A Randomized, Double-blind, Placebo-Controlled, 3-Period Crossover Study Followed by 1 Open-label Comparator Period to Evaluate Central Nervous System Pharmacodynamic Activity of TAK-653 in Healthy Volunteers Using Transcranial Magnetic Stimulation
Phase: PHASE1
Conditions: Healthy Volunteers
Sponsor: Neurocrine Biosciences




Title: A Randomized, Double-blind, Placebo-Controlled, 3-Period Crossover Study Followed by 1 
Open-label Comparator Period to Evaluate Central Pharmacodynamic Activity of TAK-653 in 
Healthy Volunteers Using Transcranial Magnetic Stimulation 
NCT Number: NCT03792672
Protocol Approve Date: 04 April 2019
Certain information within this protocol has been redacted (ie, specific content is masked irreversibly from 
view with a black/blue bar) to protect either personally identifiable information (PPD) or company 
confidential information (CCI). 
This may include, but is not limited to, redaction of the following: 
Named persons or organizations associated with the study.
Proprietary information, such as scales or coding systems, which are considered confidential 
information under prior agreements with license holder.
Other information as needed to protect confidentiality of Takeda or partners, personal information, or 
to otherwise protect the integrity of the clinical study.

TAKEDA PHARMACEUTICALS
PROTOCOL
A Randomized, Double-blind, Placebo-Controlled, 3-Period Crossover Study Followed by 
1 Open-label Comparator Period to Evaluate Central Pharmacodynamic Activity of 
TAK-653 in Healthy Volunteers Using Transcranial Magnetic Stimulation 
Sponsor: 
Takeda Pharmaceuticals
Study Identifier:
TAK-653-1003
Compound:
TAK-653
Date:
04 April 2019
Amendment Number: 
01
Amendment History: 
Date
Amendment Number
Amendment Type 
Region
21 November 2018
Initial Protocol
Not applicable
Global
04 April 2019
Amendment 01
Substantial
Global
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TABLE OF CONTENTS
1.0
STUDY SUMMARY ......................................................................................................7
1.1
Protocol Amendment 01 Summary of Changes ..........................................................7
1.2
Protocol Summary .....................................................................................................8
2.0
STUDY SCHEMATIC..................................................................................................12
3.0
SCHEDULE OF STUDY PROCEDURES ....................................................................13
4.0
INTRODUCTION.........................................................................................................20
4.1
Background .............................................................................................................20
4.2
Rationale for the Proposed Study.............................................................................22
4.3
Benefit-Risk Profile .................................................................................................22
4.4
TAK-653 .................................................................................................................23
4.4.1
Ketamine ...........................................................................................................25
4.4.2
TMS ..................................................................................................................26
5.0
TRIAL OBJECTIVES AND ENDPOINTS ...................................................................27
5.1
Trial Objectives .......................................................................................................27
5.1.1
Trial Primary Objective......................................................................................27
5.1.2
Trial Secondary Objective..................................................................................27
5.1.3
Trial Exploratory Objectives ..............................................................................27
5.2
Endpoints.................................................................................................................28
5.2.1
Primary Endpoints .............................................................................................28
5.2.2
Secondary Endpoints..........................................................................................28
5.2.3
Safety Endpoints................................................................................................28
5.2.4
Exploratory Endpoints .......................................................................................28
6.0
TRIAL DESIGN AND DESCRIPTION ........................................................................30
6.1
Trial Design.............................................................................................................30
6.2
Rationale for Trial Design, Dose, and Endpoints......................................................31
6.2.1
Rationale of Trial Design ...................................................................................31
6.2.2
Rationale for Dose .............................................................................................31
6.2.3
Rationale for Endpoints......................................................................................32
6.2.4
Critical Procedures Based on Trial Objectives: Timing of Procedures ................34
6.3
Trial Design/Dosing/Procedures Modifications Permitted Within Protocol 
Parameters...............................................................................................................34
6.4
Trial Beginning and End/Completion.......................................................................35
6.4.1
Definition of Beginning of the Trial ...................................................................35
6.4.2
Definition of End of the Trial.............................................................................35
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6.4.3
Definition of Trial Discontinuation ....................................................................35
6.4.4
Criteria for Premature Termination or Suspension of the Trial............................36
7.0
SELECTION AND DISCONTINUATION/WITHDRAWAL OF SUBJECTS..............37
7.1
Inclusion Criteria .....................................................................................................37
7.2
Exclusion Criteria ....................................................................................................38
7.3
Excluded Medications, Supplements, Dietary Products............................................39
7.3.1
Concomitant Medications...................................................................................39
7.3.2
Fruit Juice ..........................................................................................................39
7.3.3
Alcohol..............................................................................................................39
7.3.4
Caffeine .............................................................................................................40
7.3.5
Smoking ............................................................................................................40
7.4
Diet, Fluid, Activity.................................................................................................40
7.4.1
Diet and Fluid ....................................................................................................40
7.4.2
Activity..............................................................................................................40
7.5
Criteria for Discontinuation or Withdrawal of a Subject...........................................40
7.6
Procedures for Discontinuation or Withdrawal of a Subject......................................41
7.7
Subject Replacement................................................................................................42
8.0
CLINICAL STUDY MATERIAL MANAGAEMENT..................................................43
8.1
Clinical Study Drug .................................................................................................43
8.1.1
Clinical Study Drug Labeling.............................................................................43
8.1.2
Clinical Study Drug Inventory and Storage ........................................................43
8.1.3
Clinical Study Drug Blinding.............................................................................43
8.1.4
Randomization Code Creation and Storage ........................................................43
8.1.5
Clinical Trial Blind Maintenance/Unblinding Procedure ....................................43
8.1.6
Accountability and Destruction of sponsor-Supplied Drugs................................44
8.2
Ancillary Supplies ...................................................................................................44
9.0
STUDY PROCEDURES...............................................................................................45
9.1
Administrative Procedures.......................................................................................45
9.1.1
Informed Consent Procedure..............................................................................45
9.1.2
Inclusion and Exclusion .....................................................................................45
9.1.3
Medical History/Demography ............................................................................46
9.1.4
Concomitant Medications...................................................................................46
9.2
Clinical Procedures and Assessments.......................................................................46
9.2.1
Full Physical Exam ............................................................................................46
9.2.2
Height and Weight .............................................................................................46
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9.2.3
BMI ...................................................................................................................46
9.2.4
Vital Signs .........................................................................................................46
9.2.5
12-Lead ECG.....................................................................................................47
9.2.6
Study Drug Administration ................................................................................48
9.2.7
Ketamine Administration ...................................................................................48
9.2.8
AE Monitoring...................................................................................................48
9.3
Laboratory Procedures and Assessments..................................................................48
9.3.1
Clinical Laboratory Tests...................................................................................49
9.3.2
Diagnostic Screening .........................................................................................50
9.4
PK and PD Evaluations............................................................................................51
9.4.1
PK Samples .......................................................................................................51
9.4.2
PK Measurements..............................................................................................51
9.4.3
PD Measurements..............................................................................................52
9.5
Confinement ............................................................................................................54
9.6
Childbearing Status and Methods of Contraception..................................................55
9.6.1
Women of Childbearing Potential ......................................................................55
9.6.2
Women of Nonchildbearing Potential.................................................................55
10.0
ADVERSE EVENTS ....................................................................................................56
10.1
Definitions and Elements of AEs .............................................................................56
10.1.1 SAEs..................................................................................................................58
10.1.2 Adverse Events of Special Interest (AESI).........................................................59
10.2
AE Procedures.........................................................................................................60
10.2.1 Assigning Severity/Intensity of AEs...................................................................60
10.2.2 Assigning Causality of AEs................................................................................60
10.2.3 Start Date...........................................................................................................60
10.2.4 End Date............................................................................................................60
10.2.5 Pattern of Adverse Event (Frequency)................................................................61
10.2.6 Action Taken With Study Treatment..................................................................61
10.2.7 Outcome ............................................................................................................61
10.2.8 Collection and Reporting of AEs, SAEs, Special Interest AEs, and Abnormal 
Liver Function Tests (LFT)s ..............................................................................62
10.2.9 Safety Reporting to Investigators, IRBs or IECs, and Regulatory Authorities.....64
11.0
STATISTICAL METHODS..........................................................................................65
11.1
Statistical and Analytical Plans ................................................................................65
11.1.1 Analysis Sets......................................................................................................65
11.1.2 Analysis of Demography and Other Baseline Characteristics .............................65
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11.1.3 PK Analysis .......................................................................................................65
11.1.4 PD Analysis .......................................................................................................66
11.1.5 Safety Analysis ..................................................................................................67
11.2
Interim Analysis and Criteria for Early Termination ................................................68
11.3
Determination of Sample Size..................................................................................68
12.0
QUALITY CONTROL AND QUALITY ASSURANCE...............................................69
12.1
Study-Site Monitoring Visits ...................................................................................69
12.2
Protocol Deviations..................................................................................................69
12.3
Quality Assurance Audits and Regulatory Agency Inspections ................................69
13.0
ETHICAL ASPECTS OF THE STUDY........................................................................70
13.1
IRB and/or IEC Approval ........................................................................................70
13.2
Subject Information, Informed Consent, and Subject Authorization .........................70
13.3
Subject Confidentiality ............................................................................................71
13.4
Publication, Disclosure, and Clinical Trial Registration Policy.................................72
13.4.1 Publication and Disclosure.................................................................................72
13.4.2 Clinical Trial Registration..................................................................................72
13.4.3 Clinical Trial Results Disclosure ........................................................................73
13.5
Insurance and Compensation for Injury....................................................................73
14.0
ADMINISTRATIVE AND REFERENCE INFORMATION.........................................74
14.1
Administrative Information......................................................................................74
14.1.1 Study Contact Information .................................................................................74
14.1.2 INVESTIGATOR AGREEMENT......................................................................75
14.1.3 Study-Related Responsibilities...........................................................................76
14.1.4 List of Abbreviations .........................................................................................76
15.0
DATA HANDLING AND RECORDKEEPING............................................................78
15.1
CRFs (Electronic and Paper)....................................................................................78
15.2
Record Retention .....................................................................................................78
16.0
REFERENCES..............................................................................................................80
17.0
APPENDICES...............................................................................................................83
LIST OF IN-TEXT TABLES
Table 4.a
Mean Exposures to TAK-653 at the NOAELs in the 13-Week Repeat-Dose
Toxicity and Neurotoxicity Studies and Clinical Margins...................................24
Table 6.a
Study Drug and Doses........................................................................................31
Table 9.a
Primary Specimen Collections ...........................................................................51
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Table 10.a
Takeda Medically Significant AE List................................................................59
LIST OF IN-TEXT FIGURES
Figure 4.a
Schematic Representation of the Different Parameters Measured Using TMS ....22
LIST OF APPENDICES
Appendix A
Responsibilities of the Investigator.....................................................................83
Appendix B
Elements of the Subject Informed Consent.........................................................85
Appendix C
Investigator Consent to the Use of Personal Information ....................................88
Appendix D
Pregnancy and Contraception.............................................................................89
Appendix E
Detailed Description of Amendments to Text.....................................................92
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1.0
STUDY SUMMARY
1.1
Protocol Amendment 01 Summary of Changes
This document describes the changes in reference to the Protocol Incorporating Amendment 
No. 01. 
Rationale for Amendment 01
The primary purpose of this amendment is to update the protocol regarding changing the primary 
and key secondary endpoints and changing the early data analysis from blinded to unblinded. 
Other minor changes in procedures are included, primarily to address inconsistencies in the text 
and schedule of events. Minor grammatical and editorial changes are included for clarification 
purposes only. Full details on changes of text are given in Appendix E, including detailed 
rationale.
Changes in Amendment 01
1. A second primary endpoint added and both endpoints are evaluated as changes from 
pre-dosing baseline, compared to placebo.
2. Modified secondary endpoints.
3. The primary endpoint analysis now includes both primary endpoints with an additional 
Hochberg step-up procedure. In addition, some details of the model are deferred to the SAP.
4. The early analysis, which may occur when at least 18 subjects have completed periods 1
through 3, will be unblinded (previously partially blinded).
5. The sample size justification is updated to include both primary endpoints.
6. The resting motor threshold (rMT) exclusion criterion is modified.
7. Three safety endpoints were deleted.
8. Subject instructions to stop concomitant medications before dosing are modified.
9. The window for predose ECG is widened to 3 hours.
10. Site clinic seizure precautions are updated for generalized use.
11. Pharmacokinetic (PK) blood sample collection instructions for ketamine analysis are added.
12. The time interval for routine collection of AEs after final dosing is clarified.
13. Deletion of the 25 hour visit.
14. Detail from study summary added to the trial design section.
15. Description of study blinding corrected.
16. Definition of safety analysis set revised.
17. Pregnancy and contraception language updated.
18. Revisions to the Schedule of Study Procedures table and footnotes.
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1.2
Protocol Summary
Name of sponsor:
Millenium Pharmaceuticals, Inc, a wholly owned subsidiary of 
Takeda Pharmaceutical Company, Ltd
40 Landsdowne Street
Cambridge MA 02139
USA
Compound:
TAK-653
Study Identifier: TAK-653-1003
Phase: 1
Protocol Title: A Randomized, Double-blind, Placebo-Controlled, 3-Period Crossover Study Followed by 
1 Open-label Comparator Period to Evaluate Central Nervous System Pharmacodynamic Activity of TAK-653 in 
Healthy Subjects Using Transcranial Magnetic Stimulation
Trial Design:
This randomized, double blind, placebo-controlled, 3-period cross-over study followed by one open label comparator 
period is designed to evaluate the central pharmacodynamic activity of TAK-653 in healthy subjects using transcranial 
magnetic stimulation (TMS). Approximately 24 healthy male and female subjects, aged 18 to 55 years, inclusive, will 
be enrolled. 
The study will include 3 treatment periods, each 1 day in duration, followed by a 2-day comparator period, alternating 
with 3 washout periods of at least 10 days (not to exceed 15 days). There will be 5 clinic visits, including screening in 
which full medical, neurological, and psychiatric examinations will be conducted; Day 1 of each of the first 3 
treatment periods, during which TMS testing will be conducted before and after subjects receive placebo or 1 of 2 
doses of TAK-653; Day 1 of the fourth treatment period, during which TMS testing will be conducted before and after 
subjects receive the (NMDA) (N-methyl-D-aspartate) antagonist ketamine, which will be open label. 
Before the start of each treatment period, the investigator will review the safety assessments for the subject, including 
vital signs, and electrocardiogram (ECG). 
On the first day of each treatment period (Day 1), each subject will undergo a TMS session assessing baseline 
TMS-elicited motor-evoked potential (MEP) amplitude and threshold, followed by administration of TAK-653 or 
placebo (Treatment Periods 1-3), or ketamine (Treatment Period 4). For the first 3 treatment periods, TMS and 
MEP/electroencephalogram assessment sets, will be conducted along with blood sample collection for 
pharmacokinetic (PK) analyses at predose and starting at 30 and 150 minutes (2 ½ hours) after dosing. The 2 ½ hour 
time point is chosen to capture Cmax, and the 30 minute time point to capture a lower exposure level in each subject. In 
Period 4, each subject will undergo a TMS session assessing baseline TMS-elicited MEP amplitude and threshold, and 
blood sample collection for PK analyses at predose, followed by administration of ketamine intravenously (0.5 mg/kg 
over 40 minutes). TMS assessments will be conducted at 150 minutes (2.5 hours) after ketamine initiation (when 
ketamine acute dissociative effects have subsided), and blood sample collection for PK analysis at selected timepoints. 
Subjects will undergo follow-up TMS session starting at 24 hours (Day 2 of Period 4) to capture ketamine modulation 
of TMS responses at a time in which antidepressant effects of ketamine are already present in a major depressive 
disorder population.
Subjects will remain in the clinic on treatment days until approximately 2 hours post-TMS procedures for safety 
observation. During the ketamine-testing period, subjects will remain overnight following the infusion, until the 24 
hour follow-up TMS assessments have been completed. Before discharge, a neurological and mental state 
examination will be performed. 
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Trial Primary Objective:
1.
To determine whether TAK-653 in comparison to placebo, increases central nervous system (CNS) excitability, 
assessed with TMS-evoked MEP in healthy subjects.
Trial Secondary Objectives:
1.
To determine whether TAK-653, in comparison to placebo, modulates responses evoked with paired TMS pulses 
that capture intracortical circuitry modulation.
2.
To determine whether ketamine increases CNS excitability assessed with TMS-evoked MEP in healthy subjects.
Trial Safety Objective
1.
To determine the safety and tolerability of TAK-653 when administered as single dose in healthy subjects 
assessing responses evoked by TMS. 
Trial Subject Population: Healthy adult subjects aged 18-55 years 
Planned Number of Subjects:
Up to approximately 24 subjects total enrolled for 
approximately 22 to complete at least Treatment 
Periods 1-3)
Planned Number of Sites:
1 site in the Netherlands
Dose Levels:
Study Drug
TAK-653 0.5 mg
TAK-653 6 mg
Matching placebo
Ketamine
0.5 mg/kg
Route of Administration:
Study Drug
Oral (Tablets)
Ketamine
Intravenous infusion
Duration of Treatment:
1 dose of study drug (TAK-653 0.5 or 6 mg or placebo) 
on Day 1 of each of 4 periods
Planned Trial Duration:
Up to approximately 15 weeks
Main Criteria for Inclusion:
To be eligible for study participation, subjects must: 
1.
Understand the study procedures and agree to participate by providing written informed consent.
2.
Be willing and able to comply with all study procedures and restrictions.
3.
Be male or female (of nonchildbearing potential) aged 18 to 55 years, inclusive, at the Screening Visit.
4.
Have a body mass index ≥18.5 and ≤30.0 kg/m2 at the Screening Visit.
5.
Be judged to be in good health by the investigator, based on clinical evaluations including laboratory safety tests, 
medical history, physical examination, 12-lead ECG, and vital sign measurements performed at the screening 
visit and before the first dose of study drug.
6.
Meet the birth control requirements outlined in the protocol.
Main Criteria for Exclusion:
A subject must be excluded from participating in the study if the subjects: 
1.
Has a positive alcohol or drug screen.
2.
Has a positive pregnancy test.
3.
Is a lactating/nursing woman.
4.
Has a clinically significant previous or current psychiatric disorder according to the (DSM5) Diagnostic and 
Statistical Manual of Mental Disorders, including substance use disorder.
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5.
Has a history of intracranial mass lesion, hydrocephalus and/or head injury or trauma. 
6.
Has metal objects in brain or skull
7.
Has a cochlear implant or deep brain stimulation device.
8.
Has a history of epilepsy, seizures, or convulsions.
9.
Has a family history of epilepsy, seizures, or convulsions.
10. Has abnormal sleeping patterns (eg, working night shifts).
11. Has a resting motor threshold (rMT) of more than 75% of the maximum stimulator output, measured using 
TMS-electromyogram (EMG) during screening.
Main Criteria for Evaluation and Analyses:
The primary endpoints of the study are:

The change of peak-to-peak amplitude of the MEP obtained with single-pulse TMS (stimulation intensity: 120% 
of baseline rMT) at 2½ hours after administration of TAK-653 from pre-dosing baseline, compared to placebo.

The change of rMT obtained with single-pulse TMS at 2½ hours after administration of TAK-653 from 
pre-dosing baseline, compared to placebo.
The secondary endpoints are the change from baseline at 2½ hours for the following: 

Magnitude of long intracortical inhibition (LICI) obtained with paired-pulse TMS (stimulation intensity 
conditioning pulse and test pulse: 120% of baseline rMT).

Magnitude of short intracortical inhibition (SICI) obtained with paired-pulse TMS (stimulation intensity: 
conditioning pulse 80% of baseline rMT; test pulse: 120% of baseline rMT).

The rMT obtained with single-pulse TMS assessing ketamine effects, as well as at 24 hours.

The peak-to-peak amplitude of the MEP obtained with single-pulse TMS (stimulation intensity: 120% of baseline 
rMT) assessing ketamine effects, as well as at 24 hours.
The safety endpoints include:

Number/percentage of subjects with at least 1 AE.

Number/percentage of subjects with at least 1 serious adverse event (SAE).

Number/percentage of subjects with at least 1 clinically-defined abnormal laboratory value.

Number/percentage of subjects with at least 1 clinically-defined abnormal vital sign value.
Statistical Considerations:
PK Analysis
Plasma concentrations of TAK-653 at each time point will be summarized from each treatment using descriptive 
statistics.
Individual plasma concentration data versus time will be presented in a data listing.
PD Analysis
Primary Endpoint Analysis
The primary endpoints are changes in rMT and changes in peak-to-peak amplitude of the MEP obtained with 
single-pulse TMS at 2 1/2 hours after administration of TAK-653 from their corresponding pre-dosing baseline levels
compared to placebo. They will be analyzed using linear mixed effect models. 
The primary endpoints will be analyzed using a linear mixed effects model appropriate for a three-period crossover 
design. Hochberg's step-up procedure will be used to adjust for multiple endpoints. One-sided t-tests comparing each 
of the primary endpoints for placebo versus treatment at each dose level will be conducted as secondary analyses, 
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adjusted for multiple testing to ensure type 1 error control at the 10% level. 
Secondary Endpoint Analysis
The magnitude of LICI and SICI obtained with paired-pulse TMS will be analyzed using linear mixed effects models 
analogous to the model used to analyze the primary endpoint. One-sided t-tests (alpha = 0.05) will be used for the 
comparison of placebo versus one of the TAK-653 treatment groups.
The change of rMT at 24 hours post ketamine dosing and peak-to-peak amplitude of the MEP obtained with 
single-pulse TMS will be analyzed using linear mixed effect models appropriate for the design.
Safety Analysis
The safety of TAK-653 will be assessed through adverse events, clinical laboratory results, physical examinations, 
ECG findings, vital signs, suicidal assessments, and close monitoring of potential tremors, convulsions and seizures.
Sample Size Justification:
The assumptions used in the sample size determination were based on consideration of a published study on Ketamine 
by di Lazzaro et al. (2003) and the preliminary results of TMS data in a CHDR study of healthy volunteers. 
Specifically, we assumed an intra-subject correlation of 0.9, a common standard deviation of 9% for rMT and 947 µV 
for the MEP peak-to-peak amplitude, a correlation coefficient of at least 0.5 between pre- and post-dosing outcome, 
and a familywise type I error rate of 10%. A sample size of 22 subjects, approximately 4 subjects for each of the 6
sequences of the first 3 treatment periods, will provide at least 80% power in detecting a reduction of 5.3 percentage 
point in rMT and/or an increase of 560 µV in the MEP peak-to-peak amplitude at the most effective dose level of 
TAK-653 versus placebo. Subjects who complete at least the first 3 treatment periods of the study are considered 
completers. Drop-out rate is expected to be low. Twenty-four subjects will be recruited (4 per sequence) to ensure at 
least 22 completers. If more than 2 subjects drop out before completing the first 3 treatment periods, up to 2 additional 
subjects may be enrolled.
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2.0
STUDY SCHEMATIC
IV: intravenous; PK: pharmacokinetics; PO: orally; TMS: transcranial magnetic stimulation.
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CONFIDENTIAL
3.0
SCHEDULE OF STUDY PROCEDURES 
Screening 
Day -28 to 
-1
Treatment Period 
TAK-653 or Placebo Single Dose
Ketamine
Period
1
2
3
4
Visit
1
2
Wash-out
10-15 Days
3
Wash-out 
10-15 
Days
4
Wash-out 
10-15 
Days
5
ET
Follow-up Phone Call
(14 ± 2 Days After
Last Dose)
Day 1
Day 2
Administrative Procedures
Informed consent
X
Inclusion/exclusion criteria
X
X
X
X
X
Medical history/ demographics
X
Prior and concomitant medication review
X
X
X
X
X
X
X
X
Clinical Procedures/ Assessments
Full physical examination
X
X
X
X
X
X
X
Neurological and psychiatric evaluation
X
C-SSRS a
X
X
X
X
X
X
X
Targeted neurological and mental state examination b
X
X
X
X
X
Height and weight / BMI
X
Semi-recumbent vital signs (HR, SBP, DBP) c
X
X
X
X
X
X
X
Other vital signs (RR, tympanic temperature)
X
X
X
X
X
X
X
Standard 12-lead ECG e
X d
X
X
X
X
X e
X
Randomization
X
AE monitoring
X
X
X
X
X
X
X
X
Seizure precautions f
X
X
X
X
X
Study drug (TAK-653/placebo) administration
X
X
X
Ketamine administration
X
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CONFIDENTIAL
Screening 
Day -28 to 
-1
Treatment Period 
TAK-653 or Placebo Single Dose
Ketamine
Period
1
2
3
4
Visit
1
2
Wash-out
10-15 Days
3
Wash-out 
10-15 
Days
4
Wash-out 
10-15 
Days
5
ET
Follow-up Phone Call
(14 ± 2 Days After
Last Dose)
Day 1
Day 2
Laboratory Procedures/ Assessments
Hematology
X
X
X
X
X
X
Chemistry
X
X
X
X
X
X
Urinalysis
X
X
X
X
X
X
Urine pregnancy test
X
Serum FSH (if applicable)
X
Hepatitis/ HIV screen 
X
Alcohol screen
X
X
X
X
X
Urine drug screen
X
X
X
X
X
PK Evaluations g
Plasma sample for TAK-653 PK
X
X
X
X
Plasma sample for ketamine
X
X
PD / Biomarker Evaluations
TMS and MEP/EEG data collection h
X j
X
X
X
X
X
Overnight stay
X
AE: adverse event; BMI: body mass index; C-SSRS: Columbia–Suicide Severity Rating Scale; CHDR: Centre for Human Drug Research; DBP: diastolic blood pressure; ECG: 
electrocardiogram; EEG: electroencephalogram; ET: early termination; FSH: follicle-stimulating hormone; HR: heart rate; MEP: motor evoked potential; PD: 
pharmacodynamic(s); PK: pharmacokinetic(s); RR: respiratory rate; SBP: systolic blood pressure; TMS: transcranial magnetic stimulation.
a C-SSRS will be administered at screening and at treatment visits.
b Targeted neurological and mental state examinations (Section 9.2.1) will be performed approximately 2 hours after TMS procedures and prior to discharging subjects from the clinic 
on treatment days.
c Vital signs and ECG measurements will be performed approximately 3 hours prior to dosing.
d The Screening (baseline) ECG will be repeated 3 times with at least a 1-minute interval between ECG measurements.
CCI
Property of Takeda: For non
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e A post-treatment ECG will be performed after TMS testing in all treatment periods before discharge.
fSee Section 9.2.8 for seizure precautions as part of AE monitoring.
gSee PK sampling times and windows in the tables below for Period 1 to 3 for TAK-653 and Period 4 for ketamine
h TMS procedures will include calculating threshold for MEP at baseline, and repeated testing of MEP amplitude at 120% of threshold at baseline and after dosing. The threshold after 
dosing will also be calculated to determine whether study drugs increased excitability. Paired pulse protocols (short intracortical inhibition, long intracortical inhibition) will be also 
tested at baseline and following dosing. In addition to the MEP assessments, TMS-evoked potentials will be collected with EEG every time TMS is assessed.
i 
 
