NIMH initiatives to facilitate collaborations among industry, academia, and government for the discovery and clinical testing of novel models and drugs for psychiatric disorders

Experimental Medicine Approaches in Early-Phase CNS Drug Development

Traditionally, Phase 1 clinical trials were largely conducted in healthy normal volunteers and focused on collection of safety, tolerability, and pharmacokinetic data. However, in the CNS therapeutic area, with more drugs failing in later phase development, Phase 1 trials have undergone an evolution that includes incorporation of novel approaches involving novel study designs, inclusion of biomarkers, and early inclusion of patients to improve the pharmacologic understanding of novel CNS-active compounds early in clinical development with the hope of improving success in later phase pivotal trials. In this chapter, the authors will discuss the changing landscape of Phase 1 clinical trials in CNS, including novel trial methodology, inclusion of pharmacodynamic biomarkers, and experimental medicine approaches to inform early decision-making in clinical development.

The Difficult Path to the Discovery of Novel Treatments in Psychiatric Disorders

CNS diseases, including psychiatric disorders, represent a significant opportunity for the discovery and development of new drugs and therapeutic treatments with the potential to have a significant impact on human health. CNS diseases, however, present particular challenges to therapeutic discovery efforts, and psychiatric diseases/disorders may be among the most difficult. With specific exceptions such as psychostimulants for ADHD, a large number of psychiatric patients are resistant to existing treatments. In addition, clinicians have no way of knowing which psychiatric patients will respond to which drugs. By definition, psychiatric diagnoses are syndromal in nature; determinations of efficacy are often self-reported, and drug discovery is largely model-based. While such models of psychiatric disease are amenable to screening for new drugs, whether cellular or whole-animal based, they have only modest face validity and, more importantly, predictive validity. Multiple academic, pharmaceutical industry, and government agencies are dedicated to the translation of new findings about the neurobiology of major psychiatric disorders into the discovery and advancement of novel therapies. The collaboration of these agencies provide a pathway for developing new therapeutics. These efforts will be greatly helped by recent advances in understanding the genetic bases of psychiatric disorders, the ongoing search for diagnostic and therapy-responsive biomarkers, and the validation of new animal models.

Targeting therapy-resistant prostate cancer via a direct inhibitor of the human heat shock transcription factor 1

Heat shock factor 1 (HSF1) is a cellular stress-protective transcription factor exploited by a wide range of cancers to drive proliferation, survival, invasion, and metastasis. Nuclear HSF1 abundance is a prognostic indicator for cancer severity, therapy resistance, and shortened patient survival. The HSF1 gene was amplified, and nuclear HSF1 abundance was markedly increased in prostate cancers and particularly in neuroendocrine prostate cancer (NEPC), for which there are no available treatment options. Despite genetic validation of HSF1 as a therapeutic target in a range of cancers, a direct and selective small-molecule HSF1 inhibitor has not been validated or developed for use in the clinic. We described the identification of a direct HSF1 inhibitor, Direct Targeted HSF1 InhiBitor (DTHIB), which physically engages HSF1 and selectively stimulates degradation of nuclear HSF1. DTHIB robustly inhibited the HSF1 cancer gene signature and prostate cancer cell proliferation. In addition, it potently attenuated tumor progression in four therapy-resistant prostate cancer animal models, including an NEPC model, where it caused profound tumor regression. This study reports the identification and validation of a direct HSF1 inhibitor and provides a path for the development of a small-molecule HSF1-targeted therapy for prostate cancers and other therapy-resistant cancers.

Progress in Developing Pharmacologic Agents to Treat Bulimia Nervosa

This paper reviews past and current progress in developing pharmacologic agents for the treatment of individuals with bulimia nervosa (BN). We searched the literature and clinical trial registries for compounds studied in BN, the related condition, binge eating disorder (BED), and preclinical models of binge-eating behavior. Drug classes evaluated included antidepressants, antiepileptic drugs, stimulants and other medications for attention-deficit/hyperactivity disorder, opioid antagonists, and weight loss agents, among others. The only available drugs with established efficacy in BN at this time include antidepressants (especially selective serotonin reuptake inhibitors [SSRIs]) and the antiepileptic topiramate, though the efficacy of these compounds is modest at best. The only medications we found currently receiving empirical study in people with BN were fluoxetine, other serotonergic antidepressants, intranasal naloxone, lisdexamfetamine dimesylate, phentermine-topiramate combination, the antiandrogenic oral contraceptive ethinyl estradiol plus drospirenone, and prazosin. Preclinical models suggest that nociceptin receptor antagonists, the selective serotonin 5-HT2C receptor agonist lorcaserin, monoamine stabilizers, and selective orexin-1 receptor antagonists might be helpful. We found no evidence of a drug developed specifically for the treatment of individuals with BN. Future areas for research in the pharmacotherapy of BN are suggested. Importantly, until drugs are developed specifically for eating disorders, drugs developed for other conditions that are centrally acting and associated with beneficial psychotropic effects and/or reduced appetite or weight loss might be considered for repurposing in BN.

