A Multisite, Fixed Dose, Randomized, Double-Blind, Placebo-Controlled 12-Week Study Evaluating the Efficacy, Safety, and Tolerability of Adjunctive Infliximab for the Treatment of Bipolar I/II Depression
Phase: PHASE2
Conditions: Bipolar Depression
Sponsor: University Health Network, Toronto

Version 10: 15/Apr/2017 
1
 A MULTISITE, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED 12-WEEK STUDY 
EVALUATING THE EFFICACY, SAFETY, AND TOLERABILITY OF ADJUNCTIVE INFLIXIMAB FOR 
THE TREATMENT OF BIPOLAR I/II DEPRESSION 
 
 
 
INVESTIGATOR: 
Roger S. McIntyre, MD, FRCPC 
Head, Mood Disorders Psychopharmacology Unit  
Toronto Western Hospital 
Main Pavilion 9M-325 
 
416 603 5279 
416 603 5368 
 
 
CO-INVESTIGATORS:   
 
Joanna Soczynska, PhD candidate 
Mood Disorders Psychopharmacology Unit  
Toronto Western Hospital 
Main Pavilion 9M-325 
 
416 603 5800 x3726 
416 603 5368 
 
 
Marion Leboyer, MD, PhD 
University of Paris-Est 
Hôpitaux Universitaires Henri Mondor 
+ 33 1 49 81 30 51 
 
 
Trisha Suppes, MD, PhD 
Stanford University School of Medicine 
3801 Miranda Ave. (151T) 
650-493-5000 x62567 
 
 
Rodrigo Mansur, MD 
Mood Disorders Psychopharmacology Unit  
Toronto Western Hospital 
Main Pavilion 9M-325 
 
416 603 3125 
416 603 5368 
 
 
 
 
 
 
 
 
 
Sidney Kennedy, MD, FRCPC 
Mood Disorders Psychopharmacology Unit  
Toronto General Hospital 
Main Pavilion 9M-329 
 
416 344 3888 
416 603-5368 

Version 10: 15/Apr/2017 
2
 
 
RATIONALE 
 
Disturbances in the immuno-inflammatory system have been implicated in the etiology, 
pathophysiology, phenomenology and comorbidity of Bipolar Disorders (BD). For example, 
preclinical and clinical studies implicate inflammatory networks in the etiology of ‘sickness 
behaviour’, a syndrome phenotypically similar to a major depressive episode. Furthermore, 
increased rates of medical comorbidity (e.g. obesity, abdominal obesity, type 2 diabetes mellitus, 
metabolic syndrome, and cardiovascular disease) relative to age-and sex-matched healthy 
volunteers, point towards common underlying pathophysiology (1). Moreover, preliminary 
evidence from genome-wide association studies, suggests common susceptibility loci for BD and 
several inflammatory-mediated chronic medical disorders (2).   
 
Elevated levels of both circulating and cerebral spinal fluid pro-inflammatory cytokines have 
been consistently replicated in individuals with mood disorders.  Elevated levels of Tumor 
Necrosis Factor-alpha (TNF-α) and its receptors, TNF-R1 and TNF-R2, are amongst the most 
consistently identified pro-inflammatory cytokine abnormalities in BD, across depressive, manic 
and euthymic states. Preliminary evidence suggests that increased inflammation may be 
associated with a more severe illness presentation and illness progression (3;4). Additional 
evidence also suggests that monocytes of individuals with BD have increased inflammatory gene 
expression, which may confer a discriminating mRNA signature in offspring of individuals with 
BD (5). Specifically, evidence suggests that susceptibility to BD may be associated with 
TNFA*2 allele and the –G308A polymorphism of the TNFα gene (6). Disturbances in 
inflammation however, are not evident in all individuals, as mixed results have been reported. 
The foregoing degree of inter-individual variability suggests that immuno-inflammatory 
mechanisms are salient to a subset of individuals with BD.  
 
Conventional mood stabilizers (e.g. lithium. antipsychotics, anticonvulsants) act in varying 
capacities to down-regulate the production of pro-inflammatory cytokine mRNA and protein 
gene expression (5;7). In keeping with this view, double-blind, randomized, placebo-controlled 
studies have documented significant antidepressant effects following adjunctive treatment with 
the anti-inflammatory agent, celecoxib, in individuals with BD and MDD (8-10). Although 
favorable results have been reported with non-steroidal anti-inflammatory drugs (NSAIDs), not 
all studies have been positive and the effect sizes are of questionable clinical significance. It 
could be hypothesized that antagonism of TNF-α, notably in individuals who manifest signs of 
inflammation, may exert more specific and superior efficacy in mitigating symptoms of bipolar 
depression.  
 
Tumor Necrosis Factor Alpha  

Version 10: 15/Apr/2017 
3
Tumor necrosis factor alpha is a 157 amino acid pro-inflammatory cytokine synthesized and 
secreted by disparate cells types including macrophages, lymphocytes, astrocytes, and microglia. 
Its expression is increased in response to injury as well as inflammatory and infectious stimuli. 
Tumor necrosis factor alpha serves a homeostatic function in both innate and adaptive immune 
responses, and is capable of exerting salutary, as well as detrimental effects on immune function. 
For example, acute modest elevations of TNF-α concentrations augment host defense 
mechanisms, while chronically elevated concentrations may contribute to allostatic load (11). 
 
Tumor necrosis factor alpha is released from cells as a soluble cytokine (sTNF, a homotrimer of 
17 kDa) after being enzymatically cleaved from its cell surface-bound precursor [transmembrane 
TNF (tmTNF), a homotrimer of 26-kDa monomers] by TNFα-converting enzyme (TACE). Both 
sTNF and tmTNF ligands are biologically active and exert their effects by binding to TNF 
receptors: TNF-R1 and TNF-R2. Both TNF receptors are membrane glycoproteins that 
specifically bind TNF-α and lymphotoxin alpha-3 (11;12). TNF-R1 mediates apoptosis, cytokine 
production, activation of transcription factors (e.g. NF-kB), as well as inflammatory gene 
activation. Activation of TNF-R1 has been shown to trigger a dual signaling cascade leading to 
apoptosis, proliferation, differentiation, or survival of different cell types. Reverse signaling can 
be initiated by TNF-R2 or TNF-α antagonist binding to cell surface tmTNF, resulting in cytokine 
suppression or apoptosis.  
 
