A new nomenclature for classifying psychotropic drugs

Research fronts and researchers of World Journal of Psychiatry in 2023: A visualization and analysis of mapping knowledge domains

BACKGROUND

In the rapidly evolving landscape of psychiatric research, 2023 marked another year of significant progress globally, with the World Journal of Psychiatry (WJP) experiencing notable expansion and influence.

AIM

To conduct a comprehensive visualization and analysis of the articles published in the WJP throughout 2023. By delving into these publications, the aim is to determine the valuable insights that can illuminate pathways for future research endeavors in the field of psychiatry.

METHODS

A selection process led to the inclusion of 107 papers from the WJP published in 2023, forming the dataset for the analysis. Employing advanced visualization techniques, this study mapped the knowledge domains represented in these papers.

RESULTS

The findings revealed a prevalent focus on key topics such as depression, mental health, anxiety, schizophrenia, and the impact of coronavirus disease 2019. Additionally, through keyword clustering, it became evident that these papers were predominantly focused on exploring mental health disorders, depression, anxiety, schizophrenia, and related factors. Noteworthy contributions hailed authors in regions such as China, the United Kingdom, United States, and Turkey. Particularly, the paper garnered the highest number of citations, while the American Psychiatric Association was the most cited reference.

CONCLUSION

It is recommended that the WJP continue in its efforts to enhance the quality of papers published in the field of psychiatry. Additionally, there is a pressing need to delve into the potential applications of digital interventions and artificial intelligence within the discipline.

Risk Factors for Falls Among Hospitalized Medical Patients - A Systematic Review and Meta-analysis

OBJECTIVE

To identify and quantify risk factors for in-hospital falls in medical patients.

DATA SOURCES

Six databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, and Google Scholar) were systematically screened until April 11, 2023, to identify relevant articles.

STUDY SELECTION

All titles and abstracts of the retrieved articles were independently screened by 2 researchers who also read the full texts of the remaining articles. Quantitative studies that assessed risk factors for falls among adult patients acutely hospitalized were included in the review. Publications that did not capture internal medicine patients or focused on other specific populations were excluded.

DATA EXTRACTION

Information on study characteristics and potential risk factors were systematically extracted. Risk of bias was assessed using the Quality in Prognosis Studies tool. Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analyses of Observational Studies in Epidemiology guidelines were followed for reporting.

DATA SYNTHESIS

The main outcome was any in-hospital falls. Using a random-effects meta-analysis model, association measures for each risk factor reported in 5 or more studies were pooled. Separate analyses according to effect measure and studies adjusted for sex and age at least were performed. Of 5067 records retrieved, 119 original publications from 25 countries were included. In conclusion, 23 potential risk factors were meta-analyzed. Strong evidence with large effect sizes was found for a history of falls (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.63-3.96; I2, 91%), antidepressants (pooled OR, 2.25; 95% CI, 1.92-2.65; I2, 0%), benzodiazepines (OR, 1.97; 95% CI, 1.68-2.31; I2, 0%), hypnotics-sedatives (OR, 1.90; 95% CI, 1.53-2.36; I2, 46%), and antipsychotics (OR, 1.61; 95% CI, 1.33-1.95; I2, 0%). Furthermore, evidence of associations with male sex (OR, 1.22, 95% CI, 0.99-1.50; I2, 65%) and age (OR, 1.17, 95% CI, 1.02-1.35; I2, 72%) were found, but effect sizes were small.

CONCLUSIONS

The comprehensive list of risk factors, which specifies the strength of evidence and effect sizes, could assist in the prioritization of preventive measures and interventions.

Psychiatric symptoms, associated pharmacological treatments and cognitive function: A population-based study of men

BACKGROUND

Psychiatric symptomatology and medications used in their treatment may be modifiable risk factors associated with cognitive function, although findings from population-based studies spanning the full adult age range are lacking. This study aimed to investigate associations between psychiatric symptomatology, psychotropic medication use and cognitive function in a population-based sample of men.

