Beyond antipsychotics: a twenty-first century update for preclinical development of schizophrenia therapeutics

Abstract

Despite 50+ years of drug discovery, current antipsychotics have limited efficacy against negative and cognitive symptoms of schizophrenia, and are ineffective-with the exception of clozapine-against any symptom domain for patients who are treatment resistant. Novel therapeutics with diverse non-dopamine D₂ receptor targets have been explored extensively in clinical trials, yet often fail due to a lack of efficacy despite showing promise in preclinical development. This lack of translation between preclinical and clinical efficacy suggests a systematic failure in current methods that determine efficacy in preclinical rodent models. In this review, we critically evaluate rodent models and behavioural tests used to determine preclinical efficacy, and look to clinical research to provide a roadmap for developing improved translational measures. We highlight the dependence of preclinical models and tests on dopamine-centric theories of dysfunction and how this has contributed towards a self-reinforcing loop away from clinically meaningful predictions of efficacy. We review recent clinical findings of distinct dopamine-mediated dysfunction of corticostriatal circuits in patients with treatment-resistant vs. non-treatment-resistant schizophrenia and suggest criteria for establishing rodent models to reflect such differences, with a focus on objective, translational measures. Finally, we review current schizophrenia drug discovery and propose a framework where preclinical models are validated against objective, clinically informed measures and preclinical tests of efficacy map onto those used clinically.

Fig. 1. Neurobiology of nontreatment-resistant and treatment-resistant schizophrenia.

Approximately 30% of schizophrenia patients do not respond to first-line antipsychotics; treatment response or non-response is associated with distinct neurobiological changes within the corticostriatal circuitry. Of treatment-resistant patients, approximately 70% do not respond to clozapine. No treatment provides meaningful improvements to negative or cognitive symptoms.