The BIO-K Study: A Single-Arm, Open-Label, Biomarker Development Clinical Trial of Ketamine for Non-Psychotic Unipolar Major Depression and Bipolar I or II Depression.
Phase: PHASE4
Conditions: Major Depression, Bipolar I Disorder, Bipolar II Disorder, Unipolar Depression
Sponsor: Mayo Clinic

 
 
The BIO-K Study: A Single-Arm, Open-Label, 
Biomarker Development Clinical Trial of 
Ketamine for Non-Psychotic Unipolar Major 
Depression and Bipolar I or II Depression 
 
NCT03156504 
 
January 13, 2021 

Version: 7.0 
Version Date:  13 January 13, 2021 
The BIO-K Study:  A Single-Arm, Open-Label, Biomarker Development 
Clinical Trial of Ketamine for Non-Psychotic Unipolar Major Depression 
and Bipolar I or II Depression. 
 
 
Sponsor Principal Investigator John Greden, MD 
National Network of Depression Centers 
 
Sponsor Co-Principal Investigator Mark Frye, MD 
Mayo Clinic (Rochester, MN) 
 
 
 
Site Lead Investigator Fernando Goes, MD 
Johns Hopkins Hospital 
 
Site Lead Investigator Jennifer Vande Voort, MD 
Mayo Clinic (Rochester, MN) 
 
Biomarker Investigator Susannah Tye, PhD 
Mayo Clinic (Rochester, MN) 
 
Site Lead Investigator Eric Achtyes, MD 
Pine Rest Christian Mental Health Services 
 
 
Site Lead Investigator Andrew Goddard, MD 
University of California at San Francisco 
 
Site Lead Investigator Sagar Parikh, MD, FRCPC 
University of Michigan 
 
Biomarker Investigator Srijan Sen, MD, PhD 
University of Michigan 
 
Site Lead Investigator Michael Thase, MD 
University of Pennsylvania 
 
 
 

 
 
Contents 
WHO TO CONTACT .................................................................................................................................... 1 
A. BRIEF SUMMARY ................................................................................................................................... 2 
B. BACKGROUND ....................................................................................................................................... 2 
B.1. Limitations of conventional pharmacotherapy for Treatment Resistant Depression (TRD) ......... 2 
B.2. Glutamate signaling as a pharmacological target for rapid antidepressive responses ................. 2 
B.3. Rapid antidepressive effects of ketamine, a glutamatergic NMDA-receptor antagonist ............. 2 
B.4. Biomarkers for antidepressive effects of ketamine: clinical significance ...................................... 3 
B.5. Ketamine antidepressive effects and mammalian target of rapamycin (mTOR) signaling: 
potential for biomarker development .................................................................................................. 3 
B.6. Overarching goal of the current project ........................................................................................ 4 
B.7. Hypotheses/Specific Aims .............................................................................................................. 5 
C. CLINICAL SITES & ORGANIZATIONAL STRUCTURE ................................................................................ 6 
C.1. Background .................................................................................................................................... 6 
C.2. Cross-site scientific and administrative coordination .................................................................... 6 
D. PRELIMINARY STUDIES & PRIOR RELATED RESEARCH .......................................................................... 7 
D.1. Core Clinical Protocol..................................................................................................................... 8 
D.2. Biomarkers ..................................................................................................................................... 8 
E. STUDY CONDUCT................................................................................................................................. 10 
E.1. Study Overview ............................................................................................................................ 10 
E.2 Protocol, Protocol Amendments and Pre-Initiation Documentation ........................................... 11 
E.3. Inclusion Criteria .......................................................................................................................... 11 
E.4. Exclusion Criteria .......................................................................................................................... 11 
E.5. Subject Recruitment and Screening ............................................................................................. 12 
E.6. Acute-Phase Administration of Ketamine .................................................................................... 13 
E.7. Biomarker Sampling ..................................................................................................................... 17 
E.8. Optional Continuation Phase ....................................................................................................... 19 
E.9. Measures ...................................................................................................................................... 20 
E.10. Case Report Forms, Data Capture and Source Documentation ................................................. 21 
E.11. Data Safety Monitoring Plan and Board .................................................................................... 22 
E.12. Record Retention ....................................................................................................................... 22 
E.13. Study Completion and Termination ........................................................................................... 23 

 
E.14. Reportable Event – Reporting to Sponsor and Site IRB/IEC ....................................................... 23 
E.15. On-Site Audits ............................................................................................................................ 25 
E.16. Statistical Analysis ...................................................................................................................... 25 
E.17. Suicide Assessment and Safety Plan .......................................................................................... 26 
E.18. Dropout Criteria and Pregnancy ................................................................................................ 26 
F.  REFERENCES ....................................................................................................................................... 28 
 
 
 

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WHO TO CONTACT 
In the event that contact is needed to report an event, or for a question regarding subject safety or 
study procedures, please contact: 
• 
Jennifer L. Vande Voort, MD (Mayo Clinic, Rochester, MN) 
o Phone: (507) 255-6782 
o Email: vandevoort.jennifer@mayo.edu   
• 
Sagar Parikh, MD (University of Michigan, Ann Arbor, MI) 
o Phone: 
 
o Email
  
• 
Jose Rico, CCRP, lead study coordinator (Mayo Clinic, Rochester, MN) 
o Phone: 
 
o Email: 
  
In the event that contact is needed regarding blood draw, biomarkers and shipments, please contact: 
• 
Susannah Tye, PhD (Mayo Clinic, Rochester, MN) 
o Phone: 
 
o Email: 
 
• 
Srijan Sen, MD, PhD (University of Michigan, Ann Arbor, MI) 
o Phone: 
 
o Email: 
  
 
 

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A. BRIEF SUMMARY 
 
This multi-site (Johns Hopkins Hospital, Mayo Clinic (Rochester, MN), Pine Rest Christian Mental 
Health Services, University of Michigan, and the University of Pennsylvania), open-label, single-
arm clinical trial is designed to develop preliminary biomarkers of ketamine response in 100 
patients with treatment-resistant non-psychotic unipolar major depression (MDD) or bipolar I or II 
depression (BPD). Ketamine will be administered intravenously (IV) at a subanesthetic dose of 
0.5 mg/kg delivered over 40-minutes or 100-minutes of infusion time.  Enrolled subjects will 
receive a total of three acute phase infusions, delivered at least every other day, within a time 
window of up to 11 days including the first infusion day.  The primary outcome will be remission, 
as defined by a Montgomery-Åsberg Depression Scale (MÅDRS) score ≤9. The secondary 
outcome measures include reduction of suicidality, as defined by a 50% reduction in the Beck 
Scale for Suicidal Ideation (BSS). Exploratory biomarkers for ketamine treatment outcome include 
baseline to endpoint change in WBC stimulated mTOR, AKT, and GSK3 signaling. Additional 
sample for the ascertainment of other biomarkers will also be taken. 
 
B. BACKGROUND 
B.1. Limitations of conventional pharmacotherapy for Treatment Resistant Depression 
(TRD) 
Pharmacotherapy with conventional antidepressants and mood stabilizing medications is 
ineffective for many patients with MDD and BPD.  Up to one-third of patients with MDD do not 
respond to conventional antidepressants and fewer than a third of patients experience durable 
symptomatic remission even after serial therapeutic antidepressant trials [1].  Depression is also 
the predominant mood state in patients with BPD over the course of illness—yet, few 
pharmacological treatments have been shown to be effective for treating depressive episodes 
associated with BPD in adults [2-4].  Not surprisingly, treatment resistance occurs frequently for 
patients with BPD depression despite intensive pharmacotherapy [5].  Moreover, response to 
vigorous pharmacological treatment is incomplete or absent for many patients with BPD 
depressive episodes [6], thus contributing to high rates of recurring and persisting depressive 
symptoms, psychiatric and general medical comorbidity, and suicide in BPD patients [7-10].  For 
patients with MDD or BPD who eventually respond to pharmacotherapy with antidepressants 
and/or mood stabilizing medications, the onset of therapeutic benefit is usually delayed for several 
weeks [11].  
 
