A Double-Blind, Placebo-controlled, Single Ascending Dose (SAD), Multiple Ascending Dose (MAD) and CSF Capture Study of the Safety, Pharmacokinetics and Pharmacodynamics of (2R,6R)-Hydroxynorketamine in Healthy Volunteers
Phase: PHASE1
Conditions: Major Depressive Disorder
Sponsor: National Institute of Mental Health (NIMH)

Protocol Ref. #: HNK-378227-03 
Page 1 of 96 
CONFIDENTIAL 
Phase 1 Evaluation of (2R,6R)-Hydroxynorketamine 
Protocol 
A Double-Blind, Placebo-controlled, Single Ascending Dose (SAD), Multiple 
Ascending Dose (MAD) and CSF Capture Study of the Safety, Pharmacokinetics 
and Pharmacodynamics of (2R,6R)-Hydroxynorketamine in Healthy Volunteers 
Protocol Status: Final 
Protocol Date: 11-15-2023 
Protocol Version: 7.0 
Investigational Product: (2R,6R)-Hydroxynorketamine 
Protocol Reference Number: HNK-378227-04 
IND/EudraCT Number: 143526 
 
 
Sponsor:  
National Institute of Mental Health 
 
 
 
 
 
 
Sponsor Signatory: 
Carlos Zarate, M.D. 
National Institute of Mental Health 
Hatfield Clinical Research Center 
Room 7-5432, MSC 1282 
Bethesda, MD 20892 
zaratec@mail.nih.gov 
 
Principal Investigator:  
Shruti Raja, MD, MHS 
Duke University Medical Center 
Box 3403 DUMC, Duke South Clinic 
Durham, NC 27710 
shruti.raja@duke.edu 
 
 
 
Information described herein is confidential and may be disclosed only with the 
express written permission of the Sponsor. 
 
 
 
 
 
 

Protocol Ref. #: HNK-378227-03 
Page 2 of 96 
CONFIDENTIAL 
History of revisions to the Phase 1 protocol.  
The following table presents the noteworthy changes for each version of the Phase 1 
protocol for (2R,6R)-Hydroxynorketamine. 
Protocol  
Version  
 
Date 
 
Section 
 
Description of Change 
2.0 
10/23/2020 Study  
Contacts 
Updated the study contact information for the 
pharmacokinetics lead to Robert Tweig.  
2.0 
10/23/2020 9.3 
Removal of relatedness aspects of the stopping 
rules.  
2.0 
10/23/2020 11.7 
Removal of unnecessary details describing the 
IDP, Diluent and administration equipment. This 
information is contained within the MOP.  
2.0 
10/23/2020 11.9 
Addition of reporting language for SAEs.   
2.0 
11/11/2020 11.9 
Addition of capture of abuse-related AE’s 
3.0 
3/3/2021 
Study  
Contacts 
Change in PK lead to Satya Avula 
4.0 
3/21/2022 
Study  
Contacts 
Change in study PI to Shruti Raja 
4.0 
3/21/2022 
Synopsis 
Edits and additional details (cohort #, dose) 
around the MAD study protocols 
4.0 
3/21/2022 
Synopsis 
Additional of the CSF Capture study protocols 
4.0 
3/21/2022 
Tables 
Revised MAD study schedule of assessments 
and procedures  
4.0 
3/21/2022 
Tables 
Added CSF Capture study schedule of 
assessments and procedures 
4.0 
3/21/2022 
Figures 
Added Visual representation of MAD and CSF 
Capture study timelines 
4.0  
3/21/2022 
TOC 
Table of contents changes 
4.0 
3/21/2022 
7.0 
Addition of CSF Capture study design section 
4.0 
3/21/2022 
Multiple 
References to the CSF Capture study design 
added throughout multiple sections 
4.0 
3/21/2022 
12.9 
Addition of AE response procedures 
4.0 
3/21/2022 
Tables 
11& 12 
Addition of CSF Capture study blood draw 
schedule and CSF draw schedule 
5.0  
5/24/2022 
 
Corrections and Updates for consistency 
6.0 
 
 
Remove CSF Capture Cohort #10, revise Cohort 
#9 
7.0 
11/15/2023 Synopsis 
Updated objectives to reflect study design 
 
 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 3 of 96 
CONFIDENTIAL 
SPONSOR AND MEDICAL MONITOR APPROVAL 
I have read the following and approve it: 
 
SPONSOR SIGNATORY 
 
 
 
 
 
Carlos Zarate, M.D. 
 
Date 
National Institute of Mental Health 
Hatfield Clinical Research Center 
Room 7-5432, MSC 1282 
Bethesda, MD 20892 
 
 
 
 
 
PRINCIPAL INVESTIGATOR 
 
 
 
 
 
 
Shruti Raja, M.D. 
 
Date 
 
Duke University Medical Center 
Box 3403 DUMC, Duke South Clinic 
Durham, NC 27710 
 
 
 
 
 
MEDICAL MONITOR 
 
 
 
 
 
 
Daniel Laskowitz, M.D. 
 
Date 
Duke Clinical Research Institute (DCRI) 
Duke University Medical Center 
Box 3403 DUMC, Duke South Clinic 
Durham, NC 27710 
 
 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 4 of 96 
CONFIDENTIAL 
STUDY CONTACTS 
 
PHARMACY SERVICES QUALITY ASSURANCE  
 
 
 
 
 
 
Nicole Lim, M.S. 
 
Date 
Office of Research Support and Compliance 
Warren Grant Magnuson Clinical Center 
National Institutes of Health 
 
 
 
 
 
PHARMACOKINETICS SERVICES MANAGMENT 
 
 
 
 
 
 
Satya Avula, Ph.D. 
 
Date 
Lead Scientist 
Bioanalytical Services 
Covance, Inc.  
 
 
 
 
STUDY INVESTIGATOR 
 
 
 
 
 
 
Craig Thomas, Ph.D. 
 
Date 
Group Leader, Division of Preclinical Innovation 
National Center for Advancing Translational Sciences 
 
 
 
 
STUDY INVESTIGATOR 
 
 
 
 
 
 
Todd Gould, M.D. 
 
Date 
Professor, Department of Psychiatry 
University of Maryland School of Medicine 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 5 of 96 
CONFIDENTIAL 
SYNOPSIS 
 
Title: A Double-Blind, Placebo-controlled, Single Ascending Dose (SAD), Multiple 
Ascending Dose (MAD)  and CSF Capture Study of the Safety, Pharmacokinetics and 
Pharmacodynamics of (2R,6R)-Hydroxynorketamine in Healthy Volunteers 
Sponsor: National Institute of Mental Health 
Name of drug substance: (2R,6R)-Hydroxynorketamine hydrochloride 
Name of investigational drug product: (2R,6R)-Hydroxynorketamine hydrochloride solution 
for injection 
Clinical Phase: Phase 1 
Clinical Site: Duke Clinical Research Institute, Duke University School of Medicine 
Objectives: 
 
Primary: 
● Determine the safe dose range of (2R,6R)-Hydroxynorketamine 
● Determine the pharmacokinetics of (2R,6R)-Hydroxynorketamine administered in 
single ascending doses 
● Determine the pharmacokinetics of (2R,6R)-Hydroxynorketamine administered in 
multiple ascending doses 
 
Exploratory: 
● Collect quantitative electroencephalography (qEEG) data following administration of 
(2R,6R)-Hydroxynorketamine in healthy Subjects as a pharmacodynamic biomarker  
● Assess the concentration of (2R,6R)-Hydroxynorketamine in cerebral spinal fluid 
(CSF) following a single IV administration 
 
Methodology/study design: 
 
A 6-cohort single ascending dose (SAD) study will be conducted in healthy volunteers 
utilizing a slow-infusion intravenous (IV) route of administration. Standard safety, 
pharmacokinetics (PK) and qEEG monitoring will be evaluated at all dose levels. 
Subsequently, a 2-cohort multiple ascending dose (MAD) study will be conducted. Doses will 
be administered on days 1,4, 8, and 11. Standard safety parameters will be monitored, and PK 
will be evaluated at all dose levels.  
Finally, a single cohort of healthy volunteers will receive a single dose by slow-infusion IV 
and have PK samples collected from both blood and cerebrospinal fluid (CSF). 
 
Study drugs, formulation, dose and route of administration: 
 
(2R,6R)-Hydroxynorketamine hydrochloride will be administered intravenously over a 
40-minute period as a solution in a 25 mM sodium phosphate 0.9% w/v saline solution. The 
SAD doses will range from 0.1 mg/kg to 4.0 mg/kg and the investigational drug product will 
be diluted into a 53 mL total volume of formulant.   

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 6 of 96 
CONFIDENTIAL 
 
Placebo will be made up of a 0.9% w/v saline solution (53 mL total volume) also administered 
via slow IV infusion over a 40-minute period.   
 
Subjects: 
 
A total of 48 Subjects are planned to be enrolled in a 6-cohort SAD study (36 in the treatment 
groups and 12 in the control groups). All SAD cohorts will have 6 Subjects in the treatment 
group and 2 Subjects in placebo group.   
 
All cohorts in the SAD study will incorporate sentinel dosing which will include 1 active and 
1 placebo Subject. All remaining Subjects will be dosed at least 24 hours after the sentinel 
cohort participants.  
 
A total of 16 Subjects are planned to be enrolled in a 2 cohort MAD study (12 in the treatment 
groups and 4 in the control groups). All MAD cohorts will have 6 Subjects in the treatment 
group and 2 Subjects in placebo group.    
 
A total of 6 subjects are planned to be enrolled in a 1 cohort CSF capture study. The CSF 
cohort will have 4 in the treatment group and 2 in the control group.  
 
Additional cohorts (both SAD and MAD) may be enrolled if it is determined that an 
intermediate or higher dose level should be evaluated upon review of both safety and PK data. 
The Institutional Review Board will be notified of this revised approach. 
 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 7 of 96 
CONFIDENTIAL 
Pharmacokinetics: 
 
Serial PK blood samples will be collected during the SAD portion for each Subject receiving 
drug and placebo at 9 timepoints (preinfusion, end-of-infusion [approximately 40 minutes], 1, 
2, 4, 8, 12, 24, and approximately 48 hr after the start of the infusion). Pharmacokinetic urine 
samples will be collected during the SAD study for each Subject receiving drug and placebo at 
set intervals following the initiation-of-infusion (0-4, >4-8, >8-12, >12-24 hr). 
Pharmacokinetic urine samples (up to 3 per subject) will be collected at key time intervals (0-
4h, >4-8h, >8-12h, >12-24h) after the start of infusion.  
 
Serial PK blood samples will be collected for the first and fourth (last) dosing in the MAD 
study for each Subject receiving drug and placebo. Blood PK samples will be obtained at 8 
timepoints (preinfusion, end-of-infusion [approximately 40 minutes], 1, 2, 4, 8, 12, and 
approximately 24hr after the start of the infusion). Two PK blood samples will be collected for 
the second and third dosing in the MAD study for each subject receiving drug and placebo at 
approximately 10 minutes predose and at the end of the infusion.  
 
Serial PK blood samples will be collected for the single dose CSF capture study for each 
Subject receiving drug and placebo. Blood PK samples will be obtained at 8 timepoints 
(preinfusion, end-of-infusion [approximately 40 minutes], 1, 2, 4, 8, 12, and approximately 
24hr after the start of the infusion). CSF samples will be obtained preinfusion, and at 2 
timepoints (1h and 8 hours post infusion).  
 
Blood and CSF samples will be analyzed for  PK of (2R,6R)-Hydroxynorketamine using a 
LC/MS/MS method to capture the following parameters: maximum plasma concentration 
(Cmax), time to Cmax (tmax), minimum plasma concentration (Cmin), area under the plasma 
concentration-time curve from 0 to infinity (AUC0-∞), area under the plasma concentration-
time curve during the dosing interval (AUC0-Tau), systemic plasma clearance (CL), volume of 
distribution during terminal phase (Vz), renal clearance (CLR), terminal half-life (t1/2). 
 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 8 of 96 
CONFIDENTIAL 
Safety: 
 
Safety will be assessed throughout the study. Baseline and follow-up safety assessments will 
include height, body mass index (BMI), weight, temperature, medical, visual and ocular 
history, physical examinations, ocular examinations, visual acuity, color vision tests, 
electrocardiograms (ECGs), vital signs (VS), clinical laboratory tests (hematology, serum 
chemistry, and urinalysis), the Profile of Mood States (POMS), the Columbia-Suicide Severity 
Rating Scale (C-SSRS), the Clinician Administered Dissociative States Scale (CADSS), and 
adverse events (AEs). Safety assessments will include AEs, ECGs, VS, clinical laboratory 
results, and physical observations. Assessment of each Subject’s level of alertness/sedation 
will be accomplished using the Modified Observer’s Assessment of Alertness/Sedation 
(MOAA/S).  
 
Evaluation of safety in the MAD study will utilize the same safety assessments used in the 
SAD study.  
 
Evaluation of safety in the CSF capture study will utilize the same safety assessments used in 
the SAD and MAD study with the exception of the CADSS and MOAA/S assessments.  
 
Monitoring of AEs will be governed by change from baselines established during prescreening 
and Day -1 examinations and clinical laboratory tests. AEs will be coded using the Medical 
Dictionary for Regulatory Activities (MedDRA) and summarized by system organ class and 
preferred term, by severity, by relationship to study drug and study procedure, and by study 
drug dose. 
 
Dose escalation in the SAD study or continued dosing in the MAD study may be stopped 
according to the predefined halting rules or if a Subject’s scores demonstrate acute suicidality 
on the C-SSRS assessment or at the discretion of the study Principal Investigator and/or 
sponsor. 
 
Determination of whether to escalate to the next dose level in the SAD study or continue 
dosing in the MAD will be made by the Principal Investigator in consultation with the Medical 
Monitor and Study Sponsor. 
 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 9 of 96 
CONFIDENTIAL 
Test products, dose, and mode of administration for SAD study: 
 
Cohort 1: (2R,6R)-Hydroxynorketamine @ 0.1 mg/kg via slow IV infusion (40 minutes) 
Cohort 2: (2R,6R)-Hydroxynorketamine @ 0.25 mg/kg via slow IV infusion (40 minutes) 
Cohort 3: (2R,6R)-Hydroxynorketamine @ 0.5 mg/kg via slow IV infusion (40 minutes) 
Cohort 4: (2R,6R)-Hydroxynorketamine @ 1.0 mg/kg via slow IV infusion (40 minutes) 
Cohort 5: (2R,6R)-Hydroxynorketamine @ 2.0 mg/kg via slow IV infusion (40 minutes) 
Cohort 6: (2R,6R)-Hydroxynorketamine @ 4.0 mg/kg via slow IV infusion (40 minutes) 
 
Test products, mode of administration and schedule for MAD study: 
 
Cohort 1: (2R,6R)-Hydroxynorketamine @ 1.0 mg/kg via slow IV infusion (40 minutes) on 
days 1, 4, 8, 11 
Cohort 2: (2R,6R)-Hydroxynorketamine @ 2.0 mg/kg via slow IV infusion (40 minutes) on 
days 1, 4, 8, 11 
 
Test products, mode of administration and schedule for CSF capture study: 
 
Cohort 1: (2R,6R)-Hydroxynorketamine @ 0.25 mg/kg via slow IV infusion (40 minutes) 
 
Control product (placebo) will be sterile saline also administered via slow IV infusion 
(40 minutes). 
 
The highest dose administered in the MAD will not exceed the highest tolerable SAD dose.  
 
Duration of patient participation in study: 
 
Participants in the SAD study: each Subject will participate in one treatment period. A 
treatment period consists of residential stay on days -1 to 2 inclusive with 1 follow up visit 
(Day 3) and phone call (Day 5-8).  
 
Participants in the MAD study: each Subject will participate in one treatment period. A 
treatment period consists of residential stay on days -1 to 5, with discharge the morning of day 
5 and re-admission on day 712 inclusive with 1 follow up phone call (Day 15) and phone call 
(Day 17-19). 
 
Participants in the CSF capture study: each Subject will participate in one treatment period. A 
treatment period consists of residential stay on days -1 to 2 inclusive with 1 follow up visit 
(Day 3) and phone call (Day 5-8).  
 
 
Study populations:  
 
The SAD, MAD and CSF capture study populations will be made up of healthy male and 
female adult volunteers (aged 18-65 years) who meet all defined inclusion/exclusion criteria. 
 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 10 of 96 
CONFIDENTIAL 
Table 1: SAD schedule of assessments and procedures 
Procedure 
Screening (Day 
–28 to Day -2) 
Day -1 
Day 1 
Day 2 
Day 3 
Day 5-8 
Informed Consent 
X 
 
 
 
 
 
Eligibility Criteria 
X 
X 
 
 
 
 
Demographics 
X 
 
 
 
 
 
Height 
X 
 
 
 
 
 
Weight, BMI 
X 
X 
 
 
X 
 
Medical history 
X 
X 
 
 
X 
X 
Physical Examination* 
X 
X 
 
X 
X 
 
Vital Signs** 
X 
X 
X 
X 
X 
 
ECG** 
X 
X 
X 
X 
X 
 
Urine Drug Test 
X 
X 
 
 
 
 
Urine Cotinine 
X 
X 
 
 
 
 
Alcohol Breath Test 
X 
X 
 
 
 
 
Pregnancy Test (Females)^ 
X 
X 
 
 
 
 
Serology (Hepatitis B, 
Hepatitis C, HIV) 
X 
 
 
 
 
 
Clinical Lab. Tests (Hema., 
Chem., Urinalysis) 
X 
X 
X 
X 
 
 
Prior and Concom. Meds. 
X 
X 
 
X 
X 
X 
Ocular Examinations*** 
 
X 
 
 
X 
 
Modified Observer’s 
Assess. of Alert./Sed. 
(MOAA/S)**** 
 
 
X 
 
 
 
Suicide Screen (C-SSRS) 
X 
X 
X 
X 
 
 
Mood and Cognitive 
Assessment (POMS) 
 
X 
X 
X 
 
X 
Clin. Admin. Diss. States 
Scale (CADSS)***** 
 
X 
X 
 
 
 
IV Drug Administration 
 
 
X 
 
 
 
Blood Sample Collection 
(PK) 
 
 
X 
X 
X 
 
Urine Sample Collection 
(PK) 
 
 
X 
X 
 
 
qEEG 
 
 
X 
 
 
 
Confinement 
 
-------------------X------------------ 
 
 
Adverse Events 
 
 
X 
X 
X 
X 
Outpatient Visit 
 
 
 
 
X 
 
Phone Call 
 
 
 
 
 
X 
An early termination visit will be scheduled on an ad hoc basis for any subject who withdraws from the study.  
* Physical examinations can be conducted at any additional time at the judgement of the Principal 
Investigator (eg, to evaluate an adverse event) 
^FSH for postmenopausal women at screening visit 
** Day 1 Timepoints: 1-hr preinfusion, and 1, 2, 4, 8, and 12 hr after the start of the infusion.  
*** Ocular examinations include visual acuity and color vision tests. 
**** On Day 1, MOAA/S is performed preinfusion, during the infusion at approximately 20 min after start 
of infusion, 40 min after start of infusion, and approximately 1 hr after the start of the infusion. 
***** On Day 1, CADSS is performed preinfusion and approximately 40 min and 80 min after the start of 
the infusion. 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 11 of 96 
CONFIDENTIAL 
Table 2: MAD schedule of assessments and procedures 
An early termination visit will be scheduled on an ad hoc basis for any subject who withdraws from the study.  
* Physical examinations can be conducted at any additional time at the judgement of the Principal 
Investigator (eg, to evaluate an adverse event) 
^FSH for postmenopausal women at screening 
** Dosing Day timepoints: 1-hr preinfusion, and 1, 2, 4, 8, and 12 hr after the start of the infusion.  
*** Ocular examinations include visual acuity and color vision tests. 
**** On Dosing days MOAA/S is performed preinfusion, during the infusion at approximately 20min 
after start of infusion, 40 min after start of infusion, and approximately 1 hr after the start of the infusion. 
***** On Dosing days, CADSS is performed preinfusion and approximately 40 min and 80 min after 
the start of the infusion. 
****** See Figure 2 for details regarding check-in/check-out schedule 
 
Procedure 
Screening 
(Day –28 
to Day -2) 
Confinement 
Follow-Up 
Day   
-1 
Day 
1 
Day 
2  
Day 
4 
Day 
5 
Day 
7 
Day 
8 
Day 
9 
Day 
11 
Day 
12 
Day 
15 
Day 
17-19 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Eligibility Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Height 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Weight, BMI 
X 
X 
 
 
 
 
 
 
 
 
X 
 
 
Medical history 
X 
X 
 
 
 
 
 
 
 
 
X 
X 
X 
Physical Examination* 
X 
X 
 
 
 
 
X 
 
 
 
X 
 
 
Vital Signs** 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
 
 
ECG** 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
 
 
Urine Drug Test 
X 
X 
 
 
 
 
X 
 
 
 
 
 
 
Alcohol Breath Test 
X 
X 
 
 
 
 
X 
 
 
 
 
 
 
Pregnancy Test 
(Females)^ 
X 
X 
 
 
 
 
X 
 
 
 
 
 
 
Serology (Hepatitis C, 
Hepatitis B, HIV) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical Lab. Tests 
(Hema., Chem., 
Urinalysis) 
X 
 
X 
X 
 
 
 
X 
X 
X 
X 
 
 
Prior and Concom. Meds. 
X 
X 
X 
 
 
X 
X 
 
 
 
X 
X 
X 
Ocular Examinations*** 
 
X 
 
X 
 
 
 
 
 
X 
X 
 
 
Modified Observer’s 
Assess. of Alert./Sed. 
(MOAA/S)**** 
 
 
X 
 
X 
 
 
X 
 
X 
 
 
 
Suicide Screening (C-
SSRS) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Mood and Cognitive 
Assessment (POMS) 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Clin. Admin. Diss. States 
Scale (CADSS)***** 
 
 
X 
 
X 
 
 
X 
 
X 
 
 
 
IV Drug Administration 
 
 
X 
 
X 
 
 
X 
 
X 
 
 
 
Blood Sample Coll. (PK) 
 
 
X 
X 
X 
 
 
X 
 
X 
X 
 
 
Check-in & Confinement 
 
X 
X 
X 
X 
 
X 
X 
X 
X 
 
 
 
Check-out****** 
 
 
 
 
 
X 
 
 
 
 
X 
 
 
Adverse Events 
 
 
X 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
Outpatient Visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
Phone Call 
 
 
 
 
 
 
 
 
 
 
 
X 
X 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 12 of 96 
CONFIDENTIAL 
Table 3: CSF Capture Study schedule of assessments and procedures 
Procedure 
Screening (Day 
–28 to Day -2) 
Day -1 
Day 1 
Day 2 
Day 3 
Day 5-8 
Informed Consent 
X 
 
 
 
 
 
Eligibility Criteria 
X 
X 
 
 
 
 
Demographics 
X 
 
 
 
 
 
Height 
X 
 
 
 
 
 
Weight, BMI 
X 
X 
 
 
X 
 
Medical history 
X 
X 
 
 
X 
X 
Physical Examination* 
X 
X 
 
X 
X 
 
Vital Signs** 
X 
X 
X 
X 
X 
 
ECG** 
X 
X 
X 
X 
X 
 
Urine Drug Test 
X 
X 
 
 
 
 
Urine Cotinine 
X 
X 
 
 
 
 
Alcohol Breath Test 
X 
X 
 
 
 
 
Pregnancy Test (Females)^ 
X 
X 
 
 
 
 
Serology (Hepatitis B, 
Hepatitis C, HIV) 
X 
 
 
 
 
 
Clinical Lab. Tests (Hema., 
Chem., Urinalysis) 
X 
X 
X 
X 
 
 
Prior and Concom. Meds. 
X 
X 
 
X 
X 
X 
Ocular Examinations*** 
 
X 
 
 
X 
 
Suicide Screen (C-SSRS) 
X 
X 
X 
X 
 
 
Mood and Cognitive 
Assessment (POMS) 
 
X 
X 
X 
 
X 
IV Drug Administration 
 
 
X 
 
 
 
Blood Sample Collection 
(PK) 
 
 
X 
X 
 
 
Cerebrospinal Fluid 
Collection (PK) 
 
 
X 
 
 
 
Confinement 
 
-------------------X------------------ 
 
 
Adverse Events 
 
 
X 
X 
X 
X 
Outpatient Visit 
 
 
 
 
X 
 
Phone Call 
 
 
 
 
 
X 
An early termination visit will be scheduled on an ad hoc basis for any subject who withdraws from the study.  
* Physical examinations can be conducted at any additional time at the judgement of the Principal 
Investigator (eg, to evaluate an adverse event) 
^FSH for postmenopausal women at screening visit 
** Day 1 Timepoints: 1-hr preinfusion, and 1, 2, 4, 8, and 12 hr after the start of the infusion.  
*** Ocular examinations include visual acuity and color vision tests. 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 13 of 96 
CONFIDENTIAL 
Figure 1: Visual representation of timeline of key events in the SAD dosing period. 
 
