Revitalizing psychiatric drug discovery

Drug targeting in psychiatric disorders - how to overcome the loss in translation?

In spite of major efforts and investment in development of psychiatric drugs, many clinical trials have failed in recent decades, and clinicians still prescribe drugs that were discovered many years ago. Although multiple reasons have been discussed for the drug development deadlock, we focus here on one of the major possible biological reasons: differences between the characteristics of drug targets in preclinical models and the corresponding targets in patients. Importantly, based on technological advances in single-cell analysis, we propose here a framework for the use of available and newly emerging knowledge from single-cell and spatial omics studies to evaluate and potentially improve the translational predictivity of preclinical models before commencing preclinical and, in particular, clinical studies. We believe that these recommendations will improve preclinical models and the ability to assess drugs in clinical trials, reducing failure rates in expensive late-stage trials and ultimately benefitting psychiatric drug discovery and development.

Investigation of Psychoactive Medications: Challenges and a Practical and Scalable New Path

In the last two decades the validity of clinical trials in psychiatry has been subject to discussion. The most accepted clinical study method in the medical area, randomized controlled trial (RCT), faces significant problems when applied to the psychiatric world. One of the causes for this scenario is the strict participant inclusion and exclusion criteria that may not represent the real world. The inconsistency of the different endpoint parameters that are used in the field is another cause. We think that psychiatric RCTs' challenges, together with the underlying complexity of psychiatry, lead to a problematic clinical practice. Today, psychoactive drugs are routinely tested not in an official clinical trial setting. Off-label psychoactive drugs are commonly prescribed, and other substances, such as herbal remedies, are also regularly consumed. Learning from those real-life experiments can teach us useful lessons. Real-world data (RWD) includes information about heterogeneous patient populations, and it can be measured with standardized parameters. Collecting RWD can also address the need for systematically documenting and sharing case reports' outcomes. We suggest using digital tools to capture objective and continuous behavioral data from patients passively. New conclusions will be constantly drawn, possibly allowing more personalized treatment outcomes. The relevant next-generation decision support tools are already available.

Preclinical screening for antidepressant activity - shifting focus away from the Forced Swim Test to the use of translational biomarkers

Depression is the world's predominant mental health problem and a leading cause of disability. Neuropharmacological research has not yet advanced treatments to sufficiently meet clinical need, largely due to the failure of animal models to predict clinical efficacy. The forced swim test (FST) has been extensively used in the field of antidepressant research but has been under scrutiny due to its perceived severity to animals. Any use of animals in experiments and testing must have a scientific or regulatory purpose and researchers need to ensure that there is no scientifically valid alternative. However, regulatory requirements have been incorrectly cited as a reason to support the use of the FST. More research is required on tests that do not involve stressing animals as replacements for the FST. Non-behavioural neurochemical measures might provide a means to advance neuropharmacological developments while reducing animal suffering. For example, brain-derived neurotrophic factor (BDNF) may be promising.

Time to re-engage psychiatric drug discovery by strengthening confidence in preclinical psychopharmacology

BACKGROUND

There is urgent need for new medications for psychiatric disorders. Mental illness is expected to become the leading cause of disability worldwide by 2030. Yet, the last two decades have seen the pharmaceutical industry withdraw from psychiatric drug discovery after costly late-stage trial failures in which clinical efficacy predicted pre-clinically has not materialised, leading to a crisis in confidence in preclinical psychopharmacology.

METHODS

Based on a review of the relevant literature, we formulated some principles for improving investment in translational neuroscience aimed at psychiatric drug discovery.

RESULTS

We propose the following 8 principles that could be used, in various combinations, to enhance CNS drug discovery: (1) consider incorporating the NIMH Research Domain Criteria (RDoC) approach; (2) engage the power of translational and systems neuroscience approaches; (3) use disease-relevant experimental perturbations; (4) identify molecular targets via genomic analysis and patient-derived pluripotent stem cells; (5) embrace holistic neuroscience: a partnership with psychoneuroimmunology; (6) use translational measures of neuronal activation; (7) validate the reproducibility of findings by independent collaboration; and (8) learn and reflect. We provide recent examples of promising animal-to-human translation of drug discovery projects and highlight some that present re-purposing opportunities.

