Inflammation-Induced CNS Glutamate Changes in Depression
Phase: PHASE4
Conditions: Depression
Sponsor: Emory University

Study Protocol 
 
Title: Inflammation-Induced CNS Glutamate Changes in Depression 
 
NCT Number: NCT03004443 
 
Protocol Version Date: February 14, 2020 
 

Emory IRB#00090667 
PI: AH Miller  
Sponsor: NIMH 
1 
Version: February 14th, 2020  
 
1. Title: Inflammation-Induced CNS Glutamate Changes in Depression (Infliximab Glutamate Study) 
 
Principle Investigator: Andrew H. Miller MD and Ebrahim Haroon MD 
Co-Investigator: Michael Treadway, PhD, Bobbi Woolwine, MSW 
 
Version: February 14th, 2020  
 
2. Précis/Abstract:  
The proposed research is designed to determine the cause and effect relationship between inflammation 
and CNS glutamate as well as the relationship between CNS glutamate and specific symptoms. To 
accomplish these aims, we will administer a single infusion of either the TNF antagonist infliximab or 
placebo (n=30 per group) to patients with high inflammation (CRP>3mg/L). A CRP>3mg/L was chosen 
because it is considered high inflammation according to guidelines by the American Heart Association.1 
Moreover, a CRP>3mg/L was associated with significantly increased basal ganglia glutamate and was 
associated with a clinical response to infliximab.2, 3 Inflammatory biomarkers, basal ganglia glutamate as 
measured by MRS, and motivation and psychomotor activity will be assessed at baseline and days 1 and 
3 and weeks 1 and 2 following infliximab or placebo administration.  Inflammation is rapidly reduced 
(within 6 hours) following infusion, and there is evidence of improved motivation within 2 weeks of the first 
infusion (see Preliminary Data).3, 4 Finally, as previously demonstrated, infliximab-treated depressed 
patients show a 4mg/L drop in plasma CRP within 1 week of infliximab infusion. 
3. Introduction and Background:  
Two emerging theories regarding the development of mood disorders involve excessive activation of 
inflammatory pathways and alterations in glutamate metabolism.5-8 For example, increased inflammatory 
markers have been reliably found in the peripheral blood and cerebrospinal fluid (CSF) of patients with 
unipolar and bipolar depression.5, 9, 10 Moreover, administration of inflammatory stimuli including interferon 
(IFN)-alpha, typhoid vaccination or endotoxin have all been shown to lead to behavioral changes that 
characterize depression including depressed mood, anhedonia, and psychomotor slowing.11-16 In addition, 
inflammatory cytokines interact with virtually every pathophysiologic domain known to be involved in the 
regulation of mood including neurotransmitter metabolism, synaptic plasticity, neuroendocrine function 
and relevant neurocircuitry.5, 17, 18 Finally, inhibition of inflammatory cytokines has been shown to lead to 
improvements in depressed mood, anhedonia, and psychomotor retardation in patients with increased 
inflammation associated with depression or medical illnesses such as autoimmune and inflammatory 
disorders as well as cancer.3, 19, 20 Alterations in glutamate metabolism have also been implicated in mood 
disorders.6 Indeed, a number of studies using magnetic resonance spectroscopy (MRS) have found 
alterations in glutamate and glutamate metabolite levels in multiple brain regions of depressed patients, 
with bipolar depressives showing relatively consistent elevations in CNS glutamate and unipolar 
depressed patients exhibiting more mixed results.21-27 In addition, loss of glial elements including 
astrocytes and oligodendrocytes as well as loss of the transporters for excitatory amino acids, which are 
responsible for the reuptake and recycling of glutamate, are some of the most reliable changes found in 
post mortem brain tissue from patients with mood disorders.6, 7, 28-30 Significant differences in methylation 
patterns specific for astrocytic dysfunction have also been associated with depressive psychopathology in 
postmortem brain samples.31 Probably the most dramatic evidence of the role of glutamate in 
psychopathology of mood disorders is derived from the profound and rapid response of treatment 
resistant depressed patients to ketamine, an antagonist of the glutamate N-methyl-d-aspartate 
(NMDA) receptor.32-34 Of note, data indicate that anhedonia may be an especially responsive symptom to 
ketamine administration.35 
Inflammation and Glutamate Pathology may be Linked Cytokines Can Alter Glutamate Metabolism 
Inflammatory cytokines have been shown to interact with glutamate pathways in several important ways 
that may contribute to altered glutamate metabolism. Inflammatory cytokines have been shown to 
decrease the expression of glutamate transporters (excitatory amino acid transporters – EAAT) on 
relevant glial elements (astrocytes and oligodendrocytes) and increase the release of glutamate from 
astrocytes via reverse efflux from the EAAT and increased secretion through the cysteine/glutamate 

Emory IRB#00090667 
PI: AH Miller  
Sponsor: NIMH 
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Version: February 14th, 2020  
antiporter.36-39 Of note, glutamate released by astrocytes has preferential access to extrasynaptic NMDA 
receptors which have been shown to decrease brain derived neurotrophic factor (BDNF) and increase 
excitotoxicity.5, 40 Moreover, blockade of glutamate reuptake has been shown to lead to anhedonic-like 
behavior in rats.41  Glutamine synthetase which converts glutamate to glutamine, potentially leading to a 
build-up of intracellular and extracellular glutamate, along with cytokine induction of nitrogen and oxygen 
free radicals, can lead to astrocyte dysfunction and death.37, 42-44 Cytokines such as TNF can also reduce 
glutamate transporter expression on oligodendrocytes and in excess is directly toxic to these cells, further 
compromising glutamate reuptake.37, 42, 44 Finally, inflammatory cytokines can activate the kynurenine 
pathway leading to production of quinolinic acid by activated microglia. Quinolinic acid has been shown to 
act as an agonist at the glycine-binding site of the NMDA receptor, but also can stimulate synaptosomal 
glutamate release and decrease astrocytic glutamate reuptake both in vitro and in inflammatory pathways 
and alterations in glutamate metabolism.5-8 For example, increased inflammatory markers have been 
reliably found in the peripheral blood and cerebrospinal fluid (CSF) of patients with unipolar and bipolar 
depression.5, 9, 10 Moreover, administration of inflammatory stimuli including interferon (IFN)-alpha, typhoid 
vaccination or endotoxin have all been shown to lead to behavioral changes that characterize depression 
including depressed mood, anhedonia, and psychomotor slowing.11-16 In addition, inflammatory cytokines 
interact with virtually every pathophysiologic domain known to be involved in the regulation of mood 
including neurotransmitter metabolism, synaptic plasticity, neuroendocrine function and relevant 
neurocircuitry.5, 17, 18 Finally, inhibition of inflammatory cytokines has been shown to lead to improvements 
in depressed mood, anhedonia, and psychomotor retardation in patients with increased inflammation 
associated with depression or medical illnesses such as autoimmune and inflammatory disorders as well 
as cancer.3, 19, 20 Alterations in glutamate metabolism have also been implicated in mood disorders.6 
Indeed, a number of studies using magnetic resonance spectroscopy (MRS) have found alterations in 
glutamate and glutamate metabolite levels in multiple brain regions of depressed patients, with bipolar 
depressives showing relatively consistent elevations in CNS glutamate and unipolar depressed patients 
exhibiting more mixed results.21-27 In addition, loss of glial elements including astrocytes and 
oligodendrocytes as well as loss of the transporters for excitatory amino acids, which are responsible for 
the reuptake and recycling of glutamate, are some of the most reliable changes found in post mortem 
brain tissue from patients with mood disorders.6, 7, 28-30 Significant differences in methylation patterns 
specific for astrocytic dysfunction have also been associated with depressive psychopathology in 
postmortem brain samples.31 Probably the most dramatic evidence of the role of glutamate in 
psychopathology of mood disorders is derived from the profound and rapid response of treatment 
resistant depressed patients to ketamine, an antagonist of the glutamate N-methyl-d-aspartate 
(NMDA) receptor.32-34 Of note, data indicate that anhedonia may be an especially responsive symptom to 
ketamine administration.35 
Inflammation and Glutamate Pathology may be Linked 
Cytokines Can Alter Glutamate Metabolism 
Inflammatory cytokines have been shown to interact with glutamate pathways in several important ways 
that may contribute to altered glutamate metabolism. Inflammatory cytokines have been shown to 
decrease the expression of glutamate transporters (excitatory amino acid transporters – EAAT) on 
relevant glial elements (astrocytes and oligodendrocytes) and increase the release of glutamate from 
astrocytes via reverse efflux from the EAAT and increased secretion through the cysteine/glutamate 
antiporter.36-39 Of note, glutamate released by astrocytes has preferential access to extrasynaptic NMDA 
receptors which have been shown to decrease brain derived neurotrophic factor (BDNF) and increase 
excitotoxicity.5, 40 Moreover, blockade of glutamate reuptake has been shown to lead to anhedonic-like 
behavior in rats.41 Glutamine synthetase which converts glutamate to glutamine, potentially leading to a 
build-up of intracellular and extracellular glutamate, along with cytokine induction of nitrogen and oxygen 
free radicals, can lead to astrocyte dysfunction and death.37, 42-44 Cytokines such as TNF can also reduce 
glutamate transporter expression on oligodendrocytes and in excess is directly toxic to these cells, further 
compromising glutamate reuptake.37, 42, 44 Finally, inflammatory cytokines can activate the kynurenine 
pathway leading to production of quinolinic acid by activated microglia. Quinolinic acid has been shown to 
act as an agonist at the glycine-binding site of the NMDA receptor, but also can stimulate synaptosomal 
glutamate release and decrease astrocytic glutamate reuptake both in vitro and in vivo.45-47 Taken 
together, these effects of inflammatory cytokines on glutamate metabolism, reuptake and release by 
astrocytes and oligodendrocytes as well as the fundamental integrity (and survival) of these glial elements 

Emory IRB#00090667 
PI: AH Miller  
Sponsor: NIMH 
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Version: February 14th, 2020  
provide an intriguing intersection of the inflammation and glutamate hypotheses of mood disorders 
including depression. Clinical data supporting the notion that inflammatory cytokines can alter CNS 
glutamate metabolism have recently been generated by our group in both patients treated with the 
inflammatory cytokine interferon (IFN)-alpha and in depressed patients with increased inflammation as 
reflected by elevated concentrations of plasma C-reactive protein (CRP). Indeed, administration of IFN-
alpha was found to increase glutamate as measured by the glutamate to creatine (Glu/Cr) ratio using 
MRS in the left basal ganglia and dorsal anterior cingulate cortex (dACC). The basal ganglia and dACC 
are brain regions that have been repeatedly implicated as targets of peripherally administered 
inflammatory stimuli including inflammatory cytokines as well as typhoid vaccination and endotoxin.11, 12, 
14-17 Of note, IFN-alpha-induced increases in glutamate in the basal ganglia in turn were correlated with 
IFN-alpha-induced depressive symptoms including anhedonia and psychomotor 
slowing.48, 49 In addition, IFN-alpha-induced increases in TNF were correlated with increased basal 
ganglia glutamate,48 suggesting a direct relationship between increased inflammatory cytokines and 
increased glutamate (as proposed in this application) and supporting the use of a TNF antagonist to 
reduce CNS glutamate as planned in Aims 1-3. Our recently published data  (MDD) also indicate that 
increased inflammation as reflected by plasma CRP is associated with increased basal ganglia glutamate 
in both a linear and stepwise fashion, with MDD patients with a CRP>3mg/L showing significantly higher 
basal ganglia glutamate than patients with a CRP<1mg/L(see Appendix 
http://www.nature.com/mp/journal/vaop/ncurrent/full/mp2015206a.html).2 Interestingly, increased basal 
ganglia glutamate was also associated with anhedonia and psychomotor slowing in MDD patients. 
Finally, pretreatment with ketamine has been shown to block the development of depressive-like behavior 
in mice as a result of the administration of the inflammatory stimulus lipopolysaccharide.50 Surprisingly, 
ketamine had no effect on LPS-induced inflammatory activation in the brain. Taken together, these data 
provide convincing evidence across distinct experimental paradigms that increased inflammation may be 
linked to altered glutamate metabolism that is manifested as increased CNS glutamate as measured by 
MRS. Nevertheless, the data to date in humans is correlational in nature, and the opportunity exists to 
block inflammation in depressed patients with high inflammation and determine whether glutamate is 
decreased in a cause and effect manner. Relevant in this regard, is a recent study conducted by our 
group demonstrating that inhibition of TNF in depressed patients with high inflammation using a 
monoclonal antibody to TNF (infliximab) led to decreased anhedonia and psychomotor retardation, which 
are the two major symptoms that have been associated with increased basal ganglia glutamate in our 
previous studies.2, 48, 49 Whether this effect of the TNF antagonist was a result of effects on CNS 
glutamate will be tested in Aims 1 and 2 of this proposal. 
4. Objectives: (Primary and secondary aims) 
Specific Aims: To establish a cause and effect relationship between increased inflammation and basal 
ganglia glutamate, we propose to administer an anti-inflammatory challenge to depressed patients with 
high inflammation and determine whether basal ganglia glutamate is decreased in association with 
increased motivation and psychomotor speed. Recent data suggest that inflammation leads to increased 
CNS glutamate which may contribute to behavioral alterations in patients with neuropsychiatric disorders 
including depression. Consistent with this notion, data from our group has shown that administration of 
the inflammatory cytokine interferon (IFN)-alpha to otherwise non-depressed subjects leads to increased 
glutamate in the basal ganglia as measured by magnetic resonance spectroscopy (MRS). Increased 
basal ganglia glutamate was in turn associated with alterations in research domain criteria (RDoC) 
involving Positive and Negative Valence systems including anhedonia and psychomotor retardation. Our 
data in patients with major depression also suggest that increased inflammation as reflected by peripheral 
blood C-reactive protein (CRP) is correlated with increased basal ganglia glutamate in association with 
anhedonia and decreased psychomotor speed. Taken together, these data suggest that inflammation 
may increase basal ganglia glutamate, leading to the development of depressive symptoms relevant to 
motivation and motor activity. Nevertheless, the data to date has been correlational in nature. Our prior 
data demonstrate that administration of the anti-inflammatory agent infliximab, a highly specific 
monoclonal antibody to TNF, powerfully reduces inflammation (e.g. CRP) and decreases symptoms of 
anhedonia and psychomotor retardation in depressed patients with high inflammation. Therefore, through 
the use of state-of-the-art MRS techniques and a biologic agent that can block inflammation (TNF 
antagonist) with limited off-target effects, the proposed research will test the hypothesis that increased 
inflammation leads to increased basal ganglia glutamate, which in turn is associated with changes in 