****When multiple procedures occur at the same timepoint, the following guides the 
approximate order of how procedures should be performed: MOAA/S > PK/lab draw > VS > 
ECG > EEG > CADSS > C-SSRS > POMS. 
 
 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 14 of 96 
CONFIDENTIAL 
Figure 2: Visual representation of timeline of key events in the MAD study. 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 15 of 96 
CONFIDENTIAL 
 
Figure 3: Visual representation of timeline of key events for Dose #1 in the MAD study. 
 
****When multiple procedures occur at the same timepoint, the following guides the 
approximate order of how procedures should be performed: MOAA/S > PK/lab draw > ECG > 
CADSS > C-SSRS > POMS. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 16 of 96 
CONFIDENTIAL 
 
 
 
Figure 4: Visual representation of timeline of key events for Dose #2 in the MAD study. 
 
 
 
****When multiple procedures occur at the same timepoint, the following guides the 
approximate order of how procedures should be performed: MOAA/S > PK/lab draw > ECG > 
CADSS > C-SSRS > POMS. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 17 of 96 
CONFIDENTIAL 
 
 
 
 
 
 
 
Figure 5: Visual representation of timeline of key events for Dose #3 in the MAD study. 
 
 
****When multiple procedures occur at the same timepoint, the following guides the 
approximate order of how procedures should be performed: MOAA/S > PK/lab draw > ECG > 
CADSS > C-SSRS > POMS. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 18 of 96 
CONFIDENTIAL 
 
 
 
 
 
 
 
 
Figure 6: Visual representation of timeline of key events for Dose #4 in the MAD study. 
 
 
 
****When multiple procedures occur at the same timepoint, the following guides the 
approximate order of how procedures should be performed: MOAA/S > PK/lab draw > ECG > 
CADSS > C-SSRS > POMS. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 19 of 96 
CONFIDENTIAL 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 7: Visual representation of timeline of key events for the CSF Capture study. 
 
 
****When multiple procedures occur at the same timepoint, the following guides the 
approximate order of how procedures should be performed: PK/lab draw > ECG > > C-SSRS > 
POMS. 
 
 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 20 of 96 
CONFIDENTIAL 
TABLE OF CONTENTS 
 
PHASE 1 EVALUATION OF (2R,6R)-HYDROXYNORKETAMINE ........................................................ 1 
SPONSOR AND MEDICAL MONITOR APPROVAL ................................................................................. 3 
STUDY CONTACTS ..................................................................................................................................... 4 
SYNOPSIS ...................................................................................................................................................... 5 
TABLE OF CONTENTS .............................................................................................................................. 20 
ABBREVIATIONS ....................................................................................................................................... 23 
1.0 INTRODUCTION ................................................................................................................................... 25 
2.0 BACKGROUND ..................................................................................................................................... 26 
2.1 NONCLINICAL STUDIES ................................................................................................... 26 
2.2 NONCLINICAL SAFETY ASSESSMENTS ........................................................................ 26 
2.3 SAFETY PHARMACOLOGY .............................................................................................. 27 
2.4 TOXICOLOGY ...................................................................................................................... 28 
2.5 GENOTOXICITY .................................................................................................................. 29 
2.6 NEUROTOXICITY ............................................................................................................... 30 
2.7 CONCLUSIONS .................................................................................................................... 30 
3.0 STUDY OBJECTIVES AND ENDPOINTS .......................................................................................... 32 
4.0 STUDY RISKS AND BENEFITS .......................................................................................................... 33 
5.0 STUDY DESIGN (SAD) ........................................................................................................................ 35 
6.0 STUDY DESIGN (MAD) ....................................................................................................................... 36 
7.0 STUDY DESIGN (CSF CAPTURE) ...................................................................................................... 37 
8.0 STUDY DESIGN RATIONALE ............................................................................................................ 38 
8.1 STUDY DRUG ...................................................................................................................... 38 
8.2 STUDY POPULATION ........................................................................................................ 38 
8.3 DESIGN ASPECTS ............................................................................................................... 38 
8.4 ROUTE OF ADMINISTRATION ......................................................................................... 38 
8.5 PLANNED DOSAGE ............................................................................................................ 39 
8.6 PHARMACOKINETIC EVALUATION .............................................................................. 40 
8.7 SAFETY AND TOLERABILITY EVALUATIONS ............................................................ 41 
9.0 SUBJECT SELECTION ......................................................................................................................... 42 
9.1 GENERAL CONSIDERATIONS .......................................................................................... 42 
9.2 INCLUSION CRITERIA ....................................................................................................... 42 
9.3 EXCLUSION CRITERIA ...................................................................................................... 43 
9.4 FERTILITY AND CONTRACEPTION REQUIREMENTS ................................................ 44 
9.5 PROHIBITIONS AND RESTRICTIONS ............................................................................. 45 
10.0 STUDY WITHDRAWAL, COMPLETION, ESCALATION, AND STOPPING 
CRITERIA ................................................................................................................................... 46 
10.1 WITHDRAWAL .................................................................................................................. 46 
10.2 REPLACEMENT ................................................................................................................. 46 
10.3 ESCALATION, CONTINUATION, AND STOPPING RULES ........................................ 46 
11.0 STUDY DRUG INFORMATION ........................................................................................................ 48 
11.1 DRUG PRODUCT IDENTITY, MANUFACTURE, SHIPMENT, AND 
RECEIVING ................................................................................................................................ 48 
11.2 INVESTIGATIONAL DRUG PRODUCT, FORMULANT, AND PLACEBO 
PHYSICAL DESCRIPTION ....................................................................................................... 48 
11.3 INVESTIGATIONAL DRUG PRODUCT AND PLACEBO PREPARATION 
AND QUALITY CONTROL ....................................................................................................... 48 
11.4 INVESTIGATIONAL DRUG PRODUCT, FORMULANT AND PLACEBO 
ACCOUNTABILITY .................................................................................................................. 48 
11.5 
INVESTIGATIONAL 
DRUG 
PRODUCT 
QUALITY 
COMPLAINT 
PROCEDURE .............................................................................................................................. 49 
12.0 STUDY PROCEDURES AND EVALUATIONS ................................................................................ 50 
12.1 STUDY SPECIFIC MATERIALS ....................................................................................... 50 
12.2 SCREENING ....................................................................................................................... 50 
12.3 INFORMED CONSENT ...................................................................................................... 51 

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12.4 SUBJECT ASSIGNMENT AND CHECK-IN ..................................................................... 52 
12.5 FASTING, MEALS, AND BEVERAGES .......................................................................... 53 
12.6 RANDOMIZATION AND BLINDING .............................................................................. 53 
12.7 DRUG PREPARATION, DOSING, AND ADMINISTRATION ....................................... 54 
12.8 SAFETY MONITORING AND REPORTING ................................................................... 54 
12.9 ADVERSE EVENTS MONITORING AND REPORTING ................................................ 57 
12.10 QUANTITATIVE ELECTROENCEPHALOGRAM (qEEG) MONITORING 
AND REPORTING ...................................................................................................................... 60 
12.11 BLOOD AND CSF DRAWS FOR CLINICAL LABORATORY AND 
PHARMACOKINETIC TESTING .............................................................................................. 61 
12.12 BLOOD AND CSF DRAW SAMPLE COLLECTION, HANDLING, SHIPPING, 
AND RECEIVING ....................................................................................................................... 64 
12.13 URINE COLLECTION, HANDLING, SHIPPING, AND RECEIVING .......................... 64 
12.14 PHARMACOKINETIC ANALYTICAL PROCEDURES ................................................ 64 
12.15 PHARMACOKINETIC PARAMETERS .......................................................................... 64 
12.16 SUBJECT RELEASE, FOLLOW-UP, AND STUDY CLOSE ......................................... 64 
13.0 STATISTICAL ANALYSIS ................................................................................................................. 65 
13.1 SAFETY DATA ................................................................................................................... 65 
13.2 PHARMACOKINETICS DATA ......................................................................................... 65 
13.3 qEEG DATA ........................................................................................................................ 66 
14.0 ADMINISTRATIVE CONSIDERATIONS AND REQUIREMENTS ................................................ 68 
14.1 BASIC PRINCIPLES ........................................................................................................... 68 
14.2 
INSTITUTIONAL 
REVIEW 
BOARD, 
ETHICAL 
COMPLIANCE, 
INVESTIGATOR RESPONSIBILTIES, AND SPONSOR RESPONSIBILITIES ..................... 68 
14.3 PRIVACY OF PERSONAL DATA ..................................................................................... 70 
14.4 PROTOCOL AMENDMENTS ............................................................................................ 71 
14.5 STUDY MONITORING ...................................................................................................... 71 
14.6 STUDY COMPLETION OR TERMINATION ................................................................... 72 
14.7 REGULATORY DOCUMENTATION ............................................................................... 72 
14.8 SUBJECT IDENTIFICATION, ENROLLMENT LOG, AND SCREENING LOG ........... 72 
14.9 DATA CAPTURE, DATA QUALITY CONTROL, AND REPORTING .......................... 72 
14.10 REGISTRATION OF CLINICAL STUDIES AND DISCLOSURE OF RESULTS
 73 
14.11 USE OF INFORMATION, DATA, AND PUBLICATION .............................................. 73 
14.12 REIMBURSEMENTS, INDEMNITY, AND INSURANCE ............................................. 73 
REFERENCES: ............................................................................................................................................. 74 
APPENDIX 1: MOAA’S .............................................................................................................................. 76 
APPENDIX 2: POMS ................................................................................................................................... 78 
APPENDIX 3: C-CSSRS .............................................................................................................................. 83 
APPENDIX 4: CADSS ................................................................................................................................. 89 
 
Tables and Figures 
Figure 1: Visual representation of timeline of events for SAD subjects ....................................................... 14 
Figure 2: Visual representation of timeline of events for MAD subjects ...................................................... 15 
Figure 3: Visual representation of timeline of events for MAD subjects (Dose 1) ....................................... 16 
Figure 4: Visual representation of timeline of events for MAD subjects (Dose 2) ....................................... 17 
Figure 5: Visual representation of timeline of events for MAD subjects (Dose 3) ....................................... 18 
Figure 6: Visual representation of timeline of events for MAD subjects (Dose 4) ....................................... 19 
Figure 7: Visual representation of timeline of events for CSF subjects ........................................................ 20 
Table 1: SAD schedule of assessments and procedures ................................................................................ 11 
Table 2: MAD schedule of assessments and procedures ............................................................................... 12 
Table 3: CSF schedule of assessments and procedures ................................................................................. 13 
Table 4: SAD planned dosing levels ............................................................................................................. 35 
Table 5: MAD planned dosing levels ............................................................................................................ 36 
Table 6: CSF planned dosing levels .............................................................................................................. 37 
Table 7: Key dosing levels and associated exposures in mouse, rat, and dog. .............................................. 39 

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Table 8: Clinical laboratory evaluations ...................................................................................................... 555 
Table 9: Blood draw volumes and uses for SAD study ................................................................................. 62 
Table 10: Blood draw volumes and uses for MAD study ............................................................................. 62 
Table 11: Blood draw volumes and uses for CSF study ................................................................................ 62 
Table 12: CSF draw volumes and uses for CSF study .................................................................................. 62 
 

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ABBREVIATIONS 
AE 
 
Adverse event 
AMPA  
α-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid 
AUC0-72  
Area under the plasma concentration-time curve from 0 to 72 hours 
AUC0-∞ 
Area under the plasma concentration-time curve from 0 to infinity 
AUC0-last 
Area under the plasma concentration-time curve from 0 to time of last 
measurable sample 
AUC0-Tau 
Area under the plasma concentration-time curve during the dosing interval 
BMI 
 
Body mass index 
C-SSRS 
Columbia-Suicide Severity Rating Scale  
CADSS  
Clinician Administered Dissociative States Scale 
CL 
 
Systemic plasma clearance 
CLR 
 
Renal clearance 
Cmax 
 
Maximum plasma concentration 
Cmin 
 
Minimum plasma concentration 
CMO  
Contract manufacturing organization 
CRF 
 
Case report form 
CSF 
 
Cerebrospinal Fluid 
DCRI  
Duke Clinical Research Institute 
DEPRU 
Duke Early Phase Research Unit 
ECG  
Electrocardiogram 
FDA  
Food and Drug Administration 
FFT 
 
Fast Fourier Transform 
FSH 
 
Follicle-stimulating hormone 
GLP 
 
Good Laboratory Practice 
GMP  
Good Manufacturing Practice 
HED  
Human equivalent dose 
HEK   
Human embryonic kidney  
hERG   
Human ether-á-go-go-related gene 
HIV 
 
Human immunodeficiency virus 
ICH 
 
International Conference on Harmonisation 
IDP 
 
Investigational drug product 
IP 
 
Intraperitoneal 
IRB  
 
Institutional Review Board  
IV  
 
Intravenous  
Ln 
 
Log transformation 
MAD   
Multiple ascending dose 
MDD   
Major depressive disorder 
MedDRA  
Medical Dictionary for Regulatory Activities 
MOAA/S  
Modified Observer’s Assessment of Alertness/Sedation 

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MOP  
Manual of Procedures 
NMDAR 
NMDA-type glutamate receptors 
NOAEL  
No observed adverse effect levels  
PD 
 
Pharmacodynamic 
PHI 
 
Protected health information 
PI 
 
Principal Investigator 
PK 
 
Pharmacokinetic(s) 
POMS  
Profile of Mood States  
PQC   
Product quality complaint  
qEEG   
Quantitative electroencephalography 
RAUC(0-∞) 
Accumulation ratio for AUC(0-∞) 
RCmax  
Accumulation ratio for Cmax 
SAD  
Single ascending dose 
SOC   
Summarized by system organ class 
SQ 
 
Subcutaneous 
t1/2 
 
Terminal half-life 
tmax 
 
Time to Cmax 
TRD   
Treatment-resistant depression  
Vz 
 
Volume of distribution during terminal phase 
WHO   
World Health Organization 
 
 

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1.0 INTRODUCTION 
Currently over 15 million Americans suffer from major depressive disorder (MDD), and 
up to 40% of these patients are resistant to current first-line pharmacological therapies 
(1). Furthermore, current first line pharmacological therapies can take over 8 weeks of 
treatment before full alleviation of the symptoms of depression often occurs. Thus, there 
is a large unmet medical need for a fast-acting antidepressant that can also effectively 
treat those patients resistant to current pharmacological therapies.  
(2R,6R)-Hydroxynorketamine is a metabolite of the drug ketamine. Ketamine, a racemic 
mixture of R-(-)ketamine and S-(+)ketamine, is an approved anesthetic and a World 
Health Organization (WHO) essential medicine (2). Ketamine has been examined as a 
therapy for treatment-resistant depression (TRD) (3). S-(+)ketamine (SpravatoTM) has 
recently been approved by the United States Food and Drug Administration (FDA) for 
this indication. However, similar to Ketamine, S-(+)ketamine also has sedative, sensory 
dissociative and abuse potential. Following administration, ketamine is rapidly 
metabolized into over twenty characterized metabolites including (2R,6R)-
Hydroxynorketamine (4). (2R,6R)-Hydroxynorketamine possesses antidepressant 
qualities in established rodent models without ketamine’s associated sedative, sensory 
dissociative or addictive actions (5). Based on this background, (2R,6R)-
Hydroxynorketamine is being evaluated in this phase 1 study to establish a safe range of 
exposure prior to being examined in patients with TRD. 
 

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2.0 BACKGROUND 
2.1 NONCLINICAL STUDIES 
At doses ranging from 5 to 125 mg/kg, (2R,6R)-Hydroxynorketamine demonstrated acute 
and sustained antidepressant-like activity in validated murine models including the 
forced-swim test, novelty-suppressed feeding test, learned helplessness test, the social 
defeat/social interaction ratio, and sucrose preference tests (5). At a dose of 10 mg/kg in 
mice (2R,6R)-Hydroxynorketamine induced an increase in hippocampus gamma-power 
(30-80 Hz) oscillations like those noted following ketamine administration in human 
studies (5). In murine models, within this antidepressant-relevant dose range there were 
no ketamine-related adverse effects observed. These included no change in locomotion 
activity or rotorod coordination, no prepulse inhibition deficits and no ketamine-like drug 
discrimination or self-administration (5). The antidepressant-like activity of 
(2R,6R)-Hydroxynorketamine could be blocked by administering a brain-penetrant 
AMPA (α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) receptor antagonist, 
implicating AMPA receptor involvement (5). (2R,6R)-Hydroxynorketamine possessed no 
quantifiable binding to the ketamine/MK801 site of the NMDA-type glutamate receptors 
(NMDAR) up to 100 μM, and modest functional inhibition of the NMDAR was limited 
to high concentrations (5,6). For example, at 10 μM concentrations, (2R,6R)-
Hydroxynorketamine did not modify NMDAR-mediated field excitatory postsynaptic 
potentials in the CA1 field of mouse hippocampal slices and NMDAR-mediated 
miniature excitatory postsynaptic currents or NMDA-evoked currents in CA1 pyramidal 
neurons of rat hippocampal slices (6). (2R,6R)-Hydroxynorketamine protected mice from 
NMDA-induced lethality with a median effective dose (ED50) of 227.8 mg/kg compared 
to 6.4 mg/kg for ketamine (6). 
 
2.2 NONCLINICAL SAFETY ASSESSMENTS 
As part of the nonclinical development of (2R,6R)-Hydroxynorketamine, key safety 
pharmacology and toxicology studies were conducted. Safety pharmacology studies 
included the central nervous system modified Irwin test, respiratory, cardiovascular, and 
human ether-á-go-go-related gene (hERG) evaluations. Single and repeat dose range 
finding studies preceded definitive Good Laboratory Practice (GLP) single dose and 
repeat-dose toxicology studies in two species (rat and dog). Genetic toxicology was 
evaluated utilizing a micronucleus test in cultured human peripheral blood lymphocytes. 
An examination of neurotoxicity was conducted by evaluating the induction of neuronal 
vacuolation and apoptotic cell death in selected regions of the brain including the 
posterior cingulate and retrosplenial cortex. All safety pharmacology and definitive 
toxicology studies were performed in accordance with the United States Food and Drug 
Administration (FDA) GLP guidelines. All in vivo safety pharmacology and toxicology 
studies were performed utilizing an intravenous (IV) infusion route of administration of 
(2R,6R)-Hydroxynorketamine.  
 

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2.3 SAFETY PHARMACOLOGY 
Central Nervous System 
Central nervous system safety pharmacology studies of (2R,6R)-Hydroxynorketamine 
were performed in male RccHan® WIST rats. Single doses of 25, 175, and 300 mg/kg 
were administered, and each animal was subjected to a modified Irwin assessment at 5 
minutes, 1.5, 5, and 24 hours postdose. Transient changes were noted at up to 1.5 hours 
postdose for animals administered doses ≥175 mg/kg with the majority of findings 
evident solely at 5-minutes postdose for those rats receiving 300 mg/kg. The changes 
included decreases in measures associated with motor activity, increases in measures 
associated with sedation, altered respiration, and decreased body temperature. All test 
article-related changes at ≥175 mg/kg had resolved by the 5-hour postdose timepoint.   
 
Respiratory 
Respiratory safety pharmacology studies of (2R,6R)-Hydroxynorketamine were 
performed in male RccHan® WIST rats. Single doses of 25, 175, and 300 mg/kg were 
administered, and each animal was subjected to head-out plethysmography for a duration 
inclusive of the infusion period through 5.5 hours postdose and 24 hours postdose. 
Transient changes in respiratory parameters were dose-related in magnitude and had 
resolved by 1.5 hours after the end of infusion. Respiration rate increases were noted for 
animals administered ≥25 mg/kg, with compensatory tidal volume decreases observed for 
animals administered ≥175 mg/kg. Given the compensatory differences in respiration rate 
and tidal volume, evident changes in minute volume were limited to a brief increase for 
animals administered 300 mg/kg. 
 
