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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