Emory IRB#00090667 
PI: AH Miller  
Sponsor: NIMH 
4 
Version: February 14th, 2020  
behavior related to motivation and psychomotor performance. Accordingly, the following specific aims are 
proposed: 
Aim 1) To determine whether inhibition of inflammation reduces basal ganglia glutamate following 
acute administration of the anti-inflammatory agent infliximab versus placebo in depressed 
patients with high inflammation. 60 medication-free depressed patients ages 21-65 with high 
inflammation (CRP >3mg/L) will be enrolled. Single-voxel MRS assessments of absolute glutamate in the 
basal ganglia and other regions of relevance including the dorsal anterior cingulate cortex (dACC) as well 
as the left medial parietal cortex (as a control region) will be assessed at baseline and on day 3 and week 
2 after a single infusion of the 
TNF antagonist infliximab or placebo. For exploratory analyses, additional metabolites will also be 
examined, and multivoxel chemical shift imaging (CSI) will be performed. Hypothesis 1: Compared to 
placebo, infliximab treated patients will exhibit decreased absolute glutamate in the basal ganglia on day 
3 and week 2. 
Aim 2) To determine the relationship between basal ganglia glutamate and anhedonia and 
psychomotor retardation following acute administration of the anti-inflammatory agent infliximab 
versus placebo in depressed patients with high inflammation. Objective and clinical measures of 
anhedonia and psychomotor retardation will be obtained in the subjects in Aim 1 at baseline and day 3 
and week 2 after administration of infliximab or placebo. Hypothesis 2: Decreased basal ganglia 
glutamate concentrations will precede and ultimately be associated with improved objective and clinical 
measures of anhedonia and psychomotor retardation. 
Aim 3) To determine the relationship between inflammatory markers and basal ganglia glutamate 
following acute administration of the anti-inflammatory agent infliximab versus placebo in 
depressed patients with high inflammation. Peripheral blood protein and gene expression markers of 
inflammation will be assessed at baseline and on post-infusion days 1 and 3 and weeks 1 and 2 along 
with central (cerebrospinal fluid) measures of protein inflammatory markers at week 2 in subjects 
recruited in Aim 1. 
Hypothesis 3: Decreased peripheral and central markers of inflammation will precede and predict 
decreases in basal ganglia glutamate. Determination of dynamic, temporal relationships among 
inflammation, CNS glutamate and behavior will provide the foundation for biomarker-driven, intelligently-
designed studies of novel therapeutic agents that target inflammation and/or glutamate for the treatment 
of alterations in motivation and motor activity in patients with depression and other neuropsychiatric 
disorders with increased inflammation. 
5. Study design and methods: Two hundred male and female participants ages 21-65 will be enrolled in 
the study to obtain 60 qualified subjects. Written informed consent will be obtained from all patients 
before protocol-specified procedures are conducted. Subjects will be drawn from an ambulatory sample 
of patients with MDD. 
Participant Selection 
Inclusion Criteria:  
a. willing and able to give written informed consent;  
b. men or women, 21-65 years of age;  
c. a primary diagnosis of DSM-V MDD, current, or Bipolar, depressed type as diagnosed by the SCID-V; 
d. score of ≥14 on the Quick Inventory of Depressive Symptomatology (QIDS)-SR-16*51 or score ≥ 15 on 
the Patient Health Questionnaire 9 item (PHQ-9) 
e. absence of significant suicidal ideation defined using the Columbia Suicide Severity Rating Scale – 
Screen Version (CSSRS) as follows: 
 
*PI discretion or 
d/w BW, AHM or 
EH, ** = refer for 
Rx. 
 
 
 
 
 
 
Yes on: 
Q6 (<30d) 
Q6 (>30d/lifetime) 
Q6 (no) 
Q3 (- Intent/- Plan) 
Exclude** 
Include* 
Include 
Q4 (+ Intent/- plan) 
Exclude** 
Exclude** 
Include 
Q5 (+ Intent/+ Plan) 
Exclude** 
Exclude** 
Exclude** 
Q6 (s/p SIB) 
Exclude** 
N/A 
N/A 
Q6 (>30d/lifetime)  
(Lifetime SIB) 
N/A 
Include 
Include 

Emory IRB#00090667 
PI: AH Miller  
Sponsor: NIMH 
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Version: February 14th, 2020  
f. off all antidepressant or other psychotropic therapy (e.g. mood stabilizers, antipsychotics, anxiolytics, 
and sedative hypnotics) for at least 4 weeks prior to the baseline visit (8 weeks for fluoxetine)*. No 
patients will be removed from their psychotropic medications for the sole purpose of participating in the 
study. 
g. sexually active participants are required to agree to abstain from sexual intercourse 14 days prior to 
study infusion and are required to use medically approved birth control methods as defined in the Birth 
Control Method Form below for the duration of the study and advised to delay conception for 6 months 
post infusion. 
 
 
  
 
BIRTH CONTROL METHOD 
 
Participant name  
 
Sex 
Male___Female___ 
DOB 
(___/___/___) 
 
Sexually active participants of childbearing potential must agree to use contraception or abstain from sexual activity as defined below.   
Please initial all that apply below: 
 
□ 
 
□ 
 
Female participants practice abstinence from sexual activity 14 days prior to date of study infusion. 
 
Male and female participants agree to use a medically approved birth control method as defined below for at least 60 days post study infusion. Participants 
are advised to delay conception for 6 months post-infusion. 
 
□ 
□ 
□ 
 
 
Female (patient or partner) not of reproductive potential 
  
Removal of ovaries and/or uterus (when: _____ ) 
Post-menopausal for at least 2 years (when: _____ )            
 
□ 
Medically approved contraception methods (participant or partner)  
(Periodic abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable methods of contraception) 
□ 
Abstinence from sexual activity that could result on pregnancy 
□ 
Sterilization surgery  
Males: vasectomy (when: _____ ) 
Females: Bilateral tubal ligation (when: _____ ) 
□ 
Condoms (male or female) with spermicide 
□ 
Diaphragm or cervical cap with spermicide 
□ 
Intrauterine device (IUD) (when: _____ ) 
□ 
Hormone-based therapy, e.g. birth control pills, Norplant, or Dep-Provera 
 
□ I have been informed of and fully understand the potential risks of the study drug (infliximab/inflectra) with pregnancy.   
 
Participant signature 
 
Date 
 
PI/NP/designee signature 
 
Date 
  
 
10/23/2019 BW                                                                                                                           __________________________________________________________________   Page 1 of 1 
 
 
Exclusion Criteria: a. any active or history of autoimmune disorder (as confirmed by laboratory testing); 
b. history of tuberculosis (by history or as discovered by chest X-ray, skin testing or blood testing) or high 
risk of tuberculosis exposure; c. hepatitis B or C infection or human immunodeficiency virus infection (as 
established by laboratory testing); d. history of fungal infection; e. history of recurrent viral or bacterial 
infections, including dental, gum, and ear infections; f. history of any type of cancer; g. unstable 
cardiovascular, endocrinologic, hematologic, hepatic, renal, or neurologic disease (as determined by 
physical examination and laboratory testing); h. history of any (non-mood-related) psychotic disorder; 
active psychotic symptoms of any type; antisocial personality disorder as determined by a clinician; 
substance abuse/dependence within 6 months of study entry (as determined by SCID)*; i. active suicidal 

Emory IRB#00090667 
PI: AH Miller  
Sponsor: NIMH 
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Version: February 14th, 2020  
plan as determined by a score >3 on item #3 on the HAM-D; j. an active eating disorder, unless limited to 
binge eating in the context of a mood disorder and in absence of purging; k. a history of a cognitive 
disorder or < 28 on the Mini-Mental State Exam*;52 l. pregnancy or lactation; m. women of child bearing 
potential who are not using a medically accepted means of contraception; n. heterosexual males and their 
partners who do not agree to practice appropriate birth control; o. known allergy to murine products or 
other biologic therapies; p. chronic use of non-steroidal anti-inflammatory agents (NSAIDS), 
glucocorticoid containing medications or statins*; q. use of NSAIDS, glucocorticoids, or statins at any time 
during the study*; r. contraindication to MRI (see Human Subjects), s. previous organ transplant, and t. 
history of CNS trauma or active seizure disorder.* Due to the high co-morbidity between anxiety disorders 
and depression, we plan to include patients with anxiety disorders  as long as depression is the primary 
diagnosis. Patients with stable medical conditions and on medications for those conditions will not be 
excluded. Finally, highly treatment resistant depressed patients who score >5 on the MGH Antidepressant 
Treatment Response Questionnaire (ATRQ) for current episode will be excluded, because these 
individuals may represent an extreme subgroup with a qualitatively distinct biology.53 *unless otherwise 
approved by the PI. 
Description of Study Procedures 
Screening: Subjects potentially qualified for enrollment will undergo a screening evaluation after written 
informed consent. Screening will involve subject interview and evaluation, as well as obtaining collateral 
history and data from other relevant sources (i.e. medical records, referring physician). Screening will 
include the following assessments: (1) Assessment of past psychiatric history and current symptom 
severity using the Structured Clinical Interview for DSM-V (SCID-V), 24-item HDRS, QIDS-16 SR or PHQ-
9, and a DSM V-based interview to rule out antisocial personality disorder (2) Assessment of past and 
current psychiatric treatment history using the ATRQ supplemented by information from medical records 
and referring physicians when available, (3) Evaluation of medical history obtained from interview of the 
patient and review of pertinent medical records. (4) Complete medical and neurological examination, (5) 
Screening laboratory evaluations as described in “medical exclusionary criteria” above, (6) Height and 
weight (provided to the pharmacy to calculate infliximab dose for patients randomized to the infliximab 
arm of the study), and (7) plasma CRP. The PI may request to perform a rapid CRP test at screening 
using the Diazyme hsCRP POC Test Kit. This kit produces rapid results using a finger prick method to 
collect 20μl of blood and is intended for the in vitro quantitative determination of C-reactive protein. 
Screening laboratory evaluations may be repeated at PI’s or PI designee’s discretion. Additional 
assessments will be conducted if more than 4 weeks from screening, unless otherwise approved by the 
PI, study physician or PI’s designee. 
Baseline: Baseline will occur over 2 days, including MRS, blood sampling and behavioral and 
neurocognitive assessments on Day 1 (Visit 1), and randomization to infliximab versus placebo on Day 2 
(Visit 2). Vital signs, safety labs, urine toxicology and adverse events will be collected as indicated in 
Table 1. 
 
