Efficacy and Safety of Esketamine Nasal Spray Plus an Oral Antidepressant in Elderly Patients With Treatment-Resistant Depression—TRANSFORM-3

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Efficacy and safety of esketamine nasal spray plus an oral antidepressant in elderly patients with treatment-resistant depression–TRANSFORM-3 Rachel Ochs-Ross M.D. , Ella J. Daly M.D. , Yun Zhang Ph.D. , Rosanne Lane M.A.S. , Pilar Lim Ph.D. , Randall L. Morrison PhD , David Hough M.D. , Husseini Manji M.D. , Wayne C. Drevets M.D. , Gerard Sanacora M.D., Ph.D. , David C. Steffens M.D., M.H.S. , Caleb Adler M.D. , Rupert McShane M.D. , ¨ Gaillard M.D., Ph.D. , Samuel T. Wilkinson M.D. , Raphael Jaskaran B. Singh M.D. PII: DOI: Reference:

S1064-7481(19)30533-0 https://doi.org/10.1016/j.jagp.2019.10.008 AMGP 1358

To appear in:

The American Journal of Geriatric Psychiatry

Received date: Revised date: Accepted date:

5 April 2019 11 October 2019 14 October 2019

Please cite this article as: Rachel Ochs-Ross M.D. , Ella J. Daly M.D. , Yun Zhang Ph.D. , Rosanne Lane M.A.S. , Pilar Lim Ph.D. , Randall L. Morrison PhD , David Hough M.D. , Husseini Manji M.D. , Wayne C. Drevets M.D. , Gerard Sanacora M.D., Ph.D. , David C. Steffens M.D., M.H.S. , Caleb Adler M.D. , Rupert McShane M.D. , ¨ Gaillard M.D., Ph.D. , Samuel T. Wilkinson M.D. , Jaskaran B. Singh M.D. , Efficacy and Raphael safety of esketamine nasal spray plus an oral antidepressant in elderly patients with treatmentresistant depression–TRANSFORM-3, The American Journal of Geriatric Psychiatry (2019), doi: https://doi.org/10.1016/j.jagp.2019.10.008

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Word Count: 4843 Efficacy and safety of esketamine nasal spray plus an oral antidepressant in elderly patients with treatment-resistant depression–TRANSFORM-3 Rachel Ochs-Ross, M.D.1*, Ella J. Daly, M.D.1, Yun Zhang, Ph.D.2, Rosanne Lane, M.A.S.1, Pilar Lim, Ph.D.1, Randall L. Morrison PhD1, David Hough, M.D.1, Husseini Manji, M.D.1, Wayne C. Drevets, M.D.3, Gerard Sanacora, M.D., Ph.D.4, David C. Steffens, M.D., M.H.S.8,Caleb Adler, M.D.6, Rupert McShane, M.D.7, Raphaël Gaillard, M.D., Ph.D.8, Samuel T. Wilkinson, M.D.4, Jaskaran B. Singh, M.D. 1

Janssen Research & Development, LLC, Titusville, NJ, USA; 2Janssen Research & Development, LLC,

Fremont, CA, USA; 3Janssen Research & Development, LLC, San Diego, CA, USA; 4Yale University School of Medicine, New Haven, CT, USA; 5University of Connecticut School of Medicine, Farmington, CT, USA;6University of Cincinnati College of Medicine, Cincinnati, OH, USA; 7University of Oxford, Oxford, United Kingdom; 8Hôpital Sainte Anne, Paris, France; Corresponding author: *Rachel Ochs-Ross, MD Janssen Research & Development, LLC 1125 Trenton-Harbourton Road Titusville, New Jersey 08560 Tel: +1 609 730-4396 Fax: +1 609 730-2069 Email: [email protected] Conflicts of Interest and Source of Funding Rachel Ochs-Ross, Ella J. Daly, Yun Zhang, Rosanne Lane, Pilar Lim, Randall L. Morrison, David Hough, Husseini Manji, Wayne C. Drevets and Jaskaran B. Singh are employees of Janssen Research & Development and may hold company stock and/or stock options. Rupert McShane reports grants and personal fees from Janssen. Raphaël Gaillard reports personal fees from Janssen, Lundbeck, Roche, Takeda, Astra Zeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Pierre Fabre, Eli Lilly, Lundbeck, Otsuka, Sanofi, and Servier Pharmaceuticals. Samuel Wilkinson reports grants and consulting fees from Janssen. He also acknowledges support from the Agency for Healthcare Research and Quality (K12HS023000), the American Foundation for Suicide Prevention, the Brain and Behavior Research Foundation (formerly NARSAD), and the Robert E. Leet and Clara Guthrie Patterson Foundation. Caleb Adler has received research support through the University of Cincinnati from Activas, Alkermes, Allergan, Cephalon, Forest, Janssen, Johnson and Johnson, Lundbeck, Merck, Otsuka, Pfizer, Shire, 1

Sunovion, Supernus, Syneurex, and Takeda, and has received grant support from Merck and Forest. He is a consultant to Sunovion, Assurex Health, and Neurocrine, and is on the Speaker’s Bureau for Janssen. Gerard Sanacora has received consulting fees from Alkermes, Allergan, AstraZeneca, Avanier Pharmaceuticals, Axsome Therapeutics, Biohaven Pharmaceuticals, Boehringer Ingelheim, Bristol-Myers Squibb, Hoffmann–La Roche, Intra-Cellular Therapies, Janssen, Merck, Minerva Neurosciences, Naurex, Navitor Pharmaceuticals, Novartis, Noven Pharmaceuticals, Otsuka, Perception Neuroscience, Praxis Therapeutics, Sage Pharmaceuticals, Servier Pharmaceuticals, Taisho Pharmaceuticals, Teva, Valeant, and Vistagen Therapeutics. He has also received research contracts from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Johnson & Johnson, Hoffmann–La Roche, Merck, Naurex, and Servier Pharmaceuticals. No-cost medication was provided to Dr. Sanacora for an NIH-sponsored study by Sanofi-Aventis. In addition, he holds shares in Biohaven Pharmaceuticals Holding Company and is a co-inventor on the patent “Glutamate agents in the treatment of mental disorders” (patent 8778979) and a provisional Patent Application No. 047162-7177P1 (00754) filed on August 20, 2018 by Yale University Office of Cooperative Research OCR 7451 US01 Abdallah, C, Krystal, JH, Duman, R, Sanacora, G. Combination Therapy for Treating or Preventing Depression or Other Mood Diseases. David Steffens reports consulting income from Janssen Research & Development. All authors meet ICMJE criteria, had access to the study data, and made the final decision about where to publish these data. This study was supported by Janssen Research & Development, LLC, Titusville, NJ, USA

Key words: Ketamine, esketamine, treatment-resistant depression, major depressive disorder, elderly

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ABSTRACT (250/250) Background: Elderly patients with major depression have a poorer prognosis, are less responsive to treatment and show greater functional decline compared with younger patients, highlighting the need for effective treatment. Methods: This phase 3 double-blind study randomized patients with treatment-resistant depression (TRD) ≥65 years (1:1) to flexibly-dosed esketamine nasal spray and new oral antidepressant (esketamine/antidepressant) or new oral antidepressant and placebo nasal spray (antidepressant/placebo). The primary endpoint was change in the Montgomery–Åsberg Depression Rating Scale (MADRS) from baseline to day 28. Analyses included a pre-planned analysis by age (65-74 vs ≥75 years) and post-hoc analyses including age at depression onset. Results: For the primary endpoint, the median-unbiased estimate of the treatment difference (95% CI) was -3.6 (-7.20, 0.07); weighted combination test using MMRM analyses z=1.89, 2-sided p=0.059. Adjusted mean (95% CI) difference for change in MADRS score between treatment groups was -4.9 (8.96, -0.89; t= -2.4 , df=127; 2-sided nominal p=0.017) for patients 65-74 years vs -0.4 (-10.38, 9.50; t= 0.09, 2-sided nominal p=0.930) for those ≥75 years, and -6.1 (-10.33, -1.81; t= -2.8, df=127; 2-sided nominal p=0.006) for patients with depression onset <55 years and 3.1 (-4.51, 10.80; t= 0.8, 2-sided nominal p=0.407) for those ≥55 years. Patients who rolled over into the long-term open-label study showed continued improvement with esketamine following 4 additional treatment weeks. Conclusions: Esketamine/antidepressant did not achieve statistical significance for the primary endpoint. Greater differences between treatment arms was seen for younger patients (65-74 years) and patients with earlier onset of depression (<55 years). HIGHLIGHTS What is the primary question addressed by this study? This first-in-kind randomized, double-blind, active-controlled trial for treatment-resistant depression (TRD) (i.e., non-response to ≥2 antidepressants in the current episode of depression) in patients ≥ 65 years of age, assessed the efficacy and safety of esketamine nasal spray plus a newly initiated oral antidepressant (esketamine/antidepressant) as compared with a newly initiated oral antidepressant and placebo nasal spray (antidepressant/placebo). What is the main finding of the study? The primary efficacy analysis did not show a statistically significant treatment difference between esketamine/antidepressant and antidepressant/placebo following 4 weeks of treatment. Subgroup analyses suggested improvement in depression in participants in the esketamine/antidepressant group who were aged 65-74 years and in those with an onset of depression <55 years of age. Further research is needed to assess esketamine treatment in the elderly. 3

