REVIEW

published: 15 May 2020

doi: 10.3389/fpsyt.2020.00443

Pharmacological Treatment of
Anxiety Disorders: The Role of
the HPA Axis
Gustavo E. Tafet 1 and Charles B. Nemeroff 2*
1 Department of Psychiatry and Neurosciences, Maimónides University, Buenos Aires, Argentina, 2 Department of Psychiatry,

University of Texas at Austin, Austin, TX, United States

Stress in general, and early life stress in particular, has been associated with the
development of anxiety and mood disorders. The molecular, biological and
psychological links between stress exposure and the pathogenesis of anxiety and
mood disorders have been extensively studied, resulting in the search of novel
psychopharmacological strategies aimed at targets of the hypothalamic-pituitary-
adrenal (HPA) axis. Hyperactivity of the HPA axis has been observed in certain
subgroups of patients with anxiety and mood disorders. In addition, the effects of
different anti-anxiety agents on various components of the HPA axis has been
Edited by: investigated, including benzodiazepines, tricyclic antidepressants (TCAs), and selective
Amir Garakani, serotonin reuptake inhibitors (SSRIs). For example, benzodiazepines, including
Yale Medicine, United States
clonazepam and alprazolam, have been demonstrated to reduce the activity of
Reviewed by:
Marian L. Logrip,
corticotrophin releasing factor (CRF) neurons in the hypothalamus. TCAs and SSRIs are
Indiana University, also effective anti-anxiety agents and these may act, in part, by modulating the HPA axis.
Purdue University Indianapolis,
In this regard, the SSRI escitalopram inhibits CRF release in the central nucleus of the
United States
Kabirullah Lutfy, amygdala, while increasing glucocorticoid receptor (GRs) density in the hippocampus and
Western University of Health Sciences, hypothalamus. The molecular effects of these anti-anxiety agents in the regulation of the
United States
HPA axis, taken together with their clinical efficacy, may provide further understanding
*Correspondence:
Charles B. Nemeroff
about the role of the HPA axis in the pathophysiology of mood and anxiety disorders,
[email protected] paving the way for the development of novel therapeutic strategies.
Keywords: pharmacology, anxiety, hypothalamic-pituitary-adrenal, corticotropin releasing hormone, stress
Specialty section:
This article was submitted to
Psychopharmacology,
a section of the journal
Frontiers in Psychiatry
INTRODUCTION
Received: 24 January 2020 Stress, and more specifically, early life stress, has been associated with the origin and development of
Accepted: 01 May 2020 depression and anxiety disorders (1–6). In this regard, it has been shown that chronic exposure to
Published: 15 May 2020
environmental stressors is followed by a set of adaptive responses, mediated by the activation of
Citation: different neural structures involved in emotional and cognitive processing in the central nervous
Tafet GE and Nemeroff CB (2020)
system (CNS), and the subsequent activation of the autonomic nervous system (ANS) and the
Pharmacological Treatment of Anxiety
Disorders: The Role of the HPA Axis.
hypothalamic-pituitary-adrenal axis (HPA) (7, 8). Environmental stressors are perceived and
Front. Psychiatry 11:443. transmitted through sensory pathways to different structures in the CNS, including the thalamus
doi: 10.3389/fpsyt.2020.00443 and limbic areas, such as the amygdala and the hippocampus, and cortical areas, mostly located

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Tafet and Nemeroff Pharmacological Treatment of Anxiety Disorders

