A New Class of Antidepressant Drugs

11
A New Class of Antidepressant Drugs in

the Treatment of Psychiatric Disorders:
The Triple Reuptake Inhibitors
B.P. Guiard
Laboratoire de Neuropharmacologie, Facult de Pharmacie, Universit Paris sud XI,
Chtenay-Malabry,
France
1. Introduction
It is well established that many antidepressant compounds with proven clinical efficacy act
on the serotonergic and noradrenergic pathways. The monoaminergic hypothesis of major
depression (MD) stipulates that a deficit in brain monoaminergic neurotransmission in
various brain areas including the frontal cortex, hippocampus, amygdala or hypothalamus
would account for some of signs and symptoms of the pathology (Katz et al., 2010a). For
instance, abnormalities in the serotonin (5-HT) transmission are associated with impulsivity,
aggressive, and anxious behaviors (Handley et al., 1995), whereas alteration in
noradrenergic transmission, with motor activity, attention, and arousal (Morilak and Frazer,
2004). The role of dopamine (DA) on the other hand, attracted less attention in the
mechanisms of action underlying MD. However, the observations that reserpine, which
depletes catecholamines, results in lowering mood (Schidkrautn 1965) or that an inhibition
of tyrosine hydroxylase induces a worsening of depressive symptoms (Miller et al., 1996),
strongly suggest that decreasing DA function may be of particular relevance. The fact that
several symptoms observed in MD, including impaired motivation, concentration, and
pleasure result from an attenuation of dopaminergic neurotransmission, strengthens the
hypothesis that DA also regulates mood (Dunlop and Nemeroff, 2007).
Most antidepressants approved, such as the selective serotonin reuptake inhibitors (SSRIs),
the norepinephrine (NE) reuptake inhibitor (NRIs) or the dual serotonin/norepinephrine
reuptake inhibitors (SNRIs), act by enhancing brain 5-HT and/or NE levels. Despite their
therapeutic action, residual symptoms remain and may explain the fact that approximately
50% of depressive individuals do not respond adequately to these agents (Berton and
Nestler, 2006). The question can be asked as to whether these remaining symptoms are
caused by the antidepressants or if they result from dysfunction in other neurotransmitters
such as a blunted DA neurotransmission. In this context, a new generation of antidepressant
drugs, the triple reuptake inhibitors (TRIs), has been developed with the hope to offer a
clinically relevant advantage over single- or dual-acting agents (Guiard et al., 2009). Indeed,
since TRIs simultaneously enhance extracellular levels of 5-HT, NE and DA
neurotransmissions in various brain regions, this class of antidepressants could exert their
therapeutic activity by treating more symptoms of MD and/or by attenuating some side
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Psychiatric Disorders Trends and Developments
effects observed in response to traditional antidepressants. As an example, it is believed that

the dopaminergic component of TRIs may prevent sexual dysfunctions induced by an
increase in brain 5-HT.
The present review describes the serotonergic, noradrenergic and dopaminergic pathways
in the brain and the specific symptoms of depression under their control. Then it focuses on
the preclinical in vitro and in vivo properties of TRIs. Indeed, the knowledge of their
pharmacological properties may help better understand their mechanism of action and
anticipate their putative efficacy over SSRIs, NRIs and SNRIs in humans. Finally, since over
75% of depressed patients suffer from painful symptoms and that monoaminergic pathways
control many of the psychological functions that are disturbed in depression and pain
perception (Hache et al., 2011), this review addresses the possibility that TRIs may exert part
of their antidepressant activity by preventing/reversing algesia in depressed patients.
2. Monoaminergic pathways in the brain and their reciprocal interactions

2.1 The serotonergic system
Serotonin (5-HT) is present in most brain regions in the central nervous system. In the brain,
serotonergic neurons originate within the brain stem. This system is comprised of a
relatively small number of neurons that are clustered in nine phylogenetically conserved
nuclei grouped into caudal (B1B5) and rostral (B6B9) nuclei including the dorsal and
median raphe (DR and MR; respectively), with the former projecting to areas of the deep
cerebellar nuclei, cortex, and spinal cord, whereas the latter extends an axonal network
throughout the forebrain and cortices (Dahlstrm and Fuxe, 1964). Of particular relevance to
mechanisms of MD are projections to structural correlates of emotionality including the
amygdala, prefrontal and cingulated cortices, hypothalamus, and thalamus (Hornung 2003).
Recently, 5-HT neurons have been classified based on genetic lineages. Specifically, 5-HT
neuronal progenitors can be subdivided into subpopulations, which are discriminated by
differing genetic transcription factors such as Pet-1 (Kiyasova et al., 2011; Hendricks, 2003).
Indeed, this factor is required for the acquisition of serotonergic identity in a majority of
neurons in the raphe nuclei including the dorsal and median raphe nuclei. However
residual 5-HT neurons outline a unique subpopulation of raphe neurons with highly
selective anatomical targets particularly the brain areas involved in stress responses with
dense innervation to the basolateral amygdala, the paraventricular nucleus of the
hypothalamus, and the intralaminar thalamic nuclei. It has thus been proposed the existence
of Pet1-dependent and Pet1-resistant 5-HT neurons targeting different brain centers that
might delineate the anatomical basis for a dual serotonergic control on stress responses
(Kiyasova et al., 2011).
2.2 The noradrenergic system
The central noradrenergic neurotransmitter system originates from two distinct groups of
cells in the brainstem (DellOsso et al., 2010). The main noradrenergic brain circuits are
located in the locus coeruleus (corresponding to A4+A6 cell groups), which send
noradrenergic projections throughout the neuroaxis innervating areas such as the frontal
cortex, hippocampus and amygdala as well as the cerebellum (Dahlstrm and Fuxe, 1965).
This ascending projection system is also referred to as the dorsal noradrenergic bundle. The
locus coeruleus is basically involved in the responsiveness to external conditions and
vigilance, providing pathways descending to the spinal cord and projecting throughout the
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A New Class of Antidepressant Drugs

