OMEGA-3 FATTY ACIDS AS FIRST-LINE TREATMENT IN PAEDIATRIC DEPRESSION. A Phase III, 36-week, Multi-centre, Double-blind, Placebo-controlled Randomized Superiority Study
Phase: PHASE3
Conditions: Depression
Sponsor: Gregor Berger

Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 1 of 108   
 
 
 
 
 
Clinical Study Protocol 
 
OMEGA-3 FATTY ACIDS AS FIRST-LINE 
TREATMENT IN PAEDIATRIC DEPRESSION. 
 
A phase III, 36-week, multi-centre, double-blind, placebo-controlled randomized 
superiority Study. 
 
The Omega-3-pMDD Study 
 
 
Study Type: 
Intervention with Investigational Medicinal Product 
(IMP)  
Study Categorisation: 
Clinical Trial with IMP Category C  
Study Registration: 
Swiss Federal Complementary Database 
Clinicaltrials.gov 
Study Identifier: 
SNF 33IC30_166826 
Sponsor, Sponsor-
Investigator and Principal 
Investigator: 
Gregor Berger 
Department of Child and Adolescent Psychiatry 
University Hospital of Psychiatry 
University of Zurich 
Neumünsterallee 9 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 2 of 108   
CH 8032 Zürich 
Switzerland 
Phone: +41 43 499 26 71 
Mobile: +41 76 464 61 54 
E-Mail: gregor.berger@puk.zh.ch 
 
Investigational Product: 
Omega-3 fatty acids 
(1000mg EPA / 500mg DHA in > in 13 years old and 
500mg EPA / 250mg DHA in < in 13 years old) 
Protocol Version and 
Date: 
Version3 of 13..07.2017 
 
CONFIDENTIAL 
The information contained in this document is confidential and the property of the Department of 
Child and Adolescent Psychiatry of the University of Zurich. The information may not - in full or in 
part - be transmitted, reproduced, published, or disclosed to others than the applicable 
Independent Ethics Committee(s) and Competent Authority(ies) without prior written authorization 
from the Department of Child and Adolescent Psychiatry of the University of Zurich, except to the 
extent necessary to obtain informed consent from those participants who will participate in the 
study. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 3 of 108   
SIGNATURE PAGES 
Study number 
 
Swiss Federal Complementary Database 
Study Title 
Omega-3 
fatty 
acids 
as 
first-line 
treatment in Paediatric Depression. A 
phase III, 36-week, multi-centre, double-
blind, 
placebo-controlled 
randomized 
superiority Study. 
 
 
 
Sponsor-Investigator (Principal Investigator): 
 
The Sponsor-Investigator and trial statistician have approved the protocol version 3 of 
13.07.2017, and confirm hereby to conduct the study according to the protocol, current 
version of the World Medical Association Declaration of Helsinki, ICH-GCP guidelines 
and the local legally applicable requirements. 
 
Gregor Berger 
 
 
 
 
Place/Date 
 
Signature 
 
 
 
 
 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 4 of 108   
 
 
Trial Statistican: 
 
The Sponsor-Investigator and trial statistician have approved the protocol version 3 of 
13.07.2017, and confirm hereby to conduct the study according to the protocol, current 
version of the World Medical Association Declaration of Helsinki, ICH-GCP guidelines 
and the local legally applicable requirements. 
 
 
Burkhardt Seifert 
 
 
 
 
Place/Date 
 
Signature 
 
 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 5 of 108   
 
 
Local Principal Investigator at study site: 
 
I have read and understood this trial protocol and agree to conduct the trial as set out in 
this study protocol, the current version of the World Medical Association Declaration of 
Helsinki, ICH-GCP guidelines and the local legally applicable requirements. 
 
Site 
 
Zürich 
Department of Child and Adolescent Psychiatry 
University Hospital of Zurich 
University of Zurich 
Neumünsterallee 9 
8032 Zürich 
 
Principal investigator 
 
Susanne Walitza 
 
 
 
 
Place/Date 
 
Signature 
 
 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 6 of 108   
 
 
Local Principal Investigator at study site: 
 
I have read and understood this trial protocol and agree to conduct the trial as set out in 
this study protocol, the current version of the World Medical Association Declaration of 
Helsinki, ICH-GCP guidelines and the local legally applicable requirements. 
 
 
Site 
 
Basel-Stadt 
Department of Child and Adolescent Psychiatry 
Universitäre Psychiatrische Kliniken (UPK) 
Schaffhauserrheinweg 55 
4058 Basel 
 
Principal investigator 
 
Klaus Schmeck 
 
 
 
 
Place/Date 
 
Signature 
 
 
 
 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 7 of 108   
 
 
Local Principal Investigator at study site: 
 
I have read and understood this trial protocol and agree to conduct the trial as set out in 
this study protocol, the current version of the World Medical Association Declaration of 
Helsinki, ICH-GCP guidelines and the local legally applicable requirements. 
 
Site 
 
Thurgau 
Clienia Littenheid AG 
Privatklinik für Psychiatrie und Psychotherapie 
9573 Littenheid 
 
Principal investigator 
 
Silke Bachmann  
 
 
 
 
Place/Date 
 
Signature 
 
 
 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 8 of 108   
 
Local Principal Investigator at study site: 
 
I have read and understood this trial protocol and agree to conduct the trial as set out in 
this study protocol, the current version of the World Medical Association Declaration of 
Helsinki, ICH-GCP guidelines and the local legally applicable requirements. 
 
 
Site 
 
St. Gallen 
Child and Adolescent Psychiatric Services St. 
Gallen 
Brühlgasse 35/37 
Postfach 447 
9004 St. Gallen 
 
Principal investigator 
 
Suzanne Erb 
 
 
 
 
Place/Date 
 
Signature 
 
 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 9 of 108   
 
 
Local Principal Investigator at study site: 
 
I have read and understood this trial protocol and agree to conduct the trial as set out in 
this study protocol, the current version of the World Medical Association Declaration of 
Helsinki, ICH-GCP guidelines and the local legally applicable requirements. 
 
Site 
 
St. Gallen 
Klinik Sonnenhof 
Sonnenhofstrasse 15 
9608 Ganterschwil 
 
Principal investigator 
 
Ulrich Müller-Knapp 
 
 
 
 
Place/Date 
 
Signature 
 
 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 10 of 108   
 
 
Local Principal Investigator at study site: 
 
I have read and understood this trial protocol and agree to conduct the trial as set out in 
this study protocol, the current version of the World Medical Association Declaration of 
Helsinki, ICH-GCP guidelines and the local legally applicable requirements. 
 
Site 
 
Thurgau 
Child and Adolescent Psychiatric Services  
Schützenstrasse 15 
8570 Weinfelden 
 
Principal investigator 
 
Bruno Rhiner 
 
 
 
 
Place/Date 
 
Signature 
 
 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 11 of 108   
 
 
Local Principal Investigator at study site: 
 
I have read and understood this trial protocol and agree to conduct the trial as set out in 
this study protocol, the current version of the World Medical Association Declaration of 
Helsinki, ICH-GCP guidelines and the local legally applicable requirements. 
 
 
Site 
 
Basel-Land 
Psychiatrie Baselland 
Bienentalstrasse 7 
4410 Liestal 
 
Principal investigator 
 
Brigitte Contin-Waldvogel 
 
 
 
 
Place/Date 
 
Signature 
 
 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 12 of 108   
 
Coordinating investigator 
I have read and understood this trial protocol and agree to conduct the trial as set out in 
this study protocol, the current version of the World Medical Association Declaration of 
Helsinki, ICH-GCP guidelines and the local legally applicable requirements. 
Gregor Berger 
 
 
 
 
Place/Date 
 
Signature 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 13 of 108   
TABLE OF CONTENTS 
SIGNATURE PAGES .............................................................................................................3 
STUDY SYNOPSIS .............................................................................................................. 17 
ABBREVIATIONS ................................................................................................................ 22 
STUDY SCHEDULE ............................................................................................................. 27 
1 
STUDY ADMINISTRATIVE STRUCTURE .................................................................. 28 
1.1 
Sponsor, Sponsor-Investigator ........................................................................... 28 
1.2 
Principal Investigator(s) ...................................................................................... 28 
1.3 
Neuropsychology ............................................................................................... 30 
1.4 
Coordinating Investigator ................................................................................... 31 
1.5 
Statistician (“Biostatistician”) .............................................................................. 31 
1.6 
Laboratory (if applicable) .................................................................................... 31 
1.7 
Monitoring Institution .......................................................................................... 32 
1.8 
Independent Data Monitoring Committee ........................................................... 33 
1.9 
Any other relevant Committee, Person, Organisation, Institution ........................ 33 
2 
ETHICAL AND REGULATORY ASPECTS .................................................................. 34 
2.1 
Study Registration .............................................................................................. 34 
2.2 
Categorisation of Study ...................................................................................... 34 
2.3 
Competent Ethics Committee (CEC) .................................................................. 34 
2.4 
Competent authority (CA) ................................................................................... 35 
2.5 
Ethical Conduct of the Study .............................................................................. 35 
2.6 
Declaration of Interest ........................................................................................ 35 
2.7 
Patient Information and Informed Consent ......................................................... 35 
2.8 
Participant Privacy and Confidentiality ............................................................... 36 
2.9 
Early Termination of the Study ........................................................................... 37 
2.10 Protocol Amendments ........................................................................................ 37 
3 
INTRODUCTION ......................................................................................................... 38 
3.1 
Background and Rationale ................................................................................. 38 
3.1.1. Adult and paediatric major depressive disorders ...................................... 38 
3.1.2 MDD and suicidality ................................................................................... 39 
3.1.3 The importance of Omega-3 fatty acids ..................................................... 40 
3.1.4 Dietary intake of Omega-3 fatty acids and MDD ........................................ 40 
3.1.5 Omega-3 fatty acids deficiency in MDD ..................................................... 41 
3.1.6 Inflammatory mediators, Omega-3 fatty acids and MDD ............................ 41 
3.2 
Investigational Product and Indication ................................................................ 41 
3.3 
Preclinical Evidence ........................................................................................... 42 
3.4 
Clinical Evidence to Date ................................................................................... 43 
3.4.1 Omega-3 fatty acids RCTS in MDD and related disorders ...................... 43 
3.4.2 Omega-3 fatty acids RCTs in MDD ......................................................... 44 
3.4.3 Omega-3 fatty acids RCTs in minors ...................................................... 44 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 14 of 108   
3.4.4 Omega-3 fatty acids RCTs in other psychiatric conditions ...................... 45 
3.4.5 Unpublished RCTs with Omega-3 fatty acids in pMDD ........................... 46 
3.5 
Dose Rationale................................................................................................... 46 
3.6 
Explanation for Choice of Comparator (or Placebo) ........................................... 47 
3.7 
Risk / Benefits .................................................................................................... 47 
3.8 
Justification of Choice of Study Population ......................................................... 49 
4 
STUDY OBJECTIVES ................................................................................................. 50 
4.1 
Overall Objective ................................................................................................ 50 
4.2 
Primary Objective ............................................................................................... 50 
4.3 
Secondary Objectives ........................................................................................ 50 
4.4 
Safety Objectives ............................................................................................... 50 
5 
STUDY OUTCOMES .................................................................................................. 51 
5.1 
Primary Outcome ............................................................................................... 51 
5.2 
Secondary Outcomes ......................................................................................... 51 
5.3 
Other Outcomes of Interest ................................................................................ 52 
5.4 
Safety Outcomes ................................................................................................ 53 
6 
STUDY DESIGN AND COURSE OF STUDY .............................................................. 53 
6.1 
General Study Design and Justification of the Design ........................................ 53 
6.2 
Study Duration and Study Schedule ................................................................... 55 
6.3 
Methods of Minimising Bias ................................................................................ 56 
6.3.1 Randomisation ........................................................................................ 56 
6.3.2 Other Methods of Minimising Bias........................................................... 57 
6.4 
Unblinding Procedures (Code break) ................................................................. 57 
7 
STUDY POPULATION ................................................................................................ 58 
7.1 
Eligibility Criteria ................................................................................................. 59 
7.1.1 Inclusion Criteria ..................................................................................... 59 
7.1.2 Exclusion Criteria .................................................................................... 59 
7.2 
Recruitment and Screening ................................................................................ 60 
7.2.1 Incentives ............................................................................................... 61 
7.3 
Assignment to Study Groups .............................................................................. 62 
7.4 
Criteria for Withdrawal/ Discontinuation of Participants ...................................... 62 
8 
STUDY INTERVENTION............................................................................................. 63 
8.1 
Identity of Investigational Product(s) ................................................................... 63 
8.1.1 Experimental Intervention ....................................................................... 64 
8.1.2 Control Intervention ................................................................................ 64 
8.1.3 Packaging, Labelling and Supply (Re-Supply) ........................................ 64 
8.1.4 Storage Conditions ................................................................................. 65 
8.2 
Administration of Experimental and Control interventions ................................... 66 
8.2.1 Experimental Intervention ....................................................................... 66 
8.2.2 Control Intervention ................................................................................ 66 
8.3 
Dose Modifications ............................................................................................. 66 
8.4 
Compliance with Study Intervention ................................................................... 66 
8.5 
Data Collection and Follow-up for Withdrawn Participants ................................. 67 
8.6 
Trial Specific Preventive Measures .................................................................... 67 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 15 of 108   
8.7 
Concomitant Intervention(s) ............................................................................... 67 
8.7.1 Hospitalisation ........................................................................................ 68 
8.7.2 Starting an antidepressant ...................................................................... 68 
8.7.3 Use of sedative medications (Benzodiazepine, antipsychotics) ............... 68 
8.8 
Study Drug Accountability .................................................................................. 68 
8.9 
Return or Destruction of Study Drug ................................................................... 69 
9 
STUDY ASSESSMENTS ............................................................................................ 69 
9.1 
Study Flow Chart(s)/Table of Study Procedures and Assessments .................... 70 
9.2 
Assessments of Outcomes ................................................................................. 71 
9.2.1 Assessment of Primary Outcome ............................................................ 71 
9.2.2 Assessment of Secondary Outcomes ..................................................... 71 
9.2.3 Assessment of Other Outcomes of Interest ............................................. 75 
9.2.4 Assessment of Safety Outcomes ............................................................ 76 
9.2.5 Assessments in Participants Who Prematurely Stop the Study ............... 77 
9.3 
Procedures at Each Visit .................................................................................... 77 
9.3.1 Visit -1 (Screening/ written informed consent) ......................................... 77 
9.3.2 Visit 0 (placebo lead-in phase) ................................................................ 78 
9.3.3 Visit 1: baseline visit................................................................................ 78 
9.3.4 Visit 2: 6 weeks ....................................................................................... 78 
9.3.5 Visit 3: 12 weeks ..................................................................................... 79 
9.3.6 Visit 4: 24 weeks ..................................................................................... 79 
9.3.7 Visit 5: 36 weeks ..................................................................................... 79 
9.3.8 Clinical Care and monitoring of clinical visits ........................................... 79 
10 
SAFETY ...................................................................................................................... 79 
10.1 Definition of (Serious) Adverse Events and Other Safety Related Events........... 80 
10.2 Recording of (Serious) Adverse Events and Other Safety Related Events ......... 81 
10.3 Assessment of (Serious) Adverse Events and Other Safety Related Events ...... 82 
10.4 Reporting of Serious Adverse Events and Other Safety Related Events ............ 82 
10.5 Follow up of (Serious) Adverse Events ............................................................... 84 
11 
STATISTICAL METHODS ........................................................................................... 85 
11.1 Hypothesis ......................................................................................................... 85 
11.2 Determination of Sample Size ............................................................................ 85 
11.3 Statistical Criteria of Termination of Trial ............................................................ 86 
11.4 Planned Analyses .............................................................................................. 86 
11.4.1 Datasets to be Analysed, Analysis Populations ....................................... 87 
11.4.2 Primary Analysis ..................................................................................... 87 
11.4.3 Secondary Analyses ............................................................................... 88 
11.4.4 Interim Analyses ..................................................................................... 89 
11.4.5 Safety Analysis ....................................................................................... 89 
11.4.6 Deviation(s) from the Original Statistical Plan ......................................... 90 
11.5 Handling of Missing Data and Drop-Outs ........................................................... 90 
12 
ELIGIBILITY OF THE PROJECT SITE(S) ................................................................... 90 
13 
DATA QUALITY ASSURANCE AND CONTROL ......................................................... 90 
13.1 Data Handling and Record Keeping / Archiving .................................................. 91 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 16 of 108   
13.1.1 Case Report Forms ................................................................................ 91 
13.1.2 Specification of Source Documents ........................................................ 92 
13.1.3 Record Keeping / Archiving..................................................................... 92 
13.2 Data Management .............................................................................................. 93 
13.2.1 Data Management System...................................................................... 93 
13.2.2 Data Security, Access and Back-up ........................................................ 93 
13.2.3 Analysis and Archiving ............................................................................ 94 
13.2.4 Electronic and Central Data Validation .................................................... 94 
13.3 Monitoring .......................................................................................................... 94 
13.4 Audits and Inspections ....................................................................................... 95 
13.5 Confidentiality, Data Protection .......................................................................... 95 
13.6 Storage of Biological Material and Related Health Data ..................................... 96 
14 
PUBLICATION AND DISSEMINATION POLICY ......................................................... 96 
15 
FUNDING AND SUPPORT ......................................................................................... 97 
15.1 Funding .............................................................................................................. 97 
15.2 Other Support .................................................................................................... 97 
16 
INSURANCE ............................................................................................................... 97 
17 
REFERENCES ............................................................................................................ 98 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 17 of 108   
STUDY SYNOPSIS 
Sponsor / Sponsor-
Investigator 
Gregor Berger 
Department of Child and Adolescent Psychiatry  
University Hospital of Zurich 
University of Zurich 
Neumünsterallee 3 
Postfach 1482 
8032 Zürich 
Switzerland 
Study Title: 
Omega-3 fatty acids as first-line treatment in paediatric 
depression. A phase III, 36-week, multi-centre, double-blind, 
placebo-controlled randomized superiority Study. 
Short Title / Study 
ID: 
Omega-3-pMDD 
Protocol Version 
and Date: 
Version 3 of 13.07.2017 
Trial registration: 
Swiss Federal Complementary Database 
Clinicaltrials.gov 
Study category and 
Rationale 
Clinical Phase with IMP Category C 
Clinical Phase: 
Clinical Phase III 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 18 of 108   
Background and 
Rationale: 
About 10% teenagers report moderate to marked depressive 
symptoms and between 1-6% will develop a paediatric major 
depressive disorder (pMDD) until adulthood. However, evidence-
based treatment approaches are sparse and the use of SSRIs is 
heavily debated due to reports of an increase in suicidal ideation 
and limited efficacy in this age group. Growing evidence suggests 
that omega-3 fatty acids may be a beneficial treatment in adult 
MDD (aMDD) with no published study in teenagers, despite of its 
face validity as a valuable first-line treatment. Meta-analyses of 
published randomized controlled trials (RCTs) in aMDD show 
moderate effect sizes, if the proportion of eicosapentaenoic acid 
(EPA) is >60% of the total omega-3 fatty acids. One small RCT in 
prepubertal children shows an even larger effect size in favour of 
omega-3 fatty acids. Higher inflammatory mediators (e.g. c-
reactive protein, interleukins and others) have been reported in 
aMDD and pMDD. Preliminary data suggests that a pro-
inflammatory state may serve as predictor for omega-3 fatty acids 
response. Furthermore, low levels of omega-3 fatty acids have 
been found in aMDD and pMDD potentially also serving as EPA-
response predictors. As MDD is a heterogeneous disease entity, 
such response predictors should be incorporated into MDD RCTs. 
Objective(s): 
1) To investigate the therapeutic efficacy and safety of omega-3 
fatty acids rich in EPA in pMDD, 2) to demonstrate clinical 
meaningful effects of omega-3 fatty acid treatment, 3) to 
investigate inflammatory and bioactive lipid markers as response 
predictors, and 4) to investigate the relationship between 
psychopathology (in particular suicidal ideation), illness course and 
cognition in relation to inflammatory and bioactive lipid markers. 5.) 
To 
establish 
a 
tissue 
repository 
of 
phenotypically 
well 
characterised children and adolescents with pMDD. 
Outcome(s): 
The German S3 Guidelines for the treatment of depression in 
children and youth define the background treatment for all 
participants. All clinical partners will be trained and monitored 
accordingly. The primary outcomes are the (continuous) Children’s 
Depression Rating Scale-revised (CDRS-R) total score and the 
(dichotomous) rates of recovery defined by the absence of pMDD 
for >4months at 36 weeks, as well as response and remission 
rates at 12 and 36 weeks. Inflammatory mediators in serum using 
immunoassays, red blood cell omega-3, 6, 9 and trans fatty acids 
using gas chromatography (GC) and bioactive lipid mediators (e.g. 
E-series resolvins) using mass spectrometry (LC-MS/MS) will be 
measured as potential response predictors. Adverse events/ harm 
endpoints (in particular suicidality) will be coded using MedDRA. 
Adherence measurements are pill counts, as well as n-3 EPA/DHA 
levels across the study. Blood samples will be taken at study entry, 
week 12 and 36. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 19 of 108   
Study design: 
A Swiss, multicentre, randomised, double-blind, placebo-controlled 
clinical trial.  
Inclusion / Exclusion 
criteria: 
The study aims to recruit a sample of 220 individuals aged 8 -17 
years, who are in- or outpatients of a participating centre and have 
a present primary diagnosis of major depression disorder with 
depressive symptoms of at least moderate severity. Participants 
with pre-existing neurological or medical conditions likely to be 
responsible for the depressive symptoms or other psycho-
pathological diagnoses are excluded. 
Measurements and 
procedures: 
The study design incorporates a 1-2week screening, a 1week lead-
in placebo and a 36week double-blind placebo-controlled 
treatment phase. The severity of the depression and psychosocial 
functioning will be assessed at baseline and at each study visit 
(twice in the acute phase and twice in the maintenance phase) 
using a variety of different questionnaires and rating scales. 
Cognitive testing and biological markers (blood, urine and saliva) 
will be sampled at baseline and at 12 and 36 weeks. Adherence to 
the study will be checked by pill count at each study visit and 
PUFA level measurements in red blood cell membranes at 
baseline, 12 and 36 weeks will be performed. 
Study Product / 
Intervention:  
In the proposed study we use for the active treatment a daily dose 
of 500mg EPA/ 250mg DHA in our 8 to <13 year olds, and 1000mg 
EPA / 500mg DHA in our 13 to <18 years olds (which corresponds 
with the omega-3 fatty acid doses used in adult MDD RCTs). The 
drug will be administered for 36 weeks. 
Control Intervention 
(if applicable): 
Placebo capsules will contain mostly medium chain triglycerides 
(MCT) and also 10mg of fish oil to mimic the fishy flavour and 
taste. 
Number of 
Participants with 
Rationale: 
We aim to include 220 participants in total, resulting in 110 
participants per treatment group. We performed a sample size 
calculation based on the effect size of 0.54 found in a previous 
meta-analysis on the effect of omega-3 fatty acids in aMDD. 
Sample size calculations were then adjusted for a higher placebo-
response rate in minors given our multi-centre study. The analysis 
resulted in the inclusion of 108 patients per treatment group to 
achieve 80% or greater power to detect a difference of 20% in 
response rates between the two treatment groups. Our sample of 
220 participants exceeds therefore the projected sample size 
needed to detect a clinical meaningful difference. A detailed 
explanation of the sample size calculation can be found under 
Section 11.2. 
Study Duration: 
The study duration is projected to be about two years and nine 
months (March 2017 – December 2019) for patient recruitment and 
assessment and another year to finish up all the analysis and 
generate the final study report.  

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 20 of 108   
Study Schedule: 
First participant in: 01.03.2017 
Last participant in: 01.03.2019 
Last participant out: 01.12.2019 
Database closure: 01.02.2020 
Final analysis: 01.05.2020 
Study report: 1.12.2020 
Investigator(s): 
Gregor Berger 
Department of Child and Adolescent Psychiatry 
University Hospital of Psychiatry 
University of Zurich 
Neumünsterallee 3 
Postfach 1482 
8032 Zürich 
Phone: +41 43 499 26 71 
Mobile: +41 76 464 61 54 
Email: gregor.berger@puk.zh.ch 
 
Susanne Walitza 
Professor and Medical Director 
Department of Child and Adolescent Psychiatry 
University Hospital of Psychiatry 
University of Zurich 
Neumünsterallee 9 
8032 Zürich 
Phone: +41 43 499 27 30 
Email: susanne.walitza@puk.zh.ch 
 
Klaus Schmeck 
Research Director 
Department of Child and Adolescent Psychiatry Research 
Department 
Universitäre Psychiatrische Kliniken (UPK) Basel 
Schanzenstrasse 13 
4056 Basel 
Phone: +41 61 265 89 84 
Email: klaus.schmeck@upkbs.ch  
 
All other investigators will be documented in the trial master file. 
Study Centre(s): 
A total of five Cantons of the German part of Switzerland agreed to 
participate in the multi-centre Omega-3-pMDD trial. The five 
Cantons include two academic centres (Zürich ZH, Basel-Stadt 
BS) as well as the inpatient and outpatient services of Canton St. 
Gallen (SG), Thurgau (TG) and Basel-Land (BL) encompassing all 
public child- and adolescent psychiatric services in a catchment 
area of 2.7 Million habitants (ZH 1446.4M, BS 190.6M, SG 
495.8M, TG 263.7, BL 283.2). 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 21 of 108   
Statistical 
Considerations: 
The continuous primary outcome measure is the CDRS-R total 
score. The dichotomous primary outcome measures are recovery, 
response and remission. Data analysis will be performed in the 
intention-to-treat sample using a (generalized) linear random 
coefficient regression model. We will use multiple imputations for 
missing data. Under the assumption of random intercepts and 
slopes for each patient, the overall and treatment group-specific 
rate of change for the two treatment groups for the primary 
outcomes will be examined. A comparison on treatment slopes 
(linear trends with time) will then be conducted. 
GCP Statement: 
This study will be conducted in compliance with the protocol, the 
current version of the Declaration of Helsinki, the ICH-GCP as well 
as all national legal and regulatory requirements.  
 
 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 22 of 108   
 
ABBREVIATIONS  
5-HIAA 
5-Hydroxindoleacetc Acid 
5-HT2 
5-Hydroxytryptamine 
AA 
Arachidonic Acid 
ADHD 
Attention Deficit Hyperactivity Disorder 
AE 
Adverse Event  
ALA 
Alpha-Linolenic Acid 
ALAT 
Alanine Transaminase 
ANT 
Amsterdam Neuropsychological Tasks 
aMDD 
Adult Major Depressive Disorder 
APA 
American Psychological Association 
ASAT 
Aspartate Transaminase 
ASEC 
Antidepressant Side Effect Checklist 
ASR 
Annual Safety Report 
AWMF 
Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen 
Fachgesellschaften 
BAI 
Beck Anxiety Inventory 
BDI 
Beck Depression Inventory 
BHS 
Beck Hopelessness Scale 
BL 
Basel -Land 
BPD 
Borderline Personality Disorder 
BRIEF 
Behaviour Rating Inventory of Executive Function 
BS 
Basel-Stadt 
CA 
Competent Authority (e.g. Swissmedic) 
CAM 
Complementary Alternative Medicine 
CBCL 
Child Behaviour Checklist 
CBT 
Cognitive behavioural therapy 
CDI-2 
Children’s Depression Inventory 
CD-RISC 
Connor-Davidson Resilience Scale 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 23 of 108   
CDRS-R 
Children’s Depression Rating Scale-revised 
CEC 
Competent Ethics Committee 
CGAS 
Children’s Global Assessment of Functioning 
CGI 
Clinical Global Impression rating scale 
CGI-I 
Clinical Global Impression rating scale-improvement 
ClinO 
Clinical Trials Ordinance 
CRF 
Case Report Form  
CRH 
Corticotropin-releasing Hormone 
CSF 
Cerebrospinal Fluid 
CTC 
Clinical Trials Centre 
CTQ-SV 
Childhood Trauma Questionnaire-Short Version 
D2 
Dopaminreceptor 2 
DHA 
Docosahexaenoic acid 
DNA 
Desoxyribonuclein acid 
DM 
Data Management 
DSM-IV 
Diagnostic and Statistical Manual of Mental Disorders-4th edition 
EBPI 
Epidemiology, Biostatistics and Prevention Institute 
ECNP 
European College of Neuropsychopharmacology 
eCRF 
Electronic Case Report Form  
EFAs 
Essential fatty acids 
EPA 
Eicosapentaenoic acid 
EPS 
Extrapyramidal-motorische Störung 
ES 
Effect Size 
FDA 
Food and Drug Administration (USA) 
FFQ 
Food Frequency Questionnaire 
fMRI 
Functional Magnetic Resonance Imaging 
GC 
Gas Chromatography 
GCP 
Good Clinical Practice  
HETE 
Hydroxyeicosatetraenoic Acid 
HFG 
Humanforschungsgesetz 
HFV 
Verordnung über die Humanforschung mit Ausnahme der klinischen 
Versuche 
HoNOSCA 
Health of the Nation Outcome Scales for Children and Adolescents 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 24 of 108   
HPA 
Hypothalamic-pituitary-adrenal 
hsCRP 
High-sensitivity C-reactive Protein 
ICD-10 
International Classification of Diseases- 10th edition 
ICH 
International Council on Harmonization 
ICH-GCP 
International Conference of Harmonisation- Good Clinical Practice 
IDMC 
Independent Data Monitoring Committee 
IEPA 
Early Intervention in Mental Health 
IES-27-J&E 
Jugend- & Elternfragebogen über impulsives Verhalten und Erleben 
IFN 
Interferon 
IICT 
Investigator Initiated Clinical Trials 
IL 
Interleukin 
IMP  
Investigational Medicinal Product 
IQ 
Intelligence Quotient 
ITT 
Intention to Treat 
KAZ 
Kantonsapotheke Zurich 
KJPP 
Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie Zürich 
KlinV 
Verordnung über klinische Versuche in der Humanforschung 
 
K-SADS-PL 
Kiddie-Schedule for Affective Disorders and Schizophrenia-Present & 
Lifetime  
 
LA 
Linoleic acid 
 
LC-MS 
Liquid chromatography-mass spectrometry 
 
LC-PUFAs 
Long-chain polyunsaturated fatty acids 
 
MARS 
Medication Adherence Rating Scale 
 
MARS-D 
Medication Adherence Reporting Scale-Deutsch 
 
MAQ 
Medication Adherence Questionnaire 
MCP-1 
Monocyte Chemoattractant Protein-1 
MCT 
Medium Chain Triglycerides 
MDD 
Major Depressive Disorder 
 
MedDRA 
Medical Dictionary for Regulatory Activities 
MS 
Mass Spectrometry 
 
n-3 FFQ 
Omega-3 Food Frequency Questionnaire 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 25 of 108   
OCD 
Obsessive Compulsive Disorder 
 
PI 
Principal Investigator  
pMDD 
paediatric Major Depressive Disorder 
 
PMS 
Premenstrual Syndrome 
 
PRN 
Pro Re Nata (as needed) 
PUFAs 
Polyunsaturated Fatty Acids 
 
RA 
Responsible Applicant 
 
Rbc 
Red blood cell membranes 
 
RCTs 
Randomized Controlled Trials 
 
RIAS 
Reynolds Intellectual Assessment Scales 
RR 
Relative Risk 
 
RWFT 
Regensburger Wortflüssigkeits-Test 
SAE 
Serious Adverse Event  
SD 
Standard Deviation 
SDQ 
Strength and Difficulty Questionnaire 
SG 
St. Gallen 
 
SIQ-Jr 
Suicide Ideation Questionnaire-Junior 
 
SMD 
Standard Mean Difference 
 
SNSF 
Swiss national science foundation 
 
SOP 
Standard Operating Procedure 
SSRI 
Selective Serotonin Reuptake Inhibitor 
 
SUSAR 
Suspected Unexpected Serious Adverse Reaction  
TADS 
Treatment for Adolescents with Depression Study 
 
TARMED 
Tarif Médical 
TG 
Thurgau 
TNF 
Tumor Necrosis Factor 
TSH 
Thyroid Stimulating Hormone 
UHR 
Ultra High Risk 
 
UK 
United Kingdom 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 26 of 108   
USZ 
Universitätsspital Zürich 
 
VMLT 
Verbaler Lern- und Merkfähigkeitstest 
 
WH 
Working Hypothesis 
WHO 
World Health Organization 
 
WI 
Working Instruction 
WISC IV 
Wechsler Intelligence Scale for Children Version IV 
 