Table 1A: Schedule of Study Procedures and Assessments 
Assessments 
Intake 
Screening 
Baseline* 
Day 1 
Day 3 
Week 1 
Week 2 
30 Day  
F/U  
Phone Call  
Visit 1 
Visit 2 
Visit 1 
Visit 2 
(Optional) 
Intake forms and assessments: Consent, HIPPA tracking, 
Release of Information**, Consent of Means of 
Communication**, Participant Payment Form**, MRI 
Screening Form**, Clinician-Assisted QIDS-16 SR** or  
Patient Health Questionnaire PHQ-9**, Medication 
Avoidance List**, Lumbar Puncture Information Guide, 
Schedule Quick Guide 
X 
 
 
 
 
 
 
 
 
 
Psychiatric screening: WRAT-3**, MMSE**,  HAM-D**, 
ATRQ, SCID V**, CSSRS, Clinical Interview Review [to be 
done in place of imported psych assessments from prior 
study] 
 
X 
 
 
 
 
 
 
 
 

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*Baseline will occur over 2 visits: Visit 1: MRS, blood and Symptom Domain Assessments; Visit 2: Infusion; see below for abbreviations, **Unless prior documentation 
available from previous study, ⁰Screening (or Baseline 1) and Week 2 only, [ ] indicates option to complete assessment, *** PCL-5 (with LEC) at Baseline 1 only, and PCL-5 
(without LEC) at Day 3 and Week 2 
 
 
 
Table 1B: Participants in the combination study will complete the above schedule in 
addition to the adapted version below: 
 
OPTIONAL: Combination Study   
 
Infliximab Administration: The dosing protocol and scheduling of the infliximab infusions for this proposal 
was derived from the standard intravenous regimen for the treatment of inflammatory bowel disease.54 
Independent pharmacists will dispense either infliximab or placebo in a 250ml saline bag according to a 
computer-generated randomization list provided by the study statistician. The placebo will be matched to 
Laboratory Screening: Anti-nuclear AB**, C-reactive 
protein, TSH, Hepatitis B surface antigen**, Hepatitis C 
antibody**, HIV antigen/antibody**, QuantiFERON-TB Gold 
or TB Gold Plus,  Hemoglobin A1c, Diazyme hsCRP POC 
Test Kit [if necessary to verify CRP], EKG, CXR 
 
X 
 
 
 
 
 
 
 
 
Serum pregnancy test 
 
X 
 
X 
 
 
 
X 
 
 
Medical History and Physical Examination or medical 
update 
 
X 
X 
X 
[X] 
X 
[X] 
X 
[X] 
X 
Adverse events, Concomitant medications [Con. Med. not 
completed at 30 day F/U phone call only] 
 
X 
X 
X 
[X] 
X 
[X] 
X 
[X] 
X 
Vital Signs, weight, height [screen only], waist-hip ratio 
[screen only] 
 
X 
X 
X 
[X] 
X 
[X] 
X 
[X] 
 
Routine Labs: CBC with differential, urinalysis w/ micro, 
comprehensive metabolic panel⁰   
 
X 
 
X 
 
 
[X] 
X 
[X] 
 
Urine toxicology 
 
X 
X 
X 
[X] 
X 
[X] 
X 
[X] 
 
Psychiatric baseline: Demographic data**, Childhood 
Trauma**,  Bipolarity Index** 
 
 
X 
 
 
 
 
 
 
 
Infusion (Infliximab or placebo) 
 
 
 
X 
 
 
 
 
 
 
Estrogen/progesterone 
 
 
 
X 
 
 
 
 
 
 
Urine pregnancy test kit 
 
 
X 
 
 
X 
X 
X 
 
 
Research blood: Cytokine Multiplex, mRNA, Plasma CRP 
 
 
X 
X 
[X] 
X 
[X] 
X 
 
 
Clinician-Administered: SHAPS-C, CSSRS⁰, SRRS⁰, HAM-
A⁰ 
 
 
X 
 
 
X 
 
X 
 
 
Self-Report: MFI, MAP, IDS-SR, BAI, PCL-5***, STAI-State 
 
 
X 
 
 
X 
 
X 
 
 
Neurocognitive Tests: FTT, RTT, DSST, Trails A 
 
 
X 
 
 
X 
 
X 
 
 
Computer Assessments: Gamble, Go No-Go, RLT, SLT 
 
 
X 
 
 
 
 
X 
 
 
MRS 
 
 
X 
 
 
X 
 
X 
 
 
PT, PTT 
 
 
 
 
 
 
 
[X] 
 
 
Lumbar Puncture (Optional) 
 
 
 
 
 
 
 
 
[X] 
 
Assessments 
Intake 
Screening 
Baseline* 
Day 1 
Day 3 
Week 1 
Week 2 
30 Day  
F/U  
Phone Call  
Self-Report: PANAS-X,  IDS-SR  
 
 
X 
 
[X] 
X 
[X] 
[X] 
 
 
Behavioral Computer Task: behEEfRT (in place of 
Gamble task) 
 
 
X 
 
 
X 
[X] 
[X] 
 
 

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PI: AH Miller  
Sponsor: NIMH 
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infliximab on the basis of color and consistency when dissolved in saline. Several factors contributed to 
the decision to use infliximab in this study. First, we have data using infliximab that demonstrates that 
patients with high inflammation administered this drug exhibit a decrease in both plasma and PBMC 
protein and gene expression of inflammatory markers as well as certain depressive symptoms.3, 4 
Second, unlike etanercept and anakinra, which require daily or several times a week dosing done at 
home, infliximab provides significant and long-lasting anti-inflammatory activity after a single infusion. 
Third, the administration of infusions at our site under our supervision guarantees that all subjects will 
receive identical medication exposure, thus eliminating adherence issues. Finally, based on our previous 
experience, infliximab was well-tolerated with no serious adverse events, no differences in side effects 
compared to placebo, and no ability to be distinguished from placebo by patients or staff.3 
Infliximab Infusion Protocol: Double-blinded infusions of infliximab or saline will be administered in the 
research outpatient unit of the Atlanta Clinical and Translational Science Institute- Clinical Research 
Network (ACTSI-CRN). Infusions will be performed following guidelines in place for patients who receive 
infliximab at the ACTSI-CRN. Specifically, intravenous access will be obtained in a sterile manner and 
infliximab (5 mg/kg body weight) or saline will be administered over a 2 to 2½ hour period while subjects 
rest quietly in an infusion chair solely used for infusions. Subjects will be monitored during the infusion 
and for 30 minutes after completion for the possible development of anaphylaxis, which occur in less than 
1% of patients receiving an initial dose of infliximab. All aspects of the infusion will be overseen by 
infliximab-trained nurses and the standard protocol for acute adverse reactions will be initiated if subjects 
develop anaphylaxis during infusion. 
Randomization: A randomly generated sequence of assignments to infliximab or saline will be created 
and maintained by the study pharmacist. Subjects will be stratified on the basis of sex to obviate any 
confounding effect of gender on the outcome variables. Subjects will be randomized in blocks of 4. 
Allocation to infliximab or saline will occur when a patient is eligible for the study and the consent for 
randomization has been obtained. If a subject drops out prior to receiving the infusion, he/she will not be 
included in data analyses and his/her randomization assignment will “roll over” to the next recruited 
subject until 60 subjects have received an infusion and at least one post infusion assessment. 
Blinding/Saline Preparation: An unblinded pharmacist will be responsible for preparing the infusion bag 
with either infliximab or normal saline based on the pre-determined order of the randomization list 
supplied by the study statistician. Study personnel responsible for administering the infusion, conducting 
psychiatric evaluations, conducting medical assessments, drawing blood and performing lab analyses will 
be blinded to subject group assignment. In the event of a significant adverse reaction to the study 
medication, the study blind will be broken if medically necessary, and the subject will be referred for 
appropriate medical care. Such adverse reactions are indicated in section on Human Subjects Protection. 
Unblinded subjects will be discontinued from the protocol. An unblinded physician not associated with the 
study will contact the study pharmacist in cases where medical intervention requiring knowledge of group 
assignment is clinically warranted. 
Lumbar Puncture (LP): On Week 2-Visit 2 (within 2 weeks, or at the discretion of the PI) of the Week 2-
Visit 1 procedures (blood sampling, neuropsychiatric assessments and MRS), all subjects will receive ~1 
liter of normal saline through an indwelling catheter to reduce incidence of post-LP headache and 
standardize hydration levels. Before the procedure, subjects will be offered pre-LP sedation (e.g. Versed) 
through IV. An anesthesiologist will review the results of the PT and PTT coagulation tests collected 1-14 
days prior. The anesthesiologist will perform the LP using standard sterile technique and local anesthesia 
with patients in the lateral decubitus position. ~10 cc of CSF will be withdrawn. After discarding the initial 
1 ml (to avoid blood contamination), remaining CSF will be collected into chilled tubes and aliquoted on 
ice in 1ml Eppendorf tubes, which will be immediately frozen at –80 C for later batched analyses. Upon 
LP completion, subjects will lay flat for ~1 hour and will be observed and treated for any side effects (e.g. 
headache or local irritation at LP site). The nurse practitioner or designee will also make a follow-up call 
1, 3, 7, and 14 days following the LP to check if patients are experiencing any other study emergent side 
effects including chronic pain. If any patient expresses persisting pain or any other study emergent 
adverse event, then the information will be forwarded to the study MD for further management. 
30 Day (Post-Infusion) Follow-Up Call: The research team will call subjects 30 days post-infusion to 
assess for any adverse events that may have occurred after study completion.      
 
 

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Optional Combination Study: Department of Psychology Task-Based fMRI Scan Visits: 
Study participants may choose to complete 2 additional scan visits as an optional extension of this study. 
These visits are a part of a Task-Based Functional MRI (fMRI) study under the Department of 
Psychology, Dynamics of Inflammation and its Blockade on Motivational Circuitry in Depression, 
IRB#00087941 (see Table 1B). The purpose of the study is to see how the brain processes different 
types of information, and the way this affects behavior. Both study visits, the Baseline: fMRI Scan Visit 
and 14 Day: fMRI Scan Visit will take place at the Emory Department of Psychology on campus. The 
combined protocol scan visits will be consistently scheduled in the following order: Baseline Visits (fMRI 
scan → MRS Scan) and 14 Day Visits (MRS Scan→ fMRI scan). All scans should be within 3 days of 
either the infusion visit or week 2. Participants will complete behavioral tasks, self-report questionnaires, 
fMRI scans, urine drug tests and urine pregnancy tests (if applicable) at each visit. Subjects will sign a 
separate consent form to participate in the combination study. Participants completing the additional 2 
day study option will be paid up to $800 in addition to the compensation received for the main study.  
 
Table 1C:  
Baseline: Task- 
Based fMRI  
scan  
** 
 
 
Baseline 
(MRS Scan) 
 
Infusion 
1 Day 
 
 
3 Day 
(MRS Scan) 
 
7 Day 
 
 
14 Day 
(MRS Scan) 
 
14 Day: 
Task- Based 
fMRI scan 
** 
LP 
Optional 
IGLU Study 
IGLU Study 
IGLU Study 
IGLU Study 
IGLU Study 
IGLU Study 
Optional 
IGLU Study 
 
Subjects participating in the combination I-Glu/Infliximab studies will complete the Additional Measures 
below as part of participation in the IGLU study schedule: 
Self-Report Measures 
The below self-report measures will be collected at the Baseline, 24-Hr, 3-Day, and 7-Day Visits.  
PANAS-X: The Positive Affect/Negative Affect Scale (PANAS) is a widely used measure of in-the-moment 
aspects of positive and negative affectivity, and will be used as an additional measure of self-reported 
changes in anhedonic symptoms following inflammation blockade.  
Inventory of Depressive Symptoms-Self Report (IDS-SR) is a 30-item self-report instrument with 
excellent psychometric properties that was designed to measure symptom constructs consistent with 
current DSM nosology and that has been widely used as a self-report outcome measure of depression in 
treatment trials.  
Optional Combination Study (con’t): 
Behavioral Computer Tasks 
The below task will replace the Gambling task administered at Baseline, 3-Day, and 7-Day visits. 
Behavioral Effort-Expenditure for Rewards Task (behEEfRT; approx. 20-25 min): The behEEfRT 
task is a multi-trial game in which participants are given an opportunity on each trial to choose between 
two different task difficulty levels in order to obtain monetary rewards. For all trials, participants make 
repeated manual button presses within a short period of time. Each button press raises the level of a 
virtual ‘‘bar’’ viewed onscreen by the participant. Participants are eligible to win the money allotted for 
each trial if they raise the bar to the ‘‘top’’ within the prescribed time period. Each trial presents subjects 
with a choice between two levels of task difficulty, a ‘high-effort’ and ‘low-effort’ task that require different 
amounts of speeded button pressing. Reward magnitudes for the high effort task vary between $1.24 and 
$4.33, while reward magnitudes for the low effort task remain constant ($1.00). Trials also vary in terms of 
3 levels of probability of winning the amount associated with the choice selected. Subjects participate in 
the task for about 20 minutes and the first 50 trials are used for analysis.  For statistical analyses the 
proportion of hard-task choices across each level of probability is calculated. Lower proportions of hard 
task choices indicate decreased motivation for monetary rewards. The EEfRT will be administered 5 

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times. The task has excellent test-retest reliability (test-retest r > 0.85), and has been successfully used in 
prior multi-session studies with similar time intervals between administrations.  
 
Criteria for Study Discontinuation (“Stopping Rules”):  
Individual: 
Subjects will be closely evaluated for worsening of psychiatric symptoms during the study. Subjects will 
be evaluated at baseline and at post-infusion Day 3 and weeks 1 and 2. Subjects will be discontinued at 
any point after screening for any of the following: 1) significant suicidal ideation as determined by 
spontaneous subject report or as clinically warranted based on the Columbia Suicide Severity Rating 
Scale – Screen Version (CSSRS),55 2) psychotic or catatonic symptoms and 3) serious complications of 
TNF antagonism (e.g. serious infection). Meeting discontinuation criteria prior to baseline will result in a 
subject not undergoing infusion. Subjects who meet discontinuation criteria following infusion will be 
discontinued. Subjects requiring discontinuation will be evaluated for danger to self or others and will 
receive emergency referral if required. In non-emergent cases, the referring clinician will be contacted 
immediately and a plan for appropriate psychiatric or medical care will be established and implemented.  
Study: 
1) If more than two individuals experience a reportable serious adverse event related to study procedures 
within a six month period, the study will be stopped and reviewed by the DSMB. 
 
