Clinical trial NCT05113771
Conditions: Treatment Resistant Depression
Keywords: TRD, Treatment Resistant Depression
Sponsor: Denovo Biopharma LLC
Start date: 2022-06-29; Completion date: 2024-03-05
Enrollment: 197 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This study was conducted as a randomized, double-blind, placebo-controlled, multi-center Phase 2b study. Approximately 180 subjects with treatment resistant depression who meet all eligibility criteria will be enrolled. The primary endpoint is to demonstrate liafensine is superior to placebo in DGM4 positive patients with TRD.

Detailed description:
This study is a randomized, double blind, placebo-controlled Phase 2b study to assess the efficacy, safety, tolerability, and pharmacokinetics of liafensine. Eligible patients were randomized 1:1:1 to receive liafensine 1 mg QD, liafensine 2 mg QD, or placebo QD. The main objectives of this study are as follows:

Primary Efficacy Objective: To demonstrate that liafensine was superior to placebo in DGM4 positive patients with TRD as assessed by the change in MADRS total score from baseline to Day 42 of double blind treatment

Key Secondary Efficacy Objective: To evaluate the change from baseline to Day 42 in DGM4 positive patients with TRD treated with liafensine vs placebo on the Clinical Global Impression-Severity Scale (CGI S)

Other Secondary Efficacy Objective: To evaluate the Clinical Global Impression-Improvement Scale (CGI I) at Day 42 in DGM4 positive patients with TRD treated with liafensine vs placebo

Safety Objective: To compare the safety and tolerability of liafensine vs placebo in all randomized patients with TRD who received at least one dose of study drug during double blind treatment

Psychiatric assessments were performed by a psychiatrist or trained and certified clinical staff member. Neurologic assessments were performed by an experienced clinician. Patients who fulfilled Hy's Law, defined as ALT or AST ≥ 3 × ULN and TBL ≥ 2 × ULN, in the absence of significant increase in ALP and in the absence of an alternative diagnosis that explained the increase in total bilirubin, were discontinued, with medical follow up as appropriate.

Arms: arm 1: Patients with TRD were treated with liafensine 1 mg QD for 6 weeks. arm 2: Patients with TRD were treated with liafensine 2 mg QD for 6 weeks. arm 3: Patients with TRD were treated with placebo 1 mg QD for 6 weeks.
Interventions: intervention 1: Liafensine intervention 2: Placebo
Intervention descriptions: intervention 1: Liafensine intervention 2: Placebo

Protocol documents:
Prot_000.pdf: 
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TITLE PAGE 
 
 
CLINICAL STUDY PROTOCOL 
 
Protocol Title: 
A Biomarker-Guided, Randomized, Double-Blind, Placebo-Controlled 
Efficacy and Safety Study of Liafensine in Patients with Treatment-
Resistant Depression 
Protocol Number: 
DB104-01 
Protocol Name: 
ENLIGHTEN 
IND Number: 
152170 
Study Sponsor: 
Denovo Biopharma LLC 
10240 Science Center Drive, Suite 120 
San Diego, CA 92121 
USA 
Medical Monitor: 
Larry Alphs 
lalphs@denovobiopharma.com 
Phone:1-858-799-1021 Ext. 740 
Version: 
Amendment 2 
Date: 
29 August 2022 
 
 
 
 
STATEMENT OF CONFIDENTIALITY 
The information contained in this protocol is confidential and is intended for the use of clinical 
investigators. It is the property of Denovo Biopharma LLC and should not be copied by or distributed 
to persons not involved in the clinical investigation of liafensine unless such persons are bound by a 
confidentiality agreement with Denovo Biopharma LLC. 


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SPONSOR APPROVAL 
 
 
 
Sponsor’s Approval 
The protocol has been approved by Denovo Biopharma LLC. 
 
Responsible Medical Officer: Larry Alphs 
 
 
 
 
Company/Sponsor Signatory 
Larry Alphs 
Sr VP, CNS Clinical Development 
Denovo Biopharma LLC 
 
Date 
 
02-Sep-2022


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PROTOCOL SYNOPSIS 
Name of Sponsor/Company: 
Denovo Biopharma LLC 
10240 Science Center Drive, Suite 120 
San Diego, CA 92121 
USA 
Name of Investigational Product: Liafensine (DB104; previously BMS-820836) 
Name of Active Ingredient: Liafensine 
Protocol Number: DB104-01 
Title of Study: A Biomarker-Guided, Randomized, Double-Blind, Placebo-Controlled Efficacy and 
Safety Study of Liafensine in Patients with Treatment-Resistant Depression 
Study Center(s): Multiple 
Phase of Development: 2b 
Rationale: 
Major depressive disorder (MDD) is a common psychiatric disorder, with a lifetime prevalence rate of 
approximately 13-17% in the United States (Hasin 2005, Kessler 2005). Although options for 
pharmacologic treatment have expanded significantly in the past 25 years, between one-third and 
two-thirds of patients will not respond to the first antidepressant prescribed, and up to 33% will not 
respond to multiple interventions (American Psychiatric Association 2013, Berlim 2008, Cain 2007). 
Novel antidepressants that produce a clinically significant improvement in patients with MDD who 
have failed to respond to more than one treatment of adequate dose and duration, without producing 
significant side effects, would represent an important advance in the treatment of treatment-resistant 
depression (TRD). 
For most of the last 30 years, the biogenic amine hypothesis of depression has been driving much of 
the research into the etiology and treatment of this debilitating psychiatric disorder. Most conventional 
antidepressants are antagonists at serotonin (5-HT) and/or norepinephrine reuptake sites, and their 
efficacy correlates reasonably well with their affinity for these receptors. At present, the most 
commonly used treatments for MDD are the selective serotonin reuptake inhibitors (SSRIs), such as 
escitalopram, or the serotonin-norepinephrine reuptake inhibitors (SNRIs), such as duloxetine. 
Recently, a compound with a novel mechanism of action, esketamine (SPRAVATO®), was approved 
in the United States (US) for the treatment of TRD in conjunction with an oral antidepressant 
(SPRAVATO 2019). While the precise mechanism of action of esketamine is unknown, the compound 
is an N-methyl-D-aspartate (NMDA) receptor antagonist. Esketamine use is associated with significant 
adverse effects including dizziness, nausea, sedation, and psychological effects, including 
dissociative/perceptual changes. Because of the risks of dissociation with esketamine, the US Food and 
Drug Administration (FDA) has established a Risk Evaluation and Mitigation Strategy (REMS) 
requiring that patients be monitored by a healthcare professional for at least 2 hours at each treatment 
session, concluding with an assessment establishing that the patient is clinically stable and may safely 
leave the healthcare setting. 


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This adverse event profile, together with esketamine’s REMS requirements, limits its clinical utility, 
and supports the continued development of novel compounds for the treatment of TRD. 
Liafensine (also known as DB104 and previously BMS-820836) is 6-[(4S)-1,2,3,4-tetrahydro-2-
methyl-4-(2-naphthalenyl)-7-isoquinolinyl]-3-pyridazinamine and it is a potent and selective inhibitor 
of the reuptake of the 3 monoamines: 5-HT, norepinephrine, and dopamine. Liafensine was developed 
to incrementally advance antidepressant treatment by synergizing these individual monoaminergic 
approaches to treating depression. 
Liafensine has been tested in 11 Phase 1 studies, and 3 Phase 2b studies (including one rollover study). 
In the Phase 1 studies, single doses of up to 5 mg, and multiple doses of up to 4 mg liafensine were 
found to be generally safe and well tolerated. The pharmacokinetic (PK) profile of liafensine was 
compatible with once-daily (QD) dosing, supporting the potential for liafensine to have low potential 
for discontinuation symptoms. In the Phase 2b studies, patients who did not experience adequate 
response to either duloxetine (Study CN162006), or duloxetine or escitalopram (Study CN162007), 
were randomized to receive either liafensine or duloxetine (CN162006), or duloxetine or escitalopram 
(CN162007), for 6 weeks. In Study CN162006, a flexible dose of liafensine was used (0.5-2 mg QD). 
In Study CN162007, several fixed dosage levels of liafensine were used (0.25, 0.5, 1, and 2 mg QD). 
In these Phase 2b studies, liafensine was found to be generally safe and well tolerated. In Study 
CN162006, the most common adverse events (AEs) reported by at least 5% of patients treated with 
liafensine were headache (7.0%), nausea (7.0%), constipation (5.3%), and anxiety (5.3%). In Study 
CN162007, the most common AEs reported by at least 5% of patients treated with any dose of 
liafensine were headache (14.3%), nausea (12.0%), nasopharyngitis (8.8%), upper respiratory tract 
infection (8.0%), dry mouth (8.0%), constipation (7.7%), dizziness (7.0%), diarrhea (5.5%), 
fatigue (5.9%), and urinary tract infection (5.5%). 
In the Phase 2b studies conducted by Bristol-Myers Squibb (BMS), there were no significant 
differences noted between the treatment groups in the decrease (improvement) of the mean 
Montgomery-Åsberg Depression Rating Scale (MADRS) total score. In an effort to identify a potential 
pharmacogenomic biomarker of response to liafensine, Denovo Biopharma LLC (Denovo) has 
conducted a genome-wide scan with human whole genome single nucleotide polymorphism (SNP) 
arrays using germline deoxyribonucleic acid (DNA) extracted from blood samples of patients in BMS 
Studies CN162006 and CN162007. From this genome-wide screening, SNP rs12217173 was identified 
as strongly associated with treatment response to liafensine (p = 6.6 x10-8). Patients with a GG 
genotype at rs12217173 showed significantly better response to liafensine compared to patients with an 
AA or AG genotype, or patients in the control arm (duloxetine or escitalopram). These findings were 
replicated using a separate validation sample set. Liafensine treatment effects in patients with the GG 
genotype were comparable for the 0.5 to 2 mg QD flexible doses in the CN162006 study and for the 
1 mg QD and 2 mg QD doses in the CN162007 study. These combined data showed that patients with 
the GG genotype had a 4.7-point difference in MADRS total score decrease from baseline in the 
liafensine arm vs the control arm (p = 0.025), while patients with the AA or AG genotype at 
rs12217173 did not show an improved treatment effect in the liafensine arm vs the control arm 
(MADRS 0.3-point difference, p = 0.74). Moreover, patients carrying different genotypes at 
rs12217173 did not exhibit different treatment responses to duloxetine or escitalopram. Thus, SNP 
rs12217173 appears to be a pharmacogenomic biomarker specific for liafensine; Denovo has termed 
rs12217173 as “DGM4” (Denovo Genomic Marker 4) and the GG genotype of DGM4 is defined as 
DGM4 positive, whereas the AA or AG genotype of DGM4 is defined as DGM4 negative.  


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Objectives: 
Primary Efficacy Objective 
• 
To demonstrate that liafensine is superior to placebo in DGM4-positive patients with TRD as 
assessed by the change in MADRS total score from baseline to Day 42 of double-blind 
treatment 
Key Secondary Efficacy Objective 
• 
To evaluate the change from baseline to Day 42 in DGM4-positive patients with TRD treated 
with liafensine vs placebo on the Clinical Global Impressions Scale-Severity (CGI-S) 
Safety Objectives 
• 
To compare the safety and tolerability of liafensine vs placebo in all randomized patients with 
TRD who received at least one dose of study drug during double-blind treatment  
• 
To evaluate safety for liafensine 1 mg QD and 2 mg QD vs placebo in both DGM4-positive 
and DGM4-negative patients 
Other Secondary Efficacy Objectives 
• 
To evaluate the Clinical Global Impressions Scale-Improvement (CGI-I) at Day 42 in DGM4-
positive patients with TRD treated with liafensine vs placebo 
• 
To evaluate the change from baseline to Day 42 in DGM4-positive patients with TRD treated 
with liafensine vs placebo on the patient-reported functionality with Sheehan Disability Scale 
(SDS) 
Exploratory Objectives 
• 
To compare the proportion of DGM4-positive patients with TRD who respond to liafensine 
after 6 weeks of treatment vs placebo (response is defined as ≥ 50% improvement from 
baseline in MADRS total score at Day 42) 
• 
To compare the proportion of DGM4-positive patients with TRD who are in remission after 
6 weeks of treatment with liafensine vs placebo (remission is defined as MADRS total score 
≤ 10 at Day 42) 
• 
To evaluate the change from baseline to Day 42 in DGM4-positive patients with TRD treated 
with liafensine vs placebo on MADRS anhedonia subscale and individual items 
• 
To compare the efficacy of liafensine vs placebo in DGM4-negative patients with TRD, as 
assessed by change in MADRS total score from baseline to Day 42 
• 
To evaluate efficacy for liafensine 1 mg QD and 2 mg QD vs placebo in both DGM4-positive 
and DGM4-negative patients 
• 
To evaluate the PK of liafensine as part of the population PK analyses 


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Endpoints: 
Primary Endpoint 
• 
Change in MADRS total score from baseline to Day 42, in DGM4-positive patients 
Key Secondary Endpoint 
• 
Change in CGI-S from baseline to Day 42, in DGM4-positive patients 
Safety Endpoints 
• 
Adverse events as characterized by type, frequency, severity, timing, seriousness, and 
relationship to study therapy 
• 
Laboratory abnormalities as characterized by type, frequency, severity, and timing 
• 
Vital signs including supine (after at least 5 min rest) and standing (after standing 1 min and 
3 min), blood pressure and heart rate, weight, electrocardiogram (ECG), clinical laboratory 
evaluation, Discontinuation-Emergent Signs and Symptoms scale (DESS) scale, and Columbia 
Suicide Severity Rating Scale (C-SSRS) data 
Other Secondary Endpoints 
• 
CGI-I at Day 42, in DGM4-positive patients 
• 
Change in SDS from baseline to Day 42, in DGM4-positive patients  
Exploratory Endpoints 
• 
Treatment response (defined as ≥ 50% improvement from baseline in MADRS total score at 
Day 42) in DGM4-positive patients 
• 
Remission (defined as MADRS total score ≤ 10 at Day 42) in DGM4-positive patients 
• 
Change in MADRS anhedonia subscale and individual items from baseline to Day 42, in 
DGM4-positive patients 
• 
Change in MADRS total score from baseline to Day 42, in DGM4-negative patients 
• 
Change in MADRS total score from baseline to Day 42 in 1 mg QD group and 2 mg QD group, 
in both DGM4-positive and DGM4-negative patients 


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Study Design: 
This study will be conducted as a multicenter, randomized, double-blind, placebo-controlled Phase 2b 
trial to assess the efficacy, safety, tolerability, and PK of liafensine in DGM4-stratified TRD patients. 
The study includes an up to 21-day screening period. 
Approximately 180 patients with TRD who meet all eligibility criteria will be randomized in a 1:1:1 
ratio to receive either liafensine 1 mg QD, liafensine 2 mg QD, or placebo QD for 6 weeks. 
Approximately 150 randomized patients carrying genotype GG at DGM4 (DGM4-positive) and 
approximately 30 randomized patients carrying genotype AA or AG at DGM4 (DGM4-negative) will 
be enrolled in this study. DGM4 status (positive vs negative) of randomized patients will be blinded to 
the sites, the patients, and sponsor. An Interactive Response Technology (IRT) system will be used for 
blinding DGM4 status, and to achieve the planned randomization ratio of 
DGM4-positive:DGM4-negative patients by randomly excluding most screened DGM4-negative 
patients (~80%). Randomization will be stratified by DGM4 status (positive vs negative) and region 
(North America vs Other). Patients who complete the study or discontinue after randomization will 
have two post-study follow-up visits (14 days after the last administered dose of study drug, and 
28 days after the last administered dose of study drug); the 2nd follow-up visit will be conducted via 
phone call. Every effort will be made to ensure that the protocol-required tests and procedures are 
completed. 
During the study, safety will be assessed on the basis of spontaneously reported AEs; the DESS; 
physical, neurological, and psychiatric examinations (including the C-SSRS); vital signs including 
supine and standing blood pressure and heart rate; weight; 12-lead ECGs; clinical laboratory test 
results; serum and urine pregnancy tests (females of childbearing potential only); and concomitant 
medication assessments. In addition to blood samples collected for PK, additional blood samples may 
be collected for determination of plasma concentrations of liafensine and its primary metabolite in 
association with the evaluation of safety signals. 
The overall study design is shown in Figure 1. The schedule of study assessments is presented in 
Table 1 with the clinical laboratory tests shown in Table 3. 
To ensure the safety of patients enrolled in this study, an Independent Data Monitoring Committee 
(IDMC) will monitor data on an ongoing basis. The IDMC will comprise individuals external to the 
sponsor and will consist of at least one medical expert in the relevant therapeutic area, at least one 
hepatologist, and at least one statistician. 
Methodology: 
This is a randomized, double-blind, placebo-controlled Phase 2b trial to assess the efficacy, safety, 
tolerability, and PK of liafensine. The primary endpoint is change in MADRS total score from baseline 
(Visit 3, Day -1) to Visit 7 (Day 42) in DGM4-positive patients. The primary analysis will be 
conducted to assess the superiority of liafensine treatment (combined liafensine 1 mg QD and 2 mg 
QD doses) vs placebo in randomized patients who are DGM4-positive. 


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Sample Size Justification: 
Eligible patients will be randomized 1:1:1 to receive liafensine 1 mg QD, liafensine 2 mg QD, or 
placebo QD. The primary analysis is to assess treatment difference in MADRS total score change from 
baseline (Visit 3, Day -1) to Visit 7 (Day 42), between the combined liafensine 1 mg QD and 2 mg QD 
doses vs placebo, in DGM4-positive patients. A sample size of 47 randomized DGM4-positive patients 
per arm is sufficient to detect a 4.5-unit difference between the combined liafensine 1 mg QD and 2 mg 
QD treatment groups and the placebo treatment group in the change in MADRS total score with 80% 
power at the 2-sided 0.05 alpha level, assuming a standard deviation of 9 units. 
To compensate for potential loss of power due to randomized patients who do not take at least one 
dose of study drug or who do not have a post-randomization efficacy evaluation (~5%), a total of 
approximately 150 DGM4-positive patients (50 DGM4-positive patients per arm) will be randomized. 
To examine trend in the total patient population and in the subgroup of DGM4-negative patients in 
order to evaluate DGM4 as a potential biomarker for predicting response to liafensine, approximately 
20% additional DGM4-negative patients (10 per arm, total approximately 30) will also be randomized. 
The sample size of 30 randomized patients in the DGM4-negative group is not estimated based on 
formal statistics in terms of power and alpha level. 
Sample size re-estimation may be conducted if the percentage of missing data at Day 42 visit is higher 
than expected and/or if the observed variance is higher than the one assumed in the sample size 
estimation. 
Number of Patients (planned): 
~180 
Diagnosis and Criteria for Inclusion: 
Subject Inclusion Criteria: 
Patients must meet all of the following inclusion criteria to be eligible for enrollment into the study: 
1. Provide signed informed consent which includes pharmacogenomic (PGx) testing. 
2. Have a diagnosis of MDD without psychotic features, according to the Diagnostic and 
Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria, based on clinical 
assessment and confirmed by the Mini International Neuropsychiatric Interview (MINI). 
3. TRD documented in the Massachusetts General Hospital (MGH) Antidepressant Treatment 
Response Questionnaire (ATRQ) (5-year version). That is: 
a. clinically meaningful inadequate response (estimated < 50% improvement per 
investigator/patient consensus and documented by the investigator) with: 
1) at least 2 treatment courses with antidepressant regimens; 
2) used at least 2 different pharmacologic treatment classes (eg, SSRI, SNRI, TCA, 
MAOI, atypical); or if only one class treatment is used, at least one combination 
treatment course; 
3) the doses have been given at accepted therapeutic doses for an adequate duration (at 
least 6 weeks), per product label; 
4) One of these inadequate response must occur within the current episode. 
Note: non-pharmacological treatment (eg, cognitive behavioral therapy, electroconvulsive 
therapy, repetitive transcranial magnetic stimulation, vagus nerve stimulation, acupuncture) are 
not counted as treatment regimen. 
4. To be eligible, patients must have DGM4 genotype results obtained from the designated 
Clinical Laboratory Improvement Amendments (CLIA) lab, and all eligible DGM4-positive 


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patients and about 20% DGM4-negative patients will be randomly included by an IRT system 
in order to achieve the appropriate randomization ratio of DGM4-positive vs negative patients. 
5. Pregnancy conception limitations 
• 
Female patients must be postmenopausal or surgically sterile or, if of childbearing 
potential and the partner is not vasectomized (6 months minimum), must agree to use a 
medically acceptable form of contraception from the time of signing the informed consent 
form (ICF) through at least 60 days following the last administration of study drug. If only 
the barrier method is used, a double barrier must be employed. Postmenopausal women 
must have had ≥ 24 months of spontaneous amenorrhea. Surgically sterile women are 
defined as those who have had a hysterectomy, bilateral ovariectomy, or bilateral tubal 
ligation. All women of childbearing potential must have a negative pregnancy test result 
before administration of study drug. 
• 
Male patients must be biologically incapable of having children (eg, vasectomized) or 
must agree to use the above forms of birth control for themselves and their partner from 
the time of signing the ICF through at least 120 days following the last administration of 
study drug. 
6. Be fluent in the local language. 
7. Male or female aged 18 to 70, inclusive, at time of Visit 1. 
8. Have a HAMD-17 total score ≥ 21 at screening and baseline. 
9. Be willing to discontinue the use of antidepressant drugs (including over-the-counter 
medications to treat depression [eg, St John’s Wort]) at least 5 half-lives (or at least 1 week for 
herbal or other over-the-counter medications for depression) prior to baseline (Day -1). For 
fluoxetine, a washout period of at least 3 weeks for ≤ 20 mg/day and at least 4 weeks for 
> 20 mg/day is required. 
Subject Exclusion Criteria: 
Patients with any of the following characteristics/conditions will be excluded from the study: 
1. Prior participation in a study with liafensine. 
2. Used any investigational drug product, device, or biologic within 3 months or 5 half-lives 
(whichever is longer) prior to baseline (Day -1). 
3. A positive pregnancy test result or currently breastfeeding. 
4. Clinically significant and/or unstable illness (including chronic, persistent, or acute infection), 
medical/surgical procedure, or trauma within 30 days prior to screening or between screening 
and baseline (Day -1) as determined by the investigator. 
5. A history or presence of a clinically significant and/or unstable hepatic, renal, gastrointestinal, 
cardiovascular, endocrine, respiratory, immunologic, hematologic, dermatologic, or neurologic 
abnormality, or any other condition, that in the investigator’s opinion, represents potential risk 
to the patient’s safety and ability to fully participate in the study, or affects the absorption, 
distribution, metabolism, or excretion of liafensine. 
6. Presence of autoimmune hepatitis, primary sclerosing cholangitis, untreated hepatitis C, active 
hepatitis B, or any other uncontrolled or unstable liver disease according to local guidance. 
7. Uncontrolled human immunodeficiency virus (HIV) infection according to local guidance. 
8. Uncontrolled abnormal thyroid function according to local guidance. 


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9. One or more clinical laboratory evaluations are outside the reference range, at screening, that are 
in the investigator’s opinion, of potential risk to the patient’s safety. 
10. Has at the Screening Visit: 
• 
Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels > 1.5x the 
upper limit of normal (ULN) at screening.  
• 
Total bilirubin (TBL) > 2 mg/dL (34.2 µmol/L) at screening, unless there is an explained 
indirect hyperbilirubinemia, eg, Gilbert’s syndrome. 
• 
Alkaline phosphatase (ALP) > 1.5x the ULN at screening. 
Note: Laboratory tests can be repeated to see if values return to normal range, but any such 
laboratory abnormality must be resolved by the Baseline Visit (Day -1). 
11. Clinically significant vital sign abnormality at screening. This includes, but is not limited to, 
the following, in the supine (after at least 5 min rest) and standing (after 1 min and 3 min 
standing): systolic blood pressure ≥ 140 mmHg; diastolic blood pressure ≥ 90 mmHg; or heart 
rate < 50 or > 90 beats per minute. If the initial blood pressure is ≥ 140/90 mmHg, the lowest 
value from up to 3 additional attempts, which also must not be ≥ 140/90 mmHg, should be 
used. Patients with symptomatic orthostatic hypotension, at the discretion of investigator, will 
be excluded. 
12. Corrected QT interval measurement according to the Fridericia rule (QTcF) > 450 msec for 
men and > 470 msec for women during controlled rest at screening, or history of long-QT 
syndrome. 
13. ECGs containing any of the following readings: 
⚫ 
Left bundle branch block 
⚫ 
Right bundle branch block with QRS duration > 140 ms 
⚫ 
Intraventricular conduction defect with QRS duration > 140 ms 
⚫ 
Long QT syndrome 
14. History of seizure, other than childhood febrile seizures. 
15. History of clinically significant head trauma, including closed head injury with loss of 
consciousness, that is, in the opinion of the investigator, likely to affect central nervous system 
function. 
16. History of clinically significant symptomatic orthostatic hypotension (ie, postural syncope). 
17. History of narrow angle glaucoma. 
18. History of cancer within 2 years prior to screening or between screening and baseline (Day -1), 
except for non-metastatic basal and/or squamous cell carcinoma of the skin. 
19. Use of prescription or nonprescription medications for attention-deficit hyperactivity disorder 
(ADHD), narcolepsy, or cognitive enhancement (eg, methylphenidate, atomoxetine, modafinil, 
ginkgo biloba, and huperzine A) within 30 days prior to screening or between screening and 
baseline (Day -1). 


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20. Regular consumption of (eg, more days than not) excessive quantities of xanthine-containing 
beverages (eg, more than five cups of coffee or the equivalent per day) within 30 days prior to 
screening or between screening and baseline (Day -1). 
21. Urine drug screen (UDS) positive for a drug of abuse, with the exception of cannabis in 
countries where it is legally available (see Table 3 for list of drugs of abuse). Where legal, 
prior use of cannabis is permitted provided the patient agrees to abstain from smoking or 
ingesting cannabis or cannabis products during the study. 
22. Use of potent inducers of CYP3A4 (eg, rifampin, rifabutin, phenytoin, carbamazepine, or 
phenobarbital) within 2 weeks prior to baseline (Day-1). 
23. Current diagnosis or history of a psychotic disorder, MDD with psychotic features, manic or 
hypomanic episode of bipolar or related disorders. 
24. Current diagnosis of anxiety disorder (if primary), post-traumatic stress disorder, obsessive-
compulsive disorder (if primary), intellectual disability (DSM-5 diagnostic code 319), 
borderline personality disorder, antisocial personality disorder, histrionic personality disorder, 
or narcissistic personality disorder according to the DSM-5 criteria, or any other psychiatric or 
neurologic disorder or symptom due to a general medical condition, that, in the judgement of 
the investigator, could pose undue risk to the patient or compromise the study. 
25. Hospitalized or discharged from psychiatric ward within 8 weeks prior to the screening visit 
and planned hospitalization for any condition(s) during the study.  
26. Moderate or severe alcohol use disorder or other substance use disorder (except nicotine or 
caffeine), within 6 months prior to screening, according to the DSM-5 criteria. 
27. Significant risk of suicide determined by: 
a. Acute suicidality as evidenced by answering “yes” to Question 5 (“In the Past Year”) on 
the C-SSRS, indicating active suicidal ideation with specific plan and intent for suicide, at 
screening, or baseline (Day -1); or 
b. History of suicidal behavior as indicated by a “yes” response on the Suicidal Behavior 
section of the C-SSRS (“In the past year”) or 
c. A score ≥ 5 on Item 10 (suicidal thoughts) of the MADRS at screening or baseline 
(Day -1); or 
d. Has attempted suicide within 6 months prior to the initial screening visit. 
28. Previous allogenic bone marrow transplant. 
29. Received non-leukocyte-depleted whole blood transfusion within 4 months prior to PGx 
testing at Screening. 
30. Currently employed by the sponsor or by a clinical trial site participating in this study, or a 
first-degree relative of an employee of the sponsor or of an employee at a participating clinical 
trial site. 
Concomitant Treatment and Study Restrictions: 
Prohibited concomitant treatments and study restrictions during the study from baseline to 
14 days after the last dose of study drug (the first half of the follow-up) include: 


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1. Any investigational drug product, device, or biologic. 
2. Any prescription or nonprescription medication for ADHD, narcolepsy, or cognitive 
enhancement (eg, methylphenidate, atomoxetine, modafinil, ginkgo biloba, and huperzine A). 
3. Any psychopharmacologic drug (including antidepressants and over-the-counter medications 
to treat depression (eg, herbal medicines like St John’s Wort, or other local herbal medicines). 
4. Potent inducers of CYP3A4 (eg, rifampin, rifabutin, phenytoin, carbamazepine, or 
phenobarbital). 
Permitted concomitant treatments, provided they meet the specific requirements detailed below, 
during the study and during the indicated periods include: 
1. Up to 3 g/day paracetamol/acetaminophen. 
2. Non-psychopharmacologic drugs provided the dose and condition being treated have been 
relatively stable for at least 2 months prior to screening and between screening and baseline 
(Day -1) and are not expected to change meaningfully during the study. 
3. Soporific drugs may be used provided the dose and condition being treated have been 
relatively stable for at least 2 months prior to screening and between screening and baseline 
(Day -1) and are not expected to change meaningfully during the study. 
4. Psychotherapy (including cognitive behavioral therapy) is permitted provided psychotherapy 
was initiated at least 2 months prior to screening and is expected to remain relatively stable 
during the study. 
5. Anxiolytic drugs which do not affect 5-HT, norepinephrine, and dopamine activity may be 
used provided the dose and condition being treated have been relatively stable for at least 2 
months prior to screening and between screening and baseline (Day -1) and are not expected to 
change meaningfully during the study. 
Note 1: if a pro re nata (PRN) use has been established prior to the study, and not expected to 
change during the trial, this is considered stable treatment.  
Note 2: Medication considered necessary for the patient’s safety and well-being may be given 
at the discretion of the investigator and recorded in the appropriate sections of the electronic 
Case Report Form (eCRF). If a psychopharmacologic medication that is otherwise prohibited is 
administered the study measurements such as MADRS and CGI should be collected prior to dosing 
when possible. If any medication that is otherwise prohibited is administered to a patient, the 
investigator should inform the medical monitor prior to administration of medication when 
possible. 
Other restrictions include: 
1. Patients will be required to maintain their normal intake of xanthine-containing foods or 
beverages, and, if permitted, vitamin and herbal supplements, during the study, including the 
screening and follow-up periods. 
2. Patients should not provide blood or plasma donations between screening and baseline 
(Day -1), during the study and for 6 weeks after the last dose of study drug. 
Investigational Product, Dosage, and Mode of Administration: 


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Investigational product (study drug) will be supplied as tablets containing 1 mg liafensine or matching 
placebo. Study drug will be taken orally, once daily in the morning (AM). Patients will be instructed to 
take the study drug whole, and not to chew, divide, or crush the tablets. 
Randomization Phase: 
Liafensine 1 mg QD 
• 
Day 1 through Day 42: one 1 mg liafensine tablet and one matching placebo tablet QD 
Liafensine 2 mg QD 
• 
Day 1 through Day 7: one 1 mg liafensine tablet and one matching placebo tablet QD 
• 
Day 8 through Day 42: two 1 mg liafensine tablets QD 
Placebo QD 
• 
Day 1 through Day 42: two placebo tablets QD 
Further details regarding the packaging, storage, handling, and administration of study drug will be 
provided in the study Pharmacy Manual. 
Duration of Study Participation: 
The duration of participation for individual patients will be up to 91 days or longer, including an up to 
21-day screening period (screening period may exceed 21 days if a prolonged washout of prior drug is 
required), a 6-week double-blind treatment period, and 2 post-study follow-up visits (at 14 days and 
28 days after the last dose of study drug). 
Reference Therapy, Dosage and Mode of Administration: 
None. 
Criteria for Evaluation: 
Efficacy: 
The primary efficacy outcome measure is the change in MADRS total score from baseline (Visit 3, 
Day -1) to Visit 7 (Day 42) in DGM4-positive patients. 
Other assessments include CGI-S, CGI-I and SDS. See Table 1 for the overall schedule of efficacy 
assessments. Note that CGIs should be completed only after the Patient Rated Depression and 
Functioning Checklist (PRDF Checklist) has been completed as instructed. 
Pharmacokinetics: 
Blood samples will be collected for determination of concentrations of liafensine and its primary 
metabolite on Day 28 (Visit 6) and on Day 42 (Visit 7) prior to dosing. The time of prior dose and time 
of blood collection will be recorded. 
If the patient discontinues before Day 42 (Visit 7), a blood sample will be collected for PK on the last 
day the patient takes a full dose of study drug or as soon as possible thereafter, but within 3 days after 
the last dose in any case. When possible, and if medically appropriate, blood samples should be 
collected for PK from patients who experience a serious adverse event (SAE) or overdose. 
Pharmacogenomics: 
PGx testing is required to determine eligibility for the study. PGx analysis may determine the 
association between genetic variations and the patient's response to treatment with liafensine. 
Safety: 


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Safety will be assessed based on spontaneously reported AEs; the DESS scale; physical, neurological, 
and psychiatric examinations (including C-SSRS); vital signs including orthostatic changes in blood 
pressure and heart rate; weight; 12-lead ECGs; clinical laboratory test results; serum and urine 
pregnancy tests (females of childbearing potential only); and concomitant medication assessments. 
Safety assessments in addition to those specified may be performed to ensure patient safety if judged 
appropriate by the investigator. 
See Table 1 for the overall schedule of safety assessments. 
Psychiatric assessments will be performed by a psychiatrist or trained and certified clinical staff 
member. Neurologic assessments will be performed by an experienced clinician. 
Patients fulfilling Hy’s law, defined as [ALT or AST ≥ 3 × ULN] and [TBL ≥ 2 × ULN], in the 
absence of significant increase in ALP and in the absence of an alternative diagnosis that explains the 
increase in total bilirubin, will be discontinued, with medical follow-up as appropriate. 
An IDMC will be established to monitor data on an ongoing basis to ensure the continuing safety of 
patients enrolled in this study. The IDMC will comprise individuals external to the sponsor and will 
consist of at least one medical expert in the relevant therapeutic area, at least one hepatologist, and at 
least one statistician. The IDMC’s responsibilities, authorities, and procedures, with details of 
decision-making guidance and dissemination of the results, will be documented in the IDMC charter. 
Statistical Methods: 
Efficacy Analyses: 
Efficacy analyses will be performed on the Full Analysis Set (FAS), which includes all randomized 
patients who took at least one dose of study drug and had a post-randomization efficacy evaluation. 
The FAS population will be analyzed by treatment randomized regardless of the actual treatment 
received. 
The primary and secondary efficacy results of the study will be based on analysis in FAS patients with 
DGM4-positive biomarker. 
The primary efficacy endpoint is the change in MADRS total score from baseline (Visit 3, Day -1) to 
Day 42 (Visit 7), in DGM4-positive patients. The primary efficacy analysis will be performed at 
2-sided significance level of 0.05 using a mixed model for repeated measures (MMRM) that includes 
the fixed effects of treatment, visit (categorical covariate), treatment-by-visit interaction, baseline 
MADRS total score (continuous covariate), and region. An unstructured variance-covariance matrix 
will be used. The least-squares (LS) mean change in MADRS total score at Day 42 from baseline for 
the combined liafensine treatment arms (1 mg QD and 2 mg QD) and placebo arm will be estimated 
from the MMRM model. Prior work suggests that both doses of liafensine may be efficacious, 
therefore, the treatment effect for the combined liafensine treatment arms vs placebo will be estimated 
using the LS means’ difference at Day 42 from the MMRM model. The comparison of the change in 
MADRS total score from baseline to Day 42 between each of the 2 liafensine treatment arms and 
placebo will be carried out using the same approach. 
The key secondary efficacy endpoint will be the change from baseline in CGI-S at Day 42 in 
DGM4-positive patients. CGI-S will be analyzed using the same MMRM model as for the primary 
efficacy endpoint.  
Other secondary efficacy endpoints include CGI-I and SDS at Day 42 as continuous endpoints. These 
endpoints will be analyzed using the same MMRM model as for the primary efficacy endpoint. 
The exploratory efficacy results of the study will also be based on analysis in FAS patients. 
Response rate, remission rate, and corresponding 95% confidence interval (CI) for each treatment 


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group will be derived by using Clopper-Pearson method. The comparison of response rates and 
remission rates between treatment groups at Day 42 will be carried out using the Cochran–Mantel–
Haenszel (CMH) test. 
Subscales, individual items, and domains of endpoints will also be analyzed in an exploratory manner, 
using the same MMRM model as for the primary efficacy endpoint. 
The change in MADRS total score from baseline in DGM4-negative patients will be analyzed using 
the same approach as described for the primary endpoint analysis in the DGM4-positive patients. The 
LS mean of the change in MADRS total score for each treatment group and the treatment difference in 
DGM4-negative patients will be estimated. The treatment effects between the DGM4-positive and 
negative patients will be compared primarily in descriptive fashion to examine the trend, and may be 
evaluated by including the interaction of DGM4 status and treatment group in the mixed model. 
Safety Analyses: 
Safety analyses will be conducted in the safety population, which includes all randomized patients who 
have received at least one dose of study drug. The safety population will be analyzed by the actual 
treatment received regardless of treatment randomized. 
The incidence and severity of treatment-emergent adverse events (TEAEs) will be summarized by 
treatment. Vital signs including orthostatic changes in blood pressure and heart rate, weight, ECG, 
clinical laboratory evaluation, DESS scale, and C-SSRS data will be summarized with descriptive 
statistics, by visit and by treatment. 
Safety and tolerability data will be summarized descriptively, including tables, listings, and graphs, as 
appropriate. Unless otherwise stated, descriptive summary statistics for continuous variables will 
include number (N), mean (ie, arithmetic mean), standard deviation (SD), minimum, median, and 
maximum. Descriptive summary statistics for categorical data will include frequency and proportion. 
All data will be presented by treatment regimen. 
Individual data for vital signs including supine and standing blood pressure and heart rate, weight, 
clinical laboratory measures, and ECG assessments will be listed and summarized for any potentially 
clinically important (PCI) values according to predetermined PCI criteria. 
There will be no imputation (substitution) for missing data unless explicitly specified otherwise in this 
protocol or in the statistical analysis plan. 
Pharmacokinetics: 
PK data collected in this study will be included in a population PK analysis of plasma concentrations 
of liafensine and its primary metabolite. It will be performed using a nonlinear mixed-effects modeling 
approach. The analysis will evaluate the effects of age, sex, ethnicity, and other covariates on the PK 
profile of liafensine. The results of this analysis with be reported separately. 
Statistical Analysis Plan: 
Additional details of the analyses will be provided in the statistical analysis plan which will be 
finalized prior to unblinding. 
Ethical Considerations: 


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This study will be conducted in accordance with applicable country-specific laws and regulations, 
including, but not limited to, International Council for Harmonisation of Technical Requirements for 
Pharmaceuticals for Human Use (ICH) Good Clinical Practice (GCP) guidelines and the ethical 
principles that have their origins in the Declaration of Helsinki. The institutional review board 
(IRB)/independent ethics committee (IEC) must review and approve the protocol and ICF before any 
patients are enrolled. Before any procedures specified in the protocol are performed, the patient must 
sign and date the IRB/IEC-approved ICFs. 


