Reducing Adolescent Suicide Risk: Safety, Efficacy, and Connectome Phenotypes of Intravenous Ketamine
Phase: PHASE2
Conditions: Adolescent Suicide, Adolescent Depression
Sponsor: Yale University

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
CLINICAL STUDY PROTOCOL
Interventional Drug or Biologic
Reducing Adolescent Suicide Risk: 
Safety, Efficacy, and Connectome 
Phenotypes of Intravenous Ketamine
Protocol Number
2000029003
Protocol Version
4.7 05SEPT2024
PRINCIPAL INVESTIGATOR:
Name: Michael Bloch, MD, MS 
Department: Child Study Center 
Telephone Number: (203)745-9921
Email Address: Michael.bloch@yale.edu
IND Number: 152866
IND Holder: Michael Bloch, MD, MS 
NCT Number: NCT04613453
Study Phase (1, 2, 3, or 4-postmarketing): Phase 2
Confidentiality Statement: The information contained in this document is confidential. It is 
intended solely for the Investigators, potential Investigators, consultants, or applicable 
independent ethics committees. It is understood that this information will not be disclosed to 
others without prior written authorization from the principal investigator, except where 
required by applicable local laws.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
HIC #2000029003
V 4.705SEPT2024
2
Contents
1
. Protocol Summary ............................................................................................................7
1.1
Synopsis.......................................................................................................................7
1.2
Schema ........................................................................................................................8
1.3
Schedules of Activities................................................................................................8
2
Introduction.......................................................................................................................12
2.1
Study Rationale..........................................................................................................12
2.2
Background................................................................................................................12
2.2.1
Preclinical Experience........................................................................................12
2.2.2
Clinical Experience ............................................................................................13
2.2.3
Background/prevalence of research topic ..........................................................17
2.3
Risk/Benefit Assessment...........................................................................................19
2.3.1
Known Potential Risks.......................................................................................19
2.3.2
Known Potential Benefits ..................................................................................25
3
Objectives & Endpoints....................................................................................................26
3.1
Overall objectives......................................................................................................26
3.2
Primary Objective......................................................................................................26
3.3
Secondary Objectives ................................................................................................26
3.4
Exploratory Objectives..............................................................................................26
3.5
Outcome Variables ....................................................................................................26
3.5.1
Primary Outcome Variables...............................................................................26
3.5.2
Secondary Outcome Variables...........................................................................27
3.5.3
Exploratory Outcome Variables.........................................................................27
4
Study Design.....................................................................................................................28
4.1
Overall Design...........................................................................................................28
4.1.1
Study Date Range and Duration.........................................................................28
4.1.2
Number of Study Sites .......................................................................................28
4.1.3
Number of Participants.......................................................................................28
4.2
Scientific Rationale for Study Design .......................................................................29
4.3
Justification for Dose.................................................................................................29
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
HIC #2000029003
V 4.705SEPT2024
3
4.4
End of Study Definition.............................................................................................30
5
Study Population...............................................................................................................31
5.1
Inclusion Criteria.......................................................................................................31
5.2
Exclusion Criteria......................................................................................................32
5.3
Lifestyle Considerations............................................................................................32
5.4
Screen Failures...........................................................................................................33
5.5
Strategies for Recruitment and Retention..................................................................33
6
STUDY INTERVENTION...............................................................................................34
6.1
Study Intervention(s) Administration........................................................................34
6.1.1
Study Intervention Description...........................................................................40
6.1.2
Dosing and Administration ................................................................................41
6.2
Preparation/Handling/Storage/Accountability ..........................................................41
6.2.1
Acquisition and accountability...........................................................................41
6.2.2
Formulation, Appearance, Packaging, and Labeling..........................................42
6.2.3
Product Storage and Stability .............................................................................42
6.2.4
Preparation .........................................................................................................42
6.3
Measures to Minimize Bias: Randomization and Blinding .......................................42
6.4
Study Intervention Compliance.................................................................................42
6.5
Concomitant Therapy ................................................................................................42
6.5.1
Rescue Medicine ................................................................................................43
7
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL................................................................................43
7.1
Discontinuation of Study Intervention.......................................................................43
7.2
Participant Discontinuation/Withdrawal from the Study...........................................44
7.3
Lost to Follow-Up .....................................................................................................44
8
STUDY ASSESSMENTS AND PROCEDURES ............................................................44
8.1
Efficacy Assessments ................................................................................................44
8.2
Safety and Other Assessments...................................................................................45
8.2.1
Safety..................................................................................................................45
8.2.2
Biomarkers/Neuroimaging Assessments............................................................46
8.3
Adverse Events and Serious Adverse Events ............................................................47
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
HIC #2000029003
V 4.705SEPT2024
4
8.3.1
Definition of Adverse Events (AE)....................................................................47
8.3.2
Definition of Serious Adverse Events (SAE).....................................................47
8.3.3
Classification of an Adverse Event ....................................................................47
8.3.4
Relationship to Investigational Product .............................................................47
8.3.5
Time Period and Frequency for Event Assessment and Follow-Up...................48
8.3.6
Adverse Event Reporting ...................................................................................49
8.3.7
Serious Adverse Event Reporting ......................................................................49
8.3.8
Reporting Events to Participants........................................................................50
8.3.9
Events of Special Interest...................................................................................50
8.3.10
Reporting of Pregnancy......................................................................................50
8.3.11
Pharmacokinetics ...............................................................................................46
8.4
Unanticipated Problems.............................................................................................50
8.4.1
Definition of Unanticipated Problems (UP).......................................................50
8.4.2
Unanticipated Problem Reporting......................................................................51
8.4.3
Reporting Unanticipated Problems to Participants ............................................51
9
STATISTICAL CONSIDERATIONS .............................................................................53
9.1
Statistical Hypotheses................................................................................................53
9.2
Sample Size Determination .......................................................................................53
9.3
Populations for Analyses...........................................................................................54
9.4
Statistical Analyses....................................................................................................54
9.4.1
General Approach ..............................................................................................54
9.4.2
Analysis of the Primary Efficacy Endpoint(s) ...................................................54
9.4.3
Analysis of the Secondary Endpoint(s)..............................................................55
9.4.4
Safety Analyses..................................................................................................56
9.4.5
Baseline Descriptive Statistics ...........................................................................56
9.4.6
Planned Interim Analyses...................................................................................57
9.4.7
Sub-Group Analyses ..........................................................................................57
9.4.8
Tabulation of Individual participant Data..........................................................57
9.4.9
Exploratory Analyses.........................................................................................57
10
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS57
10.1
Regulatory, Ethical, and Study Oversight Considerations ........................................57
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
HIC #2000029003
V 4.705SEPT2024
5
10.1.1
Informed Consent Process..................................................................................58
10.1.2
Study Discontinuation and Closure....................................................................59
10.1.3
Confidentiality and Privacy................................................................................60
10.1.4
Future Use of Stored Specimens and Data .........................................................60
10.1.5
Key Roles and Study Governance......................................................................61
10.1.6
Safety Oversight.................................................................................................61
10.1.7
Clinical Monitoring............................................................................................62
10.1.8
Quality Assurance and Quality Control..............................................................63
10.1.9
Data Handling and Record Keeping...................................................................64
10.1.10
Protocol Deviations ........................................................................................65
10.1.11
Publication and Data Sharing Policy ..............................................................66
10.1.12
Conflict of Interest Policy...............................................................................67
10.2
Additional Considerations .........................................................................................67
10.3
Abbreviations ............................................................................................................67
10.4
Protocol Amendment History....................................................................................69
11
REFERENCES..............................................................................................................70
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
HIC #2000029003
V 4.705SEPT2024
6
STATEMENT OF COMPLIANCE
SIGNATURE OF PRINCIPAL INVESTIGATOR
Protocol Title: Reducing Adolescent Suicide Risk: Safety, Efficacy, and Connectome 
Phenotypes of Intravenous Ketamine
Version and Date:  
The signatory agrees to the content of the reflected version of the clinical study protocol. 
He/she will conduct the study as presented and in compliance with all applicable regulations 
including those outlined in International Council for Harmonization (ICH) Good Clinical 
Practice (GCP) and the Code of Federal Regulations.
Name of Investigator:  
Affiliation:  
Signature: 
Date:  
Signed copies of this signature page are stored in the sponsor’s study file and investigator site 
file.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
HIC #2000029003
V 4.705SEPT2024
7
1 . Protocol Summary
This document is a protocol for a human research study. The purpose of this protocol is to 
ensure that this study is to be conducted according to ICH GCP guidelines, and according to 
CFR 21 Part 312, other applicable government regulations and Institutional research policies 
and procedures.
1.1
Synopsis
Primary Objective
The primary objective of this Phase 2 study is to determine whether ketamine rapidly reduces 
suicidal ideation (as measured by the C-SSRS, recent ideation subscale) compared to an 
active control, midazolam, in adolescents at high suicide risk (meeting criteria for SRI- 
resistant depression (having failed at least one antidepressant)AND having a suicidal event 
within the 120 days prior to enrollment).
Secondary Objectives
The secondary objectives of this study are to closely monitor the safety (cardiovascular 
function, bladder health, and cognitive function) and tolerability of a conservative repeat dosing 
ketamine paradigm and to identify functional connectome signatures predictive of efficacy or 
modified by treatment.
Exploratory objectives include describing the trajectory of mental health outcomes (suicidality, 
depressive symptoms, mental health resource utilization) over 4 months in ketamine 
responders and non-responders.
Study Duration
7 years, participant duration is 18 weeks (20 weeks for those who cross over to open ketamine)
Study Design
Parallel, double-blind, placebo-controlled RCT with option to cross-over to active treatment in 
open phase
Number of Study Sites
1) Yale University/Yale New Haven Hospital
Study Population
Adolescents (13 to 17 years old, inclusive) with SRI-resistant depression AND a history of a 
suicidal event within 120 days prior to enrollment. .A suicide event is defined as either a suicide 
attempt (i.e. act of potentially self-injurious behavior with explicit or inferred intent to die –OR– 
degree of suicidal ideation requiring an emergency evaluation or a transition to higher level of 
care (e.g. intensive outpatient program, partial hospital program, inpatient)). Participants will be 
recruited through the Yale New Haven Health System through inpatient, intensive outpatient, 
emergency, and subspecialty clinical services. We do not plan to advertise in the community 
for this study.
Number of Participants
N = 40-66 (Last subject enrollment date is planned for 8/31/26)
Primary Outcome Variables
Columbia-Suicide Severity Rating Scale (C-SSRS), recent ideation subscale, 48-hours after 
receiving first blinded treatment
Secondary and Exploratory Outcome Variables (if applicable)
Montgomery Asberg Depression Rating Scale; Children’s Depression Rating Scale-Revised; 
Clinical Global Impression; Systematic Assessment for Treatment Emergent Effects; Cogstate 
battery; Pre- and post-treatment functional connectome (derived from multimodal combination 
of task-based and resting state fMRI); mental health utilization (number of emergency, 
intensive outpatient, partial hospital, or inpatient visits during open phase)
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
HIC #2000029003
V 4.705SEPT2024
8
1.2
Schema
1.3
Schedules of Activities
The total number of study visits from Baseline through study completion is 24 for those who 
progress directly from phase A1 to B (i.e. those who are either randomized to ketamine or 
who have a significant clinical response to midazolam) and is 30 for those who complete 
phases A1, A2 (open ketamine), and B. Please see the 2 separate tables of study events that 
follow.
Study Schedule for Double Blind Treatment (Phase A1)—All participants
Phase A1
Visit No.
1
2
3
4
5
6
7
Procedures
Screening
D0
(Baseline)
D1
D2
D3
D8
D10
D11
Blinded Intervention – 
Phase A1 a
X
X
X
X
Permission and Assent
X
Diagnostic Interview
X
MINI-KID
X
Physical Exam
X
Demographics Form
X
Diagnosis & Treatment History 
Form
X
Family History Form
X
Medications Form
X
MRI Safety Questionnaire
X
Vital signs
X
X
X
X
X
Lab tests b
X
ECG
X
X
Urine toxicology
X
X
X
Urine pregnancy test c
X
X
Safety Planning Session
X
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
HIC #2000029003
V 4.705SEPT2024
9
Phase A1
Visit No.
1
2
3
4
5
6
7
Procedures
Screening
D0
(Baseline)
D1
D2
D3
D8
D10
D11
MRI Imaging
X
X
AE assessment 
(SAFTEE-SI)
X
Xd
X
X
X
X
PK Blood draw e
X
Clinical questionnaires
C-SSRS
X
X
X
X
X
X
X
MADRS
X
X
X d
X
X
X
X
CGI
X
X
X
X
X
X
CDRS-R
X
X
X
PSC
X
X
TEASAP
X
X
X
MASC
X
X
CADSS
X
X
X
X
X
X
BHS
X
X
ASQ
X
X
CTQ
X
Edinburgh Handedness 
Inventory
X
Wechsler Abbreviated 
Scale of Intelligence
X
Cogstate neurocognitive 
battery
X
X
Guess form
X
Breaking the Blind f
X
a. Subjects will be randomly assigned to receive either 0.5 mg/kg IV ketamine OR 0.045 
mg/kg IV midazolam. Both medications will be infused over 40 minutes Subjects will not 
receive more than 40 mg ketamine or 3.6 mg midazolam
b. Labs will include: CBC with differential, complete metabolic panel (including electrolytes, 
LFTs, BUN, creatinine, and glucose), TFTs, a serum pregnancy test for WOCBP, and 
routine urinalysis
c.
WOCBP will have a weekly urine pregnancy test prior to the first treatment of the week
d. These assessments will occur by phone
e. Blood for pharmacokinetics will be drawn pre-infusion; and 40, 80, 110, and 230 minutes 
post-infusion start. Total blood volume collected will not exceed 30 mL/day
f.
After breaking the blind, participants will be separated into two groups, with separate 
schedules: Open Schedule #1: Subjects assigned to midazolam who did not respondin 
Phase A1 will proceed to Phase A2; Open Schedule #2: All other subjects will proceed 
directly to Phase B
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
HIC #2000029003
V 4.705SEPT2024
10
Study Schedule for Open Treatment (Phase A2)— Only Open Schedule #1 participants
Phase A2
Visit No.
8
9
10
11
12
13
Procedures
Study 
Day
D15
D16
D17
D22
D24
D25
Open Intervention – 
Phase A2a
X
X
X
X
Vital signs
X
X
X
X
ECG
X
Urine toxicology
X
X
Urine pregnancy test b
X
X
MRI Imaging
X
AE assessment 
(SAFTEE-SI)
X
X d
X
X
X
X
PK Blood draw c
X
Clinical questionnaires
C-SSRS
X
X
X
X
X
MADRS
X
X d
X
X
X
X
CGI
X
X
X
X
X
CDRS-R
X
PSC
X
TEASAP
X
X
MASC
X
CADSS
X
X
X
X
X
BHS
X
ASQ
X
Cogstate neurocognitive battery
X
a.
Subjects will receive 0.5 mg/kg IV ketamine over 40 minutes. Subjects will not 
receive more than 40 mg ketamine.
b.
WOCBP will have a weekly urine pregnancy test prior to the first treatment of 
the week
c.
Blood for pharmacokinetics will be drawn pre-infusion; and 40, 80, 110, and 230 
minutes post-infusion start. Total blood volume collected will not exceed 30 
mL/day
d.
These assessments will occur by phone
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
HIC #2000029003
V 4.705SEPT2024
11
Study Schedule for Open Follow-up (Phase B)—All Participants (Open schedule #1 
subjects are two weeks delayed relative to Open schedule #2 subjects due to their 
participation in Phase A2)
Phase B
Visit 
#
8
9-10
11
1124-
15
18-c
19 c
220-c
23 c
24
Open Schedule 
#2
(A1 -> B)
Stud 
y  
Day*
D17
D24, 
D31
D3 
8
D45, 
D52, 
D59
D66
D73, 
D80, 
D87
D94
D101
,   
D108
,   
D115
D122
End of 
Study 
D126
Visit 
#
14
15-
16
17
18-
20
21
22-c
24
25 c
26-c
28
29 c
30
Open Schedule
#1 
(A1 -> A2 -> B)
Stud 
y  
Day*
D31
D38, 
D45
D5 
2
D59, 
D66, 
D73
D80
D87, 
D94, 
D101
D108
D115
,   
D122
,   
D129
D136
End of 
Study 
D140
CBT
X
X
X
X
X
Medication Management
X
X
X
X
X
X
X
ECG
X
X
Lab tests a,d
X
X
Urine toxicology
X
X
Physical Exam and
X
Vital Signs
X
Clinical questionnaires
C-SSRS
X
X
X
X
X
X
X
X
X
X
MADRS
X
X
X
X
X
X
X
X
X
X
CGI
X
X
X
X
X
X
X
X
X
X
CDRS-R
X
X
X
X
PSC
X
X
X
X
TEASAP
X
X
X
X
MASC
X
X
X
X
CADSS
X
X
X
X
BHS
X
X
X
X
ASQ
X
X
X
X
Cogstate 
Neurocognitive
X
X
X
X
MRI Imaging
X b
AE assessment 
(SAFTEE-GI)
X
X
X
X
X
AE assessment 
(SAFTEE-SI)
X
X
X
X
X
Discharge Discussion
X
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
HIC #2000029003
V 4.705SEPT2024
12
Phase B
Visit 
#
8
9-10
11
1124-
15
18-c
19 c
220-c
23 c
24
Open Schedule 
#2
(A1 -> B)
Stud 
y  
Day*
D17
D24, 
D31
D3 
8
D45, 
D52, 
D59
D66
D73, 
D80, 
D87
D94
D101
,   
D108
,   
D115
D122
End of 
Study 
D126
Visit 
#
14
15-
16
17
18-
20
21
22-c
24
25 c
26-c
28
29 c
30
Open Schedule
#1 
(A1 -> A2 -> B)
Stud 
y  
Day*
D31
D38, 
D45
D5 
2
D59, 
D66, 
D73
D80
D87, 
D94, 
D101
D108
D115
,   
D122
,   
D129
D136
End of 
Study 
D140
*For the open phase, study visits may be scheduled +/- 2 days for weekly visits and +/- 3 days for 
monthly batteries.
a. Labs will include: CBC with differential, complete metabolic panel (including electrolytes, LFTs,
BUN, creatinine, and glucose), TFTs, and routine urinalysis
b. This MRI scan will only be administered for subjects on Open Schedule #2 (proceeded directly from 
Phase A1 to Phase B). Subjects on Open Schedule #1 will have had their Day 17 MRI during phase 
A2
c.
These weekly mood and AE assessments can occur by phone if the participant is clinically stable 
during the final 8 weeks
d. Any spontaneous reports of abdominal pain, increased urinary frequency, urge incontinence, or 
other urinary or gastrointestinal symptoms can prompt an early medical and laboratory evaluation, if 
necessary
2 Introduction
2.1
Study Rationale
1) Suicide is the second leading cause of death in young people, and major depressive disorder 
increases the risk of adolescent death by suicide 30-fold. There have been no major updates to 
evidence-based pediatric prescribing recommendations since the TORDIA trial completed 13 years 
ago (recommending switching to a different selective serotonin reuptake inhibitor (SSRI) and adding 
CBT) and there are no evidence-based rapid-acting pharmacologic interventions to reduce suicide 
risk.
This evidence gap results in increased off label prescribing of untested medications in high- 
risk adolescents, ranging from second generation antipsychotics to ketamine. Careful, 
developmentally informed research on the safety, efficacy, and response predictors to 
ketamine is urgently needed.
The main purpose of the study is to examine the safety, efficacy, response predictors, and 
post-treatment trajectory of adolescents with SRI-resistant depression and high suicide risk 
following a highly conservative repeat dosing ketamine infusion paradigm (four infusions of 
0.5mg/kg each over two weeks) compared to an active placebo, midazolam. Those who are 
randomized to midazolam and remain ill have the option to cross-over to ketamine in the 
open phase. All participants will be followed closely for four months post-treatment and 
treated with standard of care depression treatment (medication management and cognitive 
behavioral therapy).
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
HIC #2000029003
V 4.705SEPT2024
Brain-based predictors of anti-suicidal responses will be assessed via connectome predictive 
modeling (CPM), examining functional brain circuits via fMRI before and after treatment. 
Given the unregulated use of ketamine in the community at widely varying doses and 
frequencies, the safety data gathered from this highly conservative repeat dosing paradigm is 
critical to inform the field about potential risks. Efficacy data at rapid, short-term, and 
intermediate-term (4 month) timepoints will be critical to determining whether a larger study 
is warranted in this population. The assessment of brain-based predictors of response through 
the integration of functional neuroimaging adds an important measure of biological 
engagement that will inform subsequent studies and stands to contribute towards the goal of 
personalized medicine (i.e. determining not only if a treatment works, but in whom).
2.2
Background
2.2.1
Preclinical Experience
Ketamine is an FDA-approved anesthetic agent that is commonly used to induce surgical 
anesthesia due to its low incidence of significant respiratory depression and hypotension. Its 
anesthetic effects are thought to be directly related to non-competitive inhibition of NMDA 
receptors. The majority of NMDA receptors in the forebrain consist of heterotetramers of the 
subunits NR1, NR2A, and NR2B; these subunits combine to form a cation channel, 
permeable to both sodium and calcium, that is dually gated by voltage and glutamate.
Ketamine binds non-selectively to all common NMDA receptor subtypes at a site within the 
open channel and thereby blocks the entry of calcium. Ketamine’s antidepressant actions 
have been hypothesized to relate to selective inhibition of NMDA receptors on inhibitory 
interneurons in prefrontal cortex1, as well as NMDA-receptor independent actions of the 
metabolite hydroxynorketamine (HNK) stimulatory actions at AMPA receptors2. Intravenous 
ketamine has a typical onset of action within 1–2 minutes and a short elimination half-life (2- 
4 hours)3, with effects rapidly dissipating following termination of the infusion. Ketamine 
undergoes hepatic metabolism to norketamine via cytochrome P450 enzymes, with further 
metabolism of norketamine to secondary metabolites of hydroxynorketamines and 
dehydronorketamine3 (see also 2.1.2.a, Fig 1).
Ketamine has increasingly been used in adult psychiatric populations at lower and slower 
doses than used in anesthesia, with increasing evidence for it efficacy as a rapid 
antidepressant4. Esketamine, the s-enantiomer of ketamine, (trade name Spravato) was 
recently FDA-approved for treatment resistant depression when given in conjunction with an 
oral antidepressant, for treatment-resistant depression.
Ketamine has a wide therapeutic window and has been used safely in Pediatrics for over 
50 years for sedation prior to medical procedures and dentistry5-7. Ketamine is in fact used 
more frequently in Pediatrics than in adult populations, typically at doses of 1mg/kg – 
4.5mg/kg IV over 60 seconds when used as an anesthetic agent. While treatment resistant 
depression and suicide are significant problems in the pediatric population, experience with 
ketamine and esketamine for psychiatric use in this population is limited. A small open-label 
trial8 and a few case reports9,10 have described the successful use of ketamine in pediatric 
patients with refractory psychiatric conditions (see also, Clinical Experience, 2.1.2), however 
it is not FDA-approved for this purpose. Studies of Spravato in pediatric patients with 
psychiatric disorders are ongoing. Preclinical data suggests that ketamine may reverse 
depressive phenotypes in adolescent rats11. While the anesthesia literature suggests that single 
doses of ketamine in the clinical range are clearly tolerated in adolescent populations, animal 
studies of repeat or high-dose ketamine exposure in animals suggest that it has the potential
13
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
C
for neurotoxicity (irreversible neuronal apoptosis, Olney lesions, cognitive deficits)12-14, 
particularly at early developmental stages. The toxicity threshold of repeat ketamine exposure 
is not known in adult or pediatric populations, and thus repeat dosing must be approached 
with caution and appropriate monitoring.
2.2.2
Clinical Experience
2.2.2.1
Ketamine single dose adolescent study—tolerability, pharmacokinetics
We recently completed a randomized, midazolam-controlled single-dose crossover trial of 
ketamine in adolescents (13 to 17 years) with treatment-resistant depression (TRD) (N=17) 
(NCT02579928). Participants had a primary DSM-5 diagnosis of Major Depressive Disorder 
(MDD) and a Children’s
Depression Rating Scale-Revised 
(CDRS-R) >40. Adolescents also 
must have failed at least one prior 
8-week trial of a standard 
antidepressant medication (e.g.
SSRI, SNRI) to meet TRD criteria. 
Exclusions included a lifetime 
history of psychotic disorders or 
mania, autism spectrum disorder, 
intellectual disability, substance 
use disorder, or active suicidal or 
homicidal ideation on presentation 
requiring inpatient hospitalization. 
Participants were required to 
remain on stable dosing of their 
current psychiatric medication 
regimen for the four weeks prior to 
the first infusion, and during the 
four-week trial itself. All 
participants underwent a physical 
examination and laboratory 
screening, and electrocardiography 
(ECG), and female participants 
received urine pregnancy testing. 
Treatments were randomly 
assigned by the pharmacy, with 
participants receiving a single 
infusion of either ketamine (0.5 
mg/kg over 40 minutes) or
midazolam (0.045 mg/kg) on Day 1, 
and the alternate compound 2 weeks 
later. Midazolam was chosen as an 
active placebo in keeping with its 
similar PK profile and precedent15.
Only the pharmacy was 
aware of drug identity, and 
all study personnel, 
including investigators,Fig 
2: Infusion side effects and PK
(A) CADSS scores are higher
at 1 hour compared to midazolam. (B) Ketamine transiently 
increases systolic blood pressure (SBP) and heart rate relative to 
baseline readings. Arrow indicates the end of the infusion. (C) 
Serum levels of ketamine and it’s three principle metabolites are 
shown at four post-infusion timepoints+p < 0.05 ++p < 0.01,
+++p < 0.001 timepoint versus baseline; ***p<0.001 ketamine 
versus midazolam
14
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
raters, anesthesiologists, subjects, and data analysts, were blinded to randomization order. To 
further maintain blinding, efficacy raters were not present during infusions. On infusion days, 
two intravenous catheters were placed in each arm, one for medication infusion and the other 
for PK blood draws. An ECG was performed, and pulse, blood pressure, and pulse oximetry 
were checked every 5 minutes during the infusion, and every 15 thereafter. Acute dissociative 
side effects were assessed by the Clinician-Administered Dissociative States Scale 
(CADSS)16. A different trained rater, absent during the infusion and blinded to the intra- 
infusion ratings, administered pre-infusion baseline and post-infusion ratings, up to 14 days. 
The primary outcome was depression severity (Montgomery-Asberg Depression Rating Scale 
(MADRS)17) 24 hours post-infusion.
Of the 26 evaluated adolescents, 19 consented to the trial (7 did not meet criteria), and 17 
received the first infusion (one subject withdrew due to an undisclosed medical condition and 
the other had a panic attack prior to starting the infusion pump and decided to withdraw). Of 
the remaining 17, 16 completed both infusions (one subject improved after the first infusion 
(later determined to have been ketamine) and dropped out of the trial in order to receive 
community ketamine). The study sample had significant depressive symptoms (average 
screening CDRS of 63.2
(±17.1) and MADRS of 33.1 (±9.3)) and a relatively chronic disorder (average duration of 
current episode of 21 months (± 18.8), with a median of 12 months). The average participant 
age was 15.5 years, and all ages between 13 to 17 years old were represented. All participants 
had failed at least one antidepressant trial, but the sample on average had failed 3.24 (± 1.9) 
prior antidepressant treatments and 6.1 (± 5.5) total psychiatric medications.
Ketamine and midazolam treatments were well-tolerated and there were no serious adverse
events. Dissociative symptoms 
were observed with ketamine 
treatment, although they were 
time-limited (Fig 2A) and well 
tolerated. No significant 
dissociative symptoms were 
experienced in the days 
following the treatment. Aside 
from the participant who 