Neuropsychiatric Assessments 
Structured Clinical Interview for DSM-V Axis I Disorders (SCID-V) is a semi-structured clinical 
interview that provides a wide range of DSM-V diagnoses.56 All patients will be evaluated by the SCID as 
part of the screening process. In addition to providing information for inclusion/exclusion purposes, the 
SCID will provide data about psychiatric predictors of treatment response, including number of past major 
depressive episodes, length of the current episode and presence of co-morbid anxiety disorders and/or 
dysthymia. The Mood Disorders and Alcohol/Substance Abuse Modules will be administered at all study 
assessments to evaluate whether subjects continue to meet criteria for major depression and to evaluate 
whether subjects have developed substance abuse symptoms (also confirmed by urine toxicology screen 
at each assessment). 
The MGH Antidepressant Treatment Response Questionnaire (ATRQ):57 The ATRQ provides specific 
criteria for adequate dose and adequate length of a trial for it to be considered a failure, thus allowing 
clinicians to systematically collect data aimed at assessing degree of treatment-resistance of the MD 
episode. The data obtained can then be used to calculate a score using the MGH Staging Method (MGH-
S) to classify degree of treatment resistance.58 Degree of resistance will be used as a covariate in 
relevant statistical analyses and to exclude severely treatment resistant subjects.53 
Mini-Mental State Exam (MMSE) is a 27-item interviewer-administered questionnaire widely used for the 
evaluation of general cognitive functioning and identification of altered mental status. At screening, 
subjects will be excluded for score < 28, which is a standard cutoff for clinically significant cognitive 
impairment.52 
Dependent Variables 
MRS acquisition: 
The scanner hardware and the scanning sequences described in this section are similar to those 
described previously,2 but modified for the PRISMA platform. All images will be acquired using a Siemens 
3 Prisma 3T scanner (Siemens Medical Solutions, Malvern, PA, USA) equipped with a maximum gradient 
strength of 80 mT/m and a rise time of 200 μs, which will provide nearly double the signal-to-noise ratio 
enabling high-resolution structural imaging data. The new digital RF system equipped with 64-channel RF 
head-and-neck coil and the two-channel RF excitation coils will provide better spectral resolution with 
improved signal-to-noise ratio while at the same time providing more uniform excitation pulses. For image 
guidance and MRS volume of interest prescription, anatomic images will be obtained using a T1-weighted 
MPRAGE sequence with the following parameters: TR/TI/TE =2300/900/3.02 msec; flip angle=8°; FOV 
read=256 mm; matrix=256; slice thickness=1mm; GRAPPA factor of 0; total scan time=6 minutes. 
Single Voxel MRS Acquisition: 
Single Voxel Spectroscopy (SVS) will be used to quantitate of neurometabolites of interest in specific 
brain regions with a focus on the basal ganglia (see Figure 5 for sample basal ganglia spectrum). SVS 

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will be acquired using ChemicalShift Selective (CHESS)-based MRS sequence using settings of TR/TE = 
3000/30 ms, sampling size=128 averages, bandwidth=1024Hz. Two voxels with sizes of 17 x 30 x 17 
mm3 located in the left and right basal ganglia (encompassing parts of the caudate, putamen and 
pallidum and the associated intervening white matter),one voxel in dACC (BA 24) with a size of 20 x 30 x 
10mm3, and one “control” voxel located in the left medial parietal regions of 20x20x20 mm3 (to explore 
regional specificity of the findings) will be used for SVS (see Figure 6). Spatial localization will be 
implemented using PRESS technique.59 Numerically optimized Shinnar-Le Roux (SLR) radio frequency 
pulses will be used for PRESS (90°, 180°, 180°) and CHESS (90°, 90°, 90°).60 Four unsuppressed water 
FIDs (free induction decay) will also be acquired for eddy current suppression and phase correction66 
and to compute metabolite/water ratios if needed (LC-Model). The FWHM of the unsuppressed water 
peak will be optimized to <14 Hz by shimming. Of note, to facilitate spectral acquisition in deeper regions, 
previously phantom optimized 20-channel coil will be used. The spectral data will not be apodized  
Chemical Shift Imaging (CSI): The application of a single voxel to a specific region makes it difficult to 
evaluate diffuse or global cortical and subcortical glutamate abnormalities that may occur in association 
with inflammation and have been proposed to occur in unipolar depression.61 The setting will be similar to 
those reported in our recent publication. CSI will be acquired for exploratory analyses using 2D Point 
Resolved Spectroscopy (PRESS)-based MRSI sequence using settings of TR=1590 ms, TE=30 ms, 
averages= 7, matrix=16×16, voxel size=11. 3×11.3×15 mm3, slice thickness=15mm. The raw files will be 
processed using LC-Model.62 
Post Processing: 
Metabolite Spectral Fitting: The LC-Model62 is an operator-independent commercial software package 
that fits in vivo metabolite spectra using model resonances acquired from multiple compounds in standard 
phantom solutions. The water suppressed time-domain data will be analyzed between 0.4 ppm and 4.0 
ppm without T1 and T2 correction. The basis set provided by the vendor of the LC Model62 will be used 
and then scaled to account for receiver gain differences. While the entire 18 metabolite basis set would 
be entered during metabolite fitting, the analysis will only include metabolite variances (Cramer Rao 
Lower Bounds or CRLB) <20. Use of a high field strength (Prisma 3T) scanner and short TE (=30 msec) 
sequence has enabled us to calculate metabolites at very low metabolite variance (CRLB <10) in our 
previously published MRS studies. 
Water scaling and relaxometry: The post processing pipeline will be developed to yield absolute 
metabolite quantitation as well as metabolite/water and metabolite/creatine values. LC model provides 
automated water scaling settings which will be used (DOWS). All data (water signal and water 
suppressed data) will be phased followed by quantification of water relaxometry data. The relaxometry 
data will then be fitted to obtain water reference data and in the case of gray matter following 
segregation of the CSF and tissue water constituent. Finally, water signal will be scaled to that of 
resulting value obtained in previous steps.  
Tissue correction and segmentation: T1-weighted images will be segmented into gray matter (GM), 
white matter (WM), and cerebrospinal fluid (CSF) compartments using FreeSurfer 
(https://surfer.nmr.mgh.harvard.edu/fswiki) on the whole brain T1 images. A volume of interest (VOI) will 
be generated on the T1 images, matching the location and size of MRS voxels indicated above. 
Volumes of GM, WM and CSF segments in this volume-of-interest will then be generated using 
FreeSurfer. The absolute metabolite concentrations generated by the LC-Model will then be corrected 
for CSF using the formula metabolite C = Co x 1/(1-fCSF), where C is corrected metabolite 
concentrations, Co is metabolite concentrations generated by LC-Model output and fCSF is fraction of 
CSF volume.63, 64 The final output of the absolute metabolite quantitation 
will be provided in units of molality. CSI data will be assessed using metabolite values normalized to 
creatine to minimize methodological constraints published elsewhere65 after ensuring that raw 
uncorrected concentrations of creatine (Cr) and phosphocreatine (PCr) are not significantly different 
among the different study groups in the prescribed regions of interest. 
Macromolecular separation: To address over-interpretation of MR spectra with respect to 
quantification of glutamate in the presence of overlapping glutamine and macromolecules (MM), we will 
conduct a substudy involving 10 healthy control subjects using the approach proposed by Cudalbu and 
Gottschalk et al. in all three regions.66, 67 This experimentally acquired prior-knowledge will represent 
both MM and lipids. This manual metabolite quantitation may have better accuracy than the LC-Model 
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quantitation using LC-Model and assist in interpretation of the data. We will also conduct the analysis 
using the individual values of Glu, Glx (glutamate+glutamine) and Gln (glutamine); while setting the 
Crammer-Rao lower bound (CRLB) value for Gln at high (<30%) with LC-Model processing. An 
exploratory analysis of the impact of inflammation on other metabolites of interest including 
choline (Cho), myoinositol (mI) and n-acetyl aspartate (NAA) will also be conducted. 
Neurocognitive Assessments 
In accordance with the recent RDoC proposals by NIMH,68 for our primary dependent behavioral 
variables, we have chosen to examine specific symptom domains that are relevant to the function of the 
basal ganglia and their role in moderating positive and negative valence systems (e.g. anhedonia and 
psychomotor retardation). The entire assessment will take up to approximately 120 minutes (with breaks 
as needed). The examiner will code the reliability of each test score, any alteration of standard procedure, 
and the reason (e.g., frequently repeating instructions due to difficulty with attention). Only trained 
research personnel will perform neurocognitive ratings. 
 
Positive Valence Domain (Motivation) 
Objective 
Neurocognitive Assessments 
Gamble Task: To examine the relationship between chosen certain rewards the expected values of chosen 
gambles, the difference between experienced and predicted rewards and happiness; we have added a 
Gamble Task. During this task, participants will have the option of selecting between a certain choice and a 
gamble choice, with equal probabilities of the two outcomes. There will between 50 and 150 trials with an 
equal proportion of three trial types: mixed (a certain amount of $0 with a gain and loss amount), gain (with 
a certain gain or a gamble with $0 and a larger loss), and loss (with a certain loss or a gain of $0 and a 
greater loss). Further, participants will be asked to rate their current level of happiness after every three 
trials. Also, before and after the task is complete, participants will be asked to measure their life happiness. 
Previous studies have demonstrated that this technique can be used to establish a relationship between 
task earnings and happiness. This task takes between 10-20 minutes per session. 
  
Go No-Go Variant Task: On each trial of this task, one of four possible fractal images is briefly presented to 
the subject. Each represents the combination between action (either “go” or “no-go”, carried out by button 
pressing or withholding button pressing), and valance at outcome (either win or lose). Action will be required 
in response to a circle that follows the fractal image, after a brief variable delay. The circle will appear on the 
screen for approximately 500-2500ms. In go trials, subjects will be asked to indicate which side of the 
screen the circle appeared on, by pressing a button. Subjects must make a response within a brief amount 
of time (e.g. 700 ms). In no-go trials, subjects will simply be asked to withhold any response. After a short 
delay, the outcome will be presented to a subject (win, loss, or neutral). A green upward symbol indicates a 
win of $1, a red downward symbol indicates a loss of $1, and a horizontal bar indicates an absence of win or 
loss. In “go to win” trials, a correct button press is rewarded. In “go to avoid losing” trials, a correctly avoided 
button press avoids punishment. In “no-go to” win trials, withholding the button press leads to reward. In “no-
go to avoid losing” trials, withholding a button press avoids punishment. The outcome will be designed in a 
probabilistic manner, so that 70% of correct responses are rewarded in win trials and 70% of correct 
responses are not punished in lose trials. On 50% of trials, target detection and outcome will be omitted. 
Participants will be asked to complete 4 blocks of this task, each approximately 8 minutes in length. 
 
Reinforcement Learning Task: Trials for this task involve a 1-3s cue presentation during which subjects 
choose between two abstract stimuli, and then a 3s feedback presentation with positive (monetary win), 
negative (monetary loss) or neutral outcomes. Behavioral responses will be analyzed by fitting a standard 
reinforcement learning (Q-learning) model to each subject’s sequence of choices. Based on individual 
choices and outcomes for each trial, the Q-learning algorithm will compute the expected values (Q) of 
choosing a given stimulus: Qt = Qt-1 + alpha*RPEt, where RPEt = Rewardt - Qt-1 and alpha represents the 
learning rate. This task will include between 80-120 trials and will take approximately 10-15 minutes in 
length. 
 
Subjective Value Task: In this task, subjects will be asked to repeatedly choose between two options to 
obtain a monetary reward. Each option will consist of a horizontal bar (representing reward magnitude) 
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feature one option where both the magnitude and probability are higher than the alternative option (‘catch’ 
trials). Options will be presented, during which time subjects must wait to indicate their choice. Next, a 
question mark will appear, to prompt participants to press a button to indicate their choice. Choices will be 
confirmed by a frame around the chosen option, which will remain on the screen until the outcome is 
revealed. The outcome (reward or no reward) will be indicated by the bars turning green or red, 
respectively. Outcomes are then followed by an intertrial interval (ITI).  A “prize bar” will be displayed 
between the options and will grow by the width of the reward bar when a subject options a reward. The 
subject’s goal will be to move the prize bar across a target line to win a certain amount of money. Once 
this goal is achieved, the prize bar will be reset and the subject will begin again. This task will last a 
maximum of 20 minutes.  
 
