Clinical trial NCT02909504
Conditions: Bipolar Disorder
Sponsor: Keming Gao
Start date: 2016-09-01; Completion date: 2018-11-01
Enrollment: 24 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This study is a 4-month open-label study of lithium in the acute treatment of patients with bipolar I or II disorder. Eligible patients will receive lithium 300 mg twice daily and titrated in 300 mg increments every 7 days as tolerated to levels \> 0.6 mEq/L. Blood samples are collected at baseline and at the end of study. Analyses of 45 molecule expressions in mononuclear blood cells at baseline and endpoint will be carried out after the completion of study. Fifty patients meeting Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) criteria for bipolar I or II will be enrolled.

Detailed description:

Arms: arm 1: Eligible patients will receive lithium 300 mg twice daily and titrated in 300 mg increments every 7 days as tolerated to levels \> 0.6 mEq/L
Interventions: intervention 1: Lithium
Intervention descriptions: intervention 1: Eligible patients will receive lithium 300 mg twice daily and titrated in 300 mg increments every 7 days as tolerated to levels \> 0.6 mEq/L

Protocol documents:
Prot_SAP_000.pdf: 
 
Page 1 of 12 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Biomarkers in Mononuclear Blood Cells for Lithium Treatment Response of Bipolar Disorder 
 
NCT02909504 
 
June 22, 2017 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
Page 2 of 12 
 
STUDY DESIGN AND OBJECTIVES: 
Study Design: This study is a 4-month open-label study of lithium in the acute treatment of patients 
with bipolar I or II disorder. Eligible patients will receive lithium 300 mg twice daily and titrated in 
300 mg increments every 7 days as tolerated to levels > 0.6 mEq/L. Blood samples are collected at 
baseline and at the end of study. Analyses of 45 molecule expressions in mononuclear blood cells at 
baseline and endpoint will be carried out after the completion of study (see Appendix).  Fifty patients 
meeting DSM-5 criteria for bipolar I or II will be enrolled.  
 
Patients will be seen within the Mood Disorders Program at University Hospitals Cleveland Medical 
Center, 10524 Euclid Avenue, 12th Floor, Cleveland, Ohio 44106.  Assessments will be performed by 
highly trained research assistants and psychiatrists, and required lab specimens will be collected by a 
phlebotomist in the Department of Psychiatry and analyzed at the Laboratory of University Hospitals 
Cleveland Medical Center for routine chemistry, and the laboratory of Dr. David Kaplan, MD, PhD. of 
CellPrint Biotechnology, 11000 Cedar Road, Suite 265, Cleveland, OH, 44106, for potential 
biomarkers. Dr. Kaplan, the founder of CellPrint Biotechnology, is the Co-Principal Investigator of 
this project. 
 
Primary Objectives: The primary objective of this study is to identify biomarkers that illuminate the 
lithium response in patients with bipolar disorder.   
 
Hypothesis 1: Changes in molecular expression after lithium treatment differ between responders and 
non-responders. Molecular differences between the two patient classes will help reveal the underlying 
mechanism of lithium response.   
 
Hypothesis 2: Molecular expression patterns can be used to predict response or non-response to 
lithium treatment.  Ideally, the molecular expression pattern will also vary between responsive and 
non-responsive patients before treatment. Since blood samples are easily obtained, the study has the 
potential to change the landscape of using blood to study molecular changes in patients with bipolar 
disorder or other psychiatric disorders. 
 
Study Design 
The study consists of 2 stages: screening phase and treatment phase (See Table 1 below).   
 
Screening Phase: The Screening phase is up to 4 weeks in duration.  Patients will sign the informed 
consent form, and then be evaluated by the clinician.  Diagnoses will be confirmed by the MINI for 
DSM-5 (Mini International Neuropsychiatric Interview for DSM-5).  A medical history and physical 
exam (H&P) will be completed, along with laboratory testing.   
 
