Relationship Among Changes in Brain Network Activation, Changes in Core Depressive and Cognitive Symptoms and Safety and Tolerability in Adults With Major Depressive Disorder Treated With Open-Label, Flexible-Dose Vortioxetine
Phase: PHASE4
Conditions: Major Depressive Disorder
Sponsor: Rush University Medical Center

 
 
 
 
 
 
The relationship among changes in Brain Network Activation, changes  
in core depressive and cognitive symptoms and safety and tolerability in adult outpatients with major 
depressive disorder treated with open-label, flexible-dose vortioxetine: A proof of concept study 
 
John Zajecka MD 
Rush University Medical Center 
 
 
 
Sponsor: 
Rush University Medical Center 
 
 
Treatment Research Center 
 
 
1700 W. Van Buren Street, 5th Floor 
 
 
Chicago, IL  60612 
 
 
 
and 
 
 
4711 Golf Road, Suite 1200 
 
 
Skokie, Illinois 60076 
 
Study Number: IISR-2014-100702 
 
 
IND Number: 
N/A 
 
Compound: 
Vortioxetine 
 
Contact Information: 
John Zajecka MD 
Principal Investigator 
john_zajecka@rush.edu 
312-942-5592  
 
 
 
 
                                            
 
 
 
 
 
 
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Protocol version date: May 16, 2017 
 

Study Synopsis 
This study will include adult outpatients 18-65 years of age with major depressive disorder (MDD) with 
subjective reporting of cognitive dysfunction treated with flexible-dose vortioxetine (5-20 mg/day) for 
eight weeks.  Following completion of the informed consent process, this study will consist of a 
screening period (visit 1) of 2-14 days to assess inclusion/exclusion criteria.  Subjects who continue to 
meet inclusion criteria at baseline (visit 2) will begin the assessment and treatment phase of the study. 
 
The first EEG/BNA (BNA) will be performed at the screen visit. Subsequent BNA will be at baseline, 2-
weeks after the start of treatment, and at the end of 8 weeks of treatment (or early termination).  
 
 
The Schedule of Events (Appendix I) shows detailed study procedures that will be performed at each 
visit. The table below clarifies the schedule of dosing and attendant BNA tests. 
 
Quick Summary of Study Visits, Dosing and BNA 
Visit # 
Screen 
1 
Baseline 
2 
3 
4 
5 
6 
7 
8 
9 
 
 
10 (or ET) 
Day 
-2 to -14 
0 
7 
14 
21 
28 
35 
42 
49 
56 
Treatment Week 
-1 
0 
1 
2 
3 
4 
5 
6 
7 
8 
Dose mg/day 
10  
5-10 
5-10 
5-20 
5-20 
5-20 
5-20* 
5-20* 
5-20 
BNA test 
BNA 
BNA 
BNA 
BNA 
*No dose changes allowed after visit 8 
 
Subject Population:  
Subjects aged 18 to 65 years old with acute single episode, acute recurrent MDD and acute recurrent 
MDD with incomplete inter-episode recovery who report subjective cognitive dysfunction (such as 
difficulty concentrating, slow thinking, and difficulty in learning new things or remembering things) that 
correlated with the timing of their current major depressive episode (MDE). 
 
Number of Subjects: 
40 subjects enrolled.  For purposes of IRB reporting, an enrolled subject is one who signs informed 
consent.  For purposes of data analysis and reporting to the funding organization, an enrolled subject is 
one who meets all inclusion criteria and no exclusion criteria and completes the baseline visit including 
the baseline BNA. 
 
 
Number of Sites: (U.S. Study)  
2:  Chicago, IL and Skokie, IL 
 
Dose Level(s): 
5 mg/d, 10mg/d, 15 mg/d, 20mg/d.  Route of Administration: Oral 
 
Duration of Vortioxetine Treatment:  
One dose daily for 8 weeks. 
 
 
Period of Evaluation:  
Screening phase 1-2 weeks; treatment phase 8 weeks. 
 
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Protocol version date: May 16, 2017 
 

 
 
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Protocol version date: May 16, 2017 
 

Introduction: 
Major depressive disorder (MDD) is the most common psychiatric disorder with a lifetime prevalence of 
16.2% and a 12-month prevalence of 6.6% in developed countries [1]. It represents one of the most 
serious challenges faced by healthcare providers throughout the world, being a leading cause of 
disability globally [2] [3]. MDD is characterized by the presence of 1 or more MDEs that presents with 
depressed mood, loss of interest or pleasure, disturbed sleep or appetite, low energy, and feelings of 
guilt or low self-worth [4]. 
 
 
It is well established that mood disorders are also associated with cognitive dysfunction [5,6]. In fact, 
growing evidence from neuropsychological studies suggests that the majority of patients suffering from 
MDD present with some form of dysfunction in certain cognitive domains (such as executive function [7-
10], visuospatial short-term memory and learning and on verbal learning [11]; psychomotor speed and 
in immediate and delayed free recall [12] and working memory [13]) before treatment and are among 
the most common residual symptom domains after apparent successful treatment of other core MDD 
symptoms. Patients with depression also seem to perform significantly worse than normal controls on 
effort-demanding tasks, while they did not differ on the effortless tasks [14,15]. A study by Burt [16] 
showed that patients with depression performed approximately one half of an standard deviation worse 
than healthy subjects on verbal learning and memory tests.  Other studies, however, found non-
significant or only minimal differences in neuropsychological tests among patients with MDD and normal 
controls [17-19]. 
 
Regarding prevalence of cognitive dysfunction in MDD patients, little is still known.  Afridi et al. [20], 
assessed cognitive disturbances among newly diagnosed depressed (n=30) and healthy subjects (n=30). 
He found that 63.3% of the depressed patients had cognitive difficulties compared to 3.3% of healthy-
controls, with attention/concentration being the most common domain of cognition affected, followed 
by memory disturbance. The presence or absence of cognitive dysfunction in MDD patients depends on 
a number of factors including symptom severity [21], presence of melancholic features [22], presence of 
recurrent episodes [23], presence of psychotic features [24], remitted versus acute states [25], age [26], 
and pharmacological and non-pharmacological interventions [27]. Regarding pharmacological 
interventions, some evidence shows that conventional antidepressants may worsen cognitive function 
(e.g., tricyclic antidepressants (TCAs) secondary to anticholinergic or antihistaminic effects; selective 
serotonin reuptake inhibitors (SSRIs) secondary to selective increase of serotonin (5-HT) resulting in 
diminished norepinephrine (NE) and dopamine (DA) output; mirtazapine secondary to antihistaminic 
effects [30]. 
 
Cognitive dysfunction in MDD may be a symptom of depressive illness and persist, as residual 
symptoms, despite otherwise effective antidepressant therapy [34]. As discussed above, they may also, 
however, emerge as adverse effects of some psychotropic medications, including antidepressants [26]. 
 
Various neurotransmitters are implicated in cognitive processes, including 5-HT, DA, NE, acetylcholine 
and histamine. Regarding 5-HT, it is known that 5-HT1A receptor agonists have shown differential 
effects on memory and executive function in healthy and psychiatrically ill populations [35]. In animal 
studies, 5-HT2A receptor agonists enhance 
associative learning and certain antagonists impair associative learning [36]. In addition, depletion of 5-
HT has been shown to impair discrimination reversal performance, a form of cognitive flexibility [37]. 
Dopamine is also involved in cognitive flexibility, with a role in attentional selection, reversal and 
extinction learning [38], [39]. Animal studies have shown that blockade of DA receptors in the prefrontal 
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Protocol version date: May 16, 2017 
 

cortex impairs spatial working memory [39]. Norepinephrine appears to play a role in spatial working 
memory formation [38] as well as attentional set-shifting [37,38]. Acetylcholine has been implicated in 
aspects of reversal learning in the orbitofrontal cortex [37]. Furthermore, behavioral studies in humans 
suggest that acetylcholine is responsible for maintenance of attention and increased levels of this 
neurotransmitter are related to attentional effort [40]. Finally, histamine seems to affect learning and 
memory, partly via modulating acetylcholine release [41]. In rats, blockade of 113 receptors improves 
social memory, enhances attention and improves cognitive performance. Cetirizine, an H1 receptor 
antagonist, impairs memory processing speed [42; data on file with Takeda]. 
 
Vortioxetine is a novel antidepressant with hypothetical multimodal mechanism of action.  It is thought 
to work through a combination of multiple pharmacological modes of action: 5-HT reuptake inhibition, 
5-HT3 and 5-HT7 receptor antagonism, 5-HT1A receptor agonism, and 5-HT1B receptor partial agonism 
[43]. In vivo nonclinical studies have demonstrated that vortioxetine enhances levels of the 
neurotransmitters 5-HT, NE, DA, acetylcholine and histamine in specific areas of the brain [43]. These 
affinities are all considered to be of clinical relevance and involved in the mechanism of action at 
therapeutic doses. 
 
