Role of the central cholinergic system in the therapeutics of schizophrenia

Acetylcholine modulates the temporal dynamics of human theta oscillations during memory

The cholinergic system is essential for memory. While degradation of cholinergic pathways characterizes memory-related disorders such as Alzheimer's disease, the neurophysiological mechanisms linking the cholinergic system to human memory remain unknown. Here, combining intracranial brain recordings with pharmacological manipulation, we describe the neurophysiological effects of a cholinergic blocker, scopolamine, on the human hippocampal formation during episodic memory. We found that the memory impairment caused by scopolamine was coupled to disruptions of both the amplitude and phase alignment of theta oscillations (2-10 Hz) during encoding. Across individuals, the severity of theta phase disruption correlated with the magnitude of memory impairment. Further, cholinergic blockade disrupted connectivity within the hippocampal formation. Our results indicate that cholinergic circuits support memory by coordinating the temporal dynamics of theta oscillations across the hippocampal formation. These findings expand our mechanistic understanding of the neurophysiology of human memory and offer insights into potential treatments for memory-related disorders.

Insights into the Mechanism of Action of Antipsychotic Drugs Derived from Animal Models: Standard of Care versus Novel Targets

Therapeutic intervention for schizophrenia relies on blockade of dopamine D2 receptors in the associative striatum; however, there is little evidence for baseline overdrive of the dopamine system. Instead, the dopamine system is in a hyper-responsive state due to excessive drive by the hippocampus. This causes more dopamine neurons to be in a spontaneously active, hyper-responsive state. Antipsychotic drugs alleviate this by causing depolarization block, or excessive depolarization-induced dopamine neuron inactivation. Indeed, both first- and second-generation antipsychotic drugs cause depolarization block in the ventral tegmentum to relieve positive symptoms, whereas first-generation drugs also cause depolarization in the nigrostriatal dopamine system to lead to extrapyramidal side effects. However, by blocking dopamine receptors, these drugs are activating multiple synapses downstream from the proposed site of pathology: the loss of inhibitory influence over the hippocampus. An overactive hippocampus not only drives the dopamine-dependent positive symptoms, but via its projections to the amygdala and the neocortex can also drive negative and cognitive symptoms, respectively. On this basis, a novel class of drugs that can reverse schizophrenia at the site of pathology, i.e., the hippocampal overdrive, could be effective in alleviating all three classes of symptoms of schizophrenia while also being better tolerated.

Determinants of approved acetylcholinesterase inhibitor response outcomes in Alzheimer's disease: relevance for precision medicine in neurodegenerative diseases

Acetylcholinesterase inhibitors (ChEI) are the global standard of care for the symptomatic treatment of Alzheimer's disease (AD) and show significant positive effects in neurodegenerative diseases with cognitive and behavioral symptoms. Although experimental and large-scale clinical evidence indicates the potential long-term efficacy of ChEI, primary outcomes are generally heterogeneous across outpatient clinics and regional healthcare systems. Sub-optimal dosing or slow tapering, heterogeneous guidelines about the timing for therapy initiation (prodromal versus dementia stages), healthcare providers' ambivalence to treatment, lack of disease awareness, delayed medical consultation, prescription of ChEI in non-AD cognitive disorders, contribute to the negative outcomes. We present an evidence-based overview of determinants, spanning genetic, molecular, and large-scale networks, involved in the response to ChEI in patients with AD and other neurodegenerative diseases. A comprehensive understanding of cerebral and retinal cholinergic system dysfunctions along with ChEI response predictors in AD is crucial since disease-modifying therapies will frequently be prescribed in combination with ChEI. Therapeutic algorithms tailored to genetic, biological, clinical (endo)phenotypes, and disease stages will help leverage inter-drug synergy and attain optimal combined response outcomes, in line with the precision medicine model.

Neuromodulatory control of inhibitory network arborization in the developing postnatal neocortex

Interregional neuronal communication is pivotal to instructing and adjusting cortical circuit assembly. Subcortical neuromodulatory systems project long-range axons to the cortex and affect cortical processing. However, their roles and signaling mechanisms in cortical wiring remain poorly understood. Here, we explored whether and how the cholinergic system regulates inhibitory axonal ramification of neocortical chandelier cells (ChCs), which control spike generation by innervating axon initial segments of pyramidal neurons. We found that acetylcholine (ACh) signaling through nicotinic ACh receptors (nAChRs) and downstream T-type voltage-dependent calcium (Ca²⁺) channels cell-autonomously controls axonal arborization in developing ChCs through regulating filopodia initiation. This signaling axis shapes the basal Ca²⁺ level range in varicosities where filopodia originate. Furthermore, the normal development of ChC axonal arbors requires proper levels of activity in subcortical cholinergic neurons. Thus, the cholinergic system regulates inhibitory network arborization in the developing neocortex and may tune cortical circuit properties depending on early-life experiences.

Nicotine abolishes memory-related synaptic strengthening and promotes synaptic depression in the neurogenic dentate gyrus of miR-132/212 knockout mice

Micro-RNAs (miRNAs) are highly evolutionarily conserved short-length/noncoding RNA molecules that modulate a wide range of cellular functions in many cell types by regulating the expression of a variety of targeted genes. miRNAs have also recently emerged as key regulators of neuronal genes mediating the effects of psychostimulant drugs and memory-related neuroplasticity processes. Smoking is a predominant addictive behaviour associated with millions of deaths worldwide, and nicotine is a potent natural psychoactive agonist of cholinergic receptors, highly abundant in cigarettes. The influence of miRNAs modulation on cholinergic signalling in the nervous system remains however poorly explored. Using miRNA knockout mice and biochemical, electrophysiological and pharmacological approaches, we examined the effects of miR-132/212 gene disruption on the levels of hippocampal nicotinic acetylcholine receptors, total ERK and phosphorylated ERK (pERK) and MeCP2 protein levels, and studied the impact of nicotine stimulation on hippocampal synaptic transmission and synaptic depression and strengthening. miR-132/212 deletion significantly altered α7-nAChR and pERK protein levels, but not total ERK or MeCP2, and resulted in both exacerbated synaptic depression and virtually abolished memory-related synaptic strengthening upon nicotine stimulation. These observations reveal a functional miRNAs/nicotinergic signalling interplay critical for nicotinic-receptor expression and neuroplasticity in brain structures relevant for drug addiction and learning and memory functions.

