Theory of active antidepressants: a nonsynaptic approach to the treatment of depression

Although depression is one of the major neuropsychiatric disorders, the success rate of medication for any drug is about 60%, which means that approximately 40% of the patients does not respond to the initial treatment. The major aim of this review is to provide a possible explanation for the relative inefficacy of currently used antidepressants and to propose a novel mechanism of action, which might improve the success rate of clinical treatment. According to the monoamine theory the most important neurochemical process in depression is the impairment of monoaminergic neurotransmission and the concomitant decrease of extracellular concentration of noradrenaline and/or serotonin. Since the vast majority of monoaminergic varicosities makes no synaptic contact but is able to release transmitters directly into the extrasynaptic space, the monoaminergic neurotransmission is predominantly nonsynaptic in nature. Depression can be regarded, therefore, as a disease, which is developed (at least in part) on the basis of the impairment of nonsynaptic interactions and the effective treatment has to improve this non-conventional communication in the nervous system. The currently used antidepressants (reuptake inhibitors, negative feedback inhibitors, monoamino oxidase inhibitors) can increase the monoamine levels in the extracellular space only if the monoaminergic cells are electrically active and without an action potential-induced vesicular exocytosis these compounds are ineffective. It is proposed that a selective and moderate induction of the carrier-mediated release of NA and 5-HT might be a better therapeutic approach to the treatment of depression, since this new class of antidepressants, the so-called 'active antidepressants' have a mechanism of action, which is independent from the electrical activity of monoaminergic cells, therefore the extrasynaptic concentration of monoamines and thereby the nonsynaptic communication can be enhanced more efficiently.