For training purposes only.
k The treatment period time for all drug days is detailed in the tables for Treatment Periods 1 to 3 and Period 4 below.
CCI
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CONFIDENTIAL
TAK-653 Detailed Schedule of Assessments
Treatment Period 1 to 3
Time Point   
Assessment
Predose
-40 min
0 min
30 min
70 min
150 min
185 min
240 min
300 min
360 min
Admission a
X
Inclusion/exclusion criteria
X
Concomitant medication review
Continuous
C-SSRS
X
Physical examination including 
neurological and mental state 
examination b
X
X
Vital signs c
X
X
X
X
Standard 12-lead ECG d
X
X
AE monitoring
Continuous
Study drug (TAK-653/placebo) 
administration
X
Laboratory assessments e
X
X
X
Urinalysis
X
Urine drug screen
X
TMS and MEP/EEG data 
collection f, g
X
X
X
PK sample TAK-653 i
X
X
X
Discharge
X
AE: adverse event: C-SSRS: Columbia–Suicide Severity Rating Scale; CHDR: Centre for Human Drug Research; DBP: diastolic blood pressure; ECG: electrocardiogram; EEG: 
electroencephalogram; HR: heart rate; MEP: motor-evoked potential; PK: pharmacokinetic(s); RR: respiratory rate; SBP: systolic blood pressure; TMS: transcranial magnetic 
stimulation.
a Subjects should be in a fasted state from 5 hours before arrival; standardized meals will be provided after the first postdose TMS measurement has been performed.
b Targeted physical, neurological, and mental state examinations will be performed before dosing and before discharge.
c Vital signs will include HR, SBP, DBP, and RR. Temperature will be measured during the first predose vital signs measurement and during the last post dose measurement, but not 
CCI
Property of Takeda: For no
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CONFIDENTIAL
during all vital signs measurements. Vital signs and ECG measurements will be obtained about 3 hours prior to dosing after the subject has been in the supine semi-recumbent position 
for at least 5 minutes.
d ECGs will be made at least at 1 minute intervals. ECGs will be conducted after the subject has been in a semi-recumbent position for at least 5 minutes.
e Laboratory assessments consist of: hematology, chemistry. (Results do not have to be known before dosing). 
f TMS procedures will include calculating threshold for MEP at baseline, and repeated testing of MEP amplitude at 120% of threshold at baseline and after dosing. The threshold after 
dosing will also be calculated to determine whether study drugs increased excitability. Paired pulse protocols (short-interval intracortical inhibition, long-interval cortical inhibition) 
will be also tested at baseline and following dosing. In addition to the MEP assessments, TMS-evoked potentials will be collected with EEG every time TMS is assessed.
g A time window of ±1 hour is allowed for the TMS and MEP/EEG data collection and for the 
.
h.
 
A PK blood draw sampling time window of ±5 minutes is allowed. 
CCI
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CONFIDENTIAL
Treatment Period 4
Time Point
Assessment
Predose
-40 min
0 min
to 40 
min
20 min
50 min
75 min
90 min
150 min
240 min
330 min
24 hours (Day 
2)
26 hours
Admission a
X
Inclusion/exclusion criteria
X
Concomitant medication review
Continuous
C-SSRS
X
X
Physical examination including 
neurological and mental state 
examination b
X
X
Vital signs c
X
X
X
X
X
Standard 12-lead ECG d
X
X
X
AE monitoring
Continuous
Laboratory assessments e
X
Urinalysis
X
Urine drug screen
X
Ketamine administration
X
TMS and MEP/EEG data 
collection f, g
X
X
X l
PK sample ketamine i
X
X
X
X
X
X
Discharge
X
AE: adverse event; C-SSRS: Columbia–Suicide Severity Rating Scale; CHDR: Centre for Human Drug Research; DBP: diastolic blood pressure; ECG: electrocardiogram; EEG: 
electroencephalogram; ET, early termination; HR: heart rate; MEP, motor-evoked potential; PK, pharmacokinetic(s); RR: respiratory rate; SBP: systolic blood pressure; TMS, 
transcranial magnetic stimulation.
a Subjects should be in a fasted state from 5 hours before arrival, standardized meals will be provided after the first postdose PD measurement has been performed. 
b Targeted physical, neurological, and mental state examinations will be performed before dosing and before discharge.
c Vital signs will include HR, SBP, DBP, and RR., Temperature will be measured during the first predose vital signs measurement and last post dose vital sign measurement, but not 
during all vital sign measurements. Vital signs and ECG measurements will be obtained about 3 hours prior to dosing, after the subject has been in a supine semi-recumbent position 
for at least 5 minutes.
d Triplicate ECGs will be made with at least a 1 minute interval. ECGs will be made after the subject has been in a supine semi-recumbent position for at least 5 minutes.
CCI
Property of Takeda: For non-co
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CONFIDENTIAL
e Laboratory assessments consist of: hematology, chemistry. (Results do not have to be known before dosing). 
f TMS procedures will include calculating threshold for MEP at baseline, and repeated testing of MEP amplitude at 120% of threshold at baseline and after dosing. The threshold after 
dosing will also be calculated to determine whether study drugs increased excitability. Paired pulse protocols (short-interval intracortical inhibition, long-interval cortical inhibition) 
will be also tested at baseline and following dosing. In addition to the MEP assessments, TMS-evoked potentials will be collected with EEG every time TMS is assessed. 
g A time window of ±1 hour is allowed for the TMS and MEP/EEG data collection and for the 
.
h
 
PK blood draw sampling time window of ±5 minutes is allowed.
CCI
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Property of Takeda: For non-commercial use only and subject to the applicable Terms of Use
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the a

