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Pro-motivational agent

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See also: Disorders of diminished motivation § Treatment

A pro-motivational agent is a drug which increases motivation.[1][2] They can be used in the treatment of motivational deficits, for instance in depression, schizophrenia, and attention deficit hyperactivity disorder (ADHD),[3][1] as well as in the treatment of disorders of diminished motivation (DDMs), including apathy, abulia, and akinetic mutism, for instance due to stroke, traumatic brain injury, or neurodegenerative diseases.[4][5] They are also used non-medically by healthy people to increase motivation and productivity, for instance in educational contexts.[6][2][7][8]

There are limited clinical data on medications in treating motivational deficits and disorders.[9][10] In any case, drugs used for pro-motivational purposes are generally dopaminergic agents, for instance dopamine reuptake inhibitors (DRIs) like methylphenidate and modafinil, dopamine releasing agents (DRAs) like amphetamine, and other dopaminergic medications.[1][2][11] Adenosine receptor antagonists, like caffeine and istradefylline, can also produce pro-motivational effects.[11][12][13][14] Acetylcholinesterase inhibitors, like donepezil, have been used as well.[15][16][4][9]

Some drugs do not appear to have pro-motivational effects and can actually produce anti-motivational effects.[1][11][17] Examples of these drugs include selective serotonin reuptake inhibitors (SSRIs),[17][18][19] selective norepinephrine reuptake inhibitors (NRIs),[17] and antipsychotics (which are dopamine receptor antagonists or partial agonists).[20][21][22] Cannabinoids have also been associated with motivational deficits.[23][24][25][1][26]

List of pro-motivational agents

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Dopaminergic agents

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Dopaminergic agents that have been found to produce pro-motivational effects in animals and/or humans include the following:[1][11]

A limitation of bupropion as a dopaminergic agent is that it achieves very limited clinical occupancy of the dopamine transporter (DAT).[37][38][39][40]

Dopamine D2-like receptor agonists, including pramipexole, ropinirole, rotigotine, piribedil, bromocriptine, cabergoline, and pergolide, have also been used to treat disorders of diminished motivation in humans.[16][4][5][10][41] However, the quality of evidence on these agents for this use is very limited.[10] D2-like receptor agonists are known to have sedative-like and non-rewarding effects in humans.[42][43][44] In any case, dopamine D2-like receptor antagonists, like haloperidol and other antipsychotics, are known to produce anti-motivational effects in animals[1][11][10][2] and humans.[20][21][45][46][47][48]

Other dopaminergic drugs that have been used or suggested in the treatment of disorders of diminished motivation include rasagiline (a selective monoamine oxidase B (MAO-B) inhibitor; but see more below), tolcapone (a centrally-acting catechol-O-methyltransferase (COMT) inhibitor), and amantadine (an indirectly acting dopaminergic agent that acts via unknown mechanisms).[10][16][49][15][50]

Adenosinergic agents

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Adenosine receptor antagonists, including caffeine, istradefylline, Lu AA47070, MSX-3, MSX-4, preladenant, and theophylline, have shown pro-motivational effects in animals and humans.[11][12][13][51][14][52] Caffeine and theophylline act as non-selective antagonists of the adenosine receptors (including A1, A2A, A2B, and A3).[11][53][54][55] Conversely, agents like istradefylline and preladenant are selective adenosine A2A receptor antagonists.[11] Adenosine A2A receptor antagonists, including the non-selective antagonists like caffeine, show pro-motivational effects in animals, whereas selective adenosine A1 receptor antagonists do not.[11] Adenosine A2A receptor antagonists appear to exert their pro-motivational effects in the nucleus accumbens core and can reverse the anti-motivational effects of dopamine D2 receptor antagonists like haloperidol in animals.[11][12][13][56][57] Istradefylline is approved in the treatment of Parkinson's disease and has been found to improve symptoms of apathy, anhedonia, and depression in people with the condition.[14][52]

Cholinergic agents

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Acetylcholinesterase inhibitors, like donepezil, rivastigmine, and galantamine, have been used in the treatment of disorders of diminished motivation.[15][16][4][9] These drugs inhibit acetylcholinesterase, which metabolizes the neurotransmitter acetylcholine, thereby increasing acetylcholine levels in the brain.[58] They are approved and used in the treatment of Alzheimer's disease and provide modest cognitive improvements in people with the disease.[58][59][60] Although acetylcholinesterase inhibitors have been used to treat disorders of diminished motivation, the muscarinic acetylcholine receptor agonist pilocarpine has actually shown anti-motivational effects in animals that can be reversed by the muscarinic acetylcholine receptor antagonist scopolamine.[56] In addition, scopolamine has been found to reverse the anti-motivational effects of the dopamine D2 receptor antagonist haloperidol in animals.[56] In any case, in spite of the preceding findings, acetylcholinesterase inhibitors have been found to be clinically effective, albeit modestly, for apathy in dementia and Parkinson's disease.[61][62][63]

Ineffective agents

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Norepinephrine reuptake inhibitors (NRIs) like atomoxetine and selective serotonin reuptake inhibitors (SSRIs) like escitalopram have been used and recommended in the treatment of disorders of diminished motivation.[5][15][64] However, NRIs like desipramine and atomoxetine, SSRIs like fluoxetine and citalopram, and MAO-A-inhibiting monoamine oxidase inhibitors (MAOIs) like moclobemide and pargyline have all not shown pro-motivational effects in animals.[1][11][27][65][36] In fact, they can all produce further motivational deficits in animals.[17][65][66][36] Serotonergic antidepressants like SSRIs and serotonin–norepinephrine reuptake inhibitors (SNRIs) have also been implicated in inducing apathy and emotional blunting in humans.[18][19][67]

In contrast to selegiline, selective MAO-B inhibitors without concomitant catecholaminergic activity enhancer (CAE) actions, like rasagiline, SU-11739, and lazabemide, are poorly effective in reversing behavioral deficits induced by the dopamine depleting agent tetrabenazine in animals.[68][69]

Antipsychotics, which classically act as dopamine receptor antagonists (mostly of the D2-like receptors), are well-known as having anti-motivational effects.[1][11][20][21][45][46][48] In fact, these effects may play a key role in their effectiveness against the positive and psychotic symptoms of schizophrenia by blunting the emotions underlying delusions.[20][21][45][46][48] A novel class of antipsychotics, sometimes referred to as third-generation antipsychotics, act as dopamine receptor partial agonists instead of as pure antagonists and have mixed agonistic and antagonistic effects.[70][71] These drugs include aripiprazole, brexpiprazole, and cariprazine.[71] Aripiprazole, a dopamine D2, D3, and D4 receptor partial agonist, has been suggested, at low doses, as a possible treatment for disorders of diminished motivation.[49] However, cariprazine, a D2 and D3 receptor partial agonist, has shown anti-motivational effects in animals.[22] Dopamine receptor partial agonists may differ in their intrinsic activities at the dopamine receptors and in their profiles of effects.[72]

Some atypical DRIs, like JJC8-091, in contrast to other DRIs, are not effective in producing pro-motivational effects in animals.[73]

References

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