Negative Valence Domain (Psychomotor Retardation) 
Objective 
Neurocognitive Assessments 
Finger Tapping Task (FTT): This task uses a specially adapted tapper that the subject taps as fast as 
possible using the index finger. The subject is given 5 consecutive 10-second trials for the preferred and 
nonpreferred hands. The finger tapping score is the mean of 5 trials and is computed for each hand. 
Performance norms have been established, and scores have been shown to be stable over time.73 The 
FTT is designed to assess subtle motor impairment and is altered in subjects with basal ganglia disorders 
and lesions.74 Variables: Mean and total number of taps in 90 sec. for both dominant and non-dominant 
hands 
Reaction Time Task (RTT)(CANTAB): The RTT measures simple and choice movement and reaction 
time and is divided into 5 stages requiring increasingly complex chains of responses and providing 
distinction between reaction (or decision) time and movement latencies. Movement times on the CANTAB 
reaction time task have been shown to be slowed during IFN-alpha treatment and correlate with IFN-
alpha-induced depression and fatigue.75 Variables: Simple and Choice Reaction Time and Movement 
time 
Digit Symbol Substitution Task (DSST): The Digit Symbol Substitution Task is a subtest of the 
Wechsler Adult Intelligence Scale (WAIS) and consists of rows of blank squares, each printed with a 
randomly assigned number. The test involves graphimotor speed, visual scanning and memory, with 
about half of the variance being accounted for by graphimotor speed, a third by visual scanning and 4-5% 
by memory.76 Performance on the DSST has been found to correlate with subcortical atrophy in disorders 
involving basal ganglia including Huntington’s disease and multiple sclerosis.77, 78 Variables: # Correct 
responses within 2 minutes 
Trails Making Test A:79, 80 The scale measures cognitive processing speed using a series of non-
sequentially arranged numbers where the participant is asked to sequentially track the numbers occurring 
to numerical order as quickly as possible. Variables: Completion time 
 
Clinician-Administered and Self-Report Instruments 
Snaith-Hamilton Pleasure Scale (SHAPS-C): The SHAPS-C is a 14-item clinician-administered scale 
that assesses hedonic tone.69, 70 The items 1, 4, 8 and 9 refer to interests, items 3 and 10 to food and 
drink, items 2,7,13 and 14 to social interaction and items 5, 6, 11 and 12 to sensory experiences. In a 
previous study examining hedonic capacity, confirmatory factor analysis revealed a Hedonic Capacity 
factor that was largely defined by the SHAPS.69, 71 
Motivation and Pleasure Scale (MAP): The motivation and pleasure questionnaire is an 18-item self-
report inventory that was created to disentangle state-wise motivational and consummatory components 
of everyday activities over a 24-hour period, and has been previously validated as a measure of reward-
related symptoms in psychiatric populations.72 This scale will be used to assess self-reported changes in 
symptoms of anhedonia before and after inflammation blockade. 
Retardation Rating Scale: The RRS is a 14-item, clinician-administered scale used to assess 
psychomotor retardation.81 The items of the scale are either related to motility or mental activity. In factor 
analyses, items 1-8 have been specifically associated with motor retardation in elderly depressed 
patients.82 
Multidimensional Fatigue Inventory (MFI) is a 20-item self-report instrument designed to measure 
motivation and fatigue, covering the dimensions General Fatigue (GF), Physical Fatigue (PF), Mental 

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Fatigue (MF), Reduced Motivation (RM) and Reduced Activity (RA).83 Separate scores for each of these 
five dimensions are generated from the MFI. This instrument has reasonable internal consistency 
(Cronbach’s alpha between 0.53 and 0.93) and construct validity. The Reduced Motivation score from the 
MFI has been shown to highly correlate with reduced neural activation in the ventral striatum to a hedonic 
reward task during IFN-alpha administration as determined by fMRI.12 
Assessments of Depression Severity, Suicidality and Bipolarity 
Inventory of Depressive Symptoms-Clinician Rating (IDS-SR) (Item 20) is a 30-item self-report 
instrument with excellent psychometric properties that was designed to measure symptom constructs 
consistent with current DSM nosology and that has been widely used as a self-report outcome measure 
of depression in treatment trials.51, 84 
Columbia-Suicide Severity Scale: The Columbia-Suicide Severity Rating Scale (C-SSRS) is a fully-
structured, clinical interview designed to systematically query patients regarding past and current suicidal 
ideation and behavior (SIB)55. The psychometric characteristics of the patient- reported C-SSRS have 
been assessed in multiple contexts. It has well validated to elicit suicidal ideas in depressed subjects and 
will be consequently used to identify individuals experience acute severe depressive symptoms and refer 
them for immediate treatment. 
Bipolarity Index (BI): Bipolarity will be measured as a continuous variable using the NIMH funded 
Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study.85 To quantify the 
bipolarity risk, the STEP-BD computed bipolarity index scores by rating the patient’s profile relative to five 
traits believed to be most characteristic of Bipolar I disorder. The Bipolarity Index (BI) assigns common 
clinical features along each of five dimensions using a 0–20 score, where 20 points represents the 
presence of traits considered most characteristics of Bipolar I disorder. The dimensions include: episode 
characteristics, age of onset, course of illness/associated features, response to treatment and family 
history. A theoretical case with the traits most convincing for bipolar disorder on every dimension would 
score 100 points and most Bipolar I patients score above 60. Most unipolar depressed patients score 
much lower. 
Assessments of Anxiety and PTSD Severity 
Hamilton Anxiety Rating Scale (HAM-A):86 The HAM-A is a 14-item clinician-administered scale that 
assesses the severity of symptoms of anxiety.  
Beck Anxiety Inventory (BAI):87 The BAI is a 21-item self-report measure of anxiety symptoms, rated on 
a 4-point Likert scale modified to be based on the patient's experience in the past week.  
State-Trait Anxiety Inventory (STAI) State Scale:88 This 20-item self-report scale is used to measure 
current anxiety symptoms. 
PTSD Checklist for DSM-5 (PCL-5):89 The PCL-5 is a 20-item self-report measure that assesses the 20 
DSM-5 symptoms of PTSD, rated on a 5-point Likert scale modified to be based on the patient's 
experience in the past week. The accompanying Life Events Checklist (LEC) and Criterion A assessment 
measures trauma exposure. 
 
Safety and Tolerability 
Adverse Event Recording: All adverse events will be coded in standard MeDRA terms (Version 14.1), 
and whether events are expected and study-related will be determined by the study PI or designee. In 
addition, severity and start and end dates will be recorded as well as any evidence of unanticipated 
problems. This information will be provided to the Department of Psychiatry and Behavioral Sciences 
DSMB and IRB annually as described in the Human Subjects Section. 
Laboratory and Biological Variables: 
Blood collection: At Baseline Visits 1 and 2, and post-treatment Days 1 and 3 and Weeks 1 and 2, study 
bloods will be collected under fasting conditions between 8am-10am by venipuncture into two 6mL and 
one 10mL EDTA-containing vacutainer tubes using standard sterile technique. Plasma for the evaluation 
of plasma concentrations of cytokines and their receptors as well as CRP will be obtained by 
centrifugation of whole blood at 1000 x g for 10 minutes at 4°C. Plasma will be removed and aliquoted 
into siliconized polypropylene tubes and stored at -80°C until batch assay. Blood for mRNA analyses will 
be collected in Tempus tubes and stored at -80°C for later RNA extraction. 
Plasma and CSF cytokines and soluble cytokine receptors: Fluorokine MAP Multiplex Human 
Biomarker Panels (R&D Systems, Minneapolis, MN) will be used to measure plasma and CSF TNF-
alpha, sTNFR2, IL-1ra, IL-6, sIL-6R, IL-10, and monocyte chemoattractant protein (MCP)-1. These 

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cytokines and their receptors have all been found to be altered in depression,5 and TNF and sTNFR2 
have been found to predict response to infliximab and to correlate with basal ganglia glutamate.3, 48, 49 
Each determination requires 50-100 μl, and all samples will be assayed in duplicate according to 
manufacturer’s instructions. Quality control plasma of both low and high cytokine concentrations will be 
included with every assay. The mean inter- and intra-assay coefficients 
of variation for control samples are reliably 10% or less. 
C-reactive protein (CRP): Plasma and CSF CRP will be assessed with a high sensitivity turbidimetric 
assay based within the Emory University Hospital. Sensitivity of the assay is rated at 0.18 mg/L, range of 
measure is 0.2 to 80 mg/L, and functional sensitivity (at 20% CV) is 0.2 mg/L. 
Estrogen and Progesterone: Serum estrogen and progesterone will be collected at the ACTSI CRN on 
the day of the subject’s infusion and sent to the EUH laboratory for analysis. Processed in the Emory 
Medical Laboratory. 
Gene Expression: RNA will be isolated from Tempus tubes using 5 Prime PerfectPure RNA Blood kit 
(Gaithersburg, MD). RNA quality will be verified using the Agilent Bioanalyzer, and only samples with a 
RIN factor >7.0 will be included. Samples will be analyzed in the Emory Integrated Genomic Core for 
gene expression analysis using an Illumina platform (Illumina, San Diego, CA). Raw microarray scan files 
from the Illumina HT-12 v4.0 arrays will be exported using the Illumina Beadstudio program and loaded 
into R for downstream analysis (http://www.R-project.org). The data will be transformed and normalized 
using the variance stabilizing normalization method.90 An Illumina probe detection p-value of <0.01 in 5% 
of the individuals will be used to filter non-expressed transcripts which will be excluded from analyses. To 
correct for confounding due to batch effects, expression profiles will be normalized using ComBat, an 
empirical Bayes method for batch correction.91 The results will be corrected for multiple testing using the 
permutation of regressor residuals test as implemented in the R package glmperm (http://cran.r-
project.org/web/packages/glmperm/ index.html).92 
6. Participant selection: 
Recruitment and Informed Consent Process 
Male and female subjects with depression will be recruited from local (inter-Departmental) referrals, 
medical record queries and/or social media recruitment campaign(s). Subjects in this study may also be 
referred from our Behavioral Immunology Program “Recruitment Clinic” protocol, Psychiatric Research 
Screening Clinic: IRB0000075162, which uses the screening strategy for this protocol to recruit and 
screen patients with depression for our active studies through IRB approved social media campaigns. An 
overview of the study will initially be provided in person or over the phone by study clinicians or trained 
study staff.  A telephone prescreening interview will be conducted on candidates providing verbal 
consent. If a subject shows interest in the study, research staff members will describe the general 
procedures involved and will answer relevant questions. If a subject remains interested in participation, 
the detailed nature, purpose, procedures, benefits, risks of, and alternatives to this research study will be 
explained to each subject, and written informed consent will be obtained by a study clinician, in a private 
office space, who provides this information. To ensure comprehension of the informed consent 
information, the clinician will allow time for questioning and administer a WRAT-3 brief screening level of 
reading to determine if participant is at least evaluated at an 8th grade reading level in order to understand 
the consent language. Informed consent will be documented on the Institutional Review Board-approved 
form. A copy of the signed consent form will be given to the participant and the original document filed in 
a central study consent binder. The consent binder(s) and subject casebooks containing information 
gathered as part of the study will be kept in a locked office and/or cabinet. 
Telephone Prescreen Interview 
A telephone prescreen interview will be conducted with study referrals following verbal consent. 
Candidates eligible to proceed with the study process will be scheduled for an appointment to see a study 
clinician 
Onsite visit (s): Trained personnel will obtain written informed consent from candidates prior to initiating 
study procedures. Screening information will be collected by interview and evaluation, as well as 
obtaining collateral history and data from other relevant sources (e. g. medical records, referring 
physician). Screening will include the following assessments: (1) History of medical and psychiatric 
conditions (2) screening laboratory evaluations, (3) subject height and weight measurements and waist 
circumference obtained by staff 4) Concomitant Medications 5) Adverse Events 6) MRI Safety Form 7) 
Demographics and 8) assessments below: 

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Clinician-Assisted Quick Inventory of Depressive Symptomology (QIDS-16 SR)- A 16-item self-report 
instrument that includes assessment of nine diagnostic symptom domains used to characterize a major 
depressive episode. 
Patient Health Questionnaire (PHQ-9) is a nine-item measurement used to assess depressive symptoms 
and suicidal ideation.    
Mini-Mental State Exam (MMSE) is a 27-item interviewer administered questionnaire widely used for the 
evaluation of general cognitive functioning and identification of altered mental status. At screening, 
subjects will be excluded for score <28 (unless otherwise approved by the PI), which is evidence of mild 
cognitive impairment.83  
WRAT-3 is a very brief screening measure for reading level. Participants evaluated at less than an 8th 
grade reading level may not participate unless otherwise approved by the PI.  
Child Trauma Questionnaire (CTQ) is a standardized, retrospective 28-item self-report inventory that 
measures the severity of different types of childhood trauma. Participants will not be excluded for history 
of childhood trauma.  
 
