Research report 567
Attenuation of anhedonia by cariprazine in the chronic mild
stress model of depression
Mariusz Pappa, Piotr Grucaa, Magdalena Lasoń-Tyburkiewicza, Nika Adhamb,
Béla Kissc and István Gyertyánc
The aim of this study was to evaluate whether chronic
treatment with cariprazine, a dopamine D2 and D3 receptor
partial agonist with preferential binding to D3 receptors,
shows antidepressant-like effects in the chronic mild stress
(CMS)-induced anhedonia model. Male Wistar rats were
subjected to the CMS procedure for 7 weeks; nonstressed
animals served as controls. For the last 5 weeks of the CMS
procedure, rats were injected once daily with vehicle,
imipramine (10 mg/kg), aripiprazole (1 and 5 mg/kg), or
cariprazine (0.01, 0.03, 0.065, 0.25, and 1.0 mg/kg). Activity in
reversing CMS-induced decreases in consumption of 1%
solution of sucrose was measured. CMS significantly
reduced sucrose intake. Imipramine, and both doses of
aripiprazole and cariprazine 0.03, 0.065, and 0.25 mg/kg
significantly attenuated CMS-induced reductions in sucrose
intake; the lowest and highest cariprazine doses (0.01 and
1 mg/kg) did not have this effect. Cariprazine showed
greater potency (ED50 = 0.052) relative to aripiprazole
(ED50 = 4.4) in this model. Thus, in the rat CMS model,
Introduction
The chronic mild stress (CMS) model of depression has
been used since the 1980s to measure the effects of
antidepressant treatment on anhedonia (Willner et al.,
1987), a core symptom of major depressive disorder
(MDD) and bipolar depression (Gelenberg et al., 2010).
Although not without controversy, over the years, CMS
has been used successfully by more than 60 research
groups in 20 countries and is one of the few depression
models that has predictive, face, and construct validity
(Willner, 2005; Krishnan and Nestler, 2011; Papp, 2012).
Many different drug classes that are used to treat
depression have shown a positive effect on anhedonia in
this model (i.e. attenuation of stress-induced decrease in
sucrose consumption), including tricyclic antidepressants
(Monleon et al., 1995; Marston et al., 2011; Papp, 2012),
selective serotonin reuptake inhibitors (Montgomery
et al., 2001), serotonin norepinephrine reuptake inhibitors
(Millan et al., 2001; Papp, 2012), and atypical anti-
psychotics (Orsetti et al., 2007; Marston et al., 2011; Papp,
2012).
Despite the varied treatment options for depression,
anhedonia has remained a difficult symptom to treat and
is a predictor of poor treatment response in depressed
patients (Spijker et al., 2001). The poor response of
0955-8810 © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
cariprazine showed antidepressant-like action with greater
potency than aripiprazole. These results suggest that
cariprazine may have clinical utility in the treatment of
depression and the negative symptoms of
schizophrenia. Behavioural Pharmacology 25:567–574
© 2014 Wolters Kluwer Health | Lippincott Williams &
Wilkins.
Behavioural Pharmacology 2014, 25:567–574
Keywords: anhedonia, antipsychotic agents, bipolar disorder, cariprazine,
chronic mild stress, depression, dopamine D3 receptor,
dopamine receptor partial agonist, negative symptoms, schizophrenia
a
Behavioural Pharmacology Laboratory, Institute of Pharmacology, Polish
Academy of Sciences, Kraków, Poland, bDepartment of Pharmacology, Forest
Research Institute, Jersey City, New Jersey, USA and cDivision of Pharmacology,
Gedeon Richter Plc, Budapest, Hungary
Correspondence to István Gyertyán, PhD, Gedeon Richter Plc, H-1103 Budapest
10, Gyomroi u. 19-21, Hungary
E-mail: i.gyertyán@richter.hu
Received 1 April 2014 Accepted as revised 23 June 2014
anhedonic symptoms to conventional antidepressant
treatments (tricyclic antidepressants, selective serotonin
reuptake inhibitors, serotonin norepinephrine reuptake
inhibitors) may in part be because of the fact that the
dopamine (DA) system, which is not targeted by these
compounds, likely plays a critical role in certain aspects of
anhedonia (Shelton and Tomarken, 2001; Dunlop and
Nemeroff, 2007; Der-Avakian and Markou, 2012). The
presence of anhedonic symptoms as a predictor of poor
treatment outcomes is not confined to depression, but is
also observed in schizophrenia, in which anhedonia is a
core component of negative symptoms (Andreasen, 1982;
Kay et al., 1987; Carpenter et al., 1988; Kirkpatrick et al.,
1989; Herbener and Harrow, 2002; Strauss and Gold,
2012).
The parallels between depression and schizophrenia can
be observed in the common scales that are used to
measure anhedonia in both disorders, such as the
Chapman Anhedonia Scale (Chapman et al., 1976) and
the Scale of Negative symptoms (Andreasen, 1982;
Andreasen and Olsen, 1982). A more granular definition
of anhedonia for both depression and schizophrenia has
been proposed (Treadway and Zald, 2011; Strauss and
Gold, 2012), which would distinguish between motiva-
tional and consummatory anhedonia, and may lead to a
DOI: 10.1097/FBP.0000000000000070
568 Behavioural Pharmacology 2014, Vol 25 No 5&6
better prediction of patients who may respond to
dopamine-based treatments (Treadway and Zald, 2011).
In a study that enrolled both schizophrenia patients and
depressed patients, anhedonia was a common symptom
in both disorders (45 and 37%, respectively) (Pelizza and
Ferrari, 2009), which suggests that in both disorders,
there are subgroups of patients with anhedonic features
that may particularly benefit from adjunctive or primary
treatment with dopaminergic-modulating molecules.
Multiple receptor subtypes comprise the dopamine sys-
tem. The dopamine D2 receptor has long been associated
with modulating both mood and reward behaviors
(Gershon et al., 2007; Wise, 2008). In addition, multiple
lines of evidence have supported an important role for D3
receptors in regulating mood (Laszy et al., 2005; Gross
and Drescher, 2012; Gross et al., 2013; Leggio et al.,
2013). D3 receptors are expressed at high levels in the
limbic system, including the islands of Calleja, nucleus
accumbens, and the olfactory tubercle (Sokoloff et al.,
1990; Gurevich and Joyce, 1999). These brain regions are
considered to be important in modulating emotion,
motivation, and reward-related behaviors (Sokoloff et al.,
1990; Gurevich and Joyce, 1999), which may be specifi-
cally associated with anhedonia, a core depression
symptom (Leggio et al., 2013). Stress and depression is
associated with downregulation of the D3 receptor,
whereas chronic treatment with antidepressant drugs has
been shown to enhance D3 receptor expression
(Lammers et al., 2000; Leggio et al., 2013). Studies in D3
receptor knockout mice provide further evidence sup-
porting the role of the D3 receptor in depression.
Increased grooming behavior, a marker for stress and
depression in mice, was observed in D3 receptor-
deficient mice; D3 receptor knockout mice also showed
increased sensitivity to antidepressant drugs in the forced
swim test (Leggio et al., 2008).
Although all effective antipsychotics show considerable
blockade of D2 receptors, none of the currently available
antipsychotics are associated with high levels of D3
receptor occupancy in vivo (Graff-Guerrero et al., 2009;
Mizrahi et al., 2011; McCormick et al., 2013). Novel
compounds that show high affinity at both D3 and D2
receptors may provide benefits in the treatment of schi-
zophrenia and mood disorders.
Cariprazine is an orally active and potent dopamine D2
and D3 receptor partial agonist that preferentially binds
to D3 receptors (Kiss et al., 2010). Cariprazine is currently
in late-stage clinical development for the treatment of
schizophrenia (Citrome, 2013b) and bipolar mania
(Citrome, 2013a). In addition, cariprazine is in phase II
clinical development for the treatment of bipolar
depression and adjunctive treatment of MDD. The aim
of this study was to evaluate the effects of cariprazine on
anhedonia-like behavior in the rat CMS model.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Methods
Subjects
Male Wistar rats (∼120 g) (Charles River Laboratories,
Sulzfeld, Germany) were housed in the laboratory for
2 months before the start of the experiment. Except
during stress procedures, the animals were housed indi-
vidually, with food and water freely available, and were
maintained on a 12-h light/dark cycle in a room with
constant temperature (22 ± 2°C) and humidity (50 ± 5%).
All procedures used in this study conformed to the rules
and principles of the 86/609/EEC Directive, and were
approved by the Local Bioethical Committee at the
Institute of Pharmacology, Polish Academy of Sciences,
Krakow, Poland.
Chronic mild stress procedure
The CMS procedure was performed as described pre-
viously in detail (Papp, 2012). Before administration of
the CMS procedure, the rats were first trained to con-
sume a 1% sucrose solution. This training consisted of
nine 1-h baseline tests during which the sucrose solution
was presented in the home cage after 14 h of food and
water deprivation. Sucrose consumption was monitored
at weekly intervals throughout the experiments.
The animals were divided into one of three drug treat-
ment cohorts (Table 1); these groups were further divi-
ded into two matched groups (control and stressed
animals) on the basis of baseline sucrose consumption.
Control animals were housed in a separate room with no
contact with stressed animals. Control animals had free
access to food and water, except for the 14 h preceding
each sucrose test.
Stressed animals were subjected to the CMS procedure
for a total of 7 consecutive weeks (2 weeks without drug
treatment, followed by 5 weeks of drug treatment). The
weekly stress regimen consisted of two periods each of
food or water deprivation, 45° cage tilt, intermittent
illumination (lights on and off every 2 h), and soiled cage
(250 ml water in sawdust bedding), and one period of
paired housing, followed by two periods of low intensity
stroboscopic illumination (150 flashes/min) and three
periods of no stress. All stressors were 10–14 h in duration
and were applied individually and continuously day
and night.
Drug administration
Following the initial 2 weeks of the CMS procedure
(before drug administration), stressed animals were fur-
ther subdivided into matched subgroups (n = 8/group) on
the basis of sucrose consumption. Through the sub-
sequent 5 weeks of the CMS procedure, these groups
received once-daily intraperitoneal injections of study
drug. All treatments were administered at ∼ 10:00 h each
day and the weekly sucrose tests were carried out 24 h
after the last injection.