withdrew just prior to receiving 
infusion 1, no participants 
experienced significant 
dysphoria or panic, and no 
participants required emergent 
diazepam use. Hemodynamic 
data showed significant effects 
of ketamine and midazolam 
(Fig 2B), but there were no
Fig 3: Ketamine’s antidepressant effects in adolescents with TRD.
(A) Ketamine reduced depressive symptoms relative to midazolam, as 
measured via MADRS scores, 24 hours following infusion, paired t- 
test (n=16). (B) 76% of the sample had a significant clinical response 
to ketamine (i.e. a greater than 50% reduction in MADRS within the 
first three days following treatment). 35% of the sample had a 
significant antidepressant response to midazolam. These groups share 
5 participants who had a response to both. (C) Timecourse depicting 
actual average MADRS scores after ketamine or midazolam: in 
pairwise comparisons, ketamine significantly reduces depressive 
symptoms relative to midazolam over fourteen days, with significant 
separation at Days 1, 5, 6, 10, and 14 (independent t-tests at each
data point), *p<0.05 ketamine vs midazolam
15
serious hemodynamic events. 
Ketamine raised systolic blood 
pressure (SBP) up to 55 
minutes after infusion start (i.e. 
15 minutes following the 
termination of the infusion), 
and minimally raised diastolic 
blood pressure (DBP). Four 
subjects (of 17) met criteria for
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
16
adolescent Stage 2 hypertension (140/90)18 during the ketamine infusion, but none persisted 
past the end of the infusion and none exceeded 150/95. Ketamine also raised heart rate (HR) 
with an increase from baseline up to 100 minutes post-infusion start, although no participant 
had a HR exceeding 120 beats per minute.
PK data were obtained and processed through our collaboration with Dr. Zarate (NIMH), 
including serum ketamine (K), norketamine (NK), hydroxynorketamine (HNK), and 
dehydronorketamine (DHNK) at baseline, 40m, 80m, 100m, and 230m post-infusion start 
(Fig 2C). While there is no adult comparison group built into this study design, the ranges of 
ketamine and NK are similar to those reported in adult PK studies using the same dose, 
timepoint, and analysis lab19. When compared with this published adult data, adolescents 
show 1.5 times greater HNK concentrations and five-fold lower concentrations of DNHK at 
all timepoints. These findings are intriguing given the purported NMDA-independent 
therapeutic actions of HNK2, but require verification in a sample directly comparing 
adolescents and adults.
2.2.2.2
Ketamine single dose adolescent study—efficacy
The primary outcome for this study (NCT02579928) was the MADRS at Day 1, 
comparing ketamine to midazolam. Ketamine significantly reduced MADRS scores 
compared to midazolam at Day 1 following infusion (midazolam: 24.13 ±12.08, 95% CI:
18.21 to 30.04, versus ketamine: 15.44 ±10.07, 95% CI: 10.51 to 20.37, mean difference of - 
8.69 ±15.08, 95% CI: -16.72 to -0.65, df=15, p= 0.036) (Fig 3A). There were no significant 
carryover effects observed in the trial. In the sixteen participants who completed both phases 
of the study, the average MADRS score at pre-infusion baseline was 31.88 (±9.82, 95% CI:
27.06 to 36.69) for midazolam and 30.56 (±10.63, 95% CI: 25.36 to 35.77) for ketamine. The 
mean difference between treatment arms at baseline was -1.31 (±8.73, 95% CI -7.89 to 5.27, 
df=15, p=0.68). Individual participants were assessed for significant clinical responses to 
ketamine or midazolam, which were defined as a greater than 50% reduction in MADRS 
score within three days of treatment (Fig 3B). Participants were significantly more likely to 
respond to ketamine than midazolam (McNemar χ2=4.0, df=1, p=0.046). 77% of the sample 
had a response to ketamine, which comprised 8 participants responding only to ketamine, and 
5 participants demonstrating a response to both ketamine and midazolam. 35% of the sample 
responded to midazolam, comprised of the 5 participants who responded to both infusions, 
and a single participant who responded only to midazolam and not to ketamine. Three 
participants did not respond to either infusion. Fig 3C displays the time-course data, showing 
that a significant separation of ketamine from midazolam persists until 14 days (the latest 
timepoint).
2.2.2.3
Neuroimaging of depressed adolescents treated with ketamine
A small subset of participants from the above trial participated in resting state functional 
MRI imaging, imaged at 3 timepoints in an early pilot
(N=3; baseline, 24-hours after infusion 1 and 24- 
hours after infusion 2). Imaging consisted of a 
structural scan (3D, T1, T2) and a resting-state run in 
order to examine resting state functional connectivity 
(FC) in these subjects. FC both between and within 
pre-identified canonical networks were compared 
(default mode, salience, sensorimotor, subcortical, 
frontoparietal, and medial frontal). Of the three
subjects, two had a significant clinicalresponse to
Fig 4. Functional connectivity changes
post-ketamine in adolescents.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
17
ketamine, while the third did not. Ketamine responders showed increased within-subcortical 
network functional connectivity whereas the ketamine non-responder did not. (Fig 4). This 
data demonstrates that imaging adolescents in a ketamine clinical trial at rapid timepoints is 
feasible.
2.2.2.4
Adolescent repeat ketamine dosing experience
The antidepressant and anti-suicidal effects of a single dose of ketamine are ephemeral4, 
and repeat dosing strategies have been employed to extend the duration of wellness in 
adults20,21. Based on our case report showing rapid, potent antidepressant and anti-suicidal 
effects of ketamine in a severely ill teenage boy with a repeat dosing paradigm10, we obtained 
pilot funding for a repeat dosing study (NCT03889756). This pilot study recruited a more 
severe depression phenotype, requiring 2 prior failed antidepressant trials, and did not have a 
restriction on suicidal ideation as the initial crossover trial did. The design was a 2-phase 
design: a 3-week parallel, midazolam-controlled double blind phase followed by a 6 month 
open phase in which participants assigned to midazolam who remained depressed could 
receive open ketamine and all participants received standard of care depression treatment.
This design also incorporated a limited number of symptom triggered-maintenance ketamine 
infusions during the open phase in those who responded to ketamine. We have run 3 
participants through this protocol, all 3 of whom completed the blinded phase, and two of 
three completed the open phase. Two did not respond to ketamine, but improved in the open 
phase, and one responded to ketamine (antidepressant and anti-suicidal responses (suicidal 
ideation measured via MADRS item 10 and SSI-5)) and relapsed in the fourth month.
2.2.3
Background/prevalence of research topic
Youth suicide: Suicide is now the second leading cause of death in young people in the 
United States (10 to 34 years)22 and is globally the leading cause of death in female 
adolescents (15 to 19 years)23. Suicide is a complex behavior that represents a convergence of 
genetic24, biological, psychological, social, and cultural factors25, and methods to reduce teen 
suicide are a top mental health priority26. A significant challenge to the task is that many, if 
not most, of the risk factors associated with youth suicide are either fixed (genetic or 
biological factors, perfectionism, low socioeconomic status, LGBTQ status, parental 
separation, divorce, or death, and parental psychiatric disorder)25 or historical (personal or 
family history of a suicide attempt27, early adverse experiences including physical or sexual 
abuse28). Thus, the identification of modifiable risk factors is essential. Major depressive 
disorder increases the risk of adolescent suicide by 30-fold29 and is associated with 
hopelessness, another potent suicide risk factor30. Suicide risk is further increased with 
treatment-resistance31 and in the months following discharge from an inpatient psychiatric 
unit32. This work is significant as it tests a novel, rapid-acting anti-suicidal intervention in 
high-risk adolescents.
Pediatric patients deserve evidence-based care: Pharmacologic anti-suicidal interventions 
for pediatric patients do not currently exist, and evidence-based medications for pediatric 
TRD are similarly scarce33. The sole strong recommendation for Child Psychiatrists for 
adolescents with TRD comes from the Treatment of Resistant Depression in Adolescents trial 
(TORDIA (N=334)34), which completed over a decade ago. There have been no major
NIMH-sponsored trials for pediatric TRD since, and once practitioners have followed the 
TORDIA recommendation to switch to a different selective serotonin reuptake inhibitor 
(SSRI) and add cognitive behavioral therapy (CBT), they are stranded in non-evidence based 
territory33. Lack of evidence has not prevented children from becoming depressed, nor has it
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
18
stopped Child Psychiatrists from attempting to help them. The result is that our highest risk 
children are increasing exposed to interventions with uncertain efficacy and higher harm 
potential (e.g. the escalated use of atypical antipsychotics35). The adolescent brain is a unique 
pharmacologic substrate, with active maturation of monoaminergic36 and glutamatergic37 
systems thought to underlie mood disorders and suicide38,39, highlighting the need for 
pediatric-specific evidence. This work is significant as it will provide the first evidence for a 
pharmacologic treatment beyond TORDIA recommendations in youth with TRD and high 
suicide risk.
Pediatric ketamine: community use without data or safety monitoring: Clinical 
communities are now well aware that ketamine, a glutamatergic modulator, rapidly reduces 
depression and suicidal thinking in adults with TRD40. Consistent with the sad reality of the 
pediatric evidence base33, promising interventions in adults will be used off-label in Child 
Psychiatry practice if they are available35, and ketamine is no exception41,42. While there is 
case report data10 and a small open-label trial8 suggesting potential utility in pediatric 
depression and suicidality, placebo-controlled assessments are critical to separate genuine 
pharmacologic from non-specific effects, to allow for an informed risk/benefit analysis.
While we have recently demonstrated that a single dose of ketamine is superior to an active 
placebo, midazolam, in adolescents with TRD (see Clinical Experience, 2.2.2), repeat 
dosing presents additional safety concerns in pediatric patients. While repeat dosing appears 
to extend the duration of wellness in adults20, animal studies raise specific neurotoxicity 
concerns regarding high-dose exposures in developing populations13,14, in addition to age- 
neutral concerns regarding cardiovascular, hepatobiliary, urothelial, neurocognitive, and 
abuse potential risks raised by human studies of heavy recreational ketamine users43-45. The 
use of off-label ketamine in pediatric communities occurs without oversight, regulation, or 
the evidence based needed to determine dosing and safety monitoring strategies. This work is 
significant in providing safety, efficacy, and symptom trajectory data for a conservative 
repeat dosing ketamine paradigm in adolescents.
Clinical need for predictive models of treatment response: Psychiatry suffers from a lack 
of predictive power in choosing treatments for patients. Indicators that predict the presence, 
quality, and durability of antidepressant46 and anti-suicidal responses47 and that generalize to 
novel cohorts of patients remain elusive. For example, a promising finding of ketamine 
enhancing whole brain connectivity48, recently failed to replicate in a novel dataset31.
Replication and validation are inherent to the term “predicts”, which is too often used loosely 
as a synonym for “correlates with”. True prediction means that a finding in one data set will 
also hold for novel subject, and evaluation of markers using either cross-validation or 
external data is needed for clinical utility 49,50. Establishing predictive models is necessary to 
translate biological findings into clinical tools.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
19
Connectome-Based Predictive Modeling (CPM) as a promising data-driven approach: 
Functional connectivity analyses generated from fMRI data have produced useful data about 
brain wiring in health and disease across the lifespan, and the NIH’s investment in the initial 
Human Connectome Project51 indicates the importance of this modality. Despite the 
excitement, we lack clinically oriented tools that can take advantage of this connectivity
Fig. 5: Connectome-based Predictive Modeling (CPM) Schematic: In CPM, atlases and connectivity data are 
used to generate subject-specific connectivity matrices, then edge strength (the elements of the connectivity 
matrix) can be regressed with a subject score (suicidal ideation in this case, labeled SI) and a predictive model 
relating connectivity to SI can be built. These models then identify the relevant functional phenotypes 
(essentially the edges and their strength) associated with SI. The models are validated (internally) through 
cross-validation and tested for significance. Derived networks (the functional phenotypes) are complex and 
span the whole brain.
information. We have developed connectome-based predictive modeling (CPM) as a data- 
driven approach to relate brain functional organization to behavior 52-57. There are several 
critical components to this computational technique that enhance individual differences and 
improve generalizability in heterogenous populations, which are necessary for a tool with any 
clinical utility. First, as a step towards individualized medicine, we utilize individualized 
functional brain atlases that are specific to both the patient and their brain state (from one task 
to another and at rest), which improve model prediction58. Second, our methods rely on 
perturbing cognitive circuits across multiple Research Domain Criteria (RDoC) domains 
using tasks. Just as a heart can appear normal at rest, stressing the heart may reveal important 
pathology. We have showing that “stressing” brain circuits significantly improves the ability 
to detect individual differences, particularly compared to rest59. Finally, modeling methods 
that are designed to generalize across multiple behaviors and diagnostic groups are needed60. 
For example, while task conditions are likely better at generating models of behaviors related 
to the circuits they perturb, it is unlikely that a single task can be developed that is optimal for 
complex dimensions of interest, like suicidal ideation. Instead, methods that use data from 
several tasks, tweaking the brain circuits along multiple dimensions, are thought to span the 
functional space sufficiently, such that the optimal rotation can be found to maximally 
separate subjects along the ideation axis, leading to better predictive models that generalize 
across heterogeneous groups of patients, as we have shown in autism61, ADHD53, and cocaine 
use disorder62. This work is significant as it integrates a predictive brain-based approach63 
into a clinical trial design in order to identify the functional phenotypes, or fingerprints64, 
predictive of post-treatment suicidal ideation in high-risk adolescents, and how those are 
modified with a rapid-acting treatment. The data generated here will be internally validated
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
20
with cross-validation, and will provide a strong foundation for external validation in larger 
subsequent trials and independent data sets.
2.3
Risk/Benefit Assessment
2.3.1
Known Potential Risks
(1) Ketamine: Ketamine has a wide margin of safety and is usually given in doses of 1mg/kg
– 4.5mg/kg IV over 60 seconds when used a sole anesthetic agent. It has been used routinely 
in pediatrics for over 40 years, typically at higher doses than proposed in the current study. 
Ketamine has been used to treat treatment-refractory depression in adults at Yale for over 20 
years, with robust evidence for medical and psychiatric safety. There are several potential 
risks associated with ketamine use. These include 1) Cardiovascular: elevated blood 
pressure and pulse rate (relatively common and are dose-dependent) and very rare changes in 
cardiac rhythm. 2) Respiration: respiratory rate is frequently elevated; however, with high 
dose administration severe respiratory depression and apnea have been reported (<1.5% of 
transient apneic events at anesthetic doses in pediatric emergency room settings. Ketamine 
also has rarely been associated with laryngospasm. 3) Eyes: ketamine has been associated 
with slight elevations in intraocular pressure. 4) Gastrointestinal: Anorexia, nausea and 
vomiting have been observed, however this is usually not severe. Vomiting has been seen in
<4% of children in emergency room sedation settings. 5) Neurological: enhanced skeletal- 
muscular tone resulting in tonic clonic movements have rarely been observed with acute 
administration. 6) Hepatobiliary: While not listed as an acute risk in ketamine’s safety 
insert, case series data in people who recreational abuse ketamine have shown laboratory 
signs of hepatic inflammation. 7) Urinary: in people who recreationally abuse ketamine, 
bladder inflammation and cystitis have been reported, which appear to be both dose and 
frequency dependent. 8) General: Anaphylaxis, local pain at injection site and transient rash 
have been described at the case report level. 9) Psychological: ketamine has been associated 
with a variety of transient symptoms including, but not limited to anxiety, dysphoria, 
disorientation, insomnia, flashbacks, hallucinations, and psychotic episodes. Emergence 
reactions have occurred in approximately 12% of subjects given anesthetic doses of 
ketamine. These symptoms usually last no more than a few hours. However, recurrences have 
taken place up to 24 hours after the anesthetic dose administration. Recovery agitation after 
ketamine iv sedation in the pediatric emergency room has been seen in <1.5% of children. It 
is also believed that the incidence of the psychological disturbances is reduced with the use of 
lower doses. No residual adverse psychological effects are known to have resulted from the 
medical use of ketamine. 10) Substance abuse/dependence: Ketamine has been reported as 
a drug of abuse. Reports suggest that Ketamine dependence and tolerance are possible 
following prolonged administration. A withdrawal syndrome with psychotic features has 
been described following discontinuation of long-term ketamine use. Therefore, ketamine 
should be prescribed and administered with caution. It is unclear whether exposure to 
ketamine in the laboratory can result in ketamine use or abuse. All participants are 
encouraged not to participate if they have concerns about the possibility of ketamine abuse.
Also, they are asked to contact us immediately if they become aware of a desire to use or 
abuse ketamine. All participants are advised that we would refer them to an appropriate 
treatment facility if necessary. In our experience doing research with ketamine, we are 
unaware of individuals abusing ketamine as a result of study participation. Unknown risks of 
repeated dosing: Not all of the risks of repeat ketamine dosing may be known, despite this 
paradigm being conservative.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
21
(2) Midazolam: Midazolam is used frequently in the pediatric emergency room and in 
sedation settings, either as a sole agent for anxiolysis, or in combination with other sedatives 
and anesthetics for more complex or prolonged procedures. It is typically given at doses of 
0.5-0.5mg/kg over 2 minutes, depending on the intended level of sedation (mild versus deep 
sedation). It has been used routinely in Pediatrics since the 1990’s, typically at higher doses 
than those described in this study. There are several potential risks associated with 
midazolam use: 1) Cardiovascular: decrease in blood pressure (hypotension in <3% of 
pediatrics patients at sedation dosing ref) and very rarely, changes in cardiac rhythm. 2) 
Respiration: apnea, cough, hiccups, decreased tidal volume and respiratory rate (transient 
apnea has been reported in <3% of pediatric patients at sedation dosing); with high dose 
administration severe respiratory depression, airway obstructions, apnea, and respiratory 
arrest have been reported. 3) Eyes: may cause nystagmus 4) Gastrointestinal: can be 
associated with nausea and vomiting (<3% of adult patients). 5) Neurological: may cause 
drowsiness, headache, over-sedation; like all benzodiazepines, midazolam has amnestic 
properties, more notable as dose increases 6) General: Anaphylaxis, local pain at injection 
site and transient rash have been reported. 7) Psychological: midazolam can be associated 
with paradoxical agitation (particularly in the elderly or in very young children), however is 
estimated at <1% of patients; there are also rare reports of emergence delirium, euphoria, and 
hallucinations, although these are associated with higher dosing that proposed here, 
Additionally, fast-acting reversal medications are available (flumazenil) that can terminate 
midazolam’s effects should the patient experience side effects during the infusion. 8) 
Substance abuse/dependence: As with all benzodiazepines, physical and psychological 
dependence is associated with prolonged use. The four-dose infusion paradigm proposed in 
the study is not expected to produce any physiological dependence. As all benzodiazepines 
have some abuse potential, midazolam should be prescribed and administered with caution. 
Midazolam is used frequently in pediatric medical settings, at higher doses administered over 
shorter periods of time, and this use has not been linked with subsequent addition problems. 
That said, all participants are encouraged not to participate if they have concerns about the 
possibility of midazolam abuse. Also, they are asked to contact us immediately if they 
become aware of a desire to use or abuse midazolam. All participants are advised that we 
would refer them to an appropriate treatment facility if necessary.
(3) MRI: Magnetic resonance (MR) is a technique that uses magnetism and radio waves, not 
x-rays, to take pictures and measure chemicals of different parts of the body. The United 
States FDA has set guidelines for magnet strength and exposure to radio waves, and we 
carefully observe those guidelines. Participants will be watched closely throughout the MR 
study. Some people may feel uncomfortable or anxious.  If this happens to a participant, he 
or she may ask to stop the study at any time and will be taken out of the MR scanner. On rare 
occasions, some people might feel dizzy, get an upset stomach, have a metallic taste or feel 
tingling sensations or muscle twitches. These sensations usually go away quickly we ask 
participants to tell the research staff if they occur.
There are some risks with an MR study for certain people. If subjects have a pacemaker 
or other metal objects inside the body, they may not be in this portion of the study because 
the strong magnets in the MR scanner might cause harm. Another risk is the possibility of 
metal objects being pulled into the magnet and hitting the subject. To lower this risk, all 
people involved with the study must remove all metal from their clothing and all metal 
objects from their pockets. We also ask all people involved with the study to walk through a 
detector designed to detect metal objects. No metal can be brought into the magnet room at 
any time. Also, once the participant is in the magnet, the door to the room will be closed so
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
22
that no one from outside accidentally goes near the magnet. We ask subjects to read and 
carefully answer the questions on the MR Safety Questionnaire related to personal safety.
This MR study is for research purposes only and is not in any way a complete health care 
imaging examination. The scans performed in this study are not designed to find 
abnormalities. The principal investigator, the lab, the MR technologist, and the Magnetic 
Resonance Research Center are not qualified to interpret the MR scans and are not 
responsible for providing a health care evaluation of the images. If a worrisome finding is 
seen on a participant scan, a radiologist or another physician will be asked to review the 
relevant images. Based on his or her recommendation (if any), the principal investigator or 
consulting physician will contact the participant and their parent to inform them of the 
finding and recommend seeking medical advice as a precautionary measure. The decision for 
additional examination or treatment would lie only with the participant/parent and their 
physician. The investigators, the consulting physician, the Magnetic Resonance Research 
Center, and Yale University are not responsible for any examination or treatment received 
based on these findings. The images collected in this study are not a health care MR exam 
and for that reason, they will not be routinely made available for health care purposes.
(4) Blood drawing/intravenous placement: Bruising or thrombosis can occur with 
placement of the intravenous line. A total of 70cc will be drawn over 2 weeks (30cc at 
baseline, 40cc on first infusion day (Day 1)), which equates to 1.2cc/kg – 2.0cc/kg (based on 
average weights of 13-17yo adolescents). For those who cross over to open ketamine at the 
end of week two, an additional 40cc will be drawn on the first open infusion day (i.e. a total 
of 110cc over the first 3 study weeks, equating to 1.7cc/kg - 2.4cc/kg based on average male 
and female adolescent weights). This amount drawn is considerably less than the 9.5cc/kg 
over 8-week requirement set by the review board. The risks of blood draws include brief pain 
at the time of needle insertion, bruising, swelling at needle site and rarely, fainting or 
infection.
(5) Psychiatric evaluation, rating scales and questionnaires: These are all non-invasive, 
should add no risk, and have been used without difficulty or adverse events in previous 
studies with a similar population. The major disadvantage is the time taken to completethem.
(6) Clinical Deterioration: There is a risk that a participant may experience an increase of 
suicidality or depressive symptoms due to the natural course of the illness, poor response to 
ketamine administration, or receipt of active placebo (midazolam) during the blinded phase 
(these patients will be offered ketamine treatment after Day 11). Because subjects will be 
asked to refrain from changing any psychotropic medication over the course of the blinded 
phase of the study, clinical progress will be monitored closely with frequent assessments, 
ratings scale, and contact with clinic personnel. The following are criteria for evaluation and 
possible pharmacological and/or non-pharmacological treatments: (1) an increase of 25% in 
C-SSRS or MADRS score at any time over the course of treatment, and (2) new-onset of 
suicidal ideation or an increase in suicidal ideation. In the event that a subject is judged to 
remain significantly depressed and/or at increased risk for suicidality at the end of the study, 
we will help make appropriate referrals to outpatient providers, intensive outpatient programs 
or inpatient psychiatric hospitals as clinically indicated. Investigators may continue close 
monitoring of significantly “at-risk” subjects until such referrals are provided and available to 
the study participant. Additionally, the standard of care treatment for a child or adolescent 
who insufficiently responds to initial antidepressant therapy is to try another antidepressant or 
add an additional medication. By participating in this trial, the child or adolescent would be 
delaying the standard of care change in their medication by 2-4 weeks.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
23
(7) Confidentiality: All information that is collected in connection with this study will 
remain confidential and will only be disclosed as required by U.S. or state law. This studyis
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
24
covered under an NIH Certificate of Confidentiality, which is important given our periodic 
urine drug testing. Every foreseeable precaution to protect confidentiality will be taken.
Nevertheless, despite such precautions, there is a potential risk for a loss of confidentiality 
due to reasons beyond our control (e.g., computer hacking).
(8) Remote Assessments: Like online shopping, videoconferencing technology has some 
privacy and security risks. It is possible that information could be intercepted by 
unauthorized people (hacked) or otherwise shared by accident. This risk can’t be completely 
eliminated, however Yale has approved the use of an encrypted version of zoom for 
videoconferencing sessions because the appointments take place over a secure encrypted 
network. When meeting with the team remotely for study-related activities, participants 
should be in a private space.
(9)
RISK MITIGATION PLANS:
1. Permission and Assent. At the point of enrollment into the study, a researcher will describe 
the protocol and specific procedures, as well as risks and benefits associated with the study 
participation, to the participant and his or her parent(s). The researcher will answer any 
questions the participant and their family might have regarding the protocol. Families are also 
encouraged to discuss the study with their outpatient psychiatrist. Once the family has had 
time to fully digest the procedures, risks, and benefits, the researcher will ask the participant 
to sign and IRB-approved assent form and their parents or guardians to sign an IRB-approved 
permission form agreeing to participate in the study. If there are two parents or guardians, 
both most provide permission and each must sign a separate permission form. Following the 
permission, at the beginning of the visit, the subject will be briefed on the specific procedures 
to be administered and will have an opportunity to ask additional questions. The researchers 
will remind subjects and their families that participation is voluntary and that the protocol can 
be stopped at any time with no obligation to continue and no penalties whatsoever. Refusal to 
participate will not affect the subject’s relationship with any clinics at Yale or the hospital or 
their ability to seek medical care. Participants and families are given a copy of the signed 
permission forms. Original paper forms will be stored in a separate locked file cabinet in a 
locked office. These forms are not stored with any data or other PHI, and they do not have 
subject ID numbers on them. In the case of electronic consenting, originals will be stored in 
Part 11-complaint RedCap.
2. Protection Against Risks Enumerated Above
(1) Ketamine Administration: The dose of ketamine established in prior research (0.5 
mg/kg over 40 minutes) will be used in this study to minimize risks. The maximum total 
single dose allowed in this study will be 40mg, corresponding to a weight of 80kg, as 
suggested by the FDA. In order to minimize the acute ketamine risks described above, vital 
signs will be monitored regularly throughout and for the first hour following the ketamine 
infusion. An ACLS-trained physician will be present for all infusions, with access to rescue 
equipment. Subjects will be monitored for at least 2 hours following ketamine infusion by Dr. 
Bloch or another study physician. A study doctor (Principal Investigator (PI) of the trial) will 
be present at all times during the infusion and recovery. In the event that a research subject 
has a significant psychiatric event requiring hospitalization, they will be treated on the 
adolescent unit (LV2) at Yale Psychiatric Hospital (YPH). Emergent medical care would be 
provided at Yale-New Haven Hospital. All participants will be asked not to engage in 
demanding work for the first 3 days after the ketamine infusion. If participants develop
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
25
psychiatric symptoms, we may admit them to the hospital. Hospitalization may be 
involuntary if patients are in imminent danger of harming themselves or others.
The permission forms will provide a description of what participants may experience 
during the intravenous ketamine infusion at a dose of 0.5 mg/kg over the course of 40 
minutes, so that they will be well prepared for possible responses to ketamine. Participants 
will be told that some people have reported mildly decreased concentration or a “hangover” 
on the day after ketamine infusion. A research nurse will be present throughout the study to 
monitor the patient’s response and note any changes in physical or mental state. A research
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
26
clinician will be present throughout the study to offer support and to help clarify the progress 
of the test day in case the medication causes feelings of confusion. the study PI and the study 
psychologist will also be available. The physician would be informed in case of any 
significant changes in the patient’s physical or mental state. The trained research nurse will 
also offer support and provide consistent “reality testing” for individuals experiencing 
confusion or transient psychosis. Oral diazepam (5mg) will be kept available to control 
markedly distressing behavioral effects of ketamine, should they emerge. Oral ondansetron 
(4-8mg) will be kept available to control any significant nausea or vomiting.
All participants will be asked to contact the study team at any time if any unpleasant 
effects occur. All participants will be given a card, which provides contact information for the 
