Phase 3, Multicenter, Randomized, Double-blind, Placebo-controlled Study to Evaluate the Efficacy and Safety of Adjunctive Pimavanserin in Subjects With Major Depressive Disorder and Inadequate Response to Antidepressant Treatment (ACP-103-054/059)
Phase: PHASE3
Conditions: Adjunctive Treatment of Major Depressive Disorder
Sponsor: ACADIA Pharmaceuticals Inc.

Official Title: A Phase 3, Multicenter, Randomized, Double-blind, Placebo-controlled 
Study to Evaluate the Efficacy and Safety of Adjunctive Pimavanserin in Subjects 
With Major Depressive Disorder and Inadequate Response to Antidepressant 
Treatment 
NCT Number: NCT03999918 
Document Date: 21 Jun 2020 

 
Confidential and Proprietary Information of ACADIA Pharmaceuticals Inc. 
Page 1 of 81 
 
 
CLINICAL STUDY PROTOCOL 
 
UNMASKED PROTOCOL  
 
A Phase 3, Multicenter, Randomized, Double-blind, Placebo-controlled 
Study to Evaluate the Efficacy and Safety of Adjunctive Pimavanserin in 
Subjects With Major Depressive Disorder and Inadequate Response to 
Antidepressant Treatment 
 
Protocol Number: ACP-103-054 
Amendment 4 
EudraCT Number: 2018-003251-37 
 
Original Protocol Date: 30 August 2018 
Protocol Amendment 1 Date: 05 December 2018 
Protocol Amendment 2 Date: 18 March 2019 
Protocol Amendment 3 Date: 29 October 2019 
Protocol Amendment 4 Date: 21 June 2020 
 
Confidentiality Statement 
This protocol is the confidential information of ACADIA Pharmaceuticals Inc. and is 
intended solely for the guidance of the clinical investigation. This protocol may not be 
disclosed to parties not associated with the clinical investigation or used for any purpose 
without the prior written consent of ACADIA Pharmaceuticals Inc. 

Study: ACP-103-054 
 
Final Version: 1.0 
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Date: 21 June 2020 
 
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SPONSOR SIGNATURE PAGE 
Title: A Phase 3, Multicenter, Randomized, Double-blind, Placebo-controlled Study to 
Evaluate the Efficacy and Safety of Adjunctive Pimavanserin in Subjects With Major 
Depressive Disorder and Inadequate Response to Antidepressant Treatment 
 
ACADIA President: 
 
President 
ACADIA Pharmaceuticals Inc. 
 
  
 
 
See appended electronic signature page 
 
Signature 
 Date 
 
ACADIA Study Lead: 
 
Executive Director, Clinical Research 
ACADIA Pharmaceuticals Inc. 
 
  
 
 
See appended electronic signature page 
 
Signature 
 Date 

Signature Page for ACP-103-054 Protocol Amendment 4_UNMASKED VERSION
Signature Page for ACP-103-054 Protocol Amendment 4_UNMASKED VERSION
Approve
22-Jun-2020 22:33:33 GMT+0000
Approve
22-Jun-2020 22:37:27 GMT+0000

Study: ACP-103-054 
 
Final Version: 1.0 
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Date: 21 June 2020 
 
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DECLARATION OF INVESTIGATOR 
I confirm that I have read the above protocol. I understand it, and I will work according to the 
moral, ethical, and scientific principles governing clinical research as set out in the principles 
of Good Clinical Practice, as required by International Council for Harmonisation of 
Technical Requirements for Pharmaceuticals for Human Use (ICH) Guideline E6 and as 
described in the United States (US) Code of Federal Regulations (CFR) 21 CFR parts 50, 54, 
56, and 312, and according to applicable local requirements. 
Confidentiality Statement 
The confidential information in this document is provided to you as a Principal Investigator 
or Consultant for review by you, your staff, and the applicable institutional review 
board/ethics committee. Your acceptance of this document constitutes agreement that you 
will not disclose the information contained herein to others without written authorization 
from the Sponsor. 
Principal Investigator 
 
 
Signature 
 
Date 
 
 
 
Name (printed) 
 
 
 
 

Study: ACP-103-054 
 
Final Version: 1.0 
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PROTOCOL SYNOPSIS 
Protocol Number 
ACP-103-054 
EudraCT Number 
2018-003251-37 
Protocol Title 
A Phase 3, Multicenter, Randomized, Double-blind, Placebo-controlled 
Study to Evaluate the Efficacy and Safety of Adjunctive Pimavanserin 
in Subjects With Major Depressive Disorder and Inadequate Response 
to Antidepressant Treatment 
Name of 
Investigational 
Product 
Pimavanserin tablets 
Indication 
Adjunctive treatment of major depressive disorder  
Phase of 
Development 
3 
Sponsor 
ACADIA Pharmaceuticals Inc. 
 
 
Primary Objective 
To evaluate the efficacy of adjunctive 
pimavanserin compared to placebo in subjects 
with major depressive disorder who have an 
inadequate response to antidepressant therapy 
Primary Endpoint 
Change from Baseline to Week 5 in the 
Hamilton Depression Scale (17 items) 
(HAMD-17) total score 
Secondary Objective 
To evaluate the efficacy and benefits of 
adjunctive pimavanserin compared to placebo 
in subjects with major depressive disorder 
who have an inadequate response to 
antidepressant therapy on the following:  
• Functional impairment 
• Clinician’s global impression of 
severity and improvement of depressive 
symptoms 
• Sexual functioning 
• Sleepiness 
• Treatment response and remission 
• Anxiety 
• Impulsiveness 
• Early response to treatment 
Secondary Endpoints 
• Change from Baseline to Week 5 in 
Sheehan Disability Scale (SDS) score 
• Change from Baseline to Week 5 in 
Clinical Global Impression–Severity 
(CGI-S) score for depressive symptoms 
• Clinical Global Impression–
Improvement (CGI-I) score for 
depressive symptoms at Week 5 
• Change from Baseline to Week 5 in the 
Changes in Sexual Functioning 
Questionnaire Short Form (CSFQ-14) 
• Change from Baseline to Week 5 in 
Karolinska Sleepiness Scale (KSS) 
score 
• Treatment responder rates at Week 5. 
Treatment response is defined as a 

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reduction from Baseline in HAMD-17 
total score of 50% or more. 
• Treatment remission rates at Week 5. 
Treatment remission is defined as a 
HAMD-17 total score ≤7. 
• Change from Baseline to Week 5 in the 
Hamilton Depression (HAMD) 
Anxiety/Somatization factor score 
• Change from Baseline to Week 5 in the 
Barratt Impulsiveness Scale (BIS-11) 
• Change from Baseline to Week 1 in the 
HAMD-17 total score 
Safety Objective 
To assess the safety and tolerability of 
pimavanserin compared to placebo in subjects 
with major depressive disorder who have an 
inadequate response to antidepressant therapy  
Safety Assessments 
Safety and tolerability of pimavanserin as 
described by: 
• Treatment-emergent adverse events 
(TEAEs) 
• Potentially clinically important 
laboratory abnormalities, vital signs, 
and electrocardiogram (ECG) results 
• Columbia–Suicide Severity Rating 
Scale (C-SSRS) score 
• Change from Baseline to Week 5 in 
Extrapyramidal Symptom Rating 
Scale–Abbreviated (ESRS-A) score 
• Sexual dysfunction defined as a 
CSFQ-14 total score of ≤47 for men 
and ≤41 for women 
Number of Study 
Sites 
Approximately 40 sites outside the United States (US) will participate 
in this study. 
Number of Subjects 
Planned 
The original planned sample size was 280 subjects randomized in a 
1:1 ratio to either the pimavanserin or the placebo treatment groups 
(i.e., 140 subjects in each treatment group). The study was planned to 
be conducted in non-US countries only. 
In March, 2020, in response to the emerging coronavirus disease 2019 
(COVID-19), ACADIA implemented a temporary pause to new 
enrollment into study ACP-103-054, to decrease potential exposure to 
COVID-19, minimize risks to trial integrity, and to assure the safety of 
already enrolled, ongoing study subjects. The last subject was 
randomized on 17 March 2020, for a total of 150 randomized subjects. 
ACADIA decided to combine its two ongoing, Phase III studies, 
ACP-103-059 (US-based study) and ACP-103-054 (non-US), when 
each were half enrolled, into one study with a pre-specified statistical 

Study: ACP-103-054 
 
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analysis plan. As a result, both studies closed and are proceeding with 
database lock and statistical analysis. No new patients were enrolled 
into these studies. The last subject in Study ACP-103-059 was 
randomized on 17 March 2020, at which time a total of 148 subjects 
had been randomized. 
The combined analysis therefore comprises 298 randomized subjects. 
Test Product, Dose, 
and Administration 
Pimavanserin 34 mg (provided as 2×17 mg tablets) or matching 
placebo (2×placebo tablets [size- and color-matched to pimavanserin]). 
It is recommended that the subject should take the study drug at 
approximately the same time each day. Tablets will be administered 
orally as a single dose once daily. 
Study Design 
This study will be conducted as a multicenter, randomized, 
double-blind, placebo-controlled, parallel-group study in subjects 
experiencing major depressive disorder with inadequate response to a 
selective serotonin reuptake inhibitor (SSRI) or 
serotonin-norepinephrine reuptake inhibitor (SNRI). 
This unmasked protocol version provides details of certain study 
design elements, procedures, and statistical methods that are intended 
for use only by the unmasked Sponsor and restricted Worldwide 
Clinical Trials personnel and their designated agents. 
The study will have three periods (Figure S–1): 
• Screening period (3-28 days) 
• Double-blind treatment period (6 weeks) 
• Safety follow-up period (at least 30 days) 
Screening Period (3-28 Days) 
During the screening period, subjects will be assessed for study 
eligibility and prohibited medications will be discontinued. 
Medications should be discontinued only if it is deemed clinically 
appropriate to do so and in consultation with the treating physician. 
Investigators should not withdraw a subject’s prohibited medication 
for the purpose of enrolling them into the study. The screening period 
may be extended up to 7 days to confirm subject eligibility when 
discussed with the Medical Monitor in advance. 
Double-blind Period (6 Weeks) 
The Baseline visit (Visit 2) may occur as soon as screening procedures 
are completed and subject eligibility has been confirmed by the site 
and the Medical Monitor. At Visit 2, subjects will be randomized in a 
1:1 ratio to pimavanserin 34 mg once daily or matching placebo. 
Assessments will be conducted at Week 0 (Baseline), 1, 2, 3, 4, 5, and 
6/EOT or early termination (ET). 

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Safety Follow-up Period (30 Days) 
Eligible subjects who successfully complete the 6-week double-blind 
period will be qualified to enroll in an open-label extension study; 
subjects enrolling in the open-label extension study will not enter the 
30 day safety follow-up period. For subjects who discontinue 
prematurely from the study or who do not enroll in the open-label 
extension study, a safety follow-up telephone call visit will be 
conducted at least 30 days after the last dose of study drug. 
The schedule of assessments is provided in Table S–1. 
Study Duration 
The duration of participation for individual study subjects will be up to 
15 weeks, consisting of a screening period of up to 5 weeks 
(i.e., 4 weeks, with possible extension of up to 7 days), a 6-week 
double-blind treatment period, and a safety follow-up period of at least 
30 days (for those subjects who discontinue prematurely from the 
study or who do not enroll in the open-label extension study) 
(Figure S–1). The study completion date is defined as the date the final 
subject, across all sites, completes their final protocol-defined 
assessment, which includes the safety follow-up visit/contact, if 
applicable. If the study is terminated for any reason, subjects 
remaining in the study will return to standard of care. 
Main Criteria for 
Inclusion and 
Exclusion 
To be eligible for this study, subjects must meet all of the inclusion 
criteria and none of the exclusion criteria. 
Inclusion Criteria: 
1. Is a male or female ≥18 years of age 
2. Can understand the nature of the study and protocol 
requirements and is willing to comply with study drug 
administration requirements and discontinue prohibited 
concomitant medications  
3. Provides written informed consent to participate in the study 
4. Is capable of communicating with the site personnel, able to 
complete subject-reported outcome measures and can be 
reliably rated on assessment scales (in the opinion of the 
Investigator) 
5. Has a clinical diagnosis of major depressive disorder with or 
without anxious distress by Diagnostic and Statistical Manual of 
Mental Disorders, Fifth Edition (DSM-5) criteria and confirmed 
by the Mini-International Neuropsychiatric Interview (MINI) 
during the screening period. Subject may have either recurrent or 
single episode of major depressive disorder. 
6. Is treated during the current major depressive episode with one 
of the following SSRI/SNRI antidepressants at a minimally 
effective dose for at least 8 weeks with at least the same stable 
dose over 4 weeks prior to the SAFER (State versus trait, 
Assessability, Face validity, Ecological validity, and Rule of 

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three Ps [pervasive, persistent, and pathological]) remote 
interview: 
a. Citalopram 
b. Escitalopram 
c. Paroxetine 
d. Fluoxetine 
e. Sertraline 
f. Duloxetine 
g. Venlafaxine 
h. Desvenlafaxine 
i. Venlafaxine XR 
The dose level of the antidepressant is expected to remain stable 
throughout the study.1 Adherence to the antidepressant should 
be reviewed throughout the study. 
7. Must have a detectable blood level of a prescribed SSRI/SNRI 
during Screening. A negative screening test may be repeated as 
assessed by the Medical Monitor when the subject and/or site 
can provide additional evidence of subject adherence to 
antidepressant treatment or evidence of sample or laboratory 
error. 
8. During the screening period, the subject’s inadequate response 
to SSRI/SNRI antidepressant treatment is confirmed by the 
Massachusetts General Hospital Antidepressant Treatment 
Response Questionnaire (MGH ATRQ) through the SAFER 
remote interview and the subject continues to exhibit an 
inadequate response to treatment at the time of the SAFER 
interview. 
9. Subjects who are currently taking a second antidepressant or 
antidepressant augmentation agent at a subtherapeutic dose or 
for inadequate duration at Screening are eligible for inclusion in 
the study if it is clinically appropriate to discontinue the drug 
before the Baseline visit (in the opinion of the Investigator); the 
second antidepressant/augmentation agent must be discontinued 
and washed out at least 5 half-lives prior to Baseline. This 
second antidepressant/augmentation agent should not be 
discontinued solely to make the subject eligible for enrollment 
in the study. 
10. Has a Montgomery-Asberg Depression Rating Scale (MADRS) 
total score >20 at both Screening and Baseline 
                                                 
 
 
1 Please see Appendix C for medication restrictions. 

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11. Has a Clinical Global Impression–Severity (CGI-S) score ≥4 
(moderately ill or worse) for depression at both Screening and 
Baseline 
12. If the subject is female, she must not be pregnant or 
breastfeeding. She must also be of non-childbearing potential 
(defined as either surgically sterilized or at least 1 year 
postmenopausal) OR must agree to use TWO clinically 
acceptable methods of contraception for at least 1 month prior 
to Visit 2 (Baseline), during the study, and 1 month following 
completion of the study. 
Acceptable methods of contraception include the following: 
a. A barrier method (condom, diaphragm, or cervical cap) 
with spermicide 
b. Hormonal contraception, including oral, injectable, 
transdermal, or implantable methods 
c. Intrauterine device (IUD) 
Only one of the two clinically acceptable methods can be a 
hormonal method. 
Exclusion Criteria: 
1. Has a history of schizophrenia or other psychotic disorder, 
major depressive disorder with psychotic features, bipolar I or II 
disorder. Subjects who are currently being treated or require 
treatment for post-traumatic stress disorder, acute stress 
disorder, panic disorder, or obsessive compulsive disorder are 
also not eligible. 
2. Has a current primary diagnosis of borderline, antisocial, 
paranoid, schizoid, schizotypal, or histrionic personality 
disorder, according to DSM-5 criteria 
3. Has met DSM-5 criteria for substance use disorders within the 
last 6 months prior to Screening, except for disorders related to 
the use of caffeine or nicotine 
4. Is suicidal at Visit 1 (Screening) or Visit 2 (Baseline) as defined 
below: 
a. An answer of “yes” to C-SSRS questions 4 or 5 (current 
or over the last 6 months); OR 
b. Has attempted suicide within 1 year prior to Visit 1 
(Screening); OR 
c. Is actively suicidal in the Investigator’s judgment 
5. Has current evidence of delirium or an unstable neurological, 
cardiovascular, respiratory, gastrointestinal, renal, hepatic, 
hematologic, or other medical disorder, including cancer or 
malignancies that, in the judgment of the Investigator or the 
Medical Monitor, would jeopardize the safe participation of the 

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subject in the study or significantly interfere with the conduct or 
interpretation of the study 
6. Has a history of epilepsy 
7. Has atrial fibrillation unless adequately anti-coagulated 
8. Has a history of myocardial infarction, unstable angina, acute 
coronary syndrome, or cerebrovascular accident   
9. Has a history of any of the following: 
a. Greater than New York Heart Association (NYHA) 
Class II congestive heart failure (Appendix A) 
b. Grade II or greater angina pectoris (by Canadian 
Cardiovascular Society Angina Grading Scale) 
(Appendix B) 
c. Sustained ventricular tachycardia 
d. Ventricular fibrillation 
e. Torsade de pointes 
f. Syncope due to an arrhythmia 
g. An implantable cardiac defibrillator 
10. Has laboratory evidence of hypothyroidism at Screening, as 
measured by thyroid stimulating hormone (TSH) and reflex free 
thyroxine (T4). If TSH is abnormal and the reflex free T4 is 
normal, the subject may be enrolled. 
11. Has current unstable diabetes or glycosylated hemoglobin 
(HbA1c) >8% at Screening 
12. Has a known history of a positive hepatitis B virus (HBV), 
hepatitis C virus (HCV), or human immunodeficiency virus 
(HIV) test  
13. Has a history of neuroleptic malignant syndrome or serotonin 
syndrome 
14. Has a known personal or family history of long QT syndrome or 
family history of sudden cardiac death 
15. Has any of the following ECG results at Visit 1 (Screening) or 
Visit 2 (Baseline): 
a. If the subject is not on citalopram, escitalopram, or 
venlafaxine (immediate or extended release): 
i. QTcF >450 ms, if QRS duration <120 ms 
ii. QTcF >470 ms, if QRS duration ≥120 ms 
b. If the subject is on citalopram, escitalopram, or 
venlafaxine (immediate or extended release): 
i. QTcF >425 ms, if QRS duration <120 ms 
ii. QTcF >450 ms, if QRS duration ≥120 ms 
At Screening, if the set of triplicate ECGs has a prolonged QTcF 
due to an identifiable cause, and it is medically appropriate to 
address that cause, a repeat set of triplicate ECGs may be 