Vortioxetine showed antidepressant activity in completed MDD studies in which primary endpoints 
were change in depressive symptoms.  Currently, three placebo-controlled clinical trials demonstrate 
vortioxetine’s efficacy on cognitive performance in adult outpatients with MDD (Katona, et al., 2012; 
McIntyre, et al., 2013; data on file with Takeda).  Two of the above studies (Katona, McIntyre) included 
duloxetine as a comparator antidepressant; both active antidepressants demonstrated antidepressant 
efficacy compared to placebo.  Vortioxetine, not duloxetine, showed improvement compared to placebo 
on the Digit Symbol Substitution Test (DSST).  Results of these two studies also suggested that the 
improvement with vortioxetine (and not duloxetine) was a result of direct effects versus indirect (via 
mood)  improvement in cognition.  Correlating the clinical changes in mood and cognition with 
translational imaging data could provide insight to diagnose and manage cognitive changes associated 
with MDD. 
 
Vortioxetine improved cognition sub-items in the Montgomery-Åsberg Depression Rating Scale (MADRS) 
[44] (Item 6 — concentration difficulties) [45] and Hamilton Anxiety Scale (HAM-A) [46] (Item 5 - 
concentration and memory) [47] when compared to placebo (in the trials in which the primary endpoint 
was also positive). In addition, exploratory cognitive tests for verbal learning (RAVLT — Rey Auditory 
Verbal Learning Test) [48] and executive function, working memory, processing speed and visuospatial 
attention DSST [49]) were included in a vortioxetine conducted study in elderly patients [50] with MDD 
(primary endpoint was change in depressive symptoms). In this study, vortioxetine 5 mg/day improved 
cognitive dysfunction in both tests whereas duloxetine (active reference) improved cognitive 
dysfunction in the RAVLT but not in the DSST. This finding is consistent with the literature as shown by a 
study in which elderly patients receiving duloxetine demonstrated significantly greater improvement in 
a composite cognitive score mainly driven by improved verbal learning and memory [51]. 
 
Brain Network Activation: 
Appropriate diagnosis and differential diagnosis is critical to finding a treatment that will provide 
optimal efficacy. Currently, diagnosis depends on an assumption that historical and current clinical 
information is accurate and reliable.  The need to find biomarkers to improve current diagnosis and 
differential diagnosis, and the potential to predict treatment outcome, remains a significant unmet need 
in the optimal management of MDD. 
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Protocol version date: May 16, 2017 
 

 
In recent years more attention has been devoted to the use of functional magnetic resonance imaging 
(fMRI) to assess the state of the frontolimbic circuit to diagnose depression and monitor response to 
treatment. In particular the activity of the rostral anterior cingulated cortex (rACC) measured both on 
fMRI and EEG has been demonstrated to be a reliable biomarker of depression and its response to 
antidepressant therapy.  
 
Sensory evoked potentials (SEPs) are electrical potentials, recorded from the central nervous system of 
humans or animals (usually via EEG) while stimulating sense organs. They are distinct from spontaneous 
potentials (background EEG), which are recorded without stimulation. Contrary to spontaneous 
potentials, SEPs are phase-locked to the stimulus. 
 
Event Related Potentials (ERPs) are msec by msec reflections of the direct macroscopic neural mass 
electrical activity of cell assemblies located in specific regions of the brain, during sensory, motor, and 
cognitive tasks. They are extracted from the background electroencephalogram (EEG) through a process 
of time-locked averaging process of many trials of the same type to the onset of a sensory stimulus or a 
motor response. As such, they offer a powerful technique for the noninvasive characterization of human 
brain function by means of identifying the timing, order of activation, and dynamic orchestration of 
brain regions during the unfolding of cognitive tasks.  
 
Although Positron Emission Tomography (PET) and fMRI allow for precise localization of functional 
activations during cognitive tasks, their temporal resolution is limited by the slow time course of the 
hemodynamic response that they are reflecting (peaking 5 sec after an event and subsiding after 12-15 
sec, and affecting both blocked and event-related fMRI designs). Because of the slowness of the 
hemodynamic response PET and conventional fMRI have limited temporal resolution, while ERPs allow 
selective averaging of different stimulus types within the same experimental block, thus allowing mixed-
trial analysis (such as Successful and Failed inhibitions in the Go/NoGo signal). Moreover, ERPs can 
provide unique temporal information concerning the timing and order of activations of normal and 
abnormal neural activity within the block during the unfolding of cognitive tasks which can be the only 
significant information that differentiate between those activities. Finally EEG methodology is less 
invasive, less costly, and cumbersome than PET and fMRI methodology. 
 
ERPs consist of an ordered sequence of waveforms such as P100, N100, P200, N200, P300, N400 
depending on their latency and their polarity. Early components (P100 and N100 etc.) are called 
exogenous, because they require a stimulus, and reflect activity in primary or secondary sensory areas. 
However, such early ERP waves can be modulated by sustained attention and top-down cognitive 
control processes. Longer latency components (P300, N400 etc.) are called endogenous, because they 
can be present even in response to an expected missing stimulus. P300 is elicited in visual or auditory 
oddball tasks in response to task-relevant, salient infrequent targets, with greater amplitude over the 
posterior (parietal) scalp. Another waveform of interest is the N200, a prominent N200 with a frontal 
distribution is observed in response to NoGo stimuli in Go/NoGo tasks, and it is thought to reflect 
response inhibition processes. In contrast, Go stimuli elicit the parietally distributed P300. 
 
Although spatial resolution of the ERP method is coarse, it is improved by the use of high-density and 
new active amplifiers sensor arrays.  
 
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Protocol version date: May 16, 2017 
 

Brain Network Activation (BNA) technology uses high density EEG to collect ERP data for generation of a 
reference brain network model (RBNM) based on common neural activations, or event-pairs, defined as 
any two salient electrophysiological events, each at a given scalp location, frequency band and time 
range, with a specific temporal relationship. The algorithm produces a visual display of BNA network 
patterns that is simpler to interpret than traditional EEG output, while providing information on cortical 
connectivity. In addition, a RBNM similarity index (BNA score) is calculated for the EEG components of 
time (relative and absolute), amplitude, and overall pattern (connectivity) providing objective and easily 
interpretable results. 
 
The present study aims at clarifying dynamic spatio-temporal aspects of brain functional organization 
(e.g. inhibitory control, working memory) in MDD and cognitive dysfunction associated with MDD using 
BNA during the performance of the different tasks.  
 
Recent studies have validated the use of brain network activation (BNA) analysis using ERPs to diagnose 
and predict treatment response in attention deficit hyperactivity disorder (ADHD), models of 
schizophrenia and Alzheimer’s disease, concussion, pain and fibromyalgia (data on file, ElMindA). 
 
We hypothesize that the application of BNA using ERPs may be used as a non-invasive tool to improve 
diagnosis, differential diagnosis, target-specific depression symptom domains such as cognition and 
monitoring treatment response in MDD with cognitive dysfunction.  
 
Considering the compromised course of untreated depression and its well-known robust responsiveness 
to treatment, the development of an objective diagnostic tool to help diagnose individuals with MDD 
and predict treatment response can have a significant clinical and public health impact. 
 
Rationale for the Proposed Study: 
Vortioxetine has been shown to improve core depressive symptoms and improve cognitive function in 
adult outpatients with MDD and subjective complaints of cognitive function. This pilot study is intended 
to evaluate the extent to which BNA technology can provide clinically valuable information and provide 
information toward designing a subsequent confirmatory study that will further elucidate the effect of 
vortioxetine on MDD and cognitive function in this population. This exploratory study will ascertain the 
acute changes in core depression symptoms, cognitive function, tolerability, and safety using flexible-
dose vortioxetine in adult outpatients with MDD with subjective complaints of cognitive functioning, as 
measured by BNA changes and standard outcome measures for depression and cognition. 
 
Data suggest that the impact of vortioxetine on cognition in MDD may be independent of the 
antidepressant effect, perhaps through a centrally-mediated pathway different from that involved in the 
antidepressant effects.  This study will investigate the effect of vortioxetine on cognitive dysfunction 
more broadly covering specific measures of attention, executive functioning and psychomotor speed, as 
well as assess its effect on core depressive symptoms, function and global change. The number of 
subjects treated in this study is generally accepted for exploratory studies and intended to demonstrate 
1) improvement in cognition and efficacy in conventional MDD symptom domains, 2) improvement in 
cognition but no antidepressant efficacy in conventional MDD symptom domains, and, 3) no 
improvement of cognition and no antidepressant efficacy in conventional MDD symptom domains. We 
predict distinct patterns in brain network activity among these subgroups. This preliminary data is 
expected to provide greater insight into understanding the direct versus indirect antidepressant effects 
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Protocol version date: May 16, 2017 
 

of acute treatment with vortioxetine on cognition in MDD, and provide a basis for future clinical trials 
and applications.  
 
