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tic threshold dosage. To avoid the first-pass-effect and a lot of physical-chemical interactions, nowadays depot neuroleptics are used for high dosage treatment.

It seem urgent to collect data from individual trials of untradition- al treatments and to try to determine what was effective and what was ineffective. Special TRS units are suggested to be established, linked to a central registry.

1. Dencker, S.J., Bender, W., Kulhanek, F. teds) Treatment Refractory Schizophrenia. Braunschweig: Vieweg, 1988

2. May, P.R.A., Dencker, S-J., Hubbard, J.W., Midha, K.K., Liberman, R.P. In: Dencker, S.J., Bender, W., Kulhanek, F. teds) Treatment Refractory Schizophrenia. Braunschweig: Vieweg, 1988

3. Platz, W., Fiinfgeld, E-W., Kulhanek, F. In: Hinterhuber, H., Schubert, H., Kulhanek, F. teds) Seiteneffekte und Stdrwirkun- gen der Psychopharmaka. Stuttgart-New York: Schattauer, 1986, pp 137-150

RELAPSE AFTER LITHIUM WITHDRAWAL IN SCHIZOAFFECTIVE PSYCHOSES

G. Lenz, A. Lovrek, K. Thau, A. Topitz, E. Denk, C. Simhandl, J. Wancata and R. Wolf

Psychiatric Clinic, University of Vienna, Wahringergurtel 18-20, 1090 Vienna, Austria

In an attempt to validate subtypes of schizoaffective disorder (bipolar type and depressive type, diagnosed by RDC and DSM-III-R) by means of therapy response to lithium, a double-blind placebo-con- trolled withdrawal study was undertaken with 20 bipolar type patients and 10 depressive type patients. In a crossover design patients received lithium for four months and placebo for four months. Every two weeks patients were rated using the Beth-Rafaelson scale for mania and melancholia, BPRS and GAS.

After six patients (all bipolar type, 5 male and 1 female, mean age 47.5k9.9 years, mean age of onset of illness 21f3'years, mean duration of lithium therapy 11.522.3 years, mean lithium plasma level 0.7?0.01 mval/l) had entered the trial, severe manic relapses occurred in five patients, so that the trial had to be stopped because of ethical reasons.

All relapses occurred during the placebo period within ten days to six weeks. One patient, a rapid cycler, entered the study in a subdepressive state which improved and worsened during the lithium period as well as during the placebo period (severe depression after six weeks on placebo).

The high rate of early relapse on placebo suggests the existence of a rebound phenomenon, when lithium is withdrawn suddenly in patients with schizoaffective disorder.

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TABLE 1. Six patients with schizoaffective disorder (RDC and DSM-III- R simultaneously) withdrawn from lithium

Pat. No. and initials l(KW) 2(GW) I 4(QN) 5(RE) 6(RW)

Sex/age now F/44 M/50 M/64 M/43 M/36 M/43 Age at first episode 20 21 24 21 16 24 No. of schizophr. adm. 1 2 - 1 3 1 No. of schizoaff. adm. 2 - 1 1 1 No. of manic adm. 6 1 2 3 3 6 No. of depressive adm. 2 1 1 1 Interval since last 6 rapid 10 9 1 chron. illness (years) cycles subdepr.

Neuroleptic med. no yes no no yes yes Antidepressive med. yes no no no no yes Time on lithium (yrs) 12 3 10 14 11 11 Serum-lithium before withdrawal 0.7 0.6 0.6 0.7 0.6 0.8 (mval/l)

Time on placebo 6 wk after 6 6 wk 10 d 4 wk 3 wk before relapse wk max

of de- pression

LOW DOSE FLUPHENAZINE DECANOATE AND SKILLS TRAINING IN SCHIZOPHRENIC OUTPATIENTS

Stephen R. Marder, M.D. and Robert P. Liberman, M.D.

West Los Angeles Veterans Administration Medical Center, Brentwood Division, and the UCLA Department of Psychiatry, Los Angeles, CA, USA

Two promising biobehavior treatment strategies for patients with chronic schizophrenia are being evaluated in a controlled clinical trial: (1) low dose fluphenazine decanoate maintenance therapy supplemented by either placebo or additional fluphenazine at the times when patients demonstrate early signs (or prodromal signs) of relapse; and (2) behavioral training of patients in a number of self- management skills. Self-management skills are presented in four modules: medication self-management, symptom self-management, recreation for leisure, and social problem solving. Medication and symptom self-management are presented during the first year since skills in the managing of the illness itself are viewed as the basic foundation upon which other skills may be added. The study was designed to maximize the interactions between psychosocial and pharmacological interventions. For example, patients in the self- management groups are taught to recognize the earliest signs of schizophrenic relapse and to take effective remedial action. We predict that self-management skills will yield the greatest therapeu- tic impact with patients who receive active drug when they demon- strate prodromal symptoms. Preliminary data are presented for the 25 patients who have entered the first year of the study on the feas- ibility of involving schizophrenic patients in structural behavioral therapy and on the degree to which the skills are acquired and generalized.