Rituximab - Immunotherapy for Schizophrenia Spectrum Disorder in Adults: An Open Pilot Study
Phase: PHASE2
Conditions: Schizophrenia Spectrum and Other Psychotic Disorders, Treatment-resistant Schizophrenia
Sponsor: Region Örebro County

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STUDY PROTOCOL 
 
 
 
 
Study Title: Rituximab - Immunotherapy for Schizophrenia spectrum disorder in adults. An 
open pilot study. 
 
Protocol Number: RITS-PS-2019 
 
EudraCT Number: 2018-004618-17 
Protocol Date: 2019-01-28 
 
Protocol Version: 1.2 
 
Product: Rituximab 
 
Estimated start date: Spring 2019 
 
Estimated finish date: Spring 2021 
 
 
 
 
 
SPONSOR AND PRINCIPAL INVESTIGATOR  
Susanne Bejerot, Professor, MD 
Psykiatriska kliniken, Universitetssjukhuset Örebro  
 
 
 
Signature 
Date 

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TABLE OF CONTENTS 
1 ABBREVIATIONS AND DEFINITIONS OF TERMS ....................................................4 
2 INVESTIGATORS AND STUDY ADMINISTRATIVE STRUCTURE .........................6 
3 SYNOPSIS ..........................................................................................................................7 
4 BACKGROUND INFORMATION ..................................................................................13 
4.1 Background ..............................................................................................................13 
5 STUDY OBJECTIVES AND ENDPOINTS...................................................................23 
5.1 Objectives .................................................................................................................23 
5.2 Outcomes .................................................................................................................23 
6 SELECTION AND WITHDRAWAL OF VOLUNTEERS.............................................25 
6.1 Inclusion Criteria ......................................................................................................25 
6.2 Exclusion Criteria.....................................................................................................26 
6.3 Withdrawal of patients ............................................................................................26 
7 STUDY PLAN AND DESIGN .........................................................................................27 
7.1 Study outline ............................................................................................................27 
7.2 Study Termination ...................................................................................................40 
8 STUDY MEDICATION ....................................................................................................41 
8.1 Study medication .....................................................................................................41 
8.2 Administration of study drugs ................................................................................41 
8.3 Storage and preparation of study medication .....................................................41 
9 ADVERSE EVENT, AE AND SERIOUS ADVERSE EVENT, SAE .........................42 
9.1 Adverse Events, AE ................................................................................................42 
9.2 Serious Adverse Event, SAE .................................................................................42 
9.3 Suspected Unexpected Serious Adverse Reaction, SUSAR ...........................43 
10 STATISTICS .....................................................................................................................43 
10.1 Determination of Clinical response .......................................................................43 
10.2 Statistical methods and analytical plan ................................................................44 
11 QUALITY CONTROL AND QUALITY ASSURANCE.................................................46 
11.1 Monitoring .................................................................................................................46 
11.2 Data monitoring .......................................................................................................46 

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12 ETHICS .............................................................................................................................47 
12.1 Ethical Conduct of the Trial ....................................................................................47 
12.2 Informed Consent ....................................................................................................47 
12.3 Risk/benefit assessment ........................................................................................47 
12.4 Considerations regarding group size ...................................................................48 
13 DATA HANDLING AND RECORD KEEPING .............................................................49 
13.1 Case Report Form, CRF ........................................................................................49 
13.2 Source data ..............................................................................................................49 
13.3 Data management ...................................................................................................49 
13.4 End of trial and archiving ........................................................................................49 
14 INSURANCE.....................................................................................................................50 
15 PROTOCOL AMENDMENTS ........................................................................................50 
16 PUBLICATION .................................................................................................................50 
17 REFERENCES .................................................................................................................51 
18 APPENDIX 1, DECLARATION OF HELSINKI ............................................................59 
 

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1 
ABBREVIATIONS AND DEFINITIONS OF TERMS 
AAR = Any Adverse Reactions  
ADEXI = Adult executive functioning inventory  
ANCOVA = Analysis of covariance  
ASD = Autism Spectrum Disorder  
BDNF = brain-derived neurotrophic factor  
BFCR = Bush-Francis Catatonia Rating Scale  
BOCS = Brief Obsessive Compulsive Scale  
BBQ = Brunnsviken Brief Quality of Life Inventory  
CGI-I = Clinical Global Impression-Improvement scale 
CGI-S = Clinical Global Impression-Severity scale 
CHQ-8 = Client Satisfaction Questionnaire 
CNS = Central Nervous System 
CRIES-8 = Children's Impact of Events Scale  
DMC = Data Monitoring Committee  
DSM-5 = The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition  
GAF = Global Assessment of Functioning  
HADS = Hospital Anxiety and Depression Scale  
IVIG = intravenous immunoglobulin  
M.I.N.I. = Mini International Neuropsychiatric Interview  
MRI = Magnetic Resonance Imaging 
MS = Multiple Sclerosis  
NFL = neurofilament light chain  
NGS = next generation sequencing  
NIMH GOCS = National Institute of Mental Health Global Obsessive Compulsive Scale  
NMDA = N-methyl-D-aspartate  
NSE = euronspecific enolase  
OCD = Obsessive-Compulsive Disorder  
PANDAS = Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal 
Infection 
PANS = Pediatric Acute-onset Neuropsychiatric Syndrome  
PANSS-R = Positive and Negative Syndrome Scale 
PGE = Patient's Global Evaluation of severity 

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PI = Principal investigator 
PML = Progressive Multifocal Leukoencephalopathy  
PNISSI = PsychoNeuroinflammatory Related Signs and Symptoms Inventory 
PSP = Personal and Social Performance Scale 
RAADS-R = The Ritvo Autism Asperger Diagnostic Scale-Revised  
RDoC = Research Domain Criteria  
SciLife Lab = Science for Life Laboratory  
SLE = Systemic Lupus Erythematosus  
SRIs = Serotonin Reuptake Inhibitors 
SSD = Schizophrenia Spectrum Disorders  
TB = Tuberculosis screen test 
TNF = Tumor Necrosis Factor  
UKU = UKU side effect rating scale 
VGCC = Voltage-Gated Calcium Channel  
WAIS = Wechsler Intelligence Scale  
 

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2 
INVESTIGATORS AND STUDY ADMINISTRATIVE STRUCTURE 
 
STUDY CENTER  
Örebro University hospital (USÖ) 
701 85 Örebro 
 
 
PRINCIPAL INVESTIGATOR AND SPONSOR 
Susanne Bejerot, Professor, MD  
Psykiatriska kliniken, Universitetssjukhuset Örebro/ 
Universitetssjukvårdens forskningscentrum (UFC) 
S-huset, vån. 2 
Box 1613 
701 16 Örebro 
Phone: +46-(0)70-165 51 02 
E-Mail: susanne.bejerot@regionorebrolan.se 
 
 
 
 
 

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SYNOPSIS 
 
TITLE 
Rituximab - Immunotherapy for Schizophrenia 
spectrum disorder in adults. An open pilot 
study.  
STUDY CENTER 
Psychiatry Unit, Örebro University Hospital 
AIM 
To investigate whether rituximab added to 
treatment as usual (TAU) for 20 weeks in 12 
treatment-resistant patients with schizophrenia 
spectrum disorder (SSD) will lead to clinically 
relevant overall improvement. Furthermore, the 
study aims to contribute to the understanding of 
underlying mechanisms by assessing 
inflammatory biomarkers in these patients.  
 
OBJECTIVES 
Primary objective: 
1. To investigate whether severely ill, 
treatment resistant, psychiatric patients with 
schizophrenia spectrum disorder (SSD) are 
significantly improved after treatment with 
the immunomodulatory drug rituximab 
(anti-CD20 antibodies) compared to 
baseline. 
 
Secondary objectives: 
2. To examine whether baseline levels of 
inflammatory markers predict treatment 
response. 
3. To examine whether changes in 
inflammatory markers and B-cell depletion 
correlate with treatment response. 
4. To examine metabolic mediators prior and 
after treatment and if they correlate with 
treatment response. 
5. To examine whether there is a change in gut 
permeability after treatment. 
6. To examine whether there is a change in 
cognition after treatment. 
7. To investigate if there is a change in brain 
activity after treatment. 
8. To investigate the patients’ experiences of 
the novel treatment with a qualitative 
content analysis. 
9. To assess safety and tolerability of rituximab 
during treatment for SSD 

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OUTCOME 
Primary outcome 
1. The primary outcome measure is change 
in symptoms measured as change in 
Positive and Negative Syndrome Scale 
(PANSS) score from baseline.  
Secondary outcomes:  
The secondary outcome measures are  
1. Change in Personal and Social 
Performance Scale (PSP), measuring 
overall disability from baseline up to 
week 20 
2. Change from baseline up to week 20 of 
illness severity (CGI-S) assessed by the 
clinician  
3. Difference from baseline up to week 20 
in inflammatory markers in blood (gene 
expression and proteins) in relationship 
to clinical response 
4. Proportion of responders: Three different 
informants base their CGI-I evaluations 
on independent assessments: a) The 
treating clinician, b) The patient’s self-
assessment and c) A next of kin. If the 
mean value of these three is below 2.5 
then the patient will be regarded as a 
responder (representing much or very 
much improved since baseline). 
5. Frequency, seriousness and severity of 
side effects. 
. 
Other outcomes:  
The other outcome measures are: 
1. B-cell depletion at week 5, and B-cell 
subpopulations at week 20 in relation to 
clinical response and baseline levels of 
B-cells 
2. Change from baseline to week 20 in 

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cognitive functioning 
3. Change from baseline to week 20 in 
diagnosis specific rating scales  
4. Change in brain activity in fMRI. 
Long-term outcomes: 
40 weeks follow – up: Primary outcome for 
long term is identical to that used at 20 week: 
1. Change in symptoms measured as change 
in PANSS score from baseline  
The secondary outcome measures are:  
1. Difference from baseline up to week 40 
in inflammatory markers in blood (gene 
expression and proteins) in relationship 
to clinical response 
2. Change in Personal and Social 
Performance Scale, measuring overall 
disability from baseline up to week 40 
3. Change from baseline up to week 40 of 
illness severity (CGI-S) assessed by the 
clinician  
4. Life quality measured with BBQ 
5. Global improvement. Three different 
informants base their CGI-I evaluations 
on independent assessments: a) The 
treating clinician, b) The patient’s self-
assessment and c) A next of kin 
Other outcome measures are: 
1. B-cell subpopulations at week 40 in 
relation to clinical response  
2. Change from baseline to week 40 in 
cognitive functioning 
3. Change from baseline to week 40 in 
psychiatric rating scales 
POPULATION 
Twelve psychiatric patients (ages, 18-40). 
INCLUSION CRITERIA 
1) patient ages 18 to 40 years 
2) a duration of illness exceeding 2 years 
3) correspond to “Markedly ill”, “Severely ill” 

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or ”Among the most extremely ill patients” on 
the Clinical Global Impression – Severity 
scale (CGI-S) 
4) Global Assessment of Functioning below 50 
5) current Diagnostic and Statistical Manual for 
DSM-5 diagnoses of Schizophrenia spectrum 
disorder 
6) treatment resistance, i.e. failing to remit 
despite adequate treatments 
7) if female and with any risk for pregnancy, 
willing to use contraceptives  
8) if antipsychotic treatment is prescribed the 
plasma concentrations of the drug must be 
tested and shown to be within therapeutic 
interval.  
9) subjects should be judged by the investigator 
to be lucid and oriented to person, place, time, 
and situation when giving the informed 
consent. 
10) immunoglobulin levels within the normal 
range 
 
 
EXCLUSION CRITERIA 
1) on-going immunomodulatory treatment 
2) pregnancy or breast-feeding 
3) weight below 40 kg 
4) clinically relevant on-going infection 
5) chronic infections  
6) positive screening test for hepatitis B, C, 
HIV or tuberculosis 
7) any change of psychotropic medication 
within the previous 4 weeks 
8) “much” or “very much improved” already at 
baseline according to CGI-I i.e. scores of 1 or 2 
by the clinician 
9) severe heart failure (NYHA grade IV) or 
other severe heart disease or history of cardiac 

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arrhythmia or myocardial infarction  
10) unable to make an informed decision to 
consent to the trial 
11) in compulsory treatment  
12) treatment with clozapine within the last 2 
months 
13) previous treatments with 
immunosuppressive agents 
14) malignancy currently or within 2 years 
prior to inclusion  
 
STUDY DESIGN 
 
Open pilot study, in addition a qualitative study 
using content analysis approach. 
Participants will be treated initially for 20 
weeks and followed for 52 weeks.  
STATISTICAL ANALYSIS 
 
Determination of Sample Size 
In this pilot study population of 12 participants 
is presumed to be large enough to determine 
any effect of rituximab. 
Primary objective: Effect of rituximab on 
schizophrenia symptoms measured with PANSS 
The primary outcome (as described in section 
5.2) is difference between baseline and 
endpoint on PANSS scale. 40% reduction in 
the PANSS scale. 
Analyses of laboratory data related to clinical 
response  
Laboratory data will consist of: plasma protein 
concentrations and leukocyte mRNA 
expression values for a number of cytokines 
and related substances (inflammatory markers); 
total number of B-lymphocytes and number of 
cells from various B-cell subsets at week 5, 12 
and 20, as measured through highly sensitive 
flow cytometry (HSFC); plasma proteins and 
lipids as measured through metabolomics 
analysis; and blood levels of markers for gut 
permeability. 
In order to examine whether baseline 
characteristics can predict treatment response, 
baseline values of all these measurements will 

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be compared in “responders” and “non-
responders” after completion of the study by 
means of t-tests or Mann-Whitney tests, as 
applicable. In order to examine whether 
changes in inflammatory markers and other 
measurements correlate with clinical response, 
the difference between baseline values and 
week-20 values (Δ-values) of all relevant 
measurements will be compared between 
“responders” and “non-responders” after 
completion of the study by means of t-tests or 
Mann-Whitney tests, as applicable. In addition, 
for each of these measurements, a generalized 
linear model (ANCOVA) will be built and a 
PCA analysis will be performed.  
Analyses of other clinical data related to 
clinical response  
For results on the scales (Personal and Social 
Performance Scale, CGI-S and diagnosis 
specific rating scales) the week 20 scores and 
the Δ-values (difference between scores at 
week 20 and baseline) will be compared by 
means of t-tests or Mann-Whitney tests, as 
applicable. They will also be included in an 
analysis of covariance (ANCOVA) model, 
controlling for baseline measures and other 
possible confounders, as demographic 
variables. 
Analyses of long-term outcomes 
The results at week 40 on these variables will 
be analysed with essentially the same methods 
as those at week 20, see above. 
STUDY TERMINATION 
 
LPLV – Last Patient Last Visit 
 
 
 

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4 
BACKGROUND INFORMATION 
4.1 Background 
Schizophrenia and quality of life 
Although psychiatric disorders are widespread, serious cases are concentrated among a relatively 
small proportion of cases with high psychiatric comorbidity (1-4). These individuals are usually 
unable to live independently, are repeatedly inpatients and have cognitive impairments. In addition 
to the suffering of having the disorder, the care of these patients involves high costs for society 
and constitutes a major burden for family and society as a whole. Quality of life is poor in patients 
with schizophrenia (5) and psychiatric patients as a whole have significantly lower quality of life 
than patients with physical disorders (6). Psychiatric disorders overall are the most disabling 
disorders among all disorders, according to the National Institute of Mental Health (2010). Life-
expectancy is almost 19 years shorter for schizophrenic men compared to men in the general 
population and 16.3 years shorter for women with schizophrenia (7). 
 