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Table 1: 
Schedule of Assessments 
Study Procedures a 
Screening 1 
Screening 2 
Baseline 
Double-Blind Treatment 
Follow-upb 
Visit 1 
Visit 2 c  
Visit 3 
(No visit) 
Visit 4 
Visit 5 
Visit 6 
Visit 7 
EOT 
14 days  
post-last 
dose 
28 days  
post-last 
dose 
Prior to 
Day -21 
Day -21 to 
Day -2 d  
Day -1e 
Day 1e 
Day 7 
Day 14 
Day 28 
Day 42 f  
Visit window (day) 
 
+ 3 
 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
Brief informed consent  
Xg 
 
 
 
 
 
 
 
 
 
Full informed consentg 
 
Xg 
 
 
 
 
 
 
 
 
Preliminary 
Inclusion/exclusion 
Xh 
 
 
 
 
 
 
 
 
 
Inclusion/exclusion 
 
X 
X 
 
 
 
 
 
 
 
Medical/surgical history 
X 
 
 
 
 
 
 
 
 
 
Prior medications 
 
X 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
Psychiatric evaluation via 
MINI (selected or full 
modules) 
 
X 
 
 
 
 
 
 
 
 
ATRQ (5 Year) 
 
X 
 
 
 
 
 
 
 
 
Physical examination 
 
X 
 
 
 
 
 
X 
 
 
Neurological examination 
 
X 
 
 
 
 
 
X 
 
 
Blood sampling for PGxi 
X 
 
 
 
 
X 
 
 
 
 
Randomization 
 
 
X 
 
 
 
 
 
 
 
Study drug dispensing 
 
 
X 
 
X 
X 
X 
 
 
 
Study treatment 
 
 
 
X-------------------------------------------------------X 
 
 
MADRSrater 1 
 
X 
X 
 
X 
X 
X 
X 
 
 
HAMD-17rater 1 
 
X 
X 
 
 
 
 
 
 
 
SDS 
 
 
X 
 
 
 
 
X 
 
 
PRPS 
 
 
X 
 
 
 
 
 
 
 
PRDF Checklistj 
 
X 
X 
 
X 
X 
X 
X 
 
 
CGI-Srater 2 
 
X 
X 
 
X 
X 
X 
X 
 
 
CGI-Irater 2  
 
 
 
 
X 
X 
X 
X 
 
 
C-SSRS 
 
Xk 
Xl 
 
Xl 
Xl 
Xl 
Xl 
Xl 
Xl 
DESSm 
 
 
 
 
 
 
 
 
X 
 


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Study Procedures a 
Screening 1 
Screening 2 
Baseline 
Double-Blind Treatment 
Follow-upb 
Visit 1 
Visit 2 c  
Visit 3 
(No visit) 
Visit 4 
Visit 5 
Visit 6 
Visit 7 
EOT 
14 days  
post-last 
dose 
28 days  
post-last 
dose 
Prior to 
Day -21 
Day -21 to 
Day -2 d  
Day -1e 
Day 1e 
Day 7 
Day 14 
Day 28 
Day 42 f  
Visit window (day) 
 
+ 3 
 
± 3 
± 3 
± 3 
± 3 
± 3 
± 3 
Vital signsn 
 
X 
X 
 
X 
X 
X 
X 
X 
 
Body weight 
 
X 
 
 
 
 
 
X 
 
 
Height 
 
X 
 
 
 
 
 
 
 
 
12-lead ECGo 
 
X  
X 
 
 
 
 
X 
 
 
Clinical laboratory testsp 
 
X 
Xq 
 
 
X 
X 
X 
X 
 
Urinalysis (on-site/central 
labs in the event of 
macroscopic findings) 
 
X 
Xq 
 
 
 
 
X 
 
 
Urine drug screen (on-site) 
 
X 
Xq 
 
 
 
 
X 
 
 
Pregnancy testr 
X 
 
X 
 
 
 
 
X 
 
 
Blood sampling for PKs 
 
 
 
 
 
 
X 
X 
 
 
Concomitant medications 
 
 
X-----------------------------------------------------------------------------------------------------X 
Collection of AEs 
X-------------------------------------------------------------------------------------------------------------------------------------------X 
Abbreviations: AE = adverse event; ATRQ = Antidepressant Treatment Response Questionnaire; BP = blood pressure; CGI-I = Clinical Global Impressions–
Improvement Scale; CGI-S = Clinical Global Impressions–Severity Scale; C-SSRS = Columbia–Suicide Severity Rating Scale; DESS = Discontinuation-
Emergent Signs and Symptoms scale; ECG = electrocardiogram; EOT = End-of-Treatment; FT3 = free triiodothyronine; FT4 = free thyroxine; 
HAMD-17 = Hamilton Depression Rating Scale - 17 Item; HIV = human immunodeficiency virus; MADRS = Montgomery-Åsberg Depression Rating Scale; 
MINI = Mini International Neuropsychiatric Interview; PGx = pharmacogenomics; PK = pharmacokinetics; PRDF Checklist = Patient Rated Depression and 
Functioning Checklist; SAE = serious adverse event; PRPS = Placebo Response Propensity Scale; SDS = Sheehan Disability Scale; TSH = thyroid-stimulating 
hormone. 
a Every effort should be made for visits to occur on the designated study days. A ± 3-day visit window is permitted at all visits except for Screening and Baseline 
(Day -1). The overall treatment period in the protocol should be maintained (ie, visits should be scheduled based on the baseline visit rather than the previous 
visit). Study procedures designated for a specific visit should be performed on 1 day whenever this is possible and in the best interest of the patient. If this is not 
possible and/or not in the best interest of the patient, study procedures may be performed across more than 1 day but within the visit window. 
b Randomized patients who complete the study or discontinue early will have two follow-up visits (14 and 28 days after the last dose of study drug), the 2nd 
follow-up visit will be conducted via phone call. 
 c Visit 2 activities are performed only after the confirmation of initial eligibility including PGx. Patients who screen fail due to PGx status are not eligible for re-
screening. 
 
Prior to 
Day -21 
Day -21 to 
Day -2 d  
Day -1e 
Day 1e 
Day 7 
Day 14 
Day 28 
Day 42 f  
 
 
d Screening period may exceed 20 days if a prolonged washout is required. 


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e Baseline evaluations will be performed on Day -1. Patients will be instructed to take the first dose of double-blind study drug the day after baseline evaluations 
(ie, on Day 1), and will be instructed to take double-blind study drug for the remainder of the 6-week treatment period. 
 f For patients who discontinue early from the study, safety and efficacy determinations designated for Day 42 will be performed on the last day the patient takes 
a full dose of study drug or as soon as possible thereafter, but within 3 days of their last dose in any event. 
g At Visit 1, two brief ICFs will be obtained for the purpose of genotyping and biobanking, separately. A full ICF must be obtained at Visit 2. 
h  Refer to Appendix 2 Preliminary Diagnosis Checklist  
i  A separate blood sample (6 mL) will be collected for PGx (eg, determination of DGM4 status at Screening and for future research at Visit 5). 
j The PRDF Checklist must be completed by the patient and reviewed by the rater 2 prior to CGI-S assessment. The baseline checklist entry must be compared 
by rater 2 against post-baseline entry to refresh the knowledge of patient’s baseline condition prior to CGI-I assessment.  
k C-SSRS baseline/screening version 
l C-SSRS since-last-visit version 
m For randomized patients who complete the study or discontinue early, the DESS scale will be completed daily by the patient for 14 days post-last dose. 
n Vital signs should be taken prior to blood draws when applicable and include supine (after at least 5 min rest) and standing (after 1 min and 3 min standing), BP 
and heart rate, respiration rate, and temperature. Vital signs can be repeated for up to 3 occurrences after Visit 2 to see if values return to normal range, but any 
abnormality must be resolved by the Baseline Visit. 
o ECG recordings will be completed prior to blood draws when applicable and will be performed in triplicate (at 1-minute intervals between each of the three 
recordings) for baseline. Single ECG will be performed for rest of the timepoints. 
p Hematology, blood chemistry, and urinalysis will be performed at all visits with a laboratory determination. Serologic tests for HIV, hepatitis B core antibody, 
hepatitis B surface antigen, and hepatitis C virus antibody, and a thyroid panel (TSH, FT3, and FT4) will be completed only at Screening. Laboratory tests can 
be repeated for up to 3 occurrences after Visit 2 to see if values return to normal range, but any abnormality must be resolved by the Baseline Visit. 
q To be conducted on Day -1 only if (1) the screening period exceeds 21 days; (2) a longer than 21-day prior medication washout is required, eg, fluoxetine 
> 20 mg/day; (3) per investigator’s judgement. For women of pre-menopause, an inquiry of menses status should be made in the presence of macroscopic blood 
detection before submitting the sample to the central labs for microscopic examination. 
r Serum pregnancy testing will be performed in females of childbearing potential at Screening 1 and Day 42 (Visit 7). Urine pregnancy testing will be performed 
at Baseline (Day -1, dip stick). 
s Blood samples for PK will be collected on Day 28 (Visit 6) and on Day 42 (Visit 7) prior to dose administration, or at the time of early withdrawal, if within 
3 days of last dose. Time of last dose and time of blood collection will be recorded. When possible, and if medically appropriate, blood samples should be 
collected for PK from patients who experience an SAE or overdose. 
  


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TABLE OF CONTENTS 
TITLE PAGE .............................................................................................................................. 1 
SPONSOR APPROVAL ............................................................................................................. 2 
PROTOCOL SYNOPSIS ............................................................................................................ 3 
TABLE OF CONTENTS .......................................................................................................... 20 
LIST OF TABLES .................................................................................................................... 24 
LIST OF FIGURES .................................................................................................................. 24 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS .............................................. 25 
1. 
INTRODUCTION .................................................................................................. 28 
1.1. 
Background ............................................................................................................ 28 
1.2. 
Liafensine ............................................................................................................... 29 
1.2.1. 
Study Rationale ...................................................................................................... 29 
1.2.2. 
Summary of Relevant Prior Animal Studies ............................................................ 30 
1.2.2.1. 
Absorption, Metabolism, and Drug Interactions ...................................................... 30 
1.2.2.2. 
Preclinical Toxicity................................................................................................. 30 
1.2.3. 
Pharmacokinetics in Humans .................................................................................. 31 
1.2.4. 
Clinical Studies of Liafensine ................................................................................. 33 
1.2.5. 
Potential Risks and Benefits.................................................................................... 33 
2. 
OBJECTIVES AND ENDPOINTS ......................................................................... 34 
2.1. 
Objectives............................................................................................................... 34 
2.1.1. 
Primary Efficacy Objective ..................................................................................... 34 
2.1.2. 
Key Secondary Efficacy Objective.......................................................................... 34 
2.1.3. 
Safety Objectives .................................................................................................... 34 
2.1.4. 
Other Secondary Efficacy Objectives ...................................................................... 34 
2.1.5. 
Exploratory Objectives ........................................................................................... 34 
2.2. 
Endpoints ............................................................................................................... 35 
2.2.1. 
Primary Endpoint.................................................................................................... 35 
2.2.2. 
Secondary Endpoint ................................................................................................ 35 
2.2.3. 
Safety Endpoints ..................................................................................................... 35 
2.2.4. 
Other Secondary Endpoints .................................................................................... 35 
2.2.5. 
Exploratory Endpoints ............................................................................................ 35 
3. 
INVESTIGATIONAL PLAN ................................................................................. 36 


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3.1. 
Overall Study Design .............................................................................................. 36 
3.2. 
Methodology .......................................................................................................... 37 
3.3. 
Study Duration and Follow-up ................................................................................ 37 
3.4. 
Sample Size Justification ........................................................................................ 38 
3.5. 
Number of Subjects ................................................................................................ 38 
3.6. 
Treatment Assignment ............................................................................................ 38 
3.7. 
Criteria for Study Termination ................................................................................ 38 
4. 
SELECTION AND WITHDRAWAL OF PATIENTS ............................................ 39 
4.1. 
Subject Inclusion Criteria ....................................................................................... 39 
4.2. 
Subject Exclusion Criteria ...................................................................................... 40 
4.3. 
Contraceptive Guidelines ........................................................................................ 42 
4.4. 
Patient Withdrawal Criteria .................................................................................... 42 
4.4.1. 
Withdrawal from Study Treatment or Study Participation ....................................... 42 
4.4.2. 
Withdrawal from Follow-up ................................................................................... 43 
5. 
TREATMENT OF SUBJECTS .............................................................................. 44 
5.1. 
Description of Study Treatment .............................................................................. 44 
5.2. 
Administration of Study Treatment ......................................................................... 44 
5.3. 
Concomitant Medications ....................................................................................... 44 
5.4. 
Treatment Compliance ............................................................................................ 46 
5.5. 
Randomization and Blinding................................................................................... 46 
5.6. 
Emergency Treatment Unblinding .......................................................................... 46 
6. 
STUDY DRUG MATERIALS AND MANAGEMENT ......................................... 47 
6.1. 
Liafensine/Placebo.................................................................................................. 47 
7. 
STUDY PROCEDURES AND ASSESSMENTS ................................................... 48 
7.1. 
Study Procedures .................................................................................................... 48 
7.1.1. 
Informed Consent ................................................................................................... 48 
7.1.2. 
Study Treatment Evaluations and Procedures .......................................................... 48 
7.1.2.1. 
Screening 1/Screening 2 Procedures (Visit 1 and Visit 2) ........................................ 48 
7.1.2.2. 
Evaluations on Study From Baseline to End-of-Treatment ...................................... 49 
7.1.3. 
End-of-Treatment and Follow-up Evaluations and Procedures ................................ 50 
7.2. 
Assessment of Efficacy ........................................................................................... 51 
7.3. 
Other Assessments .................................................................................................. 52 
7.4. 
Pharmacokinetics .................................................................................................... 53 


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7.5. 
Pharmacogenomics ................................................................................................. 53 
7.6. 
Assessment of Safety .............................................................................................. 53 
7.6.1. 
Safety Parameters ................................................................................................... 54 
7.6.1.1. 
Adverse Events ....................................................................................................... 54 
7.6.1.2. 
Medical History and Demographics ........................................................................ 54 
7.6.1.3. 
Vital Signs .............................................................................................................. 54 
7.6.1.4. 
Physical Examination and Neurological Examination ............................................. 54 
7.6.1.5. 
Psychiatric Assessments ......................................................................................... 55 
7.6.1.6. 
Electrocardiogram .................................................................................................. 55 
7.6.1.7. 
Laboratory Assessments ......................................................................................... 56 
7.6.1.8. 
Laboratory Abnormalities ....................................................................................... 57 
7.6.1.9. 
Pregnancy Screen ................................................................................................... 58 
7.6.2. 
Adverse and Serious Adverse Events ...................................................................... 58 
7.6.2.1. 
Definition of an Adverse Event ............................................................................... 58 
7.6.2.2. 
Serious Adverse Event ............................................................................................ 59 
7.6.2.3. 
Adverse Events of Special Interest .......................................................................... 59 
7.6.2.4. 
Relationship to Study Treatment ............................................................................. 60 
7.6.2.5. 
Recording Adverse Events ...................................................................................... 60 
7.6.2.6. 
Severity Assessment of Adverse Events .................................................................. 60 
7.6.2.7. 
Reporting Adverse Events ...................................................................................... 61 
7.6.2.8. 
Serious Adverse Event Reporting Requirements ..................................................... 61 
7.6.3. 
Pregnancy Reporting .............................................................................................. 61 
8. 
STATISTICS .......................................................................................................... 62 
8.1. 
Study Design .......................................................................................................... 62 
8.2. 
Determination of Sample Size and Statistical Rationale .......................................... 62 
8.3. 
Statistical Methods ................................................................................................. 62 
8.3.1. 
Analysis Population ................................................................................................ 62 
8.3.2. 
Primary Estimand ................................................................................................... 63 
8.3.3. 
Efficacy Analyses ................................................................................................... 63 
8.3.3.1. 
Type I Error Control for Multiple Comparisons ...................................................... 64 
8.3.4. 
Safety Analyses ...................................................................................................... 64 
8.3.5. 
Pharmacokinetics .................................................................................................... 64 
8.3.6. 
Subgroup Analyses ................................................................................................. 65 


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8.3.7. 
Statistical Analysis Plan .......................................................................................... 65 
8.3.8. 
Independent Data Monitoring Committee ............................................................... 65 
9. 
DIRECT ACCESS TO SOURCE DATA/DOCUMENTS ....................................... 66 
9.1. 
Study Monitoring.................................................................................................... 66 
9.2. 
Audits and Inspections ............................................................................................ 66 
9.3. 
Institutional Review Board ..................................................................................... 66 
9.4. 
Curriculum Vitae and Medical Licenses ................................................................. 67 
9.5. 
Financial Disclosure ............................................................................................... 67 
10. 
QUALITY CONTROL AND QUALITY ASSURANCE ........................................ 68 
11. 
ETHICS.................................................................................................................. 69 
11.1. 
Local Regulations ................................................................................................... 69 
11.2. 
Ethics Review ......................................................................................................... 69 
11.3. 
Ethical Conduct of the Study .................................................................................. 69 
11.4. 
Written Informed Consent ...................................................................................... 69 
11.5. 
Patient Confidentiality ............................................................................................ 70 
11.6. 
Patient Recruitment ................................................................................................ 70 
11.7. 
Reporting of Safety Issues and Serious Breaches of the Protocol or ICH GCP ........ 70 
12. 
DATA HANDLING AND RECORD KEEPING .................................................... 71 
12.1. 
Data/Document ....................................................................................................... 71 
12.2. 
Data Management ................................................................................................... 71 
12.3. 
Inspection of Records ............................................................................................. 71 
12.4. 
Retention of Records .............................................................................................. 72 
13. 
PUBLICATION POLICY....................................................................................... 73 
13.1. 
Communication of Results by Denovo .................................................................... 73 
13.2. 
Publications by Investigators .................................................................................. 73 
14. 
INVESTIGATOR PROTOCOL SIGNATURE PAGE ............................................ 74 
15. 
LIST OF REFERENCES ........................................................................................ 75 
16. 
APPENDICES ........................................................................................................ 77 
APPENDIX 1. GUIDANCE TO STUDY SITES ON STUDY AND PATIENT 
MANAGEMENT IN CASE OF A PUBLIC HEALTH EMERGENCY .................. 78 
APPENDIX 2. PRELIMINARY DIAGNOSIS CHECKLIST ................................................. 80 
APPENDIX 3. PATIENT RATED DEPRESSION AND FUNCTIONING 
CHECKLIST .......................................................................................................... 83 


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APPENDIX 4. PLACEBO RESPONSE PROPENSITY SCALE (CLINICAL TRIAL 
VERSION) ............................................................................................................. 93 
 
LIST OF TABLES 
Table 1: 
Schedule of Assessments ........................................................................................ 17 
Table 2: 
Investigational Product ........................................................................................... 44 
Table 3: 
Laboratory Tests ..................................................................................................... 56 
 
LIST OF FIGURES 
Figure 1: 
Overall Study Design .............................................................................................. 37 
 


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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
The following abbreviations and specialist terms are used in this study protocol. 
Abbreviation or 
Specialist Term 
Explanation 
-hCG 
-human chorionic gonadotropin 
5-HT 
serotonin 
ADHD 
attention-deficit/hyperactivity disorder 
AE 
adverse event 
AESI 
adverse event of special interest 
ALP 
alkaline phosphatase 
ALT (SGPT) 
alanine aminotransferase (serum glutamic-pyruvic transaminase) 
aPTT 
activated prothrombin time 
AST (SGOT) 
aspartate aminotransferase (serum glutamic-oxaloacetic transaminase) 
ATRQ 
Antidepressant Treatment Response Questionnaire 
AUC 
area under the curve 
BMS 
Bristol-Myers Squibb 
BP 
blood pressure 
BUN 
blood urea nitrogen 
CGI-I, -S 
Clinical Global Impressions Scale-Improvement, -Severity 
CI 
confidence interval 
CK 
creatine kinase 
CLIA 
Clinical Laboratory Improvement Amendments 
Cmax  
maximum (peak) plasma drug concentration 
CMH 
Cochran-Mantel-Haenszel 
CNS 
central nervous system 
CPK 
serum creatine phosphokinase 
CRO 
contract research organization 
CV 
curriculum vitae 
C-SSRS 
Columbia-Suicide Severity Rating Scale 
DESS 
Discontinuation-Emergent Signs and Symptoms (scale) 
DGM4 
Denovo Genomic Marker 4, a genetic biomarker for DB104 (liafensine) 
DILI 
drug-induced liver injury 
DNA 
deoxyribonucleic acid 
DSM-5 
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition 
ECG 
electrocardiogram 
eCRF 
electronic Case Report Form 
EDC 
electronic data capture (system) 


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Abbreviation or 
Specialist Term 
Explanation 
EOT 
End-of-Treatment 
FAS 
Full Analysis Set 
FDA 
(United States) Food and Drug Administration 
FT3 
free triiodothyronine 
FT4 
free thyroxine 
GCP 
Good Clinical Practice 
HAMD-17 
Hamilton Depression Rating Scale - 17 Item 
HBsAg 
hepatitis B surface antigen 
HCV 
hepatitis C virus 
HIPAA 
Health Insurance Portability and Accountability Act  
HIV 
human immunodeficiency virus 
IB 
Investigator’s Brochure 
ICH 
International Council for Harmonisation of Technical Requirements for 
Pharmaceuticals for Human Use 
ICF 
informed consent form 
IDMC 
Independent Data Monitoring Committee 
IEC 
Independent Ethics Committee 
IgM 
immunoglobulin M (antibodies) 
IMP 
investigational medicinal product 
IRB 
Institutional Review Board 
IRT 
Interactive Response Technology 
IVD 
in vitro diagnostic 
LS 
least-squares 
MAD 
multiple ascending dose 
MADRS 
Montgomery-Åsberg Depression Rating Scale 
MAOI 
monoamine oxidase inhibitor 
MCH(C) 
mean corpuscular hemoglobin (concentration) 
MCV 
mean corpuscular volume 
MDD 
major depressive disorder 
MDMA 
3,4-methylenedioxy-N-methylamphetamine (“Ecstasy”) 
(MGH) ATRQ 
(Massachusetts General Hospital) Antidepressant Treatment Response 
Questionnaire 
MINI 
Mini International Neuropsychiatric Interview 
NMDA 
N-methyl-D-aspartate 
PCI 
potentially clinically important 
PGx 
pharmacogenomics 


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Abbreviation or 
Specialist Term 
Explanation 
PI 
principal investigator 
The investigator who leads the study conduct at an individual study center. Every 
study center has a principal investigator. 
PK 
pharmacokinetic 
PRDF  
Patient Rated Depression and Functioning (Checklist) 
PRPS  
Placebo Response Propensity Scale 
SAD 
single ascending dose 
SAP 
statistical analysis plan 
SDS 
Sheehan Disability Scale 
SNP 
single nucleotide polymorphism 
QD 
once daily 
QTcF 
corrected QT interval measurement according to the Fridericia rule 
RBC 
red blood cell (count) 
REMS 
Risk Evaluation and Mitigation Strategy 
SAE 
serious adverse event 
SNP 
single nucleotide polymorphism 
SNRI 
serotonin norepinephrine reuptake inhibitor 
SOA 
schedule of assessments 
SSRI 
selective serotonin reuptake inhibitor 
SUSAR 
suspected unexpected serious adverse reactions 
TBL 
total bilirubin 
TCA 
tricyclic antidepressants 
TEAE 
treatment-emergent adverse event 
TRD 
treatment-resistant depression 
TSH 
thyroid-stimulating hormone 
UDS 
urine drug screen 
ULN 
upper limit of normal 
US 
United States 
WBC 
white blood cell (count) 


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1. 
INTRODUCTION 
1.1. 
Background 
Major depressive disorder (MDD) is a common psychiatric disorder, with a lifetime prevalence 
rate of approximately 13-17% in the United States (Hasin 2005, Kessler 2005). Although options 
for pharmacologic treatment have expanded significantly in the past 25 years, between one-third 
and two-thirds of patients will not respond to the first antidepressant prescribed, and up to 
33% will not respond to multiple interventions (American Psychiatric Association 2013, 
Berlim 2008, Cain 2007). Novel antidepressants that produce a clinically significant 
improvement in patients with MDD who have failed to respond to more than one treatment of 
adequate dose and duration, without producing significant side effects, would represent an 
important advance in the treatment of treatment-resistant depression (TRD). 
For most of the last 30 years, the biogenic amine hypothesis of depression has been driving much 
of the research into the etiology and treatment of this debilitating psychiatric disorder. Most 
conventional antidepressants are antagonists at serotonin (5-HT) and/or norepinephrine reuptake 
sites, and their efficacy correlates reasonably well with their affinity for these receptors. At 
present, the most commonly used treatments for MDD are the selective serotonin reuptake 
inhibitors (SSRIs), such as escitalopram, or the serotonin-norepinephrine reuptake inhibitors 
(SNRIs), such as duloxetine.  
Despite a plethora of pharmacologic and non-pharmacologic treatments, there is significant 
unmet need for better treatments for persons with depression. Many patients remain inadequately 
responsive to treatment. The STAR*D study found that only 37% of depressed patients 
responded to a first step in treatment with decreasing likelihood of response in later steps 
(31%, 14%, and 13%) (Rush 2006). As many as 30% of patients remain treatment resistant after 
4 different treatment steps. Nor was there any rational progression for selecting an initial 
treatment. 
Recently, a compound with a novel mechanism of action, esketamine (SPRAVATO®), was 
approved in the United States (US) for the treatment of TRD in conjunction with an oral 
antidepressant (SPRAVATO 2019). While the precise mechanism of action of esketamine is 
unknown, the compound is an N-methyl-D-aspartate (NMDA) receptor antagonist. Esketamine is 
administered intranasally through a restricted distribution system, under a Risk Evaluation and 
Mitigation Strategy (REMS), and its use is associated with significant adverse effects including 
dizziness, nausea, sedation, and psychological effects. The most common psychological effects 
of esketamine are dissociative/perceptual changes (including distortion of time and space, and 
illusions), derealization, and depersonalization. Patients may describe these symptoms as feeling 
disconnected from themselves, their thoughts and feelings, space, and time. Because of the risks 
of dissociation with esketamine, the US Food and Drug Administration (FDA) has established a 
REMS requiring that patients be monitored by a healthcare professional for at least 2 hours at 
each treatment session, concluding with an assessment establishing that the patient is clinically 
stable and may safely leave the healthcare setting. The persistent high numbers of treatment-
resistant patients, the adverse event profile and difficulty accessing both existing and newer 
treatments, and the need to find better ways of driving treatment selection to treatment-
responsive patients support the biomarker-driven development of liafensine for TRD. 