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performed during Screening at the discretion of the Medical 
Monitor. 
16. Has a heart rate <50 beats per minute, as measured by 
peripheral pulse rate, not explained by regular exercise or 
medication, in discussion with the Medical Monitor. If 
bradycardia is secondary to iatrogenic or treatable causes and 
these causes are treated, a heart rate assessment can be repeated 
during the screening period. 
17. Requires treatment with a medication or other substance that is 
prohibited by the protocol 
18. At Screening, has a body mass index (BMI) <18.5 kg/m2 or 
>35 kg/m2 or known unintentional clinically significant weight 
loss (i.e., ≥7%) over past 6 months 
19. Has a positive test for an illicit drug or cannabis at Screening or 
Baseline. Subjects who test positive for a controlled substance 
and who have a valid prescription may be retested during 
Screening if they agree to abstain from the medication for the 
length of their participation in the study. The repeat test during 
Screening must be negative for them to participate in the study. 
Additionally, DSM-5 criteria for substance use disorders should 
not be met. 
20. Has received electroconvulsive therapy, transcranial magnetic 
stimulation, or vagal nerve stimulation, or has received deep 
brain stimulation in the current episode of depression 
21. Has received new-onset psychotherapy or had a change in the 
intensity of psychotherapy within 8 weeks prior to Screening 
22. Has participated in or is participating in a noninterventional 
study or clinical trial of any investigational or marketed drug, 
device, or intervention, within 30 days or 5 half-lives, 
whichever is longer, of Visit 2 (Baseline) 
23. Has previously been enrolled in any prior clinical study with 
pimavanserin or is currently taking pimavanserin 
24. Has a significant sensitivity or allergic reaction to pimavanserin 
or its excipients 
25. Is an employee or is a family member of an employee of 
ACADIA Pharmaceuticals Inc. 
26. Is judged by the Investigator or the Medical Monitor to be 
inappropriate for the study for any reason, including if the 
subject is judged to be a danger to self or others 
Sample Size 
Calculations 
A total sample size of 266 evaluable subjects was estimated to provide 
at least 90% power at a two-sided significance level of 0.05 when 
assuming a treatment effect size of 0.4 for pimavanserin compared to 

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placebo on the change from Baseline to Week 5 in the HAMD-17 total 
score. 
Adjusting for a potential non-evaluable rate of up to 5%, 
approximately 280 subjects will be randomized. 
Statistical Methods 
Analysis Sets 
The Full Analysis Set includes all subjects who were randomized, 
received at least one dose of study drug, and have both a Baseline 
(Week 0) value and at least one post-Baseline value for the HAMD-17 
total score in the two studies. The Full Analysis Set will be used for the 
analysis of all efficacy endpoints. 
The Per-protocol Analysis Set includes a subset of subjects in the Full 
Analysis Set without any protocol deviations that could have a 
significant effect on the study conclusions. The Per-protocol Analysis 
Set will be determined prior to unblinding the studies for the final 
analysis and will be used for supportive analysis of selected efficacy 
endpoints. 
The Safety Analysis Set includes all subjects who received at least one 
dose of study drug in the two studies. 
Any other analysis sets, if necessary, will be defined in the statistical 
analysis plan (SAP). 
Efficacy Analyses 
Efficacy analyses will be conducted on the combined database from 
the ACP-103-054 and ACP-103-059 studies for the Full Analysis Set. 
The primary efficacy endpoint, change from Baseline to Week 5 in the 
HAMD-17 total score, will be analyzed using a mixed-effect model 
repeated measures (MMRM). The model will include effects for 
treatment group, visit, treatment-by-visit interaction, baseline 
HAMD-17 total score, the baseline HAMD-17 total score-by-visit 
interaction, and study. An unstructured covariance matrix will be used 
and the Kenward-Roger approximation will be used to adjust the 
denominator degrees of freedom. 
Additional sensitivity analyses will be performed to assess the impact 
of COVID-19. 
Each of the secondary endpoints, other than response and remission, 
will be analyzed using the MMRM method similar to that used for the 
analysis of the primary efficacy endpoint. For CGI-I, the baseline 
CGI-S score will be used as the covariate in the MMRM model. The 
response and remission rates will be compared between the 
pimavanserin and placebo groups using the Cochran-Mantel-Haenszel 
(CMH) test stratified by study. 

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A hierarchical approach will be used to control for multiple endpoints 
(primary and secondary). 
Safety Analyses 
Safety analyses will be conducted on the combined database from the 
ACP-103-054 and ACP-103-059 studies for the Safety Analysis Set. 
Safety results will be summarized by treatment group using descriptive 
statistics. Adverse events (AEs) will be classified into standard 
terminology using the Medical Dictionary for Regulatory Activities 
(MedDRA). All AEs will be listed and TEAEs will be summarized by 
system organ class and preferred term. A TEAE is defined as an AE 
that started after the first administration of study drug and no later than 
the last administration of study drug plus 30 days. Summaries by 
maximum severity and by relationship to study drug will also be 
provided. Serious TEAEs, fatal AEs, and TEAEs leading to 
discontinuation will also be summarized. The relationship of selected 
AEs to COVID-19 will also be assessed and COVID-19 related 
TEAEs will be tabulated. 
Clinical laboratory values for hematology, chemistry and urinalysis 
(specific gravity and pH) will be summarized by treatment group using 
descriptive statistics at Baseline and the end of treatment visit. The 
change from baseline values will also be summarized by treatment 
group. The overall minimum and maximum post-baseline observed 
and change from baseline values will also be summarized. 
The number and percentage of subjects with potentially clinically 
important (PCI) laboratory values at the end of treatment and overall 
post-baseline will be summarized by treatment group for selected 
parameters. The PCI criteria will be specified in the SAP. 
Vital signs including weight, height, and the derived BMI will be 
summarized by treatment group using descriptive statistics at Baseline 
and each post-baseline visit. The change from baseline values will also 
be summarized by treatment group at the post-baseline visits. 
Observed values of ECG parameters and the changes from Baseline 
will be summarized by treatment group and visit. Categorical analyses 
will be conducted on the incidence of subjects with prolonged QTc 
intervals and changes in QTc intervals in accordance with ICH 
guidelines. 
For the C-SSRS, the number and percentage of subjects with suicidal 
ideation or suicidal behavior during the study will be tabulated. 
Observed values and change from Baseline in the ESRS-A score will 
be summarized by treatment group and visit. The change from 
Baseline in the ESRS-A score will be analyzed using the MMRM 
method, similar to the MMRM method used to analyze the primary 
endpoint. 

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Number and percentage of subjects with sexual dysfunction (a total 
score of ≤47 for men and ≤41 for women) will be summarized and 
shift tables will be presented. 
Date 
21 June 2020 
 

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Figure S–1 
Schematic of Study Design for ACP-103-054 
 
Abbreviations: QD=once daily; R=randomization 
Note: Subjects who enroll in an open-label extension will not enter the Safety Follow-up Period. 
 
 

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Table S–1 
Schedule of Events and Assessments for ACP-103-054 
Period Screening 
Baseline 
Double-blind Treatment Period 
 
Safety 
Follow-upa 
Visit Number 
1 
2 
3 
4 
5 
6 
7 
(EOT/ET) 
8 
Unscheduled 
Visitk 
9 
Visit Day/Week 
Day -28 
to -3 
Week 
0 
Week 
1 
Week 
2 
Week 
3 
Week 
4 
Week 
5 
Week 
6 
Week 
10 
Type of Visitb 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Phone call 
Visit window (# days) 
+7 
 
±3 
±3 
±3 
±3 
±3 
±3 
 
+7 
Informed consent and if 
applicable, privacy forms 
X 
 
 
 
 
 
 
 
 
 
Inclusion/exclusion criteria 
X 
X 
 
 
 
 
 
 
 
 
Medical history, medication 
history, and demographics 
X 
 
 
 
 
 
 
 
 
 
Psychiatric history 
X 
 
 
 
 
 
 
 
 
 
MGH ATRQc 
X 
 
 
 
 
 
 
 
 
 
SAFER remote interviewd 
X 
 
 
 
 
 
 
 
 
 
MINI 
X 
 
 
 
 
 
 
 
 
 
Physical examination 
X 
X 
 
 
 
 
 
X 
 
 
Vital signs and weight 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Height 
X 
 
 
 
 
 
 
 
 
 
12-lead ECGe 
X 
X 
X 
 
 
 
 
X 
 
 
Clinical laboratory testsf 
X 
X 
 
 
 
 
 
X 
 
 
Pregnancy testg 
X 
X 
 
 
 
 
 
X 
 
 
Background antidepressant blood 
levelh 
X 
 
 
 
 
 
 
 
 
 
Urine toxicity (drug) screen 
X 
X 
 
 
 
 
 
X 
 
 
MADRS 
X 
X 
 
 
 
 
 
 
 
 
Table continues on next page 

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Table S–1 
Schedule of Events and Assessments for ACP-103-054 (Continued) 
Period Screening 
Baseline 
Double-blind Treatment Period 
 
Safety 
Follow-upa 
Visit Number 
1 
2 
3 
4 
5 
6 
7 
(EOT/ET) 
8 
Unscheduled 
Visitk 
9 
Visit Day/Week 
Day -28 
to -3 
Week 
0 
Week 
1 
Week 
2 
Week 
3 
Week 
4 
Week 
5 
Week 
6 
Week 
10 
Type of Visitb 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Clinic 
Phone call 
Visit window (# days) 
+7 
 
±3 
±3 
±3 
±3 
±3 
±3 
 
+7 
HAMD-17i 
 
X 
X 
X 
X 
X 
X 
X 
 
 
SDS 
 
X 
X 
X 
X 
X 
X 
X 
 
 
CGI-S 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
CGI-I 
 
 
X 
X 
X 
X 
X 
X 
 
 
CSFQ-14 
 
X 
X 
X 
X 
X 
X 
X 
 
 
KSS 
 
X 
X 
X 
X 
X 
X 
X 
 
 
BIS-11 
 
X 
X 
 
X 
 
X 
X 
 
 
ESRS-A 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
C-SSRSj 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Concomitant medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Assessment of adverse events 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Dispense study drug 
 
X 
X 
X 
X 
X 
X 
 
Xl 
 
Study drug accountability 
 
 
X 
X 
X 
X 
X 
X 
X 
 
Review of background 
antidepressant adherence  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Abbreviations: BIS-11=Barratt Impulsiveness Scale; CGI-I=Clinical Global Impression–Improvement; CGI-S=Clinical Global Impression–Severity; 
CSFQ-14=Changes in Sexual Functioning Questionnaire Short Form; C-SSRS=Columbia–Suicide Severity Rating Scale; ECG=electrocardiogram; 
eCRF=electronic case report form; EOT=end of treatment; ESRS-A=Extrapyramidal Symptom Rating Scale–Abbreviated; ET=early termination; 
HAMD-17=Hamilton Depression Scale (17 items); KSS=Karolinska Sleepiness Scale; MADRS=Montgomery-Asberg Depression Rating Scale; MGH 
ATRQ=Massachusetts General Hospital Antidepressant Treatment Response Questionnaire; MINI=Mini-International Neuropsychiatric Interview; 
SAFER=State versus trait, Assessability, Face validity, Ecological validity, and Rule of three Ps (pervasive, persistent, and pathological); SDS=Sheehan 
Disability Scale; SNRI=serotonin-norepinephrine reuptake inhibitor; SSRI=selective serotonin reuptake inhibitor.  
Table footnotes on next page 

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a 
This visit is a safety follow-up telephone call visit for subjects who discontinue prematurely from the study or who do not participate in the open-label 
extension study. This visit will occur at least 30 days after the last dose of study drug. 
b 
If visit was performed remotely due to the COVID-19 pandemic, please refer to Sections 3.3.2 (remote clinical assessments), 6.2.7 (efficacy assessments), 
6.3.8 (safety assessments) and 6.5.1 (unscheduled visits) for further information. 
c 
Inadequate response is defined as a response of <50% to a course of treatment of at least 8 weeks at the minimum effective dose (as listed on the ATRQ), 
which has been stable for the 4 weeks prior to the SAFER interview. 
d 
The SAFER remote interview may be conducted via telephone off-site or on-site. If conducted on-site, the site staff should not be present during the 
interview. 
e 
At Visit 1, ECG should be completed in triplicate and collected within a 3-minute period. At all other visits, a single 12-lead ECG should be completed. 
ECGs should be completed with the subject in a supine position after 5 minutes of rest. The ECG should occur before blood sampling or at least 30 minutes 
after blood sampling. 
f 
To include hematology, serum chemistry, prolactin levels, and urinalysis. 
g 
A pregnancy test is only required for women of childbearing potential. Serum pregnancy should only be performed at Visit 1; a urine pregnancy test should 
be performed at Baseline and Week 6 (EOT). If urine cannot be obtained in women of childbearing potential, a serum pregnancy test should be done in its 
place. 
h 
At Screening, blood samples will be collected for the analysis of concomitant SSRI/SNRI concentrations. The presence of SSRI or SNRI must be confirmed 
in order to qualify the subject for further consideration in the study. 
i 
The HAMD-17 is to be the first scale completed at each visit. 
j 
Suicidal assessment is required. The Baseline/Screening version of the C-SSRS will be administered at Screening. The Since Last Visit version of the 
C-SSRS will be administered at all subsequent visits. 
k 
At a minimum the safety assessments indicated should be completed at unscheduled visits. Other assessments may be completed at unscheduled visits at the 
discretion of the Investigator. 
l 
Study drug may be dispensed to the subject at unscheduled visits if needed. 
 

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TABLE OF CONTENTS 
SPONSOR SIGNATURE PAGE ............................................................................................... 2 
DECLARATION OF INVESTIGATOR ................................................................................... 4 
PROTOCOL SYNOPSIS ........................................................................................................... 5 
TABLE OF CONTENTS ......................................................................................................... 20 
LIST OF TABLES ................................................................................................................... 25 
LIST OF FIGURES ................................................................................................................. 25 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ............................................. 26 
1 
INTRODUCTION ...................................................................................................... 28 
1.1 
Background Information ............................................................................................ 28 
1.2 
Investigational Product ............................................................................................... 30 
1.3 
Previous Clinical Experience ..................................................................................... 30 
1.4 
Study Rationale .......................................................................................................... 32 
1.5 
Benefit/Risk Assessment ............................................................................................ 33 
2 
STUDY OBJECTIVES AND ENDPOINTS .............................................................. 33 
2.1 
Primary Objective....................................................................................................... 33 
2.1.1 
Primary Endpoint ....................................................................................................... 33 
2.2 
Secondary Objective................................................................................................... 34 
2.2.1 
Secondary Endpoints .................................................................................................. 34 
2.3 
Safety Objective ......................................................................................................... 34 
2.3.1 
Safety Assessments..................................................................................................... 35 
3 
STUDY DESCRIPTION ............................................................................................ 35 
3.1 
Overview of Study Design ......................................................................................... 35 
3.1.1 
Screening Period (3-28 Days) .................................................................................... 35 
3.1.2 
Double-Blind Treatment Period (6 Weeks) ................................................................ 36 
3.1.3 
Safety Follow-up Period (30 Days) ............................................................................ 36 
3.2 
Matching Study ACP-103-059 ................................................................................... 36 
3.3 
Impact of COVID-19 Pandemic on Studies -054 and -059........................................ 36 
3.3.1 
Combination of Databases of Studies -054 and -059 ................................................. 36 
3.3.2 
Remote Clinical Assessments ..................................................................................... 37 
3.3.3 
Roll Over Into Open-Label Study ACP-103-055 ....................................................... 37 
4 
SUBJECT ELIGIBILITY AND WITHDRAWAL CRITERIA .................................. 37 

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4.1 
Inclusion Criteria ........................................................................................................ 37 
4.2 
Exclusion Criteria ....................................................................................................... 39 
4.3 
Subject Withdrawal of Consent .................................................................................. 41 
4.4 
Subject or Study Discontinuation ............................................................................... 42 
4.4.1 
Handling of Subject Discontinuation During the Treatment Period .......................... 42 
4.5 
Subject Lost to Follow-up .......................................................................................... 43 
4.6 
Prior and Concomitant Therapy ................................................................................. 43 
4.6.1 
Prior Medication ......................................................................................................... 43 
4.6.2 
Concomitant Medication ............................................................................................ 43 
4.6.2.1 Permitted, Restricted, and Prohibited Medications .................................................... 43 
5 
INVESTIGATIONAL PRODUCT ............................................................................. 44 
5.1 
Investigational Product Description ........................................................................... 44 
5.1.1 
Formulation, Appearance, Packaging, and Labeling .................................................. 44 
5.1.2 
Product Storage and Stability ..................................................................................... 45 
5.1.3 
Dosing and Administration ......................................................................................... 45 
5.1.4 
Method of Assigning Subjects to Treatment Groups.................................................. 45 
5.1.5 
Blinding ...................................................................................................................... 45 
5.1.6 
Study Drug Compliance ............................................................................................. 45 
5.1.7 
Overdose ..................................................................................................................... 45 
5.2 
Investigational Product Accountability Procedures ................................................... 46 
6 
STUDY PROCEDURES ............................................................................................ 46 
6.1 
Screening Assessments ............................................................................................... 46 
6.1.1 
Medical History, Medication History, and Demographics ......................................... 46 
6.1.2 
Psychiatric History ..................................................................................................... 47 
6.1.3 
Background Antidepressant Blood Level ................................................................... 47 
6.1.4 
Massachusetts General Hospital Antidepressant Treatment Response 
Questionnaire.............................................................................................................. 47 
6.1.5 
State versus trait, Assessability, Face validity, Ecological validity, and Rule of 
three Ps (pervasive, persistent, and pathological) (SAFER) Remote Interview ........ 47 
6.1.6 
Mini-International Neuropsychiatric Interview.......................................................... 47 
6.1.7 
Montgomery-Asberg Depression Rating Scale .......................................................... 48 
6.2 
Efficacy Assessments ................................................................................................. 48 
6.2.1 
Hamilton Depression Scale (17 Items) ....................................................................... 48 
6.2.2 
Sheehan Disability Scale ............................................................................................ 48 
6.2.3 
Clinical Global Impression–Severity and Clinical Global Impression–
Improvement Scales ................................................................................................... 48 