in the prefrontal cortex (PFC). Direct projections from

the thalamus to the amygdala may provide primitive
representations of stimuli, which in turn are potentiated by
noradrenergic stimulation from the locus coeruleus (LC) to
initiate a primary stress response. Indirect projections may also
reach the amygdala from sensory and associative cortices, and
transitional cortices, associated to the hippocampus (9). Hence,
the hippocampus projects forward to the lateral nucleus of the
amygdala, as well as the hypothalamic paraventricular nucleus
(PVN), where it plays an inhibitory role (10, 11). The lateral
nucleus of the amygdala projects to the basal, accessory basal,
and central nuclei of the amygdala (CeA) (12). Therefore, the
CeA projects to the lateral nucleus of the hypothalamus, which
activates the sympathetic branch of the ANS (13), the dorsal
motor nucleus of the vagus, which activates the para-sympathetic
branch, and the PVN, therefore leading to the activation of the
HPA axis (13, 14). Hence, the HPA axis may be activated
through direct projections from the CeA, which project to the
PVN (7), where the corticotropin releasing hormone (CRH, also
termed corticotrophinreleasing factor, CRF) is synthesized and
released into the hypophyseal portal blood to reach the anterior FIGURE 1 | Graphic representation of the hypothalamic-pituitary-adrenal
pituitary. CRH stimulates the transcription of the pro-opio- (HPA) axis. The hypothalamic paraventricular nucleus (PVN) releases
melanocortin (POMC) gene, a common precursor for corticotropin releasing hormone (CRH) to the hypophyseal portal blood, to
reach the pituitary (P), where adrenocorticotropic hormone (ACTH) is
adrenocorticotropic hormone (ACTH) and related peptides.
synthesized and released to systemic blood to reach the adrenal cortex (AC),
ACTH is released into the bloodstream to reach the adrenal where in turn cortisol is synthesized and released to the main bloodstream.
cortex, where it stimulates the biosynthesis and release of The HPA is regulated by stimulatory projections from the amygdala and
glucocorticoids, mainly cortisol (illustrated in Figure 1). These inhibitory projections from the hippocampus. In addition, the PVN receives
steroid hormones exert their effects through binding to noradrenergic projections from the locus coeruleus (LC) and serotonergic
projections from the raphe nuclei (RN). Stimulatory and inhibitory feedback
mineralocorticoid receptors (MRs or type I) and glucocorticoid
loops are also represented, where cortisol is able to regulate its own
receptors (GRs or type II), constituting a hormone-receptor synthesis and release by inhibiting ACTH and CRH synthesis in the pituitary
complex, which in turn may interact with specific DNA and PVN respectively, and stimulating the hippocampus, which in turn may
sequences located in the promoter region of target genes, inhibit the PVN. Under repeated uncontrollable stress these feedback
termed glucocorticoid response element (GRE) (15), mechanisms result abolished, with the consequent hypercortisolism,
alongside with increased reactivity of the amygdala and decreased activity of
stimulating or inhibiting the expression of target genes. This
the hippocampus. Successful treatment is translated into recovery of these
has been described for the down-regulation of the POMC (16) feedback mechanisms, with the consequent normalization of cortisol,
and CRH genes (17), whereby cortisol is able to regulate its own decreased amygdala reactivity, increased hippocampal function, and
synthesis and release through the negative feedback mechanisms normalization of noradrenergic and serotonergic systems.
that regulate HPA axis activity. In addition, cortisol may also
down-regulate the HPA axis by binding to hippocampal GRs,
which in turn inhibit the PVN, as well as exerting tonic THE ROLE OF THE HPA AXIS
inhibition through binding to hippocampal MRs (18, 19).
During chronic stress these negative-feedback loops may be Hyperactivity of the HPA axis is associated with increased
abolished, resulting in persistent activation of the HPA axis synthesis and release of CRH from hypothalamic neurons in
(15). Therefore, physiological rhythms characterized by wide the PVN in response to stress. CRH-containing neurons have
diurnal variations, with morning zeniths and evening nadirs, are been also observed in other neural structures, such as the CeA
altered during chronic stress, which in turn may be translated (24, 25), which in turn activates the HPA axis through
into sustained increase in cortisol levels (1). In addition, chronic stimulatory projections to the PVN. In addition, reciprocal
stress may also lead to decreased expression of brain derived connections have been also observed between these CRH
neurotrophic factor (BDNF) in the hippocampus, which in turn neurons and aminergic nuclei, including the LC and the raphe
may reduce its capability to inhibit the HPA axis (20, 21).These nuclei (RN) (4), therefore providing additional pathways for
persistent alterations in the regulation of the HPA axis, such as reciprocal interaction between the noradrenergic and the
the observed during chronic stress, has been associated with serotonergic systems, respectively, with the HPA axis during
the origin and development of mood and anxiety disorders, the stress response (4, 26) (illustrated in Figure 1). Thus, CRH
where hyperactivity of the HPA axis, and the consequent neuronal circuits interact with the serotonergic and the
hypercortisolism, represents one of the most consistent noradrenergic systems, which are critically involved in mood
biological findings (6, 22, 23). and anxiety disorders (3). Moreover, CRH has been also

