Reducing Neural Perseveration Through Closed Loop Real Time fMRI Neurofeedback to Alleviate Depressive Symptoms
Phase: NA
Conditions: MDD
Sponsor: University of Pennsylvania

 
 
Reducing neural perseveration through closed loop real time fMRI neurofeedback 
to alleviate depressive symptoms 
 
Principal Investigator 
SHELINE, YVETTE I 
10579 - PS-Center for the Neuroscience of Depression & 
Stress 
3700 Hamilton Walk Richards 301 
Philadelphia, PA 19104-6019 
215-573-0082 sheline@mail.med.upenn.edu 
 
Regulatory Sponsor 
NIMH 
 
 
 
 
Funding Sponsor 
NIMH 
 
 
 
 
 
Protocol Number 
 
 
IRB Number 
849298 
 
 
849298
NIH Grant Number 
R61MH128492 - 01 
 
 
 
 
 
 
 
Initial version 2021.07.02 V1.1 
 
Amended 2021.12.02 V1.2 
 
Amended 2022.05.11 V1.3 
 
Amended 2022.07.18 V1.4 
 
Amended 2023.08.04 
 
 
 
 
 
 

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Table of Contents 
BACKGROUND AND STUDY RATIONALE .......................................................................... 7 
1 
INTRODUCTION ................................................................................................................. 7 
1.1 
BACKGROUND AND RELEVANT LITERATURE ..................................................................................... 7 
2 
STUDY OBJECTIVES ......................................................................................................... 8 
2.1 
PRIMARY OBJECTIVE .................................................................................................................................. 8 
2.2 
SECONDARY OBJECTIVES (IF APPLICABLE) ....................................................................... 8 
3 
INVESTIGATIONAL PLAN .............................................................................................. 8 
3.1 
GENERAL DESIGN ........................................................................................................................................ 9 
3.2 
ALLOCATION TO INTERVENTIONAL GROUP [IF APPLICABLE] ............................................ 9 
3.3 
STUDY MEASURES ....................................................................................................................................... 9 
3.4 
STUDY ENDPOINTS ................................................................................................................................... 11 
3.4.1 Primary Study Endpoints .......................................................................................... 11 
3.4.2 Secondary Study Endpoints ....................................................................................... 11 
4 
STUDY POPULATION AND DURATION OF PARTICIPATION ............................. 12 
4.1 
DURATION OF STUDY PARTICIPATION ............................................................................................... 12 
4.2 
TOTAL NUMBER OF SUBJECTS AND SITES ........................................................................................ 12 
4.3 
INCLUSION CRITERIA ............................................................................................................................... 12 
4.4 
EXCLUSION CRITERIA .............................................................................................................................. 13 
4.5 
SUBJECT RECRUITMENT.......................................................................................................................... 13 
4.6 
VULNERABLE POPULATIONS ................................................................................................................. 13 
5 
STUDY PROCEDURES ..................................... ERROR! BOOKMARK NOT DEFINED. 
5.1 
SCREENING ............................................................................... ERROR! BOOKMARK NOT DEFINED. 
5.2 
STUDY INTERVENTION OR OBSERVATIONAL PHASE (GIVE THIS SECTION A NAME THAT IS 
RELEVANT TO THE DESIGN OF YOUR STUDY) .............................................................................. 16 
5.2.1 Visit 1 (sometimes referred to as the baseline visit) ................................................. 16 
5.2.2 Visit 2 ........................................................................... Error! Bookmark not defined. 
5.2.3 Visit 3 ........................................................................... Error! Bookmark not defined. 
5.2.4 Visit X (If applicable for your study) ........................... Error! Bookmark not defined. 
5.2.5 End of Study Visit ...................................................................................................... 17 
5.3 
UNSCHEDULED VISITS ............................................................................................................................. 17 
5.4 
SUBJECT WITHDRAWAL .......................................................................................................................... 17 
5.4.1 Data Collection and Follow-up for Withdrawn Subjects .......................................... 17 
5.5 
EARLY TERMINATION VISITS ................................................................................................................ 17 
5.6 
EFFICACY EVALUATIONS (ONLY IF APPLICABLE)............................................................ 17 
5.7 
PHARMACOKINETIC EVALUATION (ONLY IF APPLICABLE) .............................................. 18 
5.8 
GENETIC TESTING (ONLY IF APPLICABLE) ...................................................................... 18 
5.9 
SAFETY EVALUATION (ONLY IF APPLICABLE) ................................................................. 18 
6 
STATISTICAL PLAN ........................................................................................................ 18 
6.1 
SAMPLE SIZE AND POWER DETERMINATION ................................................................................... 18 
6.2 
STATISTICAL METHODS .......................................................................................................................... 19 

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6.3 
CONTROL OF BIAS AND CONFOUNDING (IF APPLICABLE, TYPICALLY OBSERVATIONAL 
STUDY OR IF RANDOMIZATION IS NOT TAKING PLACE) ................................................................ 19 
6.3.1 Baseline Data ............................................................................................................ 19 
6.3.2 Analysis of Primary Outcome of Interest .................................................................. 19 
6.3.3 Pharmacokinetic Analysis (only if applicable) ......................................................... 19 
6.3.4 Interim Analysis ........................................................................................................ 19 
7 
SAFETY AND ADVERSE EVENTS ................................................................................ 19 
7.1 
DEFINITIONS ............................................................................................................................................... 19 
7.1.1 Adverse Event ............................................................................................................ 19 
7.1.2 Serious Adverse Event ............................................................................................... 19 
7.2 
RECORDING OF ADVERSE EVENTS ...................................................................................................... 20 
7.3 
RELATIONSHIP OF SAE TO STUDY ...................................................................................................... 20 
7.4 
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS .................... 21 
7.4.1 Follow-up Report ...................................................................................................... 21 
7.4.2 Investigator reporting: notifying the study sponsor (if applicable) .......................... 21 
7.4.3 Data and Safety Monitoring Plan ............................................................................. 21 
8 
STUDY ADMINISTRATION, DATA HANDLING AND RECORD KEEPING ........ 22 
8.1 
CONFIDENTIALITY .................................................................................................................................... 22 
8.2 
DATA COLLECTION AND MANAGEMENT .......................................................................................... 23 
8.3 
RECORDS RETENTION .............................................................................................................................. 24 
9 
STUDY MONITORING, AUDITING, AND INSPECTING ......................................... 24 
9.1 
STUDY MONITORING PLAN .................................................................................................................... 24 
9.2 
AUDITING AND INSPECTING ................................................................................................................... 24 
10 ETHICAL CONSIDERATIONS ....................................................................................... 24 
10.1 
RISKS ............................................................................................................................................................. 25 
10.2 
BENEFITS ..................................................................................................................................................... 26 
10.3 
RISK BENEFIT ASSESSMENT .................................................................................................................. 26 
10.4 
INFORMED CONSENT PROCESS / HIPAA AUTHORIZATION ........................................................ 26 
10.4.1 
Alterations to Typical Consent Process (only include if applicable) .................... 27 
11 STUDY FINANCES ............................................................................................................ 27 
11.1 
FUNDING SOURCE ..................................................................................................................................... 27 
11.2 
CONFLICT OF INTEREST ........................................................................................................................... 27 
11.3 
SUBJECT STIPENDS OR PAYMENTS ...................................................................................................... 27 
12 PUBLICATION PLAN ...................................................................................................... 27 
13 REFERENCES .................................................................................................................... 27 
14 ATTACHMENTS ............................................................................................................... 29 
15 APPENDICES ..................................................................................................................... 29 
15.1 
EXAMPLE: TABLE 1: SCHEDULE OF STUDY PROCEDURES ....... ERROR! BOOKMARK NOT 
DEFINED. 
15.2 
STUDIES INVOLVING RESEARCH MRIS ............................................................................................. 29 

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15.3 
STUDIES INVOLVING RESEARCH RADIATION .................................................................................. 29 
15.4 
STUDIES INVOLVING RESEARCH CT SCANS .................................................................................... 29 
15.5 
STUDIES INVOLVING NUCLEAR MEDICINE REGULATED RESEARCH PROCEDURES .............. 29 
15.5 
RESEARCH STUDIES INVOLVING PATHOLOGY AND LAB 
MEDICINE ........................................................................ 20 
REFERENCE FOR SAFETY REPORTING SECTION- COMMON DEFINITIONS FOR DEVELOPING 
ADVERSE EVENT TRACKING AND SERIOUS ADVERSE EVENT REPORTING PROTOCOL 
15.8 
SOURCE DOCUMENTS .............................................................................................................................. 31 
15.9 
CASE REPORT FORMS (CRFS) ........................................................................................ 31 

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Study Summary 
 
Title 
Reducing neural perseveration through closed loop real time fMRI 
neurofeedback to alleviate depressive symptoms 
Short Title 
Neurofeedback to treat depression 
IRB Number 
849298 
Protocol Number 
N/A 
Methodology 
Double blinded group comparison study 
Study Duration 
5 years 
Study Center(s) 
Single-center 
Objectives 
Primary overall objective is to test closed loop real time fMRI 
neurofeedback that specifically targets our hypothesized attentional 
mechanism of depression (i.e., neural perseveration of negative states) 
to reduce depression severity. 
The primary objective in the R61 phase is to compare the time spent in 
the most negative state before and after real-time neurofeedback 
training, comparing active vs sham training. The secondary objective is 
to determine the lowest # of sessions necessary. 
The primary objective of the R33 phase in a randomized controlled trial 
is to compare active an sham feedback on depression outcome and to 
determine the relationship between changes in neural perseveration and 
change in depression. 
Number of Subjects R61 Phase – 60 patients with MDD expected to enroll. R33 Phase (if 
approved) – 80 patients with MDD expected to enroll. 