METHODS

Data for 537 men were drawn from the Geelong Osteoporosis Study. Cognitive function (psychomotor function, attention, working memory and visual learning) was determined using the Cog-State Brief Battery. Current depressive and anxiety symptomatology was determined using the Hospital Anxiety and Depression Scale, and psychotropic medication use was self-reported. Linear regression models were developed to determine associations between psychiatric symptomatology and psychotropic medication use with each cognitive measure.

RESULTS

Depressive symptomatology was associated with lower overall cognitive function (b-0.037 ± 0.010, η2 = 0.025, p < 0.001), psychomotor function (b 0.006 ± 0.002, η2 = 0.028 p < 0.001) and attention (b 0.004 ± 0.001, η2 = 0.021, p < 0.001), whereas psychotropic use was associated with lower overall cognitive function (b - 0.174 ± 0.075, η2 = 0.010, p = 0.021), attention (b 0.017 ± 0.008, η2 = 0.008, p = 0.038 and working memory (b 0.031 ± 0.012, η2 = 0.010, p = 0.010). Anticonvulsant use was associated with lower overall cognitive function (b - 0.723 ± 0.172, η2 = 0.032, p < 0.001), attention (b 0.065 ± 0.018, η2 = 0.029, p < 0.001) and working memory (b 0.088 ± 0.026, η2 = 0.022, p < 0.001). All relationships were found to have a small effect. There were no significant associations between anxiety symptomatology and antidepressant and anxiolytic use with any of the cognitive domains.

CONCLUSION

Depressive symptomatology and anticonvulsant use were associated with lower cognitive function. Understanding the underlying mechanisms involved in these relationships can advance knowledge on the heterogeneity in cognitive ageing and aid in prevention initiatives.

Self-prescription with psychotropic medications by healthcare professionals working at mental health institutions in Saudi Arabia

BACKGROUND

Healthcare professionals who work in mental health institutions are more exposed to psychotropic medications than those in other healthcare institutions and are, therefore, more likely to self-prescribe. Self-prescription is a concerning phenomenon because of the potential for medication misuse, drug interaction, addiction, and other social, physical, and psychological consequences. This study investigated the prevalence of self-prescription of psychotropic medications and the most common self-prescribed psychotropic medications by healthcare professionals in mental health institutions in Saudi Arabia. It also aimed to determine the possible side effects and factors associated with self-prescription of psychotropic medications.

MATERIALS AND METHODS

This was a cross-sectional study using an electronic survey consisting of a researcher-designed checklist, targeting healthcare professionals in mental health institutions in Saudi Arabia. The independent variables were sex, nationality, occupation, place of residence, place of work, previous diagnosis of mental illness, marital, and living status. Data were analyzed, using SPSS, and frequency distribution and percentages were calculated. Chi-square test was employed to determine association between self-prescription and various independent variables.

RESULTS

The final sample size was 588; 9.5% healthcare professionals working at mental health institutions in Saudi Arabia admitted to self-prescription with psychotropic medications. Almost half of those who admitted to self-prescription (48.2%) and about 1/4 (23.2%) self-prescribed selective serotonin reuptake inhibitors and benzodiazepines, respectively. The most commonly reported side effects of self-prescription were gastrointestinal symptoms and drowsiness. The study also suggested that males were significantly more prone to self-prescribing than females (P < 0.001).

CONCLUSION

To our knowledge, this is the first study in Saudi Arabia to assess the self-prescription of psychotropic medications by healthcare professionals at mental health institutions. This study is important for decision-makers in their planning and updating of prescription policies. It is also equally important to spread awareness among healthcare professionals about the consequences of self-prescription.