study PI and study staff. All participants have close scheduled contact with study physicians 
and raters (twice weekly during acute blinded phase; weekly in open phase). Participants will 
be instructed and encouraged to contact the treatment team between scheduled meetings 
should their distress worsen. In order to enroll in the study, patients must not have a lifetime 
history of substance abuse or dependence, thereby reducing the risk of ketamine substance 
abuse/dependence by study participants.
(2) Midazolam Administration: The weight-based midazolam dosing established in prior 
ketamine trials in adults (0.045mg/kg) will be used to minimize risks, as this is considered a 
very low dose compared to the sedation literature. The maximum total dose allowed in this 
study will be 3.6mg per infusion, corresponding to a weight of 80kg. Midazolam has one of 
the shortest half-lives of all of the benzodiazepines, and thus adverse events relating to the 
drug typically are not observed more than 30 minutes following drug administration. In order 
to minimize the risks of midazolam described above, subjects will be medically screened 
prior to enrollment in the study, and participants will have identical hemodynamic monitoring 
as described above for ketamine infusions.
(3) MRI risks: All subjects will be screened for any contraindications to MRI scanning 
using the Yale University MRI Safety Questionnaire. Additionally, all participants will walk 
through a ferromagnetic detector prior to entering the MRI. MRI procedures will only be 
performed by trained personnel of the Magnetic Resonance Resource Center. Any subject 
who is distressed in the MR scanner and asks to terminate an MR imaging session will be 
removed immediately. During the permission process, we will ensure the subject understands 
that they may withdraw from the study at any time. If anything unusual in the MR scans is 
noticed by the research staff, the images will be shown to a neuroradiologist, Dr. Robert 
Fulbright, who will decide if the subject should be informed and a follow-up clinical exam 
recommended. A clinical follow-up will not be provided by the research program and must 
be pursued independently via the subject’s health care provider.
(4) Blood drawing/intravenous placement: The risks of blood draws and intravenous line 
placements are rare, and when these are done under sterile conditions by trained personnel 
the occurrence is even more remote. Numbing spray and distraction techniques will be 
offered prior to offset the discomfort of iv placement, as is commonly done in Pediatric 
medical settings. On the first infusion day, when pharmacokinetic labs are drawn, blood 
draws will occur off of the non-infusing iv in order to prevent the discomfort of repeated 
needle sticks. A total of 70cc will be drawn over 3 weeks (30cc at baseline, 40cc on first 
infusion day (Day 1)). For those who cross over to open ketamine at the end of week two, an 
additional 40cc will be drawn on the first open infusion day (i.e. a total of 110cc over the first 
3 study weeks). This amount ranges from 1.6cc/kg for a 45kg adolescent to 1.1cc/kg for a
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
27
65kg adolescent (weight range of 45kg – 65kg for 13-17yo girls and boys). This amount is 
well below the maximum of 9.5cc/kg over 8 weeks.
(5) Psychiatric evaluation, rating scales, and questionnaires: In order to minimize risks 
associated with the psychiatric ratings and ensure the accuracy of reporting, these measures 
will be administered by trained research staff and supervised by a study physician. 
Participants will be informed that they do not need to answer any question on the rating 
scales or questionnaires that make them feel uncomfortable. Participants will also be 
informed they can take a break if they become tired from any of the questions or ratings.
(6) Clinical deterioration: Given the high-risk population in this study, safety planning and 
frequent risk assessment are critical. A safety planning module is included in the baseline 
visit, which will be conducted in collaboration with our study CBT therapist. The safety 
planning module is described in more detail in Section 6.1, Study Intervention 
Administration, Baseline Visit. In brief, the safety plan module focuses on the development 
of an individualized safety plan that includes support from multiple individuals and includes 
internal and external coping strategies to be implemented should the participant experience 
suicidal urges. A copy of the plan is provided to the participant, parents, and uploaded into 
their EPIC medical record.
At each visit, risk assessment is an important component of interactions between participants 
and staff. During the double-blind phase, a credentialed clinician meets with the participant 
before discharge from each study visit to make a clinical determination of risk of imminent 
harm to self or others. Determination of risk involves inquiring about the presence and 
intensity of suicidal thinking, differentiating between passive and active thoughts, evaluating 
the presence of risk and protective factors, and inquiring about plans, access, and intent. In 
the follow-up phase of the trial, a risk assessment and review of safety plan is conducted at 
each clinical visit, as is our standard clinical practice. The assessment occurs during the CBT 
session during the first 8 weeks, and during the medication management check-in during the 
last 8 weeks once CBT has ended.
In the event that a participant is deemed to be an imminent safety risk to themselves or others 
while at a study visit, they will be transported to the Emergency Room for evaluation. For 
times in between visits, participants and parents will be given a phone number for 24-access 
to a clinical staff member. For any calls to this number, risk assessments are conducted over 
the phone, with appropriate referral to emergency services if warranted. Any no shows to 
study appointments will be vigorously pursued.
If a participant shows significant worsening of symptoms, he or she will be offered removal 
from the study and evaluated for clinically appropriate pharmacological and non- 
pharmacological treatments by a clinic psychiatrist in collaboration with their community 
psychiatric provider. If a patient is doing poorly during the blinded phase, a thorough 
discussion will take place between the subject, his or her guardian, study physicians and 
outpatient treaters as to whether subject is able to continue until Day 11, at which time they 
would be offered open ketamine treatment on Day 15 (assuming that they were receiving 
midazolam during the blinded phase). Patients will be informed that the decision to initiate a 
course of psychotropic medication will not affect their eligibility to participate in future 
studies, to receive treatment at the Yale Child Study Center or Yale New Haven Hospital, or 
to receive treatment on a private basis from a referring clinician. In the event that a subject is 
judged to remain significantly depressed and/or at increased risk for suicidality at the end of
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
28
the study, we will help make appropriate referrals to intensive outpatient programs or 
inpatient psychiatric hospitals as clinically indicated, in collaboration with their community 
psychiatric provider(s). Investigators may continue close monitoring of significantly “at risk” 
subjects until such referrals are provided and available to the study participant.
Another risk for mental illness and clinical deterioration is the experience of abuse (for 
example parental abuse of a child or intimate partner violence). As mandated reporters, any 
suspicion of abuse of a minor must be reported to the Department of Children and Families 
(DCF) in Connecticut. In the event that abuse is suspected, any participant would be provided 
a list of additional resources and possible referrals. While every participant must have an 
outpatient mental health provider in place in order to participate, we will provide additional 
information for trauma focused programs (e.g. the Yale Childhood Violent Trauma Center). 
We will also provide a list of additional support resources (e.g. DCF and the state of 
Connecticut mental health services (211) provide a number of support groups for intimate 
partner violence, sexual assault and incest, and overall mental health).
(7) Confidentiality risks: Private identifiable information will be collected (name, date of 
birth, age, telephone number, address, medical and psychiatric history, diagnoses, laboratory 
tests, and psychiatric rating scores) but will be kept confidential and will not be divulged in 
any publication emanating from this work. Please see section 10.1.2, for the protections in 
place to mitigate confidentiality risks. The Sponsor-Investigator is responsible for monitoring 
the data and conducting performance safety reviews every six months. The Sponsor- 
Investigator, the Yale the Human Investigation Committee (HIC)/IRB, and the NIMH DSMB 
have the authority to stop or modify the study. The Sponsor-Investigator will evaluate any 
adverse events and determine whether they affect the Risk/Benefit ratio of the study and 
whether modifications to the protocol or permission/assent forms are required. A summary of 
all adverse events will be reported to the IRB, at a minimum, when annual re-approval of the 
protocol is sought, and to the DSMB. The summary will include the number of subjects 
enrolled and a summary of graded adverse events to date.
(8) Remote Assessments: Subjects will be encouraged to complete assessments in person 
whenever feasible and safe. When remote sessions take place, it is possible that information 
could be intercepted by unauthorized people (hacked) or otherwise shared by accident. This 
risk can’t be completely eliminated, however Yale has approved the use of an encrypted 
version of zoom for videoconferencing sessions because the appointments take place over a 
secure encrypted network.
When video sessions are conducted, they will be performed on an encrypted zoom 
platform. Video sessions can be conducted on the subjects’ cell phone, tablet or personal 
computer enabled with a camera/microphone and internet connection.
Subjects will be instructed to use their home computer or personal device, and not a shared 
or work device, and use a home (private) Wi-Fi network, and not free (public) Wi-Fi for your 
internet connection. All zoom appointment links will be sent by email to the subject with 
password protected links.
2.3.2
Known Potential Benefits
Ketamine arm: While there may be no direct benefit from a subject’s participation in this 
study, the success of ketamine as a rapid-acting antidepressant in adult patients, as well as our 
promising preliminary data in pediatric subjects, suggest that adolescent subjects may receive
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
29
a significant benefit. Given the current design, all subjects will be exposed to the potentially 
beneficial intervention.
Midazolam arm: While the active placebo medication is not expected to significantly relieve 
depressive symptoms, the high frequency of contact with a child psychiatrist and research 
staff may provide a benefit to subjects. Patients with have scheduled contact with Child 
Psychiatry twice weekly during the blinded phase, when they may be receiving the active 
placebo. They will also have 24/7 access to a Child Psychiatrist for any patient-initiated 
contact. Midazolam is a benzodiazepine that is also utilized to ameliorate anxiety symptoms 
in many patients. All patients who receive midazolam during the blinded phase, and remain 
significantly depressed or suicidal at Day 11, will be offered active ketamine treatment.
Brain imaging: No direct benefits to the subject are to be expected.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
30
Societal Benefits: The potential benefits to society of these investigations are considerable. 
Youth suicide and treatment-resistant depression continue to be a major public health 
problem with tragic cost to the individual, the family, and the community. The present study 
may improve our understanding of depression and suicidality by providing a pharmacologic 
rationale for developing novel treatments. The neuroimaging component of this study will 
provide knowledge on the complex networks that predict suicidal ideation after receiving 
ketamine, and how those networks change with treatment. The knowledge gained in this 
study could benefit patients and society at large because we may learn important information 
about brain organization and how it relates to behavior, and could facilitate future research on 
identifying which individuals might respond to this pharmacologic anti-suicidal intervention, 
one of the main goals of personalized medicine.
2.3.3 Assessment of Potential Risks and Benefits
We judge this study to fall into the following Pediatric risk category:
45 CFR 46.405: Research involving greater than minimal risk but presenting the prospect of 
direct benefit to the individual subjects
21 CFR 50.52: Clinical investigations involving greater than minimal risk but presenting the 
prospect of direct benefit to the individual subjects
Ketamine arm: Given the efficacy of ketamine as a rapidly-acting antidepressant and 
anxiolytic in adults and in our preliminary data in pediatric patients with treatment-resistant 
depression, ketamine also may alleviate symptoms of depression and anxiety in adolescents.
Midazolam arm: Midazolam has been previously used for short-term anxiolysis in both 
children and adults, so it may reduce anxiety symptoms temporarily (for minutes to hours). 
While the active placebo medication is not expected to alleviate symptoms of depression or 
anxiety over the longer term, the high level of contact with Pediatric Psychiatry (scheduled 
contact 7 out of the 14 days post-infusion), as well as 24/7 access to Child Psychiatry may 
directly benefit the subjects.
3 Objectives & Endpoints
3.1
Overall objectives
The objectives of this 7-year, single site, clinical trial are (1) to compare the efficacy, safety, 
and tolerability of a fixed dose of intravenous ketamine (0.5mg/kg over 40 minutes) 
compared to an active placebo, midazolam (0.045mg/kg over 40 minutes) in adolescents (13 
to 17 years old; N=20-33 per group) at high suicide risk, (2) to identify connectome 
signatures associated with suicidal ideation post-treatment using CPM, and (3) to define the 
trajectory of suicidal thinking and mood symptoms in both ketamine responders and non- 
responders when experimental treatment is followed by standard of care (medication 
management based on the Children’s Texas Depression algorithm65 plus 8 weeks of cognitive 
behavioral therapy (CBT)). We define adolescents at high suicide risk as those with SRI- 
resistant depression (defined as having remained depressed despite an SRI trial at ≥ 6 weeks 
at therapeutic dosing) AND having a suicidal event within the 120 days prior to enrollment 
(suicide events include suicide attempts, as well as high levels of suicidal ideation that 
require an emergency evaluation or a transition to a higher level of care (e.g. intensive 
outpatient program, partial hospital program, inpatient)66.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
31
3.2
Primary Objective
The primary objective of this study is to determine whether ketamine reduces suicidal 
ideation (as measured via the C-SSRS, recent ideation scale) relative to an active placebo, 
midazolam, 48-hours after first administration in adolescents with SRI- resistant 
depression at high suicide risk.
3.3
Secondary Objectives
The secondary objectives of this study are to closely monitor the safety (cardiovascular 
function, bladder health, laboratory values (complete blood count and complete metabolic 
panel), and cognitive function) and tolerability of a conservative repeat dosing ketamine 
paradigm and to identify functional connectome signatures predictive of efficacy or modified 
by treatment.
3.4
Exploratory Objectives
To describe the trajectory of important mental health outcomes (suicidality, depressive 
symptoms, mental health resource utilization) over 4 months in ketamine responders and non- 
responders.
3.5
Outcome Variables
3.5.1
Primary Outcome Variables
We have chosen the C-SSRS, recent ideation subscale, as our primary outcome measure, 
which will be measured at 48-hours after the first blinded infusion (and prior to the 
administration of the second blinded infusion). The C-SSRS is a well-validated instrument in 
adolescent populations67 and adapts well to pediatric clinical trials68. This outcome will 
assess the most severe level of ideation experienced since the last visit (i.e., since Study Day 
1, when the participant received the first blinded treatment).
3.5.2
Secondary Outcome Variables
Clinical secondary outcomes: We have chosen to use the MADRS17 as the depression 
outcome measure for the rapid timepoint (48 hours) and to measure both the MADRS and the 
CDRS-R69 at the short-term timepoint (Day 11). This choice is based on our experience using 
these scales in pediatric trials of rapid-acting agents (2.1.2) and adult ketamine studies that 
demonstrate that the MADRS shows increased sensitivity to the acute changes70 as compared 
to the Hamilton Depression Rating Scale (on which the CDRS-R is based 69).
Safety outcomes: Vital signs are recorded at each infusion visit and a physical exam, 
laboratory screening (liver function tests, renal function tests, thyroid function test, and 
urinalysis), and electrocardiogram (ECG) are conducted at baseline. In addition to baseline 
medical clearance, participants will receive an ECG, liver function tests, renal function tests 
(blood urea nitrogen and creatinine), and urinalysis half-way through the open phase and at 
the study conclusion. Any spontaneous reports of abdominal pain, increased urinary 
frequency, urge incontinence, or other urinary or gastrointestinal symptoms will prompt an 
early medical and laboratory evaluation. Adverse events will be systematically assessed at 
every visit during phases A1 and A2 using the Systematic Assessment for Treatment 
Emergent Events (SAFTEE-SI)71, which examines in a systematic fashion all possible 
treatment-emergent side effects and probes specific adverse symptoms. Any adverse 
reactions to the medication or protocol will be carefully explored and documented.
Documentation of any spontaneously reported side effects or adverse events is completed at 
every visit using the case report form. In phase B, adverse events will be assessed by the
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
32
SAFTEE-GI on weekly visits, and systematically by the SAFTEE-SI with monthly batteries. 
Participants will be provided an adverse event log to track the development of any signs or 
symptoms of substance abuse, and will undergo repeat urine toxicology screening (weekly 
during ketamine treatment; halfway through the open phase, and end of open phase). The 
Cogstate battery will be used to track neurocognitive function during this study, which 
assesses attention, working memory, psychomotor function, associative learning, and 
executive functioning.
Neuroimaging outcomes: All MRI-eligible participants will be imaged at 3 timepoints: (T1) 
Baseline, (T2a) Day 3, and (T2b) Day 17 (see Fig 5). A series of 4 tasks designed to enhance 
neurocognitive differences across individuals will directly tap into specific fundamental 
cognitive processes, based on the Behavioral Assessment Methods for RDoC Constructs 
report72. See section 6.2.5, Biomarkers, for a description of tasks and acquisition protocols. 
Subject performance on all tasks will be recorded via button presses during the scan and pre- 
treatment versus post-treatment behavior will be analyzed. Finally, one run of resting-state 
will be collected at the start of the experiment and a structural scan will be completed at the 
end (3D, T1- and T2-weighted).
3.5.3
Exploratory Outcome Variables
There is no post-market surveillance data of ketamine in any psychiatric population and the 
symptom trajectory after ketamine treatment, when followed by CBT and medication 
management, is not known. All participants will have weekly assessments of mood, 
suicidality, and adverse events (MADRS, C-SSRS, CGI, SAFTEE-SI) and monthly mood 
and cognitive batteries (Fig 1). We will also collect data regarding engagement with the 
mental health system (e.g. any visits to the emergency room for psychiatric purposes, any 
change in the level of care). At the end of the blinded phase, participants will be assessed for 
treatment response (response is defined as a 50% reduction in C-SSRS (suicidality) or 
MADRS (depression)). All participants meeting criteria for a response (ketamine or 
midazolam) will be tracked for time to relapse.
4 Study Design
4.1
Overall Design
The project is composed of two phases (Fig 1): The first phase (Phase A1) will consist of 
a double-blind, midazolam-controlled parallel design trial to evaluate the safety and 
efficacy of a conservative multiple IV infusion ketamine paradigm (four infusions over two 
weeks, each 0.5mg/kg over 40 minutes) compared to midazolam (four infusions over two 
weeks, each 0.045mg/kg over 40 minutes). Investigators will be blind to the treatment 
assignment during this phase, and raters absent from the infusion paradigm will perform 
blinded clinical efficacy ratings. The second phase will consist of an open arm extension 
phase, in which those who received midazolam will be offered active treatment if they remain 
suicidal or depressed (Phase A2), and all participants will be followed closely for four months 
while being treated with medication management and an 8-week course of CBT (Phase B). For 
study participants taking psychotropic medications (i.e., antidepressants, antipsychotics, mood 
stabilizers, anticonvulsants, or any other CNS drug used to treat symptoms of MDD), they will 
remain on those medications at fixed doses during the blinded phase (or through the 2nd week 
of the open phase if they go on to receive open ketamine). Medication management and CBT
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
33
will begin post-ketamine (or post-midazolam in those that have a significant response to the 
active placebo) treatment. Those who did not respond to ketamine will be followed at the same 
frequency and treated with medication management and 8 weeks of weekly CBT.
4.1.1
Study Date Range and Duration
The total expected study date range is 7 years to enroll 40-66 adolescent subjects. There are 
two possible study durations for individual participants: (1) 4 months and 2 weeks (i.e.18 
weeks = 126 days) for those who are (a) initially randomized to ketamine OR (b) are initially 
randomized to midazolam and have clinical improvement; or (2) 4 months and 4 weeks (i.e. 
20 weeks = 140 days) for those who are initially randomized to midazolam, do not have a 
significant clinical response, and opt to receive open ketamine.
4.1.2
Number of Study Sites
This is a single site clinical trial that will take place at Yale University, New Haven, CT. 
Clinical assessments will primarily occur at the Child Study Center at the Yale School of 
Medicine, neuroimaging will take place at the Magnetic Resonance Resource Center 
(MRRC) at the Yale School of Medicine, and infusion treatments will take place at the Yale 
Psychiatric Hospital at Yale New Haven Hospital. All three of these locations are within 0.5 
miles of each other.
4.1.3
Number of Participants
We aim to enroll 40-66 adolescents over the course of 7 years (see Sample Size 
Determination in 9.2 for further justification)). Based on our prior experience, we expect to 
screen roughly 90 potential participants to enroll the target number of 40-66 by August 31, 
2026.
4.2
Scientific Rationale for Study Design
(1) Ketamine vs. esketamine: The pediatric landscape differs substantially from the adult 
landscape on the relative uses of ketamine and esketamine. In adults, dose response data for 
esketamine has been more thoroughly described73 compared to ketamine74,75. In pediatrics, 
dose response data are not available for either compound (the current Janssen pediatric 
esketamine study includes a dose response, but those data are not yet available). There is also 
considerable weight variability in the adolescent population given the growth that occurs 
across the age range of interest (13 to 17 years old), and thus the weight-based dosing of 
intravenous ketamine is desirable. A potential limitation of ketamine versus esketamine is its 
intravenous mode of administration, however our adolescents have tolerated both single and 
repeat dosing paradigms (10 and 2.2.2) well. Finally, ketamine is what is being used off-label 
in our pediatric communities41,42, and gathering the safety data that will be produced here is 
of utmost importance.
(2) Repeat dose vs. single dose design: Our primary efficacy endpoint is 48 hours following 
the administration of a first ketamine dose compared to midazolam, which may raise 
questions about the need for repeated dosing. In our first trial, while we maintained 
separation from placebo on antidepressant measures out to 14 days, the longest timepoint 
assessed, the patients who remained in contact all subsequently relapsed. Repeat dosing is 
thought to extend the duration of wellness in adults with no differences detected between 
twice-weekly versus thrice-weekly dosing20. We have demonstrated that adolescents tolerate 
repeat dosing (10 and 2.2.2) and have proposed a conservative repeat dosing paradigm here 
(four ketamine doses over 2 weeks). We have opted to refine our protocol from 2.2.2.4 by
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
34
condensing the blinded phase from three to two weeks, and the open phase from six months 
to four. There is no standardized dosing protocol in adolescents, and we have opted to reduce 
the amount of time participants are exposed to the placebo intervention. The antidepressant 
efficacy of a single ketamine dose (14 days in our small sample, section 2.2.2) is longer than 
that typically reported in adult studies (little clinical benefit after day five74), and it is not 
known what duration of response to expect in adolescents with repeat dosing. While it is 
tempting to speculate that the enhanced plasticity potential of the developing brain76 may 
enhance ketamine’s plasticity inducing effects77 compared to adults, there is simply no data at 
this point, and the results generated here will inform the design of a larger, more definitive 
trial. As roughly 2/3 adult participants who relapsed off esketamine did so by 4 months73, we 
feel that this is a reasonable timeframe for the open phase and will enhance retention.
4.3
Justification for Dose
As a dose response for ketamine’s psychiatric effects in pediatrics does not exist, the use of a 
single dose (0.5mg/kg over 40 minutes) is a potential criticism. We have chosen this design 
given (1) our promising efficacy signal at this dose in adolescents (Fig 3), (2) our PK data 
showing blood levels of ketamine and metabolites in line with the ranges published in adult 
studies (Fig 2), and (3) the adult study suggesting 0.5mg/kg as superior to 0.1mg/kg, 
0.2mg/kg, and 1.0mg/kg doses74. We believe that our measures of biological engagement 
(connectome phenotypes predictive of ketamine response, ketamine modulation of 
connectome phenotypes, and the pre-/post-treatment behavioral data we will obtain from the 
reward, working memory, response inhibition, and social perception tasks used in building 
the CPM models) will provide important measures of target engagement that can be 
leveraged in designing a larger, more definitive trial, that will potentially include a dose 
response.
4.4
End of Study Definition
We plan to enroll subjects for this trial until our original enrollment target has been met (66 
participants) or until August 31, 2026, whichever arrives first. The date of August 31, 2026 
was chosen because it allows for us to enroll at least 40 subjects given our current 
recruitment pace under the amended study inclusion/exclusion criteria.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
35
5 Study Population
Study Population: Adolescents (13 -17 years old) with “high suicide risk”, operationally 
defined as having both SRI-resistant depression (having failed at least one antidepressant) 
AND having had a suicidal event within the 120 days prior to enrollment (i.e. a suicide 
attempt OR suicidal ideation requiring an emergency room visit or escalation of care 
(intensive outpatient, partial hospital program, and inpatient unit).
Selection rationale: Here we have defined “high suicide risk” as the combination of SRI- 
resistant depression and having had a suicide event within 120 days of enrollment, an 
adaption of the criteria of the Treatment of Adolescent Suicide Attempters (TASA) study78. 
While TASA required only a depressive disorder (not necessarily a treatment resistant 
disorder), we feel that SRI-resistance is an important selection criterion as it (1) increases the 
risk for suicide31, (2) is associated with reduced placebo responses in clinical trials of mood 
disorders79, and (3) provides a stronger ethical justification for use of an experimental 
medication where the risks are not clearly defined. SRI-resistant populations may also have 
higher degrees of hopelessness80, which is also a potent risk factor for suicide30. We are 
further enriching our population for suicidal ideation by including only those patients with a 
suicide event in the 120 days prior to enrollment. As defined by the Columbia Classification 
Algorithm of Suicide Assessment, a suicide event includes bona fide suicide attempts and 
degrees of suicidal thinking that necessitate emergency services or higher levels of 
psychiatric care81. Patients with high ideation that require emergency services often make 
attempts on subsequent follow-up and are similar to patients presenting with an actual 
attempt on a wide range of clinical features in cross-sectional and longitudinal studies82,83.
Even passive ideation about wanting to be dead is a risk for completed suicide84.
5.1
Inclusion Criteria
Eligibility will be determined by the PI or by an appropriately trained designee, using the 
below requirements and a participant and parent interview.
In order to be eligible to participate in this study, an individual must meet all of the 
following criteria:
2) Ages 13-17 years, inclusive
3) Meet DSM-5 criteria for Major Depressive Disorder by structured interview (MINI-KID+)
4) Children’s Depression Rating Scale, Revised (CDRS-R) score ≥45 at screening
5) Continued clinically significant depressive symptoms despite an SRI trial (e.g. SSRI or 
SNRI) of adequate dose and duration, meaning at least 6 weeks at therapeutic dosing, 
including at least 4 weeks of stable dosing
6) Suicide event within the past 120 days (i.e. a suicide attempt (defined as an act of 
potentially self-injurious behavior with explicit or inferred intent to die) –OR– degree of 
suicidal ideation requiring an emergency evaluation or a transition to higher level of care (e.g. 
intensive outpatient program, partial hospital program, inpatient)
7) Columbia Suicide Severity Rating Scale ideation score of ≥ 1 at screening
8) Medically and neurologically healthy on the basis of physical examination, medical 
history, and the clinical judgement of the evaluating physician.
9) Parents able to provide written informed permission and adolescents must additionally 
provide assent.
10) Stated willingness to comply with all study procedures and availability for the duration 
of the study
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
36
11) Provision of signed and dated parental permission and adolescent assent form. If there are 
two parents or guardians, both must provide permission and each must sign a separate 
permission form.
5.2
Exclusion Criteria
An individual who meets any of the following criteria will be excluded from 
participation in this study:
1) History of psychotic disorder, manic episode, or autism spectrum disorder diagnosed by 
MINI-KID
2) History of substance dependence diagnosis by MINI-KID (excluding tobacco) or active 
substance use (including current alcohol use or positive urine toxicology)
3) Intellectual disability (IQ<70) per medical history
4) Pregnancy (urine pregnancy tests on the day of the first infusion of each treatment week 
for menstruating girls) or lactation
5) Prior participation in a ketamine study, prior clinical psychiatric treatment with ketamine, 
or prior recreational use of ketamine
6) Pre-existing cardiovascular disease or untreated or unstable hypertension
7) Body weight greater than 80 kgs
8) Currently taking benzodiazepines or other medications that may cause respiratory 
depression, or lamotrigine, which is hypothesized to interfere with ketamine’s mechanism of 
action
9) Inability to provide written parental permissions and adolescent assent according to the 
Yale Human Investigation Committee (HIC) guidelines in English.
For participation in the fMRI scans only (participants with contraindications or intolerance to 
fMRI may still participate in all other portions of the trial, providing they meet all other 
inclusion/exclusion criteria):
10) Any contraindication to MRI including severe claustrophobia, or metal in the body 
(including mental dental braces)
5.3
Lifestyle Considerations
During the study, participants are asked to:
1. Take proper pregnancy precautions as follows:
o
Women: During the treatment phase and for at least 30 days after the last dose of 
study medication, contraception is required for female participants of childbearing 
potential (i.e. have had their first menstrual cycle and are not surgically sterile).
Sexual abstinence is strongly recommended; however
heterosexually active female subjects must practice an acceptable form of 
contraception.