Cardiovascular 
Cardiovascular safety pharmacology studies of (2R,6R)-Hydroxynorketamine were 
performed in beagle dogs. Single doses of 15, 30, and 90 mg/kg were administered to 
telemetry-instrumented beagles and the cardiovascular function of each animal was 
assessed by qualitative or quantitative electrocardiography for a duration inclusive of the 
infusion period (20 minutes) through to 18 hours after the start of the infusion. No 
qualitative or quantitative electrocardiography effects were noted over this period for all 
doses. Administration of 15, 30, and 90 mg/kg caused lower systolic pressure (-4 mmHg, 
-6 mmHg, -16 mmHg, respectively) and arterial pulse pressure (-2 mmHg, -6 mmHg, -12 
mmHg, respectively) from 0.25 to 3 hours after the start of infusion. At 90 mg/kg, 
diastolic pressure and mean arterial pressure were significantly lower (-4 mmHg and -8 
mmHg, respectively) from 0.25 to 3 hours after the start of infusion. No (2R, 6R)-
Hydroxynorketamine-related effects on heart rate or body temperature were noted 
through 18 hours after the start of infusion. 
 
hERG 
The in vitro effect of (2R,6R)-Hydroxynorketamine on the hERG potassium channels 
was assessed using cloned hERG expressed in human embryonic kidney (HEK) cells. 
The HEK cells stably expressing hERG were held at -80 mV and exposed to drug 
treatments of 100 µM and 300 µM and onset and steady state inhibition of potassium 
current was measured using a pulse pattern with fixed amplitudes. Each recording ended 

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with a final application of a supramaximal concentration of the reference substance (E-
4031, 500 nM) to assess the contribution of endogenous currents. The remaining 
uninhibited current was subtracted off-line digitally from the data to determine the 
potency of hERG inhibition. (2R,6R)-Hydroxynorketamine inhibited hERG current by 
4.3% ± 0.1% (Mean ± SEM) at 100 µM (n = 3) and 10.3% ± 0.4% at 300 µM (n = 3) 
versus 0.2% ± 0.6% (n = 3) in control. The half maximal inhibitory concentration 
(IC50)for the inhibitory effect of (2R,6R)-Hydroxynorketamine on hERG potassium 
current was not calculated but was estimated to be greater than 300 µM. 
 
2.4 TOXICOLOGY 
Range-finding toxicology studies 
Dose range-finding studies (single- and repeat-dose) of (2R,6R)-Hydroxynorketamine 
were performed in rat and dog and were supported by toxicokinetics. In rats, single doses 
of 150, 300, or 630 mg/kg were administered and repeated doses of 150 or 375 
mg/kg/dose were administered on days 1, 4, 8, 11, and 15. The 630 mg/kg single dose 
was the maximum tolerated dose (MTD) with 1 animal death and 2 animals being 
sacrificed due to morbidity. A single dose of 300 mg/kg evoked several drug related 
observations including ataxia and low carriage and dose-dependent hypoactivity and 
squinting eyes in females administered 150 mg/kg. In the repeated dose study, clinical 
pathology findings secondary to hypoactivity, hemoconcentration, and a stress response 
were observed in rats administered ≥150 mg/kg/dose. Additionally, increased liver 
weights were noted in males administered ≥150 mg/kg/dose. Clinical effects of repeated 
doses ≤300 mg/kg/dose and 150 mg/kg/dose were considered nonadverse owing to the 
mild severity or transient nature of the findings and the overall lack of impact on animal 
health and wellbeing. 
 
In dogs, single doses of 45, 90 or 180 mg/kg and repeated doses of 90 or 180 mg/kg/dose 
were administered on days 1, 4, 8, and 15. At a single dose of 180 mg/kg, test-article 
related clinical observations included ataxia and cloudy foamy vomitus. At repeated 
doses of ≥90 mg/kg/dose excessive salivation and ataxia were noted and emesis, vomitus, 
and intermittent whole-body tremors were observed in dogs administered repeated doses 
of 180 mg/kg/dose. Other effects observed in animals administered 180 mg/kg at both 
single and repeated doses were considered nonadverse owing to the mild severity and/or 
transient nature of the findings and the overall lack of impact on animal health and 
wellbeing. 
 
Definitive GLP toxicity studies 
Definitive toxicology studies of (2R,6R)-Hydroxynorketamine were performed in two 
species (rat and dog) and were supported by toxicokinetics. Male and female rats were 
administered 0, 25, 175, or 350 mg/kg/dose (2R,6R)-Hydroxynorketamine on Days 1, 4, 
8, 11, 15, 18, 22, and 25. (2R,6R)-Hydroxynorketamine-related clinical observations for 
males included dose-dependent squinting eyes and low carriage and red discolored hair 
coat for males administered ≥175 mg/kg/dose and ataxia, swollen nose, and sternal 
recumbent body position (one animal) for males administered 350 mg/kg/dose. 
(2R,6R)-Hydroxynorketamine-related clinical observations for females included 

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dose-dependent hypoactivity and ataxia for females administered ≥175 mg/kg/dose and 
squinting eyes for females administered 350 mg/kg/dose. Irregular/labored respiration 
was also noted for animals (male and female) administered ≤350 mg/kg/dose and it was 
not clear whether this was related to (2R,6R)-Hydroxynorketamine dosing. All 
observations were transient, occurred close to tmax (1-minute postdose), generally 
resolved by 60 minutes postdose, and did not correlate with any changes in food 
consumption or body weight; therefore, they were considered nonadverse for animals 
administered 175 mg/kg/dose. However, these findings were considered adverse for 
animals administered 350 mg/kg/dose due to mortality, recumbence, and minimal 
decrease in male body weight/body weight gain (females experienced no change in body 
weight). Additionally, at the terminal sacrifice, (2R,6R)-Hydroxynorketamine-related 
increased liver weight parameters were noted in males administered 350 mg/kg/dose and 
correlated with the microscopic finding of minimal centrilobular hepatocyte hypertrophy. 
No (2R,6R)-Hydroxynorketamine-related microscopic findings or effects on organ 
weight parameters were observed at the recovery sacrifice, which was consistent with 
reversibility. Thus, the no observed adverse effect level (NOAEL) in rats was determined 
to be 175 mg/kg/dose. This dose level corresponded to mean maximum plasma 
concentration (Cmax) and AUC values of 150,000 ng/mL and 308,000 ng*hr/mL, 
respectively, in males and 147,000 ng/mL and 315,000 ng*hr/mL, respectively, in 
females on Day 25 of the dosing phase.  
 
Male and female dogs were administered 0, 8, 90, or 180 mg/kg/dose 
(2R,6R)-Hydroxynorketamine on Days 1, 4, 8, 11, 15, 18, 22, and 25 of the dosing phase. 
(2R,6R)-Hydroxynorketamine-related clinical observations for males included 
vocalization during dosing (dose-dependent) and clear eye discharge for males 
administered ≥90 mg/kg/dose and ataxia and intermittent whole-body tremors for males 
administered 180 mg/kg/dose. (2R,6R)-Hydroxynorketamine-related clinical 
observations for females included dose-dependent ataxia and vocalization during dosing 
for females administered ≥90 mg/kg/dose and excess salivation, emesis, vomitus, and 
intermittent hind limb tremors for females administered 180 mg/kg/dose. (2R,6R)-
Hydroxynorketamine was associated with higher heart rate in males administered 180 
mg/kg/dose; this effect reversed during the recovery phase. Effects for animals 
administered 180 mg/kg/dose were considered nonadverse owing to the transient nature 
of these findings and the lack of overall impact on the health and wellbeing of animals. 
Thus, the NOAEL in dogs was determined to be 180 mg/kg/dose. This dose level 
corresponded to mean Cmax and AUC0-72 values of 218,000 ng/mL and 316,000 
ng*hr/mL, respectively, on Day 25 of the dosing phase. 
 
2.5 GENOTOXICITY  
A standard battery of genetic toxicology studies has been conducted on 
(2R,6R)-Hydroxynorketamine in accordance with the Organization for Economic Co-
operation and Development (OECD) Principles on GLP. (2R,6R)-Hydroxynorketamine 
showed no evidence of mutagenicity in a bacterial reverse mutation test using 5 strains of 
Salmonella typhimurium (TA98, TA100, TA1535, TA1537, and TA102) and test 
concentrations of 5 to 5000 µg/plate in the absence or presence of exogenous metabolic 

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activation (Aroclor 1254 induced rat liver S9). An in vitro micronucleus assay conducted 
using human peripheral blood lymphocytes and test concentrations up to 240 µg/mL 
(approximately 1 mM) showed that (2R,6R)-Hydroxynorketamine did not induce 
biologically relevant increases in the frequency of micronucleated cells following 
treatment in the absence and presence of S-9. To complete the test battery, 
(2R,6R)-Hydroxynorketamine was assessed in an in vivo rat bone marrow micronucleus 
assay using IV doses of 105, 210, or 420 mg/kg/day for 2 days. Although 1 animal given 
210 mg/kg/day was found dead at 2.5 hours post second dose, 
(2R,6R)-Hydroxynorketamine showed no evidence of induction of micronucleus 
formation in polychromatic erythrocytes following IV administration at up to 420 
mg/kg/day. Hence, (2R,6R)-Hydroxynorketamine showed no evidence of mutagenic, 
clastogenic, or aneugenic activity in a standard battery of genotoxicity studies. 
 
2.6 NEUROTOXICITY  
Although multiple lines of evidence demonstrate that (2R,6R)-Hydroxynorketamine is a 
weak NMDAR antagonist, it was deemed prudent to assess if (2R,6R)-
Hydroxynorketamine induces a specified neurological toxicity involving neuronal 
vacuolation (referred to as Olney’s lesions) that is associated with blockade of the 
NMDAR. Olney’s lesion neurotoxicity studies of (2R,6R)-Hydroxynorketamine were 
performed using male and female RccHan®:WIST rats. Both single and repeat-dose 
studies were performed. Single-dose studies involved doses of (2R,6R)-
Hydroxynorketamine of 12, 80, 120, and 160 mg/kg. Clinical observations for (2R,6R)-
Hydroxynorketamine were consistent with those noted during the GLP toxicology 
studies. The validated NMDAR antagonist MK-801 was utilized as a positive control and 
dosed at 0.5 and 0.8 mg/kg via the subcutaneous (SQ) route. MK-801-related Olney-like 
brain lesions were observed in rats administered both these doses. No microscopic brain 
lesions were noted in rats administered (2R,6R)-Hydroxynorketamine at any dose. 
Repeated dose studies employed (2R,6R)-Hydroxynorketamine at 12, 80, or 160 
mg/kg/dose administered 4 times over 2 weeks (days 1, 4, 11 and 15). MK-801 was again 
utilized as a positive control and dosed SQ at 0.5 and 0.8 mg/kg/dose at the same 
schedule (ie, 4 times over 2 weeks [days 1, 4, 11, and 15]). Data were consistent with that 
obtained in the single dose study, in that Olney-like brain lesions were observed in rats 
administered both doses of MK801. In summary, no microscopic brain lesions were 
noted in rats administered single or repeated doses of (2R,6R)-Hydroxynorketamine at 
any dose. 
 
2.7 CONCLUSIONS 
Based upon multiple nonclinical models of antidepressant effectiveness, there is now 
strong evidence that (2R,6R)-Hydroxynorketamine possesses acute and sustained 
antidepressant-like activity akin to ketamine but without the associated ketamine-like 
adverse effects including sedation, sensory dissociation, and abuse potential. Nonclinical 
toxicology studies show that there are no predicted safety pharmacology liabilities for 
(2R,6R)-Hydroxynorketamine including studies exploring the respiratory, central 
nervous, and cardiovascular systems. There was no evidence of genotoxicity of 
(2R,6R)-Hydroxynorketamine in a standard battery of genotoxicity studies (Ames test, in 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
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Protocol Ref. #: HNK-378227-03 
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vitro micronucleus test, and rat bone marrow micronucleus test). There was no observed 
effect of (2R,6R)-Hydroxynorketamine on the hERG potassium channels. Single and 
repeated-dose range finding and definitive (GLP) toxicology studies in rats and dogs 
established NOAELs of 175 mg/kg/dose and 180 mg/kg/dose, respectively.  
 
A neurotoxicity assessment of neuronal vacuolation (Olney’s lesions) demonstrated that 
there were no microscopic brain lesions in rats administered (2R,6R)-
Hydroxynorketamine at single or repeated doses up to 160 mg/kg. Overall, these data 
support clinical investigation of (2R,6R)-Hydroxynorketamine at the planned doses and 
schedule outlined (see section 8.0 Study design rationale).  
 

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3.0 STUDY OBJECTIVES AND ENDPOINTS 
The primary objective of this study is to determine the safe dose range and tolerability of 
(2R,6R)-Hydroxynorketamine HCl administered via a slow IV infusion (40 minutes) to 
healthy volunteers. A second primary objective for this study is to assess the 
pharmacokinetics (PK) of (2R,6R)-Hydroxynorketamine HCl in serum following single 
and multiple dose administrations.  
 
The exploratory objective of this study is to collect quantitative electroencephalography 
(qEEG) data as a PD biomarker (SAD). Another exploratory objective of this study is to 
assess the concentration of (2R,6R)-Hydroxynorketamine HCl  collected from 
cerebrospinal fluid following administration of a single dose(CSF capture).  
 
Study endpoints include completion of all dosing levels and timepoints with full 
collection of all safety data, adverse events (AEs) tabulation, clinical laboratory tests, PK 
endpoints (eg, Cmax, time to Cmax [tmax], minimum plasma concentration [Cmin], area under 
the plasma concentration-time curve from 0 to infinity [AUC0-∞], area under the plasma 
concentration-time curve during the dosing interval [AUC0-Tau], systemic plasma 
clearance (CL), volume of distribution during terminal phase [Vz], renal clearance [CLR], 
terminal half-life [t1/2]).  
 

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4.0 STUDY RISKS AND BENEFITS 
As with all clinical studies, there are risks. These risks include multiple venipuncture and 
blood sample collections. The blood sample collection scheme was designed to collect 
the minimum number of blood samples to collect the needed samples for thorough 
clinical laboratory testing and that accurately and completely describe the PK of study 
drug. This minimizes the number of venipunctures and the total volume of blood 
collected from each Subject during the study. The amount of blood to be collected from 
each subject over the course of the study is acceptable based on the American Red Cross 
standard (http://www.redcrossblood.org/donating-blood/eligibility-requirements). 
 
Subjects in the CSF Capture Study will also undergo lumbar puncture with placement of 
CSF catheter, a procedure associated with risk of bleeding, infection and post-procedure 
headache. The volume of CSF to be collected at each time point was calculated to be less 
than the hourly CSF production to minimize risk of headache and subjects will be kept in 
a semi-recumbent position while the CSF catheter remains in place. Procedures will be 
performed utilizing standard aseptic technique to minimize infection risk. 
 
Subjects will be asked to provide protected health information (PHI). All attempts will be 
made to keep PHI confidential within the limits of the law; however, there is a chance 
that unauthorized persons will see the subjects’ PHI. All study records will be kept in a 
locked file cabinet or maintained in a locked room at the Duke Early Phase Research Unit 
(DEPRU). Electronic files will be maintained on secure servers and transferred files with 
PHI will be password protected. Only people involved in the conduct, oversight, 
monitoring, or auditing of this study will be allowed access to the PHI that is collected. 
Any publications from this study will not use information that will identify subjects by 
name. Organizations that may inspect and/or copy research records maintained at 
DEPRU for quality assurance and data analysis include the local Institutional Review 
Board (IRB), National Institute of Mental Health and/or their designees, and the FDA. 
 
A description of this clinical study will be available at http://www.ClinicalTrials.gov, as 
required by US law. This website will not include information that can identify subjects 
and at most, it will include a summary of the results. 
 
The potential risks to the subjects enrolled in this study are moderate. To further 
minimize these risks, experienced personnel will implement the protocol and provide 
detailed instructions to the subjects. There may be other risks, discomforts, or side effects 
that are currently unknown. Overall, the risks associated with the research are justified by 
the potential public health benefits. 
 
The primary benefit to Subjects, aside from the financial compensation, is the 
contribution to a study that may prove beneficial for the discovery of a new therapy for 
TRD. 
 

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Subjects will be fully informed of the risks and requirements of the study. During the 
study, Subjects will be given any new information that may affect their decision to 
continue participation. They will be told that their consent to participate in the study is 
voluntary and may be withdrawn at any time with no reason given and without penalty or 
loss of benefits to which they would otherwise be entitled. Only Subjects who are fully 
able to understand the risks, benefits, and potential AEs of the study, and provide their 
consent voluntarily will be enrolled. 

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5.0 STUDY DESIGN (SAD) 
This is a 6-cohort, single site, first-in human, double-blind, placebo-controlled, 
randomized single ascending dose (SAD) study assessing (2R,6R)-Hydroxynorketamine 
in healthy male and female volunteers. All Subjects in the SAD study will undergo a 
screening period of up to 28 days to ensure that all eligibility requirements are met. Key 
baseline safety metrics will be taken during screening and on the first Day of 
confinement. Selected safety metrics will be collected during the on-drug portion of the 
study. A final safety assessment will be conducted via an outpatient visit and follow-up 
phone call.  
 
All cohorts will include 6 Subjects receiving drug and 2 Subjects receiving placebo. All 
cohorts will incorporate sentinel dosing of 1 active and 1 placebo Subject. Each Subject 
will only participate in a single dose level. Table 4 outlines the planned dosing levels and 
number of Subjects in each cohort. 
 
Each treatment will be administered after Subjects have fasted overnight for at least 8 
hours. 
 
Safety monitoring and assessments will be performed as described in sections 8.7 and 
12.8. Dosing may be stopped if any of the stopping criteria are met as described in 
section 10.3. Determination of whether to escalate to the next dose level if stopping 
criteria are met will be made by the Principal Investigator (PI) in consultation with the 
Medical Monitor and the Study Sponsor.  
 
Pharmacokinetic blood samples will be collected as described in section 8.6. The qEEG 
will be performed on all Subjects in the SAD study as described in section 12.10 
 
Table 4: SAD planned dosing levels 
Cohort 
Dose 
(mg/kg) 
Subjects on Active 
Drug (n) 
Subjects on 
Placebo (n) 
1A (Sentinel 1) 
0.1 
1 
1 
1B 
0.1 
5 
1 
2A (Sentinel 2) 
0.25 
1 
1 
2B 
0.25 
5 
1 
3A (Sentinel 3) 
0.5 
1 
1 
3B 
0.5 
5 
1 
4A (Sentinel 4) 
1.0 
1 
1 
4B 
1.0 
5 
1 
5A (Sentinel 5) 
2.0 
1 
1 
5B 
2.0 
5 
1 
6A (Sentinel 6) 
4.0 
1 
1 
6B 
4.0 
5 
1 
 

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National Institute of Mental Health 
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6.0 STUDY DESIGN (MAD) 
The multiple ascending dose (MAD) portion of the study is a 2-cohort single site, 
double-blind, placebo-controlled design assessing (2R,6R)-Hydroxynorketamine in 
healthy adult male and female volunteers. All Subjects in the MAD study will undergo a 
screening period of up to 28 days to ensure that all eligibility requirements are met. Key 
baseline safety metrics will be taken during screening and on the first Day of 
confinement. Selected safety metrics will be collected during the on-drug portion of the 
study. A final safety assessment will be conducted via an outpatient visit and follow-up 
phone call.  
 
All cohorts will include 6 Subjects receiving drug and 2 Subjects receiving placebo. Each 
Subject will receive a total of 4 doses (drug or placebo) administered on days 1, 4, 8, and 
11. Each Subject will only participate in a single dose level. Table 5 outlines the planned 
dosing levels and number of Subjects in each cohort. 
 
Each dose will be administered after Subjects have fasted overnight for at least 8 hours. 
 
Safety monitoring and assessments will be performed as described in sections 8.7 and 
12.8. AE monitoring and reporting will be performed as described in sections 8.7 and 
12.8. Dosing may be stopped if any of the stopping criteria are met as described in 
section 10.3. Determination of whether to escalate to the next dose level if stopping 
criteria are met will be made by the PI in consultation with the Medical Monitor and the 
Study Sponsor.  
 
Pharmacokinetic blood samples will be collected as described in section 8.6. 
 
Table 5: MAD planned dosing levels 
Cohort 
Dose (mg/kg) 
Subjects on Active 
Drug (n) 
Subjects on 
Placebo (n) 
1 
1.0 
6 
2 
2 
2.0 
6 
2 
 
 
 
 
 
 
 
 
 
 
 
 
 

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National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
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7.0 STUDY DESIGN (CSF CAPTURE) 
 
The cerebrospinal  fluid capture (CSF Capture) portion of the study is a 1-cohort single 
site, double-blind, placebo-controlled design assessing (2R,6R)-Hydroxynorketamine in 
healthy adult male and female volunteers. All Subjects in the CSF Capture study will 
undergo a screening period of up to 28 days to ensure that all eligibility requirements are 
met. Key baseline safety metrics will be taken during screening and on the first Day of 
confinement. Selected safety metrics will be collected during the on-drug portion of the 
study. A final safety assessment will be conducted via an outpatient visit and follow-up 
phone call.  
 
The cohort will include 5 Subjects receiving drug and 3 Subjects receiving placebo. Each 
Subject will receive a total of 1 dose (drug or placebo) administered on day 1. Each 
Subject will only participate in a single dose level. Table 6 outlines the planned dosing 
level and number of Subjects in each cohort. 
 
Each dose will be administered after Subjects have fasted overnight for at least 8 hours. 
 
Safety monitoring and assessments will be performed as described in sections 8.7 and 
12.8. AE monitoring and reporting will be performed as described in sections 8.7 and 
12.8. Dosing may be stopped if any of the stopping criteria are met as described in 
section 10.3. Determination of whether to escalate to the next dose level if stopping 
criteria are met will be made by the PI in consultation with the Medical Monitor and the 
Study Sponsor.  
 
Pharmacokinetic blood and CSF samples will be collected as described in section 8.6. 
 
