PET and MRI Brain Imaging of Bipolar Disorder

Study Overview
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Brief Summary
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The primary aims of this study are to: Quantify serotonin transporter (5-HTT) binding potential (BP) in vivo in bipolar disorder patients (BPD) during a major depressive episode (MDE). Assess the effect of lithium treatment of bipolar disorder on 5-HTT. Assess the effect of lithium treatment of bipolar disorder on 5-HT1A BP. Assess the effect of lamotrigine treatment of bipolar disorder on 5-HTT and 5-HT1A BP. Assess the effect of lithium treatment of unipolar depression on 5-HTT BP.

Detailed Description
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PET and MRI imaging will be used to investigate the aims described above in patients who have bipolar disorder or unipolar depression and are currently experiencing a depressive episode. Both healthy controls and depressed participants with bipolar disorder or unipolar depression will be recruited. Patients who are on medication before enrolling in the study will have a three week washout. At baseline, healthy controls and patients will have an MRI consisting of both structural and functional sequences. Psychological measures will also be obtained at baseline. Within one week of the MRI, both patients and healthy controls will have one CUMI and one DASB PET scan. Following the baseline PET scans, patient participants will begin medication treatment with either lithium or lamotrigine, based on the clinical judgement of the treating psychiatrist. Psychological measures will be obtained every 2 weeks. After 6 weeks of medication treatment at a therapeutic dose, patients will be assessed for remission (defined as a 50% decrease in the HDRS score from baseline). If this criteria is met, patient participants will then have follow-up PET scans (one CUMI and one DASB). If this criteria is not met, the patient will be switched to the other medication under study and will be reevaluated after an additional 4 weeks of medication treatment. Patients who still do not demonstrate a 50% decrease in their HDRS will be considered non-responders and will have repeat CUMI and DASB scans.

Official Title
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Pathophysiology and Treatment of Bipolar Disorder as Assessed by in Vivo Imaging

Conditions
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Bipolar Disorder, Bipolar Depression, Unipolar Depression

Intervention / Treatment
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* Drug: Lithium
* Drug: Lamotrigine