Contributions of animal models of cognitive disorders to neuropsychopharmacology

Cognitive disorders and symptoms are key features of many mental and neurological diseases, with a large spectrum of impaired domains. Because of their possible evolution and detrimental functioning impact, they are a major pharmacological target for both symptomatic and disease-modifier drugs, while few cognitive enhancers have been marketed with an insufficient efficiency. It explains the need to model these cognitive disorders beyond the modelization of mental or neurological diseases themselves. According to the experimental strategy used to induce cognitive impairment, three categories of models have been identified: neurotransmission-driven models; pathophysiology-driven models; environment-driven models. These three categories of models reflect different levels of integration of endogenous and exogenous mechanisms underlying cognitive disorders in humans. Their comprehensive knowledge and illustration of their pharmacological modulation could help to propose a renewing strategy of drug development in central nervous system (CNS) field at a time when the academic and industrial invest seems to be declining despite the medical and social burden of brain diseases.

Oxidative Stress-Related Mechanisms in Schizophrenia Pathogenesis and New Treatment Perspectives

Schizophrenia is recognized to be a highly heterogeneous disease at various levels, from genetics to clinical manifestations and treatment sensitivity. This heterogeneity is also reflected in the variety of oxidative stress-related mechanisms contributing to the phenotypic realization and manifestation of schizophrenia. At the molecular level, these mechanisms are supposed to include genetic causes that increase the susceptibility of individuals to oxidative stress and lead to gene expression dysregulation caused by abnormal regulation of redox-sensitive transcriptional factors, noncoding RNAs, and epigenetic mechanisms favored by environmental insults. These changes form the basis of the prooxidant state and lead to altered redox signaling related to glutathione deficiency and impaired expression and function of redox-sensitive transcriptional factors (Nrf2, NF-κB, FoxO, etc.). At the cellular level, these changes lead to mitochondrial dysfunction and metabolic abnormalities that contribute to aberrant neuronal development, abnormal myelination, neurotransmitter anomalies, and dysfunction of parvalbumin-positive interneurons. Immune dysfunction also contributes to redox imbalance. At the whole-organism level, all these mechanisms ultimately contribute to the manifestation and development of schizophrenia. In this review, we consider oxidative stress-related mechanisms and new treatment perspectives associated with the correction of redox imbalance in schizophrenia. We suggest that not only antioxidants but also redox-regulated transcription factor-targeting drugs (including Nrf2 and FoxO activators or NF-κB inhibitors) have great promise in schizophrenia. But it is necessary to develop the stratification criteria of schizophrenia patients based on oxidative stress-related markers for the administration of redox-correcting treatment.

The Phenomenology and Neurobiology of Visual Distortions and Hallucinations in Schizophrenia: An Update

Schizophrenia is characterized by visual distortions in ~60% of cases, and visual hallucinations (VH) in ~25-50% of cases, depending on the sample. These symptoms have received relatively little attention in the literature, perhaps due to the higher rate of auditory vs. visual hallucinations in psychotic disorders, which is the reverse of what is found in other neuropsychiatric conditions. Given the clinical significance of these perceptual disturbances, our aim is to help address this gap by updating and expanding upon prior reviews. Specifically, we: (1) present findings on the nature and frequency of VH and distortions in schizophrenia; (2) review proposed syndromes of VH in neuro-ophthalmology and neuropsychiatry, and discuss the extent to which these characterize VH in schizophrenia; (3) review potential cortical mechanisms of VH in schizophrenia; (4) review retinal changes that could contribute to VH in schizophrenia; (5) discuss relationships between findings from laboratory measures of visual processing and VH in schizophrenia; and (6) integrate findings across biological and psychological levels to propose an updated model of VH mechanisms, including how their content is determined, and how they may reflect vulnerabilities in the maintenance of a sense of self. In particular, we emphasize the potential role of alterations at multiple points in the visual pathway, including the retina, the roles of multiple neurotransmitters, and the role of a combination of disinhibited default mode network activity and enhanced state-related apical/contextual drive in determining the onset and content of VH. In short, our goal is to cast a fresh light on the under-studied symptoms of VH and visual distortions in schizophrenia for the purposes of informing future work on mechanisms and the development of targeted therapeutic interventions.

Behavioral Tasks Evaluating Schizophrenia-like Symptoms in Animal Models: A Recent Update

BACKGROUND

Schizophrenia is a serious mental illness that affects more than 21 million people worldwide. Both genetics and the environment play a role in its etiology and pathogenesis. Symptoms of schizophrenia are mainly categorized into positive, negative, and cognitive. One major approach to identify and understand these diverse symptoms in humans has been to study behavioral phenotypes in a range of animal models of schizophrenia.

OBJECTIVE

We aimed to provide a comprehensive review of the behavioral tasks commonly used for measuring schizophrenia-like behaviors in rodents together with an update of the recent study findings.

METHODS

Articles describing phenotypes of schizophrenia-like behaviors in various animal models were collected through a literature search in Google Scholar, PubMed, Web of Science, and Scopus, with a focus on advances over the last 10 years.