B.2. Glutamate signaling as a pharmacological target for rapid antidepressive responses 
The need for more effective treatments with a faster onset of therapeutic effect has been long-
recognized, as has the need for discovering novel mechanisms of depressive illness and 
antidepressive treatment response that go beyond biogenic amine transporter and receptor-ology 
based mechanisms [12].  Converging evidence from post-mortem and in vivo neuroimaging 
studies shows glutamate abnormalities in the pathophysiology of mood disorders [13-27]. These 
discoveries demonstrated strong evidence of disrupted glutamate signaling through N-methyl-D-
aspartate (NMDA) receptors in depressive mood states, and prompted investigations of the 
antidepressive activity for compounds that interact with NMDA receptors. 
 
B.3. Rapid antidepressive effects of ketamine, a glutamatergic NMDA-receptor antagonist 
Multiple controlled trials have now demonstrated the short-term effectiveness of single or serial 
administration of low-dose IV ketamine, a potent non-competitive NMDA antagonist [28], for 
treating the symptoms of depression in patients with MDD and BPD who failed to respond to 

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multiple trials of pharmacotherapy and, in some cases, electroconvulsive therapy [29].  Those 
who benefitted from ketamine experienced rapid (within hours) onset of clinical antidepressive 
response [30].  Positive benefit from ketamine persisted for 3-14 days on average following single 
infusions [30-38], and for 18-19 days following serial infusions administered over 12-14 days 
[39,40].  The duration of antidepressive response demonstrated in these clinical studies is well in 
excess of what would be predicted by ketamine’s short elimination half-life of 2-3 hours [41,42].   
 
B.4. Biomarkers for antidepressive effects of ketamine: clinical significance 
The therapeutic potential of ketamine (i.e., rapid symptom relief and response in treatment-
resistant patients) has stimulated considerable interest in the psychiatric community [43], and the 
clinical use of ketamine infusion for the treatment of depression is now an intense focus of 
research worldwide.  However, this further progress is challenged by the absence of reliable and 
valid predictors of antidepressive response to ketamine.  The rates of positive antidepressive 
response to I.V. ketamine are highly variable (25%-85%) after single infusions.[7] When the 
results of controlled and uncontrolled studies of single and multiple IV infusions of ketamine for 
treatment-resistant depression are considered, there is an even more striking degree of variability 
in the cumulative rates of positive antidepressive response during short-term treating, ranging 
from 7%-90% [44-46].  Currently, there is no evidence-based approach to determining which 
patients with treatment-resistant MDD or BPD are more likely to respond to IV ketamine infusion 
therapy.  Reliable biomarkers of ketamine response would allow clinicians to risk-stratify patients 
who are eligible for ketamine treatment according to their likelihood of responding to ketamine, a 
treatment that is not without potential serious risks, including psychomimetic effects, changes in 
hemodynamic measures, etc. 
 
B.5. Ketamine antidepressive effects and mammalian target of rapamycin (mTOR) signaling: 
potential for biomarker development 
     B.5.a. mTOR signaling, cellular energetics, and potential importance for depressive 
symptoms.   
mTOR signaling plays a significant role in modulating cell energy homeostasis and survival [47]. 
Accumulating evidence shows that rapid antidepressant effects of ketamine are directly mediated 
by this intracellular pathway, activation of which promotes synapse formation and efficiency [48]. 
This rapid potentiation of synaptic plasticity is thought to be the overarching mechanism through 
which antidepressant actions are conferred to behavioral (preclinical) or mood (clinical) related 
changes [49].   
 
     B.5.b. mTOR signaling changes with ketamine may be crucial to its antidepressive 
effect, and subsequent biomarker development.  
The few biomarker investigations in this area have failed to reliably distinguish ketamine 
responders and nonresponders, in part because of their focus on simple pharmacokinetic or 
metabolomic measures for predicting ketamine antidepressive response [50-54]. This approach 
is not aligned with emerging data showing that antidepressive effects of ketamine are critically 
mediated through glutamatergic neurotransmission and subsequent mTOR-dependent cell 
signaling cascades, which rapidly upregulate functional and structural synaptic plasticity in mood-
regulating neural pathways [55,56].  These structural and functional changes at the molecular and 
neural network level appear to be critical to an individual’s potential for ketamine treatment 
response [55,57]  It follows that biomarker development efforts will require multimodal, integrated 
measures across neuroimaging and molecular domains. 
 
Specific to this biomarker development project, mTOR signaling target engagement has been 
shown to directly correlate with antidepressant treatment response to ketamine [58]. Project 

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overarching goal of this project is to develop multiple biomarkers of ketamine’s antidepressive 
effects in adults with treatment-resistant depression using a time-efficient approach.  To 
accomplish this goal, the investigative sites will be comprised of members of the National Network 
of Depression Centers (NNDC), several of which have active and successful translational 
research and biomarker development programs.   
 
While the overarching goal of this collaboration is to develop multiple biomarkers, the primary 
initial aims of this project will focus on developing a WBC marker of impaired mTOR-dependent 
cellular energy regulation for predicting ketamine-induced antidepressive response (see §B.5.c). 
A panel of investigators across multiple sites with experience in the development of biomarkers 
for severe affective disorders and with the treatment of depression will identify additional specific 
blood-based biomarkers for predicting antidepressive response to ketamine in adults with 
treatment-resistant unipolar or bipolar major depression (Samples Subcommittee, see §C.2.b). 
These additional biomarkers will be tested using blood samples from enrollees in this project.  
 
B.7. Hypotheses/Specific Aims 
We will enroll 100 adults with treatment-resistant unipolar or bipolar major depression (TRD) 
across 8 clinical sites and provide three IV ketamine infusions (0.5 mg/kg, infused over at 40-
minutes for first infusion and subsequent infusions at either 40-minutes or 100-minutes) and 
measure their depressive symptom responses.  Biomarkers will be developed using blood 
samples from study subjects, taken prior to (predictive biomarkers) and following ketamine 
treatment (change biomarkers).  We will begin by studying the predictive value of mTOR target 
engagement by ketamine using a WBC assay for antidepressive response to ketamine (Aim 1); 
however, samples will be used to develop multiple blood-based biomarkers for ketamine 
antidepressive effects (Aim 2).  We will also examine the effect of combining multiple blood-based 
biomarkers for predicting antidepressive response to ketamine in adults with TRD (Aim 3).  
 
Specific to Mayo Clinic-Rochester, a subset of 10 subjects with treatment-resistant unipolar major 
depression will be enrolled in support of Mayo Clinic IRB # 17-011373, “Central versus Peripheral 
Glutamate Biomarkers for Treatment Response during a Single Infusion of Intravenous Ketamine 
for Treatment-Resistant Depression”. Subjects will be provided one IV ketamine infusion (0.5 
mg/kg, infused over 40 minutes) and will have measured their depressive symptom responses. 
In this subset of subjects, adults (aged 18-65 years) with treatment-resistant depression will be 
included. For this subset of subjects, blood draw schedule will defer to those IRB-approved for 
IRB # 17-011373. Blood samples will be drawn by CRTU staff from the subject before the first 
ketamine infusion (81ml), during the infusion (1ml at 20 minutes), at infusion stop time (81ml at 
40 minutes), and twice after infusion stop time (1ml at 1 hour after the infusion and 1ml at 24 
hours after the infusion) for a total of 165ml at Acute Infusion #1. A subject may be eligible to 
enroll in both trials through trial-specific informed consent forms. If a subject enrolls in both trials, 
collection of blood samples at Acute Infusion #1 will serve purposes of both trials.  
 