WM 
White Matter 
 
ZH 
Zürich 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 27 of 108   
STUDY SCHEDULE 
Study visit 
 
 
-1 
 
1 
2 
3 
4 
5 
 
 
Time (min) 
Examiner 
Screening/ 
written 
consent
Placebo 
Lead in  
Baselin
e 
Acute 
phase 
Main- 
tenance 
phase 
Drop-out 
Weeks 
 
 
-2 
±5d 
-1 
±5d 
0 
 
6 
+/-3d 
12 
+/-3d 
24 
+/-5d 
36 
+/-5d 
 
Study information 
15 
RC 
x 
 
 
 
 
 
 
 
Informed consent 
5 
RSP 
x 
 
 
 
 
 
 
 
Inclusion / exclusion 
5 
R 
x 
 
x 
 
 
 
 
 
Sociodemographic data 
1 
R 
x 
 
 
 
 
 
 
 
Medical  incl. psychiatric history 
1 
R 
x 
 
 
 
 
 
 
 
Family history 
1 
RSP 
x 
 
 
 
 
 
 
 
Physical Health (incl. Tanner) 
1 
R 
 
x 
 
 
 
 
x 
 
Current medication use 
1 
R 
x 
 
x 
x 
x 
x 
x 
x 
Omega-3 Food questionnaire 
5 
S 
 
x 
 
 
x 
 
x 
x 
WHO Assist 3.0 Drug Use 
10 
R 
x 
 
 
 
x 
 
x 
x 
PTBS Checklist 
5 
S 
x 
 
 
 
 
 
 
 
Intervention 
- 
- 
- 
Pla 
Active/Placebo 
 
 
Main outcome variables 
Children’s Depression Rating Scale CDRS-R 
15 
R 
x 
 
x 
x 
x 
x 
x 
x 
Diagnostic interview (K-SADS-PL) 
60 
R 
x 
 
x* 
x* 
x* 
x* 
x 
x 
 
Clinician rated variables (at each clinical visit) +/- 2 weeks 
Clinical Global impression Scale CGI-S/I 
1 
C 
 
 
x 
x 
x 
x 
x 
x 
Children Global Assessment Scale CGAS 
1 
C 
 
 
x 
x 
x 
x 
x 
x 
Attrition check list inkl. HoNOSCA 
8 
C 
 
 
x 
x 
x 
x 
x 
x 
 
Self-report variables (self rating for 13-<18yr, parent rating for 8-<13yr)  
Children’s Depression Inventory DIKJ 
15 
S 
 
 
x 
x 
x 
x 
x 
x 
Beck Hopelessness Scale II BHS 
5 
S 
 
 
x 
x 
x 
x 
x 
x 
Beck Anxiety inventory BAI II 
5 
S 
 
 
x 
x 
x 
x 
x 
x 
Suicidal ideation questionnaire SIQ-Jr 
5 
S 
 
 
x 
x 
x 
x 
x 
x 
The Insomnia Severity Index 
1 
S 
 
 
x 
x 
x 
x 
x 
x 
Perceived Stress Scale PSS-10 
5 
S 
 
 
x 
 
x 
 
x 
x 
Connor-Davidson Resilience Scale 
10 
S 
 
 
x 
x 
x 
x 
x 
x 
KIDscreen-CAT-27 
15 
SP 
x(P) 
 
x 
 
x 
 
x 
x 
SDQ 
5 
SP 
x(P) 
 
x 
 
x 
 
x 
x 
IES-27-J 
15 
SP 
x(P) 
 
x 
 
x 
 
x 
x 
ASEC (AD side effect self report scale) 
5 
S 
 
 
x 
x 
x 
x 
x 
x 
 
Cognitive outcome variables 
BRIEF (executive Functioning questionnaire) 
10 
SP 
X(P) 
x (S) 
 
 
x 
 
x 
 
Cognitive battery 
50 
R 
 
x 
 
 
x 
 
x 
 
RIAS (short IQ test for matching) 
20 
R 
 
 
 
 
 
x 
 
 
 
Biological outcome variables 
Clinical bloods, hsCRP (2-3d prior randomization) 
5 
N 
 
x 
 
 
 
 
x 
x 
Red blood cells (PUFAs), Serum (e.g. immune 
multiplex marker chip), Buffy coat for tissue 
repository (e.g. genetic, epigenetic markers) 
N 
 
x 
 
 
x 
 
x 
x 
Urine (drug screen, F2 isoprostane) 
5 
N 
 
x 
 
 
x 
 
x 
x 
Saliva cortisol 
1 
N 
 
x 
 
 
x 
 
x 
x 
 
Other measures 
Drug dispensing/ Pill count/appointment 
1 
R 
 
x 
x 
x 
x 
x 
 
 
AE 
 
 
 
 
x 
x 
x 
x 
x 
x 
MARS-D 
3 
S 
 
 
x 
x 
x 
x 
x 
 
Approx. time requirement for patient / family only (min) 
180  
 
90 
90 
90 
210 
120 
210 
200 
 
* Only subscale ‘depressive disorders’ will be performed 
 
 R = researcher; C = clinician; S = self-rated; P = parent-rated; N = study nurse 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 28 of 108   
1 STUDY ADMINISTRATIVE STRUCTURE  
This multicentre trial is centrally coordinated by the Department of Child and Adolescent 
Psychiatry of the University of Zurich and conducted in five Cantons of the German part of 
Switzerland (ZH, BS, BL, TG, SG). Below are the personnel involved in the study at this stage. 
A list of co-investigators and other study team members such as doctoral students and study 
nurses involved in the clinical trial will be given in the study team contact summery form in the 
Study Master File and at each Investigator Site File.  
 
1.1 Sponsor, Sponsor-Investigator  
Gregor Berger 
Department of Child and Adolescent Psychiatry  
University Hospital of Psychiatry 
University of Zurich 
Neumünsterallee 3 
Postfach 1482 
8032 Zürich 
Phone: +41 43 499 26 71 
Mobile: +41 76 464 61 54 
Email: gregor.berger@puk.zh.ch  
 
Main applicant and PI, overall governance of the project, responsible for the conceptualisation, 
trial design, overall management and implementation of the Omega-3-pMDD Study in the main 
and partner centres, development of the research protocol, case report forms (CRFs), standard 
operating procedures (SOPs), training and supervision of research staff, recruitment process, 
management of serious adverse events (SAE), data management (DM) and analysis, contact 
and coordination with laboratories and external agencies (incl. industrial partners, Clinical Trials 
Centre (CTC), clinical trials pharmacy and Independent Data Monitoring Commitee (IDMC), 
local and national ethics committees, as well as the Antistress AG Burgerstein who provides the 
study medication incl. placebo, dissemination of trial results (organization of conference 
attendances, publication strategy, media releases). 
 
 
1.2 
Principal Investigator(s) 
Zurich 
Susanne Walitza 
Professor and Medical Director 
Department of Child and Adolescent Psychiatry 
University Hospital of Psychiatry 
University of Zurich 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 29 of 108   
Neumünsterallee 9 
8032 Zürich 
Phone: +41 43 499 27 30 
Email: susanne.walitza@puk.zh.ch  
 
Clinical responsibility for the management / realization of the trial at Zurich. Overall governance 
of project, conceptualisation, realisation, data analysis, writing, publication and promotion of the 
project, support in networking, academic mentorship Dr. G. Berger. 
 
Basel-Stadt 
Klaus Schmeck 
Research Director 
Department of Child and Adolescent Psychiatry Research Department 
Universitäre Psychiatrische Kliniken (UPK) Basel 
Schanzenstrasse 13 
4056 Basel 
Phone: +41 61 265 89 84 
Email: klaus.schmeck@upkbs.ch  
Governance of Basel site, concepualisation, realisation, data analzsis, writing, publication and 
promotion of the project. 
 
Alain Di Gallo 
Department of Child and Adolescent Psychiatry 
Universitäre Psychiatrische Kliniken (UPK) 
Schaffhauserrheinweg 55 
4058 Basel 
Phone: +41 61 685 21 21 
Email: alain.digallo@upkbs.ch  
 
Basel-Land 
Brigitte Contin-Waldvogel 
Psychiatrie Baselland 
Bienentalstrasse 7 
4410 Liestal 
Phone: +41 61 553 59 01 
Email: brigitte.contin@pbl.ch 
 
Thurgau 
Silke Bachmann 
Clienia Littenheid AG 
Privatklinik für Psychiatrie und Psychotherapie 
9573 Littenheid 
Phone: +41 71 929 60 60 
Email: silke.bachmann@clienia.ch  
www.clienia.ch 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 30 of 108   
Lars Wöckel 
Clienia Littenheid 
Privatklinik für Psychiatrie und Psychotherapie 
9573 Littenheid 
Phone: +41 71 929 60 60 
Email: Lars.Woeckel@clienia.ch  
 
Bruno Rhiner 
Child and Adolescent Psychiatric Services Thurgau 
Schützenstrasse 15 
8570 Weinfelden 
Phone: +41 71 686 47 01 
Email : bruno.rhiner@stgag.ch 
 
St. Gallen 
Suzanne Erb 
Child and Adolescent Psychiatric Services St. Gallen 
Brühlgasse 35/37 
Postfach 447 
9004 St. Gallen 
Phone: +41 71 243 45 45 
Email: Suzanne.Erb@kjpd-sg.ch   
 
St. Gallen 
Michael Schmid 
Child and Adolescent Psychiatric Services St. Gallen 
Brühlgasse 35/37 
Postfach 447 
9004 St. Gallen 
Phone: +41 71 243 45 45 
Email: Michael.Schmid@kjpd-sg.ch  
 
St. Gallen 
Ulrich Müller-Knapp 
Klinik Sonnenhof 
Sonnenhofstrasse 15 
9608 Ganterschwil 
Phone:+41 71 983 26 33 
Email: Ulrich.Mueller-Knapp@kjpz.ch 
 
 
1.3 Neuropsychology 
 
Renate Drechsler 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 31 of 108   
Head of Neuropsychology laboratory 
University Clinic of Child and Adolescent Psychiatry 
University of Zurich 
Eisengasse 16 
8008 Zürich 
Phone: + 41 43 556 40 50 
Email: renate.drechsler@kjpd.uzh.ch  
 
Investigation of omega-3 fatty acids effects on cognition. PhD Supervisor. 
1.4 
Coordinating Investigator  
Gregor Berger 
Department of Child and Adolescent Psychiatry  
University of Zurich 
Neumünsterallee 3 
Postfach 1482 
8032 Zürich 
Phone: +41 43 499 26 71 
Mobile: +41 76 464 61 54 
Email: gregor.berger@puk.zh.ch  
1.5 
Statistician (“Biostatistician”) 
Burkhardt Seifert 
Epidemiology, Biostaticis and Prevention Institute (EBPI) Department of Biostatistics 
University of Zurich 
Hirschengraben 84 
8001 Zürich 
Phone : +41 (0)44 634 46 44 
Email : seifert@ifspm.uzh.ch  
 
Alexander Roth 
Biostatistician KJPP 
Department of Child and Adolescent Psychiatry 
University of Zurich 
Neumünsterallee 9 
8032 Zürich 
Phone : +41 (0)43 499 27 67 
Email : alexander.roth@kjpd.uzh.ch  
1.6 
Laboratory (if applicable) 
 
Edna Grünblatt 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 32 of 108   
Head of Neurobiochemistry laboratory 
University Clinic of Child and Adolescent Psychiatry 
University Zurich  
Wagistrasse 12 (5th Floor Room K118) 
8952 Schlieren 
Phone: +41 (0)43 556 40 39 
Email: edna.gruenblatt@kjpd.uzh.ch  
Inflammatory mediators / Blood processing / Tissue repository 
 
 
Martin Hersberger 
Head of the Division of Clinical Chemistry and Biochemistry University Children’s Hospital 
Zurich 
Steinwiesstrasse 75 
8032 Zürich 
Phone: +41 (0)44 266 75 41 
Email: martin.hersberger@kispi.uzh.ch  
Bioactive Lipids 
 
 
Clemens von Schacky 
CEO 
Omegametrix GmbH 
Am Klopferspitz 19 
82152 Martinsried 
Germany 
Phone:+49 89 559 63 007 
Email:  c.vonschacky@omegametrix.eu  
PUFAs 
 
Anne Eckert 
 
Department of Neurobiology 
Universitäre Psychiatrische Kliniken Basel 
Wilhelm Klein-Strasse 27 
4002 Basel 
Phone: +41 61 325 5487 
Email: anne.eckert@upkbs.ch 
1.7 
Monitoring Institution 
Clinical Trials Centre (CTC) 
University of Zurich 
Rämistrasse 100 
8091 Zürich 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 33 of 108   
Phone : +41 (0)44 634 55 09 
Email : ctc-zkf@usz.ch 
 
Monitoring and data management 
1.8 Independent Data Monitoring Committee 
The safety and integrity of the study will be judged on a regular basis by an independent 
committee of experts (Independent Data Monitoring Committee; IDMC), at a frequency of at 
least once a year. Members of the IDMC will include an expert in child and adolescent 
psychiatry (Prof. Dr. med. Romuald Brunner, Vice Director of the Centre for Child and 
Adolescent Psychiatry, Heidelberg University Hospital), an expert in biostatistics (Prof. Dr. Milo 
Puhan, Director of the Epidemiology, Biostatistics and Prevention Institute of the University of 
Zurich) and an expert in pharmacology and ethics (Prof. Dr. Med. Jürgen Drewe, Director of 
Preclinical Research of Max Zeller Soehne AG). 
The members of this board will have access to all SAEs and SUSARs and to the inclusion and 
drop-out rates. Key task will be to monitor safety and harm data, in particular to monitor the 
number of suicide attempts. SAE will be reported to the ethics committee and the IDMC in 
writing. If the IDMC deems it necessary additional information can be provided. If the IDMC 
deems it necessary to perform an interim analysis of the safety or harms data, the IDMC can 
directly liaise with the CTC and clinical trials pharmacist to do so. In case that the IDMC deems 
it unethical to continue the trial because of a premature (prior to achieving the n=220) difference 
between active and placebo (either efficacy or safety data), the trial can be terminated at their 
request. 
The IDMC is also authorised to suggest changes to the protocol or to provide an altered 
judgement of feasibility when information from the annual safety report or new information about 
the applied study medication has become available. If deemed necessary for their evaluation, 
the IDMC is allowed to review unblinded data. The central study team members will not be 
exposed to these data analysis, unless the study is terminated prematurely.  
1.9 
 Any other relevant Committee, Person, Organisation, Institution  
Clinical Trials Pharmacy 
Kantonsapotheke Zürich 
Spöndlistrasse 9 
8006 Zürich 
Phone : +41 44 255 45 46 
Email :  info@kaz.zh.ch 
Blinding, packaging and labelling of medication 
 
Burgerstein Vitamine 
Antistress AG 
Fluhstrasse 30 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 34 of 108   
8640 Rapperswil-Jona 
Switzerland 
Phone: +41 55 220 12 12 
www.burgerstein.ch 
 
2 
PRODUCTION OF STUDY MEDICATION; ACTIVE AND PLACEBOETHICAL AND 
REGULATORY ASPECTS 
Before this study will be conducted, the protocol, the proposed participant information and 
consent form as well as other study-specific documents will be submitted to a properly 
constituted Competent Ethics Committee (CEC) and Competent Authorities (Swissmedic) in 
agreement with local legal requirements, for formal approval. Any amendment to the protocol 
must as well be approved. 
The decision of the CEC and Swissmedic concerning the conduct of the study will be made in 
writing to the Sponsor-Investigator before commencement of this study. The clinical study can 
only begin once approval from all required authorities has been received. Any additional 
requirements imposed by the authorities shall be implemented. 
2.1 Study Registration 
The study will be registered in both the Swiss Federal Complementary Database (“Portal”) and 
the Clinicaltrials.gov registry database, before participant recruitment in the study starts. 
2.2 Categorisation of Study 
The study is considered to fall under category C according to ClinO Art. 19. 
 
2.3 Competent Ethics Committee (CEC)  
Approval from the appropriate constituted Competent Ethics Committee is sought for each study 
site in the clinical trial (zuständige kantonale Ethikkommissionen) and the national competent 
authority (SwissMedic). The reporting duties and allowed time frame are respected. No 
substantial changes are made to the protocol without prior Sponsor, CEC, CA approval, except 
where necessary to eliminate apparent immediate hazards to study participants. Premature 
study end or interruption of the study is reported within 15 days. The regular end of the study is 
reported to the CEC within 90 days, the final study report shall be submitted within one year 
after study end. Amendments are reported according to chapter 2.10. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 35 of 108   
2.4 Competent authority (CA)  
The Sponsor will obtain approval from Swissmedic before the start of the clinical trial. Reporting 
will be done within the allowed time frame. Planned or premature study end are reported within 
90 and 15 days, respectively. The final report will be submitted to the CA within one year after 
the end of the study. Amendments are reported according to chapter 2.10. 
2.5 Ethical Conduct of the Study 
The study will be carried out in accordance with principles enunciated in the current version of 
the Declaration of Helsinki, the guidelines of Good Clinical Practice (GCP) issued by ICH, and 
Swiss competent authority’s requirements.  
CEC and competent authorities will receive annual safety and interim reports and be informed 
about study stop/ end in agreement with local requirements. 
2.6 Declaration of Interest  
We declare no conflict of interest.  
2.7 Patient Information and Informed Consent 
 
Participation in the study is preceded by counselling by the treating doctor/ psychologist or 
investigator in accordance with ICH-GCP guidelines, during which the patients and their 
guardians must be informed about the nature and entire course of the study, potential individual 
benefits and personal risk shall be explained. Here it will be re-emphasised that participation is 
absolutely voluntary. Given that this study is conducted in a psychiatric setting, the study 
information may also be given by a research psychologist. In this case, the research 
psychologist will sign the informed consent additionally to the psychiatrist. Potential participants 
and their parents/ guardians are given sufficient time to read all the provided information 
(approved by the appropriate authorities), and clarify any questions with the treating doctor/ 
psychologist or investigator. Participation only becomes possible after the patients, their 
guardians as well as the investigator/doctor have signed the informed consent document. This 
consent can be revoked at any time without citing reasons and without any consequences. No 
examinations or other activities will take place before the informed consent procedure is 
completed. A copy of the consent form and the patient information sheet will be given to the 
participants and their guardians.  
In case the patient information sheet or the consent form change, participants will be informed 
immediately and relevant information will be passed on to the ethic committees for approval. 
New patient information and consent will be discussed in detail again, the participant will again 
be asked for written consent, and a copy of the documents will be given to the subject. 
 
Given participants are between 8 and 17 years old at the start of the study, informed consent 
are provided by their legal representatives/parents, in line with the Clinical Trial Directive, the 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 36 of 108   
Declaration of Helsinki and ICH-GCP. Their consent must represent the minor’s presumed will 
and may be revoked at any time, without detriment to the minor. Whenever appropriate, the 
minor should participate in the informed consent process together with the parents. The 
researcher will also obtain the minor’s assent in addition to the consent of the legal 
representatives/parents. The minor’s assent is not sufficient to allow participation in the study; 
informed consent of the legal representatives/parents is required. Consent from legal 
representatives/parents and assent from the minor should be sought at the same time. In any 
case, the minor will receive information according to its capacity of understanding, from staff 
with experience in minors, regarding the study, its risks and benefits. The explicit wish of a 
minor who is capable of forming an opinion and assessing this information to refuse 
participation will be followed; in such case, the minor can be withdrawn from the study at any 
time. If a minor subject does not want to participate, they will not be included in the study. This 
is also explicitly stated in the patient information sheet. 
In case a minor reaches adulthood (age of 18) during the study, the researcher is obliged to 
obtain informed consent from this participant as soon as possible. Informed consent from legal 
representatives/parent is no longer required, although it is recognised that an adolescent is still 
vulnerable and may require additional discussions and explanations. 
 
2.8 Participant Privacy and Confidentiality 
The investigator affirms and upholds the principle of the participant's right to privacy and that 
they shall comply with applicable privacy laws. Especially, anonymity of the participants shall be 
guaranteed when presenting the data at scientific meetings or publishing them in scientific 
journals.  
Individual subject medical information obtained as a result of this study is considered 
confidential and disclosure to third parties is prohibited. Subject confidentiality will be further 
ensured by utilising subject identification code numbers to correspond to treatment data in the 
computer files. 
Such medical information may be given to the participant’s personal physician or to other 
appropriate medical personnel responsible for the participant’s welfare, if the patient has given 
his/her written consent to do so. 
For data verification purposes, authorised representatives of the Sponsor (-Investigator), a 
competent authority (e.g. Swissmedic), or an ethics committee may require direct access to 
parts of the medical records relevant to the study, including participants’ medical history. 
 
Regarding data privacy, subjects will be informed about pseudonymous recording. The 
allocation of a unique study number that can be traced back to the patient if necessary will be 
used. The list with patients’ names and contact details are kept with the principal investigators. 
Outside laboratories will only be provided with coded documentation not enabling them to 
identify the individual patient. The sharing of data will be done in accordance with ICH-GCP 
guidelines. In case subjects cannot agree to this central collection of data they cannot 
participate in the study. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 37 of 108   
2.9  Early Termination of the Study  
The Sponsor-Investigator may terminate the study prematurely according to the following 
circumstances: 
 
ethical concerns, 
 
insufficient participant recruitment, 
 
when the safety of the participants is doubtful or at risk, respectively, 
 
alterations in accepted clinical practice that make the continuation of a clinical trial 
unwise,  
 
early evidence of benefit or harm of the experimental intervention  
 
recommendations of the Independent Data Monitoring Committee 
 
the sponsors general expertise regarding the significance of the accumulating data or 
 
other important reasons such as accumulating external evidence or quality concerns.  
2.10  Protocol Amendments 
In order to maintain comparable conditions in all study sites and to obtain an unobjectionable 
data analysis changes of the protocol are not intended. If nonetheless changes become 
necessary they are reported as amendment and submitted to the responsible ethics committees 
(die zuständigen kantonale Ethikkommissionen) and, if necessary, to the national authorities 
(SwissMedic) according to the regulations, taking into account the distinction between 
substantial and non-substantial amendments. 
 
Substantial amendments (significant changes) are only implemented after approval of the CEC 
and CA respectively. 
 
Significant changes to be authorised by the CEC are the following: 
 
changes affecting the participants’ safety and health, or their rights and obligations;  
 
changes to the protocol, and in particular changes based on new scientific knowledge 
which concern the trial design, the method of investigation, the endpoints or the form of 
statistical analysis; 
 
a change of trial site, or conducting the clinical trial at an additional site; or 
 
a change of sponsor, coordinating investigator or investigator responsible at a trial site. 
 
Significant changes to be authorised by Swissmedic are the following: 
 
changes to the therapeutic product, or to its administration or use; 
 
changes based on new preclinical or clinical data which may affect product safety; or  
 
changes concerning the production of the therapeutic product which may affect product 
safety. 
 
Under emergency circumstances, deviations from the protocol to protect the rights, safety and 
well-being of human participants may proceed without prior approval of the sponsor and the 
CEC/CA. Such deviations shall be documented and reported to the sponsor and the CEC/CA as 
soon as possible. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 38 of 108   
All Non-substantial amendments are communicated to the CA as soon as possible if applicable 
and to the CEC within the Annual Safety Report (ASR).  
 
The sponsor is responsible for all protocol amendments and for communicating potential 
protocol modifications to all relevant parties. All principal investigators are allowed to make 
suggestions for protocol amendments to the sponsor, who will decide whether the proposed 
amendments are necessary. In case of an amendment, all study centres and other relevant 
parties will be informed by the sponsor by email, and the amendments will be submitted to the 
responsible ethic committees. In addition, a private protected study website will be provided. All 
the relevant documents will also be available in the master trial file and at each individual site 
file.  
3 INTRODUCTION 
3.1 Background and Rationale 
3.1.1. Adult and paediatric major depressive disorders 
 
Adult Major Depressive Disorders (aMDDs) are characterized by the presence of at least five of 
the following symptoms for most of the time lasting for at least 2 weeks or more: sadness, 
emptiness or hopelessness (in children and adolescents sadness often manifests as irritable 
mood); loss of interest or pleasure in activities; psychomotor retardation or agitation (observed); 
decreased energy or fatigue; worthlessness or inappropriate guilt; thoughts of death and 
suicide; diminished concentration or indecisiveness; insomnia or hypersomnia; change in weight 
or appetite [1]. In childhood most presentations are first-onset presentations that have a slightly 
better prognosis than recurrent forms of MDD. About 60% of a clinical cohort meeting DSM 
criteria for paediatric major depressive disorder (pMDD) will recover within 9 months (in contrast 
to adjustment disorders with depressive features that have a faster and better recovery rate). 
The mean length of pMDD is about 9 months [2, 3]. Childhood- and adolescent-onset 
depression have similar clinical presentations except of the melancholic symptoms that are 
more prevalent in adolescence [4]. The natural illness course warrants a long study duration to 
address the efficacy and effectiveness of a proposed treatment. 
In a recent school survey about one in ten adolescents in Zürich reported moderate to marked 
depressive symptoms, and one in three if you include mild depressive symptoms [5], which 
corresponds quite well to national and international surveys [6]. Upon use of structured clinical 
interviews in <18year olds 1-6% meet criteria for a MDD [7]. Depressive disorders are often 
emerging in adolescence, are often not recognized even by professionals [8] and only about a 
quarter receive appropriate treatment [9]. These findings are alarming given that between 10 
and 24 year olds MDD is the leading cause of disability [10]. An early onset of the disease is a 
risk factor for chronic and recurrent forms of depression in adulthood with more than half 
experiencing a first relapse within five years [11]. MDD is associated with difficulties in 
relationships, impaired school and work functioning, and an increased risk of substance abuse 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 39 of 108   
[12, 13]. MDD is a major contributor to the burden of suicide and poor long-term health later in 
life (in particular ischaemic heart disease) [14, 15]. 
 
3.1.2 MDD and suicidality 
 
Three recent Cochrane reviews analysing psychological [16], pharmacological [17] and relapse 
preventive interventions [18] in pMDD illustrate how poor the currently available evidence-based 
knowledge is for treating this vulnerable patient population. In fact, there have been major 
concerns that the use of antidepressant medications in this age group may worsen suicidal 
behaviours [19]. Following a thorough and comprehensive review of all available published and 
unpublished RCTs of antidepressants in children and adolescents in October 2004, the U.S. 
Food and Drug Administration (FDA) issued a public warning about an increased risk of suicidal 
thoughts or behaviours in children and adolescents treated with SSRI medications. In 2006, the 
FDA extended the warning to include young adults up to the age of 25. Other agencies across 
the world such as the Swissmedic, the UK Medicines and Health Care Products Regulatory 
Agency and the European Medicines Agency followed [20]. The debate that SSRIs may 
increase suicidal ideation has contributed to a lot of insecurity in affected individuals and their 
families, as well as in the professional community [21-23]. A consequence of the “black box 
warning” was that prescribing practices of antidepressants have decreased for young people 
[24]. Additionally a recent reanalysis of the SmithKline Beecham study 329, a placebo-
controlled RCT with paroxetine in pMDD [25, 26] provides evidence that despite negative 
findings on all a priori primary outcomes, the study was “sold” as a positive study based on a 
post-hoc outcome that was introduced after trial initiation. As a consequence Paroxetine has 
been prescribed to tens of thousands of children and adolescents with pMDD without sound 
scientific evidence. In contrary, the safety data showed that the paroxetine group reported more 
suicidal ideations than the placebo group [27]. However, epidemiological data provides some 
evidence that in regions with the strongest decrease in antidepressant use showed an increase 
in suicide rates in children and adolescents [28]. More recent data in severe forms of 
depression provides some evidence that the regular intake of fluoxetine, sertraline and to some 
extent citalopram in severe forms of depression may be protective against suicide (probably by 
treating the underlying illness) despite of an increase in suicidal ideation [29]. This debate is 
certainly also of relevance for Switzerland, as the age-corrected mean suicide rate in this age 
group over the last 13 years is 7.6 per 100’000 teenagers and is above the worldwide average 
[30]. 
Based on the current partially conflicting evidence, the use of SSRIs in the treatment of pMDD 
should be evaluated very carefully and should mainly be considered in the more severe cases 
of pMDD. Nevertheless, in regions where child and adolescent therapists trained in cognitive 
behavioural or interpersonal therapy practices are not readily available, the use of 
antidepressants may often be the only choice [16]. However, patients and their parents are 
often very sceptical about the use of antidepressants, in particular since the intensive media 
attention about the increase in suicidal ideation has emerged [31]. In some cases this critical 
attitude probably results in a delay or premature discontinuation of necessary treatments of 
severe forms of pMDD potentially contributing to a poorer outcome, or even to suicides [32, 33].  
Experts in the field propose a stepwise approach from more benign to more invasive 
treatments. In line with the German S3 Guidelines (AWMF-Nr. 028-043) [34] cognitive 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 40 of 108   
behavioural or interpersonal psychotherapy is considered a good first-line treatment and the 
golden standard in the treatment of pMDD. The timing at what point a combination of fluoxetine 
with CBT shall be introduced depends on the severity of depression and the availability of 
psychological treatment options. The decision to start an antidepressant should whenever 
possible be reserved for the more severe cases and be based upon a careful clinical expert 
decision. The latter decision should not be made easily as no single novel antidepressant is 
approved for pMDD in Switzerland (e.g. Swissmedic even does not recommend the use of 
Fluoxetine in <18 year olds despite the strongest evidence within its class; in Switzerland any 
SSRI use in pMDD is therefore “off label”). Nevertheless, in the real world about 50% of all 
SSRIs in children and adolescents are prescribed by general practitioners and paediatricians 
despite the fact that they themselves report that they have not been adequately trained to do so. 
Non-specialists often overestimate the benefit over the risk associated with SSRI use in minors 
[35, 36].  
 
3.1.3 The importance of Omega-3 fatty acids 
 
The precursors of omega-3 fatty acids (alpha-Linolenic acid ALA) and omega-6 fatty acids 
(Linoleic acid LA) are essential fatty acids (EFAs) meaning that humans cannot synthesise them 
de novo. Humans have to supply EFAs through diet similar to vitamins. Since the industrial 
revolution human lifestyle and diet underwent major changes, one of them being a dramatic 
shift from a balanced omega-6 to omega-3 fatty acids diet to an excess in omega-6 and trans 
fatty acids intake in Western societies [37]. Therefore, humans living in modern societies are 
exposed to a nutritional environment that does not match their genetic constitution resulting in 
the hypothesis that the rapid rise in civilization diseases such as diabetes, cardiovascular 
disorders, but also psychiatric disorders such as depression may beside other reasons also be 
the consequence to these dietary changes [38]. The source of the omega-3 LC-PUFAs is 
mainly oily fish, e.g. salmon or sardines, whereas the precursor ALA is also present in plant oils, 
such as canola oil, nut oils, or algae oils. A small proportion of the essential precursors ALA and 
LA can be transformed into bioactive long-chain polyunsaturated fatty acids (LC-PUFAs), such 
as the omega-6 arachidonic acid (AA) and its metabolites, and the omega-3 eicosapentaenoic 
acid (EPA) and docosahexaenoic acid (DHA) and their bioactive metabolites (see page 20  
Fig.1). LC-PUFAs and their bioactive lipids have important physiological roles in normal brain 
development, but also other processes such as inflammation and immunity. A range of 
epidemiological and experimental studies provide some evidence for a link between 
cardiovascular disorders, metabolic syndrome or depressive disorders that are all proposed to 
be associated with an increase in proinflammatory cytokines and a deficiency in omega-3 fatty 
acids. The latter may have direct implications for prevention and treatment [38, 39]. 
 
3.1.4 Dietary intake of Omega-3 fatty acids and MDD 
 
Epidemiological studies found an inverse association between the intake of oily fish (rich in 
omega-3 fatty acids) and the prevalence [40-45] and incidence [46-48] of depressive disorders, 
postpartum depression [49] and bipolar disorder [50]. A recent meta-analysis of 26 studies 
involving 150’278 participants found that fish intake may have a protective effect comparing the 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 41 of 108   
highest versus lowest fish consumption group with a pooled relative risk (RR) of depression of 
0.83 [51]. Furthermore, inverse relationships between fish intake, membrane omega-3 fatty 
acids and number of suicide attempts have also been reported by independent groups [41, 52, 
53].  
 