What is the meaning of the finding? The study was designed to assess efficacy and safety of esketamine in a dedicated study of older patients.The primary results were not statistically significant. However, subgroup analyses suggest improvement in “younger” elderly patients. Additional analyses were supportive and suggested longer treatment duration may be useful; the safey profile was comparable with other esketamine studies in younger patients. INTRODUCTION Major depressive disorder (MDD) significantly impacts older adults, and is associated with increased disability, diminished quality of life, functional and cognitive decline, increased hospitalization, and increased caregiver burden.1 Electroconvulsive therapy (ECT) is used more frequently in older, compared with younger, patients because of poorer response and remission rates to conventional therapies in older MDD patients.2, 3 While ECT is beneficial, despite recent methodological improvements, patients may experience increased blood pressure (BP)4, impaired cognition, and significant tolerability issues.5 Therefore, an unmet need for novel anti-depressant treatment exists. Recently, results from a doubleblind crossover pilot study in older patients with treatment-resistant depression (TRD), showed greater efficacy of ketamine, compared with an active control (midazolam).6 Esketamine, the S-enantiomer of ketamine racemate, has a 3- to 4-fold higher affinity to N-methyl-Daspartate receptors than the R-enantiomer.7, 8 Two phase 2 randomized clinical trials of esketamine (intravenous and nasal spray) in TRD patients under 65 years, demonstrated rapid-onset, dose-related antidepressant effects.9, 10 A nasal spray, versus intravenous administration, was developed for easier patient access. Phase 3 studies of esketamine nasal spray administered with a newly-initiated oral antidepressant in TRD aged patients 18-64 years11, 12 subsequently demonstrated rapid onset versus a newly initiated oral antidepressant (active comparator) plus placebo nasal spray, with maintenance of the treatment effects following long-term intermittent dosing.13 This phase 3, randomized, double-blind, multicenter study compared the efficacy and safety of flexiblydosed (28 mg, 56 mg or 84 mg) esketamine nasal spray plus a newly-initiated oral antidepressant with a newly-initiated oral antidepressant (active comparator) plus placebo nasal spray in adults ≥65 years of age with TRD. Additional efficacy analyses included a pre-planned assessment by age subgroup at study entry and post-hoc analyses assessing age of depression onset, impact of the interim analysis (IA) including an unweighted analysis, dose effects, and potential impact of an additional four weeks of treatment. Safety and tolerability were assessed. METHODS Ethical Practices An Institutional Review Board (United States) or Independent Ethics Committee (Europe) approved study protocol and amendments. The study (NCT02422186; clinicaltrials.gov) was conducted in

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accordance with the Declaration of Helsinki, Good Clinical Practices, and applicable regulatory requirements. All participants provided written informed consent. Study Design This phase 3, randomized, double-blind, active-controlled, multicenter study, conducted in 13 countries between August 2015 and August 2017, had 3 phases: (1) 4-week screening/prospective observational phase assessing response to current antidepressant treatment; (2) 4-week double-blind induction phase with flexibly-dosed nasal spray study medication (esketamine or placebo) plus a newly-initiated oral antidepressant; (3) 2-week post treatment follow-up phase assessing safety and tolerability, including potential withdrawal symptoms. Following the 4-week double-blind induction phase, regardless of treatment response, patients could participate in a long-term open-label safety study (NCT02497287).14 Otherwise, patients who received ≥1 dose of nasal spray study medication, and either withdrew early from the double-blind induction phase or did not participate in the long-term open-label safety study, entered the 2-week follow-up. Study Participants Patients were ≥65 years old and diagnosed with recurrent moderate to severe MDD without psychotic features (Table 1). Randomized patients had TRD, defined as no clinically meaningful improvement following treatment with ≥2 different antidepressant agents, prescribed in adequate dosages for adequate duration, during the current episode of depression (Table 1). Key exclusion criteria included diagnosis of a psychotic disorder, MDD with psychotic features, bipolar or related disorders, current obsessive-compulsive disorder, intellectual disability, cognitive impairment, suicidal ideation with intent to act within 6 months and uncontrolled hypertension. Patients were required to have normal vital signs (including BP and pulse oximetry) and normal 12-lead ECG. Supplementary Digital Content S1 lists complete inclusion/exclusion criteria. Randomization and Blinding A computer-generated randomization schedule was used to randomize patients (1:1) to nasal spray treatment, either esketamine or placebo, stratified by country and by class of the oral antidepressant medication (serotonin-norepinephrine reuptake inhibitor [SNRI] or selective serotonin reuptake inhibitor [SSRI]). Patients, investigators, site personnel, and those involved in study design, implementation, data management or statistical analysis were blinded to study treatment. Placebo and 5

esketamine nasal spray devices were indistinguishable, and to simulate the taste of esketamine, a bittering agent (denatonium benzoate) was added to the placebo solution. Nasal Spray Study Drug Patients were randomized (1:1) to flexibly-dosed esketamine or placebo nasal spray (28 mg, 56 mg or 84 mg), and dosed twice-weekly for 4 weeks. Patients self-administered the study drug at the study site under direct supervision of site staff (Table 2). Patients initially received 28 mg of esketamine or placebo nasal spray. Subsequent study drug dose adjustments (28 mg, 56 mg, 84 mg) were based on investigator determination of efficacy and tolerability (Table 2). Newly Initiated Oral Antidepressant Antidepressant/(s) was (were) tapered/discontinued at the end of the screening/prospective observational phase. Investigators, using clinical judgment and prior history, selected one of four new open-label oral antidepressant (duloxetine, escitalopram, sertraline, or venlafaxine XR) not used in the current depressive episode. Daily dosing, beginning on day 1, was titrated to the maximally tolerated dose. Efficacy Assessments The primary efficacy endpoint, change in Montgomery–Åsberg Depression Rating Scale (MADRS) total score from baseline to endpoint, was assessed telephonically by remote raters (since transient dissociation, caused by esketamine, may have biased research staff) using the MADRS structured interview guide.15 Additional efficacy endpoints included: rates of response (≥50% reduction from baseline in the MADRS total score) and rates of remission (MADRS ≤12) at day 28, change from baseline to endpoint in severity of depressive illness (Clinical Global Impression–Severity [CGI-S]16, Patient Health Questionnaire 9-Item [PHQ-9])17, and function assessed by the Sheehan Disability Scale (SDS).18 Rapidity of response was not assessed because of anticipated sub-therapeutic efficacy of the initial 28 mg dose. Safety Treatment-emergent adverse events (TEAEs) and other safety assessments [hematology and serum chemistry, urinalysis, physical examination, electrocardiogram, suicidal ideation and behavior based on Columbia Suicide Severity Rating Scale C-SSRS19] were monitored throughout the study. Vital signs, 6

