54135419SUI3002: A Study to Evaluate the Efficacy and Safety of Intranasal Esketamine in Addition to Comprehensive Standard of Care for the Rapid Reduction of the Symptoms of Major Depressive Disorder, Including Suicidal Ideation, in Adult Participants Assessed to be at Imminent Risk for Suicide

Clinical global impression-severity of suicidality-revised (CGI-SS-R) scale is revised version of the clinical global impression severity scale (CGI-S),a global rating scale that gives an overall measure of the severity of a participants illness. The CGI-SS-R summarizes the clinician's overall impression of severity of suicidality on a 7-point scale from 0 (normal, not at all suicidal) to 6 (among the most extremely suicidal participants), based on the totality of information available to the clinician. Higher score indicates a more severe condition. Negative change in score indicates improvement.

Time frame: Baseline (Day 1, predose) and 24 hours first post dose (Day 2)

Population: Analysis was performed on full efficacy analysis set. Here 'N' (number of participants analyzed) signifies number of participants analyzed for this outcome measure.

MADRS is clinician-rated scale designed to be used in participants with Major Depressive Disorder (MDD) to measure depression severity and detect changes due to antidepressant treatment. It evaluates apparent sadness, reported sadness, inner tension, sleep, appetite, concentration, lassitude, interest level, pessimistic and suicidal thoughts. Scale consists of 10 items, each of which is scored from 0 (item not present or normal) to 6 (severe or continuous presence of symptoms), summed for total possible score of 0 to 60. Higher scores represent more severe condition. Negative change in score indicates improvement.

Time frame: Baseline (Day 1, predose) and 24 hours first post dose (Day 2)

Population: Full efficacy analysis set included all randomized participants who received at least 1 dose of intranasal study agent during DB treatment phase and had both baseline and post baseline evaluation for MADRS total score or CGI-SS-R. Here, 'N' (number of participants analyzed) signifies number of participants analyzed for this outcome measure.

BHS is a self-reported measure to assess one's level of negative expectations or pessimism regarding future. It consists of 20 true-false items that examine respondent's attitude over past week by either endorsing a pessimistic statement or denying an optimistic statement; 9 are keyed false and 11 are keyed true. For every statement, each response was assigned score of 0 or 1. Total BHS score is sum of item responses, ranged from 0-20, where higher score represented higher level of hopelessness.

Time frame: Baseline, Days 8 and 25

Population: Analysis was performed on full efficacy analysis set. Here, 'n' (number analyzed) signifies number of participants analyzed for each specified time point.

CGI-SS-R is revised version of the CGI-S. The CGI-SS-R summarizes the clinician's overall impression of severity of suicidality on a 7-point scale from 0 (normal, not at all suicidal) to 6 (among the most extremely suicidal participants), based on the totality of information available to the clinician. A higher score indicates a more severe condition. Negative change in score indicates improvement.

Time frame: Baseline (Day 1, predose), Days 1 (4 hours postdose), 2, 4, 8, 11, 15, 18, 22 and 25

Population: Analysis was performed on full efficacy analysis set. Here 'n' (number analyzed) signifies number of participants analyzed for each specified time point.

The CGI-SR-I is a scale summarizing the clinician's best assessment of the likelihood that the participant will attempt suicide in the next 7 days. The CGI-SR-I rating is scored on a 7-point scale: where' 0 (no imminent suicide risk); 1 (minimal imminent suicide risk), 2 (mild imminent suicide risk), 3 (moderate imminent suicide risk), 4 (marked imminent suicide risk), 5 (severely imminent suicide risk), 6 (extreme imminent suicide risk). Higher score indicates a more severe condition. Negative change in score indicates improvement.

Time frame: Baseline (Day 1, predose), Days 1 (4 hours postdose), 2, 4, 8, 11, 15, 18, 22 and 25

Population: Analysis was performed on full efficacy analysis set. Here, 'n' (number analyzed) signifies the number of participants analyzed at each specified time point.

EQ-5D-5L is a 2-part instrument for use as a measure of health outcome, designed for self-completion by respondents. It consists of EQ-5D-5L descriptive system and EQ VAS. EQ-5D-5L descriptive system comprises of 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each has 5 levels of perceived problems (1-no problem, 2-slight problems, 3-moderate problems, 4-severe problems, 5-extreme problems). Participant selects answer for each of 5 dimensions considering response that best matches his/her health today. Responses were used to generate a HSI. HSI ranges from 0 (dead) to 1.00 (full health). Positive change in score indicates improvement.

Time frame: Baseline, Days 2, 11 and 25

Population: Analysis was performed on full efficacy analysis set. Here, 'n' (number analyzed) signifies the number of participants analyzed for each specified time point.