STUDY OBJECTIVES AND OUTCOMES 
 
OBJECTIVES 
 
Primary Objective: 
• 
To explore BNA changes from baseline to endpoint on 1) efficacy of core MDD symptoms and, 2) 
improvement of cognitive dysfunction with acute treatment of flexible dose vortioxetine in adult 
outpatients with MDD and subjective complaints of cognitive dysfunction. 
 
Secondary Objectives: 
• 
To evaluate the  efficacy over eight weeks of treatment of flexible-dose vortioxetine 
(5-20 mg/day) on standard outcome measures for core depression symptoms 
• 
To evaluate the changes in cognitive function from baseline to endpoint with flexible-
dose vortioxetine (5-20 mg/day)   
• 
To evaluate the changes in functionality over eight weeks of treatment with flexible-
dose vortioxetine (5-20 mg/day)   
• 
To explore baseline BNA patterns and clinical baseline features of: 
 
 
 
- core MDD symptoms (including severity) 
 
 
 
 
 
- cognitive dysfunction  
 
 
 
 
 
 
 
- functionality  
• 
To explore change in BNA patterns and clinical changes on: 
 
 
 
 
- core MDD symptoms  
 
 
 
 
 
 
 
- cognitive function 
 
 
 
 
 
 
 
 
- functionality  
 
 
 
 
 
 
 
 
- adverse events attributed to vortioxetine (per investigator opinion) 
• 
To explore correlations between patterns of BNA changes and evaluated changes in 
RDOC (Research Domain Criteria) domains and structures 
• 
To explore differences in BNA patterns and identify potential neural pathways that 
may impact core depressive symptoms different from cognitive function  
• 
To explore change in BNA patterns from baseline to after 2 weeks of treatment with 
vortioxetine with efficacy, using standard outcome measures of core depression 
symptoms at the end of acute treatment  
• 
To strengthen the level of confidence with BNA patterns observed during the course 
of treatment that may allow identification of potential trends observed as a result of 
treatment, by having a screen and baseline BNA done prior to receiving treatment 
• 
To obtain baseline BNA data in adult outpatients with MDD and subjective cognitive 
dysfunction prior to treatment that can be utilized for identification of BNA patterns 
associated with MDD   
• 
To confirm the safety and tolerability of vortioxetine (5-20mg/day). 
 
 
 
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Protocol version date: May 16, 2017 
 

OUTCOMES 
 
Primary Outcome: 
The primary outcome of this study is to explore changes in BNA patterns from baseline to endpoint with 
1) antidepressant response status; response defined as  > 50 % change in total MADRS score from 
baseline to endpoint and, 2) change in cognitive function defined as change from baseline to endpoint 
on change in total number of correct symbols on the DSST . 
 
Secondary Outcomes: 
1. Explore effect of core MDD symptoms, cognitive function, and functionality from baseline 
through eight weeks of treatment with vortioxetine: 
a. Depressive symptoms  
i. HDRS-17 total score 
ii. QIDS-SR-16 total score 
iii. HDRS-28 total score 
iv. Response defined as ≥50% decrease in MADRS total score 
v. Remission defined as <11 MADRS total score at endpoint 
vi. Asymptomatic remission defined as MADRS total score <4  
vii. Cognition and functionality  
viii. MGH-CPFQ total score 
ix. PDQ 
x. TMT-A/B 
xi. Stroop Test 
xii. UPSA 
xiii. WLQ 
b. Global clinical status  
i. CGI-Severity 
ii. CGI-Improvement 
2. Explore effect of core MDD symptoms, cognitive function, and functionality from baseline to 
endpoint following treatment with vortioxetine and the relationship between changes in BNA 
patterns from baseline to endpoint on: 
a. Depressive symptoms (change from baseline to endpoint) 
i. HDRS-17 total score 
ii. QIDS-SR-16 total score 
iii. HDRS-28 total score 
iv. Response defined as ≥50% decrease in MADRS total score 
v. Remission defined as <11 MADRS total score at endpoint 
vi. Asymptomatic remission defined as MADRS total score <4  
b. Cognition and functionality (change from baseline to endpoint) 
i. MGH-CPFQ total score 
ii. PDQ 
iii. TMT-A/B 
iv. Stroop Test 
v. UPSA 
vi. WLQ 
c. Global clinical status (change from baseline to endpoint) 
i. CGI-Severity 
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Protocol version date: May 16, 2017 
 

ii. CGI-Improvement 
3. To explore changes in BNA patterns from baseline in predicting clinical outcome at endpoint on: 
a. Depressive symptoms (change from baseline, 2 week, 8 week) 
i. MADRS total score 
ii. HDRS-17 total score 
iii. HDRS-28 total score 
iv. QIDS-SR-16 total score 
b. Cognitive function and functionality (change form baseline, 2 week , 8 week) 
i. MGH-CPFQ total 
ii. PDQ 
iii. WLQ 
c. Clinical global status (change from baseline, 2 week, 8 week) 
i. CGI-Severity 
ii. CGI-Improvement 
4. To explore differences in BNA patterns and identify potential neural pathways that may impact 
core depressive symptoms different from cognitive function: 
a. Explore differences in patterns of BNA changes from baseline to endpoint between: 
i. 
Subjects meeting antidepressant efficacy criteria (based on response and 
remission criteria for MADRS, HRSD, QIDS) and improvement in cognition (based 
DSST). 
ii. Subjects failing to meet antidepressant efficacy criteria (based on response 
criteria for MADRS, HRSD, QIDS) but show improvement in cognition (based on 
DSST). 
iii. Subjects failing to meet antidepressant efficacy criteria (based on response 
criteria for MADRS, HRSD, QIDS) and failing to show improvement in cognition 
(based on DSST). 
iv.  
v.  
5. To explore changes in BNA patterns in MDD with cognitive dysfunction prior to receiving 
treatment with vortioxetine and:  
a. Severity of MDD as measured by baseline MADRS total score, QIDS-SR-16 total score, 
HDRS-28 item total score and CGI-Severity. 
b. Severity of cognition dysfunction and functionality as measured by baseline DSST, TMT-
A/B, TMT-B, Stroop, MGH-CPFQ total score, UPSA, WLQ. 
c. Prediction of achieving symptomatic remission of MDD as measured by remission status 
on MADRS total score, HDRS-17 total score and CGI-Improvement (1 or 2) 
d. Prediction of cognitive improvement measured by DSST score; cutoff 70% improvement 
from baseline. 
6. Explore relationship with changes in BNA patterns in remitted vs. non-remitted subjects after 8 
weeks of treatment with vortioxetine as measured by MADRS total score, HDRS-17 total score,  
QIDS total score,, and CGI-Improvement. 
7. Assess safety and tolerability of 8 weeks open-label, flexible-dose vortioxetine in all subjects for: 
a. Spontaneously reported adverse events 
b. Clinical safety laboratory tests (when indicated, vital signs, weight, EKGs and physical 
exam) 
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Protocol version date: May 16, 2017 
 

c. Evaluate relationship between adverse events after 2 and 8 weeks of treatment with 
changes in BNA patterns for nausea, worsening of baseline suicidal ideation (as 
measured by MADRS item 10, HDRS-17 item 2 and C-SSRS) 
 
Informed Consent: 
The informed consent document, in conjunction with verbal discussion of the protocol, will be used to 
explain the study, including the risks and benefits, to the subject in simple terms before the subject is 
entered into the study.  The investigator is responsible to see that informed consent is obtained from 
each subject and to obtain the appropriate signatures and dates on the informed consent document 
prior to the performance of any protocol procedures and prior to any changes made to a subject’s 
medical treatment plan for the purpose of study participation.  The original signed consent form will be 
retained by the investigator. 
 
All subjects will take part in the informed consent process prior to participating in any study specific 
assessments or procedures, including assessment of study specific inclusion and exclusion criteria. The 
principal investigator and his designee will conduct the informed consent process in compliance with 
Good Clinical Practice Guidelines. Subjects will then be eligible for Screening Visit. 
 
Subject Selection:  
Subjects will be screened for study inclusion and exclusion criteria, and the case report form (CRF) will 
be reviewed by the principal investigator prior to Baseline Visit (Visit 2). 
 
Main Criteria for Inclusion: 
• 
The subject has single episode or recurrent MDD (acute onset of recurrence of recurrent MDD 
with poor inter-episode recovery) (inter-episode periods cannot meet full MDD criteria) as the 
primary diagnosis according to DSM-IV-TR criteria. The current MDE will be confirmed using the 
Mini International Neuropsychiatric Interview (MINI V6.0.0). 
• 
The subject has a MADRS total score ≥26. 
• 
Subject reports subjective cognitive dysfunction (such as difficulty concentrating, slow thinking, 
and difficulty in learning new things or remembering things). 
• 
The reported duration of the current MDE is at least 3 months and no longer than 24 months. 
• 
The subject is a man or woman between 18 and 65 years old, inclusive. 
• 
Right-handed, normal (corrected) vision, and normal hearing. 
 