dissociative symptoms [using the Clinician-Administered Dissociative States Scale (CADSS)20], and the 4-item positive symptom subscale of the Brief Psychiatric Rating Scale (BPRS)21 were assessed on dosing days at baseline and at 40 minutes, 1 hour (vital signs only), and 1.5 hours after dosing. Computerized cognitive battery (Cogstate)22, 23 was used to assess multiple cognitive domains, including attention (simple and choice reaction time), visual learning and memory, executive function; the Hopkins Verbal Learning Test-Revised (HVLT-R)24 was used to measure verbal learning and memory. Post-dose sedation was measured prior to dosing, and every 15 minutes up to 1.5 hours after dosing, using the Modified Observer’s Assessment of Alertness/ Sedation scale (MOAA/S)25. Investigators assessed patients’ discharge readiness (based on overall clinical status, including sedation, BP, and adverse events) using the Clinical Global Assessment of Discharge Readiness (CGADR) scale at 1 hour and 1.5 hours after dosing. The 20-item Physician Withdrawal Checklist (PWC-20) was used to assess withdrawal effects during the follow-up phase.26 Statistical Methods Efficacy analyses in the double-blind phase were based on analysis sets that included all randomized patients who received ≥1 dose of nasal spray study medication and one dose of oral antidepressant medication. Safety assessments during double-blind phase were summarized for the safety analysis set which included all randomized patients who received ≥1 dose of study drug or 1 dose of oral antidepressant. Analyses were performed using SAS, version 9.2. The maximum sample size planned for this study was calculated assuming a treatment difference, after the double-blind induction phase, of 6.5 points in MADRS total score between esketamine and the active comparator, with a standard deviation (SD) of 12, a two-sided significance level of 0.05, and a drop-out rate of 25%. A maximum of approximately 74 patients were to be randomized to each treatment group to achieve 80% power using a fixed design assuming no IA. The treatment difference and SD were based on results of Panel A from a phase 2 study9 and on clinical judgment. An IA occurred after 51 patients were randomized to re-estimate sample size or stop the study due to futility. No esketamine team members, or investigational site personnel, were informed of the results of the IA or of any adjustments made to the sample size. Statistical tests used a two-sided significance level of 0.05 unless otherwise specified. The primary efficacy variable was analyzed using a mixed-effect model for repeated measures (MMRM) with baseline MADRS total score as a covariate with treatment, region, class of antidepressant (SSRI or SNRI), day, and day-by-treatment interaction as fixed effects. Least square (LS) means (i.e. adjusted for terms included in the MMRM model) were provided at each timepoint. To adjust for the IA, the primary 7

endpoint was analyzed using a weighted combination test that defined test statistics from the MMRM analyses as a weighted sum of stage 1 (pre-IA) and stage 2 (post-IA) test statistics. Stages were weighted equally regardless of the sample size in each stage. The median-unbiased estimate and flexible confidence interval were used for estimation of the treatment difference from antidepressant/placebo at day 28.27 Additional measures of efficacy including response and remission rates were summarized at each visit. Additionally, number needed to treat (NNT), the average number of patients needed to produce one more responder/remitter in the esketamine/antidepressant group than in the antidepressant/placebo group was calculated for response and remission. The odds ratio for an improved CGI-S score was estimated by mapping the ordinal scale to a continuous scale using item response modelling via the logit model28, 29 and analyzed using an ANCOVA model. Descriptive statistics of actual values and changes from baseline were provided for PHQ-9 and SDS. Additional efficacy analyses for the primary endpoint using MMRM models were performed for a preplanned assessment of age (65-74 or ≥75 years) and a post-hoc assessment of age at MDD onset (<55 or ≥55 years). Models included baseline MADRS total score as a covariate, and treatment, region, class of antidepressant (SSRI or SNRI), age, day, treatment-by-day, treatment-by-age, and treatment-by-day-byage interaction as fixed effects. Additional analyses investigating age at study enrollment, and at MDD onset, as continuous variables were performed using a similar MMRM model. The estimated change in MADRS total score at day 28, and the 95% confidence band versus age and age of onset, were plotted for each treatment group. Additional post-hoc analyses included MMRM analysis by study stage and using an unweighted analysis. Frequency distributions or descriptive statistics were provided for adverse events, clinical laboratory tests, vital signs, electrocardiograms values, cognitive tests and scores for clinician reported outcomes (including C-SSRS, MOAA/S, CADSS and CGADR). RESULTS The pre-planned IA of efficacy data conducted 4 weeks after randomizing 51 patients determined a final sample size of 100, the minimum sample size for the study. Patients in, or about to enter, the screening phase could continue the study resulting in over 100 patients being randomized. Participants Of 302 screened patients, 138 were randomized (esketamine/antidepressant [n=72]; antidepressant/placebo [n=66]); 122 (88.4%) completed the double-blind phase (Fig. 1). A total of 77.8% patients in the esketamine/antidepressant, and 81.5% in the antidepressant/placebo, group received treatment on all 8 dosing days. One patient in the antidepressant/placebo group did not receive study medication and was not included in the safety and full analysis sets; 16 (11.6%) patients withdrew prior to completing the double-blind

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phase. Six (4.3%) withdrew following a TEAE (most common reason): 4 treated with esketamine/antidepressant and 2 with antidepressant/placebo. Fifteen patients entered the follow-up phase (n=11 completed, n=4 withdrew); 111/138 (80.4%) entered the long-term safety study14 and 2 entered the long-term safety extension study (NCT02782104). Baseline characteristics were similar between treatment groups (Table 3). The mean (SD) baseline MADRS total score was 35.2 (6.16). Based on CGI-S scores, 49.6% (67/137) of patients were markedly ill and 24.8% (34/137) were severely ill. Efficacy Primary Endpoint Change in MADRS total score from baseline to day 28, based on the weighted MMRM analysis, did not reach statistical significance (Table 4). The median unbiased estimate of the difference (95% CI) between the esketamine/antidepressant and the antidepressant/placebo group was -3.6 (-7.20, 0.07); weighted combination test (based on MMRM analyses) z=1.89, 2-sided p=0.059. Additional Endpoints Response rates were 27.0% (17/63) in the esketamine/antidepressant and 13.3% (8/60) in the antidepressant/placebo group (Fig 2). The NNT for response at day 28 was 8. Remission rates were 17.5% (11/63) in the esketamine/antidepressant versus 6.7% (4/60) in the antidepressant/placebo group. NNT for remission at day 28 was 10. Decreased severity of depressive symptoms based on the CGI-S is shown in Figure 3. The median (range) change from baseline was -1.0 (-4, 1) in the esketamine/antidepressant versus 0 (-4, 3) in the antidepressant/placebo group. The odds ratio (95% CrI) of 5.3 (1.85, 15.85), showed odds of an improved CGI-S score for patients treated with esketamine/antidepressant that was 5.3 times that of those treated with antidepressant/placebo. The mean (SD) changes from baseline for SDS (esketamine/antidepressant: -6.1 [8.35] vs antidepressant/placebo: -3.8 [5.95]) and PHQ-9 total scores (esketamine/antidepressant: -6.0 [7.17] versus antidepressant/placebo: -3.3 [7.09]) are in Fig. 4. Additional Efficacy Analyses A forest plot of the LS means (95% CI) treatment difference of change in MADRS total score using MMRM from baseline to day 28 by subgroups including patient age during the study, age of onset of depression and impact of the IA is shown in Fig. 5 and discussed below. (1) Pre-specified analysis by age at study entry (age groups required by the European Medicines Agency [EMA]), showed a LS mean difference (95% CI) of -4.9 (-8.96, -0.89) (t = -2.4 , df=127; 2-sided nominal p9

