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. 2002 May 25;324(7348):1278.

Hyperprolactinaemia caused by antipsychotic drugs

Endocrine antipsychotic side effects must be systematically assessed

Oliver Howes 1, Shubulade Smith 1
PMCID: PMC1123228  PMID: 12028991

Editor—Wieck and Haddad highlight the fact that hyperprolactinaemia is a common side effect of antipsychotic treatment, but they do not indicate just how often it occurs.1

We have found that three quarters of women and one third of men taking typical antipsychotics have prolactin concentrations above the upper limit of the normal range, and there is a highly significant relation between the dose of antipsychotic treatment and prolactin concentrations.2 Oestradiol and progesterone concentrations were below the lower limit of the normal range in 85% of the women.

This evidence supports the authors' suggestion that antipsychotic induced hyperprolactinaemia is linked to clinically important hypogonadism. Furthermore, preliminary results indicate that over 40% of patients taking prolactin raising antipsychotics show osteopenia associated with hypogonadism (A Meaney et al, proceedings of the British Association of Psychopharmacology, Harrogate, 2001). We are currently measuring bone mineral density in patients taking prolactin sparing antipsychotics, and we hope that this study will address some of the evidence needs raised by Wieck and Haddad.

The authors point out that prolactin sparing atypical antipsychotics offer a new management strategy for antipsychotic induced hyperprolactinaemia. However, there are risks associated with reversing hyperprolactinaemia and hypogonadism, as indicated by reports of unplanned pregnancies after patients changed to prolactin sparing antipsychotics.3 Many of these patients also experienced a relapse of their psychotic illness after the pregnancy. It is important that patients are counselled about the change in fertility associated with changing to a prolactin sparing atypical and given contraceptive advice.

The national service framework has emphasised that patients with severe mental illness have increased physical morbidity and that assessment should include their physical health.4 Wieck and Haddad point to the contribution that endocrine antipsychotic side effects may make to the increased physical morbidity, and these side effects should be monitored.

We recently helped to develop a drug review model that provides patients receiving long term antipsychotic treatment with systematic and periodic assessment of psychopathology, quality of life, and side effects. It is an alternative to the traditional depot clinic style of practice, which often meant that patients took antipsychotics for many years while receiving only ad hoc and limited review. The model represents a move in line with the national service framework towards more proactive patient centred care, and a management approach to the adverse effects of antipsychotics, including the frequently neglected endocrine effects.

References

  • 1.Wieck A, Haddad P. Hyperprolactinaemia caused by antipsychotic drugs. BMJ. 2002;324:250–252. doi: 10.1136/bmj.324.7332.250. . (2 February.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2. Smith S, Wheeler M, Murray R, O'Keane V. The effects of antipsychotic induced hyperprolactinaemia on the hypothalamic-pituitary gonadal axis. J Clin Psychopharmacology (in press). [DOI] [PubMed]
  • 3.Sridharan B, Arshad P, Marcos M. Risk of pregnancy when changing to atypical antipsychotics. Br J Psychiatry. 2002;180:83–84. doi: 10.1192/bjp.180.1.83. [DOI] [PubMed] [Google Scholar]
  • 4.Department of Health. Mental health national service framework: modern standards and service models. London: DoH; 1999. [Google Scholar]
BMJ. 2002 May 25;324(7348):1278.

Physical complications of mental illness must be remembered

Sally Winning 1

Editor—The physical complications of mental illness, both primary and iatrogenic, tend to be poorly recognised and treated. The editorial by Wieck and Haddad discusses hyperprolactinaemia caused by antipsychotic drugs.1-1 The tendency to focus on extrapyramidal side effects is presumably due to patients' subjective awareness of these unpleasant side effects. Relatively silent side effects such as endocrine disturbance tend not to get the same attention.

As well as antipsychotics, other psychotropic medicines such as selective serotonin reuptake inhibitors (with the exception of sertraline) may cause hyperprolactinaemia.1-2 In depressive disorders hypercortisolism mediated by the stress system contributes to osteoporosis.1-3,1-4,1-5 Depression, as well as cardiovascular disease, must be regarded as a risk factor for osteoporosis.

Many patients with schizophrenia, bipolar affective disorder, or depressive illness take drugs long term, and often combinations of antipsychotic and antidepressant drugs. Pharmacotherapy may confound underlying biological processes acting on the hypothalamopituitary-adrenal axis and accelerate sequelae such as osteoporosis.

Increased awareness of the physical diseases associated with mental illness is essential if optimal care is to be provided.

References

  • 1-1.Wieck A, Haddad P. Hyperprolactinaemia caused by antipsychotic drugs. BMJ. 2002;324:250–252. doi: 10.1136/bmj.324.7332.250. . (2 February.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Goodnick P, Chaudry T, Artadi J, Arcey S. Women's issues in mood disorders. Expert Opinion on Pharmacotherapy. 2000;1:903–916. doi: 10.1517/14656566.1.5.903. [DOI] [PubMed] [Google Scholar]
  • 1-3.Deuschle M, Weber B, Colla M, Depner M, Heuser I. Effects of major depression, aging and gender upon calculated diurnal free plasma cortisol concentrations: a re-evaluation study. Stress. 1998;2:281–287. doi: 10.3109/10253899809167292. [DOI] [PubMed] [Google Scholar]
  • 1-4.Gold PW, Chrousos GP. The endocrinology of melancholic and atypical depression: relation to neurocircuitry and somatic consequences. Proc Assoc Am Physicians. 1999;111:22–34. doi: 10.1046/j.1525-1381.1999.09423.x. [DOI] [PubMed] [Google Scholar]
  • 1-5.Schweiger U, Deuschle M, Korner A, Lammers CH, Schmider J, Gotthardt U, et al. Low lumbar density in patients with major depression. Am J Psychiatry. 1994;151:1691–1693. doi: 10.1176/ajp.151.11.1691. [DOI] [PubMed] [Google Scholar]

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