Conditions: Depressive Disorder Anhedonia
Keywords: depression anhedonia reward
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 45
Healthy volunteers: no

Brief summary:
This project is designed to examine the neuronal KCNQ2/3 potassium (K+) channel subtype as a novel treatment target for mood disorders through the administration of the KCNQ-selective channel opener ezogabine (Potiga, GlaxoSmithKline; FDA-approved for the treatment of seizure disorders).

Detailed description:
Depressive disorders are among the most disabling medical conditions worldwide and currently available treatments fall short of addressing this large public health burden. Dysfunction within the brain reward system is emerging as a core feature of depressive disorders, in particular related to deficits in motivation, interest, and response to pleasure (e.g., anhedonia: markedly diminished response to pleasure). Evidences from a series of preclinical studies from our group highlighted the KCNQ subtype of neuronal potassium (K+) channel as a novel target for the treatment of depressive disorders and our human pilot study showed a reduction in anhedonia and related symptoms, and an increased brain response to reward (as measured by functional magnetic resonance imaging \[fMRI\]) following treatment with ezogabine. Building on this data, the current project will assess reward circuit activity following treatment with ezogabine in depressed patients with a current depressive disorder (Major depressive disorder \[MDD\], persistent depressive disorder, other specified depressive disorder) and anhedonia (defined by a score ≥ 20 on the Snaith-Hamilton Pleasure Scale \[SHAPS\]), using fMRI to investigate the cortico-striatal circuit to reward.

This study represents the first part of the R61/R33 National Institutes of Health (NIH) founded project. A clear increase in reward circuit activation in at least one ezogabine treatment group compared to placebo, given acceptable tolerability, will constitute a "go" and the project will move to the next phase (R33), where we aim to examine the relationship between treatment, reward circuit activity, and behavioral and clinical outcomes in a larger, confirmatory efficacy trial of ezogabine for depression with anhedonia.

Arms:
arm 1: Participants will receive treatment with ezogabine up to 900mg/day. arm 2: Participants will receive treatment with a matching placebo pill.

Interventions: intervention 1: Ezogabine intervention 2: Placebos
Intervention descriptions: intervention 1: daily for 5 weeks intervention 2: placebo pill daily for 5 weeks

Protocol document:
Prot_001.pdf: 
Developing Neuronal KCNQ Channel Modulators for Mood Disorders 
PI: Dr. James Murrough 
NCT03043560 
Document Date: 6/12/2019


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SPONSOR: JAMES W. MURROUGH, MD 
 
INSTITUTION: ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI (ISMMS) 
 
Clinical Trial Protocol 
 
DEVELOPING NEURONAL KCNQ CHANNEL MODULATORS FOR MOOD DISORDERS 
 
 
Protocol Number: 
EZOR61-01 
Version #: 
2.4 
Version Date: 
6/12/2019 
Investigational Product: 
Ezogabine (Potiga, GlaxoSmithKline) 
IND Number: 
Exempt  
Development Phase: 
Phase IIa 
Sponsor: 
James W. Murrough, MD, PhD 
Assistant Professor of Psychiatry and Neuroscience 
Icahn School of Medicine at Mount Sinai 
1 Gustave L. Levy Place, Box 1230 
New York, New York 10029 
Telephone: 212-585-4640  
Funding Organization: 
National Institutes of Health (NIH)/ 
National Institute of Mental Health (NIMH) 
Principal Investigator: 
James W. Murrough, MD 
 
Assistant Professor of Psychiatry and Neuroscience 
Icahn School of Medicine at Mount Sinai 
1 Gustave L. Levy Place, Box 1230 
New York, New York 10029 
Telephone: 212-585-4640 
Fax: 212-241-3354 
E-mail: james.murrough@mssm.edu 
 
Medical Monitor: 
Dan V. Iosifescu, M.D., M.Sc. 
Associate Professor of Psychiatry 
NYU School of Medicine 
 
New York, NY 10016 
Phone 646-754-5156 
Fax 212-263-7460 
Dan.Iosifescu@nyumc.org 
 
 
Coordinating Center: 
Icahn School of Medicine at Mount Sinai 
1 Gustave L. Levy Place, Box 1230 
New York, New York 10029 
Participating site(s) 
Baylor College of Medicine  
Mood & Anxiety Disorders Program, Psychiatry  
PI: Sanjay Mathew, MD 


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Approval: 
 
 
 
 
PI or Sponsor Signature (Name and Title)  
 
 
Date 
This confidential information about an investigational product is provided for the exclusive use of 
investigators of this product and is subject to recall at any time.  The information in this document may 
not be disclosed unless federal or state law or regulations require such disclosure.  Subject to the 
foregoing, this information may be disclosed only to those persons involved in the study who have a 
need to know, with the obligation not to further disseminate this information 


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PROTOCOL AGREEMENT 
 
I have read the protocol specified below. In my formal capacity as Investigator, my duties 
include ensuring the safety of the study subjects enrolled under my supervision and 
providing the Sponsor (Dr. James Murrough, MD) with complete and timely information, as 
outlined in the protocol. It is understood that all information pertaining to the study will be 
held strictly confidential and that this confidentiality requirement applies to all study staff 
at this site. Furthermore, on behalf of the study staff and myself, I agree to maintain the 
procedures required to carry out the study in accordance with accepted GCP principles and 
to abide by the terms of this protocol. 
 
Protocol Number: EZOR61-01 
Protocol Title: DEVELOPING NEURONAL KCNQ CHANNEL MODULATORS FOR MOOD 
DISORDERS  
 
Protocol Date: 9/28/2018 
 
 
 
 
 
 
 
Investigator Signature 
 
 
 
 
 
Date 
 
 
 
 
Print Name and Title 
 
Site # 
 
Site Name 
 
Address 
 
 
 
 
 
 
 
Phone number 
 
 


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TABLE OF CONTENTS 
1 
BACKGROUND ................................................................................................................................ 10 
1.1 
OVERVIEW OF NON-CLINICAL STUDIES ....................................................................................................... 10 
1.2 
OVERVIEW OF CLINICAL STUDIES ............................................................................................................... 10 
2 
STUDY RATIONALE ......................................................................................................................... 11 
2.1 
RISK / BENEFIT ASSESSMENT .................................................................................................................... 12 
3 
STUDY OBJECTIVES ......................................................................................................................... 15 
3.1 
PRIMARY OBJECTIVE ............................................................................................................................... 15 
3.2 
SECONDARY OBJECTIVES .......................................................................................................................... 16 
4 
STUDY DESIGN ................................................................................................................................ 16 
4.1 
STUDY OVERVIEW .................................................................................................................................. 16 
5 
CRITERIA FOR EVALUATION ............................................................................................................ 17 
5.1 
PRIMARY EFFICACY ENDPOINT .................................................................................................................. 17 
5.2 
SECONDARY EFFICACY ENDPOINTS ............................................................................................................. 17 
5.3 
SAFETY EVALUATIONS .............................................................................................................................. 18 
5.4 
OTHER EVALUATIONS .............................................................................................................................. 19 
6 
SUBJECT SELECTION ........................................................................................................................ 20 
6.1 
STUDY POPULATION ................................................................................................................................ 20 
6.2 
INCLUSION CRITERIA ............................................................................................................................... 20 
6.3 
EXCLUSION CRITERIA ............................................................................................................................... 20 
7 
CONCURRENT MEDICATIONS .......................................................................................................... 22 
7.1 
ALLOWED MEDICATIONS AND TREATMENTS ................................................................................................ 22 
7.2 
PROHIBITED MEDICATIONS AND TREATMENTS .............................................................................................. 22 
8 
STUDY TREATMENTS ...................................................................................................................... 22 
8.1 
METHOD OF ASSIGNING SUBJECTS TO TREATMENT GROUPS ........................................................................... 23 
8.2 
BLINDING .............................................................................................................................................. 22 
8.3 
TEST AND CONTROL FORMULATION ........................................................................................................... 23 
8.4 
SUPPLY OF STUDY MEDICATION AT THE SITE ................................................................................................ 24 
8.5 
STUDY MEDICATION ACCOUNTABILITY ........................................................................................................ 25 
8.6 
MEASURES OF TREATMENT COMPLIANCE .................................................................................................... 25 
9 
STUDY PROCEDURES AND GUIDELINES ........................................................................................... 26 
9.1 
CLINICAL ASSESSMENTS ........................................................................................................................... 26 
9.2 
CLINICAL LABORATORY MEASUREMENTS ..................................................................................................... 33 
9.3 
PHARMACOKINETICS MEASUREMENTS ........................................................................................................ 33 
10 
EVALUATIONS BY VISIT ................................................................................................................... 33 
10.1 
SCREENING VISIT (VISIT -1) ................................................................................................................. 33 
10.2 
BASELINE (VISIT 0) ............................................................................................................................. 35 
10.3 
DOUBLE BLIND TREATMENT PERIOD (VISITS 1 – 49) ................................................................................ 35 
10.4 
PRIMARY OUTCOME VISIT (VISIT 5) ....................................................................................................... 36 
10.5 
TAPER PERIOD (PHONE CALLS* 1-2) ..................................................................................................... 37 
10.6 
STUDY EXIT VISIT (VISIT 6) AND EARLY WITHDRAWAL ................................................................................ 39 
11 
ADVERSE EXPERIENCE REPORTING AND DOCUMENTATION ............................................................ 39 


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11.1 
ADVERSE EVENT ................................................................................................................................ 40 
11.2 
SERIOUS ADVERSE EVENTS (SAE) ......................................................................................................... 41 
11.3 
UNANTICIPATED PROBLEMS (UP) ......................................................................................................... 44 
11.4 
MEDICAL MONITORING ...................................................................................................................... 45 
12 
DISCONTINUATION AND REPLACEMENT OF SUBJECTS .................................................................... 46 
12.1 
EARLY DISCONTINUATION OF STUDY DRUG ............................................................................................. 46 
12.2 
WITHDRAWAL OF SUBJECTS FROM THE STUDY ......................................................................................... 46 
12.3 
REPLACEMENT OF SUBJECTS ................................................................................................................. 47 
13 
PROTOCOL DEVIATIONS ................................................................................................................. 47 
14 
DATA SAFETY MONITORING PLAN .................................................................................................. 48 
15 
CLINICAL MONITORING .................................................................................................................. 49 
16 
STATISTICAL METHODS AND CONSIDERATIONS .............................................................................. 50 
16.1 
DATA SET ANALYZED ........................................................................................................................... 50 
16.2 
DEMOGRAPHIC AND BASELINE CHARACTERISTICS ..................................................................................... 50 
16.3 
ANALYSIS OF PRIMARY ENDPOINT ......................................................................................................... 50 
16.4 
ANALYSIS OF SECONDARY ENDPOINT ..................................................................................................... 51 
16.5 
INTERIM ANALYSIS ............................................................................................................................. 51 
16.6 
SAMPLE SIZE AND RANDOMIZATION ...................................................................................................... 51 
17 
DATA COLLECTION, RETENTION AND MONITORING ....................................................................... 51 
17.1 
DATA COLLECTION INSTRUMENTS ......................................................................................................... 51 
17.2 
DATA MANAGEMENT PROCEDURES ....................................................................................................... 52 
17.3 
DATA QUALITY CONTROL AND REPORTING ............................................................................................. 52 
17.4 
ARCHIVAL OF DATA ............................................................................................................................ 53 
17.5 
AVAILABILITY AND RETENTION OF INVESTIGATIONAL RECORDS .................................................................... 53 
17.6 
SUBJECT CONFIDENTIALITY .................................................................................................................. 53 
18 
ADMINISTRATIVE, ETHICAL, REGULATORY CONSIDERATIONS ......................................................... 53 
18.1 
PROTOCOL AMENDMENTS ................................................................................................................... 54 
18.2 
INSTITUTIONAL REVIEW BOARDS AND INDEPENDENT ETHICS COMMITTEES .................................................... 54 
18.3 
INFORMED CONSENT FORM ................................................................................................................. 54 
18.4 
PUBLICATIONS AND DATA SHARING ....................................................................................................... 55 
18.5 
CONFLICT OF INTEREST ....................................................................................................................... 56 
18.6 
INVESTIGATOR RESPONSIBILITIES ........................................................................................................... 56 
19 
REFERENCES ................................................................................................................................... 58 
20 
APPENDIX ....................................................................................................................................... 63 
TABLE 1. LIST OF PROHIBITED MEDICATIONS ......................................................................................................... 63 
TABLE 2: SCHEDULE OF ASSESSMENTS, OUTCOME MEASURES, LABS, AND PROCEDURE ................................................. 65 
MAGNETIC RESONANCE IMAGING (MRI) PROCEDURES APPENDIX ............................................................................. 66 
 


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List of Abbreviations 
 
ACC 
Anterior cingulate cortex 
AE 
Adverse Event 
CFR 
Code of Federal Regulations 
CTOBB 
Clinical Trials Operations and Biostatistics Branch 
CNS 
Central Nervous System 
CRF 
Case Report Form 
CRP 
C-reactive protein 
DMC 
Data Monitoring Committee 
DS 
Dorsal Striatum 
DSMB 
Data Safety Monitoring Board 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act of 1996 
fMRI 
functional Magnetic Resonance Imaging 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IFT 
Incentive Flanker Task 
IRB 
Institutional Review Board 
MDD 
Major Depressive Disorder 
MID 
Monetary Incentive Delay  
mPFC 
Medial Prefrontal Cortex 
MRI 
Magnetic Resonance Imaging 
NAc 
Nucleus Accumbens 
NIH 
National Institutes of Health  
NIMH 
National Institute of Mental Health 
PI 
Principal Investigator 
PK 
Pharmacokinetic 
SAE 
Serious Adverse Event 
VS 
Ventral Striatum 
WHODAS 
WHO Disability Assessment Schedule 
WHO 
World Health Organization 


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PROTOCOL SYNOPSIS 
TITLE 
Developing Neuronal KCNQ Channel Modulators for Mood 
Disorders 
SPONSOR 
James W. Murrough, MD 
FUNDING 
ORGANIZATION 
National Institutes of Health (NIH) 
National Institute of Mental Health (NIMH) 
NUMBER OF SITES 
2 
RATIONALE 
Depressive disorders are among the most disabling medical conditions 
worldwide and currently available treatments fall short of addressing 
this large public health burden. Dysfunction within the brain reward 
system is emerging as a core feature of depressive disorders, in 
particular related to deficits in motivation, interest, and response to 
pleasure (e.g., anhedonia: markedly diminished response to pleasure). 
Evidences from a series of preclinical studies highlighted the KCNQ 
subtype of neuronal potassium (K+) channel as a novel target for the 
treatment of depressive disorders and data from human pilot study 
showed a reduction in anhedonia and related symptoms, with an 
increased brain response to reward (as measured by functional 
magnetic resonance imaging [fMRI]) following treatment with 
ezogabine, a KCNQ channel opener. Building on these data, the 
current project will assess reward circuit activity following treatment 
with ezogabine in depressed patients with anhedonia, and will 
examine the relationship between change in reward circuit activity 
and clinically relevant symptom and behavior outcomes.  
STUDY DESIGN 
This is a phase IIa, randomized, parallel arm, placebo-controlled 
clinical trial. 
PRIMARY OBJECTIVE 
To establish target engagement of a KCNQ channel opener (ezogabine) 
in patients with depressive disorder and anhedonia 
SECONDARY OBJECTIVES 
To determine if treatment with ezogabine is associated with a 
reduction in clinical symptoms of depression and anhedonia, and 
modulation of behavioral responses to reward. 
NUMBER OF SUBJECTS 
48 randomized across both sites (n=24 in each treatment group) 
SUBJECT SELECTION 
CRITERIA 
(ABBREVIATED) 
Inclusion Criteria: Participants will be aged 18-65 years, with clinically 
significant anhedonia (Snaith-Hamilton Pleasure Scale [SHAPS] ≥ 20) 
and a current diagnosis of depressive disorder (Major depressive 
disorder [MDD], persistent depressive disorder, other specified 
depressive disorder) according to DSM-5 and at least moderate 
current illness severity at least moderate (Clinical Global Impression–
Severity [CGI-S] Scale ≥ 4).  
Exclusion Criteria: A primary psychiatric diagnosis other than a 
depressive disorder as defined by DSM-5, neurocognitive disorder, 
substance use disorder within the past 6 months, contraindication to 


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MRI, history of retinal abnormalities, and any unstable medication 
condition or any other condition that is contraindicated for treatment 
with ezogabine according to the FDA. 
TEST PRODUCT, DOSE, 
AND ROUTE OF 
ADMINISTRATION 
Ezogabine at 900 mg daily. 
Product will be administered orally according to FDA recommended 
titration and taper schedule.  
CONTROL PRODUCT, 
DOSE AND ROUTE OF 
ADMINISTRATION 
The placebo product used in this study will be manufactured according 
to GMP and will contain inert substances. Product will be administered 
orally. 
DURATION OF SUBJECT 
PARTICIPATION AND 
DURATION OF STUDY 
Subjects will be on study for up to 14 weeks 
Screening:  up to 6 weeks 
Titration and Treatment Period: 5 weeks  
Taper Period: 3 weeks 
The total duration of the study is expected to be 24 months.  
CONCOMMITANT 
MEDICATIONS 
See Table 1 for protocol prohibited medications 
EFFICACY EVALUATIONS 
 
PRIMARY ENDPOINT 
Change in activation within the reward circuit (VS/mPFC) from Visit 
0 (baseline) to Study Visit 5, as measured by functional magnetic 
resonance imaging (fMRI) and a validated reward task (a variant of the 
monetary incentive delay task [MID]).  
SECONDARY ENDPOINTS 
Change in behavioral and clinical symptoms of anhedonia and on 
depressive symptoms assessed through a behavioral task and self- 
and clinician administered ratings scales 
OTHER EVALUATIONS 
Pharmacokinetics evaluation: plasmatic ezogabine concentrations 
will be determined at specific time point and summarized by study 
visit.  
SAFETY EVALUATIONS 
Frequency and severity of observed adverse events over the 
ezogabine titration, treatment and tapering periods. Suicidal ideation 
and behavior will be monitored throughout the study. According to 
FDA recommendations, a complete ophthalmological exam at Visit -1 
(screening) and at Visit 6 (Study Exit) will be performed. 
PLANNED INTERIM 
ANALYSES  
None / Not applicable 
STATISTICS 
Primary Analysis Plan 
The primary endpoint is the baseline-corrected fMRI activation in an a 
priori bilateral ventral striatum (VS) area mask during the gain cue 
contrasted with neutral cue of the Incentive Flanker Task (IFT) . A 
linear mixed effects model will be used to assess the change in 
activation of the bilateral VS by treatment group.  


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Rationale for Number of 
Subjects 
Based on our pilot data, the within-subject effect of time (ezogabine 
900 mg daily) on the neural reward circuit was Cohen’s d = 0.95. 
Assuming a placebo effect on the brain of Cohen’s d = 0.15, we 
estimate a between-group effect of 0.8 standard deviations. A 
sample size of 48 provides 85% power to detect a difference in 
means between groups of 0.8 standard deviations assuming a 
correlation of 0.6 between a pair of measurements made on the 
same subject using a two-sided 0.05 significance level test. 
 
 


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1 
BACKGROUND 
 
Ezogabine (Potiga®, GlaxoSmithKline) is a first-in-class KCNQ-selective potassium (K+) 
channel opener approved by the U.S. Food and Drug Administration (FDA) for the 
adjunctive treatment of partial-onset seizures. Ezogabine selectively binds to and activates 
KCNQ transmembrane K+ ion channels enhancing trans-membrane potassium currents 
mediated by the KCNQ (Kv7.2 to 7.5) family of ion channels. By activating KCNQ channels, 
ezogabine is thought to stabilize the resting membrane potential and reduce brain 
excitability. In vitro studies suggest that ezogabine may also exert therapeutic effects 
through augmentation of GABA-mediated currents. 
For more detail refer to the Package Insert. 
 
1.1 
Overview of Non-Clinical Studies 
 
Recent work demonstrates a causal role for the KCNQ-type K+ channel in reversing 
depressive phenotypes following social defeat stress (Chaudhury et al., 2013; Friedman et 
al., 2014). Mice manifesting the depressive/anhedonic phenotype (compared to resilient 
mice) show a failure to increase KCNQ channel activity within the ventral tegmental area 
(VTA) – Ventral Striatum (VS) reward circuit. This susceptible phenotype can be reversed 
through (a) overexpression of KCNQ channels, (b) direct VTA injection of KCNQ channel 
openers, or (c) peripheral injection of KCNQ channel openers. Remarkably, repeated 
peripheral daily administration the KCNQ channel opener ezogabine completely reversed 
the depressive/anhedonic phenotype in susceptible mice. These results provide a direct 
validation of KCNQ channel openers as a completely novel class of antidepressants. The 
proposed project takes advantage of the availability of ezogabine for human use to test this 
hypothesis in patients with depression. This “re-purposing” approach is hoped to speed 
novel drug discovery since crucial knowledge concerning pharmacokinetics (PK), toxicology, 
brain exposure and safety has already been established for ezogabine, thereby considerably 
de-risking its development. 
 