Laboratory Variables 
Research bloods will be collected by venipuncture into EDTA-containing vacutainer tubes using standard 
sterile technique. Plasma and buffy coat for the evaluation of concentrations of cytokines and their 
receptors as well as CRP will be obtained by centrifugation of whole blood at 1000 x g for 10 minutes at 
4°C. Plasma and buffy coat will be removed separately, aliquoted into siliconized polypropylene tubes, 
and stored at -80°C until batch assay. Bloods will also be collected by venipuncture into Tempus mRNA 
tubes and directly placed in freezer storage at -20°C. In order to further assess immune cell profiles, we 
will additionally collect 10 ml of whole blood in EDTA at room temperature for immune cell extraction. 
Tempus tubes and buffy coats will be sent to the Emory Integrated Genomics Core for RNA extraction, 
gene expression, mRNA profiling, epigenetic evaluation and measurement of gene polymorphisms. Some 
samples may be sent to other labs for additional analysis. 
Plasma cytokines and soluble cytokine receptors: Customized high sensitivity Fluorokine MAP 
Multiplex Human Biomarker Panels (R&D Systems, Minneapolis, MN) will be used to measure plasma 
TNF-alpha, sTNFR1 and 2, IL-1ra, IL-6 and sIL-6R. All samples will be assayed in duplicate according to 
manufacturer’s instructions. Quality control plasma of both low and high cytokine concentrations will be 
included with every assay. The mean inter- and intra-assay coefficients of variation for control samples 
are reliably 10% or less. 
C-reactive protein (CRP): Plasma CRP will be assessed with a high sensitivity turbidimetric assay. 
Sensitivity is 0.18 mg/L, range of measure is 0.2 to 80 mg/L, and functional sensitivity (at 20% CV) is 0.2 
mg/ L. 
Tryptophan and Kynurenine: Free tryptophan and kynurenine plasma concentrations will be determined 
by high-performance liquid chromatography in the laboratory of Dr. Dietmar Fuchs or other laboratories 
with equivalent expertise at the PI’s discretion. 
Gene expression and epigenetics: As indicated above, blood will be obtained for analysis of 
inflammatory mediators and signaling pathways. 
7. Management of MRS Incidental Findings 
The purpose of these scans is not to make a clinical determination of patients’ brain health.  However, if 
any incidental finding is noticed during the scan, the information will be provided to patients or their 
medical provider-of-record for further management.  Incidental findings are those abnormalities seen in 
patients’ brain images during the scanning process, which may or may not be of clinical importance.  
Follow-up of the scan findings will be the responsibility of the patients’ Emory Healthcare provider-of-
record.  
8. Sources of Materials: Research material will be derived from clinician-administered and self-report 
questionnaires, blood, urine, cerebrospinal fluid and MRS scans. Material for evaluating baseline medical 
status and subject safety prior to infusion will be obtained from blood and urine. Data to be recorded from 
subjects will include standardized ratings of emotional, cognitive and physical symptoms, as well as 
clinical information derived from medical records when available, interviews with the subject, referring 
physicians and family members when relevant. Data on cardiac functioning will be obtained from EKG. 
Data will be obtained from peripheral blood, including complete metabolic panel, CBC with differential, 
serum pregnancy test, anti-nuclear antibodies, rheumatoid factor, serum concentrations of estrogen and 

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progesterone, blood tests for fungal infection (aspergillus antibody, blastomyces antibody, coccidioides 
antibody, histoplasma antibody) plasma concentrations of TNF-alpha, sTNFR 2, IL-1 beta, IL-1ra,IL-6, 
sIL-6R, IL-10, MCP-1, and CRP. CSF will be used to measure concentrations of TNF-alpha, sTNFR 2, IL-
1 beta, IL-1ra, IL-6, sIL-6R, IL-10, MCP-1, and CRP. Blood for mRNA expression analyses will also be 
collected. Data obtained from urine will include urinalysis and toxicology screen. Clinical data that will be 
used to assess eligibility and safety will be collected via interview and documented by study clinicians. 
Standardized clinician administered and self-report questionnaires will be administered and collected by 
study physicians or study coordinator. Blood and urine samples at screening will be obtained by the study 
coordinator and nursing staff at the Emory Clinical Research Network (CRN). Blood and urine for the 
baseline assessment (Visits 1 and 2) and subsequent assessments on days 1 and 3 and weeks 1 and 2 
for study bloods and weeks 1 and 2 for safety labs will also be obtained by CRN nursing staff. All data, 
including questionnaires and blood and urine samples will be coded by unique identifying numbers. 
Subjects’ names will not appear elsewhere in any form that would link them specifically to data. Subject 
name and identifying number will be kept on separate forms in a locked office separate from data files. 
Only the study coordinator and study physicians will have access to subject identities. Research 
personnel analyzing blood data or entering data into the database will not be provided information from 
which they could identify subjects by name. Only the identifying number will be used during MRS 
 scanning and post processing. All information will be obtained solely to determine eligibility for study 
participation or for research purposes or to monitor subject safety following the infusion. Nevertheless, 
any abnormalities uncovered will be reported to the subject and his/her treating physician for follow-up or 
will be used by study clinicians to determine appropriate medical care in the case of adverse events 
related to the infusion. 
9. Data Collection and Management: The data management team will use REDCap.93 REDCap allows 
database construction, an interface for collecting data, data validation, and automated export procedures 
for data downloads to statistical packages (SPSS, SAS, Stata, R). Dr. Miller is currently using REDCap 
for 3 of his currently funded projects, and he and his staff have extensive experience with its usage. 
Caveats and Considerations 
It should be noted that in this study we are using peripheral blood CRP as a proxy measure for CNS 
inflammation. Our previous data in two published reports have demonstrated that plasma 
CRP is associated not only with basal ganglia glutamate, but also connectivity between ventral striatum 
and ventral medial prefrontal cortex, both of which were correlated with anhedonia.2, 94 In addition, plasma 
CRP was a robust predictor of the clinical response to infliximab.3 Finally, peripheral CRP highly 
correlates with CSF CRP (see Figure 7), and CSF CRP not only correlated with left basal ganglia 
glutamate using CSI in our recently published work,2 but also significantly correlates with CSF IL-6, CSF 
sTNFR2 and CSF MCP-1 (all p<0.05). Therefore, for the purposes of identifying patients that are likely to 
exhibit increased inflammation and its consequences in the CNS, we believe plasma CRP is an excellent 
proxy measure for CNS inflammation. Another caveat is that infliximab does not cross an intact blood 
brain barrier (BBB). Nevertheless, previous studies have shown that blockade of peripheral inflammation 
through the use of monoclonal antibodies like infliximab can abrogate stress-induced depressive-like 
behavior in rodents.95 These data suggest that peripheral inflammation may drive central inflammatory 
responses and their effects on behavior, and blocking peripheral inflammation may reduce central 
inflammation and its effects on the brain.8 This possibility will be examined for the first time in Aim 3 by 
sampling CSF inflammatory markers after inhibition of peripheral inflammation by infliximab. Finally, we 
should note that the MRS glutamate signal is a proxy measure for glutamate concentrations in the brain 
including both intracellular and extracellular compartments. Moreover, the modeling which determines 
glutamate concentrations in the brain provides an approximation of several confluent spectral peaks 
including glutamate, glutamine, GABA and glutathione, with glutamate representing the primary 
component. As indicated above, however, various strategies are proposed to address this issue. 
10. Statistical Analyses 
Aim 1: To determine whether inhibition of inflammation reduces basal ganglia glutamate. 
Hypothesis 1. Compared to placebo, infliximab-treated patients will exhibit decreased absolute 
glutamate in the basal ganglia on day 3 and week 2. Mixed-effects models for repeated measures 
(MMRM) will be employed to examine effects of group, time and their interaction on left and right basal 
ganglia glutamate controlling for baseline glutamate concentrations. Relevant covariates including age, 
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as number of depressive episodes, length of current depressive episode (in months), treatment 
responsiveness (ATRQ), age of onset, bipolarity index score and family history of depression (yes/no) will 
be sequentially teste tested in the conducted for the dACC and medial parietal voxels. 
Aim 2. To determine the relationship between basal ganglia glutamate and anhedonia and 
psychomotor retardation. 
Hypothesis 2. Decreased basal ganglia glutamate concentrations will be associated with improved 
objective and clinical measures of anhedonia and psychomotor retardation. Random intercept 
linear mixed models will be used to assess whether change in left or right basal ganglia glutamate predict 
change in motivation and psychomotor activity. Models will be adjusted for relevant clinical covariates as 
indicated above. Separate analyses will be run for each behavioral outcome of motivation (Gamble Task, 
Go No-Go, RLT, PRT SHAPS-C, MAP) and psychomotor speed (FTT, RTT, DSST, Trails, RRS, MFI) as 
well as total depression severity scores using the IDS-SR. Type I errors as a result of multiple testing will 
be controlled by using a step down Bonferroni procedure.96 Given that changes in basal ganglia glutamate 
may occur prior to changes in behavior, lagged regressor models will also be explored to determine 
whether early changes in basal ganglia glutamate predict subsequent changes in motivation and motor 
activity in separate analyses. Finally, exploratory analyses will be conducted to examine the impact of 
basal ganglia glutamate on suicidality (STS), given that the relationship between inflammation and 
suicidality may be mediated by glutamate. This possibility is supported by the impact of the glutamate 
antagonist ketamine on suicidality as well as the relationship between gene expression of glutamate 
signaling pathways and suicide in postmortem brain tissue.97, 98 
Aim 3: To determine the relationship between inflammatory markers and basal ganglia glutamate. 
Hypothesis 3. Decreased peripheral and central markers of inflammation will precede and predict 
decreases in basal ganglia glutamate. Random intercept linear mixed models will be used to assess 
whether change in inflammatory variables predict change in left or right basal ganglia glutamate 
controlling for relevant covariates as appropriate (see above). In the first model, only the effect of CRP 
will be tested.  Subsequent models will include the cytokines and their receptors in both blood and CSF. 
In the case of collinearity among inflammatory measures, principal component analyses will be used for 
the purposes of data reduction. Given the rapid changes that will likely occur in inflammatory markers 
prior to changes in basal ganglia glutamate, lagged regressor models will also be explored to determine 
whether early changes in inflammatory variables predict subsequent changes in basal ganglia glutamate. 
For analysis of mRNA expression, separate delta values between baseline and day 3 and baseline and 
week 2 will be calculated for both mRNA expression and basal ganglia glutamate. Regression analyses 
will then be performed on delta values to identify mRNA transcripts that are significantly correlated with 
delta glutamate (FDR<0.05). RNA transcripts found to significantly predict changes in basal ganglia 
glutamate will be entered into pathway analyses using a number of tools including the WebGestalt 
WikiPathways tool and Bibliosphere™ data mining software from Genomatix. Overrepresentation of 
specific transcription binding factors such as NF-kB in the promoters of the associated transcripts will be 
tested using the cREMaG interface (http://149.156.177.116/cremag/), TRAP (http://trap.molgen.mpg.de) 
and the TELIS database. (http://www.telis.ucla.edu).99 Transcript origin analysis will also be used.100 This 
analysis examines specific patterns of gene expression that are associated with immune 
cell subtypes and generates a cell origin diagnosticity score, which provides information on which cell 
types are contributing to changes in gene expression observed between groups.100, 101 Exploratory 
analyses will be conducted using the strategies indicated above for CSI measurements of glutamate and 
other metabolites normalized to creatine. 
11. Power Analysis: A power analysis was conducted using our preliminary data examining a cohort of 
50 unmedicated patients with major depression. The sample size was powered on the basis of Aim 1, 
which represents the primary hypothesis of the study that decreasing inflammation will decrease basal 
ganglia glutamate. The effect size (d) of the differences in glutamate concentrations between high 
(>3mg/L) and low (<1mg/L) CRP was 1.15 using absolute tissue-corrected glutamate concentrations. 
Using a beta/alpha error ratio of 4, the proposed sample size of 60 patients (30 infliximab and 30 placebo) 
will yield a power of 0.99 with an alpha error probability of 0.001 and beta error probability of 0.005 
(computed using G*power). Linear analysis-based power calculations using r=0.43 and d=0.95 (from our 
preliminary data) with the proposed sample size of 60 and 5 predictors (age, sex, race, BMI, CRP) will 
have a power of 0.93, with alpha error of 0.01 and beta error of 0.07. Given our anticipated attrition rate of 
10%, we will still have ample power for the proposed analyses. 