EQ-5D-5L consists of EQ-5D-5L descriptive system and EQ visual analogue scale (EQ-VAS). EQ-5D-5L descriptive system comprises 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each has 5 levels of perceived problems (no problem, slight, moderate, severe and extreme problems). Participant selects answer for each of 5 dimensions considering response that best matches his/her health today. Responses were used to generate Health Status Index (HSI). HSI ranges from 0 (dead) to 1.00 (full health). EQ-VAS self-rating records respondent's own assessment of his/her overall health status at time of completion, on a scale of 0 (worst imaginable health)-100 (best imaginable health). Sum score ranges from 0 -100. Sum score=(sum of the scores from the 5 dimensions minus 5)\*5. Higher score indicates worse health state. Negative change in score indicates improvement.

Time frame: Baseline, Days 2, 11 and 25

Population: Analysis was performed on full efficacy analysis set. Here, 'n' (number analyzed) signifies the number of participants analyzed for each specified time point.

EQ-5D-5L is a 2-part instrument for use as a measure of health outcome, designed for self-completion by respondents. It consists of EQ-5D-5L descriptive system and EQ VAS. The EQ VAS self-rating records the respondent's own assessment of his or her overall health status at the time of completion, on a scale of 0 (the worst health you can imagine) to 100 (the best health you can imagine). Positive change in score indicates improvement.

Time frame: Baseline, Days 2, 11 and 25

Population: Analysis was performed on full efficacy analysis set. Here, 'n' (number analyzed) signifies the number of participants analyzed for each specified time point.

MADRS is a clinician-rated scale designed to be used in participants with MDD to measure depression severity and detect changes due to antidepressant treatment. MADRS evaluates apparent sadness, reported sadness, inner tension, sleep, appetite, concentration, lassitude, interest level, pessimistic thoughts, and suicidal thoughts. The instrument consists of 10 items, each of which is scored from 0 (item not present or normal) to 6 (severe or continuous presence of the symptoms), for a total possible score of 0 to 60. Higher scores represent a more severe condition. Negative change in score indicates improvement.

Time frame: Baseline (Day 1, predose), Days 1 (4 hours postdose), 2, 4, 8, 11, 15, 18, 22 and 25 (predose and 4 hours postdose)

Population: Analysis was performed on full efficacy analysis set. Here 'n' (number analyzed) signifies number of participants analyzed for each specified time point.

The QLDS is a disease-specific patient-reported outcome designed to assess health-related quality of life in patients with MDD, it captures the impact of depression and its treatment from the participant's perspective. The instrument has a recall period of at the moment and contains 34 items with true/not true response options. The total score range is from 0 (good quality of life) to 34 (very poor quality of life). A higher score indicates a more severe condition. Negative change indicates improvement.

Time frame: Baseline, Days 2, 11 and 25

Population: Analysis was performed on full efficacy analysis set. Here, 'n' (number analyzed) signifies the number of participants analyzed for each specified time point.

SIBAT is an assessment tool that captures suicidal ideation, behavior, and risk. It permits assessment of change in suicidal ideation and behavior and documents clinician assessment of severity of suicidality and suicide risk. SIBAT is organized into 8 modules divided into 2 major divisions: patient-reported section (Modules 1-5) and clinician-rated section (Modules 6-8). Patient-reported section has modules of demographics and suicide history, risk/protective factors, suicidal thinking, suicide behavior, and suicide risk. Question 3 from Module 5 asks participants to describe their thinking about suicide right now from 5 response options ranging from 0 (I have no suicidal thoughts) to 4 (I have suicidal thoughts all of time).

Time frame: Baseline, Days 1 (4h postdose), 2, 4, 8, 11, 15, 18, 22 and 25

Population: Analysis was performed on full efficacy analysis set. Here, 'n' (number analyzed) signifies the number of participants analyzed for each specified time point.

SIBAT is assessment tool that captures suicidal ideation, behavior, and risk. It permits assessment of change in suicidal ideation and behavior and documents clinician assessment of severity of suicidality and suicide risk. SIBAT has 8 modules divided into 2 major divisions: patient-reported section (Modules 1-5) and clinician-rated section (Modules 6-8). Clinician-rated section has modules for semi-structured interview, clinical global impressions of current severity of suicidality and imminent suicide risk, clinical global impression of long-term suicide risk, and clinical judgment of optimal suicide management. The score anchor point as in participant report frequency of suicidal thinking that is, response options from never to all the time. Module 7-FoST score ranges from 0-5; higher score indicates more severe condition. Negative change in score indicates improvement.