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4.0
INTRODUCTION
4.1
Background
TAK-653 is an alpha-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA) type 
glutamate receptor positive allosteric modulator in clinical development as a potential therapeutic 
for patients with treatment-resistant depression (TRD). The TRD field has recently been 
rejuvenated by the finding that ketamine, an N-methyl-d-aspartate (NMDA) glutamate receptor 
open channel blocker, has rapid-onset antidepressant properties in the TRD population and in 
rodent models of depression (eg, reduction of submissive behavior model). The rationale for an 
AMPA receptor potentiator to treat TRD follows from the observation that the antidepressant 
actions of ketamine in rodents are blocked with the co-administration of the AMPA receptor 
blocker NBQX. In addition, ketamine administration causes an increase in extracellular cortical 
glutamate, which can act on downstream AMPA receptors [1]. A current hypothesis on the 
mechanisms of the rapid-acting antidepressant effect of ketamine posits that increased AMPA 
receptor function is a key element in this mechanism. Taken together, these data suggest that by 
directly potentiating AMPA receptors, TAK-653 may act as a rapid onset antidepressant without 
the psychotomimetic side effects associated with ketamine administration.
To date, TAK-653 has shown no evidence of pharmacodynamic (PD) effects in humans, including 
no dose-related adverse events (AEs) suggestive of central nervous system (CNS) activity, such as 
dizziness or tremors. In a phase 1 single rising dose (SRD) and multiple rising dose (MRD) study, 
TAK-653 exhibited favorable safety/tolerability and pharmacokinetic (PK) profiles. In nonclinical 
studies, TAK-653 was not genotoxic but did show convulsions in rats and monkeys and 
neuropathology in rats at high doses. Accordingly, human exposures are limited by the maximum 
observed plasma concentration (Cmax) no-observed-adverse-effect-level (NOAEL) for convulsions 
in monkeys (350 ng/mL) and the area under the plasma concentration-time curve (AUC) NOAEL 
for neuropathology in rats (17,400 h*ng/mL). Detecting CNS PD activity at sufficiently low doses
is therefore critical for progression of TAK-653 into a clinical proof-of-concept (POC) study.
Nonclinical studies revealed effects of TAK-653 in rodent cognitive tasks and in a task relevant to 
depression (reversal of submissive behavior model in rat) at low doses; however, it’s not clear if 
these paradigms are translatable to human depression studies. More recently, a transcranial 
magnetic stimulation (TMS) study in rats demonstrated that the same low doses of TAK-653 that 
elicited behavioral effects in nonclinical models can also modulate brain circuitry activity in a 
manner that can also be tested in humans. Therefore, to establish a therapeutic window and provide 
a firm basis for selecting a dose for a clinical dose-ranging trial in TRD, the present study is 
focused on determining if TAK-653 has measurable PD activity in healthy subjects at exposures 
being targeted for testing in the POC TRD study. 
TMS is a noninvasive neurostimulation method involving the application of brief magnetic pulses 
to the skull that, based on the principles of electromagnetic induction, create an orthogonal electric 
current that can be sufficient to depolarize neurons and activate neuronal circuits. TMS has been 
used for many years to map epileptic foci and surrounding “eloquent” regions of cortex that must 
be avoided during neurosurgery. This diagnostic purpose uses single pulse TMS, in which TMS is 
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applied 1 stimulus at a time; other paradigms include paired-pulse TMS, in which pairs of stimuli 
are separated by a variable interval, and repetitive TMS (rTMS), in which TMS pulses are 
delivered in trains of various durations. rTMS use is rapidly expanding for a wide variety of 
therapeutic purposes, including psychiatric disorders (depression, acute mania, bipolar disorders, 
panic, hallucinations, obsessions/compulsions, schizophrenia, catatonia, posttraumatic stress 
disorder, and drug craving); neurologic diseases (Parkinson disease, dystonia, tics, stuttering, 
tinnitus, spasticity, epilepsy, and post-stroke rehabilitation); and pain syndromes, (neuropathic 
pain, visceral pain, and migraine). 
Noninvasive brain stimulation techniques like TMS offer an opportunity to study mechanisms of 
cortical physiology at the systems level of the human brain [2]. The combination of brain 
stimulation with CNS-active drugs might help assessing the effects of these drugs on brain 
physiology. Combined with electroencephalography (EEG) and/or electromyography (EMG), 
both cortical excitability and the modulatory effects of CNS-penetrant drugs can be quantified. 
Although excitability of the cortex has been particularly relevant to the field of epilepsy and 
different anticonvulsants are known to affect different TMS measures of motor cortical 
excitability, it also holds potential for pathophysiological research in mood disorders and 
quantifying the effects novel glutamatergic drugs for the treatment of depression. However, 
although benzodiazepines have been shown to affect TMS-EEG and TMS-EMG in a few studies 
[3], the effects of excitatory glutamatergic compounds remain to be established.
The most extensively studied response using TMS is the motor-evoked potential (MEP) produced 
in the index finger after TMS stimulation of the motor cortex, Figure 4.a. Pharmacological 
modulation of MEP threshold and amplitude can be used to assess PD effects [4], and this endpoint 
is proposed to depend heavily on AMPA receptor function [4], and modulated by ketamine [5].
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Figure 4.a
Schematic Representation of the Different Parameters Measured Using TMS
<
Source: Badawy et al, 2012 [6].
EEG: electroencephalogram; EPI: echo planar image; fMRI: functional magnetic resonance imaging; ISI: 
interstimulus interval; M1: motor area; SMA: supplementary motor area; SPM: statistical parametric mapping; TMS: 
transcranial magnetic stimulation.
a) Motor cortical excitability showing (I) motor evoked potential recorded with a single pulse. Latency is measured 
from stimulus artefact to initial deflection in baseline; amplitude is measured peak to peak. Examples of (II) 
short-interval intracortical inhibition at the 2 ms ISI, (III) intracortical facilitation at the 10 ms ISI, and (IV) 
long-interval intracortical inhibition at the 250 ms ISI.
b) Averaged EEG responses evoked by TMS. The signals are arranged according to the layout of the electrodes. The 
amplitudes of the responses are highest in the vicinity of the stimulated site (highlighted) and attenuate with increasing 
distance from stimulation.
c) Sample of a connectivity map obtained after repetitive TMS of the right motor area on fMRI. SPMs are 
threshholded for corrected clusters (p<0.05 corrected for multiple comparisons) and are superimposed on the main 
EPI image. 
4.2
Rationale for the Proposed Study
Given the absence of evidence for human target engagement or PD activity of TAK-653, the goal 
of this study is to leverage a translatable preclinical finding to assess PD activity in healthy 
subjects. Of specific interest is to determine whether low doses of TAK-653 modulate CNS 
activity. Based on these data, the study described herein will determine if doses and exposures of 
TAK-653 correlate with PD effects in TMS-evoked muscle evoked potentials and EEG signals. 
4.3
Benefit-Risk Profile
This phase 1 trial has been designed to mitigate the known risks associated with AMPA receptor 
potentiators as a class and the potential risks based on the nonclinical toxicity data and preliminary 
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clinical data for TAK-653. In addition, this trial has been designed to mitigate the known clinical 
risks of ketamine. As this trial will be conducted in healthy subjects, there is no expected clinical 
benefit to trial participants.
The principal mitigations for these potential risks include the maintenance of an appropriate safety 
margin based on nonclinical study use of low doses that yield low drug exposure, appropriate 
selection of the trial population, the prespecified safety monitoring procedures, and the selection of 
the trial facility, where close monitoring can be performed and rapid institution of appropriate care 
can be given. The potential risks associated with AMPA receptor potentiators as a class, the 
potential risk based on nonclinical toxicity data, and the known clinical risks of ketamine can be 
monitored clinically and/or with laboratory tests and have been considered when determining the 
stopping rules for this clinical trial.
In addition to the potential risks associated with study drug administration, there is minimal risk 
associated with trial procedures including scheduled, periodic phlebotomy (limited to <500 mL) 
and noninvasive procedures including vital sign assessments, electrocardiograms (ECGs), and 
TMS assessment. Overall, the benefit-risk profile is considered appropriate for this trial.
4.4
TAK-653
TAK-653, like other AMPA receptor potentiators, may induce convulsions through the 
overactivation of AMPA receptors. Other potential risks of AMPA receptor potentiators include 
tremors. Based on nonclinical findings with TAK-653, the potential risks associated with the drug 
are seizures, convulsions and vomiting.
In the 2-part, first-in-human (FIH) trial (TAK-653-1001), 88 healthy subjects were enrolled and 
administered study drug (66 TAK-653 vs 22 placebo) in 6 SRD cohorts (0.3, 1, 3, 5, 9, and 18 mg) 
in Part 1 and 5 SRD/MRD cohorts (0.3, 1, 3, 6 and 9 mg once daily [QD] for 13 days) in Part 2. 
TAK-653 was generally well tolerated at single doses up to 18 mg and multiple doses up to 9 mg 
QD. No serious treatment-emergent adverse events (TEAEs), including serious CNS TEAEs or 
adverse events of special interest (AESIs) (seizures, convulsions), were reported. There were no 
concerning trends in clinical laboratory, vital sign, telemetry, ECG, or EEG data, and all AE were 
reported as mild in intensity and not related to the study drug.
PK data from Part 1 indicated that the mean Cmax values increased slightly less than dose 
proportionally, ranging from 3.63 to 126 ng/mL, whereas the mean area under the plasma 
concentration-time curve from time 0 to infinity (AUC∞) values increased dose proportionally, 
ranging from 148 to 8882 h*ng/mL, across the single-dose range (from 0.3 mg to 18 mg).
Mean exposures to TAK-653 in the 13-week toxicity studies and margins relative to exposures in 
human subjects administered a single oral dose of TAK-653 (6 and 18 mg) and an oral dose of 
TAK-653 (6 mg QD for 13 days) are presented in Table 4.a.
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Table 4.a
Mean Exposures to TAK-653 at the NOAELs in the 13-Week Repeat-Dose
Toxicity and Neurotoxicity Studies and Clinical Margins
Cmax
(ng/mL)
Cmax
Margin a
AUC24
(h*ng/mL)
AUC
Margin a
Rat (B151026-Report) (13-week study)
Male
1130 b
26.9/9.0/7.6
10,800 c
4.6/1.2/3.7
Female
2320 
NA
28,900 c
12.4/3.3/9.9
Rat (B170759-Report) (Day 14)
Male
1290
30.7/10.2/8.7
17,000
7.3/1.9/5.8
Female
1670
39.8/13.3/11.3
17,800
7.6/2.0/6.1
Monkey (1015-1193, 1015-1193 Amendment 1, 1015-1193 Amendment 2) 
(13-week study)
Male
350 d
8.3/2.8/2.4
18,400 e
7.9/2.1/6.3
Female
362 d
8.6/2.9/2.4
18,900 e
8.1/2.1/6.4
Human (Study TAK-653-1001)
6 mg single dose
42.0
2328 f
18 mg single dose
126
8882 f
6 mg multiple dose (QD for 13 days)
148
2933 g
AUC: area under the plasma concentration-time curve; AUC24: area under the plasma concentration-time curve from 
time 0 to 24 hours; Cmax: maximum observed plasma concentration; NA: not applicable; NOAEL: 
no-observed-adverse-effect level; QD: once daily.
a 6 mg single dose/18 mg single dose/6 mg multiple dose (QD for 13 days). 
b Day 1 at 50 mg/kg/day (males).
c Day 91 at 50 (males) and 100 (females) mg/kg/day.
d Day 2 at 10 (males) and 3 (females) mg/kg/day.
e Day 91 at 10 (males) and 6 (females) mg/kg/day.
f Area under the plasma concentration-time curve from time 0 to infinity.
g Area under the curve from 0 to time t.
Although data from the FIH trial suggest that the single doses (0.5 and 6 mg) proposed for the 
current trial were safe and well tolerated in healthy subjects, the potential risks described above, 
based on the mode of action of TAK-653, nonclinical findings, and human experience with other 
AMPA receptor potentiators, must still be considered. 
As this protocol entails brain stimulation procedures using TMS, there is a risk for increasing the 
likelihood of convulsions and seizures. The TMS protocols used in this study have rarely resulted 
in seizures, but the risk should be considered especially in combination with TAK-653.
Given the above-mentioned potential risks, the following risk mitigation measures will be applied 
during the conduct of the current trial:
1. Subjects at risk of seizures will be excluded (see Section 10.1).
2. Convulsions and seizures will be monitored and reported as AESIs (see Section 10.1.2).
3. Subjects will be provided with emergency contact information to be carried on their person at 
all times.
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4. The site will provide study physicians trained in basic life support and management of 
convulsions and seizures.
4.4.1
Ketamine
The administration of multiple subanesthetic doses of ketamine was generally well tolerated in 
previous studies performed at the Centre for Human Drug Research (CHDR) and in literature 
[7-11]. However, subjects who have no/limited experiences with the effects of recreational 
psychoactive substances such as alcohol may have a higher risk of intolerability to ketamine 
effects. Psychotomimetic reactions include anxiety, chest pain, palpitations, agitation, flashbacks, 
delirium, dystonia, psychosis and schizophrenia-like symptoms. The psychotomimetic reactions 
seem related to the infusion of ketamine and disappear soon after the discontinuation of the 
infusion [12]. Potential adverse effects of ketamine administration include hypersalivation, 
hyperreflexia, muscle hypertonicity, transient clonus, increased intraocular pressure, emesis, 
transient rash, agitation dizziness and seizures. Hypertension, tachycardia, increase pulmonary 
pressures, increased intraocular pressure and pulmonary edema can also be seen as an effect of 
sympathomimetic stimulation by ketamine. Laryngospasm (during infusion) is frequently cited as 
an adverse effect of ketamine, but it is rarely observed.
Ketamine undergoes extensive metabolism by hepatic cytochrome P450 (CYP). In 
humans, N-demethylation to norketamine is the major route of metabolism, which can undergo 
further metabolism into 2 diasteromeric HK (hydroxyketamine) and 6 diastereomeric HNK 
(hydroxynorketamine) metabolites and DHNK (dehydronorketamine) [13-15]. The major human 
hepatic CYPs that catalyze ketamine N-demethylation in vitro are CYP2B6 and CYP3A4, 
although there is ambiguity as to their comparative contributions to clinical ketamine metabolism 
[13,16,17]. The CYP enzymes responsible for the formation of norketamine metabolites include 
CYP2A6 and CYP2B6 [13]. Quantifiable concentrations of ketamine metabolites were found to be 
present up to 3 days after ketamine infusion [18]. Of the different active ketamine metabolites 
(2R,6R)-HNK induces an acute increase in glutamatergic signaling, followed by a long-term 
adaptation involving the upregulation of synaptic AMPA receptors, as evidenced by an increase in 
GluA1 and GluA2 in hippocampal synapses [19].
Ketamine has a wide therapeutic range and exhibits multiexponential compartmental PK after 
intravenous (IV) administration. The mean systemic clearance, steady-state distribution volume, 
and terminal disposition half-life (t1/2z) values were 14.8 mL/min/kg, 2.2 L/kg, and 196 minutes 
respectively, following IV administration of ketamine to 10 healthy subjects [20]. The mean 
concentration was 187 ng/mL at 40-minutes post dose in 21 patients with depression who received 
0.5 mg/kg of ketamine as a 40-minute infusion [21]. Ketamine will be administered once in the 
present study; IV at a dose level of 0.5 mg/kg over 40 minutes.
The use of ketamine in doses of 1 to 3 mg/kg has been associated with emergence reactions (~12% 
of subjects), which are unpleasant dreams or hallucinations when emerging from the dissociative 
state that ketamine induces. The psychological manifestations vary in severity between pleasant 
dream-like states, vivid imagery, hallucinations, and emergence delirium. In some cases, these 
states have been accompanied by confusion, excitement, and irrational behavior, which a few 
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patients recall as an unpleasant experience. The duration of these reactions ordinarily is no more 
than a few hours. In a few cases, however, recurrences have taken place up to 24 hours after 
ketamine administration.
Emergence phenomena are less frequent and less severe with the use of lower subanesthetic doses 
of ketamine (<1 mg/kg), as in the current trial. Emergence reactions may be reduced if verbal, 
tactile, and visual stimulation of the patient is minimized during the recovery period. If the subject 
experiences severe dissociative or hallucinatory experiences during the administration of 
ketamine, the infusion of ketamine should be immediately stopped. Supportive or other measures 
(ie, rescue medications) will be administered, if necessary.
Ketamine increases blood pressure and heart rate, and both parameters will be closely monitored 
during ketamine infusions. If the subject experiences an increase in systolic blood pressure to >180 
mm Hg or an increase in diastolic blood pressure to >110 mm Hg during the ketamine infusion, the 
infusion rate will be reduced by half and blood pressure will continue to be carefully monitored. 
Supportive or other measures (ie, rescue medications) will be administered, if necessary.
During the ketamine infusion, all appropriate and necessary monitoring or other supportive 
measures will be followed in accordance with the current package labeling and medical use of 
ketamine. A qualified physician will always be present during ketamine administration and will 
examine subjects before they are discharged. Subjects will not be discharged until recovery from 
the effects of ketamine and/or other agents is complete. Recovery from the psychological 
manifestations of ketamine infusion will be confirmed with a mental state examination. Subjects 
will remain in the clinic overnight following the ketamine infusion.
Please refer to the current package labeling for ketamine for detailed information regarding the 
safety risks and risk mitigation measures for ketamine.
4.4.2
TMS
There are several side effects of TMS that have been reported, including scalp burns from 
electrodes as well as transient headache, local pain, neck pain, toothache, paresthesia, hearing 
changes, cognitive/neuropsychological changes, and EEG after effects. The most serious side 
effect reports have been neurocardiogenic syncope and epileptic seizures, which are sometimes 
clinically difficult to distinguish. The overwhelming majority of these events have occurred in the 
setting of rTMS, and the few that have been reported in single pulse TMS paradigms have 
occurred in patients with either epileptic risk factors (eg brain lesions in a patient with multiple 
sclerosis) or on seizure threshold-lowering medications such as many common anti-depressants 
[22].
Seizure risk is considered extremely low in the present study, as the TMS paradigms are limited to 
single and paired pulse protocols (vs. rTMS). Seizure risk will be mitigated by excluding subjects 
with a personal or family history of seizures; excluding subjects with histories of head trauma, 
psychiatric disorders, drug abuse, or abnormal sleep patterns; excluding use of all concomitant 
medications; and allowing only moderate alcohol consumption consistent with baseline use (ie 
instructing subjects not to change their normal drinking habits).
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5.0
TRIAL OBJECTIVES AND ENDPOINTS
5.1
Trial Objectives
5.1.1
Trial Primary Objective
The primary objective of the study is to determine whether TAK-653, in comparison to placebo, 
increases CNS excitability, assessed with TMS-evoked MEP in healthy subjects. 
5.1.2
Trial Secondary Objective
The secondary objective(s) of the study are:
1. To determine whether TAK-653, in comparison to placebo, modulates responses evoked with 
paired TMS pulses that capture intracortical circuitry modulation.
2. To determine whether ketamine increases CNS excitability assessed with TMS-evoked MEP 
in healthy subjects.
3. To determine the safety and tolerability of TAK-653 when administered as single dose in 
healthy subjects assessing responses evoked by TMS. 
5.1.3
Trial Exploratory Objectives
Exploratory objectives of this study include: 
CCI
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5.2
Endpoints
5.2.1
Primary Endpoints
The primary endpoints of the study are:
!
The change of peak-to-peak amplitude of the MEP obtained with single-pulse TMS 
(stimulation intensity: 120% of baseline resting motor threshold [rMT]) at 2½ hours after 
administration of TAK-653 from pre-dosing baseline, compared to placebo.
!
The change of rMT obtained with single-pulse TMS at 2 1/2 hours after administration of 
TAK-653 from pre-dosing baseline, compared to placebo.
5.2.2
Secondary Endpoints
Secondary endpoints include the change from baseline at 2 1/2 hours for the following:
1. Magnitude of long intracortical inhibition (LICI) obtained with paired-pulse TMS (stimulation 
intensity conditioning pulse and test pulse: 120% of baseline rMT).
3. Magnitude of short intracortical inhibition (SICI) obtained with paired-pulse TMS (stimulation 
intensity: conditioning pulse 80% of baseline rMT; test pulse: 120% of baseline rMT).
4. The rMT obtained with single-pulse TMS assessing ketamine effects, as well as at 24 hours.
5. The peak-to-peak amplitude of the MEP obtained with single-pulse TMS (stimulation 
intensity: 120% of baseline rMT) assessing ketamine effects, as well as at 24 hours.
5.2.3
Safety Endpoints
Safety endpoints include:
1. Number/percentage of subjects with at least 1 AE.
2. Number/percentage of subjects with at least 1 serious adverse event (SAE).
3. Number/percentage of subjects with at least 1 clinically-defined abnormal laboratory value.
4. Number/percentage of subjects with at least 1 clinically-defined abnormal vital sign value.
5.2.4
Exploratory Endpoints
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6.0
TRIAL DESIGN AND DESCRIPTION
6.1
Trial Design 
This randomized, double blind, placebo-controlled, 3-period cross-over study followed by one 
open label comparator period is designed to evaluate the central pharmacodynamic activity of 
TAK-653 in healthy subjects using transcranial magnetic stimulation (TMS). Approximately 24 
healthy male and female subjects, aged 18 to 55 years, inclusive, will be enrolled. 
The study will include 3 treatment periods, each 1 day in duration, followed by a 2-day comparator 
period, alternating with 3 washout periods of at least 10 days (not to exceed 15 days). There will be 
5 clinic visits, including screening in which full medical, neurological, and psychiatric 
examinations will be conducted; Day 1 of each of the first 3 treatment periods, during which TMS 
testing will be conducted before and after subjects receive placebo or 1 of 2 doses of TAK-653; 
Day 1 of the fourth treatment period, during which TMS testing will be conducted before and after 
subjects receive the (NMDA) (N-methyl-D-aspartate) antagonist ketamine, which will be open 
label. 
Before the start of each treatment period, the investigator will review the safety assessments for the 
subject, including vital signs, and electrocardiogram (ECG). 
On the first day of each treatment period (Day 1), each subject will undergo a TMS session 
assessing baseline TMS-elicited motor-evoked potential (MEP) amplitude and threshold, followed 
by administration of TAK-653 or placebo (Treatment Periods 1-3), or ketamine (Treatment Period 
4). For the first 3 treatment periods, TMS and MEP/electroencephalogram assessment sets, will be 
conducted along with blood sample collection for pharmacokinetic (PK) analyses at predose and 
starting at 30 and 150 minutes (2 ½ hours) after dosing. The 2 ½ hour time point is chosen to 
capture Cmax, and the 30 minute time point to capture a lower exposure level in each subject. In 
Period 4, each subject will undergo a TMS session assessing baseline TMS-elicited MEP 
amplitude and threshold, and blood sample collection for PK analyses at predose, followed by 
administration of ketamine intravenously (0.5 mg/kg over 40 minutes). TMS assessments will be 
conducted at 150 minutes (2.5 hours) after ketamine initiation (when ketamine acute dissociative 
effects have subsided), and blood sample collection for PK analysis at selected timepoints. 
Subjects will undergo follow-up TMS session starting at 24 hours (Day 2 of Period 4) to capture 
ketamine modulation of TMS responses at a time in which antidepressant effects of ketamine are 
already present in a major depressive disorder population.
Subjects will remain in the clinic on treatment days until approximately 2 hours post-TMS 
procedures for safety observation. During the ketamine-testing period, subjects will remain 
overnight following the infusion, until the 24 hour follow-up TMS assessments have been 
completed. Before discharge, a neurological and mental state examination will be performed. 
EEG and MEP signals evoked by TMS, as PD endpoints for assessing the effects of TAK-653 
were selected on the basis of pre-clinical data showing that TAK-653 increases the amplitude of 
MEPs in rats. The goal of this study is to evaluate the PD effects of TAK-653 after single dose 
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treatment as measured by responses to TMS. Healthy adult (age 18 to 55 years) subjects are the 
intended population in this trial. 
The planned dose levels of TAK-653 to be evaluated are outlined in Table 6.a. The study drug will 
be 6 mg TAK-653 for the high dose, 0.5 mg TAK-653 for the low dose, or placebo administered 
orally on Day 1 of Treatment Periods 1 to 3 at the clinical testing site. Both doses and placebo 
treatments will be delivered with 2 tablets, as indicated in Section 8.0. On Treatment Period 4, 
ketamine 0.5 mg/kg IV will be administered for 40 minutes.
Table 6.a
Study Drug and Doses
Study Drug
Regimen
Comments
6 mg TAK-653 PO 
0.5 mg TAK-653 PO
Placebo
Single dose, PO administration on 
Day 1 of treatment periods 1-3
Double-blind, Placebo-controlled, 
Randomized, 3-period crossover 
(Treatment Periods 1-3)
Ketamine 0.5 mg/kg
Single dose, IV infusion over 40 
minutes on Day 1
Open-label, Treatment Period 4
IV: intravenous; PO: orally.
6.2
Rationale for Trial Design, Dose, and Endpoints
6.2.1
Rationale of Trial Design 
The crossover design has been selected because it is the most efficient design from the statistical 
perspective, as treatment comparisons are based on intra-subject differences which are associated 
with low variability. TAK-653 has been evaluated in a SRD and MRD study in healthy subjects at 
doses up to 18 mg in the SRD and 9 mg QD in the MRD. PK data indicate that TAK-653 has a 
mean t1/2z of approximately 40 hours, and longer in some subjects. Therefore, a >4 × t1/2z
(~10 days) washout between the dose regimens of each treatment period is sufficient to ensure that 
there is no TAK-653 carryover effect. Ketamine was chosen as an active comparator, which will 
be administered to all subjects on Treatment Period 4 as open label. TMS assessments on the 
ketamine period will be 2½ hours after the start of infusion to capture acute effects and 24 hours 
after the infusion to capture a time point in which increased AMPA function is present, providing 
the basis for the antidepressant effect of ketamine. 
6.2.2
Rationale for Dose 
The dose of TAK-653 will be 6 mg for the high dose and 0.5 mg for the low dose, compared with 
placebo administered once orally on Day 1 of each treatment period according to the sequence 
group assigned. In the phase 1 SRD/MRD study, among 66 healthy subjects who took TAK-653, 
no SAEs or clinically meaningful changes in safety laboratory results, physical examinations, vital 
signs, ECGs or EEGs were observed. Given the ~40-hour t1/2z of TAK-653, the mean Cmax
associated with single 0.5 and 6 mg doses (estimated at 4.53 ng/mL for 0.5 mg and measured as 
42.0 ng/mL for 6 mg) are similar to that with multiple daily dosing of 0.2 and 2 mg, which are the 
anticipated dose range to be used in a phase 2 study of TAK-653 for TRD to obtain maximal 
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treatment response while maintaining sufficient margins to potential class-based adverse effects 
(seizures). The lower dose of 0.5 mg will test whether plasma exposures that had activity in animal 
models have similar PD activity in healthy human subjects. Specifically, nonclinical studies 
revealed behavioral efficacy and PD effects with plasma concentrations ranging between 5 and 
45 ng/mL. As multiple doses ranging between 0.5 and 2 mg provided plasma concentrations in that 
range in our safety studies, this will be the range we will explore for efficacy in subsequent studies, 
provided this study indicates modulation of CNS circuit activity at those exposures. 
The NMDA antagonist, ketamine was chosen as an active comparator to be assessed during 
Treatment Period 4, open label. Ketamine will be delivered at subanesthetic doses, typically used 
for an antidepressant effect (0.5 mg/kg, IV, 40 minutes). Ketamine has been shown to increase 
excitability in a TMS study similar to what is proposed here [5].
6.2.3
Rationale for Endpoints
6.2.3.1
Safety Endpoints
Standard safety of TEAEs, vital signs, clinical laboratory test results, and 12-lead ECG parameters 
will be used to assess safety and tolerability of the investigational drug product. In addition, there 
are 2 compound-specific safety assessments in this study:
Seizures
Tremors, convulsions, and seizures are identified risks for TAK-653. Although TAK-653 was well 
tolerated at doses 3 times higher than the high dose in this study, adequate measures have been 
taken to minimize the occurrence of these risks in the study by limiting the top dose to below 
one-eighth the NOAEL exposure for convulsions observed in primates, and by excluding subjects 
who might be at increased risk for seizures. These events will be monitored during the study, as 
during all treatment periods subjects will don an EEG cap, and EEG signals will be recorded per 
exploratory objectives. In case of tremors, TMS procedures will be halted and the EEG signal will 
be collected to determine whether there was seizure like activity.
TMS also carries some risk for seizures, although this is extremely low and has been only seen 
with rTMS paradigms in healthy subjects; the risk is minimized in the present study by limiting 
TMS to single and paired-pulse TMS protocols, which carry a very low liability for seizures. EEGs 
will be recorded immediately if any of the events occur and steps outlined in Section 4.4 on 
whether to stop or suspend dosing in a cohort or the study will be followed. The standard query 
forms for the events in the electronic case report form (eCRF) will also be completed.
Columbia Suicide Symptoms Rating Scale 
Suicidal ideation will be assessed using the Columbia Suicide Symptoms Rating Scale C-SSRS at 
the times stipulated in the Schedule of Study Procedures (Section 3.0). Two versions of the 
C SSRS will be used in this trial: The Screening C-SSRS Lifetime (Version 14Jan2009) and the 
Since-Last-Visit C-SSRS (Version 14Jan2009).
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6.2.3.2
PK Endpoints
Blood samples (approximately 126.5 ml in total over the study) will be collected for the 
determination of the plasma concentrations of TAK-653 and ketamine. The sampling scheme is 
indicated in the Schedule of Events.
6.2.3.3
PD Endpoints
This study employs several functional tests to assess their utility as potential PD markers for the 
effects of TAK-653 and ketamine using EEG and electromyography (EMG) data driven by TMS 
in order to develop a toolbox to be used in future proof of activity studies as well as proof of 
concept studies as exploratory PD markers.
Primary PD Endpoints:
The peak-to-peak amplitude of MEP obtained with single-pulse TMS (stimulation intensity:
120% of baseline rMT), assessing change from pre-dosing baseline for each treatment period.
Enhancing MEP driven by TMS was selected as a primary PD endpoint on the basis of nonclinical 
data demonstrating that TAK-653 enhances TMS MEPs in rats.
The rMT of MEP obtained with single-pulse TMS assessing the change from pre-dosing baseline 
is the other primary endpoint.
A reduction in the threshold for TMS-evoked MEP was chosen as ketamine has been shown to 
increase TMS-driven excitability assessed with threshold to MEPs in healthy volunteers [5]. MEP 
amplitude and threshold capture modulation of excitatory synapses in motor cortex and spinal cord
[4].
Secondary PD Endpoints:
LICI and SICI are TMS stimulation paradigms that capture modulation of cortical 
excitation-inhibition balance with pairs of TMS pulses. Because this is a local cortical circuitry 
driven phenomenon, it has the potential to expand the sensitivity of TMS as a biomarker of CNS 
activation beyond single pulse TMS for certain pharmacologies, including glutamate mediated 
neurotransmission.
Exploratory PD Endpoints:
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6.2.3.4
Exploratory Biomarker Research
6.2.4
Critical Procedures Based on Trial Objectives: Timing of Procedures 
For this trial, TMS-evoked MEP is the critical procedure. 
!
TMS postdose assessments need to be performed as close to the exact nominal time 
point/scheduled time as possible.
!
All other procedures should be performed as close as possible (either before or after the 
nominal time of the critical procedure).
!
ECG and vital signs measurements should be performed before the PK blood draw, if 
scheduled together
!
The order of priority can be changed during the study with joint agreement of the investigator 
and the sponsor.
!
Any nonscheduled procedures required for urgent evaluation of safety concerns take 
precedence over all routine scheduled procedures.
6.3
Trial Design/Dosing/Procedures Modifications Permitted Within Protocol 
Parameters
This is a phase 1 assessment of TAK-653 in humans, and the PK, PD and safety profiles of the 
compound are still being elucidated. This protocol is written with some flexibility to accommodate 
the inherent dynamic nature of phase 1 clinical studies. Modifications to the dose, dosing regimen, 
and/or clinical or laboratory procedures, as outlined below, may be required to achieve the 
scientific goals of the study objectives and/or to ensure appropriate safety monitoring of the study 
subjects.
As such, the following alterations from the currently outlined dose and/or dosing regimen may be 
permitted on the basis of newly available data, but the maximum daily dose/exposure may not 
exceed that currently outlined in Section 6.1.
!
The duration of the washout period between doses may be increased.
!
The length of the washout period between doses may be decreased, if supported by safety and 
PK data.
!
A PK data review may be added.
!
The PK sampling scheme may be modified during the study. If indicated, these collected 
samples may also be assayed in an exploratory manner for metabolites.
CCI
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
Up to an additional 25 mL of blood may be drawn for PK and/or PD analyses. This blood 
volume may include repeat samples or modified PK/PD time points on the basis of emerging 
data. The total blood volume withdrawn from any single subject will not exceed the maximum 
allowable volume during his/her participation in the entire study.

The timing of planned procedures for assessment of safety procedures (eg, vital signs, ECGs, 
safety laboratory tests, etc) may be modified during the study based on newly available safety, 
tolerability, PK or PD data (eg, to obtain data closer to the [tmax] time of first occurrence of 
Cmax). These changes will not increase the number of study procedures for a given subject 
during their participation in the entire study.

Additional laboratory safety tests may be added to blood samples previously drawn to obtain 
additional safety information.
It is understood that the current study may employ some or none of the alterations described above. 
Any alteration made to this protocol to meet the study objectives must be detailed by the sponsor in 
a letter to the Trial File and forwarded to the investigator for retention. The letter may be 
forwarded to the institutional review board (IRB) /independent ethics committee (IEC) at the 
discretion of the investigator.
6.4
Trial Beginning and End/Completion
6.4.1
Definition of Beginning of the Trial
The overall study begins when the first subject signs the study informed consent form.
6.4.2
Definition of End of the Trial
The overall study ends when the last subject completes the last planned or follow-up 
visit/interaction associated with a planned visit (this can be a phone contact), discontinues from the 
study, or is lost to follow-up (ie, the investigator is unable to contact the subject).
6.4.3
Definition of Trial Discontinuation
Study discontinuation because of nonsafety reasons, such as the following:

A finding (eg, PK, PD, efficacy, biologic targets) from another nonclinical or clinical study 
using the study treatment(s) results in the study being stopped for a nonsafety-related reason.

Data from comparators, drugs of the same class, or methodologies used in this study become 
available and results in the study being stopped for a nonsafety-related reason.

The study is stopped because of nonscientific and nonsafety reasons, such as slow enrollment.
Study discontinuation because of safety reasons:

Early study termination because of unanticipated concerns of safety to the study subjects 
arising from clinical or nonclinical studies with the study treatments, comparators, drugs of the 
same class, or methodologies used in this study.
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6.4.4
Criteria for Premature Termination or Suspension of the Trial
6.4.4.1
Criteria for Premature Termination or Suspension of Trial Sites
A study site may be terminated prematurely or suspended if the site (including the investigator) is 
found in significant violation of Good Clinical Practice, protocol, or contractual agreement, or is 
unable to ensure adequate performance of the study, or as otherwise permitted by the contractual 
agreement.
6.4.4.2
Procedures for Premature Termination or Suspension of the Trial or the Participation of
Trial Sites
In the event that the sponsor, an IRB/IEC, or regulatory authority elects to terminate or suspend the 
study or the participation of an investigational site, a study-specific procedure for early 
termination or suspension will be provided by the sponsor; the procedure will be followed by 
applicable investigational sites during the course of termination or study suspension.
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7.0
SELECTION AND DISCONTINUATION/WITHDRAWAL OF SUBJECTS
7.1
Inclusion Criteria 
Subject eligibility is determined according to the following criteria before the first dose of study 
drug:
1. The subject must understand the study procedures and agree to participate by providing written 
informed consent.
2. The subject must be willing and able to comply with all study procedures and restrictions.
3. The subject must be male or female (of nonchildbearing potential) aged 18 to 55 years, 
inclusive, at the screening visit.
4. The subject must have a body mass index (BMI) ≥18.5 and ≤30.0 kg/m2 at the screening visit.
5. The subject must be judged to be in good health by the investigator, based on clinical 
evaluations including laboratory safety tests, medical history, physical examination, 
12-lead ECG, and vital sign measurements performed at the screening visit and before the first 
dose of study drug.
6. The subject must meet the following birth control requirements:

Is a male subject who is sterile or agrees to use an appropriate method of contraception, 
including a condom with or without spermicidal cream or jelly, from the first dose of study 
drug until 100 days after the last dose of study drug. No restrictions are required for a 
vasectomized male subject provided the subject is at least 1 year post-bilateral vasectomy 
procedure before the first dose of study drug. A male subject whose vasectomy procedure 
was performed less than 1 year before the first dose of study drug must follow the same 
restrictions as a non-vasectomized man. Appropriate documentation of surgical procedure 
should be provided.

Is a male subject who agrees to not donate sperm from the first dose of study drug until 100 
days after the last dose of study drug.