Table 1 Treatments administered in each animal treatment cohort
Cohort
Cohort 1a
Cohort 2b
Cohort 3a
a
Each drug treatment group had a corresponding nonstressed control group.
b
Sole nonstressed control group was injected with vehicle.
Drugs
The following drugs and compounds were used in this
study: 1% methylcellulose (Sigma-Aldrich, St Louis,
Missouri, USA), imipramine HCl (Sigma-Aldrich), car-
iprazine (Forest Research Institute, Jersey City, New
Jersey, USA), aripiprazole (Gedeon Richter Plc,
Budapest, Hungary), 2-hydroxypropyl-β-cyclodextrin
(HPβCD) (Gedeon Richter Plc), 0.1 N NaOH (POCh,
Gliwice, Poland), and 1 N methanesulfonic acid (POCh).
Imipramine was dissolved in 0.9% sterile saline.
Cariprazine was suspended in 1% methylcellulose and
homogenized. Aripiprazole was dissolved in 25%
HPβCD; pH was adjusted by adding appropriate
amounts of NaOH and methanesulfonic acid. All dosing
solutions were administered at a volume of 1 ml/kg and
prepared freshly for each administration.
Statistical analyses
The significance of the effect of stress on sucrose con-
sumption was evaluated by repeated-measures analysis of
variance (ANOVA) with stress/no stress as a between-
groups factor and successive sucrose tests (up to the
beginning of drug administration) as the repeated-
measures factor.
The significance of drug effects was determined using
repeated-measures ANOVA, with treatment as a
between-groups factor (i.e. nonstressed, stressed-vehicle,
and stressed-treated groups) and time as the repeated-
measures factor (i.e. weeks 3–7). In addition, where
possible, drug effects in nonstressed animals were ana-
lyzed statistically by repeated-measures ANOVA, with
drug treatment as a between-groups factor and successive
sucrose tests during the treatment period as the repeated-
measures factor (treatment by time). One animal in the
cariprazine 1.0 mg/kg control group died during week 4;
therefore, to complete the within-subjects analysis,
means were substituted for the individual data for weeks
4 and 5.
If the ANOVA yielded a significant treatment effect or
treatment-by-time interaction, post-hoc comparisons
(Duncan test) were performed. Specifically, post-hoc
analyses included evaluation of the effect of the CMS
procedure (baseline sucrose consumption vs. consump-
tion in weeks 1 and 2), reversal of the CMS-induced
decrease in sucrose consumption by drug treatment
(comparison of mean sucrose consumption for weeks 3–7
vs. 2 for each treatment), and restoration of sucrose
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cariprazine in the chronic mild stress model Papp et al. 569
Treatment
Vehicle (1% methylcellulose at 1 ml/kg), aripiprazole (1 or 5 mg/kg), or imipramine (10 mg/kg)
Vehicle (1% methylcellulose at 1 ml/kg) or cariprazine (0.01, 0.03, or 0.065 mg/kg)
Vehicle (1% methylcellulose at 1 ml/kg), cariprazine (0.065, 0.25, or 1.0 mg/kg), or imipramine 10 mg/kg
consumption to control values (stressed-treated group by
applicable week vs. control animals).
The magnitude of drug effects on sucrose consumption
over the 5-week treatment period was calculated
according to the following algorithm: (a) area under curve
(AUC) values were calculated for all treatment groups
between weeks 2 and 7 using the trapezoidal rule; (b) the
overall effect of CMS was expressed as the area between
curves of the nonstressed and the stressed groups (cal-
culated by subtracting the AUC of the stressed group
from AUC of the nonstressed group); (c) the effect of the
test compound was expressed as the area between curves
of stressed group and the stressed + treatment group
(calculated by subtracting the AUC of the former from
AUC of the latter); and (d) these values were then used to
calculate the percentage drug effect using the following
equation:
Percentage drug effect
ðAUCstressedþtreatment AUCstressed Þ ð1Þ
¼ 100:
ðAUCnonstressed AUCstressed Þ
If the ANOVA yielded a significant treatment effect,
post-hoc comparisons (Duncan test) were performed
between the main effects (i.e. averaged for all levels of
the ‘time’ factor) of the various treatments; the sig-
nificance values obtained between the vehicle and trea-
ted stressed groups were used to characterize the
statistical significance of the calculated percent of effect
of the dose/treatment administered. Where appropriate,
dose by percentage drug effect was plotted and the 50%
effective dose (ED50) values were determined by linear
regression. The cariprazine 0.065 mg/kg group value for
this analysis was calculated by pooling data from Cohorts
2 and 3.
Results
Sucrose consumption
In all three cohorts, CMS produced a state of anhedonia-
like behavior, as indicated by reduced sucrose intake, by
the end of the initial treatment-free 2 weeks of the pro-
cedure (Figs 1–3). ANOVA analyses yielded a significant
interaction between stress and sucrose consumption in all
three experiments [Cohort 1: F(2,124) = 28.83, P < 0.001;
Cohort 2: F(2,76) = 14.14, P < 0.001; Cohort 3:
F(2,156) = 52.58, P < 0.001]. In Cohorts 1 and 3, non-
stressed animals were also treated with the same doses of
test drug that were used in stressed animals; no treatment
570 Behavioural Pharmacology 2014, Vol 25 No 5&6