CONCLUSIONS

We hope that this review will re-awaken the pharma industry and mental health advocates to the opportunities for improving psychiatric pharmacotherapy and so restore confidence and justify re-investment in the field.

The translational value of animal models in orphan medicines designations for rare paediatric neurological diseases

Rare diseases are characterized by a substantial unmet need mostly because the majority have limited, or no treatment options and a large number also affect children. Appropriate animal models, based on the knowledge of the molecular pathology of the human disease, are a significant element to support the medical plausibility of an orphan designation during the development of orphan medicines for rare neurological diseases. This observational, retrospective study aims to investigate the clinical or nonclinical nature of data submitted to support medical plausibility of orphan designations in the EU (2001-2019), for a group of rare and paediatric neurological diseases. From our sample of 30 diseases, 70% are rare with paediatric onset and 37% have approved orphan designations. The use of nonclinical data was significantly higher than clinical data (65% vs. 35%, p = 0.013) to support medical plausibility. Examples of diseases, with orphan designations based only in nonclinical data, are also discussed: Aicardi-Goutières syndrome and Centronuclear myopathy animal disease models, potentially used to support medical plausibility of medicines. Nonclinical appropriate models, assessing disease relevant endpoints, may contribute to increase the translational value of animal models, in paediatric and rare neurological area, to accelerate research and the effective development of treatment options.

Rescuing the attentional performance of rats with cholinergic losses by the M1 positive allosteric modulator TAK-071

RATIONALE

Loss of basal forebrain cholinergic neurons contributes to the severity of the cognitive decline in age-related dementia and, in patients with Parkinson's disease (PD), to impairments in gait and balance and the resulting risks for falls. Contrasting with the extensive evidence indicating an essential role of cholinergic activity in mediating cognitive, specifically attentional abilities, treatment with conventional acetylcholinesterase inhibitors (AChEIs) has not fulfilled the promise of efficacy of pro-cholinergic treatments.

OBJECTIVES

Here, we investigated the potential usefulness of a muscarinic M1 positive allosteric modulator (PAM) in an animal model of cholinergic loss-induced impairments in attentional performance. Given evidence indicating that fast, transient cholinergic signaling mediates the detection of cues in attentional contexts, we hypothesized that a M1 PAM amplifies such transient signaling and thereby rescues attentional performance.

RESULTS

Rats performed an operant sustained attention task (SAT), including in the presence of a distractor (dSAT) and during a post-distractor (post-dSAT) period. The post-dSAT period served to assess the capacity for recovering performance following a disruptive event. Basal forebrain infusions of the cholino-specific immunotoxin 192 IgG-saporin impaired SAT performance, and greater cholinergic losses predicted lower post-dSAT performance. Administration of TAK-071 (0.1, 0.3 mg/kg, p.o., administered over 6-day blocks) improved the performance of all rats during the post-dSAT period (main effect of dose). Drug-induced improvement of post-dSAT performance was relatively greater in lesioned rats, irrespective of sex, but also manifested in female control rats. TAK-071 primarily improved perceptual sensitivity (d') in lesioned rats and facilitated the adoption of a more liberal response bias (B˝_D) in all female rats.

CONCLUSIONS

These findings suggest that TAK-071 may benefit the attentional performance of patients with partial cholinergic losses and specifically in situations that tax top-down, or goal-driven, attentional control.