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Main Inclusion and 
Exclusion Criteria 
Inclusion: 
• gender, inclusive 
• adult aged 18 – 65 
• meets Diagnostic and Statistical Manual of Mental Disorders 
(DSM-5) criteria for MDD according to the Clinician- 
Administered MDD Scale for DSM-5 (unipolar depression or 
bipolar II depressed) 
• scores at least a minimum score of 16 on Montgomery Asberg 
Depression Rating Scale (MADRS) 
• normal cognition 
• participants must be able to read and understand English 
• participants must be able to provide consent 
Exclusion: 
• pregnancy (female participants) 
• outside age range 
• MRI contraindications (medical implant, claustrophobia, etc.) 
• use of psychoactive medication (including antidepressants) or 
currently in therapy 
• neurological disorder or any condition that in the view of the PI 
could impact brain data, cause depression, require medication 
that could cause depressive symptoms, or otherwise result in 
participant being unfit for study (for example, co-morbid 
psychotic disorders, neurological disorders, developmentally or 
cognitively disabled/impaired, active alcohol or drug 
abuse/dependence within the past 6 months) 
• non-English speaking 
• non-correctable vision loss 
• refusal to provide informed consent 
• representing an active suicide risk 
Intervention 
Behavioral intervention (neurofeedback) 
Statistical 
Methodology 
Linear mixed effects regression modeling will be used to assess changes 
in neural perseveration and MADRS over time in the active 
neurofeedback group. Multiple linear regression will be used to assess 
the relationship between reduced neural perseveration and reduced 
MADRS scores. Two-sample t-tests will assess group differences in 
task performance and symptoms after each session of treatment in order 
to determine the necessary dose of neurofeedback for reducing neural 
perseveration. 

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Data and Safety 
Monitoring Plan 
We have elected to utilize a Data and Safety Monitoring Board as part 
of our data and safety monitoring plan. 
 
 
Background and Study Rationale 
 
This study will be conducted in full accordance with all applicable University of Pennsylvania 
Research Policies and Procedures and all applicable Federal and state laws and regulations. 
 
1 
Introduction 
Depressed individuals process negative stimuli differently from healthy participants, leading to 
differences in attention, memory, and cognitive control (Mogg and Bradley 2005, Mogg, Field et 
al. 2005, Gotlib and Joormann 2010, Sanchez, Vazquez et al. 2013, Snyder 2013, Jones and 
Sharpe 2017, Koster 2017). Depressed participants also tend to show larger and more prolonged 
neural responses to negative stimuli (Disner, Beevers et al. 2011). Relatedly, other studies have 
found that depressed individuals specifically have difficulty in disengaging from negative stimuli 
(Armstrong and Olatunji 2012, Sanchez, Vazquez et al. 2013, Mennen, Norman et al. 
2019). This inability to transition out of negative states may manifest clinically as rumination-- 
the automatic, perseverative replay of negative thoughts (Gotlib 1982, Nolen-Hoeksema, Wisco 
et al. 2008). 
 
Behavioral training has been the main approach to reduce attentional biases in depression, yet 
behavioral measures such as button presses and eye movements are downstream effects of 
underlying neural differences. Neural feedback, such as from functional magnetic resonance 
imaging (fMRI), allows for measures that are “closer to the source” of the biases, and thus have 
the potential to be more sensitive and informative. Indeed, depressed participants can show 
enhanced neural processing of negative stimuli that are presented quickly even in the absence of 
any indication from behavior (Fales, Barch et al. 2008, Suslow, Konrad et al. 2010, Victor, Furey 
et al. 2010). We therefore seek to combine the advantages of adaptive feedback with the 
potentially enhanced sensitivity of neural measurements of attention. 
 
1.1 
Background and Relevant Literature 
 
Depression is one of the most prevalent, chronic and debilitating illnesses; it affects 10% 
of individuals within the past 12 months (Hasin, Sarvet et al. 2018) and is the leading cause of 
disability world-wide (Kessler, Aguilar-Gaxiola et al. 2009, Collins, Patel et al. 2011). Effective 
pharmacotherapies are available but produce responses in only approximately half of patients 
((APA 2013); STAR-D) and following nonefficacy with an initial SSRI, only about 20% remit 
(Rush, South et al. 2020). Thus, finding additional treatment strategies to achieve better 
treatment outcome is highly desirable. 

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In this R61/R33 proposal we will test the efficacy of a new psychotherapeutic strategy, 
closed loop real time fMRI neurofeedback, in reducing negative attention bias and depressive 
symptoms. This is the first real time feedback therapy to use the person’s brain state (based on 
all of the person’s brain signal) for cloud based machine learning decoding and feedback rather 
than the more typical approach of conveying feedback through a separate gauge or scale. It is 
well established that depressed individuals have accentuated processing of negative stimuli, 
leading to differences in attention, memory, and cognitive control (M1-5) and more prolonged 
neural responses to negative stimuli (6), manifesting clinically as rumination (M1, 7). Neural 
feedback from functional magnetic resonance imaging (fMRI), provides measures that are “close 
to the source” of the biases, with the potential to be sensitive and informative. In a pilot study 
(Mennen et al, BP 20) we adapted a closed loop procedure and showed feasibility data for 
reducing neural measures of negative attention bias that was correlated with reductions in 
depressive symptoms. 
Thus, this project will establish real-time fMRI neurofeedback as a means of reducing 
attention to negative stimuli by reducing neural perseveration of negative states as a treatment for 
MDD. Results from this line of research will inform feedback strategies and improve 
understanding of neural mechanisms underlying negative attention and MDD. 
 
2 
Study Objectives 
 
2.1 
Primary Objective 
 
The overall objective of this R61/R33 is to test whether closed loop real time fMRI 
neurofeedback that specifically targets our hypothesized attentional mechanism of depression 
(i.e., neural perseveration of negative states) reduces depression severity. This study will be the 
first dose-finding test of real-time fMRI effect on negative attention bias. 
 
2.2 
Secondary Objectives (if applicable) 
 
Phase R61: 
• Aim 1: Target Engagement. Response to real-time vs sham neurofeedback will be 
determined by pre-post change in selective attention to negative stimuli. 
• Aim 2: Determine the lowest “dose” of training necessary to reduce selective attention to 
negative stimuli. 
• Exploratory Aim: Examine behavioral perseveration on negative stimuli. 
 
Phase R33 will be conducted only if Phase R61 is successful: 
• Aim 1: Conduct a randomized controlled trial (RCT) to compare the effect of real-time 
neurofeedback vs. sham on depression outcome in patients with MDD. 
• Aim 2: Determine the relationship between the markers of neural perseveration 
established in the R61 phase and the reduction in depressive symptoms. 
• Aim 3: Determine the durability of the treatment effect. 
3 
Investigational Plan 

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Following ascertainment of inclusion and exclusion criteria and consent, participants will be 
enrolled and randomized to either the active or sham group. In subsequent daily visits, they will 
perform the gaze task and receive neurofeedback training. In general, it is expected that the visits 
will occur on sequential days, except for weekends, but there will be flexibility for patient 
schedule. Participants will also complete 2 follow-ups. See below for visit breakdown. 
• R61 phase will include: 
o 1 pre-training session (includes screening) 
o 4 training sessions (the first session includes a baseline MRI scan) 
o 1 post-training session 
o 2 follow-up sessions 
• R33 phase will include: 
o 1 pre-training session (includes screening) 
o training sessions (number of sessions will be determined in the R61 phase) 
o 1 post-training session 
o 2 follow-up sessions 
 
3.1 
General Design 
 
This study uses neurofeedback to target neural mechanisms underlying attentional bias in 
participants with major depressive discover (MDD), with the goal of evaluating whether this 
intervention can be used to reduce the negative attentional bias. 
 