Fig. 1 Fig. 3

18 18 Control CAR 1.0

Mean sucrose consumption (g)

Mean sucrose consumption (g)

Control IMI CAR 0.065 IMI

16 ARI 1.0 Vehicle 16 CAR 0.25 Vehicle
ARI 5.0
14 14
12 12
∗ ∗
10 ∗ ∗ 10
∗ ∗ ∗
8 8
6 6
4 Treatment 4
2 Stress 2 Treatment
Stress
0 0
Baseline 1 2 3 4 5 6 7 Baseline 1 2 3 4 5 6 7
Weeks Weeks

Sucrose consumption in Cohort 1 from baseline to week 7 with Sucrose consumption in Cohort 3 from baseline to week 7 with high-
aripiprazole and imipramine treatment. All values are mean + SEM. dose cariprazine or imipramine treatment. All values are mean + SEM.
Control values are nonstressed, vehicle-treated animals. *P < 0.05, Control values are nonstressed, vehicle-treated animals. *P < 0.05,
† †
P < 0.01, §P < 0.001 versus week 2; all noncontrol week 1 and week 2 P < 0.01, §P < 0.001 versus week 2; all noncontrol week 1 and week 2
values were significantly reduced versus the prestress baseline (not values were significantly reduced versus the prestress baseline (not
indicated on graph). ARI, aripiprazole; IMI, imipramine. indicated on graph). CAR, cariprazine; IMI, imipramine.