Treatment Phase:  Eligible patients will receive lithium treatment at Baseline (Visit 2).  Any 
psychotropic medications (with the exception of allowed rescue medications) will be tapered off by 
week 4. The study psychiatrist will work with an individual participant concerning how quickly and to 
what schedule the prohibited medication(s) will be weaned off.  Participants will be closely monitored, 
and will come in for unscheduled visits if necessary (typically 1 visit per week, though can be as 
frequent as required), and will be encouraged to contact the clinic if they have questions or concerns.  
The participant will be discontinued from the trial if their mood worsens to a significant degree and/or 
they cannot discontinue excluded concomitant medication(s).   
 
 


 
Page 3 of 12 
 
TARGET STUDY POPULATION 
Inclusion Criteria  
For inclusion in this study, subjects must meet all of the following criteria:  
1) Able to provide informed consent before beginning any study-specific procedures;  
2) Male or female, 18-70 years old; 
3) Meets current DSM-5 criteria for bipolar I or II disorder as assessed by the MINI; 
4) Any symptomatic phase of bipolar I or II disorder including, depressive, manic, mixed or 
hypomanic  
5) Global Clinical Impression-Severity for Bipolar Disorder (CGI-S-BD) ≥3; 
6) Willing to take lithium;  
7) If a sexually active female of childbearing potential, be using a double barrier method of 
contraception for the duration of the study; 
8) Women with reproductive potential must have a negative urine pregnancy test; 
9) Willing to have blood drawn: 
 
Exclusion Criteria  
Any of the following is regarded as a criterion for exclusion from the study: 
1) Unwilling to comply with study requirements; 
2) Renal impairment (serum creatinine >1.5 mg/dL);   
3) Thyroid stimulating hormone (TSH) over >20% above the upper normal limit (participants 
maintained on thyroid medication must be euthyroid for at least 3 months before Visit 1;   
4) Other contraindication to lithium,   
5) Patients who have had severe adverse reaction to Lithium; 
6) Patients who require inpatient care; 
7) Drug/alcohol dependence requiring immediate acute detoxification; 
8) Pregnancy as determined by serum pregnancy test or breastfeeding; 
9) History of nonresponse to lithium at doses ≥ 900 mg/d for ≥ 8 weeks; 
10) Unwilling to have blood drawn 
11) Patients with chronic medical conditions such as diabetes, coronary artery disease, immune 
diseases, infectious diseases and neurological disorders; 
12) Active suicidal ideation with a plan or intent, a suicide attempt within past 6 months or more 
than 2 suicide attempts within the past 2 years. 
13) Currently on lithium 
 
STUDY SPECIFIC PROCEDURES 
 
After obtaining the informed consent, all potential research participants will be assessed with a 
systemic clinical interview and a structured interview with MINI. For those who meet the diagnostic 
inclusion criteria, psychiatric assessments will be administered. All eligible participants will also 
complete a Clinical Record Form. The form includes demographics (including date of birth, sex, race, 
and ethnicity), previous treatment history, the number of previous episodes, family history, and other 
historical correlates.  
 
Medical History: Medical history includes current and previous history of disease(s) related to all 
body systems, diabetes mellitus risk factors, and other cardiovascular disease risk factors such as the 
Framingham Risk Score (FRS) which will be assessed by a sex-specific algorithm developed by 
D’Agostino (2008) and Wilson (2007) respectively, based on the Framingham Study. The updated 


 
Page 4 of 12 
 
FRS enables identification of risk for any and all initial atherosclerotic cardiovascular disease events 
and is ideally designed for primary care (D’Agostino et al., 2008). 
 
Prior and Current Medications: including medication name, dose, frequency, and duration. 
 
Adverse Events (Side Effects): including duration, severity and outcome. 
 
MINI-for DSM-5: Mini-International Neuropsychiatric Interview-for DSM-5:  Diagnostic evaluation 
tool done at screening to ensure the participant is eligible for the protocol.  This version accounts for 
current diagnoses.   
 
CIRS: (Cumulative Illness Rating Scale, Linn et al., 1968): used to assess overall well-being both 
physically and mentally. 
 
TLFB:  The Timeline Follow back procedure for substance use completed by the research coordinator 
in all participants regardless of whether they meet the DSM-5 criteria for a substance use disorder. 
 
Side Effects/Safety Measure:  
a. FIBSR/GRSEB: Frequency, Intensity, and Burden of Side Effects Ratings/Global Rating of 
Side Effects Burden is a 3-item self-rated measure of medication side effects including 
intensity, frequency, and impairment.  
b. C-SSRS: Columbia Suicide-Severity Rating Scale (Posner et al 2007) will be used to monitor 
the safety and side effects. 
 
