Lithium is the most well-established mood-stabilizer in the practice of psychiatry ( Jermain et al., 1991; Landersdorfer et al., 2017). A recent propensity-score adjusted and matched longitudinal cohort-study evaluating the effectiveness of the newer mood stabilizers: olanzapine (n=1477), quetiapine (n=1376), and valproate (n=1670), in comparison to lithium (n=2148), found that patients treated with lithium experienced reduced rates of both unintentional injury and self-harm ( Hayes et al., 2016). However, due to lithium’s narrow index of 0.5–1.2 mEq/mL, Therapeutic Drug Monitoring (TDM) is the standard-of-care to ensure patient safety using pharmacokinetic principles in medical practice ( Hiemke et al., 2011). Actually, if TDM is applied broadly among medical specialties, pharmacogenomic reports that focus on pharmacokinetic-based gene-drug interactions (e.g. CYP2D6-Paroxetine or CYP2C19-Clopidogrel) may not be necessary in all cases and insurance reimbursement would not be a rate-limiting step in advancing genomic medicine. Although, this approach alone would not account for the hypersensitivity-type pharmacogenomic reactions; however, a TDM pharmacogenomic-hypersensitivity reaction hybrid approach may be an option when concerns about the electronic medical record costs, genotyping and/or sequencing machine costs, and data server infrastructure costs are prohibitive factors causing hospital systems and primary care clinics not to implement pharmacogenomic testing.

A limitation of TDM-only approach, rather than a gene-drug testing, is that one would need to administer the drug and measure a blood concentration after the drug is administered, which may not be an option in life-threatening cases (e.g. stent thrombosis and Clopidogrel). Contrastingly, a profound area of concern for pharmacogenomic testing reports are that hospitals are not implementing actionable pharmacogenomic alerts in the patient medical records if the patient did not have the pharmacogenomic testing at their hospital laboratory due concerns of being a certified genomics laboratory and concerns of litigation when knowingly prescribing a drug that the patient cannot metabolize and scanned into the medical record.

It is important to note that pharmacogenomic reports do not necessarily account for drug-drug-gene interactions – which are often the case – when patients are prescribed three or more medications. In such cases, hospital systems should embed clinical pharmacologist physicians, as is done by leading hospitals globally (e.g. Karolinska Institute in Stockholm Sweden awarding the Nobel Prize, the Mayo Clinic, and more) that aim to maintain high rates of patient drug safety and hospital quality outcome measures ( Eichelbaum et al., 2018; Eugene & Eugene, 2018). However, even after accounting for drug doses and drug selection to avoid adverse drug reactions, divergent clinical response rates, among genders, are well-known and reported in psychiatric patients treated with lithium ( Viguera et al., 2000).

In a 1986, Zetin and colleagues published the results of a study that evaluated four methods for predicting lithium daily dosages, and the final equation resulted in a 147.8mg/day increased dosage-adjustment for male patients ( Zetin et al., 1986). Similarly, a later study by Lobeck and colleagues corroborated the 147.8 mg/day male increase dose requirement for the lithium maintenance dose in bipolar patients ( Lobeck et al., 1987). However, neither do the current dosing guidelines recommend a gender-based dose adjustment using pharmacometrics methods, to avoid toxicity, nor are gender-specific gene expression screening panels available to predict lithium efficacy currently available and implemented.

A recent large-scale meta-analysis of human body-tissue gene expression reported that the body organ with the most abundant gender-biased gene expression is the anterior cingulate cortex within the frontal cortex of the brain ( Mayne et al., 2016). Thus, these findings suggest that therapeutic drug response may be influenced not only via drug absorption, distribution, metabolism, and elimination, but also within the underlying gene signatures across the human transcriptome and mechanisms of gene-gene interactions that regulate physiology. Beech and colleagues conducted a study to identify gene expression differences from the peripheral blood in patients classified as lithium responders and non-responders ( Beech et al., 2014). However, the study reported that no significant gender-biased gene expression differences were found (p-value=0.941) in patients who were randomized to optimal therapy (control), defined as one FDA-approved mood stabilizer, versus patients treated with lithium plus optimal therapy ( Beech et al., 2014). Despite these initially reported findings, a recent study by Labonté and colleagues, which used RNA-Seq to evaluate the transcriptome in patients diagnosed with major depressive disorder (MDD), concluded that gender dimorphism exists at the transcriptome-level in MDD patients and that gender-specific treatments should be investigated ( Labonté et al., 2017).