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Tafet and Nemeroff Pharmacological Treatment of Anxiety Disorders

associated with anxiety and encoding of emotional memories (3,

22) thus highlighting the critical role of the CRH system in the
stress response and its role as an important factor in the long-
lasting effects of stress, particularly regarding early life stressful
experiences. In this regard, it has been shown that the impact of
traumatic events during childhood represents a critical factor of
vulnerability in the origin and development of mood and anxiety
disorders later in life (4, 27, 28). The link between early adverse
experiences, such as abuse, neglect or loss, and the development
of mood and anxiety disorders has been shown to occur as a
consequence of stressful conditions during different periods of
life (29). Various studies focused on alterations in different
limbic structures and the HPA axis. In this regard, it has been
shown that exposure to early stressful events may lead to
decreased availability and reduced efficacy of hippocampal GRs
(27), which in turn may lead to glucocorticoid resistance and
increased reactivity of the HPA axis in response to stressful
situations later in life. Moreover, it has been shown that
increased concentrations of cortisol along with decreased GRs
induced by early stressful events were associated with decreased FIGURE 2 | Graphic representation of 5HT projections from the raphe nuclei
hippocampal function and volume in adulthood (30). Therefore, (RN). The dorsal RN (DRN) sends stimulatory projections to the central
nucleus of the amygdala (CeA) and the bed nucleus of the stria terminalis
the impact of early adverse events may lead to long lasting changes, (BNST), which participate in increased fear and anxiety, inhibitory projections
including hyper-reactivity of neural and neuroendocrine responses to the periaqueductal grey (PAG) and the striatum, which participate in
to stress, reflected in increased CRH, glucocorticoid resistance and passive behavior, inhibitory projections to the medial prefrontal cortex (MPFC),
reduced volume of the hippocampus (27, 31), all of which may and stimulatory projections to the nucleus accumbens (NAc), which
participate in the regulation of complex behaviors and expression of
contribute to shape potential responses to further stressful
emotions. Conversely, the MPFC sends inhibitory projections to the DRN and
experiences later in life. the amygdala, which may be translated into anti-anxiety effect. The medial RN
(MRN) sends stimulatory projections to the hippocampus, which have been
associated to increased tolerance to adverse stimuli and decreased anxiety.
Under repeated uncontrollable stress the amygdala is increasingly stimulated
THE ROLE OF THE SEROTONERGIC by the DRN, which results in increased anxiety, the PAG and striatum are
SYSTEM inhibited by the DRN, with the resulting passivity, and the serotonergic
activation from the MRN to the hippocampus results impaired. Increased
reactivity of the amygdala and decreased activation of the hippocampus may
It has been shown that deficient or altered serotonergic
lead to increased activation of the hypothalamic-pituitary-adrenal (HPA) axis.
neurotransmission in the CNS plays a critical role in the origin Successful treatment is translated into recovery of these feedback
and development of anxiety and depressive symptoms (26). The mechanisms, with the consequent normalization of cortisol, decreased
serotonergic system has its main sources in the RN, which amygdala reactivity, increased hippocampal function, and normalization of the
project to diverse neural structures (illustrated in Figure 2). serotonergic systems.
Serotonergic projections to the forebrain originate mainly in the
dorsal (DRN) and medial RN (MRN) (32). The DRN-forebrain aversive stimuli (43), such as those perceived during chronic
tract innervates various structures, many of them associated with stress, and adaptive control on negative emotional experiences
anxiety-related and adaptive responses to stress (33–35), (11). Thererfore, dysfunction of this system, particularly
including the CeA (36), the bed nucleus of the stria terminalis involving MRN-hippocampal projections, has been associated
(BNST) (37), the PVN, the nucleus accumbens (NAc), and with decreased tolerance to aversive stimuli, learned helplessness,
certain areas of the PFC, particularly the medial PFC (MPFC) and subsequent depression (34). Serotonergic neurons in the RN
(38). In addition, the DRN also innervates structures related to have also been shown to interact with the noradrenergic and
regulation of fight-or-flight behavioral responses, such as the dopaminergic systems (44).
periaqueductal grey (PAG) (39, 40) and the striatum, which have Serotonin (5-hydroxitryptamine, 5HT) released in the
been shown to be involved in passive coping behavior (41). Both synaptic cleft binds to one or more of several 5HT receptors,
neural structures, the PAG and the striatum, have also been classified as 5HT1A−F, 5HT2A−C; 5HT3, 5HT4, 5HT5, 5HT6, and
associated with the state of anticipatory anxiety that plays a 5HT7, most of them belonging to a family of G protein-coupled
critical adaptive role in situations of danger, contributing to receptors (GPCRs), with the exception of the 5HT3 receptor,
inform the amygdala about the current impact of negative which is a ligand-gated ion channel (45). The 5HT1A−F receptor
experiences and the consequent emotional reactions (11). The family and the 5HT5 receptor couple with Gi protein, which
MRN-forebrain tract projects to complementary neural inhibits adenylate cyclase (AC) activity, the 5HT4, 5HT6, and
structures, including the hippocampus and the hypothalamus 5HT7 receptors couple with Gs protein, which stimulates AC
(34, 42), and has been associated with tolerance to persistent activation, and the 5HT2A−C receptor family couple with Gq