Acceptable methods of contraception include the following:

Hormonal contraception being taken for at least 1 month prior to screening.

Intrauterine device (IUD).
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
37

Condom with spermicide (cream, spray, foam, gel, suppository, or polymer 
film).

Diaphragm with spermicide (with or without condom).

Cervical cap with spermicide (with or without condom).

Vaginal sponge impregnated with spermicide used with a condom.

Sexual abstinence is strongly recommended and subjects who practice total 
abstinence from sexual intercourse as their preferred lifestyle are not 
required to use additional contraception. For each subject, the reliability of 
sexual abstinence will be evaluated in relation to the duration of the study 
and the preferred and usual lifestyle of the subject.
o
Men: During the treatment phase and for at least 90 days after the last dose of 
study medication, contraception is required for male participants of childbearing 
potential (i.e. have reached spermarche and have not been vasectomized for at 
least 3 months prior to screening). Sexual abstinence is strongly recommended; 
however, heterosexually active male subjects must:

Practice an acceptable method of contraception with his female partner 
from those listed above (see examples of contraception provided above for 
female subjects).

Use a condom if his partner is pregnant.

Agree not to donate sperm.
2. Not engage in demanding work for the first 3 days after the treatment infusions (i.e. 
during the weekdays of the 2-week blinded phase, and the 2-week open phase if they go 
on to receive open ketamine).
3. Not drive or operate heavy machinery 24 hours after an infusion.
4. Attend all scheduled appointments.
5. Refrain from using any illegal substances, including alcohol (urine toxicology tests are 
regularly administered to monitor any illicit substance use)
5.4
Screen Failures
Please see detailed screening procedures as described in section 6.1. Briefly, after an initial 
phone screen to rule out any clear exclusion from the study protocol, potential subjects will 
be scheduled for a screening visit at the Yale Child Study Center or undergo a screening visit 
through telepsychiatry assessment. At the screening visit, a member of our research team will 
discuss all aspects of the study: its purpose, the procedures that will be performed, any/all 
risks of the procedures, possible benefits, and possible alternative treatments. If the patient is 
considered eligible for the study and agrees to proceed, the patient and his/her 
parents/guardians will be asked to sign the assent and parental permission forms, 
respectively.
Once consented, the participant will undergo a standard clinical evaluation consisting of 
psychiatric history, physical, laboratory and mental status exams with one of the study 
doctors as described in detail in section 6.1, Screening. The purpose of the screening 
procedures is to ensure that the participants meets all inclusion/exclusion criteria. If the 
subject is potentially traveling a long distance for the study, screening may be conducted 
over two sessions where consenting, all the necessary assessments and psychiatric history 
is gathered remotely and then an in-person visit is scheduled at a later time to complete 
physical exam and laboratory assessments. Subjects who fail screening may re-screen at a 
later date in certain circumstances (e.g. if they fail screening due to taking a restricted
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
38
medication (e.g. lamtrotrigine) but later discontinue this medication their outpatient 
providers and wish to re-screen).
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
39
5.5
Strategies for Recruitment and Retention
We will conduct outreach and education with our most likely recruitment sources, which 
include 3 inpatient units in the Yale system ((1) Winchester 1, 14 years old and younger, (2) 
Liberty Village 2, 14 to 17 years old, and (3) Washington Square 3 (16 to 25 years old)), the 
adolescent intensive outpatient unit, Pediatric Emergency services, and the in-home child 
services team. We have existing close relationships with all of these sites, and outreach will 
consist of a lecture describing the study and population of interest, and leaving fliers with 
inclusion and exclusion criteria, as well as study staff contact information. We do not plan to 
have any direct advertising or recruitment to patients or the public and expect the majority of 
patients to come through the referral of physician or mental health provider. Based on our 
prior experience with these studies, we expect that we may receive some direct patient 
inquiries by virtue of being listed on ClinicalTrials.gov. In order to potentially expand the 
geographic area for enrollment we will offer remote assessment and CBT 
treatment/medication management during the open-phase of the trial when clinically 
appropriate and at the preference of the family.
Enrollment in research will not disrupt, hold, or alter placement of the patient in the clinically 
appropriate level of care. Similarly, research participation will not result in a reduction of 
participant contact with trained pediatric mental health providers for monitoring and safety 
assessment.
This 2-phase study requires a significant amount of participant contact with the research 
team. In the first phase (2 weeks), participants have a half-day of baseline assessments and an 
hour-long fMRI scan. Then there are 4 treatment days where participants receive ketamine or 
midazolam, and an additional 1-hour fMRI scan prior to the second treatment. In our 
experience with a similarly designed ketamine study in adolescents, we have had 100% 
retention through the blinded phase. Our participants have tolerated the treatments well, and 
in general they express feeling like the treatments and interactions are of value.
In the open phase (4 months), participants who received placebo but remain significantly 
symptomatic will be offered open ketamine according to the schedule described above. There 
is one additional neuroimaging session in the first week of the open phase, and participants 
are asked to have labs drawn, an ECG, and urinalysis at the end of months 2 and 4 for safety 
monitoring. All participants are offered 8 weeks of weekly CBT and medication 
management. Participants have weekly mood assessments and monthly mood and cognitive 
batteries. While there are some retention risks with the open phase, particularly in those who 
do not respond to ketamine, we believe that the close attention, medication management, and 
CBT provided by the study is superior to what is generally provided in Child Psychiatry 
outpatient clinics, which have a severe shortage of providers.
To ensure that the inherent costs of participating (e.g. transportation) are not a significant 
barrier to joining the study if it is clinically appropriate to do so, compensation is provided to 
offset costs related to travel and time.
Participants will be paid $40 for completing the 2-week double blind phase. For those that 
meet criteria for crossing over to the open ketamine phase, they will receive an additional $40 
for completing the 2-week open treatment phase. They will receive the following 
compensation in the open phase:
Completing all 4 visits and rating scales in Month 1: $80 
Completing all 4 visits and ratings scales in Month 2: $80 
Completing all 4 visits and rating scales in Month 3: $80
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
40
Completing all 5 visits and rating scales in Month 4: $80
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
41
Payments will be made using a Bank of America pre-paid debit card. Subjects will be paid at 
the end of the last completed visit for that compensation block.
6 STUDY INTERVENTION
6.1
Study Intervention(s) Administration 
Screening:
After an initial phone screen to rule out any clear exclusion from the study protocol, 
potential subjects will be scheduled for a screening visit at the Yale Child Study Center or 
undergo a screening visit through telepsychiatry assessment. At the screening visit, a 
member of our research team will discuss all aspects of the study: its purpose, the 
procedures that will be performed, any/all risks of the procedures, possible benefits, and 
possible alternative treatments. All potential participants will have the opportunity to 
discuss study participation without their parents or guardians present. If the patient is 
considered eligible for the study and agrees to enroll, the patient and his/her 
parents/guardians will be asked to sign the assent and parental permission forms, 
respectively.
Once consented, the participant will undergo a standard clinical evaluation consisting of 
psychiatric history, physical, laboratory and mental status exams with one of the study 
doctors. This assessment includes collection of detailed information about all prior 
psychiatric therapies, including dose, duration of treatment, side effects, and partial efficacy. 
The participant and his/her parent/guardian will also receive a clinical diagnostic interview 
using the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI- 
KID)85. Additionally, the participant and his/her parent/guardian will complete clinical 
ratings related to the participant’s 1) depressive and suicidality symptoms and 2) symptoms 
of other commonly comorbid psychiatric conditions. A medical assessment including vital 
signs, physical exam, baseline serum labs (i.e. CBC with differential, complete metabolic 
panel (CMP) (including electrolytes, LFTs, BUN, creatinine and glucose), TFTs, a serum 
pregnancy test, and routine urinalysis) and urine drug screen will be completed prior to 
enrollment. Participants must be medically and neurologically healthy on the basis of 
physical examination, medical history, and the clinical judgement of the evaluating physician 
in order to participate. Examples of medical rule-outs include but are not limited to: unstable 
hypertension, recent severe neurologic injury, a history or current signs/symptoms of liver or 
renal insufficiency, and current diagnoses of cardiac, vascular, pulmonary, gastrointestinal, 
endocrine, neurologic, hematologic, rheumatologic, or metabolic disorders that are deemed 
clinically significant based on investigator judgement. If the subject is potentially traveling a 
long distance for the study, screening may be conducted over two sessions where consenting, 
all the necessary psychiatric assessments and history is gathered remotely and then an in- 
person visit is scheduled at a later time to complete medical assessment -- physical exam and 
laboratory assessments.
We will also request that participants and their families sign a release to speak with their 
current psychiatric care providers, in order to confirm the relevant aspects of the history, to 
answer any questions about the trial, and to facilitate ongoing collaboration. We will also 
send a written letter to these providers. We will describe the frequency of study contact 
(several days a week during the treatment period, then weekly during the follow-up phase). 
We will review how the study visits may integrate with the participant’s ongoing mental 
health schedule. We will strongly encourage continuous contact between the outpatient and 
study teams, particularly if a participant reports potential side effects or worsening symptoms.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
42
We will ensure that the outpatient team has the contact information for the study team, 
including the PI and the 24-hour clinical access number. The clinical assessment will take 
approximately 2 hours.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
43
Female subjects of childbearing potential will require urine/serum pregnancy testing prior 
to enrollment in the protocol. Because full confidentiality regarding pregnancy cannot be 
entirely guaranteed, these testing requirements and the limited scope of confidentiality will be 
made known to all subjects during the permission and assent procedure. In this manner, 
young women who would not be comfortable with pregnancy testing or sharing the results of 
such testing can “opt out” of the study at the time of the initial assent, without having to 
declare specific reasons. If the pregnancy test is positive, the subject will not be able to 
participate in the protocol.
Additionally, in order to participate in this protocol, the pediatric subject will need to be 
asked questions about his/her prior and/or current illicit drug use and undergo drug testing 
(urine). Because drug use will exclude the minor from participating, the parent may ask why 
the child or adolescent was asked not to participate or to leave the study. Therefore, parents 
and/or minors who are uncomfortable with questions about drug use can "opt out" of the 
study at the time of initial permission, without having to declare specific reasons. If subjects 
choose not to enroll, then any previously collected drug test results will be destroyed.
Adolescent drug use information will not be shared with parents unless the study team 
feels that the minor is exhibiting behaviors that would pose an immediate threat to the minor 
or to others. The PI or co-investigator will ask the minor if the study team can share the drug 
testing results with parents. If the minor declines, the study team will refer the minor for 
evaluation based upon the clinical judgment of the Principal Investigator. In all cases, the 
safety and well-being of the minor will be protected. We will explicitly inform parents and 
minors, in the permission and assent documents, and orally with regard to these guidelines. 
As an NIH-funded study, drug use information is protected under a Certificate of 
Confidentiality.
If the adolescent participant meets all inclusion and exclusion criteria, they will be scheduled 
for Baseline and treatment visits.
Baseline (Study Day 0, Visit 1)
Baseline visits will generally be conducted on Mondays in order to facilitate flow into the 
established treatment procedures at Yale Psychiatric Hospital’s Interventional Psychiatry 
Service (IPS), in which ketamine treatments are administered on Tuesdays and Thursdays. 
Baseline assessments include clinical questionnaires and neuroimaging. Participants will 
present to the Child Study Center to complete the clinical questionnaires and obtain a weight, 
then will walk with research staff to the MRRC (~5 minute walk) in order to complete the 
one-hour neuroimaging scan.
Clinical Questionnaires on the Baseline Day are as follows:
1) C-SSRS: assessment of suicidal ideation and behavior in clinical and research settings66,86
2) CDRS-R: a standardized rating scale that assesses depression severity in children and 
adolescents69
3) MADRS: a standardized rating scale that assesses depression severity in children and 
adolescents17
4) Pleasure Scale for Children (PSC)87: a standardized rating scale to assess anhedonia88
5) Treatment-Emergent Activation and Suicidality Assessment Profile (TEASAP): a rating 
scale designed to detect increased behavioral activation and suicidality89
6) Multidimensional Anxiety Scale for Children (MASC): a multidimensional assessment of 
anxiety in children and adolescents90
7) CADSS: interviewer administered items that evaluate dissociative symptoms 16
8) Clinical Global Impressions (CGI): a widely used instrument used to assess overall severity
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
44
of illness and symptom improvement on 1-7 point scales91,
9) Beck Hopelessness Scale (BHS): instrument to assess hopelessness92
10) Adolescent Stress Questionnaire (ASQ): a 56-item instrument for measuring current 
stressors across a range of domains 93
11) Childhood Trauma Questionnaire (CTQ): a self-report screening measure for maltreatment 
histories94
12) Edinburgh Handedness Inventory
13) Wechsler Abbreviated Scale of Intelligence
14) Cogstate neurocognitive battery
The participant and their family will be introduced to the study CBT therapist. During this 
introduction they will complete a Safety Planning Module together. The safety planning 
module focuses on the development of an individualized safety plan that includes support 
from multiple individuals and includes internal and external coping strategies to be 
implemented should the participant experience suicidal urges. We emphasize with 
participants and their parents that the creation of the safety plan is a collaboration between 
the patient, therapist, and parents, and that all involved must understand steps for and 
assessment of safety.
The safety plan includes the following: identification of risk behaviors, identification of 
coping strategies, identification of family support and others to provide support, creation for 
plan of ‘In case of emergency’, identification of resources to call in crisis (including the 24- 
hour access number for a study clinician (e.g., doctor, therapist, or psychologist), and 
signature from child or adolescent, parent, and therapist (indicating all on board with plan). 
Copies of the completed plan will be provided for the participant, the participant’s family, 
and uploaded into their EPIC medical record. We ask families to place the plan in an easily 
accessible locations (e.g. on the refrigerator, bedroom wall). If the adolescent wishes to use 
a smartphone, they may also take a picture of the plan using the phone’s camera function.
The MRI scan will last approximately 1 hour and will include a combination of anatomical 
and functional (task and rest) scans. Subjects will perform 4 tasks (Table 1) during each scan 
session. The MRI scans will take place on one of the 3T Siemens scanners located at the 
Magnetic Resonance Research Center. A licensed MR technician will perform all MR scans, 
and all scans will use standard clinical sequences. A member of the research team will 
accompany the subjects to the MRRC and will stay with them for the duration of the scan.
All planned MR sequences are currently FDA-approved MR imaging sequences; none exceed 
the FDA Guidelines for 3T MR imaging systems. Tasks performed during the experiment 
sessions will include:
1. Card guessing task (e.g.,95): In this reward response task, subjects will be shown a card on 
a screen and will have to guess whether the number on the other side of the card is less than
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
45
or greater than five. The card will then be flipped over and subjects will receive reward 
feedback based on their response.
2. N-back task96,97: Subjects will be asked to watch a set of pictures (or words) and push a 
button if a new picture (or word) is different than the previous item (1-back condition) or 
than the item that came two items before (2-back condition).
3. Response inhibition task/Stop-Signal (e.g.,98): Subjects will see items on the screen and 
either respond (go trial) or not respond (no-go trial), depending on the presented item.
4. Understanding mental states task: Subjects will be asked to infer the perspective of others, 
either by looking at photographs of their eyes and labeling the photographed subjects’ 
emotions99, or by responding to questions that require them to interpret social “hints” in 
vignettes100.
5. Perception: Subjects will passively watch images on the screen or listen to sounds through 
headphones. Possible stimuli include flashing checkerboards, movie clips, beeps and tones, 
blank screens, etc.
6. Resting state run: Subjects will be asked to stay still with eyes open during the resting runs. 
There is no task involved.
Phase A1: Blinded Intervention (Visits 2 – 7):
Subjects will receive four infusions of either ketamine (0.5mg/kg IV) or midazolam 
(0.045mg/kg IV) over a two-week period. Infusions are delivered over 40 minutes while on 
continuous cardiac monitoring and pulse oximetry; they will be monitored for 2 hours post- 
infusion (or until pharmacokinetic blood draws are complete on Day 1, 230 minutes post- 
infusion)
First Blinded Infusion (Day 1, Visit 2)
The participant will be instructed to follow American Society of Anesthesiologists NPO 
guidelines the night before the infusion. These guidelines allow milk or a light meal 6 hours 
prior to the procedure and clear liquids up to 2 hours prior to the procedure. Subjects will 
present to the Child Study Center to complete pre-infusion questionnaires and receive a urine 
toxicology (and urine pregnancy, if applicable) test. Pre-infusion clinical measures are the C- 
SSRS, MADRS, and CGI.
The participant will then walk to the Interventional Psychiatry Service (IPS) at Yale 
Psychiatric Hospital with research staff (~ 5 minute walk). One hour prior to the infusion, 
two IVs will be placed, one to administer the infusion, and the second to facilitate blood 
collection for pharmacokinetic blood draws. The blinded infusion will be administered over a 
40-minute period, either ketamine at a dose of 0.5mg/kg, or midazolam at a dose of 0.045 
mg/kg, randomized by the Investigational Drug Service. Doses of both medications not to 
exceed a maximum total dose corresponding to a weight of 80kg.
Ketamine and midazolam administrations will be performed on the IPS service at YPH under 
ACLS-accredited physicians with experience with midazolam-controlled ketamine studies, 
including those conducted in pediatric populations. During the infusion, vital signs are 
recorded every 5 minutes. Once the infusion is complete, they are recorded every 15 minutes. 
The psychotomimetic side effects of ketamine or midazolam, and the mental status of the 
participant will also be monitored every hour for two hours following the infusion.
Pharmacokinetic blood draw timepoints are pre-infusion, 40-minutes post-infusion start (i.e. 
as the infusion is completing), 80 minutes, 110 minutes, and 230 minutes. These timepoints 
were chosen for consistency with the published adult PK literature and with our previous 
pediatric ketamine work. Participants will be monitored through the 230-minute timepoint, at
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
46
which time they will be released with a parent or guardian. Prior to visit discharge, research 
staff will use the SAFTEE-SI to systematically assess for potential adverse events. In 
addition, a credentialed clinician will review the participant’s individualized safety plan and 
make a clinical determination of risk of imminent harm to self or others. Assessment of risk 
involves inquiring about the presence and intensity of suicidal thinking, differentiating 
between passive and active thoughts, evaluating the presence of risk and protective factors, 
and inquiring about plans, access, and intent. If a participant were deemed to be an imminent 
safety risk to themselves or others, they would be transported to the Emergency Room for 
further evaluation.
Remote follow-up (Day 2, Visit 3): Participants will be contacted by phone to follow-up 
regarding mood (MADRS) and any potential adverse events (SAFTEE-SI). A member of 
the research staff will speak with both the participant and a parent and will confirm return 
instructions for the following day. This day is purposefully designed to be a day with low 
scheduled interaction given the large number of procedures and interactions on Days 1 and
3. Participants will be reminded that study staff, study physicians, and the PI are all 
available should there be any questions, concerns, or problems. This assessment may be 
done either by telephone or through telepsychiatry video assessment.
Primary Outcome (48-hour C-SSRS), Neuroimaging, Second Blinded Infusion (Day 3, 
Visit 4): Participants will again be instructed to follow American Society of 
Anesthesiologists NPO guidelines the night before the infusion (milk or a light meal 6 hours 
prior to the procedure, and clear liquids up to 2 hours prior to the procedure). Participants will 
present to the Child Study Center to complete the pre-infusion questionnaires (C-SSRS, 
MADRS, CGI). Note that this administration of the C-SSRS is the primary outcome of the 
efficacy portion of the study. The timeframe for the clinical measures is “since last visit”.
Participants will then walk to the MRRC with research staff (~5 minute walk) in order to 
complete the second neuroimaging scan. Tasks and rest conditions will be identical to those 
described above (Baseline visit). Following neuroimaging, participants will walk with 
research staff across the street to the Interventional Psychiatric Service (~1 minute walk). A 
single IV will be placed, as there are no pharmacokinetic blood draws on this or subsequent 
infusions. As above, the blinded infusion will be administered over a 40-minute period, either 
ketamine at a dose of 0.5mg/kg, or midazolam at a dose of 0.045 mg/kg, as previously 
determined by the Investigational Drug Service.
Ketamine and midazolam administrations will be performed on the IPS service at YPH under 
ACLS-accredited physicians with experience with midazolam-controlled ketamine studies, 
including those conducted in pediatric populations. During the infusion, vital signs are 
recorded every 5 minutes. Once the infusion is complete, they are recorded every 15 minutes. 
The psychotomimetic side effects of ketamine or midazolam, and the mental status of the 
participant will also be monitored every hour for two hours following the infusion. Prior to 
visit discharge, research staff will use the SAFTEE-SI to systematically assess for adverse 
events. As with all infusion visits, a credentialed clinician will make a clinical determination 
of risk of imminent harm to self or others. After two hours, if participants have returned to 
baseline mental and physical status, they will be discharged in the care of their parent or 
guardian.
Third and Fourth Blinded Infusions (Days 8 and 10, Visits 5 and 6):
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
47
Participants will present to the Child Study Center for pre-infusion questionnaires (Days 8 
and 10) and urine toxicology (and urine pregnancy, as applicable) (Day 8), and will have 
been instructed to follow the same NPO guidelines as previous infusions. Infusion procedures 
for the third and fourth blinded infusions are identical to those described for the second 
blinded infusion.
Mood/Cognitive Battery, Breaking of the Blind (Day 11, Visit 7):
All participants will return on study day 11 (Visit 7) for assessment of the mood and 
cognitive measures described in the Schedule of Activities. Important secondary clinical 
outcomes will be collected on this date, including the MADRS and the CDRS-R. After all 
clinical measures are collected and response criteria are calculated, the PI will contact the 
Investigational Drug Service in order to break the blind. The Investigational Drug Service 
will provide the treatment assignment for the participant in writing via electronic 
communication.
The PI will discuss the clinical and treatment results with the participant and their family. In 
the event that the participant had been randomized to ketamine, they will proceed to the open 
phase (Phase B, which includes CBT and medication management as standard of care 
treatment) regardless of treatment response. In the event that the participant had been 
randomized to midazolam and they did not experience a treatment response, they will be 
offered open ketamine treatment (Phase A2) prior to progressing to Phase B. In the event the 
participant was randomized to midazolam and they did experience a significant treatment 
response, they will proceed to Phase B and will not be offered any open ketamine treatments.
Phase A2: Open Ketamine Intervention for Midazolam Non-responders (Visits 8 – 13): 
Participants will follow an identical schedule to that described for the blinded phase (Phase 
A1) above, with the exception that the four infusions will be ketamine treatments (open 
treatment in which both the participant and the study physicians are aware of the treatment). 
In brief, the following days have the following treatments (please see detailed descriptions in 
Phase A1) for procedures each day:
First Open Ketamine Infusion (Day 15, Visit 8), includes pharmacokinetic blood draw 
Phone Follow-up (Day 16, Visit 9)
Neuroimaging (Third Scan), Second Open Ketamine Infusion (Day 17, Visit 10) 
Third Open Ketamine Infusion (Day 22, Visit 11)
Fourth Open Ketamine Infusion (Day 24, Visit 12) 
Mood Cognitive Battery (Day 25, Visit 13)
Phase B: Open Phase with Standard of Care Depression Treatment 
(Visits 8 – 24 for participants proceeding directly from Phase A1) 
(Visits 14 – 30 for participants proceeding from Phase A2)
At this point in the trial, all subjects will have completed any trial-associated infusion 
procedures. All of the remaining clinical interventions (8 weeks of weekly CBT and 
medication management according to the modified Texas Children’s Medication Algorithm) 
are considered standard of care depression treatments.
For the first 8-weeks (Visits 8-15 in those proceeding directly from A1; Visits 14 – 21 for 
those proceeding from A2), the general assessment schedule will be weekly meetings.
These meetings will include a 45-minute CBT session, a 15-minute medication 
management visit, and a limited amount of clinical ratings (C-SSRS, MADRS,
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
48
CGI, SAFTEE-GI). The study team aims to integrate study procedures and clinical care to 
facilitate ease of participation for study families and to rational information flow through the 
visits. Visits will begin with the study assessments, and those scores will be passed on to the 
CBT therapist and Child Psychiatrist. The CBT session will follow, and any important 
information will be relayed to the Psychiatrist conducting the medication check component of 
the visit. A risk assessment and review of the safety plan occurs at every visit, as is our 
standard clinical practice.
In the event that pandemic- or public health-related conditions preclude a participant from 
attending one of the above in-person sessions, the session may need to be conducted via 
telehealth. Any telehealth appointments must follow the requirement for the presence of a 
parent or guardian in the home during the telehealth session. When clinically appropriate, 
families may also choose to conduct these sessions remotely via video telehealth sessions. 
Sessions will only be conducted via telehealth when this is preferred by the family and 
judged to be clinically appropriate by both the CBT therapist and PI/study doctor.
In the group who progressed directly from phase A1, the third neuroimaging session (Day 17, 
Visit 8) will occur prior to the therapy and medication management session (see study 
schedule of activities). Every fourth week, a more extensive mood and cognitive battery will 
be completed. At the end of this 8-week period (Day 66, Visit 15 in those from A1, and Day 
80, Visit 21 in those from A2), participants will have a medical surveillance battery 
consisting of an ECG, serum labs, urinalysis, and urine toxicology. The 8-week course of 
CBT is slated to end at this time.
For the final 8-weeks (Visits 16- 24 in those proceeding directly from A1; Visits 22- 30 in 
those proceeding from A2), weekly mood and AE check-ins can occur by telephone or via 
video telehealth visit if the participant is clinically stable. The monthly mood and cognitive 
batteries will still occur in person and can coincide with continued 15-minute medication 
management visits.
Participants may request to continue weekly visits in-person visits (rather than remote visits) 
during this time, and any phone assessments that are indicative of clinical deterioration will 
prompt an unscheduled, in-person visit. A final set of medical surveillance labs will be 
collected at the end of this 8-week period, as above (Day 122, Visit 23 in those from A1, and 
Day 136, Visit 29 in those from A2).
Weekly mood assessments are estimated to take approximately 30 minutes to complete and 
monthly mood and cognitive batteries are estimated to take 1.5-2 hours to complete.
Participants will have a final in-person visit on the day of study discharge (Day 126, Visit 24 
in those progressing directly from A1; Day 140, Visit 30 in those progressing from A2).
On Study Visits
Please see the detailed description of study visits and procedures in section above and 
summarized on the Schedule of Activities (Section 1.3)
End of Study and Follow-up
The study has a significant follow-up phase built in following the acute blinded phase 
intervention (the 4-month open phase). The study is considered completed at the end of the 4- 
month open phase. During the follow-up phase, important safety, efficacy, and resource 
utilization measures are collected (see section 3.5, Outcome Variables). Participants who 
withdraw from the study early will be offered continued follow-up for mood and cognitive
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
49
assessments if they are amenable to such. Participants may request copies of their lab results 
or clinical ratings if they would like a copy for their records or to share with their outpatient 
mental health provider. Any incidental or concerning findings revealed in the neuroimaging
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
50
portion of the study will be reported to the patient, who will be encouraged to follow-up with 
a medical provider outside of the study.
6.1.1
Study Intervention Description
Ketamine (Ketalar) has FDA approval as a sole anesthetic agent for diagnostic and 
surgical procedures that do not require skeletal muscle relaxation. Ketamine has been 
increasingly used as a rapid-acting antidepressant in adult populations with treatment- 
resistant depression4, but it is not FDA-approved for this indication. As of March 5th, 2019, 
the FDA granted approval to Spravato (esketamine) nasal spray, in conjunction with an oral 
antidepressant, for the treatment of depression in adults who have tried other antidepressant 
medicines but have not benefited from them (treatment-resistant depression). Esketamine is 
the s-enantiomer of ketamine. Because of the risk of serious adverse outcomes resulting from 
sedation and dissociation caused by Spravato administration, and the potential for abuse and 
misuse of the drug, it is only available through a restricted distribution system, under a Risk 
Evaluation and Mitigation Strategy (REMS). An open-label trial8 and several case reports 
have described the successful use of ketamine in pediatric patients with refractory psychiatric 
conditions (see also, Clinical Experience, 2.1.2), however it is not FDA-approved for this 
purpose. Studies of Spravato in pediatric patients with psychiatric disorders are ongoing.
Ketamine hydrochloride injection USP 50 mg/ml, 10 ml vials, will be procured by the 
Investigational Drug Service (IDS), a specialized pharmacy at Yale (obtained from the 
manufacturer or supplier of FDA-approved ketamine that is currently in use by the Yale New 
Haven Hospital IDS). The medication dose used in the protocol (0.5mg/kg infused over 40 
minutes) is substantially lower than doses that are used for anesthesia (1mg/kg – 4.5mg/kg IV 
over 60 seconds). The maximum number of ketamine infusions in this protocol is four, and 
the maximum total dose per infusion is 40mg per infusion (corresponding to a weight of 
80kg). The PI holds a therapeutic license for administering controlled substances.
Midazolam HCl (Versed, the active placebo in this study) is FDA approved in children 
and adolescents for sedation, and is often used as an anxiolytic agent prior to induction of 
general anesthesia with other anesthetic agents, or as a sole sedating agent for minor 
procedures. Midazolam hydrochloride injection USP 5 mg/ml, 1 ml vials, will also be 
procured by the IDS (obtained from the manufacturer or supplier of FDA-approved 
midazolam that is currently in use by the Yale New Haven Hospital IDS) . The medication 
dose used in the protocol (0.045mg/kg infused over 40 minutes) is substantially lower than 
doses that are used for anesthesia (0.5mg - 2mg IV push, repeated every 2-3 minutes to a 
maximum of 10mg). The maximum number of midazolam infusions in this protocol is four, 
and the maximum total dose per infusion is 3.6mg (corresponding to a weight of 80kg). As 
with ketamine, the PI holds a therapeutic license for administering controlled substances.
6.1.2
Dosing and Administration
Infusions (Day 1, 3, 8, and 10, Visits 2 - 6): Subjects who, in the opinion of the PI, are 
eligible to continue with the protocol procedures (after the results of the screening/baseline 
measures and diagnostics are considered) will present to the Interventional Psychiatry Service 
(IPS) at Yale Psychiatric Hospital for the first infusion on Study Day 1. The participant will 
be instructed to follow American Society of Anesthesiologists NPO guidelines the night 
before the infusion. These guidelines allow milk or a light meal 6 hours prior to the procedure 
and clear liquids up to 2 hours prior to the procedure. One hour prior to the infusion, IV’s will 
be placed, two IV’s on days that include bloodwork (ketamine metabolites on Day 1 only)
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
51
and one IV on infusion days without bloodwork (Day 3, 8, and 10). The infusion will be 
administered over a 40-minute period, either ketamine at a dose of 0.5mg/kg, or midazolam 
at a dose of 0.045 mg/kg (doses of both medications not to exceed a maximum total dose 
corresponding to a weight of 80kg).
Ketamine and midazolam administrations will be performed on the IPS service at YPH under 
ACLS-accredited physicians with experience with midazolam-controlled ketamine studies, 
including those conducted in pediatric populations. The participant’s vital signs will be 
monitored every 5 minutes during the infusion and every 15 minutes thereafter up to two 
hours following the infusion. The psychotomimetic side effects of ketamine or midazolam, 
and the mental status of the participant will also be monitored every hour for two hours 
following the infusion. During this acute phase of the study, patients will receive four 
infusions, scheduled on Study Days 1, 3, 8, and 10 (corresponding to visits 2 – 6). All 
participants will return on Study Day 11 (Visit 7) for extensive mood and cognitive measures. 
After the mood and cognitive battery on Study Day 11, the blind will be broken to determine 
which arm the participant was randomized to. Those who were randomized to midazolam and 
remain symptomatic will be offered open ketamine, will be treated as described above on 
Study Days 15, 17, 22, and 24 (Visits 8-12), and will have a follow-up post-ketamine mood 
and cognitive battery on Study Day 25 (Visit 13).
6.2
Preparation/Handling/Storage/Accountability
6.2.1
Acquisition and accountability
Ketamine hydrochloride injection USP 50 mg/ml, 10 ml vials manufactured by Hikma 
pharmaceuticals will be acquired from wholesaler McKesson or from the manufacturer or 
supplier that is being used by the Yale New Haven Hospital Investigative Drug Service at the 
time of medication preparation.
Midazolam hydrochloride injection USP 1 mg/ml, 5 ml vials manufactured by Hikma 
pharmaceuticals will be acquired from wholesaler McKesson or from the manufacturer or 
supplier that is being used by the Yale New Haven Hospital IDS at the time of medication 
preparation.
6.2.2
Formulation, Appearance, Packaging, and Labeling
The formulation, appearance, packaging, and labeling of Ketamine and Midazolam can be 
found in the package inserts included in this application. Investigational drug accountability 
and management (purchase, storage, preparation, dispensing, and disposition) will be 
conducted by Yale-New Haven Health IDS Pharmacy.
6.2.3
Product Storage and Stability
Investigational drugs will be stored per package insert. All vials will be used as single dose 
vials.
Ketamine: Store at 20° to 25°C (68° to 77°F) [See USP Controlled Room Temperature]. 
Protect from light.
Midazolam: Store at 20°-25°C (68°-77°F), excursions permitted to 15°-30°C (59°-86°F) [See 
USP Controlled Room Temperature].
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
52
6.2.4
Preparation
Ketamine will be diluted in sodium chloride 0.9% to a total volume of 100mL, delivered 
intravenously at a rate of 150 mL/hr
Midazolam will be diluted in sodium chloride 0.9% to a total volume of 100mL, delivered 
intravenously at a rate of 150 mL/hr
6.3
Measures to Minimize Bias: Randomization and Blinding
Participants will be randomized to ketamine or midazolam in the double-blind phase by the 
Investigational Drug Service, 1:1. Only the Investigational Drug Service will know the 
identity of the experimental compound. Medication labels in the double-blind phase read 
“Ketamine or Midazolam”, followed by “Investigational Study Drug”. All medication 
infusion solutions are made to a total volume of 100mL so that infusion instructions are 
identical, protecting the blind for the nursing staff. Although this is a double-blind study, 
additional measures are being taken to protect the blind. Efficacy raters will not be present 
during the infusions, i.e. there will be separate raters for intra-infusion ratings (side effect 
ratings scales) and for efficacy.
The first phase of this trial is a double blind, randomized controlled trial. At the end of the 
blinded phase, there will be a scheduled breaking of the blind in order to proceed to the open 
phase of the trial. After the clinical ratings are complete on Study Day 11, the Investigational 
Drug Service will be contacted, and they will send a written electronic communication to the 
PI with the randomization information for that subject. This information is needed in order to 
determine whether the participant meets criteria to proceed to open ketamine administration 
in the following phase.
6.4
Study Intervention Compliance
The study intervention will be administered on site by medical staff in the presence of a 
member of the study team, therefore intervention compliance will be assured.
6.5
Concomitant Therapy
Participants are allowed to remain on their current psychiatric medications in this study. This 
design choice was made for several reasons. For patients with difficult-to-treat depression, a 
complete washout of medications is potentially problematic and may contribute to: (1) acute 
worsening of mood resulting in hospitalization or suicide; (2) inflation of baseline scores, 
which may bias response rates; and (3) a systematic selection bias due to elimination of 
participants who cannot tolerate drug withdrawal and who refuse to consider a washout. We 
also believe that continuing current medications approximates the “real world” conditions in 
which ketamine is given to pediatric patients off-label. We ask that patients refrain from any 
dose or agent changes during the blinded phase of the protocol (or the first two weeks of the 
open protocol if they qualify to receive open ketamine). The open phase of the protocol 
includes medication management based on the Texas children’s medication algorithm65, an 
adaptation that allows for antipsychotic augmentation.
There are, however, several medication restrictions (see exclusion criteria 5.2) to avoid any 
potential interactions with the investigation medications. These include a prohibition of
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
53
benzodiazepines or any other standing medications that have significant respiratory 
depressive activities. Lamotragrine (Lamictal) is also a restricted medication as its biological 
action is thought to potentially inhibit ketamine’s antidepressant actions at the mTOR 
pathway.
6.5.1
Rescue Medicine
An ACLS-trained physician with access to airway equipment will be present throughout the 
infusions (although we believe that the likelihood of a serious event at the doses proposed in 
this study is low). Subjects will be monitored for at least 2 hours following ketamine or 
midazolam infusion by Dr. Bloch. A study doctor (Principal Investigator (PI) of the trial) will 
be present at all times during the infusion and recovery. In the event, that a research subject 
has a significant psychiatric event requiring hospitalization, they will be treated on the 
adolescent unit (LV2) at Yale Psychiatric Hospital (YPH). Emergent medical care would be 
provided at Yale-New Haven Hospital.
Oral diazepam (5mg) will be kept available to control markedly distressing behavioral effects 
of ketamine, should they emerge. Oral ondansetron (4-8mg) will be kept available to control 
any significant nausea or vomiting. Please also see section 2.3.1, Risk Mitigation Plans.
7 STUDY INTERVENTION DISCONTINUATION 
AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL
7.1
Discontinuation of Study Intervention
Patients may withdraw at any time or be dropped from the study, at the discretion of the PIs, 
should medical contraindications develop, if intolerable adverse reactions occur, if the patient 
becomes manic or psychotic, or if the patient worsens to such a degree that further 
participation puts the patient at risk (e.g., active suicidality). If a patient worsens during the 
blinded phase, a thorough discussion will occur with the patient, their family, their outpatient 
psychiatrist, and the treatment team to discuss the risks and benefits of continuing in the 
study. If the participant has been randomized to midazolam and is still symptomatic, then 
they are able to receive ketamine at the end of the blinded phase (two weeks maximum). The 
PI must assess subjects who decide to withdraw from the study to ensure their care is 
transitioned to the provider
If a participant needs to be hospitalized during the blinded phase, all efforts will be made to 
have them hospitalized within the Yale New Haven Hospital (YNHH) System. As soon as the 
study team is aware, they will reach out to the treating physician at the participant’s location. 
The team will discuss the participant’s clinical status and the main study requirements during 
the 2-week double blind phase (including avoiding benzodiazepines and refraining from 
making changes to standing medications). Study treatments occur at the Yale Psychiatric 
Hospital and the clinical units will be aware of the study through recruitment outreach, which 
we hope will facilitate working through any clinical or logistical challenges to meet the best 
interest of the patient. If a participant is hospitalized outside of the YNHH system, the study 
team will still make every effort to reach and collaborate with their clinical staff.
7.2
Participant Discontinuation/Withdrawal from the Study
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
54
Subjects may withdraw voluntarily at any time for any reason. An investigator may 
discontinue or withdraw a participant from the study for the following reasons:
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
55