Therefore, there is a clinical need to investigate if indeed a gender dimorphism exists in lithium treatment by applying a combination of statistics and data science/engineering methods to advance precision and genomic medicine in psychiatry. These findings may improve prediction of clinical drug response of lithium prior to initiating drug therapy in patients with bipolar or schizoaffective disorders, who often cannot risk drug inefficacy for obvious safety reasons. Therefore, the overall aim for our study is to define gender-specific transcriptional-level regulators of lithium treatment response that may influence treatment of bipolar or schizoaffective disorders. We will test the hypothesis that biologically plausible gene expression differences exist, prior to lithium treatment, in patients diagnosed with bipolar disorder in the following three patient subgroups: (1) male and female patients who were later clinically classified as lithium treatment responders; (2) male-responders versus male-non-responders; (3) female-responders versus female-non-responders.

Table 1 provides the patient age and sample sizes used during subgroup analyses. In our first analysis, which aimed to group patients based on gender alone and not based on clinical variables detailed in the original study, data-driven gene analytics identified four female-labeled patient samples with gene expression levels similar to that found in male patients for the following Y-chromosome genes: RPS4Y1, EIF1AY, KDM5D, RPS4Y2; and the XIST gene located on the X-chromosome. Therefore, all subsequent hypothesis-testing were analyzed with the updated male-gender classification for the following NCBI GEO patient samples: GSM1105526 (baseline lithium-non-responder), GSM1105528 (1-month lithium-non-responder), GSM1105546 (baseline lithium-non-responder), and GSM1105548 (1-month lithium-non-responder). Figure 2 illustrates the gene expression findings resulting in re-classification for the aforementioned patient samples. The Decision Tree rule states: if RPS4Y1 < 9.643 then the patient is a female with a probability of 100%. Whereas, if the RPS4Y1 ≥ 9.643 then the patient is a male with a probability of 9%. After proceeding with the machine learning analysis of both the ‘training’ and ‘validation’ datasets, the final ‘test’ dataset resulted in the following diagnostic test evaluation parameters: Sensitivity=100% (95% C.I. 66.37%-100.00%), Specificity=100% (95% C.I. 78.20%-100.00%), and an AUROC of 1. Figure 3 illustrates the variable importance plots used in the machine learning process for classifying patients as being a male-lithium-responder or female-lithium-responder relative to the full patient population. The results show, in descending order of predictive power, the genes selective for male lithium-responders versus the full patient population being RBPMS2, CDH23, and SIDT2. Similarly, in descending order of predictive power, for female lithium-responders versus the entire patient population, the FHL3, ABRACL, RPL10A, and RPS23 genes are most selective.

Table 2 provides the results for the gender-specific differentially expressed genes from the entire study population using a fold-change (FC) threshold of 0.5. A total of five genes met the a priori FC requirements and were found to be RPS4Y1, EIF1AY, KDM5D, RPS4Y2, and EIF1AY. These five down-regulated male-biased genes were all found on the Y-chromosome. Contrastingly, a total of 10 upregulated female-biased genes were found to be: XIST, S100P, IFIT3, TNFAIP6, IFITM3, IFIT2, CHURC1, ANXA3, ADM, and PROK2. The RPS4Y1 gene in males (FC= -4.9807, p=7.36E-47) and the XIST gene (FC=1.7615, p=2.98E-36), found on the X-chromosome, in females resulted in the greatest expression changes between genders. The male-favored genes resulted in a larger expression change than compared to the females.

Table 3 provides the results for the differentially expressed genes that were found between male and female responders prior to initiation of lithium and optimal therapy, meeting the FC criteria of at least 0.5. In male lithium responders, we found 5 differentially expressed while the RNA binding protein with multiple splicing 2 ( RBPMS2) gene ranked with the greatest FC of -1.351 (unadjusted p=0.00111). Whereas, 9 genes were associated with female lithium responders, with greatest expression change being the major histocompatibility complex class-1-H (HLA-H) at 1.602 (unadjusted p-value=0.00099). The neuroblastoma breakpoint family member-14 ( NBPF14) gene met the Benjamani-Hochberg adjusted p-value criteria and resulted with an expression change of 0.586 (adjusted p=0.0462). Figure 4 illustrates the heat-map and dendrogram overview of the two-way unsupervised hierarchical cluster analysis of the reported differentially expressed genes among male and female responders to lithium therapy at baseline that correspond to values reported in Table 3.

Using the baseline blood sample microarray data, the predictive modeling results for identifying lithium-responders from the complete study population of male and female controls and treatment samples, resulted in a validation/test sample cohort for males of: Sensitivity=95.83% (95% C.I. 78.88%-99.89%), Specificity=not calculated due sample size of test dataset, and an AUROC = 0.92 using the RBPMS2 and LILRA5 genes. Likewise, in the test dataset for females: Sensitivity=91.67% (95% C.I. 61.52%-99.79%), Specificity= not calculated due sample size of test dataset, and an AUROC = 1 with the ABRACL, FHL3, and the NBPF14 genes. Therefore, we developed a 2-gene predictive model for men and a 3-gene predictive model for women classifying lithium response in bipolar patients from a general population of bipolar patients using transcriptional signatures at baseline, prior to prescribing and treating a patient with lithium.

