In Reply

SIR: We appreciate the comments from Dr. Poindexter. The possible effect of the concomitant medications on the efficacy of propranolol are important. Phenobarbital has many potential adverse effects on behavior and cognition. It is intriguing to speculate that it was the use of this medication that prevented an adequate response. Because of the design of the study, in which current medications were not altered before the initiation of propranolol, we were unable to discontinue the phenobarbital or switch patients to a better-tolerated anticonvulsant. However, in our clinical care of patients with aggressive behavior, the initial step is the determination of whether current medication may be contributing to the problem.^1,2