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Posttraumatic stress disorder (PTSD) is a serious and debilitating mental condition that affects a significant proportion of the general population at some time in their lives. To date, however, the U.S. Food and Drug Administration has approved only 1 pharmacologic treatment for this indication. Additional effective therapies are urgently required to control the destructive symptoms experienced by individuals with PTSD. This article reviews the effects of the novel antiepileptic drug topiramate on 3 patients meeting DSM-IV criteria for chronic PTSD. In these previously treatment-refractory patients, topiramate had a marked effect: reducing and even eliminating trauma-related intrusive memories and nightmares and normalizing depressed mood. Adverse events were effectively controlled with careful drug titration and discontinuation of concomitant therapies. These findings, together with observations in more than 30 additional patients (reported elsewhere), suggest that further study of topiramate as a treatment for PTSD is warranted.

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We reframe the longitudinal treatment of persons with schizophrenia from the perspective of phases in adult development. This approach articulates the need for different interventions of varying intensities over the person's lifetime. The paper discusses the implications of an adult developmental perspective in managing pharmacologic treatment and psychosocial interventions, and in reallocating financial resources for improved long-term outcomes. This perspective is especially useful in the context of a comprehensive community mental health program permitting access to a continuum of services throughout the lifecycle.

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In this position paper drafted by the committee on psychopathology of the Group for the Advancement of Psychiatry, the authors discuss merits and disadvantages of three different approaches to equitable coverage of mental illness: coverage for selected psychiatric diagnoses, coverage based on severity of impairment, and coverage of services. They believe that coverage of selected disorders has political appeal but is discriminatory and arbitrary; it is also impractical because clinicians may overdiagnose conditions covered by insurance and underdiagnose excluded conditions. Coverage based on severity of impairment, or disability, has similar limitations. The authors believe services should be the principal basis for coverage, as under general medical insurance. The approach is nondiscriminatory, and costs can be controlled through such means as managed care, changes in the payment system, or benefit design.

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The predictive value of two methods of predicting therapeutic lithium dose was evaluated in 19 patients. A single time point lithium level determination method, modified by the use of a 900-mg instead of a 600-mg test dose, was found to be a reliable and safe predictor. A mathematical model used for predictions was found to be moderately accurate but to generally predict a lower dose than was actually required.

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Propranolol, a beta-adrenergic blocking agent, has been proposed previously as potentially useful in the treatment of certain otherwise treatment-unresponsive psychotic patients. This article reviews the published clinical trials of the efficacy of propranolol in schizophrenia to characterize those patients in whom it might be helpful and for whom future clinical trials should be designed. Despite a large number of inconsistent reports, the evidence to date favors its potential value as an adjunct to neuroleptic therapy in neuroleptic-resistant chronic schizophrenic patients. Several recommendations are made to improve the methodology of future clinical trials with this agent for the treatment of schizophrenia.

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This retrospective review of the naturalistic use of reserpine in combination with neuroleptics for symptoms refractory to neuroleptics and lithium demonstrated a moderate to dramatic response rate in 50% of 36 chronically disabled psychotic patients. Observed improvement was in marked contrast to the baseline pattern of chronically persistent psychotic symptoms and poor functioning in these patients. Female patients and patients with schizoaffective or bipolar diagnoses responded best to treatment. Reserpine may be an underutilized adjunctive treatment for refractory psychotic states, and further investigation into its clinical applications is warranted.

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Three cases of chronic severe psychosis associated with a history of extensive phencyclidine usage successfully treated with reserpine are described. In two cases, reduction in reserpine dosage did not result in relapse into psychosis.

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