Severity Scales:  Current symptom severity will be assessed using the following: 
a. Clinical Global Impression-Severity for Bipolar Disorder (CGI-S-BD, Spearing et al., 2007) 
will be used to measure the overall bipolar illness severity. 
b. CGI-EI: Clinical Global Impression-Efficacy Index: The CGI-EI integrates rated benefit and 
harms to yield scores that can be compared across interventions [Guy, 1976]. Thus, the CGI-EI 
provides a ratio of benefit to harm that reflects overall therapeutic effects in relationship to side 
effects. Therapeutic Effects are rated between 1 (unchanged or worse) and 4 (complete or 
nearly complete remission of all symptoms). Side Effects are also rated between 1 (none) and 4 
(outweigh therapeutic effect). CGI-EI scores are ratios of Therapeutic Effects/Side Effects, and 
thus range from 0.25 (=1/4) to 4.00 (=4/1), with higher ratings representing more favorable 
benefit/harm ratios. 
c. Montgomery Depression Rating Scale (MADRS, Montgomery & Asberg 1979) will be used to 
measure the severity of depression. It has become a standard rating scale in bipolar depression 
studies. 
d. 16 Quick Inventory of Depression Symptomatology-Self Report (QIDS-SR16, Rush et al., 
2003) will also be used to measure depression severity. This self-reported questionnaire was 
developed based on the DSM-V diagnostic criteria for a major depressive disorder episode. 
e. Young Mania Rating Scale (YMRS, Young et al., 1978) will be used to measure manic 
symptoms severity 
f. Hamilton anxiety score (HAM-A, Hamilton, 1959) will be used to measure anxiety severity. 
g. Snaith-Hamilton Pleasure Scale (SHAPS, Snaith et al., 1995) will be used to assess feelings of 
anhedonia. 
 
Functional Impairment and Quality of Life: Functional impairment and quality of life will be 
assessed using the following: 


 
Page 5 of 12 
 
a. SDS (Sheehan Disability Scale, Leon et al., 1997) will be used to measure disability and 
impairment.   
b. Quality of Life Enjoyment and Satisfaction Questionnaire – Short Form (Q-LES-Q-SF, 
Endicott et al., 1991) will be used to measure of the degree of enjoyment and satisfaction in 
various areas of daily living. 
c. Iowa Fatigue Scale (IFS) will be used to measure the severity of fatigue.  
 
Physical and Laboratory Monitoring: Vital signs, weight, and waist circumference will be recorded 
at all study visits and height will be assessed at screening.  A urine pregnancy test will be completed at 
screening and end of study for all women of childbearing potential.  If a female participant has a 
positive urine pregnancy test at screening, they will be excluded from participating.  A blood draw of 
approximately 3 teaspoons will be obtained from all patients at screening and end of study to measure 
CBC w/ diff, Comprehensive Metabolic Panel (including electrolytes, kidney function and liver 
function), and TSH and an additional 1 teaspoon of blood will be drawn for the analyses done by 
CellPrint Biotechnology. Lithium levels will be drawn as needed during the study and at end of study, 
with each draw containing approximately 1 teaspoon of blood.  The labs will be drawn by a 
phlebotomist at University Hospitals and analyzed at University Hospitals Laboratory Services 
Foundation and results of test will be reviewed by a study doctor.     
 
Patients may return to the site any time their condition warrants medical attention. At these 
Unscheduled Visits, study related procedures may be performed at the discretion of the investigator. 
Unscheduled Visits should not replace scheduled visits for the patient.  Otherwise, all scheduled visits 
and corresponding assessments to be completed can be found in Table 1. 
 