Pregnancy

Significant study intervention non-compliance

If any clinical adverse event (AE), laboratory abnormality, or other medical condition or 
situation occurs such that continued participation in the study would not be in the best 
interest of the participant

Disease progression that requires discontinuation of the study intervention

If the participant meets an exclusion criterion (either newly developed or not previously 
recognized) that precludes further study participation

Study termination
The occurrence of a hospitalization or other suicide event per se is not on its own a sufficient 
reason for automatic removal. Any serious adverse event will prompt a review of the current 
risks and benefits of study participation with the participant, their family, and any other 
medical personnel involved in their care. Recommendations of whether to continue or to 
discontinue will be based on a consensus of what is believed to be in the best interest of the 
participant at that time.
The reason for participant discontinuation or withdrawal from the study will be recorded in 
the participant binder by the relevant clinician. Subjects who sign the informed assent form 
(with corresponding parental permissions) and are randomized but do not receive the study 
intervention may be replaced. Subjects who sign the informed assent form (with 
corresponding parental permissions), and are randomized and receive the study intervention, 
and subsequently withdraw, or are withdrawn or discontinued from the study, will not be 
replaced.
7.3
Lost to Follow-Up
A participant will be considered lost to follow-up if he or she does not respond to phone or 
email communications. After 2 weeks a letter will be sent to their address and they will be 
informed of their discontinuation from the study.
Any no-shows to study visits will be vigorously pursued. The following actions will be taken 
if a participant fails to return to the clinic for a required study visit:
• The site will attempt to contact the participant and their parent and reschedule the 
missed visit as soon as possible. Research staff will counsel the participant on the 
importance of maintaining the assigned visit schedule and ascertain if the participant 
wishes to and/or should continue in the study.
• If the participant or parent are unable to be reached, a member of the study team will 
check the participant’s electronic medical record to ascertain whether any new visits 
have occurred to psychiatric or medical services within the YNHH system.
• Before a participant is deemed lost to follow-up, the investigator or designee will 
make every effort to regain contact with the participant (where possible, 3 telephone 
calls and, if necessary, a certified letter to the participant’s last known mailing address 
or local equivalent methods). These contact attempts will be documented in the 
participant’s medical record or study file.
Should the participant continue to be unreachable, he or she will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
56
8 STUDY ASSESSMENTS AND PROCEDURES
8.1
Efficacy Assessments
Please also see section 3.5 Outcome Variables and the Schedule of Activities, which includes 
both efficacy and baseline assessments.
1) C-SSRS: assessment of suicidal ideation and behavior in clinical and research settings66,86- 
Primary outcome at Study Day 3; administered at baseline, prior to each infusion during blinded 
phase; administered weekly in open phase
2) CDRS-R: a standardized rating scale that assesses depression severity in children and 
adolescents69- administered at baseline, at Day 11, and in monthly mood and cognitive batteries
3) MADRS: a standardized rating scale that assesses depression severity in children and 
adolescents17- administered at baseline, prior to each infusion during the blinded phase; 
administered weekly in the open phase
4) Pleasure Scale for Children (PSC)87: a standardized rating scale to assess anhedonia88- 
administered at baseline, at Day 11, and in monthly mood and cognitive batteries
5) Treatment-Emergent Activation and Suicidality Assessment Profile (TEASAP): a rating 
scale designed to detect increased behavioral activation and suicidality89- administered at 
baseline, at Day 11, and in monthly mood and cognitive batteries
6) Multidimensional Anxiety Scale for Children (MASC): a multidimensional assessment of 
anxiety in children and adolescents90- administered at baseline, at Day 11, and in monthly mood 
and cognitive batteries
7) Clinical Global Impressions (CGI): a widely used instrument used to assess overall severity 
of illness and symptom improvement on 1-7 point scales91- administered at baseline, prior to 
each infusion during the blinded phase; administered weekly in the open phase
8) Beck Hopelessness Scale (BHS): instrument to assess hopelessness92- administered at 
baseline, at Day 11, and in monthly mood and cognitive batteries
9) Adolescent Stress Questionnaire (ASQ): a 56-item instrument for measuring current 
stressors across a range of domains93
8.2
Safety and Other Assessments
8.2.1
Safety
1) Vital signs are recorded at each infusion visit
2) Baseline: a physical exam, laboratory screening (liver function tests, renal function 
tests, thyroid function test, and urinalysis), and electrocardiogram (ECG) are 
conducted
3) Follow-up medical surveillance: participants will receive an ECG, liver function tests, 
renal function tests (blood urea nitrogen and creatinine), and urinalysis half-way 
through the open phase and at the study conclusion
4) Adverse reactions will be systematically assessed at visits as detailed in the Schedule 
of Activities. Staff will use the Systematic Assessment for Treatment Emergent 
Events (SAFTEE-GI or SAFTEE-SI)71, as described in the Schedule of Activities, 
which examines in a systematic fashion all possible treatment-emergent side effects 
and probes specific adverse symptoms. Any reactions to the medication or protocol 
will be carefully explored and documented. Documentation of any spontaneously
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
57
reported or inquiry-elicited side effects or adverse events is completed at every visit 
using the case report form.
5) Any spontaneous reports of abdominal pain, increased urinary frequency, urge 
incontinence, or other urinary or gastrointestinal symptoms will prompt an early 
medical and laboratory evaluation. Participants will be provided an adverse event log 
to track the development of any signs or symptoms of substance abuse and will 
undergo repeat urine toxicology screening (weekly during blinded infusions or open 
ketamine treatment; halfway through the open phase, and end of open phase).
6) The Cogstate battery will be used to track neurocognitive function during this study, 
which assesses attention, working memory, psychomotor function, associative 
learning, and executive functioning; it is administered at baseline, Day 11, and in the 
monthly mood and cognitive batteries
8.2.2
Pharmacokinetics
On the first infusion day (Day 1) of the blinded phase, pharmacokinetic blood samples with 
be collected, to be analyzed by our collaborator, Dr. Carlos Zarate, at the NIMH. To facilitate 
participant comfort, two intravenous catheters will be placed on that day, one for the infusion 
and the other to draw off of for PK blood samples. Timepoints are as follows: pre-infusion, 
40-minutes post infusion start, 80 minutes, 110 minutes, and 230 minutes. Total blood 
volume to be drawn that day is not to exceed 30mLs. In the event that a participant crosses 
over in the open phase to receive ketamine, there will be an identical procedure for the first 
infusion (Day 15).
8.2.3
Biomarkers/Neuroimaging Assessments
There are no serum biomarkers being collected as part of this study. Neuroimaging measures 
could, however, be considered biomarkers. We plan to scan participants at 3 timepoints: 
baseline, Day 3 (prior to second blinded infusion), and Day 17 (prior to second open infusion 
in those who crossover to open ketamine, and at a comparable timepoint to those receiving 
CBT and medication management in the open phase).
Total magnet time will be under 1 hour for each scanning session. Continuous performance 
tasks: A series of 4 tasks designed to enhance neurocognitive differences across individuals 
will directly tap into specific fundamental cognitive processes, based on the Behavioral 
Assessment Methods for RDoC Constructs report72. Positive Valence. To perturb reward 
circuitry, the (i) card guessing task will be used95,101,102, which has been extensively validated, 
shows good construct validity, psychometric properties, and characterization of individual 
differences72, and has been used in clinical populations103-108. Cognitive Systems. The 
constructs of working and declarative memory will be simultaneously probed using a version 
of the common, extensively validated (ii) N-back task 96,97,109. The construct of response 
inhibition will be assessed using the (iii) stop-signal paradigm98,110. This task has been 
extensively validated72, shown to have good construct validity and reliability 111,112, and used 
in clinical populations 110. Social Processes. To probe perception and understanding of others, 
the (iv) Reading the Mind in the Eyes Test will be used99. This task can be used in clinical 
populations 113 and in adults without ceiling effects 99. Its revised version has been shown to 
have good reliability and construct validity113-115. Subject performance on all tasks will be 
recorded via button presses during the scan and pre-treatment versus post-treatment behavior 
will be analyzed. Finally, one 6-minute run of passive movie-watching, one 6-minute run of
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
58
resting-state, and a structural scan will be completed (3D, T1- and T2-weighted).
Acquisition Protocol: The imaging protocol will match the Human Connectome Project 
(HCP) protocols as closely as possible. Imaging will be performed on a 3T Siemens Prisma, 
32-channel head coil. T1-weighted anatomic slices (FLASH: 72 slices 2mm thick, 
TR=300ms, TE=2.47ms, FoV=220mm, matrix=192x192, Flip angle= 70º, bandwidth = 
300Hz/pixel) aligned with the AC-PC providing whole-brain coverage including the 
cerebellum. Each of the 4-task runs and 1-resting-state run will be acquired over 6 minutes 
(total of 30 minutes of connectivity data) using multiband EPI (voxel size 2mm3)116, 8 TRs to 
achieve steady-state, matrix 104x90, multiband=8, flip=52o, TE=33ms, TR=720ms, 72 slices, 
FOV=208x180mm (584 frames per run). Structural data will be obtained using 3D T1- 
weighted MPRAGE: thickness 0.7mm, matrix size=224×224, TR=2400ms, TE=2.14ms, Flip 
angle=8°, and a T2-weighted 3D SPACE, thickness 0.7mm, matrix size= 224×224, 
TR=3200ms, TE=56ms, Flip angle =variable, isotropic 0.7mm voxel resolution. The total 
MRI session is less than 60 minutes.
8.3
Adverse Events and Serious Adverse Events
8.3.1
Definition of Adverse Events (AE)
Adverse event (AE) means any untoward medical occurrence associated with the use of an 
intervention in humans, whether or not considered intervention-related (21 CFR 312.32 (a)).
8.3.2
Definition of Serious Adverse Events(SAE)
An AE or suspected adverse reaction is considered "serious" (SAE) if, in the view the 
Sponsor-Investigator, it results in any of the following outcomes:

death,

a life-threatening adverse event,

inpatient hospitalization or prolongation of existing hospitalization,

a persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions,

a congenital anomaly/birth defect, or

An important medical event that may not result in death, be life-threatening, or 
require hospitalization may be considered serious when, based upon appropriate 
medical judgment, they may jeopardize the participant and may require medical or 
surgical intervention to prevent one of the outcomes listed in this definition. Examples 
of such medical events include allergic bronchospasm requiring intensive treatment in 
an emergency room or at home, blood dyscrasias or convulsions that do not result in 
inpatient hospitalization, or the development of drug dependency or drug abuse.
8.3.3
Classification of an Adverse Event 
Severity
Adverse events will be graded according to [name grading scale, e.g. CTCAE v5.0]. For AEs 
not included in the protocol defined grading system, the following guidelines will be used to 
describe severity.

Mild – Events require minimal or no treatment and do not interfere with the 
participant’s daily activities.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
59

Moderate – Events result in a low level of inconvenience or concern with the 
therapeutic measures. Moderate events may cause some interference withfunctioning.

Severe – Events interrupt a participant’s usual daily activity and may require systemic 
drug therapy or other treatment. Severe events are usually potentially life-threatening 
or incapacitating. Of note, the term “severe” does not necessarily equate to “serious”.
Relationship to Investigational Product
All AEs must have their relationship to study intervention assessed by the clinician who 
examines and evaluates the participant based on temporal relationship and his/her clinical 
judgment. The degree of certainty about causality will be graded using the categories below. 
In a clinical trial, the study product must always be suspect.

Definitely Related – There is clear evidence to suggest a causal relationship, and other 
possible contributing factors can be ruled out. The clinical event, including an 
abnormal laboratory test result, occurs in a plausible time relationship to study 
intervention administration and cannot be explained by concurrent disease or other 
drugs or chemicals. The response to withdrawal of the study intervention 
(dechallenge) should be clinically plausible. The event must be pharmacologically or 
phenomenologically definitive, with use of a satisfactory rechallenge procedure if 
necessary.

Probably Related – There is evidence to suggest a causal relationship, and the 
influence of other factors is unlikely. The clinical event, including an abnormal 
laboratory test result, occurs within a reasonable time after administration of the study 
intervention, is unlikely to be attributed to concurrent disease or other drugs or 
chemicals, and follows a clinically reasonable response on withdrawal (dechallenge). 
Rechallenge information is not required to fulfill this definition.

Potentially Related – There is some evidence to suggest a causal relationship (e.g., the 
event occurred within a reasonable time after administration of the trial medication). 
However, other factors may have contributed to the event (e.g., the participant’s 
clinical condition, other concomitant events). Although an AE may rate only as 
“possibly related” soon after discovery, it can be flagged as requiring more 
information and later be upgraded to “probably related” or “definitely related”, as 
appropriate.

Unlikely to be related – A clinical event, including an abnormal laboratory test result, 
whose temporal relationship to study intervention administration makes a causal 
relationship improbable (e.g., the event did not occur within a reasonable time after 
administration of the study intervention) and in which other drugs or chemicals or 
underlying disease provides plausible explanations (e.g., the participant’s clinical 
condition, other concomitant treatments).

Not Related – The AE is completely independent of study intervention administration, 
and/or evidence exists that the event is definitely related to another etiology. There 
must be an alternative, definitive etiology documented by the clinician.
Expectedness
The Principal Investigator will determine the expectedness of each AE based on the listed 
adverse event section of the Reference Safety Information in the most recent US package 
insert.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
60
An AE will be considered unexpected if the nature, severity, or frequency of the event is not 
consistent with the risk information described in the US Package Insert.
8.3.4
Time Period and Frequency for Event Assessment and Follow-Up
The occurrence of an adverse event (AE) or serious adverse event (SAE) may come to the 
attention of study personnel during study visits and interviews of a study participant 
presenting for medical care, or upon review by a study monitor.
All AEs including local and systemic reactions not meeting the criteria for SAEs will be 
captured on the appropriate case report form. Information to be collected includes event 
description, time of onset, clinician’s assessment of severity, relationship to study product 
(assessed only by those with the training and authority to make a diagnosis), and time of 
resolution/stabilization of the event. All AEs occurring while on study must be documented 
appropriately regardless of relationship. All AEs will be followed to adequate resolution.
Any medical condition that is present at the time that the participant is screened will be 
considered as baseline and not reported as an AE. However, if the study participant’s 
condition deteriorates at any time during the study, it will be recorded as an AE.
Changes in the severity of an AE will be documented to allow an assessment of the duration 
of the event at each level of severity to be performed. AEs characterized as intermittent 
require documentation of onset and duration of each episode.
The principal investigator or other clinician seeing the participant will record all reportable 
events with start dates occurring any time after parental permission and assent is obtained 
until 7 (for non-serious AEs) or 30 days (for SAEs) after the last day of study participation. 
At each study visit, the participant will be asked about the occurrence of AE/SAEs since the 
last visit. Events will be followed for outcome information until resolution or stabilization.
8.3.5
Adverse Event Reporting
Adverse events will be reported to the FDA, Yale IRB, the DSMB, and NIMH (see Table 2 
below for reporting requirements) in accordance with all local applicable laws and 
regulations.
8.3.6
Serious Adverse Event Reporting
The identification of SAEs will begin when a member of the research team reports an adverse 
event. The site PI or her designee will conduct prompt investigations of all reported adverse 
events. All SAEs will be documented on an SAE form, entered in the appropriate CRF, and 
communicated to the appropriate team members.
Reporting to the Yale IRB
SAEs will be reported to the Yale IRB in accordance with IRB Policy 710 (see also section 
8.4, Unanticipated Problems). We will additionally report SAEs to the IRB that may be 
expected in the clinical population but are considered severe in nature (e.g. attempted suicide, 
psychiatric or medical hospitalization) regardless of their potential relationship to the study
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
61
interventions. All adverse events that involve risk but do not meet the prompt reporting 
requirements described in Policy 710 will be reported to the IRB in summary form at the time 
of continuing review.
Reporting to the FDA
For studies conducted under an IND, there are two types of Safety Reports submitted to FDA:

7-Calendar-Day FDA Telephone or Fax Report: The sponsor-investigator will 
directly notify the FDA, within 7 calendar days after initial receipt of the information, 
of any adverse event that is fatal or life-threatening, unexpected, and considered at 
least possibly related to the investigational product.