RESULTS

Numerous studies have used a range of animal models and behavioral paradigms of schizophrenia to develop antipsychotic drugs for improved therapeutics. In establishing animal models of schizophrenia, the candidate models were evaluated for schizophrenia-like behaviors using several behavioral tasks for positive, negative, and cognitive symptoms designed to verify human symptoms of schizophrenia. Such validated animal models were provided as rapid preclinical avenues for drug testing and mechanistic studies.

CONCLUSION

Based on the most recent advances in the field, it is apparent that a myriad of behavior tests are needed to confirm and evaluate the congruency of animal models with the numerous behaviors and clinical signs exhibited by patients with schizophrenia.

A Review of the Cholinergic System and Therapeutic Approaches to Treat Brain Disorders

Since its identification over a hundred years ago, the neurotransmitter acetylcholine (ACh) has proven to play an essential role in supporting many diverse functions. Some well-characterized functions include: chemical transmission at the neuromuscular junction; autonomic function in the peripheral nervous system; and, sustained attention, sleep/wake regulation, and learning and memory within the central nervous system. Within the brain, major cholinergic projection pathways from the basal forebrain and the brainstem support these centrally mediated processes, and dysregulation of the cholinergic system is implicated in cognitive decline associated with aging and dementias including Alzheimer's disease. ACh exerts its effects by binding to two different membrane-bound receptor classes: (1) G‑protein coupled muscarinic acetylcholine receptors (mAChRs), and (2) ligand-gated nicotinic acetylcholine receptors (nAChRs). These receptor systems are described in detail within this chapter along with discussion on the successes and failures of synthetic ligands designed to selectively target receptor subtypes for treating brain disorders. New molecular approaches and advances in our understanding of the target biology combined with opportunities to re-purpose existing cholinergic drugs for new indications continue to highlight the exciting opportunities for modulating this system for therapeutic purposes.

Nicotine consumption during the prodromal phase of schizophrenia - a review of the literature

Recent research has fueled a debate concerning the role of nicotine in the emergence of schizophrenia. The three main hypotheses are: (a) the self-medication effect, (b) the causal relationship hypothesis, or (c) the shared diathesis hypothesis. To explore this role, the study of nicotine consumption during the initial prodromal phase of schizophrenia offers important opportunities. In the present work, 10 relevant studies are reviewed, out of 727 retrieved citations, in order to address questions regarding the prevalence of smoking in the prodromal period, the time of smoking initiation, existing patterns of tobacco use in relation with the escalation of prodromal symptoms into first psychotic episode, and potential differences in symptomatology between smokers and nonsmokers. Even though there was considerable heterogeneity among studies, relevant findings are discussed. Prevalence of nicotine use during the prodromal period was reported to be 16.6-46%. Tobacco use was found to be taken up most often before or during the prodromal period of schizophrenia. Even though a protective role of smoking has been reported by one study, other studies report an increased risk for psychosis, with hazard ratios 2.77 (95% CI: 2.34-3.43) and 2.21 (95% CI: 1.11-4.42) for female and male heavy smokers (11-20 and >20 cigarettes/day), respectively. In a different study, the risk of onset was associated with the progressive use of cannabis and tobacco prior to onset, particularly with rapid escalation to the highest levels of use. Also, nicotine use in ultra high risk (UHR) for developing psychosis subjects is associated with elevated cognitive performance, namely better processing speed, visual learning, and spatial working memory. As a conclusion, it appears that evidence accumulates supporting a possible etiologic role of smoking, in the emergence of schizophrenia along with diverse effects on patients' symptomatology, already demonstrable at the prodromal phase. Future research employing better-defined criteria should further explore the patterns of use and effects of nicotine during the schizophrenia prodrome.

New Insights Into Cholinergic Neuron Diversity

Cholinergic neurons comprise a small population of cells in the striatum but have fundamental roles in fine tuning brain function, and in the etiology of neurological and psychiatric disorders such as Parkinson’s disease (PD) or schizophrenia. The process of developmental cell specification underlying neuronal identity and function is an area of great current interest. There has been significant progress in identifying the developmental origins, commonalities in molecular markers, and physiological properties of the cholinergic neurons. Currently, we are aware of a number of key factors that promote cholinergic fate during development. However, the extent of cholinergic cell diversity is still largely underestimated. New insights into the biological basis of their specification indicate that cholinergic neurons may be far more diverse than previously thought. This review article, highlights the physiological features and the synaptic properties that segregate cholinergic cell subtypes. It provides an accurate picture of cholinergic cell diversity underlying their organization and function in neuronal networks. This review article, also discusses current challenges in deciphering the logic of the cholinergic cell heterogeneity that plays a fundamental role in the control of neural processes in health and disease.

Effects of different analgesia regimens on early post-operative cognitive dysfunction in elderly patients undergoing radical resection of cervical carcinoma

This study was designed to compare the effects of epidural and intravenous analgesia on early post-operative cognitive dysfunction (POCD) in elderly patients undergoing radical resection of cervical cancer. For this purpose, 74 patients aged 60-78 years [body mass index (BMI), 18-25 kg/m²; American Society of Anesthesiologists (ASA) classification score of I-III) undergoing radical resection of cervical cancer were divided into the epidural group (group E) and parenteral group (group P) groups (37 patients in each group). All patients underwent their surgical procedures under epidural anesthesia and intravenously-delivered general anesthesia. Patient-controlled analgesia (PCA) was supplied for 72 h after the surgery. Epidural analgesia was provided for the patients in group E and intravenous analgesia was provide for those in group P. General patient information was recorded and peripheral blood neutrophil counts, C-reactive protein (CRP) levels and interleukin (IL)-6 concentrations were measured immediately prior to the surgery (T₀), and at 24, 48 and 72 h after the procedure (T₁, T₂ and T₃, respectively). Visual analog scale (VAS) scores were also recorded at T₁, T₂ and T₃, and the mini-mental state evaluation (MMSE) scores at T₀, T₁, T₂, and T₃ were calculated. Patients were diagnosed as having POCD according to their MMSE score differences between the peri-operative and post-operative values. The results revealed that the levels of CRP and IL-6 significantly increased in both groups after the surgery (T_1-3). However, the CRP and IL-6 levels in group E were significantly lower than those in group P at all time points examined (P<0.05). The VAS scores in group E at T₁, T₂ and T₃ were significantly lower than those in group P (P<0.05). Finally, the incidence of POCD in group E was significantly lower than that in group P (P<0.05). On the whole, the post-operative epidural analgesia reduced the systemic inflammatory response, the perceived pain, and the incidence of POCD in patients undergoing radical resection of cervical cancer, when compared with the effects of intravenous analgesia.