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1.2. 
Liafensine 
Liafensine (also known as DB104 and BMS-8208361) is 6-[(4S)-1,2,3,4-tetrahydro-2-methyl-4-
(2-naphthalenyl)-7-isoquinolinyl]-3-pyridazinamine and it is a potent and selective inhibitor of 
the reuptake of the 3 monoamines: 5-HT, norepinephrine, and dopamine. Liafensine was 
developed to incrementally advance antidepressant treatment by synergizing these individual 
monoaminergic approaches to treating depression. 
1.2.1. 
Study Rationale 
Liafensine has been tested in 11 Phase 1 studies, and 3 Phase 2b studies (including one rollover 
study). In the Phase 1 studies, single doses of up to 5 mg, and multiple doses of up to 4 mg 
liafensine were found to be generally safe and well tolerated. The pharmacokinetic (PK) profile 
of liafensine was compatible with once-daily (QD) dosing, supporting the potential for liafensine 
to have low potential for discontinuation symptoms. In the Phase 2b studies, patients who did not 
experience adequate response to either duloxetine (Study CN162006), or duloxetine or 
escitalopram (Study CN162007), were randomized to receive either liafensine or duloxetine 
(CN162006), or duloxetine or escitalopram (CN162007), for 6 weeks. In Study CN162006, a 
flexible dose of liafensine was used (0.5-2 mg QD). In Study CN162007, several fixed dosage 
levels of liafensine were used (0.25, 0.5, 1, and 2 mg QD). In these Phase 2b studies, liafensine 
was found to be generally safe and well tolerated. In Study CN162006, the most common 
adverse events (AEs) reported by at least 5% of patients treated with liafensine were 
headache (7.0%), nausea (7.0%), constipation (5.3%), and anxiety (5.3%). In Study CN162007, 
the most common AEs reported by at least 5% of patients treated with any dose of liafensine 
were headache (14.3%), nausea (12.0%), nasopharyngitis (8.8%), upper respiratory tract 
infection (8.0%), dry mouth (8.0%), constipation (7.7%), dizziness (7.0%), diarrhea (5.5%), 
fatigue (5.9%), and urinary tract infection (5.5%). 
In the Phase 2b studies conducted by Bristol-Myers Squibb (BMS), there were no significant 
differences noted between the treatment groups in the decrease (improvement) of the mean 
Montgomery-Åsberg Depression Rating Scale (MADRS) total score. In an effort to identify a 
potential pharmacogenomic biomarker of response to liafensine, Denovo Biopharma LLC 
(Denovo) has conducted a genome-wide scan with human whole genome single nucleotide 
polymorphism (SNP) arrays using germline deoxyribonucleic acid (DNA) extracted from blood 
samples of patients in BMS Studies CN162006 and CN162007. From this genome-wide 
screening, SNP rs12217173 was identified as strongly associated with treatment response to 
liafensine (p = 6.6 x10-8). Patients with a GG genotype at rs12217173 showed significantly better 
response to liafensine compared to patients with an AA or AG genotype, or patients in the 
control arm (duloxetine or escitalopram). These findings were replicated using a separate 
validation sample set. Liafensine treatment effects in patients with the GG genotype were 
comparable for the 0.5 to 2 mg QD flexible doses in the CN162006 study and for the 1 mg QD 
and 2 mg QD doses in the CN162007 study. These combined data showed that patients with the 
GG genotype had a 4.7-point difference in MADRS total score decrease from baseline in the 
liafensine arm vs the control arm (p = 0.025), while patients with the AA or AG genotype at 
rs12217173 did not show an improved treatment effect in the liafensine arm vs the control arm 
 
1 BMS-820836-03 was selected for the dosage form development and is also referred to as BMS-820836. 


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(MADRS 0.3-point difference, p = 0.74). Moreover, patients carrying different genotypes at 
rs12217173 did not exhibit different treatment responses to duloxetine or escitalopram. Thus, 
SNP rs12217173 appears to be a pharmacogenomic biomarker specific for liafensine; Denovo 
has termed rs12217173 as “DGM4” (Denovo Genomic Marker 4) and the GG genotype of 
DGM4 is defined as DGM4 positive, whereas the AA or AG genotype of DGM4 is defined as 
DGM4 negative. 
DGM4 is located at the ANK3 gene locus, and the ANK3 gene has been found to be associated 
with depression and other central nervous system (CNS) disorders, including bipolar disorder 
(Schizophrenia Working Group of the Psychiatric Genomics Consortium 2014, Craddock 2013, 
Mühleisen 2014, Rangaraju 2016). Additionally, Zhu et al. found that in a genetic mouse model 
with conditional disruption of forebrain Ank3 pyramidal neurons (Ank3 cKO), repeated social 
defeat stress resulted in repeated episodes of dramatic behavioral changes ranging from 
hyperactivity to “depression-like” behavior (Zhu 2017). 
Taken together, these data strongly support the potential utility and further study of liafensine in 
DGM4-positive patients with TRD. 
1.2.2. 
Summary of Relevant Prior Animal Studies 
Background information in addition to that presented below is available in the Investigator’s 
Brochure. 
1.2.2.1. 
Absorption, Metabolism, and Drug Interactions 
Based on in vitro studies, the metabolism of liafensine is judged to be primarily mediated by 
CYP3A4 with additional contributions from CYP1A1/2, CYP2D6, CYP2C9, and CYP2C19. 
In vitro, liafensine exhibited some inhibition of CYPs 2C9, 2C19, and 2D6, with IC50 estimates 
of > 1 µM. Liafensine was a time-dependent inhibitor of CYP3A4 and does not induce relevant 
human CYPs. Liafensine was a weak inhibitor of P-gp with an IC50 of ~20 M (~7.3 g/mL). 
Clinically relevant concentrations of liafensine are in the low ng/mL range, suggesting a low 
potential for drug interactions involving P-gp inhibition, CYP induction, or CYP inhibition at the 
doses examined. Similarly, low plasma concentrations of its active metabolite, 821007, in vivo 
suggest low potential for drug interactions at clinically relevant concentrations. 
Because liafensine is a substrate for CYP3A4, exposure to liafensine may be altered by 
co-administered drugs that are inhibitors or inducers of this enzyme.  
1.2.2.2. 
Preclinical Toxicity 
Liafensine has a moderate potential for acute toxicity. Single oral doses up to 20 mg/kg were 
tolerated in the rat, and a dose of 0.6 mg/kg was tolerated in monkeys, with clinical findings 
consistent with targeted inhibition of monoamine reuptake including stereotypic behaviors and 
elevations in body temperature; increased activity, abnormal respiration in rats; and decreased 
feeding behavior and evidence of skeletal muscle injury in monkeys. 
After repeated dosing, liafensine was clinically tolerated up to 3 mg/kg/day in rats and 
1 mg/kg/day in monkeys for up to 3 months. The primary treatment-related findings were 
pharmacologically-mediated effects including decreases in food consumption and body weight, 


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increased activity, and stereotypic behaviors at all doses. Target organs were limited to skeletal 
muscle in rats and monkeys after 2 weeks of dosing and the liver in rats after chronic dosing. 
Liafensine-related skeletal muscle injury and repair, which may have been a consequence of 
pharmacologically mediated increases in activity and/or direct adrenergic stimulation, were 
observed only at higher doses in rats (up to 6 mg/kg/day) and monkeys (up to 5 mg/kg/day) after 
dosing (area under the curve [AUC] multiples at ≥ 12-fold in the rat and 3.8-fold in the monkey). 
The generally minimal severity and limited distribution of these drug-related skeletal muscle 
changes likely accounted for the absence of correlative increases in serum muscle-related 
enzymes (AST, CK). There was no skeletal muscle injury noted in rats or monkeys after 
3 months of dosing at systemic exposure multiples up to 61- and 4-fold, respectively. The lack of 
liafensine-related effects on the skeletal muscle after 3 months suggests accommodation with 
repeat dosing. Routine evaluation of serum AST and CK activities are anticipated to be adequate 
for monitoring for the development of skeletal muscle changes in humans in the clinical studies. 
There was liafensine-related hepatotoxicity in rats after 3 and 6 months of dosing, which 
included the dose-related presence of multinucleate hepatocytes, Kupffer cell hypertrophy and 
pigment accumulation, and increases (1.2 to 4-fold) in liver transaminases. A lack of progression 
of the hepatotoxicity in rats was noted, comparing incidence and severity from subchronic to 
chronic studies. Moreover, there was no evidence of hepatic inflammation or fibrosis associated 
with chronic treatment in rats. Evidence of partial or complete recovery of most liafensine-
related findings including all target organ effects were noted in rats. Test article-related hepatic 
changes were not associated with increased hepatocellular proliferation or ultrastructural changes 
indicative of abnormal cell division. 
There were no liafensine-related effects on the liver in monkeys after subchronic (3 months) or 
chronic (9 months) of dosing, where systemic exposures overlapped with those that produced 
liver changes in rats. Moreover, there were no liafensine-related effects on the liver in mice 
treated for up to 3 months. Collectively, the absence of drug-related hepatic changes at 
overlapping or higher systemic exposures in monkeys and mice treated subchronically/ 
chronically with liafensine suggests the treatment-related hepatotoxicity is rat specific. 
1.2.3. 
Pharmacokinetics in Humans 
The absorption of liafensine from either oral solution or tablet formulation was relatively slow. 
From the oral solution, the median tmax was approximately 5.0–7.2 hours postdose after single 
doses (0.025 to 5 mg), and 4–5 hours after once-daily doses for 14 days (0.1 to 4 mg). In the 
relative bioavailability study (CN162004), the median tmax was 7 hours from both the solution 
and tablet. Additionally, the PK of liafensine from the tablet formulation given with a high-fat 
meal was comparable to that under fasting conditions. The adjusted geometric means ratio of the 
Cmax and AUC(0-72h) from the tablet with the high-fat meal vs tablet under fasting conditions was 
1.021 (90% CI: 0.955, 1.092) and 1.018 (90% CI: 0.966, 1.071), respectively. Therefore, 
liafensine may be administered without regard to food. 
Steady state of liafensine was achieved after approximately 10 days of QD dosing (0.1 to 2 mg 
QD), and by Day 12 after 3 mg titration. The accumulation of liafensine AUCt after 14 days of 
once daily dosing ranged from 2.67 to 4.59. 
Liafensine exhibited low to moderate variability in plasma exposures. The variability 
(% coefficient of variation [CV]) of Cmax and AUC ranged from 14% to 29% and 12% to 44%, 


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respectively, in the single ascending dose (SAD) study, and 6% to 40% and 8% to 40%, 
respectively, in the multiple ascending dose (MAD) studies. 
Based on in vitro studies, liafensine is primarily metabolized by multiple CYP enzymes, 
including CYP3A4 as a predominant enzyme, with additional contributions from CYP1A1/2, 
CYP2C9/19, and CYP2D6. The elimination of liafensine was relatively slow. The mean t½ 
ranged from 34–57 hours after single doses, and 44–74 hours after repeat daily doses for 14 days. 
Following a single oral dose administration of [14C]liafensine in adult male healthy volunteers, 
63% and 78% of the dose was recovered by Day 22 and Day 64, respectively. When extrapolated 
to infinity, approximately 83% of the dose would have been recovered. The radioactive dose was 
mainly excreted in the feces (62%) compared to 21% in the urine. 
The Cmax and AUC-time curve extrapolated to infinity (AUC∞) of liafensine increased slightly 
greater than in proportion to dose after single doses ranging from 0.025 to 5 mg. After once-daily 
doses (0.1 to 2 mg QD), the Cmax and AUCt of liafensine increased slightly less than proportional 
to dose on Day 14. There has been no evidence of time-dependent PK after repeat dosing of 
liafensine due to either autoinhibition or autoinduction. The observed degree of accumulation in 
liafensine is consistent with the elimination t½ of liafensine. 
There were no apparent sex differences in the PK of liafensine and its active metabolite 821007 
in the completed Phase 1 studies. In the MAD study (CN162002), although the geometric means 
of liafensine Cmax and AUCt in the female subjects appeared to be lower than those in the male 
subjects in the 1 mg dose groups, there were marked overlaps in these PK parameters between 
the female and male subjects. 
The PK of liafensine in healthy elderly subjects was evaluated in a ketoconazole DDI study 
(CN162015). The elderly population in the study included 12 healthy male (N = 8) and female 
(N = 4) subjects 65 to 85 years old, inclusive, and received a single 1 mg oral dose of liafensine 
administered alone. Dose-normalized analysis showed that liafensine Cmax was 38% lower and 
AUC∞ was 19% higher in the elderly subjects than the young subjects. t½ was longer in the 
elderly compared to young subjects (84 hours vs 49 hours). No meaningful difference was 
observed in the metabolite-to-parent Cmax ratio between the two populations. 821007 t½ could not 
be characterized in the elderly due to insufficient sampling in the terminal phase of the profile. 
The Cmax and AUC∞ values of liafensine were comparable in the elderly male and female 
subjects. 
Co-administration of liafensine with the strong CYP3A4 inhibitor ketoconazole (CN162015) 
increased Cmax and AUC∞ of liafensine by 15% and 32%, respectively, compared to 
administration of liafensine alone. Coadministration with ketoconazole also increased Cmax and 
AUC∞ of 821007, the active metabolite of liafensine, by 16% and 25%, respectively, compared 
to administration of liafensine alone. Because of the observed small increases in liafensine 
exposures when co-administered with the potent CYP3A inhibitor ketoconazole, CYP3A4 
inhibitors will not be excluded in this study. 
Co-administration of liafensine with rifampin (Study CN162017) decreased Cmax and AUC∞ of 
liafensine by 34% and, 66%, respectively, compared to administration of liafensine alone. 
Therefore, in this study, liafensine should not be taken with strong inducers of CYP3A4 and 
those may lower liafensine exposure and reduce its effectiveness. 


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1.2.4. 
Clinical Studies of Liafensine 
The Investigator’s Brochure (IB) lists 14 completed studies in which liafensine was administered 
to 470 subjects in 11 Phase 1 studies and 1,264 subjects in 3 Phase 2b studies including a 
rollover study. These studies are summarized in the Investigator’s Brochure. 
1.2.5. 
Potential Risks and Benefits 
Please see the Investigator’s Brochure for additional discussion and information for the 
following section. 
A number of safety monitoring practices are being employed by this protocol (including, but not 
limited to, physical examinations, vital signs including orthostatic changes in blood pressure and 
heart rate monitoring at specified intervals, triplicate 12-lead ECGs, clinical laboratory 
evaluations, and AE collection) in order to ensure the patients’ safety. 
There is an anticipated health benefit for study patients from receipt of study drug. The previous 
Phase 2b studies conducted by Bristol-Myers Squibb (BMS) did not demonstrate clinically 
meaningful and statistically significant improvement in depression symptoms in general TRD 
patient population. However, the pharmacogenomic analysis conducted by Denovo indicates a 
strong correlation between DGM4 status and symptom improvement in liafensine-treated 
patients, suggesting that liafensine may provide significant treatment benefit in DGM4-positive 
TRD patients. 


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2. 
OBJECTIVES AND ENDPOINTS 
2.1. 
Objectives 
2.1.1. 
Primary Efficacy Objective 
• To demonstrate that liafensine is superior to placebo in DGM4-positive patients with 
TRD as assessed by the change in MADRS total score from baseline to Day 42 of 
double-blind treatment 
2.1.2. 
Key Secondary Efficacy Objective 
• To evaluate the change from baseline to Day 42 in DGM4-positive patients with TRD 
treated with liafensine vs placebo on the Clinical Global Impressions Scale-Severity 
(CGI-S) 
2.1.3. 
Safety Objectives 
• To compare the safety and tolerability of liafensine vs placebo in all randomized 
patients with TRD who received at least one dose of study drug during double-blind 
treatment  
• To evaluate safety for liafensine 1 mg QD and 2 mg QD vs placebo in both 
DGM4-positive and DGM4-negative patients 
2.1.4. 
Other Secondary Efficacy Objectives 
• To evaluate Clinical Global Impressions Scale-Improvement (CGI-I) at Day 42 in 
DGM4-positive patients with TRD treated with liafensine vs placebo  
• To evaluate the change from baseline to Day 42 in DGM4-positive patients with TRD 
treated with liafensine vs placebo on the patient-reported functionality with Sheehan 
Disability Scale (SDS) 
2.1.5. 
Exploratory Objectives 
• To compare the proportion of DGM4-positive patients with TRD who respond to 
liafensine after 6 weeks of treatment vs placebo (response is defined as ≥ 50% 
improvement from baseline in MADRS total score at Day 42) 
• To compare the proportion of DGM4-positive patients with TRD who are in 
remission after 6 weeks of treatment with liafensine vs placebo (remission is defined 
as MADRS total score ≤ 10 at Day 42) 
• To evaluate the change from baseline to Day 42 in DGM4-positive patients with TRD 
treated with liafensine vs placebo on MADRS anhedonia subscale and individual 
items 
• To compare the efficacy of liafensine vs placebo in DGM4-negative patients with 
TRD, as assessed by change in MADRS total score from baseline to Day 42 


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• To evaluate efficacy for liafensine 1 mg QD and 2 mg QD vs placebo in both DGM4-
positive and DGM4-negative patients 
• To evaluate the PK of liafensine as part of the population PK analyses 
2.2. 
Endpoints 
2.2.1. 
Primary Endpoint 
• Change in MADRS total score from baseline to Day 42, in DGM4-positive patients 
2.2.2. 
Secondary Endpoint 
• Change in CGI-S from baseline to Day 42, in DGM4-positive patients 
2.2.3. 
Safety Endpoints 
• Adverse events as characterized by type, frequency, severity, timing, seriousness, and 
relationship to study therapy 
• Laboratory abnormalities as characterized by type, frequency, severity, and timing 
• Vital signs including supine (after at least 5 min rest) and standing (after standing 
1 min and 3 min), blood pressure and heart rate, weight, electrocardiogram (ECG), 
clinical laboratory evaluation, Discontinuation-Emergent Signs and Symptoms scale 
(DESS) scale, and Columbia Suicide Severity Rating Scale (C-SSRS) data 
2.2.4. 
Other Secondary Endpoints 
• CGI-I at Day 42, in DGM4-positive patients 
• Change in SDS from baseline to Day 42, in DGM4-positive patients 
2.2.5. 
Exploratory Endpoints 
• Treatment response (defined as ≥ 50% improvement from baseline in MADRS total 
score at Day 42) in DGM4-positive patients 
• Remission (defined as MADRS total score ≤ 10 at Day 42) in DGM4-positive 
patients 
• Change in MADRS anhedonia subscale and individual items from baseline to Day 42, 
in DGM4-positive patients 
• Change in MADRS total score from baseline to Day 42, in DGM4-negative patients 
• Change in MADRS total score from baseline to Day 42 in 1 mg QD group and 2 mg 
QD group, in both DGM4-positive and DGM4-negative patients 


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3. 
INVESTIGATIONAL PLAN 
3.1. 
Overall Study Design 
This study will be conducted as a multicenter, randomized, double-blind, placebo-controlled 
Phase 2b trial to assess the efficacy, safety, tolerability, and PK of liafensine. The study includes 
an up to 21-day screening period (the screening period may exceed 21 days if a prolonged 
washout is required). 
Approximately 180 patients with TRD who meet all eligibility criteria will be randomized in a 
1:1:1 ratio to receive either liafensine 1 mg QD, liafensine 2 mg QD, or placebo QD for 6 weeks. 
Approximately 150 randomized patients will be genotype GG for DGM4 (DGM4-positive) and 
approximately 30 randomized patients will be genotype AA or AG for DGM4 (DGM4-negative). 
DGM4 status (positive vs negative) of randomized patients will be blinded to the sites, patients, 
and sponsor. An Interactive Response Technology (IRT) system will be used for blinding to 
DGM4 status, and to achieve the correct randomization ratio of DGM4-positive:DGM4-negative 
patients by randomly excluding most screened DGM4-negative patients (~80%). Randomization 
will be stratified by DGM4 status (positive vs negative) and region (North America vs Other). 
Patients who complete the study or discontinue after randomization will have 2 post-study 
follow-up visits (14 days after the last administered dose of study drug, and 28 days after the last 
administered dose of study drug); the 2nd follow-up visit will be conducted via phone call. 
During the study, safety will be assessed on the basis of spontaneously reported AEs; the 
Discontinuation-Emergent Signs and Symptoms scale (DESS); physical, neurological, and 
psychiatric examinations (including the Columbia-Suicide Severity Rating Scale [C-SSRS]); 
vital signs including orthostatic changes in blood pressure and heart rate; weight; 12-lead 
electrocardiograms (ECGs); clinical laboratory test results; serum and urine pregnancy tests 
(females of childbearing potential only); and concomitant medication assessments. In addition to 
blood samples collected for PK, additional blood samples may be collected for determination of 
plasma concentrations of liafensine and its primary metabolite in association with the evaluation 
of safety signals. 
The overall study design is shown in Figure 1. The schedule of study assessments is presented in 
Table 1 with the clinical laboratory tests shown in Table 3. 
To ensure the safety of patients enrolled in this study, an Independent Data Monitoring 
Committee (IDMC) will monitor data on an ongoing basis (Section 8.3.8). The IDMC will 
comprise individuals external to the sponsor and will consist of at least one medical expert in the 
relevant therapeutic area, at least one hepatologist, and at least one statistician. 


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Figure 1: 
Overall Study Design 
 
Abbreviations: ATRQ = Antidepressant Treatment Response Questionnaire; DGM4 = Denovo Genomic Marker 4; 
HAMD-17 = Hamilton Depression Rating Scale - 17 Item; QD = once daily; R = randomization. 
3.2. 
Methodology 
This is a randomized, double-blind, placebo-controlled Phase 2b trial to assess the efficacy, 
safety, tolerability, and PK of liafensine. The primary endpoint is change in MADRS total score 
from baseline (Visit 3, Day -1) to Visit 7 (Day 42) in DGM4-positive patients. The primary 
analysis will be conducted to assess the superiority of liafensine treatment (combined liafensine 
1 mg QD and 2 mg QD doses) vs placebo in randomized patients who are DGM4-positive. 
3.3. 
Study Duration and Follow-up 
The duration of participation for individual patients will be up to 91 days or longer, including an 
up to 21-day screening period (screening period may exceed 21 days if a prolonged washout is 
required), a 6-week double-blind treatment period, and 2 post-study follow-up visits (at 14 days 
and 28 days after the last dose of study drug); the 2nd follow-up visit will be conducted via phone 
call (Figure 1). 


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3.4. 
Sample Size Justification 
Eligible patients will be randomized 1:1:1 to receive liafensine 1 mg QD, liafensine 2 mg QD, or 
placebo QD. The primary analysis is to assess treatment difference in MADRS total score 
change from baseline (Visit 3, Day -1) to Visit 7 (Day 42), between the combined liafensine 
1 mg QD and 2 mg QD doses vs placebo, in DGM4-positive patients. A sample size of 
47 randomized DGM4-positive patients per arm is sufficient to detect a 4.5-unit difference 
between the combined liafensine 1 mg QD and 2 mg QD treatment groups and the placebo 
treatment group in the change in MADRS total score with 80% power at the 2-sided 0.05 alpha 
level, assuming a standard deviation of 9 units. 
To compensate for potential loss of power due to randomized patients who do not take at least 
one dose of study drug or who do not have a post-randomization efficacy evaluation (~5%), a 
total of approximately 150 DGM4-positive patients (50 DGM4-positive patients per arm) will be 
randomized. 
To examine trend in the total patient population and in the subgroup of DGM4-negative patients 
in order to evaluate DGM4 as a potential biomarker for predicting response to liafensine, 
approximately 20% additional DGM4-negative patients (10 per arm, total approximately 30) will 
also be randomized. The sample size of 30 randomized patients in the DGM4-negative group is 
not estimated based on formal statistics in terms of power and alpha level. 
Sample size re-estimation may be conducted if the percentage of missing data at Day 42 visit is 
higher than expected and/or if the observed variance is higher than the one assumed in the 
sample size estimation. 
3.5. 
Number of Subjects 
Approximately 180 patients will be enrolled in the study. 
3.6. 
Treatment Assignment 
Patients who meet all of the inclusion criteria and none of the exclusion criteria will be 
randomized through an IRT system in a 1:1:1 ratio to receive either liafensine 1 mg QD, 
liafensine 2 mg QD, or placebo QD for 6 weeks. 
3.7. 
Criteria for Study Termination 
The sponsor may decide to terminate the study at any time. Furthermore, the sponsor will 
consider recommendations provided by an external IDMC with regards to study continuation, 
modification, and/or termination (Section 7.6). 


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4. 
SELECTION AND WITHDRAWAL OF PATIENTS 
This study can fulfill its objectives only if appropriate patients are enrolled. The following 
eligibility criteria are designed to select patients for whom participation in the study is 
considered appropriate. All relevant medical and nonmedical conditions should be taken into 
consideration when deciding whether a patient is suitable for this protocol. 
Patient eligibility should be reviewed and documented by an appropriate member of the 
investigator’s study team before patients are included in the study. 
4.1. 
Subject Inclusion Criteria 
Patients must meet all the following inclusion criteria to be eligible for enrollment into the study: 
1. Provide signed informed consent which includes pharmacogenomic (PGx) testing. 
2. Have a diagnosis of MDD without psychotic features, according to the Diagnostic and Statistical 
Manual of Mental Disorders, 5th Edition (DSM-5) criteria, based on clinical assessment and 
confirmed by the Mini International Neuropsychiatric Interview (MINI). 
3. TRD documented in the Massachusetts General Hospital (MGH) Antidepressant Treatment 
Response Questionnaire (ATRQ) (5-year version). That is: 
a. clinically meaningful inadequate response (estimated < 50% improvement per 
investigator/patient consensus and documented by the investigator) with: 
1) at least 2 treatment courses with antidepressant regimens; 
2) used at least 2 different pharmacologic treatment classes (eg, SSRI, SNRI, TCA, MAOI, 
atypical); or if only one class treatment is used, at least one combination treatment 
course; 
3) the doses have been given at accepted therapeutic doses for an adequate duration (at least 
6 weeks), per product label; 
4) One of these inadequate response must occur within the current episode. 
Note: non-pharmacological treatment (eg, cognitive behavioral therapy, electroconvulsive 
therapy, repetitive transcranial magnetic stimulation, vagus nerve stimulation, acupuncture) are 
not counted as treatment regimen. 
4. To be eligible, patients must have DGM4 genotype results obtained from the designated Clinical 
Laboratory Improvement Amendments (CLIA) lab, and all eligible DGM4-positive patients and 
about 20% DGM4-negative patients will be randomly included by an IRT system in order to 
achieve the appropriate randomization ratio of DGM4-positive vs negative patients. 
5. Pregnancy conception limitations 
• 
Female patients must be postmenopausal or surgically sterile or, if of childbearing potential 
and the partner is not vasectomized (6 months minimum), must agree to use a medically 
acceptable form of contraception from the time of signing the informed consent form (ICF) 
through at least 60 days following the last administration of study drug. If only the barrier 
method is used, a double barrier must be employed. Postmenopausal women must have had 
≥ 24 months of spontaneous amenorrhea. Surgically sterile women are defined as those who 
have had a hysterectomy, bilateral ovariectomy, or bilateral tubal ligation. All women of 
childbearing potential must have a negative pregnancy test result before administration of 
study drug. 
• 
Male patients must be biologically incapable of having children (eg, vasectomized) or must 
agree to use the above forms of birth control for themselves and their partner from the time 
of signing the ICF through at least 120 days following the last administration of study drug. 


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6. Be fluent in the local language. 
7. Male or female aged 18 to 70, inclusive, at time of Visit 1. 
8. Have a HAMD-17 total score ≥ 21 at screening and baseline. 
9. Be willing to discontinue the use of antidepressant drugs (including over-the-counter 
medications to treat depression [eg, St John’s Wort]) at least 5 half-lives (or at least 
1 week for herbal or other over-the-counter medications for depression) prior to baseline 
(Day -1). For fluoxetine, a washout period of at least 3 weeks for ≤ 20 mg/day and at 
least 4 weeks for > 20 mg/day is required. 
4.2. 
Subject Exclusion Criteria 
Patients with any of the following characteristics/conditions will be excluded from study: 
1. Prior participation in a study with liafensine. 
2. Used any investigational drug product, device, or biologic within 3 months or 5 half-lives 
(whichever is longer) prior to baseline (Day -1). 
3. A positive pregnancy test result or currently breastfeeding. 
4. Clinically significant and/or unstable illness (including chronic, persistent, or acute infection), 
medical/surgical procedure, or trauma within 30 days prior to screening or between screening and 
baseline (Day -1) as determined by the investigator. 
5. A history or presence of a clinically significant and/or unstable hepatic, renal, gastrointestinal, 
cardiovascular, endocrine, respiratory, immunologic, hematologic, dermatologic, or neurologic 
abnormality, or any other condition, that in the investigator’s opinion, represents potential risk to 
the patient’s safety and ability to fully participate in the study, or affects the absorption, 
distribution, metabolism, or excretion of liafensine. 
6. Presence of autoimmune hepatitis, primary sclerosing cholangitis, untreated hepatitis C, active 
hepatitis B, or any other uncontrolled or unstable liver disease according to local guidance. 
7. Uncontrolled human immunodeficiency virus (HIV) infection according to local guidance. 
8. Uncontrolled abnormal thyroid function according to local guidance. 
9. One or more clinical laboratory evaluations are outside the reference range, at screening, that are in 
the investigator’s opinion, of potential risk to the patient’s safety. 
10. Has at the Screening Visit: 
• 
Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels > 1.5x the upper 
limit of normal (ULN) at screening.  
• 
Total bilirubin (TBL) > 2 mg/dL (34.2 µmol/L) at screening, unless there is an explained 
indirect hyperbilirubinemia, eg, Gilbert’s syndrome. 
• 
Alkaline phosphatase (ALP) > 1.5x the ULN at screening. 
Note: Laboratory tests can be repeated to see if values return to normal range, but any such 
laboratory abnormality must be resolved by the Baseline Visit (Day -1). 
11. Clinically significant vital sign abnormality at screening. This includes, but is not limited to, the 
following, in the supine (after at least 5 min rest) and standing (after 1 min and 3 min standing): 
systolic blood pressure ≥ 140 mmHg; diastolic blood pressure ≥ 90 mmHg; or heart rate < 50 or 


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> 90 beats per minute. If the initial blood pressure is ≥ 140/90 mmHg, the lowest value from up to 
3 additional attempts, which also must not be ≥ 140/90 mmHg, should be used. Patients with 
symptomatic orthostatic hypotension, at the discretion of investigator, will be excluded. 
12. Corrected QT interval measurement according to the Fridericia rule (QTcF) > 450 msec for men 
and > 470 msec for women during controlled rest at screening, or history of long-QT syndrome. 
13. ECGs containing any of the following readings: 
⚫ 
Left bundle branch block 
⚫ 
Right bundle branch block with QRS duration > 140 ms 
⚫ 
Intraventricular conduction defect with QRS duration > 140 ms 
⚫ 
Long QT syndrome 
14. History of seizure, other than childhood febrile seizures. 
15. History of clinically significant head trauma, including closed head injury with loss of 
consciousness, that is, in the opinion of the investigator, likely to affect central nervous system 
function. 
16. History of clinically significant symptomatic orthostatic hypotension (ie, postural syncope). 
17. History of narrow angle glaucoma. 
18. History of cancer within 2 years prior to screening or between screening and baseline (Day -1), 
except for non-metastatic basal and/or squamous cell carcinoma of the skin. 
19. Use of prescription or nonprescription medications for attention-deficit hyperactivity disorder 
(ADHD), narcolepsy, or cognitive enhancement (eg, methylphenidate, atomoxetine, modafinil, 
ginkgo biloba, and huperzine A) within 30 days prior to screening or between screening and 
baseline (Day -1). 
20. Regular consumption of (eg, more days than not) excessive quantities of xanthine-containing 
beverages (eg, more than five cups of coffee or the equivalent per day) within 30 days prior to 
screening or between screening and baseline (Day -1). 
21. Urine drug screen (UDS) positive for a drug of abuse, with the exception of cannabis in countries 
where it is legally available (see Table 3 for list of drugs of abuse). Where legal, prior use of 
cannabis is permitted provided the patient agrees to abstain from smoking or ingesting cannabis 
or cannabis products during the study. 
22. Use of potent inducers of CYP3A4 (eg, rifampin, rifabutin, phenytoin, carbamazepine, or 
phenobarbital) within 2 weeks prior to baseline (Day-1). 
23. Current diagnosis or history of a psychotic disorder, MDD with psychotic features, manic or 
hypomanic episode of bipolar or related disorders. 
24. Current diagnosis of anxiety disorder (if primary), post-traumatic stress disorder, obsessive-
compulsive disorder (if primary), intellectual disability (DSM-5 diagnostic code 319), borderline 
personality disorder, antisocial personality disorder, histrionic personality disorder, or narcissistic 
personality disorder according to the DSM-5 criteria, or any other psychiatric or neurologic 
disorder or symptom due to a general medical condition, that, in the judgement of the 
investigator, could pose undue risk to the patient or compromise the study. 


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25. Hospitalized or discharged from psychiatric ward within 8 weeks prior to the screening visit and 
planned hospitalization for any condition(s) during the study.  
26. Moderate or severe alcohol use disorder or other substance use disorder (except nicotine or 
caffeine), within 6 months prior to screening, according to the DSM-5 criteria. 
27. Significant risk of suicide determined by: 
a. Acute suicidality as evidenced by answering “yes” to Question 5 (“In the Past Year”) on the 
C-SSRS, indicating active suicidal ideation with specific plan and intent for suicide, at 
screening, or baseline (Day -1); or 
b. History of suicidal behavior as indicated by a “yes” response on the Suicidal Behavior section 
of the C-SSRS (“In the past year”) or 
c. A score ≥ 5 on Item 10 (suicidal thoughts) of the MADRS at screening or baseline (Day -1); 
or 
d. Has attempted suicide within 6 months prior to the initial screening visit. 
28. Previous allogenic bone marrow transplant. 
29. Received non-leukocyte-depleted whole blood transfusion within 4 months prior to PGx testing at 
Screening. 
30. Currently employed by the sponsor or by a clinical trial site participating in this study, or a 
first-degree relative of an employee of the sponsor or of an employee at a participating clinical 
trial site. 
4.3. 
Contraceptive Guidelines 
Female patients must be postmenopausal or surgically sterile or, if of childbearing potential and 
the partner is not vasectomized (6 months minimum), must agree to use a medically acceptable 
form of contraception from the time of signing the ICF through at least 60 days following the last 
administration of study drug. If only the barrier method is used, a double barrier should be 
employed. Postmenopausal women must have had ≥ 24 months of spontaneous amenorrhea. 
Surgically sterile women are defined as those who have had a hysterectomy, bilateral 
ovariectomy, or bilateral tubal ligation. All women of childbearing potential must have a 
negative pregnancy test result before administration of study drug. 
Male patients must be biologically incapable of having children (eg, vasectomized) or must agree 
to use the above forms of birth control for themselves and their partner from the time of signing 
the ICF through at least 120 days following the last administration of study drug. 
4.4. 
Patient Withdrawal Criteria 
Patients have the right to withdraw from study at any time for any reason. 
4.4.1. 
Withdrawal from Study Treatment or Study Participation 
Patients must be discontinued from study treatment for any of the following reasons: 
• Unacceptable toxicity in the opinion of treating investigator that the risk outweighs 
potential benefit for the subject. For laboratory abnormality meeting withdrawal criteria, 
please refer to Section 7.6.1.8. 