15-Calendar-Day FDA Written Report: The sponsor-investigator will directly notify 
the FDA within 15 calendar days after initial receipt of the information, of any serious 
adverse event (other than those that are fatal or life-threatening) that is unexpected 
and considered at least possibly related to the investigational product.
Serious Adverse Events which do not meet the criteria for expedited reporting will be 
reported to the FDA in the IND Annual Report.
Table 2
Reporting to
Description of Event
Timeframe
Other
Yale IRB
Adverse events or injuries that 
are serious, unexpected, and at 
least possibly related;
Within 5 calendar days 
of the Principal 
Investigator becoming 
aware of the event.
UPIRSO Reporting Form (710 FR 
4)
Adverse events or injuries that 
are non-serious, expected, or 
unrelated
At the time of continuing 
review.
Reported to the IRB in summary 
form; such summary may be a 
simple brief statement that events 
have occurred at the expected 
frequency
and level of severity as previously 
documented
Deaths not attributed to the 
research (e.g., from “natural 
causes,” accidents, or 
underlying disease when
the Principal Investigator has 
ruled out any connection 
between the study procedures 
and the subject’s
death)
At the time of continuing 
review.
Reported to the IRB in summary 
form; such summary may be a 
simple brief statement that events 
have occurred at the expected 
frequency
and level of severity as previously 
documented
FDA
Any adverse event that is fatal 
or life-threatening, 
unexpected, and considered at 
least possibly related to the 
investigational product.
Within 7 calendar days 
after initial receipt of the 
information,
MedWatch Form FDA 3500
Any serious adverse event 
(other than those that are fatal 
or life-threatening) that is 
unexpected and considered at
Within 15 calendar days 
after initial receipt of the 
information,
MedWatch Form FDA 3500
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
62
Reporting to
Description of Event
Timeframe
Other
least possibly related to the 
investigational product.
Serious Adverse Events which 
do not meet the criteria for 
expedited reporting
IND Annual Report
NIMH DSMB
Death Definitely, Probably, or 
Potentially Related
Immediately (within 5 
business days)
The SAE should be reported as 
soon as possible to the NIMH 
DSMB, within 5 business days for 
deaths related to study 
participation. The SAE will also be 
included in the SAE section of the 
next DSMB Report.
Serious Adverse events; 
Unexpected: and Definitely, 
Probably, or Potentially 
Related
DSMB Immediately 
(within 5 days)
The SAE should be reported as 
soon as possible to the NIMH 
DSMB, within 5 business days 
for unexpected serious adverse 
events related to study
participation The SAE will also be 
included in the SAE section of the 
next DSMB Report.
Serious Adverse events; 
Expected events: regardless of 
relation to study (related and 
unrelated)
DSMB Tri-Annually
The SAE will be listed in the SAE 
section of the DSMB Report 
(currently a tri-annual report). No 
need to notify the DSMB on an 
immediate basis.
Serious Adverse events; 
Unexpected: and Unlikely or 
NOT Related
DSMB Tri-Annually
The SAE will be listed in the SAE 
section of the DSMB Report 
(currently a tri-annual report). No 
need to notify the DSMB on an 
immediate basis.
Death Unlikely or NOT 
Related
DSMB Tri-Annually
The SAE will be listed in the SAE 
section of the DSMB Report 
(currently a tri-annual report). No 
need to notify the DSMB on an 
immediate basis.
NIMH
Program 
Officer
Deaths related to study 
participation
Reported immediately 
(no later than within 5 
business days) of the 
principal investigator 
first learning of the death
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
63
Reporting to
Description of Event
Timeframe
Other
Unexpected Serious Adverse 
Events related to study 
participation
10 business days of the 
study team becoming 
aware of the SAE.
All reports must be made in 
writing to the NIMH Program 
Official (PO). These reports should 
indicate that the monitoring 
entities (i.e., the PI and IRB, 
DSMB) and appropriate regulatory 
entities (e.g., OHRP, FDA) have 
been notified in accordance with 
the approved monitoring plan and 
federal regulations. Reports should 
be submitted to the monitoring 
entity (e.g., a DSMB or ISM) at 
least annually on a schedule 
determined by the monitoring 
entity’s policy. Monitoring entities 
may require more frequent 
reporting.
AEs and SAEs that are
Summary should be
deemed expected and/or
submitted to the NIMH
unrelated to the study,
PO with the annual
progress report.
8.3.7
Reporting Events to Participants
The AEs and SAEs that will be reported to participants are determined by the Yale IRB in 
accordance with Yale IRB Policy 710.
8.3.8
Events of Special Interest
Not applicable.
8.3.9
Reporting of Pregnancy
Female participants will receive a serum pregnancy test with baseline screening labs. Urine 
pregnancy tests will be administered at the start of the week (prior to any infusion) during the 
blinded phase and in the event of a cross-over to open ketamine. Because full confidentiality 
regarding pregnancy cannot be entirely guaranteed, these testing requirements and the limited 
scope of confidentiality will be made known to all subjects during the permission and assent 
procedures. In this manner, young women who would not be comfortable with pregnancy 
testing or sharing the results of such testing can “opt out” of the study at the time of the initial 
assent, without having to declare specific reasons. If the pregnancy test is positive, the subject 
will not be able to participate in the protocol. Please see also section 5.3, Lifestyle 
Considerations, which details contraceptive requirements.
8.4
Unanticipated Problems
8.4.1
Definition of Unanticipated Problems (UP)
The Office for Human Research Protections (OHRP) considers unanticipated problems 
involving risks to participants or others to include, in general, any incident, experience, or 
outcome that meets all of the following criteria:
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
64
1. Is unexpected (in terms of nature, specificity, severity, or frequency) given (a) the 
research procedures described in the protocol-related documents, such as the IRB- 
approved protocol and informed permission document and (b) the characteristics 
of the subject population being studied; AND
2. Is related or possibly related to participation in the research (possibly related 
means there is a reasonable possibility that the incident, experience, or outcome 
may have been caused by the procedures involved in the research); AND
3. Suggests that the research places subjects or others at greater risk of harm 
(including physical, psychological, economic, legal, or social harm) than was 
previously known or recognized.
Unanticipated Problems Involving Risks to Subjects or Others (UPIRSOs) may be medical or 
non-medical in nature, and include – but are not limited to – serious, unexpected, and related 
adverse events and unanticipated adverse device effects
8.4.2
Unanticipated Problem Reporting
UPIRSOs will be reported by the PI to the IRB in accordance with Yale IRB Policy 710, 
using the appropriate forms found on the website. All study-related events involving risk but 
NOT meeting the prompt reporting requirements described in IRB Policy 710 will be 
reported to the IRB in summary form at the time of continuing review. If appropriate, such 
summary may be a simple brief statement that events have occurred at the expected 
frequency and level of severity as previously documented.
Events that require prompt reporting include adverse events, if the events are unexpected, 
related, and serious, and may include subject complaints, protocol deviations, and other 
untoward events involving risk. Prompt reporting entails the following timeframes:
1. Events that may require a temporary or permanent interruption of study activities 
to avoid potential harm to subjects will be reported to the IRB immediately (if 
possible), followed by a written report to the IRB using the UPIRSO Reporting 
Form (710 FR 4) no more than 5 calendar days after the PI becomes aware of the 
event
2. Internal events (those occurring at a study site under the jurisdiction of the Yale 
IRB) will be reported to IRB within 5 calendar days of the PI becoming aware of 
the event
The following events may represent UPIRSOs that should be promptly reported:
o
Adverse device effects that are unanticipated;
o
Adverse events or injuries that are serious, unexpected, and related;
o
Breaches of confidentiality involving risks;
o
DSMB reports, interim analyses, or other oversight committee/monitoring reports 
altering the risk/benefit profile by identification of increased risks;
o
Revisions to safety information, such as Investigational New Drug (IND) Safety 
Reports, SUSARS and MedWatch Reports, that meet the definition of a UPIRSO;
o
New information indicating an unexpected increase in risks or decrease in potential 
benefits (e.g.literature/scientific reports or other published findings);
o
Protocol deviations, violations, or other accidental or unintentional changes to the 
protocol or procedures involving risks or with the potential to recur;
o
Unapproved changes made to the research to eliminate an apparent immediate hazard 
to a subject;
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
65
o
Other problem or finding (e.g., loss of study data or forms) that an investigator or 
research staff member believes could influence the safe conduct of the research.
UPIRSOs will also be reported to the DSMB, OHRP and the NIMH PO within 10 business 
days of the investigator learning of the event. UPIRSOs that are also AEs would additionally 
be reported to the FDA according to the schedules described in Table 2.
Suspensions or Terminations and Serious or Continuing Noncompliance
Any suspension or termination of approval of the study by the FDA/DSMB/OHRP/IRB must 
include a statement of the reason(s) for the action and must be reported promptly to the 
NIMH PO within 3 business days of receipt. Serious or continuing noncompliance will be 
Reported to the NIMH PO within 10 business days of IRB determination
According to HHS regulations 45 CFR 46.103(a) and (b)(5), The Yale Human Research 
protection Program has written procedures to ensure that the following incidents related to 
regulatory requirements pertaining to research conducted under an OHRP- approved 
assurance are promptly reported to OHRP: a) Any unanticipated problems involving risks to 
subjects or others; b) Any serious or continuing noncompliance with this policy or the 
requirements or determinations of the IRB; and c) Any suspension or termination of IRB 
approval.
8.4.3
Reporting Unanticipated Problems to Participants
The unanticipated problems that will be reported to participants are determined by the Yale 
Institutional Review Board (IRB) in accordance with IRB Policy 710.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
66
9 STATISTICAL CONSIDERATIONS
9.1
Statistical Hypotheses
Aim 1: To evaluate the safety of treating adolescents with SRI-resistant depression at high 
suicide risk with a conservative repeat-dosing ketamine paradigm followed by standard of 
care treatment over 4 months.
Hypothesis: We anticipate no untoward effects on medical outcomes (cardiovascular 
function and bladder health) or cognitive function (measured via Cogstate).
Aim 2: To evaluate the 48-hour impact of ketamine on suicidal ideation compared to 
midazolam, and to identify connectome phenotypes predictive of ideation post-treatment.
Hypothesis: Ketamine will reduce suicidal thinking (Columbia Suicide Rating Scale, 
recent ideation subscale) compared to midazolam. CPM will identify networks 
predictive of ideation, validated via k-fold or leave-one-out cross-validation within the 
sample. The network measures obtained at this fixed ketamine dose will inform the 
design of larger clinical trials.
Aim 3 (exploratory): To describe the trajectory of suicidal thinking, depressive symptoms, 
and use of mental health resources in both ketamine responders and non-responders over 4 
months.
9.2
Sample Size Determination
The original effect size calculation was based on power analysis of a single, randomized- 
controlled trial of ketamine involving 80 adult subjects using the Scale for Suicidal Ideation. 
As noted below (in italics), there are additional sources of information that were used in 
recalculating the anticipated range of possible effect sizes for important primary and 
secondary outcomes in this trial and the anticipated sample size has been readjusted to 40- 
66 subjects.
Primary outcome (suicidality, as measured by the C-SSRS recent ideation subscale: to 
detect an effect size of 0.75117 of ketamine versus midazolam at this rapid timepoint with 
80% power at the two-sided 0.05 significance level, using a two sample t-test, a sample size 
of 30 subjects per group is required. An additional 3 subjects per group will be enrolled to 
accommodate a 10% attrition rate, requiring a total sample size of 33 subjects per group 
(N=66).
Rationale for the Revised Anticipated Effect Size: 0.75-0.85 for the Primary Outcome

The power calculation for the original grant proposal was based on a randomized, 
midazolam-controlled trial of 80 adult subjects with Major depression and suicidal 
ideation, which demonstrated an effect size of 0.75 at 1 day following initial infusion on 
the Scale for Suicidal Ideation. 117 (BLUE in Figure 6)

A meta-analysis which included data from 176 individual adult participants from 10 randomized 
controlled trials of ketamine for depression including adults with treatment-resistant depression 
and suicidal ideation demonstrated an effect size of 0.85 at 1 day following initial infusion as 
measured on the MADRS item 10 that measures suicidal ideation.119 (GRAY in Figure 6)
Secondary Aims Analyses: Secondary outcome analysis will apply the Benhamini-
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
67
Hockberg procedure118 to control for multiple testing. For an alpha = 0.01 (corrected) for 
depression outcomes and 80% power, the minimal detectable effect size would be 0.91. Our 
prior studies with ketamine in depressed adolescents demonstrate an effect size of 0.75 for 
depression endpoints (MADRS) at rapid timepoints, and thus we are powered to 
approximately 60% to detect a difference for antidepressant outcomes.
Rationale for the Revised Anticipated Effect Size: 0.78-0.89 for the Depression 
Symptoms

Our original single-dose, midazolam-controlled, crossover trial in adolescents with 
treatment-resistant depression which provided the pilot data for this initial grant 
proposal demonstrated an effect size of 0.78 on the MADRS at day 1 for improving 
depressive symptoms.120 (ORANGE in Figure 6)

The meta-analysis which included data from 176 individual adult participants from 10 
randomized controlled trials of ketamine for depression including adults with 
treatment-resistant depression and suicidal ideation demonstrated an effect size of 0.89 
at day 1 following initial infusion for improving depression symptoms on the MADRS 
scale. 119 (YELLOW in Figure 6)
Given that even with our original sample size we were underpowered to detect secondary 
outcomes if we adjust for multiple hypothesis testing, we instead plan not to adjust for 
multiple comparisons in secondary analyses (use alpha=0.05) and treat the analyses as 
exploratory and limit reporting to point estimates and 95% CI without formal hypothesis 
testing.121
Imaging outcomes: The current study proposes to image 66 adolescents, half initially 
randomized to ketamine and half to midazolam. CPM has successfully built predictive 
models using only 25 subjects55, and thus we believe that 33 subjects per group is sufficient 
to perform the proposed treatment phenotyping. We have estimated an attrition rate of 10% 
based on previous experience with pediatric ketamine trials, although participant 
withdrawal generally occurs later in the course of the trial (while the imaging is occurring 
relatively early on). Even with an additional attrition of 15% for miscellaneous causes (e.g. 
braces, motion, severe claustrophobia), we still meet the threshold of 25 subjects. \We 
anticipate that a sample size between 40-66 will get us the necessary sample size to have 
the power to complete neuroimaging analysis (N≥25) with currently expected additional 
exclusion (e.g. due to braces and permanent retainers) or declining participation in the 
MRI portion of the study (e.g. due to claustrophobia or additional subject burden).
Figure 6 depicts power versus sample size for the four effect sizes discussed above. Table 3 
describes the anticipated power for sample sizes for the 4 possible anticipated effect sizes 
described above in the range of 30-66 subjects. Based on the above power calculations, we 
would need to enroll 46-58 subjects to have 80% power to detect a between-group 
difference in our primary outcome related to suicidal ideation and a total of 42-54 subjects 
to have 80% power to detect a between-group difference in our secondary exploratory 
outcomes.
Table 3: Power Calculation for Anticipated Effect Sizes regarding Suicidal Ideation 
and Depression Symptoms
Total 
Sample 
Size
Suicidal 
Ideation
Depression
d=0.75
d=0.85
d=0.78
d=0.89
30
50.9%
61.3%
54.1%
65.3%
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
68
32
53.7%
64.3%
57.0%
68.3%
34
56.4%
67.1%
59.7%
71.1%
36
58.9%
69.8%
62.3%
73.7%
38
61.4%
72.2%
64.8%
76.1%
40
63.7%
74.5%
67.1%
78.3%
42
66.0%
76.7%
69.4%
80.3%
44
68.1%
78.6%
71.5%
82.2%
46
70.1%
80.5%
73.5%
83.9%
48
72.0%
82.2%
75.3%
85.5%
50
73.8%
83.8%
77.1%
86.9%
52
75.6%
85.2%
78.8%
88.2%
54
77.2%
86.5%
80.3%
89.4%
56
78.7%
87.8%
81.8%
90.5%
58
80.1%
88.9%
83.1%
91.5%
60
81.5%
89.9%
84.4%
92.4%
62
82.8%
90.9%
85.6%
93.2%
64
84.0%
91.7%
86.7%
93.9%
66
85.1%
92.5%
87.7%
94.5%
SAMPLE SIZES NEEDED TO ACHIEVE 80%
POWER
58
46
54
42
Table 3: Power Calculation for Anticipated Effect Sizes regarding Suicidal Ideation and Depression 
Symptoms. Table 3 depicts the power calculations for the anticipated range of observed effect sizes for 
suicidal ideation and depression symptoms for possible sample sizes in the current study assuming 
alpha=0.05 and a 100% completion rate. Sources utilized for the range of anticipated effect sizes for 
suicidal ideation and depression are outlined above. Shading of the effect sizes in the table correspond to 
the corresponding color of the power curve for that effect size in Figure 6.
Figure 6: Power Curve for Anticipated Effect Sizes regarding Suicidal Ideation and Depression 
Symptoms
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
69
Figure 6: Power Curve for Anticipated Effect Sizes regarding Suicidal Ideation and Depression 
Symptoms. Figure 6 depicts the power curves for anticipated effect sizes for suicidal ideation (solid lines) 
and depressive symptoms (dashed lines) over the potential sample size range for this trial if granted a 2- 
year no cost extension. Sources utilized for effect sizes used for power calculations for suicidal ideation3-4 
and depression2,4 are described above.
9.3
Populations for Analyses
•
Intention-to-Treat (ITT) Analysis Dataset (i.e., all randomized participants)
•
Per-Protocol Analysis Dataset: defines a subset of the participants in the full analysis 
(ITT) set who complied with the protocol sufficiently to ensure that these data would 
be likely to represent the effects of study intervention according to the underlying 
scientific model
9.4
Statistical Analyses
9.4.1
General Approach
There are no RCTs testing ketamine’s rapid anti-suicidal effects in high-risk youth, and 
our ability to predict responses to treatment based on biological data is poor. The primary 
outcome is C-SSRS, recent ideation subscale, at 48-hours post-dose comparing participants 
who were randomized to ketamine to those who received the active placebo, midazolam. Key 
secondary outcomes include 48-hour MADRS and Day 11 C-SSRS, MADRS, and CDRS-R. 
CPM will be used to identify pre-treatment connectome fingerprints that predict treatment 
response and how circuits change post-treatment.
Data will be examined prior to analysis using descriptive statistics, presented as means ± 
SD or median (interquartile range) for continuous characteristics, and as frequencies (%) for 
categorical characteristics. Where appropriate, randomized groups will be compared on 
baseline continuous characteristics (e.g. age) using two-sample Welch’s t-test or Wilcoxon 
rank sum test, and on categorical characteristics using the chi-square test or Fisher’s exact 
test as appropriate. Continuous outcome measures will be assessed for normality using
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
70
histograms and Q-Q plots, and transformations will be applied as necessary. Short-term 
outcomes will be analyzed by linear mixed models with rating scales as the dependent 
variables and baseline values, treatment, time (48 hours, Day 11), and treatment-by-time 
interaction as independent variables (fixed effects). Subjects will be modeled as a random 
effect to account for the correlated data from same subject. Linear contrasts will be used to 
estimate treatment group differences and 95% confidence intervals at each timepoint. We will 
formally test the predictive power of a variety of features associated with outcome in clinical 
trials in depression and suicidality by including them as covariate(s) separately and together 
(except for age and age-at-onset) in the analytical models described above.
9.4.2
Analysis of the Primary Efficacy Endpoint(s)
The primary outcome of C-SSRS at 48-hours will be compared between groups using an 
analysis of covariance (ANCOVA) model, with treatment group (ketamine versus
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
71
midazolam) and baseline C-SSRS as the independent variables (covariates). Our primary 
analyses will be intent-to-treat using all available data.
9.4.3
Analysis of the Secondary Endpoint(s)
Safety outcomes: To examine the safety and tolerability of 4 doses of ketamine in this 
developmental population we will closely track adverse events and side effects in both the 
ketamine and midazolam treated groups for the duration of the study. We will use descriptive 
statistics to characterize the rates of these events for both groups and will use Fisher’s exact 
tests to test for differences between the groups.
Additional clinical outcomes: Short-term outcomes (e.g. MADRS, CDRS-R) will be 
analyzed by linear mixed models with rating scales as the dependent variables and baseline 
values, treatment, time (48 hours, Day 11), and treatment-by-time interaction as independent 
variables (fixed effects). Subjects will be modeled as a random effect to account for the 
correlated data from same subject. Linear contrasts will be used to estimate treatment group 
differences and 95% confidence intervals at each timepoint. We will formally test the 
predictive power of a variety of features associated with outcome in clinical trials in 
depression and suicidality by including them as covariate(s) separately and together (except 
for age and age-at-onset) in the analytical models described above. Comparison of response 
proportions: Response is defined as a 50% reduction in C-SSRS (suicidality) or MADRS 
(depression). The proportion of responders at rapid (48-hour) and short-term (Day 11) 
timepoints between treatment groups will be performed by the generalized linear mixed 
models with a random subject effect in which binary response outcome is modeled as a 
function of covariates including treatment, time, treatment by time interaction and baseline 
value. Depression status as a mediator of anti-suicidal response: Lastly, as exploratory 
analysis, to estimate the direct effect and indirect mediation effects of MADRS on the 
association of treatment with C-SSRS scores, we will fit multilevel mediation models122 
within multilevel structural equation modeling framework using Mplus software. We will 
also consider an alternative mediation analysis method within the mixed-effect modeling 
framework described by Bauer123. These secondary clinical outcomes shall be considered 
exploratory and used for hypothesis generating purposes for future studies as our statistical 
threshold will be set at p<0.05 and will not correct for multiple comparisons.
Neuroimaging/ CPM outcomes: FMRI data will be motion corrected using SPM12. Data 
will be analyzed using BioImage Suite124,125 and custom scripts in Matlab (Mathworks).
Linear and quadratic drift, mean signal from white matter, gray matter, cerebrospinal fluid, 
and a 24-parameter motion model (6 motion parameters, 6 temporal derivatives, and their 
squares) will be regressed from the data. Finally, data will be temporally smoothed with a 
zero mean unit variance Gaussian filter. Data from runs with excessive head motion (a priori 
as > 2 mm translation or > 3 degrees rotation during a single run) will be excluded. Head 
motion, calculated as mean frame-to-frame displacement, will be measured as a function of 
state between different task or rest runs to ensure that motion is not a primary driver of 
condition. Uniform smoothing will be run to remove residual effects of motion 126. The best 
performing individual atlas will initially be registered to individual participant space via 
concatenation of a series of linear and non-linear registrations between the functional images, 
2D and 3D anatomical scans as previously described58. From this step the individualized atlas 
will proceed and a custom atlas for each subject at each time point will be produced with 
information on the correspondence between nodes across (time and subject) atlases 
maintained. Connectivity matrices are then calculated for the different acquisition conditions 
and fed into the multidimensional CPM along with subject C-SSRS data.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
72
Multidimensional CPM algorithm: We have extended our original CPM framework by 
modifying the feature selection step to incorporate information from multiple connectivity 
matrices (from both task- and resting-state acquisitions). For the new feature selection step, 
we use canonical correlation analysis (CCA) instead of linear regression. CCA is a 
multivariate method for inferring information from cross-covariance matrices by finding 
linear combinations of the data that maximizes the correlation between the data (i.e. 
connectivity matrices from task and rest) and variable of interest (suicidal ideation as 
measured via the C-SSRS). Latent brain networks from multiple task conditions are used to 
predict latent behavioral profiles in a single modeling step. Similar to CPM, edges are 
selected if the CCA produces a significant correlation as measured by the likelihood test 
(using p-value threshold of 0.01). Once the most predictive edges are selected, the new 
projections of those edges estimated from the CCA are summed to form a single subject 
suicidal ideation summary score.
Model Validation: After the CPM model is built from the training data, it can be used to 
predict scores from connectome data for novel subjects. We will initially test leave-one-out 
analyses but as the size of the data set grows we will perform k-fold cross-validation (k=10).
Such test data sets allow performance to be evaluated using either the mean squared error 
(MSE) or the correlation between the predicted and observed behavioral values. Lower MSE 
and higher correlation indicate a more predictive model. Validation in novel subjects is aimed 
at demonstrating that the models generalize and are not simply over-fitting a specific set of 
data.
Connectome Changes: To examine the impact of treatment on the functional connectome 
identified above we can compare masked connectivity matrices across timepoints. Here the 
pre-treatment multidimensional CPM identifies edges and nodes that are associated with 
suicidal ideation. These model edges and nodes can be contrasted with data collected post- 
treatment (for both placebo and ketamine) to determine the extent to which treatment 
modifies this pre-treatment functional phenotype. This contrast can be performed with a 
paired t-test corrected for multiple comparisons and the change distribution can be compared 
with the change distribution from the placebo group to measure the significance of this 
change. Such connectivity changes can also be regressed with the pre- and post-treatment 
suicidal ideation score change to test the hypothesis that the extent of change in the functional 
connectome is associated with the degree of change in ideation score.
9.4.4
Safety Analyses
Please see section 9.4.3. Safety Outcomes and section 9.4.6 Planned Interim Analyses.
9.4.5
Baseline Descriptive Statistics
Data will be examined prior to analysis using descriptive statistics, presented as means ± SD 
or median (interquartile range) for continuous characteristics, and as frequencies (%) for 
categorical characteristics. Where appropriate, randomized groups will be compared on 
baseline continuous characteristics (e.g. age) using two-sample Welch’s t-test or Wilcoxon 
rank sum test, and on categorical characteristics using the chi-square test or Fisher’s exact 
test as appropriate. Continuous outcome measures will be assessed for normality using 
histograms and Q-Q plots, and transformations will be applied as necessary. Sex will be
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
73
treated as a biological variable in our analyses. We will explicitly test for sex effects in all 
aspects of this work by building both joint and separate sex-based CPMs and then contrasting 
the nodes and edges identified in the separate models from the joint model to test for sex 
effects (paired t-test with correction for multiple comparisons based on the number of edges 
selected in the models).
9.4.6
Planned Interim Analyses
There is no interim analysis for efficacy outcomes.
Given the importance of monitoring safety outcomes with this experimental treatment, we 
have developed an interim safety analysis plan and stopping guidelines based on monitoring 
the rates of suicide events. Suicide events include suicide attempts, interrupted suicide events, 
and high levels of suicidal ideation that necessitate emergency evaluation or hospitalization. 
In addition to tables and listings of adverse and serious adverse events, these specific 
analyses will be presented to the DSMB at all meetings following study initiation.
1) Comparison of rates of suicide events between randomized groups (ketamine and 
midazolam) during the double-blind phase. A Fisher’s exact test will be used and if the p- 
value crosses the one-tailed 0.025 significance level (indicating a greater likelihood of events 
in the ketamine group), further enrollment and ketamine treatment will be stopped until the 
DSMB has reviewed the data and made a recommendation about study discontinuation.
2) Evaluation of the rate of suicide events in all participants who receive ketamine to 
determine if it is unacceptably higher than expected. We will compare the rate of suicide 
events in all subjects that receive ketamine (i.e. those initially randomized to ketamine and 
those that cross-over to receive ketamine following the double blind phase) to an acceptable 
rate of 33.8%/6 months. Using a one-sided 0.025 significance level, if the rate is significantly 
higher than 33.8%/6 months, further enrollment and ketamine treatment will be stopped, until 
the DSMB has reviewed the data and made a recommendation about study discontinuation.
In order to maintain the blind and the integrity of the study data, the study team has both a 
blinded and unblinded statistician. Any DSMB reporting of data by treatment group (i.e. 
blinded data) will be prepared solely by the unblinded statistician and sent directly to the 
DSMB liaison. The unblinded statistician will not discuss the results of these analyses with 
the rest of the study team in a manner which challenges the blind. Any relevant DSMB 
queries of this data will go directly to the unblinded statistician, and DSMB communications 
regarding ongoing reviews will proceed as detailed in the NIMH DSMB charter.
9.4.7
Sub-Group Analyses
NA
9.4.8
Tabulation of Individual participant Data
Coded individual participant data will be listed by measure and time point.
9.4.9
Exploratory Analyses
Weekly data on mood and suicidal ideation will be analyzed by mixed-effects regression 
methods to model the trajectories over the 4-month open phase, regardless of the treatment
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
74
assignments. Significance changes of these data from D15 will be tested, with least square 
mean values estimated at each follow-up time points. These estimates and corresponding 95 
CI% will be compared across the 5 response groups. The number of ER, IOP, PHP, or 
inpatient visits between ketamine responders and non-responders will be compared by the 
Poisson or negative-binomial regression analysis. Paired t-tests will be used to compare the 
changes of mood and suicidal ideation in patients who did not have a response to midazolam 
in the blinded phase and went on to receive an open ketamine.
10SUPPORTING DOCUMENTATION 
AND OPERATIONAL 
CONSIDERATIONS
10.1 Regulatory, Ethical, and Study Oversight Considerations
This study will be conducted in accordance with the ethical principles that have their origin in 
the Declaration of Helsinki.
Institutional Review Board (IRB) Review
The protocol will be submitted to the IRB for review and approval. Approval of the protocol 
must be obtained before initiating any research activity. Any change to the protocol or study 
team will require an approved IRB amendment before implementation. The IRB will 
determine whether informed permission and assent and HIPAA authorization are required. 
The IRB will conduct continuing review at intervals appropriate to the degree of risk, but not 
less than once per year. A study closure report will be submitted to the IRB after all research 
activities have been completed. Other study events (e.g. data breaches, protocol deviations) 
will be submitted per Yale University’s IRB's policies.
Study Modification
Any study modifications will be completed in writing to the protocol documents, 
permissions, and assents, and submitted to the Yale IRB for approval, as well as to the 
relevant regulatory authority prior to implementation. Version control will be used to track all 
changes, and only the most recent versions of IRB-approved documents will be used. If a 
modification causes a substantial change to permission or assent documents, participants and 
parents will be re-consented with the up-to-date documents.
In addition to IRB review and approval, the NIMH DSMB may require review of 
protocol/study modifications that are substantial, such as modifications to the eligibility 
criteria or study design. In ambiguous cases, the Sponsor-Investigator will inquire with the 
DSMB to ascertain if review is warranted.
10.1.1 Informed Consent Process
Informed Permission and Assent Processes

Only the most recent IRB-approved version of the informed permission and assent 
documents will be used to consent/assent potential subjects.