Fig. 2 sucrose intake observed at week 2 (Fig. 1). Imipramine

18
reversed the stress-induced decrease in sucrose intake by
Mean sucrose consumption (g)

week 6. Aripiprazole 1 and 5 mg/kg significantly reversed

16
sucrose intake by weeks 4 and 3, respectively. All active
14
treatment groups restored sucrose intake to nonstressed
12
∗ control levels by week 7 (the differences between treat-
10
ment and nonstressed control groups were nonsignificant,
8
P > 0.05).
6 Control CAR 0.065
CAR 0.01 Vehicle
4 CAR 0.03
Cohort 2 (low-dose cariprazine)
2 Treatment
In Cohort 2, ANOVA analyses for low-dose cariprazine
Stress
0 showed significant effects of treatment [F(4,35) = 16.63;
Baseline 1 2 3 4 5 6 7
P < 0.001] and time effect [F(5,175) = 8.09; P < 0.001], and
Weeks
a significant treatment by time interaction
Sucrose consumption in Cohort 2 from baseline to week 7 with low- [F(20,175) = 2.18; P < 0.01].
dose cariprazine treatment. All values are mean + SEM. Control values
are nonstressed, vehicle-treated animals. *P < 0.05, †P < 0.01, Cariprazine doses as low as 0.03 mg/kg attenuated CMS-
§
P < 0.001 versus week 2; all noncontrol week 1 and week 2 values induced decreases in sucrose consumption (Fig. 2).
were significantly reduced versus the prestress baseline (not indicated Cariprazine 0.03 mg/kg reversed the effect of stress on
on graph). CAR, cariprazine.
sucrose consumption by week 6 and restored sucrose
consumption to nonstressed control levels (no significant
difference between groups, P > 0.05). Treatment with
showed any effect on sucrose consumption in non- cariprazine 0.065 mg/kg resulted in a significant differ-
stressed controls (nonsignificant treatment effect and ence during the first week of treatment (week 3) relative
treatment-by-time interactions, data not shown). to pretreatment week 2; statistical significance was
maintained for the rest of the treatment period (weeks
4–7). Cariprazine 0.01 mg/kg did not significantly alter
Cohort 1 (aripiprazole and imipramine)
sucrose consumption relative to pretreatment week 2. At
Repeated-measures ANOVA for aripiprazole and imi-
week 7, restoration of sucrose intake to nonstressed
pramine showed significant effects of treatment
control levels was observed with cariprazine 0.03 and
[F(4,35) = 13.33, P < 0.001] and time [F(5,175) = 13.63,
0.065 mg/kg (no significant difference between groups,
P < 0.001], and a significant treatment by time interaction
P > 0.05).
[F(20,175) = 3.05, P < 0.001].
Post-hoc analyses showed that both aripiprazole and Cohort 3 (high-dose cariprazine)
imipramine were effective in restoring sucrose con- In the repeated-measures ANOVA, high-dose cariprazine
sumption following the CMS-induced reduction in yielded significant effects of treatment [F(5,42) = 7.75,