A Comparison of Knowledge, Attitude, and Practice (KAP) Between Private- and Government-Sector Pharmacists With Regard to Psychotropic Medications in Riyadh City

Background Pharmacists play a significant role in patient care, and many patients consider them to be their primary source of information regarding medications. Therefore, pharmacists must have an adequate level of knowledge about psychotropic medications. This study aims to assess and compare the levels of knowledge, attitudes, and practices regarding psychotropic medications in governmental and private-sector pharmacists in Riyadh, Saudi Arabia. Methods An observational cross-sectional study was conducted, which included 355 pharmacists (governmental and private sector pharmacists). Each pharmacist was interviewed and asked to answer a structured questionnaire that consisted of four sections: demographic data, knowledge, attitude, and practice regarding psychotropic medications. Results Our findings indicate that the overall knowledge regarding psychotropic medications among private and government-sector pharmacists is insufficient. While 282 (79.4%) had insufficient knowledge, 20.6% of pharmacists had adequate knowledge regarding psychotropic medications, and good knowledge was detected among 29.1% of government-sector pharmacists compared to 18.1% of private-sector pharmacists (P = .033). Our results also revealed that 31.5% of the pharmacists felt comfortable with their knowledge of psychotropic agents. In addition, 18.9% of the pharmacists reported that they received adequate training on psychotropic medications (12.7% of the governmental group versus 20.7% of the private-sector group; P =.048). Conclusion The insufficient knowledge among pharmacists regarding psychotropic medications highlights the importance of providing more training programs and educational courses to improve pharmacists' knowledge about psychotropic medications in Saudi Arabia.

Antipsychotics in Perspective: Past, Present, and Future

For more than half a century, there has been controversy and conflict over using psychotropic medications ("psychotropics") as strategies to modulate behavior, enhance mood, and address cognitive issues for nursing home residents. The current situation reflects a long history of investigation, reports, discussions, government and professional activity, and other attempted improvement. Although attention has focused primarily on the use of antipsychotics, particularly to manage symptoms associated with dementia, there are much broader issues. The use of all psychotropics has arguably been challenging and inconsistent. Although antipsychotic use in nursing homes has been reduced substantially, many controversies and concerns remain, such as the continuing significant use of other psychotropics. It is tempting to conclude that efforts to reduce the use of these medications might have been deliberately stymied, and that more drastic-if not coercive-measures are needed to correct these issues. However, many other compelling considerations must be defined accurately and addressed. Further improvement in the current situation requires reconsidering some current beliefs and approaches. A pause and reopening of meaningful discussion is needed. This 3-part series (in this and the next 2 issues of The Senior Care Pharmacist) will examine the history of the issues (this month), various perspectives on the issues (part 2), and lessons and recommended approaches for the future (part 3).

International study of the Complex Stress Reaction Syndrome: Implications for transdiagnostic clinical practice

BACKGROUND

The debate regarding diagnostic classification systems in psychiatry (categorial vs dimensional systems) has essential implications for the diagnosis, prevention and treatment of stress reactions. We previously found a unique pattern of stress reaction in a study executed during the coronavirus disease 2019 pandemic using large representative samples in two countries, and termed it the Complex Stress Reaction Syndrome (CSRS).

AIM

To investigate CSRS, Type A (psychiatric symptoms, spanning anxiety, depression, stress symptoms, and post-traumatic stress disorder (PTSD)), with or without long-coronavirus disease (COVID) residuals (CSRS, Type B, neuropsychiatric symptoms spanning cognitive deficits and fatigue, excluding systemic symptoms). Our two-tailed hypothesis was that CSRS is a condition related to an unrecognized type of stress reaction in daily life in the general population (Type A) or that it is related to the severe acute respiratory syndrome coronavirus 2 infection and its long-COVID residuals (Type B).

METHODS

977 individuals in four continents (North America, Europe, Australia and the Middle East) completed the online study questionnaire in six languages using the Qualtrics platform. The study was managed by six teams in six countries that promoted the study on social media. The questionnaire assessed anxiety, depression, stress symptoms and PTSD (CSRS, Type A), cognitive deficits and fatigue (CSRS, Type B). The data were analyzed using Proportion Analyses, Multivariate Analysis of Co-Variance (MANCOVA), linear regression analyses and validated clinical cutoff points.