Following random assignment, participants will begin the protocol with either active 
neurofeedback or sham (yoked) neurofeedback. 
 
3.2 
Allocation to Interventional Group 
 
Participants will be randomly assigned to treatment with active neurofeedback or sham. At the 
end of the initial assessment, a computer-generated random number list will be used to allocate 
participants to the two treatment conditions. 
 
3.3 
Study Measures 
 
Sources of data includes fMRI data from MRI scanner, clinical evaluations (diagnoses, observer 
ratings), and behavioral gaze data. 
 
In the R61 phase we will compare cloud based real time fMRI feedback with placebo (sham 
feedback) in reducing negative attention bias and depressive symptoms. This study will be the 
first dose-finding test of real-time fMRI effect on negative attention bias. Measures include: 
• Structured Clinical Interview for DSM-5 (SCID) 
o Clinician-administered diagnostic exam 
o Completed during pre-training session for screening and eligibility assessment 
• Montgomery Asberg Depression Rating Scale (MADRS) 
o Clinician-administered scale used to assess the severity of depression 

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o Obtained during pre-treatment session (for screening and eligibility assessment), 3 
training sessions, post-training session, and 2 follow-up sessions 
• State-Trait Anxiety Inventory (STAI) 
o Self-report questionnaire used to measure types of anxiety 
o Obtained during pre-treatment session, 3 training sessions, post-training session, 
and 2 follow-up sessions 
• Mood and Anxiety Symptom Questionnaire (MASQ) 
o Self-report questionnaire used to measure mood symptoms 
o Obtained during pre-treatment session, 3 training sessions, post-training session, 
and 2 follow-up sessions 
• Negative perseveration during a go/no-go task 
o Go/no-go task with overlaid face/scene stimuli; brain response triggers next 
stimulus 
o Obtained in 3 training sessions and post-training session 
• Negative gaze 
o Negative gaze collected in gaze data following each real time fMRI feedback 
session 
o Obtained during 3 training sessions and post-training session 
 
In the R33 phase we will compare the effect of real-time neurofeedback vs. sham on depression 
outcome in patients with MDD. The number of training sessions will be determined in the R61 
phase. 
• Structured Clinical Interview for DSM-5 (SCID) 
o Clinician-administered diagnostic exam 
o Completed during pre-training session for screening and eligibility assessment 
• Montgomery Asberg Depression Rating Scale (MADRS) 
o Clinician-administered scale used to assess the severity of depression 
o Obtained during pre-treatment session (for screening and eligibility assessment), 3 
training sessions, post-training session, and 2 follow-up sessions 
• State-Trait Anxiety Inventory (STAI) 
o Self-report questionnaire used to measure types of anxiety 
o Obtained during pre-treatment session, 3 training sessions, post-training session, 
and 2 follow-up sessions 
• Mood and Anxiety Symptom Questionnaire (MASQ) 
o Self-report questionnaire used to measure mood symptoms 
o Obtained during pre-treatment session, 3 training sessions, post-training session, 
and 2 follow-up sessions 
• Negative perseveration during a go/no-go task 
o Go/no-go task with overlaid face/scene stimuli; brain response triggers next 
stimulus 
o Obtained in training sessions and post-training session, although exact number 
will be determined in R61 phase 

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3.4 
Study Endpoints 
 
3.4.1 
Primary Study Endpoint 
 
Our primary aim to test the efficacy of the closed loop real time fMRI neurofeedback: does this 
neurofeedback that specifically targets our hypothesized attentional mechanism of depression 
(i.e., neural perseveration of negative states) lead to reduced depression severity? The primary 
endpoint would then be a change in negative attention bias following training visits. Phase R61 
will focus on this negative attention bias, and Phase R33 will focus on change in depressive 
symptom severity. 
 
3.4.2 
Secondary Study Endpoints 
 
Phase R61: 
• Aim 1: Target Engagement. Response to real-time vs sham neurofeedback will be 
determined by pre-post change in selective attention to negative stimuli. Following 
behavioral and symptom assessment participants will receive 3 training sessions 
conducted in the fMRI scanner, during which participants will view overlaid neutral 
scenes and negative faces while attending to the scenes. Multivariate pattern analysis will 
quantify attention to the scenes vs. faces in real-time using a cloud-based framework that 
adjusts each subsequent image to reward or punish based on attention to the current 
image. Feedback will be delivered by changing the opacity of the images of the scene 
target vs face distractor. We have identified a potential neural locus of the negative 
attentional bias — the inability of MDD to escape from a brain state in which they are 
attending to negative face distractors even though task irrelevant, what we refer to as 
“neural perseveration” (higher conditional probability of staying in the same negative 
state vs. healthy individuals). 
• Exploratory aim: Behavioral perseveration on negative stimuli. In addition to a neural 
target we will also explore a behavioral perseveration target using a gaze task (R61 
Exploratory Aim). In that task, patients view a screen with positive, neutral and negative 
images. Using an eye-tracker, the amount of time that participants spend looking at 
negative stimuli after first fixating on those stimuli will be recorded and compared. To 
further support the hypothesis that understanding negative perseveration is relevant to 
brain mechanisms in depression, we will measure the same probability at the end of each 
day of neurofeedback treatment. The progressive change over time will provide further 
comparisons in the active vs sham groups. 
• Aim 2: Determine the lowest “dose” of training necessary to reduce selective attention to 
negative stimuli. Neural and behavioral markers obtained after each session will be used 
to determine the lowest number of sessions that produce a significant effect, which will 
be chosen for the R33 phase. 
 
R33 Phase: 
• Aim 1: To conduct a randomized controlled trial (RCT) to compare the effect of real-time 
neurofeedback vs. sham on depression outcome in patients with MDD. 
• Aim 2: To determine the relationship between the markers of neural perseveration 
established in the R61 phase and the reduction in depressive symptoms. Neural 

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perseveration on negative distractors and behavioral looking at negative stimuli will be 
correlated with MADRS scores. 
• Aim 3: To determine the durability of the treatment effect. 
 
4 
Study Population and Duration of Participation 
 
4.1 
Duration of Study Participation 
 
Following consent and ascertainment of inclusion and exclusion criteria during pre-training 
session, participants will be enrolled and randomized to either the active or sham group. In 
subsequent daily visits, they will perform the gaze task and receive neurofeedback training. In 
general, it is expected that the visits will occur on sequential days, except for weekends, but there 
will be flexibility for patient schedule. Participants will also complete a follow-up at 1 month. 
The patients will follow the treatment course as best as possible, however, the protocol does 
allow for flexibility contingent on patient availability, MRI availability, and other scheduling 
factors. 
 
As a result, total duration is expected to be approximately 6 weeks, with some room for 
flexibility in scheduling. A schedule of visits for Phase R66 is included below: 
 
Visit 
Pre NF 
NF 1 
NF 2 
NF 3 
Post NF 
1 
Month 
Inclusion/Exclusion 
SCID-5 
- 
- 
- 
- 
- 
Depression 
Severity 
MADRS 
MADRS 
MADRS 
MADRS 
MADRS 
MADRS 
Mood Symptom 
Self Report 
STAI & 
MASQ 
STAI & 
MASQ 
STAI & 
MASQ 
STAI & 
MASQ 
STAI & 
MASQ 
STAI & 
MASQ 
MRI Acquisition 
- 
Structural 
- 
- 
- 
- 
- 
Go/no-go 
Go/no- 
go 
Go/no- 
go 
- 
- 
Behavioral 
Assessment 
Gaze 
Gaze 
Gaze 
Gaze 
- 
- 
 
4.2 
Total Number of Subjects and Sites 
 
Enrollment and administrative site will be at the University of Pennsylvania. 
 
R61 Phase will enroll 60 patients with MDD, and R33 Phase will enroll 80 patients with MDD. 
To account for attrition 60 participants will be enrolled in R61 Phase with 54 anticipated to 
complete full data collection (27 in each arm). To account for attrition 80 participants will be 
enrolled in R33 Phase with 72 anticipated to complete full data collection (36 in each arm). 
 