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

P < 0.001] and time effect [F(5,210) = 8.96, P < 0.001],
and a significant treatment-by-time interaction
[F(25,210) = 2.22, P < 0.01].
Both cariprazine and imipramine were effective in
restoring sucrose consumption following CMS-induced
decreases in sucrose intake observed at pretreatment
week 2 (Fig. 3). Imipramine treatment significantly
attenuated reduced sucrose intake by week 5 in stressed
animals, and restoration of sucrose intake to control levels
was observed at weeks 6 and 7. Significant reversal of
reduced sucrose intake to levels above pretreatment
week 2 was observed by week 3 (P < 0.05) with car-
iprazine 0.065 mg/kg and was maintained for the rest of
the treatment period. Restoration of sucrose intake to
levels that were comparable with nonstressed controls
was obtained by week 3 and continued through week 7
(no significant difference between groups, P > 0.5).
Cariprazine 0.25 mg/kg significantly reversed stress-
induced deficits in sucrose consumption by week 5;
however, this dosage did not completely restore sucrose
intake to the levels observed in nonstressed control ani-
mals. Cariprazine 1 mg/kg did not significantly increase
sucrose intake in stressed animals relative to pretreat-
ment (week 2).
Magnitude of drug effect and 50% effective dose values
Imipramine 10 mg/kg showed a significant drug effect in
animals exposed to CMS in Cohort 3 (49%, P < 0.01), but
not in Cohort 1 (19%). Significant, dose-proportional
differences were observed in drug effect (percent
restoration of sucrose consumption) with both aripipra-
zole doses (1 mg/kg: 28%, P < 0.05; 5 mg/kg: 52%,
P < 0.001) compared with vehicle in CMS-exposed ani-
mals (Table 2). Significant drug effects were also
observed with cariprazine 0.03 mg/kg (33%, P < 0.05),
0.065 mg/kg (43%, P < 0.01 in Cohort 2 and 69%,
P < 0.001 in Cohort 3), and 0.25 mg/kg (47%, P < 0.05) in
animals exposed to CMS. Cariprazine 0.01 and 1 mg/kg
did not show a significant treatment effect (–21 and 17%,
respectively).
Table 2 Percentage drug effect versus vehicle in stressed animals
Treatment
Cohort 1 Aripiprazole 1 mg/kg
Aripiprazole 5 mg/kg
Imipramine 10 mg/kg
Cohort 2 Cariprazine 0.01 mg/kg
Cariprazine 0.03 mg/kg
Cariprazine 0.065 mg/kg
Cohort 3 Cariprazine 0.065 mg/kg
Cariprazine 0.25 mg/kg
Cariprazine 1 mg/kg
Imipramine 10 mg/kg
*P < 0.05.
†
P < 0.01.
§
P < 0.001 versus vehicle on the basis of the Duncan test.
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Cariprazine in the chronic mild stress model Papp et al. 571
As the dose–response curve of cariprazine followed an
inverted U shape and aripiprazole was only tested at two
doses, ED50 values could not be determined properly.
Nevertheless, for a numerical comparison of the poten-
cies of the two compounds, ED50 values were calculated
for the ascending portion of the dose–response curve of
cariprazine (0.01–0.065 mg/kg) and for the two doses of
aripiprazole (Fig. 4). In this series of experiments, the
cariprazine ED50 value was 0.052 mg/kg, almost 100
times lower than that of aripiprazole (4.4 mg/kg).
Discussion
MDD is a serious and often chronic illness that is con-
sidered a leading cause of disability worldwide (Murray
and Lopez, 1997). Anhedonia, a core symptom of MDD,
has a prevalence rate of 37% in depressed patients
(Pelizza and Ferrari, 2009) and is one of the most
challenging-to-treat symptoms associated with depres-
sion (Spijker et al., 2001). CMS is considered one of the
best-validated animal models available currently to test
novel drug treatments for anhedonic-like symptoms
(Papp, 2012).
In this series of three experiments, anhedonia was mea-
sured by a decrease in sucrose consumption from pre-
stress baseline. CMS-induced anhedonia-like behavior
(decreased sucrose consumption) was observed con-
sistently within 2 weeks of CMS initiation; the decrease
in sucrose consumption at week 2 was significant in all
CMS groups tested across all experiments. Control
unstressed animals did not show a significant change in
sucrose consumption following treatment administration,
suggesting that drug treatment alone did not affect
sucrose intake in nonstressed animals. This validated the
Fig. 4
100
90 Cariprazine ED50 = 0.052 mg/kg
80 Aripiprazole ED50 = 4.4 mg/kg
70
% Inhibition
60
50
40
30
20
10
Effect (%)
0
28*
52§ 0.01 0.1 1 10
19 Dose (mg/kg orally)
–21
33*
43†
Dose versus percent inhibition of chronic mild stress-induced
decreased sucrose consumption for aripiprazole 1.0 mg/kg and
69§
47*
cariprazine 0.065 mg/kg. Percent inhibition was calculated on the basis
17
of area between curve values as described in the Statistical analyses
49†
section. The effect of the 0.065 mg/kg cariprazine dose was calculated
from pooled Cohorts 2 and 3 data. ED50 values were determined by
linear regression and in the case of cariprazine fitted to the ascending
portion of the dose–response curve. ED50, 50% effective dose.
572 Behavioural Pharmacology 2014, Vol 25 No 5&6
CMS model and suggested that there were no non-
specific drug effects for imipramine, aripiprazole, or car-
iprazine that might influence sucrose intake and
confound experimental results.
In these experiments, CMS-induced anhedonia was
reversed by imipramine, which served as the positive
control in Cohorts 1 and 3. These results were similar to
other previously published studies (Muñoz and Papp,
1999; Papp, 2012). Anhedonia was also reversed