1.2 
Overview of Clinical Studies 
 
The efficacy of ezogabine as adjunctive therapy in partial-onset seizures was established in 
3 multicenter, randomized, double-blind, placebo-controlled studies in 1,239 adult patients 
(Ezogabine product information). The most common adverse effects of ezogabine are 
dizziness (23%), drowsiness (22%) and fatigue (15%). For more detail refer to the FDA 
Package Insert. 
 
Based on the data mentioned above and the knowledge that ezogabine readily crosses the 
blood brain barrier (BBB) (Orhan et al., 2012; Large et al., 2012), our group examined the 
effects of ezogabine on reward circuit responses in patients with depression using fMRI and 
a variant of the Monetary Incentive Delay (MID) task developed by our group called the 
Incentive Flanker Task (IFT) (Stern et al., 2011). N=9 patients with Major Depressive 
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underwent functional Magnetic Resonance Imaging (fMRI) and completed clinical and 
behavioral assessments at baseline and following treatment with ezogabine titrated to 900 
mg daily. Ezogabine was well tolerated, no subjects discontinued the treatment protocol 
and no serious adverse events (SAEs) occurred and no unexpected adverse events (AEs) 
occurred. Baseline and outcome scans were available for n=6 patients. Based on our 
mechanistic model, we hypothesized that ezogabine would lead to an increase in brain 
responses to both reward expectancy (e.g., anticipation) and reward responsiveness (e.g., 
consumption) within the cortico-striatal reward circuit (Der-Avakian & Markou, 2012; 
Grabenhorst & Rolls, 2011; Levy & Glimcher, 2012; Delgado et al., 2000; Elliott, et al., 2000; 
Knutson et al., 2001; Knutson et al., 2005; Haber & Knutson, 2010). Following treatment 
with ezogabine compared to baseline (Time 2>Time 1), brain responses to both reward 
expectancy and reward responsiveness were enhanced. Specifically, activation during 
anticipation was increased within the caudate, putamen, and medial prefrontal cortex 
(mPFC); activation during feedback was increased within the VS/nucleus accumbens (NAc). 
Clinically, ezogabine led to a reduction in depression severity with a comparatively larger 
improvement in symptoms specifically linked to an altered reward processing, namely 
anhedonia, loss of interest, and reduced motivation [t(8)=4.4, p=0.002]. Overall, our 
preliminary data are consistent with the ability of ezogabine to modulate reward circuit 
activity in humans and the plausibility of KCNQ potentiation as a novel treatment approach 
for reward alterations in depression. 
 
 
2 
STUDY RATIONALE 
 
Depressive disorders – chief among them MDD and persistent depressive disorder 
(previously ‘dysthymia’) – are among the most disabling medical conditions worldwide 
(Collins, 2011; Whiteford et al., 2013). Depression ranks first in disability in both high and 
low income countries among all brain-based disorders, including all psychiatric, 
neurological and substance disorders (Collins et al., 2011). In the United States, the total 
economic cost of depression in 2012 was estimated to be $188 billion (Mrazek et al., 2014). 
Contributing to the problem, a substantial proportion of patients with depression fail to 
achieve a clinically meaningful improvement in illness severity despite numerous 
antidepressant trials and augmentation strategies (Rush et al., 2006; Trivedi et al., 2006).  
 
Currently available psychotropic medications for the treatment of depression largely share 
the same basic pharmacology and mechanism of action based on discoveries made decades 
ago (Berton & Nestler, 2006). This lack of mechanistic diversity is an important cause of the 
observed limitations in the efficacy of these treatments, and leaves little opportunity for 
personalized medicine. In contrast, rational drug discovery based on a mechanistic 
understanding of disease pathology promises to deliver more effective, targeted therapies 
(Berton & Nestler, 2006; Hasler et al., 2004; Agid et al., 2007; Anacker, 2014; Millan et al., 
2015). The current project represents a set of translational experiments stemming from 
fundamental research into the molecular basis of depression (Chaudhury et al., 2013; 
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Krishnan & Nestler, 2008; Cao et al., 2010; Tye et al., 2013; Russo & Nestler, 2013; Walsh 
et al., 2014). Our unique investigational team is poised to translate these recent discoveries 
into urgently needed, mechanistically novel treatments for patients with depression.  
 
This study represents the first part of the R61/R33 National Institutes of Mental Health 
(NIMH) funded project. A clear increase in reward circuit activation in the ezogabine 
treatment group compared to placebo, given acceptable tolerability, will constitute a “go” 
and the project will move to the next phase (R33) (see paragraph “Primary Outcome 
Measure: Neuroimaging Methods”, section 9 “Study procedures and guidelines” and 
section 16.3 “Analysis of Primary Endpoint” for details); the R33 will examine the 
relationship between treatment, reward circuit activity, and behavioral and clinical 
outcomes in subjects suffering from depression and anhedonia.  
 
2.1 
Risk / Benefit Assessment 
 
The most common adverse effects of ezogabine are dizziness (23%), drowsiness (22%) and 
fatigue (15%). No contraindications to treatment were reported in the manufacturer’s 
label. Since QT prolongation has been observed, ECG will be monitored at screening and 
study exit. Skin discoloration around the lips or nail bed, either blue or gray, has been 
reported and is estimated to affect up to 10% of patients treated for more than two years. 
Below we summarize the risks of the study drug and strategies to mitigate risk. In addition, 
please see section 5.3 “Safety Evaluation” for additional description of study safety 
evaluations.  
 
QT Prolongation: 
QT prolongation has been observed in healthy subjects during a randomized, double-blind 
study where the maximum mean increase of QT interval of 7.7 msec was observed at 3 
hours after 22 days of treatment with ezogabine 1,200 mg daily. No effects on heart rate, 
PR, or QRS intervals were noted. In our trial, the dosage of 1200 mg daily will not be reached 
and participants will be at the highest dose of 900 mg per day, respectively, for one week. 
Moreover, since patients who are prescribed ezogabine with medicines known to increase 
QT interval or who have known prolonged QT interval, congestive heart failure, ventricular 
hypertrophy, hypokalemia, or hypomagnesemia should be observed closely, to ensure 
participants’ safety we will exclude from the trial subjects with: 
- unstable medical illness including ischemic heart disease or other cardiovascular disease; 
- history of QT prolongation or congenital QT syndrome 
- prolonged QT interval at screening (QTc > 480 msec) 
- clinically significant abnormalities of laboratory tests and EKG 
To reduce risks for participants in this trial, an EKG will be performed at the screening, at 
visit 4 (to monitor any QT effects that have emerged prior to escalating to the highest dose; 
see Section 10.3 “Double Blind Treatment Period” for additional details) and at study exit 
visits. 
 
Skin Discoloration: 


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Skin discoloration around the lips or nail bed, either blue or gray, has been reported and is 
estimated to affect up to 10% of patients treated for more than two years. Given the limited 
exposure to the study drug in the current study, we anticipate the risk of skin discoloration 
to study participants will be very small.  
 
Suicidality: 
Antiepileptic drugs (AEDs), including ezogabine, have been found to increase the risk of 
suicidal thoughts or behavior in pooled analyses. Pooled analyses of 199 placebo-controlled 
clinical trials (mono- and adjunctive-therapy) of 11 different AEDs showed that patients 
randomized to one of the AEDs had approximately twice the risk (adjusted relative risk 1.8, 
95% confidence interval [CI]: 1.2, 2.7) of suicidal thinking or behavior compared to patients 
randomized to placebo. In these trials, which had a median treatment duration of 12 weeks, 
the estimated incidence of suicidal behavior or ideation among 27,863 AED-treated 
patients was 0.43% compared to 0.24% among 16,029 placebo-treated patients, 
representing an increase of approximately 1 case of suicidal thinking or behavior for every 
530 patients treated. There were 4 suicides in drug-treated patients in the trials and none 
in placebo-treated patients, but the number is too small to allow any conclusion about drug 
effect on suicide. Suicide ideation and behavior will be monitored during the length of the 
study through clinical assessments at screening and exit visits, and weekly during the 
treatment period. The Columbia Suicide Severity Rating Scale (C-SSRS) will also be 
conducted at each study visit to monitor suicidal ideation and behavior. If, at any point 
during the clinical trial, a participant will be assessed with a suicidal ideation with any intent 
or plan, as measured by a C-SSRS score of greater than 3 during the past week and/or with 
a Global Clinical Impression – Severity Scale (GCI-S) score ≥6 (indicating extreme illness 
severity) or a Global Clinical Impression – Improvement Scale (CGI-I) score ≥ 6 (indicating 
an extreme worseness of the symptoms), a safety review will be performed by the site PI, 
or his designee, to determine the appropriate course of action including whether acute 
intervention is needed and whether it is in the best interests of the subject to continue in 
the study. For more information, refer to paragraphs 5.3 “Safety evaluations” and section 
9 “Study Procedures and Guidelines”.  
 
Other Adverse Effects: 
Other side effects include urinary retention, neuropsychiatric symptoms (confusional state, 
psychotic symptoms, and hallucinations) and withdrawal seizures. To protect participants 
from these possible side effects the following actions will be completed: 
- urologic symptoms will be carefully monitored and a comprehensive evaluation of urologic 
symptoms prior to and during treatment with ezogabine will be completed; 
- neuropsychiatric symptoms will be investigated at screening and ezogabine will be titrated 
on a 5-week period according to the FDA package insert in order to reduce the risk of 
psychosis and hallucinations; to monitor the impact of dizziness and somnolence, that 
usually occur during the titration phase, subjects will be evaluated on a weekly based by a 
study physician;  
- withdrawal symptoms will be prevented by a gradual withdrawn over a period of at least 
3 weeks, unless safety concerns require abrupt withdrawal. 


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Retinal Changes: 
The FDA had issued a black box warning regarding the potential for retinal abnormalities 
following treatment with ezogabine, with an unknown relationship to vision loss. In June 
2015, the FDA issued a Safety Alert stating that there was no evidence for treatment 
associated vision loss following a review. In keeping with FDA recommendations, study 
participants undergo full ophthalmological exams at screening and study exit. For more 
information please refer to sections 5.3 “Safety evaluations” and 9 “Study procedures and 
guidelines. 
 
Potential for Unforeseen Risks: 
In addition to these risks there may be other risks associated with ezogabine, which are 
currently unknown as the study drug has never been used on a sample of anhedonic 
subjects with mood and anxiety disorders. Data from our pilot study show that ezogabine 
was well tolerated, no subjects discontinued the treatment protocol, no SAEs and no 
unexpected AEs occurred. 
 
Potential for Harms Unrelated to Study Drug: 
The following additional sources of potential discomfort or harm could also occur: 
• Psychological Screening: Subjects that meet exclusion criteria (e.g. positive pregnancy 
test) may become distressed when informed. All information will be shared in a private 
office with the door closed and a trained study team member will be available to offer 
information, support, and referral for any services indicated. 
• Medical Screening: Participants may experience minor discomfort or pain when a 
needle is used to draw blood. Bruising, infection, and dizziness are also common side 
effects. Risks of venipuncture are minimized by having experienced nursing personnel 
who will perform the procedure. Infection is avoided by adequate cleansing of the skin 
prior to intravascular line insertion.  
• fMRI Scans: The fMRI procedure is very safe and exposes the study subjects to minimal 
risk or discomfort. The MRI scanning involves the subject placing their head in a tube 
and some subjects may experience a feeling of claustrophobia while in the scanner. 
However, a study investigator will be present for all scanning sessions in case of any 
unexpected complications. In addition, the participant will remain in verbal contact with 
a study investigator (via intercom) throughout the procedure so that they may 
communicate immediately any problems, or express a desire to terminate the scan at 
any time. 
• Questionnaires: Some participants may experience psychological distress when asked 
to answer personal questions about their emotions. In this case, experimenters will 
remind subjects that they can refuse to answer any upsetting questions. Clinicians will 
also be available to meet with any distraught individuals.  
• Privacy risks: There always exists the potential for loss of private information; however, 
there are procedures in place to minimize this risk. Please refer to page 40 section “Data 
Collection, Retention and Monitoring” for more details. 
 


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To protect subjects from such unknown risks we will not allow subjects to participate in the 
study if they have: 1) any clinically significant abnormality on the screening tests; 2) any 
clinically significant history of medical, psychiatric, or substance use-related disorder other 
than a mood and anxiety spectrum disorder; 3) excessive alcohol intake or unwillingness to 
stop alcohol consumption for the duration of the study; 4) taken any prescribed or not 
prescribed medication prohibited by the protocol within 30 days of the first study visit, or 
need to continue any of the abovementioned medications during the study; 5) QT 
prolongation, electrolyte abnormalities, concomitant medications that may augment QT 
prolongation, or any underlying cardiac abnormality which may potentiate risk; 6) any 
alteration emerging at the ophthalmological exam performed at screening that in the 
opinion of the ophthalmologist or the Principal Investigator (PI), may increase risk for 
potential retinal abnormalities for the subject. For more details on study eligibility, see 
section 6 “Subject Selection”. 
 
Subjects may not receive any direct benefit from participating in this study. There is a small 
possibility that we may detect an unrelated medical condition during the procedures 
conducted in this study that could have health benefits for some individuals. Some 
individuals may experience improvement in their symptoms through participation in the 
study, though some are likely to remain the same or get worse. The information obtained 
from this study may help improve the treatment of future patients with MDD or other mood 
disorders. Since the available treatments for patients with MDD have significant limitations 
(Trivedi et al., 2006), this study has the potential to take steps to address these limitations 
by: 1) establishing that ezogabine is a safe and efficacious treatment for MDD; 2) exploring 
the impact of the drug on a discrete brain circuit for reward 3) validating a new class of 
treatments for an important medical problem, with significant impact on patients and on 
society; 4) exploring the impact of ezogabine on behavioral and clinical measures of 
anhedonia and depression. As mentioned before, this study represents the first part of the 
R61/R33 NIH funded project. A clear increase in reward circuit activation (in terms of both 
significance and effect size) in the ezogabine treatment group compared to placebo, given 
acceptable tolerability, will constitute a “go” and the project will move to the phase (R33).  
 
3 
STUDY OBJECTIVES 
 
3.1 
Primary Objective 
 
The primary objective of the current study is to assess evidence of target engagement by 
the study drug as measured by change in the cortico-striatal circuit response to reward in 
a sample of subjects with a current depressive disorder (MDD, persistent depressive 
disorder, other specified depressive disorder) and anhedonia (indexed by a score of ≥ 20 on 
the Snaith-Hamilton Pleasure Scale [SHAPS]). Two treatment conditions in a parallel arm 
design will be: (1) ezogabine arm (ezogabine 900 mg/day), or (2) placebo. The effect of 
ezogabine relative to placebo on the reward circuit will be assessed studying the brain 
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9 “Study Procedures and Guidelines” for a description of the procedures and specific 
instrument that will be used. 
 
Go/No-Go Decision: A clear increase in reward circuit activation in the ezogabine treatment 
group compared to placebo, given acceptable tolerability, will constitute a “go” and the 
project will move to the R33 phase.  
 
3.2 
Secondary Objectives 
 
Secondary efficacy objective: the study will examine the effects of ezogabine on clinical and 
behavioral measure of anhedonia, depressive symptoms, and suicide ideation in an 
exploratory manner. In addition, general functioning will be measured with the WHO 
Disability Assessment Schedule 2.0 (WHODAS 2.0; World Health Organization [WHO], 
2012). Please, refer to sections 9 “Study procedures and guidelines” for more details.  
 
Secondary safety objective: to examine the safety and tolerability of ezogabine in patients 
with depressive disorder.  
 
 
4 
STUDY DESIGN 
 
4.1 
Study Overview 
 
This is a multi-center, phase IIa, parallel arm, double-blind, randomized, placebo-
controlled, clinical trial. Forty-eight treatment-seeking patients with a primary diagnosis of 
depressive disorder according to Diagnostic and Statistical Manual of Mental Disorders-
Fifth Edition (DSM-5; MDD, persistent depressive disorder, other specified depressive 
disorder), clinically significant anhedonia (defined SHAPS ≥ 20) and at least moderate 
current illness severity (measured as Clinical Global Impression–Severity [CGI-S] Scale ≥ 4) 
will be enrolled. Each subject will be randomly assigned to one of the treatment arms 
(ezogabine, placebo) in a 1:1 fashion under double-blind conditions; randomization will be 
under the direction of the coordinating center and stratified by center. Screening data will 
be reviewed by the site PI to determine subject eligibility. Subjects who meet all inclusion 
criteria and none of the exclusion criteria will be entered into the study. Study participants 
will undergo assessments at baseline then following study drug/placebo weekly for five 
weeks (titration period and primary outcome visit) and then after three weeks (taper period 
and exit visit). During the taper period participants will undergo weekly phone calls from a 
member of the study team to assess compliance and side effects. Please, refer to Table 2 
“Schedule of Assessments, Outcome Measures, Labs, and Procedures.” 
 
Following screening and randomization, study participants undergo a 5-week medication 
titration schedule according to the FDA package insert. For more information about 
randomization, treatment and taper schedules please refer to section 8 “Study 
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The following treatment regimens will be used: 
• Ezogabine group: ezogabine at 900 mg daily 
• Placebo group: inactive compound daily. 
Total duration of subject participation will be up to 14 weeks. Total duration of the study is 
expected to be 24 months. 
 
 
5 
CRITERIA FOR EVALUATION 
 
5.1 
Primary Efficacy Endpoint 
 
Our primary efficacy endpoint is change in activation within the bilateral VS from baseline 
(Study Visit 0) to week 5 (Study Visit 5) as measured by fMRI during the IFT. Patients with 
depression show abnormal responses to reward expectancy and reward responsiveness 
within the cortico-striatal reward circuit (VS/mPFC/Anterior cingulate cortex [ACC]) and 
data from our pilot study on ezogabine showed that following treatment with ezogabine, 
brain responses to reward expectancy and reward responsiveness were enhanced. The VS 
is considered to be the principal reward related region and therefore functions as the 
primary region of interest (ROI). The right and left VS regions will be combined (averaged) 
into a single bilateral ROI as there are no laterality hypotheses regarding effect of treatment 
on the VS. 
 
5.2 
Secondary Efficacy Endpoints 
 
Similarly to  the primary efficacy endpoint, change in activation within other regions of 
the reward cortico-striatal circuit (for example, mPFC and ACC) from baseline to week 5 
will be measured by fMRI during the IFT. 
 
Clinical outcome 
Change in clinical symptoms of anhedonia (as measured by the SHAPS, Temporal 
Experience of Pleasure Scale [TEPS], Specific Loss of Interest and Pleasure Scale [SLIPS], 
Anticipatory and Consummatory Interpersonal Pleasure Scale [ACIPS] and on depressive 
symptoms assessed through clinical ratings scales (Montgomery-Asberg Depression Rating 
Scale [MADRS]). Global illness improvement and severity will be evaluated through changes 
in CGI-I and CGI-S scores. The level of disability and functioning will also be investigated via 
the World Health Organization Disability Assessment Schedule (WHODAS 2.0). For more 
details on the clinician and self-report measure that will be administered, please refer to 
section 9 “Study procedures and guidelines”, paragraph 9.1.6 “Other clinical procedures”. 
 
Behavioral outcome 
Change in behavioral symptoms of anhedonia will be captured through a computer-based 
task, the Probabilistic Reward Task (PRT). In this task, a signal detection theory approach is 
used, whereby subjects must discriminate between two ambiguous stimuli, displayed 


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rapidly on a computer screen, in order to receive a monetary reward. Unbeknownst to the 
subjects, correct identification of one stimulus is reinforced three times more frequently 
than the other stimulus. Under these experimental circumstances, healthy subjects reliably 
develop a response bias (that is, preference) for the stimulus that is reinforced more 
frequently, regardless of which stimulus was actually presented. Thus, reward 
responsiveness assessed in this task reflects the rapid shaping of future behavioral choices 
based on prior reinforcement experiences. Subjects with MDD and healthy subjects with 
elevated depressive symptoms fail to develop this biased response for the more frequently 
reinforced stimulus, and tend to respond similarly to both stimuli, reflecting decreased 
responsiveness to rewards. Moreover, response bias was found to predict current and 
future anhedonic symptoms in both nonclinical and clinical samples. For more details on 
PRT, please refer to section 9 “Study procedures and guidelines”, paragraph 9.1.6 “Other 
clinical procedures”. 
 