value=0.017) between treatment groups for change in MADRS total score at day 28 for patients 65-74 years vs -0.4 (-10.38, 9.50) for patients ≥75 years (t = -0.09, df= 127; 2-sided nominal p-value=0.930) (Fig. 5,6). Patients 65-74 years had an earlier separation between treatment groups, compared with those ≥75 years. Assessment of age as a continuous variable also showed greater improvement with esketamine/antidepressant in younger patients (Fig. 7). (2) Age of patient at depression onset showed greater improvement in patients with an earlier age of depression onset based on a post-hoc analysis. LS means (95% CI) treatment difference for the change in MADRS total score at day 28 was -6.1 (-10.33, -1.81) (t = -2.8, df=127; 2-sided nominal p-value=0.006) with an onset of depression <55 years vs. 3.1 (-4.51, 10.80) (t = 0.8, df=127; 2-sided nominal pvalue=0.407) with onset ≥55 years (Fig. 8). Using age of depression onset as a continuous variable, showed greater improvement for the esketamine/antidepressant at earlier ages of depression onset (Fig. 9). (3) A treatment difference for change in MADRS total scores between treatment groups was seen between stage 1 and 2 (pre and post IA) (Fig.10): LS mean (95% CI) difference of -1.6 (-6.85, 3.70) in stage 1 vs -5.6 (-10.78, -0.32) in stage 2. Since an IA was performed, the primary analysis used a weighted combination test with equal weights pre-specified for each stage. However, stage 2 (n=86) had more patients than stage 1 (n=51). Therefore, data from stage 2 were down-weighted (86 patients in stage 2 given the same weight as 51 in stage 1). An unweighted analysis using MMRM, showed a LS mean difference of -4.0 (95% CI: -7.71, -0.25) between esketamine/antidepressant vs antidepressant/placebo (Fig. 11). (4) Doses used in this trial were lower compared with doses used in esketamine trials of patients aged 18-64 years (56 and 84 mg). Investigators increasingly used higher doses of esketamine during the later portion of the study, possibly due to familiarity with the compound (Fig. 12). As a result, the percentage of patients who received 84 mg at day 25 was 52.2% (stage 1) vs 71.8% (stage 2). (5) Treatment duration: 111/138 (80.4%) patients entered the long-term open-label safety and efficacy study14 that included 88 (79.3%) non-responders (entered a second 4-week induction period) and 23 (20.7%) responders (entered the optimization/maintenance phase). Similar percentages of patients received 84 mg at the end of the second induction period (68%) as in the current study (65%).14 The oral antidepressant was unchanged in all patients. MADRS total scores continued to decrease in 93% (82/88) of patients who completed the additional 4-week second induction phase with 69.5% (52/82) responders and 46.3% (38/82) remitters (Fig. 13). Improvements were observed in both patients aged 65-74 years and in those ≥75 years (Supplementary Digital Content S3). SAFETY During the double-blind phase, TEAEs occurred in 70.8% (51/72) of patients receiving esketamine/antidepressant, and 60.0% (39/65) receiving antidepressant/placebo (Table 5). The most common TEAEs in the esketamine/antidepressant group were dizziness (20.8%), nausea (18.1%), a generally transient elevation in BP (resolved in 2 hours in approximately 80% of patients), fatigue,

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headache, and dissociation (12.5% for each). In the antidepressant/placebo group, the most common TEAEs were anxiety, fatigue, and dizziness (7.7% for each). Discontinuation due to ≥1 TEAE occurred in 5.6% (4/72) in the esketamine/antidepressant vs 3.1% (2/65) in the antidepressant/placebo group (Table 6). Most TEAEs were mild or moderate in severity and resolved on the nasal dosing day. Serious adverse events (SAEs) were reported in 5 patients during the double-blind phase: 3 in the esketamine/antidepressant and 2 in the antidepressant/placebo group (Table 6). No deaths were reported. History of hypertension was reported in 73/137 (53.3%) patients. The greatest mean increase in systolic BP was 16.0 mm Hg (esketamine/antidepressant) vs 11.1 mm Hg (antidepressant/placebo) and 9.5 mm Hg (esketamine/antidepressant) vs 6.8 mm Hg in diastolic BP. Increases in BP peaked at 40 minutes postdose and generally returned to near pre-dose values by 1.5 hours post-dose (Supplementary Digital Content S4); increases in mean BP in the antidepressant/placebo group occurred at each post-dose timepoint. In the induction phase, the TEAE of BP increased was reported in 12.5% (9/72) of patients in esketamine/antidepressant, and 4.6% (3/65) in the antidepressant/placebo group. Treatment-emergent acute hypertension with a systolic BP ≥180 mm Hg, was seen in 2/72 (2.8%) patients in the esketamine/antidepressant and 1/65 (1.5%) patient in the antidepressant/placebo group; diastolic BP ≥100 mm Hg was seen in 7/72 (9.7%) patients in the esketamine/antidepressant and 3/65 (4.6%) in the antidepressant/placebo group. One patient in each group had a diastolic BP ≥105 mm Hg while no patients had diastolic BP ≥110 mm Hg. (Supplementary Digital Content S5). No clinically significant changes in laboratory evaluations, electrocardiograms, nasal tolerability (using the nasal examination) were reported in the double-blind phase. No clinically significant decreases in respiratory rate or cases of interstitial cystitis were reported. No suicide attempts or suicidal behavior were reported; most patients (≥79.4%) had a score of 0 on the CSSRS at baseline. In the esketamine/antidepressant group, the maximum baseline C-SSRS score of 3 (active suicidal ideation - no intent) was reported in 1 (1.4%) patient. In the antidepressant/placebo group, the maximum baseline score on the C-SSRS was 2 (non-specific suicidal thought) reported in 2 (3.1%) patients. Eight of 70 (11.4%) patients in the esketamine/antidepressant and 9/65 (13.8%) in the

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antidepressant/placebo group had postbaseline suicidal ideation; none had suicidal ideation at baseline. (Supplementary Digital Content S6). Mean CADSS scores in the esketamine/antidepressant group peaked at the 40-minute post-dose assessment and returned to near pre-dose values at 1.5-hour post-dose (Supplementary Digital Content S7), indicating that dissociative and perceptual symptoms occurred shortly after the start of esketamine dosing, generally resolving by 1.5 hours post-dose. Moderate or greater sedation (MOAA/S score ≤3) was reported in ≤3.4% of patients in the esketamine/antidepressant group on each treatment day (Supplementary Digital Content S8). Six patients (8.3%) manifested moderate or greater sedation at any time during the induction phase in the esketamine/antidepressant group vs 1 (1.5%) patient in the antidepressant/placebo group. During the induction phase 1 (1.4%) patient reported the TEAE of somnolence in the esketamine/antidepressant vs 3 (4.6%) patients in the antidepressant/placebo group. Most patients were considered ready for discharge at 1.5 hours after dosing: 90% in the esketamine/antidepressant (range 1.5 to 3 hours [median 1.75 hours]), and 95% in the antidepressant/placebo (range 1.5 to 3.25 hours [median 1.75 hours]) group, based on the CGADR. Approximately 50% of patients in the esketamine/antidepressant and 85% in the antidepressant/placebo arm were considered ready for discharge 1 hour after dosing. For the remaining patients, readiness for discharge post-dose in the esketamine/antidepressant group ranged from 1.5 to 3 hours (median 1.75 hours) vs 1.5 to 3.25 hours (median 1.75 hours) in the antidepressant/placebo group. The 2-week follow-up phase included 15 patients (n=12, esketamine/antidepressant; n=3, antidepressant/placebo). The most frequently reported (≥2 patients) new or worsened symptoms in the esketamine/antidepressant group on the PWC-20 included difficulty concentrating, remembering (n=3), loss of appetite (n=2), anxiety-nervousness (n=2), and nausea-vomiting (n=2) vs 2 patients with dizziness-lightheadedness in the antidepressant/placebo group. There was no evidence of a withdrawal syndrome with esketamine. Analyses of cognitive test performances conducted for the safety analysis set showed slight improvement, or findings comparable to baseline, at the end of the double-blind induction phase, including all measures of higher cognitive function (visual, verbal, and working memory, executive function) in both treatment groups (Supplementary Digital Content S9). Slowing of simple reaction time (Cogstate Detection Test) was observed at day 28 versus baseline for both treatment groups. The slowing for each group was small; the Cohen’s d value for change in simple reaction time from baseline to day 28 in the esketamine/antidepressant group was 0.12 vs 0.18 in the antidepressant/placebo group. Therefore, this finding was considered to have doubtful clinical relevance. 12