by all except the highest (1.0 mg/kg) and the lowest
(0.01 mg/kg) cariprazine doses tested. In the lowest dose
group, the systemic cariprazine exposure may be too low
to engage D2 and D3 receptors to a sufficient level to
observe antidepressant-like effects. Conversely, in the
highest cariprazine group (1.0 mg/kg), it is possible that at
this very high dose, sedative effects might be con-
founding the antidepressant-like effects observed with
the 0.03–0.25 mg/kg doses.
The onset of treatment effect in reversing CMS-induced
anhedonia for cariprazine 0.065 mg/kg was observed
2 weeks before a significant improvement in sucrose
consumption was observed with imipramine 10 mg/kg.
However, only one dose of imipramine was tested (a dose
shown to be effective in previous studies) (Papp et al.,
1996; Papp, 2012) and was included as a positive control,
which limits comparisons between the two drugs.
Although both cariprazine 0.065 mg/kg and aripiprazole
5.0 mg/kg could significantly reverse anhedonia by week
3, the ED50 data of cariprazine suggested that it was
almost 100 times more potent than aripiprazole in this
model. However, the two compounds were not tested in
the same cohort and the ED50 values should be con-
sidered as rough estimates. Therefore, these data should
be interpreted with caution.
Interestingly, the nearly 100-fold higher potency differ-
ential between cariprazine and aripiprazole in this CMS
model was much greater than that observed in rodent
models predictive of antipsychotic activity, where car-
iprazine showed only 20–30-fold greater potency than
aripiprazole (Gyertyán et al., 2011). This may suggest that
significant antidepressant effects of cariprazine may occur
within its antipsychotic dosing range whereas aripiprazole
may require much higher dosing for significant anti-
depressant activity relative to antipsychotic activity.
Atypical antipsychotics (e.g. risperidone and olanzapine)
have previously shown antidepressant-like effects in the
CMS-induced anhedonia model (Marston et al., 2011)
and some antipsychotics (aripiprazole, quetiapine, and
olanzapine) have shown clinical efficacy as adjunctive
treatment in MDD (Han et al., 2013). The mechanism of
action for the antidepressive effects of the atypical anti-
psychotics, such as olanzapine and quetiapine, has been
postulated to be a combination of D2 and 5HT2A receptor
antagonism (Yatham et al., 2005). In addition, a metabo-
lite of quetiapine, norquetiapine, has been shown to be a
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
norepinephrine reuptake inhibitor, which may also con-
tribute toward its antidepressant activity. Aripiprazole
acts as a D2 receptor partial agonist similar to cariprazine,
but unlike cariprazine, shows lower in-vitro affinity for D3
relative to D2 receptors (Kiss et al., 2010) and low occu-
pancy of D3 receptors in rats (Adham et al., 2013); the
antidepressive effects of aripiprazole are postulated to
arise from blockade of the D2 and 5-HT1A receptors
(DeLeon et al., 2004).
Cariprazine is unique among atypical antipsychotics by
having the highest in-vitro affinity and selectivity for D3
versus D2 receptors along with high and balanced occu-
pancy of D2 and D3 receptors in vivo. Notably, a sig-
nificant occupancy of the D3 receptor may contribute
toward the mechanistic basis for the efficacy of car-
iprazine in a broad range of animal models, including
those of psychosis, mood, anxiety, and cognition
(Gyertyán et al., 2011; Adham et al., 2013; Zimnisky et al.,
2013). In support of this hypothesis, in studies in a mouse
model of PCP-induced cognitive impairment, cariprazine
showed procognitive effects in wild-type mice, but not
D3 receptor knockout mice (Zimnisky et al., 2013). The
pattern of D3 receptor expression in the brain, upregu-
lation of D3 receptors by antidepressants, and studies in
D3 receptor knockout mice implicate the D3 receptor in
modulating mood and cognition. These converging lines
of evidence suggest that the D3 receptor is a promising
target for the treatment of mood and psychotic disorders
(Richtand et al., 2001a, 2001b; Sokoloff et al., 2006;
Gyertyán et al., 2008; Kiss et al., 2008; Gross and
Drescher, 2012; Gross et al., 2013; Leggio et al., 2013).
The results of this study support the role of the D3
receptor in mood regulation. The greater potency dif-
ferential between cariprazine and aripiprazole in the
CMS model (cariprazine is ∼ 100 times more potent)
relative to antipsychotic models (cariprazine is 20–30
times more potent) aligns with potency differences
observed for D2 receptor (30-fold greater potency) and
D3 receptor (>70-fold greater potency) occupancy (Kiss
et al., 2012). This suggests that the high affinity of car-
iprazine at D3 receptors may underlie the greater potency
relative to aripiprazole in this model. Preliminary results
in D3 receptor knockout mice in the chronic unpredict-
able stress paradigm show that the antidepressant activity
of cariprazine may be at least partly meditated by the D3
receptor (Duman et al., 2012), further supporting this
hypothesis.
Conclusion
In summary, the data presented here suggest that at
doses that have previously shown antipsychotic-like
efficacy (Gyertyán et al., 2011), cariprazine may also
have antidepressant-like activity. The antidepressant-
like effects of cariprazine may be advantageous in the
treatment of depression and the negative symptoms
associated with schizophrenia. Additional research into