4.3 
Inclusion Criteria 
 
• gender, inclusive 
• adult aged 18 – 65 

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• meets Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for MDD 
according to the Clinician-Administered MDD Scale for DSM-5 (unipolar depression or 
bipolar II depressed) 
• scores at least a minimum score of 16 on Montgomery Asberg Depression Rating Scale 
(MADRS) 
• normal cognition 
• participants must be able to read and understand English 
• participants must be able to provide consent 
 
4.4 
Exclusion Criteria 
 
• pregnancy (female participants) 
• outside age range 
• MRI contraindications (medical implant, claustrophobia, etc.) 
• use of psychoactive medication (including antidepressants) or currently in therapy 
• neurological disorder or any condition that in the view of the PI could impact brain data, 
cause depression, require medication that could cause depressive symptoms, or otherwise 
result in participant being unfit for study (for example, co-morbid psychotic, neurological 
disorders, developmentally or cognitively disabled/impaired, active alcohol or drug 
abuse/dependence within the past 6 months). 
• non-English speaking 
• non-correctable vision loss 
• refusal to provide informed consent 
• representing an active suicide risk 
4.5 
Subject Recruitment 
 
All participants will be recruited through the University of Pennsylvania and surrounding 
community. For both phases, recruitment will occur through the Center for Neuromodulation is 
Depression and Stress (CNDS) directed by the PI. All subjects will express interest by initiating 
contact with the research staff for a center wide phone screening or self-screening procedure. All 
subjects fitting inclusion criteria will be approached by study staff to continue in the study. This 
study will also be advertised on online sources such as Facebook. Study coordinators in the 
present study will use the results in REDCap as a source of recruitment, at which point those 
subjects will undergo the full phone-screen. This phone screen will also be collected and stored 
in REDCap. In addition to recruiting from the CNDS, we will recruit from the larger 
Philadelphia community through targeted advertisements and referral streams at the University 
of Philadelphia. This includes both print and online sources. All recruitment materials, including 
but not limited to flyers, brochures, referral letters, online postings, and email templates will be 
IRB-approved before distribution of any of these material. 
 
4.6 
Vulnerable Populations: N/A 
 
Children, pregnant women, fetuses, neonates, or prisoners are not included in this research study. 

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5 
Study Procedures 
 
In the R61 phase we will compare cloud based real time fMRI feedback with placebo (sham 
feedback) in reducing negative attention bias and depressive symptoms. This study will be the 
first dose-finding test of real-time fMRI effect on negative attention bias. 
 
In the R33 phase, if approved in future, we will compare the effect of real-time neurofeedback 
vs. sham on depression outcome in patients with MDD. The number of training sessions will be 
determined in the R61 phase. 
 
Sources of data includes fMRI data from MRI scanner, clinical evaluations (SCID, MADRS), 
self-report questionnaires (STAI & MASQ), and behavioral gaze data (behavioral assessment 
from go/no-go task). Below is a table that outlines what assessments and procedures will be 
completed at each visit: 
 
Procedure 
Pre-training 
Session 
(Screening Visit) 
Training 
Session 1 
Training 
sessions (2- 
3) 
Post-training 
session 
Follow-up 
Session 
Clinical 
Assessments 
X (SCID & MADRS) 
X (MADRS) 
X (MADRS) 
X (MADRS) 
X (MADRS) 
Self-report 
Questionnaires 
X 
X 
X 
X 
X 
Medication 
History 
 
X 
 
 
 
Demographics 
Survey 
 
X 
 
 
 
MRI Scan 
X (baseline) 
X 
 
Behavioral Task 
X 
X 
X 
 
 
During the initial week, there will be one initial pre-training/screening visit (approx. 3-4 hours), 
3 training visits (approx. 4-5 hours each), and one post-training visit (approx. 1 hour). Within 3 
months, there are 2 follow-up sessions after the treatment is over (approx. 1 hour each). 
 
Does your study use MRI? (CAMRIS is the appropriate contact for all studies involving MRIs) 
 Yes 
No (If No, no CAMRIS review needed) 
 
Check of all that apply: 
1.5T MRI 
  3T MRI 
7TMRI 
 
Does the MRI use investigational sequences and/ or coils? 
(See Experimental Device Clause) 
Yes 
 No 
Unsure (if unsure be sure to contact 

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CAMRIS) 
 
Does your study include pregnant women? 
(See Pregnancy Clause and Justification) 

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Yes 
 No 
 
Does the MRI require the use of Contrast Agents? 
(See Contrast Risks) 
Yes 
 No 
 
Does your study involve the exposure to radiation, radiotracers and/or radiological imaging 
modalities? 
Yes 
 No (If No, no RRSC review is needed) 
 
Will any of the radiation exposure result from procedures that are or could be performed solely 
as a result of a subject’s participation in the research protocol? 
Yes 
 No 
 
The following are examples of procedures involving ionizing radiation: 
(Review appendix 15.3 and appendix 15.5) 
 
• X-rays (examples: CT scan, chest x-ray, hand/wrist x-ray, abdomen x-ray, DEXA, 
pQCT, Fluoroscopy/Angiography) 
• Nuclear Medicine scans (examples: FDG-PET, PET/CT, Tc-99m, SPECT, 
MUGA, bone scan) 
• If you are unsure please contact Will Davidson in EHRS (wed@ehrs.upenn.edu). 
 
 
Ultrasound 
Yes 
 No 
If yes, there is no protocol specific language to include but please contact Susan Schultz at: susan.schultz@uphs.upenn.edu 
 
Will your study be using CT Scans? (CACTIS is the appropriate contact for studies involving CT 
scans) 
Yes 
 No 
 
 
Studies involving Nuclear Medicine: Will subjects be undergoing any of the following 
procedures specific to research: 
MUGA 
(See Nuclear Medicine-Muga Scan) 
PET/CT Scan 
(See PET/CT Scan) 
Bone /DXA 
(See Bone Scan) 
 
Check off all of the following procedures that will be performed in your research- each option 
you select will link to the template language document: 
Apheresis/plasma exchange 

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Leukapheresis 
Bone Marrow Biopsy or Aspirate 
Use of AP clinical specimens 
Biopsies- check those which apply 
Blood draw 
 
5.1 
Pre-Training Visit 
 
The pre-training visit will include screening procedures. 
 
Participants will be recruited, consented, and evaluated. They will also complete MRI safety 
screening forms and self-report medical history. This includes completing informed consent. 
Each patient’s medical history is reviewed by Dr. Sheline and, when clinically indicated, a 
physical examination and appropriate laboratory tests will be obtained to ensure that patients are 
diagnostically eligible. Consenting patients will be diagnosed with the Structured Clinical 
Interview for DSM-5. Participants who meet eligibility requirements will be screened using the 
MADRS, which will be the primary outcome measure and will have a minimum score of 16. 
Participants will also complete the STAI & MASQ. 
 
In addition to a neural target we will also explore a behavioral perseveration target using a gaze 
task. In that task, patients view a screen with positive, neutral and negative images. Using an 
eye-tracker, the amount of time that participants spend looking at negative stimuli after first 
fixating on those stimuli will be recorded and compared. To further support the hypothesis that 
understanding negative perseveration is relevant to brain mechanisms in depression, we will 
measure the same probability at the end of each day of neurofeedback treatment. The progressive 
change over time will provide further comparisons in the active vs sham groups. 
 
5.2 
Study Intervention or Observational Phase (Give this section a name that is relevant to the 
design of your study) 
 
5.2.1 
Training Visit 1 
 
Following ascertainment of inclusion and exclusion criteria and consent, participants will be 
enrolled and randomized to either the active or sham group. The active training group will 
receive baseline structural and functional MRI scans, which will function as the baseline MRI 
scans. Participants will also perform the behavioral gaze task and complete a MADRS, STAI, 
and MASQ. 
 
5.2.2 
Training Visits 2-3 
 
In subsequent daily visits, they will perform the gaze task and receive neurofeedback training. 
Participants will also complete a MADRS, STAI, and MASQ. 

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5.2.3 
Post-training Visit 
 
During the post-neurofeedback training session, participants will complete only a MADRS, 
STAI, and MASQ. 
5.2.4 
Follow-up Visits 1-2 
 
Participants will also complete 1 follow-up visit: at one month from the post treatment visit, 
participants will complete a MADRS, STAI, and MASQ during these follow-up visits. 
 
5.2.5 
End of Study Visit 
 
N/A 
 
5.3 
Unscheduled Visits 
 
Unscheduled visits will be handled only if deemed necessary by study staff, for instance 
a participant presented to the ER during study participation, study staff may request the 
patient come in between visits for evaluation. 
 
5.4 
Subject Withdrawal 
 
Participants may be withdrawn from the study by staff if deemed necessary for their 
health or safety or if participants have not been following instructions. We anticipate that 
some participants may withdraw. We do not expect early termination of participation due 
to patient or investigator withdrawal to have any impact on safety or well-being of 
participants. 
 
