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Naming names
Editorial
What’s in a name? When it comes to psychotropic drugs, a lot. For doctors, a second-generation antipsychotic might sound like a newer, better, more advanced option. For patients who have finally summoned the courage to seek help for an anxiety disorder, being prescribed an antidepressant might suggest that the doctor wasn’t listening to them and dishes out happy pills to everyone. People prescribed an antipsychotic for depression might legitimately be concerned that their psychiatrist, without telling them, believes they have a psychotic disorder. For decades, the taxonomy for psychotropic medications has been based on indication, with some molecular structure or receptor function thrown in. Some antidepressants are named after their structure, such as tricyclic antidepressants, and some by their function, such as selective serotonin reuptake inhibitors. Antipsychotic classifications of typical and atypical, or first and second generation, provide no clues as to how they might work. Many terminologies were coined when there was only one known indication for a particular medication, so it made sense to classify them as an anxiolytic or an antipsychotic, whereas today we know that one drug may have many uses and that symptoms overlap between conditions. Current psychotropic nomenclature does little to help rational prescribing practices or aid patient psychoeducation. Is it time to change? Many leading psychopharmacologists think it is. To bring about a change in terminology requires a concerted and coordinated response across the medical community, which is now being called for. After almost a decade of collaboration between the European, American, Asian, and International Colleges of Neuropsychopharmacology, and the International Union of Basic and Clinical Pharmacology, the new Neuroscience-based Nomenclature (NbN) proposes to change the way we describe psychotropics. The aim is to reflect their pharmacological properties, rather than the mental health conditions that they are usually used to treat. The NbN includes 108 compounds, which represents most available psychotropics, and classifies them into 11 pharmacological domains, with ten modes of action. It is recognised that some compounds will have more than one mode of action. Pharmacological domains reflect our understanding of which neurotransmitter systems are modified by the drug in question, whether it be acetylcholine, histamine, or www.thelancet.com/psychiatry Vol 3 June 2016
serotonin; modes of action define whether the drug is a receptor agonist or antagonist, or an enzyme inhibitor. The NbN aims to provide a rationale for the use of particular medications, to help clinicians determine the next logical step in prescribing, and to be future-proof, with room to add new drugs as they are licensed. Changing language and habits formed over decades will be a long process. Journals, including The Lancet Psychiatry, should consider these proposals carefully; the NbN’s free glossary app helps to translate former descriptions of psychotropics to NbN terms. But is it worth it? There will doubtless be hitches on the way from translating old terminology to NbN terms. Working out gaps in the evidence base and directions for future research relies on carrying out thorough systematic reviews: work published before NbN will use old terminology and require searching under possible indication, chemical structure, and functional properties, and there will inevitably be a time period during which doctors will need to be able to use both old and new names. It is unlikely that anything can be truly future-proof, and advances in translational neuroscience might render parts of the newly carefully translated app as arbitrary as a description of a thirdgeneration drug. There is also the danger that rather than leading to more rational prescribing, the use of NbN could have the opposite effect, and lead to people being given unnecessary and excessive medications; for example, prescription of a “dopamine receptor antagonist” might be easier to justify to patients than an “antipsychotic”. Particularly in psychiatry, however, where there has been a lack of targeted therapeutics for a long time and the use of language often suffers from a similar lack of precision, changing names to reflect contemporary pharmacological knowledge and specific underlying neuroscience is important. A new language is not in itself sufficient to change practice, and needs to be accompanied by the actions that should naturally lead from it—namely, a trans-diagnostic approach and commitment to updating the new nomenclature; rational prescribing practices; and better communication with patients about the rationale for use of medications. The desire to cling to established nomenclature is understandable. But to do so risks using an outdated map to navigate new and complex territory. Please write or tweet @TheLancetPsych to tell us what you think. ■ The Lancet Psychiatry
Arie Van ‘T Riet/Science Photo Library
Naming names
