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Correll CU, Solmi M, Cortese S, Fava M, Højlund M, Kraemer HC, McIntyre RS, Pine DS, Schneider LS, Kane JM. The future of psychopharmacology: a critical appraisal of ongoing phase 2/3 trials, and of some current trends aiming to de-risk trial programmes of novel agents. World Psychiatry 2023; 22:48-74. [PMID: 36640403 PMCID: PMC9840514 DOI: 10.1002/wps.21056] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 01/15/2023] Open
Abstract
Despite considerable progress in pharmacotherapy over the past seven decades, many mental disorders remain insufficiently treated. This situation is in part due to the limited knowledge of the pathophysiology of these disorders and the lack of biological markers to stratify and individualize patient selection, but also to a still restricted number of mechanisms of action being targeted in monotherapy or combination/augmentation treatment, as well as to a variety of challenges threatening the successful development and testing of new drugs. In this paper, we first provide an overview of the most promising drugs with innovative mechanisms of action that are undergoing phase 2 or 3 testing for schizophrenia, bipolar disorder, major depressive disorder, anxiety and trauma-related disorders, substance use disorders, and dementia. Promising repurposing of established medications for new psychiatric indications, as well as variations in the modulation of dopamine, noradrenaline and serotonin receptor functioning, are also considered. We then critically discuss the clinical trial parameters that need to be considered in depth when developing and testing new pharmacological agents for the treatment of mental disorders. Hurdles and perils threatening success of new drug development and testing include inadequacy and imprecision of inclusion/exclusion criteria and ratings, sub-optimally suited clinical trial participants, multiple factors contributing to a large/increasing placebo effect, and problems with statistical analyses. This information should be considered in order to de-risk trial programmes of novel agents or known agents for novel psychiatric indications, increasing their chances of success.
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Affiliation(s)
- Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Marco Solmi
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
- Department of Mental Health, Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute (OHRI) Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Samuele Cortese
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK
- Solent NHS Trust, Southampton, UK
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
- Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York, NY, USA
| | - Maurizio Fava
- Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mikkel Højlund
- Department of Public Health, Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark
- Mental Health Services in the Region of Southern Denmark, Department of Psychiatry Aabenraa, Aabenraa, Denmark
| | - Helena C Kraemer
- Department of Psychiatry and Behavioral Sciences, Stanford University, Cupertino, CA, USA
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Daniel S Pine
- Section on Developmental Affective Neuroscience, National Institute of Mental Health, Bethesda, MD, USA
| | - Lon S Schneider
- Department of Psychiatry and Behavioral Sciences, and Department of Neurology, Keck School of Medicine, and L. Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - John M Kane
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
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Zohar J, Stahl S, Moller HJ, Blier P, Kupfer D, Yamawaki S, Uchida H, Spedding M, Goodwin GM, Nutt D. A review of the current nomenclature for psychotropic agents and an introduction to the Neuroscience-based Nomenclature. Eur Neuropsychopharmacol 2015; 25:2318-25. [PMID: 26527055 DOI: 10.1016/j.euroneuro.2015.08.019] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/20/2015] [Accepted: 08/27/2015] [Indexed: 01/04/2023]
Abstract
Neuroscience based Nomenclature (NbN) is a new system of classifying psychotropic drugs by their pharmacological profile. The NbN was developed to replace the current indication-based nomenclature and to provide an up-to-date and more useful framework to better inform pharmacological decisions. NbN provides updated relevant and specific scientific, regulatory and clinical information, aiming to support rational and lucid prescribing. This pharmacologically driven nomenclature, which highlights pharmacological domains and modes of action, may also increase drug adherence as it clarifies the rationale for selecting a specific psychotropic agent.
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Affiliation(s)
- Joseph Zohar
- Department of Psychiatry, Sheba Medical Center, and Sackler School of Medicine, Tel Aviv University , Tel Hashomer, Israel.
| | - Stephen Stahl
- Department of Psychiatry, University of California, San Diego, USA
| | - Hans-Jurgen Moller
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany
| | - Pierre Blier
- Department of Psychiatry and Cellular & Molecular Medicine, University of Ottawa, Canada K1Z 7K4
| | - David Kupfer
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shigeto Yamawaki
- Department of Psychiatry and Neurosciences, Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Michael Spedding
- Spedding Research Solutions SARL, 6 Rue Ampere, Le Vesinet 78110, France
| | - Guy M Goodwin
- University Department, Warneford Hospital, Oxford OX3 7JX , UK
| | - David Nutt
- Centre for Neuropsychopharmacology Division of Brain Sciences Imperial College, London, UK
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Zohar J, Nutt DJ, Kupfer DJ, Moller HJ, Yamawaki S, Spedding M, Stahl SM. A proposal for an updated neuropsychopharmacological nomenclature. Eur Neuropsychopharmacol 2014; 24:1005-14. [PMID: 24630385 DOI: 10.1016/j.euroneuro.2013.08.004] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 08/13/2013] [Accepted: 08/17/2013] [Indexed: 11/24/2022]
Abstract
Current psychopharmacological nomenclature remains wedded in an earlier period of scientific understanding, failing to reflect contemporary developments and knowledge, does not aid clinicians in selecting the best medication for a given patient, and tends to confuse patients by prescribing a drug that does not reflect their identified diagnosis (e.g. prescribe "antipsychotics" to depression). Four major colleges of Neuropsychopharmacology (ECNP, ACNP, Asian CNP, and CINP) proposed a new template comprising a multi-axial pharmacologically-driven nomenclature tested by four surveys. The template has five axes: 1-class (primary pharmacological target and relevant mechanism); 2-family (reflecting the relevant neurotransmitter and mechanism); 3-neurobiological activities; 4-efficacy and major side effects; and 5-approved indications. The results of the surveys suggest that the clinicians found the available indication-based nomenclature system dissatisfactory, non-intuitive, confusing, and doubt-inducing for them and the patients. The proposed five-axis template seeks to upend current usage by placing pharmacology rather than indication as the primary axes, with the proposed nomenclature relating primarily to Axis 1-the class, and usage of the other axes would largely depend upon the extent to which the clinician seeks to deepen the scientific and clinical base of his involvement. A significant proportion of the participants in the four surveys were in favour of the proposed system, a similar number wanted to consider the idea further, and only a small proportion (8.6%) were against it. The proposed five-axis pharmacology based nomenclature template is a system which might refresh and reflect the current scientific concepts of neuropsychopharmacology.
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Affiliation(s)
- Joseph Zohar
- Department of Psychiatry, Sheba Medical Center, and Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel.
| | - David J Nutt
- Neuropsychopharmacology Unit, Division of Experimental Medicine, Imperial College London, London, United Kingdom
| | - David J Kupfer
- Department of Psychiatry, University of Pittsburgh School of Medicine and Western Psychiatric Institute and Clinic, Pittsburgh, PA, USA
| | - Hans-Jurgen Moller
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany
| | - Shigeto Yamawaki
- Department of Psychiatry and Neurosciences, Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | | | - Stephen M Stahl
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA; Department of Psychiatry, University of Cambridge, United Kingdom
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