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• The efficacy of lithium carbonate as a treatment for alcoholism was examined in a double-blind, placebo-controlled study of 104 men and women meeting DSM-III criteria for alcohol dependence. Subjects entered the study during inpatient treatment and were subsequently followed up for 12 months. Survival analysis disclosed essentially three categories of treatment response: one for noncompliant subjects (0% to 7% abstinent), one for compliant subjects not attaining therapeutic serum lithium levels (31% to 44% abstinent), and one for compliant subjects with therapeutic serum levels (67% abstinent). Two findings led us to believe that therapeutic serum levels of lithium were associated with better outcome over and above a behavioral compliance effect. First, in a doseresponse analysis, serum lithium levels and abstinence rates were not linearly associated. Second, all subjects who started lithium carbonate therapy as inpatients were significantly less likely to relapse to drinking during the first month than were placebo-compliant subjects. There was no evidence that depressed alcoholics showed a better treatment response than nondepressed alcoholics or that lithium had any significant impact on the mood or social adjustment of alcoholics. Although the sample size and the difficulties of ascertaining placebo compliance caution against drawing firm conclusions, the data add further support to the hypothesis that lithium has an effect on drinking behavior not related to the treatment of affective symptoms.

IN REPLY.— We are pleased that Dr Flemenbaum, an early advocate of lithium carbonate trials for alcoholic patients with primary subsyndromal affective disorder, brought his article1 and hypotheses to our attention, and we apologize for overlooking it in our initial reports. In his 1974 report, he proposed symptomatic criteria that might distinguish between primary alcoholism and alcoholism secondary to subsyndromal affective disorder and, therefore, between alcoholics who might and might not benefit from lithium carbonate therapy.In the course of the 1985 American Psychiatric Association presentation, Dr Flemenbaum mentioned that one of us (J.F.) reported preliminary results of our study on lithium carbonate therapy for alcoholism.2,3 The numbers Dr Flemenbaum attributes to us are not the same numbers we presented, and this error accounts for our different interpretations. Our research staff interviewed patient subjects and significant others between seven and 21 days following admission to an inpatient alcoholism rehabilitation