STUDY DRUG AND DOSING: 
Lithium will be initiated at 300 mg per day for 3 nights and then increased to 600 mg/d as tolerated. 
After at least 5 days of treatment with lithium 600 mg/d, a lithium level will be done. If necessary, 
titration in 300 mg increments every 7days as tolerated will take place to achieve blood lithium levels 
> 0.6mEq/L. This routine will require the investigator to titrate Lithium to whatever is maximally 
tolerated without any side effects, not just 0.6. If adverse effects occur, the dose will be decreased. The 
titration scheme ensures that patients receive the highest possible dose while not experiencing side 
effects that would compromise retention (Hopkins & Gelenberg, 2000) and has been in place since 
1985 when the NIMH Consensus Development Conference issued this recommendation. If subjects do 
not tolerate at least 600mg/d, they may be discontinued.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
Page 6 of 12 
 
Table 1: Flow Chart of the Study 
* PRN  
** If clinically indicated 
*** End of Study:  these assessments in addition to the visit the subject is attending 
 
Criteria for study discontinuation:   
Patients may be discontinued from study treatment and assessments at any time. Specific reasons for 
discontinuing a patient from this study are, but not limited to:   
 Voluntary discontinuation by the subject who are at any time free to discontinue their 
participation in the study, without prejudice to further treatment; 
 
Screening Baseline 
Lithium Treatment Phase 
End of 
Study*** 
Visit 
1 
2 
3 
4 
5 
6 
7 
8 
9 
11 
Weeks 
 
0 
1 
2 
4 
6 
8 
12 
16 
 
Consent 
X 
 
 
 
 
 
 
 
 
 
MINI- DSM-5  
X 
 
 
 
 
 
 
 
 
 
H&P 
X 
 
 
 
 
 
 
 
 
X 
CIRS 
X 
 
 
 
 
 
 
 
 
X 
CBC w/ diff 
X 
 
 
 
 
 
 
 
 
X 
CMP 
X 
 
 
 
 
 
 
 
 
X 
TSH 
X 
 
 
 
 
 
 
 
 
X 
Urine Pregnancy  
X 
 
 
 
 
 
 
 
 
X 
Lithium level* 
 
 
X 
 
 
 
 
 
 
X 
Cell Biomarkers 
X 
 
 
 
 
 
 
 
 
X 
ECG** 
X 
 
 
 
 
 
 
 
 
 
Vitals 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
MADRS 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
YMRS 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
HAMA 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
QIDS-SR16 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
CGI-S-BP 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
CGI-EI 
 
 
X 
X 
X 
X 
X 
X 
X 
 
SDS 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
FIBSR 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
Q-LES-Q-SF 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
C-SSRS 
 
X 
 
 
 
X 
 
 
X 
 
FRS 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
IFS 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
TLFB 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
Physician Visit 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Events (Side 
effects) 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
Medication History/Con 
Meds 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 


 
Page 7 of 12 
 
 Safety reasons as judged by the investigator, particularly a clinically significant or serious 
adverse event that would not be consistent with continuation in the study or an imminent risk of 
suicide; 
 Laboratory test results outside the reference range considered by the investigator to be 
clinically significant and that would not be consistent with continuation in the study;   
 Incorrect enrollment (i.e., the subject does not meet the required inclusion/exclusion criteria) of 
the subject;  
 Development of a condition included in the exclusion criteria may require discontinuation;  
 Use of concomitant medication prohibited by the protocol;  
 The patient is unable to tolerate the assigned dose of medication;  
 Severe non-compliance to protocol as judged by the  investigator;  
 Patient lost to follow-up;  
 The patient becomes pregnant; 
 In the case of a neutrophil count of <1.0x109/L, the test must be repeated within one day.  If the 
second neutrophil count is <1.0x109/L, this must be reported as an AE and the patient must be 
discontinued from the study.  Additionally, these patients should be monitored with a Complete 
Blood cell Count (CBC) and White Blood Cell (WBC) differential count weekly until their 
counts recover. While experiencing neutropenia, patients should avoid invasive procedures 
such as dental work, rectal exams, or enemas; exposure to people who are obviously ill; and 
exposure to fresh fruits, vegetables, or flowers. If a patient develops fever or symptoms of 
infection, he/she should contact his/ or her physician and acquire a CBC count with WBC 
differential count immediately; 
 Patient enters an Inpatient Treatment Program; or,  
 The study is terminated by the Investigator, Regulatory Authorities, or the Institutional Review 
Board of the site.  
 
Patients who discontinue the study will be treated as clinically appropriate as detailed below. 
 