5.3 
Safety Evaluations 
 
Safety will be monitored by the evaluation of potential adverse events, clinical laboratory 
test results, vital signs measurements, physical examination, ECG and ophthalmological 
findings. Our safety evaluations include frequency and severity of observed adverse events 
over the study treatment period. The frequency and severity of adverse events will be 
compared between the treatment conditions. For a complete discuss of risks associated 
with the study drug, please see section 2.1 “Risk/Benefit Assessment”. For a complete 
discussion of study procedures, please see section 9 “Study Procedures and Guidelines”. 
Below, we outline specific safety evaluations conducted as part of the study protocol. 
 
Monitoring for Worsening Depression and Suicidal Ideations or Behaviors 
Participants will meet with a study clinician weekly during the treatment period. The 
interval medical history will be obtained and adverse events, changes to concomitant 
medications and dosing compliance will be recorded. Suicidal ideation and behavior will be 
specifically assessed, including a review of the Columbia Suicide Severity Rating Scale (C-
SSRS) and the overall severity of symptoms will be monitored by the clinical global 
impression scale (CGI-S).  If, at any point during the clinical trial, a participant will be 
assessed with a suicidal ideation with any intent or plan, as measured by a C-SSRS score of 
greater than 3 during the past week and/or with a GCI-S score ≥6 (indicating extreme illness 
severity) or a CGI-I score ≥ 6 (indicating an extreme worseness of the symptoms), the site 
PI, or his designee, will conduct  a safety review to determine the appropriate course of 
action including whether acute intervention is needed and whether it is in the best interests 
of the subject to continue in the study.  
 
Safety review:  The safety review will consist of a separate review of safety and well-being 
of the participant by the site PI or his designee. This review will be documented by a Safety 
Review Form (SRF) that will be filed in the subject binder and that will consist of a brief 
description of the case and of the event that triggered the review. Outcome of the review 
will be the decision whether to continue or discontinue the subject from the protocol (if 


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this is the case, appropriate clinical care will be provided). In the eventuality the event 
satisfies the definition of an adverse event (AE) or of a serious adverse event (SAE), it will 
be reported accordingly. For more detail about adverse event monitoring and reporting, 
please refer to section 11 “Adverse experience reporting and documentation”.   
 
Ophthalmological exams 
 All the participants will also undergo a complete ophthalmological exam at screening and 
at study end by a study ophthalmologist, to include the following procedures: Visual acuity, 
Color plates, Amsler grid, Visual field test, Dilated fundus exam, Fundus photography, and 
Ocular coherence tomography (OCT) of the macula. Should patient exhibit any changes in 
fundus exam and/or OCT from screening, they will undergo a fluorescein angiogram and 
possibly electroretinogram depending on the discretion of the Ophthalmologist. After 
cessation of medication the regularity of baseline dilated eye exams will be determined by 
the presence or absence of retinal pathology at the discretion of the Ophthalmologist. 
 
Additional Safety Monitoring 
In addition to the procedures described above, the following procures are performed as 
part of the study safety evaluations. Medical history, current and past physical and 
psychiatric history, venous blood sampling for clinical laboratory tests (comprehensive 
metabolic panel, CBC, TSH), vital signs, urine toxicology, pregnancy test (if applicable), and 
ECG will be performed by qualified staff. For more information refer to sections 2.1 
“Risk/Benefit Assessment” and 9 “Study Procedures and Guidelines”. 
 
Provision of study follow-up for treatment emergent adverse events at study exit: in case 
of any adverse event (including, but not limited to suicidal ideation or behavior) present at 
the study exit visit, subject will be referred to follow-up care until the event is resolved 
and/or a stable care plan is in place. The site PI will follow up with the subject until the 
abnormal parameter or symptom has resolved or stabilized. 
 
5.4 
Other evaluations 
 
Pharmacokinetic (PK) Procedures: Venous blood samples will be collected for determination 
of plasmatic ezogabine concentrations at the primary outcome visit (V5). Drug 
concentrations will be used to determine protocol adherence, inclusion in the planned per-
protocol analysis and to examine PK – pharmacodynamic (PD) relationships. Plasmatic 
ezogabine levels will be used to determine drug concentration.  
 
 
6 
SUBJECT SELECTION 
 
6.1 
Study Population 
 
Subjects who will meet DSM-5 criteria for depressive disorder (MDD, persistent depressive 
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and at least moderate current illness severity (Clinical Global Impression–Severity [CGI-S] 
Scale ≥ 4) at the time of screening meeting all study inclusion and exclusion criteria will be 
eligible for participation in this study.  
 
Recruitment feasibility: The research plan calls for the randomization of n=48 patients ages 
18-65 with a primary diagnosis of current depressive disorder and significant anhedonia 
across the two performance sites (ISMMS and BCM) over a 20-month recruitment period, 
which is 1.2 patients randomized per month per site. This is a feasible goal based on current 
patient flow at the two sites, and our demonstrated track record of enrollment at similar 
rates in prior studies recruiting from similar populations.  
 
6.2 
Inclusion Criteria 
 
1. Written informed consent obtained from subject and ability for subject to comply with 
the requirements of the study; 
2. Men and women, age 18-65; 
3. Participants must meet DSM-5 criteria for current depressive disorder (major 
depressive disorder [MDD], persistent depressive disorder, other specified depressive 
disorder) as determined by a study psychiatrist and confirmed using the Structured 
Clinical Interview for DSM-5 Research Version (SCID-5-RV);  
4. Clinically significant anhedonia as determined by a SHAPS score ≥ 20 at screening; 
5. Current illness severity is at least moderate, defined as a score of ≥4 on the Clinical 
Global Impression–Severity (CGI-S) Scale; 
6. If female of childbearing potential, must agree to use of a medically accepted form of 
contraception, or else agree to abstinence. 
 
6.3 
Exclusion Criteria 
 
1. A primary psychiatric diagnosis other than a depressive disorder as defined by DSM-5; 
[co-morbid anxiety disorders (including agoraphobia, generalized anxiety disorder, 
social anxiety disorder and panic disorder) and Posttraumatic Stress Disorder (PTSD) are 
allowed]; 
2. Diagnosis of a major cognitive disorder or evidence of cognitive impairment as assessed 
by a score of the Mini Mental Status Exam (MMSE) of <24;  
3. Meets criteria for a substance or alcohol use disorder in the past 6 months; 
4. Suicidal ideation with any intent or plan as measured by a Columbia Suicide Severity 
Rating Scale [C-SSRS] score of greater than 3 during the past month at the time of 
screening; 
5. Female participants who are pregnant, breastfeeding, or may become pregnant, or 
unwilling to practice birth control during participation in the study; 
6. Positive urine toxicology screen for drugs of abuse at the time of screening*; 
7. Inability to swallow capsules; 


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8. Any unstable medical illnesses including hepatic, renal, gastroenterologic, respiratory, 
cardiovascular (including ischemic heart disease), endocrinologic, neurologic, 
immunologic, or hematologic disease; 
9. Clinically significant abnormalities of laboratory tests, physical examination, or ECG; 
10. Positive Hepatitis B surface antigen (HBsAg) and/or Hepatitis C Anti-Hepatitis C virus 
(HCV) antibody† 
11. Moderate to severe renal insufficiency at the time of screening or at any point 
throughout study participation; 
12. Prolonged QT Interval at screening, operationalized as a QTc of > 480 ms; 
13. History of abnormal QT prolongation or congenital QT syndrome; 
14. Concomitant use of a medication with a known significant risk of QT prolongation;  
15. A history of retinal abnormalities (i.e., pigment changes, retinal dystrophy) or findings 
of retinal pathology on ophthalmological exam at baseline; 
16. Presence of a condition or abnormality that in the opinion of the Investigator would 
compromise the safety of the patient or the quality of the data; 
17. Use of any dis-allowed medication according to the study protocol**; 
18. Serious and imminent risk of self-harm or violence as determined by the PI; 
19. Extreme illness severity as defined by a GCI-S score >6; 
20. Any contraindication to MRI including claustrophobia, any trauma or surgery which may 
have left magnetic material in the body, magnetic implants or pacemakers, and inability 
to lie still for 1 hour or more; 
21. History of non-response to electroconvulsive therapy in the current depressive episode 
 
* Exceptions: 
a) Subjects with a positive urine drug screen for cannabinoids, barbiturates, opiates, 
amphetamines, or benzodiazepines may be allowed in the study provided that the drug was 
used for a documented, legitimate medical purpose and/or the use of such products may be 
discontinued (documented by a negative repeat test) prior to randomization; Subjects with 
a positive urine drug screen for drugs of abuse at any study visit following the randomization 
visit (e.g. V5 or V8) will not be discontinued from the study. 
b) Medically appropriate episodic use (up to 3 days) of narcotic analgesics for acute medical 
indications is allowed (Discussion with PI required) 
 
** Potential participants will not be discontinued from medication for the purposes of this 
study. If a patient is taking a protocol dis-allowed medication at the time of screening, the 
patient may discontinue the medication under the supervision of their treating physician in 
the case that the patient is not benefiting from the medication or otherwise wishes to 
discontinue the medication. In no case will a dis-allowed medication be discontinued for the 
purpose of study participation if the patient is receiving clinical benefit from the medication.  
 
† Subjects who will test positive for Hepatitis B or C at the time of the screening will not 
allowed to participate in the study. If a subject tests positive for Hepatitis B or C, the study 
physician will inform the participant and provide a referral for medical evaluation and 
treatment as appropriate. 


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7 
CONCURRENT MEDICATIONS 
 
All subjects should be maintained on the same medications throughout the entire study 
period, as medically feasible, with no introduction of new chronic therapies. Refer to Table 
1 for list of prohibited medications during the study.  
 
7.1 
Allowed Medications and Treatments 
 
Study subjects are required to be free of antidepressant and other dis-allowed medication 
with CNS activity for a duration equivalent to 5 half-lives of the medication at the time of 
randomization. As needed (e.g., “PRN) use of non-benzodiazepine hypnotic agents 
(including zolpidem, zaleplon, eszopliclone, diphenhydramine, suvorexant, and ramelteon) 
or benzodiazepines not in excess of the equivalent of 2 mg of lorazepam daily will be 
allowed. Subjects will be prohibited from taking as needed benzodiazepines or other as 
needed therapy with CNS activity on the day of study assessments. Subjects receiving 
psychotherapy may continue to receive psychotherapy provided this therapy has been 
stable in terms of frequency for at least 2 months prior to screening and is expected to 
remain unchanged during the study treatment period. 
 
7.2 
Prohibited Medications and Treatments 
 
A list of medications prohibited during the study is provided in Table 1 (“List of Prohibited 
Medications”). The administration of the cited drugs will be considered a protocol violation. 
In general, the following classes of medication are prohibited: (1) antidepressants, (2) 
antipsychotics, (3) anticonvulsants/mood stabilizers, (4) lithium, and (5) stimulants. In 
addition, concomitant use of a medication with a known significant risk of QT prolongation 
is prohibited. 
 
 
8 
STUDY TREATMENTS 
 
8.1 
Method of Assigning Subjects to Treatment Groups 
 
Central randomization will be implemented in this study by the coordinating site. Forty-
eight eligible patients will be randomly assigned to ezogabine (900 mg/day; n=24) or 
placebo treatment (n=24) groups in a 1:1 ratio using a computer-generated randomization 
scheme developed by the coordinating site. The randomization will be balanced by using 
randomly permuted blocks. The interactive web response system (IWRS) will assign a 
unique treatment code, which will dictate the treatment assignment and matching study 
drug kit for the subject.  
 
8.2 
Blinding 
 


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Patients who meet all entry criteria will be randomly assigned to one of the treatment arms, 
and assigned randomization numbers in consecutive order. The randomization list will be a 
computer-generated random-number list generated by the research pharmacist (who has 
no patient contact) at the coordinating site using a permuted block procedure. The 
randomization list will be provided by the research pharmacist at the coordinating site to 
the research pharmacist at the collaboration site. Due to the objective of the study, the 
identity of test and control treatments will not be known to investigators, research staff, or 
patients. 
 
The following study procedures will be in place to ensure double-blind administration of 
study treatments: 
• Access to the randomization code will be strictly controlled; 
• Packaging and labeling of test and control treatments will be identical to maintain the 
blind; 
• Investigators, study coordinators and all study personnel with study patient contact will 
remain blind to the treatment assignment. 
 
The study blind will be broken on completion of the clinical study and after the study 
database has been locked. During the study, the blind may be broken by the research 
pharmacist only in emergencies when knowledge of the patient’s treatment group is 
necessary for further patient management.  
 
8.3 
Test and Control Formulation 
 
8.3.1 
Formulation of Test Product 
Ezogabine (Potiga®, GlaxoSmithKline) is approved by the FDA for the adjunctive treatment 
of partial-onset seizures in patients aged 18 years and older. Ezogabine is produced by 
GlaxoSmithKline and supplied as film-coated immediate-release tablets for oral 
administration: 50 mg, purple, round, film-coated tablets debossed with “RTG 50” on one 
side; 200 mg, yellow, oblong, film-coated tablets debossed with “RTG-200” on one side; 
300 mg, green, oblong, film-coated tablets debossed with “RTG-300” on one side; and 400 
mg, purple, oblong, film-coated tablets debossed with “RTG-400” on one side. The tablets 
should be swallowed whole. The study drug will be formulated and manufactured according 
to currently established commercial production standards. 
 
8.3.2 
Formulation of Control Product 
A placebo tablet for oral administration will be provided by the Investigational Drug Service 
at each site ready for administration in a drug case labeled with the required FDA warning 
statement, the protocol number, a treatment number, the name of the Sponsor, and 
directions for patient use and storage. The placebo product used in this study will be 
manufactured according to GMP and will contain inert substances. The research pharmacist 
at ISMMS will centrally randomize participants at all performance sites.  
 


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8.3.3 
Packaging and Labeling 
Packaging: Study drug will be supplied in a drug case at the research pharmacy at each site 
in the dosage prescribed by the PI or his designee (another study M.D. approved by the PI 
and the Institutional Review Board [IRB] for this role). 
Labeling: Each drug case of study drug will be labeled with the required FDA warning 
statement, the protocol number, a treatment number, the name of the Sponsor, and 
directions for patient use and storage 
 
8.4 
Supply of Study Medication at the Site 
 
Ezogabine will be purchased by the research pharmacy at each site by an appropriate 
wholesale drug company. The Investigational Drug Service at ISMMS purchases ezogabine 
for research purposes from Amerisouce-Bergen Corporation, based in Chesterbrook, 
Pennsylvania. The initial study drug shipment will be shipped after site activation. 
Subsequent study drug shipments will be made after site request for resupply. 
 
8.4.1 
Dosage/Dosage Regimen 
Titration Period. Study drug titration will follow the guidelines contained within the FDA 
package insert and will not exceed the maximum approved dose for partial-onset seizures 
(1,200 mg daily). For this study, a daily dose of 900 mg has been selected, along with 
placebo.  
 
For the ezogabine arm, participants start at 100 mg 3 times daily (300 mg per day) and 
increase at weekly intervals by 150 mg (50 mg 3 times per day) up to a stable dosage of 900 
mg daily. A 150 mg increase each week is the maximum increase recommended by the FDA. 
Those assigned to receive placebo will receive capsules containing an inactive compound 
at a frequency comparable to those in active treatment (i.e., 1 capsule, 3 times per day). 
Dose titration will be conducted based on subject tolerability.  
Subjects who are unable to tolerate a protocol-specified dose increase will be retained in 
the study at the highest tolerated dose for that subject through to the Primary Outcome 
Visit (V5), before beginning to taper off of the medication. In the event that a subject 
experiences a potential dose-dependent adverse medication effect in the opinion of the 
investigator, the subject will be maintained at the subject’s highest previously tolerated 
dose. One dose reduction for the purpose of resolving suspected medication-related 
adverse effects will be allowed per subject. Subjects who continue to experience tolerability 
issues despite the dose reduction will initiate the taper phase and will be exited early from 
the study protocol. The taper schedule will follow procedures reported in section 10.5 
“Taper Period” and section 10.6 “Study Exit Visit” (Visit 6) and early withdrawal”. All 
available data for each subject will be included in the statistical analyses, including from 
subjects who discontinue early for any reason. Study subjects who discontinue early for any 
reason, however, will not be replaced. During the trial, the following dosages of ezogabine 
will be used: 50 mg, 200 mg and 300 mg. To assure the blindness of the trial, the research 
pharmacist at each site will encapsulate every pill so that all study pills regardless of dosage 
will look identical.  


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8.4.2 
Dispensing 
The drug will be dispensed by the pharmacist of the research pharmacies of both study sites 
where it will be collected by study personnel. The Research pharmacy at each site will 
encapsulate study drug and placebo so that all study pills will look identical. Only the 
research pharmacist at each site will know the true identify of the study pills for each 
participant.  
 
8.4.3 
Administration Instructions  
Following FDA packaging information, ezogabine will be given orally according to the 
titration and taper schedule described above. Participants will be instructed to swallow the 
whole tablet, with or without food. At every study visits the subject will receive the study 
drug in a drug case labeled with the required FDA warning statement, the protocol number, 
a treatment number, the name of the Sponsor, and directions for patient use and storage. 
The dosage will be prescribed by the PI or the Study Doctor, according to the period of the 
study (titration, treatment, and taper period), tolerability showed by the participant and 
length from the subsequent visits. 
 
8.4.4 
Storage 
Study drug should be stored by the study site at controlled room temperature, 15 to 30ºC 
(59 to 86ºF). If the temperature of study drug storage in the clinic/pharmacy exceeds or 
falls below this range, this should be reported to the PI or designee and captured as a 
deviation. Subjects will be instructed to store the medication in original packaging 
(protected from light) at room temperature.  
 
8.5 
Study Medication Accountability 
 
An accurate and current accounting of the dispensing of study drug for each subject will be 
maintained on an ongoing basis by a member of the study site staff. The number of study 
drug dispensed will be recorded on the Investigational Drug Accountability Record.  
 
8.6 
Measures of Treatment Compliance 
 
Subsequent to randomization, study participants are provided with study drug or placebo 
in identical packaging and sufficient medication to reach the next visit is dispensed (plus a 
few extra days supply to account for scheduling and related issues).  Adherence to study 
medication will be measured throughout the study using pill count, patient diary, subject 
report, and drug plasmatic levels. Subjects will be asked to keep a patient diary noting the 
date and time they take the study drug and any adverse effects. They will be asked to bring 
their patient diary to each study visit along with all used and unused study drug containers. 
Compliance monitoring by pill counting will occur at each study visit: pills will be returned 
for pill counting in the study drug containers. A study team member will count the number 
of returned pills and record the number on the “Pill tracking log”. Venous blood samples 
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specified and will be summarized by visit. Drug concentrations will be used to determine 
protocol adherence, inclusion in the planned per-protocol analysis and to examine PK and 
PD relationships. 
 
 
9 
STUDY PROCEDURES AND GUIDELINES 
 
A Schedule of Events representing the required testing procedures to be performed for the 
duration of the study is summarized in Table 2. 
 
Prior to conducting any study-related activities, written informed consent and the Health 
Insurance Portability and Accountability Act (HIPAA) authorization must be signed and 
dated by the subject.  
 
9.1 
Clinical Assessments 
 
9.1.1 
Concomitant Medications 
All concomitant medication and concurrent therapies will be documented at screening (V-
1) and at each study visit, and at early termination when possible. Dose, route, unit 
frequency of administration, and indication for administration and dates of medication will 
be captured using the Concomitant Medication Log case report form. 
 
9.1.2 
Demographics  
Demographic information (date of birth, gender, race) will be recorded at screening (V-1). 
The case report forms used to capture this information include the Demographics Form 
and the Edinburg Handedness Inventory. 
 
9.1.3 
Medical History  
Relevant medical history, including history of current disease, other pertinent history, and 
information regarding underlying diseases will be recorded at screening (V-1). Case report 
forms used to record the medical history include the Medical History Form, Family 
Psychiatric History Form, and the Anti-Depressant Treatment History Form (ATHF). 
 
9.1.4 
Physical Examination 
A complete physical examination will be performed by qualified staff (MD, NP, RN, or PA) 
at screening (V-1) and at study end (V6). New abnormal physical exam findings must be 
documented and will be followed by a physician or other qualified staff at the next 
scheduled visit. According to FDA recommendation, all study participants will undergo a 
complete ophthalmological exam at screening and at study end by a study ophthalmologist, 
to include the following procedures: Visual acuity, Color plates, Amsler grid, Visual field test, 
Dilated fundus exam, Fundus photography, and Ocular coherence tomography (OCT) of the 
macula. For more information about the measures to minimize participants risks related to 
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Assessment” and 5.3 “Safety evaluation”. This is documented on the Physical Exam case 
report form.  
 