in the Treatment of Psychiatric Disorders: The Triple Reuptake Inhibitors
293
limbic system and diencephalon (Racagni and Brunello). Efferents from the lateral
tegmentum (corresponding to A1, A2, A5 and A7 cell groups) have less extensive
projections (Dahlstrm and Fuxe, 1965). They provide predominant innervation of the
hypothalamus and also innervate areas of the septum and the extended amygdala nuclei
including the bed nucleus of the stria terminalis (Moore and Card, 1984). Interestingly,
noradrenergic and serotonergic systems overlap at several levels and are far away to be
independent, both distributing to broad cortical areas (Brhl et al., 2010). Reciprocal
projections between the major groups of 5-HT and NE cell bodies have been reported,
creating ample opportunity for cross-modulation between these systems. For example, it is
well established that NE stimulates the neuronal activity of 5-HT neurons in the DR
(Mongeau et al., 1997). In a marked contrast, 5-HT projections from the DR nucleus to the
locus coeruleus, impose a tonic inhibitory tone on the firing of NE neurons (Dremencov et
al., 2009).
2.3 The dopaminergic system
Most DA-producing neurons in the brain are located in brainstem nuclei: the retro-rubro
field (A8), the substantia nigra pars compacta (A9), and the ventral tegmental area (VTA)
(A10) (Dunlop and Nemeroff, 2007). Projection pathways of the axons arising from these cell
bodies follow specific pathways via the medial forebrain bundle to innervate specific cortical
and subcortical structures, unlike the more diffuse innervation patterns of serotonergic and
noradrenergic cells. The nigrostriatal pathway projects from the substantia nigra pars
compacta to the dorsal striatum (caudate and putamen) and has a prominent role in the
motor planning and execution of movement, although it clearly also plays an important role
in non-motor functions, such as cognition (McClure et al., 2003). The mesocortical pathway
arises from the VTA and projects to the frontal and temporal cortices, particularly the
anterior cingulate, enthorinal, and prefrontal cortices. This pathway is believed to be
important for concentration and executive functions such as working memory. The
mesolimbic pathway also arises from the VTA but projects to the ventral striatum (including
the nucleus accumbens), bed nucleus of the stria terminalis, hippocampus, amygdala, and
septum. It is particularly important for motivation, the experience of pleasure and reward.
The tuberoinfundibular pathway arises from the arcuate nucleus of the hypothalamus (A12)
and projects to the median eminence of the hypothalamus, where DA released into the
portal vessels acts to inhibit the secretion of prolactin from the anterior pituitary (BenJonathan and Hnasko, 2001). The incertohypothalamic pathway originates from cell bodies
in the medial portion of the zona incerta (A13) and innervates amygdaloid and
hypothalamic nuclei involved in sexual behavior. Unlike the other dopaminergic pathways,
the "thalamic dopamine system" arises from multiple sites, including the periaqueductal
gray matter and may contribute to the control of nociception (Hache et al., 2011).
Importantly, serotonergic and noradrenergic neurons also display a high degree of
anatomical and functional connectivity with the dopaminergic system. For instance, in
addition to its tonic inhibition of NE transmission, 5-HT is believed to inhibit the firing of
DA neurons in the VTA (Guiard et al., 2008a; 2008b). The influence of NE on DA neurons is
more complex since both excitatory and inhibitory impacts have been reported (Guiard et
al., 2008a; 2008b; Linner et al., 2001). On the other and, growing evidence suggest that DA
may modulate the activity of 5-HT and NE neurons. It is suspected that DA directly
increases the neuronal activity of 5-HT neurons in the DR (Haj-Dahmane, 2001; Martin-Ruiz
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et al., 2001), thereby enhancing local 5-HT outflow (Ferre et al., 1994; Ferre and Artigas,
1993; Martin-Ruiz et al., 2001). In contrast, multiple source of evidence demonstrates that
DA inhibits the neuronal activity of NE neurons in the LC (Guiard et al., 2008a, 2008b;
Deutch et al., 1986; Elam et al., 1986).
3. Depression: monoaminergic symptoms and disturbances

Based on the findings from studies of antidepressants, it may be possible to assign specific
symptoms of depression to specific neurochemical mechanisms (Nutt, 2008a). Knowing
which particular neurotransmitters are associated with particular symptoms of depression
may help determine appropriate treatments that target specific mechanism that in turn
target specific depression symptoms. 5-HT may be related to anxiety, compulsions and sleep
disturbances; NE to alertness and energy as well as anxiety, attention, and interest in life;
and DA to motivation, pleasure, and reward, as well as interest in life (Figure 1). Increasing
any of these 3 neurotransmitters will elevate mood, but the other elements of depression
may be particularly responsive to a certain neurotransmitter.
Fig. 1. Monoamine regulation of mood behavior (Adapted from Nutt, 2008).