Postmortem studies indicate that individuals with BD exhibit regional abnormalities in the size, 
shape, and density of neurons and glia. Tumor necrosis factor alpha may via activation of 
caspase 3 mediate the observed regional abnormalities in BD. Cellular and biochemical studies 
indicate that TNF-α binding to its canonical receptors subsequently activates an intracellular 
cascade that results in recruitment of the TNF receptor associated death domain. This adapter 
protein subsequently recruits Fas-associated death domain that leads to caspase-3 activation (11). 
Caspase-3 activation is part of the ‘pro-apoptotic’ machinery that possibly mediates neuronal and 
glial apoptosis in BD. Taken together, these observations provide a framework for hypothesizing 
that activated pro-inflammatory cytokines are integral to the neurotoxic process in BD. 
 
Anti-TNF Antagonists 
There are several commercially available biologic agents that specifically inhibit TNF-α, and 
have approved indications for several inflammatory-based diseases, including rheumatoid 
arthritis, Crohn’s disease, ankylosing spondylitis, psoratic arthritis, and ulcerative colitis (12). 
There are no commercially available biosimilar agents to the available TNF antagonists in North 
America. Infliximab is a chimeric monoclonal antibody that has recently been shown to mitigate 
depressive symptoms in individuals treated for other medical conditions, with only preliminary 
evidence for its efficacy in a subgroup of individuals with treatment resistant depression.   
 

Version 10: 15/Apr/2017 
4
Infliximab is a chimeric IgG1k monoclonal antibody for TNF-α with a molecular weight of 150 
kDa. It is composed of human constant and murine variable regions of the antibody. Infliximab 
is supplied as a sterile, white, lyophilized powder for intravenous injection; following 
reconstitution with 10 mL of sterile water for injection with a pH of approximately 7.2. Each 
single-use vile contains 100 mg of infliximab, 50 mg sucrose, 0.5 mg polysorbate 80, 2.2 mg 
monobasic sodium phosphate, monohydrate, and 6.1 mg d dibasic sodium phosphate, dehydrate, 
with no added preservatives (12). Infliximab binds with high affinity to the soluble and 
transmembrane forms of TNF- α and inhibits binding of TNF- α with its receptors (12). 
Treatment with infliximab reduces the access of inflammatory cells into inflamed areas in 
particular inflamed joints or intestine areas in patients with rheumatoid arthritis and Crohn’s 
disease, respectively. Decreases in serum IL-6 and C-reactive protein have also been reported 
following infliximab treatment (13).  
 
Single intravenous (i.v.) infusion of infliximab results in a linear increase between the maximum 
serum concentration and dose of administration (3–20 mg/kg). Infliximab is primarily distributed 
in the vascular compartment. Its volume of distribution at steady state is independent of dose. 
Single dose infusion of 3–10 mg/kg indicates that the median terminal half-life is 8.0–9.5 days. 
Repeated infusions of infliximab at 2 and 6 weeks result in predictable concentration-time 
profiles following each treatment. No systemic accumulation occurs at 4- or 8-week intervals 
with 3–10 mg/kg dosing. At 8 weeks, mean serum concentrations of infliximab range from 0.5 to 
6.0 mcg/mL (12). 
 
TNF Antagonists in Depression 
Several lines of trans-disciplinary evidence indicate that TNF antagonists improve measures of 
depression in individuals with psoriasis, rheumatoid arthritis, Crohn’s disease and ankylosing 
spondylitis. Treatment with TNF antagonists has been associated with lower rates of MDD and 
anxiety disorders in individuals with rheumatoid arthritis, as compared to individuals who did 
not receive these medications (14). In a 6-week, open-label study, infliximab (5 mg/kg 
administered at 0, 2 weeks and 6 weeks) was associated with reduced depressive and anxious 
symptom severity in individuals with ankylosing spondylitis (15). In a single-dose study of 
infliximab, a significantly smaller proportion of subjects met criteria for depression at 4 weeks 
(16% vs. 24%) as compared to baseline (16). In a single-blinded study of patients with Crohn’s 
disease (n = 14), each of whom received placebo (i.e. saline) at baseline, followed by infliximab 
(5 mg/kg) at 2 weeks, demonstrated a significant effect of infliximab on depressive symptom 
severity at 4 weeks (17). In patients with advanced cancer (n = 17), open-label infliximab was 
associated with improvements in fatigue, anxiety and depression subscores (18). Taken together, 
the results demonstrate that infliximab at 5 mg/kg may offer therapeutic benefit for depressive 
symptoms associated with BD.  
 

Version 10: 15/Apr/2017 
5
Studies with other TNF antagonists also provide support for their putative antidepressant 
properties.   In an animal model of depression, 5 weeks of etanercept treatment was 
demonstrated to exert antidepressant-like effects on the Forced Swim Test (19). In clinical trials, 
12 weeks of etanercept was demonstrated to result in a reduction of depressive symptom severity 
on the Hamilton Depression Rating scale (HAMD) and Beck Depression Inventory (BDI) in 
individuals with plaque psoriasis (20;21). Significant improvement in depressive symptom 
severity has also been demonstrated in individuals with Crohn’s disease following adalimumab 
maintenance therapy (40 mg every other week) (22).  
 
To our knowledge, there is only one published study that has evaluated the effects of infliximab 
in a primary depressed population. Individuals with treatment resistant depression (N=60; MDD: 
n=51; BD: n=9) were enrolled in a 12-week, randomized, double-blind, placebo-controlled study 
with infliximab (5 mg/kg). Infliximab was administered at baseline, week 2 and week 6. 
Infliximab was superior to placebo in mitigating depressive symptom severity on the HAMD, 
only in individuals who exhibited elevated inflammation at baseline [i.e. high sensitivity C-
reactive protein (hsCRP) level of > 5mg/L].  This subgroup also exhibited a significantly higher 
response rate following treatment with infliximab as compared to placebo (62% and 33%). No 
significant time by drug interaction was observed in the full analysis set. Infliximab was well 
tolerated; the most commonly reported side effect was headaches (67%), followed by coughing 
and insomnia (17%), sore throat, upper respiratory infection, rash, and sinus congestion (13%), 
diarrhea and yeast infection (10%), panic attacks (7%) and fever (3%) (23). 
 