9.1.5 
Vital Signs 
Body temperature, blood pressure, pulse and respirations will be performed after resting 
for 5 minutes at screening (V-1) and at study end (V6). This is documented on the Vitals 
case report form. 
 
9.1.6 
Other clinical procedures 
 
Screening and baseline procedures 
Structured Clinical Interview for DSM-5 (SCID-5). The Structured Clinical Interview for DSM-
5 (First et al., 2015) is the most recent version of the SCID and is the first update since the 
SCID-IV-TR (First et al., 2002). The SCID-5 is a semi-structured interview guide for making 
DSM-5 diagnoses. It includes an overview to obtain information about demographics, work 
history, chief complaint, history of present illness, past history, treatment history, and 
current functioning. The main body of SCID-5 includes 9 modules that are designed to 
diagnose 51 mental illnesses in all. During the study screening period, the SCID-5 will be 
administered by a trained study team member who has completed SCID-5-RV training and 
who is familiar with the DSM-5 classification and diagnostic criteria. The current study will 
utilize the most comprehensive version of the SCID-5, the SCID-5-Research Version (RV), 
which contains more disorders than the Clinician Version and includes all of the relevant 
subtypes, severity, and course specifiers. An important feature of the SCID-5-RV is its 
customizability, allowing the instrument to be tailored to meet the requirements of a 
particular study. The SCID-5-RV comes in a standard "core" configuration that includes the 
disorders most researchers are likely to assess routinely for most studies, as well as in an 
“enhanced” configuration that includes a number of optional disorders, in addition to the 
disorders from the "core" configuration. 
 
Snaith-Hamilton Pleasure Scale (SHAPS): The SHAPS (Snaith et al., 1995) is a well-validated 
14-item self-report questionnaire commonly used to assess anhedonia. Each item on the 
SHAPS is worded so that higher scores indicate greater pleasure capacity. A total score can 
be derived by summing the responses to each item. Items answered with “strongly agree” 
are coded as “1”, while a “strongly disagree” response was assigned a score of “4.” Total 
scores on the SHAPS can range from 14 to 56, with higher scores corresponding to higher 
levels of anhedonia. This scale provides our primary measure of anhedonia in the study.  
 
Clinical Global Impression - Severity (CGI-S): this is a widely administered clinician rated 
global measure of subject overall illness severity (Guy, 1976). Subjects are rated on a 1-7 
scale where 1 corresponds to “Normal, Not at All Ill”, 2 is “Borderline Mentally Ill”, the 
anchor for 3 is “Mildly Ill”, the anchor for 4 is “Moderately Ill”, 5 is “Markedly Ill”, 6 is 
“Severely Ill”, and 7 is “Among the Most Extremely Ill Patients”. It will be administered at 
screening and at all study visits. 
 


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World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0): the 
WHODAS 2.0 (World Health Organization, 2012) is a 12-item generic assessment 
instrument that measures investigating the level of functioning in six domains: Cognition, 
Mobility, Self-care, Getting along, Life activities, and Participation. For all six domains, 
WHODAS 2.0 provides a profile and a summary measure of functioning and disability that 
is reliable and applicable across cultures, in all adult populations. WHODAS 2.0 has proven 
useful for assessing health and disability levels in the general population and in specific 
groups (e.g. people with a range of different mental and physical conditions).  
 
Mini–Mental State Examination (MMSE): The MMSE (Folstein et al., 1975) is a 30-point 
questionnaire that is used extensively in clinical and research settings to measure cognitive 
impairment. It is commonly used to screen for dementia, to estimate the severity and 
progression of cognitive impairment and to follow the course of cognitive changes in an 
individual over time. Administration of the test takes between 5 and 10 minutes and 
examines functions including registration, attention and calculation, recall, language, ability 
to follow simple commands and orientation. The MMSE will be used in the current study in 
order to exclude for cognitive impairment at screening. 
 
Primary Outcome Measure: Neuroimaging Methods  
 
fMRI Task Description. The current proposal will implement a variation of the monetary 
incentive delay (MID) task, the incentive flanker task (IFT). The IFT incorporates a longer 
mean cue time, jittered cue time, and catch trials, all features that facilitate differentiation 
between reward expectancy and reward responsiveness (Stern et al., 2011), though data 
should be comparable to that obtained from the MID for purposes of comparison (thereby 
facilitating the NIH common data elements initiative). We have demonstrated in our 
laboratory that the IFT robustly engages the cortico-striatal reward circuit. During the 
flanker conflict portion of the task, participants are instructed to press the left response 
button for target letters S/K and the right response button for letters H/C (letter assignment 
is counterbalanced across subjects). Target letters are flanked by letters representing same 
or different button presses. Cues presented prior to letter stimuli (2-6 s) designate the 
monetary value for each trial: (1) “gain” cues indicate that subjects earn 50 cents with a 
correct response (and fail to gain with an error); (2) “loss” cues indicate that subjects can 
avoid a loss of 50 cents with a correct response (and lose money with an error); (3) “neutral” 
cues indicate that no money is at stake. Two-thirds of all cues will be followed by the letter 
stimuli. Immediately after the response, outcome feedback is presented for 2 s, followed 
by a blank inter-trial interval (ITI) for 2–6s before the next trial begins with a new cue. One-
third of cues will be followed by a blank screen for 2s (“catch” trials), which will break co-
linearity between the cue and feedback, allowing differentiation of brain activity related to 
expectancy and feedback response despite the slow hemodynamic response of the Blood-
Oxygen-Level-Dependent (BOLD) signal. Even though BOLD signals to the button press 
response and outcome are not distinguishable in the current paradigm, comparisons 
between gain, loss, and null outcomes will subtract out brain activity related to motor 
responses occurring in each condition. 


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fMRI Task Analysis. Prior to analyzing imaging data, task behavioral data including reaction 
time (RT) and accuracy in response to flanker stimuli will be analyzed using ANCOVAs 
(including site, and any potential confounds) to examine main effects and interactions of 
treatment condition and cue type on reaction time and accuracy. fMRI data will undergo 
preprocessing using a combination of AFNI, FSL, and Advanced Normalization Tools (ANTs), 
including despiking, motion correction, alignment to anatomical image (using boundary-
based registration), intensity normalization, smoothing (FWHM = 5mm), and warping to 
standard space. Motion and intensity outliers will be regressed out the data.  
Following preprocessing, we will first conduct subject-level (also called ‘first-level’) 
analyses. As is the norm in the field, subject-level analyses conduct multiple linear 
regressions for each subject whereby the BOLD signal is predicted from a series of 
categorical regressors specifying the presence or absence of the conditions of interest 
across the full timeseries. As an example, in a trial where a cue is shown for 4 seconds 
followed by an outcome for two seconds, followed by another cue for 4 seconds, the cue 
regressor would be coded “1” (present) for the first and last 4 timepoints (in seconds) and 
“0” (absent) for the 2 middle timepoints where the outcome was shown. For each subject, 
regressions are performed within a standardized neuroimaging analysis software (such as 
Statistical Parametric Mapping, FSL, or AFNI), producing a single beta weight for each 
regressor reflecting the relationship between the presence/absence of condition of interest 
and BOLD signal at each voxel in the brain. For all analyses, the predicted BOLD signal is 
convolved with a standard hemodynamic response function (hrf) to model the slow rise and 
fall of the hemodynamic response in the brain. For each subject, the beta weights are then 
linearly combined to create contrasts (gain > neutral cue contrast, the primary contrast of 
interest for this study, is the beta weight for gain cue minus beta weight for neutral cue). 
This contrast represents the mental construct of reward anticipation. 
Group level analysis is described in Section 16, Statistical Methods and 
Consideration.  
 
Resting State fMRI (R-fMRI). Approximately 10 minutes worth of resting state fMRI data will 
be collected at both sites, pre- and post-treatment. Participants will be instructed to rest, 
eyes open and fixed on a central fixation cross, and to try to remain as still as possible. R-
fMRI data will be examined primarily as an exploratory aim and additionally contributes to 
the common data element initiative. As there are a number of serious, potential confounds 
to the analysis of R-fMRI, advanced processing and analytic methods will be employed, 
including the use of robust artifact detection and removal (Pruim et al., 2015). We will 
conduct targeted analysis to explore whether treatment alters connectivity and network 
patterns with known abnormalities and that are specifically impacted by our treatment 
(e.g., fronto-striatal connectivity implicated in reward; see Heller et al., 2013).  
 
Please see MRI Procedures Appendix for details regarding image acquisition, data transfer, 
processing, and multi-site data quality assurance.  
 
Secondary Outcomes and Safety Measures 


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Clinical Assessments 
 
Temporal Experience of Pleasure Scale (TEPS): The TEPS is an 18-item self-report 
measurement of anticipatory (10 items) and consummatory (eight items) components of 
anhedonia which consists of a series of statements that must be rated according to how 
accurate they are for the individual (Gard et al. 2006).  The scale differentiates the role of 
anticipatory pleasure (‘wanting’) from consummatory pleasure (‘liking’). This scale provides 
a measure of anhedonia and will be used in exploratory analyses.  
 
Anticipatory and Consummatory Interpersonal Pleasure Scale (ACIPS): The ACIPS (Gooding 
& Pflum, 2014) is a measure specifically designed to assess hedonic capacity for social and 
interpersonal pleasure. Given the importance of social rewards for normal human 
experience, and for depressive psychopathology, we include the recently developed ACIPS 
in our current study as an exploratory measure. The ACIPS was designed to assess one's 
ability to experience pleasure in the interpersonal domain. It is a 17-item self-report 
measure that consists of seven anticipatory and 10 consummatory items. The ACIPS is 
scored on a Likert scale, ranging from 1 (very false for me) to 6 (very true for me). The 
format is therefore quite similar to that of the TEPS. Validation studies show good internal 
consistency, convergent and discriminant validity, and good test-retest stability. 
 
Specific Loss of Interest and Pleasure Scale (SLIPS): The SLIPS (Winer et al., 2014) is a 
recently developed and validated measure of anhedonia that is tailored to detect recent 
changes in anhedonia. Many scales, including the SHAPS and the TEPS, appear tailored 
more towards assaying trait-like features related to anhedonia. The scale consists of 23 
items; items range from 0-3 to indicate the degree of change in interest or pleasure from a 
specific experience, relative to the past. Validation studies show that the SLIPS is internally 
consistent, converged with existing state measures of anhedonia and depression, and 
diverged from general measures of affect and trait anticipatory and consummatory 
pleasure. The SLIPS predicted recent changes in anhedonia independent of existing 
measures. Moreover, in respondents reporting moderate or severe symptoms of 
depression, only the SLIPS was associated with recent changes in anhedonia. 
 
The Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR): The QIDS (Rush 
et al. 2003) is a 16-item self-rated instrument designed to assess the severity of depressive 
symptoms. The 16 items cover the nine symptom domains of major depression, and are 
rated on a scale of 0-3. Total score ranges from 0 to 27, with ranges of 0-5 (normal), 6-10 
(mild), 11-15 (moderate), 16-20 (moderate to severe), and 21+ (severe). 
 
Montgomery-Asberg Depression Rating Scale (MADRS) (Montgomery & Asberg, 1979): this 
is a 10-item instrument used for the evaluation of depressive symptoms in adults and for 
the assessment of any changes to those symptoms.  Each of the 10 items is rated on a scale 
of 0 to 6, with differing descriptors for each item. These individual item scores are added 


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together to form a total score, which can range between 0 and 60 points. The MADRS 
provides a measure of the overall level of depression.  
 
The Mood and Anxiety Symptoms Questionnaire (MASQ) (Wardenaar et al., 2010): This is a 
30-item self-report questionnaire, designed to measure dimensions of depression and 
anxiety and has been validated in both clinical and non-clinical samples. The MASQ provides 
three factors with good construct validity: negative affect, positive affect and somatic 
arousal. The scale will be used in the current study to explore changes in the dimensions of 
depression and anxiety. 
 
Clinical Global Impression - Improvement (CGI-I): this is a widely administered clinician 
rated global measure of the degree of improvement from the initial assessment in subject 
overall illness severity. Subjects are rated on a 1-7 scale where 1 corresponds to “Very Much 
Improved”, 2 is “Much Improved”, the anchor for 3 is “Minimally Improved”, the anchor for 
4 is “No Change”, 5 is “Minimally Worse”, 6 is “Much Worse”, and 7 is “Very Much Worse”. 
It will be administered at all subject visits. During the course of the trial subjects for whom 
the CGI-I is greater than 5 will be removed from the study and appropriate care given, for 
safety purposes. 
 
Columbia-Suicide Severity Rating Scale (C-SSRS): The Columbia-Suicide Severity Rating Scale 
(C-SSRS) (Posner et al., 2007) is a comprehensive, semi-structured interview that uniquely 
measures the full spectrum of suicidality including passive and active suicidal ideation, 
suicidal intent as well as suicidal behaviors. Subjects will be assessed at every visit with the 
CSSRS by a qualified rater. Study participants will meet with a study physician at each study 
visit, which will include a review of the C-SSRS. Any subject with an increase in suicidality 
and all those subjects found to have a plan or intent will undergo thorough assessment by 
the study psychiatrist. If, at any point during the clinical trial, a participants will be assessed 
by the study physician with a suicidal ideation with any intent or plan, as measured by a C-
SSRS score of greater than 3 during the past week and with either a GCI-S score ≥6 
(indicating extreme illness severity) or a CGI-I score ≥ 6 (indicating an extreme worseness 
of the symptoms), the site PI, or his designee, will conduct  a safety review to determine 
the appropriate course of action including whether acute intervention is needed and 
whether it is in the best interests of the subject to continue in the study. For more details 
regarding the safety review procedures, please refer to section 5.3 “Safety evaluation”.  
 
Behavioral assessment 
 
Probabilistic Reward Task (PRT): This 25-min task is presented on a 17” PC monitor using E-
Prime (version 1.1; Psychology Software Tools, Inc, Pittsburgh, PA). Stimuli consist of simple 
cartoon faces presented in the center of the monitor. At the beginning of the trial, the face 
has no mouth. After a given delay, either a straight mouth of 11.5 mm (“short mouth”) or 
13 mm (“long mouth”) is presented for 100 ms. On each trial, subjects are instructed to 
press an appropriate button to decide whether a long or small mouth had been presented.  
Unbeknownst to subjects, correct identification of one stimulus (the “rich stimulus”) is 


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rewarded three times more frequently (“Correct! You won 20 cents”) than the other 
(“lean”) stimulus. In healthy controls, this reinforcement schedule leads to a response bias 
(i.e., a preference for the more frequently rewarded stimulus). The task consists of three 
100-trial blocks, and the degree of response bias toward the more frequently reinforced 
stimulus is used for operationalizing sensitivity to reward.  An index of reward learning 
across the task is then computed by subtracting the total response bias in the first block 
from the total response bias in the last block. Stimulus exposure (100 ms) and the difference 
between mouth sizes (11.5 vs. 13 mm) are identical to those in prior studies using this 
paradigm (Pizzagalli et al., 2005, Pizzagalli et al., 2008, Vrieze et al., 2013) and were selected 
to achieve optimal psychometric properties (e.g., overall hit rates of 75-85%).   
 
9.1.7 
Adverse Events 
 
Information regarding occurrence of adverse events will be captured throughout the study. 
Duration (start and stop dates and times), severity/grade, expectedness, outcome, 
treatment and relation to study drug will be recorded on the case report form (CRF). Please 
refer to section 11 “Adverse experience reporting and documentation” for more details. 
 
We will further protect subjects from unanticipated risks by monitoring for adverse effects 
at every visit during treatment by carefully checking for any adverse reactions and by 
assessing suicidality with the CSSRS (Posner et al., 2007).  The careful monitoring of suicidal 
ideation and behavior is a critical component of any study conducted in patients with 
depressive disorder and treatment emergent suicidal ideation has been associated with the 
use of antidepressants and other drugs with CNS penetration. A study clinician assesses SI, 
suicidal behavior and risk at each study visit and a CSSRS is completed.  
 
If, at any point during the clinical trial, a participant will be assessed by the study physician 
with a suicidal ideation with any intent or plan, as measured by a C-SSRS score of greater 
than 3 during the past week and with either a GCI-S score ≥6 (indicating extreme illness 
severity) or a CGI-I score ≥ 6 (indicating an extreme worseness of the symptoms), the site 
PI, or his designee, will conduct a safety review to determine the appropriate course of 
action including whether acute intervention is needed and whether it is in the best interests 
of the subject to continue in the study. For more details regarding the safety review 
procedures, please refer to section 5.3 “Safety evaluation”. 
 
9.2 
Clinical Laboratory Measurements 
 
9.2.1 
Hematology and Blood Chemistry Profile 
Blood will be obtained and sent to each site’s clinical hematology lab for a complete blood 
count with differential, Hemoglobin, Hematocrit, Electrolytes, Metabolic Panel, Lipid Panel, 
Thyroid Function Tests, Hepatic and Renal Function Tests, Serology (only at screening) and 
plasmatic drug concentrations. Blood samples for determination of plasmatic ezogabine 
concentrations will be collected at the Primary outcome visit (V5), stored at each site (at 
MSSM blood sample will be stored at Russo Lab, Mount Sinai School of Medicine, 1425 


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Madison Avenue, ICAHN 10 – 26, New York, NY 10029) and will be processed at a specialized 
lab during the course of the study. These samples will be handled, processed, and mailed 
in accordance with applicable state, federal, and international regulations. 
 
Please, refer to table 2 “Schedule of Assessments, Outcome Measures, Labs, and 
Procedures.” 
 
9.2.2 
Pregnancy Test 
A urine pregnancy test will be obtained from female subjects who are of childbearing age 
prior to their participation in the study (screening visit, V-1), at baseline (V 0), at the primary 
outcome visit (V5), and at study end (V6). 
 
9.2.3 
Urinalysis 
Urine will be obtained and each site’s clinical laboratory for determination of color, urine 
special gravity, osmolality, cellules, proteins and bacteria prior to their participation in the 
study (screening visit; V-1) and at study exit (V6). A urine toxicology screen for drugs of 
abuse will be performed at screening (V-1), baseline (V0), primary outcome visit (V5) and 
study exit (V6).  
 
9.3 
Pharmacokinetics Measurements 
Venous blood samples will be collected for determination of plasmatic ezogabine 
concentrations at the time point specified in Table 2 and will be summarized by visit. Blood 
samples will be stored at each site and will be processed at a specialized lab throughout the 
course of the study. Results will be sent to the study data manager (unblinded member of 
the Mount Sinai study team) via the lab website’s secure online account portal.  
 
10 EVALUATIONS BY VISIT 
 
Study visits may occur within 3 days before or after the scheduled visit, except for V5 
(Primary outcome visit), which may occur at any point after participants have been on their 
highest tolerated treatment dose from at least one week (7 days) up to a maximum of two 
weeks (14 days), and V8 which may take place within six weeks of the Primary Outcome 
Visit (V5).Please refer to Table 2 “Schedule of Assessments, Outcome Measures, Labs, and 
Procedures.” 
 
10.1 Screening Visit (Visit -1) 
 
1. Review the study with the subject and obtain written informed consent and HIPAA 
authorization. 
2. Review inclusion and exclusion criteria. 
3. Assign the subject a unique screening number. 
4. Record demographics data. 
• Demographics Form  
• Edinburg Handedness Inventory 


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5. Perform a clinical interview. 
6. Record medical, psychiatric, medication and treatment history, diagnosis date, and 
prior treatments. 
• Medical History Form  
• Family Psychiatric History Form 
• Anti-Depressant Treatment History Form 
7. Record concomitant medications and tapering of prohibited medications (if applicable). 
8. Perform a complete physical examination. 
9. Perform and record vital signs and EKG. 
10. Perform an ophthalmological exam. 
11. Collect blood for clinical laboratory tests (complete blood count with differential, 
Hemoglobin, Hematocrit, Electrolytes, Metabolic Panel, Lipid Panel, Thyroid Function 
Tests, Hepatic and Renal Function Tests, and serology) and urine for urinalysis, urine 
toxicology and pregnancy test (female subjects who are of childbearing age). 
12. Perform self and clinician administered ratings scale: 
• SCID-5-RV 
• SHAPS 
• CGI-S 
• CSSRS 
• MMSE 
13. Schedule subject for Visit 0 within 6 weeks. 
 