RESULTS

The results of the Proportion Analyses showed that the prevalence of 4 symptoms spanning anxiety, depression, stress symptoms, and PTSD was significantly higher than the most prevalent combinations of fewer symptoms across 4 continents, age groups, and gender. This supports the transdiagnostic argument embedded in the CSRS (Type A). The same pattern of results was found in infected/recovered individuals. The prevalence of the 4 psychiatric symptoms combination was significantly greater than that of 5 and 6 symptoms, when adding cognitive deficits and fatigue, respectively. MANCOVA showed a significant three-way interaction (age × gender × continent). Further analyses showed that the sources of this three-way interaction were threefold relating to two sub-populations at-risk: (1) Individuals that self-identified as non-binary gender scored significantly higher on all 4 psychiatric symptoms of the CSRS, Type A at young age groups (< 50 years old) in North America compared to (self-identified) women and men located in the 4 continents studied, and to other ages across the adult life span; and (2) This pattern of results (CSRS, Type A) was found also in women at young ages (< 40 years old) in North America who scored higher compared to men and women in other continents and other ages. Linear regression analyses confirmed the MANCOVA results.

CONCLUSION

These results show a combined mental health risk factor related to stress reactivity, suggesting that the CSRS is sensitive to populations at risk and may be applied to future identification of other vulnerable sub-populations. It also supports the transdiagnostic approach for more accurate prevention and treatment. Time will tell if such transdiagnostic syndromes will be part of the discussions on the next revisions of the traditional classification systems or whether the crisis in psychiatry further evolves.

Inside the Bell Jar of Social Media: A Descriptive Study Assessing YouTube Coverage of Psychotropic Medication Adherence

The global mental health crisis is a longstanding one that impacts a multitude of patient populations worldwide. Within this crisis, psychiatric medication adherence is yet another complex public health challenge that continues to persist and contribute towards the chronic nature of the increased incidence and prevalence of psychiatric morbidities, which in turn result in the sequalae of substantial costs to humanity, the healthcare system, lost productivity, functioning and disability among patients with mental disorders. Psychotropic medication adherence is a significant part of psychiatric care and treatment across severity levels of mental illness. This health behavior is also filled with complexities, given the abundance of social and behavioral determinants as well as intrinsic and extrinsic factors that surround this health behavior. Examining contexts for promoting this health behavior change is crucial in determining directions for addressing it more optimally. There have been several published studies on considerations and interventions to address this health behavior; however, to date, no studies have been published on assessing coverage and directions of content across social media platforms, which trend as a rising health communication medium in our digital era. The present study is the first of its kind to dive into exploring the nature of widely viewed content and deliverers of this content on a prominent social media platform, YouTube, as the basis to determine potential directions for future intervention that can extend to reaching more patients struggling with this high-risk health behavior across the world, given the global reach of social media.

Not one thing at a time: When concomitant multiple stressors produce a transdiagnostic clinical picture

A condition of exposure to multiple stressors resulting in a mixed clinical picture spanning conventional categories without meeting any of them in full, encompasses a risk for a list of comorbidities preventing appropriate prevention and treatment. New transformative transdiagnostic approaches suggest changes spanning conventional categories. They base their systems of classification on biomarkers as well as on brain structural and functional dysregulation as associated with behavioral and emotional symptoms. These new approaches received critiques for not being specific enough and for suggesting a few biomarkers for psychopathology as a whole. Therefore, they put the value of differential diagnosis at risk of avoiding appropriate derived prevention and treatment. Multiplicity of stressors has been considered mostly during and following catastrophes, without considering the resulting mixed clinical picture and life event concomitant stressors. We herewith suggest a new category within the conventional classification systems: The Complex Stress Reaction Syndrome, for a condition of multiplicity of stressors, which showed a mixed clinical picture for daily life in the post coronavirus disease 2019 era, in the general population. We argue that this condition may be relevant to daily, regular life, across the lifespan, and beyond conditions of catastrophes. We further argue that this condition may worsen without professional care and it may develop into a severe mental health disorder, more costly to health systems and the suffering individuals. Means for derived prevention and treatment are discussed.