If there are two parents or guardians, both most provide permission and each must sign a 
separate permission form. Completed parental permission forms and the adolescent assent
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
75
document must be obtained from every subject who takes part in a study prior to 
performing any study-related activities.

When a potential study subject is identified, the investigator or delegate discusses the 
study in detail with the participant and their parents. An explanation of the study, its risks 
and benefits, and what would be required of the subject is discussed. The potential subject 
and parents or guardians are given a copies of the informed parental permission form and 
assent documents to read in a quiet environment without distraction, including the option 
to take the form home to review and discuss with others. Ample time and opportunity are 
provided for the potential subject, parents, and/or legally authorized representative to ask 
about the details of the study, to consider other available options, and to decide whether 
to participate. All potential participants have the opportunity to discuss study participation 
without their parents or guardians present, to ensure maximum privacy and comfort in 
discussing any sensitive issues (e.g. pregnancy, drug use) and asking study-related 
questions, and to ensure that the adolescent is freely choosing to participate without any 
undue pressure or influence. All questions and concerns to both the adolescent and their 
parents/guardians are addressed throughout this process by the individual obtaining 
permission and assent.

The individual obtaining permission/assent will ensure to the degree possible, and based 
on his/her judgment, that the potential subject and parents or guardian have 
comprehended the information provided about the research. A short quiz at the end of the 
informed consent forms will aid in assessing understanding.

If a potential subject and parents/guardians decide to participate, the parents/guardians are 
asked to sign the permission form only after all questions and concerns have been 
addressed. The adolescent subject is similarly asked to sign the assent document only 
after all questions and concerns have been addressed

The permission forms and adolescent assent form must be signed and dated by the parents 
and participant, along with the individual obtaining consent.

This study will allow for e-consenting using the Part 11-compliant RedCap system. The 
RedCap ICF documents will be identical to their HIC-approved paper counterparts. While 
we anticipate that many or most study discussions and consenting will occur in person, 
the capacity for e-consenting allows flexibility should a participant want to take some 
more time to review the study documents at home after an initial discussion.  We may 
also remotely consent potential subjects when subjects need to travel a long distance in order 
to participate in the trial.
o
The e-consent process is as follows: Any time a permission/assent/consent process 
is conducted remotely, study staff will be present with the participant and their 
family via Zoom session. Participants and parents identify an electronic device to 
access REDCap and open the eConsent as a survey. Time is allotted for any 
additional review of the research study with the participant, answering questions, 
and completing the assessment quiz. Research staff review the results of the quiz 
and review any remaining questions. Participant signature is obtained in RedCap. 
In the part 11-compliant system, each participant and parent will have a unique 
login and password to verify their identity, which only they will know. Staff will 
then review the eConsent form to confirm it is filled out correctly and sign the 
eConsent as the ‘person obtaining consent’.
o
A compact PDF copy of the signed eConsent will be automatically stored in the 
File Repository. A copy of the signed eConsent can be provided to the participant 
and their family either as a paper or electronic document

All signed paper consents will be uploaded and stored in the same Part 11-compliant 
RedCap EDC. The paper original signed permission forms and adolescent assents will be 
kept in a locked filing cabinet in the Child Study Center.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
76

A copy of the parental permission documents, adolescent assent, and any other 
documentation about the research (e.g., calendars, instructions) shall be provided to the 
subject and their parent or guardian.

Documentation of the permission and assent processes will be entered in the subject’s 
source documents (see section on Documentation Related to the Informed 
Permission/Assent Process below).
Additional Assent Information: Assent is an adolescent’s affirmative agreement to participate 
in research. Assent will be sought in addition to the permission of a legally authorized 
representative or surrogate when the individual is sufficiently cognitively capable of 
understanding the nature of his or her participation in a research study, failure to object will 
not be construed as assent (45 CFR 46.402(b); 21 CFR 50.3(n)). A child is any individual 
who at the time of enrollment in a research study has not attained the legal age for consent to 
treatments or procedures involved in the research under the applicable law of the jurisdiction 
in which the research will be conducted (45 CFR 46.402(a); 21 CFR 50.3(o)). In the state of 
Connecticut, the age of majority is 18. Assent will be documented through the adolescent 
signing an assent form. The assent form will be written in language that is appropriate to the 
child or adolescent subject’s maturity and cognitive level and used as part of the assent 
process to 1) describe the research study, including the research procedures, risks and 
benefits, and 2) obtain the child or adolescent’swritten agreement to participate in the study.
Informed Consent Process: If a participant turns 18 while participating in the study, their 
initial assent and parental permissions are no longer sufficient. Once the participant turns 18, 
they will now be asked to provide consent for the study, using a separate consent document. 
The informed consent document is identical to the permission form, with the content 
addressed to “you” rather than “your child or adolescent”. The same principles of informed 
consent apply, as described above for permission and assent.
Re-permission/re-assent/re-consent: If during the course of the study, the protocol has been 
modified in such a way that changes are made to the informed permission or assent forms, 
subjects who have already given their informed permission/provided their assent may be 
required by the IRB to be re-permissioned using the updated form. If the IRB determines that 
re-consenting is required or if it is deemed appropriate by the PI but in the absence of an IRB 
requirement, all subjects currently enrolled in the study must sign the updated informed 
permission form to acknowledge the changes. The subject may be re-consented at the next 
site visit unless otherwise stated by the IRB or Sponsor-Investigator.
Immediate hazards or issues of safety, however, should be communicated to the participant 
and the participant’s parent/guardian upon receipt of the new information or as directed by 
the Sponsor-Investigator. This communication shall be documented in the medical 
record/research chart by the individual who communicated the information to the participant.
Documentation of the Permission/Assent/Consent Process
The individual obtaining informed permission will document the process via a note or 
completion of the source document template. The documentation will include information 
pertinent to the Permission Process (initial consenting and all follow-up consenting through 
the completion of the study):
o
Name and title of person who explained the study
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
77
o
Date(s) of study explanation (if different than date of document signing)
o
Name and title of person who obtained Informed Permission/Assent/Consent (if different 
than above)
o
The actual date Informed Permission/Assent was obtained
o
Individual(s) present when Informed Permission/Assent was obtained
o
Summary of the consenting process that describes that the study was discussed in detail 
including the study design, risk and potential benefits for their participation in the study, 
alternative treatments available, and voluntary nature of participation. In addition, 
indicate that sufficient time was provided for potential subject and their parents to 
read/review permission and assent forms and have questions answered to his or her 
satisfaction and has signed the document and received a copy, and has contact 
information if questions arise.
o
Score of quiz, list of any questions that were missed, and summary of discussion around 
missed questions
10.1.2 Study Discontinuation and Closure
If the study is prematurely terminated or suspended, the Principal Investigator (PI) will 
promptly inform study participants, the Institutional Review Board (IRB), and the DSMB and 
will provide the reason(s) for the termination or suspension. Study participants will be 
contacted, as applicable, and be informed of changes to study visit schedule.
Circumstances that may warrant termination or suspension include, but are not limited to:

Determination of unexpected, significant, or unacceptable risk to participants (please 
see Section 9.4.4, Safety Analyses)

Insufficient compliance to protocol requirements

Data that are not sufficiently complete and/or evaluable
10.1.3 Confidentiality and Privacy
Subject confidentiality is held in strict trust by the research team. Subject medical record 
review will be limited to the just the elements needed to complete the study. Only authorized 
HIPAA and GCP trained study team members will be allowed to extract research data from 
medical records and enter it into RedCap. No direct subject identifiers will be entered into 
RedCap. All NIH-funded research is covered by a Certificate of Confidentiality, which 
applies to the current study. Each subject will be assigned a unique study number. A master 
list linking the unique study number to the human subject will be maintained in a locked 
drawer in the Child Study Center.
Clinical data, outcomes of diagnostic instruments, and research data will be collected by the 
principal investigator and other study personnel and stored in a locked file cabinet in a locked 
office. Data will be entered into a database on a password-protected computer in a locked 
office, by study personnel. Since this is an investigator-initiated study, the PI and study team 
will develop Clinical Research Forms (CRFs) for this study. These forms will be labeled with 
a unique random study code that cannot identify the patient. The key linking the code to the 
subject’s identifiable information will be kept in an electronic excel file which is kept in a 
password protected file, on a password protected computer on the secure Yale server. A paper 
copy of this “master file” will be kept in a locked file cabinet as noted above. This master file 
will be kept separately from any coded data so that the identity of the participant will not be 
disclosed. The results of the medical and psychiatric evaluations conducted as part of this
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
78
research will be available to clinicians caring for the subject unless the participant requests 
otherwise. The Yale Human Investigation Committee may review records of this research. In 
the case of published reports of this study, the identities of all participants will be protected. 
All data obtained from subjects will be coded and stored in locked cabinets/password 
protected computer in an office that is locked to ensure confidentiality. Information that will 
breach subject confidentiality will not be shared. Rather, data will only be released upon 
written consent of the subject and will be available for review by the Yale Human 
Investigation Committee. The PI will also conduct periodic assessments to ensure that 
confidentiality provisions established at the onset of the study are maintained throughout the 
study and during data analysis. Additionally, all staff involved in the handling of subject data 
are/or will be trained on the requirements of HIPAA Privacy Rule and Human Subject 
Protection. If the PI should leave Yale, the PI will collaborate with her Department Chair and 
Faculty Advisor to ensure that proper and continued protection of individually identifiable 
information and protected health information continues.
10.1.4 Future Use of Stored Specimens and Data
Data will be kept in a locked filing cabinet whose access is only obtainable by study 
personnel and electronic clinical data will be kept on a password protected server. As an 
NIMH-funded study, data sharing through the NIMH Data Archive (NDA) is required. NDA 
is a large database where deidentified study data from many NIMH studies are stored and 
managed. Any researcher who requests access to the deidentified data of the NDA is bound to 
adhere to strict data safety practices and to avoid any attempts at deidentification. The 
intention to submit deidentified subject data to the NDA is included in permission and assent 
documents, and participants or guardians are able to opt out of this data sharing at any time.
Opting out of NDA data sharing does not in any way impact trial eligibility.
With the parental permission and participant’s assent, and as approved by the IRB, de- 
identified biological samples will be stored to examine the pharmacokinetics of ketamine 
metabolism in pediatric patients. The specimens will be coded in a way that allows linkage to 
the phenotypic data from each participant, maintaining the blinding of the identity of the 
participant. During the conduct of the study, the parents or an individual participant can 
choose to withdraw permission/assent to have biological specimens stored for future research. 
However, withdrawal of permission/assent with regard to bio sample storage may not be 
possible after the study is completed.
10.1.5 Key Roles and Study Governance
The Study team is led by the PI, Dr. Michael Bloch, MD, MS. Dr. Bloch will oversee all of 
the clinical trial operations, including patient screening, enrollment and consent, treatment, 
and follow up. His clinical team includes an efficacy rater who conducts the blinded ratings 
(this rater in not present during any of the ketamine or midazolam infusions), a pediatric 
psychotherapist with experience working with adolescents with CBT, and a clinical 
coordinator, who schedules patients and assessments, and also assists with the upkeep of 
regulatory binders and reports.
Dr. Gerard Sanacora, MD, PhD, serves as the Scientific Director of the Interventional 
Psychiatry Service (IPS, where medication treatments will occur during this study), and will 
act as a liaison between the study team and IPS to facilitate participant treatment flow.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
79
Dr. Angeli Landeros, MD, is an associate research scientist with extensive experience 
running pediatric depression clinical trials for rapid antidepressants with Dr. Bloch. She will 
assist with participant recruitment and trial logistics.
Dr. R. Todd Constable, PhD, serves as the co-Director of the Magnetic Resource Research 
Center. He will oversee the neuroimaging portion of the study, including leadership on MRI 
sequence parameters, development of the individualized node parcellation algorithm, data 
analysis and pre-processing, and connectcome-based predictive modeling algorithms.
Dr. Eugenia Buta, PhD is responsible for the statistical analysis of the clinical data and 
generating reports for the DSMB.
10.1.6 Safety Oversight
The study will have a NIMH constituted Data Safety Monitoring Board (DSMB) who will 
periodically review and evaluate the accumulated study data for participant safety, study 
conduct, progress, and efficacy. The PI will also conduct an internal review every six months 
to monitor data collection and management of timelines (e.g., implementing data quality 
assurance procedures; updating, editing, and data checking all files; ensuring that protocol 
procedures are being followed, as per the site’s related SOPs). Dr. Dai and the support 
services at the Yale Center for Analytic Science are experienced in study design, preparation 
of study forms, and management of data and preparation of reports related to the progress of 
each study, and will be responsible for preparing reports for the DSMB.
Safety Monitoring:
Participants are very closely monitored in this study, with twice weekly in-person visits 
during the 2-week blinded phase, and weekly visits during the 4-month open phase. The first 
8 weeks of the open phase will be in-person assessments that coincide with the weekly CBT 
that the patient is receiving. During the last 8 weeks of the open phase, weekly assessments 
may be either in person or over the phone if the participant is doing well. There are four 
monthly in-person full batteries that include mood and anxiety assessments, as well as 
cognitive testing. Finally, there are medical safety screens built into our protocol, such that an 
ECG, serum laboratory values (hematologic, hepatic, and renal function) and a urinalysis are 
obtained at baseline, the end of month 2 of the open phase, and the end of month 4 of the 
open phase. Any participant who presents with new symptoms or physical complaints will 
have a medical and laboratory exam prior to the scheduled timepoint.
The multidisciplinary clinical team (efficacy rater, clinical coordinator, psychotherapist, 
and other participating trial staff) is led by the PI, and meets weekly to coordinate treatment 
efforts, monitor each patient’s progress, and to determine whether further participation puts the 
patient at risk. The PI may discontinue a patient from study participation if it appears that the 
study is causing medical or psychiatric safety risks. A patient is also withdrawn at any time if 
he or she so requests or if a female patient becomes pregnant. At the end of the study or when 
a patient discontinues the study prematurely, efficacy evaluations are repeated. In addition, a 
physical exam, vital signs, weight, and laboratory measurements are obtained. Patients are also 
assessed for adverse experiences with the SAFTEE-GI and SAFTEE-SI.
Please also see section 9.4.4, Safety Monitoring, regarding ongoing safety monitoring at the 
group level.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
80
10.1.7 Clinical Monitoring
Clinical site monitoring is conducted to ensure that the rights and well-being of human 
subjects are protected, that the reported trial data are accurate, complete, and verifiable, and 
that the conduct of the trial is compliant with currently approved protocol/amendment(s), 
with GCP, and with applicable regulatory requirement(s). The main features are below.

Monitoring for this study will be performed by NIMH Clinical Research Education, 
Support and Training Program (CREST)

Monitoring will be conducted throughout the study, and involve targeted data 
verification of key data variables

The site PI will be provided copies of monitoring reports within 10 days of each visit 
and will be provided to the NIMH DSMB liaison within 30 days of the visit.

Details of clinical site monitoring are documented in the CMP. The CMP describes 
who will conduct the monitoring, at what frequency monitoring will be done, at what 
level of detail monitoring will be performed, and the distribution of monitoring 
reports.