Treatment-resistance and schizo-obsessive disorder 
A considerable proportion of the severely ill psychiatric patients does not improve despite 
adequate treatments. Among individuals with Schizophrenia spectrum disorder (SSD), treatment 
resistance occurs in approximately 30 % (8). Treatment resistance is associated with early onset 
(9), catatonia and comorbidity particularly with obsessive-compulsive disorder (10). This is 
sometimes referred to as schizo-obsessive disorder (11). This subgroup of schizophrenia, present 
in approximately 15 % of the patients, is characterized by severe OCD that tend to appear during 
the prodromal stages of psychosis. Schizo-obsessive patients have an earlier onset of psychosis 
compared to other patients with schizophrenia, and show more depressive symptoms, suicide 
attempts and motor abnormalities. They have increased rates of hospitalization, greater 
dysfunction, higher impairment in social behaviour, smaller social networks and poorer quality of 
life. They tend to be more socially hostile and more anxious, as evidenced by their greater number 
of panic attacks and phobias and they tend to be treatment resistant. In summary, obsessive 
compulsive symptoms seems to have a deleterious effect on schizophrenia outcome. However 
schizo-obsessive disorder has not yet been included in the DSM-5 diagnostic manual, for a review 
of schizo-obsessive disorder, see (12).  
 
Psychiatric diagnostics and RDoC  
Psychiatric diagnoses are solely based on reported symptoms and observed behaviours. Specific 
diagnostic biological markers have not been identified. Each diagnosis may have several different 
causes with complex interrelationships and symptom overlap.  

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A strong genetic component has been reported for most psychiatric diagnoses (13). Moreover, 
studies have shown a large overlap between different psychiatric disorders in terms of genetic risk 
factors; these are not disorder specific (14, 15). However, polygenic risk scores have been used in 
efforts to link certain genes to various clinical phenotypes such as treatment response, symptoms, 
imaging findings etc. In line with this, The National Institute of Mental Health (NIMH) launched 
Research Domain Criteria (RDoC) to support an agnostic, bottom-up reclassification, crossing 
traditional boundaries by setting aside conventional, categorical diagnostic entities (16). Recently 
motor abnormalities that cut-across many psychiatric, neuropsychiatric and neurological disorders 
have been proposed as a putative domain within the NIMH Research Domain Criteria framework 
(17). Motor abnormalities are common in neurodevelopmental disorders (i.e. schizophrenia, 
obsessive compulsive disorder, autism spectrum disorders and PANS) (18). 
According to the researchers at NIMH it is obsolete to perform research based on categorical 
psychiatric diagnoses alone, without taking biological markers into account. RDoC intends to shift 
the focus of research (and eventually clinical practice) away from existing diagnostic categories, 
towards ”new ways of classifying psychopathology based on dimensions of observable behaviour 
and neurobiological measures”. To us this is the key issue. We question the value of the present 
psychiatric diagnostic entities in the severely mentally ill, treatment resistant, low function 
psychiatric patients with extensive comorbidity. These patients tend to present autistic, obsessive-
compulsive and psychotic symptoms, and we can therefore expect extensive comorbidity in the 
patients in our study. The extent of the comorbidity needs to be explored as this may affect the 
outcome (example of comorbidity is shown in figure 1).  
The immune system 
The immune system is a host defense system comprising many biological structures and processes 
that protects against disease (19). The immune system must detect a wide variety of 
agents (pathogens) from e.g. viruses and distinguish them from the organism's own healthy tissue 
in order to function properly. In humans, the immune system is classified into subsystems: 
the innate immune system versus the adaptive immune system. The innate immunity is the first 
line of defence. It is more primitive, and dispatch foreign pathogenes without much precision. The 
innate immunity initiates the inflammatory response, in which white blood cells gather at the site 
of infection and release the inflammatory response with proteins that induce heat and swelling. 
The adaptive immune system consists mainly of cells called T lymphocytes and B lymphocytes, 
which can recognize a specific pathogen, resulting in a targeted attack against it. In a small percent 
of the population, the adaptive immunity instead cause autoimmune diseases such as multiple 
sclerosis or arthritis by attacking cells in the individual’s own tissues. For long researchers thought 
that the immune system simply worked by distinguishing an organism’s own constituents from 
non-self ones. But more recently this has shown not to be true. Eventually more complex theories 
have emerged.  
The immune system regulates the body’s tissues in order to maintain equilibrium at all types of 
insults, regardless if they come from an external or internal source. However, pathogens can 
rapidly evolve and adapt, and thereby hide and avoid being recognized by the immune system. 
Nevertheless, multiple defence mechanisms have also evolved to recognize and neutralize 
pathogens. The immune system is also highly active in the healthy brain and essential to its 
functioning. 

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Immune cells, native to the CNS, are called microglia and exist in the healthy brain. Immune cells 
from elsewhere in the body (so-called peripheral immune cells) are not usually found in the 
healthy brain. The blood-brain barrier (BBB) protects the brain and keeps them out. Thus, 
the BBB protects the brain by separating the peripheral immune system from the neuroimmune 
system, however it is not a permanent wall. Pathogens can penetrate the BBB. The BBB is made 
from tightly packed endothelial cells (walls of blood vessels) that form a blockage. It prevents 
substances and immune cells to enter the parenchyma of the brain. Cells called astrocytes and a 
structure called the basement membrane reinforce the barrier. However, in the case of a brain 
disease the BBB becomes activated and allows immune cells to cross over. 
How the immune system exerts its influence in the CNS is not fully understood. After all, apart 
from microglia, no immune cells are present within the parenchyma of healthy individuals. 
Proteins called cytokines, generated from peripheral immune cells, can affect the behaviour of 
other cells and they can influence the brain. Presumably, they enter the brain through areas that 
lack the regular BBB and could directly impact the brain through the vagus nerve (which runs 
from the brain to the abdomen). Moreover, immune cells within the meninges—the membranes 
that surround the brain—are thought to be another source of cytokines. Cerebrospinal fluid from 
the meninges enters the brain parenchyma through spaces surrounding the blood vessels (gap 
junctions) and thus can carry cytokines from the peripheral immune cells deep into the brain to 
influence neuron behaviour. Reversely the meninges contain lymphatic vessels that remove toxins 
and other waste from the brain parenchyma and thereby convey information about brain infections 
to the immune system. By these mechanisms, the immune cells in the meninges communicate with 
the brain. It is however still unclear how immune cells enter the meninges and produce their 
cytokines (19).  
Inflammation as aetiology for severe psychiatric disorder 
There is a strong genetic association, established by GWAS studies, between the human leukocyte 
antigen (HLA) locus and schizophrenia. Maternal immune activation, induced clinically through 
prenatal exposure to one of several infectious diseases, has shown to be a risk factor in the 
development of schizophrenia. HLA proteins are mediators of the T-lymphocyte responses, and 
genetic variability is well-established as a risk factor for autoimmune diseases as well as 
susceptibility to infectious diseases. Taken together, the findings strongly suggest that 
schizophrenia risk in a subgroup of patients, is caused by an infectious disease or an autoimmune 
process. 
Immunological processes can cause mental illness and sequelae resulting in severe brain damage 
(20). Immune reaction causes inflammation, which in turn may result in elevated levels of anti-
neuronal antibodies and cytokines in the blood and CSF, and signs of microglia activation 
(suggestive of inflammation) in the brain. Microglia cells, one of the main indicators of 
neuroinflammation, release cytokines, prostaglandins and glutamate in the brain. An activation of 
microglia has been observed in SSD according to brain imaging and post mortem studies (21). 
NMDA receptor antibody encephalitis is an acute inflammation of the brain, first categorized in 
2007 (22). It is caused by an immune system that attacks the NMDA receptor of the brain, 
mediated by autoantibodies that may diffuse across a disrupted blood-brain barrier and somehow 
reach the NMDA receptors of neuronal cell membranes.  
The affected patients develop psychiatric symptoms such as agitation, psychosis, catatonia and 
paranoia. Grimacing and finger movements similar to those in PANS and chronic schizophrenia 
are also present. Consequently, patients with anti-NMDA receptor encephalitis run a risk of being 
misdiagnosed as schizophrenia. Subsequently, other types of antibodies have been linked to 

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psychiatric symptoms, and it is presently unknown to what extent patients diagnosed as 
schizophrenia may be afflicted by any of these putative autoimmune mechanisms. 
Thus autoimmunity are evidently involved in the pathophysiology of schizophrenia but also in 
depression (23-25) and elevated levels of pro-inflammatory cytokines have been identified in 
various psychiatric disorders (26-28) (29) (30). In a highly influential GWAS study of 
schizophrenia (31), the genetic loci linked to schizophrenia were strongly enriched by B-
lymphocyte lineages involved in acquired immunity (CD19 and CD20 lines). Out of multiple cell 
lines in the body, this B-cell enrichment was equalled only by cell lines derived from cortical 
brain regions, providing strong genetic support for immune dysregulation as a pathogenetic 
mechanism in schizophrenia, specifically implicating B-lymphocytes. 
Several anti-neuronal antibodies are associated with personality change, psychotic and depressive 
symptoms (32). A childhood onset psychiatric disorder, Pediatric Autoimmune Neuropsychiatric 
Disorders Associated with Streptococcal Infection, PANDAS (33) goes with OCD, but psychotic 
symptoms are likewise common in many of these patients (34). PANDAS is assumed to be an 
autoimmune reaction resulting from a streptococcal infection (35). The infection generates 
antineural antibodies assumed to cross-react with neuronal structures of the brain causing 
behavioral and motor abnormalities. This hypothesis resembles the known mechanism behind 
Sydenham’s chorea; a childhood disorder characterized by involuntary movements and 
neuropsychiatric symptoms, such as obsessive-compulsive behavior (33). The patients are often 
prescribed off-label treatment with immunomodulatory drugs and antibiotics. 
The hypothesis of PANDAS has been shown using rat models, both through active injection of 
antibodies into neuronal tissue of rats, as well as through passive transport (36). In the rat models, 
the antibodies caused compulsive behavior (manifested as increased induced-grooming) and motor 
abnormality (manifested as impaired food manipulation and beam walking), in line with the 
clinical picture of PANDAS. In addition, the administered antibodies cross-reacted with specific 
proteins responsible for important signaling cascades in the brain, such as dopamine and serotonin 
signaling cascades. IgG deposits were seen in striatum, frontal cortex and thalamus, areas 
proposed to have a central role in the symptomatology of PANDAS, and concomitant alteration of 
dopamine and glutamate levels in cortex and basal ganglia (37) in line with the pathophysiology 
of Sydenham’s chorea and related neuropsychiatric disorders. Furthermore, the blood-brain barrier 
integrity seemed important in determining the distribution of antibodies in the neuronal tissue of 
the rats, as well as determining the neuropsychiatric outcomes (36). 
Accordingly, immunological factors are hypothesized as being important determinants for the 
pathophysiology of several psychiatric disorders. Based on present knowledge on NMDA-receptor 
encephalitis and PANS, these mechanisms are more likely to be involved in the more severe, 
comorbid and treatment-resistant cases. The term Immunopsychiatry was recently coined (24) 
which covers this new field of research.  
Cytokines in Schizophrenia spectrum disorder 
Recent findings provide a strong evidence of a concomitant process of inflammatory activity in 
schizophrenia (38-40). The association between proinflammatory cytokines and schizophrenia is 
well accepted in the literature. Cytokine serum levels have been correlated with 
exacerbation/remission of the symptoms and with antipsychotic treatments (41, 42). 

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In a systematic review the existence of cytokines abnormalities in schizophrenia is confirmed (43). 
Immune imbalances such as increased levels of some cytokines (either at protein level or at 
mRNA expression), cytokine mRNAs, as well as cytokine gene polymorphisms have been 
reported with a large support in schizophrenia. Increased levels of the cytokines IL-6 in 
schizophrenia seem to be involved in its pathophysiology of schizophrenia. TNF-α contributes to 
the progress of the inflammatory response in schizophrenia. Moreover, the soluble receptors 
(sTNFR1 and sTNFR2) had increased levels in plasma or serum, and it has been considered an 
inflammatory marker in severe mental disorders. IL-10 Anti-inflammatory cytokine, whose levels 
were found altered in chronic patients with schizophrenia, may be due to an increased 
compensatory stimulus of the type 2 cytokine pattern. Also, IL-10 may suffer down-regulation by 
the use of antipsychotic drugs. Increased concentrations of IFN-γ were reported in several studies, 
correlating with the first episode of schizophrenia. Furthermore, high levels of IFN-γ were 
correlated with acute exacerbations and in subsequent antipsychotic treatment. IL-1β is a cytokine 
involved in neurodegenerative and neuroprotective processes, and in the modulation of synaptic 
plasticity. Reports have shown an increased concentration of IL-1β in schizophrenia. IL-8 is a 
chemoattractant cytokine. The role of IL-8 in schizophrenia is associated with treatment resistance 
and negative symptoms. Also, IL-8 levels are increased in schizophrenia. IL-2 and its soluble 
receptor (sIL-2R) levels were associated with schizophrenia and psychotic stages. These abnormal 
levels are also linked with antipsychotic treatments. IL-1 receptor agonist (IL-1Ra) is produced in 
response to diverse stimuli of inflammation such as IL-1β and IL-6. This cytokines is expressed in 
many cells, including neurons. Evidence shows that IL-1Ra levels are increased in schizophrenia, 
as well as the consequent immune activation and inflammatory processes. In studies of cytokine 
gene polymorphisms it is shown that IL-6 gene polymorphism is associated with the pathology of 
schizophrenia, which levels are increased. IL-6 gene polymorphism, specifically IL-6 -174G/C, 
was also linked to schizophrenia.  
TNF-α is a pleiotropic cytokine (neuroprotective and neurodegenerative effects, and immune and 
inflammatory responses), which levels were significantly higher in schizophrenia. TNF-α gene is 
one of the most studied and best described polymorphism, correlating to schizophrenia 
susceptibility.  
Cytokine mRNAs levels are correlated with schizophrenia: cognitive deficits and anatomic 
abnormalities such as decrease brain volume and abnormal cortical folding. IL-6, TNFR1/TNFR2 
and IL-1β mRNAs were the mostly repeatedly investigated, and their levels are associated with 
the pathophysiology of schizophrenia.  
In our own research group we have found similar associations. In a mixed sample of 40 severely 
ill psychiatric patients with obsessive-compulsive disorder, schizophrenia spectrum disorder, 
autism spectrum disorder and/or non-suicidal self-injury disorder and 40 healthy subjects, gene 
expressions of inflammatory-related genes were analysed using real-time qPCR. From plasma, 
protein levels were measured using electrochemiluminescence ELISA technology.  
Cytokine levels for the IL-1 family showed significant higher levels for IL1Ra (p<0.0001) and IL-
18 (p=0.0005) in patients compares to controls, but not for the IL-1β levels. Patients also had 
higher levels of the cytokines TNF (p = 0.0001) and IL-6 (p <0.0001), but not IL-8.  
We found increase in patients’ gene expression compared to controls in CASP1 (p = 0.0005), 
NLRP3 (p = 0.0426), PYCARD (p = 0.0484), IL1B (p = 0.0014) and IL-1RN (p = 0.0013). 
However, IL18 levels did not differ. For more general markers of inflammation, TNF (p = 0.0308) 
was significantly increased compared to controls, but not IL6 and IL10. Together our data indicate 
that individuals with severe psychiatric disorders have increased inflammatory activity (44). 
 