Main Criteria for Exclusion: 
• 
The subject has a score of ≥70 on the DSST at the Baseline Visit. 
• 
Failure to respond to or inability to tolerate an adequate trial of vortioxetine in the past. 
• 
Exposure to an investigational compound 30 days prior to enrollment  
• 
Exposure to any psychoactive or otherwise excluded medication within five half-lives of the 
baseline visit or during the study. Excluded medications include: antidepressants, anxiolytics, 
anticonvulsants,  barbiturates, chloral hydrate, lithium, antipsychotics, benzodiazepines, 
hypnotics, MAO-Inhibitors, muscle relaxers, triptans, centrally-acting antihistamines, central 
alpha-2 agonists, decongestants, psychostimulants, dopamine agonists, opioid pain medications, 
oral corticosteroids, L-methylfolate, SAMe, 5-HTP, St. John's Wort. 
• 
The subject has 1 or more of the following: 
o Primary psychiatric disorder other than MDD as defined in the DSM-IV-TR (as assessed 
by the MINI, Version 6.0.0). 
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Protocol version date: May 16, 2017 
 

o Current or history of attention deficit hyperactivity disorder (ADHD), pervasive 
developmental disorder, manic or hypomanic episode, schizophrenia, or any other 
psychotic disorder, including major depression with psychotic features, mental 
retardation, organic mental disorders, or mental disorders due to a general medical 
condition as defined in the DSM-IV-TR. 
o Current diagnosis of alcohol or other substance abuse or dependence (excluding 
nicotine or caffeine) as defined in the DSM-TV-TR that has not been in sustained full 
remission for at least 6 months (for abuse) and 12 months (for dependence)  prior to 
Screening.  
o Positive urine drug screen prior to Baseline. 
o Presence or history of a clinically significant neurological disorder (including epilepsy) or 
severe head injury, or any condition that has caused an abnormal EEG or that may 
interfere with an EEG recording in the opinion of the investigator. 
o Neurodegenerative disorder (Alzheimer Disease, Parkinson Disease, multiple sclerosis, 
Huntington Disease, etc). 
o Any unstable medical condition as determined by the principal investigator (PI). 
o Any DSM-IV Axis II disorder that might compromise the study as determined by the PI. 
• 
The subject has any other disorder for which the treatment takes priority over treatment of 
MDD or is likely to interfere with study treatment or impair treatment compliance. 
• 
The subject has physical, cognitive, or language impairment of such severity as to adversely 
affect the validity of the data derived from the neuropsychological tests. 
• 
The subject has a significant risk of suicide according to the PI's clinical judgment.  
• 
The subject, in the opinion of the PI, poses a risk of harm to others. 
• 
The subject has initiated formal cognitive or behavioral therapy, systemic psychotherapy within 
less than 6 months of study screening, or has plans to initiate such therapy during the study. 
• 
The subject has received electroconvulsive therapy, vagus nerve stimulation, or repetitive 
transcranial magnetic stimulation within 12 months prior to Screening. 
• 
The current MDE is considered by the PI to have been resistant to 2 adequate antidepressant 
treatments of at least 6 weeks duration each at the recommended dose. 
• 
The subject is pregnant or breastfeeding, or is intending to become pregnant before, during, or 
within 30 days after participating in this study. 
• 
Hair or scalp conditions that may significantly compromise the quality of an EEG with 64 scalp 
electrodes, including but not limited to braids or significant alopecia, in the opinion of the 
investigator (collaboration with ElMindA will be sought if unclear). 
 
Contraception 
From signing of the informed consent through the duration of the study (and for no less than 30 days 
after last dose of study medication), female subjects of childbearing potential* who are sexually active 
with a nonsterilized male partner** must use adequate contraception. In addition they must be advised 
not to donate ova during this period. 
 
*Females NOT of childbearing potential are defined as those who have been surgically sterilized 
(hysterectomy, bilateral oophorectomy or tubal ligation) or who are postmenopausal (e.g., defined as at 
least 1 year since last regular menses with an FSH>40 IU/L or at least 5 years since last regular menses, 
confirmed before any study medication is implemented).  
 
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Protocol version date: May 16, 2017 
 

**Sterilized males should be at least 1 year post-vasectomy and have confirmed that they have obtained 
documentation of the absence of sperm in the ejaculate. 
 
An acceptable method of contraception is defined as one that has no higher than a 1% failure rate. 
 
In this study, the only acceptable methods of contraception are:   
• 
Barrier methods (male condom PLUS spermicide; cap (plus spermicidal cream or jelly) PLUS male 
condom and spermicide; diaphragm (plus spermicidal cream or jelly) PLUS male condom and 
spermicide 
• 
Intrauterine devices (IUDs) (copper T PLUS condom or spermicide; progesterone T PLUS condom 
or spermicide 
• 
Hormonal contraceptives (implants; hormone shot/injection; combined pill; minipill; patch; 
vaginal ring PLUS male condom and spermicide) 
 
Female subjects will be provided with information on acceptable methods of contraception as part of 
the subject informed consent process and will be asked to sign a consent form stating that they 
understand the requirements for avoidance of pregnancy and donation of ova during the course of the 
study and within 30 days following the study completion.  
 
A urine pregnancy test will be performed at the screening visit for women of childbearing potential and 
may be repeated at the investigator’s discretion. 
 
Pregnancy 
If any subject is found to be pregnant or breastfeeding during the study, she will be withdrawn and any 
sponsor-supplied drug will be immediately discontinued.   
 
If the pregnancy occurs during administration of active study medication (e.g., after Visit 2 or within 30 
days of the last dose of active study medication), the pregnancy will be reported immediately to the IRB 
using standard procedures per the sponsor and PI.  
 
If the female subject agrees to her primary care physician being informed, the investigator will notify the 
primary care physician that the subject was participating in a clinical study at the time she became 
pregnant and provide adequate details of treatment the subject received. 
 
All pregnancies discovered post-baseline will be referred to the subject’s primary care physician, 
obstetrician or other designated medical care provider and followed via regular communication for 30 
days (including any premature termination). 
 
STUDY PROCEDURES 
 
See Schedule of Events (Appendix I) for complete list of study procedures performed at each visit. 
 
All BNA procedures will be done as early in the visit as possible to avoid any confounding factors that 
may impact the outcome, except during the screen visit (at this visit, the BNA will occur after the subject 
completes the informed consent process and clinician-assessed inclusion/exclusion criteria are 
assessed). The screening visit can be split into 2 visits, as long as the screening period does not exceed 
the 14-day screen period.  
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Visit 1 (Screen) 
• 
Following the informed consent process, subjects will begin the Screening Visit (Visit 1), which 
will include a psychiatric/medical history, vital signs, urinalysis, urine drug screen, urine 
pregnancy test (females), EEG/BNA,  blood drawn for laboratory tests (CMP, CBC w/diff, TSH), 
ECG, and clinician- and patient-rated scales.  
 
Visits 2-10 
All Subjects 
• 
Subjects who meet all inclusion criteria and no exclusion criteria following the screening visit will 
enter the study. Weekly study visits will be conducted for efficacy, safety, and tolerability.  No 
dose changes will be allowed after Visit 8.   
• 
A baseline EEG/BNA will be taken before the subject begins taking vortioxetine and follow-up 
EEG/BNA readings will be taken at Visit 4, and Visit 10 (or last study visit if a subject is 
withdrawn early).   
• 
Vital signs, review of adverse events, study drug accountability and clinician- and patient-rated 
scales will be conducted at specific study visits. 
 
Description of BNA 
BNA is a method of analyzing electrophysiological and neuropsychological brain network activity using 
multichannel signals acquired by EEG/ERP non-invasive system hardware.  The following sections 
describe the EEG methodology and the neurocognitive tasks. 
 
EEG Procedures 
Subjects will be fitted with a net containing 64 EEG electrodes.  While wearing the net, subjects will 
complete a series of cognitive tasks during which time data will be collected.   
Standard EEG recording will be performed using the FDA system manufactured by Electrical Geodesics, 
Inc (EGI) from 64 locations by using Ag-AgCl electrodes mounted in an elastic net, referenced to 
electrode Cz. Channels will be sampled at 250 Hz.  
 
The EEG system complies with the standard electrical safety (EN 60601-1) and EMC compatibility. During 
the recording of ERPs, triggers sent by the test presentation script to mark the onset of the stimuli and 
the subject response are recorded concurrently with EEG signals. 
 
Neurocognitive tests (ERPs) 
The following battery of tasks will be performed by subjects during the EEG.  If total recording time 
reaches 60 minutes, the Delayed match-to-sample task below may be excluded.   
 