3.1.5 Omega-3 fatty acids deficiency in MDD 
 
LC-PUFAs can be measured in red blood cell membranes (rbc) or plasma. Due to the high 
fluctuation of free fatty acids, the measurement of rbc LC-PUFAs is a better proxy for the mean 
LC-PUFA intake over the last couple of weeks. A meta-analysis including a total of 3318 
patients with MDD [51, 54] confirms a significant decrease in total omega-3 fatty acids (ES=-
0.51, p<0.0001), in particular in EPA (ES=-0.18, p=0.004) and DHA (ES=-0.35, p=0.0002) [49]. 
Similar deficits are also present in postpartum depression [55] and social anxiety disorder [56]. 
High n-6/n-3 omega fatty acid ratios are frequently reported [57-60]. Similar changes could also 
be observed in pMDD [61].  
 
3.1.6 Inflammatory mediators, Omega-3 fatty acids and MDD 
Proinflammatory cytokines in both plasma and CSF have been found to influence the 
progression and severity of depressive disorders in different populations. Studies have shown 
elevated serum levels of Il-1, Il-6, TNF-alpha und MCP-1 in depressed patients, but have 
presented mixed results with Il-8 serum levels and with Il-6 and MCP-1 CSF levels [62]. A 
recent omega-3 fatty acid RCT in aMDD found that the ratio between pro- and antiinflammatory 
markers (hsCRP, IL-6, IL-1ra, Leptin, Adiponectin) is a strong predictor of omega-3 fatty acids 
response [63]. 
 
3.2 Investigational Product and Indication 
In the proposed study we decided to use for the active treatment a daily dose 500mg EPA/ 
250mg DHA in our 8 to <13 year old, and 1000mg EPA / 500mg DHA for the 13 to <18 years 
old. Omega-3 fatty acids are used worldwide as nutritional supplements with important physical 
and psychosocial health benefits. Pre-clinical data demonstrate very low level of oral toxicity of 
omega-3 fatty acids. Please note that omega-3 fatty acids have been proven safe at much 
larger doses of up to 3 g/day in a total of more than 100’000 cardiovascular patients [64, 65]. 
Active and placebo will contain mixed tocopherol (vitamin E) to prevent oxidation and the 
capsule shell will be made out of gelatin (from fish) and glycerol. The main filling ingredient in 
the placebo capsules will be medium chain triglycerides, because they do not contain any 
insaturated fatty acids and are therefore very stable and in these small quantities they do not 
have any pharmacological effect. Placebo will also contain a very small amount of fish oil to 
mimic the fishy flavour and taste and prevent unblinding. More information can be found in the 
Investigator’s Brochure. 
Burgerstein will produce specially manufactured child capsules as study medication that can 
easily be swallowed by children. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 42 of 108   
3.3 Preclinical Evidence 
The underlying mechanisms of the potential preventive and therapeutic actions of omega-3 fatty 
acids against depression are still unclear. Preclinical and clinical data point towards several 
mechanisms that most likely act in concert [66]. Some of them might be more responsible for 
the postulated short-term, other for the more long-term effects of omega-3 fatty acids: 
- Omega-3 fatty acids, stress and the HPA-axis: Major depression is linked to a 
range of mediators of the stress response system (e.g. the subgenual prefrontal 
cortex, the hippocampus and the amygdala) that is mainly modulated by the 
noradrenergic system and the CRH/HPA axis resulting in a markedly 
exaggerated, persistent elevation of the stress response [67]. Omega-3 fatty 
acids have shown to attenuate stress-related changes in animal models with 
depressive features [68-71] and humans [72-74]. 
- Omega-3 fatty acids and brain development: An association between 
depression and abnormal brain development has been suggested [75]. 
Myelination and synaptic pruning are core processes during normal pubertal 
brain development. The regulation of PUFA metabolism is crucial for both 
processes [76, 77]. Of particular interest is a preclinical study investigating 
cognition and behaviour across different developmental stages. Omega-3 fatty 
acids deficient diets across consecutive generations produced a modality-
selective and task-dependent impairment in cognitive and motivated behaviour in 
adolescence distinct from the deficits observed in adults [78, 79]. Omega-3 fatty 
acids attenuate such depression-like animal behaviours during critical periods of 
brain development [80]. Furthermore, the FADS haplotype determining LC-
PUFAs availability and concentrations in white matter (WM) showed age-related 
WM differences (significant age x genotype interactions, p(corrected) < 0.05) in 
humans. PUFA metabolism is therefore likely to play a role in disorders of 
neurodevelopmental origin [81].  
- Omega-3 
fatty 
acids, 
neuroplasticity, 
neurotrophic 
and 
protective 
hippocampal effects: Hippocampal changes in depression are well documented 
[82]. Animal models with structural hippocampal alterations with depression-like 
and anxiety-like behaviours [83, 84] provide evidence that omega-3 fatty acids 
have a preventive and neurotrophic effect against such changes [85, 86]. Our 
own group could demonstrate that omega-3 fatty acids enhance hippocampal cell 
viability and are able to protect hippocampal cells from stress-related damage 
[87].  
- Omega-3 fatty acids and monoaminergic neurotransmission: Monoaminergic 
transmitter systems are proposed to be involved in the pathogenesis of 
depression. Animal experiments of omega-3 fatty acids deprived rats provide 
evidence for an increase in serotonin 2 (5-HT2) and a decrease in dopamine 2 
(D2) receptor density in the frontal cortex, as well as an increased serotonin 
turnover in the prefrontal cortex and decreased midbrain tryptophan hydroxylase-
2 expression [88-94]. In humans, omege-3 intake is associated with an increase 
in cerebrospinal fluid 5-HIAA release [95, 96]. 
- Omega-3 fatty acids, immune-modulation, anti-inflammation and anti-
oxidation: Several lines of evidence support an altered immune-modulation in 
the pathophysiology of depression [97-99]. Omega-3 fatty acids have immune-

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 43 of 108   
modulatory, anti-inflammatory and pro-resolving properties [100], e.g. via the 
down-regulation of pro-inflammatory omega-6, the promotion of proresolvins, 
neuroprotectins and anti-inflammatory mediators [101-103]. Omega-3 fatty acids 
seem to induce protective in vivo brain mechanisms against oxidative stress. The 
main applicant could demonstrate that Ethyl-EPA supplementation is associated 
with a marked increase of glutathione, a strong intracellular antioxidant using 
proton magnetic resonance spectroscopy in patients with a first-episode 
psychosis [104]. Another group found similar effects in older patients at risk for 
depression [105]. Some evidence regarding the measurement of glutathione in 
peripheral blood is also suggestive that omega-3 fatty acids may support the 
antioxidative defence system in individuals at ultra-high risk for psychosis [106]. 
- Omega-3 fatty acids, membrane structure and function: A decrease in 
membrane fluidity can affect the rotation and diffusion of proteins and other bio-
molecules within the membrane, thereby affecting the functions of these 
molecules and processes. An increase in membrane fluidity results in a more 
flexible membrane and facilitates transmission (e.g. in the retina) [107]. In vivo 
imaging techniques such as diffusion tensor imaging could demonstrate that 
omega-3 fatty acids are closely linked to PUFA metabolism [81]. The effect of 
omega-3 fatty acids on membrane structure [108] may contribute to its clinical 
effects, in particular in augmentation studies. The principal investigator was 
involved in a study that could demonstrate that T2-relaxation time normalizes 
under the influence omega-3 fatty acids potentially being a signifier of 
normalization in membrane structure [109]. 
3.4 Clinical Evidence to Date 
3.4.1 Omega-3 fatty acids RCTS in MDD and related disorders 
Several clinical research groups investigated the use of omega-3 fatty acids in controlled 
treatment trials in a range of conditions that also assessed depressive symptoms: 
- Primary diagnosis of adult major depressive disorders (MDD) [63, 110-123] 
- Depressive episodes in bipolar affective disorders [124-130] 
- Depression during or post pregnancy (postpartum depression) [131-133]  
- Depression in non-MDD mood disorders (e.g. PMS, dysthymia) [134-139] 
- Depression in other psychiatric conditions (e.g. borderline personality, self-harm, 
OCD) [140-144] 
- Depression in established schizophrenia [110, 145] 
- Depression in Alzheimer’s dementia/mild cognitive impairment [121, 146, 147] 
- Depression in Parkinson disease [148]  
- Depression in medical conditions (cerebro-vascular and metabolic diseases or 
cancer) [149-153] 
- Depressive symptoms in healthy individuals [154-159]  
Several critical meta-analytic reviews have tried to integrate the above-mentioned very 
heterogeneous group of controlled treatment trials investigating the effects of omega-3 fatty 
acids on mood symptoms [160-166]. Most meta-analysis confirmed a statistical significant effect 
in favour of omega-3 fatty acids with minimal to moderate effect sizes depending on the 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 44 of 108   
selection of studies (except of one meta-analysis [164]). Effect sizes in favour of omega-3 fatty 
acids [51] are larger if RCTs are selected based on 1.) a EPA/DHA ratio >60% of the overall 
omega-3 fatty acids [161, 163] and 2.) only RCTs with a primary diagnosis of MDD are included 
[161, 166]. To our knowledge, only one pilot RCT (n=20) in children with a mean age of 10 was 
performed [167].  
 
3.4.2 Omega-3 fatty acids RCTs in MDD 
Martins et al [161] meta-analysis including RCTs with primary and secondary MDD found a 
significant overall SMD = -0.291 but with study heterogeneity and evidence for publication bias. 
A more recent meta-analysis by Sublette et al [163] only including primary MDD RCTs 
dichotomized according to a EPA-content >60% of the overall omega-3 fatty acids content 
found a moderate effect size (SMD=0.558) with negligible contribution of random effects or 
heteroscedasticity. Bloch and Hannestadl’s meta-analysis [164] including studies with mild 
depression could not replicate previous meta-analyses, however a sub-analysis restricted to 
moderate to marked depression confirmed a SMD of 0.42. It is likely that Rogers et al [134] 
study investigating the effects of omega-3 fatty acids in mild depression in a large non-clinical 
population was responsible for the negative overall outcome as the study accounted for 31.7% 
of the overall weight [168]. Grosso et al [166] found a SMD=0.56 for primary MDD, an 
SMD=0.22 for non-primary MDD, and an overall SMD=0.38 in favour of omega-3 fatty acids 
treatment compared to placebo. The above mentioned meta-analyses confirmed that the use of 
EPA rather than DHA rich formulations is responsible for the clinical efficacy of omega-3 fatty 
acids. Two RCTs encompassing a large proportion of patients with refractory depression 
highlight the potential use of EPA-enriched omega-3 fatty acids as an augmentation treatment 
(potentially via an increase in membrane fluidity) [110, 111]. Two RCTs in populations with other 
than a primary MDD provide evidence of an association between inflammation and omega-3 
fatty acids response: 1.) A placebo-controlled trial investigating the positive effects of omega-3 
fatty acids on depressive symptoms and chronic inflammation in haemodialysis patients [169], 
and 2.) a study [170] that found a preventive effect of EPA against the development of 
depressive symptoms in IFN-alpha-treated hepatitis C virus carriers (associated with a very high 
risk of drug-induced depressive symptoms). The latter two studies suggest that omega-3 fatty 
acids rich in EPA may modulate its antidepressant properties via immune-modulatory strategies 
(see below, mechanism of action), which is of interest in the light of more recent models of the 
underlying pathophysiology of depression [171].  
Interestingly, the use of purified or DHA-enriched oils was not successful in treating depression, 
postnatal depression or OCD [112, 172, 173]. This finding is in contrast to the greater face 
validity of DHA, which is the major brain omega-3 fatty acids and lower in brain tissue of 
depressed suicide victims [174].  
 
3.4.3 Omega-3 fatty acids RCTs in minors 
To our knowledge no omega-3 fatty acids RCT in teenagers with MDD has been published so 
far. However, the above mentioned small pilot omega-3 RCT in prepubertal children with 
childhood-onset depression showed the largest effect size (SMD=1.2) of all omega-3 fatty acids 
RCTs in MDD [167] Most other omega-3 fatty acids RCTs in children were done in attention 
deficit and hyperactivity disorders (ADHD). Bloch et al meta-analysis [175] including 699 ADHD 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 45 of 108   
children of ten RCTs between 7 – 12 years found a beneficial effect in favour of omega-3 fatty 
acids with a SMD of 0.31 with no evidence of publication bias and a significant dose 
dependency; RCTs using a daily dose of 500 to 750mg EPA were the most effective ones [176]. 
But the effect size of stimulant treatment with methylphenidate or dexamphetamines is still two 
to three times stronger compared to omega-3 fatty acids. Future research has to address the 
question if subgroups of ADHD patients may benefit more from omega-3 fatty acids (e.g. those 
with co-morbid depression, or low baseline levels of omega-3 fatty acids or increased 
inflammatory mediators) [177]. Omega-3 fatty acids also seem to help children with 
developmental coordination disorders that often present with ADHD symptoms [178]. 
Furthermore, a RCT in adolescents with a first-episode psychosis [179], as well as a RCT in 
adolescents at ultra-high risk for psychosis [180] were performed. The use of omega-3 fatty 
acids in prevention of mental disorders is promising, yet an avenue to be further explored. The 
main applicant is the senior author of a pilot RCT in 81 adolescents at ultra-high risk (UHR) for 
developing a psychotic disorder (mean age 16.4) that used 1.2g of an EPA-enriched omega-3 
fatty acids oil as a sole agent [180]. 27.5% in the placebo group progressed towards a first 
psychotic episode compared to only 4.9% in the omega-3 fatty acids group. This pilot study has 
recently been replicated but study results are not available yet (the NEURAPRO study [181]). 
Another multinational multi-centre omega-3 RCT in prodromal schizophrenia will start in the 
near future (the PURPOSE trial), where the main applicant acts as a consultant. A further study 
carried out by the main applicant demonstrates that omega-3 fatty acids augmentation 
treatment in first episode psychosis may result in a better tolerability (less EPS, less sexual side 
effects) and faster response to antipsychotic medication, however at the end of the three month 
treatment period, there was no difference in treatment effects on all primary outcome measures 
between active and placebo [179] (the main applicant was supported by a young investigator 
fellowship of the Swiss National Science Foundation (University of Basel)). A meta-analysis of 
Dr. Fusar-Poli and the main applicant came to the conclusion that omega-3 fatty acids in 
established (but not prodromal) schizophrenia have no or only minor additional efficacy 
compared to currently available treatments (also not on depressive symptoms in schizophrenia) 
[182]. 
 
3.4.4 Omega-3 fatty acids RCTs in other psychiatric conditions 
There is some evidence that omega-3 fatty acids augmentation may have some beneficial 
effects in bipolar affective disorders [124], in particular against depressive symptoms [126, 183]. 
Furthermore, EPA-enriched omega-3 fatty acids may also attenuate impulsivity in patients with 
Borderline Personality Disorder [142, 184] and incarcerated young males [185]. The latter 
findings may be of particular importance for male pMDD individuals that sometimes presents 
with impulsive and aggressive behaviour rather than sadness [132]. A recently published trial in 
adolescents with conduct disorders highlights the importance to implement long study durations 
(e.g. one year) to be able to demonstrate potential positive effects of omega-3 fatty acids on 
difficult to treat behavioural traits [186]. Worth mentioning is a recent RCT in premenstrual 
syndrome (PMS) showing some beneficial effects on depression, nervousness, anxiety, lack of 
concentration and a reduction of somatic symptoms such as bloating, headaches and breast 
tenderness [139].   

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 46 of 108   
3.4.5 Unpublished RCTs with Omega-3 fatty acids in pMDD 
We searched the US National (https://clinicaltrials.gov/ ) and the WHO trials registries 
(http://apps.who.int/trialsearch/ ) using “omega-3 fatty acids”, “depression” or “MDD”; “child” or 
“children” or “adolescents” to identify planned or currently on-going RCTS. We identified five 
RCTs: 1. Arnold et al from NIMH (NCT01341925) recruit children from 7-14 with MDD or 
dysthymic disorder.  Gabbay et al (NCT00962598) from the Mount Sinai School of Medicine 
recruit 12-19 year old adolescents meeting the criteria for MDD using psychopathology and 
proton magnetic resonance spectroscopy as primary outcome.  McNamara et al 
(NCT00511810) recruit children and adolescents with MDD using psychopathology and 
functional magnetic resonance imaging (fMRI) as primary outcomes. All these studies have 
target numbers of 40 to 80 and often use biological outcome measures as primary outcomes. 
Simon Rice et al (ACTRN12613001352796) aim to recruit 400 depressed adolescents and 
young adults aged 15 to 25 in a nationwide multi-centre RCT of omega-3 fatty acids 
supplementation (the YoDa-F study) [187]. Participants will be recruited in headspace centres 
across Australia (http://headspace.org.au/about-us/ ). Headspace centres are community health 
centres with a very low threshold (not like the specialist mental health service). The clients 
accessing the Headspace centres are comparable with our youth counselling services of the 
social welfare system in Zurich (e.g. Sozialzentren der Stadt Zürich oder die regionalen Jugend- 
und Familienberatungsstellen). The majority of the YoDA-F participants will be outpatients and 
most likely encompass less severe cases than in our planned omega-3 pMDD study that will 
solely enrol patients treated in specialised child and adolescent psychiatric inpatient and 
outpatient services. We can therefore expect that our sample will have a higher baseline 
depression severity. Furthermore, we will recruit in fewer centres compared to the YoDa-F study 
(across Australia 60 headspace centres are in the process of being established). The latter two 
aspects are of major concern for the YoDa-F study, as the Australian study will most likely need 
to deal with a large placebo-effect which might be quite challenging as demonstrated by two 
reviews [188, 189]). Based on previous studies conducted by the main applicant who worked at 
ORYGEN Youth Health, Melbourne Australia from 1999-2006 [104, 179], about 35% of 
participants in the YoDa-F study will be under the age 18. Our study will include younger pMDD 
cases with higher baseline depression severity compared to the Australian study. Finally, our 
study will implement several means to reduce the known placebo effect in adolescent 
depression studies (see below). Rice et al targets a n=400 based on the assumption of a 
relatively small effect size of 0.31, probably to account for exactly these challenges associated 
with their study design [187]. According to the WHO trials registry, the study has not started 
recruitment yet (18.9.2015).  
 
3.5 Dose Rationale  
Omega-3 fatty acids have been tested in many different conditions. However a wide array of 
omega-3 fatty acid compositions in different doses and EPA/ DHA ration has been used. In 
dyslipidaemia and cardiovascular disorders the efficacy has been proven in many studies 
encompassing several thousand patients with an excellent safety profile [190]. Thousands of 
hypertriglyceridemia patients have been treated with sometimes very large doses of omega-3 
fatty acids up to 10g per day with no life-threatening side effects [191]. Omega-3 fatty acids 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 47 of 108   
doses up to 4g per day have also been used in minors with metabolic disorders without any 
major tolerability issues [192, 193].  
Most successful omega-3 fatty acids RCTs in adult MDD used around 1000mg EPA per day. As 
outlined above [163], any study drug should contain an EPA content > 60% of all omega-3 fatty 
acids as only those preparations seem to be more effective than placebo; a small amount of 
DHA seems to be favourable in comparison to purified Ethyl-EPA (probably by inhibiting the 
conversion of EPA to DHA). In prepubertal children Nemets et al [167] used 400mg EPA and 
200mg DHA. Bloch et al meta-analysis in ADHD children [175] found a significant dose 
dependency with RCTs using a daily dose of 500 to 750mg EPA having the biggest effect. In 
the proposed study we decided to use for the active treatment a daily dose 500mg EPA/ 250mg 
DHA in our 8 to <13 year olds, and 1000mg EPA / 500mg DHA for the 13 to <18 years olds 
(which corresponds with the omega-3 fatty acid doses used in adult MDD RCTs).  
3.6 Explanation for Choice of Comparator (or Placebo)  
Placebo capsules will be matched to the active comparator in size and appearance and will 
contain medium chain triglycerides (MCT). MCT oils do not contain any unsaturated fatty acids 
and therefore are very stable and do not show tendency to rancidity. In addition, MCT oils in 
these quantities do not have any pharmacological effect. Worth mentioning is that many 
different forms of placebo have been used in previous trials, such as canola, sunflower or olive 
oil. However, these oils may be physiological active (e.g. olive oil is a constituent of the 
Mediterranean diet that has shown a range of health benefits [194, 195]). Mineral or liquid 
paraffin oils as placebo (like the first trial of the PI [179] or the YoDa-F trial [187]) may cause 
diarrhea, in particular in children that may already react quite sensitively to more than 1g of 
mineral oil. 
A major concern is often that omega-3 fatty acids capsules could be “unblinded” because of the 
fishy taste. However, the recent formulations have nearly no fishy taste anymore. To further 
minimise the risk of “unblinding”, we will put a very small amount of fish oil into the placebo 
capsules to mimic the taste. A recent double blind controlled trial addressing exactly this 
question demonstrated that test persons were not able to differentiate between active (omega-3 
fatty acids) and placebo [198]. Another concern could be the size of the capsules. Burgerstein 
will produce specially manufactured child capsules as study medication that can easily be 
swallowed by children. In addition, both capsules will contain natural orange oil for a pleasant 
odor when opening the bottle and so optimizing compliance. 
3.7 Risk / Benefits 
Children and adolescents suffering from mental problems, in particular depression often do not 
seek help because of the stigma associated with mental illness [196]. Parents are hesitant to 
see professionals because they are ashamed that they may have failed as parents. Three out of 
four patients with a mental illness are not treated [197-199]. Psychiatrists are often looked at as 
“drug vendors”. Being open to novel treatments such as omega-3 fatty acids that are closely 
linked to lifestyle, food and general wellbeing may indirectly encourage families of children and 
adolescents suffering from mental illness to seek help sooner. We can have the best and most 
effective treatments, but our patients need to take them early enough. In other areas of 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 48 of 108   
medicine, early recognition and treatment has become the gold standard, but in psychiatry the 
opposite still often applies. However, the consequences for children and adolescents with an 
emerging serious mental illness such as depression are underestimated, as the duration of 
untreated illness is an important prognostic factor for long-term outcome in depression [9]. 
While patients and their families wait and see, consequences of an untreated depression for 
social, psychological and neurobiological development may be neglected for far too long. 
Omega-3 fatty acids as a benign first-line treatment are likely to be a well-accepted first step in 
a comprehensive treatment plan and may serve as a “door opener” to engage patients and 
families for other more invasive treatments if omega-3 fatty acids have failed. But if the omega-3 
fatty acids prove ineffective, other more effective treatments might be delayed because of an 
unjustified trial of omega-3 fatty acids as a sole, but ‘ineffective’ treatment. There is a need to 
investigate novel evidence based treatment approaches as already today depression causes 
the largest burden of disease in the age group from 10 – 24 [10]. Despite over a dozen well-
designed relatively small RCTs in adult MDD and several critical and well-performed meta-
analyses, the available evidence is not conclusive enough to promote or refute the use of 
omega-3 fatty acids in standard clinical care (see above) [51]. There is a need to perform larger 
scale studies (similar to Phase III trials of novel drugs). Further small scale RCTs are unlikely to 
provide any additional value, as they can easily be questioned whatever outcome they will have.  
Omega-3 fatty acids are potentially even more efficacious in paediatric depression than in 
aMDD because of the bigger brain plasticity [200] and the underlying on-going major 
developmental processes, e.g. via the modulation of pruning and myelinisation that all involve a 
large turn-over of LC-PUFAs. The use of omega-3 fatty acids in child development and critical 
transition periods such as the onset of puberty might therefore be very relevant for its efficacy 
(see above: Potential mechanism of action). In line with this assumption are some animal 
studies and pilot studies in children that have shown some unexpected large effect sizes [167, 
180]. 
Psychiatric patients often seek complementary alternative medicine (CAM) in addition to school 
medicine [201] that usually offer non-evidence based treatments. However, such treatments 
may delay or even hinder access to evidence-based treatments. Patients often do not inform 
their doctors about such alternative treatments [202]. The current lack of evidence-based data 
for CAM underscores the need for controlled trials like the proposed one that may lift omega-3 
fatty acids from an alternative treatment approach into the field of evidence-based best practice. 
If omega-3 fatty acids prove efficient in pMDD, the consequences will be significant for several 
reasons 1.) routine clinical care, 2.) the health food industry (they are already now testing 
encapsulated omega-3 fatty acids to introduce larger doses of omega-3 fatty acids in processed 
food, and 3.) in basic and clinical research, for new drug targets, as well as future development 
and use of bioactive lipids in treatment of affective disorders. In particular the new avenues for 
the health food industry may finally even have an impact on the prevalence and incidence of 
depressive disorders (similar to the addition of iodine to the table salt which contributed to the 
near disappearance of thyroid goitres in Switzerland). At this stage, the epidemiological, 
preclinical and limited clinical evidence supports such a rather optimistic view of the omega-3 
story in depression [49, 203, 204].  
In the field of lipid research, increasing evidence is emerging that pro- and anti-inflammatory 
mediators are of pivotal importance for brain development, synaptic plasticity and brain 
functioning [62, 63, 101, 205]. The identification of inflammatory and/or bioactive lipid markers 
that are predictive for omega-3 fatty acids response might open up new treatment targets for 
future drug development for MDD. Our study includes the a priori hypothesis that in particular 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 49 of 108   
pMDD cases with elevated inflammatory mediators may benefit from omega-3 fatty acids 
treatment. If such an approach can be proven, the measurement of such markers will identify 
omega-3 fatty acids responsive patients contributing towards a personalized and evidence-
based decision-making process to indicate who might benefit at what point from the use of EPA-
rich omega-3 fatty acids – and possibly even more importantly, under what conditions omega-3 
fatty acids are not helpful.  
The relationship between important psychopathological features such as suicidal ideation or 
overt aggression and bioactive lipids is another more explorative aim of the study that may help 
to further characterize subgroups of pMDD at increased risk of harm, a group of subjects where 
early detection and monitoring is critical.  
The establishment of a BioBank in accordance with the Swiss HFG/KlinV/HFV regulations of 
this well-characterized patient population with medium-term follow up data will enable further 
exploration of identified candidate biomarkers at a gene and protein level. There are very few 
tissue repositories of pMDD or first onset depression cases. In our pMDD sample effects of 
chronicity of illness and past treatments are minimized enabling the investigation of the 
underlying neurobiology with minimal confounders. The resulting tissue repository will therefore 
become a source for other researchers to investigate the underlying causes and dysfunctions of 
pMDD and MDD. The repository will be open to the wider research community in accordance 
with the Swiss HFG/KlinV/HFV regulations. 
 
3.8 Justification of Choice of Study Population  
Depressive disorders already emerge in childhood and adolescence, but no pharmacological 
treatment with antidepressant medication is approved in Switzerland. All prescribed treatments 
are “off label”. There is some evidence that in particular adolescents respond with an increase 
in suicidal ideation in the early phase of SSRI treatment. There is a need for novel treatment as 
the treatment with cognitive behavioural therapy might not always be feasible or sufficiently 
effective.   
Omega-3 fatty acids in adults have shown some beneficial effects in MDD, however, so far only 
small scale RCTs have been performed. Even so meta-analyses have shown moderate effect 
sizes in adults, results may not be directly transferrable to paediatric MDD given the bigger 
brain plasticity and the underlying on-going major developmental processes, as described 
above (see chapter 3.4.3). Therefore, the inclusion of minors is necessary. Participation in the 
study is preceded by counselling by the treating doctor / psychologist or investigator, during 
which the minor and its legal representative/parents are informed about the nature and entire 
course of the study. Age-adjusted patient information sheets for adults and for minors are 
available. Informed consent will be sought at the same time by the minors themselves and their 
legal representatives/ parents. The explicit wish of a minor who is capable of forming an opinion 
and assessing this information to refuse participation will be followed; in such case, the minor 
can be withdrawn from the study at any time. If a minor subject does not want to participate, 
they will not be included in the study. This is also explicitly stated in the patient information 
sheet. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 50 of 108   
4 STUDY OBJECTIVES  
4.1 Overall Objective 
 
The key research question is if omega-3 fatty acids rich in EPA are an effective and safe 
treatment for pMDD. In addition, we want to investigate if inflammatory mediators, LC-PUFAs 
and their bioactive lipid markers are response predictors for omega-3 fatty acids treatment or 
not. Furthermore, we want to investigate if LC-PUFAs and bioactive lipids are associated with 
particular phenotypic characteristics, e.g. suicidal ideation, impulsivity, cognitive impairment, 
symptom severity and illness course. Finally, we want to establish a tissue repository (BioBank) 
in accordance with the HFG/KlinV/HFV.  
 
4.2 Primary Objective 
Our primary objective is to investigate the therapeutic efficacy of omega-3 fatty acids in pMDD 
(WH 1). 
 
4.3 Secondary Objectives 
Our secondary objective is to demonstrate a clinical meaningful effectiveness of omega-3 
fatty acids (WH 2a-d). Furthermore, we want to investigate immune-modulatory markers, Lc-
PUFAs and their bioactive lipids and inflammatory mediators (e.g. cytokines) as predictors for 
Omega-3 fatty acids treatment response (WH 3a-c). Additionally, we want to investigate if 
phenotypic characteristics (e.g. suicidal ideation, impulsivity, aggression, anhedonia, 
hopelessness, cognitive impairment and illness course) are associated with particular LC-
PUFAs or their bioactive lipids (WH 4a-d).  
 
Finally, we want to establish a Biobank of this phenotypically well-characterized pMDD sample 
with longitudinal outcome data that will be made available for future research in accordance with 
the Swiss HFG/KlinV/HFV. 
 
4.4 Safety Objectives 
Our safety objectives are to investigate if Omega-3 fatty acids have an impact on suicidal 
ideation (in particular because to the reported increased suicidal ideation in association with 
SSRIs), and is well tolerated in children and adolescents (WH 5a).  