Aim 1:  Determine the effectiveness of a WBC marker of impaired cellular energy regulation 
(see §B5.c.) as a biomarker for predicting antidepressive response to ketamine in adults 
with TRD. 
Hypothesis 1a:  Baseline WBC markers of impaired cellular energy regulation will be associated 
with measures of clinical response to ketamine (predictive biomarker);  
Hypothesis 1b: Changes in WBC markers of impaired cellular energy regulation will be associated 
with clinical response to ketamine (change biomarker). 
 
Aim 2:  Examine the effectiveness of other blood-based biomarkers with strong potential 
for predicting antidepressive response to ketamine in adults with TRD.   

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For this exploratory aim, we have formed a panel of investigators across multiple sites with 
experience in the development of biomarkers for severe affective disorders and with the treatment 
of TRD using IV ketamine (see §B.6., para. 2). These additional biomarkers will be measured 
using blood samples collected from study participants, and will be correlated with IV ketamine-
associated treatment response in order to provide preliminary validation. 
Aim 3: Examine the effectiveness of combining blood-based biomarkers for predicting 
antidepressive response to ketamine in adults with TRD.   
A similar approach will be taken to develop additional biomarkers that are of interest to project 
collaborators. 
C. CLINICAL SITES & ORGANIZATIONAL STRUCTURE 
C.1. Background 
This multi-site biomarker development clinical trial is sponsored by the National Network of 
Depression Centers (NNDC) and will occur at 6 participating academic centers (clinical sites): 
Johns Hopkins Hospital, The Mayo Clinic, University of California at San Francisco, University of 
Michigan, Pine Rest Christian Mental Health Services, and the University of Pennsylvania. The 
activation of each recruiting site will be on a rolling basis, meaning pre-initiation documentation 
must be provided to the sponsor before the protocol is implemented at each site. All clinical sites 
are members of the NNDC, a non-profit consortium of 25 leading clinical and academic Member 
Centers in the U.S. – including more than 600 interdisciplinary faculty, staff, and trainees – that 
seeks to integrate innovative research, clinical translation, education, and public policy to better 
diagnose and treat individuals with depression or bipolar illness and related mood disorders.   
 
Preliminary biomarker development efforts for ketamine antidepressive effects could be carried 
out at single clinical sites.  However, our experience has shown that clinical antidepressive 
response biomarker studies can be very challenging to conduct in terms of recruitment.  
Additionally, the variable positive treatment response rates, the multifactorial nature of 
antidepressive treatment response, and the anticipated heterogeneity of enrolled subjects require 
that a reasonably large sample be recruited for even preliminary development of robust treatment 
response biomarkers.  As such, the enrollment target of 100 persons with treatment-resistant 
depression is ambitious but necessary, and the 7-site collaboration for this project is intended to 
accomplish just that. 
 
C.2. Cross-site scientific and administrative coordination 
     C.2.a. Global administrative coordination across study sites.  
To coordinate efforts across sites, the chief administrative responsibilities for this project will be 
carried out at two sites (Fig. 1).  Protocol development and execution, as well as biospecimen 
storage (all samples) will occur at Mayo Clinic (Rochester, MN). Biomarker analysis (for primary 
initial aim) will occur at Mayo Clinic (Rochester, MN), and will be further supported at the 
University of Michigan.  Subject enrollment, conductance of the clinical study per this protocol, 
and data collection will occur at 3 clinical sites:, Johns Hopkins Hospital, Mayo Clinic (Rochester, 
MN), and University of Michigan. For this protocol version, the sponsor NNDC has discontinued 
recruitment at site Pine Rest Christian Mental Health Services and reassigned it biomarker 
development responsibility; the sponsor NNDC has discontinued recruitment at site University of 
Cincinnati.  A site lead investigator at each site will have responsibility over all site-specific aspects 
of clinical trial conduct, including the collection of biological specimens.  However, a centralized 
database for clinical and biomarker data will be maintained at the University of Michigan.  A 
steering committee composed of the lead investigators from each clinical site, selected sub-
investigators,  and administrative officers, biostatistics consultants, and The Bio-K Data Safety 

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clinical protocol for this study.  Section D.2 will summarize prior research supporting the WBC 
marker of impaired cellular energy regulation as a biomarker for predicting antidepressive 
response to ketamine in adults with TRD. 
 
D.1. Core Clinical Protocol 
The feasibility of serial acute (Studies 1 and 2) and continuation phase (Study 2) ketamine 
infusions, 0.5 mg/kg over 100 minutes was demonstrated in two clinical trials at Mayo Clinic: 
 
Serial Ketamine Infusion Study 1 – twice-weekly acute phase infusions.   
Clinical researchers from this NNDC investigative team conducted a pilot study of ketamine 
infusions administered twice weekly (0.5 mg/kg administered over 100 minutes) to 10 patients 
with treatment-resistant Major Depression or Bipolar Disorder depression until either remission 
was achieved or four infusions were given [60].  Patients were followed at weekly intervals for 
four weeks after completion of the infusions. All subjects received ongoing treatment with oral 
antidepressive medications.  This group demonstrated a rapid reduction in symptoms with a 50% 
remission rate (50% sustained 1 month after last infusion) and minimal side effects.  Cumulative 
remission rates after 1, 2, and 4 infusions were 10%, 40%, and 50%, respectively. A secondary 
analysis identified that concurrent benzodiazepines, known to impact NMDA receptor occupancy 
and functioning, were associated with reduced ketamine response [61].  None of the subjects 
experienced significant changes in hemodynamic parameters.  There were no significant changes 
from baseline in manic symptoms (as measured by the Young Mania Rating Scale [62]) or 
psychotic or psychomimetic symptoms (as measured by the Brief Psychiatric Rating Scale total 
and positive symptom subscale scores [63]).  One patient experienced a transient visual 
hallucination.     
Serial Ketamine Infusion Study 2 – thrice-weekly acute phase infusions + 4 weekly 
continuation phase infusions (acute-phase remitters only).   
The same has also safely infused ketamine thrice weekly (0.5 mg/kg administered over 100 min) 
to 12 inpatients with treatment-resistant Bipolar Disorder depression (n=3) or Major Depression 
(n=9) who were at high risk for suicide (Patient Health Questionnaire-9 [PHQ-9] item 9 score of 1 
or higher, or Suicide Status Form-2 [SSF-2] score >3+ on the item assessing ‘overall risk of 
suicide’) [64].  Subjects received pharmacotherapy with antidepressants and/or mood stabilizing 
medications at the discretion of their primary inpatient clinical teams.  None were allowed 
electroconvulsive therapy or concurrent benzodiazepines on any infusion day.  The study included 
an initial acute phase (thrice-weekly infusions of ketamine, 0.5 mg/kg administered over 100 
minutes). Those who remitted during the acute phase entered into a continuation phase, and 
received 4 weekly IV ketamine infusions (0.5 mg/kg administered over 100 minutes). Five of 12 
patients (42%) remitted and 7 of 12 (58%) responded to ketamine treatment during the acute 
phase. Four of the five remitters did so after the first acute-phase infusion, whereas one additional 
patient did so after the third acute phase infusion.  All 5 acute-phase remitters retained their 
remission status during the continuation phase.    
 
