Hemodynamic changes in schizophrenic patients who received electroconvulsive therapy

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ant patients). The study show that neither sociodemographic variables (age, sex etc.) nor illness-related variables (e.g. BPRS) contributed to explaining lack of compliance. Significant group differences were found in individual treatment-related variables (medication dosage, side effects) and particularly in illness concepts. Treating physicians were also able to differentiate prospective patient behavior in taking medication (estimation of cooperation: p<0.001). In a stepwise regression analysis illness concepts contributed to an explanation of the variance, but only to the extent of 4%. Thus, the prediction of compliance remains largely an unsolved problem.

F L U O X E T I N E T R E A T M E N T OF DE NO VO OBSESSIVE-COMPULSIVE S Y M P T O M S IN SCHIZOPHRENIA AFTER CLOZAPINE TREATMENT G. M a k a r i c , V. F o l n e g o v i c - S m a l c , N. M i m i c a , Z. F o l n e g o v i c Psychiatric Hospital Vrapee, University Department of Psychiatry, HR-IO090 Zagreb, Bolnieka c. 32, Croatia Several reports have associated clozapine treatment with de novo or exacerbated obsessive-compulsive symptoms in schizophrenic patients. The data suggest that the effects of clozapine on serotonin neurotransmission account of these symptoms, as serotoninergic dysfunction has been implicated in obsessivecompulsive disorder. We assessed de novo obsessive-compulsive symptoms occurred in schizophrenic patients during clozapine treatment and its course after fluoxetine application. Five female and three male patients were enrolled: 1 patient with Undifferentiated Type, 2 patients with Disorganised Type, 5 with Paranoid Type of Schizophrenia, according to DSM IV. Average age was 31.7_+5.90. Obsessions and compulsions were measured before and during fluoxetine treatment in 24-week trial. At baseline all of the patients had moderate obsessions, and seven had moderate compulsions. Subjects in trial were treated with daily doses of 40 60mg of fluoxetine. Efficacy measures were the Yale-Brown Obsessive Compulsive Scale, CGI Obsessive Compulsive Scale, Hamilton Rating Scale for Anxiety. Statistically significant improvement was observed on all efficacy measures, based on endpoint analyses after 12 weeks, which was either showed in additional 12 weeks as a sustained improvement. Results support the safety, efficacy and tolerability of fluoxetine 40 60 mg daily doses in the acute and maintenance treatment of that particular group of schizophrenic patients.

A C O M P A R I S O N OF T R E A T M E N T R E S P O N S E B E T W E E N EARLY- A N D ADULT-ONSET SCHIZOPHRENIA W . G . H o n e r , L.C. K o p a l a , G . N . Smith, S.W. F l y n n , D . H . F r e d r i k s o n , K . P . G o o d , S. A l t m a n , G.W. MacEwan Department o f PsyehiatiT, University o f British Columbia. 2660 Oak Street, Vancouver, BC, V6H 3Z6, Canada Clinical and brain imaging evidence suggests that there may be at least two types of schizophrenia, early- ( 1st hospitalization

before age 21) and adult-onset forms of the illness. At first episode, an early-onset (n = 11 ) group and an adult-onset group (n = 28 ) had comparable improvement in overall PANSS scores following treatment with risperidone. However, the early-onset group had significantly less improvement in positive (p = 0.003) and cognitive (p=0.05) symptom factor scores compared to the adult-onset group. In a second comparison of treatment resistant patients, early-onset (n = 34) and adult-onset (17=23) patients had similar improvement following clozapine in total PANSS scores, and in all symptom factor scores as well. This suggested the response to optimum treatment might change over time, especially in the adult-onset group. Combining all early-onset patients, the magnitude of response to risperidone in the first episode subgroup was not different from the response to clozapine in the treatment resistant subgroup. In marked contrast, within the combined adult-onset group, the response of the first episode subgroup to risperidone was significantly better than the response of the treatment resistant subgroup to clozapine for total PANSS scores (p =0.0001 ) as well as positive (p=0.0001), psychosocial withdrawal ( p - 0 . 0 0 2 ) , excitation p = 0.0001 ), depression ( p = 0.004 ) and cognitive ( p = 0.0003 ) factor scores. At the onset of illness, there may be subtle differences in treatment response profiles between early- and adult-onset patients. The pathways to developing a treatment resistant state may also differ between early- and adult-onset patients.

F. E C T

H E M O D Y N A M I C C H A N G E S IN S C H I Z O P H R E N I C PATIENTS W H O RECEIVED ELECTROCONVULSIVE THERAPY S h i n - M i n Lee *l, P i n g - K e u n g Yip 2, J e n g - S h i n g Jeng 2, C h e n w e n - k o r 1, C h a n g M i n g ~ t Milita13' 7418 Psychiatric Center, Taiwan, R.O.C. and '-Department ofNeurology, National Taiwan University Ho,sT~ital. Taipei, Taiwn, R. O. C *(~,'respondence: No. 60 Hsin-Min Road, Pei-Tou 112, Taipei. Taiwan, R. O. C. This study was performed to evaluate the possible hemodynamic changes after electroconvulsive therapy (ECT) in schizophrenia. Material and methods: 13 schizophrenic patients who received electroconvulsive therapy were monitored by transcranial ultrasonography (TCD) in order to record the hemodynamic changes in the middle cerebral artery (MCA) during the peri-ECT period. Results: after ECT, the mean flow velocity (Vmean) of MCA in these patients did not increase drastically as previous reported but actually decreased by 49%. The pulsatility index (PI) was increased after ECT and in some of the patients up to 107% compared with the pre-ECT state. All these hemodynamic changes were stabilised approximately 30 minutes after ECT. Conclusion: The primary results from our

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study reveal: under usual conditions, but not general anesthesia, cerebral blood flow after ECT in schizophrenic patients decreases, probably as a result of changes of distal resistance.