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 51 of 108   
5 STUDY OUTCOMES  
5.1 
Primary Outcome 
WH 1 – Based on the findings of Omega-3 fatty acids treatment studies in adult MDD [161, 163, 
166], and one small RCT in prepubertal children [167], we assume that we will find a Treatment 
x Time interaction for the CDRS-R total score in pMDD in favour for Omega-3 fatty acids 
treatment. The recovery and remission rate based on the structured clinical interview (K-SADS-
P) in conjunction with a CDRS-R total score ≤28, as well as the response rates (a 30% 
decrease in total baseline CDRS-R score after the placebo-lead-in week as proposed by Emslie 
et al [206]) will be higher in the Omega-3 fatty acids compared to the placebo group at week 12 
(response, remission rate) and 36 (recovery, remission rate).  
5.2 Secondary Outcomes 
WH 2a – We hypothesize that more pMDD patients in the placebo group will be put on 
antidepressant medication compared to the Omega-3 fatty acids group. 
WH 2b – We hypothesize that the Omega-3 fatty acids group will achieve a higher level of 
functioning (a higher CGAS score) and a better quality of life (overall and within the five 
dimensions as assessed with KIDscreen-CAT -27) compared to the placebo group. 
WH 2c – We hypothesize that the Omega-3 fatty acids group will spend fewer days in hospital 
and will have a lower outpatient service use (measured with the attrition check list) compared to 
the placebo group also resulting in a reduction in overall costs (calculated via TARMED points). 
WH 2d – We hypothesize that the overall retention rate will be higher in the Omega-3 fatty acids 
group compared to the placebo group (or, in other words the placebo group will have more and 
earlier drop outs due to lack of efficacy). This hypothesis will be tested by two means: 1.) in the 
ITT sample independent if they received an antidepressant in the due course of the trial, as well 
as 2.) in a modified ITT sample, where those subjects that are put on an antidepressant will be 
considered as drop-outs from the day they received the first dose of an antidepressant. 
WH 3a – Based on the recent meta-analysis [62] showing increased inflammatory mediators in 
adult MDD, we assume that at least 50% of participants will have a baseline increase of 
inflammatory mediators (in particular hsCRP, IL-1, IL-6) and a decrease of anti-inflammatory 
markers (IL-10). Based on a recent Omega-3 fatty acids treatment study in adult MDD [63], we 
hypothesize that Omega-3 fatty acid response will be predicted by the ratio between pro- and 
anti-inflammatory markers. 
WH 3b – Based on the meta-analysis by Lin et al [54] as well as the study of Potalla et al [61] in 
pMDD, we hypothesize that about 80% of participants with pMDD will have a reduction in red 
blood cell Omega-3 fatty acids content, in particular EPA and DHA (used to calculate the 
Omega-3 index® [207, 208]). We hypothesize that those with an omega-3 index® <4 at 
baseline will benefit more from Omega-3 fatty acids treatment, whereas those with an omega-3 
index >5 (approx. 20%) will not show a marked benefit from Omega-3 fatty acids treatment. We 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 52 of 108   
further hypothesize that a high n-6/n-3 Omega ratio at baseline will be associated with a better 
response to Omega-3 fatty acids. 
WH 3c – We hypothesize that low levels of direct metabolites of EPA, in particular HETEs and 
the E-series-resolvins (RvE1 & 2) will be a strong predictor of Omega-3 fatty acids response. 
WH 4a – Based on the meta-analysis of Lin et al [54], we hypothesize that severity of 
depressive symptoms will be associated with a pro-inflammatory state, as well as an increase in 
omega-6/3 ratio and a decrease in omega-3 index. Normalization of these parameters will 
correlate with improvements in depression scores (CDRS-R, DIKJ).  
WH 4b - Based on the study by Huan et al [52], we assume an inverse correlation between 
Omega-3 fatty acids and suicidal ideation (SIQ-Jr), in particular high levels of EPA will protect 
against suicidal ideation. 
WH 4c  – Based on the study by Beier et al [209] we assume that low Omega-3 fatty acids, in 
particular low EPA levels (and a low omega-3 index) will be associated with affect 
dysregulation, impulsivity/ emotionality (IES-27) and overall psychopathology. 
WH 4d – Based on Kiecolt-Glaser et al [205], we hypothesize that high levels of overall stress 
(as measured with the PSS scale) will correlate with low levels of Omega-3 fatty acids, a pro-
inflammatory state, increased saliva cortisol, and high levels of PUFAs oxidation products as 
measured by F2 Isoprostanes in the urine and be inversely correlated with the Conner-
Davidsons Resilience Scale. 
5.3 Other Outcomes of Interest  
Cognitive deficits in MDD are consistent, replicable, nonspecific and clinically significant. 
Pronounced deficits in executive function (≥1 SD below the normative mean) are evident in 
about 20-30% of individuals with adult MDD. A recent meta-analysis of children and 
adolescents with MDD demonstrates that they perform 0.194-0.772 (p < 0.001) standardized 
mean differences worse than healthy controls in neuropsychological test procedures. The most 
pronounced deficits of children and adolescents with MDD were seen in inhibition capacity 
(SMD = 0.772; p = 0.002), phonemic verbal fluency (SMD = 0.756; p = 0.0001), sustained 
attention (SMD = 0.522; p = 0.000), verbal memory (SMD = 0.516; p = 0.0009) and planning 
(SMD = 0.513; p = 0.014) [210], with some conflicting results [211]. Other replicated 
abnormalities are in the domains of working memory, attention, and psychomotor processing 
speed. Cognitive deficits may account for the largest percentage of variance with respect to the 
link between psychosocial dysfunction (notably workforce performance) and MDD [212]. We 
expect that those with the lowest omega-3 index and the highest omega-6/omega-3 index will 
have the most severe impairments in cognition. We expect that those patients are the ones that 
benefit most from omega-3 fatty acids.  
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 53 of 108   
5.4 Safety Outcomes 
WH 5a – We hypothesize that Omega-3 fatty acids treatment will be a safe treatment with no 
drug-related SUSARs, in particular with no increase in suicidal ideation (SIQ-Jr). 
 
6 STUDY DESIGN AND COURSE OF STUDY 
6.1 General Study Design and Justification of the Design 
We will apply a 36week, multi-centre, double-blind, placebo-controlled, fixed dose, parallel 
group design to study the efficacy of Omega-3 fatty acids on pMDD. The double blind RCT 
includes a 12week acute treatment phase and a 26week maintenance phase. A single-blinded 
placebo-run in phase will try to minimize the initial placebo response and contribute to the 
elimination of false positive inclusions in rapid placebo responders. In order to do this reliably, 
220 patients aged 8 – 17 years with a primary diagnosis of depression will be randomly 
allocated to receive a daily dose of  omgea-3 fatty acid (500mg EPA / 250 mg DHA for the 8 < 
13 years old ; 1000mg EPA / 500mg DHA for the 13 < 18 years old) or matching placebo 
capsules for 36 weeks. A study of this size should have enough power to detect whether 
omega-3 fatty acid is an efficient treatment for pMDD.  
 
After written consent and extensive screening of the patients, the one-week placebo lead-in 
phase will commence. After completion of the placebo lead-in phase, the Children’s Depression 
Rating Scale (CDRS-R) will be applied to determine whether the patients still fulfill the criterion 
of a moderate depression (score > 40), and then the patient will be randomly assigned to a 
study group. After an extensive baseline examination, subsequent assessments will occur at 6 
weeks, 12 weeks, 24 weeks and 36 weeks. At each assessment depressive symptoms and 
other psychological variables will be assessed using a variety of different rating scales. 
Assessment of cognitive functioning occurs at baseline, week 12 and week 36. Blood, urine and 
saliva will be taken at the screening visit and after 12 and 36 weeks. 
 
Assignment to a treatment arm will be performed randomly to eliminate the possible influence of 
arbitrary allocation of subjects on the study results. Using random assignment, known and 
currently unknown factors potentially influencing outcomes (e.g. demographic factors, findings 
at screening examination) are evenly distributed among the two groups, which increases the 
validity of statistical analyses. Administration of medication will be double-blind in order to 
minimize the influence of expectancy regarding the type of medication on data collection and 
analysis. A placebo arm is included as the effectiveness of omega-3 fatty acids in the treatment 
of depression will be examined, and no other psychopharmacological treatment is 
recommended in pMDD in children and adolescents.  All the children will receive concomitant 
standard treatment as advised by their clinicians.  
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 54 of 108   
The study examines the effectiveness of omega-3 fatty acids in children aged 8-17 years old. 
Inclusion of minors is essential as no current pharmacological treatment for pMDD exists and 
data of adults might be not transferrable as fatty acids have been implicated in the process of 
adolescent brain maturation. 
 
 

e 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 55 of 108   
6.2 Study Duration and Study Schedule 
 
Months
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49
Date
May 16
Jun 16
Jul 16
Aug 16
Sep 16
Oct 16
Nov 16
Dec 16
Jan 17
Feb 17
Mar 17
Apr 17
May 17
Jun 17
Jul 17
Aug 17
Sep 17
Oct 17
Nov 17
Dec 17
Jan 18
Feb 18
Mar 18
Apr 18
May 18
Jun 18
Jul 18
Aug 18
Sep 18
Oct 18
Nov 18
Dec 18
Jan 19
Feb 19
Mar 18
Apr 19
May 19
Jun 19
Jul 19
Aug 19
Sep 19
Oct 19
Nov 19
Dec 19
Jan 20
Feb 20
Mar 20
Apr 20
May 20
100% Clinical Trials Coordinator
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48
100% RA 1 (ZH/BS mit CTC)
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
100% RA 2 (SG/ TG)
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
20% Research nurse
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
Advertising staff 
Contracts SNF/ industriel partners
Finalisation Protocol (incl. Ethics forms)
Investigational brochure
Prereview Ethics University of Zürich
Reg. CH/ WHO Trialregistry
CRFs
SecuTrial (CTC)
Ethics ZH (lead ethics committee)
Ethics Swiss
Ethics SG
Ethics TG
SOP laboratory
SOP for Clinicians (background tx)
Training RA/ Clinicians
Cases
Advertising activities ZH/BS/SG/TG 
Recruitment  ZH (Prof. Walitza)
1
1
2
2
3
3
2
3
3
2
3
3
2
3
3
2
3
3
2
3
3
2
3
3
2
2 no new recruitments
64
Recruitment BS (Prof. Schmeck)
0
1
1
2
1
1
2
1
1
2
1
1
2
1
1
2
1
1
2
1
1
2
1
1
2
1 no new recruitments
33
Recruitment BL (Dr. Contin-Waldvogel)
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1 no new recruitments
25
Recruitment Littenheid TG (Dr. Wöckel)
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1 no new recruitments
25
Recruitment Ganterschwil SG (Dr. Müller-Kapp)
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1 no new recruitments
25
Recruitment SG amb. Dienste (Dr. Erb)
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1 no new recruitments
24
Recruitment TG amb. Dienste (Dr Rhiner)
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1 no new recruitments
24
Milestones (number enrolments)
Double entry of data
Cleaning database
Closure database
Closing site visits
Data analysis (Prof. Seifert)
Paper writing
Concerence presentations
Grant application 2-year Follow up study
220
1 year
2 year
3 year
4 year

Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 56 of 108   
 
 
6.3 Methods of Minimising Bias  
6.3.1 Randomisation  
The active and maintenance treatment phase consists of a 1:1 randomized placebo-controlled 
allocation sequence for the 36-week study period. A dynamic computerized 1:1 randomisation 
stratified for age, gender, type of treatment (in- or outpatient) and hsCRP across each site will 
be applied. A minimisation algorithm integrated in SecuTrial® will provide a balanced 
distribution between the two treatment groups (active/ placebo) for each site and strata.  
 
Access to the SecuTrial® generated randomisation list will be restricted to the Clinical Trial 
pharmacist, in case of an interims analysis to the IDMC, upon request to the regulatory 
authorities and to the data management at the USZ CTC. The study medication will be labelled 
at the KAZ and will be sent out to the study sites in two batches.  
 
The algorithm and allocation process is implemented in SecuTrial and the development of the 
algorithm is done by the data manager of the Clinical Trial Centre and cannot be influenced by 
the investigators. The clinicians and researchers who enrol the patients just provide the relevant 
stratification data. The minimization algorithm contains an element of chance so that even with 
the knowledge of all previous allocations the next allocation cannot be determined.  
 
Participants, parents, treating clinicians and doctors, research assistants, all involved 
researchers including the PI remain blind to the allocation of participants to the study drug 
(active/ placebo). SecuTrial® only provides one single randomisation number making it 
impossible to guess the allocation. Data analyst (Prof. B. Seifert, Dr. Alex Roth) will only get 
access to the randomisation code list after completion of data entry, double entry of a subset of 
data and final closure of the database. The only person who has access to the computer-
Preparation phase 
Study year 1 
Study year 2 
Study year 3 
Study year 4  
Milestones: 11/ 2016 Protocol 
finalized, Contracts/ agreements 
signed; Required approvals and 
authorizations (Swissmedic, ethics 
commission, etc.) for first study site  
November 2016 Data management 
system ready 
December 2016 QA/monitoring 
system ready 
January 2017 Safety reporting 
system ready; Milestones agreed 
with SNSF 
Milestones:  
1.3.2017 First 
patient first visit 
1.4.2017 all 
study sites 
active 
Milestones:  
All study sites on 
track with patient 
recruitment 
Milestones:  
All study sites on 
track with patient 
recruitment 
Milestones:  
12/2019 Last 
patient last 
visit 
2/2020 
Database 
cleaned 
5/2020 Final 
analysis  
n 
@ 
6 
months:  
41 
n 
@ 
18 
months: 
131 
n 
@ 
30 
months: 
220 
n 
@ 
end 
of 
the 
study: 
220 
n @ 12 
months: 
86 
n 
@ 
24 
months: 
176 
n 
@ 
36 
months: 
220 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 57 of 108   
generated allocation code is the data manager of the CTC and the clinical trial pharmacist of the 
Clinical Trials Pharmacy of the Universities of Zürich (Kantonsapotheke Zürich KAZ).  
If deemed necessary, the IDMC is allowed to review unblinded data as further specified in the 
IDMC SOP. 
 
6.3.2 Other Methods of Minimising Bias  
Based on two comprehensive meta-analyses on placebo-response [188, 189] and a RCT 
comparing fluoxetine versus placebo in pMDD with a low placebo-response [206] we 
implemented a number of measures to minimize the placebo-response:  
 
As the number of sites is a strong predictor of placebo-response, we have limited the 
number of sites (the lead centre (ZH), one additional academic centre (BS), as well as 
three further Cantons (TG, SG, BL) in the proximity of the lead centre (ZH)). Many of the 
senior clinicians in the regional centres were trained or worked as consultants in the 
academic lead centre (ZH). Furthermore, the academic and non-academic centres have 
a joint training program for their trainees for several years providing a good foundation 
that all participant will undergo a similar treatment approach.   
 
We will implement regular meetings with therapists from the participating centres to 
improve adherence with the S3 guidelines.  
 
The number of research assessments has also been identified as a predictor for 
placebo-response [188, 189]. We have limited the research assessments to three 
assessments during the active treatment phase (baseline, 6 and 12 week), and two 
further assessments in the maintenance phase (24 and 36 week), what is much lower 
than in comparable trials.  
 
Based on previous RCTs in pMDD [213], we expect a 10-20% drop in overall CDRS-R 
score during the 1week placebo-lead in phase. If a participant drops below a CDRS-R 
total score <40 at the end of the placebo lead in phase, the participant will not be 
enrolled in the double-blind randomized study period (as he does not meet inclusion 
criteria anymore). Similar strategies were already applied in other RCTs of pMDD and 
could attenuate placebo response and eliminated false-positive enrolments (a 
participants that has such a dramatic decrease in symptom load within the one week 
placebo lead-in phase is unlikely to suffer from “true MDD”, but more likely from an 
adjustment disorder) [213, 214]. We will offer placebo-responders to be followed up 
separately as a non-randomized comparison group to better understand the 
characteristics of such placebo-responders (an important “by-product” of the proposed 
study [215]). Finally, to reduce the likelihood that a site can estimate a possible 
allocation sequence, we will not provide stratification blocks to the clinicians (see 
allocation concealment) [206].  
6.4 Unblinding Procedures (Code break)  
An Emergency Code Break will be available through SecuTrial®. The only person authorised to 
unblind a patient is the sponsor-investigator Dr. Gregor Berger, and the two principal 
investigators Prof. S. Walitza and Prof. K. Schmeck who can do so in case of an emergency 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 58 of 108   
unblinding, e.g. in case of a Suspected Unexpected Serious Adverse Reaction (SUSAR). The 
unblinding procedure can be triggered by SecuTrial®. Once a patient is unblinded by 
SecuTrial®, all users of the software will know the patient’s assigned treatment group and the 
unblinding procedure cannot be reversed. Therefore, the participant will be considered a drop-
out. A drop-out visit will be performed in a clinically meaningful time frame. 
Emergency unblinding is indicated in the following situations: 
 
Unblinding is necessary for the subjects emergency treatment at the clinicians 
or investigator’s discretion.  
 
Unblinding is required by local laws or regulations (in case of SUSAR).  
 
The IDMC decides that unblinding is necessary for proper study management of 
the subjects and the overall safety of the other subjects in the study.  
After closing of the database every site will be informed about each subject’s assigned 
treatment group. 
7 STUDY POPULATION 
A total of five Cantons of the German part of Switzerland agreed to participate in the multi-
centre omega-3-pMDD trial. The five Cantons include two academic centres (Zürich ZH, Basel-
Stadt BS) as well as the inpatient and outpatient services of Canton St. Gallen (SG), Thurgau 
(TG) and Basel-Land (BL) encompassing all public child- and adolescent psychiatric services in 
a catchment area of 2.7 Million habitants (ZH 1446.4M, BS 190.6M, SG 495.8M, TG 263.7, BL 
283.2).  
 
Based on the referral rates of previous years for each site, all participating centres provided 
their estimated annual referral rates of eligible patients for screening based on following codes 
ICD-10 F32, F33, F34.1, F38, F39, F43.2, F41.2, F92. Based on this information and based on 
the experience of each centre in recruitment, we estimated the following number of enrolments 
per site:  
The main centre, the Clinic for Child and Adolescent Psychiatry and Psychotherapie KJPP in 
Zürich encompasses seven outpatient clinics (Ambulatorien), two inpatient facilities 
(Neumünsterallee/ Brüschhalde), three day clinics and the policlinic. The KJPP ZH has over 
2000 new referrals per year. We expect that about 400 cases will be eligible for screening and 
that about half of them will meet inclusion criteria. We estimate that about 15-20% of those 
cases will agree to participate in the study resulting in a conservative enrolment estimate of 35-
40 cases per year.  
 
The sites have provided following recruitment estimates based on previous recruitment 
experiences, annual reports and PSYREC statistics:  
 
64 at KJPP ZH  
 
33 at the Child and Adolescent Psychiatric Services of Basel  
 
25 at the Clienia Klinik Littenheid   
 
25 at the Klinik Sonnenhof in Ganterschwil  

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 59 of 108   
 
24 at the child- and adolescent outpatient departments of the Canton St. Gallen  
 
24 at the psychiatric outpatient services Thurgau  
 
25 at the child- and adolescent outpatient departments of the Canton Basel-Land 
We will first start to screen and recruit in the seven official centres including solely child and 
adolescent psychiatric services. If we will not achieve the expected numbers of recruits within 
the first six months since the first inclusion of a trial patient, we will extend our advertising 
strategy to paediatric centres of the Cantons Zürich, Basel-Stadt, Basel-Land, St. Gallen and 
Thurgau, as well as write letters with our study flyers to private child and adolescent 
psychiatrists, as well as paediatricians and general practitioners.  
 
7.1 Eligibility Criteria 
7.1.1 Inclusion Criteria 
Participants fulfilling all of the following inclusion criteria are eligible for the study: 
 
 
Male or female in- or outpatients of a participating centre (ZH, BS, SG, TG, BL). 
 
Children aged 8 to ≤ 13 years or teenagers 13 to < 18 years at time of study entry 
(inclusion up to the 18th birthday is possible, as long as participants remain in the 
responsibility of a participating child and adolescent psychiatric service until 
completion of the 36 week trial period).  
 
Written informed consent of the subject (Appendix Informed Consent Forms). For 
individuals younger than 18 years of age the parents / legal representatives need 
to give consent, and the subject need to provide assent.  
 
Depressive symptoms of at least moderate severity as defined by a CDRS-R total 
score of ≥40. 
 
A present primary diagnosis of major depressive disorder (single or recurrent) as 
defined by DSM-IV criteria and confirmed in the K-SADS-PL. 
 
Able to swallow the study medication without difficulty. 
 
No clinically significant laboratory findings in haematology, chemistry, and urine 
analysis at study entry based on the judgment of the treating doctor. 
 
7.1.2 Exclusion Criteria 
 
The presence of any one of the following exclusion criteria will lead to exclusion of the 
participant: 
 
Exclusion criteria: 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 60 of 108   
 
Contraindications to the class of drugs under study, e.g. known hypersensitivity or 
allergy to class of drugs or the investigational product (i.e. a checklist will be provided 
asking patients about intolerance or hypersensitivity to fish and whether they have a 
coagulation disorder. Coagulation parameters will be additionally assessed through 
laboratory screening), 
 
More than 4 weeks of regular omega-3 supplementation (>2 daily capsules standard 
strength providing > 600mg combined EPA/DHA) within the last 6 months, 
 
Women who are pregnant or breast feeding,  
 
Intention to become pregnant during the course of the study,  
 
Lack of safe contraception, defined as: Female participants of childbearing potential and 
who are sexually active, not using and not willing to continue using a medically reliable 
method of contraception for the entire study duration, such as oral, injectable, or 
implantable contraceptives, or intrauterine contraceptive devices, or who are not using 
any other method considered sufficiently reliable by the investigator in individual cases, 
 
Pre-existing neurological (such as brain tumour, temporal lobe epilepsy, HIV 
encephalopathy) or medical conditions (ICD-10 F06-F07) likely to be responsible for the 
depressive symptoms,  
 
Laboratory screening values considered clinically relevant by a medical doctor for 
transaminases, thyroid hormones or coagulation parameters,  
 
Known or suspected non-compliance, 
 
Inability to follow the procedures of the study, e.g. due to language problems, 
psychological disorders, dementia, etc. of the participant, 
 
Participation in another study with investigational drug within the 30 days preceding and 
during the present study, 
 
Previous enrolment into the current study, 
 
Enrolment of the investigator, his/her family members, employees and other dependent 
persons, 
 
Substance dependency (ICD-10 F1x.2) within the last six months (but not misuse), 
 
Life-time diagnosis of schizophrenia and related disorders (ICD-10 F20-F25), 
 
Life-time diagnosis of bipolar affective disorder in the K-SADS-PL (ICD-10 F30, F31), 
 
Current eating disorders within the last six months (ICD-10 F50.0 & F50.2), 
 
Mental retardation (ICD-10 F70-73), 
 
Pervasive developmental disorders (ICD-10 F84.x). 
  
7.2 Recruitment and Screening 
Children and Adolescents meeting criteria for clinical depression will be recruited from mental 
health in- and outpatient units of the Cantons Zürich, Basel-Stadt, Basel-Land, St.Gallen and 
Thurgau.  
 
There will be three different enrolment strategies:  
1) The study site investigator will check all potential eligible new referrals on a weekly basis 
based on the clinical entry diagnosis. The investigator will check the clinical file and if a 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 61 of 108   
patient is potentially suitable for the study, he will contact the responsible clinician and 
discuss if the patient may be eligible or not. If the treating doctor / psychologist agree on 
the suitability of the patient, the family will be contacted by the investigator.  
2) The treating doctor / psychologist contact the investigator if he has a patient who might 
be eligible to participate. 
3) Depressed children and adolescents or their families learn of the study through other 
participants or through flyers and posters available at each study site and contact the 
investigator directly. In that case, the investigator will contact the treating doctor / 
psychologist to determine eligibility. 
4) A study website, accessible to the public, will be established containing the same 
information as the flyer, poster and patient information sheets. 
 
After the eligibility of a patient has been established, the clinician and/ or the investigator will 
contact the patient, his parents or his/her guardian and explore the willingness to participate in 
the study in accordance with ICH-GCP guidelines.  
The subject will be informed about the nature and entire course of the study, potential individual 
benefits and personal risk shall be explained. This may be carried out by a trained research 
psychologist. Here it will be re-emphasized that participation is absolutely voluntary. Potential 
patients and their parents/ guardians are given sufficient time to read all the provided 
information (approved by the appropriate authorities), and clarify any questions with the treating 
doctor/ psychologist or investigator. Regarding data privacy, subjects will be informed about 
pseudonymous recording. The allocation of a unique study number that can be traced back to 
the patient if necessary will be used. The list with patients’ names and contact details are kept 
with the principal investigators. Outside laboratories will only be provided with coded 
documentation not enabling them to identify the individual patient. The sharing of data will be 
done in accordance with ICH-GCP guidelines. In case subjects cannot agree to this central 
collection of data they cannot participate in the study. Participation only becomes possible after 
the subject as well as the investigator/doctor have signed the informed consent document. This 
consent can be revoked at any time without citing reasons and without any consequences. No 
examinations or other activities will take place before the informed consent procedure is 
completed. A copy of the consent form and the patient information sheet will be given to the 
patient.  
In case the patient information sheet or the consent form change, patients will be informed 
immediately and relevant information will be passed on to the ethic committees for approval. 
New patient information and consent will be discussed in detail again, the patient will again be 
asked for written consent, and a copy of the documents will be given to the subject. 
 
After written informed consent is provided, the patient is screened extensively for in- and 
exclusion criteria as described in detail in chapter 9.3.1.   
 
 
7.2.1 Incentives 
There may not be any financial inducement to enroll a patient into the study; no financial 
incentive 
should 
be 
offered 
except 
compensation 
and 
expenses 
for 
the 
legal 
representatives/parents or for travel expenses. As a compensation for the invested time and the 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 62 of 108   
burden caused by the blood taking procedure, patients will receive a cinema voucher or 
equivalent at following time points: baseline, week 12 and week 36. 
 
7.3 Assignment to Study Groups  
Once the patient/ parent/ guardian have given written informed consent, the investigator will 
enter the relevant information (Site,Gender, Age, Treatment Type (in- or outpatient) und 
hsCRP) in the SecuTrial® randomization form. SecuTrial® will then assign the subject to the 
group which leads to least imbalance within all strata. The software will then provide a 
randomization number from a list implemented previously and display only this number but not 
the group name. This number will be transmitted to the clinical trials pharmacy (KAZ) who will 
send out the trial medication accordingly. Numbered study medication sets will be sent out to 
the centres in advance with half of them consisting of the active treatment and the other one 
consisting of placebo capsules. Study medication will be sent out in two different batches. The 
randomization number of study medication sets will be provided by SecuTrial® to the research 
psychologist responsible for the study site, as well as the postdoctoral study coordinator. Every 
centre has slightly more medication sets to incorporate small deviations in recruitment numbers.  
 
7.4 Criteria for Withdrawal/ Discontinuation of Participants 
Clinicians/ treating doctors/ patients and their relatives can withdraw a patient at any time if they 
think it is in his best interest. To support clinicians in their decision making at what point a 
patients shall be withdrawn from the study for safety reasons, we defined following exit criteria.  
 
Reasons to terminate a subject’s participation: 
 
A subject withdraws her/his consent 
 
Non-compliance with medication (no intake of study medication for more than 
three out of seven days in two consecutive weeks) 
 
Daily omega-3 supplementation in addition to study medication (>600 mg 
combined EPA/DHA per day for more than one week) 
 
The clinician or investigator considers a subject’s continued participation in the 
study to be unjustifiable on medical grounds (i.e. because of the emergence of 
another serious medical condition).  
 
The subject falls below a score of 40 on the Children’s Depression Rating Scale 
at the end of the placebo lead-in phase. 
 
Acute Suicidality/ overt hostility: Clinicians and research assistants will monitor 
suicidality/hostility at each visit. If a clinician/ researcher considers the suicidal 
risk/ hostility as high requiring some sort of clinical action (e.g. a suicide watch 
plan as an outpatient, or restricted leave as an inpatient because of intense 
suicidal ideation/hostility), patients shall be withdrawn from the study if the 
clinician considers a potential connection with the study drug and a SUSAR shall 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 63 of 108   
be reported. The number and type of SUSARs will be compared between the 
treatment groups (active versus placebo). 
 
Intolerance to the study drug. Life-threatening side effect other than suicidality/ 
hostility (SUSAR): In case of an unexpected life-threatening side effect (e.g. a 
severe allergic reaction to one of the ingredients of the study medication), a 
patient must be withdrawn from the study. 
 
The development of a major axis one disorder listed under the exclusion criteria 
(e.g. a first psychotic or manic episode is considered as a serious adverse 
event).  
 
Unwanted but not life-threatening adverse events: If the side effect persists, the 
study medication shall be ceased and the patient discontinued due to lack of 
tolerability (an important further outcome criteria). 
Given that drop-out is also one of our secondary outcome measures, patients who discontinued 
the study will not be replaced, except if the patient drops out prior to study visit 1 (six weeks) or 
meets criteria for non-compliance within the first six weeks of treatment. If a patient drops out of 
the study (e g. if he changes diagnosis to bipolar affective disorder or schizophrenia) we will 
perform a drop out visit at the earliest convenient time, as described in section 9.2.5 
If somebody does not turn up to a study visit, we will contact the patient and his parents to 
clarify the reason of non-attendance and schedule a study visit at the earliest convenient time. 
To avoid “non-shows”, we will perform follow up visits at their parent’s home. During the acute 
treatment phase (visit 2, 3), research assessment range is +3 days, for the maintenance phase 
(visit 4, 5) research assessment range is +5 days. For the clinician-rated scales we allow a time 
window of ± 2 weeks to account for the usual contact frequency between clinicians and patients. 
8 STUDY INTERVENTION 
8.1 Identity of Investigational Product(s) 
1.5 gram/day omega-3 polyunsaturated fatty acids will be given daily in six 0.6-g gelatin 
capsules, which contain a daily intake of 1000 mg of EPA and 500 mg of DHA. Patients younger 
than 13 years of age will receive half of the dose (three capsules a day) resulting in a daily 
intake of 500mg EPA / 250 mg DHA. This EPA:DHA ratio of 2:1 has been proven safe and 
effective in multiple clinical trials. 
Additionally, the capsules will also contain mixed tocopherol (vitamin E) to prevent oxidation. 
The placebo-capsules will contain a small amount of fish oil to mimic the taste of the active 
compound. In addition, both types of capsules contain orange oil for a pleasant odour. The 
placebo capsules will be indistinguishable from the active treatment in form, size or taste. 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 64 of 108   
8.1.1 Experimental Intervention 
 
Treatment A (Omega-3 fatty acid) 
 
Omega-3 fatty acids 
 
Approx.168 mg EPA and 84 mg DHA per capsule 
 
Children < 13 years of age are advised to take 3 capsules resulting in approx. 500 mg 
EPA and 250 mg DHA per day 
 
Teenagers > 13 years of age are advised to take 6 capsules resulting in approx. 1000 
mg EPA and 500 mg DHA per day. 
 
In addition, the capsules also contain mixed tocopherols and d-alpha-tocopherol (vitamin 
E) derived from soy oil. 
 
They also contain 3mg of orange oil. 
 
 
8.1.2 Control Intervention 
 
Treatment B (placebo) 
 
418 mg medium chain triglycerides 
 
In addition, the capsules also contain mixed tocopherols and d-alpha-tocopherol (vitamin 
E) derived from soy oil. 
 
The capsules contain about 1mg of fish oil and 3mg of orange oil 
 
As in the active treatment, children < 13 years of age are advised to take 3 capsules and 
teenagers > 13 years of age are advised to take 6 capsules, respectively. 
 
 
Burgerstein will produce specially manufactures child capsules as study medication that can 
easily be swallowed by children. Further information can be found in the Investigator’s 
Brochure. 
 
8.1.3 Packaging, Labelling and Supply (Re-Supply) 
 
The Antistress AG will provide the clinical trials pharmacy of the canton of Zurich with active 
substance and placebo. The Cantonal Pharmacy will receive the randomization list from the 
CTC. Package, labelling and storage of study medication will be performed by the Cantonal 
Pharmacy according to the randomization procedure. Labelled study medication will then be 
shipped to the centres and study drug will be dispensed through the on-site person responsible 
for clinical trials. 
 
An example of how the medication is labelled is below: 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 65 of 108   
 
 
Below is the label for the placebo lead-in phase: 
 
 
Labelled study medication containers will be dispensed for the whole study period (Clinical 
Trials unit, Zurich Cantonal Pharmacy) to the Child and Adolescent Psychiatric Service. Upon 
receipt of the study treatment supplies, an inventory must be performed and a drug receipt log 
filled out and signed by the person accepting the shipment. It is important that the designated 
study staff counts and verifies that the shipment contains all the items noted in the shipment 
inventory. Any damaged or unusable study drug in a given shipment will be documented in the 
study files.  
The research psychologist will dispense the study drug at each study visit. Administration will be 
double-blinded throughout the trial period. Regular study drug reconciliation will be performed to 
document drug assigned; drug consumed, and drug remaining. Patients will be asked to return 
study medication bottles and unused medication, and/or report non-compliance at each visit. 
The number of used/ returned capsules will be recorded. Missed doses and reasons for missed 
doses are entered in the eCRF and explained. The reconciliation will be logged on the drug 
accountability form, and signed and dated by the study team. 
8.1.4 Storage Conditions  
 
The gel capsules used in the clinical trial will be packed in dark brown glass bottles, which are 
closed with a pressure seal lid in order to maximize stability of the capsules as well as possible. 
The bottles will be packed in cardboard boxes to further protect the capsules from light.  Each 
single sample including packaging is labelled. Samples are kept in a secure, limited access 
storage area under the recommended storage condition (see IB).  

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 66 of 108   
 
8.2 Administration of Experimental and Control interventions  
8.2.1 Experimental Intervention  
 
Patients above the age of 13 years will be advised to take 6 pills containing a daily dose of 
1000mg EPA/ 500mg DHA. Patients under the age of 13 years old will be advised to take only 3 
pills receiving only half the dose of the study medication. Patients will be advised to take the 
study medication once a day with their main meal  as the bioavailability seems to be better after 
intake of large doses compared to smaller split doses (probably due to a favourable oxidation 
rate and better incorporation into membrane phospholipids [216]).  
There will be no titration phase because of the good tolerability of the study medication. If a 
dose has been forgotten, patients will be advised to take the forgotten dose with the next meal 
or the next study dose. Compliance will be measured and controlled for (see below).  
 
8.2.2 Control Intervention 
As in the experimental intervention, patients over the age of 13 will be advised to take 6 pills 
while patients under the age of 13 will be advised to take 3 pills. The placebo capsules contain 
a small amount of fish oil to mimic the fishy taste. All the instructions are exactly the same as in 
the experimental condition.  
8.3 Dose Modifications  
Given that side effects of omega-3 fatty acids are usually mild, no dose modifications are 
permitted during the trial. If a patient cannot tolerate the study medication, he or she will be 
discontinued from the study. 
8.4 Compliance with Study Intervention 
The investigator will perform pill counts at each study research visit and patients will complete 
the MARS-D questionnaire (in <13 year olds, with parents support) every week. Red blood cell 
omega-3 fatty acids measurements will be used to monitor compliance, a commonly used 
method in previous trials [180]. On a study team level, regular meetings with the omega-3-
pMDD study side teams will address site specific adherence issues (e.g. the postdoctoral study 
coordinator or one of the applicants will join a clinical meeting where most clinicians are present 
to address questions around the trial).  
Non-compliance is defined as the discontinuation of taking the study medication for longer than 
three days out of seven days in two consecutive weeks, regardless of the circumstances, prior 
to completion of the trial. If a patient fulfills criteria of non-compliance, the participation will be 
terminated. The data will still be included into statistical analyses as the number of drop outs 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 67 of 108   
due to cessation/non-compliance is also an outcome measure between the groups. The reason 
for a subject discontinuing the study will be recorded in the eCRF.   
 