D.2. Biomarkers 
D.2.a. White blood cell (WBC) biomarker for ketamine response 
Researchers at one of the NNDC investigative sites, and others, have demonstrated that the 
antidepressant-like effects of ketamine in animal models of depression are mediated by 
mammalian target of rapamycin (mTOR) signaling pathways [65,66].  Specifically, investigators 
demonstrated a strong and highly significant positive correlation between phosphorylation of 
mTOR and the antidepressant actions of ketamine in an animal model of depression (Fig. 1).  The 
same group recently developed an assay for quantification of mTOR in peripheral white blood 

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E.2 Protocol, Protocol Amendments and Pre-Initiation Documentation 
Neither the sponsor nor the investigators will modify this protocol without a formal amendment by 
the sponsor. All protocol amendments must be issued by the sponsor, and signed and dated by 
the investigator and approved by site IRB/IEC. Protocol amendments must not be implemented 
without prior IRB/IEC approval, except when necessary to eliminate immediate hazards to the 
subjects, in which case the amendment must be promptly submitted to the IRB/IEC and relevant 
competent authority. 
Documentation of amendment approval by the investigator and IRB/IEC must be provided to the 
sponsor. During the course of the study, a situation may arise where a departure from the protocol 
is necessary and unavoidable. In such an instance, the investigator or appropriate study-site 
personnel will contact the sponsor. 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. 
Pre-initiation documentation must be provided to the sponsor before the protocol is implemented 
at each site. Each site will be provided with a separate document identifying all pre-initiation 
documents required to be provided to the sponsor, and another pre-enrollment list of documents 
required by the sponsor before enrollment of first subject. 
E.3. Inclusion Criteria 
For inclusion in this study, the following are required: 
• 
Ability to provide informed consent; 
• 
Current psychiatric inpatient (voluntary only) or outpatient treatment; 
• 
Male or female; 
• 
Age 18-65 years; 
• 
Meets DSM-5 diagnostic criteria for major depressive disorder, bipolar I disorder, or 
bipolar II disorder; 
• 
PHQ-9 total score > 15 at screening and at baseline (just prior to first acute phase 
ketamine infusion); 
• 
Treatment-resistant depression, as defined by failure of at least two previous 
antidepressant or mood stabilizing treatments within the current depressive episode.  
Failed antidepressant or mood stabilizing treatments can include pharmacotherapy for 
depression at an adequate dose for at least 8 weeks, or an acute series of at least 6 
administrations of electroconvulsive therapy (ECT); 
• 
Ability to pass a comprehension assessment test related to effects of ketamine and trial 
objectives and criteria. 
E.4. Exclusion Criteria 
Based on ketamine’s known difficulties with induction of perceptual/psychomimetic symptoms, 
exclusion criteria for this study are as follows: 
• 
Patients with a BMI >40. 
• 
Diagnosis of schizophrenia, schizoaffective disorder, or active psychotic symptoms; 
• 
Ongoing prescription of > 4 mg lorazepam equivalents (total) daily, or morning dosing of 
any benzodiazepine at the time of assessment; 
• 
Currently undergoing ECT, transcranial magnetic stimulation, vagal nerve stimulation, or 
deep brain stimulation as either an acute or maintenance treatment of depression; 
• 
Any active or unstable medical condition judged by the study psychiatrist as conferring too 
great a level of medical risk to allow inclusion in the study; 

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• 
A cannabis use disorder by DSM-5 criteria in partial remission of less than 3 months will 
be an exclusion from enrollment. Cannabis use disorders in partial remission of at least 3 
months will defer this exclusion. 
• 
Any patient-reported abuse or dependence of cannabis within the prior 3 months from 
date of screening will be an exclusion. 
• 
Any positive urine toxicology screen as part of the screening visit for illicit, non-prescribed, 
drug use will be an exclusion.; 
• 
Any current abuse or dependence of alcohol or drugs (excluding nicotine,caffeine, and 
cannabis).  Note: Persons will be allowed to enroll in this study if their drug or alcohol 
abuse/dependence is in complete (not partial) and sustained (> 1 year) remission; 
• 
Use of any MAOI is prohibited two weeks prior to administration of study drug; if patients 
are on an MAOI when enrolled, study drug will not be administered until two weeks off 
MAOI. 
• 
CYP3A4 inducers carbamazepine and modafinil are prohibited two weeks prior to 
administration of study drug and at least 24 hours after last dose of study drug. 
• 
Current use of Naltrexone. 
• 
History of traumatic brain injury that resulted in loss of consciousness; 
• 
Developmental delay, mental retardation, or intellectual disorder; 
• 
Clinical or self-reported diagnosis of delirium, encephalopathy, or related clinical diagnosis 
within the prior 12 months; 
• 
Cognitive disorder (mild and major categories per DSM-5); 
• 
Current or prior clinical treatment by ketamine for depression or prior or current 
participation in another study of ketamine for depression within the prior 6 months.; 
• 
History of either poor antidepressive response to or poor tolerability of ketamine (any route 
of administration) when previously administered for treating symptoms of depression; 
• 
History of hypothyroidism unless taking a stable dose of thyroid medication and 
asymptomatic for 6 months; 
• 
Significant unstable medical condition 
• 
Hepatic insufficiency (2.5 X ULN for AST or ALT) within 1 year of consent, past liver 
transplant recipient, and/or clinical diagnosis of cirrhosis of the liver; 
• 
A diagnosis of Complex Regional Pain Syndrome (CRPS); 
• 
Males active in attempting to conceive a child. 
• 
Pregnancy, or nursing; 
• 
Prisoners; 
• 
Involuntary psychiatric hospitalization. 
 
E.5. Subject Recruitment and Screening 
E.5.a. Overview 
Subjects will be patients recruited from either outpatient clinics or adult inpatient psychiatric units, 
and provide voluntary informed consent to participate in the study.  Each study site will retain 
decisional authority as to whether recruitment at their site will occur in outpatient setting, inpatient 
settings, or both.  Patients will be identified for potential inclusion in the study by study 
coordinators or other study personnel designated by the site lead investigator.  Eligible patients 
will be approached by study staff and the elements of the study will be explained. If the patient 
meets all inclusion and no exclusion criteria, a site investigator (not providing care for the patient), 
will further describe the protocol to patient, administer the comprehension assessment test 
(detailed below), and obtain informed consent. Patients will have the opportunity to have an IRB 
patient advocate or a significant other present during the consent procedure if desired. One 
hundred patients will be recruited in the study.   
 

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Each site will complete a screening log and subject identification log to facilitate the identification 
of each subject enrolled and progressed through the study. The subject identification and 
enrollment log will be treated as confidential, and kept in the master file at each site. All essential 
documents related to any subject will identify subjects by their assigned identification code and 
date of birth. For subjects consented and then withdrawn and not having received the first infusion 
of ketamine, thus no subject identification code assigned, correspondence identifying the subject 
will include date seen and date of birth. The screening log, made available to all sites as a 
separate document, reports on all subjects seen by a site investigator to determine eligibility of 
inclusion in the study. 
 
 
E.5.b. Comprehension assessment test 
A 8-question true or false quiz (comprehension assessment) based on aspects of the study will 
be administered to each patient, after the co-investigator explains the study, to ensure the patient 
understands the key concepts, potential side effects of ketamine, and goals of the study. Any 
incorrect answer will be reviewed by the participant and investigator with an initial by the patient 
with the answer that has been corrected. For any participant who answers 3 or more questions 
incorrectly, the study will be postponed with the patient being re-consented within the next 3 days, 
but no sooner than the following day. If there are still 3 or more questions answered incorrectly, 
the subject will not be enrolled in the study. 
 
E.5.c. Confirmation of qualifying mood disorder diagnosis 
After informed consent, major depressive disorder or bipolar I or bipolar II depression will be 
confirmed by the study coordinator utilizing the Depression Module of the Structured Clinical 
Interview for DSM-IV (SCID) [53]. The utilization of the SCID will be to define entry into the study.  
 
E.5.d. Additional screening procedures 
Assessments will also be used to confirm severity of depression and suicidal ideation, and will 
also serve as baseline scores at initial infusion of study drug. The PHQ-9 will be used to define a 
threshold score of >15 for enrollment into the study.  All qualifying subjects will be administered 
the Montgomery-Åsberg Depression Scale (MÅDRS) [54] as an additional measure of depressive 
psychopathology, and the Suicide Status Form (SSF II-R) [55] as a measure of suicide potential.  
Pregnancy tests will be administered for women < 55 years of age, and urine drug of abuse 
screens will be reviewed for all participants. The study entry criterion of having failed at least two 
previous antidepressant or mood stabilizing treatments within the current depressive episode will 
be assessed using an Antidepressant Treatment History Form (ATHF). 
 