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The lack of reproducible biomarkers 
A problematic dilemma concerning these concepts is the lack of reproducible biomarkers related 
to the hypothesised mechanisms. As already mentioned, in the case of PANS/PANDAS, treatment 
results, as well as clinical findings and animal studies, coherently support an autoimmune 
mechanism. In spite of this, the purported biomarkers have not hitherto been validated (64). This 
failure, however, does not prove that the hypothesis is wrong, just that the methods attempted to 
validate the hypothesis have yet been insufficient. It also compellingly suggests that patients may 
well have immunological processes that affect brain circuits, thereby producing psychiatric 
symptoms, while we are left unable to substantiate these processes with biomarkers. If the 
immunology is present in PANS/PANDAS, it may well be present in such adult OCD cases where 
biomarkers are difficult to identify. 
It behoves ethical thinking to take responsibility for treatment research that potentially may result 
in novel methods for reducing suffering. This is the main incentive for our study, and we believe 
that the aggregate support for immunological mechanisms supersedes the lack of reproducible 
biomarkers. In this situation, a trial of a potent immune modulator, effective in autoimmune 
disorders, has the potential to move us forward towards an effective treatment for severe suffering. 
 
Effects of Rituximab on the brain 
Rituximab is a monoclonal antibody that binds to a membrane protein, CD20, which is located on 
the surface of pre-B cells and mature B lymphocytes. Binding of the antibody to the B cell leads to 
B cell cytolysis (cell death of specific B cells). The B cell fills multiple functions in the immune 
system, including as antigen presentator (activation of T cells and other cells), production of 
immunomodulating cytokines, and production of antibodies. In rituximab treatment, the antigen-
presenting and immunomodulating function of the B cell is thought to be largely the property that 
gives rise to the treatment effect, i.e. not the elimination of the antibodies. CD20 is not expressed 
on hematopoietic stem cells, pro B cells (precursor to pre-B cells and B lymphocytes), plasma 
cells (challenged B lymphocytes produced antibodies) or in normal tissue, which means: 1) the 
effect of rituximab is reversible and upon completion of treatment, the patient eventually recovers 
its B cells and thus regains its function in the immune system, 2) already engineered plasma cells 
will continue to produce antibodies, and 3) other tissues in the body that do not express CD20 are 
not affected. A number of findings support that there is a B and T cell involvement in the 
psychiatric diseases we intend to investigate. In addition, communication between B and T cells 
clarifies how an anti-B cell therapy affects more immune system processes than just the 
production of antibodies. The hypothesis that the role of the immune system in mental illness not 
only is mediated by antibodies but also by interaction between B and T cells and cytokines was 
presented as an important information by several prominent researchers at the Swedish Medical 
Association's Translational Research Symposium for Immunopsychiatry, which was launched in 
April 2018. A possible effect of rituximab treatment may be that lack of activation via B cells 
contributes to the normalization of T-cell-driven inflammation in the brain, which in turn leads to 
a normalization of microglia activity and thus a decrease in symptoms. In summary, we consider 
that we have presented a scientifically based hypothesis that CD-20 antibodies may affect severe 
psychiatric disease. 

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Rituximab is a standard drug for the treatment of rheumatoid arthritis and is widely used for 
difficult-to-treat MS. The effect of rituximab on neuroinflammation has clearly been shown by its 
effect in the treatment of MS, which is a disorder of the brain. Rituximab is a first-hand treatment 
in primary B cell type lymphoma. It was previously assumed (based on early pharmacokinetic 
studies) that CNS lymphoma would be hard to access with rituximab. However, a recent study 
showed that addition of rituximab to a combined treatment was as effective as the addition of 
radiotherapy. CSF concentrations of rituximab, significantly lower than plasma levels, also 
appeared to be sufficient to contribute to this effect (45). In addition, one controlled randomized 
study showed a beneficial effect of rituximab on cerebral symptoms in patients with chronic 
fatigue symptoms (46). This study unraveled the connection between inflammation and chronic 
fatigue. For long chronic fatigue was gathered to solely have a psychological origin, thus the 
rituximab study had a dramatic impact on the understanding of the pathophysiological mechanism 
behind chronic fatigue.  
In the case of rheumatoid arthritis (which in most cases is an extracerebral disorder), there are 
several case reports indicating that a significantly lower dose (< 10 %) than the currently 
recommended appears to be effective in a majority of cases, suggestive of a generous margin in 
dosage recommendations (47). In a pilot study on healthy volunteers, it was shown that < 1% of 
the recommended dose resulted in a clinically relevant depletion of B cells (48). The action of 
rituximab is thought to primarily be associated to its blocking effect on B cells in the periphery 
which subsequently leads to decreased B cell entry into the CNS (from the bloodstream), i.e. not 
due to a central blockage of B cells in the CNS.  
The blood-brain barrier (BBB) can be damaged by a variety of factors, e.g. skeletal trauma. 
Inflammatory activity itself is probably another important factor, since it increases BBB 
permeability.  
In this context, it should be emphasized that clinical psychiatry (at least in Sweden), lacks routines 
regarding the determination of BBB injury. As a result, even severely ill patients with difficult-to-
treat psychiatric symptoms are normally not diagnosed with respect to barrier injury. 
Immunomodulatory treatments  
Intriguingly, treatments recommended for treatment-resistant psychosis are clozapine and 
minocycline. Both these drugs have immunomodulatory effects (49, 50) (51). A recent case-report 
presented a complete remission from a treatment-resistant schizophrenia after a bone marrow 
transplantation (52) and, conversely, another case-report described onset of treatment resistant 
psychosis after receiving bone-marrow from a schizophrenic donor (53). These studies strongly 
support the hypothesis of the immune system’s impact on psychiatric symptoms. However, to date 
very few immunomodulatory drug trials for severe psychiatric disorders have been published and 
rituximab has not been studied in any of them (54-56).  

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Why we want to study rituximab rather than other immunomodulatory drugs  
In a case study rituximab was described as successful for treating PANS (57). Rituximab is 
included in the treatment guidelines of anti-NMDA receptor encephalitis (58) and is generally 
well-tolerated (59). Moreover, rituximab targets B-lymphocytes of CD19-CD20 lineage, exactly 
the cells that were found to enrich schizophrenia genome in the above-mentioned GWAS study. 
While rituximab selectively targets B-cells, studies have suggested that the treatment effect is 
largely antibody-independent and that other B-cell functions such as antigen presentation and 
cytokine production contributes to amelioration of autoimmune diseases after B-cell depletion 
therapies (60). B cells with increased production of inflammatory cytokines such as lymphotoxin, 
TNF and IL-6 are elevated in patients suffering from autoimmune disorders. Additionally, lower 
levels of cytokines associated with regulatory B cells, such as IL-10, is seen and B-cell depletion 
by rituximab has shown to normalize these immune perturbations (61, 62). In the present study we 
want to test if rituximab can ameliorate symptoms in treatment resistant markedly ill psychiatric 
patients with schizophrenia spectrum disorder (SSD).  
Although the experience with immunomodulatory drugs such as corticosteroids, intravenous 
immunoglobulin (IVIG) and methotrexate is longer, as compared to rituximab, they have 
drawbacks: Corticosteroids strongly increase the risk for mania in psychiatric patients, which may 
further impair psychiatric health; IVIG is a blood-derived product, which makes its availability 
limited and furthermore, according to experience with patients with PANS, monthly treatments are 
often required to keep the patient symptom free. This makes IVIG costly and complicated. Trials 
with methotrexate on psychiatric populations have not yet been published, but we anticipate that 
psychiatric patients are reluctant towards a weekly intake of chemotherapy. Mycophenolate 
mofetil and azathioprine are other similar options used in autoimmune encephalitis and other 
autoimmune disorders, but not as far as we are aware, for psychiatric disorders. A fourth option is 
adding the antibiotic minocycline, which has anti-inflammatory properties, but minocycline must 
be dosed twice daily, which may affect compliance. Finally, since rituximab is regarded as 
sufficiently safe in large populations suffering from autoimmune disorders, thus we expect it to be 
likewise safe in psychiatric patients. Interestingly, a prevailing opinion on the mechanism of IVIG 
(hitherto the best immunomodulator in PANS treatment) is its modulation of B-cell function (63) 
which is also the main mechanism of rituximab). Accordingly, we expect the presumed benefits of 
rituximab to overrun the possible harm caused by this drug in markedly ill psychiatric patients 
with SSD. 
Our experience of the treatment and the patient group 

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Already in 2013 we started our research on children and young adults assessed for Pediatric 
Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Bacteria (PANDAS) and 
Pediatric Acute Neuropsychiatric Syndrome (PANS) (EPN in Stockholm 2014/551-31/2 and No. 
2015 / 964-31). We interviewed 53 patients and their families in their homes all around Sweden. 
We interviewed each of them between 3 and 5 hours and tested their cognitive abilities. These 
children and young adults have obsessive-compulsive symptoms, but many also had psychotic 
symptoms and some were diagnosed with schizophrenia (34). We were alarmed by the extreme 
complexity of the symptoms in these patients, the poor treatment response to psychiatric 
medication and the extremely low quality of life that affected the whole family. Many patients 
were desperate and had spent large savings in search for relief. We also drew blood to investigate 
the diagnostic properties of the commercially marked panel for diagnosing PANDAS and PANS 
(the Cunningham panel) in these patients. When we compared the results with those of patients 
suffering from other psychiatric disorders and with healthy controls we could show that the 
Cunningham panel was unreliable. Healthy children had elevated levels to a high extent and the 
panel could not differentiate any of the groups (64). This led Wieslab, the company that marketed 
the Cunningham panel in Europe, to removed this analysis from their platform in December of 
2017.  
We also studied inflammatory markers in these patients in collaboration with researchers at KI 
(Thomas Poiret) and currently writing up findings supporting the idea of molecular mimicry as 
aetiology for PANDAS. More recently we have investigated gene expression of inflammatory 
markers in a pooled sample of 40 severely ill psychiatric patients (children and adults) with 
diagnoses such as SSD, OCD, non-suicidal self-injury disorder and ASD, and compared the 
markers with those of healthy age and sex matched controls from the same area (EPN in Uppsala, 
No 2016/091). Our preliminary data (as described above) shows large differences in gene 
expressions between the patients and the controls (manuscript in preparation) as well as elevated 
protein levels of cytokines and support the notion of elevated level of inflammation in psychiatric 
patients. Our results strongly support that our group of comorbid, severely ill psychiatric patients 
have an up-regulated immune system with inflammatory activity that do not correspond to 
detectable inflammation in the peripheral body. Hence, neuroinflammatory activity is a likely 
explanation. Also, we have followed the clinical picture in a large number of patients with 
PANDAS and PANS who were treated with IVIG or other immunomodulatory agents. Two of 
these PANDAS patients received rituximab because of comorbid autoimmune disorders 
(neuromyelitis optica and Mb Chron, respectively). Notably, psychiatric symptoms are not 
included in the symptomatology of these disorders. In both cases we noted remarkable 
improvements in the psychiatric symptoms, and in one patient all psychotic symptoms remitted 
(65). 
Figure 1. A schematic illustration of diagnostic overlaps in severe psychiatric disorder  
 
 

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Overall, our research group consists of clinical researchers (psychiatrists) with extensive 
experience of patients with severe psychiatric illness, including children. The PI has worked 
decades as a senior consultant and currently assess treatment resistant psychiatric patients with 
SSD, OCD and ASD at the Psychiatric clinic in Örebro on weekly basis. Also Mats Humble, 
psychiatrist, PhD and collaborator in this study, has extensive clinical experience with severe 
treatment resistant psychiatric patients. Three doctoral students are involved in various projects 
related to inflammation in psychiatric patients. One of the PhD students, a nurse, is accustomed to 
perform blood tests in the homes of the patients, thus they don’t have to go to a clinic. We closely 
collaborate with preclinical senior researchers at Therapeutic immune design, CMM, Karolinska 
institutet and the research group at iRiSC, Örebro University. Our collaborators have extensive 
experience in working with the research methods needed for our analyses and have long 
experience of the in vitro systems to be used on whole blood and its components. In the present 
study we will also collaborate with the Department of Clinical and Experimental Medicine at 
Linköping University and the Department of Radiology at Örebro University Hospital to conduct 
an imaging study on inflammation in CNS. We will collaborate with Nutrition-Gut-Brain 
Interactions Research Centre (NGBI) at Örebro University for research on the effect of rituximab 
treatment on gut microbiom. For research on metabolic markers we will work together with Man-
Technology-Environment research centre (MTM) at Örebro University. For bioinformatics we 
will collaborate with Faculty of Health, Science and Technology at Karlstad University. Finally, 
we will collaborate with clinical researchers within the fields of occupational therapy, paediatrics, 
child and adolescent psychiatry and rheumatology. For health economy analysis we will 
collaborate with researcher at University health care research centre (UFC) in Örebro.  
Clinical significance  
In this trial we will study rituximab in markedly ill psychiatric patients diagnosed with 
schizophrenia spectrum disorder and with considerable impairment. Regularly they are treated 
with high dosages of psychiatric drugs nevertheless they suffer from symptoms as well as 
significant side effects.  
The inflammatory hypothesis of psychiatric disorder predicts that rituximab treatment should 
improve the condition, and that the improvement should be associated with change in biological 
markers. Large gains by reduced suffering and lowered healthcare costs may be achieved with this 
treatment. If participants are improved this may entirely transform the outcome for large groups of 
psychiatric patients.  
This study will be an interdisciplinary collaboration between clinicians and researchers within the 
fields of immunology, psychiatry, rheumatology, gastroenterology, psychology and laboratory 
disciplines, which may open up new work paradigms for exploring new treatments for severe 
psychiatric illnesses.  
Trial design 
Open pilot intervention study, in addition a qualitative study using content analysis approach. 
 