Table 4 provides the list of 10 differentially expressed genes found in male lithium responders (5-genes) and male lithium-non-responders (5-genes). The RNA binding protein with multiple splicing 2 ( RBPMS2) gene (FC= -1.326, unadjusted p=0.001358) in male lithium responders and the Ribosomal protein S23 ( RPS23) gene (FC=1.521, unadjusted p=0.013306) were found to result in the largest expression change differences between subgroups. However, in female responders and female non-responders, the Family with Sequence Similarity 117 Member B ( FAM117B) gene (FC=0.5257, unadjusted p=0.0048554) and the Golgin B1 ( GOLGB1) gene (FC= -0.6536, unadjusted p=0.0003716) were differentially expressed, respectively and shown in Table 5.

The purpose of this investigation was to define gender-specific transcriptome-level regulators of lithium treatment response prior to the initiation of lithium treatment. We first established the gender-relevant transcriptional control genes across all study-participant blood samples and specifically to male- and female-responders using a differential gene expression threshold of 0.5. We found that in the downloaded data from the Gene Expression Omnibus, some patients were mislabeled as males and females. Therefore in our first quality control analysis that established the methodology for subsequent gender-specific lithium responders, the following Decision Tree rule for accurate classifying of gender: if RPS4Y1 < 9.643, then patient is female with a probability of 100% and if RPS4Y1 ≥ 9.643, then the patient is a male with a lower probability. The differential gene expression threshold of 0.5 was found to be adequate and corroborated with similar studies that used a similar threshold for establishing gene transcription signatures ( Jansen et al., 2014; Mayne et al., 2016). However, when comparing the male-responders to male non-responders, as well as, the female responders to female non-responders, we set an inclusion fold-change threshold to 0.3. This approach is not unusual, since it is already established that both large and subtle expression changes produce to significant biological and physiological processes ( Wurmbach et al., 2002). Our results are hypothesis-generating and establish a computational methodology that provides insight to the importance of subgroup analysis in genomic medicine, irrespective of patient small sample-sizes. The end-goal of such analyses serves as a testing methodology for establishing gene screening panels to improve precision medicine in vulnerable and high-risk patient populations. In these patient populations, it is often not feasible to wait for weeks to determine whether a prescribed medication will work and in some cases manic patients are neither able to fully comprehend and be objectively assessed using the CGI-BP-S ( Spearing et al., 1997).

When reviewing the heat-map and dendrogram hierarchical cluster analysis patterns, specifically the numerous non-responders clinically-labeled and illustrated in Figure 6, they suggest that the underlying etiology resulting in clinical symptoms (e.g. mania) that led to the diagnosis of bipolar disorder may need re-classification. Further, the subsequent treatments may need to be tailored in data-driven computational psychiatry approaches. In Figure 6, for the females, the samples in the center cluster illustrates that a group of patients are clear non-responders while the patients clustered in the far-right are partial-responders, from a molecular perspective. The natural questions that arise are: (1) How to best convert the non- and partial-responders to treatment-responders? (2) Is a behavioral intervention, in this select group of patients, for whom lithium is not effective, the best answer because the symptoms maybe of a different etiology? If indeed the symptoms are of a different etiology (e.g. inflammatory), from the lithium treatment-responders, then other diagnostic (e.g. electrophysiological neuroimaging) tools may be warranted and corresponding most efficacious treatments sought.

When differentiating between male and female patients, we found that the Ribosomal Protein S4, Y-linked 1 ( RPS4Y1, adjusted p-value=7.36E-47) male-linked gene and the X Inactive Specific Transcript ( XIST, adjusted p-value=2.98E-36) female-linked gene were the most differentially expressed among genders, which is consistent with previously published studies ( Guillén et al., 2014; Jansen et al., 2014; Mayne et al., 2016). The genes that are specific to male lithium responders, relative to female lithium responders, are RBPMS2, SIDT2, CDH23, LILRA5, and KIR2DS5. Using the same methodology, genes identifying female lithium responders, relative to male lithium responders, are HLA-H, RPS23, FHL3, RPL10A, NBPF14, PSTPIP2, FAM117B, CHST7, and ABRACL. The Neuroblastoma Breakpoint Family Member 14 ( NBPF14, adjusted p-value=0.0462, Fold-change=0.586) achieved the Benjamani-Hochberg adjusted p-value of 0.0462, and has been reported to be associated with cortical neurogenesis ( Suzuki et al., 2017).