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• Pregnancy 
Patients may be discontinued from study participation for any of the following reasons: 
• Intercurrent illness 
• Withdrawal of consent 
• Death 
• Study terminated by the sponsor, relevant regulatory agencies, or institutional review 
board (IRB)/independent ethics committee (IEC) 
All patients who discontinue from study treatment are encouraged to continue the study 
participation, and at a minimum undergo the End-of-Treatment (EOT) assessments, unless 
consent is withdrawn, as indicated in the schedule of events (Table 1). If a patient does not return 
for a scheduled visit, every effort should be made to contact the patient. 
4.4.2. 
Withdrawal from Follow-up 
Patients may withdraw or may be withdrawn from study follow up for any of the following 
reasons: 
• Consent withdrawn/refuses follow up 
• Death 
• Study terminated by the sponsor 
• Lost to Follow-up 
• Other, specify 


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5. 
TREATMENT OF SUBJECTS 
5.1. 
Description of Study Treatment 
Patients will be randomly assigned through an IRT system in a 1:1:1 ratio to receive either 
liafensine 1 mg QD, liafensine 2 mg QD, or placebo QD for 6 weeks (Table 2). 
Randomization Phase: 
Liafensine 1 mg QD 
• Day 1 through Day 42: one 1 mg liafensine tablet and one matching placebo tablet 
QD 
Liafensine 2 mg QD 
• Day 1 through Day 7: one 1 mg liafensine tablet and one matching placebo tablet QD 
• Day 8 through Day 42: two 1 mg liafensine tablets QD 
Placebo QD 
• Day 1 through Day 42: two placebo tablets QD 
Table 2: 
Investigational Product 
Product Name: 
Liafensine Tablets 1 mg 
Placebo for Liafensine Tablets 1 mg 
Dosage Form: 
Tablet 
Tablet 
Unit Dose 
1 mg 
N/A 
Route of Administration 
Oral 
Oral 
Physical Description 
White to off-white round 
film-coated tablet 
White to off-white round 
film-coated tablet 
Manufacturer 
Patheon Inc. 
(Toronto, Canada) 
Patheon Inc. 
(Toronto, Canada) 
5.2. 
Administration of Study Treatment 
Investigational product (study drug) will be supplied as tablets containing 1 mg liafensine or 
matching placebo. Study drug will be taken orally, once daily. Patients will be instructed to take 
the study drug whole, and not to chew, divide, or crush the tablets and take the study drug at the 
same approximate time each day in the morning. 
5.3. 
Concomitant Medications 
Prohibited concomitant treatments and study restrictions during the study from baseline to 
14 days after the last dose of study drug (the first half of the follow-up) include: 
1. Any investigational drug product, device, or biologic. 
2. Any prescription or nonprescription medication for ADHD, narcolepsy, or cognitive 
enhancement (eg, methylphenidate, atomoxetine, modafinil, ginkgo biloba, and 
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3. Any psychopharmacologic drug (including antidepressants and over-the-counter 
medications to treat depression (eg, herbal medicines like St John’s Wort, or other local 
herbal medicines). 
4. Potent inducers of CYP3A4 (eg, rifampin, rifabutin, phenytoin, or carbamazepine, 
phenobarbital). 
Permitted concomitant treatments, provided they meet the specific requirements detailed 
below, during the study and during the indicated periods include: 
1. Up to 3 g/day paracetamol/acetaminophen. 
2. Non-psychopharmacologic drugs provided the dose and condition being treated have 
been relatively stable for at least 2 months prior to screening and between screening and 
baseline (Day -1) and are not expected to change meaningfully during the study. 
3. Soporific drugs may be used provided the dose and condition being treated have been 
relatively stable for at least 2 months prior to screening and between screening and 
baseline (Day -1) and are not expected to change meaningfully during the study. 
4. Psychotherapy (including cognitive behavioral therapy) is permitted provided 
psychotherapy was initiated at least 2 months prior to screening and is expected to remain 
relatively stable during the study. 
5. Anxiolytic drugs which do not affect 5-HT, norepinephrine, and dopamine activity may 
be used provided the dose and condition being treated have been relatively stable for at 
least 2 months prior to screening and between screening and baseline (Day -1) and are 
not expected to change meaningfully during the study. 
Note 1: if a pro re nata (PRN) use has been established prior to the study, and not 
expected to change during the trial, this is considered stable treatment.  
Note 2: Medication considered necessary for the patient’s safety and well-being may be 
given at the discretion of the investigator and recorded in the appropriate sections of the 
electronic Case Report Form (eCRF). If a psychopharmacologic medication that is 
otherwise prohibited is administered the study measurements such as MADRS and CGI 
should be collected prior to dosing when possible. If any medication that is otherwise 
prohibited is administered to a patient, the investigator should inform the medical 
monitor prior to administration of medication when possible. 
Other restrictions include: 
1. Patients will be required to maintain their normal intake of xanthine-containing foods or 
beverages, and, if permitted, vitamin and herbal supplements, during the study, including 
the screening and follow-up periods. 
2. Patients should not provide blood or plasma donations between screening and baseline 
(Day -1), during the study and for 6 weeks after the last dose of study drug. 


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5.4. 
Treatment Compliance 
Compliance with study drug must be stressed and assessed at each visit. Study drug compliance 
will be assessed by the investigator and/or study personnel at designated visits by direct 
questioning and recording tablet counts from the previously dispensed bottles (ie, returned tablet 
counts). In the events of poor compliance, eg, < 80%, investigator and/or study personnel should 
follow up closely with patients and make every effort to improve patients’ treatment compliance. 
All study drug dispensed and returned must be recorded in the Drug Accountability Log. 
The study site will keep a record of all drugs dispensed to and returned by patients throughout 
the study. Start and end dates of doses of study drug administered since the last dispensing visit 
will be recorded in the eCRFs (study drug dosage administration record) at visits specified in the 
table of assessments (Table 1). Deviations from the prescribed dosage regimen should be 
recorded in the eCRF. 
Each patient should be instructed to return all study drug packaging and unused material to the 
study site at each visit. Study site personnel will destroy unused medication unless it is the site’s 
policy to return to Denovo or its designee at the end of the study. 
5.5. 
Randomization and Blinding 
DGM4 status (positive vs negative) of randomized patients will be blinded to the sites, the 
patients, and sponsor. An IRT system will be used for blinding to DGM4 status, and to achieve 
the correct randomization ratio of DGM4 positive:DGM4-negative patients by randomly 
excluding most screened DGM4-negative patients (~80%). 
The study team from the sponsor will also be blinded for DGM4 status of individual patients; 
however, the sponsor will be informed of the total number of patients enrolled in the 
DGM4-positive group by an independent unblinding team who supports the IDMC meetings in 
order to ensure the target enrollment is achieved in this group. 
Treatment randomization will be stratified by DGM4 status (positive vs negative) and region 
(North America vs Other). Treatment assignment is blinded to the study site, patients, and the 
sponsor. 
5.6. 
Emergency Treatment Unblinding 
Unblinding during the study is discouraged and should only happen if knowledge of the patient’s 
study drug would affect subsequent treatment and such knowledge is essential for the clinical 
management of the patient. In such a case, the investigator should contact the sponsor’s medical 
monitor before breaking the treatment code whenever possible. The treatment assignment shall 
only be shared, if necessary and feasible, with personnel involved in the clinical management of 
the patient. Personnel exclusively involved in the clinical trial conduct, eg, study coordinators, 
study manager, and representatives from the contract research organization (CRO)/sponsor, shall 
remain blinded. The sponsor will be notified once the treatment code is broken and should 
remain blinded to the treatment assignment. 


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6. 
STUDY DRUG MATERIALS AND MANAGEMENT 
6.1. 
Liafensine/Placebo 
Investigational product (study drug) will be supplied by Denovo as tablets containing 1 mg of 
liafensine or matching placebo. The tablets must not be crushed or broken for administration. 
Details of study drug packaging, labeling, and storage conditions will be provided in the study 
Pharmacy Manual. 
The pharmacist or designee will dispense study drug kit(s) containing an adequate number of 
tablets, including overage, for each dosing cycle. Details of study drug dispensing and 
compliance will be provided in the Pharmacy Manual. 


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7. 
STUDY PROCEDURES AND ASSESSMENTS 
7.1. 
Study Procedures 
7.1.1. 
Informed Consent 
Written informed consent must be obtained by signing an IRB or IEC approved ICF. Informed 
consent may be obtained more than 21 days prior to randomization. 
Informed consent for study procedures will be obtained over 2 visits in the following manner: 
Visit 1: Two separate brief ICFs will be completed, including 
1. A brief ICF to explain sampling for PGx testing for the purpose of genotyping only. 
2. A brief ICF to explain future scientific research biobanking; includes the 
option (checkbox for participation) to participate in the future scientific research 
program for all subjects. 
Visit 2: A full ICF that explains the study procedures from V2 to EOS. 
Results from physical exam, laboratory test, or other routine medical care performed prior to the 
date of informed consent, but within the allowed timeframe for screening procedures, can be 
used for determining the patient’s eligibility if obtained as part of the patient’s standard of care. 
If such results or evaluations are used in the determination of eligibility, this must be clearly 
documented in the patient’s source documents. 
All materials used for the baseline assessments and follow-up of patients, or for the investigation 
of AEs, may be duplicated and made available to the sponsor and/or an authorized independent 
body for review. 
7.1.2. 
Study Treatment Evaluations and Procedures 
7.1.2.1. 
Screening 1/Screening 2 Procedures (Visit 1 and Visit 2) 
Unless otherwise noted below, all screening procedures, aside from DGM4 genotyping 
(performed prior to Day -21), must be performed within 21 days prior to randomization. 
Screening 1 and Screening 2 procedures will be conducted over two visits as detailed in Table 1. 
Screening 2 will only be performed after the initial eligibility including PGx (DGM4 status) is 
confirmed. 
Laboratory testing and the assessment of vital signs can be repeated for up to 3 occurrences after 
Visit 2 to see if values return to normal range, but any abnormality must be resolved by the 
Baseline Visit.  
All procedures as presented in Table 1 must be completed, including: 
Visit 1 
• Brief informed consents  
• Inclusion/exclusion criteria – preliminary determination (not include MINI and ATRQ) 
• A complete medical history 


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• Demographics 
• Preliminary diagnosis checklist 
• Biomarker: blood draw for DGM4 status 
• Pregnancy test 
• An assessment of adverse events 
Visit 2 
• Full informed consent 
• Inclusion/exclusion criteria determination (continued) 
• Psychiatric evaluations (MINI and ATRQ) 
• Blood draw for clinical laboratory evaluations 
• Complete physical and neurological examinations  
• PRDF Checklist 
• CGI-S 
• MADRS 
• HAMD-17 
• C-SSRS, baseline/screening version 
• Vital signs including supine (after at least 5 min rest) and standing (after 1 min and 3 min 
standing), blood pressure and heart rate 
• Body weight and height 
• Single 12-lead ECG will be performed 
• Urinalysis (on-site unless macro-findings are observed and central lab assessment is 
required) 
• Urine drug screen (on-site) 
• Prior medications 
• Assessment of adverse events 
Note: Rater 1 is to assess HAMD-17 and MADRS; rater 2 is to assess CGI-S after reviewing 
PRDF Checklist; the rest of scales maybe collected by either rater. 
7.1.2.2. 
Evaluations on Study From Baseline to End-of-Treatment 
Please see Table 1 for all study procedures and timing. 
• Continuation of inclusion/exclusion criteria determination 
• Complete physical and neurological examinations 
• Patient questionnaires and scales including PRPS, MADRS, HAMD-17, PRDF Checklist, 
CGI-S, CGI-I, SDS and C-SSRS (since-last-visit version) 
• Vital signs including supine (after at least 5 min) and standing (after 1 min and 3 min 
standing), blood pressure and heart rate 


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• ECGs will be performed. 12-lead ECG recordings will be performed in triplicate (at 
1-minute intervals between each of three recordings) at baseline. Single ECG will be 
performed at other visits. 
• Clinical laboratory tests will be performed 
• Urine drug screen 
• Urine pregnancy test at baseline 
• Blood samples for PK per patient will be collected. Time of last dose and time of blood 
collection will be recorded. When possible, and if medically appropriate, blood samples 
should be collected for PK from patients who experience an SAE or overdose. 
• Concomitant medications 
• Assessment of adverse events 
Note: Rater 1 is to assess HAMD-17 and MADRS; rater 2 is to assess CGI-S after reviewing 
PRDF Checklist, and CGI-I after reviewing current and baseline PRDF Checklist and other 
baseline symptoms; the rest of scales maybe collected by either rater. 
7.1.3. 
End-of-Treatment and Follow-up Evaluations and Procedures 
Please see Table 1 for Day 42 EOT and Follow-up procedures and timing. 
• Physical and neurological examinations 
• Patient questionnaires and scales including MADRS, PRDF Checklist, CGI-S, CGI-I , 
SDS, C-SSRS (since-last-visit version), and DESS. 
• Vital signs including supine (after at least 5 min rest) and standing (after 1 min and 3 min 
standing), blood pressure, heart rate, and body weight. 
• ECGs will be performed on Day 42 (Visit 7) or at the time of early withdrawal, if within 
3 days of last dose. Single 12-lead ECG will be performed. 
• Clinical laboratory tests (including hematology, blood chemistry) 
• Urinalysis (on-site unless macro-findings are observed and central lab assessment is 
required) 
• Urine drug screen 
• Serum pregnancy test 
• Blood samples for PK per patient will be collected on Day 42 (Visit 7) or at the time of 
early withdrawal, if within 3 days of last dose. Time of last dose and time of blood 
collection will be recorded. When possible, and if medically appropriate, blood samples 
should be collected for PK from patients who experience an SAE or overdose. 
• Assessment of adverse events 
• Concomitant medications 
Note: Rater 1 is to assess HAMD-17 and MADRS; rater 2 is to assess CGI-S after reviewing 
PRDF Checklist, and CGI-I after reviewing current and baseline PRDF Checklist and other 
baseline symptoms; the rest of scales maybe collected by either rater. 


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7.2. 
Assessment of Efficacy 
The primary efficacy outcome measure is the change in MADRS total score from baseline 
(Visit 3, Day -1) to Visit 7 (Day 42) in DGM4-positive patients. Other efficacy assessments 
include CGI-S, CGI-I, and SDS. 
The overall schedule of efficacy assessments is provided in Table 1. Note that CGIs should be 
completed only after the Patient Rated Depression and Functioning Checklist (PRDF Checklist) 
has been completed as instructed. 
Montgomery-Åsberg Depression Rating Scale (MADRS) 
The Montgomery-Åsberg Depression Rating Scale (MADRS) is a 10-item clinician-administered 
scale, designed to be particularly sensitive to antidepressant treatment effects in patients with 
major depression (Montgomery 1979). Each MADRS item is rated on a 0 to 6 scale. The 
MADRS total score is calculated as the sum of the 10 individual item scores; the total score can 
range from 0 to 60. Higher MADRS scores indicate higher levels of depressive symptoms. 
A structured interview guide for Montgomery-Asberg (SIGMA) will be provided. 
Clinical Global Impressions Scale-Severity (CGI-S) 
The CGI-Severity (CGI-S) asks the clinician one question: “Considering your total clinical 
experience with this particular population, how mentally ill is the patient at this time?” which is 
rated on the following seven-point scale: 1 = normal, not at all ill; 2 = borderline mentally ill; 
3 = mildly ill; 4 = moderately ill; 5 = markedly ill; 6 = severely ill; 7 = among the most 
extremely ill patients (Guy 1976). 
This rating is based upon observed and reported symptoms, behavior, and function in the past 
seven days. Clearly, symptoms and behavior can fluctuate over a week; the score should reflect 
the average severity level across the seven days. 
Clinical Global Impressions Scale-Improvement (CGI-I) 
The CGI-Improvement (CGI-I) is similarly simple in its format (Guy 1976). Each time the 
patient is seen after medication has been initiated, the clinician compares the patient's overall 
clinical condition to the one-week period just prior to the initiation of medication use (the 
so-called baseline visit). The CGI-S score obtained at the baseline (initiation) visit serves as a 
good basis for making this assessment. Again, only the following one query is rated on a 
seven-point scale: “Compared to the patient's condition at admission to the project (prior to 
medication initiation), this patient's condition is: 1 = very much improved since the initiation of 
treatment; 2 = much improved; 3 = minimally improved; 4 = no change from baseline (the 
initiation of treatment); 5 = minimally worse; 6 = much worse; 7 = very much worse since the 
initiation of treatment.” 
The CGI-I score generally tracks with the CGI-S such that improvement in one follows the other. 
Anchors for scoring, however, are quite different, and the CGI-I is based upon changes from the 
initiation of treatment in contrast to changes from the preceding week of treatment. 
Consequently, the two CGI scores can occasionally be dissociated such that a clinician may 
notice changes in the CGI-I relative to baseline despite no recent changes in the overall CGI 
severity score or vice versa. 


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Patient Rated Depression and Functioning Checklist (PRDF Checklist) 
PRDF Checklist is used to assess overall depression symptoms and the psychosocial impact over 
the last week. It will be completed by patients and reviewed with the clinician before finalizing. 
The post-baseline entry must be compared to baseline checklist entry to refresh the knowledge of 
patient’s baseline condition. The checklist must be administered prior to the administration of 
CGIs. 
Sheehan Disability Scale (SDS) 
The SDS will be used to assess functional impairment in three major life domains: work, social 
life/leisure activities, and family life/home responsibilities (Sheehan 2008). It is a five-item scale 
that will be completed by the participant. Three items use a Likert scale with a 10-point range 
(0 / Moderately to 10 / Extremely) and two items are open-ended (eg, “On how many days in the 
last week did you…?”). The scale is expected to take about 5 minutes to complete. 
7.3. 
Other Assessments 
Hamilton Depression Rating Scale – 17 Item (HAMD-17) 
The Hamilton Rating Scale for Depression – 17 Item (HAMD-17) is used to quantify the severity 
of symptoms of depression and is one of the most widely used and accepted instruments for 
assessing depression (Hamilton 1960). The standard version of the HAMD-17 is designed to be 
administered by a trained clinician, and it contains 17 items rated on either a 3- or 5-point scale, 
with the sum of all items making up the total score. The HAMD-17 may be a useful scale for 
cognitively impaired patients who have difficulty with self-report instruments. 
The HAMD-17 may be used to monitor the patient's progress during treatment, after the 
diagnosis of major depression has been established. This clinician-administered scale exists in 
several versions, ranging from 6 to 31 items; answers by patients are scored from 0 to 2 or 0 to 4 
and tallied to obtain an overall score. A decrease of 50% or more in the HAMD-17 score is often 
considered to indicate a positive treatment response, whereas a score of 7 or less is considered 
equivalent to a remission. 
In the current study, the HAMD-17 is utilized for eligibility only at screening and baseline visit. 
Massachusetts General Hospital (MGH) Antidepressant Treatment Response 
Questionnaire (ATRQ) (5-year version) 
Massachusetts General Hospital (MGH) Antidepressant Treatment Response Questionnaire 
(ATRQ) (5-year version) is a self-rated scale used to determine treatment resistance in major 
depressive disorder (MDD) (Chandler 2010). The MGH ATRQ defines a treatment period for an 
adequate duration of treatment and provides specific operational criteria for adequate dosage for 
each of the most commonly used antidepressants. 
Placebo Response Propensity Scale (PRPS) 
The Placebo Response Propensity Scale (PRPS) was developed to assess the conceptual 
constructs which may influence placebo response in a clinical trial.  


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7.4. 
Pharmacokinetics 
Blood samples will be collected for determination of concentrations of liafensine and its primary 
metabolite on Day 28 (Visit 6) and on Day 42 (Visit 7) prior to dose administration. The time of 
last dose and time of blood collection will be recorded. 
If the patient discontinues before Day 42 (Visit 7), a blood sample will be collected for PK on 
the last day the patient takes a full dose of study drug or as soon as possible thereafter, but within 
three days after the last dose in any case. When possible, and if medically appropriate, blood 
samples should be collected for PK from patients who experience a serious adverse event (SAE) 
or overdose. 
7.5. 
Pharmacogenomics 
Blood will be collected for DGM4 assessment by central laboratory. Any remaining samples not 
used for DGM4 assessment will be stored for potential future biomarker/pharmacogenomic 
research as described below. 
The DGM4 biomarker status for each patient will be blinded to the sponsor, investigative site, 
and patient. Blood will also be collected to be stored at a contracted laboratory for future 
biomarker/pharmacogenomic research. 
The biomarker/pharmacogenomic research includes studying genetic variations such as 
polymorphisms on serotonin, dopamine, or norepinephrine transporters, as well as CYP450 
genes), which may help to understand the varied responses due to liafensine among different 
patients. The blood samples can also be used for developing DGM4 in vitro diagnostic (IVD) 
assay which will be used as a companion diagnostic in the future. 
To protect patients’ confidentiality, the stored biospecimens and data generated from them will 
be coded with the patients’ study number. Biospecimens will be stored indefinitely unless a time 
limit is required by local regulations or ethical requirements. Patients can withdraw their consent 
for the use of their biospecimens at any time by making a request to the investigator, in which 
case any remaining biospecimen will be destroyed; data already generated from the 
biospecimens will continue to be stored to protect the integrity of existing analyses. Results 
generated from the biospecimen will not be provided to the patients (unless required by local 
regulations), and their family members, the investigators, or other physicians. Patients will not be 
compensated if the use of the biospecimens results in commercially viable products. 
Instructions for sample collection, processing, storage, and shipment will be provided in a 
separate document. 
7.6. 
Assessment of Safety 
Safety will be assessed on the basis of spontaneously reported AEs; the DESS scale; physical, 
neurological, and psychiatric examinations (including C-SSRS); vital signs including orthostatic 
changes in blood pressure and heart rate; weight; 12-lead ECGs; clinical laboratory test results; 
serum and urine pregnancy tests (females of childbearing potential only); and concomitant 
medication assessments. Safety assessments in addition to those specified may be performed to 
ensure patient safety if judged appropriate by the investigator. 
See Table 1 for the overall schedule of safety assessments. 


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Psychiatric assessments will be performed by a psychiatrist or trained and certified clinical staff 
member, and neurologic assessments will be performed by an experienced clinician. 
Patients fulfilling Hy’s law, defined as [ALT or AST ≥ 3 × ULN] and [TBL ≥ 2 × ULN], in the 
absence of significant increase in ALP and in the absence of an alternative diagnosis that 
explains the increase in total bilirubin, will be discontinued, with medical follow-up as 
appropriate. 
An IDMC will be established to monitor data on an ongoing basis to ensure the continuing safety 
of patients enrolled in this study (Section 8.3.8). The IDMC will comprise of individuals external 
to the sponsor and will consist of at least one medical expert in the relevant therapeutic area, at 
least one hepatologist, and at least one statistician. The IDMC’s responsibilities, authorities, and 
procedures, with details of decision-making guidance and dissemination of the results, will be 
documented in the IDMC charter. 
7.6.1. 
Safety Parameters 
Every effort should be made to ensure that the protocol-required tests and procedures are 
completed. Safety assessments will include collection of AEs, vital signs including supine and 
standing blood pressure and heart rate, physical examinations, neurological examinations, 
electrocardiograms, laboratory tests, and concomitant medications. 
7.6.1.1. 
Adverse Events 
Assessment of AEs will include the type, incidence, severity, timing, seriousness, and 
relatedness. 
Adverse events reporting requirements are provided in Section 7.6.2. 
7.6.1.2. 
Medical History and Demographics 
Demographic and baseline variables include the following: age, sex, ethnicity, and race. Other 
baseline characteristics include the following: relevant medical history and neuro-oncology 
history. 
7.6.1.3. 
Vital Signs 
Vital signs will include measurement of temperature, supine (after at least 5 min rest) and 
standing (after1 min and 3 min standing), blood pressure (BP) and heart rate. 
7.6.1.4. 
Physical Examination and Neurological Examination 
The physical and neurological assessments will be performed by an experienced clinician. 
The physical examination includes height and weight, and also examination of the heart, lungs, 
and abdomen at a minimum. 
The neurological examination includes evaluation of cranial nerves, muscle strength, tone and 
bulk, reflexes, coordination, sensory function and gait.  


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7.6.1.5. 
Psychiatric Assessments 
Psychiatric assessments will be performed by a psychiatrist or appropriately qualified clinical 
staff member.  
Columbia-Suicide Severity Rating Scale (C-SSRS) 
The Columbia-Suicide Severity Rating Scale (C-SSRS) was designed to quantify the severity of 
suicidal ideation and behavior (Posner 2011). C-SSRS is a measure used to identify and assess 
individuals at risk for suicide. Questions are phrased for use in an interview format, but can be 
completed as a self‐report measure if necessary. C‐SSRS measures four constructs: the severity 
of ideation, the intensity of ideation, behavior, and lethality. It includes “stem questions,” which 
if endorsed, prompt additional follow‐up questions to obtain more information. There are four 
versions of the scale available, including: 1) Baseline/screening version, which allows 
practitioners to gather a lifetime and recent 12 months history of suicidal ideation and/or 
behavior; 2) Since Last Visit version for assessment of suicidal thoughts and behaviors since 
C-SSRS was last administered; 3) Screen version, a shortened version of the full form 
(3-6 questions) most commonly used in clinical triage settings; 4) Risk Assessment Page, which 
provides a checklist of protective and risk factors of suicidality. 
Discontinuation-Emergent Signs and Symptoms scale (DESS) 
The DESS scale will be used to monitor patients for discontinuation symptoms (Rosenbaum 
1998). It includes 43 signs or symptoms for which the patient indicates whether there has been 
any change since their last visit – indicating new symptom, old symptom but worse, old 
symptom but improved, old symptom but unchanged, symptom not present. The DESS total 
score is calculated as the count of items with new symptoms or old symptoms but worse. The 
total score can range from 0 to 43. 
Mini International Neuropsychiatric Interview (MINI) 
The Mini International Neuropsychiatric Interview (MINI) is a structured diagnostic interview 
designed to meet the need for an accurate psychiatric interview in multicenter trials, with a short 
administration time (~26 minutes) (Sheehan 1998). The MINI was developed to explore 
17 disorders according to Diagnostic and Statistical Manual diagnostic criteria, focusing on the 
existence of current disorders. For each disorder, one or two screening questions rule out the 
diagnosis when answered negatively. Probes for severity, disability or medically explained 
symptoms are not explored symptom-by-symptom. 
7.6.1.6. 
Electrocardiogram 
Electrocardiogram (ECG): 12 lead (with a 10 second rhythm strip) tracing will be used for all 
ECGs. It is preferable that the machine used has a capacity to calculate the standard intervals 
automatically. 12-lead ECG recordings will be performed in triplicate (at approximately 
1-minute intervals between each of the three recordings) at baseline, and single ECG for rest of 
visits. 
QT corrected by Fridericia’s formula is recommended: QTcF = QT/RR0.33. 


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7.6.1.7. 
Laboratory Assessments 
Clinical laboratory assessment will be performed at the time points indicated in Table 1. 
Table 3 provides the minimum required laboratory parameters for this study. 
Table 3: 
Laboratory Tests 
Blood chemistry 
• Alanine aminotransferase (ALT/SGPT) 
• Alkaline phosphatase (ALP) 
• Aspartate aminotransferase (AST/SGOT) 
• Bilirubin (direct and total) 
• Blood urea nitrogen (BUN) 
• Calcium 
• Chloride 
• Cholesterol (total) 
• Creatine kinase (CK) 
• Creatinine 
• Glucose (serum) 
• Phosphorus 
• Potassium 
• Protein (albumin and total) 
• Sodium 
Thyroid panel (Screening only) 
• Thyroid-stimulating hormone (TSH) 
• Free triiodothyronine (FT3) 
• Free thyroxine (FT4) 
Urinalysis (routine) 
• On-site macroscopic examination Central lab 
microscopic examination (in the event of 
protein, blood, nitrite and/or leukocyte esterase 
noted in macroscopic) 
• Bilirubin 
• Blood (occult and cells) 
• Ketones 
• Leukocytes 
• Nitrite 
• pH 
• Protein 
• Specific gravity 
• Urobilinogen 
Hematology 
• Hematocrit 
• Hemoglobin 
• MCH concentration (MCHC) 
• Mean corpuscular hemoglobin (MCH) 
• Mean corpuscular volume (MCV) 
• Platelet count 
• Red blood cell (RBC) count 
• White blood cell (WBC) differential 
o Neutrophil count (absolute and %) 
o Lymphocyte count (absolute and %) 
o Monocyte count (absolute and %) 
o Eosinophil count (absolute and %) 
• Basophil count (absolute and %) 
• WBC count 
Pregnancy tests (females of childbearing 
potential only) 
• Serum -hCG test 
• Urine -hCG test 
Virology/Serology (Screening only) 
• Hepatitis C virus (HCV) 
• Hepatitis C virus antibody 
• Hepatitis B surface antigen (HBsAg) 
• Hepatitis B core antibody (HBcAb) 
• HIV antibodies  
Urine drug screen 
• Amphetamines 
• Barbiturates 
• Cocaine 
• MDMA (“Ecstasy”) 
• Methadone 
• Methamphetamine 
• Opiates 
• Oxycodone 
• Phencyclidine (“PCP”) 
• Tetrahydrocannabinol 
Abbreviations: b-hCG = b-human chorionic gonadotropin; HIV = human immunodeficiency virus; 
MDMA = 3,4-methylenedioxy-N-methylamphetamine; PCP = 1-(1-phenylcyclohexyl) piperidine; 
SGOT = serum glutamic-oxaloacetic transaminase; SGPT = serum glutamic-pyruvic transaminase. 


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7.6.1.8. 
Laboratory Abnormalities 
An increase of serum aminotransferases of > 3 x ULN must be followed by repeat testing of all 
four of the AT serum measures (ALT, AST, ALP, and TBL) within 48 to 72 hours to confirm the 
abnormalities and to determine if they are increasing or decreasing. In the urgent event that a 
local laboratory must be used, the test results must include the normal range and units. These 
results must be collected on a CRF and entered in the electronic data capture (EDC) system.  
For patients with ALT or AST > 8 × ULN, ALT or AST > 5 × ULN for more than 2 weeks, ALT 
or AST > 3 × ULN and TBL > 2 × ULN, or ALT or AST > 3 × ULN with the appearance of 
fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash, and/or 
eosinophilia (> 5%), treatment must be discontinued and the patient should be monitored, at a 
minimum, weekly until liver chemistry results (ALT, AST, ALP, and bilirubin) resolve, stabilize, 
or return to baseline values. 
In all the above situations involving elevations in liver enzymes, every attempt should be made 
to obtain the following: 
• Viral hepatitis serology including: 
o Hepatitis A immunoglobulin M (IgM) antibody 
o Hepatitis B surface antigen and hepatitis B core antibody (IgM) 
o Hepatitis C RNA 
• Blood sample for plasma PK analysis. The date and time of the PK blood sample 
collection and dates and times of the 2 previous doses of study medication must be 
recorded. 
• Serum creatine phosphokinase (CPK) 
• Fractionate bilirubin, if total bilirubin is ≥ 1.5 × ULN 
• Record of the appearance or worsening of clinical symptoms of hepatitis, including 
fatigue, decreased appetite, nausea, vomiting, abdominal pain, jaundice, fever, or rash on 
the AE report form. 
• Record of the use of concomitant medications, acetaminophen, herbal remedies, other 
over-the-counter medications, putative hepatotoxins, or alcohol on the concomitant 
medication form. 
• If these are identified, consultation with a gastrointestinal or hepatology specialist should 
be considered. 
The following are required for patients with ALT or AST ≥ 3 × ULN and total bilirubin 
≥ 1.5 × ULN but are optional for other liver chemistry results: 
• Anti-nuclear antibody, anti-smooth muscle antibody, and Type I anti-liver kidney 
microsomal antibodies 
• Liver imaging (ultrasound, magnetic resonance imaging, or computed tomography scan) 
to evaluate liver disease 


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Hy’s Law 
Hepatic function abnormality defined by an increase in AST and/or ALT to ≥ 3 × ULN 
concurrent with an increase in TBL to ≥ 2 × ULN but without increase in alkaline phosphatase 
(ie, ALP < 2 × ULN) meets the criteria for Hy’s Law and raises the concern for drug-induced 
liver injury (DILI) when no other cause of the abnormal laboratory results is identified. Follow-
up investigations and inquiries will be initiated promptly by the investigational site to determine 
whether the findings are reproducible and/or whether there is objective evidence that clearly 
supports causation by a disease (eg, cholelithiasis and bile duct obstruction with distended 
gallbladder) or an agent other than the investigational product. 
Cases meeting Hy’s Law are considered an AESI and must be reported as SAEs. Study drug 
should be permanently discontinued for a Hy’s Law case. 
7.6.1.9. 
Pregnancy Screen 
Serum pregnancy tests are required for female patients of childbearing potential. Serum 
pregnancy testing will occur at the timepoints indicated in Table 1. 
If the patient is found to be pregnant, the patient will be withdrawn from study treatment 
immediately and the sponsor or sponsor representative notified within 24 hours of awareness. If 
the patient’s partner is found to be pregnant the same procedure of reporting and follow up 
should be followed but the patient can continue study treatment. 
7.6.2. 
Adverse and Serious Adverse Events 
7.6.2.1. 
Definition of an Adverse Event 
An adverse event (AE) is any untoward medical occurrence associated with the use of a drug in 
patients, whether or not considered drug related. It can be any unfavorable and unintended sign 
(including laboratory abnormalities), symptom, or disease temporally associated with the use of a 
drug, regardless of causal relationship to the drug. 
Examples of AEs include the following: 
• Significant or unexpected worsening or exacerbation of a chronic or intermittent pre-
existing condition including either an increase in frequency and/or intensity of the 
condition. 
• Signs, symptoms, or the clinical sequelae of a suspected overdose of either study 
treatment or a concomitant medication. 
• Any abnormal laboratory test results if: 
o Accompanied by clinical symptoms 
o Leads to a discontinuation of study treatment or change in study dosing 
o Requires significant additional concomitant medication or other therapy 
o Requires additional diagnostic testing (does not include repeat testing of an abnormal 
test) or medical intervention (does not include replacing of electrolytes) 
Anticipated day-to-day fluctuations of pre-existing diseases(s) or conditions(s) present or 
detected at the start of the study that do not worsen are not considered AEs. 


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7.6.2.2. 
Serious Adverse Event 
A serious adverse event (SAE) is an AE that meets at least one of the following criteria: 
• Results in death 
• Is life-threatening (AE that places the patient at immediate risk of death from the reaction 
as it occurred; it does not include a reaction that, had it occurred in a more severe form, 
might have caused death) 
• Requires inpatient hospitalization or prolongation of existing hospitalization (see 
exceptions below) 
• Results in persistent or significant disability/incapacity (substantial disruption of the 
ability to conduct normal life functions) 
• Results in congenital anomaly/birth defect 
• Other important medical events that may not result in death, be life-threatening or require 
hospitalization may be considered SAEs when, based upon appropriate medical 
judgment, they may jeopardize the patient and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition. Examples of such 
medical events include allergic bronchospasm requiring intensive treatment in an 
emergency room or at home, blood dyscrasias, or convulsions that do not result in patient 
hospitalization, or the development of drug dependency or drug abuse 
Hospitalization 
Hospitalization is defined as any initial admission (even less than 24 hours) in a hospital or 
equivalent healthcare facility or any prolongation of an existing admission. An emergency room 
visit does not necessarily constitute a hospitalization; however, the event leading to the 
emergency room visit should be assessed for medical importance. 
Hospitalization or prolongation of hospitalization due to the following reasons or conditions 
should not be reported as an SAE. Examples include but not limited to: 
• Admission for treatment of a pre-existing condition not associated with the development 
of a new AE or with a worsening of the pre-existing condition 
• Social, administrative for insurance reimbursement, or convenience admission 
• Hospitalization for elective procedures for the treatment of pre-existing conditions (eg, 
hip replacement for pre-existing osteoarthritis) 
Admission to rehabilitation facilities, respite care, hospice facilities, nursing homes, skilled 
nursing facilities, and same-day surgeries are not considered hospitalization. 
7.6.2.3. 
Adverse Events of Special Interest 
Potential liver injury, ie, suspected and/or confirmed Hy’s Law, DILI cases will be assessed as 
adverse events of special interest (AESI) and must be reported as SAE. Information of abnormal 
laboratory test results including the course and evolvement, clinical signs and symptoms, 
detailed medical history and concurrent medication, history and current lifestyle including 
alcoholic assumption, history of exposure to environmental chemical agents will be used to 
assess the case(s). 