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5 
STUDY OBJECTIVES AND ENDPOINTS 
5.1 Objectives 
Primary Objective 
To investigate whether markedly ill, treatment resistant psychiatric patients, assumed to have an 
inflammatory aetiology for their symptoms and diagnosed with schizophrenia spectrum disorder 
(SSD), are improved after treatment with the immunomodulatory drug rituximab (anti-CD20 
antibodies). 
Secondary Objectives 
• To examine whether baseline levels of inflammatory markers predict treatment response. 
• To examine whether changes in inflammatory markers or B-cell depletion correlate with 
treatment response. 
• To examine metabolic mediators prior and after treatment and if they correlate with 
treatment response. 
• To examine whether there is a change in markers for gut permeability after treatment. 
• To examine whether there is a change in cognition after treatment. 
• To investigate the patients’ experiences of the novel treatment with a qualitative content 
analysis. 
To assess safety and tolerability of rituximab during treatment for SSD. 
 
5.2 Outcomes  
Primary outcome 
The primary outcome measure is change in symptoms measured as change in PANSS score.  
Secondary outcome 
• Global improvement at week 20, according to a balanced assessment (mean value of three 
independent assessors: 1) The treating clinician, 2) The patient’s self-assessment and 3) A 
next-of-kin) using the Clinical Global Impression-Improvement (CGI-I) scale (range 1-7; 1 
representing “Very much improved”). 
• Change in Personal and Social Performance Scale (PCP) measuring overall disability  
• Change from baseline up to week 20 of illness severity (CGI-S) assessed by the clinician 
• Difference from baseline up to week 20 in inflammatory markers in blood (gene expression 
and proteins) in relationship to clinical response (CGI-I) 
• Proportion of responders to treatment, i.e. rated as much or very much improved since 
baseline according to CGI-I assessed by three different informants: 1) The treating 
clinician, 2) The patient’s self-assessment and 3) A next of kin. If the mean value of these 
three is below 2.5 then the patient will be regarded as a responder (representing much or 
very much improved since baseline).  

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• Safety and tolerability of rituximab during treatment for SSD measured with the 
questionnaire Any Adverse Reactions (AAR). 
 
 
Other outcome measures 
• B-cell depletion at week 5, and B-cell subpopulations at week 20 in relation to clinical 
response and baseline levels of B-cells 
• Changes in cognitive functioning at 20 weeks:  
o Neuropsychological functioning assessed with e.g. visuospatial and executive tests 
• Change from baseline on rating scales that measure psychiatric symptoms specific for each 
diagnosis (shown below) during the past 2 weeks 
o BOCS for measuring obsessive-compulsive symptoms  
o RAADS-R for measuring autistic symptoms 
o PANSS for measuring psychotic symptoms 
o BFCR to measure catatonic symptoms  
o HADS for measuring depressive and anxiety symptoms 
Long-term outcomes 
40 weeks follow –up:  
Outcome measures for long term are identical to that used at 20 week.  
Change in symptoms measured as change in PANSS score.  
The secondary outcome measures are:  
• Global improvement at week 20, according to a balanced assessment (mean value of three 
independent assessors: 1) The treating clinician, 2) The patient’s self-assessment and 3) A 
next-of-kin) using the Clinical Global Impression-Improvement (CGI-I) scale (range 1-7; 1 
representing “Very much improved”). 
• Difference from baseline up to week 40 in inflammatory markers in blood (gene expression 
and proteins) in relationship to clinical response 
• Change in PSP, clinician administered version, measuring overall disability from baseline up 
to week 40 
• Change from baseline up to week 40 of illness severity (CGI-S) assessed by the clinician 
• Proportion of responders to treatment, i.e. rated as “Much improved” or “Very much 
improved” since baseline according to CGI-I 
• Life quality measured with BBQ  
Other outcome measures are: 
• B-cell subpopulations at week 40 in relation to clinical response  
• Changes in cognitive functioning at 40 weeks:   

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o Neuropsychological functioning assessed with e.g. visuospatial and executive tests 
• Change from baseline on rating scales that measure psychiatric symptoms specific for each 
diagnosis (shown below) during the past 2 weeks 
o  BOCS for measuring obsessive-compulsive symptoms  
o  RAADS-R for measuring autistic symptoms 
o  PANSS for measuring psychotic symptoms 
o  BFCR to measure catatonic symptoms 
o  HADS for measuring depressive and anxiety symptoms 
Follow-up, 1year after treatment start. Outcome is PANSS and CGI-I in relation to treatment and 
evaluated by the treating clinician, the patient’s self-assessment and a next of kin.  
Qualitative content analysis 
At endpoint 1, after 20 weeks, a qualitative content analysis will be performed.  
 
6 
SELECTION AND WITHDRAWAL OF VOLUNTEERS 
6.1 Inclusion Criteria  
To be eligible for inclusion into this study, each patient must fulfil all of the following criteria: 
1) Age: 18 to 40 years 
2) Duration of psychiatric illness: exceeding 2 years 
3) Rated “Markedly ill”, “Severely ill” or ”Among the most extremely ill patients” on the Clinical 
Global Impression – Severity scale (CGI-S) 
4) Global Assessment of Functioning below 50 
5) Current diagnosis according to Diagnostic and Statistical Manual for Mental Disorders, 5th 
edition (DSM-5) of SSD (schizophrenia spectrum disorder) 
6) Treatment resistance, i.e. failing to remit despite adequate treatments 
7) If female and with any risk for pregnancy: willing to use contraceptives.  
8) If antipsychotic treatment is prescribed the plasma concentrations of the drug must be tested 
and shown to be within the therapeutic interval. 
9) Subjects should be judged by the investigator to be lucid and oriented to person, place, time, 
and situation when giving the informed consent. 
10) Immunoglobulin levels within the normal range 
Treatment resistance is defined as poor general functioning (GAF<50) and minor or no persistent 
improvement from previous treatment attempts, according to the following specifications: At least 
2 trials with different evidence-based drug treatments for schizophrenia and at least one from the 
second generation of anti-psychotic drugs. Both drugs should have been tested for a minimum of 4 
months with adequate dosages. Clozapine must have been tested or considered not feasible  

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Fertile women will only be included in the study if they are using/agree to use adequate 
contraception during treatment with the study drug and for the following 12 months after the last 
treatment. Adequate contraception is defined as at least 1 of the following: 1) abstinence, 2) oral 
contraceptive (combined or progesterone alone), 3) implants of levonorgestrel, 4) estrogenic 
vaginal ring, 5) percutaneous contraceptive patches, 6) injectable progestogen, 7) intrauterine 
device (IUD) or 8) male partner sterilization. Non-fertile women are defined as any female that is 
surgically sterile (documented hysterectomy and/or bilateral oophorectomy or tubal ligation). 
Participants with severe SSD may not be able to respond to all questions or fill out rating scales. 
However, we will then obtain independent information whether the patient is improved or not 
according to CGI-I and PANSS even though h/she may not be able to fill out rating scales. Thus 
our primary outcome measure can be used at all times regardless of the state of the patient.  
6.2 Exclusion Criteria 
Patients are to be excluded from the trial if any of the following criteria is fulfilled: 
1) on-going immunomodulatory treatment 
2) pregnancy or breast-feeding 
3) weight below 40 kg 
4) clinically relevant on-going infection 
5) chronic infections   
6) positive screening test for hepatitis B, C HIV or tuberculosis 
7) any change of psychotropic medication within the previous 4 weeks 
8) “much” or “very much improved” already at baseline according to CGI-I i.e. scores of 1 or 2 by 
the clinician 
9) severe heart failure (NYHA grade IV) or other severe heart disease or history of cardiac 
arrhythmia or myocardial infarction 
10) unable to make an informed decision to consent to the trial 
11) in compulsory treatment  
12) treatment with clozapine within the last 2 months  
13) previous treatments with immunosuppressive agents 
14) malignancy currently or within 2 years prior to inclusion  
 
6.3 Withdrawal of patients 
The patients can at any time choose to stop participating in the study without giving any reason for 
this. If possible, the reason for the patient leaving the study should be recorded. Data collected up 
to the subject’s leaving the study will be used in the analysis of the study. 
The investigator can remove a patient from the study due to safety reasons or in case the patient is 
not able to comply with the protocol. 

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7 
STUDY PLAN AND DESIGN 
7.1 Study outline 
After a screening visit, patients who meet the inclusion criteria will be asked to participate in this 
study. Plasma drug levels of the on-going medication will be measured before inclusion. Patients 
will be allocated to treatment with rituximab. If the patient is treated with anti-hypertensive drugs 
these shall be withdrawn 12 hours prior to rituximab treatment. Patients will receive the 
premedication 1-2 h prior to rituximab in their home or at the clinic. A nurse, experienced with 
rituximab treatment, will accompany the patient during the hours of rituximab infusion. Blood 
pressure will be measured before and after treatment and at every change of the speed of the 
infusion. The temperature will be measured before and after treatment. Mabthera will be 
administered according to the guidelines for safety of the patients, see supplementary file “Rutiner 
för behandling med Mabthera inom ramen för studierna RITS-PO och RITS-PS”. Patients will rest 
for an hour after the termination of the infusion and will not be left alone during this time.   
All patients will be treated with the study drug rituximab on one single occasion and followed for 
a total of 1 year. They will have a total of 13 visits (screening prior to inclusion can be divided 
into more than one visit if necessary) with a clinician or research nurse who is experienced with 
rituximab and with psychiatric patients. An extensive psychiatric interview will be performed with 
each patient and his/her next of kin at baseline. We will also review medical records in order to 
document previous symptomatology and treatment trials. A short video recording is optional. All 
participants will be examined for psychiatric, neurological and motor symptoms, cognitive 
functioning, and a range of biomarkers. However only blood sampling and the interview are 
prerequisites for participation, all other examinations and tests are optional. Prior and post 
treatment the optional lumbar puncture and fMRI will be performed for further diagnostic 
evaluation and assessment of blood-brain barrier function. Faeces samples will also be collected 
prior to treatment and endpoint 1 of this study (optional) as well as gut biopsy prior to treatment 
(optional). Patients are requested to remain on their standard psychiatric treatment until endpoint 
1, and treatment should be stable for the last 1 month prior to baseline. Patients are allowed 
adaption of their on-going psychiatric treatments after week 20 but also earlier if the treating 
physician deems this necessary. 
Biological and psychiatric assessments will be performed at pre-decided time points (see table 1). 
Patients will be followed by additional visits to a nurse for in-between visits.  
Side effects will be monitored at each visit. Patients will continue their regular visits with the 
psychiatric staff.  
At endpoint 1 (20 weeks) a separate interview lasting approximately 45 minutes will be held for a 
qualitative analysis. 
7.1.1 Data collection, management, and analysis  
Demographic background data and treatment history will be collected from interview and medical 
records at baseline.  
Assessments will be made with established and well-validated rating scales and questionnaires in 
addition to one research interview that was developed by the principal investigator (PNISSI) (see 
list of all rating scales and questionnaires below). Sampling of biological materials will be done by 
a standard operating procedure (SOP) used for sampling for other current cohorts. We will also 
perform laboratory tests in a highly structured manner with well-validated methods in 
collaboration with researchers at Örebro University and Karolinska Institutet. Samples will be 
frozen and stored in Region Örebro County biobank (458) at -80 °C until analysis. All data 
collection forms will be stored at a safe place within Örebro hospital, Region Örebro County. 

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7.1.2. Rating scales and tests 
If more than one clinician will assess the patients rating calibration training for obtaining 
agreement on scorings will be performed.  
Due to the large data collection in combination with the severity of the disorder in these patients 
missing data will be unavoidable. We will try to avoid missing data by providing clarification if a 
patient cannot understand the meaning of a question. For each symptom rating scale the response 
rate is set at a minimum of 80 % of the questions. Isolated missing scores will be replaced with the 
individual mean.  
Demographics 
• Background data collection form 
• Pans Data Collection Form provides information about inherited physical and psychiatric 
disorders within the family. 
Diagnostic interviews 
• Mini International Neuropsychiatric Interview (M.I.N.I. version 7) is a structured clinical 
interview for psychiatric disorders. In addition the childhood onset diagnoses from the M.I.N.I. 
kid version will be amended to the adult version of M.I.N.I. (66, 67)  
• PsychoNeuroinflammatory Related Signs and Symptoms Inventory (PNISSI) in order to 
identify and measure symptoms related to neuro-inflammation and diagnose PANDAS and PANS 
(68) 
Assessment of severity, improvement and quality of life 
• Clinical Global Impression-Improvement scale (CGI-I) measures change of symptoms on a 7 
point Likert scale. CGI-I will also be administered to the next-of-kin (69)  
• Patient's Global Evaluation (PGE) provides a self-administered global measure of improvement 
on a 7 point Likert scale (70) 
• Clinical Global Impression-Severity scale (CGI-S) provides a global measure of illness severity 
on a 7 point Likert scale (69)  
• Global Assessment of Functioning (GAF) measures general disability and symptom burden (71) 
• Personal and Social Performance Scale (PSP) (72). The PSP is a 100-point single-item rating 
scale, subdivided into 10 equal intervals. The ratings are based mainly on the assessment of 
patient's functioning in four main areas: 1) socially useful activities; 2) personal and social 
relationships; 3) self-care; and 4) disturbing and aggressive behaviours.  
• Level 1 Cross-cutting symptom measure of global symptom severity is a patient or informant 
rated measure included in the DSM-5, which assesses mental health domains that are important 
across psychiatric diagnoses. It includes 13 domains. We will use it with the clinician’s assistance 
for adults (73)  
• Brunnsviken Brief Quality of Life Inventory (BBQ) is a 12-item measurement of life satisfaction 
(74, 75)  
• EuroQol Group EQ-5D™ (EQ-5D-5L) is an 5-item quality of life inventory (76) 
Obsessive-Compulsive disorder 
• Brief Obsessive Compulsive Scale (BOCS) maps self-reported symptoms and measures severity 
of obsessive-compulsive symptoms by a clinician (77)  