Participation Criteria
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Eligibility Criteria
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PATIENTS BIPOLAR Inclusion Criteria: Bipolar patients suffering from a major depressive episode currently or recently (in the month prior to scanning). Patients on psychiatric medication will have failed their current regimen for the treatment of their depression: they will meet criteria for depression, be seeking treatment for it, and have been on an adequate dose of antidepressant or mood stabilizer (as defined by the Antidepressant Treatment Form-see Oquendo et al., 2003) for 4 weeks or more. Of sufficient severity to score at least 15 on the first 17 items of the Hamilton Depression Rating Scale or a score of 10 to 14 on the first 17 items of the Hamilton Depression Scale in conjunction with a score of at least 29 on the Beck Depression Inventory. Age range 18-65 years. Off all psychotropic and other types of drugs likely to interact with serotonin transporters and 5-HT1A receptors for at least 21 days. Allowed short-acting benzodiazepines for distressing anxiety or insomnia (up to 24 hours prior to each PET scan). Patients will be off neuroleptics for 3 weeks and off fluoxetine for 6 weeks prior to study. Off serotonin depleting drugs such as reserpine for 3 months. Patient will also be off anti-coagulant/anti-platelet treatment such as coumadin, with the exception of aspirin for 10 days. Willing to travel for PET scanning Exclusion Criteria: Other major psychiatric disorders such as schizophrenia, schizoaffective illness; current drug or alcohol abuse (within past 2 months), or drug or alcohol dependence <6mos ago; anorexia nervosa or bulimia nervosa in the past year; IV drug use or ecstasy use more than two times. A first-degree family history of schizophrenia if the subject is less than 33 years old (mean age of onset for schizophrenia plus two standard deviations). Significant active physical illness particularly those that may affect the brain or serotonergic system including blood dyscrasias lymphomas, hypersplenism, endocrinopathies, renal failure or chronic obstructive lung disease, autonomic neuropathies, peripheral vascular disease, diabetes, low hemoglobin and malignancy, significant anemic disease or blood loss and the lab parameters platelet count < 80,000. Lacks capacity to consent. Actively suicidal-begins expressing a plan for suicide during the washout phase or develop suicidal ideation that warrants admission or requires medication or treatment intervention. Electroconvulsive therapy (ECT) within the past 6 months. Pregnancy, currently lactating; planning to conceive during the course of study participation or abortion in the past two months. Metal implants, pacemaker or metal prostheses or orthodontic appliances, the presence of shrapnel Current, past or anticipated exposure to radiation, that may include: being badged for radiation exposure in the workplace, participation in nuclear medicine procedures, including research protocols in the last year. A neurological disease or loss of consciousness for more than a few minutes Medicinal Patch (participants will be asked to remove before MRI) Patients who are responding satisfactorily to psychiatric medications, because they will not be washed-out for purposes of this study A documented history of a lack of response to a trial of adequate dose and duration of both lithium and lamotrigine defined as minimal clinical response to lamotrigine 200 mgs for at least 4 weeks or lithium serum levels of at least 0.8 (or dose >= 900 mgs) for at least 4 weeks. Patient is unlikely to be able to tolerate medication washout Claustrophobia Blood donation within 8 weeks of the start of the study. History of bleeding disorder or are currently taking anticoagulants. UNIPOLAR Inclusion: Unipolar patients suffering from a major depressive episode currently or recently (in the month prior to scanning). Patients on psychiatric medication will have failed their current regimen for the treatment of their depression: they will meet criteria for depression, be seeking treatment for it, and have been on an adequate dose of antidepressant or mood stabilizer (as defined by the Antidepressant Treatment Form-see Oquendo et al., 2003) for 4 weeks or more. Of sufficient severity to score at least 15 on the first 17 items of the Hamilton Depression Rating Scale or a score of 10 to 14 on the first 17 items of the Hamilton Depression Scale in conjunction with a score of at least 29 on the Beck Depression Inventory. Age range 18-65 years. Off all psychotropic and other types of drugs likely to interact with serotonin transporters and 5-HT1A receptors for at least 21 days. Allowed short-acting benzodiazepines for distressing anxiety or insomnia (up to 24 hours prior to each PET scan). Patients will be off neuroleptics for 3 weeks and off fluoxetine for 6 weeks prior to study. Off serotonin depleting drugs such as reserpine for 3 months. Patient will also be off anti-coagulant/anti-platelet treatment such as coumadin, with the exception of aspirin for 10 days. Willing to travel for PET scanning Exclusion: Other major psychiatric disorders such as schizophrenia, schizoaffective illness; current drug or alcohol abuse (within past 2 months), or drug or alcohol dependence <6mos ago; anorexia nervosa or bulimia nervosa in the past year; IV drug use or ecstasy use more than two times. A first-degree family history of schizophrenia if the subject is less than 33 years old (mean age of onset for schizophrenia plus two standard deviations). Significant active physical illness particularly those that may affect the brain or serotonergic system including blood dyscrasias lymphomas, hypersplenism, endocrinopathies, renal failure or chronic obstructive lung disease, autonomic neuropathies, peripheral vascular disease, diabetes, low hemoglobin and malignancy, significant anemic disease or blood loss and the lab parameters platelet count < 80,000. Lacks capacity to consent. Actively suicidal-begins expressing a plan for suicide during the washout phase or develop suicidal ideation that warrants admission or requires medication or treatment intervention. Electroconvulsive therapy (ECT) within the past 6 months. Pregnancy, currently lactating; planning to conceive during the course of study participation or abortion in the past two months. Metal implants, pacemaker or metal prostheses or orthodontic appliances, the presence