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7.6.2.4. 
Relationship to Study Treatment 
Liafensine is an investigational medicinal product (IMP). The causality relationship to liafensine 
for all AEs (serious and non-serious) will be assessed by the investigator. The causal relationship 
of an AE to the study treatment will be assessed as either: 
Related 
There is as at least a reasonable possibility that the drug caused the AE (ie, there is evidence or 
arguments to suggest a causal relationship between the drug and AE) 
Unrelated 
• Does not follow a reasonable temporal sequence from administration of drug 
• Does not appear to worsen when the drug is re-administered 
• There is not a reasonable possibility that the drug caused the AE 
• An alternate etiology has been established, ie, the AE is more likely explained by another 
cause (eg, other study treatments or procedures, underlying medical conditions, 
concomitant medications, etc) than the study treatment. 
7.6.2.5. 
Recording Adverse Events 
Adverse events should only be recorded by an investigator or by a healthcare provider qualified 
by training and experience. Patients should be asked in an open-ended manner about the 
occurrence of AEs. All AEs are recorded in the electronic CRF (eCRF). 
It is generally not necessary to record both a diagnosis and its associated symptoms and 
laboratory abnormalities. For example, if “acute renal failure” is recorded as an AE, “creatinine 
5 mg/dL” need not be recorded. 
If an AE necessitates a procedure, the description of the event (eg, appendicitis) rather than the 
procedure (appendectomy) should be listed as the AE. 
Any ongoing AEs and SAEs should be followed during study visits until resolution, or until the 
event is otherwise explained or judged by the investigator as stable or no longer clinically 
significant (unless the patient is lost to follow-up or withdraws consent). 
7.6.2.6. 
Severity Assessment of Adverse Events 
Adverse events will be reported, and severity graded, according to the following guidelines: 
Mild 
Awareness of signs or symptoms but easily tolerated 
Moderate 
Discomfort sufficient to cause interference with normal everyday activities 
Severe 
Incapacitating with inability to work or perform normal activities 
 
In the event of the change in severity, the existing AE should be updated accordingly. 


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7.6.2.7. 
Reporting Adverse Events 
All AEs regardless of causality will be recorded from the time a patient signs an ICF and through 
Follow-up period. 
All SAEs regardless of causality will be recorded from the time a patient signs an ICF until 
30 days after the last administration of study treatment. If SAEs are determined to be related to 
the study treatment by the investigators, these SAEs need to be reported beyond 30 days. 
7.6.2.8. 
Serious Adverse Event Reporting Requirements 
If an SAE occurs, the sponsor or designee is to be notified within 24 hours of investigator’s 
awareness of the event. The time frame also applies to follow-up information on a previously 
reported SAE and pregnancies. This can be done by completing SAE entry through eCRF in the 
EDC. In the event of EDC outage, the investigator must complete the paper SAE reporting form 
and email or fax it to the sponsor or designee. 
Investigators may be requested to obtain additional information on an SAE to allow for a 
complete assessment of the event. 
Adverse event (serious and non-serious) reporting to regulatory authorities, including Suspected 
Unexpected Serious Adverse Reactions (SUSARs), will be carried out in accordance with 
applicable local regulations by the investigator, sponsor or designee. 
All SAEs should be followed to resolution or stabilization. 
7.6.3. 
Pregnancy Reporting 
Pregnancy is not considered an adverse event. However, any patient who becomes pregnant 
during the study must be withdrawn from the study immediately. The investigator must report all 
pregnancies in the patient or partner of the patient within 24 hours of the investigator becoming 
aware of the event. 
Pregnancy and maternal information will be collected until completion or termination of 
pregnancy including outcome of pregnancy and details of birth (if applicable). 
If the outcome of the pregnancy meets the criteria for an SAE (eg. ectopic pregnancy, 
spontaneous abortion, intrauterine fetal demise, neonatal death, or congenital anomaly/birth 
defect) the investigator should follow the procedures for reporting SAEs. 


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8. 
STATISTICS 
Additional details of the analyses will be provided in the statistical analysis plan (SAP) which 
will be finalized prior to breaking the blind. 
8.1. 
Study Design 
This study will be conducted as a multicenter, a randomized, double-blind, placebo-controlled 
Phase 2b trial to assess the efficacy, safety, tolerability, and PK of liafensine. The primary 
endpoint is change in MADRS total score from baseline (Visit 3, Day -1) to Visit 7 (Day 42) in 
DGM4-positive patients. The primary analysis will be conducted to assess liafensine treatment 
effect for combined liafensine 1 mg QD and 2 mg QD doses vs placebo in randomized patients 
who are DGM4-positive. 
8.2. 
Determination of Sample Size and Statistical Rationale 
Eligible patients will be randomized 1:1:1 to receive liafensine 1 mg QD, liafensine 2 mg QD, or 
placebo QD. The primary analysis is to assess treatment difference in MADRS total score 
change from baseline (Visit 3, Day -1) to Visit 7 (Day 42) between the combined liafensine 
1 mg QD and 2 mg QD doses vs placebo, in DGM4-positive patients. A sample size of 
forty-seven (47) randomized DGM4-positive patients per arm is sufficient to detect a 4.5-unit 
difference between the combined liafensine 1 mg QD and 2 mg QD treatment groups and the 
placebo treatment group in the change in MADRS total score from baseline to Visit 7 with 80% 
power at the 2-sided 0.05 alpha level, assuming a standard deviation of 9 units. 
To compensate for potential loss of power due to randomized patients who do not take at least 
one dose of study drug or who do not have a post randomization efficacy evaluation (~5%), a 
total of approximately 150 DGM4-positive patients (50 DGM4-positive patients per arm) will be 
randomized. 
To examine trend in the total patient population and in the subgroup of DGM4-negative patients 
in order to evaluate DGM4 as a potential biomarker for predicting response to liafensine, 
approximately 20% additional DGM4-negative patients (10 per arm, total 30) will also be 
randomized. The sample size of 30 randomized patients in the DGM4 negative group is not 
estimated based on formal statistics in terms of power and alpha level. 
The sample size may be re-estimated/re-adjusted if more than expected missing data are 
observed at Day 42.  
8.3. 
Statistical Methods 
8.3.1. 
Analysis Population 
The Full Analysis Set (FAS) includes all randomized patients who took at least one dose of study 
drug and had a post-randomization efficacy evaluation. The FAS population will be analyzed by 
treatment randomized regardless of the actual treatment received. The primary and secondary 
efficacy results of the study will be based on analysis in FAS patients with positive DGM4 
biomarker. Safety Population includes all patients who took at least one dose of study drug. The 
Safety population will be analyzed by the actual treatment received regardless of treatment 
randomized. 


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8.3.2. 
Primary Estimand 
The primary estimand, the main clinical quantity of interest to be estimated in the study, is 
defined by the following three components: 
• Population: patients with treatment-resistant depression with the DGM4-positive 
biomarker 
• Endpoint: change in MADRS total score from baseline to Day 42 
• Measure of Intervention: the effect of the initially randomized treatment that would have 
been observed had all patients remained on their treatment throughout the double-blind 
phase 
The primary analysis will be based on the full analysis set, as described above, and the MADRS 
total scores collected during the double-blind treatment period. 
8.3.3. 
Efficacy Analyses 
The primary efficacy endpoint is the change in MADRS total score from baseline (Visit 3, 
Day -1) to Day 42 (Visit 7). The primary efficacy analysis will be performed in DGM4-positive 
patients at 2-sided significance level of 0.05 using a mixed model for repeated measures 
(MMRM) that includes the fixed effects of treatment, visit (categorical covariate), treatment-by-
visit interaction, baseline MADRS total score (continuous covariate), and region. An 
unstructured variance-covariance matrix will be used. The least-squares (LS) mean change in 
MADRS total score at Day 42 from baseline for the combined liafensine treatment arms 
(1 mg QD and 2 mg QD) and placebo arm will be estimated from the MMRM model. The 
treatment effect for the combined liafensine treatment arms vs placebo will be estimated using 
the LS mean difference at Day 42 from the MMRM model. The comparison of the change in 
MADRS total score from baseline to Day 42 between each of the 2 liafensine treatment arms and 
placebo will be carried out using the same approach. The key secondary efficacy endpoint for 
this study is the change in CGI-S from baseline (Visit 3, Day -1) to Day 42 (Visit 7), in DGM4-
positive patients.  
Other secondary and exploratory efficacy endpoints include the CGI-I, SDS, response (defined 
as ≥ 50% improvement from baseline in MADRS total score at Day 42), and remission (defined 
as MADRS total score ≤ 10 at Day 42), in DGM4-positive patients. CGI-S, CGI-I, and SDS will 
be analyzed using the same MMRM model as for the primary efficacy endpoint. Response rate, 
remission rate, and corresponding 95% confidence interval (CI) for each treatment group will be 
derived by using Clopper-Pearson method. The comparison of response rate and remission rate 
between treatment groups will be carried out using the Cochran–Mantel–Haenszel (CMH) test. 
Subscales, individual items, and domains of endpoints will also be analyzed in an exploratory 
manner, using the same MMRM model as for the primary efficacy endpoint. 
The change in MADRS total score from baseline in DGM4-negative patients will be analyzed 
using the same approach as described for the primary endpoint analysis in the DGM4-positive 
patients. The LS mean of the change in MADRS total score for each treatment group and the 
treatment difference in DGM4-negative patients will be estimated. The treatment effects between 
the DGM4positive and negative patients will be compared primarily in descriptive fashion to 
examine the trend, and may be evaluated by including the interaction of DGM4 status and 
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8.3.3.1. 
Type I Error Control for Multiple Comparisons 
The family-wise type I error rate will be controlled at a fixed 1-sided alpha level of 0.025 using 
a closed testing procedure for multiple dose comparisons and multiple endpoint comparisons in 
DGM4-positive patients (Marcus 1976). In the closed testing procedure, the average effect of 
1 mg and 2 mg dose groups will be first compared with the placebo group on change in 
MADRS total score from baseline to Day 42 in DGM4-positive subjects. If the one-sided 
p-value was ≤ 0.025, then the one-sided p-values are calculated for the comparisons of 1 mg 
dose vs placebo and 2 mg dose vs placebo, respectively. If both individual p-values are 
≤ 0.025, a significant treatment effect is declared for both dose groups. If only one p-value is 
≤ 0.025, a significant treatment effect is declared for the corresponding dose group. All other 
efficacy endpoints will not be controlled for multiplicity with nominal p-values provided for 
the exploratory purpose only. Additional details will be specified in the SAP. 
8.3.4. 
Safety Analyses 
The safety analyses will be conducted in the safety population, which includes all randomized 
patients who have received at least one dose of study drug. The safety population will be 
analyzed by the actual treatment received regardless of treatment randomized. 
Adverse events will be coded using the current version of the Medical Dictionary for Regulatory 
Activities (MedDRA) classification system. Listings will include the verbatim term, preferred 
term, and system organ class. The incidence and severity of treatment-emergent adverse events 
(TEAEs) will be summarized by treatment. Vital signs including supine (after at least 5 min rest) 
and standing (after 1 min and 3 min standing), blood pressure and heart rate and heart rate, 
weight, ECG, clinical laboratory evaluation, DESS scale, and C-SSRS data will be summarized 
with descriptive statistics, by visit and by treatment. 
Safety and tolerability data will be summarized descriptively, including tables, listings, and 
graphs, as appropriate. Unless otherwise stated, descriptive summary statistics for continuous 
variables will include number (N), mean (ie, arithmetic mean), standard deviation (SD), 
minimum, median, and maximum. Descriptive summary statistics for categorical data will 
include frequency and proportion. 
All data will be presented by treatment regimen. 
Individual data for vital signs including supine (after at least 5 min rest) and standing (after 
1 min and 3 min standing), blood pressure and heart rate, weight, clinical laboratory measures, 
and ECG assessments will be listed and summarized for any potentially clinically important 
(PCI) values according to predetermined PCI criteria. 
There will be no imputation (substitution) for missing data unless explicitly specified otherwise 
in this protocol or in the statistical analysis plan. 
8.3.5. 
Pharmacokinetics 
Plasma concentrations of liafensine and its metabolite will be listed by subject and time of 
collection. A population PK analysis of plasma concentrations of liafensine and its primary 
metabolite will be performed using a nonlinear mixed-effects modeling approach. The analysis 
will evaluate the effects of age, sex, ethnicity, and other covariates on the PK profile of 
liafensine. This analysis will be reported separately. 


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8.3.6. 
Subgroup Analyses 
Subgroup analyses will be considered for gender, ethnicity, and region, and may be explored 
for other factors (such as age and baseline severity in term of MADRS total score). Summary 
statistics will be provided for efficacy measures by treatment arm for each subgroup. 
8.3.7. 
Statistical Analysis Plan 
Additional details of the analyses will be provided in the statistical analysis plan which will be 
finalized prior to unblinding. 
8.3.8. 
Independent Data Monitoring Committee 
An IDMC will be established to monitor data on an ongoing basis to ensure the continuing safety 
of patients enrolled in this study. The IDMC will comprise individuals external to the sponsor 
and will consist of at least one medical expert in the relevant therapeutic area, at least one 
hepatologist, and at least one statistician. The IDMC’s responsibilities, authorities, and 
procedures, with details of decision-making guidance and dissemination of the results, will be 
documented in the IDMC charter. 


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9. 
DIRECT ACCESS TO SOURCE DATA/DOCUMENTS 
9.1. 
Study Monitoring 
Before an investigational site can enter a patient into the study, a representative of Denovo will 
visit the investigational study site to: 
• Determine the adequacy of the facilities 
• Discuss with the investigator(s) and other personnel their responsibilities with regard to 
protocol adherence, and the responsibilities of Denovo or its representatives. This will be 
documented in a Clinical Trial/Study Agreement between Denovo and the investigator. 
During the study, a monitor from Denovo or representative will have regular contacts with the 
investigational site, for the following: 
• Provide information and support to the investigator(s) 
• Confirm that facilities remain acceptable 
• Confirm that the investigational team is adhering to the protocol, that data are being 
accurately recorded in the case report forms, and that investigational product 
accountability checks are being performed 
• Perform source data verification. This includes a comparison of the data in the case report 
forms with the patient’s medical records at the hospital or practice, and other records 
relevant to the study. This will require direct access to all original records for each patient 
(eg, clinic charts, electronic medical record, shadow charts). 
• Record and report any protocol deviations not previously sent to Denovo. 
• Confirm AEs and SAEs have been properly documented on eCRFs and confirm any 
SAEs have been forwarded to Denovo and those SAEs that met criteria for reporting have 
been forwarded to the IRB/IEC. 
The monitor will be available between visits if the investigator(s) or other staff needs 
information or advice. 
9.2. 
Audits and Inspections 
Authorized representatives of Denovo, a regulatory authority, an IRB, or an IEC may visit the 
site to perform audits or inspections, including source data verification. The purpose of a Denovo 
audit or inspection is to systematically and independently examine all study-related activities and 
documents to determine whether these activities were conducted, and data were recorded, 
analyzed, and accurately reported according to the protocol, ICH GCP guidelines, and any 
applicable regulatory requirements. The investigator should contact Denovo immediately if 
contacted by a regulatory agency about an inspection. 
9.3. 
Institutional Review Board 
The principal investigator (PI) must obtain IRB/IEC approval for the investigation. Initial 
IRB/IEC approval, and all materials approved by the IRB/IEC for this study including the patient 
consent form and recruitment materials must be maintained by the investigator and made 
available for inspection. 


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9.4. 
Curriculum Vitae and Medical Licenses 
The PI is responsible for ensuring that the study is being conducted by qualified personnel. 
Documentation of these qualifications must be maintained within the Regulatory Binder, and 
includes the following: 
Curriculum Vitae (CV): CVs for the PI and all sub-investigators listed on the FDA Form 1572 
must be signed and dated. These CVs must show affiliation with the institution conducting the 
study and be current within two years of the personnel initiating their participation in the study. 
Medical Licenses: Medical licenses (eg, physicians, physician assistants, nurses) listed on the 
FDA Form 1572 must be kept current, and copies must be maintained in the Regulatory binder 
during the entire period of the person’s participation in the study. 
9.5. 
Financial Disclosure 
Documentation of each investigator’s proprietary or financial interest in Denovo is required by 
the US Code of Federal Regulations (21 CFR 54). A financial disclosure form provided by the 
sponsor must be completed, signed, and dated by the PI and each sub-investigator listed on the 
FDA Form 1572. This form must be executed prior to the personnel’s participation in the study. 
Each investigator must inform the sponsor of any change in his/her financial interest in the 
sponsor for up to 1 year after the end of the study. 


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10. 
QUALITY CONTROL AND QUALITY ASSURANCE 
To ensure compliance with GCP and all applicable regulatory requirements, Denovo or its 
representative will monitor for compliance closely and may conduct a quality assurance audit. 


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11. 
ETHICS 
11.1. 
Local Regulations 
The study must fully adhere to the principles outlined in the ICH GCP E6 Guideline (2016) and 
remain consistent with the most recent version of the Declaration of Helsinki. The investigator 
will ensure that the conduct of the study complies with the basic principles of GCP as outlined in 
the current version of 21 CFR, subpart D, Part 312, “Responsibilities of Sponsors and 
Investigators,” Part 50, “Protection of Human Subjects,” and Part 56, “Institutional Review 
Boards.” 
11.2. 
Ethics Review 
This study is being conducted under a United States (US) Investigational New Drug application 
and other regulatory applications, as applicable. This protocol (and any modifications) and 
appropriate consent procedures must be reviewed and approved by an IRB/IEC. This board must 
operate in accordance with the current federal regulations. The investigator will send a letter or 
certificate of IRB/IEC approval to the sponsor (or designee) before patient enrollment and 
whenever subsequent modifications to the protocol are made. 
11.3. 
Ethical Conduct of the Study 
This study will be conducted in accordance with applicable country-specific laws and 
regulations, including, but not limited to, ICH GCP guidelines and the ethical principles that 
have their origins in the Declaration of Helsinki. The IRB/IEC must review and approve the 
protocol and ICF before any patients are enrolled. Before any procedures specified in the 
protocol are performed, the patient must sign and date the IRB/IEC-approved ICF. 
Study personnel involved in conducting this trial will be qualified by education, training, and 
experience to perform their respective task(s). This trial will not use the services of study 
personnel for whom sanctions have been invoked or there has been scientific misconduct or 
fraud (eg, loss of medical licensure, debarment, etc.). 
11.4. 
Written Informed Consent 
Investigators must ensure that patients, or, in those situations where consent cannot be given by 
patients, their legally acceptable representatives, are clearly and fully informed about the 
purpose, potential risks, and other critical issues regarding clinical studies in which they 
volunteer to participate. 
Denovo will provide the investigator with an appropriate (ie, global or local) sample ICF which 
will include all elements required by ICH GCP and applicable regulatory requirements. The 
sample ICF will adhere to the ethical principles that have their origin in the Declaration of 
Helsinki. 


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Investigators must: 
1. Provide a copy of the consent form and written information about the study in the 
language in which the patient is most proficient prior to clinical study participation. The 
language must be non-technical and easily understood. 
2. Allow time necessary for patient to inquire about the details of the study. 
3. Obtain an informed consent signed and personally dated by the patient and by the person 
who conducted the informed consent discussion, and provide a copy of the signed 
consent to the patient. 
4. Obtain the IRB/IEC’s written approval/favorable opinion of the written ICF and any 
other information to be provided to the patients, prior to the beginning of the study, and 
after any revisions are completed for new information. 
5. Revise the informed consent whenever important new information becomes available that 
is relevant to the patient's consent. The investigator, or a person designated by the 
investigator, should fully inform the patient of all pertinent aspects of the study and of 
any new information relevant to the patient's willingness to continue participation in the 
study. This communication should be documented. 
The consent form must also include a statement that Denovo and regulatory authorities have 
direct access to patient records. 
The rights, safety, and well-being of the study patients are the most important considerations and 
should prevail over interests of science and society. 
11.5. 
Patient Confidentiality 
The confidentiality of records that could identify patients must be protected, respecting the 
privacy and confidentiality rules applicable to regulatory requirements, the patients' signed ICF 
and, in the US, the patients’ signed HIPAA Authorization. 
All clinical information is confidential, but data generated for this study must be available for 
inspection on request to representatives of the US FDA, other national or local regulatory or 
health authorities, Denovo representatives, and the associated IRB/IEC. 
All records must be kept in a secured area. 
11.6. 
Patient Recruitment 
Advertisements approved by IRBs/IECs and investigator databases may be used as recruitment 
procedures. However, Denovo will have an opportunity to review and approve the content of any 
study recruitment materials directed to potential study patients before such materials are used. 
11.7. 
Reporting of Safety Issues and Serious Breaches of the Protocol or 
ICH GCP 
Progress reports and notifications of serious adverse drug reactions will be provided to the IRB 
or IEC according to local regulations and guidelines. 


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12. 
DATA HANDLING AND RECORD KEEPING 
12.1. 
Data/Document 
The investigator must ensure that the records and documents pertaining to the conduct of the 
study and the distribution of study treatment are complete, accurate, filed, and retained. 
Examples of source documents include hospital records, clinic and office charts, laboratory 
notes, memoranda, patient’s diaries or evaluation checklists, dispensing records, recorded data 
from automated instruments, copies or transcriptions certified after verification as being accurate 
copies, microfiche, X-ray film and reports, records kept at the pharmacy and the laboratories. 
12.2. 
Data Management 
Data will be collected via eCRF. The term “case report form” includes as applicable paper forms 
and/or electronic data capture screens or forms for studies that utilize electronic data capture. For 
randomized patients, all and only data for the procedures and assessments specified in this 
protocol and required by the case report forms should be submitted on the appropriate eCRF 
(unless transmitted to the sponsor or a designee electronically, eg, laboratory data). Data from 
some procedures required by the protocol, such as physical exams or some types of laboratory 
tests, will be recorded only on the source documents. Additional procedures and assessments 
may be performed as part of the investigator’s institution or medical practice standard of care. 
Data for unscheduled or additional assessments should remain in the patient’s medical record 
and should not be recorded on eCRFs unless specifically requested. 
The eCRF must be completed and signed by the investigator or authorized delegate from the 
study staff. This also applies to records for those patients who fail to complete the study or are 
randomized and never treated. If a patient stops dosing or terminates from the study, the dates 
and reasons must be noted on the eCRF. 
All paper forms should be typed or filled out using indelible ink and must be legible. Errors 
should be crossed out but not obliterated, the correction inserted, and the change initialed and 
dated by the investigator or his or her authorized delegate. Any discrepancies in the data will be 
brought to the attention of the clinical team, and investigational site personnel, if necessary. 
Resolutions to these issues will be reflected in the database. An audit trail within the system will 
track all changes to the data. 
The investigator should ensure the accuracy, completeness, legibility, and timeliness of the data 
reported to the sponsor in the eCRF and in all required reports. 
12.3. 
Inspection of Records 
Denovo will be allowed to conduct site visits to the investigation facilities for the purpose of 
monitoring any aspect of the study. The investigator should understand that source documents 
for this study should be made available to appropriately qualified personnel from Denovo 
Quality Assurance (or designee), or to health authority inspectors after appropriate notification. 
The investigator agrees to allow the monitor to inspect the drug storage area, study treatment 
stocks, drug accountability records, patient charts and study source documents, and other records 
relative to study conduct. The verification of the eCRF data must be by direct inspection of 
source documents. 


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Upon request, the investigator will supply Denovo (or designee) with any required background 
data from the study documentation or clinic records. This is particularly important when eCRFs 
(if paper) are illegible or when errors in data transcription are suspected. In case of special 
problems or governmental queries or requests for audit inspections, it is also necessary to have 
access to the complete study records, provided that patient confidentiality is protected. 
12.4. 
Retention of Records 
The investigator must maintain adequate and accurate records to enable the conduct of the study 
to be fully documented and the study data to be subsequently verified. These documents should 
be classified into two separate categories as follows: (1) investigator’s study file and (2) patient 
clinical source documents. 
The investigator’s study file will contain as applicable the protocol and protocol amendments, 
eCRFs, query forms, IRB/IEC and governmental approval with correspondence, sample 
informed consent, drug records, staff curriculum vitae and authorization forms, and other 
appropriate documents and correspondence. 
Patient clinical source documents (usually predefined by the project to record key efficacy and 
safety parameters independent of the eCRFs) may include, but are not limited to, patient 
hospital/clinic records, physician’s and nurse’s notes, appointment book, original laboratory 
reports, ECG, electroencephalogram, computed tomography/magnetic resonance imaging scan, 
bone scan, X-ray, pathology and special assessment reports, signed ICFs, patient diaries, 
consultant letters, and patient screening and enrollment logs. 
The investigator must keep these two categories of documents on file for at least the latest of 
2 years following the marketing application approval date for the study treatment in the 
indication being investigated, 2 years after the investigation is completed or discontinued, or for 
a time consistent with local regulatory requirements. After that period of time, the documents 
may be destroyed subject to local regulations with prior written permission from the sponsor. If 
the investigator wants to assign the study records to another party or move them to another 
location, the sponsor must be notified in advance. 
If the investigator cannot guarantee the archiving requirement at the study site for any or all of 
the documents, special arrangements must be made between the investigator and the sponsor to 
store these in a sealed container outside of the study site so that they can be returned sealed to the 
investigator in case of a regulatory audit. When source documents are required for the continued 
care of the patient, appropriate copies should be made for storing outside of the study site. 


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13. 
PUBLICATION POLICY 
13.1. 
Communication of Results by Denovo 
All information obtained as a result of this study should be regarded as confidential. Denovo 
fulfills its commitment to publicly disclose clinical trial results through posting the results of 
studies to public registries in accordance with applicable local laws/regulations. 
13.2. 
Publications by Investigators 
Information regarding use or publication of study related information will be provided to the 
investigator in the Clinical Trial Agreement. 


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14. 
INVESTIGATOR PROTOCOL SIGNATURE PAGE 
I understand that all information supplied to me by Denovo Biopharma LLC is confidential. 
I understand that this protocol and all amendments must be submitted to the appropriate 
institutional review board (IRB)/independent ethics committee IEC. 
I have read protocol DB104-01 and its appendices and agree to adhere to all requirements in the 
conduct of the study. 
In signing below, I agree: 
• To assume responsibility for the proper conduct of the study at my site 
• To conduct the study in compliance with this protocol, any future amendments, and with 
any other study procedures provided by Denovo Biopharma LLC 
• That I am aware of, and will comply with Good Clinical Practices (GCP) and all 
applicable regulatory requirements 
• To ensure that all persons assisting me with the study are adequately informed about the 
study and of their study-related duties as delegated by me 
• Not to implement any changes to the protocol without written agreement from Denovo 
Biopharma LLC and prior review and written approval from the IRB/IEC except where 
necessary to eliminate an immediate hazard to study patients 
I acknowledge that failure to adhere to these stipulations may constitute a breach of 
governmental regulations, may invalidate the data, and may result in termination of the study at 
my site. 
 
 
 
Principal Investigator’s Signature 
 
Date 
 
 
 
 
Principal Investigator’s Printed Name 
 
 
 
 
Institution Name 
 


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15. 
LIST OF REFERENCES 
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 
(Fifth ed.). Arlington, VA: American Psychiatric Publishing. 2013;5–25. ISBN 978-0-89042-
555-8. 
Berlim MT, Fleck MP, Turecki G. Current trends in the assessment and somatic treatment of 
resistant/refractory major depression: An overview. Ann Med. 2008;40(2):149-59. 
Cain RA. Navigating the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) 
Study: Practical Outcomes and Implications for Depression Treatment in Primary Care. Prim 
Care. 2007;34(3):505-19. 
Chandler GM, Iosifescu DV, Pollack MH, Targum SD, Fava M. RESEARCH: Validation of the 
Massachusetts General Hospital Antidepressant Treatment History Questionnaire (ATRQ). CNS 
Neurosci Ther. 2010;16(5):322-325. 
Craddock N, Sklar P. Genetics of bipolar disorder. Lancet. 2013;381:1654-62. 
Guy W (ed). ECDEU Assessment Manual for Psychopharmacology. Rockville, MD: US 
Department of Heath, Education, and Welfare Public Health Service Alcohol, Drug Abuse, and 
Mental Health Administration, 1976. 
Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960; 23:56–62. 
Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of Major Depressive Disorder: 
Results From the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch 
Gen Psychiatry. 2005;62(10):1097-1106. 
Denovo Investigator’s Brochure, Liafensine (DB104) 2021. 
Jaeger J. Digit Symbol Substitution Test: The Case for Sensitivity Over Specificity in 
Neuropsychological Testing. Journal of Clinical Psychopharmacology. 2018;38(5):513-19. 
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime Prevalence and 
Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey 
Replication. Arch Gen Psychiatry. 2005:62(6):593-602. 
Marcus R, Peritz E, Gabriel KR. On closed testing procedures with special reference to ordered 
analysis of variance. Biometrika. 1976; Vol. 63, No. 3 , pp. 655-660. 
Montgomery SA, Asberg M: A new depression scale designed to be sensitive to change. British 
Journal of Psychiatry. 1979;134:382-389. 
Mühleisen TW, Leber M, Schulze TG, Strohmaier J. Genome-wide association study reveals two 
new risk loci for bipolar disorder. Nat Commun. 2014;5:3339. 
Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, Currier GW, Melvin 
GA, Greenhill L, Shen S, Mann JJ. "The Columbia–Suicide Severity Rating Scale: Initial 
Validity and Internal Consistency Findings From Three Multisite Studies With Adolescents and 
Adults". American Journal of Psychiatry. 2011;168:1266–77. 
Rangaraju S, Levey DF, Nho K, Jain N, Andrews KD, Le-Niculescu H, et al. Mood, stress and 
longevity: convergence on ANK3. Molecular Psychiatry. 2016;1-13. 


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Rosenbaum JF, Fava M, Hoog SL, et. al. Selective serotonin reuptake inhibitor discontinuation 
syndrome: a randomized clinical trial. Biological Psychiatry. 1988;44:77-87. 
Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed 
outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 2006; 
163:1905–1917. 
Schizophrenia Working Group of the Psychiatric Genomics Consortium. Biological insights 
from 108 schizophrenia-associated genetic loci. Nature. 2014;511:421-27. 
Sheehan KH; Sheehan DV. Assessing treatment effects in clinical trials with the discan metric of 
the Sheehan Disability Scale. International Clinical Psychopharmacology 2008;23(2):70-83. 
Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric 
Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric 
interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59 Suppl 20:22-57. 
SPRAVATO® [package insert]. Raritan, NJ. Janssen Pharmaceutica; 2019. 
Zhu S, Cordner ZA, Xiong J, Chiu C-T, Artola A, Zuo Y, et al. Genetic disruption of ankyrin-G 
in adult mouse forebrain causes cortical synapse alteration and behavior reminiscent of bipolar 
disorder. PNAS. 2017;114(39):10479 484. 


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16. 
APPENDICES 


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APPENDIX 1. 
GUIDANCE TO STUDY SITES ON STUDY AND 
PATIENT MANAGEMENT IN CASE OF A PUBLIC 
HEALTH EMERGENCY 
In the case of a public health emergency, Denovo institutes minimum study requirements, in the 
event of travel restriction, to safeguard the rights, welfare, and safety of study subjects and 
investigative site staff. These measures align with the current guidance issued the US FDA in 
March 2020 and updated 30 August 2021 (FDA 2021) in regard to the impact of COVID-19 on 
the management of clinical trials. 
Also addressed are issues in study conduct that may be impacted by a public health emergency 
such as patient visits, documentation of deviations to the protocol, and recording of data. 
Changes that may be made to the protocol and clinical trial conduct as a result of any public 
health emergency are to be considered temporary and will only remain in effect until a future 
Administrative Letter to Investigators notifies study sites to resume study conduct in accordance 
with the full protocol and normal practices. 
Where feasible, sites should continue to follow the full schedule of assessments. All assessments 
missed as a result of any public health emergency, including COVID-19, will be captured in 
the CRFs. 
Adjustments to Visit Windows and Study Assessments 
Study assessments associated with ± 3-day visit windows are assigned a ± 5-day window. Visits 
conducted within the expanded window are not considered protocol deviations. Visits outside of 
the expanded window may be considered protocol deviations. Data should be recorded on the 
CRF associated with the nominal visit day. 
Study procedures that cannot be conducted due to institutional restrictions will not be reported as 
protocol deviations if the sponsor is made aware in advance on a case-by-case basis. Such 
procedures may include PK blood sample collection and ECGs. 
Remote Patient Visits 
• If permitted by institutional guidelines, remote patient visits may be conducted with 
site staff by telephone or using video technology and/or with a visit by a home healthcare 
professional. Depending on local IRB/IEC policy, a revised ICF may be needed to allow 
remote patient visits. 
• If new local and/or central laboratories are used during remote visits for safety laboratory 
assessments (eg, hematology and chemistry), ensure all test results, laboratory 
certifications, and reference normal laboratory values and units are collected and 
documented in the site records consistent with institutional guidelines. The laboratory 
normal ranges should be provided to the sponsor for entry into the clinical database. 
• Ensure all details of remote patient visits are documented in patient site records. 
Shipment of Clinical Trial Material to Patients 
Study drug (capsules or tablets) may be shipped to the homes of study participants being visited 
by home health professionals under three conditions: 1) such clinical trial material shipment is 
permitted by local institution policy; 2) shipment is by a secure, trackable method, and 
documentation of shipment and receipt is retained with the patient or pharmacy records; 


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and 3) the material is shipped and stored per the requirements in Pharmacy Manual and the 
conditions stated on the study drug label. Clinical trial material exposed to temperature 
excursions should be replaced. In the patient’s home, clinical trial material must be stored under 
the conditions stated on the container labels and the Pharmacy Manual. Unused material and 
empty containers should be returned to the study site to enable the pharmacy to maintain 
accountability records. 
If any public health emergency impacts sites and subjects, these measures should be 
implemented immediately and remain in place until the impact from the public health emergency 
subsides. 
Missed Study Drug Administration 
If study drug administration is missed due to inability to obtain study drug during the public 
health emergency, this reason should be recorded in the patient site record and reported in the 
CRF as the reason for missed dose and will be documented as a protocol deviation. 


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APPENDIX 2. 
PRELIMINARY DIAGNOSIS CHECKLIST 
Guide to Completion 
The checklist is to be completed at Visit 1 PRIOR to collecting blood samples for genotyping. 