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6.2.4 
Changes in Sexual Functioning Questionnaire Short Form ....................................... 49 
6.2.5 
Karolinska Sleepiness Scale ....................................................................................... 49 
6.2.6 
Barratt Impulsiveness Scale ....................................................................................... 49 
6.2.7 
Impact of COVID-19 Pandemic on Efficacy Assessments ........................................ 49 
6.3 
Safety Assessments..................................................................................................... 49 
6.3.1 
Physical Examinations ............................................................................................... 49 
6.3.2 
Vital Signs .................................................................................................................. 49 
6.3.3 
Height, Weight, and Body Mass Index ....................................................................... 50 
6.3.4 
Electrocardiograms ..................................................................................................... 50 
6.3.5 
Columbia–Suicide Severity Rating Scale................................................................... 50 
6.3.6 
Extrapyramidal Symptom Rating Scale–Abbreviated ............................................... 51 
6.3.7 
Laboratory Evaluations .............................................................................................. 51 
6.3.8 
Impact of COVID-19 Pandemic on Safety Assessments ........................................... 53 
6.3.8.1 Priority Medical Assessments in Remote Visits ......................................................... 54 
6.3.8.2 Physical Examinations, Vital Signs, Height, and Weight ........................................... 54 
6.3.8.3 Electrocardiograms ..................................................................................................... 54 
6.3.8.4 Columbia-Suicide Severity Rating Scale ................................................................... 54 
6.3.8.5 Extrapyramidal Symptom Rating Scale-Abbreviated ................................................ 54 
6.3.8.6 Laboratory Evaluations .............................................................................................. 54 
6.4 
Safety Follow-up ........................................................................................................ 54 
6.5 
Unscheduled Visits ..................................................................................................... 55 
6.5.1 
Impact of COVID-19 on Unscheduled Visits ............................................................. 55 
7 
ADVERSE EVENTS ................................................................................................. 55 
7.1 
Specification of Safety Parameters............................................................................. 55 
7.1.1 
Definition of Adverse Event ....................................................................................... 55 
7.1.2 
Definition of Serious Adverse Event .......................................................................... 56 
7.2 
Classification of an Adverse Event ............................................................................ 57 
7.2.1 
Severity of Event ........................................................................................................ 57 
7.2.2 
Relationship to Study Drug ........................................................................................ 57 
7.2.2.1 Duration ...................................................................................................................... 58 
7.2.2.2 Frequency ................................................................................................................... 58 
7.2.2.3 Action Taken with Study Drug ................................................................................... 58 
7.2.2.4 Therapy ....................................................................................................................... 58 
7.2.2.5 Outcome ..................................................................................................................... 58 
7.2.2.6 Seriousness ................................................................................................................. 59 
7.2.3 
Definition of Unexpectedness .................................................................................... 59 
7.3 
Time Period and Frequency for Event Assessment and Follow-up ........................... 59 

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7.4 
Reporting Procedures ................................................................................................. 59 
7.4.1 
Adverse Event Reporting ........................................................................................... 59 
7.4.2 
Serious Adverse Event Reporting............................................................................... 60 
7.4.3 
Reporting of Pregnancy .............................................................................................. 60 
7.4.4 
Reporting of Overdose ............................................................................................... 61 
8 
CLINICAL MONITORING ....................................................................................... 61 
9 
STATISTICAL METHODS AND DATA ANALYSIS .............................................. 61 
9.1 
Statistical and Analytical Plans .................................................................................. 61 
9.2 
Statistical Hypotheses................................................................................................. 61 
9.3 
Sample Size Determination ........................................................................................ 62 
9.4 
Subject Populations for Analysis ................................................................................ 62 
9.5 
Statistical Analyses ..................................................................................................... 62 
9.5.1 
Primary Analyses ........................................................................................................ 62 
9.5.2 
Secondary Analyses .................................................................................................... 63 
9.5.3 
Safety Analyses .......................................................................................................... 63 
9.5.4 
Subgroup Analyses ..................................................................................................... 64 
9.6 
Interim Analyses ......................................................................................................... 64 
9.7 
Measures to Minimize Bias ........................................................................................ 64 
9.7.1 
Masking Procedures ................................................................................................... 64 
9.7.2 
Randomization Procedures ......................................................................................... 64 
9.8 
Breaking the Study Blind/Subject Code ..................................................................... 65 
10 
STUDY MANAGEMENT AND DATA COLLECTION .......................................... 65 
10.1 
Data Collection and Management Responsibilities.................................................... 65 
10.2 
Source Documents ...................................................................................................... 65 
10.3 
Case Report Forms ..................................................................................................... 66 
10.4 
Confidentiality ............................................................................................................ 66 
10.5 
Study Records Retention ............................................................................................ 66 
10.6 
Protocol Exceptions and Deviations........................................................................... 67 
10.7 
Protocol Amendments ................................................................................................ 67 
11 
QUALITY MANAGEMENT .................................................................................... 67 
11.1 
Risk Management ....................................................................................................... 67 
11.2 
Quality Control and Quality Assurance...................................................................... 68 
12 
ETHICAL CONSIDERATIONS ................................................................................ 69 

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12.1 
Ethical Standard ......................................................................................................... 69 
12.2 
Institutional Review Board/Ethics Committee ........................................................... 69 
12.3 
Informed Consent Process .......................................................................................... 69 
12.3.1 Consent and Other Informational Documents Provided to Subjects .......................... 70 
12.3.2 Consent Procedures and Documentation .................................................................... 70 
13 
PUBLICATION PLAN .............................................................................................. 70 
14 
CONFLICT OF INTEREST POLICY ....................................................................... 70 
14.1 
Finance, Insurance, and Indemnity............................................................................. 70 
15 
LITERATURE REFERENCES .................................................................................. 71 
16 
APPENDICES ............................................................................................................ 74 
Appendix A New York Heart Association Classification of Heart Failure ........................... 74 
Appendix B Canadian Cardiovascular Society Angina Grading Scale ................................. 75 
Appendix C Prohibited and Restricted Medications ............................................................. 76 
Appendix D Prohibited and Restricted Concomitant Medications: Inhibitors and 
Inducers of Cytochrome P450 Enzyme 3A4 ................................................... 80 
 

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LIST OF TABLES 
Table S–1 
Schedule of Events and Assessments for ACP-103-054 .................................. 17 
Table 1-1 
Receptor Profiles of Pimavanserin and Compounds With Antidepressant 
Activity ............................................................................................................ 32 
Table 6–1 
Safety Laboratory Evaluations......................................................................... 53 
 
LIST OF FIGURES 
Figure S–1 
Schematic of Study Design for ACP-103-054 ................................................. 16 
 

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LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
Term 
Definition 
5-HT 
5-hydroxytryptamine (serotonin) 
5-HT2A 
5-hydroxytryptamine (serotonin) 2A 
ADP 
Alzheimer’s disease psychosis 
AE 
adverse event 
BIS-11 
Barratt Impulsiveness Scale 
CGI-I 
Clinical Global Impression–Improvement 
CGI-S 
Clinical Global Impression–Severity 
COVID-19 
coronavirus disease 2019 
CSFQ-14 
Changes in Sexual Functioning Questionnaire Short Form 
C-SSRS 
Columbia–Suicide Severity Rating Scale  
DAT 
dopamine transporter 
DSM-5 
Diagnostic and Statistical Manual of Mental Disorders, Fifth 
Edition 
EC 
ethics committee 
ECG 
electrocardiogram 
eCRF 
electronic case report form 
ESRS-A 
Extrapyramidal Symptom Rating Scale–Abbreviated  
ET 
early termination 
GCP 
Good Clinical Practices 
HAMD-17 
Hamilton Depression Scale (17 items) 
ICF 
informed consent form 
ICH 
International Council for Harmonisation  
IRB 
institutional review board 
IRT 
interactive response technology 
KSS 
Karolinska Sleepiness Scale 
MADRS 
Montgomery-Asberg Depression Rating Scale 
MDD 
major depressive disorder 
MGH ATRQ 
Massachusetts General Hospital Antidepressant Treatment 
Response Questionnaire 
MINI 
Mini-International Neuropsychiatric Interview 
MMRM 
mixed-effect model repeated measures 
NET 
norepinephrine transporter 
PDP 
Parkinson’s disease psychosis 
PR 
PR interval of ECG 
QRS 
QRS interval of ECG 

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Term 
Definition 
QT 
QT interval for heart rate of ECG 
QTcB 
corrected QT interval using Bazett’s correction method 
QTcF 
corrected QT interval using Fridericia’s correction method 
SAE 
serious adverse event 
SAFER 
State versus trait, Assessability, Face validity, Ecological validity, 
and Rule of three Ps (pervasive, persistent, and pathological)  
SAP 
statistical analysis plan 
SDS 
Sheehan Disability Scale 
SERT 
serotonin transporter 
SNRI 
serotonin-norepinephrine reuptake inhibitor 
SSRI 
selective serotonin reuptake inhibitor 
TEAE 
treatment-emergent adverse event 
TSH 
thyroid stimulating hormone 
US 
United States 

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1 INTRODUCTION 
This document is a research protocol and the described study will be conducted in 
compliance with the protocol and the International Council for Harmonisation (ICH) 
Good Clinical Practices (GCP) Guideline.  
1.1 
Background Information 
Depression is ranked as the leading cause of disability worldwide by the World Health 
Organization (Murray and Lopez 1996). In particular, major depressive disorder (MDD) is a 
psychiatric illness that is characterized by the occurrence of one or more major depressive 
episodes, along with an absence of any history of manic, mixed, or hypomanic episodes. It is 
a serious, often recurrent medical condition, which is associated with a 15.9% lifetime risk of 
suicide attempt (Chen and Dilsaver 1996). Results of the World Mental Health Survey 
Initiative found that the average lifetime incidence of DSM-4 major depressive episodes was 
14.6%, with a 12-month prevalence of 5.5% in higher income countries (Bromet et al. 2011). 
Despite the availability of numerous pharmacological and psychological treatment options, 
fewer than 50% of all patients with depression show full remission with optimized treatment, 
including courses on numerous medications with and without concurrent psychotherapy 
(Rush et al. 2006). 
Thus, while medications have demonstrated efficacy in the treatment patients with an 
inadequate response to standard antidepressant therapies, there is a clear need for efficacious 
medications with improved tolerability and safety. Current research continues to investigate 
novel molecular and cellular mechanisms of augmentation of antidepressant therapies. 
Pimavanserin was studied in a Phase 2, randomized, double-blind, placebo-controlled, 
two-stage sequential parallel comparison design (SPCD) (Fava et al. 2016) study in adult 
subjects with MDD and an inadequate response to antidepressant therapy with concurrent 
selective serotonin reuptake inhibitor (SSRI)/serotonin-norepinephrine reuptake inhibitor 
(SNRI) (Study ACP-103-042). In the study, 207 adult patients with a confirmed inadequate 
response to existing first-line SSRI or SNRI therapy for MDD received adjunctive treatment 
of either 34 mg pimavanserin or placebo in addition to pre-existing first-line therapy for 
5 weeks (Stage 1). Those patients who did not show a response to placebo in Stage 1 were 
re-randomized to receive either pimavanserin or placebo for a second 5-week treatment 
period (Stage 2). 
Pimavanserin met the overall primary endpoint of the prespecified weighted average results 
of Stage 1 and Stage 2 by significantly reducing the 17-item Hamilton Depression Rating 
Scale (HAMD-17) total score compared to placebo (p=0.039). In addition, in Stage 1 (n=207) 
patients on pimavanserin demonstrated a highly significant improvement over placebo in 

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HAMD-17 (p=0.0003; effect size [Cohen’s d] 0.626). Importantly, this group of patients saw 
a benefit over placebo in the first week of treatment (p=0.0365; effect size [Cohen’s d] 
0.346). Fewer subjects (n=58) than anticipated proceeded to Stage 2, and no treatment benefit 
versus placebo was observed in this small set of placebo non-responders. In summary, 
pimavanserin met the overall primary endpoint of the prespecified weighted average results 
of Stage 1 and Stage 2 and demonstrated a highly significant improvement over placebo in 
HAMD-17 in Stage 1. 
On the key secondary endpoint, pimavanserin demonstrated statistically significant 
reductions compared to placebo in the Sheehan Disability Scale (SDS) score (p=0.004).  
Positive results were also observed for seven of the eleven other secondary endpoints listed 
below with nominal p-values: Clinical Global Impression–Severity (p=0.0084), Clinical 
Global Impression–Improvement (p=0.0289), Short Form-12 Mental Component Summary 
(p<0.0001), Karolinska Sleepiness Scale (p=0.0205), Massachusetts General Hospital Sexual 
Functioning Index (p=0.0003), Barratt Impulsiveness Scale (p=0.0075), as well as response 
rates (p=0.0065), defined as a 50% or greater reduction on the HAMD-17 total score.  
In this Phase 2 study, pimavanserin was generally well-tolerated. The most frequently 
reported treatment-emergent adverse events (TEAEs) included headache in the placebo group 
and headache, dry mouth, and nausea in the pimavanserin group. In Stage 1, for placebo 
subjects, TEAEs leading to discontinuation included depression, swelling face, and 
hypotension; for pimavanserin subjects, a TEAE of vomiting was reported and led to 
discontinuation. In Stage 2, a TEAE of diabetes mellitus was reported in the placebo group 
and led to discontinuation. One subject in each of the pimavanserin and placebo groups 
reported serious adverse events (SAEs). The placebo subject experienced SAEs of prostate 
cancer and calculus bladder; the pimavanserin subject experienced an SAE of acute 
myocardial infarction. These SAEs were deemed not to be related to the study drug by the 
Investigators and both subjects completed the study. No deaths were reported in the study. 
Furthermore, no meaningful differences were observed between the pimavanserin and 
placebo groups in changes in the Barnes Akathisia Scale, the Simpson Angus Scale, and the 
Abnormal Involuntary Movement Scale. Weight changes and ECG changes between the 
pimavanserin and placebo groups were generally similar. In Stage 2, there was a mean 
QTcF interval change of 7.2 ms and -0.8 ms in the pimavanserin and placebo groups, 
respectively, which is consistent with what has been observed with pimavanserin in other 
clinical studies. 
On the basis of the robust preliminary clinical evidence for efficacy and favorable tolerability 
observed in Study ACP-103-042, the present study is being initiated. 

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1.2 
Investigational Product 
Pimavanserin is an atypical antipsychotic that is present in the investigational product as 
pimavanserin tartrate salt with the chemical name, urea, N-[(4-fluorophenyl)methyl]-N-(1-
methyl-4-piperidinyl)-N’-[[4-(2-methylpropoxy)phenyl]methyl]-,(2R,3R)-2,3-
dihydroxybutanedioate (2:1). In April 2016, pimavanserin was approved in the United States 
(US) for the treatment of hallucinations and delusions associated with Parkinson’s disease 
psychosis (PDP). 
Pimavanserin is a novel small molecule designed to specifically block serotoninergic 
neurotransmission mediated by the 5-hydroxytryptamine (5-HT [serotonin]) 2A (5-HT2A) 
receptor. At higher doses, pimavanserin may block 5-HT2C receptors (Vanover et al. 2006). 
Pimavanserin shows no appreciable activity at dopaminergic, adrenergic, histaminergic, or 
muscarinic receptors. Activity at these receptors has been implicated in a range of 
dose-limiting side effects associated with existing antipsychotic drugs including cognitive 
dulling (Saeedi et al. 2006; Mehta et al. 2004; Peretti et al. 1997) and an increased risk of 
mortality in elderly patients with dementia (Wang et al. 2005). On the basis of its novel 
receptor binding profile, pimavanserin may have benefits with regard to overall tolerability 
relative to other antipsychotic agents. 
1.3 
Previous Clinical Experience 
Pimavanserin is an atypical antipsychotic that is approved for the treatment of hallucinations 
and delusions associated with PDP. Studies have also been conducted in Alzheimer’s disease 
psychosis (ADP), dementia-related psychosis and schizophrenia, and studies in Alzheimer’s 
disease agitation and aggression, dementia-related psychosis, and schizophrenia are ongoing. 
A more complete discussion of these studies is available in the current pimavanserin 
Investigator’s brochure. 
Pimavanserin is considered to be generally well tolerated and has an acceptable safety 
profile. In single and multiple dose studies in healthy subjects, the highest doses administered 
were 255 mg and 136 mg/day, respectively. In Phase 1 studies in subjects who received 
pimavanserin without concomitant medication, the most common TEAEs (>3%) were 
postural dizziness (7.7%), headache (6.9%), somnolence (4.6%), nausea (3.8%), and 
dizziness (3.1%) in the single-dose studies (N=130) and headache (15.1%), dizziness (8.6%), 
nausea (7.4%), somnolence (5.1%), and postural dizziness (3.7%) in the multiple-dose 
studies (N=350). Nausea and vomiting were considered dose-limiting. Pimavanserin doses 
≤34 mg generally had a low incidence of TEAEs, with only small differences versus placebo. 
In controlled studies of pimavanserin in subjects with PDP, the most frequent TEAEs 
experienced by subjects in the pimavanserin 34 mg group compared with the placebo group 

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were urinary tract infection (7.4% pimavanserin 34 mg vs. 6.9% placebo), nausea 
(6.9% pimavanserin 34 mg vs. 4.3% placebo), peripheral edema (6.9% pimavanserin 34 mg 
vs. 2.2% placebo), fall (6.4% pimavanserin 34 mg vs. 9.1% placebo), and confusional state 
(5.9% pimavanserin 34 mg vs. 2.6% placebo). In the long-term open-label studies in subjects 
with PDP (as of 28 April 2019), the most frequent TEAEs include fall (31.1%), urinary tract 
infection (19.1%), hallucination (14.5%), decreased weight (13.3%), confusional state 
(11.4%), and constipation (11.2%). It is difficult to interpret these incidence rates in the 
absence of a concurrent control group. The overall incidence of TEAEs appears within what 
would be expected in subjects with the underlying neurodegenerative disease, psychosis, and 
advanced age. 
As of 28 April 2019, 74 subjects have died during participation in the PDP studies, with the 
majority of deaths considered not related or unlikely related to study drug. Five of these deaths 
occurred in 6-week double-blind studies (1 subject received placebo, 1 subject received 8.5 mg 
pimavanserin, and 3 subjects received 34 mg pimavanserin), and 69 deaths occurred in the 
multi-year, long-term open-label extension studies. 
Medical reviews of all deaths occurring in the pimavanserin PDP program, including 
placebo-controlled (6-week) and open-label (long-term) studies, found no common etiology 
or unifying pathology to attribute these deaths to pimavanserin treatment. The causes of death 
(e.g., cardiovascular, respiratory, infection) were consistent with the advanced age, stage of 
illness, and comorbidities of this elderly, medically frail population. Additional information is 
provided in the current pimavanserin Investigator’s brochure. 
In a frail, elderly population of 181 nursing home patients with ADP (90 treated with 
pimavanserin; 91 with placebo), pimavanserin was well tolerated, with no new safety 
observations. There were 8 post-randomization deaths, 4 (4.4%) in each treatment group. 
More subjects had SAEs with pimavanserin (15 subjects, 16.7%) than with placebo 
(10 subjects, 11.0%), but there were fewer discontinuations due to AEs with pimavanserin 
(8 subjects, 8.9%) than with placebo (11 subjects, 12.1%). TEAEs reported in ≥10% of 
subjects in either group were (pimavanserin; placebo) fall (23.3%; 23.1%), urinary tract 
infection (22.2%; 27.5%), agitation (21.1%; 14.3%), lower respiratory tract infection (14.4%; 
13.2%), contusion (12.2%; 15.4%), aggression (10.0%; 4.4%), anemia (10.0%; 8.8%), blood 
lactate dehydrogenase decreased (4.4%; 11.0%), and hyperglycemia (4.4%; 12.1%). Mean 
weight change from Baseline to Day 85 was comparable for the two treatment groups. 
Weight loss ≥7% was more common with pimavanserin (pimavanserin, 14.6%; placebo, 
1.8%). Treatment with pimavanserin had no negative effects on cognition or motor function. 
Pimavanserin increases QT interval. The magnitude of effect in humans has been assessed in 
a thorough QT study with doses of pimavanserin ranging from 17 to 68 mg and in the Phase 3 