3.1 Depressed mood and sadness
Neuroimaging studies have associated depressed mood and sadness with abnormal
neuronal activity in the medial prefrontal cortex (Drevets, 1999). This brain region receives
innervation from serotonergic (midbrain raphe), noradrenergic (locus coeruleus) and
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dopaminergic (ventral tegmental area) pathways. Low levels of these monoamines may
decrease mood whereas antidepressants that enhance levels of monoamines have been
shown to improve depressed mood and sadness (Morilak and Frazer, 2004). Other
symptoms and/or comorbidities such as sleep or appetite disturbances as well as
nociception may be affected in patients with MD and should draw attention of physicians
when choosing antidepressants therapy. Clearly, an improved treatment of MD should start
with a good diagnosis, based on the symptoms patients encounter as disturbances in
different neurotransmitter systems.
3.2 Diminished interest and pleasure
Reduced dopaminergic activity has been linked to decreased motivation (Salamone et al.,
2003), anhedonia (loss of pleasure) and loss of interest (Willner, 1983), whereas increased
dopaminergic transmission has been linked to positive affect (Depue and Collins, 1999). The
mesocortical dopaminergic pathway, in particular the nucleus accumbens is a key regulator
of pleasure. The prefrontal cortex is believed to be important in motivation (Drevets, 2001).
A dysfunction of the mesocorticolimbic dopaminergic system innervating limbic structures
including the nucleus accumbens, amygdala, ventral hippocampus and cortical areas may
underlie the symptoms of loss of motivation, loss of interest and the inability to experience
pleasure observed in MD. Antidepressants that enhance DA release including bupropion,
may thus improve these symptoms (Dunlop and Nemeroff, 2007).
3.3 Fatigue and loss of energy
Brains areas controlling motor function such as the striatum innervated by DA and 5-HT
neurons may be involved in physical fatigue, (Stahl et al., 2008). Mental fatigue and lack of
mental energy may be related to other symptoms of depression, such as apathy (absence in
feeling, emotion, interest) and lack of motivation. Cortical brain regions, especially the
dorsolateral prefrontal cortex, are more likely to be involved in mental fatigue (MacHale et
al., 2000). Consequently, antidepressants that increase DA and 5-HT, or both, may be
preferable for patients with predominant symptoms of fatigue and loss of energy (Stahl et
al., 2008).
3.4 Anxiety
The neuronal pathway of fears involved the amygdala, which receives NE and 5-HT
innervation from the LC and DR, respectively. High levels of amygdala activation are
associated with an increased prevalence of anxiety (Davidson et al., 2002) raising the
possibility that antidepressants targeting both NE and 5-HT, may be more appropriate for
treating depressed patients with comorbid anxiety disorders (Morilak and Frazer, 2004).
3.5 Sleep disturbance
There is a very strong association between sleep disturbance and major depression.
Depressed patients usually complain of insomnia, notably of difficulties in falling asleep,
frequent awakenings during the night, early waking up, and non-refreshing sleep (Benca
et al., 1992). As well as distressing symptoms of sleep experienced by patients, changes in
sleep architecture have been reported. Compared with normal controls, sleep continuity
of depressed subjects is often impaired, with increased wakefulness (more frequent and
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longer periods of wakefulness), and reduced sleep efficiency. Sleep onset latency is
significantly increased and total sleep time reduced. Rapid eye movement (REM) latency
is often shortened, and the duration of the first REM period is increased (Nutt et al.,
2008b). The role of 5-HT in the regulation of sleep is well documented and studies
indicate that the neuronal activity of 5-HT and its release is maximal during wakefulness
(W), reduced during slow wave sleep (SWS), and minimal during rapid eye movement
(REM) sleep (Adrien, 2002). Consequently, SSRIs, which increase 5-HT function increase
REM latency, and reduce REM sleep (Wilson and Argyropoulos, 2005) may worsen sleep
disturbance early in treatment (Hicks et al., 2002) and may leave residual sleep symptoms
once mood is improved (Nelson et al., 2005). It is noteworthy that depressed patients may
also display an excessive sleep and hypersomnia, particularly in atypical depression
(Gold et al., 2002). This latter observation emphasizes the fact that a better diagnosis,
based on the different subtypes of MD is a prerequisite to optimize and individualize
antidepressant therapy.
3.6 Appetite and eating disorders
Eating disorders, the term now encompasses anorexia nervosa and bulimia nervosa
(Jimerson et al., 1993), result from alteration, at least in part, in monoaminergic
neurotransmission involved in the homeostatic control of appetite function. For example,
positive correlations between mood disturbances and eating and weight concerns have
been reported (Casper et al., 1998). Although, the background of eating disorders is
complex, the involvement of impaired hypothalamic 5-HT function in these disorders is
well documented (Wallin and Rissanen, 1994). In agreement with the observation that in
this brain region, 5-HT contributes to post-ingestive satiety, several studies have shown
that SSRIs, particularly fluoxetine, is effective in controlling bulimic episodes (Walsh,
1994). This is also the case for other serotoninergic drugs, among them fenfluramine,
which was used in the treatment of obesity (Guy-Grand, 1992). There is growing notion
that mesolimbic dopaminergic neurotransmission also contributes to the effect of DA on
feeding behavior (Volkow and Wise, 2005). Sibutramine, in addition to its effect on 5-HT,
inhibits the reuptake of other monoamines and has been shown to enhance postprandial
satiety, reduce total calorie intake and to diminish the decline in energy expenditure
usually associated with a diet-induced negative energy balance (Hansen et al., 1999).
Consequently, combined blockade of NE and 5-HT reuptake by SNRIs results in reduced
food intake and body weight that neither monoamine reuptake inhibitor could achieve on
its own. Interestingly, bupropion the dual NE releaser and DAT inhibitor (Dong and Blier,
2001), cause weight loss by combined induction of hypophagia and thermogenesis (Billes
and Cowley, 2007).
Recently there has been interest in investigating the use of SSRIs in the treatment of patients
with anorexia nervosa. Although fluoxetine has been associated with weight loss, it was
proposed that this medication, because of a favorable side effect profile, could have
advantages for treating depressive symptoms in patients with anorexia (Gwirtsman et al.,
1990).
3.7 Nociception
This is specifically illustrated in the fifth chapter of the present review.
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4. Pharmacological properties of TRIs

As described in the precedent chapter some comorbid symptoms of depression such as
anhedonia, loss of motivation and concentration are directly connected to a deficit in central
dopaminergic transmission. Consequently, triple reuptake inhibitors (TRIs) that
simultaneously inhibit the reuptake of the three monoamines 5-HT, NE, DA (Chen &
Skolnick, 2007) may provide greater symptomatic relief than SSRIs, NRIs or SNRIs. The
interest of TRIs may also rely on the excitatory effect of DA upon the serotonergic system
(Haj-Dahmane, 2001; Martin-Ruiz et al., 2001), thus suggesting that an increase in
dopaminergic neurotransmission would facilitate that of 5-HT. In accordance with this
hypothesis, it was shown that combination of SSRIs with bupropion lead to a synergy on
monoamine transmission (Ghanbari et al. 2010; Prica et al. 2008; Li et al. 2002), as well as
producing a robust antidepressant effect especially in treatment-resistant depressed patients
Fig. 2. Monoaminergic antidepressants blocking the serotonin, norepinephrine and/or