5.4.1 
Data Collection and Follow-up for Withdrawn Subjects 
 
N/A 
 
5.5 
Early Termination Visits 
 
If deemed necessary to terminate a patient’s participation in the study, they will be 
contacted by study staff to communicate this and the reason why. No other information 
will be collected from the terminated participant. Participant will complete end-of-study 
procedures as needed (receiving compensation, etc.). 
 
5.6 
Efficacy Evaluations (only if applicable) 
 
Montgomery Asberg Depression Rating Scale (MADRS) will be used to examine efficacy of 
study intervention. 

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5.7 
Pharmacokinetic Evaluation (only if applicable): N/A 
 
5.8 
Genetic Testing (only if applicable): N/A 
 
5.9 
Safety Evaluation (only if applicable) 
 
The primary investigator will routinely monitor and evaluate study procedures for 
potential increased risk. 
 
6 
Statistical Plan 
 
6.1 
Sample Size and Power Determination 
 
R61 Phase: A total of 60 (n=30 active neurofeedback, n=30 sham feedback) will be enrolled. 
Allowing for a 10% loss of subjects, based on our preliminary data, the sample size (i.e. at least 
27 patients per arm with valid post-treatment data) was chosen so that the study would have 
adequate power to detect between-group differences of moderate to large between group effect 
sizes (see power analysis below). 
• 
For a one-sample t-test with a two-sided alternative and type I error rate of 5%, 
27 participants will yield 80% power for a Cohen’s d = 0.56. This is sufficient 
power to detect the effect size of d = 0.83 for reduction in neural perseveration 
found in the pilot study. For a two-sample t-test with two-sided alternative and 
type I error rate of 5%, 27 participants per arm will yield 80% power for a 
Cohen’s d = 0.86 or larger. The statistical analysis for power determination 
and sample size is subject to change as data is collected over the course of the 
study.  
 
R33 Phase: A total of 80 participants with MDD (n=40 real time neurofeedback, n=40 sham 
feedback) will be enrolled as above in a randomized controlled clinical trial. Allowing for a 10% 
loss of subjects, based on our preliminary data, the sample size (i.e. at least 36 patients per arm 
with valid post-treatment data) was chosen so that the study would have adequate power to 
detect between-group differences of moderate to large between group effect sizes (see power 
analysis below). 
• 
For a one-sample t-test with a two-sided alternative and type I error rate of 5%, 36 
participants per arm will yield 80% power for a Cohens d = 0.53 or larger, which 
is sufficient to detect the effect size of 0.93 Visit 1 to post-treatment MADRS 
score decrease in the pilot data (Hypothesis 1). For a two-sample t-test with a 
two-sided alternative and type I error rate of 5%, 36 participants will yield 80% 
power for a Cohens d = 0.74 or larger. Hypothesis 2 will utilize Pearson 
correlation between change in MADRS and change in negative attention scores. If 
nonlinearity is detected, we will employ a Spearman correlation analysis. A 
sample size of n=36 corresponds to 80% power to detect a significant (at 5% 
alpha level) correlation as low as r=0.45, which is sufficient to detect the effect 
size of r=0.48 found in the pilot data (Figure 1). Hypothesis 3 will use a two- 
sample t-test comparing real vs sham NF. Pilot study data indicated a change in 
MADRS from baseline to 3 month follow-up corresponding to Cohen’s d=0.95. A 
two-sample t-test, with 36 per group, at 5% significance level, gives 80% power 
to detect d=0.74 or larger. 

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6.2 
Statistical Methods 
 
Statistical analysis will be performed using the R statistical environment assuming 5% type I 
error rates. Linear mixed effects regression modeling (using the lme4 R package) will be used to 
assess evidence of reduced neural perseveration and reduced MADRS over time in the active 
neurofeedback group. Two-sample t-tests will be used to compare differences in neural 
perseveration and MADRS scores between the active neurofeedback and sham (yoked) 
neurofeedback groups after each additional session of treatment in order to establish the lowest 
dose of training necessary to significantly reduce neural perseveration. We will utilize multiple 
linear regression to assess the relationship between reduced perseveration and the reduction of 
MADRS scores in the active neurofeedback group while accounting for various confounds. 
 
6.3 
Control of Bias and Confounding (if applicable, typically observational study or if 
randomization is not taking place) 
 
6.3.1 
Baseline Data 
 
Participants will be matched on demographic data. 
 
6.3.2 
Analysis of Primary Outcome of Interest 
 
We will use a two-sample t-test comparison of active neurofeedback vs sham to determine the 
effect on MADRS scores. 
 
6.3.3 
Pharmacokinetic Analysis (only if applicable): N/A 
 
6.3.4 
Interim Analysis (only if applicable): N/A 
 
 
7 
Safety and Adverse Events 
 
7.1 
Definitions 
 
7.1.1 
Adverse Event 
An adverse event (AE) is any symptom, sign, illness or experience that develops or worsens in 
severity during the course of the study. Intercurrent illnesses or injuries should be regarded as 
adverse events. Abnormal results of diagnostic procedures are considered to be adverse events if 
the abnormality: 
• results in study withdrawal 
• is associated with a serious adverse event 
• is associated with clinical signs or symptoms 
• leads to additional treatment or to further diagnostic tests 
• is considered by the investigator to be of clinical significance 
 
7.1.2 
Serious Adverse Event 
Serious Adverse Event 

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Adverse events are classified as serious or non-serious. A serious adverse event is any AE that 
is: 
• fatal 
• life-threatening 
• requires or prolongs hospital stay 
• results in persistent or significant disability or incapacity 
• required intervention to prevent permanent impairment or damage 
• a congenital anomaly or birth defect 
• an important medical event 
 
Important medical events are those that may not be immediately life threatening, but are clearly 
of major clinical significance. They may jeopardize the subject and may require intervention to 
prevent one of the other serious outcomes noted above. For example, drug overdose or abuse, a 
seizure that did not result in in-patient hospitalization, or intensive treatment of bronchospasm in 
an emergency department would typically be considered serious. 
 
All adverse events that do not meet any of the criteria for serious should be regarded as non- 
serious adverse events. 
 
For additional information on definitions and clarifications which may be helpful in creating the 
safety monitoring portion refer to appendix 15.7 
 
7.2 
Recording of Adverse Events 
 
At each contact with the subject, the investigator will seek information on adverse events by 
specific questioning and, as appropriate, by examination. Information on all adverse events will 
be recorded immediately in the source document, and also in the appropriate adverse event 
module of the case report form (CRF). All clearly related signs, symptoms, and abnormal 
diagnostic procedures results should recorded in the source document, though should be grouped 
under one diagnosis. 
 
All adverse events occurring during the study period will be recorded. The clinical course of 
each event will be followed until resolution, stabilization, or until it has been determined that the 
study intervention or participation is not the cause. Serious adverse events that are still ongoing 
at the end of the study period will be followed up to determine the final outcome. Any serious 
adverse event that occurs after the study period and is considered to be possibly related to the 
study intervention or study participation will be recorded and reported immediately. 
 
7.3 
Relationship of AE to Study 
 
The relationship of each adverse event to the study procedures will be determined by the PI and 
co-PI and relationships will be classified as either: definitely related, probably related, possibly 
related, unlikely or unrelated. 

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7.4 
Reporting of Adverse Events and Unanticipated Problems 
 
Unexpected and related Adverse Events will be reported to the IRB by study staff within 72 
hours of knowledge of the event; all other adverse events will be reported at the time of 
continuing review. Reporting of Serious Adverse Events will occur within 24 hours of 
knowledge of the event. 
 
7.4.1 
Follow-up Report 
 
If an SAE has not resolved at the time of the initial report, follow-up reports with all relevant 
new, or reassessed, information will be submitted to the IRB until the SAE resolves or stabilizes. 
 
