Deramciclane in the treatment of generalized anxiety disorder: a placebo-controlled, double-blind, dose-finding study

The role of the serotonergic and GABA system in translational approaches in drug discovery for anxiety disorders

There is ample evidence that genetic factors play an important role in anxiety disorders. In support, human genome-wide association studies have implicated several novel candidate genes. However, illumination of such genetic factors involved in anxiety disorders has not resulted in novel drugs over the past decades. A complicating factor is the heterogeneous classification of anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and diverging operationalization of anxiety used in preclinical and clinical studies. Currently, there is an increasing focus on the gene × environment (G × E) interaction in anxiety as genes do not operate in isolation and environmental factors have been found to significantly contribute to the development of anxiety disorders in at-risk individuals. Nevertheless, extensive research on G × E mechanisms in anxiety has not resulted in major breakthroughs in drug discovery. Modification of individual genes in rodent models has enabled the specific study of anxiety in preclinical studies. In this context, two extensively studied neurotransmitters involved in anxiety are the gamma-aminobutyric acid (GABA) and 5-HT (5-hydroxytryptamine) system. In this review, we illustrate the complex interplay between genes and environment in anxiety processes by reviewing preclinical and clinical studies on the serotonin transporter (5-HTT), 5-HT1A receptor, 5-HT2 receptor, and GABAA receptor. Even though targets from the serotonin and GABA system have yielded drugs with known anxiolytic efficacy, the relation between the genetic background of these targets and anxiety symptoms and development of anxiety disorders is largely unknown. The aim of this review is to show the vast complexity of genetic and environmental factors in anxiety disorders. In light of the difficulty with which common genetic variants are identified in anxiety disorders, animal models with translational validity may aid in elucidating the neurobiological background of these genes and their possible role in anxiety. We argue that, in addition to human genetic studies, translational models are essential to map anxiety-related genes and to enhance our understanding of anxiety disorders in order to develop potentially novel treatment strategies.

Classical and novel approaches to the preclinical testing of anxiolytics: A critical evaluation

Over 80% of current anxiety studies employ one of the tests that were developed earlier than, or concurrently with the elevated plus-maze, i.e. before 1985. Considering 1985 as a historical reference point, we briefly review here 115 new tests and models of anxiety, the development of which was likely prompted by the poor predictive validity of classical tests as shown here by the comparison of preclinical and clinical findings with putative novel anxiolytics. The new approaches comprise major innovations to classical tests, the pre-test application of manipulations that mimic etiological factors of anxiety disorders, and entirely new approaches including anxiety disorder-specific tests. Thus, intensive test development over the last 27 years created a large pool of novel approaches. However, these are infrequently used and as such, their impact on anxiolytic drug development remains low. We suggest here that test/model development should step over the intensive phase when several new methods are proposed each year and should start selecting and establishing the methodologies that would successfully replace or complement classical tests. We propose here a novel strategy for improving the validity of anxiety testing that includes the retrospective analysis of the predictive validity of new procedures (as opposed to classical pharmacological validation), and a call for concerted international efforts at both the conceptual and practical levels. Similar endeavors proved recently successful with other psychiatric disorders.

Current animal models of anxiety, anxiety disorders, and anxiolytic drugs

PURPOSE OF REVIEW

The perception that 'classical' anxiety tests are deficient was formulated in the mid-1990s. Recent clinical trials also demonstrate that the predictive power of such tests is low, which emphasizes the need for developing models of higher translational value. Several novel models are proposed each year. Here, we investigate their impact on anxiolytic-related studies performed in 2010 and 2011.

RECENT FINDINGS

Here, we depict as 'classical' all the tests that were developed at the same time as or earlier than the elevated plus-maze test. No test equaled its success in the subsequent decades; therefore, we consider it the endpoint of the period when the methodological bases of current laboratory research were laid down. Fourteen classical tests were employed in the investigated period, which were used in more than 80% of studies. Concurrently, 36 'nonclassical' tests were used and six novel tests were also proposed. These accounted for fewer than 20% of studies. 'Classical' tests were often performed under unconventional conditions that putatively increased their translational value. Taken together, half of the studies involved at least one innovative step. Yet, the new procedures were infrequently used. Out of the 36 'nonclassical' tests, only 11 were used more than once, while the amendments to 'classical tests' were almost entirely laboratory specific.

SUMMARY

Our analysis shows that there is a large interest in performing anxiety research innovatively. However, efforts are highly divergent and result in large numbers of poorly validated and infrequently used novel approaches. Thus, models with increased translational value still need to be developed.

Identifying HAM-A cutoffs for mild, moderate, and severe generalized anxiety disorder

The aim of the current study was to identify and evaluate cutoffs for mild, moderate, and severe ranges of Hamilton Anxiety Rating Scale (HAM-A) scores. Data were from a four-week randomized trial of treatment for generalized anxiety disorder. Measures included the HAM-A, SF-36, Hospital Anxiety and Depression Scale (HADS), and Clinical Global Impressions of Severity (CGI-S) scale. HAM-A cutoffs were identified based on literature review, expert panel input, and MANOVA models. The optimal cutoff set was evaluated based on association with clinician CGI-S ratings. The sample included 144 patients (56.3% female; 73.6% white; mean age = 35.7 years; mean baseline HAM-A score = 23.7). The optimal HAM-A score ranges were: mild anxiety = 8-14; moderate = 15-23; severe ≥ 24 (scores ≤ 7 were considered to represent no/minimal anxiety). Analysis of variance (ANOVA) models found statistically significant differences among these groups in the SF-36 and HADS. The HAM-A severity ranges closely corresponded to clinicians' CGI-S ratings. The study represents the first step towards developing severity ranges for the HAM-A. These cutoffs should be used with caution and validated in larger samples. If the proposed cutoffs are accepted for general use, they could make results more meaningful and interpretable for researchers, clinicians, and patients.

Research in anxiety disorders: from the bench to the bedside

The development of ethologically based behavioural animal models has clarified the anxiolytic properties of a range of neurotransmitter and neuropeptide receptor agonists and antagonists, with several models predicting efficacy in human clinical samples. Neuro-cognitive models of human anxiety and findings from fMRI suggest dysfunction in amygdala-prefrontal circuitry underlies biases in emotion activation and regulation. Cognitive and neural mechanisms involved in emotion processing can be manipulated pharmacologically, and research continues to identify genetic polymorphisms and interactions with environmental risk factors that co-vary with anxiety-related behaviour and neuro-cognitive endophenotypes. This paper describes findings from a range of research strategies in anxiety, discussed at the recent ECNP Targeted Expert Meeting on anxiety disorders and anxiolytic drugs. The efficacy of existing pharmacological treatments for anxiety disorders is discussed, with particular reference to drugs modulating serotonergic, noradrenergic and gabaergic mechanisms, and novel targets including glutamate, CCK, NPY, adenosine and AVP. Clinical and neurobiological predictors of active treatment and placebo response are considered.