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• National Institute of Mental Health Global Obsessive Compulsive Scale (NIMH GOCS) is a 
global assessment of OCD severity (78) 
Autism spectrum disorder 
• Clinician-rated Severity of Autism Spectrum and Social Communication Disorder is a DSM-5 
based measure for assessing severity of autism spectrum disorder (79) 
• RAADS-R is a self-report to assess autistic symptoms. If the patient is unable to fill it out this 
can be done by a next-of-kin (80)  
Schizophrenia spectrum disorder 
• Clinician-rated Dimensions of Psychosis Symptom Severity is a DSM-5 based measure for 
assessing severity of a psychosis (79) 
• Positive and Negative Syndrome Scale (PANSS) is a measure for psychotic symptoms in 
schizophrenia (81).  
Catatonia 
• Bush-Francis Catatonia Rating Scale (BFCR) is a 23 item measure for catatonic symptoms (82)  
Anxiety and depression 
• Hospital Anxiety and Depression Scale (HADS) is a combined brief self-report measure for 
anxiety and depressive symptoms (83) 
Trauma 
• The Children's Impact of Events Scale (CRIES-8) is an 8-item self-report to measure post-
traumatic symptoms. In the present study it will be used in adults (84)  
Personality syndrome 
• The Personality Inventory for DSM-5 Brief Form is a brief self-report (79, 85) 
Early onset psychiatric symptoms 
• Five to fifteen-Brief (FTF-Brief) consists of 24 items representing 18 of the original 22 
subdomains in the original Five to fifteen questionnaire for assessing childhood 
neurodevelopmental symptoms (86). The FTF-Brief has been validated by us to be used in 
retrospect in adults assessed in childhood for neurodevelopmental disorders, and reassessed in 
adulthood (87).  
Cognitive tests 
•  Parts of Wechsler Intelligence Scale Revised (WAIS-III-R) and/or WISC-III; WAIS-III; D 
KEFS; Wechsler Memory Scale, and from PNISSI. 
•  Block design, digit span, letter number sequencing and digit symbol coding, visuospatial test 
•  Adult executive functioning inventory (ADEXI) is a 14 item self-report of working memory and 
impulsivity (88) 
Motor skill test 
•  Nine hole peg test (89) 
•  Gross motor functioning (from PNISSI) (90)  

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Side-effects 
•  Safety and tolerability of rituximab measured in an interview (AAR). 
•  UKU side effect rating scale is a clinician-rated scale with 48 items (91). 
In addition to UKU, adverse events will be checked with the following questions at each visit:  
1. Have you noticed any new symptoms or problems since your last visit? If yes, which?  
2. Do you gather these symptoms can be related to your rituximab treatment? 
3. Have you noticed if any of your previous side effects have attenuated or increased? If yes, 
which ones? 
Treatment satisfaction 
• Client satisfaction questionnaire (CSQ-8) is an 8-item measurement that is designed to measure 
client satisfaction with services (92) 
Other rating scales 
• Bristol stool scale to evaluate the consistency of faeces and therefore obtaining a measure of 
transit through the gastrointestinal tract (93) 
Physical examination 
• General condition; blood pressure; heart rate; signs of joint inflammation; dermatological 
examination; height and weight 
• Basic neurological examination 
Video recording 
Each patient will be video recorded at base line, week 12, 20 and 40 in order to enable blinded 
assessment by an independent rater, and for the patient’s own evaluation. 
 
7.1.3 Biochemical and other measures   
There is still insufficient knowledge concerning inflammatory/immunological mechanisms of 
psychiatric disorders. Therefore, in order to increase our understanding and to extend the 
interpretational potential of clinical findings from our exploratory study, we will assess relevant 
immunological parameters, autoimmune biomarkers, genetic SNPs, etcetera. Additionally, we will 
apply routine safety biochemistry, recommended for rituximab in clinical use. 
Also all subjects will be asked if they have received standard vaccinations and if they have had 
chicken pox, i.e. immunity to Varicella zoster (positive antibodies if unknown). If not then 
vaccinations must precede the treatment with rituximab. 
Tests in blood and cerebrospinal fluid (CSF) 
Blood and CSF will be drawn at baseline (before intervention), and at week 20 (after 
intervention). Analyses will include:  
Blood only 
At baseline, week 20 and week 40: 

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• Routine clinical tests for basic haematology, 5-partsdiff including neutrophil and 
lymphocyte count to be able to make the neutrophil/lymphocyte ratio and platelet counts, 
glucose, infection, liver function, renal function, electrolyte balance, thyroid status, 25-
OH-vitamin D, PTH, vitamin B12, folat 
• Expression levels of selected pro-inflammatory genes (e.g. IL-1, caspase, IL-6, IL-8), 
analysed using real-time PCR and DNA microarray technology 
At baseline and week 20: 
 
• Biomarkers for gut permeability (e.g. I-FABP, GLP-2)  
 
At baseline, week  5, 12, 20, and40: 
• B-cell populations monitoring, by flow cytometric phenotyping (e.g. CD19, CD24, CD27, 
CD38, CD5), to quantify the impact of rituximab treatment (if not normalized in week 40 a 
repeated test will be made in week 52) 
Routine clinical tests for 5-partsdiff including neutrophil and lymphocyte count to be able to make 
the neutrophil/lymphocyte ratio and platelet counts.Only at prescreening/baseline: 
• Serology for hepatitis B, C and HIV  
• QuantiFERON test (interferon-γ release assay) to check for response to Mycobacterium 
tuberculosis  
 
• Drug concentration of psychotropic medication 
• Assessment of autoimmune reactions against cerebral antigens (whole blood sample, stored 
in – 80° C) (application of novel findings from our group) 
• T cell activation against selected, recombinantly produced, human, cerebral peptides, using 
the method FluoroSpot, where different cytokines will act as markers for T-cell activation 
(PBMC sample, stored in – 80° C) (application of novel findings from our group) 
• Genetic analysis for identification of predisposing factors and possible outcome predictors 
(e.g. polygenic risk scores and single nucleotide polymorphisms (SNPs), related to relevant 
psychiatric disorders) by DNA microarray technology  
Blood and CSF 
At baseline, week 12 (blood only), 20 (blood and CSF) and week 40 (blood only): 
• Inflammatory markers (e.g. IL-6, IL-1Ra, sTNFR1) and chemokines (e.g. CCL2, CXCL13), 
and other immune markers (e.g. sCD14, IL-10, complement C3 and C4), measured by 
means of electrochemiluminescence immunoassay (Mesoscale instrument), hsCRP, 
Neuronal damage assessment by measuring neuron specific enolase (NSE), S100, 
neurofilament light chain (NFL), and neurotrophic substances (brain-derived neurotrophic 
factor (BDNF) and glial cell line-derived neurotrophic factor (GDNF)) 
• Metabolomics, to explore molecular target mechanisms 
Only at baseline: 
• Titres of CNS-relevant autoantibodies (e.g. anti-NMDA receptor antibodies, voltage-gated 
calcium channel (VGCC) antibodies, transglutaminase antibodies, anti-nuclear antibodies 
(ANA)) 

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CSF only  
At baseline and at week 20: 
• Routine tests for CSF (e.g. cell count, albumin and immunoglobulin quotients, oligoclonal 
bands) 
• (If sufficient number of CSF cells are available): Expression levels of pro-inflammatory 
genes (e.g. IL-1, caspase, IL-6, IL-8), analysed using real-time PCR and DNA microarray 
technology 
Microbiology 
Only at baseline: 
• Routine test for presence of group A streptococci infection 
Faeces 
At baseline and at week 20: 
Faecal samples will be collected at baseline (before intervention), and week 20 (after 
intervention). Patients will collect two spot samples of faeces in plastic containers at home at each 
time point. Analyses will include: 
• F-calprotectin 
• Metabolome 
• Microbiome; Faecal sample for quantitative and qualitative analyses of faecal microbial 
composition by 16S rRNA-based next generation sequencing (NGS). 
Urine 
Only at baseline and week 20: 
Urine samples will be collected at baseline (before interventions), and week 20 (after intervention) 
in parallel with collection of blood. Urine will be used for: 
• Screening for pregnancy prior to the rituximab treatment (week 0) 
• Illicit drug screen (baseline and week 20) 
 
At baseline and week 20: 
• 30 ml of urine, early morning sample, for assessment inflammatory markers, similar to those in 
blood 
Brain 
At baseline and week 20: 
• fMRI for assessment of altered activity and extra cellular water, which may be a sign of 
inflammation  
 
7.1.4 Procedures 
7.1.4.1 Metabolomics analyses 

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The metabolomics analyses will utilize mass spectrometry (MS) coupled with chromatographic 
separation, using two analytical approaches with broad analytical coverage. For the global 
profiling of polar metabolites, GC coupled to high resolution quadrupole-time-to-flight mass 
spectrometry (GC-QTOFMS) will be used. The analytical protocol is similar as previously 
developed for GC×GC-TOFMS (94). For the analyses of molecular lipids, ultra-high performance 
liquid chromatography combined with quadrupole-time-of-flight mass spectrometry (UHPLC-
QTOFMS) will be utilized (95).  
Orešič and Hyötyläinen, who worked together over the past eight years, have an extensive 
knowledge of these platforms for the analyses of clinical samples. Taken together, these two 
platforms allow detection of over 2000 metabolites, covering all main metabolic pathways such as 
lipid metabolism, central carbon metabolism, amino acid metabolism, urea cycle, ketogenesis as 
well metabolism, as detection of several metabolites related to nucleotide metabolism as well as 
gut microbial metabolism. The methodology combined targeted, quantitative approach with semi-
quantitative profiling. 
The lipidomics platform proposed for this study was recently assessed as part of the US National 
Institute of Standards (NIST) lipidomics ring study, which comprised 31 laboratories worldwide 
(96). Blinded NIST standard reference plasma sample (NIST SRM 1950) has been used in the 
study and we obtained excellent results (mostly within 10 % of consensus quantitative values), 
which highlights the accuracy and robustness of our lipidomics protocol. 
The Department of Natural Science and Technology at Örebro University has a state-of-the-art 
facility for metabolomics, with several MS instruments (GC-HRMS, 2 x GC-MS, 2 x UHPLC-
QqQMS, GC-QqQMS, GC-QTOFMS, UHPLC-QTOFMS, UPLC2-MS, ICP-MS), several other 
analytical instruments (CE, UHPLC) and three more instruments are being purchased in 2017 
(GC-MS, UHPLC-IM-QTOFMS, Orbitrap MS). This infrastructure can be utilised for the further 
characterization of the unknown metabolic markers. We are also currently setting up a database 
management system, including both the infrastructure (database, software) and the personnel for 
the task. 
7.1.4.2 Immune status analyses 
Analysis of inflammatory markers and immune status will be performed using a number of well-
established methods. Quantification of cytokines and other soluble markers of inflammation in 
plasma will mainly be performed using electrochemiluminscent ELISA technology, which enables 
sensitive detection coupled with a broad detection range. Furthermore, this technology allows 
multiplexing, which reduces the amount of material needed. To monitor the effect of rituximab on 
immune status, B-cells will be quantified and phenotyped using flow cytometry. Transitional, 
naı̈ve, memory and regulatory B cells will be identified using a combination of markers (CD19, 
CD24, CD27, CD38, CD5). Gene expression analysis of inflammatory genes will be performed 
using a combination of DNA microarray technology and real-time qPCR.  
These methods are available through collaboration with researchers at iRiSC. iRiSC is an 
interdisciplinary research environment that includes 10 professors and a number of junior 
scientist, all holding expertise in inflammatory regulation. The infrastructure includes data 
analysis, instruments and personnel.  
7.1.4.3 Venipuncture blood collection  

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Blood samples will be obtained for screening and routine clinical testing, analysis of pro-
inflammatory cytokines, genetic analyses and screening for biomarkers. A registered nurse or 
trained phlebotomist will utilize a sterile technique to draw blood by venipuncture. Up to 150 ml 
of blood may be obtained three times during pre-study screening, visit 7, 8 and 12 (weeks -4-0; 12, 
20 and 40), and 5 ml of blood will be obtained at visit 4 and 5 (week 2 and 5). Maximum blood 
volume is 770 ml. From the blood samples we will obtain biomarkers of inflammatory signaling 
and permeability of the gut using ELISA and Mesoscale methods.  
7.1.4.5 Lumbar puncture CSF collection 
To evaluate CSF levels of inflammatory cytokines, a lumbar puncture (LP) will be performed as 
described. LPs will be done in the L3/L4 or L4/L5 interspace following administration of local 
anesthetic. A volume of up to 20 ml of CSF will be collected in silicone-coated tubes for research. 
Tubes will be gently mixed to avoid gradient effects. CSF samples will be centrifuged at 2000g, 
8°C, for 10 minutes to remove cells (for gene expression analyses) and other insoluble material, 
aliquoted into 1 ml tubes to eliminate the need for repeated freezing and thawing, and stored at -
80oC. From the CSF samples, we will obtain biomarkers of inflammatory signaling using ELISA 
and Mesoscale methods. Mesoscale allows for complex multiplexing of up to 17 analytes in one 
sample, and will be the method of choice. The lumbar puncture is optional. 
 
 
 
7.1.4.6 Stool  
The ex vivo Ussing chamber model, well-established in the ORU lab will be used for examining 
gut permeability (97). Colonic specimens obtained by distal colonoscopy in an unprepared bowel, 
will be mounted in Ussing chambers and the effect of mucosal application of intestinal metabolites 
on intestinal transfer and permeability will be assessed in conjunction with histochemical analyses 
of the human biopsies. In all patients, in vivo segmental whole-gut permeability will be assessed 
by measuring 24-hour urinary recovery of five specific sugar probes. 
Gut microbiome. Altered gut microbiome in first episode psychosis patients has been reported. In 
a study by Schwartz (2018) (98), numbers of Lactobacillus group bacteria were elevated in first 
episode psychosis patients and signiﬁcantly correlated with symptom severity along different 
symptom domains.  
Stool samples are collected in the privacy of the patient’s own home. A kit with three containers 
will be provided to collect faeces specimen that are kept in a special isolated bag. The patient is 
requested to place the bag in the freezer of her/his home. The bag shall be kept there until a 
transport is organized to the Örebro University hospital biobank by a research assistant. To 
provide a stool sample is optional.  
7.1.4.7 Brain imaging 
Patients will undergo an fMRI-based assessment lasting approximately 2 hours (optional). Prior to 
scanning patients will be asked to once again complete a MRI checklist. Patients will also be 
asked if they have taken benzodiazepines and/or hypnotics within 24 hours of initiating MRI; 
those who have will be asked to come back for a later session. During scanning, patients will 
undergo the following protocol:  

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1. Diffusion weighted imaging: 90 gradient orientations distributed in two shells of 
b=1000 and b=2000, plus 2 b0 images; 2 mm resolution isotropic—20-minute scan 
time. We will estimate neural inflammation using a measure of regional extra-cellular 
free water derived from the diffusion weighted imaging data. We will apply to these 
data a free-water estimation algorithm that calculates the degree of cellularly 
constrained versus extra-cellular water. This method has been used reliably to 
determine levels of regional neuro-inflammation in psychiatric conditions.  
2. Brain-blood perfusion imaging: arterial spin labeling scan, 40 labeled and 40 unlabeled 
scans, 30 axial 5-mm thick axial slices, 4x4 mm in-plane resolution—6-minute scan 
time. 
3. Resting functional MRI (fMRI) scanning: blood-oxygen level dependent scan, SMS 
factor = 3, GRAPA = OFF, 32 4-mm thick axial slices with 3x3 mm in-plane 
resolution—12-minute scan time. 
4. High-resolution anatomical MRI scans:  
a. Whole-head, T1-weighted MRI scan, 1-mm isotropic voxels—6-minute scan time. 
b. Whole-head, T2-weighted MRI scan, 1-mm isotropic voxels—6-minute scan time. 
 