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Tafet and Nemeroff Pharmacological Treatment of Anxiety Disorders

protein, which stimulates the activity of phospholipase C (PLC) broader spectrum of mechanisms of action underlying the
(46). In addition to the presence of different 5HT receptors, a therapeutic effects of these agents.
critical role in the control of serotonergic neurotransmission is It has been shown that TCAs and SSRIs, in addition to their
exerted by the serotonin transporter (5HTT), which acts to well-known pharmacological effects, including blockade of
reuptake the remaining 5HT into the presynaptic terminal, neurotransmitter uptake and subsequent regulation of different
therefore regulating the concentrations of the neurotransmitter pre- and post-synaptic receptors, may also induce significant
in the synaptic cleft. The 5HTT represents the main target of changes in the HPA axis, associated with their therapeutic effects
various antidepressants, including the tricyclics (TCs) and the (61–69). Some of these, at least in part, have been attributed to
selective serotonin reuptake inhibitors (SSRIs). Blockade of the the potential effect of anti-anxiety agents on transcriptional
5HTT by these drugs result in increased concentrations of 5HT regulation of different molecules involved in the regulation of
in the synaptic cleft, leading in turn to increased activation of the HPA axis (70–74), including GRs, MRs, and CRH. In this
5HT receptors (47). The efficacy of these antidepressants is regard, it has been proposed that altered GR gene regulation,
associated with adaptive changes produced by its continuous which may be translated into diminished concentrations of GRs
administration, including desensitization or down regulation of in different neural structures, more specifically hippocampal or
somatodendritic 5HT1A auto-receptors in the RN (48) and up- hypothalamic GRs, may contribute to deficient feedback of the
regulation of post-synaptic 5HT1A (49), and desensitization of HPA system (63), which in turn may lead to the consequent
5HT2A receptors (50), mostly in the MRN-hippocampal tract. It alterations observed in patients suffering with depression or
has been shown that post-synaptic 5HT1A receptors down- chronic anxiety disorders.
regulate or desensitize in different limbic structures by Increased GR mRNA expression has been initially observed in
glucocorticoids or exposure to chronic stress (51–53). Cortisol vitro, in cell cultures derived from hypothalamus or amygdala,
may inhibit 5HT neurotransmission tonically through binding to upon incubation in the presence of desipramine or amytriptiline
MRs, while increased levels of cortisol, such as during chronically (70, 71). Similar results were also observed in studies in which
stressful conditions, bind predominantly to GRs, therefore chronic treatment with TCAs, but not short-term treatment,
interacting with GREs and inhibiting the expression of the decreases CRH mRNA expression (61, 75, 76). Similar effects
5HT1A gene (51). In addition, it has been shown that cortisol were also observed in vivo with long-term administration of
may exert a stimulatory effect on 5HT uptake in vitro, which has imipramine. In this regard, it has been shown that long-term
been attributed to an increased expression of the 5HTT gene by treatment with this TCA inhibited transcriptional regulation of
cortisol (54), further supporting the notion of reciprocal regulation the CRH gene, with the consequent decrease of CRH mRNA
between the HPA and 5HT systems, and their potential expression in the hypothalamus (76), which in turn resulted in a
interactions in the interface between stress and depression. significant reduction in HPA axis activity (73, 76).
Regarding SSRIs, in vitro and in vivo studies demonstrated
that long-term treatment with fluoxetine increased GR mRNA
expression in hippocampal neurons (77, 78). More recently, in
EFFECTS OF TCAs AND SSRIs IN THE vivo studies demonstrated that long-term treatment with
REGULATION OF THE HPA AXIS fluoxetine may also induce functional recovery of hippocampal
GRs following chronic stress (79). Moreover, increased
A considerable number of patients suffering with chronic anxiety hippocampal GRs activation, including phosphorylation and
disorders exhibit hyperactivity of the HPA axis, with the subsequent nuclear translocation, was also observed after long-
consequent hypercortisolism. This has been described in term treatment with fluoxetine, even in the absence of altered
patients with panic disorder (55) or generalized anxiety glucocorticoid secretion (79). Although these observations
disorder (GAD) (56, 57), however, hypercortisolism in patients strongly suggest that this mechanism should be involved in the
with GAD has not been observed in other studies (58, 59). therapeutic effect of fluoxetine, more recent studies have also
Regarding posttraumatic stress disorder (PTSD), considerable suggested that additional changes in GRs are not necessary for
evidence has also revealed alterations of the HPA axis (28). the behavioral efficacy of the SSRI (80).
However, patients with PTSD exhibited decreased activity of the It is noteworthy that GRs are expressed in the amygdala,
HPA axis, which has been attributed to exaggerated negative particularly in the CeA (81), where glucocorticoids have been
feedback or hypersecretion of CRH with consequent down- shown to stimulate the expression of CRH in this nucleus (82), in
regulation of the anterior pituitary CRF receptors (60). contrast to the inhibitory effect observed in the hypothalamic
Successful pharmacological approaches often result in PVN (83). Cortisol up-regulation of CRH in the amygdala may
normalization of the HPA system. This led to further be translated into activation of the whole system, because CRH
investigation of the role of the HPA axis in the pathophysiology projections from the CeA may exert stimulatory effect on the
of these disorders. Because different anti-anxiety agents, including PVN, hence resulting in increased synthesis and release of CRH
tricyclic antidepressants (TCAs), selective serotonin reuptake in the hypothalamus, with the consequent hyperactivity of the
inhibitors (SSRIs), and benzodiazepines (BZDs), have been HPA axis. In this regard, overactivity of the amygdala represents
demonstrated in some studies to normalize the HPA axis, another critical finding, frequently associated with depression
various lines of research were developed focusing on the and chronic anxiety disorders (84), which has been