The site will perform internal quality management of study conduct, data collection, 
documentation and completion. An individualized quality management plan will be 
developed to describe the site’s quality management.
10.1.8 Quality Assurance and Quality Control
The clinical site will perform internal quality management of study conduct, data and 
biological specimen collection, documentation and completion. An individualized quality 
management plan will be developed to describe a site’s quality management.
Quality control (QC) procedures will be implemented beginning with the data entry system 
and data QC checks that will be run on the database will be generated. Any missing data or 
data anomalies will be communicated to the site(s) for clarification/resolution.
Following written Standard Operating Procedures (SOPs), the monitors will verify that the 
clinical trial is conducted and data are generated and biological specimens are collected, 
documented (recorded), and reported in compliance with the protocol, International 
Conference on Harmonisation Good Clinical Practice (ICH GCP), and applicable regulatory 
requirements (e.g., Good Laboratory Practices (GLP), Good Manufacturing Practices 
(GMP)).
The investigational site will provide direct access to all trial related sites, source 
data/documents, and reports for the purpose of monitoring and auditing by the NIMH, and 
inspection by local and regulatory authorities, including the FDA.
Clinical data (including adverse events (AEs), concomitant medications, and expected 
adverse reactions data) and clinical laboratory data will be entered into Yale REDCap, a 21 
CFR Part 11-compliant data capture system provided by Yale University. The data system 
includes password protection and internal quality checks, such as automatic range checks, to 
identify data that appear inconsistent, incomplete, or inaccurate.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
81
For neuroimaging data, we perform many steps to ensure data quality in our imaging center 
including daily phantom studies to test temporal stability, SNR, ghosting measures, and 
contrast levels. The MR techs perform daily stability tests, and scripts automatically upload 
the data, analyze the above measures, and send an alert if any measures are outside the 
acceptable range. During subject scanning, we have a real-time motion correction algorithm 
that provides feedback on subject motion compliance. Subjects can be provided with verbal 
feedback to try to decrease motion if it is too high or specific runs can be repeated if the 
motion is too high. Following these steps, a number of other QC steps are taken during 
analysis as described above (including motion censoring) for those subjects that remained 
still enough to produce useable data.
Rigor: Scientific rigor for the proposed study is established in the following manner: (a) 
experimental design follows state-of-the-art study guidelines; (b) safety, efficacy, and 
neuroimaging data collection is based on well-validated protocols (see below for quality 
assurance), and the same protocol will be used for all subjects; (c) we consider important 
biological variables, such as sex, and strictly follow inclusion and exclusion criteria; (d) all 
results will be compared to well-validated, previously published results; and finally, (e) 
connectome predictors of suicidal ideation generated via CPM will be based on a 10-fold cross- 
validated prediction of constructs—from the standpoint of scientific rigor, cross-validation is a 
more conservative way to infer the presence of a brain-behavior relationship than correlation. 
All results will be corrected for multiple comparisons using the false discovery rate.
Replication: The ultimate replication is a study wherein a model is built in one population and 
validated in another. To encourage replication of this work, we (1) will make the clinical trial 
protocol available, (2) disseminate outcomes as indicated on ClinicalTrials.gov, and (3) will 
make available all of our neuroimaging data, software, and models. We are hopeful that the 
clinical results and connectome predictors identified from the current study will be inform the 
design of a larger trial in suicidal youth, consistent with the aims of the RFA.
Please see also sections 10.1.6 Safety Monitoring and 10.1.7 Clinical Monitoring above
10.1.9 Data Handling and Record Keeping
Private identifiable information will be collected (name, date of birth, age, telephone number, 
address, medical and psychiatric history, diagnoses, laboratory tests, and psychiatric rating 
scores) but will be kept confidential and will not be divulged in any publication emanating 
from this work. The urine toxicology results will not be kept and, as an NIH-funded study, 
this trial is covered by a Certificate of Confidentiality. Risks to subject confidentiality will be 
minimized by adopting suitable data storage procedures. All data for each subject will be 
identified by numerical ID. The master list of subject IDs and names will be stored in a 
locked file at a separate location. Once data are collected and entered, hard copies of the 
testing protocols and clinical notes will be stored in a locked filing cabinet. All research data 
and the clinical information containing PHI are stored separately in locked file cabinets.
Permission and assent forms are stored in yet another location. Throughout these procedures, 
all reasonable precautions are taken to minimize linking any PHI to the research data. All 
computers are password protected and furnished with firewalls and anti-spy and anti-virus 
software in accordance with the general guidelines of the Yale Information Technology and 
HIPAA offices. All data will be stored on a secure server and cloud backup managed by the 
Yale ITS Office. Reports based on these data will not identify subjects by name. The 
database will be maintained within the existing data management system, providing a high
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
82
degree of security and quality monitoring. Clinical data will be entered directly into RedCap 
from the source documents.
Access to Source Documents
Source documents include participant data and records that include but are not limited to the 
following: hospital or medical records, clinical and office charts, laboratory notes, 
memoranda, evaluation checklists, pharmacy dispensing records and records, MAR from 
infusion procedures, recorded data from automated instruments, laboratory values, subject 
files, structural and functional MRI images. Data will be collected electronically in the 
RedCap 21 CFR Part 11-compliant system whenever possible. Any paper source documents 
will be kept in binders located in rooms that are locked when not in use, and are only 
accessible to authorized, trained personnel.
Study Records
Study records include but are not limited to regulatory documents, protocols, permissions, 
assents, consenting checklists, case report forms, and subject medical records.
Retention of Records
Study documents will be retained for a minimum of 2 years after the formal discontinuation 
of clinical development of the study intervention. These documents will be retained for a 
longer period, however, if required by local regulations. No records will be destroyed without 
the written consent of the sponsor, if applicable.
Data or Specimen Storage/Security
Data collection is the responsibility of the clinical trial staff at the site under the supervision 
of the site investigator. The investigator is responsible for ensuring the accuracy, 
completeness, legibility, and timeliness of the data reported. All source documents should be 
completed in a neat, legible manner to ensure accurate interpretation of data.
Hardcopies of the study visit worksheets will be provided for use as source document 
worksheets for recording data for each participant enrolled in the study. Data recorded in 
the electronic case report form (eCRF) derived from source documents should be consistent 
with the data recorded on the source documents.
Clinical data (including adverse events (AEs), concomitant medications, and expected 
adverse reactions data) and clinical laboratory data will be entered into Yale REDCap, a 21 
CFR Part 11-compliant a data capture system provided by Yale University. The data system 
includes password protection and internal quality checks, such as automatic range checks, to 
identify data that appear inconsistent, incomplete, or inaccurate. Clinical data will be entered 
directly from the source documents.
Handling of Missing Data
We will make every reasonable effort to retain all available patients to preserve the integrity 
of the study data and to minimize possible bias due to the missing data points. We will 
minimize the loss of data by having clear data collection and performance standards to 
achieve highest data quality. We will monitor data collection to ensure quality standards are 
met, including targeted levels of data capture.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
83
We will undertake sensitivity analyses to assess the impact of the missing response data on 
our conclusions. We will perform single-step (e.g., missing values on the response variable 
replaced by predicted values from linear or generalized linear models of the longitudinal data 
over time) or multiple imputation and compare the performance of the imputed data results 
compared to complete case analyses. It is important to note that the linear mixed model 
method we propose to use is valid under the assumption that missing data is missing at 
random (MAR). Since it is not possible to test the MAR assumption and since for every 
MNAR model there is an equally well fitting MAR model, we believe that the only suitable 
approach is to perform sensitivity analyses according to different plausible scenarios for 
missing data and make sure the conclusions are consistent. If the results are not consistent 
depending on the assumptions for missing data we will report the conclusions based on each 
set of assumptions.
10.1.10
Protocol Deviations
A protocol deviation is any noncompliance with the clinical trial protocol, 
International Conference on Harmonisation Good Clinical Practice (ICH GCP), or Manual of 
Procedures (MOP) requirements. The noncompliance may be either on the part of the 
participant, the investigator, or the study site staff. As a result of deviations, corrective 
actions are to be developed by the site and implemented promptly.
These practices are consistent with ICH GCP:
•
4.5 Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3
•
5.1 Quality Assurance and Quality Control, section 5.1.1
•
5.20 Noncompliance, sections 5.20.1, and 5.20.2.
It is the responsibility of the site investigator to use continuous vigilance to identify and 
report deviations within 5 working days of identification of the protocol deviation. All 
deviations must be addressed in study source documents and reported Yale HRPP per their 
policies. The site investigator is responsible for knowing and adhering to the reviewing IRB 
requirements. All deviations will also be reported in summary format to the DSMB in the 
triannual reports and to the NIMH program officer in annual progress reports.
10.1.11
Publication and Data Sharing Policy
This study will be conducted in accordance with the following publication and data sharing 
policies and regulations:
NIH Expectation
Study Action
The applicant will ensure that clinical trial under 
the award are registered and results information is 
submitted to ClinicalTrials.gov as outlined in the 
policy and according to the specific timelines 
stated in the policy
Michael Bloch, MD, MS (PI) in 
conjunction with the Yale Center for 
Clinical Investigation (YCCI), will 
be responsible for handling 
ClinicalTrials.gov requirements for 
this project.
We will register the trial prior to 
enrolling the first patient.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
84
Informed consent forms (ICFs) for the clinical trial 
will include a specific statement relating to posting 
of clinical trial information at ClinicalTrials.gov.
Per guidance from Title 
21CFR.50.25 (Part 50, Protection of 
Human Subjects, Subpart B, 
Informed Consent of Human 
Subjects), we will include the 
following statement in the ICF: “A 
description of this clinical trial will 
be available on www.clinical 
trials.gov, as required by US Law. 
This website will not include 
information that can identify you. At 
most, the Web site will include a 
summary of the results. You can 
search this Web site at any time.”
The recipient institution has an internal policy in 
place to ensure that clinical trials registration and 
results reporting occur in compliance with policy 
requirements.
Once a record is established, we will 
confirm accuracy of record content, 
resolve problems and maintain 
records including content update 
and modifications. We will also be 
responsible for aggregate results 
reporting and adverse event 
reporting at the conclusion of the 
project.
In addition, every attempt will be 
made to publish results in peer- 
reviewed journals. Data from this 
study may be requested from other 
researchers 5 years after the 
completion of the primary endpoint 
by contacting the PI.
Under the NIH Public Access Policy, the public 
deserves access to the published results of NIH 
funded research.
The PI will ensure that all peer- 
reviewed manuscripts relating to 
this work will be digitally archived 
with PubMed Central upon 
acceptance for publication.
10.1.12
Conflict of Interest Policy
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons who 
have a role in the design, conduct, analysis, publication, or any aspect of this trial will be 
disclosed and managed. Furthermore, persons who have a perceived conflict of interest will 
be required to have such conflicts managed in a way that is appropriate to their participation 
in the trial. The study leadership in conjunction with the appropriate conflict of interest 
review committee has established policies and procedures for all study group members to 
disclose all conflicts of interest and will establish a mechanism for the management of all 
reported dualities of interest.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
85
All investigators will follow the applicable conflict of interest policies. Yale University 
maintains an up-to-date, written, enforced policy on financial conflicts of interest that 
complies with the requirements of Title 42 C.F.R. Part 50, Subpart F. As part of Yale’s 
standard process, investigators are required to disclose, in writing, significant financial 
interests that relate to their research and other Yale responsibilities. In accordance with 
Yale’s COI policy, Yale’s Conflict of Interest Committee (or its designee) determines 
whether significant financial interests (SFIs) present financial conflicts of interest, and by 
what means such conflicts should be avoided or managed.
Dr. Michael Bloch (the Principal Investigator of this award) and Drs. Angeli Landeros, Todd 
Constable, Feng Dai, and Gerard Sanacora have submitted PHS-compliant conflict of interest 
disclosures to Yale’s Conflict of Interest Office. Yale’s COI Policy, posted at 
https://your.yale.edu/policies-procedures/other/yale-university-policy-conflict-interest, 
describes the specific processes and procedures that are in place to identity, address and 
report financial conflicts of interest.
10.2
Additional Considerations
Funding from 1R01MH125203 (PI Bloch)
10.3
Abbreviations
CADSS
Clinician-Administered Dissociative States Scale
CBT
Cognitive Behavioral Therapy
CDRS-R
Children’s Depression Rating Scale- Revised
CPM
Connective-based Predictive Modeling
C-SSRS
Columbia-Suicide Severity Rating Scale
DBP
Diastolic Blood Pressure
DHNK
Dehydronorketamine
ECG
Electrocardiogram
GCP
Good Clinical Practice
HCP
Human Connectome Project
HNK
Hydroxynorketamine
HR
Heart rate
HSP
Human Subjects Protection
ICH
International Conference for Harmonisation
IDS
Investigational Drug Service
MADRS
Montgomery Asberg Depression Rating Scale
MAR
Medication Administration record
MDD
Major Depressive Disorder
MRI
Magnetic Resonance Imaging
NMDA
N-methyl-D-aspartate receptor
NK
Norketamine
PHI
Protected Health Information
SBP
Systolic Blood Pressure
SOP
Standard Operating Procedures
Abbreviation
Explanation
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
86
TORDIA
Treatment of Resistant Depression in Adolescents Trial
TRD
Treatment Resistant Depression
RDoC
Research Domain Criteria
RFA
Request for Applications
SSRI
Selective Serotonin Reuptake Inhibitor
10.4
Protocol Amendment History
Revision #
Version Date
0
09/04/2020
V1.2
09/14/2020
V1.3
09/15/2020
V1.4
10/27/2020
V2.0
03/05/21
V2.1
04/12/21
V2.2
02AUG2021
V2.3
01SEPT2021
V2.4
19OCT2021
V2.5
15NOV21
V3.0
18FEB22
V 4.4
30JAN2023
V 4.5
11SEPT2023
V 4.6
15APR2024
V 4.7
05SEPT2024
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
87
11 REFERENCES
1.
Li N, Lee B, Liu RJ, et al. mTOR-dependent synapse formation underlies the rapid 
antidepressant effects of NMDA antagonists. Science (New York, NY) 2010; 329(5994): 959- 
64.
2.
Zanos P, Moaddel R, Morris PJ, et al. NMDAR inhibition-independent antidepressant 
actions of ketamine metabolites. Nature 2016; 533(7604): 481-6.
3.
Zanos P, Moaddel R, Morris PJ, et al. Ketamine and Ketamine Metabolite 
Pharmacology: Insights into Therapeutic Mechanisms. Pharmacological reviews 2018; 70(3): 
621-60.
4.
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. The American journal of psychiatry 2015; 172(10): 950-66.
5.
Green SM, Rothrock SG, Harris T, Hopkins GA, Garrett W, Sherwin T. Intravenous 
ketamine for pediatric sedation in the emergency department: safety profile with 156 cases. 
Academic emergency medicine : official journal of the Society for Academic Emergency 
Medicine 1998; 5(10): 971-6.
6.
Green SM, Krauss B. Clinical practice guideline for emergency department ketamine 
dissociative sedation in children. Annals of emergency medicine 2004; 44(5): 460-71.
7.
Dolansky G, Shah A, Mosdossy G, Rieder M. What is the evidence for the safety and 
efficacy of using ketamine in children? Paediatrics & child health 2008; 13(4):307-8.
8.
Cullen KR, Amatya P, Roback MG, et al. Intravenous Ketamine for Adolescents with 
Treatment-Resistant Depression: An Open-Label Study. Journal of child and adolescent 
psychopharmacology 2018; 28(7): 437-44.
9.
Papolos DF, Teicher MH, Faedda GL, Murphy P, Mattis S. Clinical experience using 
intranasal ketamine in the treatment of pediatric bipolar disorder/fear of harm phenotype. 
Journal of affective disorders 2013; 147(1-3): 431-6.
10.
Dwyer JB, Beyer C, Wilkinson ST, Ostroff RB, Qayyum Z, Bloch MH. Ketamine as a 
Treatment for Adolescent Depression: A Case Report. Journal of the American Academy of 
Child and Adolescent Psychiatry 2017; 56(4): 352-4.
11.
Parise EM, Alcantara LF, Warren BL, et al. Repeated ketamine exposure induces an 
enduring resilient phenotype in adolescent and adult rats. Biological psychiatry 2013;74(10): 
750-9.
12.
Brambrink AM, Evers AS, Avidan MS, et al. Ketamine-induced neuroapoptosis in the 
fetal and neonatal rhesus macaque brain. Anesthesiology 2012; 116(2): 372-84.
13.
Sun L, Li Q, Li Q, et al. Chronic ketamine exposure induces permanent impairmentof 
brain functions in adolescent cynomolgus monkeys. Addiction biology 2014; 19(2): 185-94.
14.
Li Q, Shi L, Lu G, et al. Chronic Ketamine Exposure Causes White Matter 
Microstructural Abnormalities in Adolescent Cynomolgus Monkeys. Frontiers in 
neuroscience 2017; 11: 285.
15.
Wilkinson ST, Farmer C, Ballard ED, et al. Impact of midazolam vs. saline on effect 
size estimates in controlled trials of ketamine as a rapid-acting antidepressant. 
Neuropsychopharmacology : official publication of the American College of 
Neuropsychopharmacology 2019.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
88
16.
Bremner JD, Krystal JH, Putnam FW, et al. Measurement of dissociative states with 
the Clinician-Administered Dissociative States Scale (CADSS). Journal of traumatic stress 
1998; 11(1): 125-36.
17.
Montgomery SA, Asberg M. A new depression scale designed to be sensitive to 
change. The British journal of psychiatry : the journal of mental science 1979; 134: 382-9.
18.
Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for 
Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 
2017; 140(3).
19.
Zarate CA, Jr., Brutsche N, Laje G, et al. Relationship of ketamine's plasma 
metabolites with response, diagnosis, and side effects in major depression. Biological 
psychiatry 2012; 72(4): 331-8.
20.
Singh JB, Fedgchin M, Daly EJ, et al. A Double-Blind, Randomized, Placebo- 
Controlled, Dose-Frequency Study of Intravenous Ketamine in Patients With Treatment- 
Resistant Depression. The American journal of psychiatry 2016; 173(8):816-26.
21.
Canuso CM, Singh JB, Fedgchin M, et al. Efficacy and Safety of Intranasal 
Esketamine for the Rapid Reduction of Symptoms of Depression and Suicidality in Patients 
at Imminent Risk for Suicide: Results of a Double-Blind, Randomized, Placebo-Controlled 
Study. The American journal of psychiatry 2018; 175(7): 620-30.
22.
CDC. United States Mortality Tables by 5y Age, Race, Sex (1999-2014). National 
Vital Statistics System 2017; (https://www.cdc.gov/nchs/nvss/mortality/lcwk1.htm).
23.
Patton GC, Coffey C, Sawyer SM, et al. Global patterns of mortality in young people: 
a systematic analysis of population health data. Lancet (London, England) 2009; 374(9693): 
881-92.
24.
Roy A, Segal NL, Sarchiapone M. Attempted suicide among living co-twins of twin 
suicide victims. The American journal of psychiatry 1995; 152(7): 1075-6.
25.
Hawton K, Saunders KE, O'Connor RC. Self-harm and suicide in adolescents. Lancet 
(London, England) 2012; 379(9834): 2373-82.
26.
Health NIoM. Strategic Research Priorities. https://wwwnimhnihgov/about/strategic- 
planning-reports/strategic-research-priorities/indexshtml 2019.
27.
Steele IH, Thrower N, Noroian P, Saleh FM. Understanding suicide across the 
lifespan: a United States perspective of suicide risk factors, assessment & management. 
Journal of forensic sciences 2018; 63(1): 162-71.
28.
Beautrais AL, Joyce PR, Mulder RT. Risk factors for serious suicide attempts among 
youths aged 13 through 24 years. Journal of the American Academy of Child and 
Adolescent Psychiatry 1996; 35(9): 1174-82.
29.
Brent DA, Perper JA, Goldstein CE, et al. Risk factors for adolescent suicide. A 
comparison of adolescent suicide victims with suicidal inpatients. Archives of general 
psychiatry 1988; 45(6): 581-8.
30.
Horwitz AG, Berona J, Czyz EK, Yeguez CE, King CA. Positive and negative 
expectations of hopelessness as longitudinal predictors of depression, suicidal ideation, and 
suicidal behavior in high‐risk adolescents. Suicide and Life‐Threatening Behavior 2017; 
47(2): 168-76.
31.
Reutfors J, Andersson TM, Brenner P, et al. Mortality in treatment-resistant unipolar 
depression: A register-based cohort study in Sweden. Journal of affective disorders 2018; 
238: 674-9.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
89
32.
Chung DT, Ryan CJ, Hadzi-Pavlovic D, Singh SP, Stanton C, Large MM. Suicide 
Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis. 
JAMA psychiatry 2017; 74(7): 694-702.
33.
Dwyer JB, Stringaris A, Brent DA, Bloch MH. Annual Research Review: Defining and 
treating pediatric treatment-resistant depression. Journal of child psychology and psychiatry, 
and allied disciplines 2020; 61(3): 312-32.
34.
Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with 
or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the 
TORDIA randomized controlled trial. Jama 2008; 299(8): 901-13.
35.
Correll CU, Blader JC. Antipsychotic Use in Youth Without Psychosis: A Double- 
edged Sword. JAMA psychiatry 2015; 72(9): 859-60.
36.
Dwyer JB, Leslie FM. Adolescent Maturation of Dopamine D1 and D2 Receptor 
Function and Interactions in Rodents. PloS one 2016; 11(1): e0146966.
37.
Catts VS, Fung SJ, Long LE, et al. Rethinking schizophrenia in the context of normal 
neurodevelopment. Frontiers in cellular neuroscience 2013; 7: 60.
38.
Niciu MJ, Ionescu DF, Richards EM, Zarate CA, Jr. Glutamate and its receptors in 
the pathophysiology and treatment of major depressive disorder. Journal of neural 
transmission (Vienna, Austria : 1996) 2014; 121(8): 907-24.
39.
Mandelli L, Serretti A. Gene environment interaction studies in depression and 
suicidal behavior: An update. Neuroscience and biobehavioral reviews 2013; 37(10 Pt 1): 
2375-97.
40.
Wilkinson ST, Ballard ED, Bloch MH, et al. The Effect of a Single Dose of 
Intravenous Ketamine on Suicidal Ideation: A Systematic Review and Individual Participant 
Data Meta-Analysis. The American journal of psychiatry 2018; 175(2): 150-8.
41.
Strawn JR, Croarkin PE. Commentary: Treatment failure and success: a commentary 
on defining and treating pediatric treatment-resistant depression - reflections on Dwyer et al. 
(2020). Journal of child psychology and psychiatry, and allied disciplines 2020; 61(3): 333-5.
42.
Wilkinson ST, Toprak M, Turner MS, Levine SP, Katz RB, Sanacora G. A Survey of 
the Clinical, Off-Label Use of Ketamine as a Treatment for Psychiatric Disorders. The 
American journal of psychiatry 2017; 174(7): 695-6.
43.
Morgan CJ, Curran HV. Acute and chronic effects of ketamine upon human memory: 
a review. Psychopharmacology 2006; 188(4): 408-24.
44.
Chu PS, Ma WK, Wong SC, et al. The destruction of the lower urinary tract by 
ketamine abuse: a new syndrome? BJU international 2008; 102(11): 1616-22.
45.
Morgan CJ, Dodds CM, Furby H, et al. Long-Term Heavy Ketamine Use is 
Associated with Spatial Memory Impairment and Altered Hippocampal Activation. Frontiers 
in psychiatry 2014; 5: 149.
46.
Niciu MJ, Mathews DC, Nugent AC, et al. Developing biomarkers in mood disorders 
research through the use of rapid-acting antidepressants. Depression and anxiety 2014; 
31(4): 297-307.
47.
Schmaal L, van Harmelen AL, Chatzi V, et al. Imaging suicidal thoughts and 
behaviors: a comprehensive review of 2 decades of neuroimaging studies. Molecular 
psychiatry 2020; 25(2): 408-27.
48.
Abdallah CG, Averill LA, Collins KA, et al. Ketamine Treatment and Global Brain 
Connectivity in Major Depression. Neuropsychopharmacology : official publication of the 
American College of Neuropsychopharmacology 2017; 42(6): 1210-9.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
90
49.
Gabrieli JD, Ghosh SS, Whitfield-Gabrieli S. Prediction as a humanitarian and 
pragmatic contribution from human cognitive neuroscience. Neuron 2015; 85(1):11-26.
50.
Whelan R, Garavan H. When optimism hurts: inflated predictions in psychiatric 
neuroimaging. Biological psychiatry 2014; 75(9): 746-8.
51.
Van Essen DC, Smith SM, Barch DM, Behrens TE, Yacoub E, Ugurbil K. The WU- 
Minn human connectome project: an overview. NeuroImage 2013; 80: 62-79.
52.
Finn ES, Shen X, Scheinost D, et al. Functional connectome fingerprinting:identifying 
individuals using patterns of brain connectivity. Nat Neurosci 2015.
53.
Rosenberg MD, Finn ES, Scheinost D, et al. A neuromarker of sustained attention 
from whole-brain functional connectivity. Nature neuroscience 2016; 19(1): 165-71.
54.
Rosenberg MD, Zhang S, Hsu WT, et al. Methylphenidate Modulates Functional 
Network Connectivity to Enhance Attention. The Journal of neuroscience : the official journal 
of the Society for Neuroscience 2016; 36(37): 9547-57.
55.
Shen X, Finn ES, Scheinost D, et al. Using connectome-based predictive modeling to 
predict individual behavior from brain connectivity. Nature protocols 2017; 12(3): 506-18.
56.
Smith S. Linking cognition to brain connectivity. Nature neuroscience 2015; 19(1): 7- 
9.
57.
Rosenberg MD, Finn ES, Scheinost D, Constable RT, Chun MM. Characterizing 
Attention with Predictive Network Models. Trends in cognitive sciences 2017; 21(4): 290- 
302.
58.
Salehi M, Greene AS, Karbasi A, Shen X, Scheinost D, Constable RT. There is no 
single functional atlas even for a single individual: Functional parcel definitions change with 
task. NeuroImage 2020; 208: 116366.
59.
Finn ES, Scheinost D, Finn DM, Shen X, Papademetris X, Constable RT. Can brain 
state be manipulated to emphasize individual differences in functional connectivity? 
NeuroImage 2017; 160: 140-51.
60.
Leyton M, Kennedy SH. Neuroimaging tests for clinical psychiatry: Are we there yet?
Journal of psychiatry & neuroscience : JPN 2017; 42(4): 219-21.
61.
Lake EMR, Finn ES, Noble SM, et al. The Functional Brain Organization of an 
Individual Allows Prediction of Measures of Social Abilities Transdiagnostically in Autism and 
Attention-Deficit/Hyperactivity Disorder. Biological psychiatry 2019; 86(4): 315-26.
62.
Yip SW, Scheinost D, Potenza MN, Carroll KM. Connectome-Based Prediction of 
Cocaine Abstinence. The American journal of psychiatry 2019; 176(2): 156-64.
63.
Gao S, Greene AS, Constable RT, Scheinost D. Combining multiple connectomes 
improves predictive modeling of phenotypic measures. NeuroImage 2019; 201: 116038.
64.
Finn ES, Shen X, Scheinost D, et al. Functional connectome fingerprinting:identifying 
individuals using patterns of brain connectivity. Nature neuroscience 2015; 18(11): 1664-71.
65.
Hughes CW, Emslie GJ, Crismon ML, et al. Texas children's medication algorithm 
project: update from Texas consensus conference panel on medication treatment of 
childhood major depressive disorder. Journal of the American Academy of Child & 
Adolescent Psychiatry 2007; 46(6): 667-86.
66.
Posner K, Oquendo MA, Gould M, Stanley B, Davies M. Columbia Classification 
Algorithm of Suicide Assessment (C-CASA): classification of suicidal events in the FDA's 
pediatric suicidal risk analysis of antidepressants. The American journal of psychiatry 2007; 
164(7): 1035-43.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
91
67.
Gipson PY, Agarwala P, Opperman KJ, Horwitz A, King CA. Columbia-suicide 
severity rating scale: predictive validity with adolescent psychiatric emergency patients. 
Pediatric emergency care 2015; 31(2): 88.
68.
Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Severity Rating Scale: 
initial validity and internal consistency findings from three multisite studies with adolescents 
and adults. American journal of psychiatry 2011; 168(12): 1266-77.
69.
Mayes TL, Bernstein IH, Haley CL, Kennard BD, Emslie GJ. Psychometric properties 
of the Children's Depression Rating Scale-Revised in adolescents. Journal of child and 
adolescent psychopharmacology 2010; 20(6): 513-6.
70.
Ballard ED, Yarrington JS, Farmer CA, et al. Parsing the heterogeneity of depression: 
An exploratory factor analysis across commonly used depression rating scales. Journal of 
affective disorders 2018; 231: 51-7.
71.
Clyde DJ. SAFTEE: data system for side effect assessment scale. Psychopharmacol 
Bull 1986; 22(1): 287.
72.
Health tNAM, for CWoTaM, (RDoC) RDC. Behavioral 
Assessment
Methods for
RDoC Constructs. 2016.
73.
Daly EJ, Trivedi MH, Janik A, et al. Efficacy of Esketamine Nasal Spray Plus Oral 
Antidepressant Treatment for Relapse Prevention in Patients With Treatment-Resistant 
Depression: A Randomized Clinical Trial. JAMA psychiatry 2019.
74.
Fava M, Freeman MP, Flynn M, et al. Double-blind, placebo-controlled, dose-ranging 
trial of intravenous ketamine as adjunctive therapy in treatment-resistant depression (TRD). 
Molecular psychiatry 2018.
75.
Salloum NC, Fava M, Hock RS, et al. Time to relapse after a single administration of 
intravenous ketamine augmentation in unipolar treatment-resistant depression. Journal of 
affective disorders 2020; 260: 131-9.
76.
Meyer HC, Lee FS. Translating Developmental Neuroscience to Understand Risk for 
Psychiatric Disorders. The American journal of psychiatry 2019; 176(3): 179-85.
77.
Duman RS, Aghajanian GK, Sanacora G, Krystal JH. Synaptic plasticity and 
depression: new insights from stress and rapid-acting antidepressants. Nat Med 2016;22(3): 
238-49.
78.
Brent DA, Greenhill LL, Compton S, et al. The Treatment of Adolescent Suicide 
Attempters study (TASA): predictors of suicidal events in an open treatment trial. Journal of 
the American Academy of Child and Adolescent Psychiatry 2009; 48(10): 987-96.
79.
Brunoni AR, Lopes M, Kaptchuk TJ, Fregni F. Placebo response of non- 
pharmacological and pharmacological trials in major depression: a systematic review and 
meta-analysis. PloS one 2009; 4(3).
80.
Papakostas GI, Petersen T, Pava J, et al. Hopelessness and suicidal ideation in 
outpatients with treatment-resistant depression: prevalence and impact on treatment 
outcome. Focus 2005; 191(1): 444-145.
81.
Posner K, Oquendo MA, Gould M, Stanley B, Davies M. Columbia Classification 
Algorithm of Suicide Assessment (C-CASA): classification of suicidal events in the FDA’s 
pediatric suicidal risk analysis of antidepressants. American journal of psychiatry 2007; 
164(7): 1035-43.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
92
82.
Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide 
attempts in the National Comorbidity Survey. Archives of general psychiatry 1999; 56(7): 
617-26.
83.
Lewinsohn PM, Rohde P, Seeley JR. Adolescent suicidal ideation and attempts: 
Prevalence, risk factors, and clinical implications. Clinical Psychology: Science and Practice 
1996; 3(1): 25-46.
84.
Brown GK, Steer RA, Henriques GR, Beck AT. The internal struggle between the 
wish to die and the wish to live: a risk factor for suicide. The American journal of psychiatry 
2005; 162(10): 1977-9.
85.
Sheehan DV, Sheehan KH, Shytle RD, et al. Reliability and validity of the Mini 
International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). The 
Journal of clinical psychiatry 2010; 71(3): 313-26.
86.
Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: 
initial validity and internal consistency findings from three multisite studies with adolescents 
and adults. The American journal of psychiatry 2011; 168(12): 1266-77.
87.
Cho HS, D'Souza DC, Gueorguieva R, et al. Absence of behavioral sensitization in 
healthy human subjects following repeated exposure to ketamine. Psychopharmacology 
2005; 179(1): 136-43.
88.
Kazdin AE. Evaluation of the Pleasure Scale in the assessment of anhedonia in 
children. Journal of the American Academy of Child and Adolescent Psychiatry 1989; 28(3): 
364-72.
89.
Reid JM, Storch EA, Murphy TK, et al. Development and Psychometric Evaluation of 
the Treatment-Emergent Activation and Suicidality Assessment Profile. Child & youth care 
forum 2010; 39(2): 113-24.
90.
March JS, Parker JD, Sullivan K, Stallings P, Conners CK. The Multidimensional 
Anxiety Scale for Children (MASC): factor structure, reliability, and validity. Journal of the 
American Academy of Child and Adolescent Psychiatry 1997; 36(4): 554-65.
91.
Busner J, Targum SD. The clinical global impressions scale: applying a research tool 
in clinical practice. Psychiatry (Edgmont (Pa : Township)) 2007; 4(7): 28-37.
92.
Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: the 
hopelessness scale. Journal of consulting and clinical psychology 1974; 42(6):861-5.
93.
Byrne DG, Davenport SC, Mazanov J. Profiles of adolescent stress: the development 
of the adolescent stress questionnaire (ASQ). Journal of adolescence 2007; 30(3): 393-416.
94.
Bernstein DP, Stein JA, Newcomb MD, et al. Development and validation of a brief 
screening version of the Childhood Trauma Questionnaire. Child Abuse Negl 2003; 27(2): 
169-90.
95.
Speer ME, Bhanji JP, Delgado MR. Savoring the past: positive memories evoke 
value representations in the striatum. Neuron 2014; 84(4): 847-56.
96.
Gevins A, Cutillo B. Spatiotemporal dynamics of component processes in human 
working memory. Electroencephalogr Clin Neurophysiol 1993; 87(3): 128-43.
97.
Gevins AS, Bressler SL, Cutillo BA, et al. Effects of prolonged mental work on 
functional brain topography. Electroencephalogr Clin Neurophysiol 1990; 76(4): 339-50.
98.
Logan GD, Cowan WB, Davis KA. On the ability to inhibit simple and choice reaction 
time responses: a model and a method. J Exp Psychol Hum Percept Perform 1984; 10(2): 
276-91.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
93
99.
Baron-Cohen S, Jolliffe T, Mortimore C, Robertson M. Another advanced test of 
theory of mind: evidence from very high functioning adults with autism or asperger 
syndrome. Journal of child psychology and psychiatry, and allied disciplines 1997; 38(7): 
813-22.
100.
Corcoran R, Mercer G, Frith CD. Schizophrenia, symptomatology and social 
inference: investigating "theory of mind" in people with schizophrenia. Schizophr Res 1995; 
17(1): 5-13.
101.
Delgado MR, Nystrom LE, Fissell C, Noll DC, Fiez JA. Tracking the hemodynamic 
responses to reward and punishment in the striatum. J Neurophysiol 2000; 84(6): 3072-7.
102.
Delgado MR. Reward-related responses in the human striatum. Annals of the New 
York Academy of Sciences 2007; 1104: 70-88.
103.
Bischoff-Grethe A, McCurdy D, Grenesko-Stevens E, et al. Altered brain response to 
reward and punishment in adolescents with Anorexia nervosa. Psychiatry research 2013; 
214(3): 331-40.
104.
Casement MD, Shaw DS, Sitnick SL, Musselman SC, Forbes EE. Life stress in 
adolescence predicts early adult reward-related brain function and alcohol dependence. 
Social cognitive and affective neuroscience 2015; 10(3): 416-23.
105.
Forbes EE, Hariri AR, Martin SL, et al. Altered striatal activation predicting real-world 
positive affect in adolescent major depressive disorder. The American journal of psychiatry 
2009; 166(1): 64-73.
106.
Hanson JL, Albert D, Iselin AM, Carré JM, Dodge KA, Hariri AR. Cumulative stress in 
childhood is associated with blunted reward-related brain activity in adulthood. Social 
cognitive and affective neuroscience 2016; 11(3): 405-12.
107.
Wagner A, Aizenstein H, Venkatraman VK, et al. Altered reward processing in 
women recovered from anorexia nervosa. The American journal of psychiatry 2007; 164(12): 
1842-9.
108.
Wagner A, Aizenstein H, Venkatraman VK, et al. Altered striatal response to reward 
in bulimia nervosa after recovery. The International journal of eating disorders 2010; 43(4): 
289-94.
109.
Owen AM, McMillan KM, Laird AR, Bullmore E. N-back working memory paradigm: a 
meta-analysis of normative functional neuroimaging studies. Human brain mapping 2005; 
25(1): 46-59.
110.
Verbruggen F, Logan GD. Models of response inhibition in the stop-signal and stop- 
change paradigms. Neuroscience and biobehavioral reviews 2009; 33(5): 647-61.
111.
Congdon E, Mumford JA, Cohen JR, Galvan A, Canli T, Poldrack RA. Measurement 
and reliability of response inhibition. Frontiers in psychology 2012; 3: 37.
112.
Weafer J, Baggott MJ, de Wit H. Test-retest reliability of behavioral measures of 
impulsive choice, impulsive action, and inattention. Exp Clin Psychopharmacol 2013; 21(6): 
475-81.
113.
Baron-Cohen S, Wheelwright S, Hill J, Raste Y, Plumb I. The "Reading the Mind in 
the Eyes" Test revised version: a study with normal adults, and adults with Asperger 
syndrome or high-functioning autism. Journal of child psychology and psychiatry, and allied 
disciplines 2001; 42(2): 241-51.
114.
Fernández-Abascal EG, Cabello R, Fernández-Berrocal P, Baron-Cohen S. Test- 
retest reliability of the 'Reading the Mind in the Eyes' test: a one-year follow-up study. Mol 
Autism 2013; 4(1): 33.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024

APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024
V4.7 05SEPT2024
HIC #2000029003
94
115.
Vellante M, Baron-Cohen S, Melis M, et al. The "Reading the Mind in the Eyes" test: 
systematic review of psychometric properties and a validation study in Italy. Cogn 
Neuropsychiatry 2013; 18(4): 326-54.
116.
Feinberg DA, Moeller S, Smith SM, et al. Multiplexed echo planar imaging for sub- 
second whole brain FMRI and fast diffusion imaging.[Erratum appears in PLoS One. 
2011;6(9). doi: 10.1371/annotation/d9496d01-8c5d-4d24-8287-94449ada5064 Note: 
Gunther, Matthias [added]]. PLoS ONE [Electronic Resource] 2010; 5(12): e15710.
117.
Grunebaum MF, Galfalvy HC, Choo TH, et al. Ketamine for Rapid Reduction of 
Suicidal Thoughts in Major Depression: A Midazolam-Controlled Randomized Clinical Trial. 
The American journal of psychiatry 2018; 175(4): 327-35.
118.
Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and 
powerful approach to multiple testing. Journal of the Royal statistical society: series B 
(Methodological) 1995; 57(1): 289-300.
119.
Dwyer JB, Landeros-Weisenberger A, Johnson JA, et al. Efficacy of Intravenous 
Ketamine in Adolescent Treatment-Resistant Depression: A Randomized 
Midazolam-Controlled Trial. Am J Psychiatry. Apr 1 2021;178(4):352-362.
120.
Wilkinson ST, Ballard ED, Bloch MH, et al. The Effect of a Single Dose of 
Intravenous Ketamine on Suicidal Ideation: A Systematic Review and Individual 
Participant Data Meta-Analysis. Am J Psychiatry. Feb 1 2018;175(2):150-158.
121.
Wang R, Lagakos SW, Ware JH, Hunter DJ, Drazen JM. Statistics in medicine-- 
reporting of subgroup analyses in clinical trials. N Engl J Med. Nov 22 
2007;357(21):2189-2194.
122.
Preacher KJ, Zyphur MJ, Zhang Z. A general multilevel SEM framework for 
assessing multilevel mediation. Psychological methods 2010; 15(3): 209-33.
123.
Bauer DJ, Preacher KJ, Gil KM. Conceptualizing and testing random indirect effects 
and moderated mediation in multilevel models: new procedures and recommendations. 
Psychological methods 2006; 11(2): 142-63.
124.
Papademetris X, Jackowski MP, Rajeevan N, et al. BioImage Suite: An integrated 
medical image analysis suite: An update. The insight journal 2006; 2006: 209.
125.
Joshi A, Scheinost D, Okuda H, et al. Unified framework for development, 
deployment and robust testing of neuroimaging algorithms. Neuroinformatics 2011; 9(1): 69- 
84.
126.
Scheinost D, Papademetris X, Constable RT. The impact of image smoothness on 
intrinsic functional connectivity and head motion confounds. NeuroImage 2014; 95: 13-21.
APPROVED BY THE YALE UNIVERSITY IRB 8/21/2024