We will also use various fMRI paradigms for assessing social anhedonia, e.g. by studying 
diminished motivation for social affiliation and lack of reward from social incentives (99). 
Reward processing abnormalities have been implicated in pathophysiology of negative 
symptoms in schizophrenia, such as anhedonia and avolition. One method to study reward is 
to use monetary incentive delay task and affective incentive delay task (100). This paradigm 
has previously been used to investigate neural correlates of reward processing in substance 
abuse, pathological gambling, depression, schizophrenia, binge eating, and ADHD (101). 
The results in the patients will be compared to those of healthy controls. 
 
7.1.4.8 Qualitative content analysis 
The 12 participants from the study will be interviewed about their experiences about participating 
in the study, using a semi structured interview guide. The questions will be focusing on the 
participants’ experiences about the treatment, the approach from the staff their feelings about their 
psychiatric diagnosis. Our hypothesis is that the patients may have other thought about their 
psychiatric condition as it now can be viewed as an inflammatory disorder instead of purely a 
mental condition. Also we are interested in if the participants have reflected on any change in the 
approach of the staff since they now are regarded as “somatically ill patients” not simply 
“psychiatric patients”. The interviews will be transcribed verbatim and analyzed with qualitative 
content analysis. 
 

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Table 1 Study plan  
Week 
 
 
-4 – 0 
Screening prior to treatment 
with rituximab  
 
Decision on inclusion / 
exclusion 
• 
Evaluation of suitability  
• 
Vaccination check up (+varicella) 
• 
Information to not use attenuated vaccines, what 
risks are involved and signs of immunosuppression 
• 
Consent form 
• 
Information card about drug study participation 
• 
Demographics questionnaire including FTF-Brief 
• 
Treatment history 
• 
PNISSI and fine motor examination 
• 
Physical examination  
• 
Check anti-hypertensive medication* 
• 
Test for group A streptococcus 
• 
Blood sample 
• 
Routine safety: Test of hepatitis, HIV, TB and 
routine tests 
• 
Therapeutic drug monitoring  
• 
Urine: illicit drug screen and pregnancy test, 
inflammatory markers 
• 
Assessments (CGI-S and MINI, psychiatric rating 
scales, GAF, EQ-5D, Level 1 Cross-cutting symptom 
measure of global symptom severity)  
• 
Functioning: PSP and BBQ 
• Side-effects, AAR 
• UKU  
• Client satisfaction questionnaire (CSQ) 
• Cognitive tests Video recording I 
• Lumbar puncture (optional) 
• Faeces biopsy and sample (optional) 
• fMRI (optional) 
0  
Baseline  
Rituximab dose 1000 mg  
• 
Assessments (PANSS, CGI-I**, PGE, CGI-S) 
• 
Blood sample (inflammatory markers) 
 
2 
 Nurse check-up 
• 
Side-effects, AAR 
 
5, (+/- 1 week) 
 
• 
Side-effects, AAR 
• 
Patient evaluated improvement (PGE) 
• 
Blood sample (B-cell population) 
8 
Nurse check-up 
• 
Side-effects, AAR 
• 
Patient evaluated improvement (PGE) 
12 
 
• 
Assessments (PANSS, CGI-I**, PGE, CGI-S) 
• 
Side-effects, AAR 
• 
Patient evaluated improvement (PGE) 
• 
Blood sample (B-cell population) 
• 
Video recording II 
 16 
(+/- 1 week) 
Nurse check-up 
• 
Side-effects, AAR 
• 
Patient evaluated improvement (PGE) 
20-23 
20 w 
Interview + Assessments (PANSS, CGI-I*, PGE, CGI-S, 
and MINI, psychiatric rating scales, GAF, EQ-5D, Level 1 
Cross-cutting symptom measure of global symptom 
severity) 
• 
PSP 
• 
Side-effects, AAR 

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• 
UKU 
• 
Client satisfaction questionnaire (CSQ) 
• 
Physical examination  
• 
Cognitive and motor tests (from PNISSI and Nine-
Hole Peg Test) 
• 
Video recording III 
• 
Blood sample  
• 
Lumbar puncture (optional) 
• 
Faeces sample (optional) 
• 
Urine sample 
• 
fMRI (optional) 
20-24 
Clinician 
• 
Extended interview for content analysis  
24  
(+/- 1 week) 
Nurse check-up 
• 
Patient evaluated improvement (PGE) 
• 
Side-effects, AAR 
32 
(+/- 1 week) 
Nurse check-up 
• 
Patient evaluated improvement (PGE) 
• 
Side-effects, AAR 
40-43 
40 w  
• 
Interview + Assessments (PANSS; CGI-I*, PGE, CGI-
S, and MINI, psychiatric rating scales, GAF, EQ-5D) 
• 
PSP and BBQ 
• 
Client satisfaction questionnaire (CSQ) 
• 
Side-effects, AAR, UKU 
• 
Blood sample  
• 
Cognitive tests  
• 
Video recording IV 
52 
(+/- 1 week) 
1 year follow-up 
• Assessments (PANSS, CGI-I, PGE, CGI-S, GAF)  
• Side-effects, AAR 
*if the patient is treated with antihypertensive medication these should be withdrawn 12 h prior to the rituximab 
treatment 
**evaluated by clinician and next-of-kin 
 

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Table 2 
Week 
 
 
-4 - 0 
0 
1 
2 
5 
8 
12 
16 
20 
24 
32 
40 
52 
Visit 
 
 
1 
2 
3 
4 
(nur
se) 
5  
6 
(nur
se) 
7 
8 
(nur
se) 
9  
10 
(nurse
/other
) 
11 
(nur
se) 
12 
13 
Activity/ 
Assessment number 
CRF 
Y/N 
Time to 
complete 
Pre-Study 
Screening 
Baseline  
I:0 
 
 
 
 
 
 
 
20w 
 
 
40w 
 
ENROLMENT 
Eligibility screen, Consent form, Demographics 
questionnaire, Treatment history, PNISSI, Physical 
examination, FTF-Brief. Routine blood tests, hepatitis, HIV, 
TB. Vaccination check up (+varicella). Therapeutic drug 
monitoring, U-illicit drug screening,  
 
60 
min 
x 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy test (females) 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
INTERVENTION 
Rituximab, Dose 1: 4.5h 
 
 
 
X:1 
 
 
 
 
 
 
 
 
 
 
 
ASSESSMENTS 
MINI, Psychiatric rating scales  
 
45 
min 
x 
 
 
 
 
 
 
 
x 
 
 
x 
x 
Level 1 Cross-cutting symptom measure of global 
symptom severity 
 
 
x 
 
 
 
 
 
 
 
x 
 
 
 
 
GAF, PSP 
 
5 
min 
x 
 
 
 
 
 
x 
 
x 
 
 
x 
x 
CSQ, BBQ, EQ-5D 
 
10 
min 
x 
 
 
 
 
 
 
 
x 
 
 
x 
 
PANSS 
 
20 
min 
 
x 
 
 
 
 
x 
 
x 
 
 
x 
x 
CGI-S (clinician)  
 
5 
min 
x 
x 
 
 
 
 
x 
 
x 
 
 
x 
x 

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CGI-I (clinician and next of kin) 
 
10 
min 
 
x 
 
 
 
 
x 
 
x 
 
 
x 
x 
PGE (patient evaluated improvement) 
 
5 
min 
 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
UKU 
 
10 
min 
x 
 
 
 
 
 
 
 
x 
 
 
x 
 
Side effect open check up questions and AAR 
 
10 
min 
x 
 
 
x 
 x 
x 
x 
x 
x 
x 
x 
x 
x 
Blood sample 
 
15 
min 
x 
x 
 
 
x 
 
x 
 
x 
 
 
x 
 
Lumbar puncture 
 
30 
min 
x 
 
 
 
 
 
 
 
x 
 
 
 
 
Faeces sample 
 
5 
min 
x 
 
 
 
 
 
 
 
x 
 
 
 
 
Urine test (morning sample) 
 
5 
min 
x 
 
 
 
 
 
 
 
x 
 
 
 
 
fMRI 
 
120 
min 
x 
 
 
 
 
 
 
 
x 
 
 
 
 
Gut biopsy 
 
30 
min 
x 
 
 
 
 
 
 
 
 
 
 
 
 
Cognitive and motor test 
 
30 
min 
x 
 
 
 
 
 
 
 
x 
 
 
 
 
Video recording 
 
10 
min 
x 
 
 
 
 
 
x 
 
x 
 
 
x 
 
Extended interview for content analysis 
 
45 
min 
 
 
 
 
 
 
 
 
 
x 
 
 
 
Nurse in-between visits/ progress notes 
 
10 
min 
 
 
 
x 
 
x 
 
x 
 
x 
x 
 
 
BBQ = Brunnsviken Brief Quality of Life Inventory; CGI-S = Clinical Global Impression-Severity scale; CGI-I = Clinical Global Impression-Improvement scale; CSQ = Client Satisfaction Questionnaire; GAF = 
Global Assessment of Function; MINI = Mini International Neuropsychiatric Interview; MRI = Magnetic Resonance Imaging; PGE = Patient's Global Evaluation of improvement; UKU = Udvalg Kliniske 
Undersøgelser, side effect rating scale; Personal and Social Performance (PSP) Scale; EuroQol Group EQ-5D; Any Adverse Reactions (AAR). 
 

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7.2  Study Termination 
Patients may withdraw from the study at any time, of their own choice or by investigator 
decision, due to safety reasons or in case the patient is not able to comply with the protocol. 
Data collected up to the end of follow-up will be used in the final analysis of the study. If a 
patient wants to discontinue the study participation, data collected until that time point will be 
analysed in the study. 
Early termination of the study may occur due to decision of regulatory authority or ethics 
committee, safety issues or sponsor decision. The study is completed when the last patient has 
done their last study visit. 
 

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8 
STUDY MEDICATION 
8.1 Study medication 
Rituximab/MabThera®  
MabThera 1000 mg concentrate for solution for infusion,100 ml. 
Active substance: Rituximab 
ATC-code: L01XC02  
Rituximab is a sterile, clear, colourless, preservative-free liquid concentrate designed for 
intravenous administration. The product is supplied at a concentration of 10 mg/mL in 500-
mg (50-mL) single-use vials. Rituximab is formulated for intravenous administration in 
sodium chloride 9 mg/mL, sodium citrate dihydrate 7.35 mg/mL, polysorbate-80 0.7 mg/mL, 
and sterile water for infusion. The pH is adjusted to 6.5. 
 
8.2 Administration of study drugs 
A MabThera dose of 1000 mg will be given as intra-venous infusion in 1000 ml physiological 
saline (0.9 %, any brand provided by the pharmacy. Before administration of MabThera all 
patients will be given pre-medication to prevent or reduce possible side effects from 
MabThera.  
Premedication is delivered 1-2 hours prior to rituximab and consists of T. Paracetamol 1000 
mg, T. Loratadine 10 mg and T. Betapred (Betamethasone) 0.5 mg x 12 p.o (dissolved in a 
glass of water) in order to reduce the incidence of infusion-related reactions.  
Patients remain on their stabilized treatments with psychotropic drugs during the first phase 
(20 weeks) of the study. 
MabThera will be administered on one single occasion.  
The MabThera treatment is administrated at the Rheumatology clinic at Örebro University 
Hospital. Study staff at the department of Rheumatology will prepare the saline bag for each 
patient infusion, adding MabThera. All bags will be labelled with a study specific label 
(Error! Reference source not found.). Each bag for infusion will be prepared just in time for 
each visit.  
8.3 Storage and preparation of study medication 
All study drug, MabThera and saline for dilution, will be available at the department of 
Rheumatology at Örebro University hospital.  

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9 
ADVERSE EVENT, AE AND SERIOUS ADVERSE EVENT, SAE  
9.1 Adverse Events, AE 
An Adverse Event (AE) is any untoward medical occurrence in a patient/healthy volunteer 
administered a pharmaceutical product and which does not necessarily have to have a causal 
relationship with that treatment or usage. 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 medical (investigational) product, whether or not related to the 
product.  
Patients will be asked if they have experienced any AE by means of the following questions, 
administered at each visit:  
• Have you noticed any new symptoms or problems since your last visit? If yes, which?  
• Do you gather these symptoms can be related to a rituximab treatment? 
• Have you noticed if any of your previous side effects have attenuated or increased? If yes, 
which ones? 
We will also ask questions on specific adverse events that have been documented to be 
associated with rituximab treatment at each visit using the AAR. In addition, specific AEs, 
relevant for psychiatry, will be checked with the UKU Side Effect Rating Scale at endpoint 1 
and 2. 
The sponsor, as principal investigator or any investigator delegated to work in the study will 
record any AEs and assess the seriousness and severity (mild, moderate, severe) and whether 
the AE is related to the study medication. All investigators delegated to work in the study will 
report AEs to the principal investigator who is the sponsor in this study. 
All AEs that are observed from the time of the administration of study medication until the 
patient leaves the study will be registered, analysed and summarized at the end of the study.  
Only serious adverse events will be recorded in the medical record. 
9.2 Serious Adverse Event, SAE 
Each adverse event is to be classified by the investigator as serious or non-serious. An adverse 
event that meets one or more of the following criteria/outcomes is classified as serious: 
• 
Results in death 
• 
Is life-threatening, i.e., the patient was, in the opinion of the Investigator, at immediate 
risk of death from the event as it occurred (It does not include an event that, had it 
occurred in a more severe form, might have caused death.) 
• 
Results in persistent or significant disability/incapacity 
• 
Requires in-patient hospitalization or prolongs hospitalization 
• 
Is a congenital anomaly/birth defect 
• 
Is another medically significant event that, based upon appropriate medical judgment, 
may jeopardize the volunteer and may require medical or surgical intervention to prevent 
one of the outcomes listed above (e.g., allergic bronchospasm requiring intensive 
treatment in an emergency room or home, blood dyscrasias or convulsions that do not 
result in hospitalization, or the development of drug dependency or drug abuse) 

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SAE that occurs during the study will be documented and reported to sponsor within 24 hours 
after the investigator is aware of the SAE. SAEs will be documented, analysed and 
summarized at the end of the trial. SAE will be followed until the participation in the trial is 
ended or they are resolved. 
9.3 Suspected Unexpected Serious Adverse Reaction, SUSAR  
The sponsor reports all SUSARs that arise during the trial to The Medicinal Product Agency 
and Uppsala’s Ethics committee. Reports will be done by sending the CIOMS form to the 
MPA since sponsor does not have the resources to report electronically to the EudraVigilance 
database. 
A SUSAR that results in death or is life-threatening must be reported promptly and no later 
than 7 days after it occurred and was known by sponsor. Relevant follow-up information 
should be sent within another 8 days. Any other SUSARs should be reported as soon as 
possible but not later than 15 days after being brought to sponsors attention. 
 