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Tafet and Nemeroff Pharmacological Treatment of Anxiety Disorders

demonstrated in functional imaging studies (85–87). The which in turn operates as a transcription factor, mediating the
amygdala has been shown to play a critical role in the effects of the cAMP cascade. In order to exert its regulatory effect,
physiopathology of anxiety and, as we mentioned previously, it CREB should be activated, which is attained by phosphorylation
is critically involved in the regulation of the HPA axis, more at a single serine residue (Ser133) (96, 97). Once phosphorylated,
specifically, through CRH projections from the CeA, which CREB is able to regulate transcriptional events by binding to an
stimulate the hypothalamic PVN (88). Because the amygdala enhancer element, located in the regulatory region of different
represents one of the main sources of extra-hypothalamic CRH, genes, termed cAMP response element (CRE). It has been shown
hyper-activation of this limbic structure may be reflected in that phosphorylation of CREB may occur via activation of the
increased concentration of CRH in cerebrospinal fluid (CSF), as AC-cAMP-PKA cascade and also via the calcium-dependent
observed in many patients with depression (89–91), and elevated protein kinase (PKC) cascade, which allows CREB to act as a
CRH transcript in animal models exposed to chronic stress common downstream target of different stimuli, including those
conditions. Moreover, it was proposed that CRH mediated by TCAs and SSRIs (67, 95, 98, 99). Molecular alteration
overexpression in the CeA would be a main factor in the of the AC-cAMP-PKA cascade has been described in patients
origin and development of depression (92). Therefore, a suffering of depression (100), and various studies demonstrated
regulatory effect induced by SSRIs, translated into reduced GR that chronic treatment with different antidepressants contributed
and CRH gene expression in the CeA, may contribute, at least in to repair this cascade at various molecular levels (101), therefore
part, to down regulation of the HPA axis, which is often observed supporting the critical role played by CREB in the regulation of its
with clinical improvement. In this regard, various studies were target genes in the molecular mechanisms underlying the
performed with escitalopram, which demonstrated that the SSRI therapeutic effect of these molecules (102, 103). In this regard, it
was effective in the normalization of different physiopathological has been shown that the AC-cAMP-PKA cascade plays a critical
parameters related to HPA functioning. According to these role in the transcriptional regulation of CRH (104–107).
studies, escitalopram was effective in reducing elevated Moreover, it has been shown that transcriptional activation of
concentrations of cortisol in patients with generalized anxiety CRH depends on cAMP-PKA mediated phosphorylation of
disorder (GAD), which also was correlated with clinical CREB, with the subsequent binding to CRE in the promoter
improvement (93). In addition, escitalopram reversed the region of the CRH gene (107). Similarly, there is considerable
adverse effects of CRH overexpression in the CeA. In vivo evidence for a cAMP-PKA mediated mechanism involved in GR
studies also revealed that escitalopram was effective in reducing regulation (108), therefore suggesting potential links between
CRH expression in the hippocampus alongside increased GR chronic treatment with TCAs and SSRIs, with the subsequent
expression in the hypothalamus and hippocampus, all associated repairing effects on the AC-cAMP-PKA-pCREB cascade, and
with significant decreases in HPA axis reactivity (92). More their regulatory effects on different components of the HPA axis
recently, in a preclinical laboratory study, escitalopram at the transcriptional level.
inhibited expression of CRH and its receptors in the Various in vivo studies demonstrated that chronic treatment
hypothalamus (94). The potential effects of TCAs and SSRIs in with TCAs or SSRIs may up-regulate the expression of CREB in
the regulation of the HPA axis may provide additional certain limbic regions (109). In this regard, in vivo studies
knowledge to better understand their therapeutic effects, revealed that chronic treatment with different antidepressants,
although further research is necessary in this critical issue. including serotonin- and norepinephrine-selective reuptake
inhibitors, led to increased expression of CREB mRNA in the
hippocampus, particularly in CA1 and CA3 pyramidal cells and
SIGNALING CASCADES INVOLVED IN THE dentate gyrus granule cells (109, 110). In addition, BDNF mRNA
REGULATION OF GENE EXPRESSION expression was also increased in hippocampus after treatment
with antidepressants (95), which suggests that chronic treatment
In order to understand the molecular mechanisms involved in the with these molecules may lead to up-regulation of CREB, which in
long lasting effects of TCAs and SSRIs, various studies were turn may increase the expression of different target genes, such as
performed focusing on their regulatory effects on different the BDNF gene (109), where a CRE has been described in its
components of the HPA axis. It has been suggested that long promoter region (111, 112). Therefore, up-regulation of CREB,
lasting effects of TCAs and SSRIs may involve up-regulation of the with the subsequent increased expression of BDNF, may be
cAMP-mediated second messenger cascade, which in turn may critical to counteract the effects of stress on hippocampal
lead to transcriptional regulation of different genes (95), including neurons (30, 113). Moreover, it has been shown that BDNF
GR, CRH, and BDNF. Binding of different ligands to their specific participates in the regulation of the HPA axis (114, 115), which
GPCR are, of course, associated to second messenger cascades. In represents a potential link between the AC-cAMP-PKA molecular
this regard, stimulation of Gs-coupled receptors may induce the cascade, with the consequent activation of CREB and BDNF, with
activation of AC, with the consequent synthesis of cAMP, a its regulatory effect on the HPA axis. Although, this molecular
second messenger responsible for the activation of cAMP- mechanism remains elusive and deserves further research to
dependent protein kinase (PKA) (96). Therefore, stimulation of better understand the potential links between these molecular
the AC-cAMP-PKA cascade may be translated into the activation cascades. Because CREB has been associated with neuronal
of cAMP response element binding protein (CREB) (96, 97), survival and plasticity in the hippocampus (116) and increased