Safety and toxicity concerns 
The major risk associated with TNF-antagonists is an increased propensity for infections. As a 
result, treatment should not be initiated in patients who demonstrate evidence of acute or chronic 
infections. Patients must be monitored closely for clinical presentations suggestive of infection 
while receiving a TNF antagonist. Allergic reactions have been reported in approximately 1% of 
patients; serious allergic reactions are rare. Also, in rare cases patients treated with TNF-
antagonists may develop antibodies against the biologic agent and very rarely develop a lupus-
like syndrome. Other rare side-effects include: increased risk of serious infections, risk of 
demyelinating disorders (e.g. multiple sclerosis), psychosis, decrease in WBC and RBC count, 
and less than 1% risk of developing malignancy. Common side-effects include: mild skin 
reaction at the injection site (itchiness, redness, and mild swelling), nausea, abdominal pain, 
headache, rash and upper respiratory tract infections (such as sinusitis). 
 
Microbial Changes (optional participation) 
Every human harbors complex microbial communities (collectively, the human ‘microbiome’) 
that cover the skin and the body’s mucosal surfaces. These communities have a profound effect 
on our well-being. For instance, recent studies have outlined distinct associations between gut 
microbial communities and obesity, inflammatory bowel disease, nationality and aging. 

Version 10: 15/Apr/2017 
6
Emerging research on axenic and gnotobiotic mice indicates that the influence of the intestinal 
microbiome extends well beyond the gut to involve organs that include the skin, liver and brain.  
Research on an animal model of depression has also shown that oral administration of a probiotic 
increased plasma tryptophan levels and decreased serotonin metabolite concentrations in the 
frontal cortex and decreased dopamine metabolite concentrations in the amygdaloid cortex. To 
date, there is no data on the nature of the microbiome of patients with BD. 
As part of this investigation into the efficacy of Infliximab, we will also look at the biomarker of 
changes in the gut microbiome.  
 
HYPOTHESIS 
Primary Hypothesis 
Adjunctive treatment with intravenous infliximab (5 mg/kg) will significantly mitigate 
depressive symptoms in individuals with DSM-5-defined bipolar I/II depression as compared to 
intravenous placebo (saline). 
 
Secondary Hypothesis 
Reduction in depressive symptom severity following infliximab treatment will be mediated by 
reduction in the levels of pro-inflammatory mediators, notably TNF-α. 
Reduction in levels of pro-inflammatory mediators, notably TNF- α, following treatment with 
infliximab mediates: 
 reduction in depressive symptom severity 
 favorable changes in cold and hot cognition 
 improvements in quality of life and functioning 
 alteration in central glutamate neurotransmission 
OBJECTIVES 
Primary Objective 
The primary objective is to evaluate the efficacy of adjunctive treatment with intravenous 
infliximab (5 mg/kg) in mitigating depressive symptoms in individuals with DSM-5-defined 
bipolar I/II depression as compared to intravenous placebo (saline) as measured by the mean 
change in Montgomery-Asberg Depression Rating Scale (MADRS) total scores. 
 
Secondary Objectives 
Secondary objectives are (1) to evaluate the effect of infliximab/cytokine milieu on measures of 
cognitive function including cold cognition and hot cognition (i.e., anhedonia) (2) to evaluate the 
effect of infliximab/cytokine milieu on the neuroprogression in BD as measured by prefrontal N-
Acetyl Aspartate and choline levels as well as hippocampal and whole brain gray matter volume 
using MRS and MRI, respectively (3) to evaluate the effect of treatment on quality of life and 
functioning as measured by 36-Item Short Form Health Survey (SF-36), Sheehan Disability 

Version 10: 15/Apr/2017 
7
Scale (SDS) and Endicott Workplace Productivity Scale (EWPS), respectively (4) To evaluate if 
the gut microbial signature changes with treatment. This will be done by comparing changes pre- 
and post- treatment with Infliximab, as well as comparing the treatment group to the placebo 
group.  
STUDY DESIGN 
This is a phase II, 12-week, fixed dose, multisite, randomized, double-blind, placebo-controlled 
study of the efficacy, safety, and tolerability of adjunctive infliximab for the treatment of 
individuals with bipolar I/II depression. 
RECRUITMENT 
The two sites, Mood Disorder Psychopharmacology Unit, and Stanford University School of 
Medicine provide psychiatric assessment to approximately 20 new patients with BD per week. 
Based on experience from other interventional studies, we expect to recruit approximately 1-3 
participants per month per site for this study for a period of 2 years. An attrition rate of 30 
percent is expected; we anticipate that approximately 78 individual will be enrolled for a total of 
60 evaluable subjects. 
 
The study will be approved by the respective institutional review boards as well as Health 
Canada and FDA.  
SELECTION OF SUBJECTS  
Male and female outpatients (N=60; n=55 at Toronto Western Hospital and n=5 at Stanford 
University) between the ages of 18 and 65 who meet DSM-5 criteria for a current major 
depressive episode as part bipolar I/II disorder and are able to provide written informed consent 
will be eligible for inclusion in the study. The diagnosis of BD will be confirmed clinically 
according to DSM-5. At study entry, eligible subjects will be required to have a minimum 
Hamilton Depression Rating scale 17- item (HAMD-17) total score of >20 and Young Mania 
Rating Scale (YMRS) total score of <12; have previously failed a trial of a CANMAT BD 
guideline/FDA-approved first-line treatment for the depressive phase of BD during the index 
episode and/or during a prior episode. Treatment failure will be adjudicated either historically or 
prospectively. Female participants of childbearing potential must test negative for pregnancy and 
must be using adequate birth control measures (e.g., abstinence, oral contraceptives, intrauterine 
device, barrier method with spermicide, or surgical sterilization) throughout the study and must 
continue such precautions for 6 months after receiving the last study drug administration. 
Enrollment will be stratified based on indicators of inflammation; subjects will be randomized to 
treatment if they meet any one of the following criteria:  
 