Time frame: Baseline, Days 1 (4 hours postdose), 2, 4, 8, 11, 15, 18, 22 and 25

Population: Analysis was performed on full efficacy analysis set. Here, 'n' (number analyzed) signifies the number of participants analyzed for each specified time point.

CGI-SS-R is revised version of the CGI-S. The CGI-SS-R summarizes the clinician's overall impression of severity of suicidality on a 7-point scale from 0 (normal, not at all suicidal) to 6 (among the most extremely suicidal participants), based on the totality of information available to the clinician. Higher score indicates a more severe condition. A participant was considered to have achieved resolution of suicidality at a given time point if the CGI-SS-R score was 0 (normal, not at all suicidal) or 1 (questionably suicidal). Participants who did not met such criterion or discontinued prior to the time point for any reason were not considered to have resolution of suicidality.

Time frame: Days 1 (4 hours postdose), 2, 4, 8, 11, 15, 18, 22 and 25

Population: Analysis was performed on full efficacy analysis set.

Pulse oximetry was used to measure arterial SpO2 levels. On each dosing day, the device was attached to the finger, toe, or ear, and SpO2 was monitored and documented. If oxygen saturation levels were less than (\<) 93% at any time during the 1.5 hours postdose interval, pulse oximetry was recorded every 5 minutes until levels return to \>= 93% or until the participant is referred for appropriate medical care, if clinically indicated. Participants with at least 2 consecutive postdose oxygen saturation below 93% during the DB treatment phase were reported.

Time frame: Up to Day 25

Population: Safety analysis set included all randomized participants who received at least 1 dose of study drug in the DB treatment phase.

Number of participants with abnormal nasal examination were reported. Nasal examination of visual inspection of the epistaxis, nasal crusts, nasal discharge, and nasal erythema was performed.

Time frame: At Day 25

Population: Safety analysis set included all randomized participants who received at least 1 dose of study drug in the DB treatment phase. Here, 'n' (number analyzed) signifies number of participants analyzed for each specified category.

The CADSS used to measure present-state dissociative symptoms, and to assess treatment-emergent dissociative symptoms. It comprises 23 subjective items divided into 3 components: depersonalization (with score range from 0 to 28), derealization (with score range from 0 to 52), and amnesia (with score range from 0 to 8). Participants responses are coded on a 5-point scale (0 = Not at all, 1 = Mild, 2 = Moderate, 3 = 'Severe and 4 = Extreme). The total score is sum of the 23 items and range from 0 to 92, where 0 (best) and 92 (worst). A higher score indicates a more severe condition. Number of participants with an increase in CADSS total score (increase based on maximum CADSS total score change from predose of \> 0) was reported.

Time frame: Days 1, 4, 8, 11, 15, 18, 22 and 25

Population: Safety analysis set included all randomized participants who received at least 1 dose of study drug in the DB treatment phase. Here, 'n' (number analyzed) signifies the number of participants analyzed for each specified time point.

MADRS is clinician-rated scale designed to be used in participants with Major Depressive Disorder (MDD) to measure depression severity and detect changes due to antidepressant treatment. It evaluates apparent sadness, reported sadness, inner tension, sleep, appetite, concentration, lassitude, interest level, pessimistic and suicidal thoughts. Scale consists of 10 items, each of which is scored from 0 (item not present or normal) to 6 (severe or continuous presence of symptoms), summed for total possible score of 0 to 60. Higher scores represent more severe condition. Negative change in score indicates improvement.

Time frame: Days 1 (4 hours [h] postdose), 2, 4, 8, 11, 15, 18, 22 and 25 (predose and 4 hours postdose)

Population: Analysis was performed on full efficacy analysis set.

Number of participants with treatment emergent abnormal ECG values for variables including heart rate (abnormally low refers to less than or equal to \[\<=\] 50 beats per minute \[bpm\] , abnormally high refers greater than or equal to \[\>=\] 100 bpm), pulse rate (PR) interval (abnormally high refers to \>= 210 milliseconds \[msec\]), QRS interval (abnormally Low refers to \<= 50, abnormally high refers to \>= 120 msec) and QT interval (abnormally low refers to \<= 200, abnormally high \>= 500 msec) were reported.

Time frame: Up to Day 25

Population: Safety analysis set included all randomized participants who received at least 1 dose of study drug in the DB treatment phase. Here 'N' (number of participants analyzed) signifies number of participants analyzed for this outcome measure.