Table 6: CSF Capture study planned dosing levels 
Cohort 
Dose (mg/kg) 
Subjects on Active 
Drug (n) 
Subjects on 
Placebo (n) 
1 
0.25 
5 
3 
 

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8.0 STUDY DESIGN RATIONALE 
8.1 STUDY DRUG 
The antidepressant activity of racemic ketamine and the recent approval of S-(+)ketamine 
(esketamine, SpravatoTM) have proven to be major advances for individuals with TRD. 
However, several issues surround these drugs including unwanted side effects and the 
potential for abuse. Further, inconsistencies surround the purported mechanism of action 
(NMDAR antagonism) as other investigational drugs with optimized potency for this 
target lack consistent antidepressant activity. There are also PD questions given that 
ketamine is eliminated on a timescale (hours) that is inconsistent with the effect duration 
(days). (2R,6R)-Hydroxynorketamine is a metabolite following ketamine administration. 
(2R,6R)-Hydroxynorketamine possesses strong antidepressant activity in multiple models 
of depression and anxiety. (2R,6R)-Hydroxynorketamine is a weak NMDAR antagonist 
and, therefore, is devoid of unwanted side-effects including sedation, dissociation and 
addictive potential as tested in animal models. (2R,6R)-Hydroxynorketamine is 
manufactured as the HCl salt which yields a single polymorph and crystal form and is 
stable as both a solid and as a solution in multiple formulants. The investigational drug 
product (IDP) is a solution-based formulation of (2R,6R)-Hydroxynorketamine in 25 mM 
phosphate buffer.  
 
8.2 STUDY POPULATION 
Healthy male and female adult subjects (18-65 years old) will be enrolled in this study. It 
is expected that the PK of (2R,6R)-Hydroxynorketamine in these Subjects will be 
representative of the PK profile in patients with TRD. The cohort size in all SAD and 
MAD stages is expected to sufficiently evaluate the safety and PK of (2R,6R)-
Hydroxynorketamine. Furthermore, these cohort sizes are also expected to provide 
sufficient qEEG data to evaluate the use of qEEG as a potential PD biomarker.  
 
8.3 DESIGN ASPECTS 
The design of the SAD, MAD and CSF Capture studies are intended to mirror the 
currently accepted best practices for the administration of ketamine in the setting of 
depression (in MDD and TRD). Each design aspect (route of administration, IDP, PK 
measurements, qEEG data capture, etc.) should allow for direct comparison to existing 
clinical data on the use of ketamine as an antidepressant and should inform dose and 
schedule of (2R,6R)-Hydroxynorketamine in TRD.  
 
8.4 ROUTE OF ADMINISTRATION 
Racemic ketamine is being used to treat TRD in specialized clinics utilizing a slow IV 
infusion. To produce a comparative clinical assessment for (2R,6R)-Hydroxynorketamine 
an identical route of administration (ie, IV) and time frame (40 min) is adopted.  
 

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8.5 PLANNED DOSAGE  
The doses of (2R,6R)-Hydroxynorketamine in the SAD study are based upon both the 
presumed safety ranges as defined by the definitive toxicology studies and the doses 
which achieve efficacy in various models of depression and anxiety. Efficacious doses of 
(2R,6R)-Hydroxynorketamine achieved in mouse models of antidepressant efficacy and 
qEEG gamma changes range from 5 mg/kg to 20 mg/kg. The commonly used dose of 
10 mg/kg intraperitoneal (IP) achieved a mouse plasma Cmax of 2,587 ng/mL and plasma 
AUC of 772 ng*hr/mL. The human equivalent dose is 0.813 mg/kg utilizing an 
allometric scaling factor of 12.3. Adjusting for the bioavailability of IP dosing 
(approximately 50%), the human IV dose estimate can be corrected to 0.406 mg/kg.  
 
The (2R,6R)-Hydroxynorketamine NOAEL in rats is 175 mg/kg/dose. The human 
equivalent dose is 28.2 mg/kg utilizing an allometric scaling factor of 6.2. This dose level 
corresponded to mean Cmax and AUC values of 150,000 ng/mL and 308,000 ng*hr/mL, 
respectively, in males and 147,000 ng/mL and 315,000 ng*hr/mL, respectively, in 
females on Day 25 of the dosing phase. The (2R,6R)-Hydroxynorketamine NOAEL in 
dogs is 180 mg/kg/dose. The human equivalent dose is 100 mg/kg utilizing an allometric 
scaling factor of 1.8. This dose level corresponded to mean Cmax and AUC0-72 values of 
218,000 ng/mL and 316,000 ng*hr/mL, respectively, on Day 25 of the dosing phase. The 
human equivalent dose is 100 mg/kg utilizing an allometric scaling factor of 1.8. 
 
Table 7: Key dosing levels and associated exposures in mouse, rat, and dog. 
 
HED  
(by allometry) 
Cmax  
AUC 
Efficacious dose in 
mouse (10 mg/kg) 
 
0.813 mg/kg 
 
2,587 ng/mL 
 
772 ng*hr/mL 
Rat NOAEL  
(175 mg/kg/dose) 
 
28.2 mg/kg 
150,000 ng/mL (m) 
147,000 ng/mL (f) 
308,000 ng*hr/mL 
315,000 ng*hr/mL 
Dog NOAEL  
(180 mg/kg/dose) 
 
100 mg/kg 
 
218,000 ng/mL 
 
316,000 ng*hr/mL 
 
A second approach was applied for human dose estimation based on PK data of 
(2R,6R)-Hydroxynorketamine postketamine doses in humans using validated methods 
(7-9). Ketamine and its major metabolites were quantified in plasma after IV infusion at 
0.5 mg/kg of racemic ketamine. A parent-metabolite PK model was developed for 
racemic-ketamine and its major metabolites including rac-norketamine, rac-
dehydronorketamine and (2S,6S:2R,6R)-Hydroxynorketamine, and the model parameters 
were estimated using a stepwise approach. The estimated model parameters for 
(2S,6S:2R,6R)-Hydroxynorketamine was assumed to be the same as those for (2R,6R)-
Hydroxynorketamine to establish these estimations. Concentration of (2R,6R)-
Hydroxynorketamine was predicted at different dose levels post a 40 min infusion and 
the exposure was calculated. Based upon these methods, it was determined that an IV 
dose of 0.1 mg/kg in human could provide similar exposure as observed in mouse post 10 
mg/kg IP dose.  
 

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Based upon these collective models, the (2R,6R)-Hydroxynorketamine proposed doses 
for the SAD study range from 0.1 mg/kg to 4.0 mg/kg. Dose escalations between cohorts 
are approximately 2-fold increases between cohorts in alignment with common phase 1 
clinical trial practice. The highest proposed SAD dose of 4.0 mg/kg is approximately 7X 
lower than the NOAEL human equivalent dose in the most sensitive species (rat) and 
25X lower than the NOAEL human equivalent dose in the less sensitive species (dog) 
using allometric scaling factors of 6.2 and 1.8, respectively.  
 
The (2R,6R)-Hydroxynorketamine doses selected for the MAD portion are set at 1.0 and 
2.0 mg/kg. These doses are deemed acceptable for inclusion in the MAD study based on 
the PK, PD, safety, and tolerability outcomes obtained from the SAD section study. 
 
The (2R,6R)-Hydroxynorketamine doses selected for the CSF Capture portion are set at 
0.25 and 2.0 mg/kg. These doses are deemed acceptable for inclusion in the CSF Capture 
study based on the PK, PD, safety, and tolerability outcomes obtained from the SAD 
section study. 
 
8.6 PHARMACOKINETIC EVALUATION 
Blood samples will be obtained during the study for measurement of 
(2R,6R)-Hydroxynorketamine plasma concentrations to provide an unambiguous 
association between drug dose and systemic drug exposure. Serial PK blood samples will 
be collected during the SAD and MAD studies for each Subject receiving drug and 
placebo at 9 timepoints and 20 timepoints, respectively. For PK assessments, there will 
be an acceptable blood collection window of ± 5 minutes in the first 8 hours after a dose 
and ± 30 minutes thereafter. 
 
Serial PK blood samples will be collected during the SAD portion for each Subject 
receiving drug and placebo at 9 timepoints (preinfusion, end-of-infusion [approximately 
40 minutes], 1, 2, 4, 8, 12, 24, and approximately 48 hr after the start of the infusion). 
Pharmacokinetic urine samples (up to 3 per Subject) will be collected during the SAD 
study for each Subject receiving drug and placebo at set intervals following the initiation-
of-infusion (0-4, >4-8, >8-12, >12-24 hr).  
 
Serial PK blood samples will be collected for the first and fourth (last) dosing in the 
MAD study for each Subject receiving drug and placebo. Blood PK samples will be 
obtained at 8 timepoints (preinfusion, end-of-infusion [approximately 40 minutes], 1, 2, 
4, 8, 12, and approximately 24 hr after the start of the infusion). Two PK blood samples 
will be collected for the second and third dosing in the MAD study for each Subject 
receiving drug and placebo at preinfusion and end-of-infusion [approximately 40 
minutes] timepoints.  
 
Serial PK blood samples will be collected during the CSF Capture portion for each 
Subject receiving drug and placebo at 8 timepoints (preinfusion, end-of-infusion 
[approximately 40 minutes], 1, 2, 4, 8, 12, and approximately 24 hr after the start of the 
infusion). CSF samples will be collected during the CSF Capture portion for each Subject 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
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receiving drug and placebo at 3 timepoints (preinfusion, 1, and approximately 8 hr after 
the start of the infusion).  
 
Blood and CSF samples will be stored and shipped to LabCorp (Covance) central 
laboratories who will perform PK analysis of (2R,6R)-Hydroxynorketamine using a 
LC/MS/MS method to determine plasma concentration levels in order to calculate the 
following PK parameters: Cmax, tmax, Cmin, AUC0-∞, AUC0-Tau, CL, Vz, CLR, t1/2. 
 
8.7 SAFETY AND TOLERABILITY EVALUATIONS 
A series of safety assessments will be employed to assess drug-related AEs and assess 
tolerability in the study described in sections 12.8 and 13.1. Preclinical toxicology studies 
did not identify any anticipated or toxicology issues and, therefore, standard phase 1 
study safety assessments will be employed. Given the nature of the planned indication 
(TRD) and the relationship of (2R,6R)-Hydroxynorketamine to ketamine, 4 specialty 
assessments will be included (ie, the Profile of Mood States [POMS], the Columbia-
Suicide Severity Rating Scale [C-SSRS], the Clinician Administered Dissociative States 
Scale [CADSS], and the Modified Observer’s Assessment of Alertness/Sedation 
[MOAA/S]) as described in sections 12.8 and 13.1.  
 
Monitoring of AEs will be governed by change from baseline established during 
prescreening and Day -1 examinations and clinical laboratory tests as described in 
sections 12.9 and 13.1. The AEs will be coded using the MedDRA dictionary and 
summarized by system organ class (SOC) and preferred term, by severity, by relationship 
to study drug and study procedure, and by study drug dose. 
 
Dose escalation in both the SAD and MAD portions or continued dosing in the MAD part 
may be stopped according to the predefined halting rules or if a Subject’s scores on the 
C-SSRS assessment demonstrates acute suicidality or at the discretion of the study PI 
and/or sponsor. Dose escalation in the SAD and MAD studies or continued dosing in the 
MAD study may also be stopped for any additional reason at the discretion of the PI in 
consultation with the Medical Monitor and the Study Sponsor.  

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9.0 SUBJECT SELECTION 
9.1 GENERAL CONSIDERATIONS 
A full checklist of eligibility criteria must be completed prior to formal enrolment. 
Eligibility requirements must be re-evaluated and confirmed on Day -1 prior to dosing 
with the study drug.  
 
9.2 INCLUSION CRITERIA 
All volunteers must satisfy the following criteria to be considered for study participation. 
 
1. Be a healthy male or female between 18 and 65 years of age (inclusive). 
2. Voluntarily consents to participate in the study and provides written informed 
consent before the start of any study-specific procedures. 
3. Be willing and able to remain in the study unit for the entire duration of the 
confinement period and return for outpatient visits. 
4. Agree to comply with prohibitions and restrictions (section 9.5).  
5. Females must have a negative serum β-human chorionic gonadotropin (hCG) 
pregnancy test at screening and a negative urine pregnancy test on Day -1 
prior to study initiation.   
6. Females must be of nonchildbearing potential or agree to use appropriate birth 
control, as defined in section 9.4 Contraception Requirements. 
7. Males must be surgically sterile for at least 90 days before screening or agree 
to use a condom with spermicide when sexually active with a female partner 
who is not using an acceptable form of birth control during the study and for 
90 days after study administration. Males must also agree to not donate sperm 
starting at enrollment and for 90 days after last study drug administration. 
8. BMI (weight [kg]/[m2]) between 18 and 35 kg/m2 (inclusive) and weighs 
between 50 and 120 kg (110 – 264 pounds), inclusive. 
9. Blood pressure (after Subject is in a supine position for approximately 
5 minutes) between 90 and 145 mmHg systolic (inclusive) and no higher than 
90 mmHg diastolic at Screening and Day -1.  
10. A 12-lead ECG with no clinically significant abnormality as judged by the 
Investigator and QTcf interval ≤ 450 milliseconds at Screening and Day -1. 
11. Resting pulse rate between 45 and 100 beats per minute at Screening and 
Day -1. 
12. Clinical laboratory findings and VS within normal range, or if outside of the 
normal ranges, deemed not clinically significant in the opinion of the 
Investigator. 
13. Agree to comply with the rules regarding consumption of alcohol, caffeinated 
beverages, and tobacco/nicotine products during the study.  
 

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National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
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9.3 EXCLUSION CRITERIA 
All volunteers who do not satisfy the following criteria will be excluded from study 
participation. 
 
1. History or presence of clinically significant medical illness including (but not 
limited to) hepatic, cardiovascular, pulmonary, renal, hematologic, endocrine, 
gastrointestinal, immunologic, dermatologic, neurologic, oncologic, or 
psychiatric disease that in the opinion of the Investigator would endanger the 
safety of the Subject or the validity of the study results. 
2. Clinically significant acute illness in the 2 weeks prior to dosing. 
3. Previous or current participation in any clinical study with an investigational 
drug, device, or biologic within 30 days or five half-lives of the 
investigational product to dosing.  
4. Preplanned surgery or procedures that would interfere with the conduct of the 
study.  
5. History of severe drug or excipient allergy, or hypersensitivity to be judged at 
the discretion of the Investigator. 
6. Donation or loss of greater than 0.5 L of blood within 90 days before 
screening or study start. Donation of platelets within 40 days before screening 
or study start. Donation of plasma within 14 days before screening or study 
start. Receipt of blood products within 60 days before screening or study start.   
7. Recent history (2 years) of alcohol or drug abuse at the discretion of the 
Investigator or a positive screen for alcohol or drugs of abuse (including 
marijuana) at screening and upon check-in. 
8. Testing positive for hepatitis B, hepatitis C, or HIV, or a history of any of 
these diseases. Subjects whose results are compatible with prior immunization 
may be included at the discretion of the Investigator.  
9. History of unexplained loss of consciousness, epilepsy, or other seizure 
disorders, or cerebrovascular disease. 
10. Malignancy within 5 years of screening visit (except basal cell or squamous 
cell skin carcinoma). 
11. Inability to adhere to the study unit diet. 
12. Use of any prescription or nonprescription medication (including vitamins, 
herbal preparations, and nutritional supplements) within the 14 days prior to 
dosing except for common analgesics (acetaminophen, ibuprofen), hormonal 
contraceptives or hormonal replacement therapy or nonsedating 
antihistamines. Topical medications may be allowed at the discretion of the 
Investigator. 
13. History or current diagnosis of mental illness including (but not limited to) 
psychotic disorder, bipolar disorder, schizophrenia, borderline personality 
disorder, and antisocial personality disorder, generalized anxiety disorder, 
obsessive compulsive disorder, posttraumatic stress disorder, and eating 
disorders.  

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National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
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14. History of suicidal or homicidal ideation. 
15. Significant primary sleep disorder. 
16. Known allergy to ketamine, heparin, or any of the IDP components (see 
section 11.0 Study Drug Information).  
17. Any strenuous exercise in the 2 days prior to study drug administration. 
18. Consumption of beverages or food that contain alcohol, grapefruit, poppy 
seeds, Brussel sprouts, pomegranate, broccoli, char-grilled meat within 2 days 
prior to drug administration. Allowances for a single isolated incidental 
consumption may be evaluated and approved pending PI approval for the 
potential interactions.  
19. Use of tobacco or nicotine-containing products within 4 weeks prior to drug 
administration.  
20. Employee of the PI or study center with direct involvement in the proposed 
study or other studies under the direction of the study PI. 
21. Poor peripheral venous access.   
22. Close relative (parent, sibling, child) of clinical site employee.  
23. Subjects who, in the opinion of the PI or designee, should not participate in 
this study. 
 
9.4 FERTILITY AND CONTRACEPTION REQUIREMENTS 
Females must be of nonchildbearing potential, defined as; 
 
1. Surgically sterile for at least 180 days before study initiation. 
2. Postmenopausal for at least 1 year before study initiation. Subjects claiming 
postmenopausal status will have a Follicle Stimulating Hormone (FSH) test 
performed at screening to confirm postmenopausal status. 
-OR- 
 
Females of childbearing potential must agree to use an allowable form of birth control 
from screening until 90 days after end-of-study. The following are allowed birth control 
methods: 
 
1. Implanted or intrauterine hormonal contraceptive use for at least 180 
continuous days before drug administration. 
2. Oral, path, or injected contraceptives, or vaginal hormonal device in use for at 
least 90 continuous days before drug administration. 
3. Intrauterine device. 
4. Vasectomized partner (at least 90 days before drug administration). 
5. Nonsurgical permanent sterilization (at least 90 days before drug 
administration). 
6. Double barrier method (for example, diaphragm with spermicide, condoms 
with spermicide). 

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7. Abstinence (and agreement to use double barrier method if they become 
sexually active during the above time). 
Male Subjects must agree to one of the following birth control methods from screening to 
90 days after end-of-study. 
 
1. Be surgically sterile for at least 90 days before screening. 
2. Agree to use a condom with spermicide when sexually active with a female 
partner who is not using an acceptable method of birth control. 
3. Abstinence (with agreement to use a condom with spermicide if they become 
sexually active during the study). 
 
9.5 PROHIBITIONS AND RESTRICTIONS 
Potential Subjects must be willing to adhere to the following prohibitions and restrictions 
during the study to be eligible for participation.  
 
1. Subjects must remain at the study center until 24 hours after drug 
administration (SAD) or 24 hours after completion of the final drug 
administration (MAD).  
2. Subjects must continue using an appropriate method of birth control (see 
section 9.4 Contraception Requirements). 
3. Subjects must avoid excess daily consumption of methylxanthine-containing 
products (eg chocolate, coffee, caffeinated teas or colas) during the 
confinement period of the study. Excess consumption is defined as >1 serving 
of chocolate (1.55 ounces), 3 or more cups (0.7 liters) of coffee or caffeinated 
teas or colas.  
4. Subjects must consume standard institutional meals during the confinement 
period of the study. Excessive food consumption is not permitted.  
5. Subjects are not permitted to use tobacco or nicotine containing products 
including (but not limited to) cigarettes, e-cigarettes, cigars, bidis, kreteks, 
pipes, chewing tobacco, snuff, and dip during the confinement period of the 
study.  
6. Subjects are not permitted to use drugs of abuse including (but not limited to) 
alcohol, cannabinoids, opiates, cocaine, amphetamines, benzodiazepines, 
hallucinogens or barbiturates during the confinement period of the study.  
7. Subjects are not permitted to perform strenuous activity or exercise during the 
confinement period of the study and for 48 hours after completion of the final 
drug administration. 
8. Subjects must be advised not to donate blood for at least 90 days after 
completion of the study or to participate in any investigational drug study for 
at least 90 days after completion of the study. 

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10.0 STUDY WITHDRAWAL, COMPLETION, ESCALATION, AND STOPPING 
CRITERIA 
10.1 WITHDRAWAL 
A Subject will be withdrawn from the study for any of the following reasons. 
 
1. Withdrawal of consent. 
2. Noncompliance with any of the study requirements including failure to meet 
eligibility criteria or violation of any of the listed prohibitions and/or 
restrictions.  
3. Discontinuation of study treatment for any reason. 
4. Subject is lost to follow-up. 
Study drug assigned to the withdrawn Subject may not be assigned to another Subject and 
must be disposed of according to the instructions (see Drug Product Accountability).  
10.2 REPLACEMENT 
Subjects who withdraw before receiving the study drug will be replaced. Following 
dosing, 1 subject per cohort may withdraw before completion and may or may not be 
replaced, at the discretion of the Investigator. Should more than 1 subject from the same 
cohort voluntarily withdraw from the study following dosing, those subjects will be 
replaced unless withdrawal was due to a safety or tolerability issue. Subjects who 
received any amount of the study drug and who withdraw or are withdrawn from the 
study will be encouraged to continue follow-up (with subjects’ consent) for safety. 
Subjects withdrawing will be asked to complete an early termination visit if they do not 
wish to be followed per protocol. Any decision to replace a subject who drops out after 
receiving the study drug will be documented in the electronic data capture (EDC) system 
on an electronic case report form (CRF). 
10.3 ESCALATION, CONTINUATION, AND STOPPING RULES 
Criteria surrounding sentinel halting, study halting and/or dose escalation within the SAD 
portion of the study and study halting and/or dose continuation within the MAD portion 
of the study will governed by the following criteria.  
 
Study Halting Rules 
If any of the following events occur, the study will be stopped: 
• Any subject develops an SAE through the last study visit. 
• 2 or more subjects in any cohort experience a Grade 3 (severe) AE, including 
unsolicited clinical, ECG, VS, and laboratory AEs, that is of the same type 
(preferred term) and occurring in the same SOC.  
• Any subject develops an episode of anaphylaxis within 24 hours after receiving the 
study drug. 

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Dose Escalation Halting Rules 
The PI must review the following criteria before dose escalation: 
• SAD: A review of all available safety data for the cohort to Day 3 demonstrates 
that the study halting criteria described below have not been met. 
• MAD: A review of all available safety data to Day 12, at a minimum, 
demonstrates that the dose-escalation halting criteria described below have not 
been met. 
If any of the following dose escalation halting rules are met in either the SAD or MAD 
parts, escalation to the next planned dose cohort will not proceed until all available study 
data have been reviewed by the PI, the Medical Monitor and the Study Sponsor: 
• Any subject develops an SAE. 
• Any subject experiences a Grade 3 (severe) AE. 
• 2 or more subjects in a cohort experience a Grade 2 (moderate) or greater AE that 
is of the same type (preferred term) and occurring in the same SOC.  
 
Individual Halting Rules 
The following individual halting rules pertain to the MAD study only: 
• Any SAE. 
• Any other condition that the site PI judges to unduly increase the risk to the 
subject. 
 
Sentinel Halting Rules 
The following are SAD sentinel halting criteria, ie, if any are met, the rest of the cohort 
will not be dosed until reviewed by the PI, the Medical Monitor and the Study Sponsor: 
• Any subject develops a Grade 3 (severe) AE within 24 hours of study drug 
administration.  
 