Calcium Imaging in Drug Discovery for Psychiatric Disorders

The past 5 years have seen a sharp increase in the number of studies using calcium imaging in behaving rodents. These studies have helped identify important roles for individual cells, brain regions, and circuits in some of the core behavioral phenotypes of psychiatric disorders, such as schizophrenia and autism, and have characterized network dysfunction in well-established models of these disorders. Since rescuing clinically relevant behavioral deficits in disease model mice remains a foundation of preclinical CNS research, these studies have the potential to inform new therapeutic approaches targeting specific cell types or projections, or perhaps most importantly, the network-level context in which neurons function. In this mini-review, we will provide a brief overview of recent insights into psychiatric disease-associated mouse models and behavior paradigms, focusing on those achieved by cellular resolution imaging of calcium dynamics in neural populations. We will then discuss how these experiments can support efforts within the pharmaceutical industry, such as target identification, assay development, and candidate screening and validation. Calcium imaging is uniquely capable of bridging the gap between two of the key resources that currently enable CNS drug discovery: genomic and transcriptomic data from human patients, and translatable, population-resolution measures of brain activity (such as fMRI and EEG). Applying this knowledge could yield real value to patients in the near future.

Opportunities and challenges in modeling human brain disorders in transgenic primates

Molecular genetic tools have had a profound impact on neuroscience, but until recently their application has largely been confined to a few model species, most notably mouse, zebrafish, Drosophila melanogaster and Caenorhabditis elegans. With the development of new genome engineering technologies such as CRISPR, it is becoming increasingly feasible to apply these molecular tools in a wider range of species, including nonhuman primates. This will lead to many opportunities for brain research, but it will also pose challenges. Here we identify some of these opportunities and challenges in light of recent and foreseeable technological advances and offer some suggestions. Our main focus is on the creation of new primate disease models for understanding the pathological mechanisms of brain disorders and for developing new approaches to effective treatment. However, we also emphasize that primate genetic models have great potential to address many fundamental questions about brain function, providing an essential foundation for future progress in disease research.

Charting the landscape of priority problems in psychiatry, part 1: classification and diagnosis

Contemporary psychiatry faces major challenges. Its syndrome-based disease classification is not based on mechanisms and does not guide treatment, which largely depends on trial and error. The development of therapies is hindered by ignorance of potential beneficiary patient subgroups. Neuroscientific and genetics research have yet to affect disease definitions or contribute to clinical decision making. In this challenging setting, what should psychiatric research focus on? In two companion papers, we present a list of problems nominated by clinicians and researchers from different disciplines as candidates for future scientific investigation of mental disorders. These problems are loosely grouped into challenges concerning nosology and diagnosis (this Personal View) and problems related to pathogenesis and aetiology (in the companion Personal View). Motivated by successful examples in other disciplines, particularly the list of Hilbert's problems in mathematics, this subjective and eclectic list of priority problems is intended for psychiatric researchers, helping to re-focus existing research and providing perspectives for future psychiatric science.

Behavioral-Cognitive Targets for Cholinergic Enhancement

Cholinergic mechanisms have long been considered a promising target for enhancing cognitive functions. Two distinct yet interacting components of cholinergic activity have been proposed to mediate specific cognitive functions. Transient spikes in cholinergic activity mediate the detection of cues in situations involving attentional mode shifts. More slowly changing cholinergic neuromodulation of cortical circuitry regulates task compliance specifically in response to performance challenges. Increases in cholinergic neuromodulation enhances the generation of cholinergic transients via stimulation of α4β2* nicotinic acetylcholine receptors. Stimulation of these receptors stabilizes attentional performance and increases cue detection rates. Adjunctive treatment with agonists or modulators at these receptors is predicted to benefit unstable attentional performance and low cue detection rates that are common to several brain disorders.

