Lithium Versus Paroxetine in Major Depression

• The Young Mania Rating Scale (YMRS) [ Time Frame: Assessed after 6 weeks of treatment ] [ Designated as safety issue: No ]
  This is a standard outcome tool used to assess mania.
• The Clinical Global Impression (CGI) [ Time Frame: Assessed after 6 weeks of treatment ] [ Designated as safety issue: No ]
  The Clinical Global Impression (CGI)is a scale used to measure overall symptom severity, treatment response, and treatment efficacy in patients with mood disorders.
• The Columbia Suicide Classification Scale [ Time Frame: Assessed over 6 weeks of treatment. ] [ Designated as safety issue: Yes ]
  The Columbia Suicide Classification Scale, used in the FDA analysis of pediatric antidepressants, has become a standard tool used in clinical depression trials and will be used to monitor changes in suicide risk or self-harm weekly.
• Barnes Akathisia Rating Scale (BARS) [ Time Frame: Assessed over 6 weeks of treatment ] [ Designated as safety issue: Yes ]

  Barnes Akathisia Rating Scale (BARS):

  The BARS is a very brief clinical assessment for the presences of akathisia. Akathisia secondary to antidepressants has been associated with increased suicidality. The inclusion of the BARS will serve to delineate akathisia from psychomotor agitation as part of treatment -emergent mixed symptoms.

• Treatment -emergent symptom checklist and questionnaire [ Time Frame: Assessed over 6 weeks of treatment ] [ Designated as safety issue: Yes ]
  This checklist and questionnaire will be used to capture a potential range of treatment emergent mixed symptoms.

• The Young Mania Rating Scale (YMRS) [ Time Frame: Assessed after 6 weeks of treatment ] [ Designated as safety issue: No ]
  This is a standard outcome tool used to assess mania.
• The Clinical Global Impression (CGI) [ Time Frame: Assessed after 6 weeks of treatment ] [ Designated as safety issue: No ]
  The Clinical Global Impression (CGI)is a scale used to measure overall symptom severity, treatment response, and treatment efficacy in patients with mood disorders.
• The Columbia Suicide Classification Scale [ Time Frame: Assessed after 6 weeks of treatment. ] [ Designated as safety issue: Yes ]
  The Columbia Suicide Classification Scale, used in the FDA analysis of pediatric antidepressants, has become a standard tool used in clinical depression trials and will be used to monitor changes in suicide risk or self-harm weekly.
• Barnes Akathisia Rating Scale (BARS) [ Time Frame: Assessed after 6 weeks of treatment ] [ Designated as safety issue: Yes ]

  Barnes Akathisia Rating Scale (BARS):

  The BARS is a very brief clinical assessment for the presences of akathisia. Akathisia secondary to antidepressants has been associated with increased suicidality. The inclusion of the BARS will serve to delineate akathisia from psychomotor agitation as part of treatment -emergent mixed symptoms.

• Treatment -emergent symptom checklist and questionnaire [ Time Frame: Assessed after 6 weeks of treatment ] [ Designated as safety issue: Yes ]
  This checklist and questionnaire will be used to capture a potential range of treatment emergent mixed symptoms.

This study is being done to look at how well people respond to two different drug treatments for depression. Clinically, people can respond differently to different treatments for reasons which are not always clear. Some research shows that people with a family history of bipolar disorder or completed suicide may react differently to standard medications used to treat depression than those without a family history. The investigators need to know if these drugs are effective to use in patients with depression who have a family history of bipolar disorder or completed suicide.

• Drug: Lithium

  Study drug will be packaged and supplied in an open-label fashion. There will be a washout period of all active psychotropic medication. Psychotropics will be withdrawn over 5 half-lives with the exception of drugs known to cause withdrawal symptoms (primarily antidepressants), which will be tapered over 10 days.

  Following the enrollment period, subjects will enter a six-week randomized treatment period with either lithium or paroxetine. Lithium carbonate will be commenced at 600mgs hs, with increase to 900mgs at day 7. Dose will be flexibly titrated to give a serum level between 0.5 and 1.1mmol/l. At visit 4, the dose of lithium may be adjusted (within the range of 0.6 and 1.1 mmol/l.

  Other Name: lithium carbonate
• Drug: Paroxetine

  Study drug will be packaged and supplied in an open-label fashion. There will be a washout period of all active psychotropic medication. Psychotropics will be withdrawn over 5 half-lives with the exception of drugs known to cause withdrawal symptoms (primarily antidepressants), which will be tapered over 10 days.

  Following the enrollment period, subjects will enter a six-week randomized treatment period with either lithium or paroxetine. Paroxetine will be commenced at 10mgs and increased to 20mgs on day 7. At visit 4, the dose of paroxetine may be increased to 40mgs, if there is no response (less than 20% reduction in MADRS score) as per current Canadian guidelines.

  Other Name: paxil

• Experimental: Lithium
  Following the enrollment period, subjects will enter a six-week randomized treatment period with either lithium or paroxetine. Lithium carbonate will be commenced at 600mgs hs, with increase to 900mgs at day 7. Dose will be flexibly titrated to give a serum level between 0.5 and 1.1mmol/l. At visit 4, the dose of lithium may be adjusted (within the range of 0.6 and 1.1 mmol/l).
  Intervention: Drug: Lithium
• Active Comparator: Paroxetine
  Following the enrollment period, subjects will enter a six-week randomized treatment period with either lithium or Paroxetine.Paroxetine will be commenced at 10mgs and increased to 20mgs on day 7.At visit 4, the dose of paroxetine may be increased to 40mgs, if there is no response (less than 20% reduction in MADRS score) as per current Canadian guidelines.
  Intervention: Drug: Paroxetine

Inclusion Criteria:

• men or women
• age of 18 years or older
• meet criteria for major depressive episode, and have a family history of bipolar disorder or completed suicide

Exclusion Criteria:

• subjects not able to give informed consent
• pregnant or breast-feeding women
• current panic disorder, post traumatic stress disorder or psychosis
• subjects with a history of mania or hypomania
• subjects with active substance abuse or dependence in the last 6 months
• current depressive episode less than 4 weeks or greater than 12 months in duration
• adequate trial of lithium or paroxetine (lithium level ≥ 0.6mmols/l; paroxetine 20mgs ≥ 5 weeks) for this episode of depression
• concurrent use of other antidepressants or augmenting agents for the treatment of depression
• clinically significant medical illness, in particular renal impairment