E.5.e. Post-screening visit procedures  
Patients enrolled who continue to meet inclusion criteria will be scheduled for their first IV 
ketamine treatment. At this point, the research pharmacy will be contacted to prepare the 
ketamine infusion, and the investigator anesthesiologist will be notified of the date and time of the 
infusion. 
E.6. Acute-Phase Administration of Ketamine 
All subjects at all sites will be given 3 acute-phase IV ketamine infusions (Fig. 3). In the acute 
phase, the first infusion will be provided at a 40-minute timespan; in considering patient 
preference information and with investigator consultation for subsequent infusions, subsequent 
infusions can be provided at either a 40-minute or 100-minute timespan. An IV ketamine drip will 
be initiated at a rate of 0.5 mg/kg for the 40-minute infusion or 0.3 mg/kg for the 100-minute 
infusion, for a total dose of 0.5 mg/kg. For example, an enrolled patient that weighs 75kg would 
receive a dose of 0.938mg/per minute in the 40-minute infusion, and in the 100-minute infusion, 
would receive a dose of .375 mg/per minute, for a total dose of 37.5mg in either 40-minute or 100-
minute infusion.  At Mayo Clinic (Rochester, MN), these infusions will be performed either in the 

Page | 14 
 
recovery room of the ECT suite for inpatients or at the Center for Clinical and Translational 
Science Clinical Research Unit (CRU) for outpatient infusions. CRU staff will be key to facilitating 
the execution of IV infusion procedures. CRU staff will collaborate to prepare infusion logistics, 
establish venipuncture site, monitor infusion and vital signs during and after infusion (60 minutes). 
These infusions will be given at least every other day (minimum of 1 day between infusions, and 
a maximum of 4 days between infusions). All infusions will be completed within a window of 5 to 
11 days where the window includes the first infusion day (t0).  The allowable time window is 
defined in quantitative terms as [t0, t0 + 11].  If the final infusion date is designated as tx, then a 
given date for tx is allowable if tx < t0 + 11. 
 
For example, if the first infusion day was January 11, 2016 (a Monday), the participant could 
complete their second infusion on January 13, 2016 (Wednesday) and their final infusion on 
January 15, 2016 (a Friday).  Friday’s infusion date corresponds to a tx value of 5, and is allowable.  
The final 24 hour post-infusion assessment would take place on January 16, 2016 (Saturday).   
 
Alternatively, a participant who receives infusion 1 on a Tuesday could receive infusions 2 and 3 
on Thursday during the same calendar week and Monday the following calendar week.  In this 
case, tx takes a value of 7, which is within the allowable 11-day time window including the first 
infusion.   
 
E.6.a. Procedures on the day of acute-phase IV ketamine infusions 
On the morning of each infusion, the study coordinator (or designated member of the study team) 
will measure patient’s mood using the Montgomery-Åsberg Depression Rating Scale (MÅDRS), 
the Beck Scale for Suicide Ideation (BSS), the Snaith-Hamilton Pleasure Scale (SHAPS), and the 
Young Mania Rating Scale (YMRS). The study investigator will complete a Clinical Global 
Impression (CGI) severity subscale assessment [56].  For Mayo Clinic inpatient infusions, the 
subject will be escorted to the ECT suite recovery room for IV ketamine infusion. For Mayo Clinic 
outpatient infusions, the subject will be instructed to check-in at the CRU where the infusion will 
occur in a private room. The CRU staff will facilitate the execution of IV infusion procedures. CRU 
staff will set the venipuncture site, proceed with blood draws, monitor infusion and vital signs 
during and after infusion (60 minutes). For the other 7 sites, the patient will be escorted to the IV 
ketamine infusion area by the study coordinator, whereupon designated study staff will start the 
intravenous access. Participants will also be connected to the ECG leads, blood pressure cuff, 
and pulse oximeter (which measures blood oxygenation non-invasively). These vital signs will 
also be monitored by the study staff to ensure the participant’s safety. 
 
Infusion may be stopped for any marked abnormality in vital signs, defined by floor and ceiling 
values of the following parameters: heart rate > 130, systolic blood pressure > 160 or < 90, 
diastolic blood pressure > 95 or < 60, excessive sedation, or development of a heart arrhythmia. 
 
 
 
 
 
 
E.6.b. Administration and monitoring of IV ketamine 
Table 1 shows the schedule of assessments for this study. 
Table 1.  Schedule of assessments (acute phase treatment) 
 
Screening 
Infusion number 1 
Infusion number 
2 
Infusion number 3 
 
Baseline 
40 or 
100 
min 
24h 
post 
Before 
40 or 
100 
min 
24h 
post 
Before 
40 or 
100 
min 
24h post 

Page | 16 
 
 
Monitoring of vital signs during administration.   
ECG, blood pressure, heart rate, respiratory rate and pulse oximetry will be measured at 15 
minute intervals (or more frequently as needed, with values recorded every 15 minutes) from start 
of infusion.  Vital signs will also be recorded 30- and 60 minutes after infusion has stopped.  Again, 
infusion may be stopped for any marked vital abnormality, the parameters being defined as: heart 
rate > 130, systolic blood pressure > 160 or < 90, diastolic blood pressure > 95 or < 60, excessive 
sedation, or development of a heart arrhythmia. In the event of a marked vital abnormality 
resulting in discontinuation of study drug, the site lead investigator will notify the sponsor using 
the UPIRTSO form provided as a separate document, and must also notify their local IRB/IEC of 
the event. 
 
Clinical Assessments.   
Mood (MÅDRS) and suicide measures (BSS) will be obtained by the study coordinator at 
baseline, at the end of infusion (40-min or 100-min); and at 24 hours post-infusion time.  Thus, 
there will be three clinical outcome assessment times for these measures per infusion.  The 
Snaith-Hamilton Pleasure Scale (SHAPS) will be administered by the study coordinator at 
baseline, 24 hours following the first infusion, and 24 hours following the third (final) acute phase 
infusion.  An investigator will complete a CGI-Severity of Illness (CGI-S) assessment at baseline 
before each infusion, and an investigator will complete a CGI-Global Improvement (CGI-C) 
assessment at the end of each infusion, and at 24 hours post-infusion for each infusion.  See 
§E.8 for description of assessment measures. 
 
E.6.c. Post-ketamine administration procedures 
Inpatients will be escorted back to their inpatient unit by the study coordinator. Participants 
receiving IV ketamine infusions as outpatients must either have a known responsible adult that 
will stay for the entirety of the study visit, or have a known responsible adult that will coordinate 
with research staff the approximate pickup time and an on-campus location where they will pick-
up the patient; upon discharge, a member of the research team may escort patient to the pick-up 
site determined by the participant to meet their known responsible adult. 
 
After each infusion, investigators will complete a procedure note describing (a) all physical 
symptoms experienced during and through end of infusion, (b) vital signs taken immediately 
before start of infusion (BP, SpO2, RR and Pulse), and (c) vital signs taken at infusion stop time, 
and at 30- and 60- minutes after end of infusion. 
 
Whether patient withdraws from study or completes the course of study process, study teams will 
correspond with inpatient clinical teams (for subjects who are inpatients) or referring clinicians as 
applicable to each patient at each study site. At minimum, this communication must specify: (a) 
Participant has withdrawn or completed study process and is no longer participating in this study, 
and (b) As a result of no longer participating in this study, patient should continue to receive the 
standard level of care respective to the patient’s diagnosis. 
 