DISCUSSION While the primary endpoint of change in MADRS total score from baseline showed 3.6 points mean reduction in the esketamine/antidepressant versus the antidepressant/placebo group, this difference was not statistically significant. Notably, this between treatment group difference is comparable to the average 2 to 3-point difference observed between previously approved antidepressant and placebo groups and is in a range typically considered clinically meaningful.30, 31 This observation was corroborated by the secondary and sub-group analyses from this study and were consistent with observations from esketamine studies in younger patients.9-12 A treatment difference was suggested by the difference between treatment groups for patients aged 65-74 years and for patients with an earlier depression onset (Fig. 8). Notably, the sample size estimation was based on an anticipated -6.5-point difference between treatment groups was considerably larger than the typical 2 to 3-point difference seen in antidepressant studies; this optimistic assumption may have contributed to the lack of statistical significance in the primary outcome. The sample size determination was based on results from a phase 2 study in younger patients that did not initiate a new oral antidepressant at randomization.9 CGI-S, PHQ-9 and SDS showed magnitudes of changes consistent with those found in 18-64-year-old patients from other esketamine studies. Values for response and remission rates, while lower than rates seen in younger patients from other esketamine studies, showed comparable between group differences as those shown in previous studies of younger patients.9-12. For example, the response rate in the antidepressant/placebo group (13.8%) was relatively lower than those reported in studies of younger patients (38.9% and 52.0% in the two phase 3 short term studies).11, 12 Additional analyses assessed factors that potentially contributed to lack of statistical significance in the primary endpoint. Analysis of age of patients at study entry, a pre-specified assessment, suggested a greater reduction in MADRS total scores in 65-74-year-old patients treated with esketamine compared to placebo that was not observed in patients aged ≥75 years. Separation in the curves for the change in MADRS total score was also noted earlier in the study for 65-74-year-old patients (Fig. 6). Some delay in separation may be 13

related to the lower 28 mg starting dose in this study, compared with the 56 mg starting dose in esketamine studies with younger patients. The lack of treatment response in patients ≥75 years may be related to the small number of patients (n=21) who were ≥75 years. Factors such as comorbid medical illness (including cardiovascular disease), cognition, adverse events, or concomitant medications did not appear to influence the treatment response in either patients 65-74 years or in those ≥75 years. Adverse event rates were similar to those seen in other esketamine studies in younger patients.11, 12 Additionally, evaluating age as a continuous variable (without pre-defined age cut offs) showed less efficacy in the oldest patients (Fig 7). A later age of onset of depression does not fully explain this finding since the age on onset of depression was <55 years in 52.4% of the patients ≥ 75 years. Comparison of other variables assessed for the full data set was unlikely to yield meaningful information given the limited number of ≥75-year-old patients. Therefore, data for patients ≥75 years of age must be interpreted with caution. Age of depression onset was explored because late-onset depression (LOD) has been associated with greater treatment resistance in some studies.32 Patients with onset under 55 years of age had greater responses to esketamine vs placebo than those with onset ≥55 years. Additionally, evaluation of age of depression onset as a continuous variable (without the pre-defined age cut-off) showed decreased efficacy with onset at later ages (Fig. 9). This decrease in efficacy is consistent with literature reports of LOD associated with diverse pathophysiological underpinnings (especially cerebrovascular disease), potentially related to increased neuromorphological changes and MRI signal hyperintensities33, 34 and treatment resistance.32 Stage 1 and 2 of the IA yielded disparate results, potentially affected by operational changes during the study and by increased dosing as the study progressed (Fig. 10). Operational changes implemented because of a >90% screen failure rate (3 patients recruited in 9 months), occurred months prior to, and independent of the IA. For example, a program to train remote MADRS raters on interviewing older patients was implemented following a concern that elderly patients were reticent to report their symptoms over the telephone.35 Additionally, sites with geriatric expertise were selected that enrolled more patients after the IA. Screen failures dropped to approximately 55% following these modifications. Use of higher doses of esketamine as the study progressed, described below, potentially influenced efficacy in stage 2, after the IA. 14

Dosing may have impacted efficacy because the 28 mg dose (used initially in all patients) was not included in esketamine trials in younger patients.11, 12 The 28 mg dose was considered subtherapeutic in a phase 2 trial in younger adults, but was included in the elderly study to improve tolerability.9 However, esketamine concentrations in the current study (both in patients ≥65 years of age and those ≥75 years), were similar to those in patients <65 years of age.11 Initially, investigators used lower esketamine doses, following the adage for elderly patients “start low, go slow.” During the trial, investigators increased the dose and rate of dose escalation, possibly because of a lower than anticipated adverse events, similar to that seen in younger patients. The 4-week study duration was potentially too short for an optimal effect in elderly patients. Over 80% of patients who continued in the open-label safety study demonstrated sustained reduction in the mean MADRS total score, suggesting benefits of longer treatment duration (Fig. 13). Response and remission rates at 8 weeks resembled those in younger adults following a 4 weeks of treatment (69.5% [52/82], and 46.3% [38/82]) respectively).11 Available evidence from the literature also supports increased efficacy with longer treatment periods in older patients.33, 36 Safety profile TEAEs in this study (including patients ≥ 75 years) were consistent with those in esketamine studies of younger patients.9 The rate of TEAEs was not higher in patients with associated comorbidities (including cardiovascular and thyroid disease) and/or on concomitant medications . Most TEAEs occurred and typically resolved on dosing days. Patients tolerated higher doses; 64.5% received 84 mg. Cognitive impairment was limited to slight slowing of simple reaction time in both esketamine and the placebo-treated patients, suggesting a lack of systematic cognitive changes following esketamine/antidepressant treatment, Based on CADSS assessment, dissociative changes occurred shortly after dosing and generally resolved 1.5 hours post-dose. The magnitude of mean change in the CADSS was consistent with, and slightly lower than that seen in younger adults (possibly because of the 28 mg dose).9, 10

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Overall, safety results, including those in patients ≥75 years, were consistent with those reported in previous esketamine studies in younger adults.9, 10 Patients in this trial (as in younger patients in the esketamine TRD program) were medically stable, meeting inclusion and exclusion criteria (Supplementary Digital Content S1); approximately half had pre-existing controlled hypertension, and followed BP guidelines for dosing. No new safety concerns were identified. Limitations included potential unblinding as a result of dissociation or other side effects following esketamine administration, despite mitigation measures such as including remote independent raters to assess the primary endpoint, and addition of a bittering agent in the placebo nasal spray. Additionally, a longer double-blind treatment duration may potentially demonstrate clearer treatment effects.

CONCLUSIONS Esketamine/antidepressant did not achieve statistical significance for the primary endpoint in this study of patients with TRD ≥ 65 years. Additional analyses suggested improvement for esketamine/antidepressant versus antidepressant/placebo in younger patients (65-74 years) and in patients with earlier onset of depression (<55 years). Factors that may have contributed to the failure to achieve statistical significance conceivably included lower dosing and a need for a longer treatment duration in older patients. Overall, the adverse event profile in older patients was similar to that seen in esketamine studies of younger patients; no new safety concerns were identified. Further studies are required to better evaluate esketamine in elderly patients given several factors that potentially influenced the efficacy of esketamine in this study. FUNDING This work was supported by Janssen Research and Development, LLC, Titusville, NJ, USA ACKNOWLEDGEMENTS Stacey E. Shehin, PhD, (PRA Health Sciences) provided medical writing assistance, which was funded by Janssen Research & Development, LLC, and Harry Ma, PhD (Janssen Global Services) provided additional editorial support. The authors thank the study patients, their families, and the investigators (Supplementary Digital Content S10) for their participation in this study. PREVIOUS PRESENTATIONS Portions of these results have been previously presented at the American Association for Geriatric Psychiatry Annual Meeting, March 1-4, 2019, Atlanta, GA, USA.

