Disorganized Schizophrenia does not Deteriorate with Dopamine Agonists Cabergoline and Bromocriptine used for Ablactation

We present the case of a 39-year-old female patient with disorganized schizophrenia showing no psychotic exacerbation under serial treatment with cabergoline and bromocriptine for ablactation.

Pharmacological ablactation with dopamine agonists (DA), like cabergoline or bromocriptine, after delivery can be a necessity also in patients with schizophrenia. The dopamine hypothesis of schizophrenia justifies a treatment dilemma with possible psychotic exacerbation as plausible [1]. The clinician's dilemma is to trade the risk of inducing psychosis with the DA off against the possible risks for not stopping lactation. Although the coincidence of schizophrenia, pregnancy and the need for ablactation must be common, there is a striking absence of any data according to a selective literature review. We only know that DA administered for suppression of antipsychotics-induced hyperprolactinemia [2] [3] or for ablactation in non-schizophrenic women [4] [5] may cause psychotic exacerbation.

Here were present a first case of serial ablactation with 2 different DAs in schizophrenia without occurrence of psychotic exacerbation.

A 39-year-old Caucasian woman with a fifteen year history of disorganized schizophrenia was admitted to our psychiatric department after delivering a baby (gestation time 36 weeks) via Caesarean section the day before. She presented with incoherence, inappropriate and blunted affect, no overt psychotic phenomena, intermittent agitation and disturbed sleep, after having discontinued her antipsychotic treatment 1.5 years ago. Grossly disorganized behaviour and decline in social function had dominated over transient psychotic symptoms in the past. This had required the adoption of her first child 8 years ago (and also caused intrauterine child death due to tobacco and alcohol abuse the year before). After losing custody of the second child, ablactation was obligatory to prevent mastitis. As a single shot strategy 1 mg of cabergoline was administered on day one. Lactation subsided within days and no changes in psychopathologicy occurred. After a week, olanzapine 5 mg per day was started to treat disorganization. However, lactation recommenced and therefore olanzapine was discontinued due to its risk of causing hyperprolactinemia. In order to achieve immediate ablactation we also administered bromocriptine as the second DA for 5 days (3.75 mg per day) now achieving continued ablactation, again without psychotic exacerbation. Due to its low tendency to induce hyperprolactinemia, quetiapinefumarate 300 mg per day was then used to treat disorganization and agitation without reoccurence of milk secretion. The patient was discharged 3 weeks later.

It follows from the above that the DAs cabergoline and bromocriptine could be used effectively and safely for ablactation in disorganized schizophrenia without concomitant application of antipsychotics. Even so, schizophrenic mothers should be monitored closely after DA use, unless prospective studies have determined the risk of psychotic exacerbation with DA in all subtypes of schizophrenia. Concomitant use of antipsychotics with a low risk of causing hyperprolacinemia (i. e., quetiapine, aripiprazole [6]) in combination with bromocriptine could be the recommendation when one has to encounter the coincidence of acute psychotic symptoms and the need for ablactation.

References

• 1 Davis KL, Kahn RS, Ko G. et al . Dopamine in schizophrenia: a review and reconceptualization.  Am J Psychiatry. 1991;  148 1474-1486
• 2 Chang SC, Chen CH, Lu ML. Cabergoline-induced psychotic exacerbation in schizophrenic patients.  Gen Hosp Psychiatry. 2008;  30 378-380
• 3 Dorevitch A, Aronzon R, Stark M. Psychotic exacerbation attributed to low-dose bromocriptine treatment of galactorrhea and hyperprolactinemia.  Acta Obstet Gynecol Scand. 1991;  70 375-376
• 4 Durst R, Dorevitch A, Ghinea C. et al . Bromocriptine-associated postpartum psychotic exacerbation.  Harefuah. 1990;  118 203-204
• 5 Iffy L, Lindenthal J, Szodi Z. et al . Puerperal psychosis following ablactation with bromocriptine.  Med Law. 1989;  8 171-174
• 6 Madhusoodanan S, Parida S, Jimenez C. Hyperprolactinemia associates with psychotropics – a review.  Hum Psychopharmacol. 2010;  25 279-281

Correspondence