Cholinergic Stimulation of the Adult Zebrafish Brain Induces Phosphorylation of Glycogen Synthase Kinase-3 β and Extracellular Signal-Regulated Kinase in the Telencephalon

The sequencing of the zebrafish genome, the emergence of powerful gene-editing tools, and the development of in vivo imaging techniques have propelled the economical zebrafish into prominence as a biomedical research model. Neurodegenerative disorders with a cholinergic component, such as Alzheimer's and Parkinson's diseases, are currently modeled using zebrafish. Still, the utility of zebrafish as a research model will not be fully realized until their neurophysiological properties are thoroughly characterized. In mammals, the coupling of cholinergic receptors to the phosphorylation of glycogen synthase kinase-3 β (GSK3β) and extracellular signal-regulated kinase 1/2 (ERK1/2) is of critical importance to cognitive processes and imparts protection against neuropathogenic events. Similarly, it is known that cholinergic receptors are required for learning and memory in zebrafish and that in vivo activation of cholinergic receptors induces transient changes in evoked synaptic transmission in the telencephalon. However, the intracellular events mediating cholinergic processes in zebrafish have yet to be elucidated. In the current study, an ex vivo drug treatment assay was used to demonstrate that carbachol (CCh)-mediated cholinergic stimulation of the intact adult zebrafish brain induces phosphorylation of GSK3β and ERK1/2 in the zebrafish telencephalon. These findings suggest GSK3β and ERK1/2 may underly cognitive processes in zebrafish.

TAK-071, a novel M1 positive allosteric modulator with low cooperativity, improves cognitive function in rodents with few cholinergic side effects

The muscarinic M₁ receptor (M₁R) is a promising target for treating cognitive impairment associated with cholinergic deficits in disorders such as Alzheimer's disease and schizophrenia. We previously reported that cooperativity (α-value) was key to lowering the risk of diarrhea by M₁R positive allosteric modulators (M₁ PAMs). Based on this, we discovered a low α-value M₁ PAM, TAK-071 (α-value: 199), and characterized TAK-071 using T-662 as a reference M₁ PAM with high α-value of 1786. Both TAK-071 and T-662 were potent and highly selective M₁ PAMs, with inflection points of 2.7 and 0.62 nM, respectively. However, T-662 but not TAK-071 augmented isolated ileum motility. TAK-071 and T-662 increased hippocampal inositol monophosphate production through M₁R activation and improved scopolamine-induced cognitive deficits in rats at 0.3 and 0.1 mg/kg, respectively. TAK-071 and T-662 also induced diarrhea at 10 and 0.1 mg/kg, respectively, in rats. Thus, taking into consideration the fourfold lower brain penetration ratio of T-662, TAK-071 had a wider margin between cognitive improvement and diarrhea induction than T-662. Activation of M₁R increases neural excitability via membrane depolarization, reduced afterhyperpolarization, and generation of afterdepolarization in prefrontal cortical pyramidal neurons. T-662 induced all three processes, whereas TAK-071 selectively induced afterdepolarization. Combining sub-effective doses of TAK-071, but not T-662, with an acetylcholinesterase inhibitor, significantly ameliorated scopolamine-induced cognitive deficits in rats. TAK-071 may therefore provide therapeutic opportunities for cognitive dysfunction related to cholinergic deficits or reduced M₁R expression, while minimizing peripheral cholinergic side effects.

Cholinergic Stimulation of the Adult Zebrafish Brain Induces Phosphorylation of Glycogen Synthase Kinase-3 β and Extracellular Signal-Regulated Kinase in the Telencephalon

The sequencing of the zebrafish genome, the emergence of powerful gene-editing tools, and the development of in vivo imaging techniques have propelled the economical zebrafish into prominence as a biomedical research model. Neurodegenerative disorders with a cholinergic component, such as Alzheimer's and Parkinson's diseases, are currently modeled using zebrafish. Still, the utility of zebrafish as a research model will not be fully realized until their neurophysiological properties are thoroughly characterized. In mammals, the coupling of cholinergic receptors to the phosphorylation of glycogen synthase kinase-3 β (GSK3β) and extracellular signal-regulated kinase 1/2 (ERK1/2) is of critical importance to cognitive processes and imparts protection against neuropathogenic events. Similarly, it is known that cholinergic receptors are required for learning and memory in zebrafish and that in vivo activation of cholinergic receptors induces transient changes in evoked synaptic transmission in the telencephalon. However, the intracellular events mediating cholinergic processes in zebrafish have yet to be elucidated. In the current study, an ex vivo drug treatment assay was used to demonstrate that carbachol (CCh)-mediated cholinergic stimulation of the intact adult zebrafish brain induces phosphorylation of GSK3β and ERK1/2 in the zebrafish telencephalon. These findings suggest GSK3β and ERK1/2 may underly cognitive processes in zebrafish.

[What criteria for an ideal antipsychotic treatment?]