The practice of experimental studies in psychopharmacology: Top 10 tips from one centre's experience

OBJECTIVE

Recent efforts to optimise translation of basic research findings to successful clinical trials have led to a sharper focus on experimental medicine translational studies. This is coupled with a movement towards greater methodological integrity and openness. Although this can be achieved through preregistration and detailed reporting of study methodology, the reality of study application can often be lost.

METHODS

In practice, challenges in study application can often lead to diminished scientific robustness, even in well-designed studies. A detailed description of experiences is essential for learning and subsequent improvement. To this end, the authors undertook a description of the experience of a specialised psychopharmacology experimental study centre.

RESULTS

This centre's experiences reveal that even supposedly routine study elements, such as screening parameters, peri-drug administration, and peri-discharge procedures, can pose significant practical obstacles to the achievement of minimal protocol deviation. Ultimately, these factors impact on academic standards such as enhanced data reliability; but they have additional implications for participant clinical safety and well-being, for instance in relation to adverse event and incidental finding recording.

CONCLUSIONS

The facilitation of a scientific culture that is more transparent even at the operational level will hopefully augment translational process and probability of success.

Challenge of the translational neuroscience

The development of Neurosciences in the last few years has changed a set of paradigms in the production of knowledge, from which new scenarios have arisen in the understanding of the structure and function of the human nervous system, as well as in some of the most relevant diseases involved. Nonetheless, the impact of all the scientific information on this topic has played a limited role in the proposals in the diagnostic, therapeutic, rehabilitation and social reintegration fields, when the effect on the daily life of patients that have a neurological impairment is considered. Thus, the emergence of translational science is an alternative for a more direct and pragmatic link that allows the connection between basic research and applied research, and in the short term will achieve results that can be promoted in the communities. In addition, this process involves an interaction with technological development and transfer following a global knowledge management model. Every discipline in the neurological sciences field poses different critical challenges to tend to the new epidemiologic profiles. emerging in areas such as neurodevelopment disturbances found in the pediatric population, trauma and addictions in the young, as well as neurodegenerative diseases in older adults. This model reviews the demands from society, expecting more compelling results from the scientific community, particularly in creating strategies that actually change the natural course of neurologic diseases from the bench to the bedside.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

On 'polypharmacy' and multi-target agents, complementary strategies for improving the treatment of depression: a comparative appraisal

Major depression is a heterogeneous disorder, both in terms of symptoms, ranging from anhedonia to cognitive impairment, and in terms of pathogenesis, with many interacting genetic, epigenetic, developmental and environmental causes. Accordingly, it seems unlikely that depressive states could be fully controlled by a drug possessing one discrete mechanism of action and, in the wake of disappointing results with several classes of highly selective agent, multi-modal treatment concepts are attracting attention. As concerns pharmacotherapy, there are essentially two core strategies. First, multi-target antidepressants that act via two or more complementary mechanisms and, second, polypharmacy, which refers to co-administration of two distinct drugs, usually in separate pills. Both multi-target agents and polypharmacy ideally couple a therapeutically unexploited action to a clinically established mechanism in order to enhance efficacy, moderate side-effects, accelerate onset of action and treat a broader range of symptoms. The melatonin MT1/MT2 agonist and 5-HT(2C) antagonist, agomelatine, which is effective in the short- and long-term treatment of depression, exemplifies the former approach, while evidence-based polypharmacy is illustrated by the adjunctive use of second-generation antipsychotics with serotonin reuptake inhibitors for treatment of resistant depression. Histone acetylation and methylation, ghrelin signalling, inflammatory modulators, metabotropic glutamate-7 receptors and trace amine-associated-1 receptors comprise attractive substrates for new multi-target and polypharmaceutical strategies. The present article outlines the rationale underpinning multi-modal approaches for treating depression, and critically compares and contrasts the pros and cons of established and potentially novel multi-target vs. polypharmaceutical treatments. On balance, the former appear the most promising for the elaboration, development and clinical implementation of innovative concepts for the more effective management of depression.

