The subject of this grant, recurrence of Bipolar I (BP I) major depressive episode (MDE), is now recognized as a major mental health problem. Recurrent BP I MDE is a disorder with no satisfactory therapy, and its treatment remains a challenge to clinicians. To date, initial and long-term therapy of BP I MDE has been based on un-validated practice guidelines. These guidelines recommend limiting antidepressant drug (AD) use during initial therapy of BP I MDE, and completely avoiding AD use during long-term therapy. There is, however, no empirical evidence to suggest that mood stabilizer (MS) monotherapy is superior to combined MS plus AD therapy in preventing recurrent BP I MDE. Nor is there evidence to suggest that long-term MS plus AD therapy results in more manic switch episodes. We present evidence that AD-induced mania during long-term therapy of BP I MDE has been over-estimated, and that long-term use of MS plus AD therapy may be superior to MS therapy alone in preventing recurrent BP I MDE. In this application, we will ask: """"""""Does continuation therapy with combined lithium plus fluoxetine result in fewer MDE relapses and recurrences vs. lithium monotherapy?"""""""" To answer this question, patients with BP I MDE will receive combined lithium plus fluoxetine therapy for 8 weeks. Responders who stay well for an additional 4 weeks of consolidation therapy will then be randomized to double-blind continuation therapy with either (i) combined lithium plus fluoxetine, or (ii) lithium alone (following fluoxetine taper and discontinuation) for an additional 50 weeks. We hypothesize that long-term lithium plus fluoxetine therapy will result in fewer MDE relapses and recurrences vs. lithium monotherapy. We will also ask: """"""""What is the relative safety, tolerability, and frequency of syndromal and sub-syndromal manic, hypomanic, and mixed state conversions during continuation treatment with combined lithium plus fluoxetine vs. lithium monotherapy?"""""""" To answer this question, we will measure: the frequency, severity, and duration of syndromal and sub-syndromal manic, hypomanic, and mixed state conversions;frequency, severity, and duration of treatment-emergent adverse events;frequency of treatment discontinuation;time to onset of first syndromal and sub-syndromal conversion event;time to first treatment intervention of each syndromal and sub-syndromal conversion event;and, time to onset of increase in suicidal ideation event. We hypothesize that lithium plus fluoxetine therapy will result in a similar frequency of syndromal and sub-syndromal conversion events, and a similar frequency of treatment- emergent adverse events. We further hypothesize that lithium plus fluoxetine therapy will result in fewer suicide ideation events and fewer study discontinuations vs. lithium monotherapy. We believe that the results of this trial may have an important public health impact on the current practice guidelines for treating BP I MDE.

Public Health Relevance

This application comports with the public health intent of PA-07-092 which seeks to """"""""support collaborative intervention trials in the treatment, prevention, or rehabilitation of those with mental disorders."""""""" This is a linked collaborative grant mechanism that allows for the use of a common protocol among two or more sites in order to increase sample size and accelerate patient recruitment. The principal investigators of the sites have an established """"""""mechanism for cross-site coordination, quality control, data management, statistical analysis, and reporting."""""""" This grant employs state-of-the-art clinical therapy and outcome measures to identify the best long- term therapy of Bipolar I (BP I) major depressive episode (MDE). Results from this study may provide new information on the prevention of relapse and recurrence of BP I MDE, and may have an important public health impact on current practice guidelines for BP I MDE. Results from this study may also inform new research hypotheses for future trials in BP I disorder.

Agency
National Institute of Health (NIH)
Institute
National Institute of Mental Health (NIMH)
Type
Research Project (R01)
Project #
5R01MH080097-04
Application #
8272669
Study Section
Interventions Committee for Adult Mood and Anxiety Disorders (ITMA)
Program Officer
Pearson, Jane L
Project Start
2009-07-15
Project End
2014-03-31
Budget Start
2012-04-01
Budget End
2013-03-31
Support Year
4
Fiscal Year
2012
Total Cost
$396,000
Indirect Cost
$148,500
Name
University of Pennsylvania
Department
Psychiatry
Type
Schools of Medicine
DUNS #
042250712
City
Philadelphia
State
PA
Country
United States
Zip Code
19104
Amsterdam, Jay D; Lorenzo-Luaces, Lorenzo; DeRubeis, Robert J (2017) Comparison of treatment outcome using two definitions of rapid cycling in subjects with bipolar II disorder. Bipolar Disord 19:6-12
Lorenzo-Luaces, L; Amsterdam, J D; Soeller, I et al. (2016) Rapid versus non-rapid cycling bipolar II depression: response to venlafaxine and lithium and hypomanic risk. Acta Psychiatr Scand 133:459-69
Amsterdam, Jay D; Lorenzo-Luaces, Lorenzo; DeRubeis, Robert J (2016) Step-wise loss of antidepressant effectiveness with repeated antidepressant trials in bipolar II depression. Bipolar Disord 18:563-570
Amsterdam, Jay D; Lorenzo-Luaces, Lorenzo; Soeller, Irene et al. (2016) Short-term venlafaxine v. lithium monotherapy for bipolar type II major depressive episodes: effectiveness and mood conversion rate. Br J Psychiatry 208:359-65
Amsterdam, Jay D; Lorenzo-Luaces, Lorenzo; Soeller, Irene et al. (2015) Safety and effectiveness of continuation antidepressant versus mood stabilizer monotherapy for relapse-prevention of bipolar II depression: A randomized, double-blind, parallel-group, prospective study. J Affect Disord 185:31-7
Fournier, Jay C; DeRubeis, Robert J; Amsterdam, Jay et al. (2015) Gains in employment status following antidepressant medication or cognitive therapy for depression. Br J Psychiatry 206:332-8
Lorenzo-Luaces, Lorenzo; German, Ramaris E; DeRubeis, Robert J (2015) It's complicated: The relation between cognitive change procedures, cognitive change, and symptom change in cognitive therapy for depression. Clin Psychol Rev 41:3-15
Amsterdam, Jay D; Luo, Lola; Shults, Justine (2013) Efficacy and mood conversion rate during long-term fluoxetine v. lithium monotherapy in rapid- and non-rapid-cycling bipolar II disorder. Br J Psychiatry 202:301-6
Amsterdam, Jay D; Newberg, Andrew B; Newman, Cory F et al. (2013) Change over time in brain serotonin transporter binding in major depression: effects of therapy measured with [(123) I]-ADAM SPECT. J Neuroimaging 23:469-76
Newberg, Andrew B; Amsterdam, Jay D; Wintering, Nancy et al. (2012) Low brain serotonin transporter binding in major depressive disorder. Psychiatry Res 202:161-7

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