Is a female subject of nonchildbearing potential, defined by at least 1 of the following 
criteria:
a) Postmenopausal (defined as 12 months of spontaneous amenorrhea in women aged >45 
years or 6 months of spontaneous amenorrhea in women aged >45 years with 
serum follicle-stimulating hormone levels [FSH] >40 mIU/mL). Appropriate 
documentation of FSH levels is required.
b) Surgically sterile by hysterectomy and/or bilateral oophorectomy with appropriate 
documentation of surgical procedure.
c) Had a tubal ligation with appropriate documentation of surgical procedure.
d) Has a congenital condition resulting in no uterus.
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7.2
Exclusion Criteria
1. The subject has participated in another investigational study within 4 weeks (or based on local 
regulations) before the screening visit. The 4-week window will be derived from the date of 
the last study procedure and/or AE related to the study procedure in the previous study to the 
screening visit of the current study.
2. The subject is an employee of the sponsor or study site or immediate family member (eg, 
spouse, parent, child, sibling) of the sponsor or study site.
3. The subject has a history of cancer (malignancy).
4. The subject has a history of significant multiple and/or severe allergies (eg, food, drug, latex 
allergy) or has had an anaphylactic reaction or significant intolerance to prescription 
or nonprescription drugs or food.
5. The subject has a known hypersensitivity to any component of the formulation of TAK-653 or 
related compounds.
6. The subject has a positive alcohol or drug screen.
7. The subject has a positive pregnancy test.
8. The subject is a lactating/nursing woman.
9. The subject has a positive test result for hepatitis B surface antigen, hepatitis C virus antibody, 
or human immunodeficiency antibody/antigen, at the Screening Visit. Note: Subjects with 
positive hepatitis B virus or hepatitis C virus serology may be enrolled if 
quantitative polymerase chain reaction for hepatitis B virus or hepatitis C virus RNA is 
negative.
10. The subject had major surgery or donated or lost 1 unit of blood (approximately 500 mL) 
within 4 weeks before the screening visit.
11. The subject is unable to refrain from or anticipates using medications (see Section 7.3.1) 
beginning approximately 7 days before administration of the first dose of study drug, 
throughout the study (including washout intervals between treatment periods), until the 
follow-up phone call.
12. The subject has a history of alcohol consumption exceeding 2 standard drinks per day on 
average (1 glass is approximately equivalent to the following: beer [354 mL/12 oz], wine [118 
mL/4 oz], or distilled spirits [29.5 mL/1 oz] per day).
13. Participants who regularly smoke more than 5 cigarettes daily or equivalent and unable or 
unwilling not to smoke during the in-house period.
14. The subject consumes excessive amounts, defined as greater than 6 servings (1 serving is 
approximately equivalent to 120 mg of caffeine) of coffee, tea, cola, energy drinks, or other 
caffeinated beverages per day.
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15. The subject has a previous or current clinically significant psychiatric disorder according to 
(DSM-5) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, including 
substance use disorder.
16. The subject has a history of intracranial mass lesion, hydrocephalus and/or head injury or 
trauma. 
17. The subject has metal objects in brain or skull.
18. The subject has a cochlear implant or deep brain stimulation device.
19. The subject has a history of epilepsy, seizures, or convulsions.
20. The subject has a family history of epilepsy, seizures, or convulsions.
21. The subject has abnormal sleeping patterns (eg, working night shifts)
22. The subject has an rMT of more than 75% of the maximum stimulator output, measured using 
TMS-EMG during screening.
7.3
Excluded Medications, Supplements, Dietary Products
7.3.1
Concomitant Medications
Subjects are instructed to stop concomitant medications 7 days before administration of the first 
dose of study drug, throughout the study until the follow-up phone call. Subjects must be 
instructed not to take any medications without first consulting with the investigator. Any 
concomitant medication use must first be discussed with the sponsor, unless the investigator or 
designee considers immediate administration is necessitated. It is allowed to give medication to 
treat AEs, for example midazolam for a seizure.
The occasional use of acetaminophen (approximately <1 g/day) is allowed.
7.3.2
Fruit Juice
Subjects will refrain from consuming grapefruit juice, grapefruits, and products containing 
grapefruit beginning approximately 2 weeks before administration of the first dose of study drug, 
throughout the study (including the washout interval between treatment periods), and until the 
follow-up phone call.
Subjects also will refrain from consuming all juices 24 hours before and after administration of 
each dose of study drug. Consumption of all fruits other than grapefruit is allowed on all days of 
the study.
7.3.3
Alcohol
Subjects will refrain from consuming alcohol 7 days before the screening visit and from 7 days 
before dosing and until the last PK blood sample has been collected in each treatment period. At all 
other times, alcohol consumption is limited to no more than approximately 2 alcoholic beverages 
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or equivalent (1 alcoholic beverage is approximately equivalent to: beer [354 mL/12 oz], wine 
[118 mL/4 oz], or distilled spirits [29.5 mL/1 oz]) per day.
7.3.4
Caffeine
Subjects will refrain from consuming caffeinated beverages 24 hours before the Screening Visit 
and from 24 hours before dosing and until the last PK blood sample has been collected in each 
treatment period. At all other times, caffeinated beverages or xanthine-containing products will be 
limited to amounts of no more than 6 servings per day (1 serving=120 mg of caffeine).
7.3.5
Smoking
The use of tobacco will not be permitted from 48 hours before dosing until the end of the 
residential period and participants will be asked to limit tobacco use to a maximum of 5 cigarettes 
a day or equivalent amount of tobacco during the out-clinic period until follow-up.
7.4
Diet, Fluid, Activity 
7.4.1
Diet and Fluid
Subjects will fast from all food and drink except water for at least 8 hours before screening as well 
as before study drug dosing in all 4 treatment periods. Subjects will receive a single oral dose of 
study drug (TAK-653 or placebo tablets in Treatment Periods 1 to 3) ketamine and TMS 
procedures, and a meal will be delivered after the second TMS assessment on dosing days, along 
with approximately 240 mL of water. Water will be restricted 1 hour before and 1 hour after study 
drug administration.
A standard breakfast, lunch, dinner, and snacks will be provided to subjects present during meal 
times on scheduled study visit days listed in the schedule of study procedures. Subjects will fast 
from all food and drink except water between meals and snacks. The caloric content and 
composition of meals will be the same for all subjects in each treatment period. For Period 4, after 
the 24-hour postdose procedures have been completed, subsequent meals and snacks will be 
unrestricted in caloric content, composition, and timing.
7.4.2
Activity
Subjects will avoid unaccustomed strenuous physical activity (ie, weight lifting, running, 
bicycling, etc) from the screening visit until administration of the initial dose of study drug, 
throughout the study (including washout intervals between treatment periods), and until the 
follow-up phone call.
7.5
Criteria for Discontinuation or Withdrawal of a Subject
The primary reason for discontinuation or withdrawal of the subject from the study or study drug 
should be recorded in the eCRF using the following categories.
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1. Pretreatment event (PTE) or AE. The subject has experienced a PTE or AE that requires early 
termination because continued participation imposes an unacceptable risk to the subject’s 
health or the subject is unwilling to continue because of the PTE or AE.
2. Liver Function Test (LFT) Abnormalities
Study drug should be discontinued immediately with appropriate clinical follow-up (including 
repeat laboratory tests, until a subject’s laboratory profile has returned to normal/baseline 
status), if the following circumstances occur at any time during study drug treatment:

Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) >8 × upper limit of 
normal (ULN), or
ALT or AST >5 × and persists for more than 2 weeks, or

ALT or AST >3 × ULN in conjunction with elevated total bilirubin >2 × upper limit of 
normal or international normalized ratio >1.5, or

ALT or AST >3 × ULN with appearance of fatigue, nausea, vomiting, right upper quadrant 
pain or tenderness, fever, rash and/or eosinophilia (>5%).
3. Significant protocol deviation. The discovery postrandomization that the subject failed to meet 
protocol entry criteria or did not adhere to protocol requirements, and continued participation 
poses an unacceptable risk to the subject’s health.
4. Lost to follow-up. The subject did not return to the clinic and attempts to contact the subject 
were unsuccessful. Attempts to contact the subject must be documented in the subject’s source 
documents.
5. Voluntary withdrawal. The subject wishes to withdraw from the study. The reason for 
withdrawal, if provided, should be recorded in the eCRF.
Note: All attempts should be made to determine the underlying reason for the withdrawal and, 
where possible, the primary underlying reason should be recorded (ie, withdrawal due to 
an AE should not be recorded in the “voluntary withdrawal” category. 
6. Study termination. The sponsor, IRB, IEC, or regulatory agency terminates the study.
7. Pregnancy. The subject is found to be pregnant.
Note: If the subject is found to be pregnant, the subject must be withdrawn immediately.
7.6
Procedures for Discontinuation or Withdrawal of a Subject
The investigator may discontinue a subject’s study participation at any time during the study when 
the subject meets the study termination criteria described in Section 7.5. In addition, a subject may 
discontinue his or her participation without giving a reason at any time during the study. Should a 
subject’s participation be discontinued, the primary criterion for termination must be recorded by 
the investigator. In addition, efforts should be made to perform all procedures scheduled for the 
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early termination visit. For all endpoints except safety, only subjects that complete Treatment 
periods 1 to 3 will be included in the analyses.
7.7
Subject Replacement
If a subject discontinues from the study, a replacement subject may be enrolled, if deemed 
appropriate by the investigator and sponsor. The study site should contact the sponsor for the 
replacement of subject’s treatment assignment and allocation number.
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8.0
CLINICAL STUDY MATERIAL MANAGAEMENT
8.1
Clinical Study Drug 
Details regarding the dosage form description and strengths, or composition for the 
extemporaneous preparation, of the active drug and placebo can be found in the pharmacy manual 
or in the referenced compounding manual when applicable. Study drug will be packaged to 
support enrollment and replacement of subjects as required.
8.1.1
Clinical Study Drug Labeling
A clinical label will be affixed to study drug containers in accordance with local regulatory 
requirements.
8.1.2
Clinical Study Drug Inventory and Storage
Study drug must be stored in a secure, limited-access location under the storage conditions 
specified on the label and must remain in the original container until dispensed. The temperature 
excursion information can be found in the pharmacy manual or in the referenced compounding 
manual when applicable. Receipt and dispensing of study drug must be recorded by authorized 
personnel at the study site.
8.1.3
Clinical Study Drug Blinding
This is a double-blind study; the investigator and subjects are blinded to sequence group 
assignment. An unblinded study drug supply will be provided to an unblinded pharmacist or other 
qualified personnel at the study site who will blind the study supplies. Treatment identity (name 
and strength or potency) will be included on the study drug container label. Randomization 
code/disclosure envelopes or lists will be provided per the standard operating procedures of the 
study site.
8.1.4
Randomization Code Creation and Storage 
Randomization personnel of the sponsor or designee will generate the randomization schedule. All 
randomization information will be stored in a secured area, accessible only by authorized 
personnel.
8.1.5
Clinical Trial Blind Maintenance/Unblinding Procedure
The study drug blind will be maintained through a randomization schedule held by the unblinded 
pharmacist at the study site or by the sponsor or designee. The study drug blind shall not be broken 
by the investigator unless information concerning the study drug is necessary for the medical 
treatment of the subject. If possible, the medical monitor should be contacted before the blind is 
broken. Unblinding will be performed per the standard operating procedures of the study site.
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8.1.6
Accountability and Destruction of sponsor-Supplied Drugs
The investigator is responsible for keeping accurate records of the study drug received from the 
sponsor or designee, the amount dispensed to and returned by the subjects, and the amount 
remaining at the end of the study. For all study sites, the local country sponsor personnel or 
designee will provide appropriate documentation that must be completed for study drug 
accountability, return, and destruction.
8.2
Ancillary Supplies
All ancillary supplies will be provided by either the study site or the sponsor or designee, 
depending upon availability. The list of ancillary supplies and source information can be found in 
the pharmacy manual or in the referenced compounding manual when applicable. If provided by 
the sponsor, unused ancillary supplies will be accounted for and disposed of as directed by the 
sponsor or designee.
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9.0
STUDY PROCEDURES
The following sections describe the study procedures to be performed and data to be collected as 
indicated in the Schedule of Study Procedures (Section 3.0). For each procedure, subjects are to be 
assessed by the same investigator or site personnel whenever possible. Please note that it may 
become necessary to perform the following procedures at unscheduled time periods, per the 
discretion of the investigator.
9.1
Administrative Procedures
9.1.1
Informed Consent Procedure
Informed consent must be obtained before the subject enters into the study and before any 
protocol-directed procedures are performed. The requirements of informed consent are described 
in Appendix B.
9.1.1.1
Assignment of Screening and Randomization Numbers 
All consented subjects will be given a unique screening number that will be used to identify the 
subject for all procedures that occur before randomization or allocation. Each subject will be 
assigned only one screening number. Screening numbers must not be reused for different subjects. 
Any subject who is screened multiple times will be assigned a new screening number for each 
screening event.
All eligible subjects will be randomly allocated and will receive a randomization number. The 
randomization number identifies the subject for all procedures occurring after randomization. 
Once a randomization number is assigned to a subject, it can never be reassigned to another 
subject. A single subject cannot be assigned more than 1 randomization number.
9.1.1.2
Study Drug Assignment
On Day 1 of Treatment Period 1, subjects will be assigned a randomization number in ascending 
numerical order at the clinical site, and in Period 4 all subjects will receive ketamine. Therefore, 
the randomization number encodes the sequence in which each subject will receive the low and 
high doses of TAK-653 and placebo according to the randomization schedule generated before the 
study. Each subject will be dispensed blinded study drug, labeled with his/her unique 
randomization number, throughout the study.
9.1.2
Inclusion and Exclusion
Each subject will be assessed through randomization, according to the eligibility criteria provided 
in Section 7.0.
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9.1.3
Medical History/Demography
Qualified site personnel will collect subject significant medical history (past and concurrent 
medical conditions), per the clinical site’s standard of care and appropriate clinical judgment, and 
subject demographics.
9.1.4
Concomitant Medications
Qualified site personnel will review subject prior and concomitant medication use. Medications 
are defined as prescription and over-the-counter drugs, vaccines, supplements, nutraceuticals, and 
oral herbal preparations.
9.2
Clinical Procedures and Assessments
9.2.1
Full Physical Exam
Qualified site personnel will conduct full physical examinations. A baseline physical examination
(defined as the assessment before first dose of study drug) will consist of the following body
systems: eyes; ears, nose, throat; cardiovascular system; respiratory system; gastrointestinal 
system; dermatologic system; extremities; musculoskeletal system; nervous system; lymph nodes; 
targeted neurological and mental health; and other.
Any abnormal finding on a pretreatment physical examination assessment must be assessed as not
clinically significant (NCS) or clinically significant (CS) by the investigator and recorded in the 
source document and eCRF.
On subsequent examinations, any abnormal change from the pretreatment physical examination
assessment occurring immediately before the start of the study drug must be assessed as NCS or
CS by the investigator and recorded in the source document and eCRF. Any CS change or new
diagnosis as a result of a CS change, as determined by the investigator, will be recorded as an AE
in source documentation and eCRF.
9.2.2
Height and Weight
Body weight and height will be obtained with the subject’s shoes off, and in underwear.
9.2.3
BMI
BMI equals a subject’s weight in kilograms divided by height in meters squared (BMI=kg/m2). 
9.2.4
Vital Signs
Body temperature will be measured with either an oral (temperature taken at floor of the mouth) or 
tympanic thermometer. The same method (ie, oral or tympanic) must be used for all measurements 
for each individual subject and should be the same for all subjects.
Subjects should rest in a semirecumbent position for at least 5 minutes before vital signs are 
measured. Vital signs will include pulse rate, respiratory rate, and systolic and diastolic blood 
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pressure. The same method (eg, same size cuff, manual or automated) must be used for all 
measurements for each individual subject and should be the same for all subjects. 
Subjects should continue to rest in a semirecumbent position from the time of dosing until 4 hours 
postdose except to stand for other study-related procedure.
9.2.5
12-Lead ECG
Special care must be taken for proper lead placement by qualified personnel. Skin should be clean 
and dry before lead placement. Subjects may need to be shaved to ensure proper lead placement. 
Female subjects may need to remove their bra. 
Subjects should be resting in a semirecumbent position for at least 5 minutes before each ECG 
measurement.
QT intervals with Fridericia correction method (QTcF intervals) will be calculated in this study.
For each treatment period, a predose ECG will be obtained within approximately 3 hours before 
study drug dosing. This measurement will be used as the baseline assessment. The principal 
investigator should arrange to have a study cardiologist available as needed to review ECG 
abnormalities.
During each treatment period, if a subject demonstrates an increase in QTcF interval 
≥40 milliseconds compared with a predose baseline measurement, the ECG will be repeated 
within 5 minutes. The average value of the QTcF interval from the 2 ECGs will represent the value 
at that time point. If the average QTcF interval increase from baseline for any postdose time point 
is ≥40 milliseconds, the subject will continue to be monitored by repeat 12-lead ECGs every 
60 minutes for at least 4 hours or until the QTcF interval is within 40 milliseconds of the baseline 
value. If prolongation of the QTcF interval ≥40 milliseconds persists, a consultation with a study 
cardiologist may be appropriate and the sponsor should be notified.
If the QTcF interval is ≥500 milliseconds, the sponsor should be notified and the ECGs should be 
reviewed by a cardiologist. The subject should be monitored by telemetry (until the QTcF interval 
is <500 milliseconds) or should be considered for transfer to a location where closer monitoring is 
available.
If the subject has unstable hemodynamics, or has any clinically significant dysrhythmias, the 
subject should be immediately transferred to an acute care setting for definitive therapy.
If repeat ECGs are required, the clinical site will decide whether to leave the electrodes in place or 
mark the position of the electrodes for subsequent ECGs. To mark the position of the electrodes, 
12-lead electrode sites will be marked on the skin of each subject with an ECG skin marker pen to 
ensure reproducible electrode placement.
The following ECG parameters will be recorded: heart rate, PR interval, QRS interval, QT 
interval, QTcF interval, and the interpretation of the ECG profile by the principal investigator.
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9.2.6
Study Drug Administration
On Day 1 of Treatment Periods 1, 2, and 3, study drug (TAK-653 or placebo) will be administered 
orally at the times and days detailed in Section 3.0.
9.2.7
Ketamine Administration
On Day 1 of treatment period 4, Ketamine 0.5 mg/kg IV will be administered for 40 minutes.
9.2.8
AE Monitoring
AE monitoring begins after signing of the informed consent form. Changes in subject health status 
from the baseline assessment until study drug administration should be captured in the subject’s 
medical history. A complete description of adverse event collections and procedures is provided in 
Section 10.0.
Seizure precautions will be taken at all clinic visits, consisting of suction set up and an ambu bag 
nearby. If there is evidence of seizure activity, subjects will be administered standard of care 
anticonvulsants as needed and remain in the clinic overnight for closer observation.
9.3
Laboratory Procedures and Assessments
Laboratory samples will be collected in accordance with acceptable laboratory procedures.
Samples will be collected following a minimum 8-hour overnight fast at the time points stipulated 
in the Schedule of Study Procedures (Section 3.0).
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9.3.1
Clinical Laboratory Tests
9.3.1.1
Hematology
Hematology will consist of the following tests:
Erythrocytes (red blood cells)
Hemoglobin
Hematocrit
Platelets
Leukocytes (white blood cells) with absolute differential
9.3.1.2
Chemistry 
Chemistry evaluations will consist of the following standard chemistry panel:
Albumin
Alkaline phosphatase
ALT
AST
Bicarbonate 
Calcium
Blood urea nitrogen
Chloride
Creatinine
Glucose
-glutamyl transferase
Sodium
Potassium
Bilirubin (total), if above the ULN total bilirubin will be 
fractionated
Protein (total)
If subjects experience ALT or AST >3× ULN, follow-up laboratory tests (at a minimum, serum 
alkaline phosphatase, ALT, aspartate aminotransferase, total bilirubin, -glutamyl transferase, and 
international normalized ratio) should be performed 48 to 72 hours after the abnormality was 
noted.
If alanine aminotransferase or aspartate aminotransferase remains elevated >3× the upper limit of 
normal on these 2 consecutive occasions, the investigator must contact the medical monitor for 
consideration of additional testing, close monitoring, possible discontinuation of study drug, and 
discussion of the relevant subject details and possible alternative etiologies. The abnormality 
should be recorded as an adverse event.
Please refer to Section 7.5 for subject discontinuation criteria regarding abnormal liver test results 
and Section 10.2.8.5 for guidance on reporting abnormal liver test results.
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9.3.1.3
Urinalysis
Urinalysis will consist of the following tests:
Leucocytes
Nitrite
Protein
pH
Blood
Specific Gravity
Ketones
Bilirubin
Glucose
Urine microscopy will be performed if urinalysis is abnormal. Microscopy consists of red blood 
cells (RBC)/high-power field, white blood cells (WBC)/high-power field, and casts.
9.3.2
Diagnostic Screening
9.3.2.1
Serum
The serum diagnostic screening assessment will include the following tests:
HIV (human immunodeficiency virus)
Hepatitis screen (hepatitis B surface antigen, hepatitis C 
virus antibody)
9.3.2.2
Alcohol Screen
Subjects will undergo an alcohol breath test. A urine alcohol test may be performed at the 
discretion of the investigator.
9.3.2.3
Urine
The urine drug screening assessment will include the following tests:
Amphetamines
3,4-methylenedioxy-methamphetamine
Barbiturates
Methadone/metabolite
Benzodiazepines
Opiates
Buprenorphine/metabolite
Oxycodone/oxymorphone
Cannabinoids
Phencyclidine
Cocaine/metabolites
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9.4
PK and PD Evaluations
9.4.1
PK Samples
Samples for plasma concentration analysis will be collected at the time points stipulated in the 
schedule of procedures (Section 3.0). Please refer to the laboratory manual for information on the 
collection, processing, and shipment of samples to the central laboratory.
It is anticipated that the total blood volume drawn in this study will be approximately 126.5 mL for 
each subject.
Primary specimen collection parameters are provided in Table 9.a
Table 9.a
Primary Specimen Collections
Specimen Name
Primary 
Specimen
Primary 
Specimen 
Derivative
Description of Intended Use
Sample 
Collection
Plasma sample for PK
Plasma
Blood
Plasma sample for PK analysis
Mandatory
PK, pharmacokinetic
9.4.2
PK Measurements 
The plasma concentrations of TAK-653 and ketamine in the PK sample will be determined for all 
evaluable subjects. Actual sampling times, rather than scheduled sampling times, will be used in 
all computations involving sampling times.
Backup samples will be stored for analyses of ketamine metabolites (including but not limited to 
norketamine, and 2S, 6S; 2R, 6R hydroxynorketamine) when deemed necessary by the sponsor. 
Additional pharmacokinetic parameters of ketamine or metabolites may be calculated as deemed 
necessary.
9.4.2.1
Plasma for PK Measurements
Blood samples for plasma concentration analysis of TAK-653 will be collected into chilled blood 
collection tubes (vacutainer) containing the anticoagulant potassium ethylenediamine tetraacetic 
acid (K2EDTA) at room temperature. After the blood draw, the tube will immediately be placed in 
a bucket with ice. The collected blood samples may be archived for additional analysis of potential 
metabolites.
Blood samples for plasma concentration analysis of ketamine will be collected into a tube 
containing the anticoagulant sodium heparin at room temperature and immediately after the 
sample is drawn placed in a tube in a bucket with ice.
Please refer to Section 3.0 SCHEDULE OF STUDY PROCEDURES for PK blood sampling 
visits, draw times and sampling windows. The actual time of sample collection will be recorded on 
the source document and electronic case report form. Sampling time points may be adjusted based 
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on the preliminary emerging concentration data collected from prior subjects, but the total number 
of samples collected per subject should not exceed the planned number.
9.4.2.2
PK Sample Analysis
Plasma concentrations of TAK-653 and ketamine will be measured by a validated 
high-performance liquid chromatography (HPLC) assay with tandem mass spectrometry assay.
9.4.3
PD Measurements
The pharmacodynamic assessments described in Section 6.2.3.3 will be performed at the time 
points stipulated in the schedule of procedures (Section 3.0). Additional details regarding these 
pharmacodynamic assessments are provided in the study manual.
9.4.3.1
Threshold and Amplitude of MEP driven by single-pulse TMS
Enhancing MEP driven by TMS was selected as the primary pharmacodynamic endpoint based on 
preclinical data demonstrating that TAK-653 enhances TMS MEPs in rats. Furthermore, ketamine 
has been shown to increase TMS-driven excitability assessed with threshold to MEPs in healthy 
volunteers [5]. MEP amplitude and threshold capture modulation of excitatory synapses in motor 
cortex and spinal cord [4].
9.4.3.2
TMS stimulation paradigms
Long interval intracortical inhibition (LICI) and short interval intracortical stimulation (SICI) are 
TMS stimulation paradigms that capture modulation of cortical excitation-inhibition balance with 
pairs of TMS pulses. Because this is a local cortical circuitry driven phenomenon, it has the 
potential to expand the sensitivity of TMS as a biomarker of CNS activation beyond single pulse 
TMS for certain pharmacologies, including glutamate mediated neurotransmission.
9.4.3.3
9.4.3.4
CCI
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CCI
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9.5
Confinement
Subjects will report to the clinical site on Day 1 of all treatment periods, and will leave after 
completion of all study-related procedures on each day on Treatment Periods 1-3. At the discretion 
of the investigator, subjects may be requested to remain in the clinical site longer.
On Day 1 of Treatment Period 4, during the ketamine-testing period, subjects will remain 
overnight following the infusion, until the 24 hr follow-up TMS assessment has been completed. 
Before discharge, a Neurological and mental state examination will be performed. 
CCI
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9.6
Childbearing Status and Methods of Contraception 
9.6.1
Women of Childbearing Potential
Women of child bearing potential are excluded from this study, and methods of contraception are 
not relevant.
9.6.1.1
Definition of Women of Childbearing Potential
A woman is considered of childbearing potential (ie, fertile) following menarche and until 
becoming postmenopausal, unless permanently sterile.
9.6.2
Women of Nonchildbearing Potential
9.6.2.1
Definition of Women of Nonchildbearing Potential
A female subject of nonchildbearing potential is defined as satisfying at least 1 of the following 
criteria:
1. Postmenopausal: At least 12 months of spontaneous amenorrhea and a follicle stimulating 
hormone (FSH concentration) >40 mIU/mL.
2. Surgically sterile by hysterectomy and/or bilateral oophorectomy with appropriate 
documentation of surgical procedure.
3. Has no uterus as a result of a congenital condition.
9.6.2.2
Contraception for Women of Nonchildbearing Potential
No contraception is required for women of nonchildbearing potential.
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10.0
ADVERSE EVENTS
10.1
Definitions and Elements of AEs
A pre-treatment adverse event (PTE) is defined as any untoward medical occurrence in a clinical
investigation subject who has signed informed consent to participate in a study but before 
administration of any study drug; it does not necessarily have to have a causal relationship with 
study participation.
An AE is defined as any untoward medical occurrence in a clinical investigation subject who has 
signed informed consent to participate in a study; it does not necessarily have to have a causal 
relationship with the treatment.
Treatment-emergent adverse event (TEAE): Any AE that starts or increases in severity during or 
after the first dose of study drug.
An AE can therefore be any unfavorable and unintended sign (eg, a clinically significant abnormal 
laboratory finding), symptom, or disease temporally associated with the use of a drug, whether or 
not it is considered related to the drug.
An untoward finding generally may:

Indicate a new diagnosis or unexpected worsening of a preexisting condition. (Intermittent 
events for pre-existing conditions or underlying disease should not be considered AEs.)