Version 10: 15/Apr/2017 
8
1. Central Obesity (ethnicity-specific waist circumference – see table below for specific 
values) OR BMI ≥30 kg/m2. 
AND 
 Raised triglycerides: ≥1.7 mmol/L (150 mg/dL) or specific treatment for this lipid 
abnormality OR 
 Reduced HDL-cholesterol:  <1.03 mmol/L (40 mg/dL) in males; <1.29 mmol/L (50 
mg/dL) in females or specific treatment for this lipid abnormality OR 
 Raised Blood Pressure: Raised blood pressure Systolic: ≥130 mm Hg or diastolic: ≥85 
mm Hg or treatment of previously diagnosed hypertension. 
2. Diabetes: 8-hour fasting plasma glucose ≥ 7.0 mmol/L or Hb-A1C test ≥ 6.5% (as per the 
2013 CDA diagnostic criteria) or previously diagnosed type 1 or 2 diabetes (current 
prescription medication for diabetes acceptable of diagnosis). Participants with child 
onset of diabetes will be excluded. 
3. Inflammatory bowel disorder (Ulcerative Colitis, Crohn's disease). 
4. Rheumatological disorders (rheumatoid arthiristis); Psoriasis.  
5. Smoking cigarettes (daily - minimum of ½ pack). 
6. Migraines (as per the International Headache Society guidelines) (24;25) 
 
7. CRP ≥5 mg/L  
 
Country/Ethnic Specific Values for Waist Circumference* 
Country/Ethnic Group 
 
Waist Circumference  
(as Measure of Central Obesity) 
 
Europeans 
 
Male ≥94 cm  
Female ≥80 cm 
South Asians 
 
Male ≥90 cm  
Female ≥80 cm 
Chinese 
Male ≥90 cm  
Female ≥80 cm 
Japanese 
 
Male ≥85 cm  
Female ≥90 cm 
*These are pragmatic cut points and better data are required to link them to risk. Ethnicity 
should be the basis for classification, not the country of residence. 
 
Participants will be excluded from the study if according to clinician judgment, they have 
another concurrent psychiatric disorder that requires primary clinical attention, a history of 
schizophrenia, active psychotic symptoms; meet criteria for substance abuse and/or dependence 
within 6 months; have received electroconvulsive therapy in the past 6 months, are actively 
suicidal or evaluated as being a suicide risk (a score of ≥3 on the HAMD-17 suicide item; a score 

Version 10: 15/Apr/2017 
9
of > 4 on the MADRS and/or according to clinical judgment using the Columbia-Suicide 
Severity Rating Scale). Participants will also be excluded if they have a clinically significant 
unstable medical illness, a history of tuberculosis (confirmed by chest radiography, a positive 
tuberculin skin test, or a blood test; as per Canadian TB standards) or a high risk of tuberculosis 
exposure; severe infections such as sepsis, abscesses, tuberculosis and opportunistic infections; 
viral hepatitis B (assessed using Public Health of Canada hepatitis B screening 
recommendation); a history of hepatitis C infection; documented or suspected human 
immunodeficiency virus (HIV) infection (confirmed by laboratory testing); any unstable 
autoimmune disorder; active fungal infection; a history of recurrent viral or bacterial infections; 
received within 3 months prior to screening or are expected to receive any live viral (e.g., 
smallpox) or live bacterial vaccinations during the trial or up to 3 months after the last 
administration of study agent; have had a C.difficile infection within the past 4 months; have a 
history of lymphoproliferative disease; a history of cancer, excluding basal cell or squamous cell 
carcinoma of the skin (fully excised with no recurrence); unstable cardiovascular, 
endocrinological, hematological, hepatic, renal or neurological disease determined by physical 
examination and laboratory testing; a concomitant diagnosis or any history of congestive heart 
failure; and/or are concomitantly treated with non-steroidal and steroidal anti-inflammatory 
medications or other biologics; have current or past exposure to anti-TNF biologics; a previous 
immediate hypersensitivity response, including anaphylaxis, to an immunoglobulin product 
( plasma-derived or recombinant, e.g., monoclonal antibody); known allergies, hypersensitivity, 
or intolerance to infliximab or its excipients; known allergy to murine proteins or other chimeric 
proteins; currently on or have used any investigational drug within 30 days prior to screening, or 
within 5 half-lives of the investigational agent. Females who are pregnant or breastfeeding will 
also be excluded from this study.  
TREATMENT AND DOSING 
Infliximab will be prescribed adjunctively to a conventional mood stabilizer or atypical 
antipsychotic agent. Eligible participants will have received conventional treatment for bipolar 
depression for a minimum of 4 weeks prior to randomization to infliximab or placebo. The 
choice and dosing of mood stabilizing agents will remain unchanged throughout the trial; 
allowing for adjunctive treatment with mechanistically dissimilar mood stabilizing agents, which 
foster recruitment.   
 
Participants will be randomized to receive intravenous infliximab (5 mg/kg) or placebo (saline 
solution) at baseline, week 2 and 6 under clinical observation. Placebo will be matched to 
infliximab in color and consistency. The dosing and dosing schedule are identical to a previously 
published RCT with infliximab in MDD.  
 
 

Version 10: 15/Apr/2017 
10
 
CONCOMITANT TREATMENTS:  
Prohibited medications: 
 Anakinra 
 Abatacept 
 Other biologics 
 Nonsteroidal and steroidal anti-inflammatory medications (exception: 81 mg aspirin if 
medically indicated) 
 
Restricted medications: 
 Medications taken on a prn basis will be reviewed and may be restricted at certain time 
points during the study (e.g., medications that interfere with cognitive function). 
 
 
SUBJECT DISCONTINUATION 
Subjects may be discontinued from the study participation at any time.   
 
Reasons for discontinuation include: 
1. Voluntary discontinuation by the subject without prejudice to further treatment. 
2. Worsened depression on 2 consecutive visits as measured by MADRS. 
3. Onset of hypo/manic symptoms, i.e., YMRS >12 on 2 consecutive visits.  
 
 
PROCEDURES 
Participants will be enrolled at the Mood Disorders Psychopharmacology Unit, University Health 
Network, University of Toronto, Canada and Department of Psychiatry, Veterans’ affairs 
Hospital, USA. 
 