Extraction techniques for bioactive compounds of cannabis

Historically, cannabis has always constituted a component of the civilized world; archaeological discoveries indicate that it is one of the oldest crops, while, up until the 19th century, cannabis fibers were extensively used in a variety of applications, and its seeds comprised a part of human and livestock nutrition. Additional evidence supports its exploitation for medicinal purposes in the ancient world. The cultivation of cannabis gradually declined as hemp fibers gave way to synthetic fibers, while the intoxicating ability of THC eventually overshadowed the extensive potential of cannabis. Nevertheless, the proven value of certain non-intoxicating cannabinoids, such as CBD and CBN, has recently given rise to an entire market which promotes cannabis-based products. An increase in the research for recovery and exploitation of beneficial cannabinoids has also been observed, with more than 10 000 peer-reviewed research articles published annually. In the present review, a brief overview of the history of cannabis is given. A look into the classification approaches of cannabis plants/species as well as the associated nomenclature is provided, followed by a description of their chemical characteristics and their medically valuable components. The application areas could not be absent from the present review. Still, the main focus of the review is the discussion of work conducted in the field of extraction of valuable bioactive compounds from cannabis. We conclude with a summary of the current status and outlook on the topics that future research should address.

A Retrospective Chart Review of Factors Impacting Psychotropic Prescribing Patterns and Polypharmacy Rates in Youth with Autism Spectrum Disorder during the COVID-19 Pandemic

High but variable rates of psychotropic polypharmacy (PP) in youth with autism spectrum disorder (ASD) have been reported in previous studies. The effect of the COVID-19 pandemic on prescribing patterns has not been well described. This study aims to examine the factors associated with psychotropic prescribing patterns, including rates of PP and multiclass polypharmacy (MPP) in youth with ASD during the COVID-19 pandemic. We examined the prescription records and clinical characteristics of youth aged between 3−21 years with a clinical diagnosis of ASD who were followed at an urban tertiary autism center psychiatry clinic between 1 January 2019, and 31 December 2020. For study purposes, we treated 2019 as the pre-pandemic year and 2020 as the pandemic year and compared the clinical characteristics of the “total clinic cohort (n = 898)” across two years. We examined the clinical characteristics of patients seen in both years (“paired-sample,” n = 473) and those seen only in 219 (“not-paired sample,” n = 378) to identify factors associated with the likelihood of patients’ return to clinic in 2020. As the total clinic cohort was a naturalistic sample containing duplicate patients, we created a separate data set by randomly assigning duplicate patients to one of the years (“random unique sample,” n = 898) and examined the clinical characteristics across two years. We defined PP and MPP broadly as the use of ≥2 unique medications (PP) and ≥2 unique medication classes (MPP) within a calendar year in this study. In the total clinic cohort, increased rates of PP (71.6% to 75.6%), MPP (61.9% to 67.8%, p = 0.027), and antidepressant prescriptions (56.9% to 62.9%, p = 0.028) were noted, although only the latter two were nominally significant. The paired-sample had a higher proportion of teens (31.0% vs. 39.7%, p < 0.001 and persons who self-identified as non-Hispanic (77.8% vs. 85.4%, p = 0.016)), higher rates of anxiety (78.9% vs. 48.7%, p < 0.001), ADHD (71.0% vs. 44.4%, p < 0.001), depression (23.9% vs. 13.0%, p < 0.001) and disruptive behavior (63.3% vs. 33.3%, p < 0.001) diagnoses, higher rates of antidepressants (63.4% vs. 48.7%, p < 0.001), ADHD medications (72.5% vs. 59.8%, p < 0.001), and antipsychotics (36.8% vs. 26.2%, p < 0.001) prescribed, and higher rates of PP (81.6% vs. 59.0%, p < 0.001) and MPP (71.0% vs. 50.5%, p < 0.001) than the not-paired sample. In the random unique sample, the patient group assigned to 2020 had higher rates of anxiety (75.0% vs. 60.2%, p < 0.001), ADHD (69.9% vs. 54.6%, p < 0.001), and disruptive behavior (57.9% vs. 45.4%, p < 0.001) diagnoses but the PP and MPP rates did not differ across years. Overall, we found high rates of PP and MPP, likely due to the broader definition of PP and MPP used in this study than those in other studies as well as the study site being a tertiary clinic. While our study suggests a possible impact of the COVID-19 pandemic on comorbidity rates and prescribing patterns, a replication study is needed to confirm how pandemic-related factors impact prescribing patterns and polypharmacy rates in youth with ASD.