Note: The screening visit may occur on up to three separate days. The whole procedures 
will be completed before the randomization day (baseline visit - visit 0) and within six 
weeks of the first screening visit. Screening measures may be completed under a separate 
screening protocol at each site. As long as the assessments are completed within four 
weeks of the signing of consent for this protocol, the screening measures will not be 
repeated.  
 
10.2 Baseline (Visit 0) 
 
1. Obtain interval medical history. 
2. Record any AEs. 
3. Record changes to concomitant medications. 
4. Collect urine for toxicology and pregnancy test (female subjects who are of childbearing 
age) 
5. Randomization of the subject. 
6. Illustrate drug administration and patient diary compilation. 
7. Perform self and clinician administered ratings scale: 
• SHAPS 
• TEPS 
• ACIPS 
• SLIPS 


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• QIDS-SR 
• MASQ 
• MADRS 
• CSSRS 
• CGI-S 
• CGI-I 
• WHODAS 
• PRT 
• Structural MRI, fMRI during IFT, resting state connectivity. 
 
Note: The Baseline/Randomization Visit should take place within six-weeks of the date 
that the subject signed consent for this study. 
 
10.3 Double Blind Treatment Period (Visits 1 – 4) 
 
1. Obtain interval medical history. 
2. Record any AEs and review subject diary for adverse experiences and dosing 
compliance. 
3. Record changes to concomitant medications. 
4. EKG* 
5. Perform self and clinician administered ratings scale: 
• SHAPS 
• TEPS 
• ACIPS 
• SLIPS 
• QIDS-SR 
• MADRS 
• CSSRS  
• CGI-S 
• CGI-I 
 
Note: Study Visits 1, 2, 3, and 4 are due to take place 1, 2, 3, and 4 weeks after the 
Baseline/Randomization Visit (Visit 0) respectively. To allow for scheduling feasibility, Visits 
1-4 can take place within 3 days before or after the scheduled visit. 
 
* During the Double Blind Treatment Period (Visits 1 – 4), EKG will occur only on visit 4, when 
participants reach drug exposure of 750 mg daily over the prior week and are poised to 
escalate to the highest dose tested in the study of 900 mg daily. The additional EKG 
screening at visit 4 will ensure that no adverse QT effects have emerged prior to escalating 
to the highest dose. If a subject will show a QT intervals over 500 milliseconds or a 60-
milliseconds increase in the QT interval from baseline, the dose will not be escalated and the 
subject will be tapered down from study medication over a three-week period. The study 
participant will be asked to return to study site to complete the primary outcome 


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assessment after one week and will be exited from study upon completion of the taper 
period. Please, refer to section 10.6 Study exit Visit (Visit) and early withdrawal. 
 
10.4 Primary outcome visit (Visit 5) 
 
1. Obtain interval medical history. 
2. Record any AEs and changes in concomitant medications and review subject diary for 
adverse experiences and dosing compliance. 
3. Collect urine for toxicology and pregnancy test (female subjects who are of childbearing 
age) 
4. Illustrate drug tapering schedule. 
5. Perform self and clinician administered ratings scale: 
• SHAPS 
• TEPS 
• ACIPS 
• SLIPS 
• QIDS-SR 
• MASQ 
• MADRS 
• CSSRS  
• CGI-S 
• CGI-I 
• WHODAS 
6. PRT 
7. Structural MRI, fMRI during Incentive Flanker Task (IFT), resting state connectivity. 
8. Beginning of the tapering period, according to FDA guidelines. 
 
Note: The Primary Outcome (Visit 5) study visit will be performed when participants are on 
the highest tolerated treatment dose from at least one week (7 days) up to a maximum of 
two weeks (14 days). During this time, subjects will remain on the same dose of study 
medication (i.e. the highest tolerate dose) and the taper will not be initiated until the 
Primary Outcome Visit has been completed.  
 
At the discretion of the investigator, the study team can repeat any and all primary outcome 
procedures on an alternate date (within the given V5 study window of + 7-14 days) if the 
visit is unable to completed as originally scheduled (e.g., due to fMRI scanner malfunction, 
due to subject and/or study team availability, etc.) given that the procedures are not 
clinically contraindicated.  
 
 
10.5 Taper Period (Phone calls* 1-2) 
 
1. Perform a brief interview and history interval. 
2. Complete the phone check-in form. 


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3. Record any new medical problems and general tolerability. 
4. Record changes to concomitant medications and review dosing compliance. 
5. Provide information on the next dose of the drug, according to the tapering schedule. 
 
The taper period will occur over a three-week period according to the following scheme: 
 
Study drug (ezogabine) 
750 mg orally daily for 1 week 
600 mg orally daily for 1 week 
300 mg orally daily for 1 week 
Discontinue  
 
Subjects who are not able to tolerate the 900mg daily dose will follow one of the below 
taper schedules depending on the maximally tolerable dose.  
 
Case 1. Patient is taking 750 mg/daily at primary outcome visit: 2-week taper 
 
Study drug (ezogabine) – 750 mg  
600 mg orally daily for 1 week 
300 mg orally daily for 1 week 
Discontinue  
 
In Case 1, subjects will be contacted by a research coordinator for Visits 6 and 7 during the 
first and second weeks of the taper period, respectively. 
 
Case 2. Patient is taking 600 mg/daily at primary outcome visit: 1-week taper 
 
Study drug (ezogabine) – 600 mg  
300 mg orally daily for 1 week 
Discontinue  
 
In Case 2, subjects will be contacted by a research coordinator for Visit 6 during the first 
week of the taper period. The Visit 7 telephone call will not take place as the Study Exit 
Visit will be scheduled after the subject completes their first week of the medication 
taper. 
 
Case 3. Patient is taking 450 mg/daily at primary outcome visit: 1-week taper 
 


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Study drug (ezogabine) – 450 mg  
300 mg orally daily for 1 week 
Discontinue  
 
In Case 3, subjects will be contacted by a research coordinator for Visit 6 during the first 
week of the taper period. The Visit 7 telephone call will not take place as the Study Exit 
Visit will be scheduled after the subject completes their first week of the medication taper 
 
Case 4. Patient is taking 300 mg/daily at primary outcome visit: No additional taper 
needed 
 
In Case 4, subjects who are taking a maximum daily dose of 300mg will not require further 
taper before ending study drug intake. In these cases, subjects will not undergo a taper 
period and/or complete a Visit 6 or Visit 7 telephone call. The study exit visit will be 
scheduled after completion of the the Primary Outcome Visit (V5).  
 
* The weekly phone calls during taper period (i.e. Visit 6 and Visit 7) will be conducted by a 
study research coordinator. The weekly phone calls will be scheduled one and two weeks 
after the Primary outcome visit (Visit 5), respectively. However, to ensure feasibility of the 
study and participants’ availability, weekly phone calls may occur within 3 days before or 
after the scheduled one.  If patients follow a one- or two-week taper period, one or two 
weekly phone calls will be scheduled respectively. An explicit request by the study 
participants or any safety concern (e.g., new and unexpected adverse effects, increased 
suicidality risk) will trigger a follow up phone call assessment by a study physician. At 
physician’s discretion, an in-person visit will be scheduled. 
 
10.6 Study exit Visit (Visit 6) and early withdrawal 
 
1. Perform a clinical interview and history interval 
2. Record any AEs. 
3. Record changes to concomitant medications and review subject diary for adverse 
experiences and dosing compliance. 
4. Perform a physical examination with recording of vital signs 
5. Perform EKG. 
6. Perform an ophthalmological exam. 
7. Collect blood for clinical laboratory tests 
8. Collect urine for urinalysis, urine toxicology and pregnancy test (applies to women of 
child-bearing potential only). 
9. Perform self and clinician administered ratings scale: 
• SHAPS 
• TEPS 


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• ACIPS 
• SLIPS 
• QIDS-SR 
• MADRS 
• CSSRS  
• CGI-S 
• CGI-I 
10. PRT*. 
11. Structural MRI, fMRI during IFT, resting state connectivity* 
 
Note: The exit visit may occur on up to three separate days, within 6 weeks of the Primary 
Outcome Visit (Visit 5). The subject will be considered exited from the study when all the 
procedures listed above will be completed. 
 
* This procedure will be performed ONLY for early withdrawal visits that take place before 
completion of the primary outcome visit. Capturing outcome data for patients who do not 
complete the full study protocol will allow a more precise estimate of the treatment effect.  
 
Provision of study follow-up for treatment emergent adverse events at study exit: in case 
of any adverse event (including, but not limited to suicidal ideation or behavior) present at 
the study exit visit, subject will be referred to follow-up care until the event is resolved 
and/or a stable care plan is in place. The site PI will follow up with the subject until the 
abnormal parameter or symptom has resolved or stabilized. 
 
11 ADVERSE EXPERIENCE REPORTING AND DOCUMENTATION 
 
11.1 Adverse Event 
 
An Adverse Event (AE) is any untoward medical occurrence in a study subject administered 
an investigational product and that does not necessarily have a causal relationship with this 
treatment. 
 
An AE therefore can be any unfavorable and unintended sign (including laboratory finding), 
symptom or disease temporally associated with participation in an investigational study, 
whether or not considered drug-related.  In addition to new events, any increase in the 
severity or frequency of a pre-existing condition that occurs after the subject signs a 
consent form for participation is considered an AE.  This includes any side effect, injury, 
toxicity, or sensitivity reaction. 
 
Any condition, laboratory abnormality, or physical finding with an onset date prior to the 
subject signing consent for study participation is considered to be pre-existing in nature and 
part of the subject’s medical history and will not be recorded as AEs. 
 


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AE Expectedness 
An unexpected AE is any adverse drug event, the specificity or severity of which is not 
consistent with the current IB or prescribing information for a marketed compound.  Also, 
reports which add significant information on specificity or severity of a known, already 
documented AE constitute unexpected AEs.  For example, an event more specific or more 
severe than described in the IB would be considered “unexpected”. 
 
AE Severity 
Adverse events will be summarized by the Medical Dictionary for Regulatory Activities 
(MedDRA) system organ class and preferred terms. Separate tabulations and listings will be 
produced for related adverse events, serious adverse events, discontinuation due to 
adverse events and events of at least grade 3 severity. 
 
List criteria for AEs according to the Medical Dictionary for Regulatory Activities (MedDRA) 
Version 19.0 (March 2016) should be used to assess and grade AE severity, including 
laboratory abnormalities judged to be clinically significant. If the experience is not covered 
in the abovementioned criteria, the guidelines shown in Table 3 below should be used to 
grade severity. Notably, the term “severe” is a measure of intensity and that a severe AE is 
not necessarily serious. 
 
Table 3.  AE Severity Grading 
Severity (Toxicity Grade) 
Description 
Mild (1) 
Transient or mild discomfort; no limitation in activity; no 
medical intervention or therapy required. The subject may be 
aware of the sign or symptom but tolerates it reasonably well. 
Moderate (2) 
Mild to moderate limitation in activity, no or minimal medical 
intervention/therapy required. 
Severe (3) 
Marked limitation in activity, medical intervention/therapy 
required, hospitalizations possible. 
Life-threatening (4) 
The subject is at risk of death due to the adverse experience as 
it occurred. This does not refer to an experience that 
hypothetically might have caused death if it were more severe. 
 
AE Relationship to Study Drug 
The relationship of an AE to the study drug should be assessed using the following the 
guidelines in Table 4. 
 
Table 4.  AE Relationship to Study Drug 
Relationship 
to Drug 
Comment 


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Definitely 
Previously known toxicity of agent; or an event that follows a reasonable 
temporal sequence from administration of the drug; that follows a known or 
expected response pattern to the suspected drug; that is confirmed by 
stopping or reducing the dosage of the drug; and that is not explained by any 
other reasonable hypothesis. 
Probably 
An event that follows a reasonable temporal sequence from administration 
of the drug; that follows a known or expected response pattern to the 
suspected drug; that is confirmed by stopping or reducing the dosage of the 
drug; and that is unlikely to be explained by the known characteristics of the 
subject’s clinical state or by other interventions. 
Possibly 
An event that follows a reasonable temporal sequence from administration 
of the drug; that follows a known or expected response pattern to that 
suspected drug; but that could readily have been produced by a number of 
other factors. 
Unrelated 
An event that can be determined with certainty to have no relationship to 
the study drug. 
 
11.2 Serious Adverse Events (SAE) 
 
An SAE is defined as any AE occurring at any dose that results in any of the following 
outcomes: 
• Death 
• Life threatening experience defined as any adverse experience that places the subject, 
in the view of the treating physician, at immediate risk of death at the time of 
occurrence; i.e, 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 an existing hospitalization (except 
scheduled hospitalizations for non-acute, unrelated cause such as an elective surgery) 
• Results in persistent or significant disability/incapacity 
• Is a congenital anomaly/birth defect in the offspring of an exposed subject 
• Important medical events that may not result in death, be life threatening, or require 
hospitalization, may be considered an SAE when, based upon appropriate medical 
judgment, it jeopardizes the subject and may require medical or surgical intervention 
to prevent one of the outcomes listed in this definition. 
• Any death occurring within 30 days of the subject receiving study drug, regardless of 
the subject having discontinued from the protocol, must be reported as an SAE. 
 
Other important medical events may also be considered an SAE when, based on 
appropriate medical judgment, they jeopardize the subject or require intervention to 
prevent one of the outcomes listed. 
 
11.2.1 AE/SAE Reporting Procedures 
 


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To local PPHS (IRB) and Sponsor (e.g., Study PI, Murrough) 
 
AEs are reportable to the IRB and to the Study PI (Dr. Murrough) within 5 business days 
when they meet the following definition: 
Any harm experienced by a subject or other individual that in the opinion of the 
investigator is unexpected AND at least probably related to the research 
A harm is at least probably related to the research if in the opinion of the 
investigator the research procedures more likely than not caused the harm 
All AE/SAEs with an onset date after the subject signs consent for study participation must 
be reported to the IRB at the time of annual renewal. Details of the event must include 
severity, relationship to study drug, duration, action taken, and outcome.    
 
All AE/SAEs that are considered related to study drug must be followed to resolution or 
stabilization if improvement is not expected. AE/SAEs that completely resolve and then 
recur should be recorded as a new AE/SAE. AE/SAEs that are considered related to study 
drug and continuing at 30 days post-last dose should have a comment in the source 
documents by the site PI that the event has stabilized or is not expected to improve. 
 
To NIMH DSMB 
 
All AEs and SAEs will be reported to the NIMH DSMB in data reports prepared three times 
annually. Details of the event must include the AE, severity, expectedness, relationship to 
study drug, duration (start/ stop date), action taken, and outcome. In addition, SAEs that 
meet the following definition are considered immediately reportable SAEs and will be 
reported to the NIH DSMB within 3 business days of the site PI awareness of the event: 
 
• All deaths and immediately life-threatening events, whether related or unrelated; 
• SAEs that are unexpected and at least probably related;  
• SAEs that are expected or unrelated, and are not deaths or immediately life 
threatening (i.e., suicide attempts), will be reported to the DSMB/NIMH in the tri-
annual report. 
 
All AE/SAEs that are considered related to study drug must be followed to resolution or 
stabilization, if improvement is not expected. AE/SAEs that completely resolve and then 
recur should be recorded as a new AE/SAE. AE/SAEs that are considered related to study 
drug and continuing at 30 days post-last dose should have a comment in the source 
documents by the PI that the event has stabilized or is not expected to improve. Other 
supporting documentation of the event may be requested by the DSMB/NIMH and should 
be provided as soon as possible.    
 
To FDA 
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(1) serious, unexpected suspected reaction (the investigator judges there is 
evidence to suggest a causal relationship); 
(2) findings from other clinical, animal, or in-vitro studies that suggest significant 
human risk and 
(3) a clinically important increase in the rate of a serious suspected adverse reaction 
no later than 15 days after determining that the information qualifies for reporting. 
 
Unexpected fatal or life-threatening suspected SAEs should be reported no later than 7 
calendar days after initial receipt of the information. 
 
Pregnancy 
Subjects will be asked to immediately inform the study team and her doctor if any of the 
following occur: 
• She becomes pregnant while taking the study drug 
• She misses her menstrual period, or experiences unusual menstrual bleeding 
• She stops using birth control 
• She thinks, FOR ANY REASON, that she may be pregnant 
 
Pregnancies occurring while the subject is participating in the study or within 30 days after 
the subject’s administration of study drug are considered expedited reportable events. 
Ezogabine is to be discontinued immediately and the subject instructed to return any drug 
to the Investigator.  The pregnancy will be considered an immediately reportable event and 
will be reported to the DSMB and the study PI/Sponsor within 3 business days of the site PI 
becoming aware of the event. The event will also reported to the site local IRB within 5 
business days or following the local IRB regulations, whichever is more conservative.  
 
According to the ezogabine packaging information, physicians are advised to recommend 
that pregnant patients who took ezogabine enroll in the North American Antiepileptic Drug 
(NAAED) Pregnancy Registry. This can be done by calling the toll-free number 1-888-233-
2334, and must be done by patients themselves. Information on the registry can also be 
found at the website www.aedpregnancyregistry.org. 
 
Suicidality 
The careful monitoring of suicidal ideation (SI) and suicidal behavior is a critical component 
of any study conducted in patients with MDD as treatment emergent suicidal ideation has 
been associated with the use of antidepressants and other drugs with CNS penetration. A 
study clinician assesses SI, suicidal behavior, and risk at each study visit and a CSSRS is 
completed.  
 
If, at any point during the clinical trial, a participant will be assessed with a suicidal ideation 
with any intent or plan, as measured by a C-SSRS score of greater than 3 during the past 
week and/or with a GCI-S score ≥6 (indicating extreme illness severity) or a CGI-I score ≥ 6 
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conduct  a safety review to determine the appropriate course of action including whether 
acute intervention is needed and whether it is in the best interests of the subject to 
continue in the study. For more information refer to section 2.1 “Risk/Benefit Assessment” 
and 5.3 “Safety evaluations.” 
 
11.3 Unanticipated Problems (UP) 
 
The Office for Human Research Protections (OHRP) considers unanticipated problems 
involving risks to participants or others to include, in general, any incident, experience, or 
outcome that meets all of the following criteria: 
 
• Unexpected in terms of nature, severity, or frequency given (a) the research 
procedures that are described in the protocol-related documents, such as the IRB-
approved research protocol and informed consent document; and (b) the 
characteristics of the participant population being studied; 
• Related or possibly related to participation in the research (“possibly related” 
means there is a reasonable possibility that the incident, experience, or outcome 
may have been caused by the procedures involved in the research); and 
• Suggests that the research places participants or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously 
known or recognized.  
 
This study will use the OHRP definition of UP. 
 
11.3.1 Unanticipated Problem Reporting  
Incidents or events that meet the OHRP criteria for UPs require the creation and completion 
of an UP report form.  It is the site investigator’s responsibility to report UPs to their IRB 
and to the DCC/study sponsor. The UP report will include the following information: 
 
• Protocol identifying information: protocol title and number, PI’s name, and the IRB 
project number; 
• A detailed description of the event, incident, experience, or outcome;  
• An explanation of the basis for determining that the event, incident, experience, or 
outcome represents an UP;  
• A description of any changes to the protocol or other corrective actions that have 
been taken or are proposed in response to the UP. 
 
To satisfy the requirement for prompt reporting, UPs will be reported using the following 
timeline:   
 
• UPs that are SAEs will be reported to the IRB, NIMH DSMB, and to the DCC/study 
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• Any other UP will be reported to the IRB, the NIMH DSMB, and to the DCC/study 
sponsor within 2 weeks of the investigator becoming aware of the problem.  
• All UPs should be reported to appropriate institutional officials (as required by an 
institution’s written reporting procedures), the supporting agency head (or 
designee), and OHRP within one month of the IRB’s receipt of the report of the 
problem from the investigator. 
 
11.4 Medical Monitoring 
 
Dr. Dan Iosifescu, MD is the medical monitor for the study. Dr. Iosifescu is a Board-certified 
psychiatric and clinical investigator with over a decade of experience in clinical trials of 
psychopharmacological agents in depression and other mood disorders. The medical 
monitor for this study will act as a safety officer who is separate from the study team and 
will assist the study Sponsor/PI in ensuring the quality of the medical monitoring during the 
study. The medical monitor will perform the following specific activities: 
 
• Review all SAEs 
• Review all UPs 
• Review all major protocol deviations (PDs) 
• Review all DSMB and IRB annual safety reports  
• In addition, the medical monitor will be available as a resource to the site PIs and 
the Sponsor/overall project PI in order to assist with review of individual subject 
eligibility 
 
All SAEs, UPs, and major (serious) protocol deviations will be sent to Dr. Iosifescu for 
review within three business days of site awareness. Dr. Iosifescu will provide feedback as 
to whether any action should be taken in regards to the subject’s participation in the trial.   
 