7.4.2 
Investigator reporting: notifying the study sponsor (if applicable) 
 
N/A 
 
7.4.3 
Data and Safety Monitoring Plan 
 
 
7.4.3.1 Data Safety Monitoring Board (if applicable) 
 
Because study subjects will be receiving a device-based intervention as part of this study 
protocol, we have elected to utilize a Data and Safety Monitoring Board as part of our data and 
safety monitoring plan. The frequency of Penn DSMB review for this protocol will be once 
every 12 months based on IRB recommendations consistent with the assessed risk status of the 
study. 
Dr. Sheline will convene a Data and Safety Monitoring Board (DSMB). The DSMB will include 
a biostatistician with expertise in randomized clinical trial methodology, a researcher with 
expertise in neuroimaging, and a clinical psychologist or psychiatrist. The members of the 
DSMB will not be involved in this project and will not be collaborators on any other of the 
investigators’ projects nor in their employ. DSMB members will provide the PI (and NIH, as 
required) with qualifications and a statement indicating that they have no direct involvement 
with the study or any conflicts of interest with the investigators or institutions conducting the 
study. They will meet annually to 1) monitor the safety, quality and conduct of this study and 2) 
decide whether adequate subject safeguards are in place. The DSMB will review: 1) the progress 
of the proposed study, including assessments of data quality and participant recruitment, accrual 
and retention; 2) outcome and adverse event data to determine whether there is any change to the 
anticipated benefit-to-risk ratio of study participation and whether the study should continue, be 
changed, or terminated; 3) external factors or relevant information (e.g., pertinent scientific 
literature reports or therapeutic developments, results of related studies) that may have an impact 
on the safety of study participants or the ethics of the research study; and 4) study procedures 
designed to protect the privacy of the research subjects and the confidentiality of their research 
data. The study statistician will be responsible for generating a de-identified annual report of key 
events that will be reviewed as part of the safety monitoring of the protocol. The tentative list of 
key events will include and more specifically indicate: 1) side effects to the study treatment, 2) 
hospitalization, and 3) premature drop-out from treatment. The key events will be reviewed at 

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the first meeting of the DSMB to obtain the DSMB members’ input into the list and to add any 
other events or measures that they feel would be relevant to include for evaluating the safety and 
conduct of the clinical trial. Prior to each DSMB meeting, the data manager/research 
coordinators will prepare a report to be reviewed during that meeting. The report will include the 
number of participants who signed consent for the study and were randomized, the number of 
post-randomization dropouts, reasons for these dropouts, and any safety concerns, adverse 
events, etc. An up-to-date consent form will be provided, as well as a summary of measures 
taken to protect confidentiality (e.g. data storage, use of coded ID numbers, etc). The PI will also 
prepare a report summarizing any new data/evidence that might alter the risk/benefit ratio for 
participating in the study (e.g., newly published studies, etc.). Data will be presented to the 
DSMB in such a way as to maintain patient confidentiality. Based on the information provided 
to the Penn DSMB, once every 12 months the DSMB will issue a report that summarizes the 
following: All serious and unexpected adverse events or other unanticipated problems that 
involve risk to study participants, and whether these appear related to the study based 
interventions or research assessment protocols. Reports will not disclose the treatment arm of 
the study for relevant subjects unless this disclosure is required for safety reasons. Note that any 
serious adverse event (SAE) will be reported to the Penn IRB within 24 hours according to 
standard regulations. The IRB defines a serious adverse event as: “any adverse experiences 
occurring that result in any of the following outcomes: death, a life-threatening adverse 
experience, inpatient hospitalization or prolongation of existing hospitalization, a persistent or 
significant disability/incapacity, or a congenital anomaly/birth defect. For the purposes of this 
policy, death is never expected.” The PI will take responsibility for reporting any serious and 
unexpected adverse events in a timely fashion directly to the Penn DSMB. The PI will also 
report serious and unexpected adverse events or other unanticipated study problems or variances 
to the Penn IRB. Actions taken by the IRB in response to adverse event reports will be 
immediately reported to the Penn DSMB. Statistical analysis of adverse event data will be 
provided by Dr.Shinohara, the study Biostatistician. 
 
8 
Study Administration, Data Handling and Record Keeping 
 
8.1 
Confidentiality 
 
We will collect the following PHI: name, address, social security number (for compensation 
purposes) visit dates, telephone number, and email address. Patients entering the study will be 
given a unique identifying code. This code will be used on all data obtained from scans or study 
visits. Only one password protected document connecting the code with the participant name (in 
the form of first two letters of the first name, first three letters of the last name) will exist. 
Everything will be immediately coded and this coded information will be stored in secure 
cabinets inside locked rooms or in password protected, IRB compliant online databases, such as 
REDCap. PHI will be stored separately in secure cabinets inside locked rooms. Coded data will 
be stored on a secure server at the University of Pennsylvania through the Neuroscience 
Neuroimaging Group computing cluster. MRI data are securely copied on the uphs network 
directly from the MRI machine at Stellar Chance to this computing cluster without separate 
physical storage. Coded data are directly uploaded to the computing cluster from the computers 
on which the data are collected. The Penn computers are in our secured lab space and connected 
directly to the uphs encrypted network. None of these data will contain personal identifiers such 

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as name, social security number, address, or phone number. At the conclusion of the study, 
coded copies of the data may be maintained at the University of Pennsylvania in its de-identified 
form for future analyses. Computer-based files containing electronic PHI, that are not part of the 
EMR, will be kept on the Penn Network server. 
 
The PI will directly train the study staff in issues of maintaining data integrity and confidentiality 
and will stress the critical importance of subject confidentiality in training of all project staff and 
will keep reiterating this point as opportunities arise in handling of such material. All data 
collection and storage will use the following safeguards to protect data integrity and subject 
confidentiality: (1) All members of the project will receive human subjects training and 
certification through the Collaborative Institutional Training Initiative (CITI) curriculum; (2) all 
staff will undergo the necessary required trainings; and (3) all project staff will maintain up-to- 
date certification on research subject confidentiality and privacy. Data from interviews and 
questionnaires will be collected by members of the clinical assessment team. The research staff 
will be responsible for immediate transfer of the data to the secure storage area, and for entering 
the data to secure online databases. All data will be identified and labeled only by subject ID 
numbers and will be stored separately from the identifying information and from consent and 
assessment forms. This study will utilize the secure, web-based Research Electronic Data 
Capture (REDCap) system for data input. Imaging data will be de-identified and stored on secure 
servers. Access to password-protected databases will be limited to the investigators and trained 
staff. Paper forms and data will be stored securely within the lab of Dr. Sheline. Data access will 
be limited to the Investigators and study staff who will receive human subjects training and 
certification through the CITI curriculum. Any staff member who has access to subjects or data 
will sign a confidentiality agreement before handling data and will receive training in the critical 
importance of subject confidentiality. Every effort, and ongoing adjustments, will be made to 
ensure that the identity of subjects cannot be determined by the use of the data. Future use of the 
data includes research, demonstration, publication, public performance and archiving. Subjects’ 
permission for further use of their data, in de-identified form, will be obtained via consent. Data 
will be presented in aggregate form with identifiers removed. 
 
8.2 
Data Collection and Management 
 
Data from interviews and questionnaires will be collected by members of the clinical assessment 
team. The research staff will be responsible for immediate transfer of the data to the secure 
storage area, and for entering the data to secure online databases. All data will be identified and 
labeled only by subject ID numbers and will be stored separately from the identifying 
information and from consent and assessment forms. This study will utilize the secure, web- 
based Research Electronic Data Capture (REDCap) system for data input. Imaging data will be 
de-identified and stored on secure servers, as clarified below. Access to password-protected 
databases will be limited to the investigators and trained staff. Paper forms and data will be 
stored securely within the lab of Dr. Sheline. Data access will be limited to the Investigators and 
study staff who will receive human subjects training and certification through the CITI 
curriculum. Any staff member who has access to subjects or data will sign a confidentiality 
agreement before handling data and will receive training in the critical importance of subject 
confidentiality.  
 
Additionally, our analysis pipeline will send scan data to cloud computing resources via an SSL 

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connection provided by the UPHS IT Group hosted in their Microsoft Azure environment. All 
metadata fields containing PHI will be removed prior to sending the scan data to the cloud. 
UPHS IT uses an Azure ExpressRoute, which is a private, dedicated connection, to extend on-
premises networks into the cloud while following Penn Medicine policies and standards for data 
management and security within a hybrid environment. This in part rests upon HIPAA 
compliance through our existing BAA with Microsoft. Azure has enabled the physical, technical, 
and administrative safeguards required by HIPAA and the HITECH Act inside the in-scope 
Azure services. In this way, cloud and on-premises resources will be on secure and isolated 
networks and require the same security credentials and Role Based Access Controls (RBAC). 
The data will be transmitted over the ExpressRoute for processing in the cloud and may be 
temporarily stored on encrypted disk in the Azure based compute resource. In this way the 
movement of data from the on-premises computer in the scanner to the UPHS Azure compute 
resource will never leave the UPHS hybrid network environment. At the conclusion of the study, 
coded copies of the data may be maintained at the University of Pennsylvania in its de-identified 
form for future analyses. Computer-based files containing electronic PHI, that are not part of the 
EMR, will be kept on the Penn Network server. 

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8.3 
Records Retention 
 
Future use of the data includes research, demonstration, publication, public performance, and 
archiving. Subjects’ permission for further use of their data, in de-identified form, will be 
obtained via consent. 
 