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12. Potential Study Risks: There are 7 major areas of potential risk in the proposed study stemming 
from 1) neuropsychiatric assessments, 2) blood drawing, 3) lumbar puncture, 4) MRS scanning, 5) 
infusion of infliximab, 6) placebo treatment, and 7) loss of confidentiality. Neuropsychiatric assessments 
may uncover strong and potentially disturbing feelings about the subject’s past or present emotional state. 
The risks of blood drawing include discomfort, bruising, infection, bleeding, and fainting. Undergoing MRS 
scan poses no more risk than undergoing a routine MRI scan. Physical discomfort due to lying in the 
scanner, occasional headaches due to scanner sounds and previously unrecognized claustrophobic 
attacks are the prominent adverse effects of the procedure. Some patients experience some lower back 
pain after a lumbar puncture. This is usually felt in and around the area where the needle was inserted. In 
most cases, the pain will ease after a few days and it can be treated with analgesics, such as 
acetaminophen, if necessary. Headache and lower back pain are the most common side effects of a 
lumbar puncture, usually developing within 24 to 48 hours of the procedure. There is a small risk of a 
lumbar puncture leading to intracerebral bleeding, although this is very rare. The likelihood of a lumbar 
puncture causing an infection in the spine is also very small. Use of infliximab has been associated with a 
number of short and long term risks (in 10%-50% of subjects), including mild allergic reaction to the 
medication, stomach pain, nausea, diarrhea, heartburn, upper respiratory tract infections, sore throat, 
sinusitis, coughing, runny nose, rash, fatigue, fever, headache, joint pain, back pain, urinary tract infection 
and hypertension. Very rarely (less than 1%), more serious adverse events have been reported, including 
severe anaphylactic reaction to the infusion, development of serum sickness following infusion, 
reactivation of tuberculosis, development of serious and occasionally life threatening infections, induction 
of autoimmunity, worsening of congestive heart failure, bone marrow suppression, optic neuritis, seizures, 
cerebral demyelination and development of lymphoma or other cancers including skin cancer. Of note, 
early data from pooled randomized clinical trials revealed increased malignancy including lymphoma with 
TNF inhibitors in rheumatoid arthritis (RA) leading to the current FDA black box warning.102 Nevertheless, 
more recent data in RA patients (including analysis of more than 40,000 patients and 150,000 patient-
years exposure) indicate that TNF inhibitors are not clearly associated with increased malignancy in RA 
excluding skin cancer.103 Finally, although there is a possibility of drug-drug interactions with infliximab, 
according to MicroMedex, an evidence-based drug information resource (used by Emory Healthcare), 
there are few drug-drug interactions with infliximab excluding other immunosuppressants, other 
monoclonal antibodies, and “moderate” interactions with the following psychotropic agents: phenytoin, 
thioridizine and pimozide (all of which are exclusionary). Subjects in this study also have a 50% chance of 
receiving a placebo infusion. Risks of placebo include lack of efficacy relative to active antidepressant 
treatments that might lead to a worsening of depressive symptoms, including the development of suicidal 
ideation. Finally, there is a risk of loss of confidentiality. Confidentiality of all subjects will be protected per 
institutional and NIH and other federal requirements, and as described in greater detail below. 
Alternatives include not participating in the proposed study. An array of demonstrated effective treatments 
for depression exists and include, but are not limited to: selective serotonergic antidepressants (i.e. 
fluoxetine, paroxetine, etc.), serotonin-norepinephrine reuptake inhibitors (i.e. venlafaxine, duloxetine), 
atypical antidepressants (i.e. bupropion, mirtazapine, nefazodone), tricyclic antidepressants, monoamine 
oxidase inhibitors, electroconvulsive therapy (ECT) and psychotherapy (i.e. interpersonal and cognitive 
behavioral therapies). Risks and side effects of these agents vary in type and severity depending on 
class, but include sexual dysfunction, gastrointestinal distress, anxiety, anticholinergic symptoms, 
induction of mania, suicidal ideation and potential lethality in overdose. Common risks of ECT include 
short term memory loss, head and body aches and risks related to anesthesia. Benefits of 
antidepressants and ECT include documented efficacy in the treatment of depression. In addition to 
approved modalities, trials of novel treatments for more severe depressions are ongoing and include the 
use of vagal nerve stimulation and deep brain stimulation. Benefits of these modalities may include 
efficacy for patients who have failed traditional agents. Risks include the possibility that these modalities 
are not effective. There are also surgery-related risks of infection and anesthesia involved with these 
modalities. At screening, study clinicians’ will discuss benefits and side effects of these alternative 
treatments with subjects compared to the risks and potential benefits of study participation. 
13. Adequacy of Protection Against Risks:  
Recruitment and Informed Consent: 
Subjects with major depression will be recruited from outpatient evaluation clinics within the Department 
of Psychiatry and Behavioral Sciences, Emory University School of Medicine and from advertising in 

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radio, television, internet and print media. The Emory outpatient clinics evaluate potential subjects for 
appropriateness for participation in several on-going trials of various modalities for MD. Most frequently, 
subjects come to these clinics as a result of referral from their primary physicians or as a result of 
seeing/hearing advertisements. An overview of the study will initially be provided in person or over the 
phone by study clinicians. If a subject shows interest in the study, research staff members will describe 
the general procedures involved and will answer relevant questions. If a subject remains interested in 
participation, the detailed nature, purpose, procedures, benefits risks of, and alternatives to this research 
study will be explained to each subject, and written informed consent will be obtained by a study clinician 
who provides this information. Informed consent will be documented on an Emory Institutional Review 
Board-approved form. A copy of the signed form will be given to the subject and a copy will be placed in a 
case-book containing relevant demographic data for the subject. Of note, because this case-book will 
contain personal identifiers (i.e. name), it will be kept separate from any data 
gathered as part of the study, and will be kept in a locked office. Protection Against Risk: Every effort will 
be taken to prevent injury or distress that may result from this study. 
Neuropsychiatric Assessments: 
Care will be taken to avoid bringing about undue psychological distress during the neuropsychiatric 
interviews. This will be accomplished by using trained raters (clinicians) for all neuropsychiatric 
assessments. In the event that a subject becomes unduly distressed, Drs. Miller or Haroon will be 
immediately contacted, and an appropriate clinical intervention plan will be developed. Drs. Miller and 
Haroon are Board Certified psychiatrists, consultation-liaison, inpatient and outpatient psychiatry. In 
cases where patients need extra time to collect their thoughts and emotions, mental health clinicians will 
be available for emotional support after all interviews. 
Blood Draws: Standard sterile procedure for blood withdrawal will be used. Blood draws will be 
conducted by clinicians with significant experience in the technique. In addition, the volume of blood 
withdrawn for this study will not exceed 200 ml over a maximum 4-week period (from screening to study 
completion). 
MRS scans: To minimize discomfort during the MRS scanning, patients will be provided with a head 
cushion and ear plugs. Patients will also be informed about the progress of the procedure through a 
remote microphone. In the case of patients developing acute anxiety or panic the scanning session will be 
terminated and patient provided enough support to cope with the feelings induced by the scanner. 
Lumbar Puncture: On day of the Emory outpatient CRN admission, subjects will receive approximately 
~1 liter of fluid iv as a result of a KVO (keep vein open) flow of normal saline through the indwelling 
catheter. This administration of iv fluids has been found in our experience to markedly reduce the 
incidence of post-LP headache. It will also help standardize hydration levels between subjects. An 
anesthesiologist will review the results of the PT and PTT coagulation tests collected 1-7 days prior. The 
anesthesiologist will perform the LP, using standard sterile technique and local anesthesia with patients in 
the lateral decubitus position. Approximately 10 cc of CSF will be withdrawn. After discarding the initial 1 
ml (to avoid blood contamination), the remaining CSF will be collected into chilled tubes and aliquoted on 
ice in 1 ml Eppendorf tubes, which will be immediately frozen at –80 C for later batched analyses. Upon 
completion of the LP, subjects will lie flat for approximately one hour and subsequently discharged. Some 
patients experience some lower back pain after a lumbar puncture. This is usually felt in and around the 
area where the needle was inserted. In most cases the pain will ease after a few days and it can be 
treated with analgesics, such as acetaminophen, if necessary. A headache is a common side effect of a 
lumbar puncture, usually developing within 24 to 48 hours of the procedure. Most people describe a dull 
or throbbing pain at the front of their head and this can sometimes spread to the neck and shoulders. The 
pain is usually worse while standing or sitting up and is usually relieved by lying down. The headache can 
usually be treated with simple painkillers such as acetaminophen. Some people have also reported that 
drinks containing caffeine, such as coffee, tea and or cola, have helped reduce the discomfort. If post-
lumbar puncture headaches persist, are particularly severe, or are accompanied by sickness and 
vomiting, the patient will be advised to call the study physician to be triaged appropriately. For intractable 
post LP headaches, the current standard-of-care is to apply an epidural blood patch. At Emory, 
anesthesiologists conduct this procedure, which can be performed 24 hours a day for emergencies. 
There is a small risk of a lumbar puncture leading to intracerebral bleeding, although this is very rare. The 
likelihood of a lumbar puncture causing an infection in the spine is also very small. However, patients will 

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be asked to call the study physician, if the patient develops a temperature or sensitivity to bright lights, or 
if the lumbar puncture site becomes painful and swollen. 
Infliximab: Several procedures will be put in place to reduce the risks associated with receiving 
infliximab. At screening, subjects will be carefully evaluated for the presence of any medical conditions 
that might increase the risk of an adverse reaction to the medication. For example, because anaphylactic 
reactions are more common after subsequent dosages of infliximab, all subjects will be naïve to the 
medication so that they will be receiving their first dose of infliximab in this protocol. It should be noted 
that the medical exclusion criteria for the protocol are very conservative and address all areas of potential 
concern, including outcomes such as cancer (including skin cancer), which has been linked to the use of 
infliximab in some studies. Moreover, to reduce the risk of inducing autoimmunity, subjects will be 
excluded for a history of autoimmune conditions such as RA and Inflammatory Bowel Disease (IBD), for 
which infliximab has FDA approval and has been established as safe enough to warrant widespread use. 
Subjects will be excluded for presence of autoantibodies to nuclear antigens and the presence of 
rheumatoid factor. A full list of all exclusionary criteria is presented in the text of the proposal (see 
Research Strategy). To further reduce risks associated with infliximab, all infusions will be conducted in 
the research outpatient unit of the Atlanta Clinical and Translational Science Institute- Clinical Research 
Network. All infusions will be conducted by specially-trained infliximab infusion nurses who will follow the 
standard protocol for acute adverse reactions if necessary. Subjects will be evaluated by medical 
personnel 1 and 2 weeks post-infusion and will be available 24/7 if problems arise. Safety labs will be 
drawn prior to and up to 2 weeks after the infusion to screen for adverse responses to the medication. 
Prior to the infusion, a study clinician will review potential adverse events and will explain symptoms to 
look for (i.e. signs of infection or sickness, rash, fatigue, etc.) and report. The ACTSI-CRN has standard 
protocols in place for the treatment of acute allergic reactions to the infliximab infusion as follows: 
FOR MILD REACTIONS: Headache, chills, itching, hives, rash, chest tightness, low grade fever: 
A. Stop infliximab infusion 
B. Monitor patient closely for further side effects (monitor vital signs q 5 minutes x 15-30 minutes) 
C. May give acetaminophen 325-1000 mg po 
D. May give diphenhydramine 25-50 mg IV or po 
E. Restart infliximab infusion at reduced rate (10 cc/hour x 15 minutes and increase by 5 cc/hour @ 15 
minute intervals once symptoms subside and patient is reassured by physician 
FOR SEVERE REACTIONS: Hypotension, bronchospasm, wheezing, shortness of breath, throat 
tightening, swelling, body temperature >101 F. 
A. Stop infusion of infliximab immediately 
B. Call M.D. Administer 02 
C. Call 911 if patient acutely unstable 
D. 0.9 normal saline IV fluid per physician order 
E. Monitor patient closely for airway, breathing, circulation. Monitor vital signs q 5 minutes 
F. Give diphenhydramine 25-50 mg IV push (may repeat in 2-3 hours) 
G. Give solucortef 250 mg IV push per M.D. 
H. Give epinephrine 1 mg in 1:1000 concentrate IV push (may repeat q 2-5 minutes as needed for blood 
pressure/heart rate support) per M.D. 
I. Place oral airway, lay flat, start CPR if needed. STAY WITH PATIENT. Call 911. 
Placebo: 
To reduce the risks associated with not receiving an active treatment, only subjects judged to have no 
active suicidal plan or intent will be recruited. Between signing consent and completing the screening 
assessment, a period of no more than 2 weeks will pass until baseline, and during this period a study 
clinician will evaluate each depressed subject every 7 days to ensure that symptoms haven’t worsened 
appreciably or that suicidal ideation has not developed. In the case of either of these eventualities, 
subjects will be discontinued from the study immediately and appropriate psychiatric referral will be made. 
Specific indications for discontinuation (Stopping Rules) between screening and study endpoint for any 
subject will include any of the following: 1) the development of significant suicidal ideation, plan or intent 
as determined by spontaneous subject report or as determined by the Columbia Suicide Severity Rating 
Scale – Screen Version (CSSRS), 2) the development of psychotic or catatonic symptoms, 3) the 
development of serious complications of cytokine antagonism (e.g. serious infection), and 4) a 25% 
increase from baseline of IDS-SR score. Other criteria for discontinuation between screening and the 

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baseline visit include: hospitalization for any reason or a clinical judgment that a subject is an imminent 
threat to self or others. Subjects will be evaluated for the appropriate level of care, including emergency 
hospitalization if indicated. Subjects with non-emergent symptoms but who disqualify for further 
participation and who are in active treatment will be referred back to their primary psychiatric physician. 
Appropriate follow-up care will be arranged for subjects not in active psychiatric treatment. An 
individualized plan will be crafted for each subject to ensure psychiatric back-up should emergency 
psychiatric care be required after hours or on weekends. Upon completion of the study protocol, all 
depressed subjects without a current psychiatrist will be offered an appropriate referral. 
 