Antipsychotics are, by definition, drugs to treat all symptomatic dimensions of schizophrenia, even if, following the discovery of chlorpromazine, the effect assessment has been focused on the ability to reduce positive symptoms. Nevertheless, expectations of treatment are no longer limited to only support this one dimension, but integrate the need to treat negative, cognitive and affective symptoms, through long-term modulation of dopamine transmission but also non-dopaminergic pathways. Beyond symptomatic treatment, it is also necessary to have a treatment modifying the evolution course of the disease (disease modifier), acting by a long-term effect on neuropathological and neurochemical abnormalities. The limitation of long-term effect remains the issue of therapeutic observance. Moreover, this concern for efficiency should be at the cost of reduced induction of adverse effects to maximize the benefit/risk ratio. All these dimensions should the components to profile an ideal antipsychotic treatment in 2015.

Dehydroepiandrosterone, its metabolites and ion channels

This review is focused on the physiological and pathophysiological relevance of steroids influencing the activities of the central and peripheral nervous systems with regard to their concentrations in body fluids and tissues in various stages of human life like the fetal development or pregnancy. The data summarized in this review shows that DHEA and its unconjugated and sulfated metabolites are physiologically and pathophysiologically relevant in modulating numerous ion channels and participate in vital functions of the human organism. DHEA and its unconjugated and sulfated metabolites including 5α/β-reduced androstane steroids participate in various physiological and pathophysiological processes like the management of GnRH cyclic release, regulation of glandular and neurotransmitter secretions, maintenance of glucose homeostasis on one hand and insulin insensitivity on the other hand, control of skeletal muscle and smooth muscle activities including vasoregulation, promotion of tolerance to ischemia and other neuroprotective effects. In respect of prevalence of steroid sulfates over unconjugated steroids in the periphery and the opposite situation in the CNS, the sulfated androgens and androgen metabolites reach relevance in peripheral organs. The unconjugated androgens and estrogens are relevant in periphery and so much the more in the CNS due to higher concentrations of most unconjugated steroids in the CNS tissues than in circulation and peripheral organs. This article is part of a Special Issue entitled "Essential role of DHEA".

Profile of minocycline and its potential in the treatment of schizophrenia

Accumulating evidence suggests that neuroinflammation affecting microglia plays an important role in the etiology of schizophrenia, and appropriate control of microglial activation may be a promising therapeutic strategy for schizophrenia. Minocycline, a second-generation tetracycline that inhibits microglial activation, has been shown to have a neuroprotective effect in various models of neurodegenerative disease, including anti-inflammatory, antioxidant, and antiapoptotic properties, and an ability to modulate glutamate-induced excitotoxicity. Given that these mechanisms overlap with neuropathologic pathways, minocycline may have a potential role in the adjuvant treatment of schizophrenia, and improve its negative symptoms. Here, we review the relevant studies of minocycline, ranging from preclinical research to human clinical trials.

Adjunctive use of nonsteroidal anti-inflammatory drugs for schizophrenia: a meta-analytic investigation of randomized controlled trials

OBJECTIVE

To meta-analytically assess the efficacy and tolerability of nonsteroidal anti-inflammatory drugs (NSAIDs) vs placebo in schizophrenia.

METHOD

Searching PubMed, PsycINFO, ISI Web of Science, and the US National Institute of Mental Health clinical trials registry from database inception to December 31, 2012, we conducted a systematic review/meta-analysis of randomized placebo-controlled studies assessing the efficacy of adjunctive NSAIDs. Primary outcome was the change in Positive and Negative Syndrome Scale (PANSS) total score. Secondary outcomes included change in PANSS positive and negative subscores, all-cause discontinuation, and tolerability outcomes. Random effects, pooled, standardized mean changes (Hedges' g) and risk ratios were calculated.

RESULTS

Across 8 studies, including 3 unpublished reports (n = 774), the mean effect size for PANSS total score was -0.236 (95% CI: -0.484 to 0.012, P = .063, I(2) = 60.6%), showing only trend-level superiority for NSAIDs over placebo. The mean effect sizes for the PANSS positive and negative scores were -0.189 (95% CI: -0.373 to -0.005, P = .044) and -0.026 (95% CI: -0.169 to 0.117, P = .72), respectively. The relative risk for all-cause discontinuation was 1.13 (95% CI: 0.794 to 1.599, P = .503). Significant superiority of NSAIDs over placebo regarding PANSS total scores was moderated by aspirin treatment (N = 2, P = .017), inpatient status (N = 4, P = .029), first-episode status (N = 2, P = .048), and (in meta-regression analyses) lower PANSS negative subscores (N = 6, P = .026).

INTERPRETATION

These results indicate that adjunctive NSAIDs for schizophrenia may not benefit patients treated with first-line antipsychotics judged by PANSS total score change. NSAIDs may have benefits for positive symptoms, but the effect was minimal/small. However, due to a limited database, further controlled studies are needed, especially in first-episode patients.

Complex relationships of nicotinic receptor actions and cognitive functions

Nicotine has been shown in a variety of studies to improve cognitive function including learning, memory and attention. Nicotine both stimulates and desensitizes nicotinic receptors, thus acting both as an agonist and a net antagonist. The relative roles of these two actions for nicotine-induced cognitive improvement have not yet been fully determined. We and others have found that acute nicotinic antagonist treatment can improve learning and attention. Nicotine acts on a variety of nicotinic receptor subtypes. The relative role and interactions of neuronal nicotinic receptor subtypes for cognition also needs to be better characterized. Nicotine acts on nicotinic receptors in a wide variety of brain areas. The role of some of these areas such as the hippocampus has been relatively well studied but other areas like the thalamus, which has the densest nicotinic receptor concentration are still only partially characterized. In a series of studies we characterized nicotinic receptor actions, anatomic localization and circuit interactions, which are critical to nicotine effects on the cognitive functions of learning, memory and attention. The relative role of increases and decreases in nicotinic receptor activation by nicotine were determined in regionally specific studies of the hippocampus, the amygdala, the frontal cortex and the mediodorsal thalamic nucleus with local infusions of antagonists of nicotinic receptor subtypes (α7 and α4β2). The understanding of the functional neural bases of cognitive function is fundamental to the more effective development of nicotinic drugs for treating cognitive dysfunction.