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DISCLOSURES Rachel Ochs-Ross, Ella J. Daly, Yun Zhang, Rosanne Lane, Pilar Lim, Randall L. Morrison, David Hough, Husseini Manji, Wayne C. Drevets and Jaskaran B. Singh are employees of Janssen Research & Development and may hold company stock and/or stock options. Rupert McShane reports grants and consultation fees from Janssen and consultation fees from Sage. Raphaël Gaillard reports personal fees from Janssen, Lundbeck, Roche, Takeda, Astra Zeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Pierre Fabre, Eli Lilly, Lundbeck, Otsuka, Sanofi, and Servier Pharmaceuticals. Samuel Wilkinson reports grants and consulting fees from Janssen. He also acknowledges support from the Agency for Healthcare Research and Quality (K12HS023000), the American Foundation for Suicide Prevention, the Brain and Behavior Research Foundation (formerly NARSAD), and the Robert E. Leet and Clara Guthrie Patterson Foundation. Caleb Adler has received research support through the University of Cincinnati from Activas, Alkermes, Allergan, Cephalon, Forest, Janssen, Johnson and Johnson, Lundbeck, Merck, Otsuka, Pfizer, Shire, Sunovion, Supernus, Syneurex, and Takeda, and has received grant support from Merck and Forest. He is a consultant to Sunovion, Assurex Health, and Neurocrine, and is on the Speaker’s Bureau for Janssen. Gerard Sanacora has received consulting fees from Alkermes, Allergan, AstraZeneca, Avanier Pharmaceuticals, Axsome Therapeutics, Biohaven Pharmaceuticals, Boehringer Ingelheim, Bristol-Myers Squibb, Hoffmann–La Roche, Intra-Cellular Therapies, Janssen, Merck, Minerva Neurosciences, Naurex, Navitor Pharmaceuticals, Novartis, Noven Pharmaceuticals, Otsuka, Perception Neuroscience, Praxis Therapeutics, Sage Pharmaceuticals, Servier Pharmaceuticals, Taisho Pharmaceuticals, Teva, Valeant, and Vistagen Therapeutics. He has also received research contracts from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Johnson & Johnson, Hoffmann–La Roche, Merck, Naurex, and Servier Pharmaceuticals. No-cost medication was provided to Dr. Sanacora for an NIHsponsored study by Sanofi-Aventis. In addition, he holds shares in Biohaven Pharmaceuticals Holding Company and is a co-inventor on the patent “Glutamate agents in the treatment of mental disorders”

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(patent 8778979) and a provisional Patent Application No. 047162-7177P1 (00754) filed on August 20, 2018 by Yale University Office of Cooperative Research OCR 7451 US01 Abdallah, C, Krystal, JH, Duman, R, Sanacora, G. Combination Therapy for Treating or Preventing Depression or Other Mood Diseases. David Steffens reports consulting income from Janssen Research & Development. All authors meet ICMJE criteria, had access to the study data, and made the final decision about where to publish these data.

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11. Popova V, Daly EJ, Trivedi M, et al.: Efficacy and Safety of Flexibly Dosed Esketamine Nasal Spray Combined With a Newly Initiated Oral Antidepressant in Treatment-Resistant Depression: A Randomized Double-Blind Active-Controlled Study. Am J Psychiatry. 2019;176:428-438. 12. Fedgchin M, Trivedi M, Daly EJ, et al.: Efficacy and Safety of Fixed-Dose Esketamine Nasal Spray Combined With a New Oral Antidepressant in Treatment-Resistant Depression: Results of a Randomized, Double-Blind, Active-Controlled Study (TRANSFORM-1). Int J Neuropsychopharmacol. 2019. 13. Montgomery SA, Asberg M: A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134:382-389. 14. Wajs E, Aluisio L, Holder R, et al.: Esketamine Nasal Spray Plus Oral Antidepressant in Patients with Treatment-Resistant Depression: Assessment of Long-term Safety in a Phase 3, Open-label Study (SUSTAIN-2). J Clin Psychiatry. 2019;In Press. 15. Williams JB, Kobak KA: Development and reliability of a structured interview guide for the Montgomery-Åsberg Depression Rating Scale (SIGMA). The British Journal of Psychiatry. 2008;192:5258. 16. Busner J, Targum SD: The clinical global impressions scale: applying a research tool in clinical practice. Psychiatry (Edgmont). 2007;4:28-37. 17. Spitzer RL, Kroenke K, Williams JB: Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282:1737-1744. 18. Leon AC, Olfson M, Portera L, et al.: Assessing psychiatric impairment in primary care with the Sheehan Disability Scale. Int J Psychiatry Med. 1997;27:93-105. 19. 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. Am J Psychiatry. 2011;168:1266-1277. 20. Bremner JD, Krystal JH, Putnam FW, et al.: Measurement of dissociative states with the ClinicianAdministered Dissociative States Scale (CADSS). J Trauma Stress. 1998;11:125-136. 21. Overall JE, Gorham DR: The Brief Psychiatric Rating Scale. Psychological Reports. 1962;10:799-812. 22. Fredrickson J, Maruff P, Woodward M, et al.: Evaluation of the usability of a brief computerized cognitive screening test in older people for epidemiological studies. Neuroepidemiology. 2010;34:65-75. 23. Maruff P, Thomas E, Cysique L, et al.: Validity of the CogState brief battery: relationship to standardized tests and sensitivity to cognitive impairment in mild traumatic brain injury, schizophrenia, and AIDS dementia complex. Arch Clin Neuropsychol. 2009;24:165-178. 24. Benedict RHB, Schretlen D, Groninger L, et al.: Hopkins Verbal Learning Test – Revised: Normative Data and Analysis of Inter-Form and Test-Retest Reliability. The Clinical Neuropsychologist. 1998;12:4355. 25. Chernik DA, Gillings D, Laine H, et al.: Validity and reliability of the Observer's Assessment of Alertness/Sedation Scale: study with intravenous midazolam. J Clin Psychopharmacol. 1990;10:244-251. 26. Rickels K, Garcia-Espana F, Mandos LA, et al.: Physician Withdrawal Checklist (PWC-20). J Clin Psychopharmacol. 2008;28:447-451. 27. Brannath W, König F, Bauer P: Estimation in flexible two stage designs. Stat Med. 2006;25:33663381.

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28. Fox J-P: Bayesian item response modeling: Theory and applications, Springer Science & Business Media; 2010. 29. Wong WL, Li X, Li J, et al.: Accounting for Standard Errors of Vision-Specific Latent Trait in Regression Models. Invest Ophthalmol Vis Sci. 2014;55:5848-5854. 30. Kim J, Farchione T, Potter A, et al.: Esketamine for Treatment-Resistant Depression - First FDAApproved Antidepressant in a New Class. N Engl J Med. 2019;381:1-4. 31. Montgomery SA, Moller HJ: Is the significant superiority of escitalopram compared with other antidepressants clinically relevant? Int Clin Psychopharmacol. 2009;24:111-118. 32. Naismith SL, Norrie LM, Mowszowski L, et al.: The neurobiology of depression in later-life: clinical, neuropsychological, neuroimaging and pathophysiological features. Prog Neurobiol. 2012;98:99-143. 33. Katona C, Hansen T, Olsen CK: A randomized, double-blind, placebo-controlled, duloxetinereferenced, fixed-dose study comparing the efficacy and safety of Lu AA21004 in elderly patients with major depressive disorder. Int Clin Psychopharmacol. 2012;27:215-223. 34. Knochel C, Alves G, Friedrichs B, et al.: Treatment-resistant late-life depression: challenges and perspectives. Curr Neuropharmacol. 2015;13:577-591. 35. Fiske A, Wetherell JL, Gatz M: Depression in older adults. Annu Rev Clin Psychol. 2009;5:363-389. 36. Lenze EJ, Mulsant BH, Blumberger DM, et al.: Efficacy, safety, and tolerability of augmentation pharmacotherapy with aripiprazole for treatment-resistant depression in late life: a randomised, doubleblind, placebo-controlled trial. The Lancet. 2015;386:2404-2412.

