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Overview of the Neuroscience-based nomenclature, and how new developments in psychosis are reflected
Interview with Dr. Stephen Stahl, recorded at ECNP Congress 2016, Vienna
Neuroscience-based nomenclature (NbN) – the way drugs are named in psych and psychopharmacology has become irrational. At first they were named based on illnesses, like antidepressants. But as time went on, it became clear that there was crossover: some antidepressants were also antipsychotics. In reality, drugs do not target disease states in psychiatry – they are just collections of symptoms. Drugs work on symptoms because they work on receptors or enzymes, not on the symptoms directly. In other areas of medicine, drugs are named for receptors; it was time to join the 21st century and move disease-named nomenclature to mechanism of action-based nomenclature. The nomenclature is driven by the target of the drug – its pharmacological mechanism of action. The word antipsychotic is no longer used; it is replaced by drugs for psychosis – those that work on serotonin, dopamine or both. Moving from descriptive-based nomenclature to a mechanism-based nomenclature is helping move psychiatry into the 21st century.
Q. Could you give a background to the development of the Neuroscience-based Nomenclature (NbN)?
A. The background to the development of a neuroscience-based nomenclature (NbN) is that the way we name our drugs in psychiatry and psychopharmacology has become irrational. We have named them in the past based on illnesses, like ‘antidepressants’ or ‘antipsychotics’ but, as time has gone on, we have found out that some antipsychotics were antidepressants. This made for stigma, and it made for poor communication, and it also narrowed the way we thought about the drugs. We got into a box and, if something was an antipsychotic, we just thought of it in a certain way. The reality is that drugs do not target disease states, because we don’t have any in psychiatry. Psychiatry diagnoses are collections of symptoms, and drugs do not work on symptoms because they target symptoms, but drugs work on symptoms because they target receptors, or enzymes, or various types of known neuroscience-based targets. The rest of medicine does this: you have beta-blockers instead of just antihypertensives, and you have drugs that go after specific receptors and are named for those in other areas of medicine. We thought we would join the 21st century and do the same thing. The idea was to reduce stigma, increase communication, make it clear and move the paradigm from disease-named nomenclature, to targeted, scientific neuroscience or pharmacological-based, mechanism of action-based nomenclature.
Q. Could you explain the NbN, in terms of its structure (e.g., the domains, modes of action and layers/dimensions)?
A. Yes, the neuroscience-based nomenclature starts with a mode of action or mechanism of action, which is the presumed target of the drug. Then we also put its approval, because drugs are approved for conditions – so we would put, next, that different countries have different approvals and we would indicate where in the world it is approved for something or other. Then we would have other comments on the efficacy and side effects, and some of the neurobiological mechanisms, and just the committee makes notes. The main thing is that the nomenclature is driven by the target of the drug, and the target is its mechanism of action, pharmacologically.
Q. How are new developments in psychosis reflected in NbN?
A. New developments in psychosis are reflected in NbN because we have tried to drop the term ‘antipsychotics’. We finesse that a little by saying ‘drugs for psychosis’, or ‘drugs for schizophrenia’, and the whole world is divided into drugs for schizophrenia that act on dopamine, serotonin, or both. The new development is that, instead of calling something an ‘atypical antipsychotic’ or a ‘conventional antipsychotic’, or a ‘second generation antipsychotic’, we don’t use the word ‘antipsychotic’ at all. We say ‘drugs for psychosis’, and there are selective drugs for serotonin now, which do not act on dopamine at all; there are old drugs that act mostly just on dopamine and, if they work almost as strongly or more strongly on serotonin as well, we have drugs in the middle that are serotonin and dopamine. That is how we name them, by their mechanism.
Q. What are the next steps for NbN?
A. The next steps for NbN have to do with going into paediatric uses of drugs and how we name them; ‘neurological’ as opposed to just ‘psychiatric’, because central nervous system drugs are used by neurologists as well as psychiatrists. It is also about developing nomenclature for brand new drugs, that have new targets, to name them. These new drugs will target a receptor and they will first come to home as an indication for depression, but instead of calling [a drug] an antidepressant, we will name it for its action, because many new drugs that start in one place end up in two or three others. Thus, an antidepressant can become an anxiolytic, and it can also become an antipsychotic. These older terms are being dropped, to say that a drug that targets receptor A is a drug for psychosis, and it becomes a drug for anxiety, or it becomes a drug for depression, but it is really named for where its pharmacologic and mechanistic target lies.
Q. What is your take-home message?
A. My take-home message is that psychiatry is moving into the modern world and we are even naming our drugs in a more modern way. We can think about drugs for psychosis but we should also think about the target, because we really have the brain involved in our illnesses and in how our drugs work. We are moving more from a phenomenologically-based, descriptive-based, clinically-based action on syndromes, to a more scientific, neurobiologically-based and targeted pharmacological mechanism-based nomenclature.