Clinical trial NCT02519543: Treating Insulin Resistance as a Strategy to Improve Outcome in Refractory Bipolar Disorder
Official title: Treating Insulin Resistance to Improve Outcome in Refractory Bipolar Disorder: a Randomized, Double-blind, Placebo-control Study of the Efficacy of Metformin in Patients With Insulin Resistance and Non-remitting Bipolar Illness
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE3
Conditions: Bipolar Disorder
Keywords: insulin resistance
Lead sponsor: Nova Scotia Health Authority
Sponsor class: OTHER
Collaborators: name: Stanley Medical Research Institute
First posted: 2015-08-11
Enrollment: 50
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: In a previous study by Dr. Calkin, the principal investigator of this study, persons with bipolar disorder and either type II diabetes or insulin resistance were found to experience more severe symptoms of bipolar illness and a lower response to treatment, compared to persons with bipolar disorder who did not have type II diabetes or insulin resistance. To further explore these findings, the investigators have developed this study to see if treating insulin resistance (using metformin, a drug used to improve the body's use of insulin) may also help improve the symptoms of bipolar illness.

Detailed description: This is a 26-week randomized, double-blind, parallel group prospective study of the effectiveness of treating insulin resistance (IR) to improve mood in patients with IR and treatment-resistant bipolar depression (TRBD). The investigators will compare the effects of treating IR (with metformin) versus placebo on outcome in each patient. The primary outcome will be change in Montgomery-Ǻsberg Depression Rating Scale (MADRS) scores. Patients' current optimized mood stabilizing treatment as usual (TAU, according to the Canadian Network for Mood and Anxiety Treatments \[CANMAT\] or American Psychiatric Association \[APA\] guidelines) must remain unchanged for a period of at least 4 weeks prior to and throughout the study. Patients will undergo a baseline assessment and then be randomized to treatment with metformin or placebo with titration to full dose after 2 weeks. Patients will remain on full treatment for 24 weeks thereafter (total trial duration of 26 weeks for each patient). In those patients with TRBD assigned to treatment with the insulin sensitizer metformin, a significant improvement in depression symptoms will be mediated by the conversion of IR to insulin sensitivity.

Subjects: We aim to enrol 110 subjects with IR and TRBD from 2 sites: the primary site in Halifax, Nova Scotia, Canada, and a second site in Pittsburgh, Pennsylvania, USA.

Eligibility criteria: Inclusion Criteria:

1. 18 years of age or older
2. diagnosis of BD I or II
3. non-remitting BD as defined by the presence of mood symptoms of at least moderate severity, indicated by a MADRS score ≥ 15 despite being on optimal treatment according to the CANMAT/APA guidelines
4. HOMA-IR ≥ 1.8, indicating IR (subjects will have FPG and FSI testing done to determine whether they have IR or T2D)
5. current episode of depression 4 weeks or longer in duration
6. on a stable optimal dose of mood stabilizing treatment for at least 4 weeks prior to study entry

Exclusion Criteria:

1. Diagnoses of organic mood disorder, mood disorder not otherwise specified, alcohol dependence, T1D or T2D
2. presence of rapid cycling (by DSM-5 criteria), mania, (indicated by a Young Mania Rating Scale \[YMRS\] score \> 15), or suicide ideation (current score of 5 on the Suicidal Ideation section of the Columbia-Suicide Severity Rating scale \[C-SSRS\])
3. patient receiving metformin \< 2 weeks prior to study entry
4. metformin allergy or sensitivity
5. metformin contraindicated where liver function tests \> three times the upper limit of normal, estimated glomerular filtration rate (eGFR) \< 30, CBC revealing megaloblastic anemia or pre-existing untreated B12 deficiency
6. pregnancy or breastfeeding
7. lactose intolerance, diagnosed by a physician
8. chronic use of narcotic medications
9. patient lacks full capacity to consent to study participation.

Primary outcomes:
measure: Montgomery-Ǻsberg Depression Rating Scale (MADRS)
timeFrame: 14 weeks
Secondary outcomes:
measure: Montgomery-Ǻsberg Depression Rating Scale (MADRS)
timeFrame: 26 weeks
measure: Montgomery-Ǻsberg Depression Rating Scale (MADRS)
timeFrame: 14 and 26 weeks
measure: Inventory of Depressive Symptomatology-Self Rating (IDS-SR)
timeFrame: 14 and 26 weeks
measure: Young Mania Rating Scale (YMRS)
timeFrame: 14 and 26 weeks
measure: Hamilton Anxiety Rating Scale (HAM-A)
timeFrame: 14 and 26 weeks
measure: Clinical Global Impression modified for use in Bipolar Disorder (CGI-BP)
timeFrame: 14 and 26 weeks
measure: Global Assessment of Functioning (GAF)
timeFrame: 14 and 26 weeks
Other outcomes:
Locations:
city: Pittsburgh
country: United States
facility: Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, University of Pittsburgh
state: Pennsylvania
city: Halifax
country: Canada
facility: Nova Scotia Health Authority - Dept. of Psychiatry
state: Nova Scotia
Study officials:
affiliation: Nova Scotia Health Authority
name: Cynthia Calkin, MD FRCPC
role: PRINCIPAL_INVESTIGATOR
affiliation: Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center
name: Roy Chengappa, MD FRCPC
role: PRINCIPAL_INVESTIGATOR
References:
citation: Calkin CV, Ruzickova M, Uher R, Hajek T, Slaney CM, Garnham JS, O'Donovan MC, Alda M. Insulin resistance and outcome in bipolar disorder. Br J Psychiatry. 2015 Jan;206(1):52-7. doi: 10.1192/bjp.bp.114.152850. Epub 2014 Oct 16.
citation: Ruzickova M, Slaney C, Garnham J, Alda M. Clinical features of bipolar disorder with and without comorbid diabetes mellitus. Can J Psychiatry. 2003 Aug;48(7):458-61. doi: 10.1177/070674370304800705.
citation: Calkin CV, Gardner DM, Ransom T, Alda M. The relationship between bipolar disorder and type 2 diabetes: more than just co-morbid disorders. Ann Med. 2013 Mar;45(2):171-81. doi: 10.3109/07853890.2012.687835. Epub 2012 May 24.
citation: Calkin CV, Chengappa KNR, Cairns K, Cookey J, Gannon J, Alda M, O'Donovan C, Reardon C, Sanches M, Ruzickova M. Treating Insulin Resistance With Metformin as a Strategy to Improve Clinical Outcomes in Treatment-Resistant Bipolar Depression (the TRIO-BD Study): A Randomized, Quadruple-Masked, Placebo-Controlled Clinical Trial. J Clin Psychiatry. 2022 Feb 1;83(2):21m14022. doi: 10.4088/JCP.21m14022.