Provision for Follow-Up Care:   All subjects who have participated in the evaluation period of this 
protocol will be provided with psychiatric care (3 visits) at no cost by the investigators for a period of 
up to 3 months after the end of the study in order to ensure an effective transition to routine clinical 
care.  Patient assistance applications will be completed for those patients requiring financial assistance.  
Subjects will be provided with appropriate clinical referrals for their follow-up care.    
 
CONCOMITANT MEDICATION: 
A benzodiazepine and/or a hypnotic medication are allowed for anxiety or insomnia throughout the 
study. No other mood stabilizer(s), anticonvulsant, antidepressant, or antipsychotic will be allowed 
during the study after week 4. 
 
RISKS AND BENEFITS 
Once a patient enters the study, he or she will be seen by the study physician (either the principal 
investigator or a co-investigator) on a weekly to monthly basis.  If a patient misses an appointment, he 
or she will be contacted by study staff to assess safety and reschedule the appointment. 
 
RISKS:  
Worsening of symptoms of depression or physical symptoms due to stopping other psychotropic 
medications may result from study participation, as there is a wash-out period. There is also the risk 


 
Page 8 of 12 
 
that the subject may not respond to the active study medication and worsening of symptoms may 
result. Suicidal thoughts or a suicide attempt is a serious risk of clinical treatment and hence a serious 
risk in this study. Seventeen percent of bipolar patients commit suicide.   
 
Serious adverse reactions to lithium include kidney toxicity, hypothyroidism, SIADH (syndrome of 
inappropriate antidiuretic hormone secretion), and arrhythmias may also occur.  Less severe side 
effects include: acne, diarrhea, polyuria, tremor or weight gain.  
 
Lithium may involve unknown risks to pregnant women, the embryo or fetus, or to infants of nursing 
women.  The outcome of all pregnancies (spontaneous miscarriage, elective termination, normal birth 
or congenital abnormality) must be followed up and documented even if the patient is discontinued 
from the study.   
 
Finally, there is always the risk of loss of confidentiality.  Should there be a breach of confidentiality 
regarding the patients’ diagnosis or treatment, the patient may be exposed to discrimination. 
 
Patients will be required to give a blood sample. The total amount of blood collected during the study 
will consist of approximately 10 teaspoons of blood, but we anticipate this practice will not be 
burdensome to patients. When a blood sample is taken, participants may experience temporary 
discomfort, bruising, and/or infection or blockage of the vein where the needle is put into their arm. On 
rare occasions, fainting may occur. There are no more than minimal medical or psychological risks 
associated with this research.  
  
Participants may feel uncomfortable answering some of the questions being asked. If this occurs, the 
participant will not be forced to answer. 
 
BENEFITS: 
There may be no direct benefit to an individual participant.  However, lithium is a standard medication 
for bipolar disorder, and a trial of lithium is standard clinical practice. The outcome of lithium 
treatment can guide future treatment of a patient. In addition, as most study procedures are clinically 
indicated as routine, there are several additional potential benefits to participation. 
Potential benefits from study participation include an evaluation of symptoms and discussions with the 
research coordinator, and help in referrals for additional treatment if needed at no cost to the patient. 
Patients may experience relief from the symptoms of their bipolar. Positive responses to the study 
medication may provide doctors with other options in the treatment of Bipolar Disorder and therefore 
benefit other patients. Data collected during this study may help doctors and researchers understand the 
pathophysiology of bipolar disorder.  
 
FINANCIAL CONSIDERATIONS 
Subjects will be compensated $30 for baseline and end of study visits and $15 for each additional visit 
completed for their time, parking and other travel-related costs.     
 
The study will provide psychiatric evaluations, follow up psychiatric visits for four months, lithium, 
and laboratory monitoring for those who do not have any insurance or cannot afford the medications.  
Subjects who have insurance will be responsible for the costs of laboratory monitoring and 
medications, but will receive psychiatric follow-ups at no cost. 
 