Confidentiality and Data Management: 
Loss of confidentiality is a risk of research participation. Every effort will be made to maintain subject 
confidentiality throughout the study. All project personnel, including those involved in data entry, have 
completed an on-line course in human subjects’ protection for patient-related research with annual 
recertification. Each subject will be assigned a unique ID number that will be used in all data files and on 
all measures in place of personal identifiers. Data entry forms will be developed using the REDcap 
database system developed at the Vanderbilt Institute for Clinical and Translational Research (CTSA). 
REDCap (Research Electronic Data Capture) is an Oracle-based, secure, password-protected, HIPAA-
compliant, web-based application designed to support data capture for research studies. REDCap 
provides: 1) an intuitive interface for data entry (with intrinsic data validation); 2) audit trails for tracking 
data manipulation and export procedures; 3) automated export procedures for seamless data downloads 
to common statistical packages (SPSS, SAS, Stata, R); 4) procedures for importing data from external 
sources; 5) Real-time data cleaning and validation; 6) Automatic field computation; 7) Data dropdowns for 
choice lists (including condition selections based on earlier responses); 8) Data entry warnings for out of 
range or missing values; and 9) Electronic scheduling. Data entry can be performed anywhere using the 
internet and provides 128-bit SSL security. All electronic and hard entry forms will include unique patient 
identifiers to maintain patient confidentiality and will not relate to the patient in any way. Any protected 
personal health information will be encrypted and stored separately. The only link between identifying 
information (e.g.name, contact information) and project data will be in a key stored on a password-
protected computer accessible only to the PIs and to the project coordinators, who will be making 
appointments and assigning research personnel to meet with the participant. Paper forms will be stored in 
locked file cabinets accessible only to study personnel. 
 
Appointment Scheduling & Reminders: 
All participants will be given the opportunity to receive appointment reminders and scheduling information 
via text message on their mobile phones. If the subject consents to this form of communication, study 
staff will only use OhMD Texting Service to communicate with participants. This platform provides a 
Desktop and Mobile Version of OhMD for the research team to securely communicate with participants 
and maintain subject confidentiality. This service will only be used for communicating relevant 
appointment information and never used for PHI. Participants will receive the following text message from 
the study team upon first contact: “Please do NOT send any personal information via text. You may call 
the study team at 404-727-9828 to discuss any personal or health details.” Any PHI received via text 
message will be reported to the IRB as a potential breach of confidentiality. 
 
Compensation to Participants: 
 
Participants will receive up to $560-$2225 for completion of the study. Participants will be 
compensated using ClinCard. The ClinCard is a web based, reloadable, debit card that automates 
reimbursements for clinical research participants. An additional $25 will be provided to cover travel 
expenses for participants that travel equal to or greater than 50 miles to Atlanta. 
Visit 
Total Amount  
Amount put on Clincard 
immediately after visit  
Amount put on 
Clincard at the end of 
study participation 
Intake 
$25 
$25 
 

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(Visit Total) 
$25 
 
 
Screening  
 
 
 
Psychiatric evaluation, history 
and physical, EKG, chest x-ray 
and lab work  
$50* 
$50* 
 
(Visit Total) 
$50 
 
 
Baseline Visit 1 
 
 
 
Medical and psychiatric 
assessments, lab work 
research blood, 
neurocognitive tests, and self-
report surveys 
$50 
$50 
 
Computer Motivation Tasks 
(depending on choice made 
on the computer) 
$5-$100 
 
$5-$100 
Complete Scan 
$300 
 
$300 
Incomplete Scan 
$25** 
$25** 
 
Extended break 
$50*** 
$50*** 
 
(Visit Total) 
$80-$500 
 
 
Baseline Visit 2 
 
 
 
Infusion (Infliximab or 
placebo) and all scheduled 
assessments  
$150 
$50 
$100 
(Visit Total) 
$150 
 
 
Post-Treatment Day 1 
(Optional) 
 
 
 
Medical assessment, lab work, 
research blood 
$50 
$50 
 
(Visit Total) 
$50 
 
 
Post-Treatment Day 3 
 
 
 
Medical assessment, lab work, 
research blood, 
neurocognitive tests, and self-
report surveys 
$50 
$50 
 
Complete Scan 
$300 
 
$300 
Incomplete Scan 
$25** 
$25** 
 
Extended break 
$50*** 
$50*** 
 
(Visit Total) 
$75-$400 
 
 
Post-Treatment Week 
1 (Optional) 
 
 
 
Medical assessment, lab work, 
research blood 
$50 
$50 
 
(Visit Total) 
$50 
 
 
Post-Treatment Week 
2  
 
 
 

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Medical assessment, lab work 
research blood, 
neurocognitive tests, and self-
report surveys 
$50 
$50 
 
Computer Motivation Tasks 
$5-$100 
 
$5-$100 
Complete Scan 
$300 
 
$300 
Incomplete Scan 
$25** 
$25** 
 
Extended break 
$50*** 
$50*** 
 
(Visit Total) 
$80-$500 
 
 
Post-Treatment Week 
2-Visit 2 (Optional) 
 
 
 
Spinal Tap (Lumbar Puncture)  
$500 
 
$500 
(Visit Total) 
$500 
 
 
Total Study 
Compensation 
$560-$2225 
 
*=Screening visit may be divided across 2 visits and paid $25 per visit  
**= Unable to complete scan leading to termination from the study 
***=Subject can leave and return to complete visit if break is a minimum of 2 hours 
 
 
 
POTENTIAL BENEFITS OF THE PROPOSED RESEARCH TO THE SUBJECTS AND OTHERS 
The direct benefits of study participation will include receiving a psychiatric and medical evaluation, 
including standard blood and urine-based laboratory tests, EKG and MRI scan – done prior to MRS scan 
to enable voxel placement. In addition, subjects will have a 50% chance of receiving a medication that 
may have efficacy for the treatment of their symptoms (infliximab). In addition, placebo interventions are 
effective in reducing or remitting depressive symptoms in some patients and hence may be of benefit to 
some study subjects. Subjects will also have the chance to contribute to a scientific investigation, which 
may be of benefit to future patients. Benefits to others may include gaining significant knowledge 
regarding the role of inflammatory activation in the pathophysiology and treatment of severe depressions. 
As a result of this knowledge, this study may contribute to novel therapeutic strategies for patients with 
major depression. The side effect burden of infliximab is mild and most frequently manifests as minor 
infusion reaction symptoms such as headache and low grade fever. In our pilot study, no differences in 
side effects between infliximab and placebo were found at any point during the study, and neither 
subjects nor staff were able to discern group assignment. These findings suggest that some of the 
reported reactions to infliximab in patients with autoimmune or inflammatory disorders may represent an 
interaction between the drug and their disease. Rates of serious adverse events, such as severe 
anaphylactic reaction or development of serious infection, are rare (less than 1%). In comparison, 
subjects who will be administered infliximab in this study will meet criteria for major depression, a 
condition characterized by severe symptoms, a chronic course and a profound decrement in quality of life 
and social and occupational functioning. Given data that TNF antagonists improve emotional functioning 
in patients with RA and IBD, it is reasonable to expect that subjects who receive infliximab may derive a 
benefit that outweighs the risks involved, especially given evidence that effects from a single infusion of 
infliximab can last for several months. Study subjects who receive a saline infusion will be exposed to the 
risk of venipuncture and of exposure to a pharmacologically inactive treatment. However, subjects 
receiving placebo frequently demonstrate symptomatic improvement. Given the low risk involved with the 
saline infusion and the likelihood that many patients will obtain at least some symptomatic benefit, we feel 
that the risks of the study are reasonable in relationship to the benefits for subjects receiving placebo. 
IMPORTANCE OF THE KNOWLEDGE TO BE GAINED 
Successful treatment modalities both arise from, and contribute to, our understanding of disease 
pathophysiology. Mounting data indicate that depression is associated with evidence of 

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immune/inflammatory activation, and that patients with major depression may be especially likely to 
demonstrate increased proinflammatory cytokine production/release. Furthermore, alterations in the 
functioning and/or metabolic recycling of glutamate and neurotransmission have been demonstrated 
extensively in bipolar depressions and some unipolar depressions as well as anxiety disorders. 
Nevertheless, studies conducted to date have not explored the connection between inflammation and 
glutamate, leaving unanswered questions about the direct relevance of inflammation to the 
phenomenology and/or treatment of major depression as it relates to alterations in CNS glutamate. In 
addition, just as evidence for a conclusive role for monoamines in depression first arose 
from studies of medications that affected the bio-availability of these neurotransmitters, agents that block 
proinflammatory cytokine activity may represent a novel and important strategy for evaluating whether 
inflammation contributes to alterations of glutamate systems that are believed to be directly involved in 
the genesis of depression and responsiveness to treatment. Understanding the mechanisms by which 
inflammatory changes alter glutamate will provide key insights into the association between glutamate 
changes and treatment of depression. Given the current evidence that medications that block NMDA 
glutamate receptor have antidepressant efficacy, this study will reveal mechanisms underlying glutamate 
alterations in depression. Because a wide range of inflammatory indices are being examined, data from 
the proposed study may also shed light on novel biomarkers of inflammation that may help identify 
patients with increased CNS glutamate and may be most likely to respond to therapies targeting the 
immune system and/or glutamate metabolism. For these reasons, we feel that risks to subjects are 
reasonable in relationship to the value of the knowledge (both theoretical and practical) to be gained. 
Investigational Drug Status 
Infliximab has FDA approval for the treatment of RA and IBD. The current proposal represents the use of 
infliximab as an experimental tool to dissect the role of inflammatory processes leading to changes in 
glutamate turnover and changes in specific symptom domains. The proposed study meets the 
requirements for an IND waiver for the following reasons: 
1) Results from the proposed study are not intended to be reported to the FDA in support of a new 
indication for use or to support any other significant change in the labeling for infliximab. 
2) Results from this study are not intended to support a significant change in the advertising for the 
product. 
3) The design of the study does not call for any new route of administration or dosage level (we will use a 
standard dose). There is no evidence that the subject population of the study (medically healthy 
individuals with treatment resistant depression) are at any greater risk than FDA-approved populations 
with RA or IBD. Indeed, our population should be at less risk, given that many patients with RA or IBD are 
also on other immunosuppressive agents. Co-administration of infliximab with other immunosuppressive 
agents (i.e. methotrexate) appears to increase the risk of serious infection with infliximab. There are no 
other factors in our design that significantly increase the risk (or decreases the acceptability of the risks) 
associated with infliximab.Data suggest that depression is associated with greater disability than RA, and 
we are selecting a patient population with a tremendous clinical need. 
4) The proposed study will be conducted in compliance with the requirements for IRB review and 
informed consent [21 CFR parts 56 and 50, respectively]. 
5) The study will be conducted in compliance with the requirements concerning the promotion and sale of 
drugs [21 CFR 312.7]. 
6) The study will not involve a waiver of informed consent in an emergency room setting. 
14. Data and Safety Monitoring Plan (DSMP) 
The DSMB for this study will consist of Larry Tune, M.D. Chairman, Boadie Dunlop, M.D., Tanja Mletzko, 
M.S. and Marian Evatt, M.D. Each of these clinical researchers has agreed to serve as the external 
DSMB for investigator-initiated clinical trials conducted by Emory researchers in the Department of 
Psychiatry & Behavioral Sciences. If the DSMB requires additional specialized expertise to evaluate 
safety issues related to the performance of this study, a relevant specialist will be consulted by the 
DSMB. The frequency of the Department of Psychiatry and Behavioral Sciences DSMB review for this 
protocol will be once every year based on IRB recommendations consistent with the assessed risk status 
of the study. Of note, based on a random internal audit (not for cause) of the previous infliximab trial, 
accolades were given for regulatory compliance and documentation of all adverse events as well as 
timely reporting and processing with the Emory DSMB and IRB. 
Procedures and Responsibilities of the Emory DSMB 

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At least four weeks prior to each DSMB meeting, the data manager/research coordinator 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 may  be 
provided, as well as a summary of measures taken to protect confidentiality (e.g., data storage, use of 
coded ID numbers, etc.) The PIs 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 Department of Psychiatry and Behavioral Sciences DSMB, once 
every year the DSMB will issue a letter to the PI to be included in the annual Emory IRB Continuing 
Review submission. The letter will inform the Emory IRB that the study is approved to proceed or state 
any safety related concerns expressed by the committee.  Reports will not specifically disclose the 
treatment arm of the study for relevant subjects unless this disclosure is required for safety reasons.  
 
PI and designated trained study personnel will review all pertinent aspects of study conduct including 
patient safety, compliance with protocol, data collection and efficacy. Periodic chart monitoring will be 
conducted by study personnel to validate integrity of the data. 
 
Adverse Event Reporting 
Note that any adverse event or serious adverse event (SAE) meeting Emory IRB criteria for on 
Unanticipated Problem will be reported to the Emory IRB and the study DSMB 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.” According to the Emory 
IRB, an AE meets criteria for an Unanticipated Problem (UP) if all of the following criteria are met: 1) The 
AE is unexpected 1) the AE is related or possibly related to participation in the research 3) the AE 
suggests that the research places subjects or others at a greater risk of harm that was previously know.  
 
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Reynolds A, Emery P. Malignancies associated with tumour necrosis factor inhibitors in registries and 
prospective observational studies: a systematic review and meta-analysis. Ann Rheum Dis. 
2011;70(11):1895-904. 
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