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Item 
Outcome 
Source (Select all that apply) 
Does patient have depression?  
 Yes 
 No 
 Not sure 
 Further information required 
 Written/digital medical records 
 Notes from treating physician 
 Oral report by patient 
 Other, please specify____________________ 
Does patient meet criteria for Treatment 
Resistant Depression (TRD)* within the past 5 
years? 
 Yes 
 No 
 Not sure 
 Further information required 
 Written /digital medical records 
 Notes from treating physician 
 Oral report by patient 
 Pharmacy records are available 
 Other, please specify___________________ 
How many treatment course(s) with 
antidepressants given > 6 weeks has the patient 
failed within the past 5 years? 
 One course 
 Two courses 
 Three courses 
 More than 3 courses 
 Written /digital medical records 
 Notes from treating physician 
 Oral report by patient 
 Pharmacy records are available 
 Other, please specify____________________ 
How many augmentation(s) of antidepressant 
therapy which lasted >6 weeks has the patient 
experienced in past 5 years? Note: 
augmentation can be considered failed 
treatment regimen. 
 None 
 One augmentation 
 Two augmentations 
 Three augmentations 
 More than 3 augmentations 
 Written /digital medical records 
 Notes from treating physician 
 Oral report by patient 
 Pharmacy records are available 
 Other, please specify ____________________  


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Item 
Outcome 
Source (Select all that apply) 
Do you consider that this patient meets 
preliminary diagnosis of TRD and should be 
assessed with PGx?  
 Yes 
 No 
 Not sure 
 Further information required 
 
Has the patient taken his/her prescribed 
antidepressant medication reliably in the 
past year? 
 Yes 
 No 
 Not sure 
 
*TRD is defined as within the past 5 years patient must have had a clinically meaningful inadequate response (estimated < 50% improvement per 
investigator/patient consensus and documented by the investigator to at least two treatment courses with antidepressant regimens. These must involve at least two 
different pharmacologic treatment classes and have been given at accepted therapeutic doses for an adequate duration (at least 6 weeks). One of these treatment 
failures must have occurred within the current episode. 
 


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APPENDIX 3. 
PATIENT RATED DEPRESSION AND FUNCTIONING 
CHECKLIST 
Completed by patient based on patient experience in the past week. To be reviewed with 
clinician prior to finalization. 
Guide to Completion:(Consider the current impact of your symptoms compared to when you 
were NOT depressed and/or felt okay) 
• No Impact — Your behavior or functioning related to these symptoms is not impaired 
as compared to when you were not depressed 
• Minimal Impact — There has been minimal if any impact on your behavior or 
functioning related to these symptoms as compared to when you were not depressed 
• Mild Impact — Your behavior or functioning related to these symptoms is mildly 
impaired as compared to when you were not depressed 
• Moderate Impact — Your behavior or functioning related to these symptoms is 
moderately impaired as compared to when you were not depressed 
• Severe Impact — Your behavior or functioning related to these symptoms is markedly 
impaired as compared when you were not depressed 
• Very Severe Impact — Your behavior or functioning related to these symptoms is very 
severely impaired as compared to when you were not depressed 
Note: Changes in your behavior or function refer to all aspects of your life. It includes 
maintaining expectations you or others have for you about your job or primary life role, your 
social life, and your personal interests/activities. 


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Symptom 
Questions 
Frequency of 
symptom in PAST 
WEEK 
Impact on your emotions, activities, and your 
relationships with others in the PAST WEEK 
Depressed 
thoughts/sadness 
In the past week how often have you had 
upsetting sad or depressed thoughts?  
 
What has been their impact on your 
emotions, activities and relationships with 
others? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Crying 
In the past week how often have your 
thoughts, or the actions of others upset 
you and caused you to cry (outwardly or 
inwardly). 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Low energy, easily 
get tired, fatigue, 
feeling "slowed 
down" 
In the past week how often have you 
found that you don’t have the energy 
level to complete your daily activities? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 


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Symptom 
Questions 
Frequency of 
symptom in PAST 
WEEK 
Impact on your emotions, activities, and your 
relationships with others in the PAST WEEK 
Impaired 
communication  
In the past week how often have you 
found that you are not communicating 
with others (by phone, internet or in 
person)? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Impaired social 
interactions with 
others 
In the past week how often have you 
found that you don’t want to spend time 
with others (in person, on the phone or on 
the internet)? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Impaired ability to 
experience a wide 
range of emotions 
In the past week how often have you felt 
that you were NOT experiencing a full 
range of positive emotions like happiness, 
joy, satisfaction, and pride? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 


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Symptom 
Questions 
Frequency of 
symptom in PAST 
WEEK 
Impact on your emotions, activities, and your 
relationships with others in the PAST WEEK 
Impairment in your 
interests or activities 
In the past week how often have you 
found that your job, hobbies, sports, 
music, etc. are not interesting or 
fulfilling? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Impaired memory/ 
concentration/ 
attention/ability to 
make decisions 
In the past week how often have you 
found that your ability to remember or 
maintain your attention on tasks or 
your ability to make decisions? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Increased 
irritability/ feelings 
of anger hostility 
In the past week how often have you 
found that you get angry or are easily 
irritated by others? Think about the 
number arguments you have had with 
others. 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 


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Symptom 
Questions 
Frequency of 
symptom in PAST 
WEEK 
Impact on your emotions, activities, and your 
relationships with others in the PAST WEEK 
Suicidality/thoughts 
of death 
In the past week how often have you felt 
that life was not worth living, that you 
wished you were dead or, even, that you 
wanted to take your life? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Decreased interest in 
physical or 
emotional intimacy 
with others 
In the past week how often have you 
found that your interest in being intimate 
with others has diminished? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Decreased sexual 
desire and/or 
interest in sexual 
activities 
In the past week how often have you 
found that your sexual desire and 
activities have diminished?  
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 


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Symptom 
Questions 
Frequency of 
symptom in PAST 
WEEK 
Impact on your emotions, activities, and your 
relationships with others in the PAST WEEK 
Increased anxiety/ 
tension 
In the past week how often have you 
found that you are anxious, tense or that 
you are worrying about things? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Feelings of 
worthlessness, 
helplessness, 
hopelessness, or 
pessimism 
 In the past week how often have you felt 
pessimistic about your life with feelings 
of helplessness or worthlessness? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Feelings of guilt, 
shame or being a 
failure 
In the past week how often have you felt 
guilty about things that you have done, 
or shame, or that your life is a failure? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 


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Symptom 
Questions 
Frequency of 
symptom in PAST 
WEEK 
Impact on your emotions, activities, and your 
relationships with others in the PAST WEEK 
Feeling stressed/ 
overwhelmed/oppres
sed 
In the past week how often have you 
found that you are easily stressed, 
overwhelmed, or oppressed by your 
responsibilities? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Sleeping too much  
In the past week how often have you 
found that you are sleeping more than 
usual and still not feeling fully rested 
and revived? 
 
What has been the impact on your life? 
 Never 
 Maybe a little 
 One day 
 Some days 
 Most days 
 Every day 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Sleeping too little, 
difficulty getting to 
sleep, staying asleep 
or early-morning 
waking 
In the past week how often have you 
found it difficult to get to sleep or stay 
asleep or wake up too early? 
 
What has been the impact on your life? 
 Never 
 Maybe a little 
 One day 
 Some days 
 Most days 
 Every day 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 


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Symptom 
Questions 
Frequency of 
symptom in PAST 
WEEK 
Impact on your emotions, activities, and your 
relationships with others in the PAST WEEK 
Decreased appetite  
In the past week how often have you 
found that your appetite has decreased?  
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Overeating 
In the past week how often have you 
found that your appetite has increased? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Persistent physical 
symptoms that do 
not respond to 
treatment  
In the past week how often have you had 
physical pains like headaches, stomach 
aches, joint pains that do not respond 
well to treatment? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 


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Symptom 
Questions 
Frequency of 
symptom in PAST 
WEEK 
Impact on your emotions, activities, and your 
relationships with others in the PAST WEEK 
Other problems 
In the past week how often have you had 
other problems or concerns not 
mentioned that trouble you? If so, what 
are they? 
 
What has been the impact on your life? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 not Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
OVERALL 
IMPACT OF 
SYMPTOMS ON 
FUNCTIONING 
Overall, in the past week how much have 
the whole group of symptoms described 
above affected you, your work life, and 
your relationships with others? 
 Never 
 Seldom 
 Occasional 
 Often 
 Very often 
 All the time 
 No impact in past week 
 Minimal impact in past week 
 Mild impact in past week 
 Moderate impact in past week 
 Severe impact in past week 
 Very severe impact in past week 
Treatment 
 
To be used at 
baseline visit 
In the past week, how many times did you 
miss or forget to take your antidepressant 
medication? 
 Never missed 
 Missed 1 time 
 Missed 2-3 times 
 Missed 4 or more 
times 
 I don’t take 
antidepressant 
medication 
 


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Symptom 
Questions 
Frequency of 
symptom in PAST 
WEEK 
Impact on your emotions, activities, and your 
relationships with others in the PAST WEEK 
Treatment 
 
To be used at all 
post-baseline visits 
In the past week, how many times did you 
miss or forget to take your 1 pill from 
bottle A and 1 pill from bottle B of your 
study medication? 
 Never missed 
 Missed 1 time 
 Missed 2-3 times 
 Missed 4 or more 
times 
 


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APPENDIX 4. 
PLACEBO RESPONSE PROPENSITY SCALE 
(CLINICAL TRIAL VERSION) 
Overview 
The Placebo Response Propensity Scale (PRPS) was designed to assess the probability of 
placebo response within clinical trials and population-based studies. Within clinical trials the 
PRPS should be administered at the Screening and/or Baseline visit. In a clinical trial the term 
health condition(s) in the PRPS instructions should be changed to the health condition under 
study (eg, in a depression study the questions should ask about depression). The PRPS can be 
patient completed or administered by the site. Mode of administration should be included in the 
study data file. Any translations should be developed in collaboration with the developer 
following ISPOR guidelines and be certified. 
Using the PRPS within trials allows assessment of results with and without those with a high 
propensity for PBO response allowing for more confidence when trying to establish a true 
signal of efficacy. Each study using the PRPS provides an opportunity for additional analysis 
of the data giving more confidence in study results and helps identify patients most likely to be 
responders. 


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For the first set of questions, please think about your beliefs and experiences in general. For each item below, please select one answer 
to indicate the extent to which you agree or disagree with the statement. 
 
Completely 
Disagree 
Mostly 
Disagree 
Moderately 
Disagree 
Slightly 
Disagree 
Neutral 
Slightly 
Agree 
Moderately 
Agree 
Mostly 
Agree 
Completely 
Agree 
I forget to take my 
medications when I am 
supposed to 
 
 
 
 
 
 
 
 
 
I am responsible for my 
health 
 
 
 
 
 
 
 
 
 
Doctors have helped me 
a lot in the past 
 
 
 
 
 
 
 
 
 
I take my medications 
exactly as I am supposed 
to 
 
 
 
 
 
 
 
 
 
I find medications to be 
helpful 
 
 
 
 
 
 
 
 
 
I do not take my 
medications if I think I 
can do without them 
 
 
 
 
 
 
 
 
 
I think people in 
research studies should 
be paid money 
 
 
 
 
 
 
 
 
 


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CONFIDENTIAL 
For each item below, please select one response to indicate the extent to which you agree or disagree with the statement relative to 
your health condition(s). 
 
Completely 
Disagree 
Mostly 
Disagree 
Moderately 
Disagree 
Slightly 
Disagree 
Neutral 
Slightly 
Agree 
Moderately 
Agree 
Mostly 
Agree 
Completely 
Agree 
Whether or 
not I get 
better 
depends on 
factors or 
things outside 
of my control 
 
 
 
 
 
 
 
 
 
I am ashamed 
of my 
condition 
 
 
 
 
 
 
 
 
 
My condition 
will probably 
get better on 
its own 
 
 
 
 
 
 
 
 
 
No one 
understands 
my condition 
 
 
 
 
 
 
 
 
 
My condition 
limits my 
ability to 
enjoy life 
 
 
 
 
 
 
 
 
 
I talk with 
other people 
about my 
condition 
 
 
 
 
 
 
 
 
 
Medications 
 
 
 
 
 
 
 
 
 


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Page 96 of 99 
CONFIDENTIAL 
 
Completely 
Disagree 
Mostly 
Disagree 
Moderately 
Disagree 
Slightly 
Disagree 
Neutral 
Slightly 
Agree 
Moderately 
Agree 
Mostly 
Agree 
Completely 
Agree 
for my 
condition are 
not likely to 
help me 
I have 
struggled 
with this 
condition for 
a long time 
 
 
 
 
 
 
 
 
 
My condition 
is serious  
 
 
 
 
 
 
 
 
 
So far, I like 
the study 
doctor(s) 
 
 
 
 
 
 
 
 
 
Whether or 
not I get 
better 
depends on 
factors or 
things outside 
of my control 
 
 
 
 
 
 
 
 
 
 


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CONFIDENTIAL 
For each item below, please select one response to indicate the extent to which you agree or disagree with the statement relative to 
your health condition(s). 
 
Completely 
Disagree 
Mostly 
Disagree 
Moderately 
Disagree 
Slightly 
Disagree 
Neutral 
Slightly 
Agree 
Moderately 
Agree 
Mostly 
Agree 
Completely 
Agree 
The clinic staff at study 
site listen carefully to 
what I say 
 
 
 
 
 
 
 
 
 
I think I will get placebo 
(sugar pill) in this study 
 
 
 
 
 
 
 
 
 
I think I will improve 
even if I get a placebo 
(sugar pill) in this study 
 
 
 
 
 
 
 
 
 
I think the study doctor 
spends, or will spend, a 
lot of time with me 
 
 
 
 
 
 
 
 
 
The study doctor is not 
concerned about my 
condition 
 
 
 
 
 
 
 
 
 
The study doctor is an 
expert in my condition 
 
 
 
 
 
 
 
 
 
The study doctor helps, 
or will help, me to get 
better 
 
 
 
 
 
 
 
 
 
The study doctor makes 
me feel comfortable 
 
 
 
 
 
 
 
 
 
The clinic staff at study 
site really know what 
they are doing 
 
 
 
 
 
 
 
 
 
 
 


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CONFIDENTIAL 
For each item below, please select one response to indicate the extent to which you agree or disagree with the statement relative to 
your health condition(s). 
 
Completely 
Disagree 
Mostly 
Disagree 
Moderately 
Disagree 
Slightly 
Disagree 
Neutral 
Slightly 
Agree 
Moderately 
Agree 
Mostly 
Agree 
Completely 
Agree 
I really want to be 
treated for my condition 
 
 
 
 
 
 
 
 
 
I am not likely to get 
better with the study 
medicine 
 
 
 
 
 
 
 
 
 
I have, or expect I will, 
improve with the study 
medicine 
 
 
 
 
 
 
 
 
 
Seeking to participate in 
this study has made me 
feel better 
 
 
 
 
 
 
 
 
 
I like or will like coming 
to the study site clinic 
for my appointments 
 
 
 
 
 
 
 
 
 
I make, or will make, 
myself better with the 
study medication 
 
 
 
 
 
 
 
 
 
I have a feeling that the 
study medicine brings, 
or will bring, about good 
for me 
 
 
 
 
 
 
 
 
 
 


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For the following question, please choose the response that applies to your health condition(s). 
 
0 
1 
2-3 
4-5 
More than 5 
Please indicate the 
number of research 
studies in which you 
have previously 
participated 
 
 
 
 
 
For the following question, please choose the response that applies to your health condition(s). 
 
Very Much 
Better 
Much Better 
A Little Better 
Unchanged 
A Little 
Worse 
Much Worse 
Very Much 
Worse 
Compared to how 
you feel now, 
how do you 
expect to feel at 
the end of the 
study? 
 
 
 
 
 
 
 
For the following question, please choose the response that applies to your health condition(s). 
 
Very Much 
Better 
Much Better 
A Little Better 
Unchanged 
A Little 
Worse 
Much Worse 
Very Much 
Worse 
How do you think 
the study 
medication will 
make you feel? 
 
 
 
 
 
 
 
 

SAP_001.pdf: 
 
CONFIDENTIAL 
                                  
 
TITLE PAGE 
 
 
DB 104-01 Statistical Analysis Plan 
 
 
A Biomarker-Guided, Randomized, Double-Blind, Placebo-Controlled 
Efficacy and Safety Study of Liafensine in Patients with 
Treatment-Resistant Depression 
 
 
Sponsor: 
Denovo Biopharma LLC 
10240 Science Center Drive, Ste 130 
San Diego, CA 92121 USA 
www.denovobiopharma.com 
Study Drug: 
liafensine 
Protocol Number: 
DB104-01 
Date of Issue: 
18Mar2024 
Version: 
2 
 
Denovo 
Biopharma 
RINJS 


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CONFIDENTIAL
APPROVALS
Role
Name/Function
Signature
Prepared By:
Dave Cavanaugh
Principal Biostatistician
NJS Associates
Approved By:
Holly Huang
VP of Biometrics
Denovo Biopharma LLC
Approved By:
Matt Spear
Chief Medical Officer
Denovo Biopharma LLC
1
0:u::; 
V 
Signer Name: Dave Cavanaugh 
L 
Signing Reason: I am the author of this document 
Signing Time: 18-Mar-202412:55:06 PM PDT 
8EAA7DB01CD548D681F1D6FCE2DBEE32 
r
:;u:dby 
V 
Signer Name: Holly Huang 
L
Signing Reason: I approve this document 
Signing Time: 18-Mar-202412:57:19 PM PDT 
ADC4B946B09241D0B5724A2D64FBB7F4 
Ii 
DocuSigned by: 
~a.srw-
V 
Signer Name: Matthew A. Spear 
L
Signing Reason: I approve this document 
Signing Time: 18-Mar-2024 I 3:08:41 PM PDT 
8988BA4200244079A4ABEAF6217847E6 


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VERSION HISTORY 
Version
Date 
Changes 
Rationale 
0.7 
04Jan2024 
Draft submitted in SN 0018 for FDA review 
Initial draft 
1 
31Jan2024 
Version submitted in SN 0019 prior to early data readout 
Section 5.3: Updated calculation for treatment duration 
from weeks to days; added calculation for dosing 
compliance 
Section 5.4.3: Removed CGI-I analysis by biomarker 
status 
Minor updates 
for clarity 
2 
18Mar2024 
Version submitted in SN 0021 prior to database lock 
Section 4.1: Added randomized analysis set (RAS) 
Section 5.1.3: Added 2nd age group of < 
 65 
Section 5.4.1.1: 
a. Added sensitivity analyses based on RAS to the list 
of sensitivity analyses 
b. Added clarifications that MMRM will be 
implemented using SAS Mixed procedure with the 
default REML (restricted maximum likelihood) 
estimation 
c. Listed intercurrent events (ICEs) in this study 
Section 5.4.1.2: 
a. Added use of the algorithm (Lu 2010) to assist in the 
convergence if the MMRM model does not converge
b. Added clarifications that the LSMESTIMATE 
statement in SAS Mixed procedure will be used to 
test the global null hypothesis of no treatment 
difference between both active arms and placebo 
while keeping all 3 treatment groups separately 
c. Added clarifications that all available data collected 
from all subjects before or after ICEs will be 
included in the analysis unless otherwise specified 
d. Added clarifications that for MADRS, the total score 
is set to missing if 50% or more items are missing at 
an assessment. When this occurs, the change from 
baseline value will be imputed without using any of 
the non-missing items. 
e. Updated the tables and figures to assess the MAR 
assumption based on ICEs 
Section 5.4.1.3: 
a. Added sensitivity analyses based on RAS: a set of 
sensitivity analyses listed under this section will be 
performed using DGM4-positive patients in RAS. 
The same MMRM in the primary and sensitivity 
analyses described in the previous section of SAP 
To address FDA 
review comments 
on draft SAP 
V0.7 
65 and~ 


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CONFIDENTIAL 
Version
Date 
Changes 
Rationale 
will be carried out. The model will include the fixed 
effects of treatment, visit (categorical covariate), 
treatment by visit interaction, baseline MADRS total 
score (continuous covariate), and region. 
b. Grouped ICEs with corresponding strategy in one of 
the sensitivity analyses 
c. Per b above, added a hypothetical strategy for 
subjects on prohibited medications 
Section 7: Added a new reference (Lu 2010) 
Section 8: Added sample SAS codes 
 


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CONFIDENTIAL 
TABLE OF CONTENTS 
TITLE PAGE ...................................................................................................................................1 
APPROVALS ..................................................................................................................................2 
VERSION HISTORY ......................................................................................................................3 
TABLE OF CONTENTS .................................................................................................................5 
LIST OF TABLES ...........................................................................................................................8 
LIST OF FIGURES .........................................................................................................................8 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ..................................................9 
1. 
INTRODUCTION ......................................................................................................11 
1.1. 
Objectives ...................................................................................................................11 
1.1.1. 
Primary Objective .......................................................................................................11 
1.1.2. 
Secondary Objectives .................................................................................................11 
1.1.3. 
Exploratory Objectives ...............................................................................................11 
1.2. 
Endpoints ....................................................................................................................12 
1.2.1. 
Primary Endpoint ........................................................................................................12 
1.2.2. 
Secondary Endpoints ..................................................................................................12 
1.2.3. 
Exploratory Endpoints ................................................................................................12 
2. 
STUDY DESIGN .......................................................................................................13 
2.1. 
Design Overview ........................................................................................................13 
2.2. 
Schedule of Assessments ............................................................................................14 
2.3. 
Sample Size Calculation .............................................................................................14 
2.4. 
Timing of Analysis .....................................................................................................15 
2.4.1. 
Interim Analysis ..........................................................................................................15 
2.4.2. 
Final Analysis .............................................................................................................15 
3. 
GENERAL STATISTICAL CONSIDERATIONS ....................................................16 
3.1. 
General Methods .........................................................................................................16 
3.2. 
Definition of Baseline .................................................................................................16 
3.3. 
Study Day ...................................................................................................................16 
3.4. 
Study Visits .................................................................................................................16 
3.5. 
Coding Dictionaries ....................................................................................................17 
3.6. 
Stratified Analysis ......................................................................................................17 
3.7. 
Testing Hypotheses and Multiple Comparisons .........................................................17 


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3.8. 
Assessments ................................................................................................................18 
3.8.1. 
Montgomery-Åsberg Depression Rating Scale ..........................................................18 
3.8.2. 
Clinical Global Impressions Scale-Severity ...............................................................18 
3.8.3. 
Clinical Global Impressions Scale-Improvement .......................................................19 
3.8.4. 
Sheehan Disability Scale ............................................................................................19 
3.8.5. 
Columbia-Suicide Severity Rating Scale ....................................................................19 
3.8.6. 
Discontinuation-Emergent Signs and Symptoms Scale .............................................20 
3.9. 
Handling of Missing Data ...........................................................................................20 
3.9.1. 
Handling of Partial Dates for Adverse Events ............................................................20 
3.9.2. 
Handling of Partial Dates for Medications .................................................................20 
3.9.3. 
Handling of Missing Data for MADRS ......................................................................21 
3.9.4. 
Handling of Missing Data for Other Efficacy Scales .................................................21 
4. 
ANALYSIS SETS ......................................................................................................22 
4.1. 
Randomized Analysis Set ...........................................................................................22 
4.2. 
Full Analysis Set .........................................................................................................22 
4.3. 
Safety Analysis Set .....................................................................................................22 
4.4. 
Per Protocol Analysis Set ...........................................................................................22 
5. 
STATISTICAL METHODOLOGY ...........................................................................23 
5.1. 
Population Characteristics ..........................................................................................23 
5.1.1. 
Study Subjects Disposition .........................................................................................23 
5.1.2. 
Protocol Deviations ....................................................................................................23 
5.1.3. 
Demography and Baseline Characteristics .................................................................24 
5.1.4. 
Medical History ..........................................................................................................24 
5.1.5. 
Prior and Concomitant Medications ...........................................................................24 
5.2. 
Concomitant Procedures .............................................................................................25 
5.3. 
Exposure of Study Treatment .....................................................................................25 
5.4. 
Efficacy Analysis ........................................................................................................25 
5.4.1. 
Primary Endpoint: Change in MADRS Total Score from Baseline to Day 42, 
in DGM4-Positive Patients .........................................................................................25 
5.4.1.1. 
Estimand .....................................................................................................................25 
5.4.1.2. 
Main Estimator ...........................................................................................................26 
5.4.1.3. 
Sensitivity Estimator ...................................................................................................28 


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5.4.2. 
Key Secondary Endpoint: Change in CGI-S from Baseline to Day 42, in 
DGM4-Positive Patients .............................................................................................30 
5.4.3. 
Other Secondary Endpoint: CGI-I at Day 42, in DGM4-Positive Patients ................30 
5.4.4. 
Other Secondary Endpoint: Change in SDS from Baseline to Day 42, in 
DGM4-Positive Patients .............................................................................................31 
5.4.5. 
Subgroup Analyses .....................................................................................................31 
5.5. 
Safety Analysis ...........................................................................................................31 
5.5.1. 
Adverse Events ...........................................................................................................31 
5.5.2. 
Clinical Laboratory Evaluation ...................................................................................33 
5.5.3. 
Vital Signs ..................................................................................................................34 
5.5.4. 
DESS scale and C-SSRS data .....................................................................................34 
5.5.5. 
12-Lead Electrocardiograms .......................................................................................35 
5.5.6. 
Physical and Neurological Exam ................................................................................35 
5.6. 
Exploratory Analysis ..................................................................................................35 
5.6.1. 
Treatment Response in DGM4-Positive Patients .......................................................35 
5.6.2. 
Remission in DGM4-Positive Patients .......................................................................35 
5.6.3. 
Change in MADRS Anhedonia Subscale and Individual Items from Baseline 
to Day 42, in DGM4-Positive Patients .......................................................................36 
5.6.4. 
Change in MADRS Total Score from Baseline to Day 42, in DGM4-
Negative Patients ........................................................................................................36 
5.6.5. 
Change in MADRS Total Score from Baseline to Day 42 in Liafensine 1 mg 
QD Group and 2 mg QD Group, in both DGM4-Positive and DGM4-
Negative Patients ........................................................................................................36 
5.7. 
Pharmacokinetics ........................................................................................................36 
5.7.1. 
Plasma Concentrations ................................................................................................36 
6. 
CHANGES FROM ANALYSES PLANNED IN THE PROTOCOL .......................37 
7. 
REFERENCES ...........................................................................................................38 
8. 
APPENDIX: SAMPLE SAS CODES ........................................................................39 
8.1. 
SAS Code for Multiple Imputations Based on the Non-missing Values in the 
Same Arm with FCS and REGPMM Options ............................................................39 
8.2. 
SAS Code for Treatment Comparisons in MMRM ....................................................39 
8.3. 
SAS Code for Summarizing Treatment Comparison Results from Multiple 
Imputations Using Proc MIANALYZE ......................................................................41 
8.4. 
SAS Code for Imputation Using Non-missing Values in the Control Arm ...............41 


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8.5. 
SAS Code for Imputation Using Non-missing Values in the Control Arm or 
the Same Arm per Intercurrent Events .......................................................................42 
8.6. 
SAS Code for Imputation Pertaining to Use of Prohibited Medications ....................43 
8.7. 
SAS Code for Tipping Point Analysis ........................................................................44 
8.8. 
SAS Code for Stratified CMH Test ............................................................................45 
 
LIST OF TABLES 
Table 1. Imputation Rules for Adverse Event Partial Dates ..........................................................20 
Table 2. Imputation Rules for Medication Partial Dates ...............................................................21 
Table 3. Clinical Laboratory Tests .................................................................................................33 
Table 4. Changes from Protocol-Specified Analyses ....................................................................37 
 
LIST OF FIGURES 
Figure 1. 
Study Design ...............................................................................................................13 
Figure 2. 
Statistical Testing Procedure ......................................................................................18 
 


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CONFIDENTIAL 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation 
Definition 
AE 
adverse event 
AESI 
adverse event of special interest 
ALP 
alkaline phosphatase 
ALT (SGPT) 
alanine aminotransferase (serum glutamic-pyruvic transaminase) 
AST (SGOT) 
aspartate aminotransferase (serum glutamic-oxaloacetic transaminase) 
ATC 
Anatomical Therapeutic Chemical 
ATC-2 
Anatomical Therapeutic Chemical (subgroup level 2) 
ATRQ 
Antidepressant Treatment Response Questionnaire 
BP 
blood pressure 
CGI-I, -S 
Clinical Global Impressions Scale-Improvement, -Severity 
CMH 
Cochran-Mantel-Haenszel 
CRF 
case report form 
C-SSRS 
Columbia-Suicide Severity Rating Scale 
DESS 
Discontinuation-Emergent Signs and Symptoms (scale) 
DGM4 
Denovo Genomic Marker 4, a genetic biomarker for DB104 (liafensine) 
DILI 
drug-induced liver injury 
ECG 
Electrocardiogram 
EDC 
electronic data capture (system) 
EOT 
End of Treatment 
FAS 
full analysis set 
FCS 
fully conditional specification 
HAMD-17 
Hamilton Depression Rating Scale - 17 Item 
HR 
heart rate 
ICE 
intercurrent event 
IRT 
interactive response technology 
LS 
least-squares 
MADRS 
Montgomery-Åsberg Depression Rating Scale 
MAR 
missing at random 
MDD 
major depressive disorder 
MedDRA 
Medical Dictionary for Regulatory Activities 
MMRM 
mixed model for repeated measures 


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CONFIDENTIAL 
Abbreviation 
Definition 
PK 
Pharmacokinetic 
PT 
preferred term 
QD 
once daily 
RAS 
randomized analysis set 
REML 
restricted maximum likelihood 
SAP 
statistical analyses plan 
SAF 
safety analysis set 
SD 
standard deviation 
SDS 
Sheehan Disability Scale 
SE 
standard error 
SOC 
system organ class 
TBL 
total bilirubin 
TEAE 
treatment-emergent adverse event 
TRD 
treatment-resistant depression 
ULN 
upper limit of normal 
WHO 
World Health Organization 
 
 
 


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CONFIDENTIAL 
1. 
INTRODUCTION 
This document is the statistical analysis plan (SAP) for the Denovo Biopharma LLC (Denovo) 
study DB104-01 titled A Biomarker-Guided, Randomized, Double-Blind, Placebo-Controlled 
Efficacy and Safety Study of Liafensine in Patients with Treatment-Resistant Depression.
prepared based on Protocol Amendment 2 dated 29 Aug 2022 and Case Report Form (CRF) 1.0 
dated 23 Mar 2023. 
Populations for analysis, data handling rules, and statistical methods are described within this 
document. The statistical analyses and summary tabulations described in this document, 
including safety, tolerability, efficacy, and pharmacokinetics (PK), will provide the basis for the 
results sections of the clinical study report for this trial. 
The statistical analysis for the study will be performed by NJS Associates, a Denovo-designated 
contract research organization. 
1.1. 
Objectives 
1.1.1. 
Primary Objective 
The primary efficacy objective is to demonstrate that liafensine is superior to placebo in Denovo 
Genomic Marker 4 (DGM4)-positive patients with treatment-resistant depression (TRD) as 
assessed by the change in Montgomery-Åsberg Depression Rating Scale (MADRS) total score 
from baseline to Day 42 of double-blind treatment. 
1.1.2. 
Secondary Objectives 
The key secondary efficacy objective is to evaluate the change from baseline to Day 42 in 
DGM4-positive patients with TRD treated with liafensine vs placebo on the Clinical Global 
Impressions Scale-Severity (CGI-S). 
Safety Objectives: 
 To compare the safety and tolerability of liafensine vs placebo in all randomized patients 
with TRD who received at least one dose of study drug during double-blind treatment 
 To evaluate safety for liafensine 1 mg once daily (QD) and 2 mg QD vs placebo in both 
DGM4-positive and DGM4-negative patients 
Other Secondary Efficacy Objectives: 
 To evaluate Clinical Global Impressions Scale-Improvement (CGI-I) at Day 42 in 
DGM4-positive patients with TRD treated with liafensine vs placebo 
 To evaluate the change from baseline to Day 42 in DGM4-positive patients with TRD 
treated with liafensine vs placebo on the patient-reported functionality with Sheehan 
Disability Scale (SDS) 
1.1.3. 
Exploratory Objectives 
 To compare the proportion of DGM4-positive patients with TRD who respond to 
 50% 
improvement from baseline in MADRS total score at Day 42) 
" 
" It is 
• 
• 
• 
• 
• 
liafensine after 6 weeks of treatment vs placebo (response is defined as 2: 


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 To compare the proportion of DGM4-positive patients with TRD who are in remission 
after 6 weeks of treatment with liafensine vs placebo (remission is defined as MADRS 
 10 at Day 42) 
 To evaluate the change from baseline to Day 42 in DGM4-positive patients with TRD 
treated with liafensine vs placebo on MADRS anhedonia subscale and individual items 
 To compare the efficacy of liafensine vs placebo in DGM4-negative patients with TRD, 
as assessed by change in MADRS total score from baseline to Day 42 
 To evaluate efficacy for liafensine 1 mg QD and 2 mg QD vs placebo in both 
DGM4-positive and DGM4-negative patients 
 To evaluate the PK of liafensine as part of the population PK analyses 
1.2. 
Endpoints 
1.2.1. 
Primary Endpoint 
 Change in MADRS total score from baseline to Day 42, in DGM4-positive patients 
1.2.2. 
Secondary Endpoints 
Key Efficacy Endpoint: 
 Change in CGI-S from baseline to Day 42, in DGM4-positive patients 
Safety Endpoints: 
 Adverse events (AEs) as characterized by type, frequency, severity, timing, seriousness, 
and relationship to study therapy 
 Laboratory abnormalities as characterized by type, frequency, severity, and timing 
 Vital signs including supine (after at least 5-min rest) and standing (after 1-min and 
3-min standing), blood pressure (BP) and heart rate (HR), weight, electrocardiogram 
(ECG), clinical laboratory evaluation, Discontinuation-Emergent Signs and Symptoms 
(DESS) scale, and Columbia-Suicide Severity Rating Scale (C-SSRS) data 
Other Secondary Efficacy Endpoints: 
 CGI-I at Day 42, in DGM4-positive patients 
 Change in SDS from baseline to Day 42, in DGM4-positive patients 
1.2.3. 
Exploratory Endpoints 
 
 50% improvement from baseline in MADRS total score 
at Day 42) in DGM4-positive patients 
 