Regardless of whether patient withdraws from study or completes the course of study process, 
the participant will be offered one optional research follow-up visit by the study coordinator or 
designated study staff.  The research follow-up visit will occur within 5 working days following the 
24-hour follow-up of the participant’s last infusion (infusions 1 or 2 for those who do not complete 
the acute phase, or infusion 3 for those who complete the acute phase). For participants who 
enter into the optional continuation phase of the study (see §E.7), the research follow-up visit will 
occur 5 working days following the 24-hour follow-up of the subject’s final continuation phase 
infusion.  
 
Qualitative Study (Talk-K): 

Page | 17 
 
Each recruiting site will contact participants that were enrolled in the Bio-K study.  Participants 
will be contacted 12-36 months after their last infusion and invited to answer additional questions 
related to their experience in the ketamine trial as well as follow-up information since their last 
study treatment.  Research staff from the University of Michigan will be conducting the research 
that includes informed consent, a 5-minute questionnaire and 45-60 minute interview.  Answering 
these additional qualitative questions will help providers better understand the participant’s 
experience and improve future research.   
  
The 5-minute questionnaire will ask about their mood since treatment and their current status.  
The interview will be conducted using a HIPAA compliant and secure Zoom video conference 
method that participants can join by phone or a website link.  These interviews will be recorded, 
transcribed and then the recording will be destroyed.  The interview will ask open-ended questions 
about their experience during the IV ketamine treatments and since the last study treatment.   
 
E.6.d. Hospitalized patients who are discharged prior to study completion 
For hospitalized participants, if dismissed from the hospital before completing all 3 acute phase 
infusions, then remaining infusions will be conducted on an outpatient basis. Specific procedures 
will be site-specific. 
 
The patients in need of receiving outpatient infusions will be scheduled per the standard process 
at each site, at which point they will be greeted by the study coordinator and the process from 
there will be identical to that for inpatients. The 1-2 hours post-infusion outcome measures, as 
well as the 24-hour post infusion assessments, will be conducted in the study coordinator’s office 
or by telephone. When receiving infusions as outpatient, Site Lead Investigator or Site Co-
Investigator must evaluate the patient before patient discharges from outpatient infusion visit, and 
discharge will occur only when all physical symptoms are completely resolved. Evaluation must 
include review of vitals for possible side effects of study drug. For additional patient safety, patient 
must either have a known responsible adult that will stay for the entirety of the study visit, or have 
a known responsible adult that will coordinate with research staff the approximate pickup time 
and an on-campus location where they will pick-up the patient; upon discharge, a member of the 
research team may escort patient to the pick-up site determined by the participant to meet their 
known responsible adult. 
 
 E.6.e. Treatment as usual 
All enrolled subjects will receive treatment as usual while participating in this protocol, at the 
discretion of study clinicians.  This can include psychotherapy, other forms of psychosocial 
treatment, and pharmacotherapy, as appropriate.  The only exceptions will be ECT, TMS, or DBS, 
which will not be allowed during participation in this protocol. Further restrictions are any ongoing 
prescription of ≥4mg Lorazepam equivalents total daily on date of infusion, or any morning dosing 
of any benzodiazepine at time of assessment on date of infusion. 
E.7. Biomarker Sampling 
E.7.a. Overview and timeline 
Recall that our initial biomarker development efforts will focus on a peripheral WBC marker of 
mTOR/GSK3 target engagement; however, additional sample will be taken to develop additional 
biomarkers as part of future work. A list of additional specific biomarkers is provided below in 
Table 2. For all 100 subjects, there are biomarker blood draws and serum collections at the 
following time points, collected by CRU staff.   
• 
Before and after the first acute phase ketamine infusion;  
• 
After the third (final) acute phase ketamine infusion;  

Page | 21 
 
symptoms and has been shown to be sensitive to therapeutic effects. This scale will be 
used at each rating visit to assess for treatment emergent (hypo)mania. Hypomania will 
be defined as an YMRS >12 and mania will be defined as an YMRS ≥20. 
• 
Clinical Global Impression (CGI):  Overall clinical judgment symptom severity (I) and 
change for a preceding phase (II). Dropout criteria will be any 1 rating of CGI II – 5 (much 
worse) or 6 (very much worse) [70]. 
• 
Open-ended assessment of perceptual changes with ketamine treatment:  Patients 
will be asked open ended questions related to whether they noticed any visual 
hallucinations, dizziness, vertigo, or any strange feelings or thoughts. 
• 
 Comprehension of study protocol assessment:  Test to assess understanding of 
purpose of study given to patients as part of entry process.  
• 
Antidepressant Treatment History Form (ATHF): This form will be used at time of 
enrollment to collect pertinent information on past and present anti-depressant trials, 
including dosage, length of use, and treatment resistance. 
• 
Snaith-Hamilton Pleasure Scale (SHPS): This questionnaire is designed to measure the 
ability to experience pleasure in the last few days [71]. Used repeatedly to score for 
anhedonia. 
• 
Ketamine Side Effects Scale: This scale was developed to measure side effects to 
ketamine when administered for antidepressive effects [72].   
• 
Repeatable Battery for the Assessment of Neuropsychological Status:  The RBANS 
is a brief, standardized, individually administered battery to measure cognitive change in 
immediate memory, visuospatial/constructional orientation, language (naming, fluency), 
attention, and delayed memory.  The 12 subtests that comprise the RBANS requires 
approximately 30 minutes to administer. 
 
E.10. Case Report Forms, Data Capture and Source Documentation 
Case report forms are provided for each subject in electronic format. Research Electronic Data 
Capture (REDCap), developed at Vanderbilt University but widely used internationally, is a 
secure, web-based application designed to support data capture for research studies. REDCap 
provides: 1) an intuitive interface for data entry (with data validation); 2) audit trails for tracking 
data manipulation and export procedures; 3) automated export procedures for seamless data 
downloads to common statistical packages (SPSS, SAS, STATA, R); 4) procedures for importing 
data from external sources; and 5) advanced features, such as branching logic and calculated 
fields within electronic forms and the survey feature. Data will be uploaded securely from each 
research site via REDCap. 
 
Electronic source documentation must be made available to confirm data collected properly. In 
the event that a paper version CRF was used as the primary medium for data collection at any 
study site, and subsequently entered into REDCap, the paper CRF will serve as the source 
document. Source document data includes author initials and date of entry to source 
documentation. Also, the necessary fields for source documentation review are subject 
identification code, eligibility, study identification, study discussion and date of signed informed 
consent, dates of visits, record of all UPIRTSO and non-UPIRTSO and results of reporting, 
concomitant medications, drug order and dispensing records (de-identified), study drug 
administration information, date subject completed or discontinued study, date and reason study 
drug was discontinued early, if applicable. Subject measures completed by subject, investigator 
or subject personnel will also be considered source documents. It will be the responsibility of the 
investigator to verify that all data entries in the CRFs are accurate and correct. 

Page | 22 
 
E.11. Data Safety Monitoring Plan and Board 
Monitoring responsibilities for this study will be assigned to investigators Dr. William Bobo (Mayo 
Clinic), Dr. Sagar Parikh (University of Michigan), Jose Rico, CCRP (Mayo Clinic) or appropriate 
designee determined by the sponsor. Neither investigator will serve to monitor their own site. 
Three on-site monitoring visits will be made: pre-initiation, post-initiation and a close-out visit at 
each site. In addition, either of the investigator monitors will perform the on-site monitoring visits 
as frequently as necessary. The designated investigator monitor will record dates of the site visits 
in a study site visit log that will be kept at the study site. The post-initiation visit will be scheduled 
after enrollment of the 3rd subject has occurred at each site and the close-out visit will occur once 
recruitment is completed.  
 
At these visits, the investigator monitor will compare the entered CRF data with the source 
documents. The nature and location of all source documents will be identified to ensure that all 
sources of original data required to complete the CRF are known to the investigator monitor and 
study-site personnel, and are accessible for verification by the investigator monitor and study-site 
personnel. If electronic records are maintained at the study site, the method of verification must 
be discussed with the investigator monitor and a report will be generated. 
 
