Clozapine for Treatment-Resistant Mania

INCLUSION CRITERIA: Males or females 18 to 65 years of age; Diagnosis: DSM-IV Bipolar I Disorder, current episode manic or mixed with or without psychotic features as determined by SCID-P. This criteria includes the following diagnoses: 296.4X, Bipolar I Disorder, Most Recent Episode Manic, and 296.6X, Bipolar I Disorder, Most Recent Episode Mixed; YMRS greater than or equal to 20 at Visits 1 and 2; No decrease in total score of YMRS of greater than or equal to 20% during washout (between Visits 1 and 2); Meet criteria for treatment resistance. Patients must have experienced at least two manic or mixed episodes within five years prior to study entry; DSM-IV rapid cyclers will be permitted to participate in this study; Each patient must have a level of understanding sufficient to agree to all the tests required by the protocol; Each patient must understand the nature of the study and must sign an informed consent document. Before participating in this study, we will advise all patients to complete a NIH Advance Directive Form. However, completing a NIH Advanced Directive form is not a requirement for participating in this study. Previous lack of response (during a manic episode) to any two of the following antimanic agents: lithium, valproate, carbamazepine, oxcarbazepine, typical antipsychotic drug, or atypical antipsychotic drug (olanzapine, risperidone, ziprasidone, aripiprazole, quetiapine). If the subject has only taking one of these antimanic treatments, then the research physician may start one of them at NIH. Subjects not responding to a 3 week trial of an antimanic agent of their choice (at least a 50% decrease on the YMRS rating scale form baseline) will be eligible to be randomized if they continue to meet study criteria. EXCLUSION CRITERIA: WBC count is less than 3500/mm(3) or history of a myeloproliferative disorder. History of meeting criteria for DSM-IV criteria for schizophrenia or other psychotic disorder; History of DSM-IV substance abuse or dependence, including alcohol within the last four weeks; Acute or unstable medical illnesses, (e.g., delirium, metastatic cancer, unstable diabetes, decompensated cardiac, hepatic, renal or pulmonary disease, or stroke or myocardial infarction within the last six months); Current pregnancy or plan to become pregnant during the first three months (the duration of the study) in woman of childbearing age; breast-feeding in woman with infants; Previous treatment with clozapine; History of seizures; History of leukopenia or agranulocytosis; Uncorrected hypo- or hyperthyroidism; Clinically significant abnormal laboratory tests; Concomitant use carbamazepine or other concomitant medication with primarily CNS activity; Has received an investigational drug within 30 days of enrollment. Has received an antidepressant within 4 weeks prior to Visit 1 (8 weeks for fluoxetine); No course of ECT (electroconvulsive therapy) within the preceding 4 weeks to Visit 1; Treatment with an injectable depot neuroleptic within less than one dosing interval prior to Visit 1; Has an acute or chronic illness likely to impair drug absorption, distribution, metabolism or excretion; General MRI exclusion criteria.