Attention and the Cholinergic System: Relevance to Schizophrenia

Traditional methods of drug discovery often rely on a unidirectional, "bottom-up" approach: A search for molecular compounds that target a particular neurobiological substrate (e.g., a receptor type), the refinement of those compounds, testing in animal models using high-throughput behavioral screening methods, and then human testing for safety and effectiveness. Many attempts have found the "effectiveness" criterion to be a major stumbling block, and we and others have suggested that success may be improved by an alternative approach that considers the neural circuits mediating the effects of genetic and molecular manipulations on behavior and cognition. We describe our efforts to understand the cholinergic system's role in attention using parallel approaches to test main hypotheses in both rodents and humans as well as generating converging evidence using methods and levels of analysis tailored to each species. The close back-and-forth between these methods has enhanced our understanding of the cholinergic system's role in attention both "bottom-up" and "top-down"-that is, the basic neuroscience identifies potential neuronal circuit-based mechanisms of clinical symptoms, and the patient and genetic populations serve as natural experiments to test and refine hypotheses about its contribution to specific processes. Together, these studies have identified (at least) two major and potentially independent contributions of the cholinergic system to attention: a neuromodulatory component that influences cognitive control in response to challenges from distractors that either make detection more difficult or draw attention away from the distractor, and a phasic or transient cholinergic signal that instigates a shift from ongoing behavior and the activation of cue-associated response. Right prefrontal cortex appears to play a particularly important role in the neuromodulatory component integrating motivational and cognitive influences for top-down control across populations, whereas the transient cholinergic signal involves orbitofrontal regions associated with shifts between internal and external attention. Understanding how these two modes of cholinergic function interact and are perturbed in schizophrenia will be an important prerequisite for developing effective treatments.

Medications development for substance-use disorders: contextual influences (dis)incentivizing pharmaceutical-industry positioning

INTRODUCTION

The significant contribution of substance-use disorders (SUDs) to the global-disease burden and associated unmet medical needs has not engendered a commensurate level of pharma-industry research and development (R&D) for novel SUD therapeutics invention. Analysis of contextual factors shaping this position suggests potential routes toward incentivizing R&D commitment for that purpose.

AREAS COVERED

This article considers multiple primary factors that have consorted to disincentivize pharma industry's operating in the SUD space: ill-understood pathology; variegated treatments and patient profiles; involved clinical trials; and - with particular reference to SUDs-negative cultural/business stigmas and shallow commercial precedent. Industry incentivization for SUD drug innovation requires progress on several fronts, including: translational experimental data and systems; personalized, holistic SUD treatment approaches; interactions among pharma, nonindustry constituencies, and the medical profession with vested interests in countering negative stereotypes and expanding SUD treatment options; and public-private alliances focused on improving SUD pharmacotherapy.

EXPERT OPINION

Given the well-entrenched business stance whereby the prospect of future profits in major markets largely determines drug-company R&D investment trajectory, strategic initiatives offering substantial reductions in the risks and opportunity (i.e., time and money) costs associated with SUD drug discovery are likely to be the most potent drivers for encouraging mainstream industry positioning in this therapeutic area. Such initiatives could originate from front-loaded R&D operational and back-loaded patent, regulatory, marketing and health-care policy reforms. These may be too involved and protracted for the turbulent pharmaceutical industry to entertain amid its recent retrenchment from psychiatric/CNS diseases and intense pressures to increase productivity and shareholder value.

Optogenetics in psychiatric animal models

Optogenetics is the optical control of neuronal excitability by genetically delivered light-activated channels and pumps and represents a promising tool to fuel the study of circuit function in psychiatric animal models. This review highlights three developments. First, we examine the application of optogenetics in one of the neuromodulators central to the pathophysiology of many psychiatric disorders, the dopaminergic system. We then discuss recent work in translating functional magnetic resonance imaging in small animals (in which optogenetics can be employed to reveal physiological mechanisms underlying disease-related alterations in brain circuits) to patients. Finally, we describe emerging technological developments for circuit manipulation in freely behaving animals.

The rational use of animals in drug development: contribution of the innovative medicines initiative

Animal models are still widely used to assess the efficacy or safety of new pharmaceutical products. Since their limitations in predicting actions of drugs in humans are becoming more and more apparent, there is an urgent need to revisit the use of animals in pharmaceutical research. Herein, we review how the Innovative Medicines Initiative (IMI), the largest public-private partnership in the life sciences, is reducing, refining and replacing the use of animals in the context of its global mission, namely, to boost research and the development of new medicines across the European Union.