Investigator monitor visit expectations include the availability of the study-site personnel, 
accessible source documentation, and a suitable environment for review of study-related 
documents. The investigator monitor will meet or correspond with the Site Lead Investigator 
during the study to provide feedback on the study conduct. 
 
The Bio-K Data Safety Monitoring Board (DSMB) shall have the responsibility to review on a 
scheduled basis accumulating data and monitoring reports from all sites. The DSMB advises the 
sponsor NNDC regarding the continuing safety of trial subjects and potential subjects, and the 
continuing validity and scientific merit of The Bio-K Study.  
E.12. Record Retention 
In compliance with the ICH/GCP guidelines, the sponsor, site lead investigator and site institution 
will maintain all Essential Documents (CRFs and source documents related to each study subject) 
as well as all study documents as specified in ICH/GCP Section 8 – Essential Documents for the 
Conduct of a Clinical Trial of Guideline for Good Clinical Practice E6: ICH Harmonised Tripartite 
Guideline. The site lead investigator and institution will take appropriate measures to prevent 
misplacement, accidental or premature destruction of study documents. The  essential documents  
are  grouped  in  three  sections  according  to  the  stage  of  the  trial  during  which  they  will  
normally  be generated: 1) before the clinical phase of the trial commences, 2) during the clinical 
conduct of the trial, and 3) after completion  or termination of the trial. Together, these essential 
documents constitute a trial master file to be established with the sponsor and at each site before 
it begins the clinical phase of the trial.  
 
Essential documents must be retained until at least 2 years have elapsed since the formal 
discontinuation of clinical development of the investigational product related to this study. These 
documents will be retained for a longer period if required by local IRB/IEC or by an agreement 
with the sponsor. It is the responsibility of the sponsor to inform the investigator/institution as to 
when these documents no longer need to be retained. 
 
In the event that the responsible site lead investigator retires, relocates, or for other reasons 
withdraws from the responsibility of keeping the study records, custody must be transferred to a 
person who will accept the responsibility. The sponsor must be notified in writing of the name and 
address of the new custodian at that site. Under no circumstance shall the investigator relocate 
or dispose of any study documents before having obtained written approval from the sponsor.  

Page | 23 
 
 
If it becomes necessary for the sponsor or the appropriate regulatory authority to review any 
documentation relating to this study, the site lead investigator/institution must permit access to 
such reports. 
E.13. Study Completion and Termination 
The study is considered completed with enrollment of the 100th subject. The final data from the 
study site will be sent to the sponsor after completion of the final subject assessment at that study 
site. 
 
The sponsor reserves the right to close the study site or terminate the study at any time for any 
reason at the sole discretion of the sponsor. Study sites will be closed upon study completion. A 
study site is deemed in closed status when all required study documents have been collected and 
a study-site closure visit has been performed by the designated investigator monitor. 
 
The sponsor or site investigator monitor may initiate study-site closure 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 a study site by the sponsor or investigator may include but are not limited 
to failure of the investigator to comply with the protocol, the requirements of the IRB or local health 
authorities, the sponsor’s procedures, or GCP guidelines, and inadequate recruitment of subjects 
by the investigator 
E.14. Reportable Event – Reporting to Sponsor and Site IRB/IEC 
Adverse Effects.   
Patients will be asked open ended questions about any adverse perceptual effects of ketamine 
during the infusion, such as visual hallucinations, dizziness, or vertigo, every 15 minutes during 
infusions and at 30- and 60 minutes after each infusion. Infusions will be stopped if side effects 
seem severe or if the patient wishes it to be stopped or infusion may also be stopped for any 
marked vital abnormality, as noted above.  Side effects will also be monitored utilizing the 
Ketamine Side Effects Scale (KSES) [58] and the YMRS. The KSES and YMRS will be completed 
for the 40 min infusion, recorded at baseline, at 30 min during infusion, at 20 min post infusion 
stop (t60), at 60 min post infusion stop (t100). For the 100 min infusion, KSES and YMRS will be 
recorded at baseline; at 30, 60 and 100 minutes after start of infusion; and 60 minutes post 
infusion stop. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) 
is administered in the acute phase at baseline (prior to the first ketamine infusion) and at 24 hours 
following the 3rd acute phase infusion, and in the optional continuous phase, at 24 hours after the 
4th continuous phase infusion, to assess cognitive effects.  See §E.8 for description of assessment 
measures. 
 
The sponsor has established the Standard Operating Procedure in conformity with regulatory 
requirements to ensure appropriate reporting of Unanticipated Problem Involving Risk to Subjects 
or Others (UPIRTSO) and non-UPIRTSO events to the sponsor and local IRB/IEC. Including 
notification to local IRB/IEC of an UPIRTSO or non-UPIRTSO, each site is provided as a separate 
document the names and telephone numbers of individuals who should be contacted regarding 
safety issues and/or with questions regarding the study. In addition, each site will be provided an 
UPIRTSO form to be submitted to the sponsor describing the event, subject identification code, 
subject date of birth, and date seen. 
 
An UPIRTSO is defined as any problem or event which, in the opinion of the local Investigator, 
meets all three of the following criteria: 
1. Serious: Serious problems or events that result in significant harm, (which may be 
physical, psychological, financial, social, economic, or legal) or places subjects or others 
at a greater risk of harm than was previously known or recognized.. 

Page | 24 
 
2. Unanticipated: A problem or event is "unanticipated" when it was unforeseeable at the 
time of its occurrence and is:  
a. Not already described as a potential risk in the approved informed consent 
b. Not already described as a potential risk in the approved protocol 
c. Not listed in the Investigator’s Brochure 
d. Not part of an underlying disease 
e. Occurred at an increased frequency or at an increased severity than expected, 
3. Related: A problem or event is "related" if it is possibly related to the research procedures. 
 
An UPIRTSO can include but isn’t limited to adverse drug reactions (both serious and 
unexpected), adverse events, serious adverse events, protocol deviations and protocol violations 
occurring in this study meeting the criteria that the event was serious, unanticipated and related 
to study procedures. Reporting to sponsor and local IRB/IEC should occur as soon as possible 
and in accordance with local IRB/IEC reporting guidelines. In contrast, a non-UPIRTSO, although 
still reportable, is defined as a reportable event that does not meet all three criteria in the definition 
of an UPIRTSO. 
 
An Adverse Drug Reaction is defined as an unexpected, unintended, undesired, or excessive 
response by a patient to a medication that could not have been prevented and having one or more 
of the following characteristics: 
• 
Requires hospitalization 
• 
Prolongs length of stay 
• 
Requires use of antidote(s), prescription drug therapy, extra diagnostic activities, or other 
corrective therapeutic measures (e.g. monitoring, discontinue medication) 
• 
Fatality or permanent disability 
• 
Significantly complicates diagnosis 
• 
Negatively affect prognosis 
• 
Medication incompatibility not previously identified 
• 
A serious reaction not listed on the product package insert 
 
An Adverse Event is defined as any untoward medical occurrence in a patient or clinical 
investigation subject administered a pharmaceutical product and which does not necessarily have 
to have a causal relationship with this treatment.  
A Serious Adverse Event is any untoward medical occurrence that at any dose results in death, 
is life-threatening, requires inpatient hospitalization or prolongation of existing hospitalization, 
results in persistent or significant disability/incapacity, a congenital anomaly/birth defect.  
 