Computational psychiatry methods that analyze objective clinical signals (e.g. electroencephalography) and various data-types (e.g. gene expression [RNA], single-nucleotide polymorphisms [DNA], plasma drug concentrations) to classify patients in psychiatry, as advocated by the National Institute of Mental Health’s Research Domain Criteria (RDoC), are essential in psychiatry, especially in patients with developmental delay, language difficulty, and conditions of potentially different etiologies than traditionally taught ( Clark et al., 2017; Eugene & Masiak, 2016). Ideally, in such cases, alternative FDA-approved mood stabilizers may be initially selected prior to any pharmacological intervention by simply using a blood test. Perhaps, a gene expression screening panel at baseline, prior to the initiation of lithium and/or other FDA-approved mood stabilizer, may be better in high-risk patient populations.

These findings suggest that when implementing genomic medicine, clinical research teams should move beyond the single-gene approach when screening for treatment response biomarkers. This approach is currently the standard when screening for patient toxicity at standard doses in poor or ultra-rapid metabolizers using drug pharmacokinetics; however, as more transcription factors are discovered that regulate the cytochrome (CYP) P-450 system of genes, multi-gene pharmacokinetic panels are inevitable and may be included in future Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. Next, medical management of patients with mania and psychosis either with pharmacotherapy and/or behavioral intervention should be tailored to biological gender due to known neuronal circuitry differences in age-matched patients with psychosis ( Eugene et al., 2015). Further, as a result of lithium not being hepatically metabolized, but rather transported and renally excreted as well as, the known myriad drug-drug interactions, patient dose selection may benefit from pharmacometrics modeling by American Board of Clinical Pharmaology certified physicians in applied clinical pharmacology/clinical pharmacology ( Perera et al., 2014; Zetin et al., 1986).

Further, clinical pharmacologist physicians are essential for advancing genomic medicine and providing consults in pharmacogenomics. These physicians would confirm the applicability of embedding machine learning results integrated within artificial intelligence applications in the electronic medical record. Figure 5 shows the machine learning classification results of gene expression levels that determine (a) sample gender, (b) male lithium treatment responders, and (c) female lithium treatment responders. These very study results – though with a small treatment responder population – presents an approach for data science and engineering methods for use in genomics and medicine.

The limitations of our analysis – as in most pharmacogenomic clinical studies – are understandably due to a small patient sample size and multiple-comparison p-value adjustments ( Dudoit et al., 2003). The fundamental aims of our research questions were designed to answer biological questions of gender and clinical response to lithium and not meant to be driven exclusively by multiple comparisons adjusted p-values or limited by not having enough patients. This approach has led to various successes in pharmacogenomics, specifically, in genome-wide association studies; however, understandably, the limitations are thoroughly acknowledged. In reference to patient sample sizes, 9 out of the 28 patients who received lithium and optimal therapy were classified as lithium treatment responders. Further, 30% of men and 33% of women, who were treated with lithium, were found to be responders at the respective gender categories ( Beech et al., 2014). However, the strengths of our findings are in the gender-gene screening capability for lithium treatment-responders in the general population of 60 patients at baseline, minus the tested responder group. Opportunities exist for any further clinical studies, prospective clinical trials, and application of the methods outlined in this work for other therapeutic agents across several medical specialties and other disciplines.

We explored the Lithium Treatment-Moderate dose Use Study clinical trial gene expression data with the aim of identifying gender-specific transcriptome-level regulators of lithium treatment response. We found that male and female labeled patients were misclassified and used the following Decision Tree rule for accurate classifying of gender: if RPS4Y1 < 9.643, then patient is female with a probability of 100%. Further, using machine learning, we successfully developed a pre-treatment gender- and gene-expression-specific predictive model selective for lithium responders with an AUROC of 0.92 for male lithium responders (sensitivity=96%) and an AUROC of 1 for female lithium responders (sensitivity=92%). Moreover, by using well-established Bayesian statistical methods, to identify differentially expressed genes and then machine learning, we discovered 2-genes (RBPMS2 and LILRA5) selective for male lithium responders and 3-genes (ABRACL, FHL3, and NBPF14) selective for female lithium responders that will inform physicians and the medical staff of whether the patient will respond to lithium prior to being prescribed the mood stabilizer. Further, due to the small number of patients classified as responders from the clinical trial, our results should be confirmed. Lastly, in an overall context, our results suggest that the methodology used in this analysis may be extended to other therapeutic drug classes and provides insight to the gender-based gene transcriptome differences influencing lithium pharmacodynamics.

Data used in this study are available from https://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE45484