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PDP program with a clinical dose of 34 mg. An average prolongation of approximately 5-8 ms 
was observed. No clinically significant patterns have been observed in SAEs and there has 
been no evidence of pimavanserin-related laboratory abnormalities.  
Always refer to the latest version of the pimavanserin Investigator’s brochure for the overall 
benefit/risk assessment and the most accurate and current information regarding drug 
metabolism, pharmacokinetics (PK), efficacy, and safety. 
1.4 
Study Rationale 
5-HT2A serotonin receptors represent important targets for depression. A variety of studies 
have shown antidepressant activity from compounds with potent antagonist or inverse agonist 
activity at 5-HT2A receptors, and to varying degrees 5-HT2C receptors, but low affinity to 
SERT, NET, and DAT, either alone or when coadministered with SSRIs (Table 1-1). These 
compounds include volinanserin, pruvanserin, ketanserin, ritanserin, mirtazapine, mianserin, 
and trazodone (Table 1-1). Pimavanserin, with its potent activity as a 5-HT2A 
antagonist/inverse agonist and lesser activity as a 5-HT2C antagonist/inverse agonist, has a 
similar receptor profile to many compounds with antidepressant activity. Therefore, although 
there are no preclinical data on pimavanserin in animal models of depression, it would also 
be expected to have antidepressant activity. 
Table 1-1 
Receptor Profiles of Pimavanserin and Compounds With 
Antidepressant Activity 
Target 
PIM 
RIT 
VOL 
PRUV 
PIP 
KET 
MIRT 
MIAN 
TRAZ 
SERT 
Low 
Low 
Low 
Low 
N/A 
Low 
Low 
Low 
350 
NET 
Low 
Low 
Low 
Low 
N/A 
Low 
Low 
70 
Low 
DAT 
Low 
Low 
Low 
Low 
N/A 
Low 
Low 
Low 
Low 
5-HT2A 
0.4 
0.1 
0.2 
0.7 
5 
2 
70 
3 
35 
5-HT2C 
16 
3 
125 
Low 
120 
125 
40 
3 
200 
Other 
noteworthy 
targets 
None 
None 
None 
None 
D4 (5) 
α2 (35) 
α1 (15-20) α2 (15-20) 
H1 (1) 
α2 (4-20) 
H1 (1) 
5-HT1A 
(100) 
Sources: Data on file, except for pipamperone (Schotte et al. 1996); trazodone and mianserin (PDSP Ki 
database, see Roth et al. 2000); and mirtazepine (Brayfield 2014 and Wikström et al. 2002) 
Abbreviations: α1=alpha1 adrenergic receptor; α2=alpha2 adrenergic receptor; DAT=dopamine transporter; 
H1=histamine 1 receptor; KET=ketanserin; MIAN=mianserin; MIRT=mirtazepine; N/A=not available; 
NET=norepinephrine transporter; PIM=pimavanserin; PIP=pipamperone; PRUV=pruvanserin; 
RIT=ritanserin; SERT=serotonin transporter; TRAZ=trazodone; VOL=volinanserin 
Note: Values represent the affinity (Ki) in nM of the indicated ligands and transporters/receptors. For 
“Other noteworthy targets,” Ki values are provided in parentheses. “Low” denotes a Ki >1000 nM. 
Clinical data with pimavanserin have been consistent with these preclinical data, 
demonstrating efficacy in PDP and ADP with an acceptable tolerability and safety profile. 
Furthermore, the robustness of the clinical evidence for efficacy and favorable tolerability 

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observed in Study ACP-103-042 supports further investigation of pimavanserin in the 
treatment of subjects with major depressive disorder who have had an inadequate response to 
antidepressant therapy. 
1.5 
Benefit/Risk Assessment 
This study will examine a range of symptoms to explore the efficacy and safety of adjunctive 
pimavanserin in the treatment of patients with MDD.  
Pimavanserin, with its potent activity as a 5-HT2A antagonist/inverse agonist and lesser 
activity as a 5-HT2C antagonist/inverse agonist, has a receptor profile similar to that of many 
compounds with antidepressant activity. In a randomized, double-blind, placebo-controlled 
Phase 2 study (ACP-103-042) exploring adjunctive pimavanserin, adult MDD patients with 
inadequate response to antidepressant therapy showed improvements in measures of 
depression, disability, clinical global impression, sleepiness, and sexual functioning, as 
summarized in Section 1.1.  
Clinical studies conducted in a range of patient populations (approximately 2720 exposed 
subjects, including patients with PDP, ADP, Alzheimer’s disease agitation and aggression, 
schizophrenia, and MDD, as well as healthy subjects) have shown that pimavanserin is 
generally well tolerated and has an acceptable safety profile. In the Phase 2 study 
(ACP-103-042) no new safety signals were observed in the MDD patient population that 
were not already described in the approved NUPLAZID® prescribing information 
(ACADIA Pharmaceuticals Inc. 2019).  
On the basis of nonclinical and clinical data, it is therefore believed that pimavanserin has 
potential for benefit in the adjunctive treatment of MDD, with an acceptable safety profile. 
A more complete assessment of the overall benefit/risk profile of pimavanserin is provided in 
the current Investigator’s Brochure. 
2 STUDY OBJECTIVES AND ENDPOINTS 
2.1 
Primary Objective 
The primary objective of this study is to evaluate the efficacy of adjunctive pimavanserin 
compared to placebo in subjects with major depressive disorder who have an inadequate 
response to antidepressant therapy. 
2.1.1 
Primary Endpoint 
The primary endpoint of this study is the change from Baseline to Week 5 in the Hamilton 
Depression Scale (17 items) (HAMD-17) total score. 

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2.2 
Secondary Objective 
The secondary objective of this study is to evaluate the efficacy and benefits of adjunctive 
pimavanserin compared to placebo in subjects with major depressive disorder who have an 
inadequate response to antidepressant therapy on the following: 
• Functional impairment 
• Clinician’s global impression of severity and improvement of depressive symptoms 
• Sexual functioning 
• Sleepiness 
• Treatment response and remission 
• Anxiety 
• Impulsiveness 
• Early response to treatment 
2.2.1 
Secondary Endpoints 
The secondary endpoints of this study are the following: 
• Change from Baseline to Week 5 in Sheehan Disability Scale (SDS) score 
• Change from Baseline to Week 5 in Clinical Global Impression–Severity (CGI-S) 
score for depressive symptoms 
• Clinical Global Impression–Improvement (CGI-I) score for depressive symptoms at 
Week 5 
• Change from Baseline to Week 5 in the Changes in Sexual Functioning Questionnaire 
Short Form (CSFQ-14) 
• Change from Baseline to Week 5 in Karolinska Sleepiness Scale (KSS) score 
• Treatment responder rates at Week 5. Treatment response is defined as a reduction 
from Baseline in HAMD-17 total score of 50% or more. 
• Treatment remission rates at Week 5. Treatment remission is defined as a HAMD-17 
total score ≤7. 
• Change from Baseline to Week 5 in the Hamilton Depression (HAMD) 
Anxiety/Somatization factor score 
• Change from Baseline to Week 5 in the Barratt Impulsiveness Scale (BIS-11) 
• Change from Baseline to Week 1 in the HAMD-17 total score 
2.3 
Safety Objective 
The safety objective of this study is to assess the safety and tolerability of pimavanserin 
compared to placebo in subjects with major depressive disorder who have an inadequate 
response to antidepressant therapy.  

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2.3.1 
Safety Assessments 
The safety assessments in this study include the following: 
• Treatment-emergent adverse events (TEAEs) 
• Potentially clinically important laboratory abnormalities, vital signs, and 
electrocardiogram (ECG) results 
• Columbia–Suicide Severity Rating Scale (C-SSRS) score 
• Change from Baseline in Extrapyramidal Symptom Rating Scale–Abbreviated 
(ESRS-A) score 
• Sexual dysfunction defined as a CSFQ-14 total score of ≤47 for men and ≤41 for 
women 
3 STUDY DESCRIPTION 
3.1 
Overview of Study Design 
This study will be conducted as a multicenter, randomized, double-blind, placebo-controlled, 
parallel-group study in subjects with MDD and inadequate response to antidepressant 
treatment. Approximately 40 sites outside of the US will participate in this study. The 
duration of participation for individual study subjects will be up to 15 weeks.  
The study will have three periods (Figure S–1): 
• Screening period (3-28 days) 
• Double-blind treatment period (6 weeks) 
• Safety follow-up period (at least 30 days) 
The study completion date (or when a subject is considered to have completed the study) is 
defined as the date the final subject, across all sites, completes their final protocol-defined 
assessment. Please note that this includes the safety follow-up visit/contact, whichever is 
later. Procedures for when a subject is lost to follow-up are provided in Section 4.5. 
If the study is terminated for any reason, subjects remaining in the study will return to 
standard of care. 
3.1.1 
Screening Period (3-28 Days) 
During the screening period, subjects will be assessed for study eligibility and prohibited 
medications will be discontinued if medically appropriate. Subject eligibility will be assessed 
by the site and the Sponsor through an eligibility review process. The screening period may 
be extended up to 7 days to confirm subject eligibility when discussed with and approved by 
the Medical Monitor in advance. 

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Investigators should not withdraw a subject’s prohibited medication for the purpose of 
enrolling them into the study. Medications should only be discontinued if it is deemed 
clinically appropriate to do so and in consultation with the treating physician. 
3.1.2 
Double-Blind Treatment Period (6 Weeks) 
The Baseline visit (Visit 2) may occur as soon as screening procedures are completed and 
subject eligibility has been confirmed by the site and the Medical Monitor. At Visit 2, 
subjects will be randomized in a 1:1 ratio to pimavanserin 34 mg once daily or matching 
placebo. It is recommended that the subject should take the study drug at approximately the 
same time each day. Assessments will be conducted at Weeks 0 (Baseline), 1, 2, 3, 4, 5, and 
6/EOT or early termination (ET). 
3.1.3 
Safety Follow-up Period (30 Days) 
Eligible subjects who successfully complete the 6-week double-blind period will be qualified 
to enroll in an open-label extension study. For subjects who discontinue prematurely from the 
study or who do not enroll in the open-label extension study, a safety follow-up telephone 
call visit will be conducted at least 30 days after the last dose of study drug. 
3.2 
Matching Study ACP-103-059 
Study ACP-103-059, conducted only in the US, is identical in design with Study ACP-103-
054, conducted in parallel outside of the US. 
3.3 
Impact of COVID-19 Pandemic on Studies -054 and -059 
In March, 2020, the emerging coronavirus disease 2019 (COVID-19) pandemic resulted in 
the implementation of measures designed to ensure subject safety in both studies. Screening 
and randomization of new subjects into studies ACP-103-054 and ACP-103-059 were 
temporarily paused. All randomized subjects that were ongoing in the studies at the time 
screening was paused were allowed to complete as per protocol and enroll in the OLE 
provided that the subject, investigator and medical monitor agreed that it was in the best 
interest of the subject to do so, and the investigator could assure the site’s ability to properly 
monitor the safety and well-being of the study subject, in accordance to study protocol. 
3.3.1 
Combination of Databases of Studies -054 and -059 
At the time screening was paused, approximately half of the planned subjects had been 
randomized in each study. ACADIA decided to combine the two studies, ACP-103-059 and 
ACP-103-054, into one study with a pre-specified statistical analysis plan. As a result, both 
studies closed and are proceeding with database lock and statistical analysis. No new patients 
were enrolled into these studies. The modifications to the statistical handling of the study are 
described briefly in Section 9 and in detail in the Statistical Analysis Plan. 

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3.3.2 
Remote Clinical Assessments 
In the interim between the pause in screening and the termination of the studies, several 
subjects remained in the study who could not attend clinic visits. These subjects were allowed 
to conduct remote visits via telephone or video, or site personnel could conduct the visit in a 
subject’s home. Remote visits were not recommended for the Week 1 and Week 6 visits as 
these visits required ECGs. Subjects were not allowed to roll over into the open-label 
extension study unless they came to the research site to conduct an in-person Week 6 visit.   
Sites were required to document details of all visits that were administered remotely.  
Further details about accommodations and modifications to assessments, relating to the 
COVID-19 pandemic, can be found in Sections 6.2.7 (efficacy assessments), 6.3.8 (safety 
assessments) and 6.5.1 (unscheduled visits) and Section 9 (additional sensitivity analyses).    
3.3.3 
Roll Over Into Open-Label Study ACP-103-055  
Subjects may have rolled over into the ACP-103-055 study (open-label extension) provided 
that the subject, Investigator and medical monitor agreed that it was in the best interest of the 
patient, and the study site could assure its ability to properly monitor the safety and well-
being of the patient in accordance with the study protocol.  
Additionally, all inclusion/exclusion criteria must have been verified prior to rollover and the 
subject must have presented to the clinic in person to sign the ACP-103-055 informed 
consent form (ICF) and have all ACP-103-054 end of treatment procedures. 
4 SUBJECT ELIGIBILITY AND WITHDRAWAL CRITERIA 
To be eligible for this study, subjects must meet all of the inclusion criteria and none of the 
exclusion criteria. 
4.1 
Inclusion Criteria 
A subject must meet all of the following inclusion criteria to be eligible for participation in 
the study: 
1. Is a male or female ≥18 years of age 
2. Can understand the nature of the study and protocol requirements and is willing to 
comply with study drug administration requirements and discontinue prohibited 
concomitant medications  
3. Provides written informed consent to participate in the study 
4. Is capable of communicating with the site personnel, able to complete subject-reported 
outcome measures and can be reliably rated on assessment scales (in the opinion of the 
Investigator) 

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5. Has a clinical diagnosis of major depressive disorder with or without anxious distress by 
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria 
and confirmed by the Mini-International Neuropsychiatric Interview (MINI) during the 
screening period. Subject may have either recurrent or single episode of major 
depressive disorder. 
6. Is treated during the current major depressive episode with one of the following 
SSRI/SNRI antidepressants at a minimally effective dose for at least 8 weeks with at 
least the same stable dose over 4 weeks prior to the SAFER (State versus trait, 
Assessability, Face validity, Ecological validity, and Rule of three Ps [pervasive, 
persistent, and pathological]) remote interview: 
a. Citalopram 
b. Escitalopram 
c. Paroxetine 
d. Fluoxetine 
e. Sertraline 
f. Duloxetine 
g. Venlafaxine 
h. Desvenlafaxine 
i. Venlafaxine XR 
The dose level of the antidepressant is expected to remain stable throughout the study.2 
Adherence to the antidepressant should be reviewed throughout the study. 
7. Must have a detectable blood level of a prescribed SSRI/SNRI during Screening. A 
negative screening test may be repeated as assessed by the Medical Monitor when the 
subject and/or site can provide additional evidence of subject adherence to 
antidepressant treatment or evidence of sample or laboratory error. 
8. During the screening period, the subject’s inadequate response to SSRI/SNRI 
antidepressant treatment is confirmed by the Massachusetts General Hospital 
Antidepressant Treatment Response Questionnaire (MGH ATRQ) through the SAFER 
remote interview and the subject continues to exhibit an inadequate response to 
treatment at the time of the SAFER interview. 
9. Subjects who are currently taking a second antidepressant or antidepressant 
augmentation agent at a subtherapeutic dose or for inadequate duration at Screening 
are eligible for inclusion in the study if it is clinically appropriate to discontinue the 
                                                 
 
 
2 Please see Appendix C for medication restrictions. 

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drug before the Baseline visit (in the opinion of the Investigator); the second 
antidepressant/augmentation agent must be discontinued and washed out at least 
5 half-lives prior to Baseline. This second antidepressant/augmentation agent should 
not be discontinued solely to make the subject eligible for enrollment in the study. 
10. Has a Montgomery-Asberg Depression Rating Scale (MADRS) total score >20 at both 
Screening and Baseline 
11. Has a Clinical Global Impression–Severity (CGI-S) score ≥4 (moderately ill or worse) 
for depression at both Screening and Baseline 
12. If the subject is female, she must not be pregnant or breastfeeding. She must also be of 
non-childbearing potential (defined as either surgically sterilized or at least 1 year 
postmenopausal) OR must agree to use TWO clinically acceptable methods of 
contraception for at least 1 month prior to Visit 2 (Baseline), during the study, and 
1 month following completion of the study. 
Acceptable methods of contraception include the following: 
a. A barrier method (condom, diaphragm, or cervical cap) with spermicide 
b. Hormonal contraception, including oral, injectable, transdermal, or 
implantable methods 
c. Intrauterine device (IUD) 
Only one of the two clinically acceptable methods can be a hormonal method. 
4.2 
Exclusion Criteria 
A subject must meet none of the following exclusion criteria to be eligible for the study: 
1. Has a history of schizophrenia or other psychotic disorder, major depressive disorder 
with psychotic features, bipolar I or II disorder. Subjects who are currently being 
treated or require treatment for post-traumatic stress disorder, acute stress disorder, 
panic disorder, or obsessive compulsive disorder are also not eligible. 
2. Has a current primary diagnosis of borderline, antisocial, paranoid, schizoid, 
schizotypal, or histrionic personality disorder, according to DSM-5 criteria 
3. Has met DSM-5 criteria for substance use disorders within the last 6 months prior to 
Screening, except for disorders related to the use of caffeine or nicotine 
4. Is suicidal at Visit 1 (Screening) or Visit 2 (Baseline) as defined below: 
a. An answer of “yes” to C-SSRS questions 4 or 5 (current or over the last 
6 months); OR 
b. Has attempted suicide within 1 year prior to Visit 1 (Screening); OR 
c. Is actively suicidal in the Investigator’s judgment 
5. Has current evidence of delirium or an unstable neurological, cardiovascular, 
respiratory, gastrointestinal, renal, hepatic, hematologic, or other medical disorder, 