Diuretics: a contemporary pharmacological classification?

Diuretics are drugs that increase the flow of urine. They are commonly used to treat edema, hypertension, and heart failure. Typically, the pharmacological group consists of five classes: thiazide diuretics, loop diuretics, potassium-sparing diuretics, osmotic diuretics, and carbonic anhydrase inhibitors. This traditional classification and the nomenclature of diuretics have not changed over the last decades, which means that it was not adapted to current pharmacological research. Modern approaches in the field of pharmacological nomenclature suggest the introduction of mechanism-based drug class designations, which is not yet reflected in the group of diuretics. Moreover, included drug classes have lost their relevance as diuretic agents. Carbonic anhydrase inhibitors, for example, are mainly used in the treatment of glaucoma. Newer agents such as vasopressin-2 receptor antagonists or SGLT2 inhibitors possess diuretic properties but are not included in the pharmacological group. This review discusses the currentness of the pharmacological classification of diuretics. We elaborate changes in the field of nomenclature, the contemporary medical use of classical diuretics, and new diuretic agents.

Research Review: Pediatric anxiety disorders - what have we learnt in the last 10 years?

BACKGROUND

Anxiety disorders first emerge during the critical developmental periods of childhood and adolescence. This review synthesizes recent findings on the prevalence, risk factors, and course of the anxiety disorders; and their neurobiology and treatment.

METHODS

For this review, searches were conducted using PubMed, PsycINFO, and clinicaltrials.gov. Findings related to the epidemiology, neurobiology, risk factors, and treatment of pediatric anxiety disorders were then summarized.

FINDINGS

Anxiety disorders are high prevalence, and early-onset conditions associated with multiple risk factors including early inhibited temperament, environment stress, and structural and functional abnormalities in the prefrontal-amygdala circuitry as well as the default mode and salience networks. The anxiety disorders are effectively treated with cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs).

CONCLUSIONS

Anxiety disorders are high prevalence, early-onset conditions associated with a distinct neurobiological fingerprint, and are consistently responsive to treatment. Questions remain regarding who is at risk of developing anxiety disorders as well as the way in which neurobiology predicts treatment response.

Antioxidant Properties of Second-Generation Antipsychotics: Focus on Microglia

Recent studies suggest a primary role of oxidative stress in an early phase of the pathogenesis of schizophrenia and a strong neurobiological link has been found between dopaminergic system dysfunction, microglia overactivation, and oxidative stress. Different risk factors for schizophrenia increase oxidative stress phenomena raising the risk of developing psychosis. Oxidative stress induced by first-generation antipsychotics such as haloperidol significantly contributes to the development of extrapyramidal side effects. Haloperidol also exerts neurotoxic effects by decreasing antioxidant enzyme levels then worsening pro-oxidant events. Opposite to haloperidol, second-generation antipsychotics (or atypical antipsychotics) such as risperidone, clozapine, and olanzapine exert a strong antioxidant activity in experimental models of schizophrenia by rescuing the antioxidant system, with an increase in superoxide dismutase and glutathione (GSH) serum levels. Second-generation antipsychotics also improve the antioxidant status and reduce lipid peroxidation in schizophrenic patients. Interestingly, second-generation antipsychotics, such as risperidone, paliperidone, and in particular clozapine, reduce oxidative stress induced by microglia overactivation, decreasing the production of microglia-derived free radicals, finally protecting neurons against microglia-induced oxidative stress. Further, long-term clinical studies are needed to better understand the link between oxidative stress and the clinical response to antipsychotic drugs and the therapeutic potential of antioxidants to increase the response to antipsychotics.