Eyes Open/Eyes Closed tasks:  EEG will be recorded at rest (no cognitive task), 2 minutes with eyes open 
and 2 minutes with eyes closed. The aim of the resting EEG recording is to extract patterns of the default 
mode network (DMN). The DMN is a network comprising many brain regions which show in fMRI studies 
reduced activation during task execution. Recently, the DMN has been studied also in EEG signals (Laufs 
et al. 2003). There is evidence that the DMN is impaired during emotional processing in MDD patients 
(for example see Grimm et al. 2009).  
 
Auditory oddball task: The oddball task is a classic EEG paradigm that has been extensively used for 
many years, in numerous studies and in many neurological patient populations. It is considered to 
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involve executive functions, attention and memory processes. During the task, sounds will be presented, 
at an average rate of 1 every 1.5 sec. A total of 80% of the sounds ("standard') will be tones of repeating 
frequency and intensity. A total of 10% of the sounds ("target") will be tones of another frequency to 
which participants will respond by pressing a button. The remaining 10% of sounds ("novel") will be 
multi-frequency sounds, different for each trial). Segments of 1200 ms will be averaged separately for 
"standard", "target," and "novel" sounds.  The task duration is approximately 12 minutes. 
 
Visual Go-Nogo: The Go stimuli consist of white color English alphabetic letters the NoGo stimuli consist 
of white colored X symbol. The NoGo appears 20% of the time and the Go stimuli appears 80%. The 
stimuli are presented in the center of a black background computer screen for 150 ms, and are located 
between two vertical white lines which remain constant on the screen. Subjects are instructed to press a 
key as quickly as they can when presented with the Go stimulus and withhold pressing the key when the 
NoGo stimulus appears. The task duration is approximately 14 minutes. 
 
Delayed match-to-sample: Memory and emotional processing related evoked potentials will be 
measured by presenting pairs of fearful or neutral faces with a delay of 1.8 sec. Subjects will judge 
whether the second face stimulus matches or not the first one. The task duration is approximately 13 
minutes. 
 
Optional tasks: 
If recording time allows, additional, optional tasks may be completed which will be chosen from the 
following list, for a total EEG recording time of approximately 45-60 minutes. 
 
Inter hemispheric transfer time (IHTT): In this task the subject needs to count red dots that appear in 
the middle of the screen while white squares flashes either in the left or right visual fields. At the end of 
each block the subject reports the number of red dots. The inter-hemispheric transfer time is calculated 
from the evoked response to the peripheral stimuli. The task duration is approximately 12 minutes. 
 
Auditory Go/No Go test:  The Go/NoGo paradigm is among the most well-characterized assays of 
response inhibition to perceptual stimuli. Go/NoGo tasks involve the presentation of a continuous series 
of “Go” or “target” cues to which subjects are asked to respond as quickly as possible, and “NoGo” or 
“distractor” cues that require subjects to inhibit motor responses. ERP studies reliably identify a 
negative-going component occurring 200 – 400 ms following NoGo stimuli known as the “NoGo N2”, 
which occurs maximally at fronto-central scalp locations. On NoGo trials, the N2 is followed by a 
positive-going shift. This positive complex, termed the “NoGo P3”, also occurs maximally at fronto-
central scalp sites and is typically seen 300 – 700 ms following the NoGo stimulus.  There is evidence 
showing a specific deficit in response inhibition in depressed patients, which requires executive control. 
 
Both ERP source localization and fMRI data have demonstrated that the right ventral lateral prefrontal 
cortex (PFC), particularly the inferior frontal gyrus (IFG), is consistently activated with successful motor 
control on Go/NoGo tasks, and lesions to the IFG impair such inhibitory control.  The IFG has been 
showing abnormal activity and connectivity in MDD.  Based on these observations, the Go/NoGo may be 
a useful tool for assessing well-defined neural pathways in major depression. The task duration is 
approximately 18 minutes. 
 
LDAEP:   Subjects are seated with open eyes and are asked to look at a fixation cross in front of them. 
Tones (1000 Hz, 40 ms duration with 10 ms rise and 10 ms fall time, ISI randomized between 1800 and 
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2200 ms) of five intensities (54, 64, 74, 84, 94 dB sound pressure level) are presented binaurally in a 
pseudorandomized form by earphones. Before the study, the sound pressure level of the headphones 
should be calibrated with a sound level. The task duration is approximately 13 minutes. 
 
INITIAL ASSESSMENT: 
 
Mini International Neuropsychiatric Interview Version 6.0.0 (MINI or eMINI) 
The MINI is a short structured diagnostic interview developed jointly by psychiatrists and clinicians in the 
United States and Europe for DSM-IV and International Classification of Diseases 10th Revision 
psychiatric disorders. With an administration time of approximately 15 minutes, it was designed to meet 
the need for a short but accurate structured psychiatric interview for multicenter clinical trials and 
epidemiology studies. It is to be used as a first step in outcome tracking in non-research clinical settings. 
Validation and reliability studies have been done comparing the MINI to the Structured Clinical Interview 
for DSM-IV, Patient Edition and the Composite International Diagnostic Interview. The results of these 
studies showed that the MINI has acceptably high validation and reliability scores, but can be 
administered in a much shorter period of time (mean 18.7±11.6 minutes, median 15 minutes) than the 
above referenced instruments.  
 
Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist 
The ASRS is a tool to help screen for ADHD in adult patients.  Insights gained through this screening may 
suggest the need for a more in-depth clinician interview.  The questions in the ASRS are consistent with 
DSM-IV criteria and address the manifestations of ADHD symptoms in adults.  The checklist takes less 
than 5 minutes to perform. 
 
DESCRIPTION OF CLINICAL OUTCOME MEASURES 
 
DEPRESSION: 
 
Montgomery and Åsberg Depression Scale (MADRS) 
The MADRS is a 10-item rating scale designed to assess the severity of the symptoms in depressive 
illness that was shown to be sensitive to treatment effects. Items in the scale assess apparent sadness, 
reported sadness, inner tension, reduced sleep, reduced appetite, concentration difficulties, lassitude, 
inability to feel, pessimistic thoughts and suicidal thoughts. Symptoms are rated on a 7-point scale from 
0 (no symptom) to 6 (severe symptom). Definitions of severity are provided at 2-point intervals. The 
total score of the 10 items ranges from 0 to 60. An experienced clinician can use the MADRS after a 
training session. It takes approximately 15 to 20 minutes to administer and rate the MADRS.  All efforts 
will be made to keep the rater consistent. 
 
Hamilton Depression Rating Scale (HDRS) 
The HDRS is a clinician-rated used to rate the patient’s depressive state based on feelings of depression, 
guilt, suicidality, anxiety, agitation, level of insight, patterns of insomnia, loss of interest in work and 
other activities, weight loss, hypochondriasis, and degree of psychomotor retardation.  It also can be 
used to identify genital and somatic symptoms. This instrument will be administered by an experienced 
rater meeting the training requirements and qualifications set by the rater training vendor.  All efforts 
will be made to keep the rater consistent. 
 
 
 
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Quick Inventory of Depressive Symptomatology – Self-Report (QIDS-16-SR) 
The QIDS-16-SR is a 16-item self-rated assessment of the severity of depressive symptoms. The QIDS 
assesses all the criterion symptom domains designated by the American Psychiatry Association 
Diagnostic and Statistical Manual of Mental Disorders - 4th edition, text revised (DSM-IV-TR) (APA 1994) 
to diagnose a major depressive episode. These assessments can be used to screen for depression, 
although they have been used predominantly as measures of symptom severity. The seven day period 
prior to assessment is the usual time frame for assessing symptom severity.  
 
COGNITION AND FUNCTIONALITY: 
Digit Symbol Substitution Test (DSST) 
The DSST is a cognitive test designed to assess psychomotor speed of performance requiring visual 
perception, spatial decision-making and motor skills. The DSST consists of 133 digits and requires the 
subject to substitute each digit with a simple symbol in a 90-second period. The number of correct 
symbols within the allowed time (eg, 90 sec) is measured. It takes approximately 5 minutes to complete 
and score the DSST. 
 
University of San Diego Performance-based Skill Assessment and UPSA-Brief 
The UPSA was designed to evaluate the abilities of individuals to perform everyday tasks that are 
considered necessary for independent functioning in the community. The UPSA uses role-playing 
situations to evaluate skills in 5 areas: household chores (eg, preparing a shopping list for a specific 
cooking task and shopping for items in a mock grocery store); communication (eg, emergency call, 
dialing a number from memory, calling to reschedule a doctor’s appointment); finance (eg, counting 
change, reading a utility bill, and write and record a check for the bill); transportation (eg, planning the 
use of a public bus system); planning recreational activities (eg, preparing for an outing to the beach or 
zoo).  
 
Subscale scores for these scales range from 0 to 20 points, and total scores range from 0 to 100 points; 
higher scores reflect better performance. Administration of the UPSA requires about 30 minutes to be 
completed.  
 
