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Neurobiological Underpinnings of Depression

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Thank you for contacting us about the study. If you are interested in learning more, please fill out the following questionnaire. Please note that this survey is confidential, but you do not have to respond to any questions which you do not feel comfortable answering. You may also contact MGHNBPstudy@partners.org or 617-724-9458 for more detailed study information.

A screening questionnaire asks you to answer questions about your health and medical history to find out if you might qualify for a study. Our on-line screening questionnaire will be transmitted to study staff using a secure system called "REDCap." There is a small risk that giving your name and/or contact information on the form will result in a loss of confidentiality and/or privacy. We take steps to protect the confidentiality of your information and your privacy. For example, we will destroy any identifiable information you provide if you do not come in for an in-person Screening Visit at MGH. Please note: if you agree, we will keep your contact information so that we may contact you in the future with information about other studies for which you may be eligible, based upon the information you provided.

Complete information about Partners Privacy policies can be found here: http://www.partners.org/Assets/Documents/Notices/Partners_Privacy_Policy_English.pdf

Name:

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It is MGH policy to send emails about research studies with a "send-secure" encryption, which requires an additional login step, to protect your confidentiality. If you prefer, we can send you an email without this encryption, although the confidentiality of these emails cannot be guaranteed. Which would you prefer?

Encrypted emails

Unencrypted emails

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Phone number:

Can we leave a detailed message at this number if we can't reach you?

Yes

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Preferred method of contact:

Phone

Either

What is the best time of day to reach you by phone?

How did you hear about our study?

Which MBTA line?

How old are you?

What gender do you identify with?

Male

Female

Other

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Have you felt sad, blue, or down in the dumps over the past few months for most of the day, nearly every day?

Yes

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Have you lost interested in most of your usual activities or pastimes most of the day, nearly every day?

Yes

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Please list any psychological conditions you have experienced, been treated for, or diagnosed with (e.g., OCD, anxiety, depression, bipolar disorder, bulimia, PTSD, substance abuse).

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Please list any medical conditions you have been treated for or diagnosed with.

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Please list any antidepressant medications you are taking or treatments (e.g. therapy, ECT) you are receiving currently.

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Please list any other medications you are currently taking.

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Have you ever taken Wellbutrin (bupropion) in the past?

Yes

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If yes, why did you stop taking it?

I stopped because of adverse side effects/reactions.

I stopped because it wasn't working.

I stopped because I ran out of medication and didn't refill it.

I stopped for another reason.

Please list any other antidepressant medications you have taken in the past.

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Do you have any metal implants, such as body piercings or permanent retainers, that you cannot remove?

Yes

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If yes, please specify.

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Have you ever experienced:

Seizures

Head injury

Concussions

Did you lose consciousness for more than 2 minutes?

Yes

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Would you be able to come to MGH in Boston, MA for 10 sessions once a week?

Yes

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If you are found ineligible for this study, would you be interested in learning more about other studies for which you may be eligible?

Yes

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