dopamine transporter. These agents are in various clinical* or preclinical** phases of
development in MD or comorbidities. Selective serotonin reuptake inhibitor (SSRI),
norepinephrine reuptake inhibitor (NRI), dopamine reuptake inhibitor (DRI),
serotonin/norepinephrine reuptake inhibitor (SNRI), norepinephrine/dopamine reuptake
inhibitor (NDRI), triple reuptake inhibitor (TRI). #This agent is a dopamine reuptake
inhibitor and a norepinephrine releaser (Dong and Blier, 2001).
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(Leuchter et al. 2008; Zisook et al. 2006). A number of compounds with the ability to bind and
block all three monoamine transporters have been developed. DOV Pharmaceutical, Inc. is the
first company having provided in vitro and in vivo preclinical data with their triple reuptake
inhibitors DOV216303 and DOV21947. New molecules have followed such as NS2330
(tesofensine, GlaxoSmith-Kline/NeuroSearch), SEP225289 (Sepracor Inc.), CNS-1 and CNS-2
(Albany Molecular Research Institute Inc), PRC-025, PRC-050, PRC-200SS (Mayo Foundation),
JNJ7925476 (Johnson & Johnson Pharmaceutical Research & Development), WF-23 (Eli Lilly)
and JZAD-IV-22 (PsychoGenics). Lundbeck laboratories develop their own compounds such
as LuAA24530 but with the difference that they also antagonize monoaminergic receptors.
Others compounds will undoubtedly emerge in a near future. Indeed, it is interesting to note
that in 2010-2011, the pharmacological profiles of nine new compounds, studying the structure
activity relationship (SAR), have been reported (Shao et al., 2011a; 2001b; 2011c; Caldarone et
al., 2010; Carter et al., 2010; Lee et al., 2010; Lucas et al., 2010; Micheli et al., 2010a, 2010b;
Schoedel et al., 2010). Despite the emergence of these compounds, older molecules with the
abilities to inhibit all three monoamines transporters were already available such as the
tryciclic agent nefopam approved in Europe (Heel et al., 1980), bicifadine in phase III (Basile et
al., 2007) or indatraline (Lengyel et al., 2008) (Figure 2).
4.1 Preclinical in vitro properties
4.1.1 Binding properties
Many studies provide Kd values for their compounds, or Ki values, which are sometimes
used interchangeably. These values for the SERT, NET and DAT are provided in Table 1. It
can be noticed that some TRIs such as the PRC series preferentially bind to the SERT and
NET while displaying a lower affinity for the DA transporter (DAT). This is, however, not
the case for the other compounds which display a similar or higher affinity for the DAT than
for the SERT or the NET. Interestingly, the affinity of most of these new compounds for
monoamines transporters is lower than that of SSRIs and NRIs at binding SERT and NET,
respectively (Hache et al., 2011). Therefore, the analysis of the binding properties and
functional activity of the TRIs indicates that the novelty of these pharmacological agents lies
in their relative balanced binding profile rather than in their potency at blocking
monoamines transporters (Hache et al., 2011).
TRIs
Bicifadinea
Indatralinea
DOV216303a
DOV21947a
JNJ7925476a
PRC025b
PRC050b
PRC200-SSb
SERT
2400
0.6
190
110
0.9
6
12
2.1
In vitro binding
(Ki or Kd in nM)
NET
5000
2
380
260
16
10
1.2
1.5
References
DAT
5200
4
190
210
5
53
43
61
Basile et al., 2007

Lengyel et al., 2008
Chen and Skolnick, 2007
Skolnick et al., 2003
Aluisio et al., 2008
Shaw et al., 2007
Shaw et al., 2007
Liang et al., 2008
Table 1. In vitro binding affinities of triple reuptake inhibitors (TRIs). aKi values are
expressed in nM (Ki for inhibition of radioligand binding). bKd values are expressed in nM
and represent the equilibrium dissociation constant. The smaller the Kd values, the higher
affinity of a drug is for the corresponding monoaminergic transporter.
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4.1.2 Functional activity: Synaptosomes