8.5 Data Collection and Follow-up for Withdrawn Participants  
If a patient drops out of the study we will try to perform a drop out visit at the earliest convenient 
time. During the drop out visit, the primary reason for discontinuation will be determined by the 
investigator and recorded in the eCRF. Current medication, drug use and intake of food rich in 
omega-3 fatty acids will be recorded. Depressive symptoms will be assessed with the Children’s 
Depression Rating Scale (CDRS-R) and other psychopathological variables will be assessed 
using a diagnostic interview (K-SADS-PL). Clinician will rate the general functioning of the 
patients using the Clinical Global Impression rating scale (CGI), the Children’s Global 
Assessment of Functioning (CGAS), and the attrition checklist (HoNOSCA). Further 
psychopathological variables and symptoms will be assessed using a variety of self- and 
parent-rated questionnaires (Children’s Depression Inventory, Beck Hopelessness Scale, Beck 
Anxiety Inventory, Suicidal ideation questionnaire, Insomnia Severity Index, Perceived Stress 
Scale, Connor-Davidson Resilience Scale, KIDscreen-CAT-27, Strength and Difficulty 
Questionnaire, IES-27). In addition, a short IQ test (RIAS) will be performed. Potential side 
effects will be assessed with the Side Effect Self Report Scale (ASEC), and any AE will be 
determined and entered into the eCRF.   
 
8.6 Trial Specific Preventive Measures 
Patients will be monitored for the emergence of psychiatric illnesses other than major 
depression. Otherwise, patients will receive standard treatment for depression as advised by 
their clinician (see below).  Female adolescents that are sexually active are advised to use 
proper contraceptive methods (the pill, coil). However, at the current state of research, omega-3 
fatty acids have no teratogenic effects. We do not expect any impact on study objectives. 
Hormonal contraception may be associated with mood symptoms that will be monitored in the 
context of the trial. As this is a RCT, study participants will be excluded from the trial in case of 
pregnancy. They will be followed up clinically to determine any unwanted or unknown side 
effects on the unborn child by the sponsor-investigator. The sponsor-investigator will liaise with 
the responsible obstetrician to guarantee that all potential unknown side effects of the study 
medication will be recorded and relevant authorities will be informed.  
 
8.7 Concomitant Intervention(s) 
The background treatment across both groups (active/ placebo) is standardized based upon the 
German S3 Guidelines for the treatment of depression in children and adolescents [34]. All 
participating sites will be trained accordingly. The core elements of the standardized 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 68 of 108   
background treatment will be based on the cognitive behavioural therapy (CBT) method 
including individual CBT as well as psycho-educational family sessions. The involvement of the 
school/ employer (in case the adolescent has already started working) is an integral part of the 
treatment.  
 
8.7.1 Hospitalisation 
The clinician together with the responsible consultant will review the clinical progress at each 
clinical visit. If no clinical improvement or even a worsening in psychopathology and functioning 
occurs despite regular psychological treatment according to the S3 Guidelines for the treatment 
of pMDD, the treating team together with the patient, parents and significant others should 
consider starting a more intensive treatment (e.g. hospital admission and/ or the addition of an 
antidepressant). This decision shall be made completely independent of the research team.  
 
8.7.2 Starting an antidepressant 
Starting an antidepressant is not a withdrawal criterion, but will be considered as an outcome 
measure in data analysis (e.g. we assume that the omega-3 fatty acids group will need less 
antidepressants compared to the placebo group). As the number of patients and the time on 
antidepressants is a secondary outcome criteria, this decision shall be made completely 
independent of the research team.  
 
8.7.3 Use of sedative medications (Benzodiazepine, antipsychotics) 
The use of subtherapeutic doses of antipsychotic medication (e.g. 100-200mg quetiapine, or up 
to 2mg of risperidone) is permitted in case of medically required behavioural control (i.e. 
significant worsening of behavioural problems in an inpatient setting) at study entry, as well as 
during the study as long as it is not prescribed for one of the listed conditions under exclusion 
criteria.  
Use of benzodiazepines is not limited or directed by the protocol. Subjects who start using or 
continue using PRN benzodiazepines (e.g. Temesta® for anxiety, or Stilnox® for sleeping) can 
do so. Existing prescriptions of other psychiatric medication is evaluated at baseline and 
continued if clinically indicated (e.g. stimulant treatment of a longstanding ADHD). We will 
compare the duration and dose of concomitant (PRN) medication between active and placebo, 
a further secondary outcome measure. 
 
All concomitant and/or rescue treatment(s) will be recorded in the eCRF. 
 
8.8 Study Drug Accountability 
Subjects will be asked to return any unused medication to the site. Accountability and subject 
adherence will be assessed by maintaining drug dispensing and return records. Adherence to 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 69 of 108   
the study medication will also be monitored by self-report, and the measurement of the omega-3 
to omega-6 ratio in blood at screening and after six months will provide a measure of drug 
compliance (see above) 
A Drug Accountability Log must be kept current and should contain the following information: 
 
the identification of the subject to whom the medication was dispensed 
 
the date[s], quantity of the medication dispensed to the subject 
 
the date[s] and quantity of the medication returned by the subject 
This inventory must be available for inspection by the monitor. The shipping, receipt, returning 
and destruction will be tracked and documented in line with Good Clinical Practice (GCP) 
guidelines.  
 
8.9 Return or Destruction of Study Drug 
At the completion of the study, there will be a final reconciliation of drug shipped, drug 
consumed, and drug remaining. This reconciliation will be logged on the drug accountability 
form, signed and dated. Any discrepancies noted will be investigated, resolved, and 
documented prior to return or destruction of unused study drug. Drug destroyed on site will be 
documented in the study files. 
9 STUDY ASSESSMENTS 
 
Study assessments will be done according to the Study Flow Chart (9.1).  
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 70 of 108   
9.1 Study Flow Chart(s)/Table of Study Procedures and 
Assessments 
Study visit 
 
 
-1 
 
1 
2 
3 
4 
5 
 
 
Time (min) 
Examiner 
Screening/ 
written 
consent
Placebo 
Lead in  
Baselin
e 
Acute 
phase 
Main- 
tenance 
phase 
Drop-out 
Weeks 
 
 
-2 
±5d 
-1 
±5d 
0 
 
6 
+/-3d 
12 
+/-3d 
24 
+/-5d 
36 
+/-5d 
 
Study information 
15 
RC 
x 
 
 
 
 
 
 
 
Informed consent 
5 
RSP 
x 
 
 
 
 
 
 
 
Inclusion / exclusion 
5 
R 
x 
 
x 
 
 
 
 
 
Sociodemographic data 
1 
R 
x 
 
 
 
 
 
 
 
Medical  incl. psychiatric history 
1 
R 
x 
 
 
 
 
 
 
 
Family history 
1 
RSP 
x 
 
 
 
 
 
 
 
Physical Health (incl. Tanner) 
1 
R 
 
x 
 
 
 
 
x 
 
Current medication use 
1 
R 
x 
 
x 
x 
x 
x 
x 
x 
Omega-3 Food questionnaire 
5 
S 
 
x 
 
 
x 
 
x 
x 
WHO Assist 3.0 Drug Use 
10 
R 
x 
 
 
 
x 
 
x 
x 
PTBS Checklist 
5 
S 
x 
 
 
 
 
 
 
 
Intervention 
- 
- 
- 
Pla 
Active/Placebo 
 
 
Main outcome variables 
Children’s Depression Rating Scale CDRS-R 
15 
R 
x 
 
x 
x 
x 
x 
x 
x 
Diagnostic interview (K-SADS-PL) 
60 
R 
x 
 
x* 
x* 
x* 
x* 
x 
x 
 
Clinician rated variables (at each clinical visit) +/- 2 weeks 
Clinical Global impression Scale CGI-S/I 
1 
C 
 
 
x 
x 
x 
x 
x 
x 
Children Global Assessment Scale CGAS 
1 
C 
 
 
x 
x 
x 
x 
x 
x 
Attrition check list inkl. HoNOSCA 
8 
C 
 
 
x 
x 
x 
x 
x 
x 
 
Self-report variables (self rating for 13-<18yr, parent rating for 8-<13yr)  
Children’s Depression Inventory DIKJ 
15 
S 
 
 
x 
x 
x 
x 
x 
x 
Beck Hopelessness Scale II BHS 
5 
S 
 
 
x 
x 
x 
x 
x 
x 
Beck Anxiety inventory BAI II 
5 
S 
 
 
x 
x 
x 
x 
x 
x 
Suicidal ideation questionnaire SIQ-Jr 
5 
S 
 
 
x 
x 
x 
x 
x 
x 
The Insomnia Severity Index 
1 
S 
 
 
x 
x 
x 
x 
x 
x 
Perceived Stress Scale PSS-10 
5 
S 
 
 
x 
 
x 
 
x 
x 
Connor-Davidson Resilience Scale 
10 
S 
 
 
x 
x 
x 
x 
x 
x 
KIDscreen-CAT-27 
15 
SP 
x(P) 
 
x 
 
x 
 
x 
x 
SDQ 
5 
SP 
x(P) 
 
x 
 
x 
 
x 
x 
IES-27-J 
15 
SP 
x(P) 
 
x 
 
x 
 
x 
x 
ASEC (AD side effect self report scale) 
5 
S 
 
 
x 
x 
x 
x 
x 
x 
 
Cognitive outcome variables 
BRIEF (executive Functioning questionnaire) 
10 
SP 
X(P) 
x (S) 
 
 
x 
 
x 
 
Cognitive battery 
50 
R 
 
x 
 
 
x 
 
x 
 
RIAS (short IQ test for matching) 
20 
R 
 
 
 
 
 
x 
 
 
 
Biological outcome variables 
Clinical bloods, hsCRP (2-3d prior randomization) 
5 
N 
 
x 
 
 
 
 
x 
x 
Red blood cells (PUFAs), Serum (e.g. immune 
multiplex marker chip), Buffy coat for tissue 
repository (e.g. genetic, epigenetic markers) 
N 
 
x 
 
 
x 
 
x 
x 
Urine (drug screen, F2 isoprostane) 
5 
N 
 
x 
 
 
x 
 
x 
x 
Saliva cortisol 
1 
N 
 
x 
 
 
x 
 
x 
x 
 
Other measures 
Drug dispensing/ Pill count/appointment 
1 
R 
 
x 
x 
x 
x 
x 
 
 
AE 
 
 
 
 
x 
x 
x 
x 
x 
x 
MARS-D 
3 
S 
 
 
x 
x 
x 
x 
x 
 
Approx. time requirement for patient / family only (min) 
180  
 
90 
90 
90 
210 
120 
210 
200 
 
* Only subscale ‘depressive disorders’ will be performed 
 
 R = researcher; C = clinician; S = self-rated; P = parent-rated; N = study nurse 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 71 of 108   
 
9.2 Assessments of Outcomes  
 
9.2.1 Assessment of Primary Outcome  
 
 
The Children’s Depression Rating Scale-revisedTM CDRS-R is the most widely used 
rating scale for assessing severity of depression and change in depressive symptoms 
for clinical research trials in children and adolescents. The CDRS-R quantifies 
childhood [217] and adolescent [218, 219] depressive symptoms and is evaluated in 
German [218]. The CDRS-R is a 17-item scale with items ranging from 1 to 5 or 1 to 7 
(possible total score from 17 to 113), that will be rated by the research interviewer via 
interviews with the child and parent/ guardian. A score of ≥40 is indicative of moderate 
to severe depression (35-40 for mild depression), whereas a score ≤28 is often used to 
define remission (minimal or no symptoms). The CDRS-R will be completed at each 
research visit. The time requirement is about 15 minutes.  
 
The Kiddie - Schedule for Affective Disorders and Schizophrenia - Present and Lifetime 
Version K-SADS-PL [220] is an interviewer-based diagnostic interview designed to 
assess current and past DSM-IV diagnoses in children and adolescents, by 
interviewing the parent(s) and child. The section for diagnosing the presence of a 
current major depressive disorder will confirm the presence of a MDD at baseline, and 
the recovery from a depressive episode in conjunction with the CDRS-R total score 
<28. Lifetime assessments will be completed at baseline and week 36, also to exclude 
the emergence of another major psychiatric disorder. At month three and six, the mood 
section of the K-SADS-P will be done to determine the recovery status of a study 
participant. 
To increase inter-rater reliability the research coordinator and research interviewers will be 
trained in the use of all applied instruments. Inter-rater reliability sessions will be done. All 
researchers will also attend a GCP course module I&II. 
 
9.2.2 Assessment of Secondary Outcomes 
 
9.2.2.1 Clinician-Rated secondary outcome measures 
 
 
The Clinical Global Impression rating scales CGI [221] is three-item observer-rated 
scale to measure symptom severity, global improvement/ change and therapeutic 
response. The Clinical Global Impression – Severity scale (CGI-S) is a 7-point scale 
that requires the clinician to rate the overall severity. The Clinical Global Impression 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 72 of 108   
(CGI-I) is a 7 point scale that requires the clinician to assess how much the patient's 
illness has improved or worsened relative to a baseline state (1, very much improved; 
2, much improved; 3, minimally improved; 4, no change; 5, minimally worse; 6, much 
worse; or 7, very much worse). The Impression – Efficacy Index is a 4×4 point index 
that results out of the therapeutic effect versus side effects.  
 
The Children’s Global Assessment of Functioning CGAS [222] is a numeric scale (1 
through 100) used by mental health clinicians to rate the general functioning of children 
under the age of 18. 
 
The Health of the Nation Outcome Scales for Children and Adolescents – HoNOSCA 
[223] is a mandatory quality and outcome measure for clinicians working in child- and 
adolescent psychiatric services in Switzerland (many other countries have also 
implemented this short and comprehensive outcome scale for service evaluation). The 
HoNOSCA scores the behaviour, impairments, symptoms and social functioning of 
children and teenagers with mental health problems using 13 global items. The severity 
of each problem is scored on a scale of 0-4. Clinician will rate the HoNOSCA together 
with the CGI and CGAS and the attrition checklist requiring about 10 minutes.  
All three scales will be administered at baseline and at each clinical visit. Given that these 
assessments depend on the clinicians’ appointments with the patients, the time frame 
for these particular scales is extended to ± 1 week. 
 
9.2.2.2 Self- and parent-rated secondary outcome measures 
 
The Children’s Depression Inventory DIKJ [224] is a 26-item scale used to assess 
depressive symptoms in children and adolescents and has been evaluated in German. 
It is derived from the BDI but modifies some questions to be more appropriate for 
younger ages. The DIKJ asks about key symptoms of depression, such as a child’s 
feelings of worthlessness and loss of interest in activities. Each item allows the patient 
to respond to 3 choices that indicate 3 levels of symptoms: 0 (absence of symptoms), 1 
(mild or probable symptoms), or 2 (definite symptoms). The DIKJ can be used with 
patients who are aged 8 to <18years, and usually takes about 15 to 20 minutes to 
complete.  
 
The Beck Anxiety Inventory BAI [225] is a 21-question self-report inventory that is used 
for measuring the severity of anxiety in children and adults. The questions used in this 
measure ask about common symptoms of anxiety of the past month (such as 
numbness and tingling, sweating not due to heat, and fear of the worst happening). It is 
designed for individuals who are of 7 years of age or older and takes 5 to 10 minutes to 
complete. Several studies have found the Beck Anxiety Inventory to be an accurate 
measure of anxiety symptoms in children and adults. Scoring the BAI is based on a 0-3 
point scale (0: “not at all”, 3 severe: “It bothered me a lot”). The BAI has a maximum 
score of 63. 
 
The Beck Hopelessness Scale BHS [226, 227] is a 20-item self-report inventory that 
measures three major aspects of hopelessness: feelings about the future, loss of 
motivation, and expectations. The test was designed for adults, but is also used in 
adolescents [228, 229]. It measures the extent of the respondent's negative attitudes, 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 73 of 108   
or pessimism about the future. It has been used as an indicator of suicidal risk in 
depressed people who have made suicide attempts. The scale will only be used in 
adolescents aged 13 to <18 years. 
 
The Suicide Ideation Questionnaire-Junior SIQ-Jr [230-232] is a 30-item version for 12-
15 year old teenagers to assess suicidal risk, but can also be used with younger 
children. The 30-item questionnaire takes 5-10 minutes to complete.  
 
The Insomnia Severity Index [233, 234] consists of 7 items assessing subjective sleep 
quality and is completed within 1-2min. 
 
The Cohen’s Perceived Stress Scale [235] is a very widely used 10-item self-report 
questionnaire 
to 
quantify 
the 
perception 
of 
stress 
(see 
also 
http://www.psy.cmu.edu/~scohen/scales.html). The PSS scale has a 5-point scale and 
has been translated und used in German (Prof. Dr. Arndt Büssing, University of 
Witten/Herdecke). It takes less than five minutes to complete. 
 
The 25-item Connor-Davidson Resilience Scale CD-RISC [236, 237] is a well validated 
instrument that assesses the stress coping ability and, as such. The CD-RISC 
comprises of 25 items, each rated on a 5-point scale (0–4), with higher scores 
reflecting greater resilience and can be administered in 5-10 minutes. Resilience is an 
important factor in depression outcome, as it may explain some of the variance in the 
illness course. The CDRISC has sound psychometric properties and distinguishes 
between those with greater and lesser resilience. The scale demonstrates that 
resilience is modifiable and can improve with treatment, with greater improvement 
corresponding to higher levels of global improvement. It has been translated and used 
in German [238]. 
 
The KIDscreen-CAT-27 [239] is a widely used self-report questionnaire to measure 
quality of life in five dimensions in children and adolescents that has also been used in 
large-scale German studies. It can be completed in 10 - 15 minutes depending on 
reading capacity. A self-rated and a parent-rated version will be used. 
 
Der Jugend- & Elternfragebogen über impulsives Verhalten und Erleben von Kindern 
und Jugendlichen – IES-27-J&E [240] is a German questionnaire especially developed 
to measure impulsivity and emotionality in Borderline Personality Disorders. A currently 
unpublished study (provided to us by Priv.- Doz. Dr. Christoph Kröger, Humboldtstraße 
33, D-38106 Braunschweig) was able to discriminate between impulsivity in the context 
of BPD and externalizing behaviour in minors. The assessment of Borderline features 
is of importance as several studies could demonstrate that omega-3 fatty acids exert 
some positive effects on Borderline-like behaviours [142]. Teenagers > 13 years of age 
will fill in the questionnaire themselves, while the parents will complete a parent-rated 
version for children < 13 years of age. 
 
The Strength and Difficulty Questionnaire SDQ is a brief behavioural screening 
questionnaire, consisting of 25 items asking about difficulties (emotional, conduct, 
hyperactivity, relationship problems) and strengths (prosocial behaviour). A self-rated 
(> 11 years of age) and a parent-rated version (< 11 years of age) are available. It 
takes about 5 min to complete. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 74 of 108   
9.2.2.3 Cognitive outcome measures 
We have selected following battery of neuropsychological tests to capture the key deficits 
associated with depression at baseline, week 12 and week 36 after study entry: Verbal Memory:  
- Verbal Memory Learning Test VMLT (with parallel versions for retests) [241] (20 
min) 
- Verbal fluency RWFT [242] (5 Min.) 
- Inhibition/Flexibility: Shifting Attentional Visual Set (ANT) [243] (3 parts, a total of 
12-15 min) 
- Emotion Recognition: Identifying Facial Emotions (ANT) [243] (8-10 Min) 
- Verbal Working memory: Digit Span forward and backward (WISC IV) [244] (5 
min). 
The BRIEF Cognition will be assessed at baseline, week 12 and week 36 after study entry 
[245].  
Total duration of cognitive testing is approximately 50-55 minutes. A short IQ test (for group 
matching) will be conducted only once, at week 24 (RIAS, 20-25 min) [246].  
 
9.2.2.4 Biological outcome measures 
Blood sampling procedures will be described in a Standard Operating Procedure ‘Blood 
Sampling’ (jointly developed by Prof. Dr. E. Grünblatt and Prof. Dr. M. Hersberger together with 
the main applicant). Blood samples will be drawn from pMDD subjects after enrolment, at 
week12 and week36 to assess routine laboratory parameters. 
- Haemoglobin  
- Haematocrit  
- Leucocytes 
- Thrombocytes 
- Thyroid (TSH only) 
- Liver function test (ALAT, ASAT) 
- hsCRP  
The remaining blood will be stored for PUFAs (omega-3, 6 and 9 and trans fatty acids), 
bioactive lipids (e.g. E-series resolvins), immune parameters (including but not restricted to 
interferon-γ, interleukin (IL)-1α, IL-1RA, IL-5, Il-6, IL-10, IL12p40, IL-15, IL-18 and tumour 
necrosis factor-α, as well as leptin and adiponetin), and for the tissue repository. In addition, 
2.7ml blood will be drawn in order to assess mitochondrial metabolism. 
Except for hsCRP (a stratification variable) all markers of prediction will be measured at the end 
of trial after completion of the final visit of the last patient (to prevent unblinding), except of the 
baseline data that might be used in the context of planed add-on projects that will be submitted 
as amendments (e.g. sleep project, imaging project). Altered levels of these parameters have 
been shown in MDD and other disorders, and may predict both the course of the illness and 
how levels of bioactive lipids, and immune parameters are related to both: a.) if these blood 
parameters are able to serve as potential biomarkers that may predict clinical outcome and b.) if 
these blood parameters are associated with psychopathology and illness course.  
Since multiple studies are currently investigating biomarkers in MDD, serum, lymphocytes, 
erythrocyte, platelets and DNA will be stored after the end of the study to measure potential 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 75 of 108   
novel biomarkers. Genetic and epigenetic markers of interest (e.g. FADS haplotypes) include 
but are not restricted to genes relevant for bioactive lipid metabolism. The establishment of the 
genetic tissue repository is part of the project but will be financed separately, as this is not core 
to the proposed IICT. Ethics approval for the generation of the tissue repository has been 
granted (Applicant Prof. S. Walitza, BASEC-Nr. 2016-00101).  
The aim is to collect all blood samples for all subjects. However if subjects do not want to have 
subsequent blood samples drawn, they can still participate in the study. In a separate consent 
form, subjects will be asked to provide blood for BioBanking in accordance with the Swiss legal 
regulations. Over the course of the entire study, a total amount of approximately 50 ml blood will 
be maximally drawn: After signing the consent from 3x3ml to perform standard clinical 
laboratory tests, 4 ml for bioactive lipids, 10 ml for (epi)genetic markers, 10 ml for immune 
markers, 10ml for specialized pro-resolving lipid mediators (SPM), and 3ml for mitochondrial 
metabolism will be drawn. The laboratory blood sampling must be done for all subjects after 
written informed consent has been obtained as this information is required for the minimization 
procedure (stratification). The further bloods shall be taken if possible, but are not mandatory for 
participation in the clinical trial. If too many subjects refuse the additional blood samples, total 
sample size may need to be reconsidered to be able to address secondary and tertiary outcome 
measures. 
In addition, patients will provide a urine sample for later drug screening and F2 isoprostane, and 
a saliva sample to measure cortisol concentrations. 
 
 
9.2.3 Assessment of Other Outcomes of Interest 
 
 
The PTBS Checklist  is a self-report scale that aims to detect past experiences of 
traumas and allows to make the diagnosis of posttraumatic stress disorder according to 
DSM-V.. Trauma experiences in childhood are often associated with depressive 
symptoms. We will co-vary for trauma load in secondary analysis.  
 
Tanner Criteria [247] Self-report form on pubertal status. The assessment of the 
pubertal status will enable us to investigate if the developmental stage has an impact 
on omega-3 fatty acids effects. If the children are > 13 years of age, parents are asked 
to fill in the questionnaire due to the explicit nature of the pictures. 
 
The Omega-3 Food Frequency Questionnaire n-3 FFQ [248] is a 21-item self-report 
that was developed using the National Cancer Institute’s Diet History Questionnaire as 
a model. The scale was adapted to reflect local fish intake and was developed in 
conjunction with Prof. Herter of the ETH. The n-3 FFQ takes 10 minutes to complete, 
and assesses the average n-3 intake over the last 6 months. Items in the n-3 FFQ 
included an extensive list of specific seafood and fish available in Switzerland, as well 
as walnuts, flaxseed, flaxseed oil, cod liver oil and canola oil. The questionnaire also 
includes specific questions about type and dosage of n-3 PUFA dietary supplements 
(individuals taking supplements will be excluded).  
 
The WHO Assist 3.0 [249] is a widely used structured Interview to quantify substance 
and drug abuse that will be completed by the research interviewer enabling us to 
control for substance misuse. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 76 of 108   
 
The Antidepressant Side Effect Checklist (ASEC) [250] is a 21-item self-report scale 
quantifying the most commonly described side-effects of antidepressants. It has a 0-3 
scoring (0 = absent, 1 = mild, 2 = moderate, 3 = severe) and asks the patients if he 
believes that there is a link with the study medication for each item. 
 
The Medication Adherence Reporting Scale-Deutsch (MARS-D) is the German Version 
of a self-report adherence reporting scale that has been developed by K. Thompson at 
ORYGEN Youth Health [251], a specialized clinic for young people with emerging 
mental disorders, but is now used in a broader sense [252]. The scale includes 5 items. 
In the initial validation study, an internal consistency reliability of α = 0.75 was found. 
MARS examines adherence behaviours and attitudes toward medication. We choose 
MARS as it has been used in young people with emerging mental illness and has been 
evaluated in German. 
 
9.2.4 Assessment of Safety Outcomes 
9.2.4.1 Adverse Events  
 
 
The investigator controls weekly if any AE or SAE has occurred. If so, the investigator contacts 
the clinician to get informed about the circumstances which led to the AE, and together with the 
principal investigator the connection between the AE and the study drug is clarified. If a 
connection has been established, the SUSAR will be reported according to the principles stated 
in Section 10. Furthermore, at each study visit, the Antidepressiva side effect Self Report Scale 
(ASEC) will be administered. In case the patient reports any abnormalities, the investigator will 
inform the clinician and principal investigators to determine whether an AE or SAE occurred. A 
detailed description of collaboration and responsibilities between researchers and clinicians can 
be found in the SOP (collaboration between research and clinic). 
9.2.4.2 Laboratory Parameters 
 
At screening and at nine months (or the drop out visit), blood will be drawn for standard clinical 
laboratory 
tests. 
Clinical 
blood 
parameters 
(haemoglobin, 
haematocrit, 
leucocytes, 
thrombocytes, TSH (thyroid function test), ALAT & ASAT (liver function test), and 
thromboplastin (blood coagulation) will be assessed in order to screen the patient for abnormal 
blood parameters. These analyses will be done in the Children’s hospital of Zurich. The results 
will be entered into the eCRF as they are part of the inclusion criteria and will also provide the 
stratification parameter (hSRF). All the other blood samples will be stored for analyses as 
outlined in the protocol.  
 
9.2.4.3 Vital Signs 
Vital signs will be assessed in the lead-in phase and again at the end of the study (week36) by 
the study nurse or investigator (e.g. heartbeat, blood pressure, body temperature, height and 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 77 of 108   
weight). ). 
9.2.5 Assessments in Participants Who Prematurely Stop the Study 
 
A drop-out visit shall be performed including documentation of reasons for drop out in case a 
patient drops out, or a parent / clinician / investigator withdraws a patient from the study. The 
drop-out visit will be performed at the earliest convenient time and will include an assessment of 
physical health and current medication use. Depressive symptoms will be assessed using the 
CDRS-R and the K-SADS-PL. In addition, psychosocial functioning will be assessed with a 
range of clinician rated scales (CGI-S/I, CGAS, HoNOSCA) and self-reported scales (DIKJ, 
BHS, BAI II, SIQ-Jr, PSS-10, Connor-Davidson Resilience Scale, SDQ, Insomnia Severity 
Index, IES-27-J). Patients will fill in the ASEC for assessing putative side effects. If the patient 
agrees, blood, urine and saliva will be sampled, and a short IQ test will be performed.  
 
9.3 Procedures at Each Visit 
 
 
9.3.1 Visit -1 (Screening/ written informed consent) 
During the first meeting with the investigator or psychologist, the study will be explained to the 
subject including possible benefits and disadvantages of participation. When the patient’s 
willingness is assured and written informed consent is provided, the subject will be screened for 
in- and exclusion criteria. Information about sociodemographic, medical and family history, 
current medication use, psychiatric history, drug use, and childhood trauma will be collected.  
Current and past episodes of psychopathology will be determined using the semi-structured 
diagnostic interview Schedule for Affective Disorders and Schizophrenia for School Aged 
Children (K-SADS-PL) in cases where no K-SADS-PL interview has been done in the last 4 
weeks. If a K-SADS-PL interview has already been performed in the last 4 weeks in the context 
of standard clinical praxis, the K-SADS-PL shall not be repeated given the extensive nature of 
the full interview. In that case, the results should be transferred from the clinical records into the 
study database. The Children’s Depression Rating Scale (CDRS-R) is used to determine 
severity of depressive symptoms. 
The K-SADS and the CDRS are both completed once with the patient and once with a parent / 
caregiver. At the time of the appointment with the parents, also the other parent-rated 
questionnaires (PTBS Checklist, BRIEF-E, SDQ-E, KIDscreen-Cat-E,IES27-E) shall be 
administered so that only one appointment in the first week with the parent is necessary. The 
interview with the patient may be at the same time or at a different time, depending on the 
convenience and age of the patient (+-5 days).  
Thereafter the patient enters the single-blind, placebo lead-in period (7 to 10 days), and all the 
patients will get placebo capsules for the whole period. The patient and parents do not know 
that a placebo lead in phase occurs. The research interviewer will also schedule appointments 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 78 of 108   
during the placebo-lead in phase to sample biological variables and further assess psychosocial 
and cognitive functioning. 
9.3.2 Visit 0 (placebo lead-in phase) 
During the placebo lead-in phase samples will be taken to perform standard clinical laboratory 
tests. This can be done any time before baseline but not thereafter. To minimise the burden for 
participants, blood to assess levels of bioactive lipids, (epi)genetic markers and immune 
parameters will be collected simultaneously. In addition, a physical examination will be 
conducted where heart rate, blood pressure, weight, height and body temperature will be 
measured. Cognitive testing will be performed before baseline and a short questionnaire 
regarding executive functioning (BRIEF) will be filled in. The current intake of Omega-3 fatty 
acids will be assessed with the FFQ. An appointment for the baseline visit will be scheduled. 
 
9.3.3 Visit 1: baseline visit 
The baseline visit takes place at the end of the placebo-lead-in phase. First, depressive 
symptoms will be assessed with the CDRS-R and the subscale depressive disorders of the K-
SADS-PL. Parent’s ratings can be obtained in person or over the phone. If the patient still fulfils 
the diagnosis of a major depressive disorder with at least moderate severity, the patient is 
enrolled using the computerized 1:1 randomization procedure described above. Current 
medication use, AEs and the Medication Adherence Reporting Scale is assessed. Clinician rate 
the patient according to the CGI, CGAS, and the HoNOSCA. Depressive symptoms will be 
further assessed with the Children’s Depression Inventory (DIKJ), the Beck Hopelessness Scale 
II (BHS), the Beck Anxiety Inventory (BAI II), the suicidal ideation questionnaire and the 
Insomnia Severity Index. Further self-reported questionnaires are filled in by the patients 
including the Perceived Stress Scale (PSS-10), the Connor-Davidson Resilience Scale, the 
KIDscreen-Cat-27, the Strength and Difficulty Questionnaire (SDQ), and the IES-27-J. In 
patients > 13 years of age, self-rating questionnaires shall be completed with help of the parents 
or the research investigators. Patients > 13 years shall complete the questionnaires themselves 
(parents are instructed not to influence the patent’s self-ratings). Self-rating questionnaires may 
be directly entered online into the data base by the patients / families themselves. Perceived 
side effects will be assessed with the Antidepressant Side Effect Checklist (ASEC). At the end 
of the baseline visit, study medication will be dispensed for the first time and new appointments 
will be scheduled. 
9.3.4 Visit 2: 6 weeks 
 
After 6 weeks a brief follow-up assessment will be done. During this visit, information about 
current medication use, adverse events and possible side effects (ASEC) will be collected. In 
addition, certain measures of symptomatology and psychosocial functioning that are performed 
at baseline will be repeated (CDRS-R, affective disorder subscale of the K-SADS-PL, DIKJ, 
BHS, BAI II, SIQ-Jr, Insomnia Severity Index, Connor-Davidson Resilience Scale). Clinician will 
rate the patients’ functioning on the CGI and CGAS, and will fill in the attrition checklist. Patients 
and their parent/ guardian will return study medication at each research visit for pill counts and 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 79 of 108   
complete a Medication Adherence Rating Scale (MARS German version). New study 
medication will be dispensed and a further appointment scheduled.  
 