 
Page 9 of 12 
 
SAFETY 
Data Safety & Monitoring Board:  Safety monitoring for this study will be conducted by a Data 
Safety Monitoring Board (DSMB). The chair of this board is Taylor Seagraves, M.D. Dr. Seagraves is 
not involved as an investigator on any studies with the Mood Disorders Program at UHCMC and is 
independent. The rest of this committee consists of research staff at the University Hospitals site and 
includes Stephen Ganocy, PhD - Statistician, Brittany Brownrigg, BA - Data Coordinator and Carla 
Conroy, MPH - Research Project Manager. 
  
The Chair of the DSMB will conduct real-time monitoring of all Serious Adverse Events that occur. 
The Principal Investigator will make this determination. This assessment should occur within 24 hours 
of notification of the Serious Adverse Event. For studies where the Serious Adverse Event is 
determined to be Study Related, the DSMB Chair will review the Serious Adverse Event within 24 
hours and determine whether it is expected or unexpected. The DSMB Chair will ensure that the SAE 
is reported to the IRB according to established IRB guidelines. 
  
The DSMB meets quarterly, and a review of all study-related Serious Adverse Events will occur with 
the entire DSMB membership present.   
 
PRIVACY AND CONFIDENTIALITY 
Protecting Patient Privacy:  Study information is collected in a private office by the research 
assistants and study doctors.  Information will be provided by the participant through interviews and 
patient rated assessments.  In some cases collaborating information may also be obtained from the 
input of a caregiver, as chosen by the participant, if one is present at the time of the interview.  In 
addition, blood and urine samples will be collected by the laboratories at University Hospitals and the 
results are returned to the investigators office. Discussions regarding participant information or patient 
care will be restricted to private offices and involvement will be limited to study related staff. 
 
Certificate of Confidentiality: In order to further protect the patient’s privacy, we will apply for a 
Certificate of Confidentiality (CoC) in order to protect potentially sensitive participant information (i.e. 
on drug use, etc.).  Obtaining the CoC is pending until initial IRB approval of this protocol, which is 
needed to apply to the NIMH/FDA. 
 
Protecting Data Confidentiality:  Patient medical records are stored electronically, in Ambulatory 
Electronic Medical Record (aEMR), and are password protected.  Chart notes and scanned items (i.e. 
Releases of Information, executed Informed Consent Forms) are entered in to aEMR via restricted 
means. Therefore, only those who work in the Department of Psychiatry are able to see those notes and 
scanned items.  All subject data will be kept strictly confidential, and no subject-identifying 
information will be released to anyone outside the project. Confidentiality will be through several 
mechanisms. Each subject will be assigned an anonymous study unique subject number which will 
then be used on all study forms, including the electronic data capture system (EDC). Any study forms 
or paper records that contain subject information will be kept at the clinical sites in secured, locked 
areas, and coded by unique subject number. Access to all subject data and information, including 
laboratory specimens, will be restricted to authorized personnel. In the case of computerized data, this 
restricted access will be assured through user logon IDs and password protection. This protects forms 
from unauthorized view and modifications as well as inadvertent loss or damage.  
 
 


 
Page 10 of 12 
 
FLOW CYTOMETRIC ANALYSIS  
Blood Sample 
Blood samples will be transferred to CellPrint Biotechnology within 3 hours of the draw. Peripheral 
blood mononuclear cells will be isolated by ficoll/hypaque discontinuous gradient centrifugation and 
cryopreserved for subsequent batch analysis.  The tubes will be de-identified and the key will remain 
with the principal investigator.  Flow cytometric analysis will be accomplished with the technologists 
blind to the clinical status of the patient who provided the specimen.   
 
Antibodies  
Antibodies to cellular proteins for potential analyses (see Appendix) will be obtained from commercial 
sources.  Each antibody will be tested for use with CellPrint™.  We anticipate that at least 75% of the 
proposed antibodies will pass the quality control measures.  It is possible that we can replace 
antibodies that do not pass QC testing with alternate forms or with antibodies targeting molecules not 
included in the originally proposed panel.  The molecules targeted for analyses will cover a wide range 
of cellular processes potentially affected in bipolar disorder.  These cellular processes include 
apoptosis, cell cycle, cell signaling, macromolecular folding (chaperones), circadian rythym, electron 
transfer, protein turnover, heat shock response, growth factors, histone modification, inflammation, 
lipid transport, transcription factors, and ion channels (see appendix). 
 