the pharmacological mechanisms of the antidepressant-
like activity of cariprazine is warranted.
Acknowledgements
This study was funded by Forest Research Institute,
Gedeon Richter Plc., and Forest Laboratories Inc. (New
York, New York). Writing assistance and editorial support
during manuscript preparation and revision were pro-
vided by Adam Ruth, PhD, Neva West, PhD, and
Apurva Davé, PhD, of Prescott Medical Communications
Group (Chicago, IL, USA).
Conflicts of interest
Nika Adham acknowledges a potential conflict of interest
as an employee of Forest Research Institute. Béla Kiss
and István Gyertyán acknowledge a potential conflict of
interest as employees of Gedeon Richter Plc. For the
remaining authors there are no conflicts of interest.
References
Adham N, Gyertyán I, Kiss B (2013). At antipsychotic-like effective doses,
cariprazine displays potent dopamine D3 and D2 receptor occupancy in vivo
and efficacy across animal models. 166th Annual Meeting of the American
Psychiatric Association. San Francisco, CA: American Psychiatric
Association.
Andreasen NC (1982). Negative symptoms in schizophrenia. Definition and
reliability. Arch Gen Psychiatry 39:784–788.
Andreasen NC, Olsen S (1982). Negative v positive schizophrenia. Definition and
validation. Arch Gen Psychiatry 39:789–794.
Carpenter WT Jr, Heinrichs DW, Wagman AM (1988). Deficit and nondeficit
forms of schizophrenia: the concept. Am J Psychiatry 145:578–583.
Chapman LJ, Chapman JP, Raulin ML (1976). Scales for physical and social
anhedonia. J Abnorm Psychol 85:374–382.
Citrome L (2013a). Cariprazine in bipolar disorder: clinical efficacy, tolerability, and
place in therapy. Adv Ther 30:102–113.
Citrome L (2013b). Cariprazine in schizophrenia: clinical efficacy, tolerability, and
place in therapy. Adv Ther 30:114–126.
DeLeon A, Patel NC, Crismon ML (2004). Aripiprazole: a comprehensive review
of its pharmacology, clinical efficacy, and tolerability. Clin Ther 26:649–666.
Der-Avakian A, Markou A (2012). The neurobiology of anhedonia and other
reward-related deficits. Trends Neurosci 35:68–77.
Duman RS, Duric V, Banasr M, Adham N, Kiss B, Gyertyán I (2012). Cariprazine
exhibits dopamine D3 receptor-dependent antidepressant-like activity in the
chronic unpredictable stress model of anhedonia. Neuropsychopharmacology
38 (S1):S84.
Dunlop BW, Nemeroff CB (2007). The role of dopamine in the pathophysiology of
depression. Arch Gen Psychiatry 64:327–337.
Gelenberg AJ, Freeman MP, Markowitz JC, Rosenbaum JF, Thase ME, Trivedi MH,
et al. (2010). Practice guideline for the treatment of patients with major
depressive disorder. 3rd ed. Washington, DC: American Psychiatric
Association.
Gershon AA, Vishne T, Grunhaus L (2007). Dopamine D2-like receptors and the
antidepressant response. Biol Psychiatry 61:145–153.
Graff-Guerrero A, Mamo D, Shammi CM, Mizrahi R, Marcon H, Barsoum P, et al.
(2009). The effect of antipsychotics on the high-affinity state of D2 and D3
receptors: a positron emission tomography study With [11C]-(+)-PHNO. Arch
Gen Psychiatry 66:606–615.
Gross G, Drescher K (2012). The role of dopamine D(3) receptors in anti-
psychotic activity and cognitive functions. Handb Exp Pharmacol
213:167–210.
Gross G, Wicke K, Drescher KU (2013). Dopamine D3 receptor antagonism – still
a therapeutic option for the treatment of schizophrenia. Naunyn
Schmiedebergs Arch Pharmacol 386:155–166.
Gurevich EV, Joyce JN (1999). Distribution of dopamine D3 receptor expressing
neurons in the human forebrain: comparison with D2 receptor expressing
neurons. Neuropsychopharmacology 20:60–80.
Gyertyán I, Sághy K, Laszy J, Elekes O, Kedves R, Gémesi LI, et al. (2008).
Subnanomolar dopamine D3 receptor antagonism coupled to moderate D2
affinity results in favourable antipsychotic-like activity in rodent models: II.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cariprazine in the chronic mild stress model Papp et al. 573
behavioural characterisation of RG-15. Naunyn Schmiedebergs Arch
Pharmacol 378:529–539.
Gyertyán I, Kiss B, Sághy K, Laszy J, Szabó G, Szabados T, et al. (2011).
Cariprazine (RGH-188), a potent D3/D2 dopamine receptor partial agonist,
binds to dopamine D3 receptors in vivo and shows antipsychotic-like and
procognitive effects in rodents. Neurochem Int 59:925–935.
Han C, Wang SM, Kato M, Lee SJ, Patkar AA, Masand PS, Pae CU (2013).
Second-generation antipsychotics in the treatment of major depressive dis-
order: current evidence. Expert Rev Neurother 13:851–870.
Herbener ES, Harrow M (2002). The course of anhedonia during 10 years of
schizophrenic illness. J Abnorm Psychol 111:237–248.
Kay SR, Fiszbein A, Opler LA (1987). The positive and negative syndrome scale
(PANSS) for schizophrenia. Schizophr Bull 13:261–276.
Kirkpatrick B, Buchanan RW, McKenney PD, Alphs LD, Carpenter WT Jr (1989).
The Schedule for the Deficit syndrome: an instrument for research in schi-
zophrenia. Psychiatry Res 30:119–123.
Kiss B, Laszlovszky I, Horváth A, Némethy Z, Schmidt E, Bugovics G, et al. (2008).
Subnanomolar dopamine D3 receptor antagonism coupled to moderate D2
affinity results in favourable antipsychotic-like activity in rodent models: I.
neurochemical characterisation of RG-15. Naunyn Schmiedebergs Arch
Pharmacol 378:515–528.
Kiss B, Horváth A, Némethy Z, Schmidt E, Laszlovszky I, Bugovics G, et al. (2010).
Cariprazine (RGH-188), a dopamine D(3) receptor-preferring, D(3)/D(2)
dopamine receptor antagonist-partial agonist antipsychotic candidate: in vitro
and neurochemical profile. J Pharmacol Exp Ther 333:328–340.
Kiss B, Horti F, Bobok A (2012). Cariprazine, a D3/D2 dopamine receptor partial