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including cancer or malignancies that, in the judgment of the Investigator or the 
Medical Monitor, would jeopardize the safe participation of the subject in the study or 
significantly interfere with the conduct or interpretation of the study 
6. Has a history of epilepsy 
7. Has atrial fibrillation unless adequately anti-coagulated 
8. Has a history of myocardial infarction, unstable angina, acute coronary syndrome, or 
cerebrovascular accident   
9. Has a history of any of the following: 
a. Greater than New York Heart Association (NYHA) Class II congestive heart 
failure (Appendix A) 
b. Grade II or greater angina pectoris (by Canadian Cardiovascular Society 
Angina Grading Scale) (Appendix B) 
c. Sustained ventricular tachycardia 
d. Ventricular fibrillation 
e. Torsade de pointes 
f. Syncope due to an arrhythmia 
g. An implantable cardiac defibrillator 
10. Has laboratory evidence of hypothyroidism at Screening, as measured by thyroid 
stimulating hormone (TSH) and reflex free thyroxine (T4). If TSH is abnormal and the 
reflex free T4 is normal, the subject may be enrolled 
11. Has current unstable diabetes or glycosylated hemoglobin (HbA1c) >8% at Screening 
12. Has a known history of a positive hepatitis B virus (HBV), hepatitis C virus (HCV), or 
human immunodeficiency virus (HIV) test  
13. Has a history of neuroleptic malignant syndrome or serotonin syndrome 
14. Has a known personal or family history of long QT syndrome or family history of 
sudden cardiac death 
15. Has any of the following ECG results at Visit 1 (Screening) or Visit 2 (Baseline): 
a. If the subject is not on citalopram, escitalopram, or venlafaxine (immediate or 
extended release): 
i. QTcF >450 ms, if QRS duration <120 ms 
ii. QTcF >470 ms, if QRS duration ≥120 ms 
b. If the subject is on citalopram, escitalopram, or venlafaxine (immediate or 
extended release): 
i. QTcF >425 ms, if QRS duration <120 ms 
ii. QTcF >450 ms, if QRS duration ≥120 ms 

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At Screening, if the set of triplicate ECGs has a prolonged QTcF due to an identifiable 
cause, and it is medically appropriate to address that cause, a repeat set of triplicate 
ECGs may be performed during Screening at the discretion of the Medical Monitor. 
16. Has a heart rate <50 beats per minute, as measured by peripheral pulse rate, not 
explained by regular exercise or medication, in discussion with the Medical Monitor. 
If bradycardia is secondary to iatrogenic or treatable causes and these causes are 
treated, a heart rate assessment can be repeated during the screening period. 
17. Requires treatment with a medication or other substance that is prohibited by the 
protocol 
18. At Screening, has a body mass index (BMI) <18.5 kg/m2 or >35 kg/m2 or known 
unintentional clinically significant weight loss (i.e., ≥7%) over past 6 months 
19. Has a positive test for an illicit drug or cannabis at Screening or Baseline. Subjects 
who test positive for a controlled substance and who have a valid prescription may be 
retested during Screening if they agree to abstain from the medication for the length of 
their participation in the study. The repeat test during Screening must be negative for 
them to participate in the study. Additionally, DSM-5 criteria for substance use 
disorders should not be met. 
20. Has received electroconvulsive therapy, transcranial magnetic stimulation, or vagal 
nerve stimulation, or has received deep brain stimulation in the current episode of 
depression 
21. Has received new-onset psychotherapy or had a change in the intensity of 
psychotherapy within 8 weeks prior to Screening 
22. Has participated in or is participating in a noninterventional study or clinical trial of 
any investigational or marketed drug, device, or intervention, within 30 days or 
5 half-lives, whichever is longer, of Visit 2 (Baseline) 
23. Has previously been enrolled in any prior clinical study with pimavanserin or is 
currently taking pimavanserin 
24. Has a significant sensitivity or allergic reaction to pimavanserin or its excipients 
25. Is an employee or is a family member of an employee of ACADIA Pharmaceuticals 
Inc. 
26. Is judged by the Investigator or the Medical Monitor to be inappropriate for the study 
for any reason, including if the subject is judged to be a danger to self or others 
4.3 
Subject Withdrawal of Consent 
In accordance with the Declaration of Helsinki and other applicable regulations, a subject has 
the right to withdraw from the study at any time, and for any reason, without prejudice to his 
or her future medical care. 

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Should a subject request or decide to withdraw consent, every reasonable effort should be 
made to complete and report observations as thoroughly as possible up to the date of 
withdrawal, including the evaluations specified at the ET or safety follow-up visit (whichever 
visit is applicable), as outlined in Table S–1. 
4.4 
Subject or Study Discontinuation 
Subjects may be discontinued from the study for a number of reasons, including, but not 
limited to, those listed below: 
• Adverse event 
• Death 
• Lack of efficacy 
• Lost to follow-up (Section 4.5) 
• Non-compliance with study drug 
• Physician decision 
• Pregnancy 
• Protocol deviation 
• Study terminated by Sponsor 
• Use of prohibited medication 
• Other 
The Sponsor reserves the right to discontinue the study at any time for any reason. Such 
reasons may be any of, but not limited to, the following: 
• Occurrence of AEs unknown to date in respect of their nature, severity, and duration or 
the unexpected incidence of known AEs 
• Medical, ethical or business reasons affecting the continued performance of the study 
Regulatory authorities also have the right to terminate the conduct of the study in their region 
for any reason. 
4.4.1 
Handling of Subject Discontinuation During the Treatment Period 
Unless the subject has withdrawn consent to be contacted for this study, every reasonable 
effort should be made to complete Visit 8/ET and the safety follow-up visit (as outlined in 
Table S–1) if a subject discontinues prematurely during the treatment period of the study for 
any reason. All information will be reported on the applicable pages of the electronic case 
report form (eCRF). 

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If a subject is discontinued from the study because of an AE, every reasonable attempt should 
be made to follow the subject until the AE resolves or until the Investigator deems the AE to 
be chronic or stable. For subjects who continue to be followed for safety, SAEs should 
continue to be reported as described in Section 7.4.2. All SAEs will continue to be followed 
until such events have resolved or the Investigator deems them to be chronic or stable. 
4.5 
Subject Lost to Follow-up 
A subject will be considered lost to follow-up if they fail to attend a scheduled visit 
(including the safety follow-up visit) and is unable to be contacted by the study site. 
Every reasonable effort should be made to contact the subject and will include a minimum of 
three documented phone calls (each performed at different times of the day) and, if necessary, 
a certified letter to the subject’s last known mailing address or local equivalent methods. All 
contact attempts are to be documented in the source documents. 
4.6 
Prior and Concomitant Therapy 
All medications used from study screening until completion of the safety follow-up visit are 
to be recorded. 
4.6.1 
Prior Medication 
Prior medication is defined as any medication taken before the date of the first dose of study 
drug. 
4.6.2 
Concomitant Medication 
Concomitant medication is defined as any medication taken on or after the date of the first 
dose of study drug. 
In order to ensure that appropriate concomitant therapy is administered, it is essential that 
subjects be instructed not to take any medication without prior consultation with the 
Investigator (unless the subject is receiving treatment for a medical emergency). 
The Investigator may prescribe appropriate medication to treat AEs. Relationship to 
COVID-19 will be assessed for selected medications. The Sponsor and Investigator or 
designee will confer to determine whether it is appropriate to continue such a subject in the 
trial if a prohibited medication is prescribed. 
4.6.2.1 
Permitted, Restricted, and Prohibited Medications 
Prohibitions and restrictions for concomitant medications should be followed between the 
initial screening visit and Visit 8/ET as specified in Appendix C and Appendix D. These 
appendices do not constitute an exhaustive list and any questions regarding prohibited and 
restricted medications should be discussed with the Medical Monitor or designee. 

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Use of medications that could interfere with study conduct or any questions regarding 
prohibited and restricted concomitant medications should be reviewed and/or discussed with 
the Medical Monitor or designee. 
Medications that can prolong QT interval are prohibited (or restricted if approved by the 
Medical Monitor) as specified in Appendix C. 
Permitted concomitant medications should remain at a stable dose throughout the study.  
If a subject is on a medication restricted by the protocol, the medication should be adjusted if 
it is determined by the Investigator to be clinically appropriate (e.g., if the subject’s 
symptoms are not well-controlled or if the subject cannot tolerate the current medication) in 
consultation with the treating physician. 
Subjects who require current treatment with a prohibited medication will be withdrawn from 
the study. 
Subjects who have previously taken a prohibited medication during the study will be 
withdrawn from the study unless: 
• the prohibited medication has been discontinued AND 
• withdrawal from the study presents an unacceptable medical risk to the subject 
The justification to allow the subject who has taken a prohibited medication to continue in 
the trial will be made by the Sponsor/Medical Monitor, with medical input from the 
Investigator, and will be documented. If a subject is allowed to remain in the trial, this will be 
reported as a major protocol deviation and not a waiver. 
5 INVESTIGATIONAL PRODUCT 
5.1 
Investigational Product Description 
The investigational product will be pimavanserin 34 mg (provided as 2×17 mg tablets) or 
matching placebo (2×placebo tablets). Placebo tablets will be size- and color-matched to the 
pimavanserin tablets. Tablets will be administered orally as a single dose once daily. 
5.1.1 
Formulation, Appearance, Packaging, and Labeling 
The Sponsor will supply pimavanserin 17 mg tablets and matching placebo tablets. 
Pimavanserin tartrate is a white to off-white powder. Pimavanserin 17 mg tablets include the 
active compound (pimavanserin tartrate) and the following excipients: pregelatinized starch, 
magnesium stearate, and microcrystalline cellulose, and the tablet coating is 
 
 
. The drug product is formulated with standard pharmaceutical excipients at 
17 mg strength (20 mg of pimavanserin tartrate). 

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Placebo tablets contain all of the same excipients as pimavanserin 17 mg tablets but do not 
contain any pimavanserin tartrate. 
Pimavanserin and placebo tablets are manufactured under current Good Manufacturing 
Practices. 
During the treatment period, study drug will be distributed in a quantity sufficient to ensure 
the subject has an adequate supply of study drug between study visits. 
5.1.2 
Product Storage and Stability 
Investigational product must be stored between 15°C and 30°C (59°F and 86°F) in a secure 
area with restricted access and according to local and national regulations. 
5.1.3 
Dosing and Administration 
The first dose of study drug will be administered at the site. Study drug kits will then be 
dispensed to the subject to take home. Each daily dose consists of two individual tablets that 
should be taken together. Subjects should be instructed to take two whole tablets, orally, once 
daily. Subjects should be instructed to not crush the tablets. The tablets may be taken with or 
without food. 
5.1.4 
Method of Assigning Subjects to Treatment Groups 
At Week 0 (Visit 2), eligible subjects who meet inclusion and do not meet exclusion criteria 
will be randomized in a 1:1 ratio to receive either 34 mg pimavanserin once daily or placebo. 
5.1.5 
Blinding 
Treatment assignments will be blinded to all study subjects, Investigators, raters, site 
personnel, and Sponsor personnel. In the event of a potential suspected unexpected serious 
adverse reaction (SUSAR), in accordance with current health authority guidance, treatment 
assignments for the affected subject may be unblinded to a controlled group of the Sponsor’s 
Safety and/or Regulatory personnel for reporting purposes.  
Details regarding medical emergency unblinding procedures are provided in Section 9.8. 
5.1.6 
Study Drug Compliance 
If a subject misses one dose of study drug, he or she should not take an extra dose the next 
day. Subjects who are less than 80% compliant with study drug as assessed at more than one 
study visit should be discussed with the Medical Monitor or designee. 
5.1.7 
Overdose 
An overdose is a deliberate or inadvertent administration of a treatment at a dose higher than 
the maximum recommended dose per protocol. It must be reported, irrespective of outcome, 

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even if toxic effects were not observed (Section 7.4.4). All events of overdose are to be 
captured as protocol deviations. 
5.2 
Investigational Product Accountability Procedures 
The Investigator or designee will keep current and accurate records of the study drug product 
dispensed, used, and returned for each subject to assure the regulatory authority and the 
Sponsor that the study drug is being handled appropriately. Subjects should be instructed to 
return all packaging and unused study drug to the Investigator at regularly scheduled clinic 
visits and ET visits. Any study drug supplied is for use in this study only and should not be 
used for any other purpose. 
At appropriate intervals during the study, study drug reconciliation will be performed by the 
Sponsor (or designee) who may return appropriate unused study drug and used and unused 
packaging to the Sponsor’s designee for destruction. 
At the conclusion of the study, final study drug reconciliation will be conducted at the site. 
Final study drug accountability documentation will be maintained at both the site and at the 
Sponsor. Any remaining unused study drug and all used and unused packaging will be sent 
back to the Sponsor’s designee for destruction, as allowed by country specific regulations. 
Documentation of study drug destruction will be recorded and maintained by both the 
Sponsor and the Sponsor’s designee. 
6 STUDY PROCEDURES 
Study specific procedures are detailed below. All assessments will be completed according to 
the schedule described in Table S–1. Every effort should be made to complete the required 
procedures and evaluations at the designated visits and times. 
6.1 
Screening Assessments 
Subject eligibility will be assessed during the Screening period by the site and the Sponsor 
through an eligibility review process. The Screening period (between the Screening and 
Baseline visit) may be extended by up to 7 days when awaiting results to confirm subject 
eligibility when discussed with the Medical Monitor in advance. 
6.1.1 
Medical History, Medication History, and Demographics 
A complete medical history and medication history will be obtained from each potential 
subject. Demographic information, including date of birth, gender, race, and ethnicity 
(if allowed by local regulations) will be recorded as well. Any new medical condition 
beginning after the ICF has been signed will be captured as an AE. In addition, a history of 
the medications that the subject has taken for the current depressive episode should be 

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obtained. Subjects may be asked to provide pharmacy or medical records to substantiate the 
medication history. 
6.1.2 
Psychiatric History 
Details of the subject’s psychiatric history and treatment will be collected. 
6.1.3 
Background Antidepressant Blood Level 
At Screening, blood samples for the analysis of the concomitant selective serotonin reuptake 
inhibitor (SSRI)/serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants will be 
collected. At Screening, the presence of SSRI or SNRI must be confirmed in order to qualify 
the subject for further consideration in the study. Review of subject adherence with 
background antidepressant therapy should be conducted at screening visit and all visits.  
6.1.4 
Massachusetts General Hospital Antidepressant Treatment Response 
Questionnaire 
The MGH ATRQ (Fava and Davidson 1996; Fava 2003) is a clinician-assisted questionnaire 
that examines a patient’s antidepressant treatment history using specific anchor points to 
define the adequacy of both the dose and duration of each antidepressant course, as well as 
the degree of symptomatic improvement obtained with each course. This validated 
questionnaire allows for the determination of inadequate response to antidepressant therapy 
in MDD (Chandler et al. 2010). Inadequate response is defined as a response of <50% to a 
course of treatment of at least 8 weeks at the minimum effective dose (as listed on the 
ATRQ), which has been stable for the 4 weeks prior to the SAFER interview.  
6.1.5 
State versus trait, Assessability, Face validity, Ecological validity, and Rule of 
three Ps (pervasive, persistent, and pathological) (SAFER) Remote Interview 
To ensure that appropriate subjects are entered into the study, an interview will be conducted 
. 
The interview may be conducted via telephone off-site or on-site, during Screening. If 
conducted on-site, the site staff should not be present during the interview. The assessments 
administered will be the SAFER Interview, which will include the MADRS, the CGI-S, and 
the MGH ATRQ. Sites will be notified of the results within 24 hours of the interview. 
6.1.6 
Mini-International Neuropsychiatric Interview 
The MINI is a brief, structured, diagnostic interview covering a broad range of major 
psychiatric disorders in DSM-5 and ICD-10 (Sheehan et al. 1998). The MINI is divided into 
modules, with each module corresponding to a diagnostic category. After completing the 
questions in each module, the interviewer (i.e., the Investigator or designee) assesses whether 
the diagnostic criteria are met. 