New antipsychotic drugs for the treatment of agitation and psychosis in Alzheimer's disease: focus on brexpiprazole and pimavanserin

Behavioral and psychological symptoms of dementia are symptoms of disturbed perception, mood, behavior, and thought content that occurred frequently. These symptoms, which include apathy, depression, anxiety, psychosis, agitation, and aggression, can serve as predictors of and early clinical diagnostic markers for Alzheimer's disease (AD) and are common precipitants of institutional care. Agitation and psychosis are associated with accelerated disease progression and increased tau phosphorylation in patients with AD. Current guidelines recommend the use of second-generation antipsychotics for the treatment of agitation and psychosis in AD, but only after first-line non-pharmacological interventions and for no longer than 12 weeks because long-term use of these drugs is associated with an increased risk of mortality and an increased frequency of cerebrovascular events. Therefore, new antipsychotic drugs with improved efficacy and safety are needed as an alternative to current antipsychotic drugs. In this report, we discuss some of the most relevant advances in the field of agitation and psychosis in AD and focus on the recent positive clinical evidence observed with two new antipsychotics drugs: brexpiprazole and pimavanserin. Brexpiprazole is a receptor partial agonist (D2, D3, 5-HT1A), receptor antagonist (5-HT2A/B, α1B/α2C) according to the neuroscience-based nomenclature. Two recent phase III clinical trials have shown that brexpiprazole 2 mg/day is effective for the treatment of agitation in patients with AD and has an improved tolerability and safety profile compared with currently available second-generation antipsychotics. Pimavanserin is a receptor antagonist (5-HT2A, 5-HT2C) that has been given market authorization for psychosis occurring in Parkinson's disease. Recent phase II studies suggest that this drug is effective in AD patients with more severe psychosis, although further long-term studies are needed to better define the efficacy and long-term safety profile of pimavanserin for the treatment of psychosis in AD.

A simple mechanistic terminology of psychoactive drugs: a proposal

Antidepressants, antiepileptics, mood stabilizers, and antipsychotics are extremely broadly used psychoactive drugs. These drug terms are universally used in the literature. However, the indications of these drugs have broadened substantially and overlap. The mismatch between drug classification and clinical uses causes a lot of confusion in communication and renders literature searches increasingly difficult. Therefore, we propose to drop the above terms altogether and replace them by simple mechanistic terms. Antidepressants are re-named as norepinephrine/serotonin (NE/5-HT) enhancers, antiepileptics comprising drugs with different mechanisms become neuronal inhibitors with pleiotropic effects (NIPEs), and antipsychotics become antagonists at multiple G protein-coupled receptors (mGPCR antagonists). Alkali metal ions, comprising lithium, are integrated into NIPEs. The terms "typical/first-generation/conventional" and "atypical/second-generation/non-conventional" antipsychotics should be dropped, because the original criterion for distinction, i.e., the presence and absence of extrapyramidal motor effects, respectively, is not valid anymore. The suggested changes in drug nomenclature have already been implemented into a recent textbook (Seifert R, Basic Knowledge of Pharmacology). The revised nomenclature ensures consistency with other fields of pharmacology and assignment of drug classes to indications without causing confusion. The authors acknowledge that the change in drug nomenclature is a cultural process that will take time and openly discuss the problems associated with the proposal. Ultimately, international learned societies will have to agree on a new nomenclature.