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Tafet and Nemeroff Pharmacological Treatment of Anxiety Disorders

expression of CREB in hippocampus has been associated with neurotransmitter in the CNS (132). It has been shown to be
therapeutic effects, it may represent a potential target for the closely involved in the regulation of hypothalamic function
design of novel therapeutic agents (110). (133–135). Inhibitory GABAergic input has been shown to
The therapeutic effect of TCAs and SSRIs has long been innervate hypophysiotropic CRH neurons in the medial
associated to up-regulation of 5HT1A hetero-receptors (49, 117– parvocellular hypothalamic PVN (136, 137) through direct
119), which primarily work via Gi, therefore inhibiting the AC- input from peri-PVN sources or indirectly from diverse limbic
cAMP-PKA signaling cascade. Long-lasting effects of TCAs and structures. Direct GABAergic projections may reach the PVN
SSRIs may involve activation of AC-cAMP-PKA, which in turn from adjacent hypothalamic nuclei and the BNST (138) or
requires stimulation of GPCRs associated to Gs, to activate this indirectly from various cortical and limbic structures, including
signaling cascade. In order to understand this apparent paradox, it is the hippocampus, through the ventral subiculum, the amygdala,
important to take into consideration that 5HT1A hetero-receptors and the PFC, particularly the ACC, prelimbic, and infralimbic
may activate indirect signaling mechanisms. Among these, it has areas (137). Local GABAergic projections to the PVN may in
been shown that activation of 5HT1A, associated to Gi, may exert turn be activated or inhibited by glutamatergic or GABAergic
inhibitory effects on inhibitory pathways. In this regard, the effect of projections from cortical and limbic areas, which are closely
hippocampal 5HT1A receptors, particularly in the dentate gyrus, has involved in adaptive responses to stress and, therefore in the
been associated to inhibition of GABAergic interneurons (120). regulation of the HPA axis (139). The inhibitory role of the
Additional mechanisms have been also proposed, involving other hippocampus in the regulation of the HPA axis is therefore, in
GPCRs, which may also interact with 5HT1A–mediated signaling part, mediated by GABAergic projections from the ventral
pathways. In this regard, 5HT4 receptors have been described in subiculum to the PVN, which may allow hippocampal
different neural structures, including the PFC, amygdala, and processing, including information related to previous
hippocampus (121). It has been shown that 5HT4 receptors are experiences and to the current context, exert adaptive influence
associated to Gs (122) and therefore are known to stimulate the AC- on the stress response (137).
cAMP-PKA cascade, with the consequent phosphorylation of At the molecular level, GABAergic effects in the CNS are
CREB. This, in turn, plays a critical role in the synthesis of BDNF, mediated by two types of postsynaptic receptors, GABA-A and
with the resulting facilitation of hippocampal neurogenesis (123, GABA-B (140). The GABA-A receptor is a complex, constituted
124). In this regard, activation of 5-HT4 receptors have been also by diverse sub-units, with specific binding sites for its natural
associated with the therapeutic effect of SSRIs (121, 125), therefore ligand, GABA, benzodiazepines (BZDs), and barbiturates. Upon