Inhibition of [3H]-5-HT or [3H]-NE reuptake in synaptosomes, is one of the most widespread
method to assess the in vitro potency of reuptake inhibitors (Sanchez and Hytell, 1999) and
to predict indirectly, their selectivity on biogenic amines transporters. In addition, it is
noteworthy that the binding properties of triple reuptake inhibitors do not necessarily
correspond to their in vitro functional activity assessed from rat brain synaptosomes (Tables
1 and 2). For example, although in vitro studies with PRC compounds (PRC025, PRC050 and
PRC200SS: 1S,2S-isomer of racemic PRC050), revealed a perfect correlation between binding
affinity and functional activity towards monaminergic transporters (i.e. the rank of potency
is NET>SERT>DAT), DOV216303 which preferentially binds to SERT and DAT, mainly
inhibits the uptake of [3H]5-HT and [3H]NE (Chen and Skolnick, 2007; Skolnick et al., 2003).
Such a discrepancy could be explained by the fact that the uptake of [3H]NE from
synaptosomal fractions involved the DAT. Indeed, unselective reuptake mechanisms have
been previously reported with monoaminergic systems. In particular, it is well established
that the clearance of DA from the extracellular space can occur through the NET in various
brain regions including the hippocampus, the FC and the NAcc (Carboni et al., 2004;
Bymaster et al., 2002; Moron et al., 2002). More recent evidence shows that DA may also be
taken up by the SERT (Larsen et al., 2011).
4.2 Preclinical in vivo properties
In vivo strategies for characterizing the selectivity and potency of monoamines reuptake
inhibitors examine the electrophysiological and neurochemical effects of these compounds,
generally in rat or mouse brain. At presynaptic level, when the 5-HT or NE transporters are
blocked on the serotonergic or noradrenergic cell bodies, respectively, there results an
accumulation of 5-HT or NE in the vicinity of somatodendritic 5-HT1A or 2 autoreceptors
in the dorsal raphe (DR) or locus coeruleus (LC). This lead to an attenuating firing of DR 5HT or LC NE neurons in a dose-dependent manner due to the activation of these neuronal
elements exerting a negative feedback influence (Tremblay and Blier 2006). This parameter
can be used to characterize the pharmacological profile of reuptake inhibitors. At nerve
terminals, an accumulation of 5-HT or NE also occurs in response to the inactivation of the
5-HT or the NE transporter by SSRIs or NRIs, and the enhancement of extracellular levels of
monoamines can be probed by microdialysis in various brain regions (Guiard et al., 2009).
This approach constitutes a second parameter to study the functional activity of reuptake
inhibitors. Nevertheless, since microdialysis methodology may vary between laboratories,
the electrophysiological approach seems to be more appropriate to establish relevant
comparisons between compounds.
4.2.1 Functional activity: Electrophysiology
Electrophysiological recordings with TRIs (in comparison with single- or dual-acting agents)
on monoamines neuronal activities have yet to be determined. Nevertheless, an initial study
reported, that relative high intravenous doses of the TRIs SEP225289 and DOV216303 were
required to inhibit the electrical activities of DR 5-HT, LC NE and VTA DA neurons.
Although this may result from a lower affinity for the monoaminergic transporters than
selective reupake inhibitors or from a poor brain penetration, 5 mg/kg; iv of DOV216303,
produced an inhibition of 80% of LC NE neuronal activity but only of 30% and 40% of DR 5HT and VTA DA neurons; respectively (Guiard et al., 2011). The observation that both TRIs
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exerted a predominant effect in the LC, while producing only a partial decrease in DR 5-HT
firing activity was puzzling given the equal in vitro affinity and potency of the former drugs
for all three transporters. The reciprocal interactions between monoaminergic neurons
might have thus contributed to alter the functional in vivo activity of TRIs because the
majority of SSRIs, NRIs and SNRIs produce a complete suppression of DR 5-HT neurons
firing (Hache et al., 2011). The possibility has been raised that the lesser than expected effect
of SEP225289 or DOV216303 on the firing activity of 5-HT neurons resulted, at least in part,
from the accumulation of DA and NE in the DR, which are supposed, as abovementioned to
be excitatory on the neuronal activity of 5-HT neurons (Katz et al., 2010b).
4.2.2 Functional activity: Intracerebral microdialysis
With respect to microdialysis data, as expected all TRIs increase extracellular monoamines
levels with distinct intensities, depending on their pharmacological properties, on the brain
regions studied and their relative equipment in monoamines transporters and, on the model
used nave vs depressed animal (Table 2). In a recent study performed in control rats,
PRC200-SS was shown to increase the extracellular levels of the three monoamines in the
medial prefrontal cortex cortex (mPFC) and the Nucleus accumbens (NAcc) (Liang et al.,
2008). In the mPFC, in agreement with its in vitro pharmacological profile, PRC200-SS (5 and
10 mg/kg; ip) significantly increased extracellular levels of NE and 5-HT with a more
pronounced effect for NE. Nevertheless, in this brain region PRC200-SS failed to modify the
extracellular levels of DA. This result is somewhat surprising given the dense dopaminergic
innervation and the high expression of DAT in the frontal cortex (Kuikka et al., 1995). The
lack of increase in cortical DA extracellular levels may be explained by its heterologous
reuptake from the NET (Moron et al., 2002; Giros et al., 1994). However the observations
that catecholamine uptake blockers such as nomifensine, desipramine or GBR12909 increase
DA levels (Devoto et al., 2004; Valentini et al., 2004; Gresh et al., 1995) could emphasize the
importance of the reciprocal interactions between the DA and NE or 5-HT system at nerve
terminal. Indeed if NE and/or 5-HT exert an inhibitory influence on cortical dopaminergic
projections, as describe in the VTA (Guiard et al., 2008a), this might have produced counterproductive effects. However, in the core of the NAcc, where the density of DAT is relatively
high, PRC200-SS (10 mg/kg; ip) increased DA and, to a lower extent, 5-HT outflow without
affecting NE, probably because of the absence of noradrenergic innervation in this brain
area (Carboni et al., 2006). Using microdialysis in the cortex of freely moving rats,
confirmation of the blocking activity of JNJ7925476 on the SERT, NET and DAT has also
been provided. A robust and dose-dependent increase in all three monoamines, lasting for
several hours, was detected with a maximal effect for DA compared to 5-HT and NE at the
highest dose tested (10 mg/kg; sc) (Aluisio et al., 2008). These results strongly contrast with
in vitro data showing that JNJ7925476 displayed a better in vitro binding affinity and
blocking activity for SERT than for DAT (Aluisio et al., 2008). Differences in transporter
occupancy cannot explain these findings since this parameter followed the same trend
observed with cortical extracellular monoamines levels. It has therefore been proposed that
the high cortical levels of DA might have resulted from the blockade of the NET by this
drug, which displays a high affinity for the DAT (Moron et al., 2002; Giros et al., 1994).
Another possibility would be that JNJ7925476 acted by stimulating the release of DA but this
property has not been demonstrated yet. Indirect effects might have also involved
functional interaction between monoaminergic neurons leading to high extracellular levels
of cortical DA. Together, these findings illustrate the fact that the in vivo activity of TRIs does
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not necessarily reflect their in vitro functional activity, probably due, at least in part, to
functional interactions between monoaminergic neurons. Another interesting example of
unexpected results comes from neurochemical studies with bicifadine. Indeed, microdialysis
studies in normal waking rats indicated that bicifadine preferentially increase DA and 5-HT
than NE extracellular levels in the nucleus accumbens at the highest dose tested (60 mg/kg;
i.p.) despite the higher potency of this TRI at binding and inhibiting the SERT and NET
(Nicholson et al., 2009; Basile et al., 2007). Although the selectivity of this compound at the
dose tested can be questioned, it is possible that the combined elevation in 5-HT and DA
produce robust inhibitory effect on the noradrenergic system.
In olfactory bulbectomized rats, a model of depression (Song et al., 2005), it has been shown
that the removal of olfactory bulbs results in a significant decreased in DA, but not 5-HT
and NE, cortical extracellular levels when compared to sham operated. Interestingly,
although after acute administration, DOV216303 increased DA, 5-HT and NE outflow in
sham and bulbectomized rats, chronic administration resulted in a blunted rise in
neurotransmitter (Prins et al., 2011; Prins et al., 2010). In the hippocampus, no changes in
monoamines levels were observed in bulbectomized rats, DOV216303 increase DA, 5-HT
and NE in both sham and bulbectomized rats either after acute or chronic treatment (Prins et
al., 2011). This raises the possibility that monamines homeostasis in response to TRIs is
regulated in a region-dependant manner. In the search for new drugs, adaptations in
receptor and transporter density pre- and post-synaptically after chronic drug
administration should be investigated as well.
TRI
In vitro uptake
(Kd or IC50 in nM)
SERT
NET
DAT
In vivo uptake
References
5-HT
NE
DA
Bicifadinea
117
55
910
+++
++
+++
DOV216303a
30
45
80
+++
++
++
DOV21947a
12
23
96
ND
ND
ND
JNJ7925476a
2.5
+++
+++
+++
JZAD-IV-22a
15
84
120
++
+++
+++
PRC025b
PRC050b
PRC200-SSb
SEP225289a
6
6
2
14
19
0.4
0.6
4
100
120
18
2
ND
ND
+
ND
ND
ND
+++
ND
ND
ND
++
ND
Nicholson et al.,
2009 ; Basile et al.,
2007
Caldarone et al.,
2010 ; Prins et al.,
2010
Skolnick et al.,
2003
Caldarone
et al., 2010
Shaw et al., 2007
Shaw et al., 2007
Liang et al., 2008
Guiard et al., 2011
Table 2. In vitro and in vivo functional activity of triple reuptake inhibitors (TRIs) from
synaptosomes and intracerebral microdialysis; respectively. aValues are expressed in IC50.
bValues are Kd expressed in nM and represent the equilibrium dissociation constant. The
smaller the Kd values, the higher inhibitory effect of a drug is for the corresponding
monoaminergic transporter. In microdialysis experiments, signs + reflects the relative
increase in 5-HT, NE and DA obtained with the highest acute dose used. ND: not determined.
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4.3 Antidepressant-like activity