9.3.5 Visit 3: 12 weeks 
 
At the fourth visit (week 12) a longer assessment will be held. In addition to the psychological 
rating scales which are repeated as in the baseline condition, also cognitive testing will be 
performed and biological parameters will be sampled (blood, urine and saliva). The study nurse 
will go and see the patients either at home, or at the clinic to take blood and urine. Patients and 
their parents will be given a saliva kit with the instruction to sample saliva in the morning after 
waking up. New study medication will be dispensed and a further appointment scheduled. 
 
9.3.6  Visit 4: 24 weeks 
The fourth visit will be the same as visit 2. In addition, a short IQ test (RIAS) will be 
administered. New study medication will be dispensed and a further appointment scheduled. 
 
9.3.7 Visit 5: 36 weeks 
This will be the last visit of the trial. Similar to visit 4, a longer research assessment will be held. 
All scales already assessed at baseline will be repeated, cognitive testing will be performed, 
and blood, urine and saliva will be sampled, and non-used pills will be counted.  
 
9.3.8 Clinical Care and monitoring of clinical visits 
Usually clinicians will see outpatients on a weekly basis for the first six weeks, and gradually 
increase the time lap between visits (e.g. on a two weekly bases between week 6-12), and 
thereafter as clinically indicated. However, clinicians are allowed to see patients whenever 
clinically indicated. Clinicians will perform clinician-based assessments (CGI, CGAS, and 
HoNOSCA) and complete the attrition checklist that includes the documentation of service use 
and adverse events at any clinical visit.  
10 SAFETY  
The Sponsor’s SOPs provide more detail on safety reporting. 
During the entire duration of the study, all adverse events (AE) and all serious adverse events 
(SAEs) are collected, fully investigated and documented in source documents and case report 
forms (eCRF). Study duration encompassed the time from when the patient signs the informed 
consent until the last protocol-specific procedure has been completed, including a safety follow-
up period.  

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 80 of 108   
10.1  Definition of (Serious) Adverse Events and Other Safety 
Related Events 
Adverse events 
Adverse events (AEs) are defined as any untoward medical occurrence in a patient or clinical 
investigation participant administered a pharmaceutical product and which does not necessarily 
have a causal relationship with this treatment. An AE can therefore be any unfavourable and 
unintended sign (including an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of a medicinal study product, whether or not related to the medicinal 
study product.  
An AE may also consist of a new disease, an exacerbation of a pre-existing illness or condition, 
a recurrence of an intermittent illness or condition, a set of related signs or symptoms, or a 
single sign or symptom. 
AEs observed by the investigator and/or reported by the participant must be reported in the 
eCRF during the entire study period, i.e. the period of time from the first (= signature of informed 
consent) to the last protocol-specific procedure regardless of the medicinal study product 
relation assessment.  
For all AEs, sufficient information will be pursued and/or obtained so as to permit an adequate 
determination of the outcome of the event (i.e., whether the event should be classified as an 
SAE) and an assessment of the causal relationship between the AE and the investigational drug 
or study treatment(s).    
Whenever available, the underlying disease or condition for which a therapeutic or diagnostic 
procedure is required should be reported as the AE term. Surgeries or other invasive 
procedures that had already been planned prior to the start of the study do not have to be 
documented as AEs. These planned procedures will be recorded in the eCRF by the 
investigator at the baseline visit. It is not important if the condition was known before enrolment, 
only if the procedure was planned before. 
 
Serious Adverse Event 
An SAE is any untoward medical occurrence that at any dose results in  
• death,  
• is life-threatening,  
• requires participant hospitalization or prolongation of current hospitalization,  
• results in persistent or significant disability/incapacity, or  
• is a congenital anomaly/birth defect,  
• any important medical event and any event which, though not included in the above, may 
jeopardise the participant or may require intervention to prevent one of the outcomes listed 
above. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 81 of 108   
Any other medically important condition that may be not immediately life-threatening or results 
in death or hospitalization but may jeopardize the participant or may require intervention to 
prevent one of the outcomes listed above should also usually (i.e. based on medical and 
scientific judgment) be considered serious. For example: intensive treatment at home for 
allergic bronchospasm; certain laboratory abnormalities (e.g. blood dyscrasias); convulsions 
that do not result in hospitalisation; development of drug dependency. 
SAEs should be followed until resolution or stabilisation. Participants with ongoing SAEs at 
study termination (including safety visit) will be further followed up until recovery or until 
stabilisation of the disease after termination.  
 
Unexpected Adverse Drug Reaction 
An “unexpected” adverse drug reaction is an adverse reaction, the nature or severity of which is 
not consistent with the applicable product information (e.g. Investigator’s Brochure for drugs that 
are not yet approved and Product Information for approved drugs, respectively). 
 
Suspected unexpected serious adverse reaction (SUSAR) 
A serious adverse reaction, the nature or severity of which is suspected to be not consistent 
with the applicable product information as stated in the Investigator’s Brochure.   
 
Safety Signals 
All suspected new risks and relevant new aspects of known adverse reactions that require 
safety-related measures. 
10.2  Recording of (Serious) Adverse Events and Other Safety Related Events 
Clinical investigators and ultimately the protocol Principal Investigator (PI) have the primary 
responsibility for AE identification, documentation, grading, and assignment of attribution to the 
investigational agent/intervention. 
Clinical study participants will be routinely questioned about AEs at study visits. The well-being 
of the participants will be ascertained by neutral questioning ("How are you?"). The investigator 
is responsible for reporting all AEs occurring during the course of the study. In case of any 
reported (S)AE, the research interviewer will inform the clinician and the GCP-certified study 
doctor (Prüfarzt) who will then classify the AE according to the criterion noted below. 
All observed or volunteered adverse drug events (serious or non-serious) and abnormal test 
findings, regardless of treatment group or suspected causal relationship to the investigational 
drug or study treatment(s) will be recorded in the patient file and subsequently in the eCRF.   
AEs or abnormal test findings felt to be associated with the study treatment(s) will be followed 
until the event (or its sequelae) or the abnormal test finding resolves or stabilizes at a level 
acceptable to the investigator. 
An abnormal test finding will be classified as an AE if one or more of the following criteria are 
met: 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 82 of 108   
 
The test finding is accompanied by clinical symptoms. 
 
The test finding necessitates additional diagnostic evaluation(s) or medical/surgical 
intervention; including significant additional concomitant drug treatment or other therapy  
Note: simply repeating a test finding, in the absence of any of the other listed criteria, 
does not constitute an AE.   
 
The test finding leads to a change in study dosing or discontinuation of participant 
participation in the clinical study. 
All AEs, serious and non-serious, will be fully documented in the appropriate eCRF. For each 
AE, the investigator will provide the onset, duration, intensity, treatment required, outcome and 
action taken with the investigational product.  
10.3  Assessment of (Serious) Adverse Events and Other Safety Related Events 
The investigator will promptly review documented AEs and abnormal test findings to determine 
if  
 
the abnormal test finding should be classified as an AE, 
 
if there is a reasonable possibility that the AE was caused by the investigational drug or 
study treatment(s), and 
 
if the AE meets the criteria for an SAE. 
The intensity of an AE will be assessed by the investigator as being  
 
mild (hardly noticeable, negligible impairment of well-being),  
 
moderate (marked discomfort, but tolerable without immediate relief), or  
 
severe (overwhelming discomfort, calling for immediate relief). 
 
The assessment of causality to the study drug by the investigator is done according to the 
following definitions: 
Unrelated 
 
The event started in no temporal relationship to medicinal product 
applied and  
 
The event can be definitely explained by underlying diseases or other 
situations.  
Related 
 
 
The event started in a plausible temporal relationship to medicinal 
product applied and  
 
The event cannot be definitely explained by underlying diseases or 
other situations.  
10.4  Reporting of Serious Adverse Events and Other Safety 
Related Events 
The principal investigator is responsible for reporting of any SAEs to the Sponsor immediately, 
i.e. within 24 hours.  
The Investigator is responsible for SAE reporting to the CEC according to the following details: 
 Reporting to CEC any SAE which resulted in death: 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 83 of 108   
- without delay, and no later than 7 calendar days. 
 Reporting to CEC of fatal SAEs if evaluated as “suspected”, “unexpected” and “drug related” 
(SUSAR) 
- without delay and no later than 7 calendar days following awareness that event  
   meets criteria for an SUSAR. 
 Reporting to CEC of non-fatal SAEs if evaluated as “suspected”, “unexpected” and “drug 
related” (SUSAR): 
- promptly and no later than 15 calendar days following awareness that event  
   meets criteria for a SUSAR. 
 All other SAEs will be summed up in the annual safety update report. 
 
The Sponsor is responsible for SAE reporting to Swissmedic according to the following details: 
 
Compliance with the regulatory requirements of Swissmedic regarding prompt reporting of 
unexpected SAEs for which a causal relationship with the study drug cannot be ruled out.  
 
Reporting to Swissmedic of fatal SAEs if evaluated as “suspected”, “unexpected” and 
“drug related” (SUSAR): 
- without delay and no later than 7 calendar days following awareness that event  
   meets criteria for a SUSAR; 
 
Reporting to Swissmedic of non-fatal SAEs if evaluated as “suspected”, “unexpected” and 
“drug related” (SUSARs): 
- promptly and no later than 15 calendar days following awareness that event  
   meets criteria for a SUSAR. 
 
Sending Annual Safety Reports (ASR), starting one year after the date of notification to 
Swissmedic. These reports should contain:  
- A concise critical summary of the safety profile of the drug studied as well as the 
  safety issues that have arisen; 
- A listing of all SUSARs that have occurred in Switzerland and at international 
   level (if applicable);  
- Ideally all adverse drug reactions at international level. 
- The accompanying letter provided with the Annual Safety Report should contain a short 
summary of the status of the clinical trial in Switzerland (number of centres open/closed, 
number of patients recruited/recruitment closed, and number of SAR/SUSAR.  
 
A list of all SAEs and SUSARs will be generated annually. The annual safety report contain 
information from all sites. The summery table will be composed by the central study team, 
signed by the applicant and co-applicant and submitted to the participating investigators, the 
IDMC and to the appropriate authorities. The participating investigators submit it to the local 
committees. The summary table will be arranged by organ systems. A review of all new 
scientific data as well as new safety signals will be included. If possible (if timing of the meeting 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 84 of 108   
and Annual Safety and Progress Report coincide), a cost-benefit evaluation performed by the 
Independent Data Monitoring Committee is included, based on a complete safety analysis and 
an evaluation of the balance between the efficacy and the harmfulness of the medicine under 
investigation. 
 
Reporting of Safety Signals 
All suspected new risks and relevant new aspects of known adverse reactions that require 
safety-related measures, i.e. so called safety signals, must be reported to the Sponsor-
Investigator within 24 hours. The Investigator must report the safety signals within 7 days to the 
local Ethics Committee (local event via local Investigator) and the Sponsor to Swissmedic, 
respectively. The Sponsor-Investigator must immediately inform all participating Investigators 
about all safety signals. The other in the trial involved Ethics Committees will be informed about 
safety signals via the Sponsor-Investigator. 
 
Reporting and Handling of Pregnancies 
Pregnancy per se does not classify as an AE. However, AEs related to a pregnancy have to be 
reported like any other AEs. Pregnancy should be confirmed by a reliable laboratory test. 
Pregnant participants must be immediately withdrawn from the clinical study. All pregnancies 
occurring during the treatment phase of the study and within 30 days after discontinuation of 
study medication have to be reported to the Sponsor-Investigator within 24 hours of the 
investigational sites knowledge of the pregnancy and recorded on the eCRF. The Sponsor-
Investigator will contact the attendant physician by phone during pregnancy and after the 
estimated date of delivery to enquire about course and outcome of the pregnancy. Course of 
the pregnancy and health status of the new born child have to be documented on the Follow-Up 
Pregnancy Report Form.  
10.5  Follow up of (Serious) Adverse Events 
Participants terminating the study (either regularly or prematurely) with 
 
reported ongoing SAE, or 
 
any ongoing AEs of laboratory values or of vital signs being beyond the alert limit 
will return for a follow-up investigation. This visit will take place up to 30 days after terminating 
the treatment period. Follow-up information on the outcome will be recorded on the respective 
AE page in the eCRF. All other information has to be documented in the source documents. 
Source data has to be available upon request. 
In case of participants lost to follow-up, efforts should be made and documented to contact the 
participant to encourage him/her to continue study participation as scheduled. In case of minor 
AEs a telephone call to the participants may be acceptable. 
All new SAE or pregnancies that the investigators will be notified of within 30 days after 
discontinuation of study medication have to be reported in appropriate report forms and in the 
eCRF if required.  

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 85 of 108   
Follow-up investigations may also be necessary according to the investigator’s medical 
judgment even if the participant has no AE at the end of the study. However, information related 
to these investigations does not have to be documented in the eCRF but must be noted in the 
source documents. 
 
11 STATISTICAL METHODS  
Descriptive statistics will be provided for all data broken down by medication (omga-3 fatty acids 
and placebo), group (patients who recovered from the depression, patients who did not recover) 
and visit. Mean, median, standard deviation, range and number of observations will describe 
continuous variables. Frequencies and percentages will describe discrete variables. All 
statistical tests will be carried out two-tailed; the alpha (level of significance) is 5%. Efficacy of 
the treatment will be assessed using a linear random coefficient regression model. 
 
11.1  Hypothesis 
 
The Null Hypothesis is defined as no difference in response rates between the two treatment 
groups while the Alternative Hypothesis states that the two groups differ at least 20% in 
response rates. If the treatment group shows an increase in response rates of at least 20%, the 
main study objective will be met.  
11.2  Determination of Sample Size  
Sample size estimation was done by Prof. Burkhardt Seifert from the Epidemiology, Biostatistics 
and Prevention Institute (EBPI), based on the assumption that we will perform a continuous 
outcome trial using a 1:1 randomization parallel-group design. Meta-analyses selecting studies 
of omega-3 fatty acids with high proportion of EPA in aMDD as primary diagnosis found an 
SMD between 0.28-0.56 [160-166]. However, no studies were performed in pMDD, except of 
one very small (n=20) pilot study in childhood depression with a large effect size (SMD=1.2) 
[167].  
We performed a sample size calculation using nQuery Advisor 7.0. Assuming the optimistic 
effect size of 0.54 using a two-group t-test for the CRSR-R scale with a 0.05 two-sided 
significance level and a 90% power to detect a difference between the groups would results a 
sample size of n=74 per treatment arm. However, as the placebo-response rate in minors is 
probably higher compared to the single centre RCTs in aMDD integrated in the above 
mentioned meta-analyses, we calculated our sample size estimation under following more 
conservative assumptions:  
a. P(omega-3) = .60, P(placebo) = .40 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 86 of 108   
b. no adjustment for loss to follow-up (see below data analysis) 
c. no adjustment for multiple comparisons; and  
d. α level of .05 for a 2-tailed test chi-scare test with continuity correction.  
Under these assumptions, 108 patients per treatment group (n = 216) will be needed to achieve 
80% or greater power to detect a difference of 20% in response rates between the two 
treatment groups (what is considered a clinical meaningful difference). The two RCTs in pMDD 
that were used as the foundation for the proposed trial design (the TADS [253, 254] and Emslie 
RCT in pMDD [213]) had similar sample sizes.  
 
11.3  Statistical Criteria of Termination of Trial  
 
The Independent Data Monitoring Committee (Prof. J. Hebebrand, Prof. M. Puhan, Prof. J. 
Drewe) has the responsibility to prevent harm as a consequence of the RCT. Therefore, the 
core task of the IDMC will be to monitor the safety of the trial.  Every SAE and SUSAR will be 
reported to the IDMC who is the sole group of researchers that can access SecuTrial in an 
unblinded manner and are able to investigate if there is a true relationship of a SAE with the 
study drug. The trial will be terminated if the IDMC considers the safety of the study population 
seriously at risk as a consequence of their monitoring activity, or if a clinical highly significant 
and relevant superiority/ inferiority of the active treatment group could be shown with sufficient 
certainty. However, premature early termination of the RCT for benefit reasons manifest a 
serious problem for adequate reporting and is likely associated with effect overestimation as 
could be shown in oncology. As all participants will receive treatment according to the S3 
German Guidelines for the treatment of depressive disorders in children and adolescents, 
premature termination for benefit reason shall only be considered if effect size between 
treatment groups is considered large (SMD > .0.8) on the children’s depression rating scale, as 
well as clinical significant in recovery rates between the two treatment groups. The first interims 
analysis shall be performed after completion of 60 participants. 
11.4  Planned Analyses  
All analyses will be carried out after closure of the database to avoid unblinding. All randomized 
patients will be included in the model, and the efficacy of omega-3 fatty acids on depressive 
symptoms will be analyzed using a linear random coefficient regression model, as described 
below.  
Furthermore, we will compare the scores between baseline and end of study (week 36) for all 
the different scales and questionnaires, which were assessed previously. Additionally, cognitive 
functioning will be compared between the beginning of the study and its end while controlling for 
the effect of depressive symptoms on cognitive outcome measures. An SOP will describe all 
planned a priori analysis.  
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 87 of 108   
11.4.1 Datasets to be Analysed, Analysis Populations 
 
The intention-to-treat (ITT) approach includes all randomized patients. 
 
The primary analysis will be performed including the ITT sample. A secondary analysis 
will be performed defining patients that were put on antidepressants as drop-outs from 
the time point of taking antidepressant medication. 
 
Furthermore, we plan to reanalyze the IIT sample according to the PUFA baseline 
status. In particular we want to compare participants with a omega-3 index <3 compared 
to those with an omega-3 index >3/5 or 8, as increasing evidence suggest that in 
particular those with a low omega-3 index may benefit from omega-3 supplementation.  
 
Furthermore, we plan to investigate the influence of inflammatory mediators as response 
predictors [63]. 
 
Finally we will reanalyze the ITT sample using compliance data (pill count, rbc EPA/DPA 
change levels, MARS score) to compare fully compliant study participants with partially 
compliant and non-compliant patients.  
 
More exploratory will be the analysis of EPA metabolites (HETE; E-series resolvins, 
prostaglandine, leukotriene) that will be measured in the context of a PhD project as 
potential predictors of omega-3 fatty acid response. 
 
11.4.2 Primary Analysis 
 
The continuous primary outcome measure is the CDRS-R total score. The dichotomous primary 
outcome measures are recovery, response and remission. Recovery is defined as the absence 
of the diagnosis of MDD for > than 4 months according to the K-SADS, remission is defined as 
a CDRS total score <28 and response is defined as a 30% drop in CRDS total baseline score 
(post placebo lead in). We will analyze efficacy measures using a (generalized) linear random 
coefficient regression model (similar to the TADS study [253, 254]). Random regression in an 
ITT sample permits estimation of changes in continuous repeated measures in the presence of 
missing data on both a population and participant-specific level without necessitating last 
observation carried forward or exclusion of participants because of missing data. We will model 
the impact of treatment on outcome as a linear function of fixed effects for treatment, time 
(defined as the natural log of days since baseline + 1) and treatment-by-time interaction and 
random effects for participant and clinical site, including all 2- and 3-way interactions in the 
initial model. Clinical site and its interaction effects will be fitted in the model as random effects. 
Under the assumption of random intercepts and slopes for each patient, the overall and 
treatment group-specific rate of change for the 2 treatment groups for the primary CDRS-R 
outcome will be examined. A comparison on treatment slopes (linear trends with time) will then 
be conducted. Supplemental between-treatment contrast analyses will be conducted on the 
adjusted week 12 and 36 means. We will ass adherence using pill count, MARS-D, as well as 
EPA baseline change levels at week 12 and week 36. We will reanalyse the data according to 
fully adherent, partial adherent and non-adherent.  
 
 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 88 of 108   
11.4.3 Secondary Analyses 
For analysis of the secondary clinician-rated outcome CGI-improvement (CGI-I), the values at 
the measurement time points will be compared, since this scale inherently measures total 
improvement. We will compare the clinician rated CGI remission rates (defined as a score of <2) 
with the researcher-rated remission rates based on the CDRS-R/ K-SADS-P. CGI-I remission 
rates will be dichotomized by the end-of-treatment CGI-I score for each treatment group and will 
be compared using a logistic regression model using multiple imputations for missing data with 
site as a covariate.  
 
For further secondary outcomes, we will apply the same statistical strategy as for the primary 
outcome measures. Analysis will include changes in overall and subscores of the in chapter 9.2 
listed secondary outcome instruments. We will analyze CDRS-R subscores, DIKJ, BHS, BAI, 
SIQ-Jr, IES-27, KIDscreen-CAT-27, PSS-10, and Resilience Scale scores and compare them 
between the treatment groups. 
Furthermore, we’ll run the following analyses to test our secondary working hypotheses: 
- WH2a: We will test differences in antidepressant medication between the 
treatment groups by means of the two proportions z-Test 
- WH2b: We will compare level of functioning and quality of life between the 
treatment groups by comparing the scores of CGAS and the KIDscreen-CAT-27  
with an independent two-sample t-Test or Mann-Whitney-U-Test, depending on 
the distribution of the data. 
- WH2c: We will test the hypothesis of fewer hospital admission and lower 
outpatient service in the Omega-3 fatty acids group than the placebo group by 
applying an independent t-Test (for normal distributed data) or Mann-Whitney-U-
Test (for non-normal data). 
- WH2d: Retention rates between the two groups will be tested by means of the 
two proportions z-Test. In addition, Kaplan-Meier survival curves will be 
compared using the log rank test, and possible mediators of drop-out rates will 
be assessed with a cox regression analysis. 
- WH3a: We will test the effect of inflammatory mediators on the efficacy of 
omega-3 treatment by introducing an additional continuous factor (ratio between 
pro- and anti-inflammatory markers) into the linear regression model described in 
11.4.2. 
- WH3b: We will calculate an omega-3 index based on red blood cell Omega-3 
fatty acids content and introduce an additional binary factor (n-6/n-3 Omega 
ration < 3 vs. n-6/n-3 Omega ratio > 5) into the linear regression model described 
in 11.4.2. 
- WH3c: We will test whether direct metabolites of EPA are a strong predictor of 
Omega-3 fatty acids by introducing  additional continuous factors (levels of 
HETEs and E-series-resolvins at baseline) into the linear regression model 
described in 11.4.2 
- WH4a: We will test association between pro-inflammatory state and depressive 
symptoms by calculating Pearson’s correlation coefficient or Spearman’s 
correlation coefficient between the severity of symptoms at baseline and the ratio 
between pro- and anti-inflammatory markers. The same procedure is also 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 89 of 108   
applied to omega-6/3 ratio and omega-3 index. To test whether normalization of 
these parameters will correlate with improvements in depression scores we’ll run 
a linear regression model with depression scores as dependent, and time and 
pro-inflammatory state, increase in omega-6/3 and omega-3 index as 
independent variables. 
- WH4b: We will calculate Pearson’s correlation coefficient or Spearman’s 
correlation coefficient of omega-3 index with SIQ-Jr scores depending on the 
distribution of the data. 
- WH4c: As above, we will calculate either Pearson’s correlation coefficient or 
Spearman’s correlation coefficient (depending on the distribution of the data) 
between omega-3 index and scores on the IES-27 and overall psychopathology 
scores. 
- WH4d: We also test correlations between levels of Omega-3 fatty acids with 
salvia cortisol, F2 isoprostanes and Connor-Davidsons Resilience Scale scores 
by calculating Pearson’s correlation coefficient or Spearman’s correlation 
coefficient, respectively. 
- WH5a: In order to compare treatment groups regarding occurrence of SUSARs, 
we will run a two proportions z-Test. Differences in suicidal ideation scores are 
tested by independent t-Test (for normal distributed data) or Mann-Whitney-U-
Test (for non-normal data). 
  
The analyses will be performed after closure of the database. The trial statisticians will perform 
all a-priori defined statistical analyses according to the statistical analyses plan. All other clinical 
outcome analyses will be declared as post-hoc analysis.  
 
Future analysis based on the BioBank or other add on projects will be subject of an own 
protocol with separately formulated hypotheses that will be approved the appropriate 
authorities.  
 
11.4.4 Interim Analyses 
 
No interim analyses are carried out to maintain the blinding of all researchers over the whole 
course of the study. Only the IDMC will run an interim analysis after 60 patients to ensure the 
safety of the patients as specified in the IDMC SOP. If the IDMC considers the number of study 
participants insufficient to address the primary outcome in the due course of the study (e.g. 
because of too many drop outs, not sufficient prepubertal participants, other reasons…), the 
total sample size may be reconsidered. 
 
11.4.5 Safety Analysis 
 
Safety and harms frequency data will be described based on actual treatment received using 
MedDRA (integrated in SecuTrial®) and the self-report side effect checklist (ASEC). The rate of 
harm- and suicide-related adverse events (e.g. SIQ-Jr) in each treatment group will be 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 90 of 108   
compared using χ2 and Fisher exact tests, and ORs will be calculated to provide an indicator of 
relative risk of the active versus the placebo condition.  
 
11.4.6 Deviation(s) from the Original Statistical Plan  
 
We will report protocol violations (non-adherence to the treatment protocol) in the CONSORT 
flow chart, in the methodology section and if appropriate in the discussion. We will state how 
many participants will have been included in the placebo-lead in phase, how many of those 
dropped below a CDRS-R score of 40 within the lead in phase, how many will have been 
randomized, how many droped out within the first six weeks due to non-compliance and how 
many will have completed the acute and maintenance treatment phase. The intention-to-treat 
(ITT) approach includes all randomized patients. We will declare all analysis not defined a priori 
as post hoc analysis.  
 
11.5 Handling of Missing Data and Drop-Outs  
 
As stated above, the applied regression model already deals with missing data. For all other 
analysis we will use multiple imputations for missing data as described by Rubin [255, 256] 
using the software ‘SOLAS for missing data analysis’ (version 3.0). 
12 ELIGIBILITY OF THE PROJECT SITE(S) 
The department of Child and Adolescent Psychiatry of the University of Zurich is the biggest 
institution of its kind in Switzerland with close to 400 employees and is well suited to 
accommodate a clinical study. All the project sites are well-established official treatment centres 
for pMDD, and emergency care is readily available at each institution. All the centres are in 
close proximity to the lead centre, and many of the senior clinicians were trained or worked as 
consultants in the academic lead centre (ZH). Furthermore, the academic and non-academic 
centres have a joint training program for their trainees for several years providing a good 
foundation for similar concomitant treatment of pMDD.  
13 DATA QUALITY ASSURANCE AND CONTROL 
The Sponsor-Investigator is implementing and maintaining quality assurance and quality control 
systems with written SOPs and Working Instructions to ensure that trials are conducted and 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 91 of 108   
data are generated, documented (record), and reported in compliance with the protocol, GCP, 
and applicable regulatory requirement(s).  
The Sponsor-Investigator is responsible to have written SOP`s and WIs in place for the study 
and to provide those to all participating study sites. The Principal Investigators at all sites must 
have a manual of the relevant SOPs and WIs for the study on site and are responsible for 
proper training of all involved study personnel for the respective procedures.  
Monitoring and Audits will be conducted during the course of the study for quality assurance 
purposes. 
13.1 Data Handling and Record Keeping / Archiving 
The study will strictly follow the protocol. If any changes become necessary, they must be laid 
down in an amendment to the protocol. All amendments of the protocol must be signed by the 
Sponsor-Investigator and submitted to CEC and Swissmedic.  
13.1.1 Case Report Forms  
 
The investigators will use electronic case report forms (eCRF), one for each enrolled study 
participant, to be filled in with all relevant data pertaining to the participant during the study. All 
participants who either entered the study or were considered not-eligible or were eligible but not 
enrolled into the study additionally have to be documented on a screening log. The investigator 
will document the participation of each study participant on the Enrolment Log.  
For data and query management, monitoring, reporting and coding an internet-based secure 
data base secuTrial® developed in agreement to the Good Clinical Practice (GCP) guidelines 
provided by the Clinical Trials Center (CTC) Zurich will be used for this study. It is the 
responsibility of the investigator to assure that all data in the course of the study will be entered 
completely and correctly in the respective data base. Corrections in the eCRF may only be done 
by the investigator or by other authorised persons. In case of corrections the original data 
entries will be archived in the system and can be made visible. For all data entries and 
corrections date, time of day and person who is performing the entries will be generated 
automatically. 
ECRFs must be kept current to reflect participant status at each phase during the course of 
study. Participants must not to be identified in the eCRF by name. Appropriate coded 
identification (e.g. Participant Number) must be used.  
It must be assured that any authorised person, who may perform data entries and changes in 
the eCRF, can be identified. A list with signatures and initials of all authorised persons will be 
filed in the study site file and the trial master file, respectively. 
Documented medical histories and narrative statements relative to the participant’s progress 
during the study will be maintained. These records will also include the following: originals or 
copies of laboratory and other medical test results which must be kept on file with the individual 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 92 of 108   
participants’ eCRF. A detailed listing of all the study parameters for each participant can be 
found in the Study Manual. 
The investigators assure to perform a complete and accurate documentation of the participant 
data in the eCRF. All data entered into the eCRF with exception of self-rating instruments that 
are entered directly online by the study participant/ parents and computerized neurocognitive 
data (for which data the eCRF will be source data) will also be available in the individual 
participant file either as print-outs or as notes taken by either the investigator or another 
responsible person assigned by the investigator.  
Essential documents must be retained for at least 10 years after the regular end or a premature 
termination of the respective study (KlinV Art. 45). Any patient files and source data must be 
archived for the longest possible period of time according to the feasibility of the investigational 
site, e.g. hospital, institution or private practice. 
13.1.2 Specification of Source Documents 
The following documents are considered source data, including but not limited to: 
• SAE worksheets 
• Nurse records, records of clinical coordinators, and  
• Medical records from other department(s), or other hospital(s), or discharge letters and 
correspondence with other departments/hospitals, if participant visited any during the study 
period and the post study period.  
Source data must be available at the site to document the existence of the study participants 
and substantiate the integrity of study data collected. Source data must include the original 
documents relating to the study, as well as the medical treatment and medical history of the 
participant. 
The following information (at least but not limited to) should be included in the source 
documents: 
• Demographic data (age, sex) 
• Inclusion and Exclusion Criteria details  
• Participation in study and signed and dated Informed Consent Forms  
• Visit dates  
• Medical history and physical examination details (including documentation of scars) 
• Key efficacy and safety data (as specified in the protocol)  
• AEs and concomitant medication  
• Results of relevant examinations  
• Laboratory printouts  
• Dispensing and return of study drug details  
• Reason for premature discontinuation  
• Randomization number 
13.1.3 Record Keeping / Archiving  
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 93 of 108   
In accordance with Swiss national laws and guidelines and the specifications of the ICH-GCP 
guidelines, the investigators from participating sites and the coordinating centre are obligated to 
archive all documents pertaining to the study for 10 years after the last subject has completed 
or discontinued from the study. Electronic data will be archived at the CTC on a server 
pertaining to the University hospital of Zurich. 
 
13.2 Data Management  
Research assistants and local investigators will enter the acquired data and examination results 
into an eCRF (SecuTrail®) that is accessible via the internet. Investigators will receive personal 
user names and passwords for this purpose, and data will be encrypted for transfer. For each 
site, it will be agreed before the start of the study which documents serve as source documents 
for all data entered into the eCRF. The investigator must (electronically) sign that entries into 
the eCRF are true and complete. At least a subset of data will be entered doubly to ensure data 
quality. 
Study sites and associated investigators will be carefully selected and comprehensively 
informed and trained regarding GCP, all study procedures and the required examinations and 
documentation before the start of the study. The quality of data acquisition will be ensured by 
regular monitoring visits and the continuous availability of the monitor and trial-coordinator for 
consultation. After data have been submitted to the study centre, another thorough inspection of 
the completeness and plausibility of entries will be conducted. If needed, questions for 
clarification will be addressed to the sites. Only after all questions regarding data quality have 
been answered, the database will be locked. 
 