A written, signed and dated informed consent should be obtained from the subject before any 
study-related procedures are performed. A member of the research staff will explain the study in 
full detail to any prospective subject in understandable, non-medical terms.  The research staff, 
as well as the investigator, will answer any questions raised and ensure that the prospective 
participant understands all the procedures and risks involved. Once the subject has had some 
time to consider the study (usually up to 24 hrs) and decides that they wish to participate, the 
study staff will confirm the subject’s voluntary and informed participation in the study.  A copy 
of the signed consent form will be given to the patient for their reference. 
The subject should then be assigned a subject number.  
 

Version 10: 15/Apr/2017 
11
Screening Visit 
Screening procedures will be performed within -28 days of the baseline (day 0) visit, unless 
approved by the principal investigator. 
 
The following information/assessments will be collected: 
 Subject demography and social characteristics 
o Date of birth (mmm/yyyy), sex, race, ethnicity 
o Marital status, employment status, education 
 Physical Activity History: International Physical Activity Questionnaire (IPAQ) 
 Medical history: Illness characteristics will be obtained from patient interview and 
hospital medical records. 
 Current medication(s) and the daily dosages will be recorded. 
 Psychiatric history and evaluation: 
o Diagnosis of Bipolar Disorder I/II will be confirmed with the Structured Clinical 
Interview for DSM Disorders (SCID). 
o Comorbid psychiatric disorders will be assessed with the MINI International 
Neuropsychiatric Interview (MINI).  
o Active psychotic symptoms as well as substance abuse/dependence will be 
assessed with the MINI.  
o Symptoms of depression will be assessed using Montgomery-Asberg Depression 
Rating Scale (MADRS) and Hamilton Depression Rating Scale (HAMD-17). 
 Other assessments 
o Symptoms of hypo/mania will be assessed using the Young Mania Rating Scale 
(YMRS). 
o Risk of suicide will be assessed using the Columbia Suicide Severity Rating Scale 
(C-SSRS). 
o Symptom severity will be assessed using the CGI-Severity. 
o Chronic stress and episodic life events will be assessed using the UCLA Life 
Stress Interview. 
 Spontaneously reported adverse events will be recorded. 
 Anthropometric measures will be recorded. 
o Height 
o Weight 
 Vital signs will be recorded. 
o Blood Pressure 
o Pulse rate 
 
Laboratory samples will be collected. 
o TB skin test; chest x-ray (if indicated) 
o HIV test 
o Hep B test 

Version 10: 15/Apr/2017 
12
o Hep C test 
o Hematology: hemoglobin, hematocrit, total and differential WBC count, platelet 
count 
o Chemistry: blood urea nitrogen/urea, creatinine, sodium, potassium, calcium, 
alkaline phosphatise, total protein, albumin, AST, ALT, total bilirubin 
o Lipid panel: triglycerides, HDL, LDL, total cholesterol 
o Insulin 
o Glucose 
o Lithium 
o Valproate 
o hCG 
o Urine drug test 
 participants will be given a stool collection kit to collect stool sample for microbial 
profile which is to be submitted within 24 hours of collection at baseline visit (optional 
participation) 
 
Baseline / Endpoint Evaluation 
The baseline visit is on day 0 of the study.  
 
The endpoint visit is on day 84 of the study. 
 
The following assessments will be completed in the aforementioned visits: 
 Symptoms of depression will be assessed using Montgomery-Asberg Depression Rating 
Scale (MADRS), Hamilton Depression Rating Scale (HAMD-17) and the Quick 
Inventory of Depressive Symptomatology – Self Report (QIDS-SR). The HAMD-17 will 
be administered at baseline. 
 Symptoms of hypo/mania will be assessed using YMRS and the Hypomania Check List 
(HCL). 
 Risk of suicide will be assessed using the Columbia – Suicide Severity Rating Scale (C-
SSRS). 
 Symptom severity will be assessed using the CGI-Severity at baseline and endpoint 
whereas symptom improvement will be assessed using CGI-Improvement at endpoint. 
 Quality of life will be assessed using Short Form - 36 (SF-36), Sheehan Disability Scale 
(SDS) and Endicott Work Place Productivity Scale (EWPS). 
 The Snaith Hamilton Pleasure Scale (SHAPS) will be administered. 
 History of childhood adversity will be assessed using the Childhood Trauma 
Questionnaire (CTQ) at baseline. 
 Digit Symbol Substitution Test (DSST) from the WAIS-III and the Rey Auditory Verbal 
Learning Test (RAVLT) will be administered. 

Version 10: 15/Apr/2017 
13
 The Perceived Deficits Questionnaire for Depression – 20 item will be administered. 
 Diet will be assessed using the Brief Diet Questionnaire (BDQ). 
 Spontaneously reported adverse events will be recorded. 
 All prescription or non-prescription drugs, herbal or nutritional supplements will be 
recorded. 
 Vital signs as well as waist circumference and weight will be measured and recorded. 
 Laboratory specimens will be collected (endpoint only). 
 Anatomical and functional magnetic resonance imaging (MRI) scan and a single voxel 
proton magnetic resonance spectroscopy (MRS) scanning will be conducted. 
 Stool sample will be collected (optional participation). 
 
Follow-up Visits 
All follow-up visits will be scheduled within ± 2 days of visit date to allow for variations in 
subject schedules, unless approved by the principal investigator. The overall treatment period in 
the protocol will be maintained. 
The following assessments will be completed in the aforementioned visits: 
 Symptoms of depression will be assessed using MADRS, the Quick Inventory of 
Depressive Symptomatology – Self Report (QIDS-SR)and the HAMD-17 (Baseline, 
Week 0 and Week 12) 
 Symptoms of hypo/mania will be assessed using YMRS and the Hypomania Check List 
(HCL). 
 Risk of suicide will be assessed using the Columbia – Suicide Severity Rating Scale (C-
SSRS). 
 Symptom severity and improvement will be assessed using the CGI-Severity and CGI-—
Improvement, respectively, at all follow-up visits. 
 Quality of life will be assessed using Short Form - 36 (SF-36) at Week 4.  
 Sheehan Disability Scale (SDS) will be administered. 
 The Snaith Hamilton Pleasure Scale (SHAPS) will be administered (Week 0, Week 6, 
Week 12) 
 Digit Symbol Substitution Test (DSST) from the WAIS-III and the Rey Auditory Verbal 
Learning Test (RAVLT) will be administered at week 2. 
 The Perceived Deficits Questionnaire for Depression – 20 item will be administered at 
week 2. 
 Diet will be assessed using the Brief Diet Questionnaire (BDQ). 
 Spontaneously reported adverse events will be recorded. 
 Weight will be recorded. 
 Vital signs will be measured and recorded. 
 Changes to medicines will be assessed. 