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In addition, one module for depressive disorders from the MINI-Plus will be used in 
conjunction with the MINI. The MINI-Plus is a more extensive version of the MINI, 
including additional disorders and disorder subtyping (Sheehan et al. 1998). 
MINI Version 7.0.2 for DSM-5 will be used in this study and will be conducted during 
Screening. 
6.1.7 
Montgomery-Asberg Depression Rating Scale 
The MADRS (Montgomery and Asberg 1979) is a 10-item, clinician-rated instrument 
measuring depression severity. It will be administered during Screening and at Baseline by 
the Investigator or designee with a Structured Interview Guide for the Montgomery-Asberg 
Depression Rating Scale (SIGMA) (Williams and Kobak 2008). The timeframe for this scale 
is the past 7 days. 
6.2 
Efficacy Assessments 
6.2.1 
Hamilton Depression Scale (17 Items) 
The HAMD-17 (Hamilton 1960) is completed with the Structured Interview Guide for the 
Hamilton Depression Rating Scale (SIGH-D) (Williams 1988) by the Investigator or designee 
based on an assessment of a patient’s symptoms. The timeframe for this scale is the past 
7 days. The HAMD-17 is to be the first scale completed at each visit. The HAMD-17 will be 
used as the primary efficacy analysis. 
The anxiety/somatization factor of the HAMD-17 (Cleary and Guy 1977) includes six items: 
psychic anxiety, somatic anxiety, gastrointestinal somatic symptoms, general somatic 
symptoms, hypochondriasis, and insight, and will be used for secondary efficacy analyses. 
6.2.2 
Sheehan Disability Scale 
The SDS (Sheehan et al. 1996) is a three-item patient-facing questionnaire used to evaluate 
impairments in the domains of work, social life/leisure, and family life/home responsibility. 
All items are rated on an 11-point continuum (0=no impairment to 10=most severe). The 
timeframe for this scale is the past week. The SDS will be used for secondary efficacy 
analyses. 
6.2.3 
Clinical Global Impression–Severity and Clinical Global Impression–
Improvement Scales 
The CGI-S and CGI-I (Guy 1976) are scales used by the Investigator or designee to rate the 
severity of the disorder and the global improvement since beginning of the study. The CGI-S 
rates the severity of a patient’s depression over the past 7 days and will be completed with a 
structured interview guide for global impressions (SIGGI) (Targum et al. 2013). The CGI-S 
will be used for secondary efficacy analyses. The CGI-I rates the change in a patient’s 

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depression over the past 7 days relative to the patient’s symptoms at Baseline and will be 
used for secondary efficacy analyses. 
6.2.4 
Changes in Sexual Functioning Questionnaire Short Form 
Sexual functioning will be assessed using the CSFQ-14 (Keller et al. 2006), a 14-item version 
of the CSFQ (Clayton et al. 1997). This is a patient-facing questionnaire, with a male version 
and a female version, that provides scores for three scales corresponding to the phases of the 
sexual response cycle (i.e., desire, arousal, and orgasm) and the five scales of the original 
CSFQ (sexual desire, sexual frequency, sexual satisfaction, sexual arousal, and sexual 
completion). The CSFQ-14 will be used for secondary efficacy analyses. 
6.2.5 
Karolinska Sleepiness Scale 
The KSS (Akerstedt and Gillberg 1990) is a patient-facing scale that measures the patient’s 
drowsiness and is frequently used in studies measuring subjective sleepiness. Scoring is 
based on a 9-point verbally anchored scale ranging from “extremely alert” to “very sleepy, 
great effort to keep awake, fighting sleep.” The timeframe for this scale is the past 7 days. 
The KSS will be used for secondary efficacy analyses. 
6.2.6 
Barratt Impulsiveness Scale 
The BIS-11 (Patton et al. 1995) is a questionnaire designed to assess the 
personality/behavioral construct of impulsiveness. It is composed of 30 items describing 
common impulsive or non-impulsive (for reverse scored items) behaviors and preferences. 
Items are scored on the following 4-point scale: Rarely/Never=1; Occasionally=2; Often=3; 
Almost Always/Always=4. The BIS-11 will be used for secondary efficacy analyses. 
6.2.7 
Impact of COVID-19 Pandemic on Efficacy Assessments 
In the interim between the pause in screening and the termination of the studies due to the 
COVID-19 pandemic, several subjects remained in the study who could not attend clinic 
visits. These subjects were allowed to participate in remote visits via telephone or video, or 
site staff could have visited subjects in their homes.  
6.3 
Safety Assessments 
6.3.1 
Physical Examinations 
A general physical examination will be conducted at Screening, Baseline, and Week 6/ET. 
6.3.2 
Vital Signs 
Vital signs will include body temperature, resting respiration rate, sitting systolic and 
diastolic blood pressure, and pulse rate. The sitting blood pressure should be measured after 
the subject has been sitting for ≥3 minutes. 
Vital signs will be measured at all scheduled and unscheduled visits. 

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6.3.3 
Height, Weight, and Body Mass Index 
Height will be measured at Screening. 
Weight will be measured at all scheduled and unscheduled visits. 
Body mass index will be calculated using the following formula: 
Weight (kg) / [height (m)]2. 
6.3.4 
Electrocardiograms 
All 12-lead ECGs will be complete, standardized recordings. At Visit 1 (Screening), the ECG 
should be completed in triplicate and collected within a 3-minute period. At all other visits, a 
single 12-lead ECG should be completed. All ECGs will be centrally read; the interpretation 
by the central cardiologist is considered the official result. 
At Visit 1 (Screening) the mean QTcF/QRS values of all the tracings of adequate quality will 
be used to determine eligibility. If a site performs additional ECGs beyond the set of triplicate 
ECGs prescribed at Screening or the single ECG prescribed at Baseline, the mean QTcF/QRS 
values of all the tracings of adequate quality will be used to determine eligibility. 
• At Screening, if the set of triplicate ECGs has a prolonged QTcF due to an identifiable 
cause, and it is medically appropriate to address that cause, a repeat set of triplicate 
ECGs may be performed during Screening at the discretion of the Medical Monitor if 
time permits during the Screening period. 
• At Baseline, a subject who met the eligibility criteria during the central read of the 
screening ECGs may be enrolled based on the machine read of the locally completed 
ECG. If the interpretation of the ECG by the central cardiologist returned after 
randomization indicates QTcF outside of the allowable range, the subject will be 
discontinued from the study, but this will not be considered a protocol deviation. 
Electrocardiograms should be performed before blood sampling or at least 30 minutes after 
blood sampling. The subject must rest in a supine position for 5 minutes before the ECG is 
obtained. ECG tracings (paper or electronic) will be reviewed and interpreted by a qualified 
clinician. ECG tracings and results (ventricular rate, PR, QRS, QT, QTcF, and QTcB 
intervals) will be included and summarized in the subject’s study records. 
6.3.5 
Columbia–Suicide Severity Rating Scale 
The C-SSRS monitors changes in suicidal thinking and behavior over time, in order to 
determine risk (Posner et al. 2011). The following four constructs are measured: the severity 
of ideation, the intensity of ideation, behavior, and lethality. 
The Baseline/Screening version will be administered at Visit 1 (Screening), and the Since 
Last Visit version will be administered at all subsequent visits, including unscheduled visits. 

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The C-SSRS results for each subject should be reviewed by the Investigator at each visit. If at 
any time the C-SSRS results for a given subject reveal potential suicidality, then the 
Investigator should assess the clinical significance of such results. If a clinically significant 
risk of suicidality is identified for a subject, then the Investigator should discontinue the 
subject and implement appropriate treatment (Section 4.4). 
6.3.6 
Extrapyramidal Symptom Rating Scale–Abbreviated 
The ESRS (Chouinard and Margolese 2005) was developed to assess drug induced 
movement disorders such as parkinsonism, akathisia, dystonia and tardive dyskinesia with 
established reliability, validity, and sensitivity. It consists of a questionnaire of parkinsonian 
symptoms, physician examination of parkinsonism, dyskinetic movements, and global 
impression of tardive dyskinesia. The ESRS-A, an accepted modified form of the original 
ESRS, will be used during the study to monitor for any worsening in extrapyramidal 
symptoms or signs at scheduled and unscheduled visits.  
6.3.7 
Laboratory Evaluations 
Clinical laboratory sample collection (including HbA1c at Screening only) is encouraged, but 
not required to be completed under fasting conditions. The laboratory evaluations will 
include, but are not limited to, the following: 
• Clinical chemistry serum tests 
o Sodium (Na), potassium (K), chloride (Cl), phosphorus (P), calcium (Ca), 
magnesium (Mg), carbon dioxide (CO2), blood urea nitrogen (BUN), 
creatinine (CR), uric acid 
 Mg should only be performed at Visit 1 (Screening) 
o Alanine aminotransferase (ALT), aspartate aminotransferase (AST), 
gamma-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), 
total bilirubin (TBIL), lactate dehydrogenase (LDH) 
o HbA1c 
 HbA1c should only be performed at Visit 1 (Screening) 
o Glucose 
o Albumin (ALB), total protein 
o Prolactin 
o Creatine kinase (CK)/creatine phosphokinase (CPK) 
o Lipid panel 
 Total cholesterol, HDL-cholesterol, triglycerides, LDL-cholesterol, 
cholesterol/HDL ratio, non-HDL cholesterol 

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• Thyroid stimulating hormone (TSH) and free thyroxine (free T4), if TSH is out of 
range 
o TSH/free T4 should only be performed at Visit 1 (Screening) 
• Pregnancy test 
o A serum pregnancy test should only be performed at Visit 1 (Table 6–1) for 
women of childbearing potential 
o A urine pregnancy test should be performed at all designated visits after 
Visit 1 (Table 6–1) for women of child-bearing potential 
 If urine cannot be obtained in women of childbearing potential, 
a serum pregnancy test should be done in its place 
• Hematology tests 
o Complete blood count (CBC) including: 
 White blood cell (WBC) count 
 Complete differential (relative and absolute) 
 Hematocrit (Hct), hemoglobin, red blood cells (RBC), platelets 
 Reticulocyte count 
• Urinalysis 
o Blood, RBCs, WBCs, protein, glucose, ketones, specific gravity, pH 
o Reasonable efforts should be made to collect a urine sample from all subjects 
• Urine toxicity (drug) screen 
o Urine toxicity (drug) screen will test for controlled substances according to the 
schedule presented in Table 6-1. Negative drug screens are required for study 
eligibility. 
o Sites will be supplied with instant-read dipstick urine toxicity (drug) screen 
tests to utilize as a tool at the Baseline and Week 6 visit in order to determine 
if the subject continues to meet eligibility. This test will not take the place of 
the urine toxicity (drug) screening performed by the central laboratory. 

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o Subjects who test positive for a controlled substance in the urine toxicity 
(drug) screen performed by the central laboratory and who have a valid 
prescription may be retested during Screening if they agree to abstain from the 
medication for the length of their participation in the study and if abstinence 
from medication usage is achieved at least 7 days prior to Visit 2 (Baseline). 
The repeat test during Screening must be negative for them to participate in 
the study. Additionally, DSM-5 criteria for substance use disorders should not 
be met.  
o Subjects who test positive in the urine toxicity (drug) screen performed by the 
central laboratory for benzodiazepines, tetrahydrocannabinol (THC), or 
opiates will be withdrawn from the study unless any prohibited medication or 
substance has been discontinued and withdrawal from the study presents an 
unacceptable medical risk for the subject. The justification to allow the subject 
to continue in the trial will be made by the Sponsor/Medical Monitor, with 
medical input from the Investigator, and will be documented. If a subject is 
allowed to remain in the trial, this will be reported as a major protocol 
deviation, not a waiver. In addition, restrictions listed in Appendix C should be 
followed. 
o Reasonable efforts should be made to collect a urine sample at applicable 
scheduled visits as described in “Urinalysis” above 
Laboratory evaluations will be completed according to the schedule presented in Table 6–1 
and procedures detailed in the study laboratory manual. Additional safety testing may be 
performed at the discretion of the Investigator or designee. 
Table 6–1 
Safety Laboratory Evaluations 
Visit 
Testsa,b 
Visit 1 (Screening) 
CHEM, TSH/free T4, CBC, UA, urine toxicity (drug) screen, and serum 
pregnancy test 
Visit 2 (Baseline) 
CHEM, CBC, UA, urine toxicity (drug) screen, and urine pregnancy test 
Visit 8 (ET/EOT) 
CHEM, CBC, UA, urine toxicity (drug) screen, and urine pregnancy test 
Abbreviations: CBC=complete blood count; CHEM=clinical chemistry serum tests; EOT=end of treatment; ET=early 
termination; HbA1c=glycosylated hemoglobin; TSH=thyroid stimulating hormone; UA=urinalysis 
a 
A pregnancy test is only required for women of childbearing potential. If urine cannot be obtained in women of 
childbearing potential, a serum pregnancy test should be done in its place. 
b 
An Mg level, HbA1c test, and TSH/free T4 test are only required at Visit 1 (Screening). 
6.3.8 
Impact of COVID-19 Pandemic on Safety Assessments 
In the interim between the pause in screening and the termination of the studies due to the 
COVID-19 pandemic, several subjects remained in the study who could not attend clinic 

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visits. These subjects were allowed to conduct remote visits via telephone or video, or site 
staff could have visited subjects in their homes.  
Some safety assessments may not have been performed, or may have been performed under 
different circumstances, due to the subject not being able to come to the clinic. Modifications 
and accommodations for safety assessments in the context of remote visits are described 
briefly below:  
6.3.8.1 
Priority Medical Assessments in Remote Visits 
The C-SSRS was to be performed as a priority, along with an assessment of AEs and 
COVID-19 symptoms. Additionally, subjects were to be queried about concomitant 
medications, and their background antidepressant and IP compliance. 
6.3.8.2 
Physical Examinations, Vital Signs, Height, and Weight 
Physical examinations, vitals, height, and weight may not have been performed because the 
visit had to be conducted remotely. If the visit was remote, subject may have reported vitals 
obtained on home devices.   
6.3.8.3 
Electrocardiograms 
ECGs may have been performed by site staff during a home visit.  
6.3.8.4 
Columbia-Suicide Severity Rating Scale 
See Section 6.3.8.1 above.  
6.3.8.5 
Extrapyramidal Symptom Rating Scale-Abbreviated 
When the ESRS-A motor examination could not be performed (e.g., when the visit was 
performed via telephone with no video component) then no scoring of symptoms was to be 
completed. The clinical interview questions were to be asked for all symptom areas in order 
to obtain information about the presence and severity of involuntary movements experienced 
by the patient and this was to be documented in the source record. The clinical significance of 
any symptoms was to be evaluated by the investigator and the adverse event page updated 
when new or worsening symptoms were reported. 
6.3.8.6 
Laboratory Evaluations 
If subjects could not attend clinic visits for laboratory evaluations, they were allowed to use 
local laboratories, or to have site staff visit them at their homes for blood draws. 
6.4 
Safety Follow-up 
A 30-day safety follow-up telephone contact is to be completed for subjects who complete 
the treatment period of the study and decide not to continue into the open-label study or are 

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not eligible for the open-label study, as well as those who discontinue prematurely from the 
study. Subjects should have the following completed at least 30 days after last dose of study 
drug: 
• Assessment of concomitant medications/treatments 
• Assessment of AEs 
6.5 
Unscheduled Visits 
Unscheduled visits may occur as determined by the Investigator. The following safety 
assessments generally should be recorded at each unscheduled visit: assessment of AEs, 
assessment of concomitant medications/treatments, measurement of vital signs and weight, 
ESRS-A, and completion of the C-SSRS (Since Last Visit version). The Investigator may 
perform any additional safety evaluations deemed by the Investigator to be clinically 
indicated. Study drug may be dispensed to the subject at unscheduled visits if needed. 
6.5.1 
Impact of COVID-19 on Unscheduled Visits 
If subjects were not able to attend the clinic for an unscheduled visit, this may have occurred 
remotely or by site staff visit to the subject’s home. 
7 ADVERSE EVENTS 
7.1 
Specification of Safety Parameters 
7.1.1 
Definition of Adverse Event 
An AE is defined as “any untoward medical occurrence in a patient or clinical study 
participant, temporally associated with the use of study drug, whether or not considered 
related to study drug”. 
An AE can therefore be any unfavorable and unintended sign (e.g., an abnormal laboratory 
finding), symptom, or disease temporally associated with the use of a drug, without any 
judgment about causality or seriousness. An AE can arise from any use of the drug 
(e.g., off-label use, use in combination with another drug) and from any route of 
administration, formulation, or dose, including an overdose. 
A suspected adverse reaction is any AE for which there is a reasonable possibility that the 
drug caused the AE. 
AEs do not include the following: 
• Stable or intermittent chronic conditions (such as myopia requiring eyeglasses) that are 
present prior to Baseline and do not worsen during the study 

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• Medical or surgical procedures (e.g., surgery, endoscopy, tooth extraction, 
transfusion). The condition that leads to the procedure is an AE if not present at 
Baseline. 
• Overdose of concomitant medication without any signs or symptoms unless the subject 
is hospitalized for observation 
• Hospitalization for elective surgery planned prior to study (situation where an 
untoward medical occurrence has not occurred) 
• Pregnancy will not be considered an AE, but if it occurs, it will be reported on a 
pregnancy form 
7.1.2 
Definition of Serious Adverse Event 
In addition to the severity rating, each AE will be classified by the Investigator as “serious” 
or “not serious.” The seriousness of an event will be defined according to the applicable 
regulations and generally refers to the outcome of an event. An SAE is one that meets one or 
more of the following: 
• Is fatal 
• Is immediately life threatening 
• Results in disability or permanent damage 
• Requires hospitalization 
• Prolongs existing hospitalization 
• Is a congenital anomaly or birth defect (in an offspring) 
• Is medically significant 
Definition of Life Threatening 
A life-threatening event places the subject at immediate risk of death from the event as it 
occurred. This does not include an AE, which, had it occurred in a more severe form, might 
have caused death. 
Definition of Hospitalization 
Hospitalization is defined by the Sponsor as a full admission to the hospital for diagnosis and 
treatment. This includes prolongation of an existing inpatient hospitalization.  
Examples of visits to a hospital facility that do not meet the serious criteria for 
hospitalization include: 
• Emergency room visits (that do not result in a full hospital admission) 
• Outpatient surgery 

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• Preplanned or elective procedures 
• Protocol procedures 
• Social hospitalization, defined as admission to the hospital as a result of inadequate 
family support or care at the subject’s primary residence  
Definition of Disability or Permanent Damage 
Disability is defined as a persistent or significant incapacity or substantial disruption of the 
ability to conduct normal life functions. 
Definition of Medically Significant 
Important medical events (medically significant events) that may not result in death, be life 
threatening, or require hospitalization may be considered to be an SAE when, based upon 
appropriate medical judgment, they may jeopardize the subject or may require medical or 
surgical intervention to prevent one of the outcomes listed in this definition. Examples of 
such events are intensive treatment in an emergency room or at home for allergic 
bronchospasm, blood dyscrasias, or convulsions that do not result in hospitalization or 
development of drug dependency or drug abuse. 
An SAE may also include any other event that the Investigator or Medical Monitor judges to 
be serious or that suggests a significant hazard, contraindication, side effect, or precaution. 
7.2 
Classification of an Adverse Event 
7.2.1 
Severity of Event 
The severity of each AE will be graded on a 3-point scale and reported in detail as indicated 
on the eCRF: 
• Mild: awareness of sign or symptom but easily tolerated, causing minimal discomfort, 
and not interfering with normal everyday activities 
• Moderate: sufficiently discomforting to interfere with normal everyday activities 
• Severe: incapacitating and/or preventing normal everyday activities 
7.2.2 
Relationship to Study Drug 
The causality of each AE should be assessed and classified by the Investigator as “related” or 
“not related.” An event is considered related if there is a reasonable possibility that the event 
may have been caused by the product under investigation (i.e., there are facts, evidence, or 
arguments to suggest possible causation). 
Consider the following when assessing causality: 
• Temporal associations between the agent and the event 

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• Response to cessation (de-challenge) or re-challenge 
• Compatibility with known class effect 
• Known effects of concomitant medications 
• Pre-existing risk factors 
• A plausible mechanism 
• Concurrent illnesses 
7.2.2.1 
Duration 
The start and stop dates for AEs will be recorded using the following criteria: 
• Start: Date of the first episode of the AE or date of significant sustained worsening in 
severity 
• Stop: Date when AE either ceased permanently or changed in severity 
7.2.2.2 
Frequency 
The frequency of the AE should be indicated according to the following definitions: 
• Single: Experienced once, without recurrence 
• Recurrent: More than one discrete episode with the same severity 
7.2.2.3 
Action Taken with Study Drug 
• Dose not changed: No change in study drug 
• Drug interrupted: Study drug temporarily stopped 
• Drug withdrawn: Study drug discontinued permanently 
7.2.2.4 
Therapy 
• None: No new treatment instituted 
• Medication: New treatment initiated as a direct result of AE 
• Other: Other action required 
7.2.2.5 
Outcome 
• Recovered/resolved: Recovered or resolved 
• Recovered/resolved with sequelae: Recovered or resolved with sequelae 
• Not recovered/not resolved: Not recovered or not resolved 
• Fatal: Death due to an AE 
• Unknown: Unknown 

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7.2.2.6 
Seriousness 
• Not serious 
• Serious 
7.2.3 
Definition of Unexpectedness 
An AE, the nature or severity of which is not consistent with the information provided in the 
Reference Safety Information section of the current pimavanserin Investigator’s brochure. 
7.3 
Time Period and Frequency for Event Assessment and Follow-up 
Adverse events will be recorded from the time informed consent is obtained through the 
study safety follow-up period. All AEs must be either resolved or stable at the end of the 
study safety follow-up period. If ongoing at the end of the study safety follow-up period, the 
subject should be referred for appropriate treatment. 
In the event that a subject discontinues and has an ongoing AE at the time of discontinuation 
(Section 4.4.1) or is withdrawn from the study because of an AE, the subject should be 
followed and treated by the Investigator until the AE has resolved, stabilized, or a new 
chronic baseline has been established. 
7.4 
Reporting Procedures 
7.4.1 
Adverse Event Reporting 
The Investigator must record all observed AEs and all reported AEs. At each visit, the 
Investigator should ask the subject a nonspecific question (e.g., “Have you noticed anything 
different since your last visit?”) to assess whether any AEs have been experienced since the 
last report or visit. 
Note that any use of medication (and specifically any newly prescribed medication) during 
the course of a study may indicate the occurrence of an AE that may need to be recorded on 
both the AE and the concomitant medication page. 
All AEs, serious and not serious, will be recorded on the AE eCRF page using appropriate 
medical terminology. Severity and relationship to study drug will be assessed by the 
Investigator. 
When possible, clinical AEs should be described by diagnosis and not by symptoms 
(e.g., “cold” or “seasonal allergies” instead of “runny nose”). 
All AEs, whether or not related to the study drug, must be fully and completely documented 
on the AE eCRF and in the subject’s notes. 