Anticholinergics in the era of atypical antipsychotics: short-term or long-term treatment?

Anticholinergic agents are usually prescribed to prevent or treat antipsychotic-induced extrapyramidal symptoms. Their long-term benefits are questionable and they carry diverse adverse effects, including cognitive impairment and worsening of tardive dyskinesia. This literature review explores the impact of anticholinergic medication discontinuation on movement disorders, cognition and psychopathology in patients receiving antipsychotics. Medline, Embase and PsycInfo were searched from 1950 to July 2011 using "cessation /withdrawal /discontinuation /stopping" with "anticholinergic*" or "antiparkinson*" and "neuroleptic*" or "antipsychotic*". Additional articles were obtained by searching the bibliographies of relevant references. Earlier studies of anticholinergic agent discontinuation in patients receiving first-generation antipsychotics reported relapse rates of extrapyramidal symptoms between 4% and 80%, reflecting the heterogeneity of the studies. Two recent studies of patients prescribed second-generation antipsychotics obtained relapse rates of 4% and 33%. Some studies suggest improvement in tardive dyskinesia with cessation of anticholinergics. Four studies examined the effects of anticholinergic agent discontinuation on cognition and all observed an improvement post-discontinuation. Changes in symptoms of schizophrenia with anticholinergic discontinuation are conflicting, with more recent studies suggesting an improvement. Given their questionable benefit with continued use, clinicians should consider a gradual withdrawal of anticholinergic agents in stable patients receiving antipsychotics.

Schizophrenia: redox regulation and volume neurotransmission

Here, we show that volume neurotransmission and the redox property of dopamine, as well as redox-regulated processes at glutamate receptors, can contribute significantly to our understanding of schizophrenia. Namely, volume neurotransmission may play a key role in the development of dysconnectivity between brain regions in schizophrenic patients, which can cause abnormal modulation of NMDA-dependent synaptic plasticity and produce local paroxysms in deafferented neural areas. During synaptic transmission, neuroredox regulations have fundamental functions, which involve the excellent antioxidant properties and nonsynaptic neurotransmission of dopamine. It is possible that the effect of redox-linked volume neurotransmission (diffusion) of dopamine is not as exact as communication by the classical synaptic mechanism, so approaching the study of complex schizophrenic mechanisms from this perspective may be beneficial. However, knowledge of redox signal processes, including the sources and molecular targets of reactive species, is essential for understanding the physiological and pathophysiological signal pathways in cells and the brain, as well as for pharmacological design of various types of new drugs.

Ginkgo biloba leaf extract (EGb 761®) and its specific acylated flavonol constituents increase dopamine and acetylcholine levels in the rat medial prefrontal cortex: possible implications for the cognitive enhancing properties of EGb 761®

Experimental and clinical data suggest that the Ginkgo biloba standardized extract EGb 761® exerts beneficial effects in conditions which are associated with impaired cognitive function. However, the neurochemical correlates of these memory enhancing effects are not yet fully clarified. The aim of this study was to examine the effect of repeated oral administration of EGb 761® and some of its characteristic constituents on extracellular levels of dopamine (DA), noradrenaline (NA), serotonin (5-HT), acetylcholine (ACh) and the metabolites 3,4-dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA) in the medial prefrontal cortex (mPFC) of awake rats by use of in vivo microdialysis technique. Subacute (14 days, once daily), but not acute, oral treatment with EGb 761® (100 and 300 mg/kg) or the flavonoid fraction, which represents about 24% of the whole extract caused a significant and dose-dependent increase in extracellular DA levels in the mPFC. Repeated administration of EGb 761® also caused a modest but significant increase in the NA levels, whereas the concentrations of 5-HT and those of the metabolites DOPAC, HVA and 5-HIAA were not affected. The same treatment regimen was used in a subsequent study with the aim of investigating the effects of two Ginkgo-specific acylated flavonols, 3-O-(2''-O-(6'''-O-(p-hydroxy-trans-cinnamoyl)-β-D-glucosyl)-α-L-rhamnosyl)quercetin (Q-ag) and 3-O-(2''-O-(6'''-O-(p-hydroxy-trans-cinnamoyl)-β-D-glucosyl)-α-L-rhamnosyl)kaempferol (K-ag). Both compounds together represent about 4.5% of the whole extract. Repeated oral treatment with Q-ag (10 mg/kg) for 14 days caused a significant increase in extracellular DA levels of 159% and extracellular acetylcholine (ACh) levels of 151% compared to controls. Similarly, administration of K-ag (10 mg/kg) induced a significant rise of DA levels to 142% and ACh levels to 165% of controls, whereas treatment with isorhamnetin, an O-methylated aglycon component of EGb 761® flavonol glycosides had no effect. None of the tested flavonoids had a significant effect on extracellular DOPAC and HVA levels. The present findings provide evidence that the subacute treatment with EGb 761® and its flavonol constituents increases DA and ACh release in the rat mPFC, and suggest that the two Ginkgo-specific acylated flavonol glycosides Q-ag and K-ag are active constituents contributing to these effects. As seen for isorhamnetin, the effect on neurotransmitter levels seems not to be a general effect of flavonols but rather to be a specific action of acylated flavonol glycosides which are present in EGb 761®. The direct involvement of these two flavonol derivatives in the increase of dopaminergic and cholinergic neurotransmission in the prefrontal cortex may be one of the underlying mechanisms behind the reported effects of EGb 761® on the improvement of cognitive function.