of shrapnel Current, past or anticipated exposure to radiation, that may include: being badged for radiation exposure in the workplace, participation in nuclear medicine procedures, including research protocols in the last year. A neurological disease or loss of consciousness for more than a few minutes Medicinal Patch (participants will be asked to remove before MRI) Patients who are responding satisfactorily to psychiatric medications, because they will not be washed-out for purposes of this study A documented history of a lack of response to a trial of adequate dose and duration of both lithium and lamotrigine defined as minimal clinical response to lamotrigine 200 mgs for at least 4 weeks or lithium serum levels of at least 0.8 (or dose >= 900 mgs) for at least 4 weeks. Patient is unlikely to be able to tolerate medication washout Claustrophobia Blood donation within 8 weeks of the start of the study. History of bleeding disorder or are currently taking anticoagulants. Past unsuccessful treatment of Lithium of adequate dose and duration. HEALTHY CONTROLS Inclusion: No lifetime history of Axis I disorders Age range 18-65 years. Willing to travel for PET scanning. Exclusion: Past or present alcohol/substance abuse or dependence; IV drug use or ecstasy use more than two times. A first-degree relative with history of major depression, schizophrenia, schizoaffective disorder, or suicide attempt; two or more first degree relatives with a history of substance dependence. Significant active physical illness particularly those that may affect the brain or serotonergic system including blood dyscrasias lymphomas, hypersplenism, endocrinopathies, renal failure or chronic obstructive lung disease, autonomic neuropathies, peripheral vascular disease, diabetes, low hemoglobin and malignancy, significant anemic disease or blood loss, and the following lab parameters: platelet count < 80,000 Lacks capacity to consent Pregnancy, currently lactating; planning to conceive during the course of study participation or abortion in the past two months Metal implants, pacemaker or metal prostheses or orthodontic appliances, the presence of shrapnel Current, past or anticipated exposure to radiation, that may include: being badged for radiation exposure in the workplace, participation in nuclear medicine procedures, including research protocols in the last year. A neurological disease or loss of consciousness for more than a few minutes Medicinal Patch (participants will be asked to remove before MRI) Subjects on drugs or medication that affect the serotonin system Claustrophobia Blood donation within 8 weeks of the start of the study. History of bleeding disorder or are currently taking anticoagulants.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Basic Science
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Lithium<br>Patients in this condition will receive lithium administered as follows: Day 1, 2 and 3, 300 mg bid; Days 4-7 lithium 300 qam and 600 qhs. Lithium level will be checked as close to Day 7 as possible and titrated to a therapeutic plasma level of 0.8-1.2 mEq/l. Subjects will not undergo lithium monotherapy if they have a documented history of at least two failed trials of lithium of at least 4 weeks duration with therapeutic blood levels for a major depressive episode | Drug: Lithium<br> <br> * Other names: lithium carbonate;|
| Other: Lamotrigine<br>Patients who have not respond to adequate prior lithium treatment while depressed, or who refuse lithium, will be given lamotrigine. Lamotrigine will be started at 25 mg bid and increased to 50 mg bid after 2 weeks and again increased to 100 mg bid after an additional 2 weeks. | Drug: Lamotrigine<br> <br> * Other names: Lamictal;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Post-Lithium Treatment Hamilton Depression Rating Scale (HDRS) | Patients will have a Hamilton Depression Rating Scale-24 (HDRS) score obtained at baseline. Minimum score 0, maximum possible score 75; the higher the score on the scale, the more severe the degree of depression. Participants must have an HDRS score of at least 15 to be eligible. After eight weeks of medication treatment, the HDRS score will be reevaluated with the HDRS-24 (and rescanned with PET and MRI). Participants who have a 50% or greater decrease in their HDRS-24 score will be considered responders (to Lithium treatment). | 8 weeks | 
| Prediction of Treatment Response | Outcome measures were generated following LASSO linear regression analysis using pretreament HDRS-24 AND.. pre-treatment 5-HTT OR pretreatment 5-HT1A OR the combination of both 5-HTT and 5-HT1A binding potential to predict post-treatment response defined by a dichotomous remission status variable (remitter vs. non-remitter, where remitter is defined a priori by HDRS-24 <10 post-treatment and a reduction of greater than or equal to 50% in HDRS-24 pre-to-post treatment). Outcome measure is reported as percent accuracy, sensitivity, or specificity in predicting remitter status outcomes. | 8 Weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Group Differences in 5-HTT Binding Potential | Differences in mean of 5-HTT binding potential between patients with depression pre-treatment, post-treatment, compared to healthy volunteers. Broadly, binding potential is defined as the ratio of the tracer concentration in tissue to the free plasma concentration. It is a measure of the density of available targets (e.g. 5-HTT) & the affinity of the ligand (tracer) to that target. | 8 Weeks | 
| Group Differences in 5-HT1A Binding Potential | Differences in mean of 5-HT1A binding potential between patients with depression pre-treatment, post-treatment, compared to healthy volunteers. Broadly, binding potential is defined as the ratio of the tracer concentration in tissue to the free plasma concentration. It is a measure of the density of available targets (e.g. 5-HT1A) & the affinity of the ligand (tracer) to that target. | 8 Weeks | 
| Relationship Between Change in 5-HTT or 5-HT1A Binding Potential Pre- to Post Treatment and Lithium Treatment Response | Linear regression & correlation to assess the relationship between between change in binding potential pre- to post treatment vs. treatment response | 8 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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binding potential, bipolar disorder, bipolar depression, serotonin transporter, serotonin receptors, brain imaging, unipolar depression