suggesting that potential interactions between 5-HT1A and 5-HT4 binding of GABA, activation of postsynaptic GABAA receptors
receptors may be involved in the mechanism of action of allows the opening of specific chloride (Cl-) ion channels, with
antidepressants. Additional mechanisms have been also described the resulting influx of Cl- and the consequent hyperpolarization
involving potential interactions between 5-HT1A and 5-HT7 of postsynaptic neurons and inhibition of cell firing. Binding of
receptors. In this regard, it has been demonstrated that different BZDs to their specific site on the GABA-A receptors enhances
GPCRs may form homodimers and heterodimers, which may differ the binding of GABA to its specific binding-site in the same
in various aspects with the non-associated GPCRs (126). It has been receptor, which leads to increased frequency of Cl- channels with
shown that 5HT1A receptors may form heterodimers with others the resulting hyperpolarization and the consequent inhibition of
GPCRs, such as 5HT7, therefore resulting in different effects in target neurons (140, 141). Therefore, BZDs represent a family of
comparison to the individual receptor by itself (127). In this regard, anti-anxiety agents, whose mechanism of action has been
5HT7 receptors have been widely described in different neural associated to their enhancement of GABAergic function in
structures, including the hippocampus, hypothalamus, PFC, and different areas of the CNS, including their potential role in the
amygdala (128, 129). The 5HT7 receptor is coupled to GS, therefore modulation of the HPA axis, particularly in those patients
its activation results in stimulation of the AC-cAMP-PKA cascade suffering with depression and anxiety disorders. In this regard,
(128). Heterodimerization of 5HT1A and 5HT7 was observed in the effect of alprazolam, a potent BZD agonist, has been studied
vitro (130), where it was shown that co-expression of both GPCRs in vivo, where it was observed that both GABA and the BZD
decreased the activation of inhibitory Gi, mediated by 5HT1A exerted inhibitory effect on the HPA axis (141) and, according to
receptors, without affecting the activation of stimulatory GS, previous studies, this effect was attributed to the effect of BZDs
mediated by 5HT7 receptors (130). Therefore, heterodimerization on GABAergic receptors inhibiting the CRH system (142). The
of both GPCRs may lead to important functional changes in presence of GABA-A receptors in the hypothalamus further
their downstream signaling, with the consequent regulatory supports this central mechanism of action. Interestingly,
effects (131). diazepam, another well known BZD, have been shown to
decrease corticosterone levels in vivo (143) and it has been
shown that BZDs decrease cortisol levels in healthy volunteers
EFFECTS OF BZDS IN THE REGULATION and depressed patients in a dose-dependent manner (141, 142).
OF THE HPA AXIS This regulatory effect was further studied in vivo with
alprazolam, where it was observed that the BZD was capable of
The HPA axis is also regulated by other neurotransmitters, inhibiting the HPA axis, and this was attributed to the effect of
including g-aminobutyric acid (GABA), the major inhibitory the BZD on CRH neurons, which may contribute to its