A Protocol Violation is defined as any change, divergence or departure from the study design or 
research procedures that is under the investigator’s control and has not been approved by the 
local IRB/IEC. A Major Protocol Violation/Deviation is defined as any change that affects the rights 
and welfare of subjects and others, increases risks to subjects and others, decreases potential 
benefits, compromises the integrity or validity of the research, or represents willful or knowing 
misconduct to include not limited to enrolling subjects who did not meet the inclusion/exclusion 
criteria, performing study procedures not approved by the IRB, failure to obtain and/or document 
informed consent, and receipt of incorrect treatment or dose by a study subject. A Minor Protocol 
Violation/Deviation is any change that did not increase the risk or decrease the benefit or 
significantly affect the subject’s rights, safety or welfare and/or the integrity of research data (e.g. 
a routine lab missed at a visit and re-drawn, shortening the duration between a planned study 
visit, using an outdated HIPAA form or consent form when there are no differences between the 
two forms other than the approval date). 
 

Page | 25 
 
A Protocol Deviation is defined as a limited prospective exception to the protocol (e.g. agreement 
between sponsor and investigator to enroll a single subject who does not meet all 
inclusion/exclusion criteria). Like protocol amendments, deviations initiated by the clinical 
investigator must be reviewed and approved by the local IRB/IEC and the sponsor prior to 
implementation, unless the change is necessary to eliminate apparent immediate hazards to the 
human subjects (21 CFR 312.66), or to protect the life or physical well-being of the subject (21 
CFR 812.35(a) (2)). 
E.15. On-Site Audits 
At any time, representatives of the sponsor's steering committee may schedule a visit of a study 
site during or after completion of the study. Purpose of such a visit is to conduct an audit of the 
study for ensuring compliance with regulatory guidelines and subject privacy. Such an audit visit 
would require access to all study records, including source documents, for review and comparison 
to the CRFs. The site lead investigator and study-site personnel would need to be made available 
for query during each audit visit conducted by the sponsor. 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 site 
investigator should immediately notify the sponsor if contacted by a regulatory agency concerning 
an upcoming inspection. 
E.16. Statistical Analysis 
The sample size of 100 has been selected based on feasibility of completion across the 7 study 
sites, and as larger pilot expansion of clinical practice feasibility. The intent is to enroll 100 
subjects (70 unipolar/ 30 bipolar) over 4 sites which would estimate 25 subjects per site. Given 
potential delays in obtaining IRB approval, some sites may over-recruit. For most data elements, 
descriptive statistics such as means and standard deviations will be reported. Comparisons of 
means before and after treatment will be based on t tests. Statistical support will be provided from 
designated psychiatry and psychology department statistician time.  
 
For Aim 1, we will compare baseline WBC markers of impaired cellular energy regulation 
(described above, see §B.5.c) between remitters and non-remitters using ANCOVA models 
adjusted for study site, age, and sex.  Analyses comparing the baseline biomarkers of responders 
and non-responders will be performed using similar models, and the association of biomarkers 
with percent change in MADRS score will be evaluated using linear regression mixed models. 
 
 For Aim 2, similar analyses will be performed comparing the other biomarker measures between 
remitters and non-remitters (and responders and non-responders), and testing for association 
between percent change in MADRS score and the other biomarker measures.    
 
For Aim 3, we will perform logistic regression analyses to evaluate the additive effects of WBC 
markers of impaired cellular energy regulation and the other biomarker measures, as predictors 
of remission (or response). Model selection will be performed using LASSO, and area under the 
receiver operating characteristic curve (AUC) will be used to evaluate the combined predictive 
potential of the WBC-based and other biomarkers.  
 
Additionally, we will evaluate whether changes in the biomarker levels (for both WBC-based 
biomarkers and other biomarkers) are associated with clinical response to ketamine, using similar 
statistical methods to those described for the analysis of baseline biomarkers.  Finally, to 
supplement the traditional regression-based approaches, statistical learning classification 
approaches, including random forests, will be utilized to predict remission (and response) using 
the different biomarkers and clinical predictors. These exploratory analyses will develop predictive 
models that will need to be evaluated in independent samples collected in future studies. 

Page | 26 
 
E.17. Suicide Assessment and Safety Plan 
This research study specifically is targeted at identifying participants with treatment resistant 
unipolar or bipolar major depression, a population of patients who are at high risk for having 
thoughts of suicide, and may be at high risk for suicide or attempted suicide in the future.  
Ketamine treatment has been shown to result in a rapid resolution of suicidality and suicide rating 
scores in previous studies.   
 
Suicide risk will be assessed in multiple domains both with brief surveys filled out by patient along 
with clinical interview and assessment. Patients will continue with their usual clinical assessment 
of suicide risk from their inpatient or outpatient care teams and will continue with treatment as 
usual related to clinical care.   
 
Suicide specific items in outcomes measures include suicide ratings measured by the MADRS 
and the PHQ-9. For more extensive assessment and analysis, the BSS will also be used to 
determine immediate changes. Finally, patients will be asked in an open-ended manner if they 
have concerns related to their safety. 
 
While patients are hospitalized, concerns will be relayed to their primary inpatient team which 
provides coverage seven days a week, 24 hours a day, and provides monitoring on inpatient 
hospital in the same manner. Patients will continue to receive their usual care and a safe 
discharge from the hospital and resolution of patient’s acute suicidal crisis will be determined by 
patient’s primary clinical team and not research staff. 
 
If there are concerns raised that are new related to suicide risk assessed by investigator/research 
assistants while patients are in the hospital, this change in status will be communicated to the 
inpatient care team. If the patient is an outpatient, this will be communicated to their treating 
psychiatrist or home medical team.  
 
For patients who are assessed by study coordinator during a repeat visit to have new onset or 
worsening of suicidal ideation, the study coordinator will contact the site lead investigator at their 
clinical site or a board certified psychiatrist study team member. This individual will assess patient 
and make determination of whether the patient needs more in depth assessment, closer 
outpatient follow-up with their team, or emergent hospitalization. This will also apply if patients 
are having a worsening of depressive symptoms without increase in thoughts of suicide. In such 
an event, study site will inform the sponsor of the event of repeat or new onset or worsening of 
suicidal ideation using the UPIRTSO form provided as a separate document, and must also notify 
their local IRB/IEC of the event.  
 
Outside the hospital as outpatients, subjects will be given listings of numbers to call if there are 
concerns in between assessments by research coordinators. These numbers will include study 
coordinator, local Emergency Department contact information, and the National Suicide 
Prevention Lifeline at 1-800-273-TALK. 
E.18. Dropout Criteria and Pregnancy 
Dropout criteria will be any 1 rating of CGI II change in severity score of either 5 (much worse) or 
6 (very much worse). Dropout criteria will also include inability to tolerate ketamine treatment as 
defined by patient and/or treating clinician or other co-investigators. Inability to tolerate treatment 
may include significant adverse effects during infusion (physiologic, emotional or cognitive) or 
emergence of worsening psychotic or perceptual changes or mania. Clinical assessment by 
primary psychiatrist of worsening of symptoms may also constitute reason for study dropout. 
Subjects may elect to dropout of study. 
 

Page | 27 
 
An existing pregnancy will serve to exclude pregnant patients from enrolling in the study. Further, 
any initial reports of pregnancy occurring during the study must be reported to the sponsor by the 
study-site personnel within 24 hours of their knowledge of the event. Each site will be provided 
with a pregnancy notification form. Abnormal pregnancy outcomes (eg, spontaneous abortion, 
stillbirth, and congenital anomaly) are considered serious adverse events and must be reported 
using the provided UPIRTSO form. Any subject who becomes pregnant during the study must be 
promptly withdrawn from the study and discontinue further study treatment. In addition to 
submitting an UPIRTSO form to sponsor, local IRB/IEC must notified per established IRB/IEC 
procedures. 
 
Because the effect of the study drug on sperm is unknown, pregnancies in partners of male 
subjects included in the study will be reported by the study-site personnel within 24 hours of their 
knowledge of the event using the appropriate pregnancy notification form to the sponsor. Follow-
up information regarding the outcome of the pregnancy and any postnatal sequelae in the infant 
will be required. 
 
 
 

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