 10 at Day 42) in DGM4-positive patients 
 Change in MADRS anhedonia subscale and individual items from baseline to Day 42, in 
DGM4-positive patients 
 Change in MADRS total score from baseline to Day 42, in DGM4-negative patients 
 Change in MADRS total score from baseline to Day 42 in 1 mg QD group and 2 mg QD 
group, in both DGM4-positive and DGM4-negative patients 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
total score ::S 
• 
Treatment response ( defined as ~ 
• 
Remission (defined as MADRS total score ::S 
• 
• 
• 


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2. 
STUDY DESIGN 
2.1. 
Design Overview 
This study will be conducted as a multicenter, randomized, double-blind, placebo-controlled 
Phase 2b trial to assess the efficacy, safety, tolerability, and PK of liafensine. The study includes 
an up to 21-day screening period (the screening period may exceed 21 days if a prolonged 
washout is required). 
Approximately 180 patients with TRD who meet all eligibility criteria will be randomized in a 
1:1:1 ratio to receive either placebo QD, liafensine 1 mg QD, or liafensine 2 mg QD for 6 weeks. 
Approximately 150 randomized patients will be genotype GG for DGM4 (DGM4-positive) and 
approximately 30 randomized patients will be genotype AA or AG for DGM4 (DGM4-negative). 
DGM4 status (positive vs negative) of randomized patients will be blinded to the sites, patients, 
and sponsor. An interactive response technology (IRT) system will be used for blinding to 
DGM4 status, and to achieve the correct randomization ratio of DGM4-positive:DGM4-negative 
patients by randomly excluding most screened DGM4-negative patients (~80%). Randomization 
will be stratified by DGM4 status (positive vs negative) and region (North America vs Other). 
Patients who complete the study or discontinue after randomization will have 2 post-study 
follow-up visits (14 days after the last administered dose of study drug, and 28 days after the last 
administered dose of study drug); the 2nd follow-up visit will be conducted via phone call. 
The overall study design is shown in Figure 1. 
Figure 1. 
Study Design 
 
Abbreviations: ATRQ = Antidepressant Treatment Response Questionnaire; DGM4 = Denovo Genomic 
Marker 4; HAMD-17 = Hamilton Depression Rating Scale - 17 Item; QD = once daily; 
R = randomization. 
Screening 
Screening 
("'3welcs) 
N=1T000-2TOOO 
✓ DGMil status 
✓ History of lnaaequate rnponsefc 50%) 
tot 2 antklepreuants, A TRQ 
✓ HAMIM7 total score t 21 
(kreenlng, llnellne Day-1) 
I 
0 
Treatment 
Randomized 
(6.weelcs) 
N = ""180 (150 DGM4+, 30DGM4-J 
(1:1:1) 
• 
Follow;m 
Follow-up 
(4welcs) 


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Patients will be randomly assigned through an IRT system in a 1:1:1 ratio to receive either 
placebo QD, liafensine 1 mg QD, or liafensine 2 mg QD for 6 weeks. 
Randomization Phase: 
Placebo QD 
 Day 1 through Day 42: two placebo tablets QD 
Liafensine 1 mg QD 
 Day 1 through Day 42: one 1 mg liafensine tablet and one matching placebo tablet QD 
Liafensine 2 mg QD 
 Day 1 through Day 7: one 1 mg liafensine tablet and one matching placebo tablet QD 
 Day 8 through Day 42: two 1 mg liafensine tablets QD 
2.2. 
Schedule of Assessments 
The schedule of assessments is found in Table 1 of the protocol. Study procedures and 
assessments are described in Section 7 of the protocol. 
2.3. 
Sample Size Calculation 
Eligible patients will be randomized 1:1:1 to receive placebo QD, liafensine 1 mg QD, or 
liafensine 2 mg QD. The primary analysis is to assess treatment difference in MADRS total score 
change from baseline (Visit 3, Day -1) to Visit 7 (Day 42), between the combined liafensine 
1 mg QD and 2 mg QD doses vs placebo, in DGM4-positive patients. A sample size of 
47 randomized DGM4-positive patients per arm is sufficient to detect a 4.5-unit difference 
between the combined liafensine 1 mg QD and 2 mg QD treatment groups and the placebo 
treatment group in the change in MADRS total score from baseline to Day 42 with 80% power at 
the 2-sided 0.05 alpha level, assuming a standard deviation (SD) of 9 units. 
To compensate for potential loss of power due to randomized patients who do not take at least 
one dose of study drug or who do not have a post-randomization efficacy evaluation (~5%), a 
total of approximately 150 DGM4-positive patients (50 DGM4-positive patients per arm) will be 
randomized. 
To examine trend in the total patient population and in the subgroup of DGM4-negative patients 
in order to evaluate DGM4 as a potential biomarker for predicting response to liafensine, 
approximately 20% additional DGM4-negative patients (10 per arm, total 30) will also be 
randomized. The sample size of 30 randomized patients in the DGM4-negative group is not 
estimated based on formal statistics in terms of power and alpha level. 
Sample size re-estimation may be conducted if the percentage of missing data at Day 42 visit is 
higher than expected and/or if the observed variance is higher than the one assumed in the 
sample size estimation. 
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2.4. 
Timing of Analysis 
2.4.1. 
Interim Analysis 
No interim analysis will be performed. 
2.4.2. 
Final Analysis 
The final analysis for the clinical study report will be performed after the database has been 
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3. 
GENERAL STATISTICAL CONSIDERATIONS 
3.1. 
General Methods 
Statistical analysis will be performed using SAS® software Version 9.4 or later (SAS 2001). 
For continuous variables, descriptive statistics will include the number of subjects (n), mean, SD, 
median, minimum, and maximum. Frequencies and percentages will be displayed for categorical 
data. Percentages by categories will be based on the number of subjects including missing data, 
ie, will add up to 100%. 
The estimated mean and median for a set of values should be calculated to one more decimal 
place than the raw (observed) data and rounded appropriately. Standard errors (SE) (or SD) 
should be calculated to two decimal places beyond the raw (observed) data and rounded 
appropriately. The decimal place for minimum and maximum should be the same as raw 
(observed) data. Percentage values should be reported with one digit to the right of the decimal 
,
.
two decimal places will be used for all summary statistics unless otherwise specified. 
Summaries presented by visit will be based on the scheduled assessments as planned in the 
protocol. Unscheduled assessments will not be included in the by-visit summary tables, however, 
will be included in the listings. Any unscheduled visit that falls within a visit window period 
without a scheduled visit will be used in summary tables. The summary tables and listings will 
be presented by DGM4 status (positive/negative) where noted, treatment group, and overall. The 
treatment groups are defined as: 
 Placebo QD 
 Liafensine 1 mg QD 
 Liafensine 2 mg QD 
 Liafensine 1 mg and 2 mg QD 
3.2. 
Definition of Baseline 
Baseline value is defined as the last available value collected before the first dose date of study 
drug for all safety laboratory, safety ECG, vital sign, and efficacy values. 
3.3. 
Study Day 
Study Day is relative to the start date of liafensine or placebo treatment: 
 If analysis date is on or after the liafensine or placebo treatment start date, 
Study Day = analysis date  treatment start date + 1. 
 If analysis date is before the liafensine or placebo treatment start date, 
Study Day = analysis date  treatment start date. 
3.4. 
Study Visits 
Study visits in the electronic data capture (EDC) datasets include Screening 1 (Visit 1) and 
Screening 2 (Visit 2), Day -1 (Visit 3), Day 7 (Visit 4), Day 14 (Visit 5), Day 28 (Visit 6), 
Day 42 (Visit 7/End of Treatment [EOT]), Day 14 and Day 28 post-last dose follow-up, and any 
point. When numerator value is "O "it should be displayed as "O "Further, a maximum of 
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unscheduled visits. Study visits will be windowed so that data recorded at any time have the 
potential to be included in summaries. The following visit window conventions will be followed: 
Visit 
Visit Number 
Day 
Window 
Screening 1 
1 
 
 
Screening 2 
2 
 
 
Visit 3 
3 
-1 
-1 to 3 
Visit 4 
4 
7 
4 10 
Visit 5 
5 
14 
11 20 
Visit 6 
6 
28 
21 34 
Visit 7/EOT 
7 
42 
35 49 
 
Unscheduled visits will not be used in the summary by visit unless otherwise specified, the 
unscheduled visit values will be considered in the summary of worst change from baseline. 
3.5. 
Coding Dictionaries 
Medical history, medical or surgical procedures, and AEs will be coded using Medical 
Dictionary for Regulatory Activities (MedDRA) Version 25.0 or higher. 
Prior and concomitant medications will be coded using World Health Organization (WHO) Drug 
Dictionary March 2022. 
Adverse events and laboratory values will be classified as mild, moderate, or severe. 
3.6. 
Stratified Analysis 
Efficacy analyses will be stratified by biomarker status and region. Details are presented under 
the analysis for each endpoint. 
3.7. 
Testing Hypotheses and Multiple Comparisons 
All statistical tests for the treatment comparison of efficacy endpoints will be based on a 1-sided 
alpha level of 0.05. For each endpoint, the null hypothesis is that the effects of each of the two 
liafensine treatment arms and placebo are the same. The alternative hypothesis is that liafensine 
is better than placebo. 
As illustrated in Figure 2, the family-wise Type I error rate will be controlled at a fixed 1-sided 
alpha level of 0.05 using a closed testing procedure for multiple dose comparisons and multiple 
endpoint comparisons in DGM4-positive patients (Marcus 1976). In the closed testing procedure, 
the average effect of liafensine 1 mg and 2 mg dose groups will be first compared with the 
placebo group on change in MADRS total score from baseline to Day 42 in DGM4-positive 
patients. If the 1-sided p-
 0.05, then the 1-sided p-values are calculated for the 
comparisons of 1 mg dose vs placebo and 2 mg dose vs placebo, respectively. If both individual 
p-
 0.05, a significant treatment effect is declared for both dose groups. If only one p-
 0.05, a significant treatment effect is declared for the corresponding dose group. All 
values are ::S 
value is ::S 
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other efficacy endpoints will not be controlled for multiplicity with nominal p-values provided 
for the exploratory purpose only. 
Figure 2. 
Statistical Testing Procedure 
 
 
3.8. 
Assessments 
3.8.1. 
Montgomery-Åsberg Depression Rating Scale 
Montgomery-Åsberg Depression Rating Scale (MADRS) is a 10-item clinician-administered 
scale, designed to be particularly sensitive to antidepressant treatment effects in patients with 
major depression (Montgomery 1979). Each MADRS item is rated on a 0 to 6 scale. The 
MADRS total score is calculated as the sum of the 10 individual item scores; the total score can 
range from 0 to 60. Higher MADRS scores indicate higher levels of depressive symptoms. 
3.8.2. 
Clinical Global Impressions Scale-Severity 
Clinical Global Impressions Scale-Severity (CGI-S) asks the clinician one question: 
-point scale: 1 = normal, not at all ill; 
2 = borderline mentally ill; 3 = mildly ill; 4 = moderately ill; 5 = markedly ill; 6 = severely ill; 
7 = among the most extremely ill patients (Guy 1976). 
This rating is based upon observed and reported symptoms, behavior, and function in the past 
seven days. Clearly, symptoms and behavior can fluctuate over a week; the score should reflect 
the average severity level across the seven days. 
Comparison of Combined I mg and 2 mg vs Placebo* 
lf p :::: 0.05, claim significance 
of I mg and 2 mg vs placebo 
/ 
Comparison of I mg 
vs Placebo 
lf p :S 0.05, 
Ifp > 0.05, 
claim 
no 
significance 
sigt1ificance 
of I mgvs 
of I mgvs 
placebo 
placebo 
Comparison of2 mg 
vs Placebo 
If p :S 0.05, 
Ifp > 0.05, 
claim 
no 
sigiiificance 
sigii ificance 
of2 mg vs 
of2 mg vs 
placebo 
placebo 
If p > 0.05 
Stop 
*All tests are based on I-sided alpba of0.05. 
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3.8.3. 
Clinical Global Impressions Scale-Improvement 
Clinical Global Impressions Scale-Improvement (CGI-I) is similarly simple in its format 
(Guy 1976). Each time the patient is seen after medication has been initiated, the clinician 
compares the patient's overall clinical condition to the one-week period just prior to the initiation 
of medication use (the so-called baseline visit). The CGI-S score obtained at the baseline 
(initiation) visit serves as a good basis for making this assessment. Again, only the following one 
query is rated on a seven-
 patient's condition at admission to the 
project (prior to medication initiation), this patient's condition is: 1 = very much improved since 
the initiation of treatment; 2 = much improved; 3 = minimally improved; 4 = no change from 
baseline (the initiation of treatment); 5 = minimally worse; 6 = much worse; 7 = very much 
 
The CGI-I score generally tracks with the CGI-S such that improvement in one follows the other. 
Anchors for scoring, however, are quite different, and the CGI-I is based upon changes from the 
initiation of treatment in contrast to changes from the preceding week of treatment. 
Consequently, the two CGI scores can occasionally be dissociated such that a clinician may 
notice changes in the CGI-I relative to baseline despite no recent changes in the overall CGI-S 
score or vice versa. 
3.8.4. 
Sheehan Disability Scale 
Sheehan Disability Scale (SDS) is used to assess functional impairment in three major life 
domains: work, social life/leisure activities, and family life/home responsibilities 
(Sheehan 2008). It is a five-item scale that will be completed by the participant. Three items use 
a Likert scale with a 10-point range (0 / Moderately to 10 / Extremely) and two items are open-
ended (eg
 
The first three items assess disruption of (1) work (2) social life/leisure activities, and (3) family 
life/home responsibilities using a 0-10 rating scale. The scores for the first three items are 
summed to create a total score of 0-30 where a higher score indicates greater impairment. It also 
has one item on days lost from school or work and one item on days when underproductive. 
3.8.5. 
Columbia-Suicide Severity Rating Scale 
Columbia-Suicide Severity Rating Scale (C-SSRS) was designed to quantify the severity of 
suicidal ideation and behavior (Posner 2011). C-SSRS is a measure used to identify and assess 
individuals at risk for suicide. Questions are phrased for use in an interview format but can be 
completed as a self-report measure if necessary. C-SSRS measures four constructs: the severity 
if endorsed, prompt additional follow-up questions to obtain more information. There are four 
versions of the scale available, including: 1) Baseline/screening version, which allows 
practitioners to gather a lifetime and recent 12 months history of suicidal ideation and/or 
behavior; 2) Since Last Visit version for assessment of suicidal thoughts and behaviors since C-
SSRS was last administered; 3) Screen version, a shortened version of the full form (3-6 
questions) most commonly used in clinical triage settings; 4) Risk Assessment Page, which 
provides a checklist of protective and risk factors of suicidality. 
point scale: "Compared to the 
worse since the initiation of treatment." 
, "On how many days in the last week did you ... ?"). 
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3.8.6. 
Discontinuation-Emergent Signs and Symptoms Scale 
Discontinuation-Emergent Signs and Symptoms Scale (DESS) is used to monitor patients for 
discontinuation symptoms (Rosenbaum 1998). It includes 43 signs or symptoms for which the 
patient indicates whether there has been any change since their last visit  indicating new 
symptom, old symptom but worse, old symptom but improved, old symptom but unchanged, 
symptom not present. The DESS total score on a given day is calculated as the count of items 
with new symptoms or old symptoms but worse over all 43 items. For missing items, it will be 
imputed as the average from the non-missing items. The total score can range from 0 to 43. The 
number and proportion of subject
 4 will be presented each 
day and by the treatment arm. Treatment comparison will be performed each day from Day 1 to 
Day 14 using the Cochran-Mantel-Haenszel (CMH) test stratified by region and biomarker 
status. The average DESS total score over the assessment period will be calculated for each 
subject and compared between treatment group using the Wilcoxon rank-sum test. 
3.9. 
Handling of Missing Data 
3.9.1. 
Handling of Partial Dates for Adverse Events 
When determining the treatment-emergent adverse events (TEAEs), partial adverse event start 
and/or end dates will be handled as shown in Table 1. 
Table 1. Imputation Rules for Adverse Event Partial Dates 
Date 
Missing Part 
Imputation Rule 
Start 
Date 
Missing Day 
Assign the first day of month unless it is the same month and year of the first 
dose of study treatment. Otherwise, assign date of first dose of study treatment 
or adverse event end date (if not missing), whichever is earlier. 
Missing Day, 
Month 
Assign Jan 01 unless the year is year of first dose of study treatment. 
Otherwise, assign date of first dose of study treatment or AE end date (if not 
missing), whichever is earlier. 
Missing Day, 
Month, Year 
Assign the date of first dose of study treatment or AE end date (if not missing), 
whichever is earlier. 
End 
Date 
Missing Day 
Assign the last date of the month or death date or data cutoff date (or end of 
study date), whichever is earliest. 
Missing Day, 
Month 
Assign Dec 31 or death date or data cutoff date (or end of study date), 
whichever is earliest. 
Missing Day, 
Month, Year 
If ongoing, the end date is missing. Otherwise, assign death date or data cutoff 
date (or end of study date), whichever is earlier. 
 
3.9.2. 
Handling of Partial Dates for Medications 
When determining if a medication is a prior or concomitant medication, partial start and/or end 
dates will be handled as shown in Table 2. 
s with the sum of zero, 1, 2, 3, and~ 


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Table 2. Imputation Rules for Medication Partial Dates 
Date 
Missing Part 
Imputation Rule 
Start 
Date 
Missing Day 
Assign the first day of month unless it is the same month and year of the first 
dose of study treatment. Otherwise, assign date of first dose of study treatment 
or medication end date (if not missing), whichever is earlier. 
Missing Day, 
Month 
Assign Jan 01 unless the year is year of first dose of study treatment. 
Otherwise, assign date of first dose of study treatment or medication end date 
(if not missing), whichever is earlier. 
Missing Day, 
Month, Year 
Assign date of first dose of study treatment or medication end date (if not 
missing), whichever is earlier. 
End 
Date 
Missing Day 
Assign the last date of the month or death date or data cutoff date (or end of 
study date), whichever is earliest. 
Missing Day, 
Month 
Assign Dec 31 or death date or data cutoff date (or end of study date), 
whichever is earliest. 
Missing Day, 
Month, Year 
If ongoing, the end date is missing. Otherwise, assign death date or data cutoff 
date (or end of study date), whichever is earlier. 
 
The imputed date will be used to categorize TEAE, prior/concomitant medication. The data 
listings will report original data instead as the imputed date. 
3.9.3. 
Handling of Missing Data for MADRS 
For MADRS, the total score is set to missing for any patient if 50% or more items are missing at 
an assessment. If less than 50% of items are missing, the missing items will take the average 
from the non-missing items. These calculated total scores will not be rounded to whole numbers. 
Missing data for the total score of MADRS will be maintained as missing unless specified 
otherwise. 
3.9.4. 
Handling of Missing Data for Other Efficacy Scales 
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4. 
ANALYSIS SETS 
4.1. 
Randomized Analysis Set 
The randomized analysis set (RAS) includes all randomized patients in this study. This analysis 
set will be used for a sensitivity analysis of the primary and key secondary efficacy endpoints for 
DGM4-positive patients. The RAS population will be analyzed by treatment randomization 
regardless of the actual treatment received. 
4.2. 
Full Analysis Set 
The full analysis set (FAS) includes all randomized patients who took at least one dose of study 
drug and had a post-randomization efficacy evaluation. The FAS population will be analyzed by 
treatment randomization regardless of the actual treatment received. The primary and secondary 
efficacy results of the study will be based on analysis in FAS patients who are DGM4 positive. 
4.3. 
Safety Analysis Set 
The safety analysis set (SAF) includes all patients who took at least one dose of study drug. The 
safety population will be analyzed by the actual treatment received regardless of treatment 
randomized. 
4.4. 
Per Protocol Analysis Set 
The per protocol analysis set (PP) excludes all patients with one of the following violations: 
 Violation of major inclusion or exclusion criteria as determined by the sponsor prior to 
the database lock 
 Study treatment compliance at < 80% or > 120% 
 Had disallowed medications during > 50% of the treatment period 
 Were mis-randomized 
 Others which may impact reliable interpretation of the outcome 
All patients with the violations above will be reviewed as potential important protocol 
deviations. The final list of per protocol deviations will be reviewed and finalized on individual 
cases prior to the database lock and unblinding. Additional information on protocol deviations is 
provided in Section 5.1.2. 
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5. 
STATISTICAL METHODOLOGY 
5.1. 
Population Characteristics 
5.1.1. 
Study Subjects Disposition 
The number of subjects in the FAS and SAF will be presented. The percentage of subjects in 
FAS will be calculated using the number of subjects in the SAF as denominator. 
 Number screened 
 Number of screen failures: due to DGM4 status vs all other reasons 
 Number randomized 
 Number and percentage of subjects who had at least one dose of study treatment 
 Number and percentage of subjects who completed or discontinued treatment, primary 
reason for discontinuation of treatment assigned to one of the reasons listed below 
o Adverse Event 
o Pregnancy 
o Study Terminated by Sponsor 
o Death 
o Withdrawal of Consent to Treatment 
o Other 
 Number and percentage of subjects who completed or discontinued the study, primary 
reason for study discontinuation assigned to one of the reasons listed below 
o Completed Protocol 
o Adverse Event 
o Withdrawal of Consent to Study 
o Death 
o Lost To Follow-Up 
o Study Terminated by Sponsor 
o Other 
Subjects disposition data will also be presented in data listings. 
5.1.2. 
Protocol Deviations 
A protocol deviation is any change, divergence, or departure from the study design or procedures 
defined in the clinical protocol. 
Protocol deviations will be classified by the sponsor or designee prior to the final analysis and 
important protocol deviations will be identified as those deviations from the study protocol that 
may significantly impact the completeness, accuracy, and/or reliability of the trial data; that may 
significantly affect a subject
-being [ICH E3(R1) Q&As, 2013]. The 
number and percentage of subjects with an important protocol deviation will be tabulated for the 
SAF. 
Separate listings for protocol deviations will also be presented. 
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5.1.3. 
Demography and Baseline Characteristics 
Descriptive statistics, including number of subjects (n), mean, SD, median, minimum, and 
maximum, will be used to summarize the following parameters: 
 Age (years) 
 Weight (kg) at Baseline 
 Height (cm) at Baseline 
 Body Mass Index (kg/m2) at Baseline 
The following demographic categories will be summarized with the number and percentage of 
subjects: 
 Age Groups (years): 18 to < 35, 
35 to < 55, and 
55; < 65 and  65 
 Gender: Male, Female 
 Ethnicity: Hispanic or Latino, Not Hispanic or Latino 
 Race: American Indian or Alaska Native, Asian, Black or African American, Native 
Hawaiian or Other Pacific Islander, White, and Other. The details of Other race will be 
listed as appropriate. 
 Baseline scores of MADRS, CGI-S, and HAMD-17 
 Number of years having major depressive disorder (MDD) or TRD 
 Prior treatment classes, including antidepressant only, combination of antidepressant with 
others, and non-antidepressant medication which is used to support treatment of 
depression. 
5.1.4. 
Medical History 
System organ class (SOC) and preferred term (PT) of medical history will be coded with 
MedDRA Version 25.0 or higher. A subject will be counted only once within one SOC and one 
PT if the subject reported the same SOC and PT multiple times. The summary will be sorted by 
the frequency of SOCs and PTs in overall total. 
 be listed in subject 
data listing. 
5.1.5. 
Prior and Concomitant Medications 
All medications will be coded using WHO Drug Dictionary March 2022. 
A medication can be classified as either prior or concomitant medication. Prior medication is 
defined as any medication taken prior to the date of the first study treatment dose. Concomitant 
medication is defined as any medication taken on or after the date of the first study treatment 
dose through the end of study. 
Prior and concomitant medications will be summarized by Anatomical Therapeutic Chemical 
(ATC) Classification (2nd level, chemical subgroup [ATC-2]) and preferred name. A subject will 
only be counted once within each ATC-2 code and within each preferred name. ATC-2 and 
preferred name will be sorted in descending frequency for the overall number of subjects and 
then alphabetically for ties. 
Prior and concomitant medications will also be presented in data listings. 
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5.2. 
Concomitant Procedures 
All procedures will be coded using MedDRA Version 25.0 or higher. 
Concomitant procedures will also be presented in data listings. 
5.3. 
Exposure of Study Treatment 
Exposure for study medications will be summarized separately using SAF by treatment group. 
The exposure summary will present descriptive statistics for the following: 
 Number of tablets taken 
 Number of tablets missed 
 Treatment duration (days) = date of last dose  date of first dose + 1 
 Actual dose = sum of actual tablets administered 
 Number of subjects with at least one dose adjustment with a breakdown of reasons for dose 
adjustment 
Overall compliance during the treatment period is calculated as: 
% of compliance = (# of tablets taken / # of tablets expected during the treatment period) * 100 
By visit summary of compliance will be presented. 
All study treatment administration data will be presented in data listings. 
5.4. 
Efficacy Analysis 
All analyses will be presented for DGM4-positive, DGM4-negative, and both DGM4-positive 
and DGM4-negative subjects. 
The analyses of the primary and key secondary efficacy endpoints will be conducted on the FAS. 
Supportive sensitivity analyses will be performed in the per protocol analysis set for primary and 
key secondary efficacy endpoints unless otherwise specified. 
5.4.1. 
Primary Endpoint: Change in MADRS Total Score from Baseline to Day 42, in 
DGM4-Positive Patients 
5.4.1.1. 
Estimand 
The following components are considered in the construction of the estimand, the main clinical 
quantity of interest to be estimated in the study: 
 Objective: To demonstrate that liafensine (1 mg QD or 2 mg QD) is superior to placebo 
in DGM4-positive patients with TRD as assessed by the change in MADRS total score 
from baseline to Day 42 of double-blind treatment 
 Intercurrent events (ICEs): Early termination of treatment due to various reasons or 
starting a prohibited medication. A detailed list of ICEs is provided at the end of this 
section. 
 Question of interest: For a patient with TRD for whom a short-term monotherapy would 
be indicated, what would be the expected effect of liafensine on severity of depressive 
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episodes at Week 6, if taken as directed for 6 weeks without initiating prohibited 
medications as defined in Protocol Section 5.3? 
The primary estimand is defined with the following components per ICH E9(R1): 
 The treatment condition of interest: TRD patients who meet all eligibility criteria will be 
randomized in a 1:1:1 ratio to receive either placebo QD, liafensine 1 mg QD, or 
liafensine 2 mg QD for 6 weeks. 
 Population: patients with TRD with the DGM4-positive biomarker 
 Endpoint at subject level: change in MADRS total score from baseline (Visit 3, Day -1) 
to Day 42 (Visit 7) 
 Population-level summary: For each treatment arm, the least-square (LS) mean of the 
primary endpoint will be calculated in each arm using the method described in Section 
5.4.1.2. Treatment comparisons will be based on the LS means. 
Intercurrent events and corresponding strategies: 
Intercurrent events to be considered for this analysis are those events that cause the MADRS 
at Day 42 to be either missing or compromised. The primary method will be mixed model for 
repeated measures (MMRM) with imputation assuming missing at random (MAR), ie, a 
hypothetical strategy per ICH E9(R1). Hence, missing values will be imputed with non-
missing values in the same treatment group. A fully conditional specification (FCS) method 
with predictive mean matching approach will be used in the imputation of missing MADRS 
score change from baseline as continuous variables (Buuren 2007). The following sensitivity 
analyses will be performed, with details described in Section 5.4.1.3: 
 A tipping-point analysis for the primary analysis result 
 MMRM without imputation 
 MMRM with multiple imputation using a patter-mixture model, as well as a tipping point 
analysis for this imputation method 
 Sensitivity analyses based on RAS 
MMRM will be implemented using SAS Mixed procedure with the default REML (restricted 
maximum likelihood) estimation. 
ICEs in this study are listed below: 
 Treatment discontinuation due to AE 
 Withdrawal of consent to treatment discontinuation 
 Other/Lost to follow-up 
 Use of prohibited medications 
 Pregnancy 
 Death 
5.4.1.2. 
Main Estimator 
The primary efficacy analysis will be performed in DGM4-positive patients at 1-sided 
significance level of 0.05 using MMRM with imputation based on the MAR assumption. The 
model will include the fixed effects of treatment, visit (categorical covariate), treatment-by visit 
interaction, treatment by baseline MADRS total score, baseline MADRS total score (continuous 
covariate), and region. Change from baseline in weekly visits at Days 7, 14, 28, and 42 will be 
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the repeated outcome measures, and the model will use an unstructured variance-covariance 
matrix. If the model does not converge the algorithm (Lu 2010) will be used to assist in the 
convergence. 
The following hypothesis will be tested based on the test statistics from the mixed model: 
H0: ui – u0 = 0 vs. HA: ui – u0 ≠ 0 
where ui is the expected mean change from baseline in MADRS for liafensine at Day 42 and u0 is 
the expected mean change from baseline in MADRS for placebo at Day 42. In H0 and HA above, 
i = 1, 2, 3 are for liafensine 1 mg, 2 mg, and both arms pooled, respectively, for implementing 
the closed testing procedure described in Section 3.7. The LSMESTIMATE statement in SAS 
Mixed procedure will be used to test the global null hypothesis of no treatment difference 
between both active arms and placebo while keeping all 3 treatment groups separately. Please 
see sample SAS code in Appendix 8.2. 
The LS mean for change from baseline in MADRS total score at Day 42 for the combined 
liafensine treatment arms (1 mg QD and 2 mg QD) and placebo arm will be estimated from the 
MMRM model. The comparison of the change in MADRS total score from baseline to Day 42 
between each of the two liafensine treatment arms and placebo will be carried out using the same 
approach. Separate figures with the mean change (± SD) and LS mean change (± SE) by visit 
will be displayed. 
In the analysis, data collected after initiation of prohibited medications will be used unless 
otherwise specified. All available data collected from all subjects before or after ICEs will be 
included in the analysis unless otherwise specified. Missing data due to any ICEs will be imputed 
using SAS MI procedure with the FCS statement and REGPMM option to implement the fully 
conditional specification method with predictive mean matching approach described in 
Section 5.4.1.1. For MADRS, the total score is set to missing if 50% or more items are missing 
at an assessment. When this occurs, the change from baseline value will be imputed without 
using any of the non-missing items. 
The following variables will be included in the imputation model: region, baseline MADRS 
score, and change from baseline at Weeks 1, 2, 4, and 6. One hundred fully imputed datasets will 
be created. The MMRM described above will be used for treatment comparisons. Treatment 
effects (difference in LS means between treatment arms) from these 100 analyses will be 
combined to generate final results using Rubin’s method implemented by SAS MIANALYZE 
procedure. 
The following tables and figures will be generated to assess the MAR assumption: 
1. A by-visit and overall summary table for (n, %), and cumulative (n, %) for reasons of 
missing value or early dropout in each arm due to: 
• AE including death 
• Withdrawal of consent to treatment discontinuation 
• Other reasons 
• Total (All of the above) 
Within each arm, the summary statistics of the primary endpoint will also be generated 
by dropout reason at each visit. This table will also be used to support the figure below. 