 
10 STATISTICS  
10.1 Determination of Clinical response 
There is no power calculation due to the nature of this study, a pilot study. If at least 2 
patients improve significantly we aim to continue with a controlled study.  
Primary outcome  
Reduction in PANSS score (30 items) is the primary outcome. 40% reduction in PANSS is 
regarded as a treatment response.  
Secondary outcomes  
CGI-I score 1 or 2 which corresponds to much or very much improved at week 20 is regarded 
as response. Assuming a SD of 1 in our sample we will be able to detect differences between 
the means before and after treatment corresponding to 0.64 points on the CGI-I scale. 
Changes in PSP and clinician rated CGI-S score between enrollment and week 20.  
PSP gives a score between 0-100 for disability.  
CGI-S is a clinician rated measure of overall clinical severity that is rated on a scale between 
1 and 7. This measure also has a floor effect that affects healthy participants, for a person with 
no clinical complaints or problems (which is most people in a population) will get a score of 
1. This floor effect is not relevant to our study population. The score 7, which indicates the 
highest level of severity is phrased as “Among the most extremely ill patients”. This may be 
true to the patient group in the present study. However, since patients currently in need of 
compulsory care are excluded from the study, a ceiling effect of the measure is unlikely. 
Repeated measures of the PSP and CGI-S will be analysed using a repeated measures 
ANOVA. 

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10.2 Statistical methods and analytical plan 
10.2.1 Primary objective: Improvement reflected in change in PANSS score  
To investigate whether markedly ill, treatment-resistant, psychiatric patients according to our 
inclusion/exclusion criteria are significantly improved after treatment with the 
immunomodulatory drug rituximab (as addition to the patients’ standard treatment). 
We will analyse the clinical data on a modified intention-to-treat (ITT) definition basis, i.e. 
including treatment dropouts who received at least one dose of rituximab as well as 
completers. In addition, a completer-only analysis will be performed. The primary outcome is 
change in PANSS score, assessed by a clinician.  
Secondary outcomes: CGI-I score (range 1-7). All CGI-I ratings are performed by three 
independent raters (the patient, his or her next of kin and a clinician). The mean value of these 
three values will be used as the patients’ scores. If one of the values is missing, the mean will 
be calculated using only two values. 
One secondary outcome is binary: the proportion of responders to treatment at week 20 (and 
similarly at week 40). Treatment response is defined as a mean value below 2.5 on the CGI-I 
(calculated as above), which corresponds to the scale step descriptors “much improved” or 
“very much improved”. Non-response is defined as a mean CGI-I value of 2.5 or higher. 
The continuous secondary outcome variables at the 20-week and 40-week end points (CGI-S, 
PSP, and diagnosis specific rating scales) will be included in analysis of covariance 
(ANCOVA) models, controlling for baseline measures and demographic variables. 
Side-effects will be closely monitored and types, frequency, severity and seriousness will be 
reported.   
10.2.2 Secondary objectives: analyses of laboratory data related to clinical response  
These objectives are explorative, and our hypotheses are that clinical improvement will in 
various ways correlate with or depend on measures of inflammation. 
1. To examine whether baseline levels of inflammatory markers predict treatment response. 
2. To examine whether changes in inflammatory markers between baseline and week 20, and B-
cell depletion at weeks 5, 12 and 20 correlate with treatment response. 
3. To examine metabolic mediators prior to and after treatment and if they correlate with treatment 
response. 
4. To examine whether there is a change in markers for gut permeability related to treatment. 
5. To examine whether there is a change in CNS activity related to reward or signs of CNS 
inflammation. 
Laboratory data will consist of: plasma protein concentrations and leukocyte mRNA 
expression values for a number of cytokines and related substances (inflammatory markers); 
total number of B-lymphocytes and number of cells from various B-cell subsets at week 5, 12 
and 20, as measured through highly sensitive flow cytometry (HSFC); plasma proteins and 
lipids as measured through metabolomics analysis; and blood levels of markers for gut 
permeability. The study of these variables in psychiatric patients is still regarded as 
exploratory. 

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All these laboratory values (except metabolomics data) will be tested for normality (Shapiro-
Wilk) and homogeneity of variances (Levene’s test) and, if deemed necessary, log transform-
ation will be used to achieve normality. If normality cannot be achieved through log trans-
formation, non-parametric test will be used for analyses. 
In order to examine whether baseline characteristics can predict response from rituximab, 
baseline values of all these measurements (except HSFC) will be compared between the two 
groups “responders” and “non-responders” after completion of the study by means of t-tests 
or Mann-Whitney tests, as applicable. Due to the explorative nature of this study, data will be 
examined both corrected and un-corrected for multiple comparisons. In addition, for each of 
these measurements, a generalized linear model (ANCOVA) will be built, with continuous 
measures of clinical improvement as dependent variable and possible confounders (e.g. age, 
sex and BMI) as covariates. 
In order to examine whether changes in inflammatory markers and other measurements 
correlate with clinical response, the difference between baseline values and week-20 values 
(Δ-values) of all relevant measurements will be compared between the two groups 
“responders” and “non-responders” after completion of the study by means of t-tests or Mann-
Whitney tests, as applicable. Due to the explorative nature of this study, data will be 
examined both corrected and un-corrected for multiple comparisons. In addition, each of these 
Δ -values will be introduced into a generalized linear model (ANCOVA), with continuous 
measures of clinical improvement as dependent variable and possible confounders (e.g. age, 
sex and BMI) as covariates. In addition, an exploratory principal component analysis (PCA) 
will be performed, in order to identify patterns of changes among the inflammatory markers 
that are related to clinical response. 
The HSFC B-cell counts at week 5 and 12 will be used as validation of rituximab immuno-
logical impact. The clinical response will be compared with statistics as above between 
patients with complete (<0.0001×109/L) and incomplete (>0.0001×109/L) depletion of B-
cells, respectively. Also B-cell subpopulations at week 20 will be correlated to clinical 
response. 
Statistical analysis of the metabolomic data (baseline and Δ -values) will be performed 
similarly, however, correction for multiple comparisons by means of the Benjamini–Hoch-
berg procedure and other methods for biostatistics and bioinformatics will be applied. 
Δ -values of markers for gut permeability will be compared between pre and post treatment, 
in order to document whether rituximab has an effect on gut permeability. 
For statistical analysis of genomic and microbiome data, appropriate methods for biostatistics 
and bioinformatics will be applied.  
10.2.3 Analyses of other clinical data related to clinical response  
1. Change in PSP, measuring overall disability from baseline up to week 20. 
2. Change from baseline up to week 20 of illness severity (CGI-S) assessed by the clinician.  
3. Change from baseline on rating scales that measure psychiatric symptoms according to 
psychiatric rating scales.  
4. To examine whether there is a change in cognition after treatment. 

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5. To investigate the patients’ experiences of the novel treatment with a qualitative content 
analysis. 
 
For results on the scales (PSP, CGI-S and psychiatric rating scales) the week 20 scores and 
the Δ-values (difference between scores at week 20 and baseline) will be tested by means of t-
tests or Mann-Whitney tests, as applicable. They will also be included in an analysis of 
covariance (ANCOVA) model, controlling for baseline measures and other possible 
confounders, as demographic variables. The cognitive tests will be analysed with established 
methods, and possible changes will be compared before and after treatment. The qualitative 
content analysis does not involve quantitative statistics. 
 
10.2.4 Analyses of long-term outcomes (week 40) 
1. Improvement according to PANSS and Clinical Global Impression-Improvement (CGI-I) at 
week 40  
2. Differences between baseline and week 40 concerning CGI-S, PSP, BBQ, diagnosis specific 
scales and cognitive function 
3. Inflammatory markers and B-cell populations at week 40 
The results at week 40 on these variables will be analysed with essentially the same methods 
as those at week 20, see above. 
 
11 QUALITY CONTROL AND QUALITY ASSURANCE 
11.1 Monitoring 
The study will be monitored at least once before start, during the study and after the study is 
completed. The monitoring will be performed to assure that the rights and wellbeing of the 
patients are protected; the study is conducted according to the protocol, that all essential 
documents are available, that data are collected, documented and reported according to ICH-
GCP (Good Clinical Practice) and applicable ethical and regulatory rules and directives.  
The aim of the monitoring is also to secure that collected data are correct, complete, legible 
and verifiable from source documents if applicable. 
Monitoring will be done by monitors from the Clinical Trials Unit (Avdelningen för kliniska 
prövningar) at Örebro University Hospital, who are in no other way involved in the study. 
11.2 Data monitoring 
The PI and the research group associated with Örebro University will constitute a data 
monitoring committee (DMC). If any patient develops severe side effect, such as progressive 
multifocal leukoencephalopathy (PML), the study shall be stopped. The PI will have access to 
the results and make the final decision to terminate the trial. 
 

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12  ETHICS 
12.1 Ethical Conduct of the Trial 
The trial will be conducted in compliance with the protocol, in accordance with the latest 
adopted version of the Helsinki declaration, ICH-GCP and the applicable regulatory 
requirements. 
12.2 Informed Consent 
Patients who may be suitable to participate in the study will be informed about the study 
during one of their regular visits at the clinic and through personnel at inpatient clinics. We 
may also inform the patient interest associations for psychiatric disorders about the study; and 
patients living in psychiatric housing located in Region Örebro County, and enable patients 
from other parts of the country to participate, if we cannot find suitable patients within our 
catchment area. Patients will be given written information about the study, time to read it and 
the opportunity to ask the investigator any questions they may have. All patients will be asked 
to sign the written consent. Individuals who do not want to participate are not included in the 
study. The patients are informed that their participation is voluntary and that they may choose 
to withdraw from the study at any time, without repercussions. Only patients who are able to 
make an informed decision the study will be included. 
If the patient agrees to participate in the study they will sign the informed consent form 
together with the investigator, who will then sign the consent form as well. A copy of the 
signed informed consent will be given to the patient. 
12.3 Risk/benefit assessment 
Patients will share personal information, which could be perceived as intrusive. However, all 
collected data will be coded and data will only be presented at a group level. Blood sampling 
and lumbar puncture can cause pain, but only for a brief period. The fMRI and gut 
examination can be experienced as difficult but it is not painful or dangerous. Handling urine 
and faeces samples may cause discomfort in the patient. In this study, only blood samples 
collected at baseline and week 20, in addition to responses to questionnaires at baseline and 
week 20 for assessment of outcome, are mandatory for participation.  
The patients' expectations of the study and its intervention may be high, which can generate 
disappointment among those who do not experience a positive effect from the study drug.  
Side effects of rituximab treatment may occur, some of those can be serious, but rituximab is 
usually well tolerated. Among patients with rheumatoid arthritis, even mild side effects are 
reported to be rare. According to the Summary of Products Characteristics (SmPC), between 
1/100 and 1/1000 patients report depression and/or increased nervousness as a side effect 
from rituximab. The prevalence for these side effects is unknown among psychiatric patients. 
However, all side effects will be carefully documented in the present study. If the patient 
becomes depressed or severely anxious discontinuation of the study drug should be 
considered. Rituximab is a standard treatment for multiple sclerosis and rheumatoid arthritis 
in Sweden. Approximately 5,000 patients with rheumatoid arthritis is treated with MabThera 
(48/100 000) and as MabThera is prescribed off label for MS another 5 to15,000 patients 
receive this treatment yearly for this indication (227/100,000 are diagnosed with MS, Danish 
data). In Örebro, rituximab is administered to the rheumatoid arthritis patients on a day-ward 
at Örebro University hospital, run by specially trained nurses.  

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The side effects of rituximab include infusion reactions, severe skin and mouth reactions, 
hepatitis B virus reactivation and in extremely rare cases (1/25000 in patients with rheumatoid 
arthritis (102), progressive multifocal leukoencephalopathy (PML), a serious brain infection 
caused by the JC virus. We will collaborate with a senior rheumatologist who is experienced 
with rituximab. Since the treatment may activate latent infections, all patients will be screened 
for hepatitis and HIV prior to the study. The patients will be pre-medicated to reduce the risk 
of infusion-related side effects, and they are carefully monitored during the course of the 
study. 
The reason to not use a standard drug for inflammation, such as cortisone, is because it may 
induce mania in susceptible individuals and is therefor not suitable for psychiatric patients.  
We will film the patients on three different occasions. This is because we want to be able to 
show the patient if there is a treatment effect or not. It may also enable a completely external 
assessment of treatment effects. Since rituximab has not been tested in trials of psychiatric 
disorder an effect of the drug can be questioned. In such case we possibly could show video 
clips of treatment effects, if the patient allows it (but this is not included in this study). The 
film clips may also support a request for further treatment with the drug.   
Early onset of severe psychiatric disability is associated with a particularly poor long-term 
prognosis. This is often the case for schizophrenia. Delayed treatment may cause persistent 
brain damage if associated with inflammation in the brain (which is presumed). We believe 
that earlier treatments may have better effects on the symptoms than treatment that are first 
provided after many years with the disease. Also, rituximab is frequently used for treating 
children and adolescents with MS (103). Thus it would be unjust to exclude them from 
participation in a trial with a medication that may prove helpful. 
The patients will remain on their standard psychiatric treatment throughout the course of the 
study and are allowed to adapt their medication dose accordingly. Therefore, we do not put 
the patient’s mental health at risk. The side effects of rituximab do not coincide with those 
that can be expected from psychiatric medication (apart from possibly clozapine), which 
implies low risk for add-on side effects.  
To conclude, chronic psychiatric disorders that do not respond to treatments may cause severe 
suffering in the patient and his/her family members. It is also associated with poor quality of 
life and increased suicide risks. Thus the possible benefits from treatment with rituximab must 
be balanced against the risk of taking the drug. Moreover, even if the treatment proves 
ineffective for treating psychiatric symptoms, the trial would nevertheless be valuable; we 
will publish the results and other research groups can take part of our findings.  
12.4 Considerations regarding group size  
The study population is small, which may conceal a treatment effect of rituximab. For this 
reason, a large study population would be beneficial. However, rituximab has not been tested 
in a trial with psychiatric patients before; we do not know how psychiatric patients will 
respond to the drug. Therefore, inclusion of a large group of patients, at this point of time, 
cannot be defended on ethical grounds. Rather, we will be careful.  
We will only include markedly ill psychiatric patients, which may endorse a selection of 
patients who is currently in a particularly poor phase of their disorder. Markedly ill patients 
with schizophrenia are rarely placebo responders. However, also chronic psychiatric disorders 
go with symptom fluctuations, and some symptoms may remit spontaneously. Improvement is 
most likely to happen in the most affected group.  