If stopping rules are triggered for any reason, the study PI will notify the Medical Monitor 
and the Study Sponsor and initiate a review that may include unblinding of treatment 
assignments. A summary of the decision making for all halts will be documented and 
submitted to the IRB.  
In the event that any of the stopping criteria are triggered, the PI in consultation with the 
Medical Monitor and Study Sponsor may take one of the following courses of action. 
 
1. Temporarily halt dosing while the event is investigated.  
2. Declare the prior tested dose level as the MTD.   
3. Recommend repeat dosing at the same level. 
4. Recommend dosing at an intermediate level. 
5. Recommend protocol amendment to increase Subject safety. 
6. Discontinue the study. 

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11.0 STUDY DRUG INFORMATION 
11.1 DRUG PRODUCT IDENTITY, MANUFACTURE, SHIPMENT, AND 
RECEIVING 
The Clinical Trial Materials include the IDP, buffered vehicle, and placebo. The IDP is a 
solution-based formulation of (2R,6R)-Hydroxynorketamine Hydrochloride. The diluting 
vehicle is a 25 mM sodium phosphate (pH 7) buffer in 0.9% (normal) saline solution. The 
placebo is 0.9% (normal) saline. The IDP will be manufactured by a Good Manufacturing 
Practice (GMP) certified contract manufacturing organization (CMO) as a 10 mg/mL 
(free base equivalent) sterile solution using a 25 mM sodium phosphate (pH 7) buffer in 
0.9% (normal) saline. The buffered vehicle is sterile solution using a 25 mM sodium 
phosphate (pH 7) buffer in 0.9% (normal) saline and will be manufactured by a GMP 
certified CMO. Placebo will be sourced by the Duke Clinical Research Institute (DCRI).  
 
The IDP will be manufactured, shipped, and stored in individual 100 mL (total volume) 
Type I clear glass vials containing a total volume of 55 mL of IDP. The IDP will be 
labeled according to FDA regulatory requirements.  
 
The buffered vehicle will be manufactured, shipped, and stored in individual 100 mL 
(total volume) Type I sterile glass vials. The buffered vehicle will be labeled according to 
FDA regulatory requirements. 
 
11.2 INVESTIGATIONAL DRUG PRODUCT, FORMULANT, AND PLACEBO 
PHYSICAL DESCRIPTION 
The IDP, formulant, and placebo are all clear, colorless solutions.  
 
11.3 INVESTIGATIONAL DRUG PRODUCT AND PLACEBO PREPARATION 
AND QUALITY CONTROL 
The stock IDP (ie, the 10 mg/mL solution) and buffered vehicle will be manufactured and 
shipped by a GMP certified CMO. Dilution of the IDP to the clinically used dose using 
the buffered vehicle will be performed by the pharmacy staff at the clinical site as 
described in section 12.7 and the Pharmacy Manual. Placebo will be sourced by the Duke 
Clinical Research Institute (DCRI). 
 
11.4 INVESTIGATIONAL DRUG PRODUCT, FORMULANT AND PLACEBO 
ACCOUNTABILITY 
The PI is responsible for ensuring that all study drug, vehicle buffer, and placebo at the 
clinical study facility is accounted for throughout the study (ie, inventoried, stored, used 
and disposed of according to set procedures). The dispensing of study drug to the Subject 
must be documented on a designated drug accountability form. All IDP and placebo 
containers and administration components must be returned to the pharmacy following 
administration for reconciliation and disposition. Unused study drug must be disposed of 
according to clinic site procedures.  

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Study drug, buffer, and placebo must be handled in strict accordance with the protocol, 
pharmacy manual, and container labels and must be stored in limited access area under 
the defined environmental conditions. Unused study drug must not be disposed of until 
the PI or his/her designee has completed drug accounting per a preset schedule.    
 
11.5 INVESTIGATIONAL DRUG PRODUCT QUALITY COMPLAINT 
PROCEDURE 
A product quality complaint (PQC) is defined as any suspicion of a product defect related 
to manufacturing, labeling, or packaging, ie, any dissatisfaction relative to the identity, 
quality, durability, or reliability of a product, including its labeling or package integrity. 
The PQCs may have an impact on the safety and efficacy of the product. Timely, 
accurate, and complete reporting and analysis of PQC information from clinical studies 
are crucial for the protection of Subjects, Investigators, and the sponsor, and are 
mandated by regulatory agencies worldwide. The sponsor has established procedures in 
conformity with regulatory requirements to ensure appropriate reporting of PQC 
information.  
 

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12.0 STUDY PROCEDURES AND EVALUATIONS 
The Time and Events Schedule for the SAD study (Table 1), MAD study (Table 2), and 
CSF Capture study (Table 3) summarizes all key procedures and evaluations.  
 
12.1 STUDY SPECIFIC MATERIALS 
The following study specific materials will be supplied to the clinical site by the Study 
Sponsor. 
 
Investigator’s Brochure 
Package Insert for Investigational Drug Product 
Manual of Procedures (MOP) including: 
Pharmacy Manual/Site Investigator Product Manual 
Laboratory Manual 
Electronic Data Capture Manual 
qEEG Manual 
Statistical Analysis Plan (safety) 
Statistical Analysis Plan (PK) 
Statistical Analysis Plan (qEEG) 
Investigational Drug Product/Placebo Container Labels 
Pharmacokinetics Labels 
C-SSRS and CADSS Questionnaires 
Investigational Drug product: (2R,6R)-Hydroxynorketamine Hydrochloride  
Formulant: 25 mM sodium phosphate (pH 7) buffer in 0.9% (normal) saline 
Placebo: 0.9% (normal) saline 
Diluting Vials: 100 mL (total volume) sterile ALK vial 
Diluting Syringes: 1 mL sterile Beckton Dickinson Syringes 
Diluting Syringes: 60 mL sterile Beckton Dickinson Syringes 
Administration Syringes: 60 mL sterile Beckton Dickinson Syringes 
Administration Tubing: Single Use Extension Set, 60-inch (152.4 cm) Tubing 
(APV = 1.1 mL) 
Administration Needles: Protect IV® Plus Safety IV Catheters (Radiopaque), 20G X 1” 
 
12.2 SCREENING 
The informed consent documents will be discussed with each potential participant and 
each Subject will sign an informed consent document for the study before any study-
specific procedures are performed. Each potential participant will have the following 
assessments performed by the Investigator or a designee at screening.  
 
1. Medical history, including psychiatric history. 
2. Demographic data, including sex, age, race, ethnicity, body weight, height, 
body mass index (BMI; kg/m2), and smoking habits. 
3. Physical examination. 
4. VS. 

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5. ECG. 
6. Clinical laboratory tests. 
7. Serology tests. 
8. Urine test for drugs of abuse, cotinine. 
9. Alcohol breath test. 
10. Serum pregnancy (all female Subjects). 
11. FSH test (females claiming postmenopausal status). 
12. Verbal confirmation that all remaining inclusion/exclusion criteria are met. 
13. C-SSRS. 
14. Prior and concomitant medication review. 
Subjects not meeting eligibility criteria at Screening may be rescreened once at the 
discretion of the Investigator. Subjects who meet eligibility criteria at Screening and are 
not dosed in a cohort (eg, alternates or because a cohort is filled) may be rescreened as 
needed to participate in future cohorts.  
12.3 INFORMED CONSENT 
Each Subject must give written consent according to local requirements after the nature 
of the study has been fully explained. The consent form must be signed before 
performance of any study-related activity. The consent form that is used must be 
approved by both the sponsor and by the reviewing IRB and be in a language that the 
Subject can read and understand. The informed consent should be in accordance with 
Principals that originated in the Declaration of Helsinki, current ICH and GCP guidelines, 
applicable regulatory requirements, and sponsor policy. 
 
Before enrollment in the study, the PI or an authorized member of the investigational staff 
must explain to potential Subjects the aims, methods, reasonably anticipated benefits, and 
potential hazards of the study, and any discomfort participation in the study may entail. 
Subjects will be informed that their participation is voluntary and that they may withdraw 
consent to participate at any time. They will be informed that choosing not to participate 
will not affect the care the Subject will receive. Finally, they will be told that the 
Investigator will maintain a Subject identification register for the purposes of long-term 
follow up if needed and that their records may be accessed by health authorities and 
authorized sponsor staff without violating the confidentiality of the Subject, to the extent 
permitted by the applicable law(s) or regulations. By signing the informed consent form, 
the Subject is authorizing such access, and agrees to allow his or her study physician to 
recontact the Subject for the purpose of obtaining consent for additional safety 
evaluations, if needed. 
 
The Subject will be given sufficient time to read the informed consent form and the 
opportunity to ask questions. After this explanation and before entry into the study, 
consent should be appropriately recorded by means of the Subject’s personally dated 
signature. After having obtained the consent, a copy of the signed informed consent form 
must be given to the Subject. 
 

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12.4 SUBJECT ASSIGNMENT AND CHECK-IN 
For the SAD part, 48 Subjects (6 cohorts of 8 Subjects) will be dosed according to the 
Time and Events Schedule for the SAD study (Table 1). For the MAD part, 16 Subjects 
(2 cohorts of 8 Subjects) will be dosed according to the Time and Events Schedule for the 
MAD study (Table 2). For the CSF Capture part, 8 Subjects (1 cohorts of 8 Subjects) will 
be dosed according to the Time and Events Schedule for the CSF Capture study (Table 
3). Additional cohorts may be enrolled after evaluation if it is determined that 
intermediate or higher dose levels should be tested. The number of Subjects planned is 
considered sufficient to characterize the safety and PK in a first-in-human clinical trial. 
Each Subject will receive an assigned treatment based on the randomization schedule 
prepared by the clinical site.  
 
Subjects in the SAD study will be randomized to receive either a single dose of active 
drug or a single dose of matching placebo. Subjects in the MAD study will be 
randomized to receive either a series of 4 doses of active drug or a series of 4 doses of 
matching placebo. Subjects in the CSF Capture study will be randomized to receive either 
a single dose of active drug or a single dose of matching placebo.  
 
For Subjects in the SAD study, the maximum duration of the study from screening to 
end-of-study will be approximately 33 days. For Subjects in the MAD study, the 
maximum duration of the study from screening to end-of-study will be approximately 
52 days. For Subjects in the CSF Capture study, the maximum duration of the study from 
screening to end-of-study will be approximately 33 days.  
 
For the SAD, MAD and CSF Capture parts, an appropriate number of alternates will be 
included as judged by the PI. Alternates not used in a cohort may be dosed in future 
cohorts if eligibility criteria are re-confirmed.  
 
At check-in (Day -1), Subjects will be admitted to the research center at an appropriate 
time the Day before study drug administration to ensure a minimum 8-hour fast prior to 
dosing. At check-in, all Subjects will be evaluated to confirm that they continue to meet 
all the inclusion criteria and none of the exclusion criteria. An alcohol breath test will be 
performed. A urine sample will be collected to screen for drugs of abuse and cotinine. If 
at any time an alcohol, cotinine, or drug test is positive, the Subject will be discontinued 
from study participation. A positive point-of-care drug test may be sent for confirmation 
to the clinical laboratory at the discretion of the Investigator (eg, suspicion of a spurious 
value). 
 
All Subjects will be asked to confirm that they still adhere to the contraceptive criteria, 
and each Subject’s response will be documented. 
 
A urine sample from each female Subject will be collected for a urine pregnancy test at 
check in. This test must be negative for the Subject to continue in the study. If an 
assessment is performed at both screening and Day -1, the Day -1 assessment will be 
considered baseline. The following additional assessments will be performed on Day -1. 
 

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1. Eligibility criteria. 
2. Weight. 
3. Medical history. 
4. Physical examination. 
5. VS. 
6. ECG. 
7. Clinical laboratory tests. 
8. Urine tests for drugs of abuse and cotinine. 
9. Breath alcohol. 
10. Ocular examination. 
11. Prior and concomitant medication review. 
12. Psychiatric/mental health assessment including the POMS, the CADSS and the 
C-SSRS assessments. 
 
12.5 FASTING, MEALS, AND BEVERAGES 
An optional meal, snack, and/or beverage will be served on the evening of check-in. All 
Subjects will then be required to fast for at least 8 hours before drug infusion, during the 
drug infusion and for 1 hour after the start of the infusion. The Subjects will be provided 
a light meal from 1 hour after the start of the infusion to 2 hours after the start of the 
infusion. Subjects will be allowed up to 240 mL of water from one hour before until one 
hour after drug treatment. At all other times, Subjects will be allowed to drink water ad 
libitum. 
 
All other meals will be provided at appropriate times thereafter. Meal/snack menus will 
be approximately the same for all cohorts.  
 
 
12.6 RANDOMIZATION AND BLINDING 
All Subjects and clinical staff, (except the unblinded pharmacist staff) will be blinded to 
treatment. An unblinded pharmacist staff will be required at the Clinical Site to comply 
with the study’s randomization and blinding requirements. At the clinical site, prior to 
study administration, the PI will be responsible for designating a qualified pharmacy staff 
to service as the unblinded pharmacy staff in the study. Unblinded pharmacy staff may 
dose Subjects, but may not participate in Subject assessments.  
 
The designated, unblinded pharmacy staff will be responsible for all drug accountability 
issues, including preparing, labelling, and dispensing study drug and placebo in 
accordance with the randomization codes provided, yet remain independent of all Subject 
assessments. The pharmacy staff will follow the Standard Operating Procedures and 
Work instructions related to pharmacy services and protocol-specific requirements. 
 
Randomization codes will be provided to the unblinded pharmacy staff. Confirmation of 
receipt of the randomization code will be required by the Sponsor. The unblinded 
pharmacy staff will be responsible for maintaining the blind, consistent with protocol 

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design, throughout the study. All documentation is to be filed in the Pharmacy Manual. 
Access to this manual will be restricted to the unblinded pharmacy staff. 
 
The Subjects, PI, and all other study personnel involved with the Subject assessments 
will be blinded to the actual treatment assignment of the Subjects. The PI will be 
ultimately responsible for ensuring the integrity of the blind, and that it is maintained 
through the study.  
 
The treatment assignment should only be unblinded at the clinic in the case of dose-
limiting toxicity or emergency when the knowledge of the study drug assignment is 
necessary for the clinical management or welfare of the Subject. Breaking the blind at the 
clinic under any other circumstance will be considered a protocol violation. The PI is 
strongly encouraged to contact the sponsor before unblinding the study drug assignment. 
If the blind is broken for any reason, the Investigator must notify the Sponsor within one 
day. In addition, the Investigator will record the date and reason for revealing the blinded 
study drug assignment for that Subject in the source documents and appropriate case 
report form page(s).  
 
12.7 DRUG PREPARATION, DOSING, AND ADMINISTRATION 
The IDP and placebo will be prepared according to the Pharmacy Manual (general 
description below and provided in the Study Drug Information (section 11).  
 
The dose of IDP will be prepared based upon the specific dose level of the cohort and the 
Subjects body weight. The exact dose will be prepared by diluting the IDP [a 10 mg/mL 
solution of (2R,6R)-Hydroxynorketamine Hydrochloride] with buffered vehicle [25 mM 
sodium phosphate (pH 7) buffer in 0.9% (normal) saline]. 
 
12.8 SAFETY MONITORING AND REPORTING 
Key safety evaluations will include monitoring of physical examinations, clinical 
laboratory outcomes, VS, ECG, and Subject self-reporting. 
 
Physical examinations will be conducted according to the Time and Events Schedule for 
the SAD part (Table 1), MAD part (Table 2), and CSF Capture part (Table 3) and will 
include evaluations of eyes, ears, nose, throat, heart, peripheral vasculature, lungs, 
musculoskeletal system, abdomen, neurological function, endocrine system, and skin.  
 
Clinical laboratory tests will be conducted according to the Time and Events Schedule for 
the SAD study (Table 1), MAD study (Table 2), and CSF Capture study (Table 3) and 
will be inclusive of tests described in Table 8.  
 
VS and ECGs will be performed according to the Time and Events Schedule for the SAD 
study (Table 1), MAD study (Table 2), and CSF Capture study (Table 3) ±30 minutes. 
 
 

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Table 8: Clinical laboratory evaluations 
Hematology  
Chemistry 
Urinalysis 
• Total white blood cell 
count 
• Platelet count 
• Hemoglobin 
• Hematocrit 
• Red blood cell count  
• Basophil count 
• Eosinophil count 
• Lymphocyte count 
• Monocyte count 
• Neutrophil count 
• Reticulocyte count 
• Aspartate 
aminotransferase 
• Alanine 
aminotransferase 
• Bilirubin, total 
• Creatinine 
• Sodium 
• Potassium 
• Glucose  
• Blood urea nitrogen 
• Calcium 
• Alkaline phosphatase 
• Bilirubin, direct 
• Albumin 
• Protein, total 
• Magnesium 
• Pregnancy test (serum) 
• FSH (confirm 
postmenopausal status) 
• pH 
• Protein 
• Blood 
• Ketones 
• Glucose 
• Bilirubin 
• Nitrites 
• Specific gravity 
• Leukocytes 
• Urobilinogen 
• Urine pregnancy test 
 
If any abnormal value is 
observed on the urine 
dipstick test, the sample 
should be further analyzed 
with urine microscopy: 
• White blood cell 
count 
• Red blood cell count 
• Cellular casts 
• Granular casts 
• Hyaline casts 
Coagulation 
Drugs of Abuse (Urine) & Alcohol 
Testing (Breath) 
Serology Screen 
• Activated partial 
thromboplastin time 
• Prothrombin time 
• International normalized 
ratio 
• Cannabinoids 
• Amphetamines 
• Barbiturates 
• Cocaine 
• Opiates 
• Benzodiazepines 
• Phencyclidine 
• Methadone 
• Cotinine 
• Alcohol (Breathalyzer) 
• Hepatitis B surface 
antigen 
• Hepatitis C antibody 
• Human 
immunodeficiency 
virus 1 & 2 
antibodies 

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VS will be monitored according to the Time and Events Schedule for the SAD study 
(Table 1), MAD study (Table 2), and CSF Capture Study (Table 3) and will include 
blood pressure, pulse rate, respiration, and temperature. The PI or designee will verify the 
eligibility of each Subject with out-of-range VS and document approval prior to dosing.  
 
Systemic blood pressure and pulse will be continuously monitored throughout drug 
administration and for 2 hours after the conclusion of study drug infusion. Monitoring of 
these parameters will be accomplished with a correct-sized finger cuff placed on either 
the index or middle finger and the Nexfin noninvasive continuous blood pressure 
monitor. 
 
The ECG measurements, collected in triplicate, will be monitored using a 12-lead ECG 
signal according to the Time and Events Schedule for the SAD study (Table 1), MAD 
study (Table 2) and CSF Capture study (Table 3). During the collection of the baseline 
ECGs, Subjects should be in a quiet setting without distractions (eg, television or cell 
phones). Subjects should rest in a recumbent position for at least 5 minutes before ECG 
collection and should refrain from talking or moving arms or legs. Baseline ECG 
recordings should be taken at a time independent of blood sampling or VS measurements.  
 
Subjects will be instructed to tell the study physician and/or research personnel of any 
AEs that occur at any time during the study. Subjects will be monitored for AEs from 
dose administration through the end-of-study. 
 
For both the SAD and MAD parts, each Subject’s level of alertness/sedation and mental 
state will be examined using 4 standard tests (ie, the MOAA/S, the POMS, the C-SSRS 
and the CADSS). The MOAA/S is a scale developed to measure the level of alertness in 
subjects who may be sedated (see Appendix #1). The POMS is a psychological rating 
scale used to assess transient, distinct mood states (see Appendix #2). The C-SSRS is a 
low-burden measure of the spectrum of suicidal ideation and behavior that was developed 
to assess severity and track suicidal events through any treatment (see Appendix #3). The 
CADSS is an instrument for the measurement of present-state dissociative symptoms (see 
Appendix #4).  For the CSF Capture study, only the POMS and C-SSRS surveys will be 
administered.  
 
These measures will be completed according to the Time and Events Schedule for the 
SAD part (Table 1), MAD part (Table 2) and CSF Capture part (Table 3). 
 
Medical emergency personnel trained in advanced cardiac life support will be on site to 
monitor Subjects during the confinement period in the research center. Emergency 
medical equipment including but not limited to intubation equipment and pulse oximetry 
shall be maintained on site to administer appropriate medical care if required. Procedures 
will be completed as specified in this protocol unless contraindicated due to a reported 
AE. 

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12.9 ADVERSE EVENTS MONITORING AND REPORTING 
Subjects will be monitored for any AEs from study drug administration until the end-of-
study. These will include a full assessment of abuse-related AEs. The Investigator or 
designee will review each event. The Investigator or designee will assess its relationship 
to the study drug. Each sign or symptom will be graded for severity and the date and time 
of onset, cessation, and resolution will be recorded. Treatment of any adverse reactions 
will be evaluated and managed by the PI, a designated physician or appropriate 
emergency responders, as appropriate. All nonserious AEs will be reported on a regular 
basis, or as specified by the Sponsor.  
 
An AE is defined as any untoward medical occurrence associated with the use of a drug 
in humans, whether or not considered drug related. An AE can be any unfavorable or 
unintended sign, symptom, or disease temporally associated with the use of a drug, 
without judgement to causality. An AE can arise from any use of the drug and from any 
route of administration, formulation, or dose, including an overdose.  
 
A life-threatening AE/life-threatening suspected adverse reaction, in the view of either 
the Investigator or Sponsor, places the Subject at immediate risk of death. It does not 
include an adverse reaction that, if it had occurred in a more severe form, may have 
caused death. 
 
A serious adverse event (SAE) or serious suspected adverse reaction in the view of either 
the Sponsor or the PI, results in any of the following outcomes. 
 