Disparate effects of first and second generation antipsychotics on cognition in schizophrenia - Findings from the randomized NeSSy trial

Cognitive impairment represents a core feature of schizophrenia. Uncertainty about demonstrable benefits of available antipsychotics on cognition remains an important clinical question relevant to patients' quality of life. The aim of our multi-center, randomized, double-blind "Neuroleptic Strategy Study" (NeSSy) was to compare the effectiveness of selected antipsychotics, conventionally classified as second- (SGAs) (haloperidol, flupentixol) and first generation antipsychotics (FGAs) (aripiprazole, olanzapine, quetiapine), on quality of life in schizophrenia. The effects on cognitive deficits represented a secondary outcome. We used an innovative double randomization for assignment of treatment group, and followed the patients with a neurocognitive test-battery upon six and 24 weeks of treatment. Psychopathology and quality of life were assessed using CGI, PANSS and SF-36. Assessment of cognitive performance was conducted in 114 of the 136 randomized patients. The SGA group (N = 62) showed beneficial effects of small to moderate effect size on cognition during the initial six weeks of treatment (executive functions, verbal fluency) and at 24 weeks (executive functions, working memory). In contrast, the FGA group (N = 52) showed moderately improved executive function, but a decline in verbal fluency at six weeks, with significant declines of moderate to large effect size in executive function, verbal learning and memory, and verbal fluency at 24 weeks. Our study indicates that SGAs present an advantage over FGAs regarding cognitive function during a medium-term treatment for schizophrenia. The results further emphasize a distinction between progression to detrimental effects of FGAs with prolonged treatment in contrast to more persistent cognitive benefits with SGA treatment.

International Union of Basic and Clinical Pharmacology CIV: The Neurobiology of Treatment-resistant Depression: From Antidepressant Classifications to Novel Pharmacological Targets

Major depressive disorder is one of the most prevalent and life-threatening forms of mental illnesses and a major cause of morbidity worldwide. Currently available antidepressants are effective for most patients, although around 30% are considered treatment resistant (TRD), a condition that is associated with a significant impairment of cognitive function and poor quality of life. In this respect, the identification of the molecular mechanisms contributing to TRD represents an essential step for the design of novel and more efficacious drugs able to modify the clinical course of this disorder and increase remission rates in clinical practice. New insights into the neurobiology of TRD have shed light on the role of a number of different mechanisms, including the glutamatergic system, immune/inflammatory systems, neurotrophin function, and epigenetics. Advances in drug discovery processes in TRD have also influenced the classification of antidepressant drugs and novel classifications are available, such as the neuroscience-based nomenclature that can incorporate such advances in drug development for TRD. This review aims to provide an up-to-date description of key mechanisms in TRD and describe current therapeutic strategies for TRD before examining novel approaches that may ultimately address important neurobiological mechanisms not targeted by currently available antidepressants. All in all, we suggest that drug targeting different neurobiological systems should be able to restore normal function but must also promote resilience to reduce the long-term vulnerability to recurrent depressive episodes.

A new nomenclature for classifying psychotropic drugs

The Neuroscience-based Nomenclature (NbN) for psychotropic drugs was developed as an alternative to the current Anatomical Therapeutic Chemical (ATC) indication-based classification in order to provide more precise designations for this drug class. The ATC nomenclature for psychotherapeutics is limited in that it fails to specify either pharmacological domains or mechanism of action and also does not describe all the potential uses of a particular agent. The disconnect between the drug classification and its clinical use is not very useful for scientific purposes and is confusing for patients and caregivers, often leading to a misunderstanding of the intended effects of the prescribed medication and, most importantly, to low treatment adherence. The NbN classifies psychopharmacological agents on the basis of contemporary scientific information on their pharmacology and mechanisms of action so as to provide physicians clear alternatives when selecting or altering therapeutic regimens. The classification of each psychotropic drug includes four additional dimensions: approved indications; efficacy and side effects; practical note; neurobiology. By emphasizing the pharmacology and the molecular mechanism of action, NbN provides a vehicle for clinicians and basic scientists to improve the understanding and clinical use of this important drug class.