Potential state-selective hydrogen bond formation can modulate activation and desensitization of the α7 nicotinic acetylcholine receptor

A series of arylidene anabaseines were synthesized to probe the functional impact of hydrogen bonding on human α7 nicotinic acetylcholine receptor (nAChR) activation and desensitization. The aryl groups were either hydrogen bond acceptors (furans), donors (pyrroles), or neither (thiophenes). These compounds were tested against a series of point mutants of the ligand-binding domain residue Gln-57, a residue hypothesized to be proximate to the aryl group of the bound agonist and a putative hydrogen bonding partner. Q57K, Q57D, Q57E, and Q57L were chosen to remove the dual hydrogen bonding donor/acceptor ability of Gln-57 and replace it with hydrogen bond donating, hydrogen bond accepting, or nonhydrogen bonding ability. Activation of the receptor was compromised with hydrogen bonding mismatches, for example, pairing a pyrrole with Q57K or Q57L, or a furan anabaseine with Q57D or Q57E. Ligand co-applications with the positive allosteric modulator PNU-120596 produced significantly enhanced currents whose degree of enhancement was greater for 2-furans or -pyrroles than for their 3-substituted isomers, whereas the nonhydrogen bonding thiophenes failed to show this correlation. Interestingly, the PNU-120596 agonist co-application data revealed that for wild-type α7 nAChR, the 3-furan desensitized state was relatively stabilized compared with that of 2-furan, a reversal of the relationship observed with respect to the barrier for entry into the desensitized state. These data highlight the importance of hydrogen bonding on the receptor-ligand state, and suggest that it may be possible to fine-tune features of agonists that mediate state selection in the nAChR.

HT1001, a proprietary North American ginseng extract, improves working memory in schizophrenia: a double-blind, placebo-controlled study

Evidence suggests that HT1001™, a proprietary North American ginseng extract containing known levels of active ginsenosides, may improve cognitive function. Importantly, individuals with schizophrenia show marked deficits in working memory, which are believed to be predictive of functional outcome in this population. The present study aimed to characterize the effect of HT1001 on working memory in a group of stable individuals with schizophrenia. In a double-blind, placebo-controlled study design, a total of 64 individuals satisfying DSM-IV criteria for schizophrenia were randomly assigned to receive either HT100 or placebo for 4 weeks. Verbal working memory and visual working memory were assessed at baseline and again at the end of the treatment phase using the Letter-Number Span Test and Visual Pattern Test, respectively. Symptoms and medication side effects were also measured at baseline and post-treatment. Visual working memory was significantly improved in the HT1001 group, but not in the placebo group. Furthermore, extrapyramidal symptoms were significantly reduced after 4 weeks treatment with HT1001, whereas no difference in extrapyramidal effects was observed in the placebo group. These results provide a solid foundation for the further investigation of HT1001 as an adjunct therapy in schizophrenia, as an improvement in working memory and a reduction in medication-related side effects has considerable potential to improve functional outcome in this population.

Muscarinic Acetylcholine Receptor Subtypes as Potential Drug Targets for the Treatment of Schizophrenia, Drug Abuse and Parkinson's Disease

The neurotransmitter dopamine plays important roles in modulating cognitive, affective, and motor functions. Dysregulation of dopaminergic neurotransmission is thought to be involved in the pathophysiology of several psychiatric and neurological disorders, including schizophrenia, Parkinson's disease and drug abuse. Dopaminergic systems are regulated by cholinergic, especially muscarinic, input. Not surprisingly, increasing evidence implicates muscarinic acetylcholine receptor-mediated pathways as potential targets for the treatment of these disorders classically viewed as "dopamine based". There are five known muscarinic receptor subtypes (M(1) to M(5)). Due to their overlapping expression patterns and the lack of receptor subtype-specific ligands, the roles of the individual muscarinic receptors have long remained elusive. During the past decade, studies with knock-out mice lacking specific muscarinic receptor subtypes have greatly advanced our knowledge of the physiological roles of the M(1)-M(5) receptors. Recently, new ligands have been developed that can interact with allosteric sites on different muscarinic receptor subtypes, rather than the conventional (orthosteric) acetylcholine binding site. Such agents may lead to the development of novel classes of drugs useful for the treatment of psychosis, drug abuse and Parkinson's disease. The present review highlights recent studies carried out using muscarinic receptor knock-out mice and new subtype-selective allosteric ligands to assess the roles of M(1), M(4), and M(5) receptors in various central processes that are under strong dopaminergic control. The outcome of these studies opens new perspectives for the use of novel muscarinic drugs for several severe disorders of the CNS.

Evaluation of state and trait biomarkers in healthy volunteers for the development of novel drug treatments in schizophrenia

Antipsychotic drugs are the mainstay of treatment for schizophrenia but they have little effect on core negative symptoms or cognitive impairment. To meet the deficiencies of current treatments, novel potential compounds are emerging from preclinical research but translation to clinical success has been poor. This article evaluates the possibility that cognitive and physiological abnormalities in schizophrenia can be used as central nervous system biomarkers to predict, in healthy volunteers, the likely efficacy of entirely new pharmacological approaches to treatment. Early detection of efficacy would focus resource on rapidly developing, effective drugs. We review the relevance of selected cognitive and physiological abnormalities as biomarkers in schizophrenia and three of its surrogate populations: (i) healthy volunteers with high trait schizotypy; (ii) unaffected relatives of patients; and (iii) healthy volunteers in a state of cortical glutamate disinhibition induced by low-dose ketamine. Several biomarkers are abnormal in these groups and in some instances there has been exploratory work to determine their sensitivity to drug action. They are generally insensitive to current antipsychotics and therefore their predictive validity cannot be established until novel, therapeutically useful drugs are discovered. Until then such biomarker studies can provide evidence of drugs engaging with the mechanism of interest and encouragement of the concept.