1. Death. The death was the outcome of the AE. Date will be included, if known. 
2. Life-threatening AE. The Subject was at substantial risk of dying at the time 
of the AE, or continued use of the Clinical Trial Material may have resulted in 
the death of the patient. 
3. Inpatient hospitalization or prolongation of existing hospitalization. 
Emergency room visits that don’t result in admission to the hospital should be 
evaluated for other serious outcomes. 
4. Disability or permanent damage. A substantial disruption in a person’s ability 
to conduct normal life function. For example, the AE resulted in a significant, 
persistent, or permanent change, impairment, damage, or disruption in the 
patient’s body function, body structure, physical activities, and/or quality of 
life. 
5. Congenital anomaly/birth defect. Exposure to Clinical Trial Material prior to 
conception or pregnancy that may have resulted in adverse outcomes for the 
child.  
6. Other serious and important medical events. Events that do not fall into the 
above categories but may jeopardize the patient and may require medical or 
surgical intervention to prevent other outcomes. For example, allergic 
bronchospasms requiring emergency room treatment, seizures, or convulsions 

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that do not result in hospitalization, or the development of drug dependence or 
drug abuse. 
All serious adverse event (SAE) reporting will adhere to the U.S. Code of Federal 
Regulations (21 CFR Part 312.32) for IND drugs. The PI will immediately report any SAEs 
to the sponsor, whether or not these are considered study intervention-related, including 
those listed in the protocol or investigator brochure; any such report must include an 
assessment of whether there is a reasonable possibility that the study intervention caused 
the event.  The PI or designee must send all SAEs on a MedWatch form to the Sponsor, 
copying the REGSupportORSC@nih.gov inbox at the time of awareness (within 24 hours 
for deaths, within 48 hours for all other SAEs). Additional information to include in the 
MedWatch Form 3500A is as follows: 
 
• IND Number 
• Protocol Number 
• Principal Investigator’s Name 
• Event Attribution 
The sponsor or designee will be responsible for determining if an SAE is reportable to the 
FDA as an IND Safety Report, i.e. the event is considered a serious unexpected suspected 
adverse reaction (SUSAR). The study sponsor will be responsible for notifying the Food 
and Drug Administration (FDA) or other applicable regulatory agency, of any unexpected 
fatal or life-threatening suspected AE as soon as possible, but in no case later than seven 
calendar days after the sponsor's initial receipt of the information. In addition, the sponsor 
must notify the FDA and all participating investigators of an Investigational New Drug 
(IND) safety report of potential serious risks, from clinical trials or any other source, as 
soon as possible, but in no case later than 15 calendar days after the sponsor determines 
that the information qualifies for reporting.  
 
All SAEs will be followed until satisfactory resolution. All AEs will be documented on 
appropriate study records, including case report forms and AE tracking logs. All AEs will 
be provided in aggregate to the sponsor upon request and no less than once a year.   
 
An unexpected AE is defined as an AE or suspected adverse reaction that is not listed on 
the PI’s Brochure or is not listed at the severity indicated. If the IB is not available, an 
unexpected AE is one that is not consistent with the risk information described in the 
general investigational plan or elsewhere in the current application, as amended. 
 
The PI or designee will notify the appropriate sponsor contact immediately after SAE 
detection, observation, or report of occurrence, regardless of relationship to test article.  
 
Serious AE reports should contain the following details. 
 
A. Study name/number. 
B. Study Drug. 
C. Investigator details (name, phone, e-mail). 
D. Subject numbers. 

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E. Subject initials. 
F. Subject Demographics. 
G. Clinical Event. 
a. Description. 
b. Date of Onset. 
c. Treatment (Drug, dose, form). 
d. AE relationship to study drug. 
e. Action taken regarding study drug in direct relationship to the AE. 
H. If the AE was fatal or life threatening. 
I. If applicable, cause of death (including whether or not the death is related to 
study drug). 
J. If applicable, autopsy findings (if available).  
In the event of an AE or SAE, the following safety measurements will be performed and 
recorded. 
 
A. Sensory test (pinprick and vibration) 
B. Motor examination, reflexes and assessment of coordination (neurological 
exam) 
C. Vital signs 
D. Additional blood and/or CSF samples may be obtained, at the discretion of 
the investigator. 
E. Day 30 (+/- 3 days) phone follow up.  
Any new SAE that occurs within one month after the last dosing in the study and is 
considered to be related to the investigational product should be recorded and reported 
immediately to the Sponsor. The person responsible for this study shall take care that this 
study has been carried out in accordance with pharmacovigilance local regulations. 
 
All serious AE reporting will adhere to the U.S. Code of Federal Regulations (21 CFR 
Part 312.32) for IND drugs (15-Day alerts). The IRB will be notified of the alert reports 
per FDA regulations. All AEs including SAEs will be followed to resolution when 
possible. All AEs and treatment administered will be recorded on the case report form. 
The sponsor will be responsible for reporting and processing any SAEs to the FDA or 
other applicable regulatory agency. 
 
Abuse-related AEs will be reported separately and include a case narrative. Case 
narratives will include the time of onset and duration of the event, dose of drug taken, 
severity, and outcomes. A pharmacokinetic analysis will also be performed to assess if an 
abuse-related AE correlates with drug exposure.  
 
The relationship between the AE and investigational product (IP) will be determined by 
the PI based on his or her clinical judgement and the following definitions. 
 
Related: The AE follows a reasonable temporal sequence from the study product 
administration and cannot be reasonably explained by the Subject’s clinical state or other 

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factors. The AE follows a reasonable temporal sequence from the study product 
administration and represents a known reaction to the drug under study or other drugs in 
its class or is predicted by the known pharmacological properties of the drug.  
 
Not Related: The AE does not follow a reasonable temporal sequence from study 
product administration or can be reasonably explained by the Subject’s clinical state or 
other factors. 
 
Pregnancies: Pregnancies will be documented and followed until birth or another 
outcome. Pregnancies will not be reported as AEs. However, if at any time the pregnancy 
outcome falls under the scope and definition of a SAE, it will be reported as such. 
 
12.10 QUANTITATIVE ELECTROENCEPHALOGRAM (qEEG) MONITORING 
AND REPORTING 
Scalp-recorded EEG will be collected on all Subjects in the SAD study for approximately 
1 hour immediately preinfusion, for 1 hour after the start of the infusion and for a 
subsequent hour following a 1 hour break (ie, collecting EEG data during hours 2→3 
after the start of the infusion; total of 3 hours recording after the start of dosing). During 
this time, there will be three, 10-minute intervals specifically dedicated to collecting 
‘clean’ resting-state (5 minutes) and visual-evoked-potential (5 minutes). The remainder 
of the session will entail passive recording of the EEG during other study activities.   
 
High-definition EEG will be acquired through a 64-channel Brain Products actiCHamp 
systems using active electrodes positioned according to an equidistant spacing, covering 
the whole head from slightly above the eyebrows to below the inion. The EEG leads will 
include horizontal and vertical electrooculography, which will be used to identify and 
remove periods of ocular artifact during postprocessing of the data. The EEG leads will 
be placed in a nylon fabric EasyCap. Prior to recording data, a thorough impedance check 
of the electrodes will be done to ensure high-quality recording. During the drug infusion, 
subjects will remain in a recumbent position with their head slightly raised.  
Approximately 40 minutes prior to infusion, as well as at approximately 40 and 160 
minutes after the start of the infusion, participants will perform 10 minutes of dedicated 
EEG activities. To begin, the subject will be cued to undergo a 5-minute routine in which 
they stay comfortably in a recumbent position with their eyes closed and relax. This 
interval will allow for capture of “clean intervals” from which to derive time-frequency, 
and spectral power measures. Immediately following this, subjects will perform a brief, 
5-minute visual evoked potential paradigm in which they passively view a contrast-
reversing checkerboard stimulus alternating pseudo-randomly at approximately 0.5 Hz.    
 
Subjects will spend the bulk of the remainder of the EEG recording time in a recumbent 
position. In the event subjects must leave the bed, the recording file will be paused, the 
EEG head cap will remain on the participant’s head while cables that connect to the 
amplifier will be ejected and clipped to the participant’s shirt to allow free movement. 
Once the participant returns, the cables will be inserted back into the amplifier, a brief 
impedance check will be done to ensure high-quality recording, and recording will then 
continue. Additional details of the EEG are in the MOP.  

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The National Institutes of Health Experimental Therapeutics and Pathophysiology 
Branch will receive the collected data. The data will undergo epoch-by-epoch visual 
artifact correction/rejection. Quantitative EEG analysis will only be carried out if a 
minimum of 30 seconds of waking, artifact free data are available for any resting-state 
scan. The data will undergo Laplacian transformation to produce current density 
estimates. The current density data will undergo spectral analysis via Fast Fourier 
Transform (FFT) with boxcar windowing to generate power estimates in the following 
frequency bands: delta (2-7Hz), theta (7-9Hz), alpha (9-12Hz), beta (12-30Hz), and 
gamma (30-60Hz). This will be carried out with the LORETA software. At each voxel 
(n=2394; voxel resolution=7 mm3), current density will be computed as the squared 
magnitude of the intracerebral current density within each of the 5 frequency bands (unit: 
amperes per square meter, A/m2). Current density estimates will be intensity-normalized 
to unity and log-transformed before statistical analyses. This will be carried out in 2-
second segments and averaged over the available artifact-free, waking data. These data 
will be used to estimate resting-state EEG current density. The primary qEEG outcome 
will be EEG gamma current density. Resting state EEG current density estimates in other 
frequency bands will be analyzed to evaluate the specificity of possible findings. 
Exploratory analysis for patterns of EEG activity that are predictors and correlates of 
outcome will be carried out using EEG power in all bands derived from all the electrodes, 
employing principal components analysis.  
 
12.11 BLOOD AND CSF DRAWS FOR CLINICAL LABORATORY AND 
PHARMACOKINETIC TESTING  
Blood and CSF draws for serial PK and clinical laboratory testing will be collected at 
defined timepoints within the SAD, MAD and CSF Capture parts according to the 
schedule of assessments and procedures (Tables 1, 2 and 3, respectively) and as described 
in section 8.6.   
 
Blood  will be stored and shipped to a LabCorp (Covance) central laboratory who will 
perform PK analysis of (2R,6R)-Hydroxynorketamine using a LC/MS/MS method to 
capture the following parameters: Cmax, tmax, Cmin, AUC0-∞, AUC0-Tau, CL, Vz, CLR, t1/2.  
CSF samples will be analyzed at NIH using an alternate LC/MS/MS method assessing 
total (2R,6R)-Hydroxynorketamine concentrations at 3 collection timepoints (predose, 1-
hr postdose and 8-hr postdose). 
 
Subjects must have consented to participate before the screening blood draw. Blood 
draws collected for PK and clinical laboratory testing will be comprised of a total of 
approximately 16 mL from each Subject. Blood draws collected only for clinical 
laboratory testing will be comprised of a total of approximately 11 mL from each 
Subject. Blood draws collected for only PK testing will be comprised of a total of 
approximately 5 mL from each Subject. The maximum amount of blood draw 
(cumulatively) for any Subject will be approximately 219 mL.  
 
Blood draws collected for clinical laboratory testing will include 4.5 mL for chemistry 
panel, 4 mL for hematology panel, 2.7 mL for coagulation panel, and 8.5 mL for serology 

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panel (see Table 9-11). Blood draws collected for PK will include approximately 5 mL 
for primary and repeat analysis of the drug substance [(2R,6R)-Hydroxynorketamine] and 
remaining samples will be stored.   
 
CSF draws will be comprised of a total of approximately 10 mL from each subject and 
will consist of 3.5 mL for both metabolomics and proteomics and 3 mL for PK (Table 
12). Subjects will have a spinal catheter placed for sample collection. Spinal catheter 
placement, sample collection and storage details will be provided in the MOP.  
 
Table 9: Blood draw volumes and uses for SAD study 
Sample 
Total Volume (mL) 
Clin. Lab. Volume 
(mL) 
PK Volume (mL) 
Screening Draw 
20  
20  
NA 
Day -1 Draw 
11  
11  
NA 
Day 1 Draw 
(preinfusion) 
16  
11  
5  
Day 1 Draw (end-of-
infusion) 
5  
NA 
5  
Day 1 Draw (1-hour 
after the start of the 
infusion) 
5  
NA 
5  
Day 1 Draw (2-hour 
after the start of the 
infusion) 
5  
NA 
5  
Day 1 Draw (4-hour 
after the start of the 
infusion) 
5  
NA 
5  
Day 1 Draw (8-hour 
after the start of the 
infusion) 
5  
NA 
5  
Day 1 Draw (12-hour 
after the start of the 
infusion) 
5  
NA 
5  
Day 2 Draw (24-hour 
after the start of the 
infusion) 
16 
11  
5  
Day 3 Draw (48-hour 
after the start of the 
infusion) 
16  
11  
5  
Total Blood Draw 
109  
 
 
 
Table 10: Blood draw volumes and uses for MAD study 
Sample 
Total Volume (mL) 
Clin. Lab. Volume 
(mL) 
PK Volume (mL) 
Screening Draw 
20  
20  
NA 
Day -1 Draw 
11 
11  
NA 
Days 1, 4, 8, 11 Draw 
(preinfusion) 
64 (4 × 16) 
44 (4 × 11) 
20 (4 × 5) 

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Days 1, 4, 8, 11 Draw 
(end-of-infusion) 
20 (4 × 5) 
NA 
20 (4 × 5) 
Days 1, 11 Draw 
(1 hour after the start of 
the infusion) 
10 (2 × 5) 
NA 
10 (2 × 5) 
Days 1, 11 Draw 
(2 hours after the start of 
the infusion) 
10 (2 × 5) 
NA 
10 (2 × 5) 
Days 1, 11 Draw 
(4 hours after the start of 
the infusion) 
10 (2 × 5) 
NA 
10 (2 × 5) 
Days 1, 11 Draw 
(8 hours after the start of 
the infusion) 
10 (2 × 5) 
NA 
10 (2 × 5) 
Days 1, 11 Draw 
(12 hours after the start 
of the infusion) 
10 (2 × 5) 
NA 
10 (2 × 5) 
Days 2, 11 Draw 
(24 hours after the start 
of the infusion) 
32 (2 x 16) 
22 (2 x 11) 
10 (2 x 5) 
Total Blood Draw 
197  
 
 
 
Table 11: Blood draw volumes and uses for CSF Capture study 
Sample 
Total Volume (mL) 
Clin. Lab. Volume 
(mL) 
PK Volume (mL) 
Screening Draw 
20  
20  
NA 
Day -1 Draw 
11  
11  
NA 
Day 1 Draw 
(preinfusion) 
16  
11  
5  
Day 1 Draw (end-of-
infusion) 
5  
NA 
5  
Day 1 Draw (1-hour 
after the start of the 
infusion) 
5  
NA 
5  
Day 1 Draw (2-hour 
after the start of the 
infusion) 
5  
NA 
5  
Day 1 Draw (4-hour 
after the start of the 
infusion) 
5  
NA 
5  
Day 1 Draw (8-hour 
after the start of the 
infusion) 
5  
NA 
5  
Day 1 Draw (12-hour 
after the start of the 
infusion) 
5  
NA 
5  
Day 2 Draw (24-hour 
after the start of the 
infusion) 
16 
11  
5  
Total Blood Draw 
93  
 
 
 

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Table 12: CSF draw volumes and uses for CSF Capture study 
Sample 
Total Volume 
(mL) 
Proteomics 
Volume (mL) 
Metabolomics 
Volume (mL) 
PK Volume 
(mL) 
Day 1 Draw 
(preinfusion) 
10 
3.5  
3.5 
3  
Day 1 Draw (end-of-
infusion) 
10 
3.5  
3.5   
3  
Day 1 Draw (8-hour 
after the start of the 
infusion) 
10 
3.5   
3.5   
3  
Total CSF Draw 
30  
10.5 
10.5 
9 
 
12.12 BLOOD AND CSF DRAW SAMPLE COLLECTION, HANDLING, 
SHIPPING, AND RECEIVING  
Blood and CSF draws collected for clinical laboratory analysis and for PK will be 
collected, labeled, inventoried, stored, and shipped as described in the detailed in the 
MOP.  
 
12.13 URINE COLLECTION, HANDLING, SHIPPING, AND RECEIVING 
Urine samples collected for clinical laboratory analysis and for PK will be collected, 
labeled, inventoried, stored, and shipped as described in the detailed in the MOP. 
 
12.14 PHARMACOKINETIC ANALYTICAL PROCEDURES 
All blood samples will be processed to plasma for analysis. Analytical procedures will 
conform to a predetermined bioanalytical method.   
 
12.15 PHARMACOKINETIC PARAMETERS 
Blood samples will be analyzed for (2R,6R)-Hydroxynorketamine levels using an 
LC/MS/MS analytical method to determine plasma concentration levels in order to 
calculate the following PK parameters: Cmax, tmax, Cmin, AUC0-∞, AUC0-Tau, CL, Vz, CLR, 
t1/2. 
 
12.16 SUBJECT RELEASE, FOLLOW-UP, AND STUDY CLOSE 
All Subjects will be released from study confinement according to the Time and Events 
Schedule for the SAD study (Table 1), MAD study (Table 2) and CSF Capture study 
(Table 3) following a final consultation with the PI or a designee. All Subjects are 
required to conform to all follow-up visits or phone calls according to the Time and 
Events Schedule for the SAD study (Table 1), MAD study (Table 2) and CSF Capture 
study (Table 3). A Subject will be considered to have completed the study if he or she 
completes the final blood draw collected for clinical laboratory analysis and for PK.   
 

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13.0 STATISTICAL ANALYSIS 
Detailed summaries of the statistical analysis plan for 1) all safety data; 2) all PK; and 3) 
all qEEG data will be prospectively described in a Statistical Analysis Plan section of the 
MOP.  
 
13.1 SAFETY DATA  
All investigational product and protocol procedure related AEs will be listed, and if the 
frequency of events allows, safety data will be summarized using descriptive 
methodology. 
 
Each incidence of investigational product and protocol procedure related AEs will be 
presented by severity and by association with investigational product as perceived by the 
PI. Symptoms/AEs reported to occur prior to study entry will be distinguished from those 
reported as new or increased in severity during the study. All AEs and symptoms will be 
classified by the most suitable term using the MedDRA and summarized by SOC and 
preferred term, by severity, by relationship to study drug and study procedure, and by 
study drug dose. 
 
The number of investigational product-related SAEs will be reported. 
 
Safety parameters that will be assessed include clinical lab parameters, VS, and ECG 
parameters. The parameters will be listed and summarized using standard descriptive 
statistics. Additional analysis will be performed if warranted upon review of the data. 
 
13.2 PHARMACOKINETICS DATA  
Pharmacokinetic parameter estimates will be calculated by standard noncompartmental 
methods of analysis. 
 
The following PK parameters will be calculated as appropriate and if possible depending 
on actual samples collected: Cmax, tmax, Cmin at the end of the dosing interval after each 
dose in the MAD study, area under the plasma concentration-time curve from 0 to time of 
last measurable sample (AUC0-last) and area under the plasma concentration-time curve 
from 0 to infinity (AUC0-∞) in the SAD study, area under the plasma concentration-time 
curve during the dosing interval (AUC0-Tau) after the first dose and the last dose in the 
MAD study, CL, CLR, Vz, t1/2, and accumulation ratio for Cmax (RCmax) and AUC(0-∞) 
[RAUC(0-∞)]. 
 
Renal clearance will be calculated as the ratio of amount excreted/AUC. This will be 
compared to the unbound glomerular filtration rate, which is estimated using creatinine 
clearance. 
 
Dose proportionality will be evaluated using a regression analysis model to assess the 
linear relationship between the exposure parameters (Cmax and AUC0-∞ or AUC0-last from 
the SAD study; Cmax and AUC0-Tau from the MAD study) and dose as a covariate after 

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log-transformation (Ln) of the data, according to the equation Ln (exposure 
parameter) = β0 + β1 × Ln (dose); dose proportionality will be established if the 
estimated values of the slope (β1) are close to 1 and the 95% confidence intervals for the 
dose-dependent parameters include the value of 1 (12). 
 
An assessment of steady state will be performed using trough concentrations (Cmin) from 
days 4, 7, 10, and 12 in the MAD study. The ratio of geometric mean of Cmin on each 
corresponding day, divided by the geometric mean of the pooled Cmin from the following 
days will be calculated according to established methods (13, 14). The first assessment 
timepoint with a calculated Cmin ratio that does not statistically differ from a value of 1 
will be defined as the timepoint at which steady state is achieved (13, 14). 
 
An interim PK analysis is planned after cohorts 1 and 2 of the SAD study to assess drug 
exposures. Additional interim PK analyses may be performed based on the results of the 
interim analyses performed following cohorts 1 and 2. Details of the interim PK analysis 
will be described in the PK Analysis Plan. 
 
13.3 qEEG DATA  
Quantitative EEG (qEEG) data will be obtained for all study subjects in the SAD cohorts. 
This data will be collected over approximately 3 hours with predefined resting-state and 
visual evoked potential intervals. Analysis of the EEG data will include preliminary 
artifact correction using PCA-based techniques to identify biological artifacts that are not 
attributed to cortical activity. This will include scrutiny of the component spectral and 
spatial profiles, ultimately eliminating components that present with nontypical cortical 
activity. The qEEG parameters that will be studied include the ones discussed below. 
Other qEEG parameters may be evaluated postacquisition and will be described in the 
Statistical Analysis Plan.  
 
Relative spectral power 
An FFT analysis will be performed on the raw EEG. From this FFT analysis, the absolute 
and relative power spectrum will be determined across all frequency bands (delta, theta, 
alpha, beta and gamma).  
 
Visual evoked time-locked data 
Analysis of sensory processing will be conducted through consideration of the visual 
evoked potential to a contrast reversing checkerboard. Time-locked, event-related 
potential will be calculated on the continuous EEG collected during the visual stimulation 
allowing for high temporal resolution of signals from the primary and secondary visual 
cortices. Past research has linked these potential to gain control mechanisms in the brain, 
and analysis of the amplitude and latency effects of infusion will be considered in this 
context.  

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Source localization 
Frequency-specific and time-locked source localization will be performed using 
sLORETA within regions-of-interest specifying Default Mode, Central Executive, and 
Somatosensory networks.  
 

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14.0 ADMINISTRATIVE CONSIDERATIONS AND REQUIREMENTS 
14.1 BASIC PRINCIPLES  
This research will be carried out in accordance with the protocol, the ICH Guideline for 
Good Clinical Practice: Consolidated Guidance (E6), and applicable regulatory 
requirement(s) including clinical research guidelines established by the Basic Principles 
defined in the U.S. 21 CFR Parts 50, 56, and 312, and the Principles enunciated in the 
Declaration of Helsinki (revised version Fortaleza 2013). 
 
14.2 INSTITUTIONAL REVIEW BOARD, ETHICAL COMPLIANCE, 
INVESTIGATOR RESPONSIBILTIES, AND SPONSOR 
RESPONSIBILITIES 
 
This study is being conducted to evaluate the safe-dose ranges and PK of 
(2R,6R)-Hydroxynorketamine after slow-IV administration to healthy Subjects. The 
results of this study will provide useful information on dose and exposure of 
(2R,6R)-Hydroxynorketamine by this mode of administration.  
 
The primary ethical concerns of this study are that this study will be performed in healthy 
Subjects who will receive no benefit from participation in the study, except for financial 
compensation for the time and inconveniences that may arise from participation in the 
study. 
 