DATA ANALYSIS PLAN 
Statistical Analyses 
Primary and secondary analyses: Data monitoring and management will be conducted by the Data 
Management Unit of the Mood Disorders Program, which is directed by Dr. Stephen Ganocy, PhD.  
 
Primary analysis: The primary analysis will compare differences in molecular expression levels of 
analytes between patients with bipolar I or II disorder who respond to lithium and those don’t respond 
to. The response is defined as at least 50% improvement from baseline for at least 8 weeks. The results 
will be analyzed for 2-sided t tests, one-way ANOVA, and Pearson’s product moment bivariate 
correlations. 
 
Secondary analyses: Secondary analyses will compare differences in molecular expression levels of 
analytes within patient groups and bi- and multi-variate correlation patterns among the analytes 
assessed. The results will be analyzed for 2-sided t tests, one-way ANOVA, Pearson’s product moment 
bivariate correlations, Fisher’s r-to-z transformation to compare correlation coefficients, multiple linear 
regression, logistic regression, principal component analysis, factor analysis, and cluster analysis.  
 
Appendix – Molecules to be Analyzed 
 
BAG1 
Apoptosis 
Bax 
Apoptosis 
cyclin D1 
Cell cycle 
Glucocorticoid receptor 
Cell Signaling 
HMGA1a 
Cell signaling 
mTor 
Cell signaling 
phospho-mTor 
Cell signaling 
phospho-Akt(ser473) 
Cell signaling 
phospho-Akt(thr308) 
Cell signaling 


 
Page 11 of 12 
 
phospho-Erk1/2 
Cell signaling 
phospho-GSK-3b 
Cell signaling 
phospho-SAPK/JNK 
Cell signaling 
S100B (glial marker protein) 
Cell signaling 
Cox-2 
Cell Signaling 
calmodulin 
Cell signaling 
DISC1 
Cell signaling (also a schizophrenia 
biomarker) 
calnexin 
Chaperone 
calreticulin 
Chaperone 
GRP78 
Chaperone 
Per2 
Circadian clock 
sepiapterin reductase (SPR) 
Electron transfer enzyme 
Succinate Dehydrogenase 
Electron transfer enzyme 
cytochrome C 
Electron transfer substrate 
Angiotensin-Converting Enzyme (ACE) 
Endopeptidase 
Calpain 2 
Endopeptidase 
Matrix Metalloproteinase-3 
Endopeptidase 
Matrix Metalloproteinase-9, total 
Endopeptidase 
Brain-derived neurotrophic factor-6 (BDNF-6) 
Growth factor 
Hepatocyte Growth Factor 
Growth factor 
HSP70 
Heat shock protein 
HDAC1 
Histone acetylation and deacetylation 
C-reactive protein (CRP) 
Inflamatory 
Carcinoembryonic Antigen (CEA) 
Inflamatory 
CD40 Ligand (CD154) 
Inflamatory 
CD5 
Inflamatory 
EN-RAGE 
Inflamatory 
IL-1 
Inflamatory 
Macrophage Inflammatory Protein-1 beta (MIP-1 beta) 
Inflamatory 
Receptor for advanced glycosylation end products 
(RAGE) 
Inflamatory 
Tumor Necrosis Factor - alpha (TNF-a) 
Inflamatory 
Tumor Necrosis Factor Receptor-Like 2 
Inflamatory 
Apolipoprotein A1 
Lipid transport 
Apolipoprotein A2 
Lipid transport 
Lipoprotein (a) 
Lipid transport 
FoxP2 
Transcription factor 
AP-2 
Transcription factor 
ATF3 
Transcription factor 
c-fos 
Transcription factor 
CREB 
Transcription factor 
NRF2 
Transcription factor 


 
Page 12 of 12 
 
Olig1 
Transcription factor 
phospho-p65 
Transcription factor 
PU.1  
Transcription factor 
SP1 
Transcription factor 
TCF7L2 (TCF4) 
Transcription factor 
XBP1 
Transcription factor 
YB-1 
Transcription factor 
ODZ1 / TENASCIN M - related to ODZ4 
Transcription factor (neural) 
REST 
Transcription factor (neural) 
CACNA1C  
Voltage dependent ion channel