9 
Study Monitoring, Auditing, and Inspecting 
 
9.1 
Study Monitoring Plan 
 
The PI will be responsible for overarching project operations and ensuring the integrity of the 
research procedures. These responsibilities include: ensuring that adequate safety protocols are 
developed and implemented, overseeing data management and data analysis, and communicating 
with the University of Pennsylvania Institutional Review Board (UPenn IRB). Dr. Sheline will 
also oversee and be responsible for procedural integrity and the safety of subjects. Prior to 
initiation of this study, the study protocol will be submitted for review and approval to the 
UPenn IRB. 
 
Dr. Sheline will assume responsibility for statistical design and analysis of the study data in 
collaboration with Co-I’s named to this project. Overseen by the PI, monitoring of data will be 
ongoing throughout the project. Specifically, the clinical assessment team will collect 
information regarding adverse events, during the clinical visits. Any adverse events that are 
reported during these sessions will be documented and reported to Dr. Sheline to determine the 
next steps (such as referral to the emergency room for further evaluation in the case of severe 
adverse events or worsening suicidality). Any unexpected adverse events, unexpected problems 
that involve risk to the participants or others, or breaches of confidentiality, will be documented 
and reported immediately to the PI, who will determine the next steps (such as reporting to the 
IRB or NIH, as indicated). All regulatory and subject research files will undergo monitoring by 
the UPenn IRB. The UPenn IRB will also ensure that the study is conducted in accordance with 
the protocol and inclusion/exclusion criteria as approved. 
 
9.2 
Auditing and Inspecting 
 
The investigator will permit study-related monitoring, audits, and inspections by the EC/IRB, 
the sponsor, government regulatory bodies, and University compliance and quality assurance 
groups of all study related documents (e.g. source documents, regulatory documents, data 
collection instruments, study data etc.). The investigator will ensure the capability for 
inspections of applicable study-related facilities (e.g. pharmacy, diagnostic laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable University compliance and quality assurance 
offices. 

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10 Ethical Considerations 
 
This study is to be conducted in accordance with applicable US government regulations and 
international standards of Good Clinical Practice, and applicable institutional research policies 
and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted independent 
Ethics Committee (EC) or Institutional Review Board (IRB), in agreement with local legal 
prescriptions, for formal approval of the study conduct. The decision of the EC/IRB concerning 
the conduct of the study will be made in writing to the investigator and a copy of this decision 
will be provided to the sponsor before commencement of this study. 
 
10.1 
Risks 
 
Clinical interview and assessment: Some discomfort may be associated with the clinical 
assessments conducted in this study. Participants may experience emotional discomfort when 
answering some questions in the questionnaires or when talking about personal information. 
Participants may choose not to answer any of the questions and to terminate your participation. 
 
MRI Scan: 
• 
Claustrophobia: participants may experience claustrophobia within the MRI scanner. A 
MRI scan requires participants lay in a partially enclosed space inside the scanner. Some 
people may find this to be uncomfortable and claustrophobic. Participants will be given 
an emergency call button in the scan and reminded to notify study staff if they suffer 
from claustrophobia. 
• 
Magnetic Fields: There are no known health risk associated with exposure to magnetic 
fields during an MRI. There are minimal risks from the loud noise associated with the 
MRI scanner and from the discomfort of lying on a hard surface. We shall provide 
participants with protective earplugs as necessary and make every attempt to ensure their 
comfort with blankets, etc. during their time in the scanner. 
• 
Flying Objects: The known risks associated with this study are minimal. Implanted 
medical devices and metallic foreign fragments inside a participant’s body may pose a 
risk if they were to enter the MRI magnet room. Therefore, each participant will complete 
an MRI safety screening form at screening and prior to each scan. The greatest risk is a 
magnetic object flying through the air toward the magnet and hitting a participant. To 
reduce this risk we require that all people involved with the study remove all magnetic 
metal from their clothing and all magnetic metal objects from their pockets. No magnetic 
metal objects are allowed to be brought into the magnet room at any time except by 
approved personnel. In addition, once participants are in the magnet, the door to the room 
will be closed so that no one inadvertently walks into the room. 
• 
Incidental Findings Clause: it is possible that during the course of the research study, 
the research staff may notice unexpected finding(s) on a participant’s images. Should this 
occur, the finding(s) will be considered by the appropriate personnel and the PI will 
inform participants if necessary for medical follow-up. These possible finding(s) will not 
be disclosed to the participant unless deemed necessary by the PI and reviewing 
radiologist in order to avoid unnecessary anxiety for participants. 

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• 
Pregnancy: although there are no known risks related to MRI on pregnant women or a 
fetus, there is a possibility of yet undiscovered pregnancy related risks. Since there is no 
possible benefit from participating in this protocol for a pregnant woman, we will exclude 
pregnant women. 
 
Risk to confidentiality: As with any research, there is a rare risk that confidentiality could be 
breached in this study. Breaches in confidentiality could impact a participant’s future insurability 
and/or employability. In compliance with HIPAA and GCP guidelines, we will protect 
participant information and PHI to the extent permitted by law with the following measures: 
 
All study materials (with the exception of informed consent, financial, and safety forms) will 
only be identified with a randomly generated research identification number. All study 
documents with identifiable information (i.e. informed consent, financial, and safety forms) will 
be stored separately from the participant file in a double-locked environment. As hard copy 
source documents are collected, they will be kept in a double- locked environment. Data 
collected during the study will be entered and stored in a password-protected database, accessible 
only to engaged study members. All electronic data will be coded and identified only with a 
randomly generated research identification number. 
 
For data sent to cloud computing resources, we mitigate risk by using the HIPAA compliant 
Azure Cloud and ExpressRoute which controls the communication path between on-premises 
and cloud computing resources through established secure channels, thus providing a level of 
isolation and Role Based Access Control as for any Penn Medicine computing system. In 
addition, during scan processing, we anonymize metadata fields containing PHI and use 
encrypted disks for any storage needed during cloud processing. 
 
10.2 
Benefits 
 
Participants may not receive any benefits from participating in this research. However, 
participants may experience a decrease in depressive symptoms. Although there may be no direct 
benefit to participants, learning further about treating depression is valuable knowledge to be 
gained. 
 
10.3 
Risk Benefit Assessment 
 
This study is minimal risk. There is essentially zero risk of harm from the research procedures 
(MRI, assessments of symptoms, etc.). The potential benefit to society through the increased 
understanding of the mechanisms of closed loop real time fMRI neurofeedback far outweighs the 
potential risk from the MRI procedures. Additionally, those who would be unable to tolerate an 
MRI scan will be screened out. 
 
Alternatives to Participation: the alternative to participation is to not participate. 
 
10.4 
Informed Consent Process / HIPAA Authorization 
 
Consent will be obtained by research coordinators or the PI. Consent will be obtained in a private 
room where the coordinator and investigator(s) can explain the purpose of the study procedures 

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and aims. Furthermore, they will explain that participating is completely voluntary and that not 
participating will not impact them negatively. The potential participant will be given the option 
to consider study enrollment and will not be forced to make a decision the same day. If they 
decide to participate, a combined consent and HIPAA form will be signed by research staff and 
the patient. The patient will be reminded before and after enrolling, and before any research 
procedure that their participation is optional and has no impact on the care they can expect. 

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10.4.1 Alterations to Typical Consent Process (only include if applicable): N/A 
 
 
10.4.1.1 Waiver of Consent (In some cases for screening/portions of that study that qualify 
as minimal risk, a waiver of documentation of consent may be permissible IRB 
SOP) 
 
10.4.1.2 Waiver of Written Documentation of Consent 
 
10.4.1.3 Waiver of HIPAA Authorization 
 
 
11 Study Finances 
 
11.1 
Funding Source 
 
NIMH pending grant. 
 
11.2 
Conflict of Interest 
 
All conflicts of interest will be disclosed, and all University of Pennsylvania Investigators will 
follow the University of Pennsylvania Policy on Conflicts of Interest Related to Research. 
 
11.3 
Subject Stipends or Payments 
 
Participants will receive compensation for their time and participation, up to $500 for study 
completion, as the study procedures include several scans per participant and assessment time 
outside of the scanner: $25 for initial pre-training/screening, $50 for each training session, $25 
for post-training session, and $25 for the follow-up session. Participants receive an additional 
$275 at the end for completing the study. 
 
Compensation will be dispensed via Greenphire ClinCard at the end of study participation, once 
all study procedures are complete. 
 
12 Publication Plan 
 
PI will have full access to data set and will be responsible for all publications that would accrue 
from this study. 
 