13.2.1 Data Management System  
 
For the electronic data capture, storage, monitor and export for statistical analyses, the latest 
version of the study software SecuTrial® will be used. SecuTrial® meets the regulatory 
requirements according to GCP and FDA 21 CFR Part 11. SecuTrial® is installed on a secure 
server provided by the University Hospital of Zurich. Only members of the CTC can access the 
server. The sponsor will set up the software before starting the trial under close supervision of 
the data manager of the CTC. All users will be trained in the handling of the software and SOPs 
will be available at each site file and in the master trial file.  
 
13.2.2 Data Security, Access and Back-up  
 
The sponsor is responsible for granting access to the electronic data. Every involved party will 
get his own password protected login and associated authorization. An audit trail documents all 
changes that are made in the system.  All communication between the software and its users 
will be encrypted and a firewall protects the access to the software. A backup of the data will be 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 94 of 108   
made every 24 hours, and the University Hospital of Zurich provides a backup server in case 
the main server would be compromised. 
13.2.3 Analysis and Archiving 
 
After data validation the sponsor will notify the CTC about the closure of the database. After 
that, no new data or changes to existing data can be made. However, the data can still be 
accessed and be used for statistical analyses. After the last statistical analyses have been 
completed, the sponsor will notify the data manager about the timing of the archiving of the 
database, after which the project cannot be accessed anymore. After archiving, the database 
can only be accessed by written request of the sponsor or on request of the relevant authorities. 
13.2.4 Electronic and Central Data Validation  
 
SecuTrial® includes among others Audit-Trial, electronic signature, programmable tests of 
plausibility, consistency and value range, a query management system for online monitoring 
and a customizable system to assign roles and authorizations. Details for the software and its 
functionalities are described in separate documents which can be provided on request. The 
CTC will perform checks of accumulating study data. These are performed regularly through the 
study, and include range, plausibility, and consistency checks. 
 
 
13.3  Monitoring 
Regular monitoring visits at the investigator’s site prior to the start and during the course of the 
study will help to follow up the progress of the clinical study, to assure utmost accuracy of the 
data and to detect possible errors at an early time point. The Sponsor-Investigator organises 
professional independent monitoring for the study.  
All original data including all patient files, progress notes and copies of laboratory and medical 
test results must be available for monitoring. The project monitor, located at the CTC Zurich, will 
perform monitoring according to national laws and guidelines and the specifications of the ICH-
GCP guidelines. The CTC project monitor will visit study sites at regular intervals to monitor the 
execution of the study. They will have access to all documents that are needed to perform their 
task according to the above mentioned guidelines. The CTC project monitor will check whether 
requirements to conduct the study are met and study procedures are followed correctly, and will 
check the study site’s documentation, the participants’ source data, eCRF entries, and the 
correct maintenance of the Investigator Site File. The monitor will review all or a part of the 
eCRFs and written informed consents. The accuracy of the data will be verified by reviewing the 
above referenced documents. The investigator's site will collaborate with the Clinical Trials 
Center (CTC) of the University Hospital Zurich to ensure regular monitoring. According to the 
CTC's Monitoring SOP the extent and nature of monitoring activities based on the objective and 
design of the study will be defined in a study specific Monitoring Plan.  

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 95 of 108   
 
13.4  Audits and Inspections 
A quality assurance audit/inspection of this study may be conducted by the competent authority 
or CEC, respectively. The quality assurance auditor/inspector will have access to all medical 
records, the investigator's study related files and correspondence, and the informed consent 
documentation that is relevant to this clinical study. 
The investigator will allow the persons being responsible for the audit or the inspection to have 
access to the source data/documents and to answer any questions arising. All involved parties 
will keep the patient data strictly confidential. 
13.5  Confidentiality, Data Protection  
Direct access to source documents will be permitted for purposes of monitoring, audits and 
inspections. Privacy laws and regulations will be adhered to during all procedures related to this 
study. The collection and processing of participants’ personal information will be limited to what 
is necessary to insure the study’s scientific practicability and to assess the research questions.  
Information collected about participants during this clinical investigation will be treated 
confidentially. The local investigator or her/his co-workers will collect data and transfer it without 
recording the subject’s name or date of birth, but coded with a subject identification code. 
Therefore, data is not directly traceable to individual subjects. A subject identification code links 
the data to the individual subject.  
The code will be safeguarded by the data manager of the CTC Zürich; the key to this subject 
identification code will be kept at the CTC (via SecuTrial®). The emergency unblinding 
procedure or access to the randomisation code list by the authorities or the IDMC is described 
above.  
Anonymous (coded) data can be relayed to the central study team for scientific analysis or 
made available, if necessary, to the responsible federal supervisory authority (in case of audits 
during the course of the study).  
Only qualified and authorised collaborators of the study sponsor will enter the pseudonymous 
data into a computerised database. The acquired data will be used without participants’ names 
for scientific analysis. Participants’ names will not be mentioned in any publication of study 
results.  
Persons monitoring the data will have access to all information needed to ensure the validity of 
the study data, and are required to keep information confidential as well as to respect data 
privacy.  
Participants have the right to look into their data and can check their data in accordance with 
the relevant judicial regulations and procedures.  
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 96 of 108   
13.6  Storage of Biological Material and Related Health Data  
A tissue repository (BioBank) will be established in accordance with the HFG/KlinV/HFV. In a 
separate consent form, subjects will be asked to provide blood for BioBanking in accordance 
with the Swiss legal regulations. If subjects do not want to have their blood samples stored, they 
can still participate in the study.  
14 PUBLICATION AND DISSEMINATION POLICY  
 
After the statistical analysis of this trial the sponsor will make every endeavour to publish the 
data in a medical journal. A Publications Committee (applicants, co-applicants, others) will be 
formed and establish a publication guideline. The scientific integrity of the project requires that 
the data from all omega-3-pMDD study sites will be analyzed and reported as such (whatever 
outcome the omega-3 pMDD Study will have). An individual center is not expected to report the 
data collected from its center alone. All presentations and publications are expected to protect 
the integrity of the major objective(s) of the study; Data that the IDMC potentially generates will 
not be presented prior to the release of mainline results. Recommendations as to the timing of 
presentation of such endpoint data and the meetings at which they might be presented will be 
given by the Publications Committee. Data will be presented as original papers in key journals. 
Prior to study commencement, the main and co-applicants will contact different high impact 
journals (JAMA, Lancet, NEJM) to explore their interest, if they would consider to publish the 
original key paper once the study is completed and the main publication is finalized. They will be 
granted access to the protocol after signing a confidentiality agreement in case they want to 
have some adaptions.  
Once the study has commenced, a trials methodology paper will be submitted. Once the 
recruitment phase has been completed, the demographic data and patient characteristic will be 
published. Papers will be published alongside the formulated hypothesis. A key responsible 
researcher will be appointed to drive the data analysis and writing of the paper. The senior 
researcher is responsible for the establishment of an optimal team of experts to address the key 
research questions. Each paper or abstract must be submitted to the appropriate Publications 
committee for review of its appropriateness and scientific merit prior to submission. The final 
approval is granted by the applicant and co-applicants (which form the publications committee). 
Study results will be presented at local, national and international conferences of the field (e.g. 
Swiss Society of Child and Adolescent annual meeting, the German Society of Child and 
Adolescent Psychiatry annual meeting, APA, ECNP, IEPA and other conferences).  
 
Reproducibility 
No later than 5 years after the collection of the 36-week post-randomisation interviews, we will 
deliver a completely de-identified data set to an appropriate data archives for sharing purposes. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 97 of 108   
15 FUNDING AND SUPPORT  
 
15.1 Funding  
This study is financed by the Swiss National Science Foundation SNSF (Nr. 33IC30-166826).  
15.2 Other Support  
The study is also supported by the University of Zurich, Department of Child and Adolescent 
Psychiatry (Prof. S. Walitza). 
16 INSURANCE 
Insurance is covered by “Haftpflichtversicherung für den Kanton Zürich betreffend das 
UniversitätsSpital Zürich“ (Policy no.: 14.970.885). 
Any damage developed in relation to study participation is covered by this insurance. So as not 
to forfeit their insurance cover, the participants themselves must strictly follow the instructions of 
the study personnel. Participants must not be involved in any other medical treatment without 
permission of the principal investigator (emergency excluded). Medical emergency treatment 
must be reported immediately to the investigator. The investigator must also be informed 
instantly, in the event of health problems or other damages during or after the course of study 
treatment. 
The investigator will allow delegates of the insurance company to have access to the source 
data/documents as necessary to clarify a case of damage related to study participation. All 
involved parties will keep the patient data strictly confidential. 
A copy of the insurance certificate will be placed in the Investigator’s Site File. 
 