FIGURE 1. Participant Flow Diagram

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FIGURE 2. Response and remission rates based on MADRS total score AD: antidepressant; Esk: esketamine; MADRS: Montgomery-Åsberg Depression Rating Scale; NNT: number needed to treat; PBO: placebo

FIGURE 3. Frequency distribution of illness severity-based CGI-S scores at baseline and double-blind phase endpoint AD: antidepressant; CGI-S: Clinical Global Impression–Severity; ESK: esketamine; PBO: placebo

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FIGURE 4. Mean change (± SE) from baseline to endpoint in PHQ-9 and SDS total scores Notes: Number of patients are given at top of each group AD: antidepressant; Esk: esketamine; PHQ-9: Patient Health Questionnaire 9-Item; SDS: Sheehan Disability Scale; SE: standard error

FIGURE 5. Least squares mean (95% CI) treatment difference of change in MADRS total score from baseline to day 28 by subgroup Notes: The primary analysis of the change in MADRS total score using MMRM was weighted to account for the interim analysis for sample size re-estimation. The unweighted analysis does not take into account that an interim analysis was performed AD: antidepressant; CI: confidence interval; ESK: esketamine; MADRS: Montgomery-Åsberg Depression Rating Scale; PBO: placebo 22

FIGURE 6. Least squares mean change (± SE) in MADRS total score for [A] 65-74 years of age and [B] ≥ 75 years of age Notes: LS mean and SE were based on MMRM with change from baseline as the response variable and the fixed effect model terms for treatment (ESK+AD, AD+PBO), day, region, class of oral antidepressant (SNRI or SSRI), age group (65-74 or ≥75), and treatment-by-day, treatment-by-age group, treatment-byday-by-age group and baseline value as a covariate. Results are not adjusted for sample size reestimation. Negative change in score indicates improvement. AD: antidepressant; ESK: esketamine; LS: Least squares; MADRS: Montgomery-Åsberg Depression Rating Scale; MMRM: mixed model for repeated measures; PBO: placebo; SE: standard error; SNRI: serotonin norepinephrine reuptake inhibitor; SSRI: selective serotonin reuptake inhibitor

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FIGURE 7. Change in MADRS total score with age Notes: Regression lines and confidence bands were based on MMRM with change from baseline as the response variable and the fixed effect model terms for treatment (ESK+AD, AD+PBO), day, region, class of oral antidepressant (SNRI or SSRI), age and treatment-by-day, treatment-by-age, treatment-by-dayby-age and baseline value as a covariate. Results are not adjusted for sample size re-estimation. Negative change in score indicates improvement. A 95% CI that does not contain 0 implies significant association between age vs MADRS. AD: antidepressant; CI, confidence interval; ESK: esketamine; LS: Least squares; MADRS: MontgomeryÅsberg Depression Rating Scale; MMRM: mixed model for repeated measures; PBO: placebo; SNRI: serotonin norepinephrine reuptake inhibitor; SSRI: selective serotonin reuptake inhibitor

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FIGURE 8. Least squares mean change (± SE) in MADRS total score for age of onset of depression [A] <55 years of age and [B] ≥55 years of age Notes: LS mean and SE were based on MMRM with change from baseline as the response variable and the fixed effect model terms for treatment (ESK+AD, AD+PBO), day, region, class of oral antidepressant (SNRI or SSRI), age of onset (<55 or ≥55), and treatment-by-day, treatment-by-age of onset, treatmentby-day-by-age of onset and baseline value as a covariate. Results are not adjusted for sample size reestimation. Negative change in score indicates improvement. AD: antidepressant; ESK: esketamine; LS: least squares; MADRS: Montgomery-Åsberg Depression Rating Scale; MMRM: mixed model for repeated measures; PBO: placebo; SE: standard error; SNRI: serotonin norepinephrine reuptake inhibitor; SSRI: selective serotonin reuptake inhibitor

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FIGURE 9. Change in MADRS total score with age of onset of depression Notes: Regression lines and confidence bands were based on MMRM with change from baseline as the response variable and the fixed effect model terms for treatment (ESK+AD, AD+PBO), day, region, class of oral antidepressant (SNRI or SSRI), age of onset, and treatment-by-day, treatment-by-age of onset, treatment-by-day-by-age of onset and baseline value as a covariate. Results are not adjusted for sample size re-estimation. Negative change in score indicates improvement. A 95% CI that does not contain 0 implies significant association between age of onset of depression vs MADRS. AD: antidepressant; CI, confidence interval; ESK: esketamine; LS: Least squares; MADRS: MontgomeryÅsberg Depression Rating Scale; MMRM: mixed model for repeated measures; PBO: placebo; SNRI: serotonin norepinephrine reuptake inhibitor; SSRI: selective serotonin reuptake inhibitor

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FIGURE 10. Least squares mean change (± SE) in MADRS total score at [A] pre-IA and [B] post-IA Notes: LS mean and SE were based on MMRM with change from baseline as the response variable and the fixed effect model terms for treatment (ESK+AD, AD+PBO), day, region, class of oral antidepressant (SNRI or SSRI), treatment-by-day, and baseline value as a covariate. Negative change in score indicates improvement. AD: antidepressant; ESK: esketamine; IA: Interim analysis; LS: least squares; MADRS: MontgomeryÅsberg Depression Rating Scale; MMRM: mixed model for repeated measures; PBO: placebo; SE: standard error; SNRI: serotonin norepinephrine reuptake inhibitor; SSRI: selective serotonin reuptake inhibitor

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FIGURE 11. Least squares mean change (± SE) in MADRS total score over time in double-blind phase Notes: LS mean and SE were based on MMRM with change from baseline as the response variable and the fixed effect model terms for treatment (ESK+AD, AD+PBO), day, region, class of oral antidepressant (SNRI or SSRI), treatment-by-day, and baseline value as a covariate. Results are not adjusted for sample size re-estimation. Negative change in score indicates improvement. AD: antidepressant; ESK: esketamine; LS: least squares; MADRS: Montgomery-Åsberg Depression Rating Scale; MMRM: mixed model for repeated measures; PBO: placebo; SE: standard error; SNRI: serotonin norepinephrine reuptake inhibitor; SSRI: selective serotonin reuptake inhibitor

FIGURE 12. Percent of patients at 84 mg esketamine dose by stage of interim analysis

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FIGURE 13. Mean change (± SE) in MADRS from initial baseline total score in the follow up long-term safety study Notes: All patients received ESK+AD in the open-label study (circles represent patients who received AD+PBO in the primary study) AD: antidepressant; ESK: esketamine; FU: follow-up; IND: induction; MA: maintenance; MADRS: Montgomery-Åsberg Depression Rating Scale; OP: optimization; PBO: placebo; SE: standard error

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Table 1: Key Inclusion Criteria Key inclusion criteria 

DSM-537 diagnosis of recurrent MDD without psychotic features, or had a single episode of MDD lasting ≥2 years, based upon clinical assessment and confirmed by the MINI38



MMSE total score of ≥25 (or ≥22 for patients with less than the equivalent of a high school education) 39



IDS-C30 total score of ≥ 31, corresponding to moderate to severe depression40



TRD: lack of clinically meaningful improvement after treatment with ≥2 different antidepressant agents prescribed in adequate dosages for adequate duration during the current episode of depression



Documented non-responsea to ≥1 but ≤8 oral antidepressant treatments taken at adequate dosage and for an adequate duration, within the current episode of depression (as assessed on the geriatric version of the MGH-ATRQ41 and confirmed by documented records) at the start of the 4-week screening/prospective observational phase.



Non-responsea to ≥1 one of the 2 failed antidepressant medications was confirmed prospectively during the screening phase of the study (Supplementary Digital Content S2).



All patients had to have been non-responsivea to at least 2 oral antidepressants prior to randomization.



Patients who failed only one oral antidepressant at screening, had to currently have been taking another antidepressant for ≥2 weeks prior to screening and show a non- response to that antidepressant during the 4-week screening period.

a

A non-response was defined as minimal, or no clinically meaningful, benefit from their ongoing

antidepressant, defined as ≤ 25% improvement in the Montgomery–Åsberg Depression Rating Scale (MADRS) total score from week 1 to week 4 and a MADRS total score of ≥ 24 at weeks 2 and 4. DSM-5, Diagnostic and Statistical Manual of Mental Disorders–5th Edition; IDS-C30, Inventory of Depressive Symptomatology - Clinician Rating; MDD, major depressive disorder; MGH-ATRQ, Massachusetts General Hospital Antidepressant Treatment Response Questionnaire; MINI, Mini International Neuropsychiatric Interview; MMSE, Mini Mental State Exam

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TABLE 2: Esketamine Dosing Day

Dose

Dose Titration

Day 1

28 mg

Day 4

28 or 56 mg

The dose may remain at 28 mg or be increased to 56 mg, as determined by the investigator based on efficacy and tolerability

Days 8, 11, 15

28, 56 or 84 mg

The dose may be maintained or increased or reduced by 28 mg from the previous dosing session, as determined by the investigator based on efficacy and tolerability. No dose increase is permitted beyond day 15.

Days 18, 22, 25

28, 56 or 84 mg

No dose increase is permitted beyond day 15. If needed for tolerability, dose reduction by 28 mg from the previous dose is permitted on days 18, 22 and 25.

Notes: Dose changes are determined by the investigator based on efficacy and tolerability and in accordance with blood pressure guidelines.