Necessitate therapeutic intervention.

Require an invasive diagnostic procedure.

Require discontinuation or a change in dose of study medication or a concomitant medication.

Be considered unfavorable by the investigator for any reason.
Diagnoses versus signs and symptoms:

Each event should be recorded to represent a single diagnosis according to the Medical 
Dictionary for Regulatory Activities (MedDRA) database. Accompanying signs (including 
abnormal laboratory values or ECG findings) or symptoms should NOT be recorded as 
additional AEs. If a diagnosis is unknown, sign(s) or symptom(s) should be recorded 
appropriately as an AE(s).
Laboratory values and ECG findings:

Changes in laboratory values or ECG parameters maybe considered AEs if they are judged to 
be clinically significant (ie, if some action or intervention is required or if the investigator 
judges the change to be beyond the range of normal physiologic fluctuation). A laboratory 
re-test and/or continued monitoring of an abnormal value are not considered an intervention. In 
addition, repeated or additional noninvasive testing for verification, evaluation or monitoring 
of an abnormality is not considered an intervention.
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
If abnormal laboratory values or ECG findings are the result of pathology for which there is an 
overall diagnosis (eg, increased creatinine in renal failure), the diagnosis only should be 
reported appropriately as an AE.
Pre-existing conditions:

A pre-existing condition (present at the time of signing of informed consent) is considered a 
concurrent medical history condition and should NOT be recorded as an AE. A baseline 
evaluation (eg, laboratory test, ECG, X-ray, etc) should NOT be recorded as an AE unless 
related to a study procedure. However, if the subject experiences a worsening or complication 
of such a concurrent medical history condition, the worsening or complication should be 
recorded appropriately as an AE (worsening or complication occurs after informed consent is 
signed). Investigators should ensure that the event term recorded captures the change in the 
condition (eg, “worsening of…”).

If a subject has a pre-existing episodic condition (eg, asthma, epilepsy), any occurrence of an 
episode should only be captured as an AE if the episodes become more frequent, serious, or 
severe in nature, that is, investigators should ensure that the AE term recorded captures the 
change from Baseline in the condition (eg “worsening of…”).

If a subject has a degenerative concurrent condition (eg, cataracts, rheumatoid arthritis), 
worsening of the condition should only be captured as an AE if occurring to a greater extent to 
that which would be expected. Again, investigators should ensure that the AE term recorded 
captures the change in the condition (eg, “worsening of…”).
Worsening of AEs:

If the subject experiences a worsening or complication of an AE after the first administration of 
study medication or after any change in study medication, the worsening or complication 
should be recorded as a new AE. Investigators should ensure that the AE term recorded 
captures the change in the condition (eg, “worsening of…”).
Changes in severity of AEs:

If the subject experiences a change in the severity of an AE that is not associated with a change 
in study medication, the event should be captured once with the maximum severity recorded.
Preplanned surgeries or procedures:

Preplanned procedures (surgeries or therapies) that were scheduled before signing of informed 
consent are not considered AEs. However, if a preplanned procedure is performed early (eg, as 
an emergency) due to a worsening of the pre-existing condition, the worsening of the condition 
should be captured appropriately as an AE. Complications resulting from any planned surgery 
should be reported as AEs.
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Elective surgeries or procedures:

Elective procedures performed where there is no change in the subject’s medical condition 
should not be recorded as AEs but should be documented in the subject’s source documents. 
Complications resulting from an elective surgery should be reported as AEs.
Overdose:

An overdose is defined as a known deliberate or accidental administration of investigational 
drug, to or by a study subject, at a dose above that which is assigned to that individual subject 
according to the study protocol. It is up to the investigator or the reporting physician to decide 
whether a dose is to be considered an overdose, in consultation with the sponsor.

All cases of overdose (with or without associated AEs) will be documented on an Overdose 
page of the (e)CRF, in order to capture this important safety information consistently in the 
database. AEs associated with an overdose will be documented on AE CRF(s) according to 
Section 9.5.

Serious adverse events (SAEs) of overdose should be reported according to the procedure 
outlined in Section 10.2.8.

In the event of drug overdose, the subject should be treated symptomatically.
10.1.1
SAEs
An SAE is defined as any untoward medical occurrence that at any dose:
1. Results in DEATH.
2. Is LIFE THREATENING.

The term “life threatening” refers to an event in which the subject was at risk of death at the 
time of the event; it does not refer to an event that hypothetically might have caused death 
if it were more severe.
3. Requires inpatient HOSPITALIZATION or prolongation of existing hospitalization.
4. Results in persistent or significant DISABILITY/INCAPACITY.
5. Is a CONGENITAL ANOMALY/BIRTH DEFECT.
6. Is an IMPORTANT MEDICAL EVENT that satisfies any of the following:

May require intervention to prevent items 1 through 5 above.

May expose the subject to danger, even though the event is not immediately life 
threatening or fatal or does not result in hospitalization.

Includes any event or synonym described in the Takeda Medically Significant AE List 
(Table 10.a).
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Table 10.a
Takeda Medically Significant AE List 
Term
Acute respiratory failure/acute respiratory 
distress syndrome
Hepatic necrosis
Acute liver failure
Torsade de pointes ventricular fibrillation / 
ventricular tachycardia
Anaphylactic shock
Acute renal failure
Malignant hypertension
Pulmonary hypertension
Convulsive seizures
Pulmonary fibrosis
Agranulocytosis
Confirmed or suspected endotoxin shock
Aplastic anemia
Confirmed or suspected transmission of infectious agent by 
a medicinal product
Toxic epidermal necrolysis/
Stevens-Johnson syndrome
Neuroleptic malignant syndrome / malignant hyperthermia
Spontaneous abortion / stillbirth and fetal death
AEs that fulfill 1 or more of the serious criteria above are to be considered SAEs and should be 
reported and followed up in the same manner (see Sections 10.0 and 10.1.1).
10.1.2
Adverse Events of Special Interest (AESI)
An adverse event of special interest (AESI) (serious or non-serious) is one of scientific and 
medical concern specific to the compound or program, for which ongoing monitoring and rapid
communication by the investigator to Takeda may be appropriate. Such events may require further 
investigation in order to characterize and understand them and are described in Section 4.4 and 
instructions provided for investigators as to how and when they should be reported to Takeda.
Based on nonclinical data to date and AMPA receptor potentiator class effects, the AESIs for this 
study are:
Seizures
Convulsions
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10.2
AE Procedures
10.2.1
Assigning Severity/Intensity of AEs
The different categories of severity/intensity are:
Mild:
An adverse event that is usually transient and may require only minimal 
treatment or therapeutic intervention. The event does not generally interfere 
with usual activities of daily living.
Moderate:
An adverse event that is usually alleviated with additional specific therapeutic 
intervention. The event interferes with usual activities of daily living, causing 
discomfort but poses no significant or permanent risk of harm to the research 
participant.
Severe:
An adverse event that interrupts usual activities of daily living, or significantly 
affects clinical status, or may require intensive therapeutic intervention.
10.2.2
Assigning Causality of AEs
The relationship of each AE to study medication(s) will be assessed using the following 
categories:
Related:
An AE that follows a reasonable temporal sequence from administration of a 
drug (including the course after withdrawal of the drug), or for which a causal 
relationship is at least a reasonable possibility, ie, the relationship cannot be 
ruled out, although factors other than the drug, such as underlying diseases, 
complications, concomitant drugs and concurrent treatments, may also be 
responsible.
Not Related:
An AE that does not follow a reasonable temporal sequence from administration 
of a drug and/or that can reasonably be explained by other factors, such as 
underlying diseases, complications, concomitant medications and concurrent 
treatments.
10.2.3
Start Date 
The start date of the AE is the date that the first signs/symptoms were noted by the subject and/or 
investigator.
10.2.4
End Date 
The end date of the AE is the date at which the subject recovered, the event resolved but with 
sequelae or the subject died.
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10.2.5
Pattern of Adverse Event (Frequency) 
Episodic AEs (eg, headache) or those which occur repeatedly over a period of consecutive days are 
intermittent. All other events are continuous or once.
10.2.6
Action Taken With Study Treatment

Drug withdrawn – a study medication is stopped due to the particular AE.

Dose not changed – the particular AE did not require stopping a study medication.

Unknown – only to be used if it has not been possible to determine what action has been taken.

Not applicable – a study medication was stopped for a reason other than the particular AE 
eg, the study has been terminated, the subject died, dosing with study medication had not yet 
started or dosing with study medication was already stopped before the onset of the AE.

Dose reduced – the dose was reduced due to the particular AE.

Dose increased – the dose was increased due to the particular AE.

Drug interrupted – the dose was interrupted due to the particular AE.
10.2.7
Outcome 

Recovered/resolved – subject returned to first assessment status with respect to the AE.

Recovering/resolving – the intensity is lowered by one or more stages: the diagnosis has or 
signs/symptoms have almost disappeared; the abnormal laboratory value improved, but has 
not returned to the normal range or to the baseline value; the subject died from a cause other 
than the particular AE with the condition remaining “recovering/resolving.”

Not recovered/not resolved – there is no change in the diagnosis, signs or symptoms; the 
intensity of the diagnosis, signs/symptoms or laboratory value on the last day of the observed 
study period has become worse than when it started; is an irreversible congenital anomaly; the 
subject died from another cause with the particular AE state remaining “Not recovered/not 
resolved.”

Recovered/ Resolved with sequelae – the subject recovered from an acute AE but was left with 
permanent/significant impairment (eg, recovered from a cardiovascular accident but with 
some persisting paresis).

Fatal – an AE that is considered as the cause of death.

Unknown – the course of the AE cannot be followed up due to hospital change or residence 
change at the end of the subject’s participation in the study.
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10.2.8
Collection and Reporting of AEs, SAEs, Special Interest AEs, and Abnormal Liver 
Function Tests (LFT)s
10.2.8.1 Collection Period
Collection of AEs (ie, AEs, SAEs, Special Interest AEs, and abnormal liver function tests (LFT)s 
will commence at the time the subject signs the informed consent. Routine collection of AEs will 
continue until the follow-up phone call on Day 14 (±2 days). For subjects who discontinue before 
the administration of study medication, AEs will be followed until the subject discontinues study 
participation. 
10.2.8.2 Reporting AEs
At each study visit, the investigator will assess whether any subjective AEs have occurred. A 
neutral question, such as “How have you been feeling since your last visit?” may be asked. 
Subjects may report AEs occurring at any other time during the study. Subjects experiencing an 
SAE before the first exposure to investigational product must be monitored until the symptoms 
subside and any clinically relevant changes in laboratory values have returned to Baseline or there 
is a satisfactory explanation for the change. Nonserious AEs that begin before the first exposure to 
investigational product, related or unrelated to the study procedure, need not be followed-up for 
the purposes of the protocol.
All subjects experiencing AEs, whether considered associated with the use of the study medication 
or not, must be monitored until the symptoms subside and any clinically relevant changes in 
laboratory values have returned to Baseline or until there is a satisfactory explanation for the 
changes observed. All AEs will be documented in the AE page of the eCRF, whether or not the 
investigator concludes that the event is related to the drug treatment. The following information 
will be documented for each event:

Event term.

Start and end date and time.

Pattern of AE (frequency).

Severity/Intensity.

Causality (Investigator’s opinion of the causal relationship between the event and 
administration of study drug[s]).

Action taken with trial drug.

Outcome of event.

Seriousness.
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10.2.8.3 Reporting SAEs
When an SAE occurs through the AE collection period it should be reported according to the 
procedure outlined below:
A Takeda SAE form must be completed, in English and signed by the investigator immediately or 
within 24 hours of first onset or notification of the event. The information should be completed as 
fully as possible but contain, at a minimum:

A short description of the event and the reason why the event is categorized as serious.

Subject identification number.

Investigator’s name.

Name of the study medication(s).

Causality assessment.
The SAE form should be transmitted within 24 hours to the attention of the contact listed in 
Section 14.1.1.
Any SAE spontaneously reported to the investigator following the AE collection period should be 
reported to the sponsor if considered related to study participation.
Reporting of SAEs that begin before first administration of investigational product will follow the 
same procedure for SAEs occurring on treatment.
SAE Follow-Up
If information is not available at the time of the first report becomes available at a later date, the 
investigator should complete a follow-up SAE form or provide other written documentation and 
fax it immediately within 24 hours of receipt. Copies of any relevant data from the hospital notes 
(eg, ECGs, laboratory tests, discharge summary, postmortem results) should be sent to the 
addressee, if requested.
All SAEs should be followed up until resolution or permanent outcome of the event. The timelines 
and procedure for follow-up reports are the same as those for the initial report.
10.2.8.4 Reporting Adverse Events of Special Interest (AESI)
If an Adverse Event of Special Interest (AESI), seizures, or convulsion as in section 10.1.2, occurs 
during the treatment period or the follow-up period, and is considered to be clinically significant 
based on the investigators clinical judgment, the AESI should be recorded in an AESI eCRF or an 
SAE Form and identified by writing AESI on the form or circle AESI if possible. The Form should
be completed and reported to the SAE reporting contact in Section 14.1.1, within 24 hours.
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10.2.8.5 Reporting of Abnormal LFTs
If a subject is noted to have ALT or AST elevated >3 ×ULN on 2 consecutive occasions, the 
abnormality should be recorded as an AE. In addition, an LFT Increases eCRF must be completed 
providing additional information on relevant recent history, risk factors, clinical signs and 
symptoms and results of any additional diagnostic tests performed.
If a subject is noted to have ALT or AST >3 ×ULN and total bilirubin >2 ×ULN for which an 
alternative etiology has not been identified, the event should be recorded as an SAE and reported 
as per Section 10.2.8.3. The investigator must contact the Medical Monitor for discussion of the 
relevant subject details and possible alternative etiologies, such as acute viral hepatitis A or B or 
other acute liver disease. Follow-up laboratory tests as described in Section 9.3 must also be 
performed. In addition, an LFT Increases eCRF must be completed and transmitted with the 
Takeda SAE form (as per Section 10.2.9). 
10.2.9
Safety Reporting to Investigators, IRBs or IECs, and Regulatory Authorities 
The sponsor will be responsible for reporting all suspected unexpected serious adverse reactions 
(SUSARs) and any other applicable SAEs to regulatory authorities, investigators and institutional 
review boards (IRB)s or institutional ethics committees (IEC)s, as applicable, in accordance with 
national regulations in the countries where the study is conducted. Relative to the first awareness 
of the event by/or further provision to the sponsor or sponsor’s designee, SUSARs will be 
submitted within 7 days for fatal and life-threatening events and 15 days for other serious events, 
unless otherwise required by national regulations. The sponsor will also prepare an expedited 
report for other safety issues where these might materially alter the current benefit-risk assessment 
of an investigational medicinal product or that would be sufficient to consider changes in the 
investigational medicinal products administration or in the overall conduct of the trial. The 
investigational site also will forward a copy of all expedited reports to his or her IRB or IEC in 
accordance with national regulations.
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11.0
STATISTICAL METHODS
11.1
Statistical and Analytical Plans
A statistical analysis plan (SAP) will be prepared and finalized before database lock. This 
document will provide further details regarding the definition of analysis variables and analysis 
methodology to address all study objectives.
11.1.1
Analysis Sets
11.1.1.1 Safety Set
The Safety Analysis Set will consist of all subjects who are randomized and received 1 dose of 
study drug. Subjects in this analysis set will be used for demographics, baseline characteristics, 
and safety summaries.
11.1.1.2 PK Set
The PK Set will consist of all subjects who receive study drug and have at least 1 measurable 
plasma concentration. 
If any subjects are found to be noncompliant in dosing schedule or with incomplete data, a 
decision will be made on a case-by-case basis as to their inclusion in the analysis, but the data will 
be presented in the subject listings.
11.1.1.3 PD Set
The PD Set will consist of all subjects who receive study drug and have at least 1 postdose PD 
measurement.
If any subjects are found to be noncompliant in dosing schedule or with incomplete data, a 
decision will be made on a case-by-case basis as to their inclusion in the analysis but will be 
presented in the subject listings.
11.1.2
Analysis of Demography and Other Baseline Characteristics
Demographic and Baseline characteristics will be summarized for all subjects in the Safety Set, by 
sequence groups as well as overall. For continuous variables (eg, age, height, weight, and BMI), 
the summary will consist of descriptive statistics (number of subjects, mean, standard deviation 
(SD), minimum, median, and maximum). For categorical variables (eg, ethnicity and race), the 
summary will consist of number and percentage of subjects in each category.
11.1.3
PK Analysis
Plasma concentrations of TAK-653 and ketamine at each time point will be summarized for each 
regimen using descriptive statistics. 
Individual plasma concentration data versus time will be presented in a data listing.
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11.1.4
PD Analysis 
11.1.4.1 Primary Endpoint Analysis
The primary endpoints are changes in rMT and changes in peak-to-peak amplitude of the MEP 
obtained with single-pulse TMS at 2 1/2 hours after administration of TAK-653 from their 
corresponding pre-dosing baseline levels, compared to placebo. They will be analyzed using linear 
mixed effect models. 
The primary endpoints will be analyzed using a linear mixed effects model appropriate for a 
three-period crossover design. Additional details of the model will be specified in the SAP. 
Hochberg's step-up procedure will be used to adjust for multiple endpoints. One-sided t-tests 
comparing each of the primary endpoints for placebo vs. treatment at each dose level will be 
conducted as secondary analyses, adjusted for multiple testing to ensure type 1 error control at the 
10% level. 
11.1.4.2 Secondary Endpoint Analysis
The magnitude of LICI and SICI obtained with paired-pulse TMS will be analyzed using linear 
mixed effect models analogous to the model used to analyze the primary endpoint. One-sided 
t-tests (alpha = 0.05) will be used for the comparison of placebo versus one of the TAK-653 
treatment groups.
The change of rMT at 24 hours post ketamine dosing and peak-to-peak amplitude of the MEP 
obtained with single-pulse TMS will be analyzed using linear mixed effect models appropriate for 
the design. Additional details will be provided in the SAP. 
11.1.4.3 Exploratory Endpoint Analysis
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Property of Takeda: For non-commercial use only and subject to the applicable Terms of Use
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11.1.5
Safety Analysis
The safety of TAK-653 will be assessed through AEs, clinical laboratory results, physical 
examinations, ECG findings, vital signs, suicidal assessments, and monitoring of potential 
tremors, convulsions and seizures. 
11.1.5.1 AEs and AESIs
Summary tables will include the number and percent of subjects in each treatment experiencing at
least 1 TEAE by system organ class and preferred term. If a subject has more than 1 AE that codes 
to the same preferred term, the subject will be counted only once for that preferred term. Similarly, 
if a subject has more than 1 AE within a system organ class category, the subject will be counted 
only once for that system organ class.
TEAEs possibly or probably related to study medication will be tabulated in the same manner. 
TEAEs will also be summarized by maximum intensity. All AEs will be listed.
AEs will be summarized for each regimen using the safety analysis set. All AEs will be coded 
using MedDRA. Data will be summarized using preferred term and primary system organ class.
11.1.5.2 Clinical Laboratory Evaluation, Vital Signs and ECG
Clinical laboratory tests (hematology, chemistry, and urinalysis), vital signs, and 12-lead ECG 
parameters will be listed. The results that meet Takeda’s criteria for markedly abnormal criteria 
will be flagged in the listing. 
Summary statistics on observed values and changes from baseline will be provided by regimen and 
scheduled time point if appropriate.
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The number and percentage of subjects who meet Takeda’s criteria for markedly abnormal criteria 
at least once postdose will be summarized by dose.
11.1.5.3 Other Safety Parameters
Summary statistics of C-SSRS scores at each visit and changes from baseline during treatment and 
follow-up visits will be provided by dose and visit. Individual C-SSRS results will be listed.
The occurrence of Tremors, convulsions, or seizures will be presented in the data listings.
Physical examination findings will be presented in the data listings.
11.2
Interim Analysis and Criteria for Early Termination
After at least 18 subjects have completed the first three periods of the study, an unblinded data 
analysis may be provided on the primary endpoints. An unblinded team not involved in the 
study conduct or the program will perform the unblinded analysis. A firewall will be set up 
between the unblinded team and the study team. Details of the procedure will be described 
in a separate document. No decision on the trial or modification of sample size will be made 
based on the analysis. The investigator and study site will not have access to the analysis results 
until the final unblinding of the study. This early data review will be conducted only for the 
purpose of sponsor programmatic forward planning that is unrelated to the conduct of the present 
study.
11.3
Determination of Sample Size
The assumptions used in the sample size determination were based on consideration of a published 
study on ketamine by di Lazzaro et al. (2003) [5] and the preliminary results of TMS data in a
CHDR study of healthy volunteers. Specifically, we assumed an intra-subject correlation of 0.9, 
a common standard deviation of 9% for rMT and 947 µV for the MEP peak-to-peak amplitude, 
a correlation coefficient of at least 0.5 between pre- and post-dosing outcome, and a familywise 
type I error rate of 10%. A sample size of 22 subjects, approximately 4 subjects for each of the 6
sequences of the first 3 treatment periods, will provide at least 80% power in detecting a reduction 
of 5.3 percentage points in rMT and/or an increase of 560 µV in the MEP peak-to-peak amplitude at 
the most effective dose level of TAK-653 versus placebo. Subjects who complete at least the first 3
treatment periods of the study are considered completers. Drop-out rate is expected to be low. 
Twenty-four subjects will be recruited (4 per sequence) to ensure at least 22 completers. If more 
than 2 subjects drop out before completing the first 3 treatment periods, up to 2 additional subjects
may be enrolled.
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12.0
QUALITY CONTROL AND QUALITY ASSURANCE
12.1
Study-Site Monitoring Visits
Monitoring visits to the study site will be made periodically during the study to ensure that all 
aspects of the protocol are followed. Source documents will be reviewed for verification of data 
recorded on the eCRFs. Source documents are defined as original documents, data, and records. 
The investigator and study site guarantee access to source documents by the sponsor or its 
designee contract research organisation (CRO) and by the IRB or IEC.
All aspects of the study and its documentation will be subject to review by the sponsor or the 
sponsor’s designee (as long as blinding is not jeopardized), including but not limited to the 
Investigator’s Binder, trial drug, subject medical records, informed consent documentation, and 
review of eCRFs and associated source documents. It is important that the investigator and other 
study personnel are available during the monitoring visits and that sufficient time is devoted to the 
process.
12.2
Protocol Deviations
The investigator should not deviate from the protocol, except where necessary to eliminate an 
immediate hazard to trial subjects. Should other unexpected circumstances arise that will require 
deviation from protocol-specified procedures, the investigator should consult with the sponsor or 
designee (and IRB or IEC, as required) to determine the appropriate course of action. There will be 
no exemptions (a prospectively approved deviation) from the inclusion or exclusion criteria.
Significant deviations include, but are not limited to, those that involve fraud or misconduct, 
increase the health risk to the subject, or confound interpretation of primary study assessment. 
12.3
Quality Assurance Audits and Regulatory Agency Inspections
The study site also may be subject to quality assurance audits by the sponsor or designees. In this 
circumstance, the sponsor-designated auditor will contact the site in advance to arrange an 
auditing visit. The auditor may ask to visit the facilities where laboratory samples are collected, 
where the medication is stored and prepared, and any other facility used during the study. In 
addition, there is the possibility that this study may be inspected by regulatory agencies, including 
those of foreign governments (eg, the Food and Drug Administration (FDA), the United Kingdom 
Medicines and Healthcare Products Regulatory Agency, the Pharmaceuticals and Medical Devices 
Agency of Japan). If the study site is contacted for an inspection by a regulatory body, the sponsor 
should be notified immediately. The investigator guarantees access for quality assurance auditors 
to all study documents as described in Section 12.1.
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13.0
ETHICAL ASPECTS OF THE STUDY
This study will be conducted with the highest respect for the individual participants (ie, subjects) 
according to the protocol, the ethical principles that have their origin in the Declaration of 
Helsinki, and the International Conference on Harmonisation (ICH) Harmonised Tripartite 
Guideline for good clinical practice (GCP). Each investigator will conduct the study according to 
applicable local or regional regulatory requirements and align his or her conduct in accordance 
with the “Responsibilities of the Investigator” that are listed in Appendix A. The principles of 
Helsinki are addressed through the protocol and through appendices containing requirements for 
informed consent and investigator responsibilities.
13.1
IRB and/or IEC Approval

This study will be conducted in accordance with the protocol and with the consensus ethical 
principles derived from international guidelines, including the Declaration of Helsinki and 
Council for International Organizations of Medical Sciences (CIOMS), International Ethical 
Guidelines, International Conference on Harmonisation (ICH) GCP guidelines, and laws and 
regulations applicable to clinical studies (including US 21 Code of Federal Regulations [CFR] 
and European regulation 536/2014).