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7.4.2 
Serious Adverse Event Reporting 
The reporting of SAEs by the Sponsor or designee to the regulatory authorities is a regulatory 
requirement. Each regulatory authority has established a timetable for reporting SAEs based 
upon established criteria. 
Serious AEs must be reported within 24 hours of discovery to the Sponsor or its designee; 
use the appropriate form for initial and/or follow-up reporting.  
At a minimum, events identified by the Sponsor to require expedited reporting as serious, 
unexpected, and related to study drug must be brought to the attention of the responsible 
institutional review board/ethics committee (IRB/EC), as per applicable regulations. These 
will be provided by the Sponsor after their assessment. For European Union member states, 
the Sponsor or its designee will provide reports of suspected unexpected serious adverse 
reactions (SUSARs) directly to the ECs, as required by local legislation. In all other 
countries, it is the Investigator’s responsibility to provide these expedited reports to the 
responsible IRB/EC. It is also the Investigator’s responsibility to notify the responsible 
IRB/EC regarding any new and significant safety information. 
When an SAE occurs, Investigators will review all documentation related to the event and 
will complete the paper SAE form (for initial and/or follow-up information) and fax or email 
(within 24 hours of discovery) to the contact information provided on the SAE form. 
Subjects will be followed through the safety follow-up period for 30 days after last dose of 
study drug for any SAEs and/or other reportable information until such events have resolved 
or the Investigator, in conjunction with the Sponsor, deems them to be chronic or stable. 
In the event of any SAE (other than death), the study subject will be instructed to contact the 
Investigator (or designee) using the telephone number provided in the ICF. All subjects 
experiencing an SAE will be seen by the Investigator or designee as soon as is feasible 
following the report of the SAE. 
Serious AEs occurring after the study follow-up period of 30 days after last dose of study 
drug should be reported if in the judgment of the Investigator there is “a reasonable 
possibility” that the event may have been caused by the product. 
SAEs should also be reported to the IRB/EC according to local regulations. 
7.4.3 
Reporting of Pregnancy 
Any female subject who becomes pregnant during the study (with or without AEs) must be 
withdrawn from the study and the pregnancy must be reported on the Pregnancy form within 
24 hours of discovery to the Sponsor or its designee. Any female subject who becomes 
pregnant during the study will be followed through the pregnancy outcome. 

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Any AEs that are the consequence of pregnancy and which meet the criteria for serious 
should also be reported via the SAE form. 
7.4.3.1 Reporting Paternal Drug Exposure 
Paternal drug exposure is defined as a father’s exposure to a medicinal product before or 
during his partner’s pregnancy. Any paternal drug exposure cases must be reported to the 
Sponsor within 24 hours of discovery via the Pregnancy form. Any AEs that are the 
consequence of paternal drug exposure and which meet the criteria for serious must also be 
reported to the Sponsor within 24 hours of discovery via the SAE form. 
7.4.4 
Reporting of Overdose 
An overdose is a deliberate or inadvertent administration of a treatment at a dose higher than 
the maximum recommended dose per protocol. It must be reported to the Sponsor or 
designee on the Overdose form within 24 hours of discovery. In addition, all events of 
overdose are to be captured as protocol deviations. 
8 CLINICAL MONITORING  
Routine monitoring of study sites is described in Section 11. 
Clinical site monitoring is conducted to ensure that the rights and well-being of human 
subjects are protected, that the reported study data are accurate, complete, and verifiable, and 
that the conduct of the study is in compliance with the currently approved protocol and 
amendment(s) as applicable, with GCP, and with applicable regulatory requirements. Details 
of the study site monitoring process are described in a separate clinical monitoring plan 
document. 
9 STATISTICAL METHODS AND DATA ANALYSIS 
9.1 
Statistical and Analytical Plans 
Statistical methods will be documented in detail in a statistical analysis plan (SAP) to be 
approved by the Sponsor prior to database lock. 
9.2 
Statistical Hypotheses 
The hypotheses for the primary endpoint are the following: 
• The null hypothesis: There is no difference in the mean change from Baseline to 
Week 5 in the HAMD-17 total score between the pimavanserin and the placebo 
treatment groups. 
• The alternative hypothesis: There is a difference in the mean change from Baseline to 
Week 5 in the HAMD-17 total score between the pimavanserin and the placebo 
treatment groups. 

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9.3 
Sample Size Determination 
This study plans to screen approximately 560 adult subjects to randomize approximately 
280 subjects, allowing for a 50% screen failure rate. These approximately 280 subjects will 
be randomized in a 1:1 ratio to either the pimavanserin or the placebo treatment groups 
(i.e., 140 subjects in each treatment group). 
A total sample size of 266 evaluable subjects was estimated to provide at least 90% power at 
a two-sided significance level of 0.05 when assuming a treatment effect size of 0.4 for 
pimavanserin compared to placebo on the change from Baseline to Week 5 in the HAMD-17 
total score. Adjusting for a potential non-evaluable rate of up to 5%, approximately 
280 subjects will be randomized. 
9.4 
Subject Populations for Analysis 
The Full Analysis Set includes all subjects who were randomized, received at least one dose 
of study drug, and have both a Baseline (Week 0) value and at least one post-Baseline value 
for the HAMD-17 total score in the two studies. The Full Analysis Set will be used for the 
analysis of all efficacy endpoints. 
The Per-protocol Analysis Set includes a subset of subjects in the Full Analysis Set without 
any protocol deviations that could have a significant effect on the study conclusions. The 
Per-protocol Analysis Set will be determined prior to unblinding the studies for the final 
analysis and will be used for supportive analysis of selected efficacy endpoints. 
The Safety Analysis Set includes all subjects who received at least one dose of study drug in 
the two studies. 
Any other analysis sets, if necessary, will be defined in the SAP. 
9.5 
Statistical Analyses 
9.5.1 
Primary Analyses 
The primary efficacy endpoint, change from Baseline to Week 5 in the HAMD-17 total score, 
will be evaluated using a mixed-effect model repeated measures (MMRM). The model will 
include effects for treatment group, visit, treatment-by-visit interaction, baseline HAMD-17 
total score, the baseline HAMD-17 total score-by-visit interaction, and study. An unstructured 
covariance matrix will be used and the Kenward-Roger approximation will be used to adjust 
the denominator degrees of freedom. 
A hierarchical approach will be used to control for multiple endpoints (primary and 
secondary). Details will be provided in the SAP. 

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Sensitivity analyses will be performed to assess the impact of missing data, including 
analyses based on a missing not at random assumption. Additional sensitivity analyses will be 
performed to assess the impact of COVID-19.  
9.5.2 
Secondary Analyses 
Each of the secondary endpoints, other than response and remission, will be analyzed using 
the MMRM method similar to that used for the analysis of the primary efficacy endpoint. For 
CGI-I, the baseline CGI-S score will be used as the covariate in the MMRM model. The 
response and remission rates will be compared between the pimavanserin and placebo groups 
using the Cochran-Mantel-Haenszel (CMH) test stratified by study. 
9.5.3 
Safety Analyses 
Safety results will be summarized by treatment group using descriptive statistics. Adverse 
events will be classified into standard terminology using the Medical Dictionary for 
Regulatory Activities (MedDRA). All AEs will be listed and treatment-emergent adverse 
events (TEAEs) will be summarized by system organ class and preferred term. A TEAE is 
defined as an AE that started after the first administration of study drug and no later than the 
last administration of study drug plus 30 days. Summaries by maximum severity and by 
relationship to study drug will also be provided. Serious TEAEs, fatal AEs, and TEAEs 
leading to discontinuation will also be summarized. The relationship of selected AEs to 
COVID-19 will also be assessed and COVID-19 related TEAEs will be tabulated. 
Clinical laboratory values for hematology, chemistry, and urinalysis (specific gravity and pH) 
will be summarized by treatment group using descriptive statistics at Baseline and the end of 
the treatment period visits. The change from baseline values will also be summarized by 
treatment group. The overall minimum and maximum post-baseline observed and change 
from baseline values will also be summarized. 
The number and percentage of subjects with potentially clinically important (PCI) laboratory 
values at the end of the treatment period and overall post-baseline will be summarized by 
treatment group for selected parameters. The PCI criteria will be specified in the SAP. 
Vital signs including weight, height, and the derived BMI will be summarized by treatment 
group using descriptive statistics at Baseline and each post-baseline visit. The change from 
baseline values will also be summarized by treatment group at the post-baseline visits. 
Observed values of electrocardiogram parameters and the changes from Baseline will be 
summarized by treatment group and visit. Categorical analyses will be conducted on the 
incidence of subjects with prolonged QTc intervals and changes in QTc intervals in 
accordance with ICH guidelines and Food and Drug Administration (FDA) E14 guidance 
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For the C-SSRS, the number and percentage of subjects with suicidal ideation or suicidal 
behavior during the study will be tabulated. 
Observed values and change from Baseline in the ESRS-A score will be summarized by 
treatment group and visit. The change from Baseline in the ESRS-A score will be analyzed 
using the MMRM method, similar to the MMRM method used to analyze the primary 
endpoint. 
Number and percentage of subjects with sexual dysfunction (a total score of <47 for men and 
<41 for women) will be summarized and shift tables will be presented.   
9.5.4 
Subgroup Analyses 
Selected analyses may be performed in subgroups. Details will be provided in the SAP. 
9.6 
Interim Analyses 
No interim analyses are planned.  
9.7 
Measures to Minimize Bias 
9.7.1 
Masking Procedures 
This unmasked protocol version provides details of certain study design elements, 
procedures, and statistical methods that are not available in the masked version of the 
protocol. 
This document is intended for use only by the unmasked Sponsor and restricted Worldwide 
Clinical Trials personnel and their designated agents for purposes of regulatory document 
preparation in conjunction with review by IRBs, IECs and regulatory authorities. Access to 
this document by other entities may be considered on a case-by-case basis by the Sponsor. 
The information contained herein is UNMASKED and CONFIDENTIAL. Therefore, it must 
NOT be shared with or communicated to any individual at an investigational site or from site 
facing members of the clinical operations team of the contract research organization except 
with explicit and fully documented authorization from the Sponsor. 
The key element revealed but that is masked in the masked protocol is that the key timepoint 
for analysis of the efficacy endpoints is Week 5. 
Investigators will receive the masked version of the clinical study protocol. 
9.7.2 
Randomization Procedures 
Eligible subjects will be randomized into one of two treatment groups (pimavanserin or 
placebo) in a 1:1 ratio using an interactive response technology (IRT) system. The 
assignments will be based on a pre-generated permuted-block randomization schedule. 
Blinding will be assured by restricting access of Investigators and Sponsor personnel and/or 

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designee to the treatment codes, and providing identical tablets and packaging for the 
pimavanserin and placebo treatments. 
9.8 
Breaking the Study Blind/Subject Code 
For the final analysis, the treatment codes for all subjects will be released to the Sponsor after 
all subjects have completed the study and the clinical database is locked. 
Unblinding of individual treatment assignment during the study is discouraged. The 
Investigator may break the blind in the event of a medical emergency if it is considered 
necessary for the care of the subject. The Investigator should attempt whenever possible to 
contact the Medical Monitor before unblinding a subject’s treatment to discuss the event. 
Lack of Medical Monitor contact does not preclude the Investigator from unblinding the 
subject. In an emergency situation, the subject’s treatment assignment may be obtained by the 
Investigator from the IRT system. Details of the process to be followed are provided in a 
separate IRT manual. In the event that the IRT system is used to perform a code break, the 
Sponsor or designee will be notified immediately via an automated notification from the 
IRT system that an unblinding has occurred. The notification only alerts the Sponsor or 
designee that the unblinding occurred, and does not include any information about the 
unblinded subject’s treatment assignment. 
10 STUDY MANAGEMENT AND DATA COLLECTION 
10.1 Data Collection and Management Responsibilities 
All documents required for the conduct of the study as specified in the ICH GCP guidelines 
will be maintained by the Investigator in an orderly manner and made available for 
monitoring and/or auditing by the Sponsor and regulatory authorities. 
The Investigator and institution must permit authorized representatives of the Sponsor or 
designees (including monitors and auditors), regulatory authorities (including inspectors), 
and the IRB/EC direct access to source documents (such as original medical records). Direct 
access includes permission to examine, analyze, verify, and reproduce any records and 
reports that are needed for the evaluation of the study. The Investigator must ensure the 
reliability and availability of source documents from which the information on the eCRF was 
derived. 
10.2 Source Documents 
All study specific information obtained at each study visit must be recorded in the subject’s 
record (source documentation) and then entered into a validated electronic data capture 
(EDC) database by trained site personnel. The source documentation may consist of source 

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notes captured by site personnel as well as laboratory reports, ECG reports, and electronic 
source data. 
10.3 Case Report Forms 
Subject data required by this protocol are to be recorded in an EDC system on eCRFs. The 
Investigator and his or her site personnel will be responsible for completing the eCRFs. The 
Investigator is responsible for the accuracy and reliability of all the information recorded on 
the eCRFs. All information requested on the eCRFs needs to be supplied, including subject 
identification data, visit date(s), assessment values, etc., and any omission or discrepancy will 
require explanation. All information on eCRFs must be traceable to source documentation at 
the site. 
10.4 Confidentiality 
The Investigator must ensure that each subject’s anonymity is maintained as described below. 
On the eCRFs or other documents submitted to the Sponsor or designees, subjects must be 
identified by a subject identification number only. Subject identifiers uniquely identify 
subjects within the study and do not identify any person specifically. Documents that are not 
for submission to the Sponsor or designees (e.g., signed ICFs, medical records submitted 
with SAE reporting) should be kept in strict confidence by the Investigator in compliance 
with Federal regulations or other applicable laws or ICH guidance on GCP. Data collection 
and handling should comply with the European Union General Data Protection Regulation 
(EU GDPR), where applicable. The Sponsor has assigned a Data Protection Officer (DPO) as 
per the EU GDPR. 
10.5 Study Records Retention 
Investigators are required to maintain all essential study documentation as per ICH GCP 
guidelines. This includes, but is not limited to, copies of signed, dated and completed eCRFs, 
documentation of eCRF corrections, signed ICFs, audio recordings, subject-related source 
documentation, and adequate records for the receipt and disposition of all study drug. 
Investigators should maintain all essential study documentation, for a period of at least 
2 years following the last approval of marketing application in an ICH region (US, Europe, 
and Japan), or until at least 2 years after the drug investigational program is discontinued, 
unless a longer period is required by applicable law or regulation. Only the Sponsor can 
notify an Investigator or vendor when any records may be discarded. Investigators should 
contact the Sponsor before destroying any files. 