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TABLE 3. Demographics and Baseline Characteristics Esk+Oral AD (N=72)

Placebo+Oral AD (N=65)

Total (N=137)

70.6 (4.79)

69.4 (4.15)

70.0 (4.52)

Male

27 (37.5)

25 (38.5)

52 (38.0)

Female

45 (62.5)

40 (61.5)

85 (62.0)

65-74

59 (81.9)

57 (87.7)

116 (84.7)

≥75

13 (18.1)

8 (12.3)

21 (15.3)

66 (91.7)

64 (98.5)

130 (94.9)

Multiple

4 (5.6)

0

4 (2.9)

Not reported

1 (1.4)

1 (1.5)

2 (1.5)

Unknown

1 (1.4)

0

1 (0.7)

European Union

35 (48.6)

24 (36.9)

59 (43.1)

United States

34 (47.2)

36 (55.4)

70 (51.1)

3 (4.2)

5 (7.7)

8 (5.8)

SNRI

31 (43.1)

30 (46.2)

61 (44.5)

SSRI

41 (56.9)

35 (53.8)

76 (55.5)

Duloxetine

25 (34.7)

23 (35.4)

48 (35.0)

Escitalopram

25 (34.7)

25 (38.5)

50 (36.5)

Sertraline

15 (20.8)

10 (15.4)

25 (18.2)

7 (9.7)

7 (10.8)

14 (10.2)

Age when diagnosed with MDD (years), mean (SD)

42.6 (16.18)

43.7 (16.28)

43.1 (16.18)

Baseline MADRS total score, mean (SD)

35.5 (5.91)

34.8 (6.44)

35.2 (6.16)a

Age (years), mean (SD)

Age category (years), n (%)

Race, n (%) White

Region, n (%)

Other Class of oral AD, n (%)

Oral AD

Venlafaxine XR

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Screening IDS-C30 total score, mean (SD)

44.2 (6.50)

43.1 (6.71)

43.7 (6.60)

Duration of current episode (weeks), mean (SD)

163.1 (277.04)

274.1 (395.47)

215.8 (341.71)

Baseline CGI-S, mean (SD)

5.1 (0.76)

4.8 (0.80)

5.0 (0.79)

Number of previous AD trial in addition to 1 AD trial assessed prospectivelyb, n (%) 1

15 (20.8)

6 (9.2)

21 (15.3)

2

31 (43.1)

32 (49.2)

63 (46.0)

3

13 (18.1)

17 (26.2)

30 (21.9)

4

12 (16.7)

4 (6.2)

16 (11.7)

≥5

1 (1.4)

6 (9.2)

7 (5.1)

a

Range: 19 to 51. In some cases, the baseline MADRS score was obtained after patients were qualified to enter the trial so the baseline MADRS could be ≤24 b Number of antidepressant medications with non-response (defined as <25% improvement) taken for at least 6 weeks during the current episode as obtained from MGH-ATRQ AD: antidepressant; CGI-S: Clinical Global Impression–Severity; Esk: esketamine; IDS-C30: Inventory of Depressive Symptoms-Clinician rated–30-item; MADRS: Montgomery-Ǻsberg Depression Rating Scale; MDD: major depressive disorder; MGH-ATRQ: Massachusetts General Hospital Antidepressant Treatment Response Questionnaire; SD: standard deviation; SNRI: serotonin and norepinephrine reuptake inhibitor; SSRI: selective serotonin reuptake inhibitor; XR: extended release.

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TABLE 4. MADRS Total Score: Change from Baseline to Day 28 Esk+Oral AD (N=72) Placebo+Oral AD (N=65) Baseline N 72 65 Mean (SD) 35.5 (5.91) 34.8 (6.44) Day 28 N 63 60 Mean (SD) 25.4 (12.70) 28.7 (10.11) Change from baseline to day 28 N 63 60 Mean (SD) -10.0 (12.74) -6.3 (8.86) MMRM analysisa Difference of LS Means (95% CI)b -3.6 (-7.20; 0.07) Two-sided p-valuec 0.059 a Weighted combination test for treatment effect is based on MMRM analyses with change from baseline as the response variable and the fixed effect model terms for treatment (esketamine/antidepressant, antidepressant/placebo), day, region, class of oral antidepressant (SNRI or SSRI), and treatment-by-day, and baseline value as a covariate. A negative difference favors esketamine b Difference from placebo is the median unbiased estimate, which is a weighted combination of the least squares means of the difference from placebo; 2-sided flexible confidence interval c p-value is based on the weighted combination test statistics; z=1.89. MADRS total score ranges from 0 to 60; a higher score indicates a more severe condition. Negative change in score indicates improvement. AD: antidepressant; CI: confidence interval; Esk: esketamine; LS: least squares; MADRS: MontgomeryǺsberg Depression Rating Scale; MMRM: mixed model for repeated measures; SD: standard deviation; SNRI: serotonin and norepinephrine inhibitor; SSRI: selective serotonin reuptake inhibitor.

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TABLE 5: Treatment-emergent Adverse Events in at Least 5% of Patients in the Double-blind Phase Esk+Oral AD, n (%) Placebo+Oral AD, n (%) (N=65) (N=72) Any TEAE 51 (70.8%) 39 (60.0%) TEAE Dizziness 15 (20.8%) 5 (7.7%) Nausea 13 (18.1%) 3 (4.6%) Blood pressure increased 9 (12.5%) 3 (4.6%) Fatigue 9 (12.5%) 5 (7.7%) Headache 9 (12.5%) 2 (3.1%) Dissociation 9 (12.5%) 1 (1.5%) Vertigo 8 (11.1%) 2 (3.1%) Urinary tract infection 6 (8.3%) 1 (1.5%) Hypoaesthesia oral 5 (6.9%) 0 Vomiting 5 (6.9%) 1 (1.5%) Dysgeusia 4 (5.6%) 3 (4.6%) Dysphoria 4 (5.6%) 0 Hypoesthesia 4 (5.6%) 1 (1.5%) Insomnia 4 (5.6%) 3 (4.6%) Paraesthesia 4 (5.6%) 2 (3.1%) Anxiety 2 (2.8%) 5 (7.7%) Notes: Incidence is based on the number of patients experiencing at least one AE, not the number of events. AEs were coded using MedDRA version 20.0 AD: antidepressant; AE: adverse event; Esk: esketamine; TEAE: treatment-emergent adverse event

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TABLE 6: Treatment-emergent Adverse Events Leading to Discontinuation of Study Medication and Serious Adverse Events (Safety Analysis Set) Esk+Oral AD, n (%) Placebo+Oral AD, n (%) Relationship to study (N=72)

(N=65)

nasal spray/oral AD

4 (5.6%)

2 (3.1%)

1 (1.4%)

0

Probable/ Doubtful

1 (1.4%)

0

Possible/ Not related

TEAEs leading to discontinuationa Blood pressure increased Blood pressure systolic increased Hip fracture

Not Related/ Not 1 (1.4%)

0

related

1 (1.4%)

0

Possible/ Possible

Anxiety

0

1 (1.5%)

Possible/ Not related

Feeling of despair

0

1 (1.5%)

Possible/ Not related

Dry eye

0

1 (1.5%)

Possible/ Possible

Eye color change

0

1 (1.5%)

Possible/ Possible

Eye inflammation

0

1 (1.5%)

Possible/ Possible

Eye pruritus

0

1 (1.5%)

Possible/ Possible

Gait disturbance

0

1 (1.5%)

Possible/ Very likely

Anxiety disorder

SAEs

a

Anxiety

1 (1.4%)

Possible/possible

Blood pressure increases

1 (1.4%)

0

Probably/not related

Hip fracture

1 (1.4%)

0

Not related/not related

Gait disturbance

0

1 (1.5%)

Possible/very likely

Dizziness

0

1 (1.5%)

Doubtful/doubtful

An adverse event that started in the double-blind phase and resulted in discontinuation in the follow-up

phase is counted as treatment-emergent in the double-blind phase Notes: Incidence is based on the number of patients experiencing at least one adverse event, not the number of events. Adverse events are coded using MedDRA version 20.0. AD: antidepressant; Esk: esketamine; SAE, serious adverse event; TEAE: treatment-emergent adverse event

36