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2. For each arm, generate a line graph for mean change from baseline (y-axis) over time 
(x-axis) by dropout reasons. There will be 4 lines on this figure to represent each dropout 
reasons: 
 None (completers) 
 Dropout due to AE including death 
 Dropout due to withdrawal of consent to treatment discontinuation 
 Dropout due to other reasons 
In addition, a figure similar to the one above will be generated, with mean change from 
baseline replaced with a line graph for each subject. Subjects with the same reason for 
dropout will have the same color. 
5.4.1.3. 
Sensitivity Estimator 
Four types of sensitivity analyses will be conducted on the primary endpoint. 
1. A tipping point analysis to assess the robustness of the primary analysis results. The 
imputed missing values will be decreased or increased gradually, and treatment 
comparisons will be repeated. If the original result is significant and a large shift from the 
original imputed values needs to be done to reverse significance, the result is considered 
robust. The steps below will be followed. 
If the primary analysis result is significant: 
1) Increase each imputed value in the active arms by 1 and repeat the primary analysis 
using MMRM. If the treatment effect is still significant, each imputed value in the 
active arms will be further increased by 1 until the result is non-significant. 
2) Repeat the tipping point analysis above but decrease each imputed value in the 
placebo arm by 1 until the result is non-significant. 
3) Repeat the tipping point analysis by increasing each imputed value in the active arms 
by 1 and decreasing each imputed value in the placebo arm by 1 until the result is 
non-significant. 
If the primary analysis result is non-significant: 
1) Decrease each imputed value in the active arms by 1 and repeat the primary analysis 
using MMRM. If the treatment effect is still non-significant, each imputed value in 
the active arms will be further decreased by 1 until the result is significant. 
2) Repeat the tipping point analysis above but increase each imputed value in the 
placebo arm by 1 until the result is significant. 
3) Repeat the tipping point analysis by decreasing each imputed value in the active arms 
by 1 and increasing each imputed value in the placebo arm by 1 until the result is 
significant. 
There are two active dose groups in this study. In the description above, significance or 
non-significance refers to the result after multiplicity adjustment, and shift from the 
imputed value only involves the active and placebo arms under tipping point analysis. 
The imputed values of the other active dose group will remain the same in the pooled 
analysis. A shift parameter will be applied to each dose arm separately in the pooled 
analysis. After each tipping point analyses is completed, up to 3 results before reaching 
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the tipping point, as well as the result that reverses statistical significance or 
non-significance will be reported. 
2. MMRM without imputation 
The same model in the primary analysis will be used without imputation using the 
treatment policy strategy per ICH E9(R1) (Polverejan 2023). This analysis will be used to 
assess the impact of imputing missing values based on the MAR assumption. 
3. MMRM with imputation using pattern mixture model 
This sensitivity estimator will be using a control-based multiple imputation method 
(Ratitch 2013). This sensitivity analysis does not rely on the MAR assumption. Data 
collected after initiation of prohibited medications will not be used unless otherwise 
specified. Missing data due to all ICEs will be handled per specifications below unless 
otherwise specified. 
In this sensitivity analysis, imputation will be implemented using SAS MI procedure with 
FCS statement and REGPMM option, as well as MNAR statement with MODELOBS 
option to identify observations from the placebo arm for deriving the imputation models, 
ie, assuming all missing data will have a profile that equals the profile of the placebo arm 
for all time points. The variables to be used in the imputation are region, baseline values, 
and change from baseline values observed at Weeks 1, 2, 4, and 6. 
One hundred fully imputed datasets will be created. The MMRM described in 
Section 5.4.1.2 will be used for treatment comparisons. Treatment effects (difference in 
LS means between treatment arms) from these 100 analyses will be combined to generate 
the final results 
method with SAS MIANALYZE procedure. 
A tipping point analysis for this sensitivity analysis will also be conducted to assess the 
robustness of the result. The same steps described in the first sensitivity analysis will be 
followed. 
4. Sensitivity Analyses based on RAS 
A set of sensitivity analyses listed below will be performed using DGM4-positive 
patients in RAS. The same MMRM in the primary and sensitivity analyses described 
above will be carried out with the exclusion of the following fixed effect: treatment by 
baseline MADRS total score. In other words, the model will include the fixed effects of 
treatment, visit (categorical covariate), treatment by visit interaction, baseline MADRS 
total score (continuous covariate), and region. 
The following analyses will be performed in this set of sensitivity analyses: 
1) The primary analysis, as well as the 1st and 2nd sensitivity analyses based on FAS will 
be repeated using RAS. 
2) For the 3rd sensitivity described above, ie, MMRM with imputation using pattern 
mixture model, the imputation will be based on intercurrent events described below. 
All randomized participants who discontinued early with missing data will be classified 
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• Group 1: Treatment discontinuation due to AE 
• Group 2: Withdrawal of consent to treatment discontinuation; Other/Lost to 
follow-up; and Pregnancy 
• Group 3: One death was observed in this study with unknown reason and 
undetermined relationship to the study drug 
For subjects who were on prohibited medications, a hypothetical strategy will be applied. 
It is plausible that these prohibited medications may have additional efficacy effect on 
top of the study medication. To eliminate the assumed additional effect, data after the 
initiation of prohibited medication will be imputed with non-missing data in the same 
arm while the subject is on study medication. If the subject terminates the study 
medication early after initiation of prohibited medication, the missing data after treatment 
termination will be imputed according to the cause of termination stated in Groups 1-3 
above. 
Multiple imputations will be implemented using the SAS MI procedure with FCS 
statement and REGPMM option, as well as MNAR statement with MODELOBS option. 
a) For missing values caused by treatment discontinuation due to AE from Group 1, 
missing values will be imputed using non-missing values in the placebo group. 
b) For missing values due to Withdrawal of consent to treatment, Other/Lost to 
follow-up, or Pregnancy from Group 2, missing values will be imputed using 
non-missing value within the same treatment group. 
c) From Group 3: One death with unknown reason and undetermined relationship to 
study drug occurred in this study. Missing data prior to death will be imputed based 
on the worst score from this subject, and data after death will not be imputed. 
Multiple imputations will be carried out using a normal random variable with mean 
equal to the worst score in the schedule visits of this subject, and variance equal to the 
observed variance from the same treatment arm at the same visit. 
d) For subjects who used prohibited medications, data after initiation of prohibited 
medication will be imputed with non-missing data in the same arm while the subject 
is on study medication, same as b) above. If the subject terminates study medication 
early after initiation of prohibited medication, missing data after treatment 
termination will be imputed according to the cause of termination stated in Groups 
1 to 3 above. See Appendix 8.6 for the implementation of multiple imputations. 
5.4.2. 
Key Secondary Endpoint: Change in CGI-S from Baseline to Day 42, in 
DGM4-Positive Patients 
The change in CGI-S from baseline (Visit 3, Day -1) to Day 42 (Visit 7) will be analyzed using 
the MMRM model without imputation similar to the one used in sensitivity analysis (2) for the 
primary efficacy endpoint described in Section 5.4.1.3. Separate figures with the mean change 
(± SD) and LS mean change (± SE) by visit will be displayed. 
5.4.3. 
Other Secondary Endpoint: CGI-I at Day 42, in DGM4-Positive Patients 
CGI-I at Day 42 (Visit 7) will be analyzed using the CMH test stratified by region. Summary 
statistics will be provided on the proportion of subjects in each category. Summary statistics on 
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5.4.4. 
Other Secondary Endpoint: Change in SDS from Baseline to Day 42, in 
DGM4-Positive Patients 
The change in SDS from baseline (Visit 3, Day -1) to Day 42 (Visit 7) will be analyzed using the 
MMRM model without imputation similar to the one used in sensitivity analysis (2) for the 
primary efficacy endpoint described in Section 5.4.1.3. 
5.4.5. 
Subgroup Analyses 
Subgroup analyses for the primary endpoint will be considered for gender, ethnicity, and region, 
and may be explored for other factors (such as duration of MDD baseline severity in term of 
MADRS total score). Summary statistics will be provided for efficacy measures by treatment for 
each subgroup. 
5.5. 
Safety Analysis 
5.5.1. 
Adverse Events 
Adverse events will be coded using MedDRA Version 25.0 or higher. 
A TEAE is any AE that starts on or after the first day of study treatment or that worsens on or 
after the first day of study treatment, and within 30 days of the last administration of study 
treatment. 
For the purpose of regulatory reporting, relationships of Related or Unrelated
assessed and presented. Related to study drug suggests there is as at least a reasonable possibility 
that the drug caused the AE (ie, there is evidence or arguments to suggest a causal relationship 
between the drug and AE). 
Unrelated to study drug will be assessed based on the following: 
 Does not follow a reasonable temporal sequence from administration of drug 
 Does not appear to worsen when the drug is re-administered 
 There is not a reasonable possibility that the drug caused the AE 
 An alternate etiology has been established, ie, the AE is more likely explained by another 
cause (eg, other study treatments or procedures, underlying medical conditions, 
concomitant medications, etc) than the study treatment 
Missing relationships will not be imputed. 
and drug-induced liver injury 
(DILI) cases will be assessed as adverse events of special interest (AESIs) and must be reported 
as serious adverse events. Information of abnormal laboratory test results including the course 
and evolvement, clinical signs and symptoms, detailed medical history and concurrent 
medication, history and current lifestyle including alcoholic assumption, and history of exposure 
to environmental chemical agents will be used to assess the case(s). 
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An overall summary of TEAEs using frequencies and percentages of subjects will be presented 
based on the following categories: 
 TEAEs 
 Study drug related TEAE 
 TEAE by worst severity 
 Serious TEAE 
 Study drug related serious TEAE 
 TEAEs leading to study drug withdrawal 
 TEAEs leading to study drug being on hold 
 TEAEs leading to death 
 AESIs 
The following events will be tabulated by SOC and PT. SOC will be sorted by descending 
frequency and then alphabetically for tie. Within each SOC, PT will also be sorted by descending 
frequency and then alphabetically for ties, by the overall number of subjects. If a SOC or PT is 
reported more than once for a subject, the subject will only be counted once in the incidence for 
that SOC or PT. 
 TEAEs 
 Study drug related TEAE 
 TEAE by worst severity 
 Serious TEAE 
 Study drug related serious TEAE 
 TEAEs leading to study drug withdrawal 
 TEAEs leading to study drug being on hold 
 TEAEs leading to death 
 AESIs 
Summaries of events by decreasing frequency of PT include: 
 TEAEs 
 Study drug related TEAE 
 Serious TEAE 
 Study drug related serious TEAE 
If a PT is reported more than once for a subject, the subject will only be counted once in the 
incidence for that PT. 
The following listings will be provided: 
 All AEs (flag TEAE) 
 Serious Aes (flag TEAE) 
 TEAEs leading to study drug withdrawal 
 TEAEs leading to study drug being on hold 
 TEAEs leading to death 
 AESIs 
 
 
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5.5.2. 
Clinical Laboratory Evaluation 
Blood chemistry, hematology, and urinalysis tests are listed in Table 3. 
Table 3. Clinical Laboratory Tests 
Blood Chemistry 
Hematology 
Urinalysis 
 
Alanine aminotransferase 
(ALT/SGPT) 
 
Alkaline phosphatase (ALP)
 
Aspartate aminotransferase 
(AST/SGOT) 
 
Bilirubin (direct and total) 
 
Blood urea nitrogen (BUN) 
 
Calcium 
 
Chloride 
 
Cholesterol (total) 
 
Creatine kinase (CK) 
 
Creatinine 
 
Glucose (serum) 
 
Phosphorus 
 
Potassium 
 
Protein (albumin and total) 
 
Sodium 
 
Hematocrit 
 
Hemoglobin 
 
MCH concentration (MCHC) 
 
Mean corpuscular hemoglobin 
(MCH) 
 
Mean corpuscular volume (MCV) 
 
Platelet count 
 
Red blood cell (RBC) count 
 
White blood cell (WBC) 
differential 
o Neutrophil count 
(absolute and %) 
o Lymphocyte count 
(absolute and %) 
o Monocyte count 
(absolute and %) 
o Eosinophil count 
(absolute and %) 
 
Basophil count 
(absolute and %) 
 
WBC count 
 
On-site macroscopic 
examination 
 
Central lab microscopic 
examination (in the 
event of protein, blood, 
nitrite and/or leukocyte 
esterase noted in 
macroscopic) 
 
Bilirubin 
 
Blood (occult and cells) 
 
Ketones 
 
Leukocytes 
 
Nitrite 
 
pH 
 
Protein 
 
Specific gravity 
 
Urobilinogen 
 
Actual value, change from baseline, and percentage change from baseline for continuous 
parameters (analytes) of blood chemistry and hematology tests will be summarized by visit and 
treatment group using descriptive statistics (mean, median, SD, minimum, maximum, and 
number of subjects). 
Baseline and post-baseline blood chemistry and hematology tests will be classified according to 
normal ranges as low, normal, and high. Shift of these tests from baseline to the maximum 
post-baseline values will be presented by treatment group using the number and percentage of 
subjects at each shift category. If applicable, some laboratory tests have two directions: hypo and 
hyper, where both directions will be presented in the shift table. 
Liver function tests will be summarized by the following: 
 Alkaline Phosphatase (ALP) 
o >1.5 × ULN 
o >2 × ULN 
o >3 × ULN 
 Alanine Aminotransferase (ALT) 
o >3 × ULN 
o >5 × ULN 
o >10 × ULN 
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 Aspartate Aminotransferase (AST) 
o >3 × ULN 
o >5 × ULN 
o >10 × ULN 
 
Total Bilirubin (TBL) 
o >1.5 × ULN 
o >2 × ULN 
o >3 × ULN 
ULN = upper limit of normal 
The risk difference between treatment arms vs placebo, and 95% confidence interval will be 
calculated. 
All laboratory values will be presented in data listings. 
All other laboratory tests, including urinalysis, thyroid, pregnancy, and urine drug screen, will be 
presented in a data listing only. 
5.5.3. 
Vital Signs 
Vital signs will include measurement of blood pressure (BP) and heart rate (HR): supine (after at 
least 5-min rest) and standing (after1-min and 3-min standing). 
Actual value of BP and HR, between supine and standing (after 1-min and 3-min standing) at 
each visit (timepoint if applicable) will be presented using descriptive statistics by treatment 
group. A figure with the mean (± SD) of vital sign parameters by visit will be displayed. 
Number of subjects with changes in HR (> 20 and > 30) will be presented at baseline and each 
post-baseline visit. The risk difference between treatment arms vs placebo, and 95% confidence 
interval will be calculated. 
A separate table with a decrease in systolic BP > 20 mmHg, or diastolic > 10 mmHg on standing 
from supine position will be presented at baseline and each post-baseline visit. The risk 
difference between treatment arms vs placebo, and 95% confidence interval will be calculated. 
Percentage of patients with maximum systolic BP by category of BP post-baseline (< 90,  90, 
 120,  140,  160, and  180) will be presented. 
Percentage of patients with maximum diastolic BP by category of BP post-baseline (< 60, > 60, 
> 90, > 110, and > 120) will be presented. 
All vital signs data will be presented in a data listing. 
5.5.4. 
DESS scale and C-SSRS data 
Discontinuation-Emergent Signs and Symptoms scale and C-SSRS data will be summarized by 
descriptive statistics at each visit and by treatment group unless otherwise specified. Change 
from baseline at each visit will be presented using descriptive statistics by treatment group for 
C-SSRS. Please see Section 3.8.6 for details on DESS. 
All DESS scale and C-SSRS data will be presented in a data listing. 
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5.5.5. 
12-Lead Electrocardiograms 
ECG parameters (Heart Rate, RR interval, QRS Duration, QT Interval, QTcF) will be assessed 
according to the schedule of assessments in Table 1 of the protocol. 
12-lead ECG recordings will be performed in triplicate (at approximately 1-min intervals 
between each of the three recordings) at baseline, and single ECG for rest of visits. 
0.33. 
Actual value, change from baseline, and percent change from baseline at each visit (timepoint if 
applicable) will be presented using descriptive statistics by treatment group. 
Shift of ECG overall interpretation from baseline to end of treatment visit will be prepared with 
number and percentage of subjects being reported with Normal, Abnormal, Abnormal Clinically 
Significant, and Not Done. 
The QTcF interval will be summarized by the frequencies of subjects with absolute value and/or 
change from baseline using the criteria identified below: 
 < 450 
 
 450 to < 480 
 
 480 to < 500 
 
 500 
 
<30 increases from baseline 
 30 to  60 increases from baseline 
 > 60 increases from baseline 
Subjects with abnormal ECG results, regardless of clinical significance, will be identified in data 
listings with flags for abnormalities. 
5.5.6. 
Physical and Neurological Exam 
Physical and Neurological exam data will be presented in a data listing. 
5.6. 
Exploratory Analysis 
5.6.1. 
Treatment Response in DGM4-Positive Patients 
 50% improvement from baseline in MADRS total score at 
Day 42 (Visit 7) in DGM4-positive patients. Response rate and corresponding 95% confidence 
interval for each treatment group will be derived by using Clopper-Pearson method 
(Clopper 1934). The comparison of response rate between treatment groups will be carried out 
using the CMH test. The percentage of subjects achieving response in MADRS by visit will be 
displayed in a bar chart. 
5.6.2. 
Remission in DGM4-Positive Patients 
Remission is 
 10 at Day 42 (Visit 7) in DGM4-positive patients. 
Remission rate will be analyzed using the same methodology as described in Section 5.6.1. The 
percentage of subjects with remission by visit will be displayed in a bar chart. 
QT corrected by Fridericia's formula is recommended: QTcF = QT/RR 
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5.6.3. 
Change in MADRS Anhedonia Subscale and Individual Items from Baseline to 
Day 42, in DGM4-Positive Patients 
Change in MADRS anhedonia subscale and individual items from baseline (Visit 3, Day -1) to 
Day 42 (Visit 7) will also be analyzed in an exploratory manner, using the MMRM model 
without imputation similar to the one used in sensitivity analysis (2) for the primary efficacy 
endpoint described in Section 5.4.1.3. Anhedonia score is the sum of MADRS items 1 (reported 
sadness), 2 (apparent sadness), 6 (concentration difficulties), 7 (lassitude), and 8 (inability to 
feel). 
5.6.4. 
Change in MADRS Total Score from Baseline to Day 42, in DGM4-Negative 
Patients 
The change in MADRS total score from baseline to Day 42 (Visit 7) in DGM4-negative patients 
will be summarized using descriptive statistics. 
5.6.5. 
Change in MADRS Total Score from Baseline to Day 42 in Liafensine 1 mg QD 
Group and 2 mg QD Group, in both DGM4-Positive and DGM4-Negative 
Patients 
The change in MADRS total score from baseline to Day 42 (Visit 7) in liafensine 1 mg and 
2 mg QD groups in both DGM4-positive and DGM4-negative patients will be analyzed using 
descriptive statistics. The treatment effects between the DGM4-positive and negative patients 
will be compared primarily in descriptive fashion to examine the trend and may be evaluated by 
including the interaction of DGM4 status and treatment group in the mixed model. 
5.7. 
Pharmacokinetics 
5.7.1. 
Plasma Concentrations 
Plasma concentrations of liafensine and its major metabolite 821007 will be listed by subject and 
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6. 
CHANGES FROM ANALYSES PLANNED IN THE PROTOCOL 
Changes from the protocol-specified analyses are listed in Table 4. 
Table 4. Changes from Protocol-Specified Analyses 
Protocol 
SAP 
Justification 
Section 8.3.3.1: The family-
wise type I error rate will be 
controlled at a fixed 1-sided 
alpha level of 0.025 using a 
closed testing procedure for 
multiple dose comparisons and 
multiple endpoint comparisons 
in DGM4-positive patients. 
Section 3.7: All statistical tests 
for the treatment comparison of 
efficacy endpoints will be based 
on a 1-sided alpha level of 0.05. 
In this Phase 2b study, the 
sample size was not powered for 
testing superiority with 
multiplicity adjustment for each 
dose. 
Section 8.3.3: The primary 
efficacy analysis will be 
performed in DGM4-positive 
patients at 2-sided significance 
level of 0.05 using a mixed 
model for repeated measures 
(MMRM) that includes the 
fixed effects of treatment, visit 
(categorical covariate), 
treatment-by-visit interaction, 
baseline MADRS total score 
(continuous covariate), and 
region. 
Section 5.4.1.2: The primary 
method will be mixed model for 
repeated measures (MMRM) 
with imputation assuming 
missing at random (MAR), ie, a 
hypothetical strategy per ICH 
E9(R1). Hence, missing values 
will be imputed with non-
missing values in the same 
treatment group. A fully 
conditional specification and 
predictive mean matching 
method will be used in the 
imputation. 
The following variables will be 
included in the imputation 
model: region, baseline MADRS 
score, and change from baseline 
at Weeks 1, 2, 4, and 6.  
One hundred fully imputed 
datasets will be created. The 
MMRM described in Section 
5.4.1.2 will be used for treatment 
comparisons. Treatment effects 
(difference in LS means between 
treatment arms) from these 100 
analyses will be combined to 
generate the final results using 
MIANALYZE procedure. 
 With multiple imputation, all 
subjects in the full analysis set 
will have a value at the 
primary time point, ie, Day 42, 
for treatment comparisons. 
 Since the original method in 
the protocol assumes missing 
at random, the same 
assumption will be used in 
multiple imputation. 
 This method allows for 
performing a tipping point 
analysis to assess the 
robustness of the results under 
the MAR assumption. 
 
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7. 
REFERENCES 
Buuren SV. Multiple imputation of discrete and continuous data by fully conditional 
specification. Stat Methods Med Res. 2007;16(3):219 242. 
Clopper CJ, Pearson ES. The use of confidence or fiducial limits illustrated in the case of the 
binomial. Biometrika. 1934;26(4):404 413. 
Guy W. ECDEU Assessment Manual for Psychopharmacology. US Dept. of Health, Education 
and Welfare, ADAMHA, NIMH Psychopharmacology Research Branch, 1976. 
ICH E3(R1). Structure and Content of Clinical Study Reports - Questions and Answers. FDA 
Guidance for Industry. 2013. 
ICH E9(R1). Statistical Principles for Clinical Trials: Addendum: Estimands and Sensitivity 
Analysis in Clinical Trials. FDA Guidance for Industry. 2021. 
Lu K, Mehrotra D. Specification of covariance structure in longitudinal data analysis for 
randomized clinical trials. Stat Med. 2010;29(4):474-488. 
Marcus R, Peritz E, Gabriel KR. On closed testing procedures with special reference to ordered 
analysis of variance. Biometrika. 1976;63(3):655-660. 
Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. British 
Journal of Psychiatry. 1979;134:382-389. 
Polverejan E
y M, Hefting N, et al. Defining clinical trial estimands: a practical guide for 
study teams with examples based on a psychiatric disorder. Ther Innov Regul Sci. 
2023;57(5):911-939. 
Posner K, Brown GK, Stanley B, et al. The Columbia suicide severity rating scale: initial 
validity and internal consistency findings from three multisite studies with adolescents and 
adults. Am J Psychiatry. 2011;168(12):1266 1277. 
statistical analysis using pattern mixture models. Pharmaceutical Statistics. 2013;12(6):337 347. 
Rosenbaum JF, Fava M, Hoog SL, et al. Selective serotonin reuptake inhibitor discontinuation 
syndrome: a randomized clinical trial. Biological Psychiatry. 1998;44(2):77-87. 
SAS Institute Inc. (2001): Base SAS® 9.4 Utilities: Reference. Cary, NC. SAS Institute Inc. 
Sheehan KH, Sheehan DV. Assessing treatment effects in clinical trials with the discan metric of 
the Sheehan Disability Scale. International Clinical Psychopharmacology. 2008;23(2):70-83. 
 
 
, O'Kell 
Ratitch B, O'Kelly M, Tosiello R. Missing data in clinical trials: from clinical assumptions to 


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8. 
APPENDIX: SAMPLE SAS CODES 
The sample SAS codes provided in this section are for reference only. The actual SAS codes to 
generate the tables will be checked through QC process. For sensitivity analyses using RAS, use 
the dataset flag for RAS and exclude GPN*base, ie, treatment-by-baseline-score interaction, in 
the model statement in Proc Mixed. 
8.1. 
SAS Code for Multiple Imputations Based on the Non-missing 
Values in the Same Arm with FCS and REGPMM Options 
%let nimpute=100; 
%let seed=10401; 
proc sort data=adqs4 out=adqs5 ; 
 where avisitn in (40 50 60 70) and dgmn=1 and gpn^=3;  
 by trt01pn usubjid dgmn gpn region base avisitn; 
run; 
proc transpose data=adqs5 out=cfb; 
  by GPN usubjid dgmn  region base; 
  var chg; 
  id avisitn; 
run; 
*** Imputation using fully conditional specification and predictive mean matching methods; 
proc mi data=cfb(rename=(_40=cfb1 _50=cfb2 _60=cfb4 _70=cfb6))  nimpute=&nimpute 
seed=&seed out=fcs; 
   by GPN; 
   class region; 
   var region base cfb1 cfb2 cfb4 cfb6; 
   FCS REGPMM; 
run; 
8.2. 
SAS Code for Treatment Comparisons in MMRM 
Note: The SAS code below is for MMRM after multiple imputations. For MMRM without 
 
%let alpha=0.10; 
data fcs2; 
 set fcs; 
 avisitn=40; CHG=cfb1; output; 
 avisitn=50; CHG=cfb2; output; 
 avisitn=60; CHG=cfb4; output; 
 avisitn=70; CHG=cfb6; output; 
proc sort data=fcs2; 
 by _imputation_; 
run; 
proc mixed data=fcs2; 
 by _imputation_; 
 class GPN avisitn region usubjid; 
imputations, use the same code for data before imputation without "by _imputation_". 


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model CHG=GPN base AVISITN   GPN*AVISITN  GPN*base region/alpha=&alpha 
DDFM = KR; 
    repeated AVISITN/sub=usubjid type=UN; 
*** contrasts for treatment comparisons; 
 
lsmestimate GPN*AVISITN 'LSMean Active Pooled Visit 40' 0.5 0 0 0  0.5 0 0 0  0 0 0 
0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'LSMean Liafensine 1 mg QD Visit 40' 1 0 0 0  0 0 0 0  0 0 
0 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'LSMean Liafensine 2 mg QD Visit 40' 0 0 0 0  1 0 0 0  0 0 
0 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'LSMean Liafensine Placebo Visit 40' 0 0 0 0  0 0 0 0  1 0 0 
0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'Liafensine 1 mg QD vs. placebo Visit 40' 1 0 0 0  0 0 0 0  -
1 0 0 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'Liafensine 2 mg QD vs. placebo Visit 40' 0 0 0 0  1 0 0 0  -
1 0 0 0/CL alpha=&alpha; 
 
lsmestimate GPN*AVISITN 'Active Pooled vs. placebo Visit 40' 0.5 0 0 0  0.5 0 0 0  -1 0 
0 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'LSMean Active Pooled Visit 50' 0 0.5 0 0  0 0.5 0 0  0 0 0 
0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'LSMean Liafensine 1 mg QD Visit 50' 0 1 0 0  0 0 0 0  0 0 
0 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'LSMean Liafensine 2 mg QD Visit 50' 0 0 0 0  0 1 0 0  0 0 
0 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'LSMean Liafensine Placebo Visit 50' 0 0 0 0  0 0 0 0  0 1 0 
0/CL alpha=&alpha; 
 
lsmestimate GPN*AVISITN 'Liafensine 1 mg QD vs. placebo Visit 50' 0 1 0 0  0 0 0 0  0 
-1 0 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'Liafensine 2 mg QD vs. placebo Visit 50' 0 0 0 0  0 1 0 0  0 
-1 0 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'Active Pooled vs. placebo Visit 50' 0 0.5 0 0  0 0.5 0 0  0 -1 
0 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'LSMean Active Pooled Visit 60' 0 0 0.5 0  0 0 0.5 0  0 0 0 
0/CL alpha=&alpha; 
 
lsmestimate GPN*AVISITN 'LSMean Liafensine 1 mg QD Visit 60' 0 0 1 0  0 0 0 0  0 0 
0 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'LSMean Liafensine 2 mg QD Visit 60' 0 0 0 0  0 0 1 0  0 0 
0 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'LSMean Liafensine Placebo Visit 60' 0 0 0 0  0 0 0 0  0 0 1 
0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'Liafensine 1 mg QD vs. placebo Visit 60' 0 0 1 0  0 0 0 0  0 
0 -1 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'Liafensine 2 mg QD vs. placebo Visit 60' 0 0 0 0  0 0 1 0  0 
0 -1 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'Active Pooled vs. placebo Visit 60' 0 0 0.5 0  0 0 0.5 0  0 0 
-1 0/CL alpha=&alpha; 


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lsmestimate GPN*AVISITN 'LSMean Active Pooled Visit 70' 0 0 0 0.5  0 0 0 0.5  0 0 0 
0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'LSMean Liafensine 1 mg QD Visit 70' 0 0 0 1  0 0 0 0  0 0 
0 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'LSMean Liafensine 2 mg QD Visit 70' 0 0 0 0  0 0 0 1  0 0 
0 0/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'LSMean Liafensine Placebo Visit 70' 0 0 0 0  0 0 0 0  0 0 0 
1/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'Liafensine 1 mg QD vs. placebo Visit 70' 0 0 0 1  0 0 0 0  0 
0 0 -1/CL alpha=&alpha;  
 
lsmestimate GPN*AVISITN 'Liafensine 2 mg QD vs. placebo Visit 70' 0 0 0 0  0 0 0 1  0 
0 0 -1/CL alpha=&alpha; 
 
lsmestimate GPN*AVISITN 'Active Pooled vs. placebo Visit 70' 0 0 0 0.5  0 0 0 0.5  0 0 
0 -1/CL alpha=&alpha;  
  lsmeans GPN*avisitn/CL alpha=&alpha pdiff; 
  ods output diffs=diffs1 lsmeans=lsmean1 tests3=tests3 convergenceStatus=convg 
LSMEstimates=LSM; 
run; 
8.3. 
SAS Code for Summarizing Treatment Comparison Results from 
Multiple Imputations Using Proc MIANALYZE 
*** Analysis result from imputation and MIANALYZE - for CSR table; 
%let alpha=0.10; 
proc sort data=lsm; 
 by label _imputation_; 
run; 
proc mianalyze data=lsm alpha=&alpha; 
  by label ; 
   modeleffects ESTIMATE; 
   stderr stderr; 
    ods output ParameterEstimates=PARA; 
run; 
8.4. 
SAS Code for Imputation Using Non-missing Values in the Control 
Arm 
proc sort data=adqs4 out=adqs5 ; 
 where avisitn in (40 50 60 70) and dgmn=1 and gpn^=3;  
 by trt01pn usubjid dgmn gpn region base avisitn; 
run; 
proc transpose data=adqs5 out=cfb; 
  by GPN usubjid dgmn  region base; 
  var chg; 
  id avisitn; 
run; 


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*** Pattern-Mixture imputation using fully conditional specification and predictive mean 
matching methods; 
proc mi data=cfb(rename=(_40=cfb1 _50=cfb2 _60=cfb4 _70=cfb6))  nimpute=&nimpute 
seed=&seed out=fcs; 
   class gpn region; 
   FCS REGPMM; 
   mnar model(cfb1 cfb2 cfb4 cfb6/modelobs=(gpn='4')); 
 
   var region base cfb1 cfb2 cfb4 cfb6; 
run; 
data fcs2; 
 set fcs; 
 avisitn=40; CHG=cfb1; output; 
 avisitn=50; CHG=cfb2; output; 
 avisitn=60; CHG=cfb4; output; 
 avisitn=70; CHG=cfb6; output; 
proc sort data=fcs2; 
 by _imputation_; 
run; 
8.5. 
SAS Code for Imputation Using Non-missing Values in the Control 
Arm or the Same Arm per Intercurrent Events 
The SAS code will follow the algorithm below. 
1) Pool subjects who terminated early due to AE in all 3 arms and subjects in the placebo 
arm. This dataset will also include placebo subjects with missing values due to 
withdrawal of consent to treatment, other/lost to follow-up, or pregnancy, but will 
exclude early terminators due to death.  
2) For the pooled datasets in 1), use sample SAS code below to impute missing values based 
on non-missing values in the place arm to create 100 datasets.  
proc mi data=cfb0(rename=(_40=cfb1 _50=cfb2 _60=cfb4 _70=cfb6))  
nimpute=&nimpute seed=&seed out=ras0; 
   class gpn region; 
   FCS REGPMM; 
   mnar model(cfb1 cfb2 cfb4 cfb6/modelobs=(gpn='4')); 
 
3) Select subjects in the 1 mg group by excluding early terminators due to AE or death. This 
dataset will include subjects without missing values and subjects with missing values due 
to withdrawal of consent to treatment, other/lost to follow-up, or pregnancy. 
4) For the datasets in 3), use sample SAS code below to impute missing values based on 
non-missing values in the same arm to create 100 datasets.  
proc mi data=cfb1(rename=(_40=cfb1 _50=cfb2 _60=cfb4 _70=cfb6))  
nimpute=&nimpute seed=&seed out=ras1; 
   class nonm region;  
*** gpn='4': control arm; 
*** gpn='4': control arm; 


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   FCS REGPMM; 
   mnar model(cfb1 cfb2 cfb4 cfb6/modelobs=(nonm='1')); 
***Variable nonm=1: completers;  
   var region base cfb1 cfb2 cfb4 cfb6; 
run; 
5) Repeat steps 3) and 4) for the 2 mg group and name the imputed datasets as ras2. 
6) One death with unknown reason and un-determined relationship to study drug occurred in 
this study. Missing data prior to death will be imputed based on the worst score from this 
subject, and data after death will not be imputed. Multiple imputations will be carried out 
using a normal random variable with mean equal to the worst score in the schedule visits 
of this subject, and variance equal to the observed variance from the same treatment arm 
at the same visit. 
missing data, where W is the worst change from baseline value of this subject and SD is 
the standard deviation for the visit from the same arm.   
call streaminit(10401); 
   do i=1 to 100; 
      cfb= 
 
      output;  
   end; 
Name the imputed dataset for this subject as ras3. 
7) Pool datasets ras0, ras1, ras2, and ras3 together, sort by imputation number, and perform 
treatment comparisons using sample SAS code in Section 8.2. 
8) Use sample SAS code in Section 8.3 to summarize and finalize the treatment comparison 
results. 
8.6. 
SAS Code for Imputation Pertaining to Use of Prohibited 
Medications 
In Sensitivity analysis 3 in Section 5.4.1.3, data collected after initiation of prohibited 
medications will not be used. They will be imputed using non-missing values in the placebo arm. 
SAS code in Section 8.4 will be used. 
In Sensitivity analysis 4 in Section 5.4.1.3, data after initiation of prohibited medication will be 
imputed with non-missing data in the same arm while the subject is on study medication. If the 
subject terminates study medication early after initiation of prohibited medication, missing data 
after treatment termination will be imputed according to the cause of termination. Two scenarios 
may occur as follows: 
1) The subject initiated prohibited medication and completed the treatment period. 
Imputation of data after initiation of prohibited medication will be the same as imputing 
missing data in Group 2 in Sensitivity analysis 4, and the SAS code in Section 8.5 will be 
applied. 
SAS function RAND('NORMAL', W, SD) will be used to generate 100 values for each 
RAND('NORMAL', W, SD) 


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2) The subject initiated prohibited medication and terminated the treatment early. If the 
cause of termination is in Group 2 in Sensitivity analysis 4, the imputation will be same 
as in 1). If the reason for termination is in Groups 1 or 3, the following steps will be 
followed. 
a. Impute data after initiation of prohibited medication as in 1). 
b. Set imputed data after termination as missing. 
c. If the cause of termination is death, impute data using the method stated in 6) in 
Section 8.5. 
d. If early termination is due to AE, perform a second set of imputation for data after 
early termination based on non-missing data in the placebo arm.  
8.7. 
SAS Code for Tipping Point Analysis 
The SAS code will follow the algorithm below. 
1) Impute missing values per SAP to create 100 datasets. 
2) In each dataset, create a variable MIFL (imputation flag) to indicate whether a data point 
was imputed or not. 
3) Increase or decrease each imputed value per macro parameter for each arm. 
4) For each dataset, perform treatment comparisons using LSMESTIMATE statements in 
Proc Mixed. 
5) Use Proc MIANALYZE to summarize the final result from the analysis of the 100 
datasets. 
%macro Tipping(indata=, cfb=, gp1=, gp2, gp4=, outdata=); 
*** Indata=input dataset from steps 1) and 2) above. For each imputed dataset, the data structure 
should be one observation per subject per visit. 
 
Cfb=variable name for change from baseline value 
 
gp1=imputed data to be shifted in the 2 mg arm 
 
gp2=imputed data to be shifted in the 1 mg arm 
 
gp4=imputed data to be shifted in the placebo arm 
 
outdata=output dataset for the final result from Proc MIANALYZE; 
data a; 
 set &indata; 
 
do; 
 
if GPN=1 then &cfb=&cfb + (&gp1); 
 
else if GPN=2 then &cfb=&cfb + (&gp2); 
 
else if GPN=4 then &cfb=&cfb + (&gp4); 
end; 
*** Include SAS code in Section 8.2 to perform treatment comparisons. 
*** Include SAS code in Section 8.3 to use Proc MIANALYZE to summarize the final result 
from the analysis of the 100 datasets and output the final result to dataset &outdata. 
%mend; 
if MIFL='Y' then 


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8.8. 
SAS Code for Stratified CMH Test 
*** CMH test for pooled analysis stratified by region; 
*** gpn=3: both active arms pooled, gpn=4: placebo arm; 
*** For 1 mg vs. placebo and 2 mg vs. placebo, replace 3 with 1 and 2, respectively.; 
proc freq data=adqs4(where=(gpn in (3 4) and dgmn=3 and avisitn=70)); 
  table region*GPN*aval / CMH ALPHA=0.10;  
run;