risperidone-induced prolonged erections following the addition of lithium

441 JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY Volume 11, Number 4, 2001 Mary Ann Liebert, Inc. Pp. 441–442 Letter to the Editor Risperidone-Induced Prolonged Erections Following the Addition of Lithium P RIAPISM IS a condition in which the penis remains erect for a prolonged period of time. Some psychiatric drugs have been implicated as occasionally causing priapism, particularly trazodone, chlorpromazine, and thioridazine (Thompson et al. 1990). Here we report a case of prolonged erections in an adolescent male taking risperidone, with the symptoms appearing only after the addition of lithium to his regimen. Mr. B was a 17-year-old adolescent with a history of bipolar disorder who was incarcerated in a state youth correctional facility. Mr. B had been treated with risperidone, 0.5 mg in the morning and 1 mg at night, for over 2 years with success and without side effects. Mr. B felt that he still had mood swings, particularly periods of irritability during which he felt impulsive. It was eventually determined that a mood sta- bilizer might augment his treatment, and lithium carbonate was started at 300 mg and then slowly increased to a dose of 300 mg each morning and 600 mg at night. Mr. B felt that the lithium was very effective in help- ing “take the edge” off his mood difficulties. About 12 weeks after starting lithium, during a routine med- ication management session, Mr. B mentioned that he had been having prolonged erections ever since his lithium dose had been at 300 mg twice a day. He said that the erections occurred between two and five times a day and lasted between 1 and 3 hours. He denied sexual thoughts, feeling aroused, physical stimulation, difficulty urinating, or any tenderness or pain. His risperidone was rapidly tapered over a period of 10 days. Mr. B’s prolonged erections stopped after the first decrease in dose (from 1.5 mg/day to 1 mg/day), and he has not experienced any prolonged erections since that time. Prolonged erections have been recognized in the literature as precursors of priapism (Griffith and Zil 1984). Tekell et al. (1995) described a case of a 41-year-old man who developed prolonged erections with risperidone, and the drug has also been implicated in cases of priapism (Emes and Millson 1994). The mechanism through which risperidone causes priapism is thought to be a 1 -adrenergic blockade (Thompson et al. 1990). In this case, the addition of lithium, which is not thought to cause priapism, was necessary be- fore the symptoms appeared. The role of lithium in this case is not clear, and there is little information in the literature on the potential toxicity of this common combination. In one case, the addition of lithium to risperidone was necessary for the emergence of dystonic symptoms in an elderly male (Durrenberger and de Leon 1999). This case highlights the need to inquire frequently about sexual side effects in patients taking psychotropic medications. REFERENCES Durrenberger S, de Leon J: Acute dystonic reaction to lithium and risperidone [letter]. J Neuropsychiatry Clin Neurosci 11:518–519, 1999. Emes CE, Millson RC: Risperidone-induced priapism [letter]. Can J Psychiatry 39:315–316, 1994. Griffith S, Zil J: Priapism in a patient receiving antipsychotic therapy. Psychosomatics 25:629–631, 1984.

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Page 1: Risperidone-Induced Prolonged Erections Following the Addition of Lithium

441

JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGYVolume 11, Number 4, 2001Mary Ann Liebert, Inc.Pp. 441–442

Letter to the Editor

Risperidone-Induced Prolonged Erections Following the Addition of Lithium

PRIAPISM IS a condition in which the penis remains erect for a prolonged period of time. Some psychiatricdrugs have been implicated as occasionally causing priapism, particularly trazodone, chlorpromazine,

and thioridazine (Thompson et al. 1990). Here we report a case of prolonged erections in an adolescent maletaking risperidone, with the symptoms appearing only after the addition of lithium to his regimen.

Mr. B was a 17-year-old adolescent with a history of bipolar disorder who was incarcerated in a stateyouth correctional facility. Mr. B had been treated with risperidone, 0.5 mg in the morning and 1 mg atnight, for over 2 years with success and without side effects. Mr. B felt that he still had mood swings, par-ticularly periods of irritability during which he felt impulsive. It was eventually determined that a mood sta-bilizer might augment his treatment, and lithium carbonate was started at 300 mg and then slowly increasedto a dose of 300 mg each morning and 600 mg at night. Mr. B felt that the lithium was very effective in help-ing “take the edge” off his mood difficulties. About 12 weeks after starting lithium, during a routine med-ication management session, Mr. B mentioned that he had been having prolonged erections ever since hislithium dose had been at 300 mg twice a day. He said that the erections occurred between two and five timesa day and lasted between 1 and 3 hours. He denied sexual thoughts, feeling aroused, physical stimulation,difficulty urinating, or any tenderness or pain. His risperidone was rapidly tapered over a period of 10 days.Mr. B’s prolonged erections stopped after the first decrease in dose (from 1.5 mg/day to 1 mg/day), and hehas not experienced any prolonged erections since that time.

Prolonged erections have been recognized in the literature as precursors of priapism (Griffith and Zil1984). Tekell et al. (1995) described a case of a 41-year-old man who developed prolonged erections withrisperidone, and the drug has also been implicated in cases of priapism (Emes and Millson 1994). Themechanism through which risperidone causes priapism is thought to be a1-adrenergic blockade (Thompsonet al. 1990). In this case, the addition of lithium, which is not thought to cause priapism, was necessary be-fore the symptoms appeared. The role of lithium in this case is not clear, and there is little information in theliterature on the potential toxicity of this common combination. In one case, the addition of lithium torisperidone was necessary for the emergence of dystonic symptoms in an elderly male (Durrenberger and deLeon 1999). This case highlights the need to inquire frequently about sexual side effects in patients takingpsychotropic medications.

REFERENCES

Durrenberger S, de Leon J: Acute dystonic reaction to lithium and risperidone [letter]. J Neuropsychiatry Clin Neurosci11:518–519, 1999.

Emes CE, Millson RC: Risperidone-induced priapism [letter]. Can J Psychiatry 39:315–316, 1994.

Griffith S, Zil J: Priapism in a patient receiving antipsychotic therapy. Psychosomatics 25:629–631, 1984.