In humans, it is accepted that antidepressant and more particularly SSRIs, typically inhibit
80% of the SERT binding sites at minimally effective doses (Blier, 2008). It is, however, not
known how much inhibition or occupancy for each transporter is required for
antidepressant action. Correlation between in vitro binding profile towards monoamines
transporters and in vivo behavioral studies may help shed light on some important and often
debated issues.
4.3.1 In test predictive of antidepressant-like activity
The most frequently paradigms used to screen the antidepressant-like activity of
pharmacological agents are the forced swimming and the tail suspension tests (FST and TST,
respectively). Interestingly in the FST a further distinction can be made in swimming and
climbing behaviors. Swimming is a parameter that reflects the activation of the brain
serotonergic system in rodents (Cryan and Lucki, 2000; Reneric and Lucki, 1998; Detke et al.,
1995). Such an association comes from the observation that pretreatment with the
tryptophan hydroxylase inhibitor parachlorophenylalanine, prevents SSRIs-induced
increase in swimming behavior (Page et al., 1999). On the other hand, climbing behavior has
been shown to reflect the activation of noradrenergic system, particularly the subpopulation
of neurons arising from the lateral tegmentum (Cryan et al., 2002). Surprisingly, none of the
studies evaluating the antidepressant-like activity of TRIs has examined the climbing
response, to compare for example, their in vivo potency at stimulating brain serotonergic
and noradrenergic neurotransmissions. It is also important to mention that only one test in
animals cannot cover all the complex depressive aspects. Ideally, novel compounds should
be tested in several behavioral paradigms and animal models in order to address their
putative antidepressant-like activity on a wide variety of symptoms of MD. In this prospect,
Guilloux et al., (2011) have recently developed a score integrating measures from different
tests to provide a robust characterization of the underlying "emotionality" of individual
mouse, similarly as mood and related syndromes are defined in humans through various
related symptoms over time.
Behavioral data currently available, have clearly demonstrated the antidepressant-like effect
of triple reuptake inhibitors that act by increasing the time of mobility and/or by reducing
the time of immobility in the FST or the TST (Aluisio et al., 2008; Liang et al., 2008; Shaw et
al., 2007; Skolnick et al., 2003) (Table 3). Among the TRIs tested, PRC200-SS and JNJ7925476
produced the most robust antidepressant-like effects in these tests. For example, JNJ7925476
(0.3 mg/kg; sc) or PRC200-SS (10mg/kg; ip) produced a greater increase in the time of
mobility in the mouse TST than that observed with PRC025, PRC050 (Aluisio et al., 2008;
Bannwart et al., 2008; Liang et al., 2008; Shaw et al., 2007; Skolnick et al., 2003). In the rat
FST, PRC200-SS is also the compound exhibiting the best performance since at the dose of 10
mg/kg; ip, it produced a more pronounced increase in the time of immobility than that
observed with the corresponding doses of DOV21947, PRC025 and PRC050. Interestingly,
both compounds (i.e. JNJ7925476 and PRC0200-SS) display a higher affinity for the SERT
and the NET compared to the others compounds, suggesting that this double action is an
important prerequisite to produce maximal effects. Since DA is known to enhance
locomotor activity, the possibility cannot be excluded that triple reuptake inhibitors
increased the time of immobility in these various studies, through a psychostimulant effect.
In various studies, however, TRIs did not modify locomotor activity at doses that produce
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303
antidepressant-like effects (Aluisio et al., 2008; Liang et al., 2008; Shaw et al., 2007; Skolnick
et al., 2003), thus suggesting that the antidepressant-like activity of TRIs does not appear to
be from false-positive results.
4.3.2 In animal models of depression
An important drawback in the development of antidepressants is the fact that the new
compounds are tested after acute administration in nave non-depressed animals. Their
chronic use in animal models is likely more relevant and would provide more informative
results to determine whether or not a new pharmacological agents worth being tested in
clinical trials. A recent study in bulbectomized rats has provided some interesting results. In
this model, a 14-day regimen of DOV216303 (20 mg/kg/day; po), normalized bulbectomyinduced hyperactivity in the open field, similar to the effect of imipramine at the same dose
(Breuer et al., 2008). Further studies in these animal models are required to precise the
potential of TRIs and dissect their mechanism of action in pathological conditions.
TRIs
DOV 216,303
Doses, routes
10 mg/kg; po
15 mg/kg; po
20 mg/kg; po
5 mg/kg; po
10 mg/kg; po
15 mg/kg; po
20 mg/kg; po
Tests
FST
(mice)
TST
(mice)
Mobility
(% of
baseline
increase)
ND
ND
ND
ND
ND
ND
ND
Immobility
(% of baseline
decrease)
-20% (*)
-20% (*)
-40% (*)
-25% (***)
-40% (***)
-40% (***)
-55% (***)
DOV 21,947
JNJ-7925476
5 mg/kg; po
10 mg/kg; po
15 mg/kg; po
20 mg/kg; po
FST
(rats)
ND
ND
ND
ND
-20% (*)
-25% (***)
-30% (***)
-40% (***)
0.3 mg/kg; po
TST
(mice)
115%
ND
5 mg/kg; ip
10 mg/kg; ip
TST
(mice)
+60% (*)
+60% (*)
-40% (*)
-40% (*)
5 mg/kg; ip
10 mg/kg; ip
FST
(rats)
+145% (*)
+100% (*)
-40% (*)
-30% (*)
5 mg/kg; ip
10 mg/kg; ip
TST
(mice)
+80% (*)
+70% (*)
-40% (*)
-80% (*)
5 mg/kg; ip
10 mg/kg; ip
FST
(rats)
PRC025
PRC200-SS
(active
enantiomere of
PRC050)
References
Skolnick et al.,
2003
Skolnick et al.,
2003
Shaw et al., 2007
www.intechopen.com
+110% (*)
+165% (*)
Shaw et al., 2007