Medical Monitor Contact Information: 
 
Dan V. Iosifescu, M.D., M.Sc. 
Associate Professor of Psychiatry 
NYU School of Medicine 
 
New York, NY 10016 
Phone 646-754-5156 
Fax 212-263-7460 
Dan.Iosifescu@nyumc.org  
 
12 DISCONTINUATION AND REPLACEMENT OF SUBJECTS 
 
12.1 Early Discontinuation of Study Drug  
 


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A subject may be discontinued from study treatment at any time if the subject, the 
investigator feels that it is not in the subject’s best interest to continue.  The following is a 
list of possible reasons for study treatment discontinuation:  
• Subject withdrawal of consent  
• Subject is not compliant with study procedures 
• Adverse event that in the opinion of the investigator would be in the best interest of 
the subject to discontinue study treatment 
• Lost to follow-up 
• Need for early termination of study 
• Positive pregnancy test (females) 
 
If a subject is withdrawn from treatment due to an adverse event, the subject will be 
discontinued from the study. The site PI will follow up with the subject until the abnormal 
parameter or symptom has resolved or stabilized.  All subjects who discontinue study 
treatment should come in for an early discontinuation visit as soon as possible. All subjects 
are free to withdraw from participation at any time, for any reason, specified or unspecified, 
and without prejudice. Reasonable attempts will be made by the investigator to provide a 
reason for subject withdrawals. The reason for the subject’s withdrawal from the study will 
be specified in the subject’s source documents. Refer to section 10.6 “Study exit Visit (Visit 
6 – Day 57) and early withdrawal” for early termination procedures. 
 
12.2 Withdrawal of Subjects from the Study 
 
A subject may be withdrawn from the study at any time if the subject or the investigator, 
feels that it is not in the subject’s best interest to continue.   
 
All subjects are free to withdraw from participation at any time, for any reason, specified 
or unspecified, and without prejudice. 
 
Reasonable attempts will be made by the Investigator to provide a reason for subject 
withdrawals.  The reason for the subject’s withdrawal from the study will be specified in 
the subject’s source documents. As noted above, subjects who discontinue study treatment 
early (i.e., they withdraw prior to Visit 6; Day 57) will have an early discontinuation visit. 
Please, refer to section 10.6 “Study exit Visit (Visit 6 – Day 57) and early withdrawal” for 
early termination procedures. 
 
At the time of study discontinuation, the study team will discuss with the participants  an 
appropriate venue of care. If appropriate and requested by the subject, reasonable efforts 
will be made by the study team to provide the participant information for consultation and 
appropriate transfer of care after study discontinuation. 
 
12.3 Replacement of Subjects 
 


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Subjects randomized who withdraw or are discontinued from the study will not be replaced. 
 
 
13 PROTOCOL DEVIATIONS  
A Protocol Deviation (PD) is defined as any change, divergence, or departure from the IRB-
approved study procedures in a research protocol. 
In the present study, protocol deviations will be classified as either minor (non- serious) 
deviations or major (serious) deviations according to the definitions listed below: 
 
Minor Protocol Deviations: 
A minor protocol deviation occurs when accidental or unintentional changes are made to 
the research protocol (or non-compliance with the protocol) that does not increase risk or 
decrease benefit to subjects, or does not have a significant effect on the subject’s rights, 
safety or welfare; and/or on the integrity of the primary outcome data. Deviations may 
result from the action of the subject, researcher, or research staff.  
 
A minor protocol deviation may be due to the research subject’s non-adherence, or an 
unintentional change to or non-compliance with the research protocol on the part of a 
researcher. Examples of a minor protocol deviation include: 
 
• A rescheduled study visit or a study visit held out of window 
• Failure to collect an ancillary self-report questionnaire 
 
Major Protocol Deviations: 
A major protocol deviation occurs when accidental or unintentional changes are made to 
(or non-compliance occurs with) the IRB approved protocol without prior sponsor and IRB 
approval that increases risk or decreases benefit to subjects, affects the subject’s rights, 
eligibility, safety, or welfare, or the integrity of the primary outcome data.  Examples of 
major protocol deviations include (but are not limited to): 
• Failure to obtain valid informed consent  
• Loss of laptop computer that contained identifiable, private information about subjects 
• Accidental distribution of incorrect study medication or dose 
Randomizing a subject who does not meet inclusion/exclusion criteria 
Failure to comply with Good Clinical Practice (GCP) guidelines will also result in a major 
protocol deviation. The PI will determine if a major protocol deviation will result in 
withdrawal of a subject. 
 
When a protocol deviation occurs, it will be discussed with the Site PI and a Protocol 
Deviation Form detailing the deviation will be generated. This form will be signed by a the 
PI or delegated co-investigator. A copy of the form will be filed in the site’s regulatory binder 
and in the Sponsor’s files. A major protocol deviation that has the potential to impact 
participant safety will be reported to the DSMB as an immediately reportable event, within 
3 business days of site awareness. Please refer to section 11.2.1 “AE/SAE Reporting 
Procedures” for more information.  


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14 DATA SAFETY MONITORING PLAN 
 
14.1 Role of PIs in Safety Monitoring 
 
The PIs will regularly monitor potential risks and procedures for protecting risk at each site. 
The PIs will have monthly teleconference meetings during which any serious adverse events 
(SAEs) or unexpected problems (UPs) will be discussed. The PIs will also meet in-person at 
a minimum of twice yearly to review all aspects of study progress and safety. Each PI is 
ultimately responsible for monitoring the data and safety at that site and will provide 
continuous, close monitoring of adverse events. The investigators and study coordinators 
will evaluate the progress of the study, including periodic assessments of data quality and 
timeliness, participant recruitment, accrual and retention, participant risk versus benefit, 
performance of the various sites, and other factors that can affect study outcome. They will 
also consider factors external to the study, such as scientific or therapeutic developments 
that may have an impact on the safety of the participants or the ethics of the study. 
 
The overall study PI/Sponsor is responsible for AE reporting to the IRB, Data and Safety 
Monitoring Board (DSMB) (see below), and any other pertinent entities. 
 
14.2 Data and Safety Monitoring Board (DSMB) 
 
A Data and Safety Monitoring Board (DSMB) will be created by the NIMH as an independent 
body charged with ensuring that the safety of study subjects is protected and that the 
scientific goals of the study are being met. The DSMB conducts a review of all adverse 
events at least three times yearly, and reports their findings to the study PIs, who will 
inform their respective IRBs regarding the findings. The DSMB will be organized in 
compliance with the NIMH Charter, to ensure the safety of study participants and the 
integrity of the data collected in the projects. To achieve this goal, the DSMB will perform 
an ongoing evaluation of the overall clinical outcomes and the safety of patients 
participating in the clinical trial. The DSMB will also review any proposed amendments to 
the study protocol, perform expedited monitoring of immediately reportable serious 
adverse events, perform ongoing monitoring of all other AEs and SAEs, as well as drop-outs, 
determine whether study procedures should be changed or the study should be halted for 
reasons related to the safety of study subjects, and perform periodic review of the 
completeness and validity of data to be used for analysis of safety and efficacy. The DSMB 
will also ensure subject privacy and research data confidentiality. The DSMB will remain 
extrinsic to the study’s infrastructure.  
 
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15 CLINICAL MONITORING 
 
Clinical site monitoring is conducted to ensure that the rights and well-being of human 
subjects are protected, that the reported trial data are accurate, complete, and verifiable, 
and that the conduct of the trial is in compliance with the currently approved 
protocol/amendment(s), with GCP, and with applicable regulatory requirement(s). See 
separate clinical monitoring plan (CMP) in APPENDIX for full details. The main features are 
below. 
 
• Monitoring for this study will be performed by NIMH Clinical Trials Operations and 
Biostatistics Branch (CTOBB) monitors.  
• Monitoring will be conducted on-site, throughout the study, and involve targeted 
data verification of key data variables 
• The site PI will be provided copies of monitoring reports within 10 days of visit, and 
will be provided to the NIMH DSMB liaison within 30 days of the visit. 
• Details of clinical site monitoring are documented in the CMP.   The CMP describes 
who will conduct the monitoring, at what frequency monitoring will be done, at 
what level of detail monitoring will be performed, and the distribution of monitoring 
reports.   
• The site will perform internal quality management of study conduct, data collection, 
documentation and completion. An individualized quality management plan will be 
developed to describe the site’s quality management.   
 
 
16 STATISTICAL METHODS AND CONSIDERATIONS 
 
The Statistical Analysis Plan (SAP) will contain any modification to the analysis plan 
described below, and in the case of a discrepancy between the protocol and the SAP, all 
analyses will be performed according to the SAP. Any modifications will be made prior to 
the unblinding of study data. 
 
16.1 Data set analyzed 
 
Data will be analyzed on an intent-to-treat basis, i.e., patients will be analyzed according to 
the treatment assigned by randomization regardless of the treatment actually received. 
Patients missing the follow up fMRI will be excluded from the primary outcome analysis. As 
it is impossible to test the missingness mechanism and data may not be missing completely 
at random, a secondary sensitivity analysis will be conducted using multiple imputation for 
the primary endpoint to investigate possible violations of the missing at random 
assumption. Extreme case imputation, whereby the lowest and highest overall observed 
values for the primary endpoint are imputed for any missing value, will also be used to 
assess the robustness of the primary endpoint analysis.  
 
 


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16.2 Demographic and Baseline Characteristics  
 
Descriptive and exploratory analyses will be conducted for all measures to characterize the 
sample. While randomization should protect against baseline group differences, the 
treatment groups will be compared with respect to key baseline assessments and 
demographic variables including race, gender, age, and BMI. Additionally, the patients who 
complete the study will be compared with those who initiate but subsequently drop out of 
the study. All comparisons will be conducted using univariate tests as appropriate (i.e. Chi-
squared test, t-test, or Wilcoxon test).  
 
  
16.3 Analysis of Primary Endpoint 
 
The primary endpoint is the change in activation of the bilateral VS, a region of the reward 
circuit in the brain, at 5 weeks from randomization. Activation will be measured by fMRI, and 
beta weights for each subject will be calculated to create a contrast between gain and neutral 
cues to model reward anticipation as described in the Neuroimaging Methods in Section 9. To 
calculate the beta weight for the bilateral VS, the beta weights for the right and left VS will be 
averaged. 
A linear mixed effects model with a single random intercept term will be used to assess the 
change in activation of the bilateral VS by treatment group.  
Although randomization is stratified by site, the primary endpoint analysis will be of the pooled 
dataset; secondary analyses will provide site-specific estimates. 
 
16.4 Analysis of Secondary Endpoint 
 
Change in activation of other regions of the cortico-striatal rewards circuit in the brain, 
namely the bilateral dorsal striatum (DS), mPFC, and ACC, will be analyzed in the same 
manner as the primary endpoint. 
 
The performance of the PRT and the clinical and self-reports will be examined by using 
descriptive statistics such as the mean, standard deviation, median and interquartile range 
for continuous measures, and by frequency distributions for categorical variables.  
 
Safety and tolerability data will be summarized by treatment group. Adverse event rates 
will be coded by body system and MedDra classification term. Adverse events will be 
tabulated by treatment group and will include the number of patients for whom the event 
occurred, the rate of occurrence, and the severity and relationship to study drug. Incidence 
of adverse events will be compared between treatment groups using Poisson regression. 
 
16.5 Interim Analysis 
 


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None 
 
16.6 Sample Size and Randomization 
 
Based on our pilot data, the within-subject effect of time (corresponding to treatment with 
high-dose ezogabine 900 mg daily) was Cohen’s d = 0.95. As noted above, we utilized mean 
values extracted from a bilateral anatomical mask in order to minimize effect size inflation. 
Assuming a placebo effect on the brain of Cohen’s d = 0.15 (see Price et al., 2008; Fournier et 
al., 2010), we estimate a between-group effect of 0.8 (Morris, 2008). A sample size of 48 
provides 85% power to detect a difference in means between groups of 0.8 standard 
deviations assuming a correlation of 0.6 between a pair of measurements made on the same 
subject using a two-sided 0.05 significance level test. 
 
17 DATA COLLECTION, RETENTION AND MONITORING 
 
17.1 Data Collection Instruments 
 
The Investigator will prepare and maintain adequate and accurate source documents 
designed to record all observations and other pertinent data for each subject treated with 
the study drug.   
 
Study personnel at each site will enter data from source documents corresponding to a 
subject’s visit into the protocol-specific electronic Case Report Form (CRF) when the 
information corresponding to that visit is available. Subjects will not be identified by name 
in the study database or on any study documents to be collected by the Sponsor (or 
designee), but will be identified by the site number, subject number and initials. If a 
correction is made on a CRF, the study staff member will line through the incorrect data, 
write in the correct data and initial and date the change.  
 
An Electronic Data Capture (EDC) system that includes several components, including a 
Screening Database and a Subject Tracking Database will be employed. Following 
completion of informed consent, a unique screening ID number will be assigned and basic 
identifying information will be collected on all individuals who undergo evaluation for study 
eligibility. This data, linked to the Screening ID, will be entered into the Screening Database 
and at a minimum will include subject name and date of birth. Once an individual meets all 
eligibility criteria and proceeds to the Randomization phase of the study, a unique Study ID 
number will be assigned and the subject will be entered into the Subject Tracking Database. 
A subject record in the Patient Tracking Database will be initiated with entries (variables) 
for each visit, and for each form included in the protocol for each visit. As patients complete 
visits the date of the visit will be entered into the database. Missed visits will be coded for 
reason (such as illness, scheduling problem, inability to contact, etc.). Within each visit, a 
field will be filled in for each form expected for that evaluation, containing either an 
indicator that the form was completed or a code indicating why it was not completed. If 


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patients terminate early, the date and reason will be coded in the Patient Tracking 
Database.  
 
The PI is responsible for all information collected on subjects enrolled in this study.  All data 
collected during the course of this study must be reviewed and verified for completeness 
and accuracy by the Investigator or his/her designee. 
 
17.2 Data Management Procedures 
 
The data will be entered into a validated database. The Data Management group will be 
responsible for data processing, in accordance with procedural documentation. Database 
lock will occur once quality assurance procedures have been completed. All procedures for 
the handling and analysis of data will be conducted using good computing practices 
meeting FDA guidelines for the handling and analysis of data for clinical trials. 
 
17.3 Data Quality Control and Reporting 
 
After data have been entered into the study database, a system of computerized data 
validation checks will be implemented and applied to the database on a regular basis. In 
EDC system queries are entered, tracked, and resolved through the EDC system directly. 
The study database will be updated in accordance with the resolved queries. All changes to 
the study database will be documented. 
 
17.4 Archival of Data 
 
The database is safeguarded against unauthorized access by established security 
procedures; appropriate backup copies of the database and related software files will be 
maintained. Databases are backed up by the database administrator in conjunction with 
any updates or changes to the database. 
 
At critical junctures of the protocol (e.g., production of interim reports and final reports), 
data for analysis is locked and cleaned per established procedures.  
 
17.5 Availability and Retention of Investigational Records 
 
The Investigator must make study data accessible to the medical monitor, other authorized 
representatives of the PI, IRB, NIMH, and Regulatory Agency (e.g., FDA) inspectors upon 
request. A file for each subject must be maintained that includes the signed Informed 
Consent, HIPAA Authorization and Assent Form and copies of all source documentation 
related to that subject. The Investigator must ensure the reliability and availability of source 
documents from which the information on the CRF was derived. 
 


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All study documents (patient files, signed informed consent forms, copies of CRFs, Study 
File Notebook, etc.) must be kept secured for a period of two years following marketing of 
the investigational product or for two years after study end.  
 
17.6 Subject Confidentiality 
 
In order to maintain subject confidentiality, only a site number, subject number and subject 
initials will identify all study subjects on CRFs and other documentation submitted to the 
Sponsor. 
 
 
18 ADMINISTRATIVE, ETHICAL, REGULATORY CONSIDERATIONS 
 
The study will be conducted according to the Declaration of Helsinki, Protection of Human 
Volunteers (21 CFR 50), Institutional Review Boards (21 CFR 56), and Obligations of Clinical 
Investigators (21 CFR 312). 
 
To maintain confidentiality, all laboratory specimens, evaluation forms, reports and other 
records will be identified by a coded number for the site and the subject number and initials 
only. All study records will be kept in a locked file cabinet and code sheets linking a patient’s 
name to a patient identification number will be stored separately in another locked file 
cabinet. Clinical information will not be released without written permission of the subject, 
except as necessary for monitoring by the NIMH or FDA. The Investigator must also comply 
with all applicable privacy regulations (Health Insurance Portability and Accountability Act 
of 1996). 
 
18.1 Protocol Amendments 
 
Any amendment to the protocol will be written by the PI.  Protocol amendments cannot be 
implemented without prior written IRB and DSMB approval except as necessary to 
eliminate immediate safety hazards to patients. A protocol amendment intended to 
eliminate an apparent immediate hazard to patients may be implemented immediately, 
provided the IRBs and the DSMB are notified within five working days. 
 
18.2 Institutional Review Boards and Independent Ethics Committees 
 
The protocol and consent form will be reviewed and approved by the IRB of each 
participating center prior to study initiation. Serious adverse experiences regardless of 
causality will be reported to the IRB in accordance with the standard operating procedures 
and policies of the IRB, and the Investigator will keep the IRB informed as to the progress 
of the study. The Investigator will obtain assurance of IRB compliance with regulations. 
 
Any documents that the IRB may need to fulfill its responsibilities (such as protocol, 
protocol amendments, Investigator’s Brochure, consent forms, information concerning 


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patient recruitment, payment or compensation procedures, or other pertinent 
information) will be submitted to the IRB.  The IRB written unconditional approval of the 
study protocol and the informed consent form will be in the possession of the Investigator 
before the study is initiated. This approval must refer to the study by exact protocol title 
and number and should identify the documents reviewed and the date of review. 
The IRB must be informed of revisions to other documents originally submitted for review; 
serious and/or unexpected adverse experiences occurring during the study in accordance 
with the standard operating procedures and policies of the IRB; new information that may 
affect adversely the safety of the patients of the conduct of the study; an annual update 
and/or request for re-approval; and when the study has been completed. 
 
18.3 Informed Consent Form  
 
Informed consent will be obtained in accordance with the Declaration of Helsinki, ICH GCP, 
US Code of Federal Regulations for Protection of Human Subjects (21 CFR 50.25[a,b], CFR 
50.27, and CFR Part 56, Subpart A), the Health Insurance Portability and Accountability Act 
(HIPAA), and local regulations. 
 
The Investigator will prepare the informed consent form and HIPAA authorization and 
provide the documents to the IRB for approval. The study DSMB will also review the 
protocol and informed consent form (ICF) prior to study initiation. The ICF generated by the 
Investigator must be approved by the IRB and the DSMB. The written consent document 
will embody the elements of informed consent as described in the International Conference 
on Harmonisation and will also comply with local regulations.  
 
A properly executed, written, informed consent will be obtained from each subject prior to 
entering the subject into the trial. Information should be given in both oral and written form 
and subjects must be given ample opportunity to inquire about details of the study.. A copy 
of the signed ICF will be given to the subject or legal representative of the subject and the 
original will be maintained with the subject’s records. 
 
18.4 Publications and Data Sharing 
 
The preparation and submittal for publication of manuscripts containing the study results 
shall be in accordance with a process determined to be appropriate by the study PI and co-
Investigators and participating institutions. The publication or presentation of any study 
results shall comply with all applicable privacy laws, including, but not limited to, the Health 
Insurance Portability and Accountability Act of 1996. 
 
This study will comply with the NIH Public Access Policy, which ensures that the public has 
access to the published results of NIH funded research.   It requires scientists to submit final 
peer-reviewed journal manuscripts that arise from NIH funds to the digital archive PubMed 
Central upon acceptance for publication. 
 


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The ICMJE policy, and the Section 801 of the Food and Drug Administration Amendments 
Act of 2007, requires that all clinical trials be registered in a public trials registry such as 
ClinicalTrials.gov, which is sponsored by the National Library of Medicine. 
 
FDAAA mandates that a “responsible party” (i.e., the sponsor or designated principal 
investigator) register and report results of certain “applicable clinical trials”; for trials of 
drugs and biologics, this entails controlled, clinical investigations, other than Phase 1 
studies, of a product subject to FDA regulation. 
 
NIH grantees must take specific steps to ensure compliance with NIH implementation of 
FDAAA. 
 
All the data from this trial will be recorded in the National Database for Clinical Trials 
Related to Mental Illness (NDCT), an informatics platform for the sharing of human subjects’ 
data from all clinical trials funded by the National Institute of Mental Health (NIMH). 
 