agonist antipsychotic, displays greater D3 receptor occupancy in vivo com-
pared with other antipsychotics. Schizophr Res 136 (Suppl 1):S190.
Krishnan V, Nestler EJ (2011). Animal models of depression: molecular per-
spectives. Curr Top Behav Neurosci 7:121–147.
Lammers CH, Diaz J, Schwartz JC, Sokoloff P (2000). Selective increase of
dopamine D3 receptor gene expression as a common effect of chronic
antidepressant treatments. Mol Psychiatry 5:378–388.
Laszy J, Laszlovszky I, Gyertyán I (2005). Dopamine D3 receptor antagonists
improve the learning performance in memory-impaired rats.
Psychopharmacology (Berl) 179:567–575.
Leggio GM, Micale V, Drago F (2008). Increased sensitivity to antidepressants of
D3 dopamine receptor-deficient mice in the forced swim test (FST). Eur
Neuropsychopharmacol 18:271–277.
Leggio GM, Salomone S, Bucolo C, Platania C, Micale V, Caraci F, Drago F (2013).
Dopamine D(3) receptor as a new pharmacological target for the treatment of
depression. Eur J Pharmacol 719:25–33.
Marston HM, Martin FD, Papp M, Gold L, Wong EH, Shahid M (2011).
Attenuation of chronic mild stress-induced ‘anhedonia’ by asenapine is not
associated with a ‘hedonic’ profile in intracranial self-stimulation.
J Psychopharmacol 25:1388–1398.
McCormick PN, Wilson VS, Wilson AA, Remington GJ (2013). Acutely adminis-
tered antipsychotic drugs are highly selective for dopamine D2 over D3
receptors. Pharmacol Res 70:66–71.
Millan MJ, Dekeyne A, Papp M, La Rochelle CD, MacSweeny C, Peglion JL,
Brocco M (2001). S33005, a novel ligand at both serotonin and nor-
epinephrine transporters: II. Behavioral profile in comparison with venlafaxine,
reboxetine, citalopram, and clomipramine. J Pharmacol Exp Ther
298:581–591.
Mizrahi R, Agid O, Borlido C, Suridjan I, Rusjan P, Houle S, et al. (2011). Effects of
antipsychotics on D3 receptors: a clinical PET study in first episode anti-
psychotic naive patients with schizophrenia using [11C]-(+)-PHNO.
Schizophr Res 131:63–68.
Monleon S, D’Aquila P, Parra A, Simon VM, Brain PF, Willner P (1995).
Attenuation of sucrose consumption in mice by chronic mild stress and its
restoration by imipramine. Psychopharmacology (Berl) 117:453–457.
Montgomery SA, Loft H, Sánchez C, Reines EH, Papp M (2001). Escitalopram
(S-enantiomer of citalopram): clinical efficacy and onset of action predicted
from a rat model. Pharmacol Toxicol 88:282–286.
Muñoz C, Papp M (1999). Alnespirone (S 20499), an agonist of 5-HT1A
receptors, and imipramine have similar activity in a chronic mild stress model
of depression. Pharmacol Biochem Behav 63:647–653.
Murray CJ, Lopez AD (1997). Global mortality, disability, and the contribution of
risk factors: Global Burden of Disease Study. Lancet 349:1436–1442.
Orsetti M, Canonico PL, Dellarole A, Colella L, Di Brisco F, Ghi P (2007).
Quetiapine prevents anhedonia induced by acute or chronic stress.
Neuropsychopharmacology 32:1783–1790.
Papp M (2012). Models of affective illness: chronic mild stress in the rat. Curr
Protoc Pharmacol Chapter 5:Unit 5.9.
Papp M, Moryl E, Willner P (1996). Pharmacological validation of the chronic mild
stress model of depression. Eur J Pharmacol 296:129–136.
574 Behavioural Pharmacology 2014, Vol 25 No 5&6
Pelizza L, Ferrari A (2009). Anhedonia in schizophrenia and major depression:
state or trait? Ann Gen Psychiatry 8:22.
Richtand NM, Goldsmith RJ, Nolan JE, Berger SP (2001a). The D3 dopamine
receptor and substance dependence. J Addict Dis 20:19–32.
Richtand NM, Woods SC, Berger SP, Strakowski SM (2001b). D3 dopamine
receptor, behavioral sensitization, and psychosis. Neurosci Biobehav Rev
25:427–443.
Shelton RC, Tomarken AJ (2001). Can recovery from depression be achieved?
Psychiatr Serv 52:1469–1478.
Sokoloff P, Giros B, Martres MP, Bouthenet ML, Schwartz JC (1990). Molecular
cloning and characterization of a novel dopamine receptor (D3) as a target for
neuroleptics. Nature 347:146–151.
Sokoloff P, Diaz J, Le Foll B, Guillin O, Leriche L, Bezard E, Gross C (2006). The
dopamine D3 receptor: a therapeutic target for the treatment of neu-
ropsychiatric disorders. CNS Neurol Disord Drug Targets 5:25–43.
Spijker J, Bijl RV, de Graaf R, Nolen WA (2001). Determinants of poor 1-year
outcome of DSM-III-R major depression in the general population: results of
the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Acta
Psychiatr Scand 103:122–130.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Strauss GP, Gold JM (2012). A new perspective on anhedonia in schizophrenia.
Am J Psychiatry 169:364–373.
Treadway MT, Zald DH (2011). Reconsidering anhedonia in depression: lessons
from translational neuroscience. Neurosci Biobehav Rev 35:537–555.
Willner P (2005). Chronic mild stress (CMS) revisited: consistency and
behavioural-neurobiological concordance in the effects of CMS.
Neuropsychobiology 52:90–110.
Willner P, Towell A, Sampson D, Sophokleous S, Muscat R (1987). Reduction of
sucrose preference by chronic unpredictable mild stress, and its restoration
by a tricyclic antidepressant. Psychopharmacology (Berl) 93:358–364.
Wise RA (2008). Dopamine and reward: the anhedonia hypothesis 30 years on.
Neurotox Res 14:169–183.
Yatham LN, Goldstein JM, Vieta E, Bowden CL, Grunze H, Post RM, et al. (2005).
Atypical antipsychotics in bipolar depression: potential mechanisms of action.
J Clin Psychiatry 66 (Suppl 5):40–48.
Zimnisky R, Chang G, Gyertyán I, Kiss B, Adham N, Schmauss C (2013).
Cariprazine, a dopamine D(3)-receptor-preferring partial agonist, blocks
phencyclidine-induced impairments of working memory, attention set-shifting,
and recognition memory in the mouse. Psychopharmacology (Berl)
226:91–100.