The innovative medicines initiative: a public private partnership model to foster drug discovery

The Innovative Medicines Initiative (IMI) is a large-scale public–private partnership between the European Commission and the European Federation of Pharmaceutical Industries and Associations (EFPIA). IMI aims to boost the development of new medicines across Europe by implementing new collaborative endeavours between large pharmaceutical companies and other key actors in the health-care ecosystem, i.e., academic institutions, small and medium enterprises, patients, and regulatory authorities. Currently there are more than 40 IMI projects covering the whole value chain of pharmaceutical R&D, but with a strong focus on drug discovery, as an ideal arena where the PPP concept of pre-competitive collaboration can rapidly deliver results. This article review recent achievements of the IMI consortia of relevance to drug discovery, providing proof-of-concept evidence for the efficiency of this new model of collaboration.

Collaboration versus outsourcing: the need to think outside the box

As has been widely reviewed elsewhere, the pharmaceutical industry is experiencing an ‘innovation deficit’ as evidenced by the decline in new chemical entity output. This decline, compounded by increased costs and regulatory requirements highlights the need to significantly revise strategic options across the drug-discovery spectrum. Within such revision(s), much of the focus has been on outsourcing to reduce, or at least contain, costs, but if the underlying predominance of ‘closed collaborations’ is not challenged to allow better use of combined knowledge and, thus, move towards a more genuine collaborative process then a ‘numbers only’ approach will not bring medium-to-long-term survival. There are many problems to confront in evolving new sustainable strategies, a real need to think differently exists and should to be cultivated. This article reviews current outsourcing and collaboration strategies to provide a perspective on how great knowledge sharing could help revise the drug-discovery process.

Prospects for neurodegenerative and psychiatric disorder drug discovery

The discovery of CNS-active drugs has, to a major extent, resulted from clinical serendipity. Once targets for such compounds were identified, conventional mechanism-based approaches were used to identify new chemical entities for the treatment of neurological and psychiatric disorders. Most of these have, however, failed to display any greater efficacy than existing psychotherapeutics and may, in fact, be less efficacious because of side effect liabilities. Among the reasons for this lack of success in drug discovery include a lack of fundamental knowledge regarding the causes of CNS disorders, the absence of biomarkers for diagnosing and monitoring these conditions, a paucity of animal models that are congruent with the human disease state and the increasing likelihood that CNS conditions are multifactorial in their etiology. These challenges force the inclusion of a Phase IIa proof of concept trial as a component of the drug discovery program. Unlike other therapeutic areas, serendipity is a major factor in the CNS translational medicine interface requiring a close collaboration between preclinical and clinical scientists trained to appreciate unusual behavioral phenotypes. When combined with conventional target-based drug discovery technologies, this increases the likelihood of identifying truly novel drugs for the treatment of CNS disorders.

Looking to the future of research in pediatric anxiety disorders

OBJECTIVE

The rapid emergence of translational developmental neuroscience as the key driver in understanding the onset of mental illness, the restructuring of academic health science centers on the NIH Roadmap, and dramatic shifts in drug, biological, device, and psychosocial intervention development all have important consequences for pediatric anxiety disorders as a field.

METHOD

This article, which tracks the final presentation at a day-long symposium on pediatric anxiety disorders at the 2010 annual meeting of the Anxiety Disorders Association of America (ADAA), will try to outline where the field will head over the next decade as these forces combine to shape research and practice.

RESULTS

After 20 years of large comparative treatment trials that have defined the place of current generation treatments, the field is shifting toward interventions that will emerge from the revolution in translational developmental neuroscience and that herald the dawn of stratified and ultimately personalized medicine. With a much more efficient discovery to translational continuum, intervention development and dissemination will benefit from the concurrent transformation of the clinical and clinical research enterprise.

CONCLUSION

Dramatic advances in science and changes in the structure of medicine will condition the future of clinical research across every therapeutic area in medicine. For the field of pediatric anxiety disorders to thrive it will be important to embrace and actively participate in this revolution so that anxious youth are viewed as a key target population and, consequently, preemptive, preventive, and curative interventions will be developed for children by first intent.