The data repository is accessible only to qualified investigators and all subject data will be 
de-identified and not linkable directly to the study participant. None of the personally 
identifiable information (PII) will be exposed and each subject will be identified with a 
Global Unique Identifier (GUID). All participants will be assigned a GUID by the Data 
Management Center (DMC) for this study. The following information will be collected and 
entered into the study database to generate a GUID: First name, Last name, Middle name 
(if applicable), Month of birth, Day of birth, Year of birth, Physical sex at birth, and Name of 
city/municipality of birth. Once the GUID is generated, all personal information will be 
deleted from the study database. 
 
During and after study conclusion, qualified study team members will send de-identified 
information of study participants to the NDCT. The de-identified study data will be 
accessible for research purposes to other researchers nationwide under the supervision of 
the NIMH that will regulate and supervise the access to study data in order to minimize the 
risks to participants’ privacy. NDCT data could also be used by NIMH to report to Congress 
and on its web site. For more information on NDCT, please refer to http://ndct.nimh.gov. 
 
18.5 Conflict of Interest 
 
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons who 
have a role in the design, conduct, analysis, publication, or any aspect of this trial will be 
disclosed and managed.  Furthermore, persons who have a perceived conflict of interest 
will be required to have such conflicts managed in a way that is appropriate to their 
participation in the trial. The study leadership in conjunction with the NIMH IC has 
established policies and procedures for all study group members to disclose all conflicts of 
interest and will establish a mechanism for the management of all reported dualities of 
interest.  


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18.6 Investigator Responsibilities 
 
By signing the Agreement of Investigator form, the Investigator agrees to: 
1. Conduct the study in accordance with the protocol and only make changes after 
notifying the PI/Sponsor (or designee), except when to protect the safety, rights or 
welfare of subjects 
2. Personally conduct or supervise the study (or investigation). 
3. Ensure that the requirements relating to obtaining informed consent and IRB review 
and approval meet federal guidelines, as stated in § 21 CFR, parts 50 and 56. 
4. Report to the PI/Sponsor or designee any AEs that occur in the course of the study, in 
accordance with §21 CFR 312.64. 
5. Ensure that all associates, colleagues and employees assisting in the conduct of the 
study are informed about their obligations in meeting the above commitments. 
6. Maintain adequate and accurate records in accordance with §21 CFR 312.62 and to 
make those records available for inspection with the PI/Sponsor (or designee). 
7. Ensure that an IRB that complies with the requirements of §21 CFR part 56 will be 
responsible for initial and continuing review and approval of the clinical study. 
8. Promptly report to the IRB and the PI/Sponsor (or designee) all changes in the research 
activity and all unanticipated problems involving risks to subjects or others. 
9. Seek IRB approval before any changes are made in the research study, except when 
necessary to eliminate hazards to the patients/subjects. 
10. Comply with all other requirements regarding the obligations of clinical investigators 
and all other pertinent requirements listed in § 21 CFR part 312. 
 


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Mood and Anxiety Symptoms Questionnaire (MASQ). Psychiatry Res. 179, 101-106 
(2010).Whiteford, H. A. et al. Global burden of disease attributable to mental and substance 
use disorders: findings from the Global Burden of Disease Study 2010. Lancet 382, 1575-
1586 (2013). 
Winer, E. S., Veilleux, J. C. & Ginger, E. J. Development and validation of the Specific Loss of 
Interest and Pleasure Scale (SLIPS). J. Affect. Disord. 152-154, 193-201 (2014). 
World Health Organization, 2012. Measuring health and disability: manual for the WHO 
Disability Assessmetn schedule (WHODAS 2.0), World Health Organization, 2010, Geneva 
Zhang, W. N., Chang, S. H., Guo, L. Y., Zhang, K. L. & Wang, J. The neural correlates of 
reward-related processing in major depressive disorder: a meta-analysis of functional 
magnetic resonance imaging studies. J. Affect. Disord. 151, 531-539 (2013). 


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20 APPENDIX 
 
Table 1. List of Prohibited Medications* 
Antidepressants 
Generic 
Trade name 
Clomipramine  
Anafranil (SR) 
Placil 
 
 
 
Sertraline 
Zoloft 
Lustral 
 
 
 
Citalopram 
Celexa 
 
 
 
 
Escitalopram 
Lexapro 
Cipralex 
 
 
 
Fluoxetine 
Prozac 
 
 
 
 
Fluvoxamine 
Luvox 
 
 
 
 
Duloxetine 
Cymbalta 
 
 
 
 
Mirtazapine 
Remeron 
Remeron SolTab 
 
 
 
Paroxetine 
Paxil 
Seroxat 
 
 
 
Venlafaxine 
Effexor 
 
 
 
 
Desvenlafaxine 
Pristiq 
 
 
 
 
Levomilnacipran 
Fetzima 
 
 
 
 
Tofenacin 
Elamol 
Tofacine 
 
 
 
Doxepine 
Sinequan 
 
 
 
 
Desipramine  
Norpramin 
Pertofran  
 
 
 
Imipramine 
Apo-Imipramine 
Norfranil 
Janimine 
Novopramine 
Impril 
Mianserine 
Tolvon 
 
 
 
 
Nefazodone 
Dutonin 
Serzone 
 
 
 
Protriptyline 
Triptil 
Vivactil 
Concordin 
 
 
Reboxetine 
Edronax 
 
 
 
 
Isocarboxazid 
Marplan 
 
 
 
 
Phenelzine  
Nardil 
 
 
 
 
Tranylcypromine 
Parnate 
 
 
 
 
Selegiline 
Deprenyl 
Eldepryl 
Emsam 
 
 
Centrally active sedating antihistamines 
Generic 
Trade name 
Azelastine HCl 
Astelin 
Optivar 
 
 
Dimenhydrinate 
Dramamine 
 
 
 
Hydroxyzine HCl 
Atarax 
Vistaril 
 
 
Levocabastine 
Livostin 
 
 
 
Methdilazine 
 
 
 
 
Promethazine 
Phenergan 
Anergan 
Pentazine 
Phenazine 
 
Phencen 
Phenerzine 
Phenoject 
Pro-50 
 
Promacot 
Pro-Med 50 
Promet 
Prorex 
 
Prothazine 
Shogan 
V-Gan-50 
 
Trimeprazine 
 
 
 
 
Antipsychotics 
Generic 
Trade name 
Aripiprazole 
Abilify 
 
 
 
Chlorpromazine  
Chlorpromanyl 
Largactil 
Novo-Chlorpromazine 
Thorazine 
Clozapine 
Clozaril 
 
 
 
Fluphenazine decanoate 
Modecate 
Prolixin Decanoate 
 
 
Fluphenazine enanthate 
Moditen Enanthate 
Prolixin 
Enanthate 
 
Fluphenazine HCl 
Anatensol 
 
 
 
Haloperidol 
Haldol 
Dozic 
Peridol 
Serenace 
Lurasidone 
Latuda 
 
 
 
Loxapine 
Loxapac 
 
 
 
Mesoridazine Besylate 
Serentil 
 
 
 
Molindone 
Moban 
 
 
 
Olanzapine 
Zyprexa 
 
 
 
Prochloperazine 
Compazine 
 
 
 
Quetiapine Fumarate 
Seroquel 
 
 
 
Risperidone 
Risperdal 
 
 
 
Thioridazine HCl 
Phenothiazines 
Serentil 
Prolixin 
Thorazine 
 
Mellaril 
Trilaton 
Vesprin 
 


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Thiothixene 
Navane 
 
 
 
Ziprasidone 
Geodon 
 
 
 
Psychotropics miscellaneous 
Generic 
Trade name 
Lithium 
Camcolit 
Carbolith 
Duralith 
Eskalith 
 
Lituane 
Lithicarb 
Lithizine 
Lithobid 
 
Lithonate 
Lithotabs 
Priadel 
Cibalith-S 
Modafinil 
Provigil 
 
 
 
R-modafinil 
Nuvigil 
Armodafinil 
 
 
Phenelzine sulfate 
Nardil 
 
 
 
Sodium oxybate 
Xyrem 
 
 
 
Stimulants 
Dextroamphetamine 
Dextrostat 
Ferndex 
 
 
Amphetamine/dextroamphe
tamine 
Adderall 
Benzedrine 
 
 
Methamphetamine 
Methedrone 
Desoxyn 
Gradumet 
 
 
Methylphenidate 
Ritalin 
Metadate 
Methylin 
Concerta 
Dopaminergic agents (e.g. levodopa, pramipexole, ) 
Generic 
Trade name 
Levodopa 
Sinemet 
 
 
 
Pramipexole 
Mirapex 
 
 
 
Ropinorole 
Requip 
 
 
 
Rotigotine 
Neupro 
 
 
 
Anti-Seizure Medications 
Generic 
Trade name 
Gabapentin 
Neurontin 
 
 
 
Valproic Acid 
Depakote 
 
 
 
Carbemazepine 
Tegretol 
 
 
 
Lamotrigine 
Lamictal 
 
 
 
Pregabalin 
Lyrica 
 
 
 
Opioids 
Generic 
Trade name 
Buprenorphine 
Suboxone 
 
 
 
Dihydrocodeinone 
Vicodin 
 
 
 
Methadone 
Methadone 
 
 
 
Morphine 
Morphine 
 
 
 
Oxycodone 
Oxycontin 
 
 
 
Tramadol 
Ultram 
 
 
 
(Dextro)propoxyphene 
Darvon 
 
 
 
Meperidine 
Demerol 
 
 
 
 
* In addition to specific medications listed, the following classes of medication are 
prohibited: 
(1) 
antidepressant 
medication, 
(2) 
antipsychotic 
medication, 
(3) 
anticonvulsant/mood stabilizer medications, (4) lithium, (5) stimulant medication. hypnotic 
medications used PRN are allowed (including zolpidem, zaleplon, eszopliclone, 
diphenhydramine, suvorexant, and ramelteon) except within 24 hours of the baseline and 
primary outcome fMRI and behavioral assessments. Benzodiazepine medications used PRN 
(not to exceed 2 mg of lorazepam equivalents daily) except within 24 hours of the baseline 
and primary outcome fMRI and behavioral assessments. 


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Table 2: Schedule of Assessments, Outcome Measures, Labs, and Procedure 
Study Phase 
Screening 
Double-Blind Treatment Period 
(Weekly Study Visits) 
Primary 
outcome 
Taper Period 
(Weekly Phone Call) 
Taper + 
Study exit 
Study Visit 
V-1 
V0 e 
V1 
V2 
V3 
V4 
V5 
PC1 f 
PC2 f 
V6 
Screening 
Informed Consent 
x 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
x 
 
 
 
 
 
 
 
 
 
Demographics 
x 
 
 
 
 
 
 
 
 
 
Medical History 
x 
 
 
 
 
 
 
 
 
 
Family Psychiatric History 
x 
 
 
 
 
 
 
 
 
 
Anti-Depressant Treatment 
History Form 
x 
 
 
 
 
 
 
 
 
 
Edinburg Handedness 
Inventory 
x 
 
 
 
 
 
 
 
 
 
SCID-5-RV 
x 
 
 
 
 
 
 
 
 
 
Study drug/Placebo administration 
 
Randomization  
 
x 
 
 
 
 
 
 
 
 
Ezogabine/Placebo Treatment 
 
 
x 
x 
x 
x 
x 
 
 
 
Ezogabine/Placebo Taper 
 
 
 
 
 
 
 
x 
x 
x 
Safety assessments, concomitant medication and compliance monitoring 
Physical Exam 
x 
 
 
 
 
 
 
 
 
x 
Vital Signs 
x 
 
 
 
 
 
 
 
 
x 
Laboratory Tests a 
x 
 
 
 
 
 
 
 
 
x 
ECG 
x 
 
 
 
 
x 
 
 
 
x 
U-Toxicology 
x 
x 
 
 
 
 
x 
 
 
x 
Pregnancy Test 
x 
x 
 
 
 
 
x 
 
 
x 
Ophthalmological Exam 
x 
 
 
 
 
 
 
 
 
x 
Adverse Events 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
C-SSRS 
x 
x 
x 
x 
x 
x 
x 
 
 
x 
Medication Compliance b 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
MMSE 
x 
 
 
 
 
 
 
 
 
 
Clinical efficacy assessments 
SHAPS c 
x 
x 
x 
x 
x 
x 
x 
 
 
x 
CGI-S c; CGI-I 
x 
x 
x 
x 
x 
x 
x 
 
 
x 
MADRS 
 
x 
x 
x 
x 
x 
x 
 
 
x 
SLIPS 
 
x 
x 
x 
x 
x 
x 
 
 
x 
ACIPS 
 
x 
x 
x 
x 
x 
x 
 
 
x 
TEPS 
 
x 
x 
x 
x 
x 
x 
 
 
x 
QIDS-SR 
 
x 
x 
x 
x 
x 
x 
 
 
x 
MASQ 
 
x 
 
 
 
 
x 
 
 
 
WHODAS 
 
x 
 
 
 
 
x 
 
 
 
Behavioral efficacy assessments 
PRT 
 
x 
 
 
 
 
x 
 
 
 
Pharmacokinetics 
Ezogabine serum level 
 
 
 
 
 
 
x 
 
 
 
Biomarkers 
Neuroimaging d 
 
x 
 
 
 
 
x 
 
 
 
* Study visits may occur 3 days before or after the scheduled visit. For V5 (Primary outcome), subjects will be on the highest tolerated treatment dose for at least one week and  up to two weeks from V4 
(during this time the subject will remain on the same dose of medication and taper will not be started until V5 is completed). Visits 6 and 7 will occur as dictated by Section 10.5 Taper Period (Phone calls* 1-
2) of the protocol, in accordance with the corresponding taper schedule that is followed. Visit 8 will occur within 6 weeks of Visit 5 (Primary Outcome).a Clinical laboratory tests include chemistry, complete 


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blood count, liver function tests, serology (only at screening) and thyroid-stimulating hormone levels (see protocol for details); b Compliance will be assessed by subject report, pill count and serum drug levels; 
c SHAPS score ≥ 20 and CGI-S score ≥ 4 required for inclusion; d Neuroimaging acquisition includes a high resolution T1 anatomical scan and BOLD acquisitions for resting state functional connectivity (rs-fMRI) 
and task-activation fMRI during the incentive flanker task (IFT); e Baseline assessment; f Weekly phone call during taper period will be conducted by a study research coordinator and may occur within 3 days 
before or after the scheduled phone call. An explicit request by the study participants or any safety concern will trigger a follow up phone call assessment by a study physician. At physician’s discretion, an 
eventual in person visit will be scheduled. 
Abbreviations: ACIPS, Anticipatory and Consummatory Interpersonal Pleasure Scale; C-SSRS, Columbia-Suicide Severity Rating Scale; CGI-I, Clinical Global Impression-Improvement; CGI-S, Clinical Global 
Impression-Severity; ECG, Electrocardiogram; fMRI, functional Magnetic Resonance Imaging; MADRS, Montgomery-Asberg Depression Rating Scale; MASQ, Mood and Anxiety Symptom Questionnaire; MMSE, 
Mini Mental State Examination, PC, Phone Call; PRT, Probabilistic Reward Task; QIDS-SR, Quick Inventory of Depressive Symptomatology-Self-Report; SHAPS, Snaith-Hamilton Pleasure Scale; SLPIS, Specific 
Loss of Interest and Pleasure Scale; TEPS, Temporal Experience of Pleasure Scale; World Health Oraganization Disability Assessment Schedule 2.0 (WHODAS 2.0).  
Magnetic Resonance Imaging (MRI) Procedures Appendix  
 
MRI data will consist of the following for each subject, at each timepoint:  
- 
MP2RAGE 0.1mm3 Anatomical Image 
- 
Multi-Echo (4) Multiband (5) MEMB 3.0mm3 Field Maps  
- 
1 x MEMB 3.0mm3 Resting State fMRI data (10 min)  
- 
4 x MEMB 3.0mm3 Task fMRI data (5m50s each)  
o Accompanying EDat file containing behavioral response data 
 
MRI data will be centrally stored and preprocessed at the MSSM site, using dedicated servers that 
will be accessible to all sites via secured on-site and off-site networking channels. Storage, 
management, and access of data will be managed using the software XNAT, a package developed 
by the Neuroinformatics Research Group at Washington University at St. Louis. The XNAT system is 
optimized for the aforementioned functions, using validated safeguards to safeguard Protected 
Health Information. Key features of the XNAT system include an easy-to-use web interface, a 
Representation State Transfer (REST) Application Program Interface (API) for programmer-level 
access to data, and easy connection to DICOM application entities. The XNAT database is organized 
by subjects, scan sessions, and individual MRI runs. Our XNAT system will also be configured to 
support other subject and scan-specific resources, such as clinical data at the subject level, and at 
the experiment-level, as well as timing files (i.e., EDat files) from fMRI tasks performed by subjects, 
to be used later at analysis stages. The MSSM site has three years of hands-on experience in 
installing and administering XNAT and keeping installations current with security and performance 
updates. The XNAT system will be managed by one or more postdoctoral fellows with expertise in 
neuroinformatics, supervised by Dr. Prantik Kundu, with additional support provided by existing 
technical personnel at the Translational and Molecular Imaging Institute (TMII) at MSSM. 
 
Prior to the first scan of the study, the MRI scanners at both sites will be configured to directly 
access the XNAT system, via a built-in DICOM catcher. This setup will enable seamless uploads of 
DICOM files during the study directly from site scanners. A Standard Operating Protocol (SOP) will 
be distributed to scan sites that will describe appropriate local and global system configuration. In 
the case of issues during initial configuration or ongoing use, the team at MSSM will provide 
technical support via phone or video-conference. If severe or time-sensitive issues arise, a member 
from the MSSM team will travel to the Baylor College of Medicine (BCM) site to correct problems. 
Each imaging session will be labeled according to the anonymized subject code, then input to 
scanners by MRI technicians, and transferred to XNAT as part of the session label. Subject names 
will not be stored on the XNAT system, and de-anonymization of data for analysis will be done at 
analysis sites, not in the framework of the XNAT system. 
 


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The XNAT system will be installed on a large-capacity storage and analysis server at MSSM. The 
system will be physically racked at the university's datacenter, which has a high-capacity AC system 
and an uninterruptable power supply (UPS) with generator back-up. The server will be hosted on 
the university network, with security by a firewall configured by MSSM system administrators to 
allow secure incoming connections from remote sites. The server will be configured with a long-
term-support Linux operating system (OS) and the ZFS file system. The ZFS will be configured to 
provide both disk and file-level redundancies so that even multiple disk-related corruptions or total 
disk failures will be transparently recovered from. In any such case, which as a matter of record and 
by design is rare, the MSSM team will be informed to allow necessary remediation. The ZFS will also 
be configured with disk-level encryption to enable further security. The ability of ZFS to make fast 
snapshots will be used for protecting system and data files regularly and especially for software or 
database updates, so errors can be recovered with minimal effort and downtime. For backup at 
BCM, the system files, database, and MRI data will be sent to cloud storage via snapshots created 
with encryption to protect PHI. This encrypted backup data will only be accessed in the case of 
catastrophic failure as by an "act of God."  
 
For each upload of MRI session data from a site scanner to the XNAT system (e.g. DICOM files), 
pipelines will be automatically launched to do quality assurance (QA) and preprocessing. 
Recognizing that MB-fMRI is among the most taxing sequences for MRI, the QA metrics for resting 
state data will be tracked to detect major changes in scanner performance. Since head motion in 
rs-fMRI data tends to indicate the overall motion seen over an MRI session, rs-fMRI motion 
diagnostics will be tracked for trends in subject behavior across sites. Feedback on these trends will 
be regularly sent to sites and be posted as interactive report pages in XNAT under the listing for 
each MRI session. The QA metrics planned are: absolute and relative root-mean-square (RMS) head 
motion, in millimeter and percent, full-width-half-max image smoothness, signal time series 
standard deviation, temporal signal-to-noise ration, and DVARS 1st and second moments. 
Moreover, montages of the acquired images will be available directly from the XNAT web interface 
to make detection of major issues easy for users across levels of expertise. QA metrics will also be 
available for later analysis as covariates to account for otherwise unmitigated variance in data 
quality.  
 
QA values will be checked by algorithm to flag if a scan is usable or requires further attention. 
Accepted data will then be preprocessed automatically, using the XNAT pipeline engine. First, 
DICOM files will converted to NIFTI files, which removes PHI, and NIFTI files for the different scans 
will be saved as session-specific resources in XNAT. In essence, this makes the raw data available to 
users via the PHI-stripped NIFTI format. Then, NIFTI files will be routed to the appropriate HCP-
based preprocessing scripts, using MRI parameters from DICOM headers to assure proper matching. 
The XNAT server will be able to fully preprocess around all data at a rate comparable to the scanning 
schedule. Final output files from HCP-style preprocessing will then be added to the XNAT session as 
NIFTI resources. These NIFTI files would also later be migrated to data repositories for open data 
sharing, in accordance with NIH mandates. 
 