As with all clinical studies, there are risks associated with the clinical procedures. To 
avoid unnecessary risks, methods including the dosing strategy and blood sample 
collection scheme were designed to minimize the number of venipunctures required to 
complete the study. Further, the total volume of blood draws in support of clinical 
laboratory testing and PK evaluations collected from each Subject during the study does 
not exceed acceptable amount of blood to be collected over the defined time periods as 
recommended by standards set by the American Red Cross. 
 
Potential Subjects will be fully informed of the risks and requirements of the study and, 
during the study, Subjects will be given any new information that may affect their decision 
to continue participation. They will be told that their consent to participate in the study is 
voluntary and may be withdrawn at any time with no reason given and without penalty or 
loss of benefits to which they would otherwise be entitled. Only Subjects who are fully able 
to understand the risks, benefits, and potential AEs of the study, and provide their consent 
voluntarily will be enrolled. 
 
Any woman who is pregnant, breast feeding, or planning to become pregnant during the 
study will be excluded from participating in the study. Potential female Subjects must be 
postmenopausal, sterile, abstinent, or, if heterosexually active, be practicing a highly 
effective method of birth control before entry and throughout the study. Women, who are 
not heterosexually active at Screening, must agree to utilize a highly effective method of 
birth control if they become heterosexually active during their participation in the study.  

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The PI is responsible for ensuring that the clinical study is performed in accordance with 
the protocol, current ICH guidelines on Good Clinical Practice (GCP), and applicable 
regulatory and country-specific requirements. 
 
The GCP is an international ethical and scientific quality standard for designing, 
conducting, recording, and reporting studies that involve the participation of human 
Subjects. Compliance with this standard provides public assurance that the rights, safety, 
and well-being of study Subjects are protected, consistent with the Principals that 
originated in the Declaration of Helsinki and that the clinical study data are credible. 
 
Before the start of the study, the PI (or sponsor where required) will provide the IEC/IRB 
with current and complete copies of the following documents: 
 
• Final protocol and, if applicable, amendments. 
• Sponsor-approved informed consent form (and any other written materials to 
be provided to the Subjects). 
• Investigator’s Brochure (or equivalent information) and amendments/addenda 
• Sponsor-approved Subject recruiting materials. 
• Information on compensation for study-related injuries or payment to Subjects 
for participation in the study, if applicable. 
• Investigator’s curriculum vitae or equivalent information (unless not required, 
as documented by the IEC/IRB). 
• Information regarding funding, name of the sponsor, institutional affiliations, 
other potential conflicts of interest, and incentives for Subjects. 
• Any other documents that the IEC/IRB requests to fulfill its obligation. 
 
This study will be undertaken only after the IEC/IRB has given full approval of the final 
protocol, amendments (if any), the informed consent form, applicable recruiting 
materials, and Subject compensation programs, and the sponsor has received a copy of 
this approval. This approval letter must be dated and must clearly identify the IEC/IRB 
and the documents being approved. 
 
During the study, the PI (or sponsor where required) will send the following documents 
and updates to the IEC/IRB for their review and approval, where appropriate: 
 
• Protocol amendments. 
• Revision(s) to informed consent form and any other written materials to be 
provided to Subjects. 
• If applicable, new or revised Subject recruiting materials approved by the 
sponsor. 
• Revisions to compensation for study-related injuries or payment to Subjects 
for participation in the study, if applicable. 
• New edition(s) of the Investigator's Brochure and amendments/addenda. 
• Summaries of the status of the study at intervals stipulated in guidelines of the 
IEC/IRB (at least annually). 

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• Reports of AEs that are serious, unlisted/unexpected, and associated with the 
investigational drug. 
• New information that may adversely affect the safety of the Subjects or the 
conduct of the study. 
• Deviations from or changes to the protocol to eliminate immediate hazards to 
the Subjects. 
• Report of deaths of Subjects under the Investigator’s care. 
• Notification if a new Investigator is responsible for the study at the site. 
• Annual Safety Report and Line Listings, where applicable. 
• Any other requirements of the IEC/IRB. 
 
For all protocol amendments (excluding the ones that are purely administrative, with no 
consequences for Subjects, data, or study conduct), the amendment and applicable 
informed consent form revisions must be submitted promptly to the IEC/IRB for review 
and approval before implementation of the change(s). 
 
At least once a year, the IEC/IRB will be asked to review and reapprove this clinical 
study. The reapproval should be documented in writing (excluding the ones that are 
purely administrative, with no consequences for Subjects, data, or study conduct). 
 
At the end of the study, the Investigator (or sponsor where required) will notify the 
IEC/IRB about the study completion. 
 
14.3 PRIVACY OF PERSONAL DATA 
The collection and processing of personal data from Subjects enrolled in this study will 
be limited to those data that are necessary to fulfill the objectives of the study. 
 
These data must be collected and processed with adequate precautions to ensure 
confidentiality and compliance with applicable data privacy protection laws and 
regulations. Appropriate technical and organizational measures to protect the personal 
data against unauthorized disclosures or access, accidental or unlawful destruction, or 
accidental loss or alteration must be put in place. Sponsor personnel whose 
responsibilities require access to personal data agree to keep the identity of study 
Subjects confidential. 
 
The informed consent obtained from the Subject includes explicit consent for the 
processing of personal data and for the Investigator to allow direct access to his or her 
original medical records for study-related monitoring, audit, IEC/IRB review, and 
regulatory inspection. This consent also addresses the transfer of the data to other entities 
and to other countries. 
 
The Subject has the right to request through the Investigator access to his or her personal 
data and the right to request rectification of any data that are not correct or complete. 
Reasonable steps will be taken to respond to such a request, taking into consideration the 
nature of the request, the conditions of the study, and the applicable laws and regulations. 

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14.4 PROTOCOL AMENDMENTS 
Neither the PI nor the Sponsor will modify this protocol without a formal amendment. 
All protocol amendments must be issued by the PI or the Sponsor and signed and dated 
by the PI. Protocol amendments must not be implemented without prior IEC/IRB 
approval, or when the relevant competent authority has raised any grounds for 
nonacceptance, except when necessary to eliminate immediate hazards to the Subjects, in 
which case the amendment must be promptly submitted to the IEC/IRB and relevant 
competent authority. Documentation of amendment approval by the Investigator and 
IEC/IRB must be provided to the sponsor or its designee. When the change(s) involve(s) 
only logistic or administrative aspects of the study, the IRB (and IEC where required) 
only needs to be notified. 
 
During the study, in situations where a departure from the protocol is unavoidable, the PI 
or other physician in attendance will contact the appropriate sponsor representative. 
Except in emergency situations, this contact should be made before implementing any 
departure from the protocol. In all cases, contact with the Sponsor must be made as soon 
as possible to discuss the situation and agree on an appropriate course of action. The data 
recorded in the CRF and source documents will reflect any departure from the protocol, 
and the source documents will describe this departure and the circumstances requiring it. 
 
14.5 STUDY MONITORING 
The Sponsor will be allowed to perform on-site monitoring visits without restriction. The 
monitor will record dates of the visits in a study site visit log that will be kept at the site. 
The Sponsor monitoring activities during visits will consist of reviews of procedures and 
data integrity. Direct access to source documentation (medical records) is allowed for the 
purpose of verifying that the data recorded in the Sponsors database are consistent with 
the original source data. Findings from comparative reviews will be discussed with the 
PI. The Sponsor expects that, during monitoring visits, the relevant investigational staff 
will be available, the source documentation will be accessible, and a suitable environment 
will be provided for review of study-related documents. The monitor will meet with the 
Investigator on a regular basis during the study to provide feedback on the study conduct. 
 
Representatives of the Sponsor’s clinical quality assurance department may visit the site 
at any time during or after completion of the study to conduct an audit of the study in 
compliance with regulatory guidelines and company policy. These audits will require 
access to all study records, including source documents, for inspection and comparison 
with the Sponsors database. Subject privacy must, however, be respected. The PI and 
staff are responsible for being present and available for consultation during routinely 
scheduled site audit visits conducted by the sponsor or its designees. 
 
Similar auditing procedures may also be conducted by agents of any regulatory body, 
either as part of a national GCP compliance program or to review the results of this study 
in support of a regulatory submission. The PI should immediately notify the sponsor if 
they have been contacted by a regulatory agency concerning an upcoming inspection. 

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14.6 STUDY COMPLETION OR TERMINATION 
The Sponsor reserves the right to terminate the study at any time for any reason at the 
sole discretion of the Sponsor. The PI may terminate the study at any time, provided there 
is reasonable cause and sufficient notice is given in advance of the intended termination. 
 
Reasons for the early closure of an investigational site by the sponsor or Investigator may 
include, but are not limited to: 
 
• Failure of the PI to comply with the protocol, the requirements of the IEC/IRB 
or local health authorities, the sponsor's procedures, or GCP guidelines. 
• Inadequate recruitment of Subjects by the PI. 
• Discontinuation of further drug development. 
 
The study is considered completed with the last visit for the last Subject participating in 
the study. The final data from the investigational site will be sent to the Sponsor after 
completion of the final Subject visit at that site, in the time frame specified in the Clinical 
Trial Agreement. 
 
14.7 REGULATORY DOCUMENTATION 
This protocol and any amendment(s) must be submitted to the appropriate regulatory 
authorities. A study may not be initiated until all regulatory requirements are met. 
 
14.8 SUBJECT IDENTIFICATION, ENROLLMENT LOG, AND SCREENING 
LOG 
The PI agrees to complete a Subject identification and enrollment log to permit easy 
identification of each Subject during and after the study. This document will be reviewed 
by the sponsor site contact for completeness. 
 
The Subject identification and enrollment log will be treated as confidential and will be 
filed by the Investigator in the study file. To ensure Subject confidentiality, no copy will 
be made. All reports and communications relating to the study will identify Subjects by 
assigned number. 
 
The PI must also complete a Subject screening log, which reports on all Subjects who 
were seen to determine eligibility for inclusion in the study. 
 
14.9 DATA CAPTURE, DATA QUALITY CONTROL, AND REPORTING 
Steps to be taken to ensure the accuracy and reliability of data include review of protocol 
procedures with the PI and associated personnel before the study, periodic monitoring 
visits by the Sponsor, and direct transmission of clinical laboratory data, ECG data, and 
EEG data from central laboratories into the Sponsor’s database. Written instructions will 
be provided for electronic transfer of data to the Sponsor’s database. The Sponsor will 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
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review for accuracy and completeness during scheduled teleconferences, on-site 
monitoring visits and after transmission to the sponsor; any discrepancies will be resolved 
with the PI or designee, as appropriate. After upload of the data into the clinical study 
database, they will be verified for accuracy and consistency with the data sources. 
 
14.10 REGISTRATION OF CLINICAL STUDIES AND DISCLOSURE OF 
RESULTS 
The sponsor will register and/or disclose the existence of, and the results of clinical 
studies as required by law. 
 
14.11 USE OF INFORMATION, DATA, AND PUBLICATION 
All information generated as a result of this study, are considered confidential and remain 
the sole property of the Sponsor. Following study termination/conclusion, the PI and the 
Sponsor will evaluate key data outcomes and collaborate on the writing, submission and 
publication of a peer-reviewed manuscript detailing all outcomes of the study within 12 
months of the study conclusion. Authorship of publications resulting from this study will 
be based on the guidelines on authorship, such as those described in the Uniform 
Requirements for Manuscripts Submitted to Biomedical Journals, which state that the 
named authors must have made a significant contribution to the design of the study or 
analysis and interpretation of the data, provided critical review of the paper, and given 
final approval of the final version. 
 
14.12 REIMBURSEMENTS, INDEMNITY, AND INSURANCE  
There is no cost to subjects for the research tests, procedures, and study product while 
taking part in this study. Procedures and treatment for clinical care may be billed to the 
subject, subject’s insurance, or third party. Subjects may be compensated for their 
participation in this study. Compensation will be in accordance with the local IRB’s 
policies and procedures, and subject to IRB approval. 
 
If it is determined by the site PI that an injury occurred to a subject as a direct result of 
the tests or treatments that are done for this study, then referrals to appropriate health care 
facilities will be provided to the subject. Study personnel will try to reduce, control, and 
treat any complications from this study. Immediate medical treatment may be provided 
by the participating site.  
 

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References: 
1. a) Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive 
disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 
2003;289(23):3095-3105. 
b) Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in 
depressed outpatients requiring one or several treatment steps: a STAR*D report. Am 
J Psychiatry. 2006;163(11):1905-1917. 
2. Sinner B, Graf BM. Ketamine. Handb Exp Pharmacol. 2008;(182):313-333. 
3. a) Newport DJ, Carpenter LL, McDonald WM, Potash JB, Tohen M, Nemeroff CB. 
Ketamine and Other NMDA Antagonists: Early Clinical Trials and Possible 
Mechanisms in Depression. Am J Psychiatry. 2015;172(10):950-966.  
4. a) Moaddel R, Venkata SL, Tanga MJ, et al. A parallel chiral-achiral liquid 
chromatographic method for the determination of the stereoisomers of ketamine and 
ketamine metabolites in the plasma and urine of patients with complex regional pain 
syndrome. Talanta. 2010;82(5):1892-1904. 
b.) Zeilhofer HU, Swandulla D, Geisslinger G, et al. Differential effects of ketamine 
enantiomers on NMDA receptor currents in cultured neurons. Eur J Pharmacol. 
1992;213(1):155-158. 
c) Morris PJ, Moaddel R, Zanos P, et al. Synthesis and N-Methyl-d-aspartate 
(NMDA) Receptor Activity of Ketamine Metabolites. Org Lett. 2017;19(17):4572-
4575. 
5. Zanos P, Moaddel R, Morris PJ, et al. NMDAR inhibition-independent antidepressant 
actions of ketamine metabolites. Nature. 2016;533(7604):481-486. 
6. Lumsden EW, Troppoli TA, Myers SJ, et al. Antidepressant-relevant concentrations 
of the ketamine metabolite (2R,6R)-hydroxynorketamine do not block NMDA 
receptor function. Proc Natl Acad Sci USA. 2019;116(11):5160-5169. 
7. Zhao X, Venkata SL, Moaddel R, et al. Br J Clin Pharmacol. 2012;74(2):304-314.  
8. Weiber J, Gugler R, Hengstmann JH, Dengler HJ. Anaesthesist. 1975;24(6):260-263.  
9. Zarate CA Jr, Brutsche N, Laje G, et al. Relationship of ketamine's plasma 
metabolites with response, diagnosis, and side effects in major depression. Biol 
Psychiatry. 2012;72(4):331-338.  
10. Ketamine Hydrochloride Injection; Safety Data Sheet No. PZ03153; Hospira: Lake 
Forest, IL, September 19th, 2016. 
https://www.pfizer.com/sites/default/files/products/material_safety_data/ketamine_H
Cl_hospira_19-sep-2016.pdf 
11. Specific Federal and International Regulations define classes of “Hazardous 
Materials” and “Dangerous Goods” 
12. Baverel P, She D, Piper E; et al. A randomized, placebo-controlled, single ascending-
dose study to assess the safety, tolerability, pharmacokinetics, and immunogenicity of 
subcutaneous tralokinumab in Japanese healthy volunteers. Drug Metab 
Pharmacokinet. 2018;33(3):150-158.  

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13. Willsie SK, Evashenk MA, Hamel LG, Hwang SS, Chiang YK, Palmer PP. 
Pharmacokinetic properties of single- and repeated-dose sufentanil sublingual tablets 
in healthy volunteers. Clin Ther. 2015;37(1):145-155.  
14. Maganti L, Panebianco DL, Maes AL. Evaluation of methods for estimating time to 
steady state with examples from phase 1 studies. AAPS J. 2008;10(1):141-147.  
 
 
 

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Appendix 1: MOAA’s 
 
 
 

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National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
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Responsiveness scores of the Modified Observer’s Assessment of Alertness/sedation 
Scale. 
Response 
Score 
Responds readily to name spoken in normal tone 
5 
Lethargic response to name spoken in normal tone 
4 
Responds only after name is called loudly of repeatedly 
3 
Responds only after mild prodding or shaking 
2 
Does not respond to mild prodding or shaking 
1 
Does not respond to noxious stimulus 
0 
 
 
 

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Appendix 2: POMS 
 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
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Abbreviated POMS (Revised Version) 
 
Name: 
 
Date: 
Below is a list of words that describe feelings people have.  Please CIRCLE THE NUMBER THAT 
BEST DESCRIBES HOW YOU FEEL RIGHT NOW. 
 
Not At All 
A Little 
Moderately 
Quite a lot 
Extremely 
Tense 
0 
1 
2 
3 
4 
Angry 
0 
1 
2 
3 
4 
Worn Out 
0 
1 
2 
3 
4 
Unhappy 
0 
1 
2 
3 
4 
Proud 
0 
1 
2 
3 
4 
Lively 
0 
1 
2 
3 
4 
Confused 
0 
1 
2 
3 
4 
Sad 
0 
1 
2 
3 
4 
Active 
0 
1 
2 
3 
4 
On-edge 
0 
1 
2 
3 
4 
Grouchy 
0 
1 
2 
3 
4 
Ashamed 
0 
1 
2 
3 
4 
Energetic 
0 
1 
2 
3 
4 
Hopeless 
0 
1 
2 
3 
4 
Uneasy 
0 
1 
2 
3 
4 
Restless 
0 
1 
2 
3 
4 
Unable to concentrate 
0 
1 
2 
3 
4 
Fatigued 
0 
1 
2 
3 
4 
Competent 
0 
1 
2 
3 
4 
Annoyed 
0 
1 
2 
3 
4 
Discouraged 
0 
1 
2 
3 
4 
Resentful 
0 
1 
2 
3 
4 
Nervous 
0 
1 
2 
3 
4 
Miserable 
0 
1 
2 
3 
4 
 
 
PLEASE CONTINUE WITH THE ITEMS ON THE NEXT PAGE 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
Page 80 of 96 
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Not At All 
A Little 
Moderately 
Quite a lot 
Extremely 
Confident 
0 
1 
2 
3 
4 
Bitter 
0 
1 
2 
3 
4 
Exhausted 
0 
1 
2 
3 
4 
Anxious 
0 
1 
2 
3 
4 
Helpless 
0 
1 
2 
3 
4 
Weary 
0 
1 
2 
3 
4 
Satisfied 
0 
1 
2 
3 
4 
Bewildered 
0 
1 
2 
3 
4 
Furious 
0 
1 
2 
3 
4 
Full of Pep 
0 
1 
2 
3 
4 
Worthless 
0 
1 
2 
3 
4 
Forgetful 
0 
1 
2 
3 
4 
Vigorous 
0 
1 
2 
3 
4 
Uncertain about things 
0 
1 
2 
3 
4 
Bushed 
0 
1 
2 
3 
4 
Embarrassed 
0 
1 
2 
3 
4 
 
 
THANK YOU FOR YOUR COOPERATION 
PLEASE BE SURE YOU HAVE ANSWERED EVERY 
ITEM 
 
 
 
Citation: 
Grove, J.R., & Prapavessis, H. 
(1992). Preliminary 
evidence for the reliability and validity of an abbreviated 
Profile of Mood States. International Journal of Sport 
Psychology, 23, 93-109. 
 
 
 
 
 
Copyright © 1993 
J.R. Grove, PhD 
The University of Western Australia 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine   
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
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*** SCORING KEY 
*** 
 
Scores for the seven subscales in the abbreviated POMS are calculated by summing the numerical ratings 
for items that contribute to each subscale. The correspondence between items and subscales is shown below. 
Item 
Scale 
Not At All 
A Little 
Moderate 
Quite a lot 
Extremely 
Tense 
TEN 
0 
1 
2 
3 
4 
Angry 
ANG 
0 
1 
2 
3 
4 
Worn Out 
FAT 
0 
1 
2 
3 
4 
Unhappy 
DEP 
0 
1 
2 
3 
4 
Proud 
ERA 
0 
1 
2 
3 
4 
Lively 
VIG 
0 
1 
2 
3 
4 
Confused 
CON 
0 
1 
2 
3 
4 
Sad 
DEP 
0 
1 
2 
3 
4 
Active 
VIG 
0 
1 
2 
3 
4 
On-edge 
TEN 
0 
1 
2 
3 
4 
Grouchy 
ANG 
0 
1 
2 
3 
4 
Ashamed 
ERA 
Reverse-score this item [0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0] 
Energetic 
VIG 
0 
1 
2 
3 
4 
Hopeless 
DEP 
0 
1 
2 
3 
4 
Uneasy 
TEN 
0 
1 
2 
3 
4 
Restless 
TEN 
0 
1 
2 
3 
4 
Can’t concentrate 
CON 
0 
1 
2 
3 
4 
Fatigued 
FAT 
0 
1 
2 
3 
4 
Competent 
ERA 
0 
1 
2 
3 
4 
Annoyed 
ANG 
0 
1 
2 
3 
4 
Discouraged 
DEP 
0 
1 
2 
3 
4 
Resentful 
ANG 
0 
1 
2 
3 
4 
Nervous 
TEN 
0 
1 
2 
3 
4 
Miserable 
DEP 
0 
1 
2 
3 
4 

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National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
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Item 
Scale 
Not At All 
A Little 
Moderate 
Quite a lot 
Extremely 
Confident 
ERA 
0 
1 
2 
3 
4 
Bitter 
ANG 
0 
1 
2 
3 
4 
Exhausted 
FAT 
0 
1 
2 
3 
4 
Anxious 
TEN 
0 
1 
2 
3 
4 
Helpless 
DEP 
0 
1 
2 
3 
4 
Weary 
FAT 
0 
1 
2 
3 
4 
Satisfied 
ERA 
0 
1 
2 
3 
4 
Bewildered 
CON 
0 
1 
2 
3 
4 
Furious 
ANG 
0 
1 
2 
3 
4 
Full of Pep 
VIG 
0 
1 
2 
3 
4 
Worthless 
DEP 
0 
1 
2 
3 
4 
Forgetful 
CON 
0 
1 
2 
3 
4 
Vigorous 
VIG 
0 
1 
2 
3 
4 
Uncertain… 
CON 
0 
1 
2 
3 
4 
Bushed 
FAT 
0 
1 
2 
3 
4 
Embarrassed 
ERA 
Reverse-score this item [0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0] 
 
 
TEN = Tension 
Note that 2 of the items on the Esteem-related 
Affect (ERA) subscale are reverse-scored prior 
to being combined with the other items. 
Total Mood Disturbance (TMD) is calculated 
by summing the totals for the negative 
subscales and then subtracting the totals for the 
positive subscales: 
TMD = [TEN+DEP+ANG+FAT+CON] – 
[VIG+ERA]. 
A constant (e.g., 100) can be added to the TMD 
formula in order to eliminate negative scores. 
ANG = Anger 
FAT = Fatigue 
DEP = Depression 
ERA = Esteem-related Affect 
VIG = Vigour 
CON = Confusion 
 
 

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Appendix 3: C-CSSRS

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine  
 
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
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COLUMBIA-SUICIDE 
SEVERITY RATING 
SCALE 
(C-SSRS) 
Baseline/Screening Version 
 
Version 1/14/09 
 
 
 
Posner, K.; Brent, D.; Lucas, C.; Gould, M.; Stanley, B.; Brown, G.; 
Fisher, P.; Zelazny, J.; Burke, A.; Oquendo, M.; Mann, J. 
 