Mouse pharmacological models of cognitive disruption relevant to schizophrenia

Schizophrenia is a debilitating cognitive disorder. The link between cognitive debilitation and functional outcome in patients with schizophrenia has prompted research to develop procognitive therapies. It is hoped that by improving cognition in these patients, their functional outcome will also improve. Although no established treatments exist as yet, progress has been made toward understanding how to evaluate putative compounds in the clinic. Genetic mouse models and pharmacological rat models of cognitive disruption are being developed that may help to evaluate these putative compounds preclinically. Considering the increased number of genetic mouse models relevant to schizophrenia, there is a need to evaluate pharmacological manipulations on cognition in mice. Here we review the current literature on mouse pharmacological models relevant to schizophrenia. In this review, we discuss where different pharmacological effects between rats and mice on cognitive tasks are observed and assess the validity offered by these models. We conclude that the predictive validity of these models is currently difficult to assess and that much more needs to be done to develop useful mouse pharmacological models of cognitive disruption in schizophrenia.

Peroxisome proliferator-activated receptors-alpha modulate dopamine cell activity through nicotinic receptors

BACKGROUND

Modulation of midbrain dopamine neurons by nicotinic acetylcholine receptors (nAChRs) plays an important role in behavior, cognition, motivation, and reward. Specifically, nAChRs containing beta2 subunits (beta2-nAChRs) switch dopamine cells from a resting to an excited state. However, how beta2-nAChRs can be modulated and thereby how dopamine firing activity is affected remains elusive. Because changes in dopamine cell activity are reflected in the dynamics of microcircuits generating altered responses to stimuli and inputs, factors regulating their state are fundamental. Among these, endogenous ligands to the nuclear receptor-transcription factor peroxisome proliferator-activated receptors type-alpha (PPARalpha) have been recently found to suppress nicotine-induced responses of dopamine neurons.

METHODS

We used both in vitro and in vivo electrophysiological techniques together with behavioral analysis to investigate on the effects of modulation of PPARalpha in Sprague-Dawley rat and C57BLJ/6 mouse dopamine neurons and their interactions with beta2-nAChRs. To this aim, we took advantage of a selective reexpression of beta2-nAChR exclusively in dopamine cells by stereotaxically injecting a lentiviral vector in the mouse ventral tegmental area.

RESULTS

We found that activation of PPARalpha decreases in vitro both dopamine cell activity and ventral tegmental area net output through negative modulation of beta2-nAChRs. Additionally, PPARalpha activation in vivo reduces both the number of spontaneously active dopamine neurons and nicotine-induced increased locomotion.

CONCLUSIONS

Our combined findings suggest PPARalpha ligands as important negative modulators of beta2-nAChRs on dopamine neurons. Thus, PPARalpha ligands might prove beneficial in treating disorders in which dopamine dysfunction plays a prominent role, such as schizophrenia and nicotine addiction.

Acetylcholine-dopamine interactions in the pathophysiology and treatment of CNS disorders

Dopaminergic neurons in the substantia nigra pars compacta and ventral tegmental area of the midbrain form the nigrostriatal and mesocorticolimbic dopaminergic pathways that, respectively, project to dorsal and ventral striatum (including prefrontal cortex). These midbrain dopaminergic nuclei and their respective forebrain and cortical target areas are well established as serving a critical role in mediating voluntary motor control, as evidenced in Parkinson's disease, and incentive-motivated behaviors and cognitive functions, as exhibited in drug addiction and schizophrenia, respectively. Although it cannot be disputed that excitatory and inhibitory amino acid-based neurotransmitters, such as glutamate and GABA, play a vital role in modulating activity of midbrain dopaminergic neurons, recent evidence suggests that acetylcholine may be as important in regulating dopaminergic transmission. Midbrain dopaminergic cell tonic and phasic activity is closely dependent upon projections from hindbrain pedunculopontine and the laterodorsal tegmental nuclei, which comprises the only known cholinergic inputs to these neurons. In close coordination with glutamatergic and GABAergic activity, these excitatory cholinergic projections activate nicotinic and muscarinic acetylcholine receptors within the substantia nigra and ventral tegmental area to modulate dopamine transmission in the dorsal/ventral striatum and prefrontal cortex. Additionally, acetylcholine-containing interneurons in the striatum also constitute an important neural substrate to provide further cholinergic modulation of forebrain striatal dopaminergic transmission. In this review, we examine neurological and psychopathological conditions associated with dysfunctions in the interaction of acetylcholine and dopamine and conventional and new pharmacological approaches to treat these disorders.

Pharmacological strategies for enhancing cognition in schizophrenia

Researchers have long recognized that individuals with schizophrenia experience challenges in a wide range of cognitive domains, and research on cognitive impairment in schizophrenia is not a recent phenomena. However, the past 10-20 years have seen an increasing recognition of the central importance of cognition to understanding function and outcome in this illness (Green et al. in Schizophr Bull 26:119-136, 2000), an awareness that has shifted the emphasis of at least some work on schizophrenia. More specifically, there has been a rapidly growing body of work on methods of enhancing cognition in schizophrenia, as a means to potentially facilitate improved outcome and quality of life for individuals with this debilitating illness. The current chapter reviews the results of a range of studies examining adjunctive pharmacological treatments to enhance cognition in schizophrenia using a range of designs, including single-dose studies, open-label repeated dosing studies, and double-blind parallel group and crossover designs with repeated dosing. Although many of the single-dose and open-label studies have suggested positive cognitive effects from a range of agents, few of the larger-scale double-blind studies have generated positive results. The current state of results may reflect the need to identify alternative molecular mechanisms for enhancing cognition in schizophrenia or the need to reconceptualize the ways in which pharmacological agents may improve cognition in this illness, with a concomitant change in the traditional clinical trial study design used in prior studies of cognitive enhancement in schizophrenia.