2015 will be the year in which we change the nomenclature of the drugs used to treat psychiatric disorders. Or rather, we adopt an approach that is driven by science rather than inertia or marketing. This will be the result of the major project undertaken by ECNP in collaboration with ACNP, CINP, AsCNP and IUPHAR to reform the old and unhelpful nomenclature. It has been driven tirelessly by Yossi Zohar. When the project started, enthusiasm was largely confined to a relatively small coalition of the willing. As it has developed the point of it has grown more and more obvious to more and more people. The founding version of the Neuroscience-based Nomenclature – NbN – was launched at the ECNP congress in Berlin as a booklet and app.

The guiding principle can be easily stated. Medicines are used to treat patients because they have a particular pharmacology and a particular indication for individual diagnoses. If there is more than one medicine for a particular indication we need to be able to use a classifier. The classification can emphasise either property, mode of action or indication. Pharmacological investigation of mode of action has had a special place in psychiatry, because effective medicines were discovered before their pharmacology was understood. The investigation of mode of action was and arguably remains a cutting-edge theme in neuroscience. It provided and provides one of the few starting points for mechanistic understanding of psychiatric disorders. By contrast, diagnosis (the indication) remains arbitrary.

So pharmacology provides the right space in which to describe, summarise and classify psychotropic medicines. Obviously some sub-classes of drugs are already described in this way. We have selective monoamine oxidase inhibitors and serotonin reuptake inhibitors (SSRIs), for example, although the latter usage was largely driven by marketing pressures in the ‘Prozac’ era. Unfortunately, we have not clearly preferred pharmacological classification over the alternatives. We have even lacked any kind of systematic approach to describing the pharmacological properties of our medicines. SNRIs are not selective noradrenaline reuptake inhibitors, for example. The NbN now proposes a reformed approach to classification based entirely on pharmacological mode of action. It is a work in progress. Thus, some of the terms we have proposed may sound infelicitous to some ears, but they are not written in stone. Moreover, consider the currently established alternatives.

First, the example of existing terminology that refers to chemistry (tricyclics, tetracyclics, phenothiazines, butyrophenones, benzamides, benzodiazepines). This has the virtue of neutrality but the vice for most of us of conveying no useful information whatsoever. Second, and predominantly, we have an overlapping primary classification by indication: antidepressants, antipsychotics, mood stabilisers, anxiolytics, analgesics and, ambiguously, stimulants. This has been nicely modulated by companies adding soothing adjectives like atypical, conventional, second generation, novel, etc. It leads to a range of problems. Thus, the primary indications of most psychiatric drugs are not unique. In the case of the antidepressants, many are effective anti-anxiety or anti-pain treatments. In the case of a number of antipsychotics, they are effective in resistant depression, quite independent of any anti-psychotic action. A number of ‘mood stabilisers’ are also anticonvulsants. Further, the addition of qualifying adjectives has been almost entirely designed to persuade, Madison Avenue-style. Who would want an old iPhone if the next generation phone were on offer? But the analogy suggested by ‘second generation’ antipsychotic drugs is entirely specious. I could go on.

It is undeniably a mess. Does this matter? It has been tolerated for a long time without serious efforts to change. Our desire to make changes now should be fuelled by embarrassment. However, there are more serious reasons to change too. We often do not know what we think until we speak. Defining our treatments by diagnoses of limited validity limits our capacity to think. An emphasis on mechanism should stimulate clinicians to think what they are doing when they prescribe for patients. It will be a continuing stimulus to stay on top of the science that underpins our understanding. Moreover, a multi-axial system for describing medicines as we propose can grow flexibly: it can accommodate mechanistic understanding at any number of levels from molecules, to systems, to cognition. There is also the potential to harness the shift in emphasis from operational diagnosis to dimensional neurobiology (enshrined in the RDoC project).

Medicine is entering a new era in which it is being transformed by the explosion of access to knowledge and soon by the internet of things. We have deliberately invested in developing an app to be available from the beginning of the project (download now on Google Play or Apple Store), which will provide the prescribing information we think doctors and patients need. The app format allows medicines to be searched under the old categories and the new ones. It will allow translation into many languages. It will soon be linked to another specialist database (IUPHAR’s). It can expand or extend through linking almost without limit. ECNP is committed to overseeing its development for public benefit. I think it’s a game changer.

So, with spirits lifted despite recent world events, I wish you my very best wishes for 2015.

Guy Goodwin
ECNP President