SAP_000.pdf: 
Developing Neuronal KCNQ Channel Modulators for Mood Disorders 
PI: Dr. James Murrough 
NCT03043560 
Document Date: June 2018


1 
 
 
 
STATISTICAL ANALYSIS PLAN 
 
 
DEVELOPING NEURONAL 
KCNQ CHANNEL 
MODULATORS FOR MOOD 
DISORDERS 
 
 
 
Sponsored By NIMH  
  
 
Clinical Coordinating Center: 
Icahn School of Medicine at Mount Sinai 
New York 
 
 
Data Coordination and Statistical Center: 
InCHOIR 
Icahn School of Medicine at Mount Sinai 
New York 
 
June 2018 
 
 
 
 
 
CONFIDENTIAL 
 
 
 
 


2 
 
Table of Contents 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ........................................................... 3 
PURPOSE OF STATISTICAL ANALYTICAL PLAN (SAP) ............................................................ 4 
1. 
INTRODUCTION ................................................................................................................... 5 
1.1 Study Objectives ........................................................................................................................ 5 
1.1.1 Primary Objective ........................................................................................................... 5 
1.1.2 Secondary Objectives ..................................................................................................... 5 
1.2 Study Design .............................................................................................................................. 5 
1.2.1 Study duration and time points ....................................................................................... 5 
1.2.2 Randomization and masking .......................................................................................... 5 
2. 
STUDY POPULATIONS ........................................................................................................ 6 
3. 
EFFICACY ENDPOINTS ....................................................................................................... 6 
3.1 Primary Endpoint ....................................................................................................................... 6 
3.2 Secondary Endpoints .................................................................................................................. 6 
3.2.1 fMRI Activation within the Reward Circuit ................................................................... 6 
3.2.2 Change in Anhedonia ..................................................................................................... 6 
3.2.3 Change in Depressive Symptoms ................................................................................... 6 
3.2.4 General Functioning ....................................................................................................... 7 
3.2.5 Reward learning .............................................................................................................. 7 
4. 
SAFETY ENDPOINTS ........................................................................................................... 7 
5. 
STATISTICAL METHODOLOGY ........................................................................................ 7 
5.1 Statistical Methods ..................................................................................................................... 7 
5.2 Handling of Dropouts and Missing Data ................................................................................... 8 
5.2.1 Missing values for the primary outcome ........................................................................ 8 
5.2.2 Missing values for the secondary outcomes ................................................................... 8 
5.2.3 Sensitivity analysis ......................................................................................................... 9 
5.3 Patient Characteristics ................................................................................................................ 9 
5.3.1 Patient Disposition .......................................................................................................... 9 
5.3.2 Protocol Deviations ...................................................................................................... 10 
5.3.3 Demographic Characteristics ........................................................................................ 10 
5.4 Efficacy Analysis ..................................................................................................................... 10 
5.4.1 Analysis of Primary Endpoint and Determination of Sample Size .............................. 10 
5.4.2 Secondary Endpoints .................................................................................................... 10 
5.5 Safety Analysis ......................................................................................................................... 11 
5.6 Interim Analysis ....................................................................................................................... 11 
6. 
REFERENCES ...................................................................................................................... 11 
 


 
3 
 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
 
ACC 
Anterior cingulate cortex 
ACIPS 
Anticipatory and Consummatory Interpersonal Pleasure Scale 
AE 
Adverse event 
CGI 
Clinical Global Impression Scale 
C-SSRS 
Columbia-Suicide Severity Rating Scale 
DS 
Dorsal striatum 
fMRI 
Functional magnetic resonance imaging 
IFT 
Incentive flanker task 
ITT 
Intent-to-treat 
IWRS 
Interactive web response system 
LOCF 
Last observation carried forward 
MADRS 
Montgomery-Asberg Depression Rating Scale 
MAR 
Missing at random 
MASQ 
Mood and Anxiety Symptoms Questionnaire 
MedDRA 
Medical Dictionary for Regulatory Activities 
MID 
Monetary incentive delay  
mPFC 
Medial prefrontal cortex 
MRI 
Magnetic resonance imaging 
NIMH 
National Institute of Mental Health 
PRT 
Probabilistic Reward Task 
QIDS-SR 
Quick Inventory of Depression Scale – Self Report 
SAE 
Serious adverse event 
SAP 
Statistical analytical plan 
SD 
Standard deviation 
SLIPS 
Specific Loss of Interest and Pleasure Scale (SLIPS) 
TEPS 
Temporal Experience of Pleasure Scale 
V0 
Visit 0 (baseline) 
V5 
Visit 5 (primary outcome assessment at week 5 post-
randomization) 
VS 
Ventral striatum 
WHODAS 
WHO Disability Assessment Schedule 
WHO 
World Health Organization 
 
 


 
4 
 
PURPOSE OF STATISTICAL ANALYTICAL PLAN (SAP) 
The purpose of this SAP is to outline the planned analyses to be completed for the 
EZOR61-01 trial. The planned analyses identified in this SAP will be included in 
abstracts and manuscripts reporting the results of the trial. Exploratory analyses not 
necessarily identified in this SAP may also be performed. Any post hoc, or unplanned, 
analyses not explicitly identified in this SAP will be clearly identified as such in any 
published papers from this study. 
 
 
 


 
5 
 
1. 
INTRODUCTION 
Depressive disorders are among the most disabling medical conditions worldwide and 
currently available treatments fall short of addressing this large public health burden. 
Dysfunction within the brain reward system is emerging as a core feature of 
depressive disorders, in particular related to deficits in motivation, interest, and 
response to pleasure (e.g., anhedonia: markedly diminished response to pleasure). 
Evidence from a series of preclinical studies highlighted the KCNQ subtype of 
neuronal potassium (K+) channel as a novel target for the treatment of depressive 
disorders, and data from human pilot study showed a reduction in anhedonia and 
related symptoms with an increased brain response to reward (as measured by 
functional magnetic resonance imaging [fMRI]) following treatment with ezogabine, 
a KCNQ channel opener. Building on these data, this study will assess reward circuit 
activity following treatment with ezogabine in depressed patients with anhedonia and 
will examine the relationship between change in reward circuit activity and clinically 
relevant symptom and behavior outcomes. 
 
1.1 Study Objectives 
1.1.1 Primary Objective 
The primary objective of this study is to establish target engagement of a KCNQ channel 
opener (ezogabine) in patients with depressive disorder and anhedonia. 
 
1.1.2 Secondary Objectives 
Secondary objectives of this study are to determine if treatment with ezogabine is 
associated with a reduction in clinical symptoms of depression and anhedonia and with a 
modulation of behavioral responses to reward. 
 
1.2 Study Design 
This study is a Phase IIa, prospective, multi-site, randomized (1:1), parallel arm, double-
blind, placebo-controlled clinical trial. 
 
1.2.1 Study duration and time points 
Participants will be followed for up to 14 weeks. The screening period may last up to 6 
weeks; after randomization, titration and treatment lasts 5 weeks at which point the 
primary endpoint is ascertained. Participants will continue to be followed for a 3 week 
medication taper period after collection of the primary endpoint. 
 
1.2.2 Randomization and masking 
Patients will be randomized in a 1:1 allocation to ezogabine or placebo. 
Randomization will be stratified by center balanced by randomly permuted blocks, 
and treatment code will be allocated through the interactive web response system 
(IWRS). Randomization will take place only after it has been determined that all 
study eligibility criteria have been met and the baseline fMRI scan has been obtained. 
 
This is a double-blind, placebo-controlled trial. Site personnel and patients will be 
blinded to treatment assignment throughout the trial. 


 
6 
 
 
 
2. 
STUDY POPULATIONS 
 
Intent-to-Treat (ITT) Population 
The ITT population is defined as all randomized subjects, regardless of when they 
withdrew from the study or received the assigned treatment. The ITT population will be 
used to present all data (including the primary endpoint) by randomized treatment group.  
Subjects will be analyzed according to the treatment to which they were randomized, 
regardless of the treatment they actually received. 
 
 
3. 
EFFICACY ENDPOINTS 
 
3.1 Primary Endpoint 
The primary endpoint of this study is the baseline-corrected fMRI activation in an a 
priori bilateral ventral striatum (VS) area mask during the “gain” cue of the Incentive 
Flanker Task (IFT) contrasted with neutral cue for reward anticipation. The primary 
outcome fMRI will be obtained at 5 weeks post-randomization. The primary endpoint 
will be used as the sole criterion for the “go-no go” decision. 
 
3.2 Secondary Endpoints 
Secondary endpoints are measured at 5 weeks post-randomization unless otherwise 
noted. The following secondary endpoints will be analyzed. All secondary analyses will 
be considered exploratory and will not influence the study “go-no/go” decision.  
 
3.2.1 fMRI Activation within the Reward Circuit 
In the same manner as the primary endpoint, fMRI activation in other regions of the 
reward cortico-striatal circuit (medial prefrontal cortex [mPFC], bilateral dorsal 
striatum [DS], and anterior cingulate cortex [ACC]), as well as whole-brain analyses, 
will be measured during the gain cue of the IFT and contrasted with neutral cue. 
 
Similarly, activation during the loss cues of the IFT task will be compared with the 
fMRI activation in neutral tasks. 
 
3.2.2 Change in Anhedonia 
Symptoms of anhedonia will be measured with the Snaith-Hamilton Pleasure Scale 
(SHAPS), the Temporal Experience of Pleasure Scale (TEPS), the Anticipatory and 
Consummatory Interpersonal Pleasure Scale (ACIPS), and the Specific Loss of 
Interest and Pleasure Scale (SLIPS). The SHAPS, TEPS, ACIPS, and SLIPS will be 
collected at baseline and weekly through the primary outcome assessment (V0 – V5). 
 
3.2.3 Change in Depressive Symptoms 
Symptoms of depression will be measured with the Quick Inventory of Depressive 
Symptomatology, Self-Report (QIDS-SR), the Montgomery-Asberg Depression 
Rating Scale (MADRS), the Mood and Anxiety Symptoms Questionnaire (MASQ), 


 
7 
 
and the Columbia-Suicide Severity Rating Scale (C-SSRS). The QIDS, MADRS, and 
C-SSRS will be collected at baseline (V0) and weekly through the primary outcome 
assessment (V1 – V5). The MASQ will be collected at baseline (V0) and primary 
outcome assessment (V5) only.  
 
3.2.4 General Functioning 
The Clinical Global Impression – Improvement and Clinical Global Impression – 
Severity scales will be used to measure overall illness severity at baseline and weekly 
through the primary outcome assessment (V0 – V5). 
 
The World Health Organization (WHO) Disability Assessment Schedule 2.0 
(WHODAS 2.0) will also measure general functioning. The WHODAS will be 
measured at baseline (V0) and at the time of the primary outcome assessment (V5). 
 
3.2.5 Reward learning 
The Probabilistic Reward Task (PRT) will be used as a behavioral assessment to 
calculate an index of reward learning at baseline (V0) and at the time of the primary 
outcome assessment (V5). 
 
 
4. 
SAFETY ENDPOINTS 
 
The incidence and frequency of all anticipated and unanticipated serious and non-
serious adverse events (AEs) that occur between randomization and study exit (V8) 
eight weeks after randomization will be determined. Severity/grade and expectedness 
will be assessed by the study clinician. The Medical Dictionary for Regulatory 
Activities (MedDRA) system organ class and preferred terms will be recorded for 
each reported AE. 
 
 
5. 
STATISTICAL METHODOLOGY 
5.1 Statistical Methods 
All data will be presented by treatment group as well as for the whole sample. 
 
For all baseline, demographic and efficacy variables, data will be summarized and 
analyzed by randomized treatment group as per ITT. 
 
In summary tables of normally distributed continuous variables, the following descriptive 
statistics will be used: minimum and maximum, mean, and standard deviation (SD). In 
summary tables of non-normally distributed variables data will be presented using the 
minimum, maximum, median and lower and upper quartiles. 
 
In summary tables of categorical variables, counts and percentages will be used. The 
denominator for each percentage will be the number of patients within the randomization 
group unless otherwise specified. 
 
Rates of events will be calculated as the ratio of the total number of events recorded 
divided by the total patient-time in study (months or days). Total patient-time will be 


 
8 
 
calculated by summing the time (in days) that patients were at risk for a specific event 
from the time they were randomized in the study until study exit. Rates and 95% 
confidence intervals will be reported. 
 
For any variable measured at multiple points in time, change from baseline will be 
calculated as the difference between the value of the variable at a specific point in time 
(e.g. 5 weeks) minus the baseline value. 
 
Relative change from baseline will be calculated as the value of a parameter at a specific 
point in time minus the baseline value of the parameter divided by the baseline value of 
the parameter. 
 
Percent change will be calculated as the relative change multiplied by 100. 
 
Hypothesis testing will be conducted at the 0.05 two-sided significance level for the 
primary endpoint. No formal hypothesis tests will be conducted for the secondary 
endpoints, rather, we will calculate estimates and 95% confidence intervals by group. 
 
P-values will be rounded to three decimal places. P-values less than 0.001 will be 
reported as <0.001 in tables. P-values greater than 0.999 will be reported as >0.999. 
 
Should any of the statistical methods proposed prove unsuitable during data analysis, 
more appropriate methods will be used. These include data transformation (for example 
to a logarithmic scale) to satisfy model assumptions such as normally distributed 
residuals with constant variance, or the application of non-parametric techniques. 
 
Additional ad-hoc analyses may be conducted as deemed appropriate. 
 
All statistical analysis will be performed using SAS V9.4 or higher. 
 
5.2 Handling of Dropouts and Missing Data 
 
Missing baseline values that are needed to compute absolute, relative, or percent change 
from baseline will be imputed using mean imputation (Thompson, 2005). The missing 
values of a variable will be replaced with the observed sample mean of that variable. Mean 
imputation is appropriate because baseline variables are independent of randomization 
assignment. 
 
5.2.1 Missing values for the primary outcome 
Missing outcome values for primary endpoint analysis will not be imputed. For the 
primary endpoint, missing data can be the result of patient refusal, missed visit, or study 
dropout (withdrawal, lost to follow-up). Missing data due to patient refusal or missed 
visits are assumed to be missing at random (MAR). Study dropout is also assumed to be 
MAR. 
 
5.2.2 Missing values for the secondary outcomes 
Missing outcome values for secondary endpoints will not be imputed. 


 
9 
 
 
5.2.3 Sensitivity analysis 
Sensitivity analyses will be conducted to investigate possible violations of the missing at 
random assumption. Specifically, we will determine if patients missing the primary 
outcome fMRI differ from patients with fMRI data at V5 in terms of: 
 
• Baseline demographics 
• Baseline rewards circuit activation 
• Longitudinal anhedonia symptoms 
• Longitudinal depression symptoms 
• Treatment group 
 
Three imputed datasets will be created to assess the robustness of the primary endpoint 
analysis: 
• Multiple imputation will be used to impute any missing V5 value of the bilateral 
VS activation  
• Lowest overall observed (across both treatment groups) of the bilateral VS 
activation will be imputed for any missing V5 value  
• Highest overall observed (across both treatment groups) of the bilateral VS 
activation will be imputed for any missing V5 value 
 
In addition, we will conduct sensitivity analyses to examine the effect of lowering the 
dose of ezogabine in patients who could not tolerate the protocol-defined maximum 
dosage. Specifically, we will determine if patients on a reduced dose compared to the 
protocol-defined dose differed in terms of 
 
• Baseline demographics 
• Baseline rewards circuit activation 
• Longitudinal anhedonia symptoms 
• Longitudinal depression symptoms 
 
We will repeat the primary endpoint analyses in the subset of patients treated per-
protocol and compare primary endpoint results between patients on a reduced dose 
versus the protocol-defined maximum dose. 
 
5.3 Patient Characteristics 
5.3.1 Patient Disposition 
The subject disposition table will summarize patients’ characteristics by randomization 
group and overall. 
 
• 
The number (%) of patients randomized 
• 
The number (%) of patients withdrawn or lost to follow-up by the primary 
outcome visit (week 5) 
 
The number (%) of subjects who complete and withdraw/lost to follow-up from the study 
and the primary reason for withdrawal will be summarized by randomization group and 


 
10 
 
overall for all subjects. 
 
The percentages will be calculated based on the total number of patients randomized in 
each randomization group. 
 
5.3.2 Protocol Deviations 
Major and minor protocol deviations are defined as deviations from the procedures 
outlined in the protocol. All statistical analyses and summaries will be conducted on an 
intent-to-treat basis (with the exception of the sensitivity analysis to examine the effect of 
dose reduction due to medication intolerance). 
 
Treatment compliance will be compared by treatment group with compliance defined as 
the number (%) of total prescribed pills taken, and subject report will be compared to 
serum drug levels.  
 
5.3.3 Demographic Characteristics 
Demographic and baseline characteristics data including age, gender, race, and ethnicity 
will be summarized using summary statistics for continuous variables or by group 
frequencies and percentages for categorical variables, as appropriate. 
 
5.4 Efficacy Analysis 
5.4.1 Analysis of Primary Endpoint and Determination of Sample Size 
The primary endpoint is the change in activation of the bilateral VS, a region of the 
rewards circuit in the brain, at 5 weeks from randomization. Activation will be measured 
by fMRI, and beta weights for each subject will be calculated to create a contrast 
between gain and neutral cues to model reward anticipation as described in the 
Neuroimaging Methods section of the protocol. To calculate the beta weight for the 
bilateral VS, the beta weights for the right and left VS will be averaged. 
 
A linear mixed effects model with a single random intercept term will be used to assess 
the change in activation of the bilateral VS by treatment group. A sample size of 48 
provides 85% power to detect a difference in means between groups of 0.8 standard 
deviations assuming a correlation of 0.6 between a pair of measurements made on the 
same subject using a two-sided 0.05 significance level test. 
 
Although randomization is stratified by site, the primary endpoint analysis will be of the 
pooled dataset; secondary analyses will provide site-specific estimates. 
 
No adjustment to the primary analysis will be made for baseline measures that are found 
to be imbalanced but, if applicable, secondary sensitivity analyses may adjust for any 
factors that are imbalanced at a significance level below p = 0.05. (Altman, 1985) (Peter 
Peduzzi, 2002) (Senn, 1989) (Senn, Testing for baseline balance in clinical trials, 1993) 
 
5.4.2 Secondary Endpoints 
All secondary analyses will be performed using the ITT population. 
 


 
11 
 
As the secondary fMRI outcomes are exploratory analyses, we will present the mean and 
95% confidence interval of the difference in change in activation between treatment 
groups rather than conducting formal hypothesis testing. As with the bilateral VS, a 
single beta weight for the bilateral DS will be calculated by averaging the beta weights 
for the left DS and right DS. 
 
Linear mixed effects models will be used to analyze the anhedonia, depression, and 
general functioning scales that are collected at multiple time points. Slopes will be 
estimated with 95% confidence intervals by treatment group. Mean change and 95% 
confidence intervals by group will be presented for measures collected at baseline and 
primary outcome only. 
 
5.5 Safety Analysis 
All adverse events in this study will be analyzed from the time of randomization. All 
adverse events will be analyzed using the ITT population. 
 
AEs will be mapped to the MedDRA coding system. The incidence of non-serious 
AEs and serious AEs will be summarized by System Organ Class, MedDRA 
Preferred Term and treatment. 
 
The number and percentage of patients with an AE or serious AE will be presented. 
For the incidence count, a patient will be counted only once for a specific MedDRA 
Preferred Term, although a MedDRA Preferred Term might be recorded more than 
once for a particular patient. 
 
The number and rate of each AE will also be presented. Differences in the incidence 
of individual AEs will be assessed using negative binomial regression with the 
treatment group as the predictor. 
 
5.6 Interim Analysis 
There is no planned interim analysis for this study. 
 
 
6. 
REFERENCES 
 
Altman, D. G. (1985). Comparability of randomized groups. Statistician, 125-136. 
Peter Peduzzi, W. H. (2002). Analysis of Randomized Controlled Trials. 
Epidemiologic Reviews, 26-38. 
Senn, S. (1989). Covariate imbalance and random allocation in clinical trials. 
Statistics in Medicine, 467-475. 
Senn, S. (1993). Testing for baseline balance in clinical trials. Statistics in Medicine, 
1715 - 1726. 
Thompson, I. R. (2005). Adjusting for partially missing baseline measurements in 
randomized trials. Statistics in Medicine, 993-1007.