 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 98 of 108   
17 REFERENCES 
1. 
Uher, R., et al., Major depressive disorder in DSM-5: implications for clinical practice and 
research of changes from DSM-IV. Depress Anxiety, 2014. 31(6): p. 459-71. 
2. 
Kovacs, M., et al., Depressive disorders in childhood. I. A longitudinal prospective study of 
characteristics and recovery. Arch Gen Psychiatry, 1984. 41(3): p. 229-37. 
3. 
Kovacs, M., Presentation and course of major depressive disorder during childhood and later 
years of the life span. J Am Acad Child Adolesc Psychiatry, 1996. 35(6): p. 705-15. 
4. 
Birmaher, B., et al., Clinical presentation and course of depression in youth: does onset in 
childhood differ from onset in adolescence? J Am Acad Child Adolesc Psychiatry, 2004. 43(1): p. 
63-70. 
5. 
Schuler, D., et al., Gesundheit im Kanton Zürich. Kurzfassung: Ergebnisse der Schweizerischen 
Gesundheitsbefragung 2012., in Institut für Sozial- und Präventivmedizin der Universität Zürich 
2014: Zürich. 
6. 
Steinhausen, H.C., Developmental psychopathology in adolescence: findings from a Swiss study-
-the NAPE Lecture 2005. Acta Psychiatr Scand, 2006. 113(1): p. 6-12. 
7. 
Kessler, R.C., et al., Age of onset of mental disorders: a review of recent literature. Curr Opin 
Psychiatry, 2007. 20(4): p. 359-64. 
8. 
Scott, E.G., et al., Screening for adolescent depression in a pediatric emergency department. 
Acad Emerg Med, 2006. 13(5): p. 537-42. 
9. 
Ghio, L., et al., Duration of untreated illness and outcomes in unipolar depression: a systematic 
review and meta-analysis. J Affect Disord, 2014. 152-154: p. 45-51. 
10. 
Gore, F.M., et al., Global burden of disease in young people aged 10-24 years: a systematic 
analysis. Lancet, 2011. 377(9783): p. 2093-102. 
11. 
Lewinsohn, P.M., et al., Natural course of adolescent major depressive disorder in a community 
sample: predictors of recurrence in young adults. Am J Psychiatry, 2000. 157(10): p. 1584-91. 
12. 
Korczak, D.J. and B.I. Goldstein, Childhood onset major depressive disorder: course of illness 
and psychiatric comorbidity in a community sample. J Pediatr, 2009. 155(1): p. 118-23. 
13. 
Weissman, M.M., et al., Depressed adolescents grown up. JAMA, 1999. 281(18): p. 1707-13. 
14. 
Ferrari, A.J., et al., The burden attributable to mental and substance use disorders as risk factors 
for suicide: findings from the Global Burden of Disease Study 2010. PLoS One, 2014. 9(4): p. 
e91936. 
15. 
Richardson, L.P., et al., Collaborative care for adolescents with depression in primary care: a 
randomized clinical trial. JAMA, 2014. 312(8): p. 809-16. 
16. 
Cox, G.R., et al., Psychological therapies versus antidepressant medication, alone and in 
combination for depression in children and adolescents. Cochrane Database Syst Rev, 2012. 11: 
p. CD008324. 
17. 
Hetrick, S.E., et al., Newer generation antidepressants for depressive disorders in children and 
adolescents. Cochrane Database Syst Rev, 2012. 11: p. CD004851. 
18. 
Cox, G.R., et al., Interventions for preventing relapse and recurrence of a depressive disorder in 
children and adolescents. Cochrane Database Syst Rev, 2012. 11: p. CD007504. 
19. 
Newman, T.B., A black-box warning for antidepressants in children? N Engl J Med, 2004. 
351(16): p. 1595-8. 
20. 
Ho, D., Antidepressants and the FDA's black-box warning: determining a rational public policy in 
the absence of sufficient evidence. Virtual Mentor, 2012. 14(6): p. 483-8. 
21. 
Hawton, K., K.E. Saunders, and R.C. O'Connor, Self-harm and suicide in adolescents. Lancet, 
2012. 379(9834): p. 2373-82. 
22. 
Barry, C.L. and S.H. Busch, News coverage of FDA warnings on pediatric antidepressant use 
and suicidality. Pediatrics, 2010. 125(1): p. 88-95. 
23. 
Hernandez, J.F., et al., A 10-year analysis of the effects of media coverage of regulatory 
warnings on antidepressant use in The Netherlands and UK. PLoS One, 2012. 7(9): p. e45515. 
24. 
Olfson, M., S.C. Marcus, and B.G. Druss, Effects of Food and Drug Administration warnings on 
antidepressant use in a national sample. Arch Gen Psychiatry, 2008. 65(1): p. 94-101. 
25. 
Doshi, P., EFPIA-PhRMA's principles for clinical trial data sharing have been misunderstood. 
BMJ, 2013. 347: p. f5164. 
26. 
Doshi, P., No correction, no retraction, no apology, no comment: paroxetine trial reanalysis raises 
questions about institutional responsibility. BMJ, 2015. 351: p. h4629. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 99 of 108   
27. 
Le Noury, J., et al., Restoring Study 329: efficacy and harms of paroxetine and imipramine in 
treatment of major depression in adolescence. BMJ, 2015. 351: p. h4320. 
28. 
Gibbons, R.D., et al., Early evidence on the effects of regulators' suicidality warnings on SSRI 
prescriptions and suicide in children and adolescents. Am J Psychiatry, 2007. 164(9): p. 1356-63. 
29. 
Gibbons, R.D., et al., Suicidal thoughts and behavior with antidepressant treatment: reanalysis of 
the randomized placebo-controlled studies of fluoxetine and venlafaxine. Arch Gen Psychiatry, 
2012. 69(6): p. 580-7. 
30. 
Berger, G.E., A. Della Casa, and D. Pauli, Suizidalität bei Adoleszenten – Prävention und 
Behandlung. Therapeutische Rundschau, 2015. 72(10): p. 619-632. 
31. 
Lu, C.Y., et al., Changes in antidepressant use by young people and suicidal behavior after FDA 
warnings and media coverage: quasi-experimental study. BMJ, 2014. 348: p. g3596. 
32. 
Beardslee, W.R., et al., Prevention of depression in at-risk adolescents: longer-term effects. 
JAMA Psychiatry, 2013. 70(11): p. 1161-70. 
33. 
Garber, J., et al., Prevention of depression in at-risk adolescents: a randomized controlled trial. 
JAMA, 2009. 301(21): p. 2215-24. 
34. 
Dolle, K. and G. Schulte-Korne, The treatment of depressive disorders in children and 
adolescents. Dtsch Arztebl Int, 2013. 110(50): p. 854-60. 
35. 
Volkers, A.C., E.R. Heerdink, and L. van Dijk, Antidepressant use and off-label prescribing in 
children and adolescents in Dutch general practice (2001-2005). Pharmacoepidemiol Drug Saf, 
2007. 16(9): p. 1054-62. 
36. 
Rushton, J.L., S.J. Clark, and G.L. Freed, Pediatrician and family physician prescription of 
selective serotonin reuptake inhibitors. Pediatrics, 2000. 105(6): p. E82. 
37. 
Simopoulos, A.P., Evolutionary aspects of diet: the omega-6/omega-3 ratio and the brain. Mol 
Neurobiol, 2011. 44(2): p. 203-15. 
38. 
Simopoulos, A.P., Omega-3 fatty acids in health and disease and in growth and development. 
Am J Clin Nutr, 1991. 54(3): p. 438-63. 
39. 
Simopoulos, A.P., Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll 
Nutr, 2002. 21(6): p. 495-505. 
40. 
Bountziouka, V., et al., Long-term fish intake is associated with less severe depressive symptoms 
among elderly men and women: the MEDIS (MEDiterranean ISlands Elderly) epidemiological 
study. J Aging Health, 2009. 21(6): p. 864-80. 
41. 
Tanskanen, A., et al., Fish consumption, depression, and suicidality in a general population. 
Archives of General Psychiatry, 2001. 58(5): p. 512-3. 
42. 
Timonen, M., et al., Fish consumption and depression: the Northern Finland 1966 birth cohort 
study. J Affect Disord, 2004. 82(3): p. 447-52. 
43. 
Suominen-Taipale, A.L., et al., Fish consumption and omega-3 polyunsaturated fatty acids in 
relation to depressive episodes: a cross-sectional analysis. PLoS One, 2010. 5(5): p. e10530. 
44. 
Appleton, K.M., et al., Depressed mood and dietary fish intake: direct relationship or indirect 
relationship as a result of diet and lifestyle? J Affect Disord, 2007. 104(1-3): p. 217-23. 
45. 
Murakami, K., et al., Fish and n-3 polyunsaturated fatty acid intake and depressive symptoms: 
Ryukyus Child Health Study. Pediatrics, 2010. 126(3): p. e623-30. 
46. 
Li, Y., et al., Fish consumption and severely depressed mood, findings from the first national 
nutrition follow-up study. Psychiatry Res, 2011. 190(1): p. 103-9. 
47. 
Sanchez-Villegas, A., et al., Long chain omega-3 fatty acids intake, fish consumption and mental 
disorders in the SUN cohort study. Eur J Nutr, 2007. 46(6): p. 337-46. 
48. 
Astorg, P., et al., Association of fish and long-chain n-3 polyunsaturated fatty acid intakes with the 
occurrence of depressive episodes in middle-aged French men and women. Prostaglandins 
Leukot Essent Fatty Acids, 2008. 78(3): p. 171-82. 
49. 
Hibbeln, J.R., Fish consumption and major depression. Lancet, 1998. 351(9110): p. 1213. 
50. 
Noaghiul, S. and J.R. Hibbeln, Cross-national comparisons of seafood consumption and rates of 
bipolar disorders. Am J Psychiatry, 2003. 160(12): p. 2222-7. 
51. 
Li, F., X. Liu, and D. Zhang, Fish consumption and risk of depression: a meta-analysis. J 
Epidemiol Community Health, 2015. 
52. 
Huan, M., et al., Suicide attempt and n-3 fatty acid levels in red blood cells: a case control study 
in China. Biol Psychiatry, 2004. 56(7): p. 490-6. 
53. 
Sublette, M.E., et al., Omega-3 polyunsaturated essential fatty acid status as a predictor of future 
suicide risk. Am J Psychiatry, 2006. 163(6): p. 1100-2. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 100 of 108   
54. 
Lin, P.Y., S.Y. Huang, and K.P. Su, A meta-analytic review of polyunsaturated fatty acid 
compositions in patients with depression. Biol Psychiatry, 2010. 68(2): p. 140-7. 
55. 
De Vriese, S.R., A.B. Christophe, and M. Maes, Lowered serum n-3 polyunsaturated fatty acid 
(PUFA) levels predict the occurrence of postpartum depression: further evidence that lowered n-
PUFAs are related to major depression. Life Sci, 2003. 73(25): p. 3181-7. 
56. 
Green, P., et al., Red cell membrane omega-3 fatty acids are decreased in nondepressed 
patients with social anxiety disorder. Eur Neuropsychopharmacol, 2006. 16(2): p. 107-13. 
57. 
Adams, P.B., et al., Arachidonic acid to eicosapentaenoic acid ratio in blood correlates positively 
with clinical symptoms of depression. Lipids, 1996. 31 Suppl: p. S157-61. 
58. 
Maes, M., et al., Fatty acid composition in major depression: decreased omega 3 fractions in 
cholesteryl esters and increased C20: 4 omega 6/C20:5 omega 3 ratio in cholesteryl esters and 
phospholipids. J Affect Disord, 1996. 38(1): p. 35-46. 
59. 
Edwards, R., et al., Omega-3 polyunsaturated fatty acid levels in the diet and in red blood cell 
membranes of depressed patients. Journal of Affective Disorders, 1998. 48(2-3): p. 149-55. 
60. 
Frasure-Smith, N., F. Lesperance, and P. Julien, Major depression is associated with lower 
omega-3 fatty acid levels in patients with recent acute coronary syndromes. Biol Psychiatry, 
2004. 55(9): p. 891-6. 
61. 
Pottala, J.V., et al., Red blood cell fatty acids are associated with depression in a case-control 
study of adolescents. Prostaglandins Leukot Essent Fatty Acids, 2012. 86(4-5): p. 161-5. 
62. 
Young, J.J., D. Bruno, and N. Pomara, A review of the relationship between proinflammatory 
cytokines and major depressive disorder. J Affect Disord, 2014. 169: p. 15-20. 
63. 
Rapaport, M.H., et al., Inflammation as a predictive biomarker for response to omega-3 fatty 
acids in major depressive disorder: a proof-of-concept study. Mol Psychiatry, 2015. 
64. 
De Caterina, R., n-3 Fatty Acids in Cardiovascular Disease REPLY. New England Journal of 
Medicine, 2011. 365(12): p. 1159-1159. 
65. 
Mozaffarian, D. and J.H.Y. Wu, Omega-3 Fatty Acids and Cardiovascular Disease Effects on 
Risk Factors, Molecular Pathways, and Clinical Events. Journal of the American College of 
Cardiology, 2011. 58(20): p. 2047-2067. 
66. 
Grosso, G., et al., Omega-3 fatty acids and depression: scientific evidence and biological 
mechanisms. Oxid Med Cell Longev, 2014. 2014: p. 313570. 
67. 
Gold, P.W., The organization of the stress system and its dysregulation in depressive illness. Mol 
Psychiatry, 2015. 20(1): p. 32-47. 
68. 
El-Ansary, A.K., S.K. Al-Daihan, and A.R. El-Gezeery, On the protective effect of omega-3 
against propionic acid-induced neurotoxicity in rat pups. Lipids Health Dis, 2011. 10: p. 142. 
69. 
Song, C., et al., Omega-3 fatty acid ethyl-eicosapentaenoate attenuates IL-1beta-induced 
changes in dopamine and metabolites in the shell of the nucleus accumbens: involved with PLA2 
activity and corticosterone secretion. Neuropsychopharmacology, 2007. 32(3): p. 736-44. 
70. 
Goshen, I., et al., Brain interleukin-1 mediates chronic stress-induced depression in mice via 
adrenocortical activation and hippocampal neurogenesis suppression. Mol Psychiatry, 2008. 
13(7): p. 717-28. 
71. 
Larrieu, T., et al., Nutritional omega-3 modulates neuronal morphology in the prefrontal cortex 
along with depression-related behaviour through corticosterone secretion. Transl Psychiatry, 
2014. 4: p. e437. 
72. 
Mocking, R.J., et al., Relationship between the hypothalamic-pituitary-adrenal-axis and fatty acid 
metabolism in recurrent depression. Psychoneuroendocrinology, 2013. 38(9): p. 1607-17. 
73. 
Assies, J., et al., Effects of oxidative stress on fatty acid- and one-carbon-metabolism in 
psychiatric and cardiovascular disease comorbidity. Acta Psychiatr Scand, 2014. 130(3): p. 163-
80. 
74. 
Mocking, R.J., et al., Fatty acid metabolism and its longitudinal relationship with the 
hypothalamic-pituitary-adrenal axis in major depression: Associations with prospective 
antidepressant response. Psychoneuroendocrinology, 2015. 59: p. 1-13. 
75. 
Lyons, D.M., Stress, depression, and inherited variation in primate hippocampal and prefrontal 
brain development. Psychopharmacol Bull, 2002. 36(1): p. 27-43. 
76. 
McNamara, R.K., J.J. Vannest, and C.J. Valentine, Role of perinatal long-chain omega-3 fatty 
acids in cortical circuit maturation: Mechanisms and implications for psychopathology. World J 
Psychiatry, 2015. 5(1): p. 15-34. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 101 of 108   
77. 
McNamara, R.K. and S.E. Carlson, Role of omega-3 fatty acids in brain development and 
function: potential implications for the pathogenesis and prevention of psychopathology. 
Prostaglandins Leukot Essent Fatty Acids, 2006. 75(4-5): p. 329-49. 
78. 
Bourre, J.M., Roles of unsaturated fatty acids (especially omega-3 fatty acids) in the brain at 
various ages and during ageing. J Nutr Health Aging, 2004. 8(3): p. 163-74. 
79. 
Janssen, C.I. and A.J. Kiliaan, Long-chain polyunsaturated fatty acids (LCPUFA) from genesis to 
senescence: The influence of LCPUFA on neural development, aging, and neurodegeneration. 
Prog Lipid Res, 2013. 53C: p. 1-17. 
80. 
Pudell, C., et al., Fish oil improves anxiety-like, depressive-like and cognitive behaviors in 
olfactory bulbectomised rats. Eur J Neurosci, 2014. 39(2): p. 266-74. 
81. 
Peters, B.D., et al., Brain white matter development is associated with a human-specific 
haplotype increasing the synthesis of long chain fatty acids. J Neurosci, 2014. 34(18): p. 6367-76. 
82. 
Bremner, J.D., et al., Hippocampal volume reduction in major depression. Am J Psychiatry, 2000. 
157(1): p. 115-8. 
83. 
Song, C. and H. Wang, Cytokines mediated inflammation and decreased neurogenesis in animal 
models of depression. Prog Neuropsychopharmacol Biol Psychiatry, 2011. 35(3): p. 760-8. 
84. 
Song, C., X.Y. Zhang, and M. Manku, Increased phospholipase A2 activity and inflammatory 
response but decreased nerve growth factor expression in the olfactory bulbectomized rat model 
of depression: effects of chronic ethyl-eicosapentaenoate treatment. J Neurosci, 2009. 29(1): p. 
14-22. 
85. 
Carlezon, W.A., Jr., et al., Antidepressant-like effects of uridine and omega-3 fatty acids are 
potentiated by combined treatment in rats. Biol Psychiatry, 2005. 57(4): p. 343-50. 
86. 
Huang, S.Y., et al., Omega-3 fatty acids on the forced-swimming test. J Psychiatr Res, 2008. 
42(1): p. 58-63. 
87. 
Bartl, J., S. Walitza, and E. Grunblatt, Enhancement of cell viability after treatment with 
polyunsaturated fatty acids. Neurosci Lett, 2014. 559: p. 56-60. 
88. 
Delion, S., et al., alpha-Linolenic acid dietary deficiency alters age-related changes of 
dopaminergic and serotoninergic neurotransmission in the rat frontal cortex. J Neurochem, 1996. 
66(4): p. 1582-91. 
89. 
Delion, S., et al., Age-related changes in phospholipid fatty acid composition and monoaminergic 
neurotransmission in the hippocampus of rats fed a balanced or an n-3 polyunsaturated fatty 
acid-deficient diet. J Lipid Res, 1997. 38(4): p. 680-9. 
90. 
Zimmer, L., et al., Modification of dopamine neurotransmission in the nucleus accumbens of rats 
deficient in n-3 polyunsaturated fatty acids. J Lipid Res, 2000. 41(1): p. 32-40. 
91. 
Yao, J.K., et al., Effects of omega-3 fatty acid on platelet serotonin responsivity in patients with 
schizophrenia. Prostaglandins Leukot Essent Fatty Acids, 2004. 71(3): p. 171-6. 
92. 
Song, C. and D. Horrobin, Omega-3 fatty acid ethyl-eicosapentaenoate, but not soybean oil, 
attenuates memory impairment induced by central IL-1beta administration. J Lipid Res, 2004. 
45(6): p. 1112-21. 
93. 
Chalon, S., Omega-3 fatty acids and monoamine neurotransmission. Prostaglandins Leukot 
Essent Fatty Acids, 2006. 75(4-5): p. 259-69. 
94. 
McNamara, R.K., et al., Omega-3 fatty acid deficiency during perinatal development increases 
serotonin turnover in the prefrontal cortex and decreases midbrain tryptophan hydroxylase-2 
expression in adult female rats: dissociation from estrogenic effects. J Psychiatr Res, 2009. 
43(6): p. 656-63. 
95. 
Hibbeln, J.R., et al., Essential fatty acids predict metabolites of serotonin and dopamine in 
cerebrospinal fluid among healthy control subjects, and early- and late-onset alcoholics. Biol 
Psychiatry, 1998. 44(4): p. 235-42. 
96. 
Hibbeln, J.R., et al., A replication study of violent and nonviolent subjects: cerebrospinal fluid 
metabolites of serotonin and dopamine are predicted by plasma essential fatty acids. Biol 
Psychiatry, 1998. 44(4): p. 243-9. 
97. 
Leonard, B. and M. Maes, Mechanistic explanations how cell-mediated immune activation, 
inflammation and oxidative and nitrosative stress pathways and their sequels and concomitants 
play a role in the pathophysiology of unipolar depression. Neurosci Biobehav Rev, 2012. 36(2): p. 
764-85. 
98. 
Lotrich, F.E., Inflammatory cytokine-associated depression. Brain Res, 2015. 1617: p. 113-25. 
99. 
Rosenblat, J.D., et al., Inflamed moods: a review of the interactions between inflammation and 
mood disorders. Prog Neuropsychopharmacol Biol Psychiatry, 2014. 53: p. 23-34. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 102 of 108   
100. 
Serhan, C.N., Pro-resolving lipid mediators are leads for resolution physiology. Nature, 2014. 
510(7503): p. 92-101. 
101. 
Freeman, M.P. and M.H. Rapaport, Omega-3 fatty acids and depression: from cellular 
mechanisms to clinical care. J Clin Psychiatry, 2011. 72(2): p. 258-9. 
102. 
Maes, M., et al., Why fish oils may not always be adequate treatments for depression or other 
inflammatory illnesses: docosahexaenoic acid, an omega-3 polyunsaturated fatty acid, induces a 
Th-1-like immune response. Neuro Endocrinol Lett, 2007. 28(6): p. 875-80. 
103. 
Muller, N., A.M. Myint, and M.J. Schwarz, The impact of neuroimmune dysregulation on 
neuroprotection and neurotoxicity in psychiatric disorders--relation to drug treatment. Dialogues 
Clin Neurosci, 2009. 11(3): p. 319-32. 
104. 
Berger, G.E., et al., Ethyl-Eicosapentaenoic Acid in First-Episode Psychosis. A 1H-MRS Study. 
Neuropsychopharmacology, 2008. 
105. 
Duffy, S.L., et al., The effect of 12-wk omega-3 fatty acid supplementation on in vivo thalamus 
glutathione concentration in patients "at risk" for major depression. Nutrition, 2015. 31(10): p. 
1247-54. 
106. 
Smesny, S., et al., Effects of omega-3 PUFA on the vitamin E and glutathione antioxidant 
defense system in individuals at ultra-high risk of psychosis. Prostaglandins Leukot Essent Fatty 
Acids, 2015. 101: p. 15-21. 
107. 
Said, T., et al., Effects of vegetable oils on biochemical and biophysical properties of membrane 
retinal pigment epithelium cells. Can J Physiol Pharmacol, 2013. 91(10): p. 812-7. 
108. 
Onuki, Y., et al., Docosahexaenoic acid and eicosapentaenoic acid induce changes in the 
physical properties of a lipid bilayer model membrane. Chem Pharm Bull (Tokyo), 2006. 54(1): p. 
68-71. 
109. 
Wood, S.J., et al., Neuroprotective effects of ethyl-eicosapentaenoic acid in first episode 
psychosis: a longitudinal T2 relaxometry pilot study. Psychiatry Res, 2010. 182(2): p. 180-2. 
110. 
Peet, M. and D.F. Horrobin, A dose-ranging study of the effects of ethyl-eicosapentaenoate in 
patients with ongoing depression despite apparently adequate treatment with standard drugs. 
Arch Gen Psych, 2002. 59(10): p. 913-9. 
111. 
Nemets, B., Z. Stahl, and R.H. Belmaker, Addition of omega-3 fatty acid to maintenance 
medication treatment for recurrent unipolar depressive disorder. Am J Psychiatry, 2002. 159(3): 
p. 477-9. 
112. 
Marangell, L.B., et al., A double-blind, placebo-controlled study of the omega-3 fatty acid 
docosahexaenoic acid in the treatment of major depression. Am J Psychiatry, 2003. 160(5): p. 
996-8. 
113. 
Su, K.P., et al., Omega-3 fatty acids in major depressive disorder. A preliminary double-blind, 
placebo-controlled trial. Eur Neuropsychopharmacol, 2003. 13(4): p. 267-71. 
114. 
Silvers, K.M., et al., Randomised double-blind placebo-controlled trial of fish oil in the treatment of 
depression. Prostaglandins Leukot Essent Fatty Acids, 2005. 72(3): p. 211-8. 
115. 
Grenyer, B.F., et al., Fish oil supplementation in the treatment of major depression: a randomised 
double-blind placebo-controlled trial. Prog Neuropsychopharmacol Biol Psychiatry, 2007. 31(7): 
p. 1393-6. 
116. 
Jazayeri, S., et al., Comparison of therapeutic effects of omega-3 fatty acid eicosapentaenoic 
acid and fluoxetine, separately and in combination, in major depressive disorder. Aust N Z J 
Psychiatry, 2008. 42(3): p. 192-8. 
117. 
Mischoulon, D., et al., A double-blind, randomized controlled trial of ethyl-eicosapentaenoate for 
major depressive disorder. J Clin Psychiatry, 2009. 70(12): p. 1636-44. 
118. 
Rondanelli, M., et al., Effect of omega-3 fatty acids supplementation on depressive symptoms 
and on health-related quality of life in the treatment of elderly women with depression: a double-
blind, placebo-controlled, randomized clinical trial. J Am Coll Nutr, 2010. 29(1): p. 55-64. 
119. 
Rondanelli, M., et al., Long chain omega 3 polyunsaturated fatty acids supplementation in the 
treatment of elderly depression: effects on depressive symptoms, on phospholipids fatty acids 
profile and on health-related quality of life. J Nutr Health Aging, 2011. 15(1): p. 37-44. 
120. 
Lesperance, F., et al., The efficacy of omega-3 supplementation for major depression: a 
randomized controlled trial. J Clin Psychiatry, 2011. 72(8): p. 1054-62. 
121. 
Sinn, N., et al., Effects of n-3 fatty acids, EPA v. DHA, on depressive symptoms, quality of life, 
memory and executive function in older adults with mild cognitive impairment: a 6-month 
randomised controlled trial. Br J Nutr, 2012. 107(11): p. 1682-93. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 103 of 108   
122. 
Gertsik, L., et al., Omega-3 fatty acid augmentation of citalopram treatment for patients with 
major depressive disorder. J Clin Psychopharmacol, 2012. 32(1): p. 61-4. 
123. 
Rizzo, A.M., et al., Comparison between the AA/EPA ratio in depressed and non depressed 
elderly females: omega-3 fatty acid supplementation correlates with improved symptoms but 
does not change immunological parameters. Nutr J, 2012. 11: p. 82. 
124. 
Stoll, A.L., et al., Omega 3 fatty acids in bipolar disorder: a preliminary double-blind, placebo-
controlled trial [see comments]. Arch Gen Psych, 1999. 56(5): p. 407-12. 
125. 
Hirashima, F., et al., Omega-3 fatty acid treatment and T(2) whole brain relaxation times in 
bipolar disorder. Am J Psychiatry, 2004. 161(10): p. 1922-4. 
126. 
Chiu, C.C., et al., Omega-3 fatty acids are more beneficial in the depressive phase than in the 
manic phase in patients with bipolar I disorder. J Clin Psychiatry, 2005. 66(12): p. 1613-4. 
127. 
Frangou, S., M. Lewis, and P. McCrone, Efficacy of ethyl-eicosapentaenoic acid in bipolar 
depression: randomised double-blind placebo-controlled study. Br J Psychiatry, 2006. 188: p. 46-
50. 
128. 
Keck, P.E., Jr., et al., Double-blind, randomized, placebo-controlled trials of ethyl-
eicosapentanoate in the treatment of bipolar depression and rapid cycling bipolar disorder. Biol 
Psychiatry, 2006. 60(9): p. 1020-2. 
129. 
Frangou, S., et al., Preliminary in vivo evidence of increased N-acetyl-aspartate following 
eicosapentanoic acid treatment in patients with bipolar disorder. J Psychopharmacol, 2007. 21(4): 
p. 435-9. 
130. 
Murphy, B.L., et al., Omega-3 fatty acid treatment, with or without cytidine, fails to show 
therapeutic properties in bipolar disorder: a double-blind, randomized add-on clinical trial. J Clin 
Psychopharmacol, 2012. 32(5): p. 699-703. 
131. 
Freeman, M.P., et al., Omega-3 fatty acids and supportive psychotherapy for perinatal 
depression: a randomized placebo-controlled study. J Affect Disord, 2008. 110(1-2): p. 142-8. 
132. 
Breland, D.J. and M.J. Park, Depression: focus on the adolescent male. Am J Mens Health, 
2008. 2(1): p. 87-93. 
133. 
Rees, A.M., M.P. Austin, and G.B. Parker, Omega-3 fatty acids as a treatment for perinatal 
depression: randomized double-blind placebo-controlled trial. Aust N Z J Psychiatry, 2008. 42(3): 
p. 199-205. 
134. 
Rogers, P.J., et al., No effect of n-3 long-chain polyunsaturated fatty acid (EPA and DHA) 
supplementation on depressed mood and cognitive function: a randomised controlled trial. Br J 
Nutr, 2008. 99(2): p. 421-31. 
135. 
Lucas, M., et al., Ethyl-eicosapentaenoic acid for the treatment of psychological distress and 
depressive symptoms in middle-aged women: a double-blind, placebo-controlled, randomized 
clinical trial. Am J Clin Nutr, 2009. 89(2): p. 641-51. 
136. 
Tajalizadekhoob, Y., et al., The effect of low-dose omega 3 fatty acids on the treatment of mild to 
moderate depression in the elderly: a double-blind, randomized, placebo-controlled study. Eur 
Arch Psychiatry Clin Neurosci, 2011. 261(8): p. 539-49. 
137. 
Antypa, N., et al., Effects of omega-3 fatty acid supplementation on mood and emotional 
information processing in recovered depressed individuals. J Psychopharmacol, 2012. 26(5): p. 
738-43. 
138. 
Mozaffari-Khosravi, H., et al., Eicosapentaenoic acid versus docosahexaenoic acid in mild-to-
moderate 
depression: 
a 
randomized, 
double-blind, 
placebo-controlled 
trial. 
Eur 
Neuropsychopharmacol, 2013. 23(7): p. 636-44. 
139. 
Sohrabi, N., et al., Evaluation of the effect of omega-3 fatty acids in the treatment of premenstrual 
syndrome: "a pilot trial". Complement Ther Med, 2013. 21(3): p. 141-6. 
140. 
Behan, P.O., W.M. Behan, and D.F. Horrobin, Effect of high doses of essential fatty acids on the 
postviral fatigue syndrome. Acta Neurol Scand, 1990. 82(3): p. 209-16. 
141. 
Warren, G., M. McKendrick, and M. Peet, The role of essential fatty acids in chronic fatigue 
syndrome. A case-controlled study of red-cell membrane essential fatty acids (EFA) and a 
placebo-controlled treatment study with high dose of EFA. Acta Neurologica Scandinavica, 1999. 
99(2): p. 112-6. 
142. 
Zanarini, M.C. and F.R. Frankenburg, omega-3 Fatty acid treatment of women with borderline 
personality disorder: a double-blind, placebo-controlled pilot study. Am J Psychiatry, 2003. 
160(1): p. 167-9. 
143. 
Fux, M., J. Benjamin, and B. Nemets, A placebo-controlled cross-over trial of adjunctive EPA in 
OCD. J Psychiatr Res, 2004. 38(3): p. 323-5. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 104 of 108   
144. 
Hallahan, B., et al., Omega-3 fatty acid supplementation in patients with recurrent self-harm. 
Single-centre double-blind randomised controlled trial. Br J Psychiatry, 2007. 190: p. 118-22. 
145. 
Fenton, W.S., et al., A placebo-controlled trial of omega-3 fatty acid (ethyl eicosapentaenoic acid) 
supplementation for residual symptoms and cognitive impairment in schizophrenia. Am J 
Psychiatry, 2001. 158(12): p. 2071-4. 
146. 
Chiu, C.C., et al., The effects of omega-3 fatty acids monotherapy in Alzheimer's disease and 
mild cognitive impairment: a preliminary randomized double-blind placebo-controlled study. Prog 
Neuropsychopharmacol Biol Psychiatry, 2008. 32(6): p. 1538-44. 
147. 
Freund-Levi, Y., et al., Omega-3 supplementation in mild to moderate Alzheimer's disease: 
effects on neuropsychiatric symptoms. Int J Geriatr Psychiatry, 2008. 23(2): p. 161-9. 
148. 
da Silva, T.M., et al., Depression in Parkinson's disease: a double-blind, randomized, placebo-
controlled pilot study of omega-3 fatty-acid supplementation. J Affect Disord, 2008. 111(2-3): p. 
351-9. 
149. 
Carney, R.M., et al., Omega-3 augmentation of sertraline in treatment of depression in patients 
with coronary heart disease: a randomized controlled trial. JAMA, 2009. 302(15): p. 1651-7. 
150. 
Bot, M., et al., Eicosapentaenoic acid as an add-on to antidepressant medication for co-morbid 
major depression in patients with diabetes mellitus: a randomized, double-blind placebo-
controlled study. J Affect Disord, 2010. 126(1-2): p. 282-6. 
151. 
Giltay, E.J., J.M. Geleijnse, and D. Kromhout, Effects of n-3 fatty acids on depressive symptoms 
and dispositional optimism after myocardial infarction. Am J Clin Nutr, 2011. 94(6): p. 1442-50. 
152. 
Bot, M., et al., Supplementation with eicosapentaenoic omega-3 fatty acid does not influence 
serum brain-derived neurotrophic factor in diabetes mellitus patients with major depression: a 
randomized controlled pilot study. Neuropsychobiology, 2011. 63(4): p. 219-23. 
153. 
Andreeva, V.A., et al., Supplementation with B vitamins or n-3 fatty acids and depressive 
symptoms in cardiovascular disease survivors: ancillary findings from the SUpplementation with 
FOLate, vitamins B-6 and B-12 and/or OMega-3 fatty acids (SU.FOL.OM3) randomized trial. Am 
J Clin Nutr, 2012. 96(1): p. 208-14. 
154. 
Fontani, G., et al., Cognitive and physiological effects of Omega-3 polyunsaturated fatty acid 
supplementation in healthy subjects. Eur J Clin Invest, 2005. 35(11): p. 691-9. 
155. 
van de Rest, O., et al., Effect of fish-oil supplementation on mental well-being in older subjects: a 
randomized, double-blind, placebo-controlled trial. Am J Clin Nutr, 2008. 88(3): p. 706-13. 
156. 
Antypa, N., et al., Omega-3 fatty acids (fish-oil) and depression-related cognition in healthy 
volunteers. J Psychopharmacol, 2009. 23(7): p. 831-40. 
157. 
Kiecolt-Glaser, J.K., et al., Omega-3 supplementation lowers inflammation and anxiety in medical 
students: a randomized controlled trial. Brain Behav Immun, 2011. 25(8): p. 1725-34. 
158. 
DeFina, L.F., et al., Effects of omega-3 supplementation in combination with diet and exercise on 
weight loss and body composition. Am J Clin Nutr, 2011. 93(2): p. 455-62. 
159. 
Kiecolt-Glaser, J.K., et al., Omega-3 supplementation lowers inflammation in healthy middle-aged 
and older adults: a randomized controlled trial. Brain Behav Immun, 2012. 26(6): p. 988-95. 
160. 
Parker, G., et al., Omega-3 fatty acids and mood disorders. Am J Psychiatry, 2006. 163(6): p. 
969-78. 
161. 
Martins, J.G., EPA but not DHA appears to be responsible for the efficacy of omega-3 long chain 
polyunsaturated fatty acid supplementation in depression: evidence from a meta-analysis of 
randomized controlled trials. J Am Coll Nutr, 2009. 28(5): p. 525-42. 
162. 
Freeman, M.P., et al., Complementary and alternative medicine in major depressive disorder: the 
American Psychiatric Association Task Force report. J Clin Psychiatry, 2010. 71(6): p. 669-81. 
163. 
Sublette, M.E., et al., Meta-analysis of the effects of eicosapentaenoic acid (EPA) in clinical trials 
in depression. J Clin Psychiatry, 2011. 72(12): p. 1577-84. 
164. 
Bloch, M.H. and J. Hannestad, Omega-3 fatty acids for the treatment of depression: systematic 
review and meta-analysis. Mol Psychiatry, 2012. 17(12): p. 1272-82. 
165. 
Lin, P.Y., et al., Are omega-3 fatty acids antidepressants or just mood-improving agents? The 
effect depends upon diagnosis, supplement preparation, and severity of depression. Mol 
Psychiatry, 2012. 17(12): p. 1161-3; author reply 1163-7. 
166. 
Grosso, G., et al., Role of omega-3 fatty acids in the treatment of depressive disorders: a 
comprehensive meta-analysis of randomized clinical trials. PLoS One, 2014. 9(5): p. e96905. 
167. 
Nemets, H., et al., Omega-3 treatment of childhood depression: a controlled, double-blind pilot 
study. Am J Psychiatry, 2006. 163(6): p. 1098-100. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 105 of 108   
168. 
Martins, J.G., H. Bentsen, and B.K. Puri, Eicosapentaenoic acid appears to be the key omega-3 
fatty acid component associated with efficacy in major depressive disorder: a critique of Bloch 
and Hannestad and updated meta-analysis. Mol Psychiatry, 2012. 17(12): p. 1144-9; discussion 
1163-7. 
169. 
Gharekhani, A., et al., The effect of omega-3 fatty acids on depressive symptoms and 
inflammatory markers in maintenance hemodialysis patients: a randomized, placebo-controlled 
clinical trial. Eur J Clin Pharmacol, 2014. 
170. 
Su, K.P., et al., Omega-3 Fatty Acids in the Prevention of Interferon-Alpha-Induced Depression: 
Results from a Randomized, Controlled Trial. Biol Psychiatry, 2014. 
171. 
Lang, U.E. and S. Borgwardt, Molecular mechanisms of depression: perspectives on new 
treatment strategies. Cell Physiol Biochem, 2013. 31(6): p. 761-77. 
172. 
Chiu, C.C., S.Y. Huang, and K.P. Su, Omega-3 polyunsaturated fatty acids for postpartum 
depression. Am J Obstet Gynecol, 2004. 190(2): p. 582-3; author reply 583. 
173. 
Chiu, C.C., et al., Omega-3 fatty acids for depression in pregnancy. Am J Psychiatry, 2003. 
160(2): p. 385. 
174. 
McNamara, R.K., et al., Lower docosahexaenoic acid concentrations in the postmortem prefrontal 
cortex of adult depressed suicide victims compared with controls without cardiovascular disease. 
J Psychiatr Res, 2013. 47(9): p. 1187-91. 
175. 
Bloch, M.H. and A. Qawasmi, Omega-3 fatty acid supplementation for the treatment of children 
with attention-deficit/hyperactivity disorder symptomatology: systematic review and meta-
analysis. J Am Acad Child Adolesc Psychiatry, 2011. 50(10): p. 991-1000. 
176. 
Sonuga-Barke, E.J., et al., Nonpharmacological interventions for ADHD: systematic review and 
meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J 
Psychiatry, 2013. 170(3): p. 275-89. 
177. 
Gillies, D., et al., Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder 
(ADHD) in children and adolescents. Cochrane Database Syst Rev, 2012. 7: p. CD007986. 
178. 
Richardson, A.J. and P. Montgomery, The Oxford-Durham study: a randomized, controlled trial of 
dietary supplementation with fatty acids in children with developmental coordination disorder. 
Pediatrics, 2005. 115(5): p. 1360-6. 
179. 
Berger, G.E., et al., Ethyl-eicosapentaenoic acid in first-episode psychosis: a randomized, 
placebo-controlled trial. J Clin Psychiatry, 2007. 68(12): p. 1867-75. 
180. 
Amminger, G.P., et al., Long-chain omega-3 fatty acids for indicated prevention of psychotic 
disorders: a randomized, placebo-controlled trial. Arch Gen Psychiatry, 2010. 67(2): p. 146-54. 
181. 
Markulev, C., et al., NEURAPRO-E study protocol: a multicentre randomized controlled trial of 
omega-3 fatty acids and cognitive-behavioural case management for patients at ultra high risk of 
schizophrenia and other psychotic disorders. Early Interv Psychiatry, 2015. 
182. 
Fusar-Poli, P. and G. Berger, Eicosapentaenoic acid interventions in schizophrenia: meta-
analysis of randomized, placebo-controlled studies. J Clin Psychopharmacol, 2012. 32(2): p. 179-
85. 
183. 
Su, K.P., W.W. Shen, and S.Y. Huang, Are omega3 fatty acids beneficial in depression but not 
mania? Arch Gen Psychiatry, 2000. 57(7): p. 716-7. 
184. 
Bellino, S., et al., Efficacy of omega-3 fatty acids in the treatment of borderline personality 
disorder: a study of the association with valproic acid. J Psychopharmacol, 2014. 28(2): p. 125-
32. 
185. 
Gesch, C.B., et al., Influence of supplementary vitamins, minerals and essential fatty acids on the 
antisocial behaviour of young adult prisoners. Randomised, placebo-controlled trial. Br J 
Psychiatry, 2002. 181: p. 22-8. 
186. 
Raine, A., et al., Reduction in behavior problems with omega-3 supplementation in children aged 
8-16 years: a randomized, double-blind, placebo-controlled, stratified, parallel-group trial. J Child 
Psychol Psychiatry, 2015. 56(5): p. 509-20. 
187. 
Rice, S.M., et al., Youth depression alleviation: the Fish Oil Youth Depression Study (YoDA-F): A 
randomized, double-blind, placebo-controlled treatment trial. Early Interv Psychiatry, 2014. 
188. 
Bridge, J.A., et al., Placebo response in randomized controlled trials of antidepressants for 
pediatric major depressive disorder. Am J Psychiatry, 2009. 166(1): p. 42-9. 
189. 
Parellada, M., et al., Placebo effect in child and adolescent psychiatric trials. Eur 
Neuropsychopharmacol, 2012. 22(11): p. 787-99. 
190. 
Schlogelhofer, M., et al., Polyunsaturated fatty acids in emerging psychosis: a safer alternative? 
Early Interv Psychiatry, 2014. 8(3): p. 199-208. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 106 of 108   
191. 
Harris, W.S., T.D. Dayspring, and T.J. Moran, Omega-3 fatty acids and cardiovascular disease: 
new developments and applications. Postgrad Med, 2013. 125(6): p. 100-13. 
192. 
Gidding, S.S., et al., A double-blind randomized trial of fish oil to lower triglycerides and improve 
cardiometabolic risk in adolescents. J Pediatr, 2014. 165(3): p. 497-503 e2. 
193. 
de Ferranti, S.D., et al., Using high-dose omega-3 fatty acid supplements to lower triglyceride 
levels in 10- to 19-year-olds. Clin Pediatr (Phila), 2014. 53(5): p. 428-38. 
194. 
Bonaccio, M., et al., Adherence to a Mediterranean diet is associated with a better health-related 
quality of life: a possible role of high dietary antioxidant content. BMJ Open, 2013. 3(8). 
195. 
Valls-Pedret, C., et al., Mediterranean Diet and Age-Related Cognitive Decline: A Randomized 
Clinical Trial. JAMA Intern Med, 2015. 175(7): p. 1094-103. 
196. 
Corrigan, P.W., et al., Challenging the public stigma of mental illness: a meta-analysis of outcome 
studies. Psychiatr Serv, 2012. 63(10): p. 963-73. 
197. 
Henderson, C., et al., Mental health-related stigma in health care and mental health-care settings. 
Lancet Psychiatry, 2014. 1(6): p. 467-82. 
198. 
Henderson, C. and G. Thornicroft, Stigma and discrimination in mental illness: Time to Change. 
Lancet, 2009. 373(9679): p. 1928-30. 
199. 
Thornicroft, G., Most people with mental illness are not treated. Lancet, 2007. 370(9590): p. 807-
8. 
200. 
Su, K.P., Y. Matsuoka, and C.U. Pae, Omega-3 Polyunsaturated Fatty Acids in Prevention of 
Mood and Anxiety Disorders. Clin Psychopharmacol Neurosci, 2015. 13(2): p. 129-37. 
201. 
Mischoulon, D., Update and critique of natural remedies as antidepressant treatments. Psychiatr 
Clin North Am, 2007. 30(1): p. 51-68. 
202. 
Simon, G.E., et al., Mental health visits to complementary and alternative medicine providers. 
Gen Hosp Psychiatry, 2004. 26(3): p. 171-7. 
203. 
Hibbeln, J.R., Seafood consumption, the DHA content of mothers' milk and prevalence rates of 
postpartum depression: a cross-national, ecological analysis. J Affect Disord, 2002. 69(1-3): p. 
15-29. 
204. 
Hibbeln, J.R., Depression, suicide and deficiencies of omega-3 essential fatty acids in modern 
diets. World Rev Nutr Diet, 2009. 99: p. 17-30. 
205. 
Kiecolt-Glaser, J.K., H.M. Derry, and C.P. Fagundes, Inflammation: Depression Fans the Flames 
and Feasts on the Heat. Am J Psychiatry, 2015: p. appiajp201515020152. 
206. 
Emslie, G.J., et al., A double-blind, randomized, placebo-controlled trial of fluoxetine in children 
and adolescents with depression. Arch Gen Psychiatry, 1997. 54(11): p. 1031-7. 
207. 
Harris, W.S., The omega-3 index: from biomarker to risk marker to risk factor. Curr Atheroscler 
Rep, 2009. 11(6): p. 411-7. 
208. 
Harris, W.S. and C. Von Schacky, The Omega-3 Index: a new risk factor for death from coronary 
heart disease? Prev Med, 2004. 39(1): p. 212-20. 
209. 
Beier, A.M., et al., Low plasma eicosapentaenoic acid levels are associated with elevated trait 
aggression and impulsivity in major depressive disorder with a history of comorbid substance use 
disorder. J Psychiatr Res, 2014. 57: p. 133-40. 
210. 
Wagner, S., et al., A meta-analysis of cognitive functions in children and adolescents with major 
depressive disorder. Eur Child Adolesc Psychiatry, 2015. 24(1): p. 5-19. 
211. 
Vilgis, V., T.J. Silk, and A. Vance, Executive function and attention in children and adolescents 
with depressive disorders: a systematic review. Eur Child Adolesc Psychiatry, 2015. 24(4): p. 
365-84. 
212. 
McIntyre, R.S., Major depressive disorder and cognitive impairment. J Psychiatry Neurosci, 2014. 
39(5): p. E36-7. 
213. 
Emslie, G.J., et al., Fluoxetine for acute treatment of depression in children and adolescents: a 
placebo-controlled, randomized clinical trial. J Am Acad Child Adolesc Psychiatry, 2002. 41(10): 
p. 1205-15. 
214. 
Emslie, G.J., N.D. Ryan, and K.D. Wagner, Major depressive disorder in children and 
adolescents: clinical trial design and antidepressant efficacy. J Clin Psychiatry, 2005. 66 Suppl 7: 
p. 14-20. 
215. 
Kovacs, M., The Emanuel Miller Memorial Lecture 1994. Depressive disorders in childhood: an 
impressionistic landscape. J Child Psychol Psychiatry, 1997. 38(3): p. 287-98. 
216. 
Ghasemifard, S., et al., What Is the Most Effective Way of Increasing the Bioavailability of Dietary 
Long Chain Omega-3 Fatty Acids--Daily vs. Weekly Administration of Fish Oil? Nutrients, 2015. 
7(7): p. 5628-45. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 107 of 108   
217. 
Poznanski, E.O., S.C. Cook, and B.J. Carroll, A depression rating scale for children. Pediatrics, 
1979. 64(4): p. 442-50. 
218. 
Keller, F., et al., [Children's Depression Rating Scale-Revised (CDRS-R): development of a 
German version and psychometric properties in a clinical sample]. Z Kinder Jugendpsychiatr 
Psychother, 2011. 39(3): p. 179-85. 
219. 
Plener, P.L., et al., Convergence of Children's Depression Rating Scale-revised Scores and 
Clinical Diagnosis in Rating Adolescent Depressive Symptomatology. Ment Illn, 2012. 4(1): p. e7. 
220. 
Kaufman, J., et al., Schedule for Affective Disorders and Schizophrenia for School-Age Children-
Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. J Am Acad Child 
Adolesc Psychiatry, 1997. 36(7): p. 980-8. 
221. 
Guy 
, 
W., 
Assessment 
Manual 
for 
Psychopharmacology 
—Revised 
1976, 
NIMH 
Psychopharmacology Research Branch, Division of Extramural Research Programs: Rockville, 
MD, U.S. . p. 218–222. 
222. 
Shaffer, D., et al., A children's global assessment scale (CGAS). Arch Gen Psychiatry, 1983. 
40(11): p. 1228-31. 
223. 
Gowers, S.G., et al., Brief scale for measuring the outcomes of emotional and behavioural 
disorders in children. Health of the Nation Outcome Scales for children and Adolescents 
(HoNOSCA). Br J Psychiatry, 1999. 174: p. 413-6. 
224. 
Stiensmeier-Pelster, J., M. Schürmann, and K. Duda, Depressions-Inventar für Kinder und 
Jugendliche (DIKJ). Handandweisung (2., überarb. und neunormierte Auflage). 2000, Göttingen: 
Hogrefe. 
225. 
Leyfer, O.T., J.L. Ruberg, and J. Woodruff-Borden, Examination of the utility of the Beck Anxiety 
Inventory and its factors as a screener for anxiety disorders. J Anxiety Disord, 2006. 20(4): p. 
444-58. 
226. 
Beck, A.T., Hopelessness as a predictor of eventual suicide. Ann N Y Acad Sci, 1986. 487: p. 90-
6. 
227. 
Beck, A.T., et al., The measurement of pessimism: the hopelessness scale. J Consult Clin 
Psychol, 1974. 42(6): p. 861-5. 
228. 
Becker, D.F. and C.M. Grilo, Prediction of suicidality and violence in hospitalized adolescents: 
comparisons by sex. Can J Psychiatry, 2007. 52(9): p. 572-80. 
229. 
Steer, R.A., G. Kumar, and A.T. Beck, Self-reported suicidal ideation in adolescent psychiatric 
inpatients. J Consult Clin Psychol, 1993. 61(6): p. 1096-9. 
230. 
Reynolds, W.M. and J.J. Mazza, Assessment of Suicidal Ideation in Inner-City Children and 
Young Adolescents: Reliability and Validity of the Suicide Ideation Questionnaire. School 
Psychology Review, 1999. 28(1): p. 17-30. 
231. 
Mazza, V.J. and W.M. Reynolds, An investigation of psychopathology in nonreferred suicidal and 
nonsuicidal adolescents. Suicide Life Threat Behav, 2001. 31(3): p. 282-302. 
232. 
Reynolds, W.M., Psychometric characteristics of the Adult Suicidal Ideation Questionnaire in 
college students. J Pers Assess, 1991. 56(2): p. 289-307. 
233. 
Gerber, M., et al., Validation of the German version of the insomnia severity index in adolescents, 
young adults and adult workers: results from three cross-sectional studies. Bmc Psychiatry, 2016. 
16. 
234. 
Bastien, C.H., A. Vallieres, and C.M. Morin, Validation of the Insomnia Severity Index as an 
outcome measure for insomnia research. Sleep Medicine, 2001. 2(4): p. 297-307. 
235. 
Cohen, S., T. Kamarck, and R. Mermelstein, A global measure of perceived stress. J Health Soc 
Behav, 1983. 24(4): p. 385-96. 
236. 
Vaishnavi, S., K. Connor, and J.R. Davidson, An abbreviated version of the Connor-Davidson 
Resilience Scale (CD-RISC), the CD-RISC2: psychometric properties and applications in 
psychopharmacological trials. Psychiatry Res, 2007. 152(2-3): p. 293-7. 
237. 
Connor, K.M. and J.R. Davidson, Development of a new resilience scale: the Connor-Davidson 
Resilience Scale (CD-RISC). Depress Anxiety, 2003. 18(2): p. 76-82. 
238. 
Schafer, J., et al., Is trait resilience characterized by specific patterns of attentional bias to 
emotional stimuli and attentional control? J Behav Ther Exp Psychiatry, 2015. 48: p. 133-9. 
239. 
Ravens-Sieberer, U., et al., The KIDSCREEN-27 quality of life measure for children and 
adolescents: psychometric results from a cross-cultural survey in 13 European countries. Qual 
Life Res, 2007. 16(8): p. 1347-56. 
240. 
Witt, O., et al., [Adult ADHD versus borderline personality disorder: criteria for differential 
diagnosis]. Fortschr Neurol Psychiatr, 2014. 82(6): p. 337-45. 

 
Omega-3-pMDD, Version 3 of 13.07.2017 
 
Page 108 of 108   
241. 
Helmstaedter, C., M. Lendt, and S. Lux, VLMT  Verbaler Lern- und Merkfähigkeitstest. 2001, 
Göttingen: Hogrefe  
242. 
Aschenbrenner, S., O. Tucha, and K.W. Lange, RWFT Regensburger Wortflüssigkeits-Test. 
2000, Göttingen: Hogrefe. 
243. 
De Sonneville, L., Amsterdam Neuropsychological Tasks (ANT). 2011, Amsterdam: Sonares. 
244. 
Wechsler, D., F. Petermann, and U. Petermann, Wechsler Intelligence Scale for Children - Fourth 
Edition. WISC-IV. 2014, Frankfurt: Pearson. 
245. 
Drechsler, R. and H.-C. Steinhausen, Verhaltensinventar zur Beurteilung exekutiver Funktionen 
BRIEF. Deutschsprachige Adaptation des Behavior Rating Inventory of Executive Function 
(BRIEF) von G. A. Gioia, P. K. Isquith, S. C. Guy und L. Kenworthy undder Self-Report Version 
(BRIEF-SR) von S. C. Guy, P. K. Isquith und G. A. Gioia. . 2013, Bern: Huber. 
246. 
Hagmann-von Arx, P. and G. A., Reynolds Intellectual Assessment Scales and Screening. 
Deutschsprachige Adaptation der Reynolds Intellectual Assessment Scales (RIAS) & des 
Reynolds Intellectual Screening Test (RIST) von Cecil R. Reynoldsund Randy W. Kamphaus. 
2014, Bern: Huber. 
247. 
Marshall, W.A. and J.M. Tanner, Variations in pattern of pubertal changes in girls. Arch Dis Child, 
1969. 44(235): p. 291-303. 
248. 
Sublette, M.E., et al., Validation of a food frequency questionnaire to assess intake of n-3 
polyunsaturated fatty acids in subjects with and without major depressive disorder. J Am Diet 
Assoc, 2011. 111(1): p. 117-123 e1-2. 
249. 
Newcombe, D.A., R.E. Humeniuk, and R. Ali, Validation of the World Health Organization 
Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): report of results from 
the Australian site. Drug Alcohol Rev, 2005. 24(3): p. 217-26. 
250. 
Uher, R., et al., Adverse reactions to antidepressants. Br J Psychiatry, 2009. 195(3): p. 202-10. 
251. 
Thompson, K., J. Kulkarni, and A.A. Sergejew, Reliability and validity of a new Medication 
Adherence Rating Scale (MARS) for the psychoses. Schizophr Res, 2000. 42(3): p. 241-7. 
252. 
Mahler, C., et al., Assessing reported adherence to pharmacological treatment recommendations. 
Translation and evaluation of the Medication Adherence Report Scale (MARS) in Germany. J 
Eval Clin Pract, 2010. 16(3): p. 574-9. 
253. 
March, J., et al., Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents 
with depression: Treatment for Adolescents With Depression Study (TADS) randomized 
controlled trial. JAMA, 2004. 292(7): p. 807-20. 
254. 
March, J., et al., The Treatment for Adolescents with Depression Study (TADS): methods and 
message at 12 weeks. J Am Acad Child Adolesc Psychiatry, 2006. 45(12): p. 1393-403. 
255. 
Rubin, D.B., Multiple imputation after 18+ years. Journal of the American Statistical Association, 
1996. 91(434): p. 473-489. 
256. 
Rubin, D.B., Multiple imputation for nonresponse in surveys. 1987, New York: John Wiley & 
Sons.