Version 10: 15/Apr/2017 
14
 Laboratory specimens will be collected (hematology and biochemistry at Week 2 and 
Week 6). 
 Changes in physical activity will be assessed using the International Physical Activity 
Questionnaire (IPAQ) (Screening, Week 6 and Week 12).  
 
 Stool sample will be collected at week 6 (optional participation). 
 
At a single time point during the study, the history of childhood and adolescent experience of 
neglect and abuse will be assessed using the Childhood Experience of Care and Abuse (CECA) 
Interview. The CECA interview will be conducted by telephone and audio-recorded. The 
interview and subsequent ratings will be made by highly trained and experienced research staff 
supervised by Dr. Kate Harkness.  
 
Laboratory Assessments 
Routine: The following laboratory tests will be completed: 
 CRP (at screening) 
 HIV testing (at screening) 
 Hep B, C testing (at screening) 
 hCG (at screening) 
 Hematology: hemoglobin, hematocrit, total and differential WBC count, platelet count 
 Chemistry: blood urea nitrogen/urea, creatinine, sodium, potassium, calcium, alkaline 
phosphatase, total protein, albumin, AST, ALT, total bilirubin 
 Lipid panel: triglycerides, HDL, LDL, total cholesterol 
 Insulin 
 Glucose 
 Lithium (if indicated) 
 Valproate (if indicated) 
 Urine drug screen (at screening) 
Biomarkers: Blood samples for biomarker analysis will be collected at baseline, week 2, week 
6, and week 12.. The samples will be collected after a 12 hour fast and centrifuged at 1000g for 
15 min at 4 oC; plasma will be stored at -80 oC. Ultrasensitive ELISA will be used to measure 
high-sensitivity CRP and TNF-α, TNF-R1 and TNF-R2.  For exploratory mechanistic analysis, 
inflammatory targets including inflammatory cytokines and receptors will be measured (e.g. 
IFN-γ, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13). Other exploratory targets include 
chemokines and receptors (e.g. MCP-1) as well as cell adhesion molecules (e.g., VCAM, 
NCAM, ICAM, e-selectin). Metabolic targets for evaluation include insulin, leptin, ghrelin, 
adiponectin and resistin levels. .  
 

Version 10: 15/Apr/2017 
15
mRNA Analysis: Blood samples for mRNA analysis will be collected at baseline, week 2, week 
6, and week 12. Samples will be stored at -80 oC until analysis. 
 
Microbiome Analysis: Fecal samples will be collected from participants and controls and 
extracted DNA will be analyzed by PCR and next-generation sequencing. Microbial community 
profiles will be generated using Illumina sequencing and paired-end assembly of 16S rRNA gene 
reads (one lane; 1-2 million reads per sample). This method has been used multiple times in the 
Neufeld lab and has been published. Importantly, no human DNA will be amplified and 
sequenced with this approach. 
 
Other: Human anti-chimeric antibody (HACA) levels will also be measured at endpoint/early 
termination. 
 
 
COMPENSATION 
Subjects will receive financial compensation for participation in the study. Subjects will be 
reimbursed up to $50.00 per visit for travel expenses (e.g. parking, public transport) and food-
related expenses.  
 
Subjects who agree to provide stool samples will receive $10.00 at visits 2, 6, and 10. 
 
 
INVESTIGATOR PRODUCT AND ADMINISTRATION 
Investigational Product 
Infliximab is supplied as a sterile white lyophilized powder for intravenous infusion. Each vial 
contains 100 mg infliximab, 500 mg sucrose, 0.5 mg polysorbate 80, 2.2 mg monobasic sodium 
phosphate, monohydrate and 6.1 mg dibasic sodium phosphate, dehydrate. No preservative are 
present.  
 
Infliximab lyophilized concentrate for IV injection is supplied in individually-boxed single-use 
vials of 100 mg dosage strength. 
 
 
Storage 
The lyophilized product will be refrigerated at 2°C to 8°C (36°F to 46°F). Reconstitution and 
dilution of infliximab will take place in controlled, aseptic conditions. The infusion solution will 
be administered within 3 hours of reconstitution and dilution. If the diluted infliximab is not used 

Version 10: 15/Apr/2017 
16
within 3 hours of preparation, the infusion solution may be stored for no longer than 24 hours at 
2°C to 8°C. 
 
Stool samples will be stored in a -80 ºC fridge at University of Toronto until transported in dry 
ice to the University of Waterloo for analysis. 
 
 
SAFETY MEASURES  
Tuberculin skin testing will be conducted at screening. All subjects will be screened for HIV, 
hepatitis B and C. Infusion will be delayed if any evidence of other infections is present at 
baseline until symptoms have resolved and/or appropriate treatment has been initiated. Treatment 
and safety at the time of infusion will be monitored by a trained Registered Nurse that has 
clinical trial experience with biologic agents. Safety measures will be evaluated at each visit and 
will include measurement of vital signs, assessment of mood symptoms and adverse event 
development; in addition, routine blood tests will be conducted at screening, week 2, 6, and 12. 
Adverse events will also be recorded at each visit by spontaneous report.  The YMRS will be 
administered at each visit to monitor induction of hypo/manic symptomatology. 
 
 
EFFICACY MEASURES 
 
Primary Endpoints 
Clinical outcome measures will be administered at baseline, week 1, 2, 3, 4, 6, 8, 10, and 12. The 
primary efficacy variable will be mean change from baseline to week 12 on the MADRS total 
score.  
 
