OBJECTIVE:This study investigated the efficacy of verapamil in acute mania.METHOD:The study was a 3-week double-blind, random-assignment, parallel-group, placebo-controlled inpatient trial of verapamil for patients with acute mania. Of the 32 study patients, 15 were given placebo and 17 were given verapamil.RESULTS:Mean absolute change scores on the Mania Rating Scale at endpoint, with baseline scores as the covariates, did not differ between the verapamil and placebo groups. There were no significant differences between the two groups in age, sex, and presence of psychosis.CONCLUSIONS:The investigators found no benefit of verapamil over placebo in treating acute mania.

The authors designed a three-phase prospective trial in which only those patients who developed an acute, neuroleptic-induced extrapyramidal side effect (EPSE) received benztropine (BZ) at 2 mg i.m. and then 1 mg p.o. b.i.d. for 2 days after their symptoms were rated for severity and type (Preparatory Phase 1). They were then randomly assigned under double-blind conditions to continue BZ or be switched to placebo for 8 days (Experimental Phase 2). Finally in Phase 3 (Followup), all patients continued on placebo in a single-blind design until Day 30. If the patient re-experienced an acute EPSE that was of sufficient severity to require immediate BZ administration, he or she was rated, treated, and then dropped from the study. EPSE scores and dropout rates did not differ in Phase 2 between the placebo- and BZ-treated groups. Implications for the continuation, cessation, or intermittent use of antiparkinsonian (AP) drugs are discussed.

The authors studied 36 acutely psychotic inpatients who were diagnosed as having either a schizophrenic (N = 30) or other psychotic (N = 6) disorder. After a washout phase averaging 18 days, all patients were placed on trifluoperazine 5 mg orally twice a day. Plasma levels of trifluoperazine were obtained on days 11 and 15 of treatment and then compared with clinical response. After 2 weeks of treatment an inverted U-shaped relationship was found between change scores on the Brief Psychiatric Rating Scale and trifluoperazine plasma levels.

The authors examined reports addressing the question of whether electroconvulsive therapy (ECT) is more effective in psychotic or nonpsychotic depressive disorders. Most ECT studies did not consider the issue directly, and those that did had varying methodologies and results. The authors then analyzed the data of 33 depressed patients to clarify the differential response to ECT in 13 psychotic and 20 nonpsychotic patients. The subjects were also examined as to type of electrode placement. ECT produced a greater reduction in Hamilton Depression Rating Scale scores in the psychotic depressives as compared to the nonpsychotics after an average of 9.2 treatments. The two patients who were nonresponders to ECT were both nonpsychotic.

High potency neuroleptics have been advocated for acute mania because their side effect profile may allow for a more rapid dose escalation and symptom resolution. Low potency neuroleptics have also been advocated because their sedative properties might better calm the acutely agitated manic patient. The authors tested these hypotheses using a double-blind design comparing thiothixene with chlorpromazine in 29 manic patients on a standard dose of lithium. They found that thiothixene and chlorpromazine produced identical rates and degree of improvement, that side effect profiles differed for each drug but did not affect overall clinical response, and that most patients had a good response on much lower than expected doses. The implications for less aggressive use of neuroleptics to treat mania are discussed.

The authors present new data on the results of the pretreatment Dexamethasone Suppression Test (DST) in 164 drug-free inpatients, as well as on the effects of age on postdex-amethasone cortisol values. Nonsuppression rates were 18% in schizophrenic patients (n = 44), versus 46% in patients with a major depression (n = 56). In addition, a significant correlation was found between age and the 4:00 PM postdexamethasone cortisol value among the depressed patients (r = 0.33). The authors then applied a metaanalysis to summarize 25 other studies that have addressed the schizophrenia/major depression dichotomy as it relates to the DST outcome. Nonsuppression rates were consistently different in schizophrenic patients (19%) when compared to patients with a major depression (51 %) or normal controls (7%). These differences were highly significant as measured by the Mantel-Haenszel chi-square statistic. A metaanalysis applied to a series of correlations obtained from 14 other studies reporting an agei'postdexamethasone cortisol relationship in affective patients indicated a modest, but significant correlation (r = 0.24) in a total of 1284 patients (p < 1 × 10−8).