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Tafet and Nemeroff Pharmacological Treatment of Anxiety Disorders

therapeutic efficacy (144). The potential role for CRH in the provide further information to better understand the molecular
pathophysiology of anxiety disorders was extensively studied mechanisms involved in their therapeutic effects, it has been
(145), therefore proposing further research on the effects of anti- shown that these effects only account for a small part of their
anxiety agents on CRH neurotransmission. In this regard, it has therapeutic and pharmacological effects, which may be reflected
been shown that acute treatment with alprazolam decreased in the partial improvement in the hypercortisolism observed in
CRH concentrations in the LC (146). Moreover, the effect of certain patients suffering depression or anxiety disorders.
alprazolam was further studied in vivo, where it was shown to
decrease CRH concentrations in the LC after acute or chronic
administration (147). The LC receives a rich CRH innervation CONCLUSION
(148) contains CRH receptors (149) and is critically involved in
the pathophysiology of stress and anxiety disorders (150). The role of the HPA axis in the pathophysiology of depression
Therefore, the effects of alprazolam on hypothalamic CRH and chronic anxiety disorders has been extensively studied,
neurons, are likely both direct and indirect through the LC including the particular role played by their different
(151). More recently, in vivo studies with lorazepam and components, including CRH neurotransmission, cortisol, and
clonazepam demonstrated that both BZDs were effective to their specific receptors, and the genes coding for each of these
reversing anxiety-like behavior, including social-avoidance, and molecules. It remains unclear, however, how important the
these effects were correlated with their inhibitory effect on the effects of anti-anxiety agents on the HPA axis activity are in
HPA axis, mediated by suppression of CRH activity (152). mediating their therapeutics benefits and moreover whether
Moreover, it has been shown that both BZDs were effective to further modulation of CRH and related systems might
reducing stress-induced CRH mRNA expression in the augment our currently available agents.
hypothalamus (152).
According to the molecular mechanisms previously described
in the aforementioned section, it has been demonstrated that anti- AUTHOR CONTRIBUTIONS
anxiety agents, including BZDs, as well as TCAs and SSRIs, may
exert certain effects on the HPA axis. However, although this may Both authors contributed equally.

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