Secondary Endpoints 
Secondary efficacy evaluations will be response (i.e. >50% reduction from baseline week 12 on 
the MADRS) and remission (i.e. MADRS <12) rates, as well as change in CGI Severity.  
STATISTICS 
Statistical Methods 
Separate randomization schedules will be prepared for each site.  
The intention-to-treat sample will include subjects who receive at least one infusion of 
infliximab or placebo and have at least one post-baseline assessment. Missing data will be 
estimated with the maximum likelihood method using a mixed model for repeated measures 
ANOVA. The mixed model repeated measures ANOVA will also be used to evaluate change 

Version 10: 15/Apr/2017 
17
from baseline to endpoint as a function of treatment status. All tests will be two tailed with 
significance defined by <0.05. 
 
All data collected during this study will be uploaded to the National Institute for Mental Health 
data respiratory. 
Interim Analysis 
No interim analysis will be conducted. 
 
Sample Size Calculation and Statistical Analysis  
Using the published literature with infliximab in MDD (23), it is estimated that 30 evaluable 
subjects per treatment arm will have better than 80% power to detect a difference in depressive 
symptoms between infliximab-treated and placebo-treated subjects at level of 5% significance.  
 
ADVERSE EVENTS 
Definitions 
Adverse event 
An adverse event is the development of an undesirable medical condition or the deterioration of 
a pre-existing medical condition following or during exposure to a pharmaceutical product, 
whether or not considered causally related to the product.  An undesirable medical condition can 
be symptoms (e.g., nausea, chest pain), signs (e.g., tachycardia, enlarged liver) or the abnormal 
results of an investigation (e.g., laboratory findings, electrocardiogram).  In clinical studies, an 
AE can include an undesirable medical condition occurring at any time, including run-in or 
washout periods, even if no study treatment has been administered. 
Serious adverse event 
A serious adverse event is an AE occurring during any study phase (i.e., run-in, treatment, 
washout, follow-up), and at any dose of the investigational product, comparator or placebo, that 
fulfils one or more of the following criteria: 
 results in death 
 is immediately life-threatening 
 requires in-patient hospitalisation or prolongation of existing hospitalisation 
 results in persistent or significant disability or incapacity 
 is a congenital abnormality or birth defect 

Version 10: 15/Apr/2017 
18
 is an important medical event that may jeopardise the patient or may require medical 
intervention to prevent one of the outcomes listed above. 
The causality of SAEs (i.e., their relationship to study treatment) will be assessed by the 
investigator(s).  Note that SAEs that could be associated with any study procedure should also be 
reported. For such events the casual relationship is implied as "yes". 
Recording of adverse events 
AEs will be collected from baseline visit to until the end of the study. At each visit, subjects will 
be asked if they have had any health problems since the previous visit.  All AEs will be recorded 
appropriately, whether or not considered related to the investigational product. This will include 
AEs spontaneously reported by the patient and/or observed by the staff as well as AEs reported 
in response to a direct question e.g. “Have you had any health problems since your last visit?”  
For each AE, the following parameters be described: 
 start and stop date 
 action taken with regards to investigational product 
 outcome 
 if the AE caused the patient to discontinue 
 a statement if the AE fulfils the criteria for a SAE or not 
 the investigator’s assessment of the causal relationship between the event and the 
investigational product 
 intensity of the AE 
o mild (awareness of sign or symptom, but easily tolerated) 
o moderate (discomfort sufficient to cause interference with normal activities) 
o severe (incapacitating, with inability to perform normal activities) 
It is important to distinguish between serious and severe AEs.  Severity is a measure of intensity 
whereas seriousness is defined by the criteria in Section.  An AE of severe intensity need not 
necessarily be considered serious.  For example, nausea that persists for several hours may be 
considered severe nausea, but not an SAE.  On the other hand, a stroke that results in only a 
limited degree of disability may be considered a mild stroke but would be an SAE.  
Symptoms associated with overdose should be reported as AEs. For further information 
regarding overdose, see section. 
Pregnancy in itself is not regarded as an AE unless there is a suspicion that an investigational 
product may have interfered with the effectiveness of a contraceptive medication.  
Follow-up of adverse events should be based upon the clinical judgement of the investigator. 
Reporting of serious adverse events 

Version 10: 15/Apr/2017 
19
Reporting of SAEs to regulatory authorities will be done by the investigator in accordance with 
local regulations. A copy of the report will also be sent to the manufacturer of the investigational 
product. 
 
 
Reference List 
 
 
(1)  McIntyre RS, Soczynska JK, Beyer JL, Woldeyohannes HO, Law CW, Miranda A, 
Konarski JZ, Kennedy SH. Medical comorbidity in bipolar disorder: re-prioritizing unmet 
needs. Curr Opin Psychiatry 2007 July;20(4):406-16. 
 
(2)  Genome-wide association study of 14,000 cases of seven common diseases and 3,000 
shared controls. Nature 2007 June 7;447(7145):661-78. 
 
(3)  Kauer-Sant'anna M, Kapczinski F, Andreazza AC, Bond DJ, Lam RW, Trevor YL, 
Yatham LN. Brain-derived neurotrophic factor and inflammatory markers in patients 
with early- vs. late-stage bipolar disorder. Int J Neuropsychopharmacol 2008 September 
4;1-12. 
 
(4)  Bob P, Raboch J, Maes M, Susta M, Pavlat J, Jasova D, Vevera J, Uhrova J, Benakova H, 
Zima T. Depression, traumatic stress and interleukin-6. J Affect Disord 2010 
January;120(1-3):231-4. 
 
(5)  Padmos RC, Hillegers MH, Knijff EM, Vonk R, Bouvy A, Staal FJ, de RD, Kupka RW, 
Nolen WA, Drexhage HA. A discriminating messenger RNA signature for bipolar 
disorder formed by an aberrant expression of inflammatory genes in monocytes. Arch 
Gen Psychiatry 2008 April;65(4):395-407. 
 
(6)  Pae CU, Lee KU, Han H, Serretti A, Jun TY. Tumor necrosis factor alpha gene-G308A 
polymorphism associated with bipolar I disorder in the Korean population. Psychiatry 
Res 2004 January 30;125(1):65-8. 
 
