an inpa­

tient substance abuse service. The 4 identified patients were

diagnosed with methadone withdrawal leading to onset of

psychotic symptoms. Two of the 4 patients had a history of apsychotic disorder. A Medline search revealed no reports of

methadone-induced psychotic disorder in pediatric popula­tions , and the ph armaceutical company did not have anyreports on file. However, there is some evidence that infants

and toddlers are supplied with medications by nonphysicians

(Schwartz et al., 1986; Shannon cr al., 1989).I would like to report a case of a pediatric methadone­

ind uced psychotic disorder, with hallucinations, with onsetprobably during intoxication. The patient is a 55-year-oldHispanic girl who presented to an outpatient clinic for treat­ment of disruptive behavior in school. She presented with

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