Low/high abnormal values are: Alanine aminotransferase (ALT)-high=200 Units per liter(U/L); ALP-high=250U/L; aspartate aminotransferase(AST)-high=250U/L; gamma glutamyl transferase(GGT)=300U/L; Albumin (low=24g/L,high=60 g/L); Bicarbonate(low=15.1, high=34.9mmol/L); Bilirubin(high=51.3micromol/L); calcium(low=1.5,high=3mmol/L);Chloride(low=94,high=112mmol/L); CK(High=990U/L); Creatinine (High=265.2micromol/L); Eosinophils(High=10%); Erythrocytes(low=3.0\*1012/L,high=6.4\*1012/L); Glucose(low=2.2,high=16.7mmol/L); Hemoglobin(low=80g/L,high=190g/L);Hematocrit(low=0.28, high=0.55 fraction); LD(high=500U/L); Leukocytes(low=2.5\*109/L,high=15.5\*109/L); Lymphocytes(low=10%,high=60%); Monocytes(high=20%); Neutrophils(low=30%,high=90%); Phosphate(low=0.7 mmol/L,high=2.6mmol/L); Platelet count(low=100\*109/L,high=600\*109/L\]; Potassium(low=3.0mmol/L,high=5.8 mmol/L\]; Protein(low=50 g/L); Sodium(low=125 mmol/L,high=155 mmol/L); Urate(low=89.2 micromol/L,high=594.8micromol/L); Urine(high=8.0 pH).

Time frame: Up to Day 25

Population: SAS: all randomized participants who received at least 1 dose of study drug in DB phase. 'N'(number of participants analyzed) signifies number of participants analyzed for this OM. 'n' (number analyzed) signifies number of participants analyzed for each specified category. mmol/L=millimoles per liter; g/L=gram per liter; ULN=upper limit of normal

An adverse event (AE) is any untoward medical occurrence in a clinical study participant administered a medicinal (investigational or non-investigational) product. An AE does not necessarily have a causal relationship with the treatment. An adverse event can therefore be any unfavorable and unintended sign (including an abnormal finding), symptom, or disease temporally associated with the use of a medicinal (investigational or non investigational) product, whether or not related to that medicinal (investigational or non-investigational) product. A TEAE is categorized as related if assessed by the investigator as possibly, probably, or very likely related to study agent.

Time frame: Up to Day 25

Population: Safety analysis set (SAS) included all randomized participants who received at least 1 dose of study drug in the DB treatment phase.

Number of participants with treatment emergent vital signs abnormalities (pulse rate in bpm \[abnormally low = a decrease from baseline of \>= 15 to a value \<= 50; abnormally high = an increase from baseline of \>=15 to a value \>=100\] , systolic blood pressure \[SBP\] in mmHg \[abnormally low = a decrease from baseline of \>= 20 to a value \<= 90; abnormally high = an increase from baseline of \>= 20 to a value \>= 180\], and diastolic blood pressure \[DBP\] in mmHg \[abnormally low= a decrease from baseline of \>=15 to a value \<= 50; abnormally high = an increase from baseline of \>= 15 to a value \>= 105) were reported.

Time frame: Up to Day 25

Population: Safety analysis set included all randomized participants who received at least 1 dose of study drug in the DB treatment phase.

MOAA/S was used to measure treatment-emergent sedation with correlation to levels of sedation defined by the American society of anesthesiologists (ASA) continuum. The MOAA/S scores range from 0 to 5 where,0 = no response to painful stimulus; ASA continuum = general anesthesia, 1 = responds to trapezius squeeze; ASA continuum = deep sedation, 2 = purposeful response to mild prodding or mild shaking; ASA continuum = moderate sedation, 3 = responds after name called loudly or repeatedly; ASA continuum = moderate sedation, 4 = lethargic response to name spoken in normal tone; ASA continuum = moderate sedation and 5 = readily responds to name spoken in normal tone (awake); ASA continuum = minimal sedation.

Time frame: Up to Day 25

Population: Safety analysis set included all randomized participants who received at least 1 dose of study drug in the DB treatment phase.

The TSQM-9 is a 9-item generic patient-reported outcome instrument to assess participants' satisfaction with medication. It covers domains of effectiveness, convenience, and global satisfaction. The TSQM-9 domain scores were calculated as recommended by the instrument authors. (i) Effectiveness = \[(item 1 + item 2 + item 3) - 3\]/18\*100, (ii) Convenience = \[(item 4 + item 5 + item 6) - 3\]/18\*100 and (iii) Global satisfaction = \[(item 7 + item 8 + item 9) - 3\]/14\*100. Each domain score can be calculated only if all the three items considered in the calculation of that score are not missing. The TSQM-9 domain score ranges from 0 to 100, with higher scores representing higher satisfaction.

Time frame: Days 15 and 25

Population: Analysis was performed on full efficacy analysis. Here, 'n' (number analyzed) signifies the number of participants analyzed for each specified time point.