Stroop Test 
The STROOP test [61] is a cognitive test designed to assess the ability to inhibit a prepotent response to reading 
words while performing a task that requires attention control. The STROOP test comprises 2 sheets with 50 words 
on each, and each word is the name of a color. On the first sheet, the Congruent STROOP Sheet, the word and ink 
color match; on the Incongruent STROOP Sheet, the word and ink color do not match. For each sheet, the subject 
has 4 minutes to name the ink color of each word. When the subject finishes the sheet, or once 4 minutes is up, 
the clinician notes the time taken and counts the number of correct and incorrect responses. It takes 
approximately 10 minutes to administer and score the STROOP test. 
 
Trail Making Test – Part A and Part B (TMT-A AND TMT-B) 
The TMT is a cognitive test designed to assess scanning, visuomotor tracking, executive function, and 
cognitive flexibility. Both parts of the TMT consist of 25 circles distributed over a sheet of paper. In Part 
A, the circles are numbered 1–25, and the subject should draw lines to connect the numbers in 
ascending order. In Part B, the circles include both numbers (1–13) and letters (A–L); as in Part A, the 
subject draws lines to connect the circles in an ascending pattern, but with the added task of alternating 
between the numbers and letters (ie, 1-A-2-B-3-C, etc.). The subject should be instructed to connect the 
circles as quickly as possible, without lifting the pen or pencil from the paper. The subject is timed as he 
or she connects the “trail.” If the subject makes an error, it is pointed out immediately and the subject is 
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Protocol version date: May 16, 2017 
 

allowed to correct it. Errors affect the subject’s score only in that the correction of errors is included in 
the completion time for the task. It is unnecessary to continue the test if the subject has not completed 
both parts after 4 minutes have elapsed. It takes approximately 10 minutes to complete the TMT. 
 
Cognitive and Physical Functioning Questionnaire (MGH-CPFQ) 
The Massachusetts General Hospital Cognitive and Physical Functioning Questionnaire is a brief scale 
used to measure cognitive and executive dysfunction in mood and anxiety disorders. It is a self-report 
unifactorial scale consisting of 7 items assessing aspects of cognitive and physical functioning, rated on a 
scale from 1 (greater than normal) to 6 (absent). The reliability and validity of this scale has been 
evaluated and results have shown it to have strong internal consistency, temporal stability and 
sensitivity to change with treatment.  
 
Perceived Deficits Questionnaire (PDQ) 
The PDQ is a subject-rated scale designed to assess cognitive function. The PDQ consists of four 5-item 
subscales: Attention/Concentration, Retrospective memory, Prospective memory and 
Planning/Organization. Each item is rated on a scale from 0 (never) to 4 (almost always). The total score 
of the 20 items ranges from 0 to 80 with higher scores reflecting greater subjective cognitive 
dysfunction. It takes approximately 15 minutes to complete the PDQ.  
 
Working Limitation Questionnaire (WLQ) 
 The WLQ has 25 items summarized as 4 scales that represent the percentage of time that a person was 
limited in particular job demands: time and scheduling demands such as working without stopping or 
taking breaks and getting going easily at the beginning of the workday (WLQ Time); physical work 
demands such as sitting, standing or staying in 1 position for longer than 15 min while working and using 
hand-held equipment (eg, phone) (WLQ Physical); mental-interpersonal work demands such as thinking 
clearly when working and speaking with people in-person, in meetings or on the phone (WLQ Mental); 
and output demands, such as working fast enough and doing work without making mistakes (WLQ 
Output). Scales are scored from 0, limited none of the time, to 100, limited 100 percent of the time. 
Scores are weighted and aggregated to generate a productivity loss index score. The index is a weighted 
sum of scale scores that indicates reduction in output per hour compared with the output of a healthy 
(not limited) employee. This questionnaire will only be administered to subjects who have been 
employed at least 14 days before baseline. 
 
GLOBAL: 
Clinical Global Impression Scales (CGI-S and CGI-I) 
The CGI consist of 2 subscales: CGI-S and the CGI-I. The CGI-S assesses the clinician’s impression of the 
subject’s current mental illness state. The clinician should use his/her total clinical experience with this 
subject population and rate the current severity of the subject’s mental illness on a 7-point scale. The 
CGI-I assesses the subject’s improvement (or worsening). The clinician is required to assess the subject’s 
condition relative to Baseline on a 7-point scale. In all cases, the assessment should be made 
independent of whether the rater believes the improvement is drug-related or not. 
 
Assessment of Suicidal Ideation and Behavior 
Columbia-Suicide Severity Rating Scale (“Lifetime Recent – Clinical” and “Since Last Visit – Clinical” 
The C-SSRS was developed by Kelly Posner, PhD and researchers at Columbia University as a tool to help 
systematically assess suicidal ideation and behavior in subjects during participation in a clinical trial. The 
C-SSRS is comprised of 23 questions divided among four domains addressing suicidal behavior and 
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Protocol version date: May 16, 2017 
 

suicidal ideation, with sub-questions assessing severity. The scale is administered via clinician interview 
with the subject. 
 
During the study, the EEG and neuropsychological tests are to be performed preferably at the same time 
of the day for an individual subject. 
 
STATISTICAL ANALYSES 
 
Primary Efficacy Analysis 
The primary endpoint is the change from Baseline in the MADRS and DSST score. The primary endpoint 
will be analyzed using analysis of covariance (ANCOVA), with treatment and center as fixed factors, and 
baseline score as covariate. The p-values, least squares (LS) treatment means, difference between the LS 
treatment means, and 95% CIs for the treatment differences will be displayed. 
 
This is a pilot study that is intended to evaluate the extent of to which BNA technology can provide 
clinically valuable information, and to provide data that will help design a future confirmatory study. 
Because this is an exploratory study, no formal sample size calculation was performed; rather, sample 
size has been based on that which is generally accepted by the medical community for a study of this 
nature. In order to strengthen the level of confidence of the results, the BNA test is performed twice 
before the subject is given medication to provide repeatability and two additional times during the 
course of treatment to allow the identification of any potential trend that may occur as a result of 
treatment. 
 
The relationship between changes in BNA and BNA total mean change from baseline and endpoint will 
be analyzed. Changes in BNA from baseline will also be analyzed by groups defined on endpoint status 
(e.g. response to MADRS, remission, change in DSST). 
 
Statistical analysis should also consider the fact that changes in brain networks may be independent of 
symptoms or neurocognitive scores; thus, the analysis of BNA changes across treatment duration should 
be also performed independently. In other words, it is possible that BNA conveys information that is not 
found in other methods; trying to find correlations may limit the correct interpretation. Therefore, 
robust trends found in BNA scores should be further researched, regardless of finding correlations to 
symptoms or neurocognitive tests. For example, it could be that a change in BNA, without a significant 
change in symptoms, means that if the treatment will be continued for a few more weeks, a delayed 
improvement will be found; etc. 
 
Secondary Efficacy Analyses 
Change from Baseline in TMT A, TMT B, , PDQ, MGH-CPFQ, UPSA, percentage of productivity loss (WLQ), 
MADRS, CGI-S, and CGI-I will be analyzed at all time points (where rated) using ANCOVA model similar to 
the one described above for the primary endpoints. 
 
MADRS responders (defined as a >50% decrease from Baseline), MADRS remission (defined as a MADRS 
total score <10).   CGI-S remission (CGT-S2), and CGI-I response (CGI-I2) will be analyzed at all time 
points by logistic regression, adjusting for baseline score and treatment. 
 
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Proportion of cognitive dysfunction improvement that is not due to an improvement in depressive 
symptoms will be analyzed using a path analysis with change from Baseline in DSST score and change 
from Baseline in MADRS total score as endogenous variables. 
 
C-SSRS will be summarized at all time points using descriptive techniques. 
 
All statistical tests will be 2-sided and at the 5% level of significance. Ninety-five percent confidence 
limits will be presented together with the p-values. 
 
Outcome Definitions 
• 
Remission (Primary Remission Criteria) 
o MADRS total score < 10; CGI-I < 2 
• 
Remission (Secondary Remission Criteria) 
o Score < 7 of first 17 items of the HDRS (28-item)   
o QIDS-SR16 total score < 5 
• 
Asymptomatic Remission 
o MADRS total score < 4 
• 
Response (Primary Response Criteria) 
o ≥50% decrease in MADRS total score from baseline 
 
• 
Response (Secondary Response Criteria) 
o ≥50% decrease from baseline of first 17 items of the HDRS (28-item) 
o ≥50% decrease from baseline in total score of HDRS (28-item)  
o ≥50% decrease from baseline in total score of QIDS-SR 16 
o ≥50% decrease from baseline in total score of MGH-CPFQ  
• 
Non-Remitted (Primary)  
o MADRS total score > 10 
• 
Non-response 
o  Change in MADRS total score from baseline < 25%, and MADRS total score > 10 
• 
Inadequate response 
o  Change in MADRS total score from baseline 25-49%, and MADRS total score > 10 
 
BNA Analysis 
 
All BNA recordings will be transmitted to ElMindA for analysis. 
 