-30% (*)
-55% (*)
304
TRIs
PRC200-SS
(active
enantiomere of
PRC050)
Doses, routes
Tests
Mobility
(% of
baseline
increase)
0.5 mg/kg; ip
1 mg/kg; ip
10 mg/kg; ip
TST
(mice)
+40% (*)
+95% (**)
+95% (**)
-40% (*)
-90% (**)
-90% (**)
FST
(rats)
+130% (*)
+246% (*)
+226% (*)
-45% (*)
-85% (*)
-75% (*)
TST
(mice)
ND
ND
ND
1 mg/kg; ip
5 mg/kg; ip
10 mg/kg; ip
15 mg/kg; ip
30 mg/kg; ip
60 mg/kg; ip
6-(3,4dichlorophenyl)1-[(methyloxy)
methyl]-3azabicyclo[4.1.0]
heptane
1-(Aryl)-6[alkoxyalkyl]-3azabicyclo[3.1.0]
hexanes and
6-(aryl)-6[alkoxyalkyl]-3azabicyclo[3.1.0]
hexanes
3-aryl-3azolylpropan-1amines
3 mg/kg; ip
10 mg/kg; ip
30 mg/kg; ip
References
Liang et al., 2008
JZAD-IV-22
15 mg/kg; ip
30 mg/kg; ip
60 mg/kg; ip
Immobility
(% of baseline
decrease)
FST
(mice)
ND
ND
ND
FST
(mice)
ND
ND
ND
1 mg/kg; ip
3 mg/kg; ip
10 mg/kg; ip
FST
(mice)
ND
ND
ND
3 mg/kg; po
TST
(mice)
10 mg/kg; po
FST
(mice)
-15% (ns)
-30% (*)
-35% (*)
-20% (ns)
-40% (*)
-70% (*)
Caldarone et al.,
2010
-30% (**)
-70% (**)
-90% (**)
Micheli et al.,
2010a
-20% (ns)
-40% (*)
-90% (**)
Micheli et al.,
2010b
-60% (*)
ND
Lee et al., 2010
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-15% (*)
ND

TRIs
4-(3,4dichlorophenyl)N-methyl1,2,3,4tetrahydronapht
halenyl amines
(compound#10)
N-methyl-1-(1phenylcyclohexyl)
methanamine
(compound #1)
N-methyl-1-(1phenylcyclohexyl)
methanamine
(compound #31)
Doses, routes
Tests
3 mg/kg; ip
10 mg/kg; ip
30 mg/kg; ip
TST
(mice)
3 mg/kg; ip
10 mg/kg; ip
30 mg/kg; ip
3 mg/kg; ip
10 mg/kg; ip
30 mg/kg; ip
Mobility
(% of
baseline
increase)
Immobility
(% of baseline
decrease)
ND
-15%
-20% (*)
-50% (*)
TST
(mice)
ND
TST
(mice)
ND
305
References
Shao et al., 2011a
-5%
-10%
-25% (*)
Shao et al., 2011b
-10%
-14% (*)
-30% (*)
Shao et al., 2011c
Table 3. Antidepressant-like activity of triple reuptake inhibitors (TRIs) in rodents assessed

in the forced swimming test (FST) or the tail suspension test (TST). Po: per os; ip:
intraperitoneal; ND: not determined. *p<0.05, **p<0.01 and p<0.001: significantly different
from vehicle-treated group.
4.4 Clinical properties of TRIs
On the basis of preclinical data, TRIs are in process of development (Millan, 2009) and most
are now in Phase II clinical trials (Table 4). A small citalopram-controlled trial of DOV216303
in severely depressed patients yielded significant improvements in Hamilton Depression
Rating Scale (HAM-D) scores in both groups at both one-week and two week time points
(Skolnick et al., 2006). Since the optimal selectivity of TRIs at the three transporter sites
remains undetermined, it is plausible that different potency ratios may result in different
clinical effects. It can be envisaged to adapt the treatment to the nature of depressive
symptoms. Drugs with high affinities for the 5-HT and NE transporters could be prescribed
to patients displaying anxious symptoms, whereas compounds with a high affinity for the
DAT could be more beneficial to patients having a loss of motivation and/or anhedonia.
Despite these encouraging data, further investigations failed to demonstrate the beneficial
therapeutic effect of NS2359 resulting in discontinued development. Of particular
importance, a concern with drugs that block DA transporters is their potential reinforcing
property and abuse liability. This comes from the fact that drugs that block DAT do not
necessarily lead to dependence. Indeed, Volkow and collaborators showed that DAtransporter-blocking drugs must induce more than 50% DAT blockade to produce
reinforcing effects (Volkow et al., 2005). Hence, DA reuptake inhibitors have been classified
into two groups: type 1 blockers, which produce addiction and euphoria, and type 2
blockers, which do not (Rothman, 1990). It is thus possible that the capacity of DA reuptake
blockers to produce dependence may involve other mechanisms that should carefully be
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considered with multi-targets agents such as TRIs. Nevertheless, although rigorous clinical
feedback is yet to come, it can be hoped that TRIs will prove to have acceptable abuse and
dependence potential and will offer improved efficacy in the management of depression.
Accordingly a recent study involving comparing tesofensine vs. placebo, D-amphetamine
and bupropion, in recreational stimulant users shows that although the effects of Damphetamine were significantly greater than those of placebo on all primary and secondary
subjective measures, tesofensine were not significantly different from those of placebo and
lower than those of D-amphetamine and bupropion suggesting that the abuse potential for
tesofensine is no greater than that of bupropion (Schoedel et al., 2010). Similar conclusions
were reported with bicifadine, which display a low abuse potential (Nicholson et al., 2009).
With respect to MD and eating disorders, weight loss has also been observed as an adverse
event in studies with tesofensine (Hauser et al., 2007; Hansen et al., 2010), prompting further
research for the indication of obesity. This effect is believed to result from appetite
suppression (Axel et al., 2010; Sjodin et al., 2010). Recently published data from the first
randomized, double-blind, Pl-controlled phase-II trial in primarily healthy, obese subjects
showed that tesofensine was able to produce a greater weight loss after 24 weeks about
twice that of currently approved drugs (Astrup et al., 2008a, 2008b). Appetite was
significantly suppressed after an overnight fast after treatment with tesofensine in this study
(Astrup et al., 2008a, 2008b).
5. Pain relief by TRIs, an example of symptom of depression

