• To determine if a given depletion treatment induces relapse, measured as the mean HAM-D 17-item score of each group. A HAM-D score of 12 points or higher will be defined as relapse, measured 24-, 48- and 96-hours post-depletion. [ Time Frame: 4 days ] [ Designated as safety issue: No ]
  

• Maximum change between each VAS item; change in HAM-D score; correlation of change in plasma tryptophan and catecholamine levels; correlation of change in plasma amino acid levels from baseline to 24 hours post-depletion. [ Time Frame: 4 days ] [ Designated as safety issue: No ]
  

Procedure: Dietary amino-acid depletion
See detailed description

The study would be conducted at a single site: the University of British Columbia. This study would involve the recruitment of out-patient responders to quetiapine who previously had the diagnosis of bipolar disorder, depressed phase. These patients could then be randomized to receive either serotonergic or catecholinergic depletion, through tryptophan or tyrosine depletion respectively. Baseline assessments would be conducted prior to the subjects being entered into the active phase of depletion.

As the depletion phase is short, i.e. a number of days, this phase of the trial would be relatively short (i.e.

one week). Participants will see a clinician at a pre-depletion screening visit that occurs (maximum) 7 days prior to commencing depletion. In addition the a physical examination and taking medical history, inclusion/exclusion criteria will be verified, an ECG will be taken by a hospital cardiologist, and blood and urine samples will be collected for standard haematology/urinalysis, and a baseline assessment of amino acid and neurotransmitter levels. Patients would be maintained on their original dose of Quetiapine throughout the course of the study. Amino acid and neurotransmitter concentrations will be determined on-site, by means of HPLC.

All depletion drinks will be mixed with 300ml of juice, to cover the taste of the amino acid mixture prepared.

Male participants receiving a tyrosine-free formula, will drink a mixture of amino acids as administered in work by Sheenan et al (1996): L-isoleucine (7.5g); L-leucine (11.25g), L-lysine monohydrochloride (8.75g), L-methionine (2.5g), L-valine (8.75g), L-threonine (5g); L-tryptophan (1.25g). Female subjects will receive drinks of the same composition, but 20% less by weight of each amino acid. Similarly, the tryptophan-free formula for males will be as prepared by Hughes et al (2000, (Hughes, Dunne & Young 2000)), and formula that is 20% less, by weight, of amino acids will be used for females: L-alanine (5.5g); L-arginine (4.9g); L-cysteine (2.7g); L-glycine (3.2g); L-histidine 3.2g); L-isoleucine (8g); L-leucine (13.5); L-lysine monohydrochloride (11g); L-methionine (3g); L-phenylalanine (5.7g); L-proline (12.2g); L-serine (6.9g); L-threonine (6.5g); L-tyrosine (6.9g); L-valine (8.9g). The depletion and post-depletion monitoring will occur daily for five (5) days, so depletion will begin on a Monday, unless circumstances require otherwise. Participants will be instructed to have a low-protein diet in the day prior to their second visit (total content of less than 20g), and fast from midnight until their visit.

Subjects will arrive at the clinic at 9AM on day 1 and commence depletion, under the supervision of the screening physician, who will monitor the subject over the next four days, including at 0- and 4-hours post-depletion. At 24 hours post-depletion, a blood sample will be drawn for analysis of amino acid and neurotransmitter levels (5mL). Subjects will not be hospitalized during their participation, unless it is deemed necessary by clinician's judgment, but will be given 24-hour contact information for the attending physician. The same physician will see a given subject for the duration of their participation, and all raters involved in this study will have previously demonstrated an inter-rater reliability of 0.85 for all scales. At all visits (1-5), subjects will have mood assessed using a Visual Analog Scale, for self-rating, and by the Hamilton Rating-Scale for Depression. Concomitant medications will also be recorded. At the final visit (96-hours post-depletion), a follow-up physical examination will be performed.