We will use a receiver operating characteristic (ROC) curve to assess the ability of each EEG BNA group 
pattern to discriminate MDD cases from controls using individual BNA similarity indices. The ROC 
analysis uses each value across the entire range of the EEG BNA pattern as the cut-off for defining a case 
and compares this classification to the “true” diagnosis, as defined by the structured diagnostic 
interview. The ROC curve plots the sensitivity versus the false positive rate (1-specificity) across the 
entire range of cut-offs.  This analysis generates a statistic called the area under the curve (AUC), which 
is proportional to the overall ability of the scale across its range of cut-offs to correctly identify both 
cases and non-cases.  
 
Secondly, we will analyze the results of EEG measurement during the test within patients to identify 
possible predictors of treatment response. Those analyses are exploratory in nature, and they could 
potentially lead to develop an EEG biomarker to predict antidepressant response.   
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In the first stage EEG signals are pre-processed using standard methods of blind source separation 
followed by band pass filtering into overlapping physiological frequency bands, epoched and averaged 
to result with ERPs. For each band, the data is reduced into a set of discrete points that denote local 
extrema, the latencies and (z-score normalized) amplitudes of which are inputted to the algorithm. 
These activity peaks naturally contain the major conventional ERP components, but all other associated 
and induced peaks as well, which fully represent the significant information in the measured data. For 
each experimental state (i.e. pre- and post-treatment, monotherapy vs. adjunctive therapy, healthy 
control vs. MDD), the algorithm then searches for peaks that have latencies synchronous across 
subjects. Next, peak-pair patterns are identified, whether within a single electrode or between any two, 
such that the inter-peak intervals were also synchronous across subjects. More complicated patterns of 
3 or more peaks are sought in a similar manner, until a state-unique multi-sited spatio-temporal pattern 
or several distinct patterns emerge – the BNA group network.  
 
In addition, BNA change analysis will be performed. Each subject participating in the drug treatment arm 
of the study is assigned similarity indices that quantify the degree to which his/her individual BNA 
repertoire match that of each group BNA. The score is computed twice for each subject – once for pre-
treatment, and once for post-treatment, the difference between them being termed 'BNA change'.  
 
Safety Analyses 
Adverse Events 
• 
Spontaneously reported AEs will be investigator-evaluated and documented throughout the 
study. 
• 
The definition of treatment-emergent adverse events (TEAEs) will be provided in the statistical 
analysis plan (SAP).  
• 
AEs that were reported more than once by a subject during the same period will be counted 
only once for that subject and period at the maximum severity. 
 
Clinical Evaluations 
• 
Absolute values and changes from screening/Baseline in clinical safety laboratory tests, vital 
signs, ECG parameters, and weight will be summarized for each treatment group using 
descriptive techniques. Values outside normal ranges and potentially clinically significant values 
will be flagged and tabulated.  
• 
Physical examination findings will also be summarized for each treatment group. 
 
RISK/SAFETY INFORMATION 
 
EEG recording is a safe and non-invasive diagnostic procedure with no significant risk for the health of 
subjects. The EEG system complies with the standard electrical safety (EN 60601-1) and electromagnetic 
(EMC) compatibility and has received FDA clearance.  Staff will be trained to minimize the discomfort 
associated with electrodes placement. Subjects will be able to communicate with staff throughout the 
procedure. The recording will be discontinued if the subject will indicate that she has become 
uncomfortable. 
 
Memory and thinking tests can sometimes make subjects tired or uncomfortable.  The study staff will try 
to make all subjects as comfortable as possible.  Subjects will be informed that they do not have to 
answer any questions they choose not to answer. 
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Protocol version date: May 16, 2017 
 

 
Antidepressant medication (vortioxetine) 
At the time of informed consent, the subject will be instructed about the risks and benefits of the 
vortioxetine that will be used throughout the study. 
 
The potential risks of the medication will be based upon the FDA-approved package insert labeling for 
vortioxetine and will include, but not limited to, spontaneous reported adverse events and potential 
serious adverse events.  Source documents will contain documentation that the subject was informed of 
risks of treatment and that there was adequate time to read and discuss this information with the 
clinician during the informed consent process. 
 
The FDA-approved package insert for vortioxetine recommends a starting dose of 10 mg/day, increased 
to 20 mg/day as tolerated.  The maximum dose is 20 mg/day, and the minimum dose is 5 mg/day if a 
higher dose is not tolerated.  This allows for individualized “flexible” dosing for efficacy and tolerability. 
 
In order to standardize this flexible dosing, all subjects will be started at 10 mg/day following visit 2 
(baseline).  The dose will be increased to a maximum of 20 mg/day after visit 4 (2 weeks of treatment) if 
tolerated by the subject.  Dose decreases may occur at any time until Visit 8 for tolerability issues, to a 
minimum dose of 5 mg/day, and the dose may be re-increased if the tolerability issue resolves. 
 
No dose adjustments may take place after visit 8 through the end of treatment (Visit 10). 
 
Safety, tolerability, and depressive symptoms/function assessments will occur at baseline and each 
subsequent visit through the end of the study. While this is an exploratory analysis, the impact of 
treatment at various points in the study will be analyzed. Baseline assessments will occur prior to the 
subject receiving medication.  
 
Drug accountability will be recorded at all visits. Subjects failing to meet at least 80% adherence to study 
medication between study visits will be discontinued from the study. 
 
Other Risks 
Whenever a subject is determined to be at risk for suicide during a clinical visit by the examining 
clinician, she or he will be escorted to the nearest emergency room. 
 
We will not share information about subjects' participation in this study with others to minimize risks 
relative to subjects' privacy. Every effort will be made to keep participation confidential. These issues 
will be clearly stated in consent forms and discussed with participants during the informed consent 
procedure. 
 
Consistent with good clinical practice, safety will be monitored by each subject's assigned clinician at 
each study visit.  This clinician will be available 24 hours a day by page.  The PI will supervise all study 
activities including ratings, reported adverse events, laboratory tests, and vital signs.  Subjects will be 
monitored for adverse events at each visit and during phone communications with the clinician.  All 
adverse events will be recorded.   
 
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Protocol version date: May 16, 2017 
 

All procedures will aim to minimize subject discomfort, and no subject will be asked to engage in 
research procedures not outlined in the consent form.  All adverse events will be reported to the PHRC 
according to PHRC guidelines. 
 
Subjects who are judged to experience a worsening of depressive symptoms as manifested by a CGI-
Improvement rating of 6 or more (1=Very much improved, 2=Much improved, 3=Minimally improved, 
4=No change, 5=Minimally worse, 6=Much worse, 7=Very much worse) or per the investigator's opinion 
for 2 consecutive visits the subject may be removed from the study and provided referrals as 
appropriate. 
 
Subjects with MDD will be offered three months of follow-up care at the completion of the study (or if 
they are required to discontinue for any reason) in which they will be seen by study staff for routine 
outpatient management of their MDD. Subjects will receive referrals to clinicians in their communities, 
either at the end of the 3 month period, or sooner upon their request or circumstances require such a 
referral as determined by the investigator. 
 
If a subject becomes pregnant or is found to be abusing substances during the study, he or she will be 
discontinued from the study and given referrals. 
 
If a subject would like to have their clinical history forwarded to his/her primary care physician, or a new 
clinician, we will forward any pertinent information upon completing release forms in compliance with 
Good Clinical Practice Guidelines. If a subject was referred from a health care provider that is 
appropriate for follow-up care, the investigator may offer this among other possible referrals after the 
last study visit. 
 
EXPECTED BENEFITS 
Potential benefits to the participants include a thorough assessment by an expert clinician, education 
about the disorder, a treatment for MDD that could be continued after the study, and the opportunity 
to contribute to medical science and thus help others with the disorder. 
 
MONITORING/REPORTING OF AE/SAE COLLECTION AND RECORDING: 
Adverse event means any untoward medical occurrence associated with the use of a drug in humans, 
whether or not considered drug related. 
 
Life-threatening adverse event or life-threatening suspected adverse reaction. An adverse event or 
suspected adverse reaction is considered “life-threatening” if, in the view of either the investigator or 
sponsor, its occurrence places the patient or subject at immediate risk of death. It does not include an 
adverse event or suspected adverse reaction that, had it occurred in a more severe form, might have 
caused death. 
 
Serious adverse event or serious suspected adverse reaction. An adverse event or suspected adverse 
reaction is considered “serious” if, in the view of either the investigator or sponsor, 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, or a congenital anomaly/birth defect. Important medical 
events that may not result in death, be life-threatening, or require hospitalization may be considered 
23 
Protocol version date: May 16, 2017 
 

serious when, based upon appropriate medical judgment, they may jeopardize the patient or subject 
and may require medical or surgical intervention to prevent one of the outcomes listed in this definition. 
Suspected adverse reaction means any adverse event for which there is a reasonable possibility that the 
drug caused the adverse event. For the purposes of IND safety reporting, “reasonable possibility” means 
there is evidence to suggest a causal relationship between the drug and the adverse event. Suspected 
adverse reaction implies a lesser degree of certainty about causality than adverse reaction, which means 
any adverse event caused by a drug. 
 
