Future Antidepressants: What is in
the Pipeline and What is Missing?

by
Bosker FJ, Westerink BH, Cremers TI, Gerrits M,
Van Der Hart MG, Kuipers SD, Van Der Pompe G,
Ter Horst GJ, Den Boer JA, Korf J.
Department of Psychiatry,
University and University Hospital of Groningen,
Groningen, The Netherlands
Biomonitoring & Sensoring,
University of Groningen, Groningen, The Netherlands
Graduate School of Behavioral and Cognitive Neurosciences
University of Groningen, Groningen, The Netherlands.
CNS Drugs. 2004;18(11):705-732.


ABSTRACT

Monoamine reuptake inhibitors still reign in the treatment of major depression, but possibly not for long. While medicinal chemists have been able to reduce the side effects of these drugs, their delayed onset of action and considerable non-response rate remain problematic. Of late, serious questions have been raised regarding the efficacy of monoamine reuptake inhibitors.The present review presents an inventory of what is (and until recently was) in the antidepressant pipeline of pharmaceutical companies. Novel antidepressant compounds can be categorised into four groups depending on their target(s): (i) monoamine receptors; (ii) non-monoamine receptors; (iii) neuropeptide receptors; and (iv) hormone receptors. Other possible targets include components of post-receptor intracellular processes and elements of the immune system; to date, however, compounds specifically aimed at these targets have not been the subject of clinical trials.Development of several compounds targeted at monoamine receptors has recently been discontinued. At least five neurokinin-1 (NK(1)) receptor antagonists were until recently in phase II of clinical testing. However, the apparent interest in the NK(1) receptor should not be interpreted as representing a departure from the monoamine hypothesis since neurokinins also modulate monoaminergic systems.In the authors' view, development of future antidepressants will continue to rely on the serendipity-based monoamine hypothesis. However, an alternative approach, based on the hypothesis that chronic stress precipitates depressive symptoms, might be more productive. Unfortunately, clinical results using drugs targeted at components of the HPA axis have not been very encouraging to date. In the short run, the authors believe that augmentation strategies offer the best hope for improving the efficacy of antidepressant treatment. Several approaches to improve the efficacy of SSRIs are conceivable, such as concurrent blockade of monoamine autoreceptors and the addition of antipsychotics, neuromodulators or hormones (HPA axis and gender related). In the long-term, however, construction of a scientifically verified conceptual framework will be needed before more effective antidepressants can be developed. It can be argued that it is not depression itself that should be treated, but rather that its duration should be reduced by pharmacological means. Animal models that take this concept into consideration and identify mechanisms for acceleration of recovery from the effects of stress need to be developed.
TCAs
SSRIs
RIMAs
Options
Bupropion
Amineptine
Nefazodone
Mirtazapine
Venlafaxine
SSRIs v TCAs
21st Century
Antidepressants
Atypical depression
Retarded depression
New antidepressants
Antidepressant metabolism
An individualised approach
Antidepressants: how fast?
Antidepressants: adverse effects
The monoamine theory of depression
Does early improvement triggered by antidepressants predict response/remission?


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