Mary S. Easton Center of Alzheimer's Disease Research at UCLA: advancing the therapeutic imperative

The Mary S. Easton Center for Alzheimer's Disease Research (UCLA-Easton Alzheimer's Center) is committed to the "therapeutic imperative" and is devoted to finding new treatments for Alzheimer's disease (AD) and to developing technologies (biomarkers) to advance that goal. The UCLA-Easton Alzheimer's Center has a continuum of research and research-related activities including basic/foundational studies of peptide interactions; translational studies in transgenic animals and other animal models of AD; clinical research to define the phenotype of AD, characterize familial AD, develop biomarkers, and advance clinical trials; health services and outcomes research; and active education, dissemination, and recruitment activities. The UCLAEaston Alzheimer's Center is supported by the National Institutes on Aging, the State of California, and generous donors who share our commitment to developing new therapies for AD. The naming donor (Jim Easton) provided substantial funds to endow the center and to support projects in AD drug discovery and biomarker development. The Sidell-Kagan Foundation supports the Katherine and Benjamin Kagan Alzheimer's Treatment Development Program, and the Deane F. Johnson Alzheimer's Research Foundation supports the Deane F. Johnson Center for Neurotherapeutics at UCLA. The John Douglas French Alzheimer's Research Foundation provides grants to junior investigators in critical periods of their academic development. The UCLA-Easton Alzheimer's Center partners with community organizations including the Alzheimer's Association California Southland Chapter and the Leeza Gibbons memory Foundation. Collaboration with pharmaceutical companies, biotechnology companies, and device companies is critical to developing new therapeutics for AD and these collaborations are embraced in the mission of the UCLA-Easton Alzheimer's Center. The Center supports excellent senior 3 investigators and serves as an incubator for new scientists, agents, models, technologies and concepts that will significantly influence the future of AD treatment and AD research.

Challenges in the search for drugs to treat central nervous system disorders

The history of drug discovery spans approximately 200,000 years. For much of this time, the identification of therapeutic agents was empirical, with the shift to a more hypothesis-driven approach occurring in the late 19th century. Since then, the objective has changed from identifying an active drug and its mechanism of action to determining therapeutic potential only after identifying drug-like compounds that interact with a target site. Although the emphasis on target identification, or "targephilia," has yielded novel drugs, overall it appears to have slowed the drug discovery process, especially for compounds used in treating central nervous system (CNS) disorders. This is because the "targephilic" approach requires a good understanding of target physiology and its integration with the target organ, with a hierarchical integration from in vitro cellular and functional tissue studies to animal models that reasonably predict human responses. Because the majority of CNS drugs were discovered empirically, drug discovery in this area appears less amenable to target-based approaches than it seems for other types of therapeutics. Improving the success rate in CNS drug discovery requires a more pharmacometric-based approach, with a renewed emphasis on defining basic CNS function in intact animals and a more systematic in vivo screening of novel structures. Efforts must also be directed toward defining the sites of action of existing CNS drugs to aid in the design of second-generation agents with improved efficacy and safety.

Defining the role of pharmacology in the emerging world of translational research

Pharmacology is focused on studying the effects of endogenous agents and xenobiotics on tissue and organ function. Analysis of the concentration/response relationship is the foundation for these assessments as it provides quantifiable information on compound efficacy, potency, and, ultimately, side-effect liability and therapeutic index. Historically, pharmacology has been viewed as a unifying, hierarchically integrated, and technologically agnostic discipline. Besides being important in the development of new medications, pharmacological research has led to a better understanding of disease pathogenesis and progression. By defining the effects of compounds in vitro and in vivo, pharmacology has provided the means to validate, optimize, and advance new chemical entities (NCEs) to human testing. With the advent of molecular biology-based assay systems and a technology-driven (high-throughput screening, combinatorial chemistry, SNP mapping, systems biology) reductionistic focus, the integrated, hypothesis-driven pharmacological approach to drug discovery has been de-emphasized in recent years. This shift in research emphasis is now viewed by many as a major factor in the decline of new drug approvals and has led to various initiatives, the most notable being the Critical Path and Phase 0 clinical trial initiatives launched by the US Food and Drug Administration (FDA). These programs underscore the growing need for individuals trained in integrative pharmacology and having a background in molecular pharmacology to drive the drug discovery process and to fostering the translational research that is now considered vital for more rapidly identifying novel, more effective, and safer medications.