0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

1
Letter   |    
Phenobarbital, Propranolol, and Aggression
Ann R. Poindexter, M.D.
The Journal of Neuropsychiatry and Clinical Neurosciences 2000;12:413-413. doi:10.1176/appi.neuropsych.12.3.413
View Author and Article Information

PropranololAggressionPhenobarbital

SIR: With great interest I read the recent article on treating aggression with propranolol.1 As has been the experience of many of us who have worked for many years with individuals with mental retardation and other developmental disabilities, I have had several previously aggressive patients who did exceptionally well when treated with this medication. As I looked carefully, however, at the results of the treatment for the persons with epilepsy who were receiving phenobarbital at the time of the study (cases 4, 7, 11, and 12 at Creedmoor Psychiatric Center), I found that none had better than an equivocal response. (I assume that Case 12 at Creedmoor was the individual who was too violent to remain in the placement.)

To the best of my knowledge, phenobarbital is almost never used now in the "real world" except, for some reason, for people with mental retardation. My own data have shown that when people have been changed from phenobarbital to other anticonvulsant drugs, their behavior has clearly improved.2 We first noticed this some years ago in an institution for people with mental retardation, when we began to simplify anticonvulsant regimens. Initially we thought that we were just stabilizing moods as we switched to valproic acid, but then we noted that anyone who was removed from phenobarbital was happier and easier to deal with, even if he or she was on phenytoin only. In an effort to remove our very strong observer bias, I went back and looked at data from years past for persons who, for one reason or another, had been taken off of barbiturates and who had a behavior program in place at the time. Without exception, we could look at the behavioral data and see when the phenobarbital taper had occurred. This factor was not noted at the time of the tapers—the behavior programs just "began working." Behaviors most clearly affected were aggression and programmatically defined refusal to cooperate.

I note that case 4 at Creedmoor was receiving 300 mg phenobarbital a day, reportedly for complex partial seizures, as well as a quite large dose of fluphenazine. Might he not have had some degree of akathisia, as well as irritability from the barbiturate?

In my opinion the issue of adverse behavioral effects of barbiturate treatment is extremely important. A recent revision of the HCFA surveyors' manual3 on the use of psychotropic medications in facilities for people with mental retardation mandates close attention to the use of barbiturates, particularly for those persons with any sort of behavioral difficulties. I have personally yet to see anyone with behavior problems who did not improve markedly when barbiturates were removed from the treatment regimen. Perhaps the four persons in this study who were receiving barbiturates would have been less aggressive if they had been receiving a more modern antiepileptic regimen. Perhaps the propranolol would have been more effective if they had been barbiturate-free.

Silver JM, Yudofsky SC, Slater JA, et al: Propranolol treatment of chronically hospitalized aggressive patients. J Neuropsychiatry Clin Neurosci  1999; 11:328—335
[PubMed]
 
Poindexter AR, Berglund JA, Kolstoe PD: Changes in antiepileptic drug prescribing patterns in large institutions: preliminary results of a five-year experience. Am J Ment Retard 1993; 98(suppl):34—40
 
Health Care Financing Administration: Psychopharmacological Medications: Safety Precautions for Persons with Developmental Disabilities. Baltimore, MD, HCFA, 1996, p. 46
 
+

References

Silver JM, Yudofsky SC, Slater JA, et al: Propranolol treatment of chronically hospitalized aggressive patients. J Neuropsychiatry Clin Neurosci  1999; 11:328—335
[PubMed]
 
Poindexter AR, Berglund JA, Kolstoe PD: Changes in antiepileptic drug prescribing patterns in large institutions: preliminary results of a five-year experience. Am J Ment Retard 1993; 98(suppl):34—40
 
Health Care Financing Administration: Psychopharmacological Medications: Safety Precautions for Persons with Developmental Disabilities. Baltimore, MD, HCFA, 1996, p. 46
 
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Web of Science® Times Cited: 3

Related Content
Books
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 14.  >
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 14.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 50.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 62.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 50.  >
Topic Collections
Psychiatric News
PubMed Articles
Phenobarbital, propranolol, and aggression. J Neuropsychiatry Clin Neurosci 2000;12(3):413.