A Study to Evaluate the Efficacy, Safety, and Tolerability of Intranasal Esketamine Plus an Oral Antidepressant in Elderly Participants With Treatment-resistant Depression

This is a randomized, double-blind (neither the researchers nor the participants know what
treatment the participant is receiving), active-controlled, multicenter study (more than 1
study site) in elderly participants with TRD to assess the efficacy, safety, and tolerability
of flexible doses of intranasal esketamine plus a newly initiated oral antidepressant
compared with a newly initiated oral antidepressant (active comparator) plus intranasal
placebo. The study will consist of 3 phases: Screening/Prospective Observational Phase (4 to
7 weeks), Double-blind induction Phase (4 weeks), Follow up Phase (2 weeks). Participants who
rollover into a long-term open-label safety study will not participate in the Follow-up
Phase. At the start of the Screening/Prospective observational Phase, participant must have
had documented nonresponse to at least one antidepressant treatment (based on Massachusetts
General Hospital - Antidepressant Treatment Response Questionnaire [MGH-ATRQ] criteria) in
the current episode of depression, and the participant is taking a different oral
antidepressant treatment on the MGH-ATRQ for at least the previous 2 weeks at or above the
minimum therapeutic dose. This antidepressant treatment will be discontinued prior to the
double-blind induction Phase. Participants taking benzodiazepines (at dosages equal to or
less than the equivalent of 6 mg/day of lorazepam) and/or permitted non-benzodiazepine sleep
medications (example, zolpidem, zaleplon) during the screening/prospective observational
phase can continue these medications. All participants will start with first dose (Day 1 as
28 milligram [mg]); second dose (Day 4) is either 28 or 56 mg. All subsequent doses may be
28, 56 or 84 mg. After the first dose, all dosing decisions are determined by the
investigator based on efficacy and tolerability. In addition, each participant will be
assigned to receive 1 of 4 oral antidepressant medications from 2 different classes of
antidepressant treatments, a Selective Serotonin Reuptake Inhibitor (SSRI) (escitalopram or
sertraline) or a Serotonin and Norepinephrine Reuptake Inhibitor (SNRI) [duloxetine or
venlafaxine extended release (XR)], initiated on Day 1 and continued through the double-blind
induction Phase. Participants will be primarily evaluated for improvement in depressive
symptoms as assessed by change in Montgomery Asberg Depression Rating Scale (MADRS) total
score at Week 4. Participants' safety will be monitored throughout the study.

Inclusion Criteria:

- At the time of signing the informed consent form (ICF), participant must be a man or
woman 65 years of age or older

- At the start of the Screening/prospective observational Phase, participant must meet
the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria
for single-episode major depressive disorder (MDD) [if single-episode MDD, the
duration must be greater than or equal to (>=) 2 years] or recurrent MDD, without
psychotic features, based upon clinical assessment and confirmed by the
Mini-International Neuropsychiatric Interview (MINI)

- At the start of the Screening/Prospective observational Phase, participant must have
an Inventory of Depressive Symptomatology-Clinician rated (IDS-C30) total score of
greater than or equal to (>=) 31

- At the start of the Screening/Prospective observational Phase, participants must have
had nonresponse (less than or equal to 25% improvement) to >=1 but less than or equal
to (<=) 8 oral antidepressant treatments taken at adequate dosage and for adequate
duration, as assessed using the Massachusetts General Hospital - Antidepressant
Treatment Response Questionnaire (MGH-ATRQ) and documented records by medical and
pharmacy/prescription records, or a letter from the treating physician, for the
current episode of depression

- Participant must be taking one of the oral antidepressant treatment with nonresponse
that is documented on the MGH-ATRQ at the start of the screening/prospective
observational phase

- The participant's current major depressive episode, depression symptom severity (Week
1 MADRS total score greater than or equal to 24 required) and treatment response to
antidepressant treatments used in the current depressive episode (retrospectively
assessed) must be confirmed for participation in a clinical study based on a
Site-Independent Qualification Assessment

- Participant must be medically stable on the basis of clinical laboratory tests
performed in the screening/prospective observational phase

Exclusion Criteria:

- The participant's depressive symptoms have previously demonstrated nonresponse to:
Esketamine or ketamine in the current major depressive episode per clinical judgment,
or all of the 4 oral antidepressant treatment options available for the double-blind
induction Phase (Duloxetine, Escitalopram, Sertraline, and Venlafaxine extended
release [XR]) in the current major depressive episode (based on MGH-ATRQ), or an
adequate course of treatment with electroconvulsive therapy (ECT) in the current major
depressive episode, defined as at least 7 treatments with unilateral ECT

- Participants who has received vagal nerve stimulation (VNS) or who has received deep
brain stimulation (DBS) in the current episode of depression

- Participant has a current or prior DSM-5 diagnosis of a psychotic disorder or MDD with
psychosis, bipolar or related disorders (confirmed by the MINI), obsessive compulsive
disorder (current episode only), intellectual disability ( intellectual disability
[DSM-5 diagnostic codes 317, 318.0, 318.1, 318.2, 315.8, and 319]), borderline
personality disorder, antisocial personality disorder, histrionic personality
disorder, or narcissistic personality disorder

- Participant has homicidal ideation/intent, per the Investigator's clinical judgment,
or has suicidal ideation with some intent to act within 6 months prior to the start of
the Screening/prospective observational Phase, per the Investigator's clinical
judgment or based on the Columbia Suicide Severity Rating Scale (C-SSRS) and also
includes history of suicidal behavior within the past year prior to start of the
screening/prospective observational phase

- Participant has a history (lifetime) of ketamine, phencyclidine (PCP), lysergic acid
diethylamide (LSD), or 3, 4-methylenedioxy-methamphetamine (MDMA) hallucinogen-related
use disorder\

- Participant has a Mini Mental State Examination (MMSE) < 25 or <22 for those
participants with less than an equivalent of high school education

- Participant has neurodegenerative disorder (eg, Alzheimer's Disease, Vascular
dementia, Parkinson's disease with clinical evidence of cognitive impairment) or
evidence of mild cognitive impairment (MCI)

- Participant has a history of uncontrolled hypertension; current or past history of
significant pulmonary insufficiency/condition;clinically significant ECG
abnormalities; current or past history of seizures; clinically significant
cardiovascular disorders including cerebral and cardiac vascular disease