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13 DATA HANDLING AND RECORD KEEPING 
13.1 Case Report Form, CRF 
A study database with all patients included in the study will be generated. The patients’ 
identity will be coded, names and social security numbers will not be entered in the CRF. The 
code list, identifying the patients, will be kept locked up, only accessible to study personnel. 
13.2 Source data 
Source data in the study will be defined in the source data list. All source data will be made 
available as requested for monitoring, audits and inspections for confirmation that all 
collected data is in keeping with the source data.   
13.3 Data management  
Data management and data handling will be completed in accordance with applicable 
regulations. Only study personnel will have access to and handle study data. 
13.4 End of trial and archiving 
The study will end when the last patient has completed the last visit. Data collected during 
the study will be archived for at least 10 years after the study has been completed. 
Study results will be summarized and submitted to the Regulatory Authority and the 
Ethics Committee within 12 months after completion of the trial. 

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14 INSURANCE 
The volunteers are covered by The Swedish Patient’s insurance and The Swedish 
Pharmaceutical Insurance during the study. 
15 PROTOCOL AMENDMENTS 
Amendments, protocol additions and essential changes of the protocol may only be 
implemented after approval of a written application to The Ethics Committee and/or The 
Medicinal Products Agency.  
16 PUBLICATION 
An annual safety report will be submitted to the Medicinal Products Agency and the Ethics 
Committee.  
Study results will be summarized and submitted in a report to the Medicinal Products 
Agency and the Ethics Committee within 12 months after completion of the trial.  
The results will be submitted for publishing in suitable scientific journals and may be 
presented at meetings and conferences. 
The results will only be presented on statistic group levels, so that no individual patient can be 
identified. 
 
 

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18 APPENDIX 1, DECLARATION OF HELSINKI 
 
WORLD MEDICAL ASSOCIATION DECLARATION OF HELSINKI 
Ethical Principles for Medical Research Involving Human Subjects 
Adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964 and amended by the: 
29th WMA General Assembly, Tokyo, Japan, October 1975 
35th WMA General Assembly, Venice, Italy, October 1983 
41st WMA General Assembly, Hong Kong, September 1989 
48th WMA General Assembly, Somerset West, Republic of South Africa, October 1996 
52nd WMA General Assembly, Edinburgh, Scotland, October 2000  
53rd WMA General Assembly, Washington DC, USA, October 2002 (Note of Clarification added) 
55th WMA General Assembly, Tokyo, Japan, October 2004 (Note of Clarification added) 
59th WMA General Assembly, Seoul, Republic of Korea, October 2008 
64th WMA General Assembly, Fortaleza, Brazil, October 2013 
 
PREAMBLE 
1. The World Medical Association (WMA) has developed the Declaration of Helsinki as a statement of ethical 
principles for medical research involving human subjects, including research on identifiable human material and 
data. 
The Declaration is intended to be read as a whole and each of its constituent paragraphs should be applied with 
consideration of all other relevant paragraphs. 
2 Consistent with the mandate of the WMA, the Declaration is addressed primarily to physicians. The WMA 
encourages others who are involved in medical research involving human subjects to adopt these principles.  
GENERAL PRINCIPLES 
3. The Declaration of Geneva of the WMA binds the physician with the words, “The health of my patient will be 
my first consideration,” and the International Code of Medical Ethics declares that, “A physician shall act in the 
patient's best interest when providing medical care.” 
4. It is the duty of the physician to promote and safeguard the health, well-being and rights of patients, including 
those who are involved in medical research. The physician's knowledge and conscience are dedicated to the 
fulfilment of this duty.  
5. Medical progress is based on research that ultimately must include studies involving human subjects. 
6. The primary purpose of medical research involving human subjects is to understand the causes, development 
and effects of diseases and improve preventive, diagnostic and therapeutic interventions (methods, procedures 
and treatments). Even the best proven interventions must be evaluated continually through research for their 
safety, effectiveness, efficiency, accessibility and quality. 
7. Medical research is subject to ethical standards that promote and ensure respect for all human subjects and 
protect their health and rights. 
8. While the primary purpose of medical research is to generate new knowledge, this goal can never take 
precedence over the rights and interests of individual research subjects. 
9. It is the duty of physicians who are involved in medical research to protect the life, health, dignity, integrity, 
right to self-determination, privacy, and confidentiality of personal information of research subjects. The 
responsibility for the protection of research subjects must always rest with the physician or other health care 
professionals and never with the research subjects, even though they have given consent. 
10. Physicians must consider the ethical, legal and regulatory norms and standards for research involving human 
subjects in their own countries as well as applicable international norms and standards. No national or 
international ethical, legal or regulatory requirement should reduce or eliminate any of the protections for 
research subjects set forth in this Declaration. 
 
 

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11. Medical research should be conducted in a manner that minimises possible harm to the environment. 
12. Medical research involving human subjects must be conducted only by individuals with the appropriate 
ethics and scientific education, training and qualifications. Research on patients or healthy volunteers requires 
the supervision of a competent and appropriately qualified physician or other health care professional. 
13. Groups that are underrepresented in medical research should be provided appropriate access to participation 
in research. 
14. Physicians who combine medical research with medical care should involve their patients in research only to 
the extent that this is justified by its potential preventive, diagnostic or therapeutic value and if the physician has 
good reason to believe that participation in the research study will not adversely affect the health of the patients 
who serve as research subjects. 
15. Appropriate compensation and treatment for subjects who are harmed as a result of participating in research 
must be ensured. 
RISKS, BURDENS AND BENEFITS  
16. In medical practice and in medical research, most interventions involve risks and burdens. 
Medical research involving human subjects may only be conducted if the importance of the objective outweighs 
the risks and burdens to the research subjects. 
17. All medical research involving human subjects must be preceded by careful assessment of predictable risks 
and burdens to the individuals and groups involved in the research in comparison with foreseeable benefits to 
them and to other individuals or groups affected by the condition under investigation. 
Measures to minimise the risks must be implemented. The risks must be continuously monitored, assessed and 
documented by the researcher.  
18. Physicians may not be involved in a research study involving human subjects unless they are confident that 
the risks have been adequately assessed and can be satisfactorily managed. 
When the risks are found to outweigh the potential benefits or when there is conclusive proof of definitive 
outcomes, physicians must assess whether to continue, modify or immediately stop the study. 
VULNERABLE GROUPS AND INDIVIDUALS 
19. Some groups and individuals are particularly vulnerable and may have an increased likelihood of being 
wronged or of incurring additional harm. 
All vulnerable groups and individuals should receive specifically considered protection. 
20. Medical research with a vulnerable group is only justified if the research is responsive to the health needs or 
priorities of this group and the research cannot be carried out in a non-vulnerable group. In addition, this group 
should stand to benefit from the knowledge, practices or interventions that result from the research. 
SCIENTIFIC REQUIREMENTS AND RESEARCH PROTOCOLS  
21. Medical research involving human subjects must conform to generally accepted scientific principles, be 
based on a thorough knowledge of the scientific literature, other relevant sources of information, and adequate 
laboratory and, as appropriate, animal experimentation. The welfare of animals used for research must be 
respected. 
22. The design and performance of each research study involving human subjects must be clearly described and 
justified in a research protocol. 
The protocol should contain a statement of the ethical considerations involved and should indicate how the 
principles in this Declaration have been addressed. The protocol should include information regarding funding, 
sponsors, institutional affiliations, potential conflicts of interest, incentives for subjects and information 
regarding provisions for treating and/or compensating subjects who are harmed as a consequence of participation 
in the research study. 
In clinical trials, the protocol must also describe appropriate arrangements for post-trial provisions. 
 
 
RESEARCH ETHICS COMMITTEES 

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23. The research protocol must be submitted for consideration, comment, guidance and approval to the 
concerned research ethics committee before the study begins. This committee must be transparent in its 
functioning, must be independent of the researcher, the sponsor and any other undue influence and must be duly 
qualified. It must take into consideration the laws and regulations of the country or countries in which the 
research is to be performed as well as applicable international norms and standards but these must not be allowed 
to reduce or eliminate any of the protections for research subjects set forth in this Declaration.  
The committee must have the right to monitor ongoing studies. The researcher must provide monitoring 
information to the committee, especially information about any serious adverse events. No amendment to the 
protocol may be made without consideration and approval by the committee. After the end of the study, the 
researchers must submit a final report to the committee containing a summary of the study’s findings and 
conclusions.  
PRIVACY AND CONFIDENTIALITY  
24. Every precaution must be taken to protect the privacy of research subjects and the confidentiality of their 
personal information. 
INFORMED CONSENT  
25. Participation by individuals capable of giving informed consent as subjects in medical research must be 
voluntary. Although it may be appropriate to consult family members or community leaders, no individual 
capable of giving informed consent may be enrolled in a research study unless he or she freely agrees. 
26. In medical research involving human subjects capable of giving informed consent, each potential subject 
must be adequately informed of the aims, methods, sources of funding, any possible conflicts of interest, 
institutional affiliations of the researcher, the anticipated benefits and potential risks of the study and the 
discomfort it may entail, post-study provisions and any other relevant aspects of the study. The potential subject 
must be informed of the right to refuse to participate in the study or to withdraw consent to participate at any 
time without reprisal. Special attention should be given to the specific information needs of individual potential 
subjects as well as to the methods used to deliver the information. 
After ensuring that the potential subject has understood the information, the physician or another appropriately 
qualified individual must then seek the potential subject’s freely-given informed consent, preferably in writing. 
If the consent cannot be expressed in writing, the non-written consent must be formally documented and 
witnessed.  
All medical research subjects should be given the option of being informed about the general outcome and 
results of the study. 
27. When seeking informed consent for participation in a research study the physician must be particularly 
cautious if the potential subject is in a dependent relationship with the physician or may consent under duress. In 
such situations the informed consent must be sought by an appropriately qualified individual who is completely 
independent of this relationship. 
28. For a potential research subject who is incapable of giving informed consent, the physician must seek 
informed consent from the legally authorised representative. These individuals must not be included in a 
research study that has no likelihood of benefit for them unless it is intended to promote the health of the group 
represented by the potential subject, the research cannot instead be performed with persons capable of providing 
informed consent, and the research entails only minimal risk and minimal burden. 
29. When a potential research subject who is deemed incapable of giving informed consent is able to give assent 
to decisions about participation in research, the physician must seek that assent in addition to the consent of the 
legally authorised representative. The potential subject’s dissent should be respected. 
30. Research involving subjects who are physically or mentally incapable of giving consent, for example, 
unconscious patients, may be done only if the physical or mental condition that prevents giving informed consent 
is a necessary characteristic of the research group. In such circumstances the physician must seek informed 
consent from the legally authorised representative. If no such representative is available and if the research 
cannot be delayed, the study may proceed without informed consent provided that the specific reasons for 
involving subjects with a condition that renders them unable to give informed consent have been stated in the 
research protocol and the study has been approved by a research ethics committee. Consent to remain in the 
research must be obtained as soon as possible from the subject or a legally authorised representative. 
31. The physician must fully inform the patient which aspects of their care are related to the research. The refusal 
of a patient to participate in a study or the patient’s decision to withdraw from the study must never adversely 
affect the patient-physician relationship. 

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32. For medical research using identifiable human material or data, such as research on material or data 
contained in biobanks or similar repositories, physicians must seek informed consent for its collection, storage 
and/or reuse. There may be exceptional situations where consent would be impossible or impracticable to obtain 
for such research. In such situations the research may be done only after consideration and approval of a research 
ethics committee. 
USE OF PLACEBO 
33. The benefits, risks, burdens and effectiveness of a new intervention must be tested against those of the best 
proven intervention(s), except in the following circumstances: 
Where no proven intervention exists, the use of placebo, or no intervention, is acceptable; or 
Where for compelling and scientifically sound methodological reasons the use of any intervention less effective 
than the best proven one, the use of placebo, or no intervention is necessary to determine the efficacy or safety of 
an intervention and the patients who receive any intervention less effective than the best proven one, placebo, or 
no intervention will not be subject to additional risks of serious or irreversible harm as a result of not receiving 
the best proven intervention.  
Extreme care must be taken to avoid abuse of this option. 
POST-TRIAL PROVISIONS 
34. In advance of a clinical trial, sponsors, researchers and host country governments should make provisions for 
post-trial access for all participants who still need an intervention identified as beneficial in the trial. This 
information must also be disclosed to participants during the informed consent process. 
RESEARCH REGISTRATION AND PUBLICATION AND DISSEMINATION OF RESULTS 
35. Every research study involving human subjects must be registered in a publicly accessible database before 
recruitment of the first subject. 
36. Researchers, authors, sponsors, editors and publishers all have ethical obligations with regard to the 
publication and dissemination of the results of research. Researchers have a duty to make publicly available the 
results of their research on human subjects and are accountable for the completeness and accuracy of their 
reports. All parties should adhere to accepted guidelines for ethical reporting. Negative and inconclusive as well 
as positive results must be published or otherwise made publicly available. Sources of funding, institutional 
affiliations and conflicts of interest must be declared in the publication. Reports of research not in accordance 
with the principles of this Declaration should not be accepted for publication. 
UNPROVEN INTERVENTIONS IN CLINICAL PRACTICE 
37. In the treatment of an individual patient, where proven interventions do not exist or other known 
interventions have been ineffective, the physician, after seeking expert advice, with informed consent from the 
patient or a legally authorised representative, may use an unproven intervention if in the physician's judgement it 
offers hope of saving life, re-establishing health or alleviating suffering. This intervention should subsequently 
be made the object of research, designed to evaluate its safety and efficacy. In all cases, new information must be 
recorded and, where appropriate, made publicly available. 

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ADDITIONAL PRINCIPLES FOR MEDICAL RESEARCH COMBINED WITH 
MEDICAL CARE 
31. The physician may combine medical research with medical care only to the extent that the research is 
justified by its potential preventive, diagnostic or therapeutic value and if the physician has good reason to 
believe that participation in the research study will not adversely affect the health of the patients who serve as 
research subjects. 
32. The benefits, risks, burdens and effectiveness of a new intervention must be tested against those of the best 
current proven intervention, except in the following circumstances: 
• The use of placebo, or no treatment, is acceptable in studies where no current proven intervention exists; or 
• Where for compelling and scientifically sound methodological reasons the use of placebo is necessary to 
determine the efficacy or safety of an intervention and the patients who receive placebo or no treatment will not 
be subject to any risk of serious or irreversible harm. Extreme care must be taken to avoid abuse of this option. 
33. At the conclusion of the study, patients entered into the study are entitled to be informed about the outcome 
of the study and to share any benefits that result from it, for example, access to interventions identified as 
beneficial in the study or to other appropriate care or benefits. 
34. The physician must fully inform the patient which aspects of the care are related to the research. The refusal 
of a patient to participate in a study or the patient’s decision to withdraw from the study must never interfere 
with the patient-physician relationship. 
35. In the treatment of a patient, where proven interventions do not exist or have been ineffective, the physician, 
after seeking expert advice, with informed consent from the patient or a legally authorized representative, may 
use an unproven intervention if in the physician's judgement it offers hope of saving life, re-establishing health 
or alleviating suffering. Where possible, this intervention should be made the object of research, designed to 
evaluate its safety and efficacy. In all cases, new information should be recorded and, where appropriate, made 
publicly available.