(7)  Pollmacher T, Haack M, Schuld A, Kraus T, Hinze-Selch D. Effects of antipsychotic 
drugs on cytokine networks. J Psychiatr Res 2000 November;34(6):369-82. 
 
(8)  Akhondzadeh S, Jafari S, Raisi F, Nasehi AA, Ghoreishi A, Salehi B, Mohebbi-Rasa S, 
Raznahan M, Kamalipour A. Clinical trial of adjunctive celecoxib treatment in patients 
with major depression: a double blind and placebo controlled trial. Depress Anxiety 
2009;26(7):607-11. 
 
(9)  Nery FG, Monkul ES, Hatch JP, Fonseca M, Zunta-Soares GB, Frey BN, Bowden CL, 
Soares JC. Celecoxib as an adjunct in the treatment of depressive or mixed episodes of 
bipolar disorder: a double-blind, randomized, placebo-controlled study. Hum 
Psychopharmacol 2008 March;23(2):87-94. 
 (10)  Muller N, Schwarz MJ, Dehning S, Douhe A, Cerovecki A, Goldstein-Muller B, 
Spellmann I, Hetzel G, Maino K, Kleindienst N, Moller HJ, Arolt V, Riedel M. The 

Version 10: 15/Apr/2017 
20
cyclooxygenase-2 inhibitor celecoxib has therapeutic effects in major depression: results 
of a double-blind, randomized, placebo controlled, add-on pilot study to reboxetine. Mol 
Psychiatry 2006 July;11(7):680-4. 
 (11)  Brietzke E, Kapczinski F. TNF-alpha as a molecular target in bipolar disorder. Prog 
Neuropsychopharmacol Biol Psychiatry 2008 August 1;32(6):1355-61. 
 (12)  Tracey D, Klareskog L, Sasso EH, Salfeld JG, Tak PP. Tumor necrosis factor antagonist 
mechanisms of action: a comprehensive review. Pharmacol Ther 2008 
February;117(2):244-79. 
 (13)  Visvanathan S, Wagner C, Marini JC, Baker D, Gathany T, Han J, van der HD, Braun J. 
Inflammatory biomarkers, disease activity and spinal disease measures in patients with 
ankylosing spondylitis after treatment with infliximab. Ann Rheum Dis 2008 
April;67(4):511-7. 
 (14)  Uguz F, Akman C, Kucuksarac S, Tufekci O. Anti-tumor necrosis factor-alpha therapy is 
associated with less frequent mood and anxiety disorders in patients with rheumatoid 
arthritis. Psychiatry Clin Neurosci 2009 February;63(1):50-5. 
 (15)  Ertenli I, Ozer S, Kiraz S, Apras SB, Akdogan A, Karadag O, Calguneri M, Kalyoncu U. 
Infliximab, a TNF-alpha antagonist treatment in patients with ankylosing spondylitis: the 
impact on depression, anxiety and quality of life level. Rheumatol Int 2012 
February;32(2):323-30. 
 (16)  Persoons P, Vermeire S, Demyttenaere K, Fischler B, Vandenberghe J, Van OL, Pierik 
M, Hlavaty T, Van AG, Noman M, Rutgeerts P. The impact of major depressive disorder 
on the short- and long-term outcome of Crohn's disease treatment with infliximab. 
Aliment Pharmacol Ther 2005 July 15;22(2):101-10. 
 (17)  Minderhoud IM, Samsom M, Oldenburg B. Crohn's disease, fatigue, and infliximab: is 
there a role for cytokines in the pathogenesis of fatigue? World J Gastroenterol 2007 
April 14;13(14):2089-93. 
 (18)  Tookman AJ, Jones CL, Dewitte M, Lodge PJ. Fatigue in patients with advanced cancer: 
a pilot study of an intervention with infliximab. Support Care Cancer 2008 May 21. 
 (19)  Krugel U, Fischer J, Radicke S, Sack U, Himmerich H. Antidepressant effects of TNF-
alpha blockade in an animal model of depression. J Psychiatr Res 2013 May;47(5):611-6. 
 (20)  Tyring S, Gottlieb A, Papp K, Gordon K, Leonardi C, Wang A, Lalla D, Woolley M, 
Jahreis A, Zitnik R, Cella D, Krishnan R. Etanercept and clinical outcomes, fatigue, and 
depression in psoriasis: double-blind placebo-controlled randomised phase III trial. 
Lancet 2006 January 7;367(9504):29-35. 
 (21)  Gelfand JM, Kimball AB, Mostow EN, Chiou CF, Patel V, Xia HA, Freundlich B, 
Stevens SR. Patient-reported outcomes and health-care resource utilization in patients 

Version 10: 15/Apr/2017 
21
with psoriasis treated with etanercept: continuous versus interrupted treatment. Value 
Health 2008 May;11(3):400-7. 
 (22)  Loftus EV, Feagan BG, Colombel JF, Rubin DT, Wu EQ, Yu AP, Pollack PF, Chao J, 
Mulani P. Effects of adalimumab maintenance therapy on health-related quality of life of 
patients with Crohn's disease: patient-reported outcomes of the CHARM trial. Am J 
Gastroenterol 2008 December;103(12):3132-41. 
 (23)  Raison CL, Rutherford RE, Woolwine BJ, Shuo C, Schettler P, Drake DF, Haroon E, 
Miller AH. A randomized controlled trial of the tumor necrosis factor antagonist 
infliximab for treatment-resistant depression: the role of baseline inflammatory 
biomarkers. JAMA Psychiatry 2013 January;70(1):31-41. 
 
(24)     Karabulut KU, Egercioglu TU, Uyar M, Ucar Y. The change of neutrophils/lymphocytes 
ratio in migraine attacks: A case-controlled study. Annals of Medicine and Surgery. 2016 
Sep 30;10:52-6. 
 
(25)     Sarchielli P, Alberti A, Baldi A, Coppola F, Rossi C, Pierguidi L, Floridi A, Calabresi P. 
Proinflammatory cytokines, adhesion molecules, and lymphocyte integrin expression in 
the internal jugular blood of migraine patients without aura assessed ictally. Headache: 
The Journal of Head and Face Pain. 2006 Feb 1;46(2):200-7.