Disclaimer: 
 
This scale is intended to be used by individuals who have received training in its administration. 
The questions contained in the Columbia-Suicide Severity Rating Scale are suggested probes. 
Ultimately, the determination of the presence of suicidal ideation or behavior depends on the 
judgment of the individual administering the scale. 
 
 
 
 
Definitions of behavioral suicidal events in this scale are based on those used in The 
Columbia Suicide History Form, developed by John Mann, MD and Maria Oquendo, MD, 
Conte Center for the Neuroscience of Mental Disorders (CCNMD), New York State Psychiatric 
Institute, 1051 Riverside Drive, New York, NY, 10032. (Oquendo M. A., Halberstam B. & 
Mann J. J., Risk factors for suicidal behavior: utility and limitations of research instruments. In 
M.B. First [Ed.] Standardized Evaluation in Clinical Practice, pp. 103 -130, 2003.) 
 
 
For reprints of the C-SSRS contact Kelly Posner, Ph.D., New York State Psychiatric Institute, 
1051 Riverside Drive, New York, New York, 10032; inquiries and training requirements 
contact posnerk@nyspi.columbia.edu 
 
© 2008 The Research Foundation for Mental Hygiene, Inc  

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine  
 
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
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SUICIDAL IDEATION 
Ask questions 1 and 2. If both are negative, proceed to “Suicidal Behavior” section. If the answer to 
question 2 is “yes”, ask questions 3, 4 and 5. If the answer to question 1 and/or 2 is “yes”, complete 
“Intensity of Ideation” section below. 
Lifetime: Time 
He/She Felt 
Most Suicidal 
Past 
Months 
1. Wish to be Dead 
Subject endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up. 
Have you wished you were dead or wished you could go to sleep and not wake up? 
If yes, describe: 
Yes 
No 
□ □ 
Yes 
No 
□ □ 
2. Non-Specific Active Suicidal Thoughts 
General non-specific thoughts of wanting to end one’s life/commit suicide (e.g., “I’ve thought about killing myself”) without 
thoughts of ways to kill oneself/associated methods, intent, or plan during the assessment period. 
Have you actually had any thoughts of killing yourself? 
If yes, describe: 
Yes 
No 
□ □ 
Yes 
No 
□ □ 
3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act 
Subject endorses thoughts of suicide and has thought of at least one method during the assessment period. This is different than a 
specific plan with time, place or method details worked out (e.g. thought of method to kill self but not a specific plan). Includes 
person who would say, “I thought about taking an overdose but I never made a specific plan as to when, where or how I would 
actually do it…and I would never go through with it.” 
Have you been thinking about how you might do this? 
If yes, describe: 
Yes 
No 
□ □ 
Yes 
No 
□ □ 
4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan 
Active suicidal thoughts of killing oneself and subject reports having some intent to act on such thoughts, as opposed to “I have 
the thoughts but I definitely will not do anything about them.” 
Have you had these thoughts and had some intention of acting on them? 
If yes, describe: 
Yes 
No 
□ □ 
Yes 
No 
□ □ 
5. Active Suicidal Ideation with Specific Plan and Intent 
Thoughts of killing oneself with details of plan fully or partially worked out and subject has some intent to carry it out. 
Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? 
If yes, describe: 
Yes 
No 
□ □ 
Yes 
No 
□ □ 
INTENSITY OF IDEATION 

Phase 1 Evaluation of 2R,6R-Hydroxynorketamine  
 
National Institute of Mental Health 
Protocol Ref. #: HNK-378227-03 
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The following features should be rated with respect to the most severe type of ideation (i.e., 1-5 from above, with 1 
being the least severe and 5 being the most severe). Ask about time he/she was feeling the most suicidal. 
Lifetime - 
Most Severe Ideation:    
 
  
 
Type # (1-5) 
Description of Ideation 
Past X Months - Most Severe Ideation:    
 
  
 
Type # (1-5) 
Description of Ideation 
Most 
Severe 
Most 
Severe 
Frequency 
How many times have you had these thoughts? 
(1) Less than once a week (2) Once a week (3) 2-5 times in week (4) Daily or almost daily (5) Many times each day 
 
 
Duration 
When you have the thoughts how long do they last? 
(1) Fleeting - few seconds or minutes 
(4) 4-8 hours/most of day 
(2) Less than 1 hour/some of the time 
(5) More than 8 hours/persistent or continuous 
(3) 1-4 hours/a lot of time 
 
 
Controllability 
Could/can you stop thinking about killing yourself or wanting to die if you want to? 
(1) Easily able to control thoughts 
(4) Can control thoughts with a lot of difficulty 
(2) Can control thoughts with little difficulty 
(5) Unable to control thoughts 
(3) Can control thoughts with some difficulty 
(0) Does not attempt to control thoughts 
 
 
Deterrents 
Are there things - anyone or anything (e.g., family, religion, pain of death) - that stopped you from wanting 
to die or acting on thoughts of committing suicide? 
(1) Deterrents definitely stopped you from attempting suicide 
(4) Deterrents most likely did not stop you 
(2) Deterrents probably stopped you 
(5) Deterrents definitely did not stop you 
(3) Uncertain that deterrents stopped you 
(0) Does not apply 
 
 
Reasons for Ideation 
What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain 
or stop the way you were feeling (in other words you couldn’t go on living with this pain or how you were 
feeling) or was it to get attention, revenge or a reaction from others? Or both? 
(1) Completely to get attention, revenge or a reaction from others 
(4) Mostly to end or stop the pain (you couldn’t go on 
(2) Mostly to get attention, revenge or a reaction from others 
living with the pain or how you were feeling) 
(3) Equally to get attention, revenge or a reaction from others 
(5) Completely to end or stop the pain (you couldn’t go 
on and to end/stop the pain 
 
living with the pain or how you were feeling) 
(0) Does not apply 
 
 
© 2008 Research Foundation for Mental Hygiene, Inc. 
C-SSRS—Baseline/Screening (Version 1/14/09) 
Page 1 of 2 
 
 

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Protocol Ref. #: HNK-378227-03 
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SUICIDAL BEHAVIOR 
(Check all that apply, so long as these are separate events; must ask about all types) 
Lifetime 
Past Years 
Actual Attempt: 
A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part thought of as method to kill 
oneself. Intent does not have to be 100%. If there is any intent/desire to die associated with the act, then it can be considered an actual 
suicide attempt. There does not have to be any injury or harm, just the potential for injury or harm. If person pulls trigger while gun 
is in mouth but gun is broken so no injury results, this is considered an attempt. 
Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or circumstances. For example, 
a highly lethal act that is clearly not an accident so no other intent but suicide can be inferred (e.g., gunshot to head, jumping from window of 
a high floor/story). Also, if someone denies intent to die, but they thought that what they did could be lethal, intent may be inferred. 
Have you made a suicide attempt? 
Have you done anything to harm yourself? 
Have you done anything dangerous where you could have died? 
What did you do? 
Did you  
as a way to end your life? 
Did you want to die (even a little) when you  
 ? 
Were you trying to end your life when you  
? 
Or Did you think it was possible you could have died from  
? 
Or did you do it purely for other reasons / without ANY intention of killing yourself (like to relieve stress, feel 
better, get sympathy, or get something else to happen)? (Self-Injurious Behavior without suicidal intent) 
If yes, describe: 
Has subject engaged in Non-Suicidal Self-Injurious Behavior? 
Yes 
No 
□ □ 
Total # of 
Attempts 
 
Yes 
No 
□ □ 
Yes 
No 
□ □ 
Total # of 
Attempts 
 
Yes 
No 
□ □ 
Interrupted Attempt: 
When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if not for that, actual attempt 
would have occurred). 
Overdose: Person has pills in hand but is stopped from ingesting. Once they ingest any pills, this becomes an attempt rather than an interrupted 
attempt. Shooting: Person has gun pointed toward self, gun is taken away by someone else, or is somehow prevented from pulling trigger. Once 
they pull the trigger, even if the gun fails to fire, it is an attempt. Jumping: Person is poised to jump, is grabbed and taken down from ledge. 
Hanging: Person has noose around neck but has not yet started to hang - is stopped from doing so. 
Has there been a time when you started to do something to end your life but someone or something stopped you 
before you actually did anything? 
If yes, describe: 
Yes 
No 
□ □ 
Total # of 
interrupted 
Yes 
No 
□ □ 
Total # of 
interrupted 

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Aborted Attempt: 
When person begins to take steps toward making a suicide attempt, but stops themselves before they actually have engaged in any self- 
destructive behavior. Examples are similar to interrupted attempts, except that the individual stops him/herself, instead of being stopped by 
something else. 
Has there been a time when you started to do something to try to end your life but you stopped yourself before 
you actually did anything? 
If yes, describe: 
Yes 
No 
□ □ 
Total # of 
aborted 
Yes 
No 
□ □ 
Total # of 
aborted 
Preparatory Acts or Behavior: 
Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a verbalization or thought, such as 
assembling a specific method (e.g., buying pills, purchasing a gun) or preparing for one’s death by suicide (e.g., giving things away, writing a 
suicide note). 
Have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting 
pills, getting a gun, giving valuables away or writing a suicide note)? 
If yes, describe: 
Yes 
No 
□ □ 
Yes 
No 
□ □ 
Suicidal Behavior: 
Suicidal behavior was present during the assessment period? 
Yes 
No 
□ □ 
Yes 
No 
□ □ 
Answer for Actual Attempts Only 
Most Recent 
Attempt 
Date: 
Most Lethal 
Attempt 
Date: 
Initial/First 
Attempt 
Date: 
Actual Lethality/Medical Damage: 
0. No physical damage or very minor physical damage (e.g., surface scratches). 
1. Minor physical damage (e.g., lethargic speech; first-degree burns; mild bleeding; sprains). 
2. Moderate physical damage; medical attention needed (e.g., conscious but sleepy, somewhat responsive; second-
degree burns; bleeding of major vessel). 
3. Moderately severe physical damage; medical hospitalization and likely intensive care required (e.g., comatose with 
reflexes intact; third-degree burns less than 20% of body; extensive blood loss but can recover; major fractures). 
4. Severe physical damage; medical hospitalization with intensive care required (e.g., comatose without reflexes; third-
degree burns over 20% of body; extensive blood loss with unstable vital signs; major damage to a vital area). 
5. Death 
Enter Code 
Enter Code 
Enter Code 
Potential Lethality: Only Answer if Actual Lethality=0 
Likely lethality of actual attempt if no medical damage (the following examples, while having no actual medical damage, 
had potential for very serious lethality: put gun in mouth and pulled the trigger but gun fails to fire so no medical damage; 
laying on train tracks with oncoming train but pulled away before run over). 
0 = Behavior not likely to result in injury 
1 = Behavior likely to result in injury but not likely to cause death 
2 = Behavior likely to result in death despite available medical care 
Enter Code 
Enter Code 
Enter Code 
2008 Research Foundation for Mental Hygiene, Inc. 
C-SSRS—Baseline/Screening (Version 1/14/09) 
Page 2 of 2 

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Protocol Ref. #: HNK-378227-01 
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Appendix 4: CADSS 
 
 

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Protocol Ref. #: HNK-378227-01 
Page 90 of 96 
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The Clinician Administered Dissociative States Scale (CADSS) 
 
Name_____________________________ ID______________ Date_______________ 
 
Subjective Items: 
 
1. Do things seem to be moving in slow motion? 
0= Not at all. 
1= Mild, things seem slightly slowed down, but not very noticeable. 
2= Moderate, things are moving about twice as slow as normally. 
3= Severe, things are moving so slowly that they are barely moving. 
4= Extreme, things are moving so slowly, I have the perception that everything has 
come to a stop, as if time is standing still. 
 
2. Do things seem to be unreal to you, as if you are in a dream? 
0= Not at all. 
1= Mild, things seem a little unreal, but I’m well aware of where I’m at. 
2= Moderate, things seem dreamlike, although I know I am awake. 
3= Severe, things seem very dreamlike, although I know that I am here, I have the 
feeling like I might be asleep. 
4= Extreme, I feel like nothing is real, like I should pinch myself to wake up, or ask 
someone if this is a dream. 
 
3. Do you have some experience that separates you from what is happening; 
for instance, do you feel as if you are in a movie or a play, or as if you are a robot? 
0= Not at all. 
1= Mild, I feel a little bit separated from what is happening, but I am basically here. 
2= Moderate, I feel somewhat separated from what is going on, or I feel as if I am in 
a movie or a play. 
3= Severe, I feel extremely separated from what is happening, but I can understand 
what people are saying. 
4= Extreme, I feel as if everyone around me is talking a foreign language, so that I 
cannot understand what they are saying, or I feel as if I am on the outside looking 
in, or like I am a robot or a machine. 
 
4. Do you feel as if you are looking at things from outside of your body? 
0= Not at all. 
1= Mild, I feel somewhat disconnected from myself, but I am basically all together. 
2= Moderate, I feel like I am just outside of my body, but not looking down upon 
myself from far above. 
3= Severe, I feel like I am twenty feet or more away from my body, looking down 
from above. 
4= Extreme, I feel as if I am hundreds of feet above myself, looking down at myself 

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and everyone else here. 
 
5. Do you feel as if you are watching the situation as an observer or a spectator? 
0= Not at all. 
1= Mild, I feel slightly detached from what is going on, but I am basically here. 
2= Moderate, I feel somewhat removed as an observer or a spectator, but I am 
definitely in this room. 
3= Severe, I feel very much as if I am an observer or a spectator, but I am still here in 
this room. 
4= Extreme, I feel completely removed from what is happening, as if I am not a part 
of this experience in any way, but totally removed from what is happening, as an 
observer or a spectator. 
 
6. Do you feel disconnected from your own body? 
0= Not at all. 
1= Mild, I feel a little bit disconnected from myself, but I am basically all here. 
2= Moderate, I feel somewhat detached from my own body, but I am basically all 
together. 
3= Severe, I feel detached from my own body, but not far removed from my body, 
and I feel as if it is me there. 
4= Extreme, I feel like I am completely out of my body, as if I am looking at my own 
body from a long way off, as if there is another person there. 
 
7. Does your sense of your own body feel changed: for instance, does your own body feel 
unusually large or unusually small? 
0= Not at all. 
1= Mild, I have a vague feeling that something about my body has changed, but I 
can’t say exactly what it is. 
2= Moderate, I feel like my body has increased or decreased in size slightly, or that it 
feels somewhat as if it is not my body. 
3= Severe, I feel as if my body has increased to twice its normal size, or decreased to 
twice its normal size, or I very much feel as if this is not my body. 
4= Extreme, I feel as if my body has swelled up to at least ten times its normal size, 
or as if it is ten times as small, or as if my arms have become like toothpicks. 
 
8. Do people seem motionless, dead, or mechanical? 
0= Not at all. 
1= Mild, people seem a little bit more motionless, dead, or mechanical than would be 
normal. 
2= Moderate, people seem to be at least twice as motionless or mechanical than 
would be normal. 
3= Severe, people seem to be barely moving, or barely alive, or very mechanical. 
4= Extreme, it’s as if everyone were frozen or completely like machines. 
 

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Protocol Ref. #: HNK-378227-01 
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9. Do objects look different than you would expect? 
0= Not at all. 
1= Mild, things seem slightly different than normal, although it is barely perceptible. 
2= Moderate, things are somewhat distorted, but I have no problems recognizing 
things around me. 
3= Severe, things are much more distorted or unreal than normal, but I am able to 
recognize things in the room. 
4= Extreme, like everything is distorted, not real, I feel like I cannot recognize 
anything, everything is alien or strange. 
 
10. Do colors seem to be diminished in intensity? 
0= Not at all. 
1= Mild, things seem slightly paler than usual if I think about it. 
2= Moderate, colors are somewhat diminished, but still recognizable. 
3= Severe, colors are extremely pale, in no way as vivid as they usually are. 
4= Extreme, as if everything is in black and white, or all the colors have been washed 
out. 
 
11. Do you see things as if you were in a tunnel, or looking through a wide angle 
photographic lens? 
0= Not at all. 
1= Mild, I feel a little bit like I am looking through a tunnel, or a wide angle lens. 
2= Moderate, the periphery of my vision is blacked out, but I still have most of my 
visual field, or things are somewhat like a wide angle lens. 
3= Severe, it seems as if I’m looking through a tunnel, or through a wide angle lens, 
but I can see everything clearly. 
4= Extreme, as if I’m looking through a pair of binoculars backwards, where 
everything around the periphery is blacked out, and I can see a little point of light 
at the end of a tunnel, with little tiny people and objects, or I am seeing things as 
if through a wide lens and things are incredibly expanded. 
 
12. Does this interview [assessment, questionnaire] seem to be taking much longer than you 
would have expected? 
0= Not at all. 
1= Mild, it seems as if this interview has gone on for at least twice as long as the true 
elapsed time. 
2= Moderate, it seems as if this interview has gone on for at least two hours. 
3= Severe, it seems as if at least ten hours have gone on since the start of the 
interview. 
4= Extreme, it seems as if time is standing still, so that we have been here at this 
point in time forever. 
 
13. Do things seem to be happening very quickly, as if there is a lifetime in a moment? 
0= Not at all. 

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Protocol Ref. #: HNK-378227-01 
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1= Mild, things are happening slightly faster than normal. 
2= Moderate, things seem to be happening at least twice as fast as normal. 
3= Severe, things seem to be happening at least 10 times faster than normal. 
4= Extreme, as if this whole experience has happened at once, or as if there is a 
lifetime in a moment. 
 
14. Have there been things which have happened during this interview [assessment] that now 
you can’t account for? 
0= Not at all. 
1= Mild, there may have been things which happened which now I can’t account for, 
but nothing pronounced. 
2= Moderate, at least once there were things which happened which now I can’t 
account for. 
3= Severe, at least twice I have lost several minutes of time, so that now there are 
things I cannot account for. 
4= Extreme, large pieces of time are missing, of ten minutes or more, so that I am 
confused about what has happened. 
 
15. Have you spaced out, or in some other way lost track of what was going on during this 
experience? 
0= Not at all. 
1= Mild, I have had some episodes of losing track of what is going on, but I have 
followed everything for the most part. 
2= Moderate, I have lost at least a minute of time, or have completely lost track of 
what is going on now. 
3= Severe, I have lost several segments of time of one minute or more. 
4= Extreme, I have lost large segments of time of at least 15 minutes or more. 
 
16. Have sounds almost disappeared or become much stronger than you would have 
expected? 
0= Not at all. 
1= Mild, things are either a little quieter than normal, or a little louder than normal, 
but it is not very noticeable. 
2= Moderate, things have become about twice as soft as normal, or twice as loud as 
normal. 
3= Severe, things have become very quiet, as if everyone is whispering, or things 
have become very loud (although not deafening). 
4= Extreme, things have become completely silent, or sounds are so loud that it is 
deafening, and I feel as if I am going to break my eardrums. 
 
17. Do things seem very real, as if there is a special sense of clarity? 
0= Not at all. 
1= Mild, things seem to be a little bit more real than normal. 
2= Moderate, things seem to be more real than normal. 

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Protocol Ref. #: HNK-378227-01 
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3= Severe, things seem to be very real or have a special sense of clarity. 
4= Extreme, things seem to have an incredible sense of realness or clarity. 
 
18. Does it seem as if you are looking at the world through a fog, so that people and objects 
appear far away or unclear? 
0= Not at all. 
1= Mild, things seem somewhat foggy and unclear, or I do have the feeling that 
things are far away, but there is not a major effect on how I perceive things 
around me. 
2= Moderate, things seem very foggy and unclear, or things seem like they are far 
away, but I can identify the interviewer and objects in the room easily. 
3= Severe, I can barely see things around me, such as the interviewer and the objects 
in the room. 
4= Extreme, I cannot make anything out around me. 
 
19. Do colors seem much brighter than you would have expected? 
0= Not at all. 
1= Mild, colors seem a little bit brighter than normal, but not more than twice as 
bright. 
2= Moderate, colors seem brighter, about twice as bright as normal. 
3= Severe, colors seem very bright, at least five times as bright as normal. 
4= Extreme, colors seem extremely bright, almost fluorescent, at least 10 times as 
bright as normal. 
 
20. Do you feel confused about who you really are? 
0= Not at all. 
1= Mild, I feel a little bit confused about who I am. 
2= Moderate, I feel confused about who I am, but I basically know who I am. 
3= Severe, I feel very confused about who I am, and at times I wonder if I am a 
person, or if I am many people. 
4= Extreme, I feel as if there were two or more sides to myself. 
 
21. Do you feel like there are different parts of yourself which do not fit together? 
0= Not at all. 
1= Mild, I feel like there are different sides of myself, but they’re basically part of 
myself. 
2= Moderate, I feel like I have different parts which don’t quite fit together. 
3= Severe, there are two or more sides to myself which have unique characteristics. 
4= Extreme, I have two or more parts to myself with unique personality 
characteristics. 
 
22. Do you have gaps in your memory? 
0= Not at all. 
1= Mild, there are some recent things which I cannot remember. 

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Protocol Ref. #: HNK-378227-01 
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2= Moderate, there have been a few gaps in my memory which lasted a few minutes. 
3= Severe, there have been large gaps in my memory which lasted for 
more than a few minutes. 
4= Extreme, I cannot piece together what is happening from one moment to the next 
due to large gaps in my memory. 
 
23. Do you feel like you have more than one identity? 
0= Not at all. 
1= Mild, I feel like there is more to me than my personality, but it’s basically part of 
my identity. 
2= Moderate, I feel like I have more than one personality, but the personalities are 
not really distinct. 
3= Severe, I have two or more personalities, although they are not fully developed as 
distinct entities. 
4= Extreme, I have two or more personalities which are distinct and have their own 
names and other unique characteristics

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Protocol Ref. #: HNK-378227-01 
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