Unexpected adverse event or unexpected suspected adverse reaction. An adverse event or suspected 
adverse reaction is considered “unexpected” if it is not listed in the investigator brochure or is not listed 
at the specificity or severity that has been observed; or, if an investigator brochure is not required or 
available, is not consistent with the risk information described in the general investigational plan or 
elsewhere in the current application, as amended. “Unexpected,” as used in this definition, also refers to 
adverse events or suspected adverse reactions that are mentioned in the investigator brochure as 
occurring with a class of drugs or as anticipated from the pharmacological properties of the drug, but 
are not specifically mentioned as occurring with the particular drug under investigation. 
 
While reports of pregnancy and overdose are not adverse experiences as defined above, notifications of 
these events will be made per procedure defined by IRB requirements and in accordance with further 
practice as designated by the PI. 
 
Any adverse event that is ongoing when a subject completes his/her participation in the study must be 
followed until any of the following occurs: 
a. The event resolves or stabilizes; 
b. The event returns to baseline condition or value (if a baseline value is available); or 
c. The event can be attributed to agent(s) other than the study product, or to factors 
unrelated to study conduct. 
 
REPORTING TO IRBs AND REGULATORY AUTHORITIES: 
The sponsor must notify FDA in an IND safety report of potential serious risks, from clinical trials or any 
other source, as soon as possible, but in no case later than 15 calendar days after the sponsor 
determines that the information qualifies for reporting under paragraph (c)(1)(i), (c)(1)(ii), (c)(1)(iii), or 
(c)(1)(iv).  The sponsor must submit each IND safety report in a narrative format or on FDA Form 3500A 
or in an electronic format that FDA can process, review, and archive.  See §312.32 of the CFR for 
guidance. 
 
STUDY OVERSIGHT 
The Principal Investigator will be responsible for monitoring and assuring the validity and integrity of all 
data and adherence to the IRB-approved protocol.  The study staff will monitor source data and case 
report forms by routine internal monitoring.  BNA data will be monitored and interpreted by ElMindA in 
collaboration with the principal investigator, sub-investigator and study staff to assure BNA data is 
accurately collected. 
 
The principal investigator and sub-investigators are responsible for monitoring the safety of the subjects 
who have entered this study and for alerting the IRB of any event that meets IRB reporting criteria.  The 
investigator is also responsible to follow, through an appropriate health care option, adverse events that 
are serious or that caused the subject to discontinue before completing the study.  The subject should 
24 
Protocol version date: May 16, 2017 
 

be followed until the event resolves or is explained.  Frequency of follow-up is left to the discretion of 
the investigator.   
 
Data and Safety Monitoring 
The principal investigator will be responsible for monitoring the safety of all subjects.  In the event the 
principal investigator is unavailable, a sub-investigator will be available to monitor the safety of all 
subjects.  Subjects will be evaluated throughout the study to assess comfort and safety. The principal 
investigator will be responsible for determining if a subject should be removed from the study. Subjects 
will be removed from the study if they decide to withdraw consent or are unable to tolerate the 
procedures due to anxiety and discomfort or if they develop a medical condition incompatible with their 
participation.  The principal investigator will also terminate a subject’s participation if they will 
determine that it is not in the subject’s best interest. 
 
IRB REVIEW/ETHICS/INFORMED CONSENT 
 
IRB Review 
Prior to enrolling any subjects, documentation will be obtained that the study protocol and informed 
consent form have been approved by the Schulman Associates Institutional Review Board.  Any change 
in the protocol or informed consent form will require prior written approval except to prevent injury or 
risk to a subject. 
 
Regulatory Considerations 
This study will be conducted in accordance with the ethical principles stated in the most recent version 
of the Declaration of Helsinki or the applicable guidelines on good clinical practice, whichever represents 
the greater protection of the individual. 
 
Recruitment 
The study population will be recruited from the greater Chicago metropolitan area. Subjects will be 
recruited from several sources, including referrals, responders to our general depression recruitment 
(advertisements on craigslist, newspapers, radio, the PMA website, private practice settings and 
community health centers). Subjects will also be recruited from ongoing clinical trials at Psychiatric 
Medicine Associates, LLC (PMA). Subjects may also be recruited from other trials only if considered 
appropriate for an open label treatment study with vortioxetine and do not meet other exclusion 
criteria. This is a study of depression in adults and therefore children will be excluded.  
 
Subjects will be reimbursed for appropriate travel expenses during participation in the study. 
 
GENERAL STUDY PROCEDURES 
All study personnel will have completed training for Good Clinical Practice guidelines prior to study 
initiation.  There will be a start-up meeting on site for all study personnel prior to initiating the trial, 
including protocol review, study procedures, delegation of responsibility, recruitment, inter-rater 
reliability (for those who are involved in clinical ratings), and to review general study issues. Updates of 
the study will occur at weekly staff meetings, including internal monitoring of study-related 
documentation, enrollment updates, and to review amendments and/or serious adverse events. 
 
All subject source documents and case report forms will be in written form and contained in a subject 
binder.  Data for clinical patient/clinician assessments/outcomes will be entered into an electronic 
25 
Protocol version date: May 16, 2017 
 

database after review by the investigator/subinvestigator and internal monitor.  Subjects will be 
assessed at each visit by investigator/subinvestigator to assure criteria are met to remain in the study. 
All study documents will be kept in a secure location and in compliance with GCP guidelines.  Medication 
dispensing and recording of accountability will be done only by personnel who have authority (e.g., MD, 
PA).  All medication will be kept in a double-locked, secure location in accordance with GCP guidelines 
and DEA requirements (for the investigational product).  Temperature logs will be maintained daily and 
kept at a temperature recommended for the investigational drug. 
 
CONFIDENTIALITY 
All information collected about subjects for the purposes of this study will be treated as confidential to 
the extent allowed by law.  The information obtained while subjects are enrolled in this study, including 
all study-related hospital and office records, will be made available to the study doctor, the study 
sponsor (Takeda), the Institutional Review Board and other regulatory agencies, including the United 
States Food and Drug Administration (U.S. FDA).   
 
Sending Specimens/Data to Research Collaborators Outside of PMA: 
EEG recordings, neurocognitive tests, depression outcomes and demographic data will also be sent to 
ElMindA Ltd headquarters in 16 Haminhara St. Beit Bachar, Herzliya 46586, Israel for analysis.  Any 
personal information and/or identifier will be removed to protect participants’ identity and privacy. 
 
ElMindA Ltd will have access to EEG data, study-related case report forms and questionnaires, and 
neurocognitive test results to perform BNA analysis (including electronic database information).  Study 
documents and data will also be accessible by the study sponsor, Takeda. 
 
INTENDED USE OF THE DATA 
The results of this research project may be presented at meetings or in publications, but the identity of 
subjects will not be disclosed in such presentations. 
 
 
 
26 
Protocol version date: May 16, 2017 
 

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Protocol version date: May 16, 2017 
 

APPENDIX  I - SCHEDULE OF EVENTS 
 
Visit # 
Screen 
1 
Baseline 
2 
3 
4 
5 
6 
7 
8 
9 
 
 
10 (or ET) 
Day 
-2 to -14 
0 
7 
14 
21 
28 
35 
42 
49 
56 
Week 
-1 to-2 
0 
1 
2 
3 
4 
5 
6 
7 
8 
Informed Consent 
X 
 
Incl/Excl Criteria 
X 
X 
 
MINI 
X 
 
ASRS 
X 
 
 
 
 
 
 
 
 
 
Medical and Psychiatric 
History 
X 
 
Demographics 
X 
 
Physical Exam 
X 
 
Laboratory tests, urinalysis, 
urine pregnancy test and 
urine drug screen1 
X 
 
Vital signs and weight2 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Height 
X 
 
12-Lead ECG 
X 
 
HDRS (28-item) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
QIDS-SR-16 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
MADRS 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
DSST 
X 
X 
UPSA 
X 
X 
TMT-A AND TMT-B 
X 
X 
Stroop Test 
X 
X 
MGH-CPFQ 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
PDQ 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CGI-S 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CGI-I 
X 
X 
X 
X 
X 
X 
X 
X 
WLQ 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
C-SSRS3 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant therapy 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study drug dispensed 
X 
X 
X 
X 
X 
X 
X 
X 
 
Study drug accountability 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse events 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
EEG (BNA reading) 
X 
X 
X 
X 
1may be repeated at investigator’s discretion 
2including body temperature (oral), blood pressure and pulse. 
3C-SSRS lifetime version at screen only; Since Last Visit version at V2-10 
32 
Protocol version date: May 16, 2017