EFFICACY OF ECT IN C H R O N I C AGGRESSIVE BEHAVIOR IN SCHIZOPHRENIC/SCHIZOAFFECTIVE D I S O R D E R INPATIENTS C.E. Miller, Z . A . S h a r i f

Columbia University/ Creedmoor Psychiatrie Center, 80-45 Winchester Bh'd, Queens Village, NYl1427, USA We report on the utility of ECT in the management of 6 chronic psychotic patients having persistent and severe aggressive behavior. This was a retrospective study of patients at a state hospital for whom ECT was court ordered on the basis of severe refractory aggressive behavior. All patients were administered bilateral ECT with stimulus set at 100% above seizure threshold. All medications except antipsychotics were discontinued prior to ECT. Symptom severity was rated by chart review before and after completion of the index course of ECT. Outcomes were assessed along the dimensions of psychotic symptoms, mood, and verbal/physical aggression. 2 patients had a diagnosis of schizophrenia; 4 had schizoaffective disorder. All patients had either failed multiple adequate trials of antipsychotics and mood stabilizers (5 patients) or were intolerant of antipsychotic medication ( 1 patient). 5 patients were rated as clear responders to ECT as evidenced by reduction of aggressive behavior. 4 of these were placed on maintenance ECT and have continued to receive treatment up to 4 years after the index course, one as an outpatient. 1 responder was discharged from the hospital but refused outpatient ECT treatment. In two of the five responders improvement in aggressive behavior was not accompanied by improvement in psychotic symptoms. 1 patient was a clear non-responder (in any domain) after 28 total ECT treatments. No significant complications occurred in any patient. These results suggest a specific and robust effect of ECT in ameliorating severe aggressive behavior refractory to other interventions in this group of patients.

EFFICACY A N D SAFETY OF C O M B I N I N G ECT A N D CLOZAPINE IN PATIENTS WITH TREATMENT REFRACTORY SCHIZOPHRENIA Z.A. Sharif, A. Raza, S. Ratakonda, C.E. Miller, J.M. Gorman

Cohtmhia UniversiO,/Creedmoor Psychiatric Center, 80-45 Winchester Bh'd Queens Village, N Y 11427, USA We examined the efficacy and safety of augmenting clozapine treatment with ECT in chronic schizophrenic patients who had

failed an adequate trial of clozapine. Patients with schizophrenia, refractory to treatment with at least two standard antipsychotics as well as clozapine at doses above 350 mg per day for > 12 weeks, were given up to 20 ECT treatments as an augmentation strategy while on clozapine. ECT was administered 3 x/week using bilateral electrode placement with treatment stimulus set 100% above seizure threshold which was determined at the first treatment. Outcome measures included weekly PANSS and MMSE. Five patients have so far completed the protocol. Their mean illness duration was 17.75 years and mean duration of hospitalization was 23 months. At study entry, mean BPRS score (derived from PANSS) was 56 and mean daily clozapine dose was 630 mg. The mean number of ECTs given during the index course was 16.4/5 patients showed > 2 0 % improvement in BPRS score. Significant improvement was seen in BPRS psychotic items (25%), in hostility (54%) and uncooperativeness (42%). Significant depression was not present at baseline. M M S E scores decreased by a mean 3.5 (12.5%). One patient was discharged, while two others showed a marked improvement in their manageability on the unit. No significant adverse effects were encountered. The results of this study suggest that combining ECT and clozapine m a y be an efficacious and well tolerated option for patients who failed a clozapine trial and for whom there is no accepted treatment of proven efficacy.

G. C o g n i t i v e R e h a b i l i t a t i o n

THE EFFECTIVENESS OF COGNITIVE T H E R A P Y WITH COPING T R A I N I N G FOR PERSISTENT A U D I T O R Y HALLUCINATIONS IN A N OUT-PATIENT POPULATION J . A . J e n n e r , G . v a n de Willige, D. W i e r s m a

Department q[ Psyehiatrv, Groningen Universio' Hospital, PO Box 30.001. 9700 RB, Groningen, The Netherkmds Background" Hallucinations are fairly c o m m o n in schizophrenia and other disorders. Recent studies suggest positive effects of cognitive therapy to psychotic symptoms, while the results of coping training are less univocal. Method Standard care with cognitive therapy plus coping training was given to forty patients with a mean duration of auditory hallucinations of 8 years ( S D = 7 . 5 ) and of 6.5 years of contact with mental health care. Patients were classified according to DSM-IV criteria as either schizophrenic (54%) or as having dissociative disorder and borderline personality disorder (46%). All were refractory to standard care. Outcome was assessed by means of a telephone interview on symptoms, other complaints, functioning and satisfaction. Results: Improvements as to hallucinations, anxiety, disturbance of thought, social interactions and daily activities were significant. Complete disappearance of hallucinations occurred in 20% of patients and even in 40% with regular termination