The protocol, informed consent forms (ICF)s, Investigator's Brochure, and other relevant 
supporting documents (eg, advertisements, information on payments and compensation 
available to subjects) must be submitted to an IRB/IEC by the investigator. Written approval of 
the protocol from the IRB/IEC must be obtained before the study is initiated, ie, the first 
subject signs the study ICF. 

The study cannot be initiated until notification is received from the sponsor.

Any amendment to the protocol, except when necessary to eliminate an immediate hazard to 
study participants, requires IRB/IEC written approval before implementation.

If required by either country or regional regulations or procedures, approval from the 
Competent Regulatory Authority will be obtained before commencement of the study or 
implementation of an amendment. 

The investigator will be responsible for the following:
–
Providing written summaries of the status of the study to the IRB/IEC annually or more 
frequently in accordance with the requirements, policies, and procedures established by the 
IRB/IEC.
–
Notifying the IRB/IEC of SAEs or other significant safety findings as required by IRB/IEC 
procedures.
13.2
Subject Information, Informed Consent, and Subject Authorization
Written consent documents will embody the elements of informed consent as described in the 
Declaration of Helsinki and the ICH Guidelines for GCP and will be in accordance with all 
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applicable laws and regulations. The informed consent form, subject authorization form (if 
applicable), and subject information sheet (if applicable) describe the planned and permitted uses, 
transfers, and disclosures of the subject’s personal and personal health information for purposes of 
conducting the study. The informed consent form and the subject information sheet (if applicable) 
further explain the nature of the study, its objectives, and potential risks and benefits, as well as the 
date informed consent is given. The informed consent form will detail the requirements of the 
participant and the fact that he or she is free to withdraw at any time without giving a reason and 
without prejudice to his or her further medical care.
The investigator is responsible for the preparation, content, and IRB or IEC approval of the 
informed consent form and, if applicable, the subject authorization form. The informed consent 
form, subject authorization form (if applicable), and subject information sheet (if applicable) must 
be approved by both the IRB or IEC and the sponsor before use.
The informed consent form, subject authorization form (if applicable), and subject information 
sheet (if applicable) must be written in a language fully comprehensible to the prospective subject. 
It is the responsibility of the investigator to explain the detailed elements of the informed consent 
form, subject authorization form (if applicable), and subject information sheet (if applicable) to the 
subject. Information should be given in both oral and written form whenever possible and in the 
manner deemed appropriate by the IRB or IEC.
The subject, must be given ample opportunity to: (1) inquire about details of the study, and (2) 
decide whether or not to participate in the study. If the subject determines he or she will participate 
in the study, then the informed consent form and subject authorization form (if applicable) must be 
signed and dated by the subject at the time of consent and prior to the subject entering into the 
study. The subject should be instructed to sign using their legal names, not nicknames, using blue 
or black ballpoint ink. The investigator must also sign and date the informed consent form and 
subject authorization (if applicable) at the time of consent and before subject entering into the 
study; however, the sponsor may allow a designee of the investigator to sign to the extent 
permitted by applicable law.
Once signed, the original informed consent form, subject authorization form (if applicable), and 
subject information sheet (if applicable) will be stored in the investigator’s site file. The 
investigator must document the date the subject signs the informed consent in the subject’s 
medical record. Copies of the signed informed consent form, the signed subject authorization form 
(if applicable), and subject information sheet (if applicable) shall be given to the subject.
All revised informed consent forms must be reviewed and signed by relevant subjects in the same 
manner as the original informed consent. The date the revised consent was obtained should be 
recorded in the subject’s medical record, and the subject should receive a copy of the revised 
informed consent form.
13.3
Subject Confidentiality
The sponsor and designees affirm and uphold the principle of the subject’s right to protection 
against invasion of privacy. Throughout this study, a subject’s source data will only be linked to 
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the sponsor’s clinical study database or documentation via a unique identification number. As 
permitted by all applicable laws and regulations, limited subject attributes, such as sex, age, or date 
of birth, and subject initials may be used to verify the subject and accuracy of the subject’s unique 
identification number.
To comply with ICH Guidelines for GCP and to verify compliance with this protocol, the sponsor 
requires the investigator to permit its monitor or designee’s monitor, representatives from any 
regulatory authority (eg, FDA, Medicines and Healthcare products Regulatory Agency, 
Pharmaceuticals and Medical Devices Agency), the sponsor’s designated auditors, and the 
appropriate IRBs and IECs to review the subject’s original medical records (source data or 
documents), including, but not limited to, laboratory test result reports, ECG reports, admission 
and discharge summaries for hospital admissions occurring during a subject’s study participation, 
and autopsy reports. Access to a subject’s original medical records requires the specific 
authorization of the subject as part of the informed consent process (see Section 13.2).
Copies of any subject source documents that are provided to the sponsor must have certain 
personally identifiable information removed (ie, subject name, address, and other identifier fields 
not collected on the subject’s eCRF).
13.4
Publication, Disclosure, and Clinical Trial Registration Policy
13.4.1
Publication and Disclosure
The investigator is obliged to provide the sponsor with complete test results and all data derived by 
the investigator from the study. During and after the study, only the sponsor may make study 
information available to other study investigators or to regulatory agencies, except as required by 
law or regulation. Except as otherwise allowable in the clinical study site agreement, any public 
disclosure (including publicly accessible websites) related to the protocol or study results, other 
than study recruitment materials and/or advertisements, is the sole responsibility of the sponsor.
The sponsor may publish any data and information from the study (including data and information 
generated by the investigator) without the consent of the investigator. Manuscript authorship for 
any peer-reviewed publication will appropriately reflect contributions to the production and 
review of the document. All publications and presentations must be prepared in accordance with 
this section and the Clinical Study Site Agreement. In the event of any discrepancy between the 
protocol and the Clinical Study Site Agreement, the Clinical Study Site Agreement will prevail.
13.4.2
Clinical Trial Registration 
In order to ensure that information on clinical trials reaches the public in a timely manner and to 
comply with applicable laws, regulations and guidance, Takeda will, at a minimum register all 
interventional clinical trials it sponsors anywhere in the world on ClinicalTrials.gov and/or other 
publicly accessible websites before start of study, as defined in Takeda Policy/Standard. Takeda 
contact information, along with investigator’s city, state (for Americas investigators), country, and 
recruiting status will be registered and available for public viewing. 
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For some registries, Takeda will assist callers in locating study sites closest to their homes by 
providing the investigator name, address, and phone number to the callers requesting trial 
information. Once subjects receive investigator contact information, they may call the site 
requesting enrollment into the trial. The investigative sites are encouraged to handle the trial 
inquiries according to their established subject screening process. If the caller asks additional 
questions beyond the topic of trial enrollment, they should be referred to the sponsor.
Any investigator who objects to the sponsor providing this information to callers must provide the 
sponsor with a written notice requesting that their information not be listed on the registry site.
13.4.3
Clinical Trial Results Disclosure 
Takeda will post the results of clinical trials on ClinicalTrials.gov or other publicly accessible 
websites, as required by Takeda Policy/Standard, applicable laws and/or regulations.
13.5
Insurance and Compensation for Injury
Each subject in the study must be insured in accordance with the regulations applicable to the site 
where the subject is participating. If a local underwriter is required, then the sponsor or sponsor’s 
designee will obtain clinical study insurance against the risk of injury to study subjects. Refer to 
the study site agreement regarding the sponsor’s policy on subject compensation and treatment for 
injury. If the investigator has questions regarding this policy, he or she should contact the sponsor 
or sponsor’s designee.
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14.0
ADMINISTRATIVE AND REFERENCE INFORMATION
14.1
Administrative Information
14.1.1
Study Contact Information 
Contact Type / Role
Contact
Serious adverse event and pregnancy reporting
PPD
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14.1.2
INVESTIGATOR AGREEMENT 
I confirm that I have read and that I understand this protocol, the Investigator’s Brochure, package 
insert and any other product information provided by the sponsor. I agree to conduct this study in 
accordance with the requirements of this protocol and also to protect the rights, safety, privacy, 
and well-being of study subjects in accordance with the following:

The ethical principles that have their origin in the Declaration of Helsinki.

International Conference on Harmonisation, E6 Good Clinical Practice: Consolidated 
Guideline.

All applicable laws and regulations, including, without limitation, data privacy laws and 
regulations.

Regulatory requirements for reporting serious adverse events defined in Section 10.2.9 of this 
protocol.

Terms outlined in the study site agreement.

Responsibilities of the Investigator (Appendix A).
I further authorize that my personal information may be processed and transferred in accordance 
with the uses contemplated in Appendix C of this protocol.
Signature of Investigator
Date
Investigator Name (print or type)
Investigator’s Title
Location of Facility (City, State/Provence)
Location of Facility (Country)
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14.1.3
Study-Related Responsibilities 
The sponsor will perform all study-related activities with the exception of those identified in the 
Study-Related Responsibilities template. The vendors identified for specific study-related 
activities will perform these activities in full or in partnership with the sponsor.
14.1.4
List of Abbreviations
AE
adverse event
AESI
adverse event of special interest
ALT
alanine aminotransferase
AMPA
alpha-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid 
ANOVA
analysis of variance
AST
aspartate aminotransferase
AUC
area under the plasma concentration-time curve
AUC∞
AUC from time 0 to infinity
AUC24
AUC from time 0 to 24 hours postdose
BMI
body mass index
CFR
code of federal regulations
CHDR
Centre Hospital for Drug Research
CIOMS
Council for Organizations of Medical Sciences
Cmax 
maximum observed plasma concentration
CNS
central nervous system
CRO
contract research organization
CS
clinically significant
C-SSRS
Columbia-Suicide Severity Rating Scale
CYP 
cytochrome P-450
ECG
electrocardiogram
eCRF
electronic case report form
EEG
electroencephalograph
FIH
first-in-human
FSH
follicle-stimulating hormone
GCP
Good Clinical Practice
HIV
human immunodeficiency virus
HPLC
high performance liquid performance
IRB
institutional review board
ICF
informed consent form
ICH
International Conference on Harmonisation
IEC
institutional ethics committee
IV 
intravenous(ly)
K2EDTA
potassium ethylenediamine tetraacetic acid
LFT
liver function test
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LICI
long intracortical inhibition
LS
least squares
MDD
major depressive disorder
MedDRA
Medical Dictionary for Regulatory Activities
MEP
motor-evoked potential
MRD
multiple-rising dose
NCS
not clinically significant
NIMH
National Institute of Mental Health
NOAEL
no-observed-adverse-effect level
PD
pharmacodynamic(s)
PGx
pharmacogenomics
PK
pharmacokinetic(s)
PO
orally
PTE
pretreatment event
QD
once daily
QTcF
QT interval with Fridericia correction method
RBC
red blood cell
rMT
resting motor threshold
rTMS
resting TMS
SAE
serious adverse event
SAP
statistical analysis plan
SICI
short intracortical inhibition
SPM
statistical parametric mapping
SPV
saccidic peak velocity
SRD
single-rising dose
SD
standard deviation
SUSARs
suspected unexpected serious adverse reactions
t1/2z
terminal disposition phase half-life
TEAE
treatment-emergent adverse event
TEP
TMS-evoked EEG potential
tmax
time of first occurrence of Cmax
TRD
treatment-resistant depression
VAS
visual analog scales
WBC
white blood cell
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15.0
DATA HANDLING AND RECORDKEEPING
The full details of procedures for data handling will be documented in the Data Management Plan. 
AEs, medical history, and concurrent conditions will be coded using the Medical Dictionary for 
Regulatory Activities (MedDRA). Drugs will be coded using the World Health Organization Drug 
Dictionary.
15.1
CRFs (Electronic and Paper)
Completed eCRFs are required for each subject who signs an informed consent.
The sponsor or its designee will supply investigative sites with access to eCRFs. The sponsor will 
make arrangements to train appropriate site staff in the use of the eCRF. These forms are used to 
transmit the information collected in the performance of this study to the sponsor and regulatory 
authorities. eCRFs must be completed in English. Data are transcribed directly onto eCRFs.
After completion of the entry process, computer logic checks will be run to identify items, such as 
inconsistent dates, missing data, and questionable values. Queries may be issued by Takeda 
personnel (or designees) and will be answered by the site. 
Corrections are recorded in an audit trail that captures the old information, the new information, 
identification of the person making the correction, the date the correction was made, and the reason 
for change. Reasons for significant corrections should additionally be included. 
The principal investigator must review the eCRFs for completeness and accuracy and must sign 
and date the appropriate eCRFs as indicated. Furthermore, the investigator must retain full 
responsibility for the accuracy and authenticity of all data entered on the eCRFs.
After the lock of the clinical study database, any change of, modification of, or addition to the data 
on the eCRFs should be made by the investigator with use of change and modification records of 
the eCRFs. The principal investigator must review the data change for completeness and accuracy, 
and must sign and date. 
eCRFs will be reviewed for completeness and acceptability at the study site during periodic visits 
by study monitors. The sponsor or its designee will be permitted to review the subject’s medical 
and hospital records pertinent to the study to ensure accuracy of the eCRFs. The completed eCRFs 
are the sole property of the sponsor and should not be made available in any form to third parties, 
except for authorized representatives of appropriate governmental health or regulatory authorities, 
without written permission of the sponsor.
15.2
Record Retention
The investigator agrees to keep the records stipulated in Section 15.1 and those documents that 
include (but are not limited to) the study-specific documents, the identification log of all 
participating subjects, medical records, temporary media such as thermal sensitive paper, source 
worksheets, all original signed and dated informed consent forms, subject authorization forms 
regarding the use of personal health information (if separate from the informed consent forms), 
electronic copy of eCRFs, including the audit trail, and detailed records of drug disposition to 
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enable evaluations or audits from regulatory authorities, the sponsor or its designees. Any source 
documentation printed on degradable thermal sensitive paper should be photocopied by the site 
and filed with the original in the subject’s chart to ensure long-term legibility. Furthermore, ICH 
E6 Section 4.9.5 requires the investigator to retain essential documents specified in ICH E6 
(Section 8) until at least 2 years after the last approval of a marketing application for a specified 
drug indication being investigated or, if an application is not approved, until at least 2 years after 
the investigation is discontinued and regulatory authorities are notified. In addition, ICH E6 
Section 4.9.5 states that the study records should be retained until an amount of time specified by 
applicable regulatory requirements or for a time specified in the Clinical Study Site Agreement 
between the investigator and sponsor.
Refer to the Clinical Study Site Agreement for the sponsor’s requirements on record retention. The 
investigator and the head of the institution should contact and receive written approval from the 
sponsor before disposing of any such documents.
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16.0
REFERENCES
1. Moghaddam B, Adams B, Verma A, Daly D. Activation of glutamatergic neurotransmission 
by ketamine: a novel step in the pathway from NMDA receptor blockade to dopaminergic and 
cognitive disruptions associated with the prefrontal cortex. Journal of Neuroscience 
1997;17(8):8. 2921.
2. Kobayashi M, Pascual-Leone A. Transcranial magnetic stimulation in neurology. Lancet 
Neurol 2003;2(3):145-56.
3. Premoli I, Castellanos N, Rivolta D, Belardinelli P, Bajo R, Zipser C, et al. TMS-EEG 
signatures of GABAergic neurotransmission in the human cortex. J Neurosci 
2014;34(16):5603-12.
4. Ziemann U, Reis J, Schwenkreis P, Rosanova M, Strafella A, Badawy R, et al. TMS and drugs 
revisited 2014. Clin Neurophysiol 2015;126(10):1847-68.
5. Di Lazzaro V, Oliviero A, Profice P, Pennisi MA, Pilato F, Zito G, et al. Ketamine increases 
human motor cortex excitability to transcranial magnetic stimulation. J Physiol 2003;547(Pt 
2):485-96.
6. Badawy RA, Loetscher T, Macdonell RA, Brodtmann A. Cortical excitability and neurology: 
insights into the pathophysiology. Funct Neurol 2012;27(3):131-45.
7. Caddy C, Giaroli G, White TP, Shergill SS, Tracy DK. Ketamine as the prototype 
glutamatergic antidepressant: pharmacodynamic actions, and a systematic review and 
meta-analysis of efficacy. Ther Adv Psychopharmacol 2014;4(2):75-99.
8. DiazGranados N, Ibrahim LA, Brutsche NE, Ameli R, Henter ID, Luckenbaugh DA, et al. 
Rapid resolution of suicidal ideation after a single infusion of an N-methyl-D-aspartate 
antagonist in patients with treatment-resistant major depressive disorder. J Clin Psychiatry 
2010a;71(12):1605-11.
9. DiazGranados N, Ibrahim L, Brutsche NE, Newberg A, Kronstein P, Khalife S, et al. A 
randomized add-on trial of an N-methyl-D-aspartate antagonist in treatment-resistant bipolar 
depression. Arch Gen Psychiatry 2010b;67(8):793-802.
10. Murrough JW, Iosifescu DV, Chang LC, Al Jurdi RK, Green CE, Perez AM, et al. 
Antidepressant efficacy of ketamine in treatment-resistant major depression: a two-site 
randomized controlled trial. Am J Psychiatry 2013;170(10):1134-42.
11. Rasmussen KG, Lineberry TW, Galardy CW, Kung S, Lapid MI, Palmer BA, et al. Serial 
infusions of low-dose ketamine for major depression. J Psychopharmacol 2013;27(5):444-50.
12. Zarate CA, Jr., Singh JB, Carlson PJ, Brutsche NE, Ameli R, Luckenbaugh DA, et al. A 
randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major 
depression. Arch Gen Psychiatry 2006;63(8):856-64.
13. Portmann S, Kwan HY, Theurillat R, Schmitz A, Mevissen M, Thormann W. Enantioselective 
capillary electrophoresis for identification and characterization of human cytochrome P450 
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enzymes which metabolize ketamine and norketamine in vitro. J Chromatogr A 
2010;1217(51):7942-8.
14. Trevor AJ, Woolf TF, Baillie TA, Adams JD, Castagnoli N. Stereoselective metabolism of 
ketamine enantiomers. In: Kamenka JM, Domino EF, Geneste P, editors. Phencyclidine and 
Related Arylcyclohexylamines, Present and Future Applications. Ann Arbor, MI: NPP Books; 
1983, p. 279-89.
15. Woolf TF, Adams JD. Biotransformation of ketamine, (Z)-6-hydroxyketamine, and 
(E)-6-hydroxyketamine by rat, rabbit, and human liver microsomal preparations. Xenobiotica 
1987;17(7):839-47.
16. Hijazi Y, Boulieu R. Contribution of CYP3A4, CYP2B6, and CYP2C9 isoforms to 
N-demethylation of ketamine in human liver microsomes. Drug Metab Dispos 
2002;30(7):853-8.
17. Yanagihara Y, Kariya S, Ohtani M, Uchino K, Aoyama T, Yamamura Y, et al. Involvement of 
CYP2B6 in n-demethylation of ketamine in human liver microsomes. Drug Metab Dispos 
2001;29(6):887-90.
18. Zhao X, Venkata SL, Moaddel R, Luckenbaugh DA, Brutsche NE, Ibrahim L, et al. 
Simultaneous population pharmacokinetic modelling of ketamine and three major metabolites 
in patients with treatment-resistant bipolar depression. Br J Clin Pharmacol 
2012;74(2):304-14.
19. Zanos P, Moaddel R, Morris PJ, Georgiou P, Fischell J, Elmer GI, et al. NMDAR 
inhibition-independent antidepressant actions of ketamine metabolites. Nature 
2016;533(7604):481-6.
20. Ihmsen H, Geisslinger G, Schuttler J. Stereoselective pharmacokinetics of ketamine: 
R(-)-ketamine inhibits the elimination of S(+)-ketamine. Clin Pharmacol Ther 
2001;70(5):431-8.
21. Zarate CA, Jr., Brutsche NE, Ibrahim L, Franco-Chaves J, Diazgranados N, Cravchik A, et al. 
Replication of ketamine's antidepressant efficacy in bipolar depression: a randomized 
controlled add-on trial. Biol Psychiatry 2012;71(11):939-46.
22. Rossi S, Hallett M, Rossini PM, Pascual-Leone A, Safety of TMSCG. Safety, ethical 
considerations, and application guidelines for the use of transcranial magnetic stimulation in 
clinical practice and research. Clin Neurophysiol 2009;120(12):2008-39.
23. Groeneveld GJ, Hay JL, Van Gerven JM. Measuring blood-brain barrier penetration using the 
NeuroCart, a CNS test battery. Drug Discov Today Technol 2016;20:27-34.
24. Wright BM. A simple mechanical ataxia-meter. J Physiol 1971;218 Suppl:27P-8P.
25. van Steveninck AL, Schoemaker HC, Pieters MS, Kroon R, Breimer DD, Cohen AF. A 
comparison of the sensitivities of adaptive tracking, eye movement analysis, and visual analog
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lines to the effects of incremental doses of temazepam in healthy volunteers. Clinical 
Pharmacology & Therapeutics 1991;50(2):172-80.
26. van Steveninck AL, van Berckel BN, Schoemaker RC, Breimer DD, van Gerven JM, Cohen 
AF. The sensitivity of pharmacodynamic tests for the central nervous system effects of drugs 
on the effects of sleep deprivation. J Psychopharmacol 1999;13(1):10-7.
27. Borland R, Nicholson A. Comparison of the residual effects of two benzodiazepines 
(nitrazepam and flurazepam hydrochloride) and pentobarbitone sodium on human 
performance. British journal of clinical pharmacology 1975;2(1):9-17.
28. Borland R, Nicholson A. Visual motor co-ordination and dynamic visual acuity. British 
journal of clinical pharmacology 1984;18(S1):69S-72S.
29. Norris H. The action of sedatives on brain stem oculomotor systems in man. 
Neuropharmacology 1971;10(2):181-91.
30. De Visser S, Van Der Post J, Pieters M, Cohen A, Van Gerven J. Biomarkers for the effects of 
antipsychotic drugs in healthy volunteers. British journal of clinical pharmacology 
2001;51(2):119-32.
31. Bond A, Lader M. The use of analogue scales in rating subjective feelings. British Journal of 
Medical Psychology 1974;47(3):211-8.
32. Bowdle AT, Radant AD, Cowley DS, Kharasch ED, Strassman RJ, Roy-Byrne PP. 
Psychedelic effects of ketamine in healthy volunteers relationship to steady-state plasma 
concentrations. Anesthesiology: The Journal of the American Society of Anesthesiologists 
1998;88(1):82-8.
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17.0
APPENDICES
Appendix A
Responsibilities of the Investigator
Clinical research studies sponsored by the sponsor are subject to ICH GCP and all the applicable 
local laws and regulations. The responsibilities imposed on investigators by the FDA are 
summarized in the “Statement of Investigator” (Form FDA 1572), which must be completed and 
signed before the investigator may participate in this study.
The investigator agrees to assume the following responsibilities by signing a Form FDA 1572:
1. Conduct the study in accordance with the protocol.
2. Personally conduct or supervise the staff that will assist in the protocol.
3. If the investigator/institution retains the services of any individual or party to perform 
trial-related duties and functions, the investigator/institution should ensure that this individual 
or party is qualified to perform those trial-related duties and functions and should implement 
procedures to ensure the integrity of the trial-related duties and functions performed and any 
data generated.
4. Ensure that study related procedures, including study specific (nonroutine/nonstandard panel) 
screening assessments are NOT performed on potential subjects, before the receipt of written 
approval from relevant governing bodies/authorities.
5. Ensure that all colleagues and employees assisting in the conduct of the study are informed of 
these obligations.
6. Secure prior approval of the study and any changes by an appropriate IRB/IEC that conform to 
21 CFR Part 56, ICH, and local regulatory requirements.
7. Ensure that the IRB/IEC will be responsible for initial review, continuing review, and approval 
of the protocol. Promptly report to the IRB/IEC all changes in research activity and all 
anticipated risks to subjects. Make at least yearly reports on the progress of the study to the 
IRB/IEC, and issue a final report within 3 months of study completion.
8. Ensure that requirements for informed consent, as outlined in 21 CFR Part 50, ICH and local 
regulations, are met.
9. Obtain valid informed consent from each subject who participates in the study, and document 
the date of consent in the subject’s medical chart. Valid informed consent is the most current 
version approved by the IRB/IEC. Each informed consent form should contain a subject 
authorization section that describes the uses and disclosures of a subject’s personal 
information (including personal health information) that will take place in connection with the 
study. If an informed consent form does not include such a subject authorization, then the 
investigator must obtain a separate subject authorization form from each subject.
10. Prepare and maintain adequate case histories of all persons entered into the study, including 
eCRFs, hospital records, laboratory results, etc, and maintain these data for a minimum of 
2 years following notification by the sponsor that all investigations have been discontinued or 
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that the regulatory authority has approved the marketing application. The investigator should 
contact and receive written approval from the sponsor before disposing of any such 
documents.
11. Allow possible inspection and copying by the regulatory authority of GCP-specified essential 
documents.
12. Maintain current records of the receipt, administration, and disposition of sponsor-supplied 
drugs, and return all unused sponsor-supplied drugs to the sponsor. 
13. Report adverse reactions to the sponsor promptly. In the event of an SAE, notify the sponsor 
within 24 hours.
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Appendix B
Elements of the Subject Informed Consent
In seeking informed consent, the following information shall be provided to each subject:
1. A statement that the study involves research.
2. An explanation of the purposes of the research.
3. The expected duration of the subject’s participation.
4. A description of the procedures to be followed, including invasive procedures.
5. The identification of any procedures that are experimental.
6. The estimated number of subjects involved in the study.
7. A description of the subject’s responsibilities.
8. A description of the conduct of the study.
9. A statement describing the treatment(s) and the probability for random assignment to each 
treatment.
10. A description of the possible side effects of the treatment that the subject may receive.
11. A description of any reasonably foreseeable risks or discomforts to the subject and, when 
applicable, to an embryo, fetus, or nursing infant.
12. A description of any benefits to the subject or to others that reasonably may be expected from 
the research. When there is no intended clinical benefit to the subject, the subject should be 
made aware of this.
13. Disclosures of appropriate alternative procedures or courses of treatment, if any, that might be 
advantageous to the subject and their important potential risks and benefits.
14. A statement describing the extent to which confidentiality of records identifying the subject 
will be maintained, and a note of the possibility that regulatory agencies, auditor(s), IRB/IEC, 
and the monitor may inspect the records. By signing a written informed consent form, the 
subject is authorizing such access.
15. For research involving more than minimal risk, an explanation as to whether any compensation 
and an explanation as to whether any medical treatments are available if injury occurs and, if 
so, what they consist of or where further information may be obtained.
16. The anticipated prorated payment(s), if any, to the subject for participating in the study.
17. The anticipated expenses, if any, to the subject for participating in the study.
18. An explanation of whom to contact for answers to pertinent questions about the research 
(investigator), subject’s rights, and IRB/IEC and whom to contact in the event of a 
research-related injury to the subject.
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19. A statement that participation is voluntary, that refusal to participate will involve no penalty or 
loss of benefits to which the subject otherwise is entitled, and that the subject may discontinue 
participation at any time without penalty or loss of benefits to which the subject is otherwise 
entitled.
20. The consequences of a subject’s decision to withdraw from the research and procedures for 
orderly termination of participation by the subject.
21. A statement that the subject will be informed in a timely manner if information becomes 
available that may be relevant to the subject’s willingness to continue participation in the 
study.
22. The foreseeable circumstances or reasons under which the subject’s participation in the study 
may be terminated.
23. A written subject authorization (either contained within the informed consent form or provided 
as a separate document) describing to the subject the contemplated and permissible uses and 
disclosures of the subject’s personal information (including personal health information) for 
purposes of conducting the study. The subject authorization must contain the following 
statements regarding the uses and disclosures of the subject’s personal information:
a) that personal information (including personal health information) may be processed by or 
transferred to other parties in other countries for clinical research and safety reporting 
purposes, including, without limitation, to the following: (1) Takeda, its affiliates, and 
licensing partners; (2) business partners assisting Takeda, its affiliates, and licensing 
partners; (3) regulatory agencies and other health authorities; and (4) IRBs/IECs;
b) it is possible that personal information (including personal health information) may be 
processed and transferred to countries that do not have data protection laws that offer 
subjects the same level of protection as the data protection laws within this country; 
however, Takeda will make every effort to keep your personal information confidential, 
and your name will not be disclosed outside the clinic unless required by law;
c) that personal information (including personal health information) may be added to 
Takeda’s research databases for purposes of developing a better understanding of the 
safety and effectiveness of the study medication(s), studying other therapies for patients, 
developing a better understanding of disease, and improving the efficiency of future 
clinical studies;
d) that subjects agree not to restrict the use and disclosure of their personal information 
(including personal health information) upon withdrawal from the study to the extent that 
the restricted use or disclosure of such information may impact the scientific integrity of 
the research; and
e) that the subject’s identity will remain confidential in the event that study results are 
published.
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24. Male subjects must use highly effective contraception (as defined in the informed consent) 
from signing the informed consent throughout the duration of the study and for 5 half lives 
PLUS 90 days after the last dose of study drug. If the partner or wife of the subject is found to 
be pregnant during the study, the investigator will offer the subject the choice to receive 
unblinded treatment information. 
25. A statement that clinical trial information from this trial will be publicly disclosed in a publicly 
accessible website, such as ClinicalTrials.gov.
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Appendix C
Investigator Consent to the Use of Personal Information
Takeda will collect and retain personal information of investigator, including his or her name, 
address, and other personally identifiable information. In addition, investigator’s personal 
information may be transferred to other parties located in countries throughout the world (eg, the 
United Kingdom, United States, and Japan), including the following:

Takeda, its affiliates, and licensing partners.

Business partners assisting Takeda, its affiliates, and licensing partners.

Regulatory agencies and other health authorities.

IRBs and IECs.
Investigator’s personal information may be retained, processed, and transferred by Takeda and 
these other parties for research purposes including the following:

Assessment of the suitability of investigator for the study and/or other clinical studies.

Management, monitoring, inspection, and audit of the study.

Analysis, review, and verification of the study results.

Safety reporting and pharmacovigilance relating to the study.

Preparation and submission of regulatory filings, correspondence, and communications to 
regulatory agencies relating to the study.

Preparation and submission of regulatory filings, correspondence, and communications to 
regulatory agencies relating to other medications used in other clinical studies that may contain 
the same chemical compound present in the study medication.

Inspections and investigations by regulatory authorities relating to the study.

Self-inspection and internal audit within Takeda, its affiliates, and licensing partners.

Archiving and audit of study records.

Posting investigator site contact information, study details and results on publicly accessible 
clinical trial registries, databases, and websites.
Investigator’s personal information may be transferred to other countries that do not have data 
protection laws that offer the same level of protection as data protection laws in investigator’s own 
country.
Investigator acknowledges and consents to the use of his or her personal information by Takeda 
and other parties for the purposes described above.
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Appendix D
Pregnancy and Contraception
Contraception and Pregnancy Avoidance Procedure
Male Subjects and Their Female Partners
From signing of informed consent, throughout the duration of the study, and for 5 half-lives PLUS 
90 days after last dose of study drug, nonsterilized** male subjects who are sexually active with a 
female partner of childbearing potential* must use barrier contraception (eg, condom with or 
without spermicidal cream or jelly). In addition, they must be advised not to donate sperm during 
this period. 
Female Subjects and Their Male Partners
Women of childbearing potential (WOCBP) will be excluded from the study.
Definitions and Procedures for Contraception and Pregnancy Avoidance
The following definitions apply for contraception and pregnancy avoidance procedures.
* A woman is considered a WOCBP, ie fertile, following menarche and until becoming 
post-menopausal unless permanently sterile. Permanent sterilization methods include 
hysterectomy, and bilateral oophorectomy. A postmenopausal state is defined as no menses for 12 
months without an alternative medical cause. A high follicle stimulating hormone (FSH) level in 
the postmenopausal range (FSH >40 IU/L) may be used to confirm a post-menopausal state in 
younger women (eg, those <45 years old) or women who are not using hormonal contraception or 
hormonal replacement therapy. However, in the absence of 12 months of amenorrhea, a single 
FSH measurement is insufficient.
Sterilized males should be at least 1 year post-bilateral vasectomy and have confirmed that they 
have obtained documentation of the absence of sperm in the ejaculate or have had bilateral 
orchidectomy.
The following procedures apply for contraception and pregnancy avoidance.
1. Highly effective methods of contraception are defined as “those, alone or in combination, that 
result in a low failure rate (ie, less than 1% failure rate per year when used consistently and 
correctly). In this study, where medications and devices containing hormones are 
included/excluded, the only acceptable methods of contraception are: 

Non-Hormonal Methods: 
–
Vasectomised partner (provided that partner is the sole sexual partner of the trial 
participant and that the vasectomised partner has received medical assessment of the 
surgical success.
–
True sexual abstinence, only if this is in line with the preferred and usual lifestyle of the 
subject. True abstinence is defined as refraining from heterosexual intercourse during 
the entire period of the study, from 1 month before the first dose until 5 half lives PLUS 
30 days after last dose.
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6. Effective method of contraception (there may be a higher than 1% failure rate) are: 

Double-barrier method (contraceptive sponge, diaphragm or cervical cap with spermicidal 
jellies or creams PLUS male condom).
7. Unacceptable methods of contraception are:

Periodic abstinence (eg, calendar, ovulation, symptothermal, post-ovulation methods).

Spermicides only.

Withdrawal.

No method at all.

Use of female and male condoms together.

Cap/diaphragm/sponge without spermicide and without condom.

Sexual abstinence is NOT an acceptable method of contraception.
8. Subjects will be provided with information on highly effective/effective methods of 
contraception as part of the subject informed consent process and will be asked to sign a 
consent form stating that they understand the requirements for avoidance of pregnancy, 
donation of ova, and sperm donation during the course of the study.
9. During the course of the study, all subjects (male and female) will receive continued guidance 
with respect to the avoidance of pregnancy and sperm donation as part of the study procedures. 
Such guidance should include a reminder of the following:
a) contraceptive requirements of the study
b) reasons for use of barrier methods (ie, condom) in males with pregnant partners
c) assessment of subject compliance through questions such as
i. Have you used the contraception consistently and correctly since the last visit?
ii. Have you forgotten to use contraception since the last visit?
iii. Are your menses late (even in women with irregular or infrequent menstrual cycles a 
pregnancy test must be performed if the answer is “yes”)
iv. Is there a chance you could be pregnant?
General Guidance With Respect to the Avoidance of Pregnancy
Such guidance should include a reminder of the following:

contraceptive requirements of the study.

reasons for use of barrier methods (ie, condom) in males with pregnant partners.

assessment of subject compliance through questions such as:
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–
Have you used the contraception consistently and correctly since the last visit?
–
Have you forgotten to use contraception since the last visit? 
Pregnancy
Women of childbearing potential will not be included in this study.
If any subject is found to be pregnant during the study she should be withdrawn and any 
sponsor-supplied drug [list all that apply] should be immediately discontinued. In addition, any 
pregnancies in the partner of a male subject during the study or for 5 half lives PLUS 90 days after 
the last dose, should also be recorded following authorization from the subject’s partner. 
Should the pregnancy occur during or after administration of blinded drug, the investigator must 
inform the subject of their right to receive treatment information. If the subject chooses to receive 
unblinded treatment information, the individual blind should be broken by the investigator. 
Subjects randomized to placebo need not be followed. 
If the female subject and/or female partner of a male subject agrees to the primary care physician 
being informed, the investigator should notify the primary care physician that the female 
subject/female partner of the subject was participating in a clinical study at the time she became 
pregnant and provide details of the study drug the subject received (blinded or unblinded, as 
applicable).
All pregnancies, including female partners of male subjects, in subjects on active study drug 
(including comparator, if applicable) will be followed up to final outcome, using the pregnancy 
form. Pregnancies will remain blinded to the study team. The outcome, including any premature 
termination, must be reported to the sponsor. An evaluation after the birth of the child will also be 
conducted.
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Appendix E
Detailed Description of Amendments to Text
The primary sections of the protocol affected by the changes in Amendment No. 01 are indicated. 
The corresponding text has been revised throughout the protocol.
Change 1: A second primary endpoint added and both endpoints are evaluated as changes from 
pre-dosing baseline, compared to placebo.
The primary changes occur in Section 5.2.1 Primary Endpoints
Initial wording: 5.2.1 Primary Endpoint
The primary endpoint of the study is:

The resting motor threshold (rMT) obtained with single-pulse TMS assessing 
the effect of TAK-653 compared with placebo.
Amended or 
new wording:
5.2.1 Primary EndpointEndpoints
The primary endpointendpoints of the study isare:

The change of peak-to-peak amplitude of the MEP obtained with 
single-pulse TMS (stimulation intensity: 120% of baseline resting motor 
threshold (rMT)[rMT]) at 2½ hours after administration of TAK-653
from pre-dosing baseline, compared to placebo.

The change of rMT obtained with single-pulse TMS assessing the effect of 
TAK-653 compared with placeboat 2 1/2 hours after administration of 
TAK-653 from pre-dosing baseline, compared to placebo.
Rationale for Change: One of the original secondary endpoints has been changed to a primary 
endpoint so that either endpoint may be used to assess excitability.
The following sections also contain this change:

Section 1.0 STUDY SUMMARY
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Change 2: Modified secondary endpoints.
The primary changes occur in Section 5.2.2 Secondary Endpoints
Initial Wording: Secondary endpoints include: 
1. The peak-to-peak amplitude of the MEP obtained with single-pulse TMS 
(stimulation intensity: 120% of baseline rMT), assessing TAK-653 effects 
over pre-dosing baseline for each treatment period (key secondary endpoint).
2. Magnitude of long intracortical inhibition (LICI) obtained with paired-pulse 
TMS (stimulation intensity conditioning pulse and test pulse: 120% of 
baseline rMT).
3. Magnitude of Short intracortical inhibition (SICI) obtained with paired-pulse 
TMS (stimulation intensity: conditioning pulse 80% of baseline rMT; test 
pulse: 120% of baseline rMT).
4. The resting motor threshold (rMT) obtained with single-pulse TMS assessing 
ketamine effects.
The peak-to-peak amplitude of the MEP obtained with single-pulse TMS 
(stimulation intensity: 120% of baseline rMT) assessing ketamine effects.
Amended or 
new wording:
Secondary endpoints include the change from baseline at 2 1/2 hours for the 
following:
1.  The peak-to-peak amplitude of the MEP obtained with single-pulse TMS 
(stimulation intensity: 120% of baseline rMT), assessing TAK-653 effects 
over predosing baseline for each treatment period (key secondary endpoint).
1. Magnitude of long intracortical inhibition (LICI) obtained with paired-pulse 
TMS (stimulation intensity conditioning pulse and test pulse: 120% of 
baseline rMT).
2. Magnitude of short intracortical inhibition (SICI) obtained with paired-pulse 
TMS (stimulation intensity: conditioning pulse 80% of baseline rMT; test 
pulse: 120% of baseline rMT).
3. The rMT obtained with single-pulse TMS assessing ketamine effects, as well 
as at 24 hours.
4.
The peak-to-peak amplitude of the MEP obtained with single-pulse TMS 
(stimulation intensity: 120% of baseline rMT) assessing ketamine effects, as well 
as at 24 hours.
Rationale for Change: To specify the 2 ½ hour change from baseline for the assessments
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Change 3: The primary endpoint analysis now includes both primary endpoints with an additional 
Hochberg step-up procedure. In addition, some details of the model are deferred to the SAP. In 
addition, some details of the model are deferred to the SAP.
The primary changes occur in Section 11.1.4.1 Primary Endpoint Analysis
Initial wording: 11.1.4.1 Primary Endpoint Analysis
The change of primary endpoint (rMT at 2 ½ hours post TAK-653 dosing 
obtained with single-pulse TMS) from pre-dosing baseline level will be analyzed 
using mixed analysis of variance (ANOVA) model appropriate for a three-period 
crossover with fixed factors for treatment, sequence, period, time, and 
treatment-by-time interaction and a random factor for subject nested in sequence. 
One-sided t-tests comparing the primary endpoint results for placebo vs. treatment 
at each dose level will be conducted as secondary analyses, adjusted for multiple 
testing to ensure type 1 error control at the 10% level. 
Amended or 
new wording:
11.1.4.1 Primary Endpoint Analysis
The change of primary endpoint (rMT at 2 ½ hours post TAK-653 dosingprimary 
endpoints are changes in rMT and changes in peak-to-peak amplitude of the 
MEP obtained with single-pulse TMS) from at 2 1/2 hours after administration 
of TAK-653 from their corresponding pre-dosing baseline levellevels, 
compared to placebo. They will be analyzed using linear mixed analysis of 
variance (ANOVA)effect models. 
The primary endpoints will be analyzed using a linear mixed effects model 
appropriate for a three-period crossover with fixed factors for treatment, 
sequence, period, time, and treatment-by-time interaction and a random factor 
forsubject nested in sequencedesign. Additional details of the model will be 
specified in the SAP. Hochberg's step-up procedure will be used to adjust for 
multiple endpoints. One-sided t-tests comparing each of the primary endpoint 
resultsendpoints for placebo vs. treatment at each dose level will be conducted as 
secondary analyses, adjusted for multiple testing to ensure type 1 error control at 
the 10% level.
Rationale for Change: Hochberg's step-up procedure is used to adjust for multiple testing. 
Deferring details to the SAP allows for refinement of the statistical analysis whilst assuring that 
the model used will be pre-specified.
The following sections also contain this change:

Section 1.0 STUDY SUMMARY
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Change 4: The early analysis, which may occur when at least 18 subjects have completed periods 
1 through 3, will be unblinded (previously partially blinded).
The primary changes occur in Section 11.2 Interim Analysis and Criteria for Early Termination
Initial wording: 11.2  Interim Analysis and Criteria for Early Termination
No interim analysis is planned. Blinded summary statistics will be provided for 
safety and primary endpoints without statistical testing. No decision on the study 
will be made based on the results.
11.3  Early Blinded Analysis of Data
After at least 18 subjects have completed the first three periods of the study, 
blinded summary statistics (number of subjects, mean, SD, minimum, median, 
and maximum) may be provided on the change of primary endpoint (rMT at 2 ½ 
hours post TAK-653 dosing obtained with single-pulse TMS) from pre-dosing 
baseline level and the peak-to-peak amplitude of the MEP obtained with 
single-pulse TMS. Only summary statistics with dummy treatment code will be 
provided. No decision on the trial or modification of sample size will be made 
based on the analysis. The investigator and study site will not have access to the 
summary statistics until the study has ended.
Amended or 
new wording:
No interim analysis is planned. Blinded summary statistics will be provided for 
safety and primary endpoints without statistical testing. No decision on the study 
will be made based on the results.
11.3
Early Blinded Analysis of Data
After at least 18 subjects have completed the first three periods of the study, 
blinded summary statistics (number of subjects, mean, SD, minimum, median, 
and maximum)an unblinded data analysis may be provided on the change of 
primary endpoint (rMT at 2 ½ hours post TAK-653 dosing obtained with 
single-pulse TMS) from pre-dosing baseline level and the peak-to-peak 
amplitude of the MEP obtained with single-pulse TMS. Only summary 
statistics with dummy treatment code will be providedendpoints. An unblinded 
team not involved in the study conduct or the program will perform the 
unblinded analysis. A firewall will be set up between the unblinded team 
and the study team. Details of the procedure will be described in a separate 
document. No decision on the trial or modification of sample size will be made 
based on the analysis. The investigator and study site will not have access to the 
summary statisticsanalysis results until the final unblinding of the study has 
ended. This early data review will be conducted only for the purpose of sponsor 
programmatic forward planning that is unrelated to the conduct of the present 
study.
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Rationale for Change: Procedures adjusted to conduct an unblinded rather than partially blinded 
analysis.
The following sections also contain this change:
No other section
Change 5: The sample size justification is updated to include both primary endpoints.
The primary changes occur in Section 11.3 Determination of Sample Size
Initial wording:
A sample size of 22 subjects, approximately four subjects for each of the six 
sequences of the first three treatment periods, will be considered sufficient for 
evaluation of the primary endpoint for this study based on consideration of a 
published study on Ketamine by di Lazzaro et al. (2003) and preliminary results 
of baseline TMS data in a CHDR study of healthy volunteers. Subjects who 
complete at least the first three treatment periods of the study are considered 
completers. Drop-out rate is expected to be low. Twenty-four subjects will be 
recruited (4 per sequence) to ensure at least 22 completers. If more than two 
subjects drop out before completing the first treatment three periods, up to two 
additional subjects may be enrolled.
Specifically, this sample-size calculation was based on a consideration of effect 
sizes of Ketamine on rMT at 0.01 mg/kg and 0.02 mg/kg, as reported in the 
study by di Lazzaro et al (2003). Based on a type-I error rate of 0.10, a common 
standard deviation of 9% and a within-subject correlation of 0.9, this study has 
at least 80% power to detect a reduction of 2.7 and 4.6 percentage point in rMT 
at the two dose levels of TAK-653 vs placebo, assuming a total of 22 
completers.
Amended or 
new wording:
Determination of Sample Size
The assumptions used in the sample size determination were based on 
consideration of a published study on ketamine by di Lazzaro et al. (2003) [5]
and the preliminary results of TMS data in a CHDR study of healthy 
volunteers. Specifically, we assumed an intra-subject correlation of 0.9, a 
common standard deviation of 9% for rMT and 947 µV for the MEP 
peak-to-peak amplitude, a correlation coefficient of at least 0.5 between 
pre- and post-dosing outcome, and a familywise type I error rate of 10%. 
A sample size of 22 subjects, approximately four4 subjects for each of the six6
sequences of the first three3 treatment periods, will be considered sufficient for 
evaluation of the primary endpoint for this study based on consideration of a 
published study on Ketamine by di Lazzaro et al. (2003)[5] and preliminary 
results of baseline TMS data in a CHDR study of healthy volunteersprovide at 
least 80% power in detecting a reduction of 5.3 percentage points in rMT 
and/or an increase of 560 µV in the MEP peak-to-peak amplitude at the 
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most effective dose level of TAK-653 versus placebo. Subjects who complete 
at least the first three3 treatment periods of the study are considered completers. 
Drop-out rate is expected to be low. Twenty-four subjects will be recruited (4 
per sequence) to ensure at least 22 completers. If more than two2 subjects drop 
out before completing the first 3 treatment three periods, up to two2 additional 
subjects may be enrolled.
Specifically, this sample-size calculation was based on a consideration of effect 
sizes of Ketamine on rMT at 0.01 mg/kg and 0.02 mg/kg, as reported in the 
study by di Lazzaro et al (2003). Based on a type-I error rate of 0.10, a common 
standard deviation of 9% and a within-subject correlation of 0.9, this study has 
at least 80% power to detect a reduction of 2.7 and 4.6 percentage point in rMT 
at the two dose levels of TAK-653 vs placebo, assuming a total of 22 
completers.
Rationale for Change: Needed to justify the power for each primary endpoint when the 
Hochberg procedure is applied.
The following sections also contain this change:

Section 1.0 STUDY SUMMARY
Change 6: The resting motor threshold (rMT) exclusion criterion is modified.
The primary changes occur in Section 7.2 Exclusion Criteria
Initial wording: 22. The subject has an rMT of more than 83% of the maximum stimulator 
output, measured using TMS-EMG during screening.
Amended or 
new wording:
22. The subject has an rMT of more than 8375% of the maximum stimulator 
output, measured using TMS-EMG during screening.
Rationale for Change: The rMT exclusion threshold was lowered to avoid a ceiling in stimulator 
output in subjects for which the rMT is at or near 83% of maximum stimulator output. One of the 
primary endpoints will be tested at 120% of the baseline rMT, so if subjects are at 83% of the 
maximum, 120% of that will be at maximum. A 75% of maximum stimulator output will enable a 
stimulation range that does not reach the apparatus limit.  
The following sections also contain this change:

Section 1.0 STUDY SUMMARY
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Change 7: Three safety endpoints were deleted.
The primary changes occur in Section 5.2.3 Safety Endpoints
Initial wording: 5.2.3  Safety Endpoints
Safety endpoints include:
1. Number/percentage of subjects with at least 1 AE.
2. Number/percentage of subjects with at least 1 SAE.
3. Number/percentage of subjects with at least 1 clinically-defined abnormal 
laboratory value.
4. Number/percentage of subjects with at least 1 clinically-defined abnormal 
vital sign value.
5. Number/percentage of subjects with at least 1 dose-limiting toxicity.
6. Number/percentage of subjects with at least 1 AE.
7. Number/percentage of subjects with at least 1 AE Grade 3 or higher.
Amended or 
new wording:
Safety endpoints include:
1. Number/percentage of subjects with at least 1 AE.
2. Number/percentage of subjects with at least 1 serious adverse event (SAE).
3. Number/percentage of subjects with at least 1 clinically-defined abnormal 
laboratory value.
4. Number/percentage of subjects with at least 1 clinically-defined abnormal 
vital sign value.
5. Number/percentage of subjects with at least 1 dose-limiting toxicity.
6. Number/percentage of subjects with at least 1 AE.
7. Number/percentage of subjects with at least 1 AE Grade 3 or higher.
Rationale for Change: The deleted endpoints are already included in the first 4 points, or are not 
applicable.
The following sections also contain this change:

Section 1.0 STUDY SUMMARY
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Change 8: Subject instructions to stop concomitant medications before dosing are modified.
The primary changes occur in Section 7.3.1 Concomitant Medications
Initial wording: Concomitant Medications
The use of concomitant medications after randomization (ie, Day 1 of Period 1) 
until the follow-up phone call is not permitted. Subjects must be instructed not to 
take any medications without first consulting with the investigator. Any 
concomitant medication use must first be discussed with the sponsor, unless the 
investigator or designee considers immediate administration is necessitated. It is 
allowed to give medication to treat AEs, for example midazolam for a seizure.
The occasional use of acetaminophen (approximately <1 g/day) is allowed.
Amended or 
new wording:
Concomitant Medications
The use ofSubjects are instructed to stop concomitant medications after
randomization (ie, Day 1 of Period 1)7 days before administration of the first 
dose of study drug and throughout the study, until the follow-up phone call is 
not permitted. Subjects must be instructed not to take any medications without 
first consulting with the investigator. Any concomitant medication use must first 
be discussed with the sponsor, unless the investigator or designee considers 
immediate administration is necessitated. It is allowed to give medication to treat 
AEs, for example midazolam for a seizure.
The occasional use of acetaminophen (approximately <1 g/day) is allowed. 
Rationale for Change: To ensure subjects are off concomitant medications one week before 
dosing and to also mirror Exclusion Criteria #11.
The following sections also contain this change:
No other section
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Study ID TAK-653-1003
Page 100 of 111
Protocol Incorporating Amendment No. 01
04 April 2019
Change 9:
The window for predose ECG is widened to 3 hours.
The primary changes occur in Section 9.2.5 12-Lead ECG
Initial wording: 9.2.5  12-Lead ECG
For each treatment period, a predose ECG will be obtained within approximately 
1 hour before study drug dosing. This measurement will be used as the baseline 
assessment. The principal investigator should arrange to have a study cardiologist 
available as needed to review ECG abnormalities.
During each treatment period, if a subject demonstrates an increase in QTcF 
interval ≥40 milliseconds compared with a predose baseline measurement, the 
ECG will be repeated within 5 minutes. The average value of the QTcF interval 
from the 2 ECGs will represent the value at that time point. If the average QTcF 
interval increase from baseline for any postdose time point is ≥40 milliseconds, 
the subject will continue to be monitored by repeat 12-lead ECGs every 
60 minutes for at least 4 hours or until the QTcF interval is within 40 milliseconds 
of the baseline value. If prolongation of the QTcF interval ≥40 milliseconds 
persists, a consultation with a study cardiologist may be appropriate and the 
sponsor should be notified
Amended or 
new wording:
For each treatment period, a predose ECG will be obtained within approximately 
13 hour before study drug dosing. This measurement will be used as the baseline 
assessment. The principal investigator should arrange to have a study cardiologist 
available as needed to review ECG abnormalities.
During each treatment period, if a subject demonstrates an increase in QTcF 
interval ≥40 milliseconds compared with a predose baseline measurement, the 
ECG will be repeated within 5 minutes. The average value of the QTcF interval 
from the 2 ECGs will represent the value at that time point. If the average QTcF 
interval increase from baseline for any postdose time point is ≥40 milliseconds, 
the subject will continue to be monitored by repeat 12-lead ECGs every 
60 minutes for at least 4 hours or until the QTcF interval is within 40 milliseconds 
of the baseline value. If prolongation of the QTcF interval ≥40 milliseconds 
persists, a consultation with a study cardiologist may be appropriate and the 
sponsor should be notified.
Rationale for Change: To permit scheduling of baseline ECG in a busy clinic and clarify timing.
The following sections also contain this change:

Section 3.0 Schedule of Study Procedures
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TAK-653
Study ID TAK-653-1003
Page 101 of 111
Protocol Incorporating Amendment No. 01
04 April 2019
Change 10: Site clinic seizure precautions are updated for generalized use.
The primary changes occur in Section 9.2.8 AE Monitoring
Initial wording:9.2.8  AE Monitoring
Seizure precautions will be taken at all clinic visits, consisting of availability of a 
hospital bed with padded side rails, suction set up and appropriately tested, and an 
ambu bag nearby. If there is evidence of seizure activity, subjects will be 
administered standard of care anticonvulsants as needed and remain in the clinic 
overnight for closer observation.
Amended 
wording:
Seizure precautions will be taken at all clinic visits, consisting of availability of a 
hospital bed with padded side rails, suction set up and appropriately tested, and an 
ambu bag nearby. If there is evidence of seizure activity, subjects will be 
administered standard of care anticonvulsants as needed and remain in the clinic 
overnight for closer observation.
Rationale for Change: To remove restrictive precautions which are already addressed in the 
clinic setting.
The following sections also contain this change:

No other section
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TAK-653
Study ID TAK-653-1003
Page 102 of 111
Protocol Incorporating Amendment No. 01
04 April 2019
Change 11: Pharmacokinetic (PK) blood sample collection instructions for ketamine analysis are 
added.
The primary changes occur in Section 9.4.2.1 Plasma for PK Measurements.
Initial wording: Blood samples for plasma concentration analysis of TAK-653 and ketamine will 
be collected into chilled blood collection tubes (vacutainer) containing the 
anticoagulant K2EDTA. The collected blood samples may be archived for 
additional analysis of potential metabolites.
The actual time of sample collection will be recorded on the source document and 
electronic case report form. Sampling time points may be adjusted based on the 
preliminary emerging concentration data collected from prior subjects, but the 
total number of samples collected per subject should not exceed the planned 
number.
Amended or 
new wording:
Blood samples for plasma concentration analysis of TAK-653 and ketamine will 
be collected into chilled blood collection tubes (vacutainer) containing the 
anticoagulant K2EDTApotassium ethylenediamine tetraacetic acid (K2EDTA) at 
room temperature. After the blood draw, the tube will immediately be 
placed in a bucket with ice. The collected blood samples may be archived for 
additional analysis of potential metabolites.
Blood samples for plasma concentration analysis of ketamine will be 
collected into a tube containing the anticoagulant sodium heparin at room 
temperature and immediately after the sample is drawn placed in a tube in a 
bucket with ice.
Please refer to Section 3.0 SCHEDULE OF STUDY PROCEDURES for PK 
blood sampling visits, draw times and sampling windows. The actual time of 
sample collection will be recorded on the source document and electronic case 
report form. Sampling time points may be adjusted based on the preliminary 
emerging concentration data collected from prior subjects, but the total number of 
samples collected per subject should not exceed the planned number.
Rationale for Change: Specific details on sample collection for ketamine analysis were omitted 
in the initial version.
The following sections also contain this change:

No other section.
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TAK-653
Study ID TAK-653-1003
Page 103 of 111
Protocol Incorporating Amendment No. 01
04 April 2019
Change 12: The time interval for routine collection of AEs after final dosing is clarified.
The primary changes occur in Section 10.2.8 Collection and Reporting of AEs, SAEs, Special 
Interest AEs, and Abnormal Liver Function Tests (LFT)s
Initial wording: 10.2.8.1 Collection Period
Collection of AEs (ie, AEs, SAEs, Special Interest AEs, and abnormal liver 
function tests (LFT)s will commence at the time the subject signs the informed 
consent. Routine collection of AEs will continue until the follow-up phone call on 
Day 14 (± 2 days), approximately 30 days after the last dose of investigational 
product. For subjects who discontinue before the administration of study 
medication, AEs will be followed until the subject discontinues study 
participation. 
Amended 
wording:
10.2.8.1 Collection Period
Collection of AEs (ie, AEs, SAEs, Special Interest AEs, and abnormal liver 
function tests (LFT)s will commence at the time the subject signs the informed 
consent. Routine collection of AEs will continue until the follow-up phone call on 
Day 14 (± 2 days), approximately 30 days after the last dose of investigational 
product. For subjects who discontinue before the administration of study 
medication, AEs will be followed until the subject discontinues study 
participation. 
Rationale for Change: Collection period clarified, based on elimination half-life of TAK-653.
The following sections also contain this change:
!
No other section
Change 13: Deletion of the 25 hour visit.
The primary changes occur in Section 5.1.3 Trial Exploratory Objectives
Initial wording:
Amended 
wording:
Rationale for Change: 25 hour assessment not needed
The following sections also contain this change:
Section 1.0 STUDY SUMMARY and Section 3.0 Schedule of Study Procedures
CCI
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TAK-653
Study ID TAK-653-1003
Page 104 of 111
Protocol Incorporating Amendment No. 01
04 April 2019
Change 14: Detail from study summary added to the trial design section.
The primary changes occur in Section  6.1 Trial Design
Initial wording: EEG and MEP signals evoked by TMS, as PD endpoints for assessing the effects 
of TAK-653 were selected on the basis of pre-clinical data showing that TAK-653 
increases the amplitude of MEPs in rats. The goal of this study is to evaluate the 
PD effects of TAK-653 after single dose treatment as measured by responses to 
TMS. Healthy adult (age 18 to 55 years) subjects are the intended population in 
this trial. 
The planned dose levels of TAK-653 to be evaluated are outlined in Table 6.a. 
The study drug will be 6 mg TAK-653 for the high dose, 0.5 mg TAK-653 for the 
low dose, or placebo administered orally on Day 1 of Treatment Periods 1 to 3 at 
the clinical testing site. Both doses and placebo treatments will be delivered with 2 
tablets, as indicated in Section 8.0. On Treatment Period 4, ketamine 0.5 mg/kg 
IV will be administered for 40 minutes.
Amended 
wording:
This randomized, double blind, placebo-controlled, 3-period cross-over 
study followed by one open label comparator period is designed to evaluate 
the central pharmacodynamic activity of TAK-653 in healthy subjects using 
transcranial magnetic stimulation (TMS). Approximately 24 healthy male 
and female subjects, aged 18 to 55 years, inclusive, will be enrolled. 
The study will include 3 treatment periods, each 1 day in duration, followed 
by a 2-day comparator period, alternating with 3 washout periods of at least 
10 days (not to exceed 15 days). There will be 5 clinic visits, including 
screening in which full medical, neurological, and psychiatric examinations 
will be conducted; Day 1 of each of the first 3 treatment periods, during 
which TMS testing will be conducted before and after subjects receive 
placebo or 1 of 2 doses of TAK-653; Day 1 of the fourth treatment period, 
during which TMS testing will be conducted before and after subjects 
receive the (NMDA) (N-methyl-D-aspartate) antagonist ketamine, which will 
be open label. 
Before the start of each treatment period, the investigator will review the 
safety assessments for the subject, including vital signs, and 
electrocardiogram (ECG). 
On the first day of each treatment period (Day 1), each subject will undergo 
a TMS session assessing baseline TMS-elicited motor-evoked potential 
(MEP) amplitude and threshold, followed by administration of TAK-653 or 
placebo (Treatment Periods 1-3), or ketamine (Treatment Period 4). For the 
first 3 treatment periods, TMS and MEP/electroencephalogram assessment 
sets, will be conducted along with blood sample collection for 
pharmacokinetic (PK) analyses at predose and starting at 30 and 150 
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TAK-653
Study ID TAK-653-1003
Page 105 of 111
Protocol Incorporating Amendment No. 01
04 April 2019
minutes (2 ½ hours) after dosing. The 2 ½ hour time point is chosen to 
capture Cmax, and the 30 minute time point to capture a lower exposure level 
in each subject. In Period 4, each subject will undergo a TMS session 
assessing baseline TMS-elicited MEP amplitude and threshold, and blood 
sample collection for PK analyses at predose, followed by administration of 
ketamine intravenously (0.5 mg/kg over 40 minutes). TMS assessments will 
be conducted at 150 minutes (2.5 hours) after ketamine initiation (when 
ketamine acute dissociative effects have subsided), and blood sample 
collection for PK analysis at selected timepoints. Subjects will undergo 
follow-up TMS session starting at 24 hours (Day 2 of Period 4) to capture 
ketamine modulation of TMS responses at a time in which antidepressant 
effects of ketamine are already present in a major depressive disorder 
population.
Subjects will remain in the clinic on treatment days until approximately 2 
hours post-TMS procedures for safety observation. During the 
ketamine-testing period, subjects will remain overnight following the 
infusion, until the 24 hour follow-up TMS assessments have been completed. 
Before discharge, a neurological and mental state examination will be 
performed. 
EEG and MEP signals evoked by TMS, as PD endpoints for assessing the effects 
of TAK-653 were selected on the basis of pre-clinical data showing that TAK-653 
increases the amplitude of MEPs in rats. The goal of this study is to evaluate the 
PD effects of TAK-653 after single dose treatment as measured by responses to 
TMS. Healthy adult (age 18 to 55 years) subjects are the intended population in 
this trial. 
The planned dose levels of TAK-653 to be evaluated are outlined in Table 6.a. 
The study drug will be 6 mg TAK-653 for the high dose, 0.5 mg TAK-653 for the 
low dose, or placebo administered orally on Day 1 of Treatment Periods 1 to 3 at 
the clinical testing site. Both doses and placebo treatments will be delivered with 2 
tablets, as indicated in Section 8.0. On Treatment Period 4, ketamine 0.5 mg/kg 
IV will be administered for 40 minutes.
Rationale for Change: Text from study summary replicated in study design section for clarity
The following sections also contain this change:
No other sections.
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TAK-653
Study ID TAK-653-1003
Page 106 of 111
Protocol Incorporating Amendment No. 01
04 April 2019
Change 15: Description of study blinding corrected.
The primary changes occur in Section 8.1.3 Clinical Study Drug Blinding
Initial wording:Clinical Study Drug Blinding
This is a double-blind study; the investigator and subjects are blinded to treatment
assignment. An unblinded study drug supply will be provided to an unblinded 
pharmacist or other qualified personnel at the study site who will blind the study 
supplies. Treatment identity (name and strength or potency) will be included on 
the study drug container label. Randomization code/disclosure envelopes or lists 
will be provided per the standard operating procedures of the study site.
Amended 
wording:
Clinical Study Drug Blinding
This is a double-blind study; the investigator and subjects are blinded to 
treatmentsequence group assignment. An unblinded study drug supply will be 
provided to an unblinded pharmacist or other qualified personnel at the study site 
who will blind the study supplies. Treatment identity (name and strength or 
potency) will be included on the study drug container label. Randomization 
code/disclosure envelopes or lists will be provided per the standard operating 
procedures of the study site.
Rationale for Change: To correctly state blinding
The following sections also contain this change:

No other section
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TAK-653
Study ID TAK-653-1003
Page 107 of 111
Protocol Incorporating Amendment No. 01
04 April 2019
Change 16: Definition of safety analysis set revised.
The primary changes occur in Section 11.1.1.1 Safety Set
Initial 
wording:
Safety Set
The Safety Analysis Set will consist of all subjects who are enrolled and received 
1 dose of study drug. Subjects in this analysis set will be used for demographics, 
baseline characteristics, and safety summaries.
Amended 
wording:
Safety Set
The Safety Analysis Set will consist of all subjects who are enrolledrandomized
and received 1 dose of study drug. Subjects in this analysis set will be used for 
demographics, baseline characteristics, and safety summaries.
Rationale for Change: To correct the definition of the safety set.
The following sections also contain this change:

No other section
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TAK-653
Study ID TAK-653-1003
Page 108 of 111
Protocol Incorporating Amendment No. 01
04 April 2019
Change 17: Pregnancy and contraception language updated.
The primary changes occur in Appendix D
Pregnancy and Contraception
Initial wording:The following procedures apply for contraception and pregnancy avoidance.
1.
Highly effective methods of contraception are defined as “those, alone or in 
combination, that result in a low failure rate (ie, less than 1% failure rate per 
year when used consistently and correctly). In this study, where medications 
and devices containing hormones are included/excluded, the only acceptable 
methods of contraception are: 

Non-Hormonal Methods: 
–
Intrauterine device (IUD).
–
Bilateral tubal occlusion.
–
Vasectomised partner (provided that partner is the sole sexual partner 
of the trial participant and that the vasectomised partner has received 
medical assessment of the surgical success.
–
True sexual abstinence, only if this is in line with the preferred and 
usual lifestyle of the subject. True abstinence is defined as refraining 
from heterosexual intercourse during the entire period of the study, 
from 1 month before the first dose until 5 half lives PLUS 30 days after 
last dose.

Hormonal Methods: Hormonal contraception may be susceptible to 
interaction with the investigative compound, comparator, concomitant 
medications, which may reduce the efficacy of the contraception method 
(Evaluate on compound-by-compound and protocol –by-protocol basis 
and obtain clinical pharmacology justification).
–
Combined (estrogen and progestogen) hormonal contraception 
associated with inhibition of ovulation initiated at least 3 months 
before the first dose of study drug OR combined with a barrier method 
(male condom, female condom or diaphragm) if for shorter duration 
until she has been on contraceptive for 3 months;

Oral †.

Intravaginal † (eg, ring).

transdermal †.
–
Progestogen-only hormonal contraception associated with inhibition 
of ovulation1 initiated at least 3 months before the first dose of study 
drug OR combined with a barrier method (male condom, female 
condom or diaphragm) if shorter till she has been on contraceptive for 
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TAK-653
Study ID TAK-653-1003
Page 109 of 111
Protocol Incorporating Amendment No. 01
04 April 2019
3 months;

oral †.

Injectable.

Implantable.
2.
If genotoxicity/teratogenicity/embryotoxicity is unlikely to be caused by the 
investigational drug, comparator, background therapy or standard of care 
medications effective methods of contraception (there may be a higher than 
1% failure rate) are: 

Double-barrier method (contraceptive sponge, diaphragm or cervical cap 
with spermicidal jellies or creams PLUS male condom).

Progestogen only hormonal contraception, where inhibition of ovulation is 
not the primary mode of action PLUS condom with or without spermicide.
Amended 
wording:
The following procedures apply for contraception and pregnancy avoidance.
1. Highly effective methods of contraception are defined as “those, alone or in 
combination, that result in a low failure rate (ie, less than 1% failure rate per 
year when used consistently and correctly). In this study, where medications 
and devices containing hormones are included/excluded, the only acceptable 
methods of contraception are: 

Non-Hormonal Methods: 
–
Intrauterine device (IUD).
–
Bilateral tubal occlusion.
–
Vasectomised partner (provided that partner is the sole sexual partner 
of the trial participant and that the vasectomised partner has received 
medical assessment of the surgical success.
–
True sexual abstinence, only if this is in line with the preferred and 
usual lifestyle of the subject. True abstinence is defined as refraining 
from heterosexual intercourse during the entire period of the study, 
from 1 month before the first dose until 5 half lives PLUS 30 days after 
last dose.

Hormonal Methods: Hormonal contraception may be susceptible to 
interaction with the investigative compound, comparator, concomitant 
medications, which may reduce the efficacy of the contraception method 
(Evaluate on compound-by-compound and protocol –by-protocol basis 
and obtain clinical pharmacology justification).
–
Combined (estrogen and progestogen) hormonal contraception 
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TAK-653
Study ID TAK-653-1003
Page 110 of 111
Protocol Incorporating Amendment No. 01
04 April 2019
associated with inhibition of ovulation initiated at least 3 months 
before the first dose of study drug OR combined with a barrier method 
(male condom, female condom or diaphragm) if for shorter duration 
until she has been on contraceptive for 3 months;

Oral †.

Intravaginal † (eg, ring).

transdermal †.
–
Progestogen-only hormonal contraception associated with inhibition 
of ovulation1 initiated at least 3 months before the first dose of study 
drug OR combined with a barrier method (male condom, female 
condom or diaphragm) if shorter till she has been on contraceptive for 
3 months;

oral †.

Injectable.

Implantable.
2.
If genotoxicity/teratogenicity/embryotoxicity is unlikely to be caused by the 
investigational drug, comparator, background therapy or standard of care 
medications effective methodsEffective method of contraception (there may 
be a higher than 1% failure rate) are: 

Double-barrier method (contraceptive sponge, diaphragm or cervical cap 
with spermicidal jellies or creams PLUS male condom).

Progestogen only hormonal contraception, where inhibition of ovulation is 
not the primary mode of action PLUS condom with or without spermicide.
Rationale for Change: To update template language to correctly match required conditions for 
the study
The following sections also contain this change:

No other section
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TAK-653
Study ID TAK-653-1003
Page 111 of 111
Protocol Incorporating Amendment No. 01
04 April 2019
Change 18: Revisions to the Schedule of Study Procedures table and footnotes.
The primary changes occur in Section 3.0 Schedule of Study Procedures
Full Physical 
Exam
Assessment added at visits 3,4,5 and ET
Vital signs
Other vital signs (RR, tympanic temperature) added on Day 2 of Period 4 
(Ketamine)
12 lead ECG: Assessments added:  Day 1 Period 4 (Ketamine) and ET visit
Urine pregnancy test added: Screening
Plasma sample for TAK-653 PK added: ET visit
Footnote to ECG: Post treatment ECG in all treatment periods before discharge
Treatment Period 1 to 3: 90 minute assessment column deleted as no assessments occur
 
Treatment period 4:
!
100 and 480, and 25 hour columns deleted as no assessments assigned.
!
The 70 minute column for ECG and vital signs adjusted to 75 minutes.
!
Ketamine administration shown as 0 to 40 minute infusion column.
!
C-SSRS 24 hr assessment added; ECG 24 hour assessment added
CCI
CCI
Property of Takeda: For non-commercial use only
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