13 References 
 
APA (2013). "Diagnostic and Statistical Manual of Mental Disorders Fifth Edition DSM-5." 
American Psychiatric Association. 
Armstrong, T. and B. O. Olatunji (2012). "Eye tracking of attention in the affective disorders: a 
meta-analytic review and synthesis." Clin Psychol Rev 32(8): 704-723. 

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Collins, P. Y., V. Patel, S. S. Joestl, D. March, T. R. Insel, A. S. Daar, B. Scientific Advisory, H. 
the Executive Committee of the Grand Challenges on Global Mental, W. Anderson, M. A. 
Dhansay, A. Phillips, S. Shurin, M. Walport, W. Ewart, S. J. Savill, I. A. Bordin, E. J. Costello, 
M. Durkin, C. Fairburn, R. I. Glass, W. Hall, Y. Huang, S. E. Hyman, K. Jamison, S. Kaaya, S. 
Kapur, A. Kleinman, A. Ogunniyi, A. Otero-Ojeda, M. M. Poo, V. Ravindranath, B. J. Sahakian, 
S. Saxena, P. A. Singer and D. J. Stein (2011). "Grand challenges in global mental health." 
Nature 475(7354): 27-30. 
Disner, S. G., C. G. Beevers, E. A. Haigh and A. T. Beck (2011). "Neural mechanisms of the 
cognitive model of depression." Nat Rev Neurosci 12(8): 467-477. 
Fales, C. L., D. M. Barch, M. M. Rundle, M. A. Mintun, A. Z. Snyder, J. D. Cohen, J. Mathews 
and Y. I. Sheline (2008). "Altered emotional interference processing in affective and cognitive- 
control brain circuitry in major depression." Biol Psychiatry 63(4): 377-384. 
Gotlib, I. H. (1982). "Self-reinforcement and depression in interpersonal interaction: the role of 
performance level." J Abnorm Psychol 91(1): 3-13. 
Gotlib, I. H. and J. Joormann (2010). "Cognition and depression: current status and future 
directions." Annu Rev Clin Psychol 6: 285-312. 
Hasin, D. S., A. L. Sarvet, J. L. Meyers, T. D. Saha, W. J. Ruan, M. Stohl and B. F. Grant 
(2018). "Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the 
United States." JAMA Psychiatry 75(4): 336-346. 
Jones, E. B. and L. Sharpe (2017). "Cognitive bias modification: A review of meta-analyses." J 
Affect Disord 223: 175-183. 
Kessler, R. C., S. Aguilar-Gaxiola, J. Alonso, S. Chatterji, S. Lee, J. Ormel, T. B. Ustun and P. S. 
Wang (2009). "The global burden of mental disorders: an update from the WHO World Mental 
Health (WMH) surveys." Epidemiol Psichiatr Soc 18(1): 23-33. 
Koster, A. (2017). "Narrative self-appropriation: embodiment, alienness, and personal 
responsibility in the context of borderline personality disorder." Theor Med Bioeth 38(6): 465- 
482. 
Mennen, A. C., K. A. Norman and N. B. Turk-Browne (2019). "Attentional bias in depression: 
understanding mechanisms to improve training and treatment." Curr Opin Psychol 29: 266-273. 
Mogg, K. and B. P. Bradley (2005). "Attentional Bias in Generalized Anxiety Disorder Versus 
Depressive Disorder." Cognitive Therapy and Research 29(1): 29-45. 
Mogg, K., M. Field and B. P. Bradley (2005). "Attentional and approach biases for smoking cues 
in smokers: an investigation of competing theoretical views of addiction." Psychopharmacology 
(Berl) 180(2): 333-341. 
Nolen-Hoeksema, S., B. E. Wisco and S. Lyubomirsky (2008). "Rethinking Rumination." 
Perspect Psychol Sci 3(5): 400-424. 
Rush, A. J., C. South, M. K. Jha, S. B. Jain and M. H. Trivedi (2020). "What to Expect When 
Switching to a Second Antidepressant Medication Following an Ineffective Initial SSRI: A 
Report From the Randomized Clinical STAR*D Study." J Clin Psychiatry 81(5). 
Sanchez, A., C. Vazquez, C. Marker, J. LeMoult and J. Joormann (2013). "Attentional 
disengagement predicts stress recovery in depression: an eye-tracking study." J Abnorm Psychol 
122(2): 303-313. 
Snyder, H. R. (2013). "Major depressive disorder is associated with broad impairments on 
neuropsychological measures of executive function: a meta-analysis and review." Psychol Bull 
139(1): 81-132. 
Suslow, T., C. Konrad, H. Kugel, D. Rumstadt, P. Zwitserlood, S. Schoning, P. Ohrmann, J. 
Bauer, M. Pyka, A. Kersting, V. Arolt, W. Heindel and U. Dannlowski (2010). "Automatic 

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mood-congruent amygdala responses to masked facial expressions in major depression." Biol 
Psychiatry 67(2): 155-160. 
Victor, T. A., M. L. Furey, S. J. Fromm, A. Ohman and W. C. Drevets (2010). "Relationship 
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14 Attachments 
 
Consent form is attached. 
 
15 Appendices 
 
15.1 
Studies Involving Research MRIs 
 
15.2 
Studies Involving Research Radiation 
 
15.3 
Studies Involving Research CT Scans 
 
15.4 Studies Involving Nuclear Medicine Regulated Research Procedures 
 
15.5 
Research studies involving Pathology and Lab Medicine 
 
15.6 Reference for Safety Reporting Section- Common Definitions for Developing Adverse Event 
Tracking and Serious Adverse Event Reporting Protocol 
 
Adverse Event Reporting Period 
The study period during which adverse events must be reported is normally defined as the period 
from the initiation of any study procedures to the end of the study treatment follow-up. 
 
Preexisting Condition 
A preexisting condition is one that is present at the start of the study. A preexisting condition 
should be recorded as an adverse event if the frequency, intensity, or the character of the 
condition worsens during the study period. 
 
General Physical Examination Findings 
At screening, any clinically significant abnormality should be recorded as a preexisting 
condition. At the end of the study, any new clinically significant findings/abnormalities that meet 
the definition of an adverse event must also be recorded and documented as an adverse event. 
 
 
Post-study Adverse Event 
All unresolved adverse events should be followed by the investigator until the events are 
resolved, the subject is lost to follow-up, or the adverse event is otherwise explained. At the last 
scheduled visit, the investigator should instruct each subject to report any subsequent event(s) 
that the subject, or the subject’s personal physician, believes might reasonably be related to 
participation in this study. The investigator should notify the study sponsor of any adverse event 
including death occurring at any time after a subject has discontinued or terminated study 

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participation, that may reasonably be related to this study. The sponsor should also be notified 
if the investigator should become aware of the development of cancer or of a congenital anomaly 
in a subsequently conceived offspring of a subject that has participated in this study. 
 
Abnormal Laboratory Values 
A clinical laboratory abnormality should be documented as an adverse event if any one of the 
following conditions is met: 
• The laboratory abnormality is not otherwise refuted by a repeat test to 
confirm the abnormality 
• The abnormality suggests a disease and/or organ toxicity 
• The abnormality is of a degree that requires active management; e.g. change 
of dose, discontinuation of the study procedures, more frequent follow-up 
assessments, further diagnostic investigation, etc. 
 
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization should be 
documented and reported as a serious adverse event unless specifically instructed otherwise in 
this protocol. Any condition responsible for surgery should be documented as an adverse event 
if the condition meets the criteria for and adverse event. 
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported as an 
adverse event in the following circumstances: 
• Hospitalization or prolonged hospitalization for diagnostic or elective surgical 
procedures for a preexisting condition. Surgery should not be reported as an 
outcome of an adverse event if the purpose of the surgery was elective or diagnostic 
and the outcome was uneventful. 
• Hospitalization or prolonged hospitalization required to allow efficacy measurement 
for the study. 
• Hospitalization or prolonged hospitalization for therapy of the target disease of the 
study, unless it is a worsening or increase in frequency of hospital admissions as 
judged by the clinical investigator. 
 
Penn IRB Definition of Unanticipated Problems Involving Risk to Subjects or Others 
Any incident, experience, or outcome that meets all of the following criteria: 
• Unexpected in nature, severity, or frequency (i.e. not described in study-related 
documents such as the IRB-approved protocol or consent form, the investigators 
brochure, etc.) 
• Related or possibly related to participation in the research (i.e. possibly related 
means there is a reasonable possibility that the incident experience, or outcome may 
have been caused by the procedures involved in the research) 
• Suggests that the research places subjects or others at greater risk of harm (including 
physical, psychological, economic, or social harm). 

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15.8 Source Documents 
N/A 
 
15.9 Case Report Forms (CRFs) 
N/A