For more on NbN see http:// nbnomenclature.org
489
What’s in a name? When it comes to psychotropic drugs, a lot. For doctors, a second-generation antipsychotic might sound like a newer, better, more advanced option. For patients who have finally summoned the courage to seek help for an anxiety disorder, being prescribed an antidepressant might suggest that the doctor wasn’t listening to them and dishes out happy pills to everyone. People prescribed an antipsychotic for depression might legitimately be concerned that their psychiatrist, without telling them, believes they have a psychotic disorder. For decades, the taxonomy for psychotropic medications has been based on indication, with some molecular structure or receptor function thrown in. Some antidepressants are named after their structure, such as tricyclic antidepressants, and some by their function, such as selective serotonin reuptake inhibitors. Antipsychotic classifications of typical and atypical, or first and second generation, provide no clues as to how they might work. Many terminologies were coined when there was only one known indication for a particular medication, so it made sense to classify them as an anxiolytic or an antipsychotic, whereas today we know that one drug may have many uses and that symptoms overlap between conditions. Current psychotropic nomenclature does little to help rational prescribing practices or aid patient psychoeducation. Is it time to change? Many leading psychopharmacologists think it is. To bring about a change in terminology requires a concerted and coordinated response across the medical community, which is now being called for. After almost a decade of collaboration between the European, American, Asian, and International Colleges of Neuropsychopharmacology, and the International Union of Basic and Clinical Pharmacology, the new Neuroscience-based Nomenclature (NbN) proposes to change the way we describe psychotropics. The aim is to reflect their pharmacological properties, rather than the mental health conditions that they are usually used to treat. The NbN includes 108 compounds, which represents most available psychotropics, and classifies them into 11 pharmacological domains, with ten modes of action. It is recognised that some compounds will have more than one mode of action. Pharmacological domains reflect our understanding of which neurotransmitter systems are modified by the drug in question, whether it be acetylcholine, histamine, or www.thelancet.com/psychiatry Vol 3 June 2016
serotonin; modes of action define whether the drug is a receptor agonist or antagonist, or an enzyme inhibitor. The NbN aims to provide a rationale for the use of particular medications, to help clinicians determine the next logical step in prescribing, and to be future-proof, with room to add new drugs as they are licensed. Changing language and habits formed over decades will be a long process. Journals, including The Lancet Psychiatry, should consider these proposals carefully; the NbN’s free glossary app helps to translate former descriptions of psychotropics to NbN terms. But is it worth it? There will doubtless be hitches on the way from translating old terminology to NbN terms. Working out gaps in the evidence base and directions for future research relies on carrying out thorough systematic reviews: work published before NbN will use old terminology and require searching under possible indication, chemical structure, and functional properties, and there will inevitably be a time period during which doctors will need to be able to use both old and new names. It is unlikely that anything can be truly future-proof, and advances in translational neuroscience might render parts of the newly carefully translated app as arbitrary as a description of a thirdgeneration drug. There is also the danger that rather than leading to more rational prescribing, the use of NbN could have the opposite effect, and lead to people being given unnecessary and excessive medications; for example, prescription of a “dopamine receptor antagonist” might be easier to justify to patients than an “antipsychotic”. Particularly in psychiatry, however, where there has been a lack of targeted therapeutics for a long time and the use of language often suffers from a similar lack of precision, changing names to reflect contemporary pharmacological knowledge and specific underlying neuroscience is important. A new language is not in itself sufficient to change practice, and needs to be accompanied by the actions that should naturally lead from it—namely, a trans-diagnostic approach and commitment to updating the new nomenclature; rational prescribing practices; and better communication with patients about the rationale for use of medications. The desire to cling to established nomenclature is understandable. But to do so risks using an outdated map to navigate new and complex territory. Please write or tweet @TheLancetPsych to tell us what you think. ■ The Lancet Psychiatry
Arie Van ‘T Riet/Science Photo Library
Naming names
For more on NbN see http:// nbnomenclature.org
489