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10.6 Protocol Exceptions and Deviations 
No prospective entry criteria protocol deviations are allowed; all subjects must meet all 
eligibility criteria in order to participate in the study. 
Protocol waivers for eligibility will not be granted by the Sponsor under any circumstances. 
If, during the course of a subject’s post-randomization participation in the trial it is 
discovered that the subject did not meet all eligibility criteria, this will be reported as a major 
protocol deviation and not a waiver. In this situation, the subject will be discontinued, unless 
the discontinuation presents an unacceptable medical risk. The justification to allow the 
subject to continue in the trial will be made by the Sponsor, with medical input from the 
Investigator, and will be documented. All follow-up safety assessments must be completed 
and documented as outlined in the protocol (Section 6.4). The Investigator must report any 
protocol deviation to the Sponsor and, if required, to the IRB/EC in accordance with local 
regulations, within reasonable time. 
Protocol deviations will be reviewed periodically over the course of the study. The review 
process, definition of the deviation categories, and the classification of a deviation as major 
or minor are detailed in the Protocol Deviation Management Plan. Protocol deviations will 
also be assessed with respect to relationship to COVID-19, and COVID-19 related protocol 
deviations will be tabulated. 
10.7 Protocol Amendments 
Changes to the protocol may be made only by the Sponsor (with or without consultation with 
the Investigator). All protocol modifications must be submitted to the site IRB/EC in 
accordance with local requirements and, if required, to regulatory authorities, as either an 
amendment or a notification. Approval for amendments must be awaited before any changes 
can be implemented, except for changes necessary to eliminate an immediate hazard to trial 
subjects, or when the changes involve only logistical or administrative aspects of the trial. 
No approval is required for notifications. 
11 QUALITY MANAGEMENT 
11.1 Risk Management 
The Sponsor utilizes the ICH E6 (GCP) Revision 2 risk management approach that includes 
methods to assure and control the quality of the trial proportionate to the risks inherent in the 
trial and the importance of the information collected. The intent is that all aspects of this trial 
are operationally feasible and that any unnecessary complexity, procedures, and data 
collection are avoided. The Sponsor’s risk management approach includes the following 
activities with a focus on critical processes and critical study data:  

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• 
Risk Identification: risks to critical trial processes, governing systems, investigational 
product, trial design, data collection, and recording are identified. 
• Risk Evaluation: identified risks are evaluated by considering the following factors: 
(a) likelihood of occurrence, (b) impact on human subject protection and data integrity, 
and (c) detectability of errors. 
• Risk Control: risks that can be reduced (e.g., mitigating) or can be accepted are 
differentiated. Risk mitigation activities are incorporated in protocol design and 
implementation, study plans, training, processes, and other documents governing the 
oversight and execution of study activities. Where possible, predefined quality 
tolerance limits are to be defined to identify systematic issues that can impact subject 
safety or data integrity and deviations from the predefined quality tolerance limits will 
trigger an evaluation and possibly an action. Contingency plans are developed for 
issues with a high risk factor that cannot be avoided. 
• Periodic risk review, communication, and escalation of risk management activities are 
ongoing during trial execution and risk outcomes are reported in the clinical study 
report (CSR). 
11.2 Quality Control and Quality Assurance 
The Sponsor or designees and regulatory authority inspectors are responsible for contacting 
and visiting the Investigator for the purpose of inspecting the facilities and, upon request, 
inspecting the various records of the trial (e.g., eCRFs and other pertinent data) provided that 
subject confidentiality is respected. Some remote monitoring of study sites was also 
performed as a result of the travel and visiting restrictions caused by the COVID-19 
pandemic. 
The Sponsor’s or designee’s monitor is responsible for inspecting the eCRFs at regular 
intervals throughout the study to verify adherence to the protocol; completeness, accuracy, 
and consistency of the data; and adherence to local regulations on the conduct of clinical 
research. The monitor should have access to subject medical records and other study-related 
records needed to verify the entries on the eCRFs. 
The Investigator agrees to cooperate with the monitor to ensure that any problems detected in 
the course of these monitoring visits are resolved. 
In accordance with ICH guidance on GCP and the Sponsor’s audit plans, a certain percentage 
of sites participating in this study will be audited. These audits may include a review of site 
facilities (e.g., pharmacy, drug storage areas, and laboratories) and review of study-related 
records may occur in order to evaluate the trial conduct and compliance with the protocol, 
ICH guidance on GCP, and applicable regulatory requirements. 

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The Sponsor’s or designee’s representatives, regulatory authority inspectors, and IRB/EC 
representatives who obtain direct access to source documents should also respect subject 
confidentiality, taking all reasonable precautions in accordance with applicable regulatory 
requirements to maintain the confidentiality of subjects’ identities. 
12 ETHICAL CONSIDERATIONS 
12.1 Ethical Standard 
The study will be conducted in compliance with the protocol, the Declaration of Helsinki, 
ICH GCP, and other applicable regulatory requirements (e.g., Serious Breach reporting, 
urgent safety measures, and European Union General Data Protection Regulation 
[EU GDPR]). 
The study will be performed in accordance with current US Health Insurance Portability and 
Accountability Act (HIPAA) regulations, US FDA GCP Regulations (US CFR 21 parts 50, 
54, 56, and 312), and ICH guidance on GCP (E6) and clinical safety data management (E2A). 
In accordance with Directive 75/318/EEC, as amended by Directive 91/507/EEC, the final 
clinical study report will be signed by an Investigator and/or Coordinating Investigator who 
will be designated prior to the writing of the clinical study report. 
12.2 Institutional Review Board/Ethics Committee 
The Investigator or designee will provide the IRB/EC with all requisite material, including a 
copy of the protocol, informed consent, and any subject information or advertising materials. 
The study will not be initiated until the IRB/EC provides written approval of the protocol and 
the informed consent and until approved documents have been obtained by the Investigator 
and copies received by the Sponsor. All amendments will be sent to the IRB/EC for 
information (minor amendment) or for submission (major amendment) before 
implementation. The Investigator will supply the IRB/EC and the Sponsor with appropriate 
reports on the progress of this study, including any necessary safety updates, in accordance 
with the applicable government regulations and in agreement with policy established by the 
Sponsor. 
12.3 Informed Consent Process 
Properly executed, written informed consent must be obtained from each subject prior to any 
screening procedures. 
The informed consent must, at a minimum, include the elements of consent described in the 
ICH guidance on GCP and the US CFR 21 part 50.25. A copy of the ICF planned for use will 
be reviewed by the Sponsor or designee for acceptability and must be submitted by the 
Investigator or designee together with the protocol, to the appropriate IRB/EC for review and 

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approval prior to the start of the study at that investigational site. Consent forms must be in a 
language fully comprehensible to the prospective subject. The Investigator must provide the 
Sponsor or designee with a copy of the IRB/EC letter approving the protocol and the ICF 
before the study drug supplies will be shipped and the study can be initiated. 
The consent form must be revised if new information becomes available during the study that 
may be relevant to the subject's willingness to continue participation. Any revision must be 
submitted to the appropriate IRB/EC for review and approval in advance of use. 
12.3.1 
Consent and Other Informational Documents Provided to Subjects 
The subject must be given a copy of the signed informed consent and the original maintained 
in the designated location at the site. 
12.3.2 
Consent Procedures and Documentation 
It is the Investigator or designee’s responsibility to obtain written informed consent from the 
subject after adequate explanation of the aims, methods, anticipated benefits, and potential 
hazards of the study. The subject must be given ample time to decide about study participation 
and opportunity to inquire about details of the study. The IRB/EC-approved consent form must 
be personally signed and dated by the subject and by the person who conducted the informed-
consent discussion. The Investigator or appropriate site personnel must document the details of 
obtaining informed consent in the subject’s study documents. 
Records related to a study subject’s participation will be maintained and processed according 
to local laws, and where applicable, the European Union General Data Protection Regulation 
(EU GDPR). The consent and study information documentation will include statements 
describing local and regional requirements concerning data privacy, and who to contact for 
questions. 
13 PUBLICATION PLAN 
All publication rights are delineated in the Clinical Study Agreement and/or other separate 
agreements with the Investigator and/or Institution, as applicable. 
14 CONFLICT OF INTEREST POLICY 
14.1 Finance, Insurance, and Indemnity 
Arrangements for finance, insurance, and indemnity are delineated in the Clinical Study 
Agreement and/or other separate agreements with the Investigator and/or Institution, as 
applicable. 
 
 

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Roth BL, Lopez E, Patel S, Kroeze WK. The multiplicity of serotonin receptors: uselessly 
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Rush AJ, Kraemer HC, Sackeim HA, et al. Report by the ACNP Task Force on Response and 
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Wikström HV, Mensonides-Harsema MM, Cremers TI, Moltzen EK, Arnt J. Synthesis and 
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2008;192(1):52-58. 

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Appendix C Prohibited and Restricted Medications 
Subjects taking prohibited medications at study entry will not be eligible for the study.  
Subjects who require current treatment with a prohibited medication will be withdrawn from 
the study. 
Subjects who have previously taken a prohibited medication during the study will be 
withdrawn from the study unless:  
• the prohibited medication has been discontinued AND  
• withdrawal from the study presents an unacceptable medical risk to the subject 
The justification to allow the subject to continue in the trial will be made by the 
Sponsor/Medical Monitor with medical input from the Investigator, and will be documented. 
If allowed to remain in the trial, this will be reported as a major protocol deviation and not a 
waiver. 
The table below lists prohibitions and restrictions by medication class, including 
representative medications within class. A prohibited medication is not allowed. A restricted 
medication is allowed only under certain conditions. 
Medication Class 
Medicationa 
Prohibition/restrictions 
Antipsychotics 
other than 
pimavanserin 
PROHIBITED 
All in class 
• 
Must be washed out 2 weeks or 
5 half-lives (whichever is longer) prior 
to Baseline 
• 
Prohibited throughout the study 
Anticholinergics 
PROHIBITED 
• 
Centrally acting 
anticholinergics 
o 
benztropine 
o 
biperiden 
o 
trihexiphenidyl 
• 
Anticholinergic medications whose 
primary mechanism of action is 
centrally acting are prohibited and 
should be washed out and discontinued 
at least 2 weeks or 5 half-lives 
(whichever is longer) prior to Baseline 
UNRESTRICTED 
• 
Peripherally acting 
anticholinergics 
• 
Peripherally acting anticholinergic 
medications are allowed without 
restriction 
Anticonvulsant and 
mood stabilizers 
PROHIBITED 
• 
carbamazepine 
• 
lamotrigine 
• 
lithium 
• 
phenytoin 
• 
valproate 
• 
Must be washed out 5 half-lives prior to 
Baseline 
• 
Prohibited throughout the study 
Antidepressants 
other than 
PROHIBITED 
• 
mirtazapine 
• 
Prohibited throughout the study 

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Medication Class 
Medicationa 
Prohibition/restrictions 
background therapy 
(see Inclusion 
Criterion #6) 
• 
nefazadone 
• 
fluvoxamine 
• 
mianserin 
• 
trazodone 
• 
amitriptyline 
• 
nortriptyline 
• 
imipramine 
• 
trimipramine 
• 
desipramine 
• 
clomipramine 
• 
bupropion 
• 
levomilnacipran 
• 
vilazodone 
• 
vortioxetine 
• 
ketamine 
• 
esketamine 
• 
Must be discontinued at least 2 weeks 
or 5 half-lives (whichever is longer) 
prior to the Baseline visit 
RESTRICTED 
• 
citalopram 
• 
escitalopram 
• 
venlafaxine 
• 
If subject is remaining on these 
medications, the dose of the permitted 
antidepressants on the left must be 
unchanged for at least 4 weeks prior to 
the SAFER Remote Interview and 
should be expected to remain 
unchanged until the subject’s final visit. 
If the medication is being discontinued, 
it must be discontinued at least 2 weeks 
or 5 half-lives (whichever is longer) 
prior to the Baseline visit. 
o 
Citalopram is restricted to a 
maximum dose of 20 mg/day  
o 
Escitalopram is restricted to a 
maximum dose of 10 mg/day  
o 
Venlafaxine is restricted to a 
maximum dose of 225 mg/day 
Antihistamines 
RESTRICTED 
• 
diphenhydramine 
• 
brompheniramine 
• 
chlorpheniramine  
 
• 
Prohibited at Baseline 
• 
First generation antihistamines are not 
allowed during the study to treat 
insomnia 
• 
Limited short-term use of first 
generation antihistamines for a few days 
is allowed during the study for 
treatment of allergies and as 
antihistamine-decongestant for colds 
only 
• 
First generation antihistamines should 
not be used within 12 hours of an 
efficacy assessment 

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Medication Class 
Medicationa 
Prohibition/restrictions 
UNRESTRICTED 
• 
cetirizine 
• 
loratadine 
• 
fexofenadine  
• 
Second and third generation 
antihistamines are allowed without 
restriction 
Anxiolytics 
PROHIBITED 
• 
chlordiazepoxide 
• 
diazepam 
• 
flurazepam 
• 
alprazolam 
• 
clonazepam 
• 
lorazepam 
• 
oxazepam 
• 
temazepam 
• 
midazolam 
• 
triazolam 
• 
Prohibited at study entry and throughout 
the study 
Hypnotics and 
sleeping agents 
PROHIBITED 
• 
zolpidem 
• 
zopiclone 
• 
eszopiclone 
• 
zaleplon 
• 
ramelteon 
• 
Prohibited at study entry and throughout 
the study 
Stimulants and 
wake-promoting 
agents 
PROHIBITED 
• 
methylphenidate 
• 
modafinil 
• 
armodafinil 
• 
amphetamine 
• 
Prohibited at study entry and throughout 
the study (see Section 6.3.7 for 
procedures related to a positive 
amphetamine test at study entry) 
Non-stimulant 
ADHD medications 
PROHIBITED 
• 
atomoxetine 
• 
Prohibited at study entry and throughout 
the study 
Serotonin 
antagonists  
PROHIBITED 
• 
cyproheptadine 
• 
Prohibited throughout the study 
• 
Must be discontinued at least 3 weeks 
prior to the Baseline visit 
Antiarrhythmic 
drugs 
PROHIBITED 
• 
ajmaline 
• 
amakalant, semantilide 
• 
amiodarone 
• 
bretylium 
• 
disopyramide 
• 
dofetilide 
• 
dronedarone 
• 
flecainide 
• 
Prohibited at study entry and throughout 
the study 

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Medication Class 
Medicationa 
Prohibition/restrictions 
• 
ibutilide 
• 
procainamide 
• 
propafenone 
• 
quinidine 
• 
sotalol, d-sotalol 
Opioids 
PROHIBITED 
• 
methadone 
• 
hydrocodone 
• 
oxycodone 
• 
codeine 
• 
morphine 
• 
Prohibited at Baseline 
• 
Subjects who require chronic treatment 
with opioid medication or who have a 
substance use disorder are not eligible 
for this study 
• 
Limited short term use of opioids for a 
few days only is allowed during the 
study for treatment of acute pain 
following trauma or surgical procedure 
• 
Opioids should not be used within 
12 hours of an efficacy assessment 
Antimicrobials, 
antifungals, and 
antimalarials 
PROHIBITED 
• 
clarithromycin 
• 
erythromycin 
• 
levofloxacin 
• 
moxifloxacin 
• 
pentamidine 
• 
roxithromycin 
• 
Prohibited at study entry and throughout 
the study 
RESTRICTED 
• 
artenimol/piperaquine 
• 
azithromycin 
• 
bedaquiline 
• 
ciprofloxacin 
• 
gemifloxacin 
• 
norfloxacin 
• 
ofloxacin 
• 
fluconazole 
• 
telavancin 
• 
telithromycin 
• 
Prohibited at Baseline but may be used 
during the course of the study to treat a 
bacterial infection (e.g., urinary tract 
infection, respiratory infection), 
post-Baseline at the discretion of the 
Principal Investigator. 
• 
The medications on the left are only 
allowed under the following conditions: 
o 
The subject has a Baseline 
ECG with a QTcF <425 ms 
IF QRS duration is <120 ms 
OR 
o 
The subject has a QTcF 
<450 ms at Baseline IF QRS 
duration ≥120 ms 
a 
Medications within each class include but are not limited to the examples listed in this table. 

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Appendix D Prohibited and Restricted Concomitant Medications: Inhibitors and 
Inducers of Cytochrome P450 Enzyme 3A4 
The information presented here is intended to provide guidance and does not constitute an 
exhaustive list of strong CYP 3A4 enzyme (CYP3A4) inhibitors and inducers. Any questions 
should be discussed with the Medical Monitor or appropriate designee. 
Subjects who require current treatment with a prohibited medication will be withdrawn from 
the study. 
Subjects who have previously taken a prohibited medication during the study will be 
withdrawn from the study unless:  
• the prohibited medication has been discontinued AND  
• withdrawal from the study presents an unacceptable medical risk to the subject 
The justification to allow the subject to continue in the study will be made by the 
Sponsor/Medical Monitor with medical input from the Investigator, and will be documented. 
If allowed to remain in the study, this will be reported as a major protocol deviation and not a 
waiver. 
The metabolism of pimavanserin is affected by strong CYP3A4 inhibitors, resulting in an 
increase in maximum (peak) observed drug concentration (Cmax) of approximately 1.5-fold 
and area under the plasma concentration-time curve (AUC) of approximately 3-fold.  
Strong inhibitors of CYP3A4 are to be stopped at least 7 days or 5 half-lives prior to 
investigational product administration, whichever is longer. Strong inducers of CYP3A4 are 
to be stopped 30 days or 5 half-lives prior to investigational product administration, 
whichever is longer. Moderate inhibitors and inducers of CYP3A4 are allowed but should be 
used with caution. 

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STRONG 
INHIBITORS 
grapefruit juice
a 
boceprevir (Victrelis®) 
clarithromycin (Biaxin®) 
cobicistat (part of Stribild®) 
conivaptan (Vaprisol®) 
fluvoxamine (Luvox®) 
indinavir (Crixivan®) 
itraconazole (Sporanox®) 
ketoconazole (Nizoral®) 
lopinavir and ritonavir (Kaletra®) 
mibefradil (Posicor®) 
nefazodone (Serzone®) 
nelfinavir (Viracept®) 
posaconazole (Noxafil®) 
quinupristin (Synercid®) 
ritonavir (Norvir®, part of Viekira 
Pak™) 
saquinavir (Invirase®) 
telaprevir (Incivek®) 
telithromycin (Ketek®) 
voriconazole (Vfend®) 
MODERATE 
INHIBITORS 
grapefruit juice
a 
amprenavir (Agenerase®) 
aprepitant (Emend®) 
atazanavir (Reyataz®) 
ciprofloxacin (Cipro®) 
darunavir/ritonavir 
(Prezista®/Ritonavir) 
diltiazem 
erythromycin (Erythrocin® 
Lactobionate) 
fluconazole (Diflucan®) 
fosamprenavir (Lexiva®) 
imatinib (Gleevec®) 
verapamil (Calan®) 
STRONG 
INDUCERS 
avasimibe 
carbamazepine (Tegretol®) 
phenobarbital (Luminal®, Solfoton®) 
phenytoin (Dilantin®)  
rifampin (Rifadin®, Rifadin® IV, 
Rimactane®) 
St. John’s Wort 
MODERATE 
INDUCERS 
bosentan (Tracleer®) 
efavirenz (Sustiva®) 
etravirine (Intelence®) 
modafinil (Provigil®) 
nafcillin (Unipen®, Nallpen®) 
a 
The effect of grapefruit juice varies widely among brands and is concentration-, dose-, and preparation-
dependent. Studies have shown that it can be classified as a “strong CYP3A inhibitor” when a certain 
preparation was used (e.g., high dose, double strength) or as a “moderate CYP3A inhibitor” when another 
preparation was used (e.g., low dose, single strength). (FDA Drug Development and Drug Interactions 
http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractionsLabelin
g/ucm093664.htm#classInhibit).