Acute and chronic pains may result from reduced levels of endogenous 5-HT, NE and DA
activities, at both the spinal and supraspinal levels (Ren and Dubner, 2002). Indeed, pain is a
bi-directional process of ascending and descending neuronal pathways involving
monoaminergic systems whose activation may have an inhibitory influence on nociception.
Despite the complexity of pharmacological interactions between monoaminergic neurons,
that sometimes may attenuate monoaminergic neurotransmission, one would expect a better
efficacy of dual-or triple-acting agents over selective 5-HT or NE reuptake inhibitors in
analgesia (Hache et al., 2011). Indeed, since all three monoamines are involved in
antinociception, the recruitment of more than one system may produce additional effects.
Selected antidepressants suppress pain by diverse mechanisms and are now considered as
an essential component of the therapeutic strategy for treatment of many types of persistent
pain (Sawnyok et al., 2001). Their main mechanism of action involves reinforcement of the
descending inhibitory pathways by increasing the amount of 5-HT and NE, but also DA in
the synaptic cleft at both supraspinal and spinal levels (Hache et al., 2011). Several openlabel randomized controlled clinical trials, meta-analyses, and systematic reviews have
confirmed the clinical efficacy of selected antidepressants in persistent pain conditions
(Dharmshaktu et al., 2011). Precedent for the use of TRIs in the treatment of clinical pain
exists with nefopam, a tricyclic agent with non-narcotic analgesic (Heel et al., 1980). It was
reported that DA played a critical role in nefopam analgesia as indicated by the observation
that rats with selective loss of DA neurons, have a marked reduction in nefopam-induced
analgesia. In a marked contrast, the lesion of the serotonergic or noradrenergic systems
induced by 5,7-duhydroxytryptamine (5,7-DHT) or DSP4, respectively, failed to affect
nefopam-induced analgesia in rats (Esposito et al., 1986; Girard et al., 2006; Girard et al.,
2011). The potential interest of TRIs in the relief of pain has been corroborated by a recent
publication characterizing the antinociceptive effects of the TRI bicifadine in acute,
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persistent and chronic models of pain (Basile et al., 2007). In this study, bicifadine potently
suppressed pain responses in two models of acute inflammatory pain in both rats and mice.
It also normalized the nociceptive threshold in the complete Freund's adjuvant model of
persistent inflammatory pain and suppressed mechanical and thermal hyperalgesia and
mechanical allodynia in the spinal nerve ligation model of chronic neuropathic pain.
Mechanical hyperalgesia was also reduced by bicifadine in the STZ model of neuropathic
pain (Basile et al., 2007). Clinical (phase II/III) studies have demonstrated that bicifadine is
an effective analgesic in the treatment of postoperative pain (Krieter et al., 2008). The impact
of bicifadine on 5-HT, NE and DA neurotransmissions was confirmed by in vitro binding
assays and intracerebral in vivo microdialysis study in freely moving rats. In a second study,
another TRI, NS7051, has shown comparable antinociceptive properties to tramadol
confirming the interest of these antidepressants in the relief of pain (Munro et al., 2008). The
molecule has undergone several Phase II and III trials for the treatment of pain, including
acute postsurgical pain and chronic low back pain, and is being evaluated for painful
diabetic neuropathy (clinical trial.gov). However, bicifadine has failed to meet endpoints in
a number of trials such as diabetic neuropathy (clinical trial.gov) suggesting that TRIs may
be used in specific pain. Other TRIs currently under development for depression should
draw attention for future investigations in the field of pain and confirm whether or not they
display any activity in diabetic neuropathy.
6. Conclusion
Numerous arguments support the contention that multi-target mechanisms may be more
effective and better tolerated than their highly selective counterparts in the management of
MD (Millan, 2009). Hence, drugs in preclinical and clinical studies (Table 4) include, but are
not limited to TRIs, which simultaneously increase brain 5-HT, NE and DA
neurotransmissions. Several lines of evidence specifically substantiate interest in dual-and
triple-acting antidepressants. First there is no single cause of major depression. A vast array
TRIs
Comparator(s)
Phases
Tesofensine
Tesofensine
placebo
placebo
I
II
DOV21947
placebo
II
SEP225289
Bicifadine
Nefopam
placebo
venlafaxine
placebo
standard analgesic treatment
dexmedetomidine
fentanyl
II
Conditions
Obesity
Obesity
Major Depressive
Disorder
Major Depressive
Disorder
III
Chronic low back pain
IV
Post operative analgesia
Table 4. Clinical studies with triple reuptake inhibitors (TRIs) in major depressive disorder
or related morbidities. Details of these studies can be found on
http://www.clinicaltrials.gov using the Boolean research for the following keywords:
Triple reuptake inhibitors.
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of interacting genes, epigenetic influences, developmental events, and environmental factors

collectively compromise mood. Second, agents that have complementary components of
action may have a greater chance of controlling both the mood deficits of depression and
other residual symptoms such as sleep disturbances, eating, sexual disorders or pain. This
review particularly focuses on nocicpetion since over 75% of depressed patients suffer from
painful symptoms (Hache et al., 2011), predicting a greater severity and a less favorable
outcome of depression. In addition, imaging, anatomical and functional studies have
demonstrated the existence of common brain structures, neuronal pathways and
neurotransmitters in depression and pain raising the possibility that managing pain in
depressed patients may help them recover more rapidly and efficiently. This is an example
illustrating the fact that MD does not rely on only one impaired system and that an
improved antidepressant therapy requires a diagnosis taking into considerations symptom
profiles.
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Psychiatric Disorders - Trends and Developments

Edited by Dr. Toru Uehara
ISBN 978-953-307-745-1
Hard cover, 514 pages
Publisher InTech
Published online 26, October, 2011
Published in print edition October, 2011

Due to their prevalence, pervasiveness and burden inflicted on men and women of today, psychiatric disorders
are considered as one of the most important, sever and painful illnesses. This impairment of cognitive,
emotional, or behavioural functioning is in some cases tragic. Aside from knowing the physical organic factors,
such as infections, endocrinal illnesses or head injuries, the aetiology of psychiatric disorders has remained a
mystery. However, recent advances in psychiatry and neuroscience have been successful in discovering
subsequent pathophysiology and reaching associated bio-psycho-social factors. This book consists of recent
trends and developments in psychiatry from all over the world, presented in the form of multifarious and
comprehensive articles. The first two sections of the book are reserved for articles on schizophrenia and
depression, two major illnesses present in this field. The third section of the book is reserved for addiction
psychiatry, related not only to socio-cultural but also biological alterations. The last section of the book, titled
Biological Neuropsychiatry, consists of three topics - updated molecular biology, fundamental neuroscience
and clinical neuropsychiatric conditions. Doubtlessly, this book will be fruitful for future developments and
collaboration in world psychiatry.
How to reference
In order to correctly reference this scholarly work, feel free to copy and paste the following:
B.P. Guiard (2011). A New Class of Antidepressant Drugs in the Treatment of Psychiatric Disorders: The Triple
Reuptake Inhibitors, Psychiatric Disorders - Trends and Developments, Dr. Toru Uehara (Ed.), ISBN: 978-953307-745-1, InTech, Available from: http://www.intechopen.com/books/psychiatric-disorders-trends-anddevelopments/a-new-class-of-antidepressant-drugs-in-the-treatment-of-psychiatric-disorders-the-triplereuptake-in
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