First Patient Enrolled in Phase 2 Trial That Tests NSI-189 for Major Depressive Disorder

Neuralstem, Inc. has announced the enrollment of its first patient in its double-blind, placebo-controlled multi-center Phase 2 study of a compound called NSI-189 for the treatment of MDD (major depressive disorder).

MDD usually consists of a persistent feeling of sadness or loss of interest. MDD can also include an inability to sleep or concentrate on tasks, changes in appetite, decreased energy level, and even thoughts of suicide.

MDD is treated with a variety of psychological therapies, such as
cognitive behavioral therapy, Behavior therapy, and Psychotherapy. Cognitive behavioral therapy is a type of talk therapy that focuses on changing a person’s thoughts in order to change their behavior and feelings. Behavior therapy focuses on changing behavior to help people break unhealthy habits. Psychotherapy treats mental or behavioral disorders through talk therapy. A medical procedure called electroconvulsive therapy is also used for some patients. Medications include antipsychotic medicines such as Aripiprazole (Abilify), anxiolytics like buspirone (Buspar), and antidepressants such as Trazodone (Oleptro), Bupropion (Wellbutrin), Duloxetine (Cymbalta) and a host of others.

The medications used to treat MDD regulate the levels of particular neurotransmitters (small molecules used neurons use to communicate with each other) in the brain.

NSI-189 works rather different from these other medications. NSI-189 activates neurogenesis, or the production of new neurons. The drug also activates the formation of new synapses and increases the volume of the hippocampus. All of these processes are thought to play a role in reversing depression. Such neurological outcomes can also enhance cognition and promote neuroregeneration.


This phase 2 trial will randomize 220 patients, in three cohorts, two of whom will receive the drug (40 mg twice a day or 40 mg once a day) and another of which will receive the placebo. Twelve different sites will participate in this MDD trial, all under the direction of Maurizio Fava.

The primary efficacy endpoint is a reduction in depression symptoms. The Montgomery-Asberg Depression Rating Scale (MADRS) will be used to assess thee severity of depression symptoms. Other endpoints will examine cognitive improvement measures.

The trial will last for 12 weeks, with an additional observational follow-up period of six months in order to assess NSI-189 long-lasting durability of benefits.

Neuralstem expects to report the results of this trial in the second half of 2017.

“A new class of treatment is needed in major depression, where existing compounds are not effective for all patients and have high side effect profile, so patients discontinue treatment,” said Fava. “We were encouraged by the signs of improvement in the depression and cognitive symptoms of MDD patients, as witnessed in Phase I with NSI-189, and look forward to validating in Phase 2.”

As mentioned in this statement to the press by Fava, NSI-189 successfully completed a phase I clinical trial for MDD in 2011. In this trial, NSI-189 was administered to 41 healthy volunteers. A phase Ib clinical trial for treating MDD in 24 patients was started in 2012 and completed in July 2014, and the results of this trial were published in December 2015.

NSI-189 works via a new pathway that is different from current antidepressants in that it appears to create long-lasting, positive structural changes in the brain.

In animal experiments, rodents treated with NSI-189 showed significant increases in synaptogenesis, neurogenesis, and hippocampal volume.

In the Phase 1b trial, therapeutic effects were observed in patients after completion of the 28-day dosing, and these improvements persisted for an additional 56 days without the drug. This seems to support the hypothesis of a new mechanism of action that induces long-lasting structural changes in key areas of the brain. In this trial, NSU-189 was shown to be safe and demonstrated large treatment effects in two key depression outcome measures.

The Phase 1b study also showed significant improvement in cognitive symptoms (as measured by the Cognitive and Physical Functioning Questionnaire), compared to placebo.

Brain imaging with quantitative EEGs showed an increase in alpha brain waves in two parts of the brain (left posterior temporal and left parietal region), both of which are involved in depression and cognition, compared to placebo.

No significant adverse effects were observed.

This new clinical trial will test the efficacy of this new drug to treat moderate to severe clinical depression.

Epilepsy Reduces The Formation of New Neurons in the Brain

An ambitious, multidisciplinary project led by Amanda Sierra and Juan Manuel Encinas, Ikerbasque from the Achucarro centre (Achucarro Basque Center for Neuroscience) has discovered that epilepsy in a mouse model system reduces the production of new cells in the brain.

The hippocampus is a region of the brain involved in learning and memory and it is also the site of a robust neural stem cell population that generates new neurons. These hippocampal neural stem cells generate new neurons throughout the adult life of mammals. The cells generated by the hippocampal neural stem cells function in certain types of learning and memory and in responses to anxiety and stress.


This new research by Sierra and Encinas has revealed that in epileptic mice, hippocampal neural stem cells stop generating new neurons and are turn into reactive astrocytes. Reactive astrocytes promote inflammation and alter communication between neurons. Could manipulation of neural stem cells provide new ways to treat epilepsy?

Reactive Astrocyte
Reactive Astrocyte

This work has recently been published in the journal Cell Stem Cell.

The results of this research also confirms previous work by the same group that showed that epilepsy, which causes hyperexcitation of neurons but does not cause convulsions, activates neural stem cells, which leads to their premature exhaustion. Thus the generation of new neurons in the hippocampus ends is chronically reduced.

Juan Manuel Encinas, the leader of this study, highlighted the fact that “this discovery has enabled us to gain a better understanding about how neural stem cells function. We have shown that in addition to generating neurons and astrocytes, neural stem cells in the adult hippocampus can generate reactive astrocytes following an epileptic seizure.”

Encinas and his colleagues carried out this work in experimental animals that were genetically engineered to be epileptic. However, this discovery has clear implications in clinical practice and in the quest to develop new therapies for epilepsy, since the generation of new neurons (neurogenesis) is a process that is negatively affected in epileptic seizures in the hippocampus. Encinas pointed out, “If we can manage to preserve the population of neural stem cells and their capacity to generate new neurons in humans, it may be possible to prevent the development of certain symptoms associated with epilepsy and very likely to mitigate the damage that is caused in the hippocampus.”

In this project, Encinas and his colleagues collaborated with research groups attached to institutions such as the Baylor College of Medicine in Houston (United States), the Université Catholique de Louvain (Belgium), the Achucarro centre itself, and the UPV/EHU’s Genetic Expression Service.

New Neuron Formation Required for Maintenance of Olfactory Nerves in Mice

For many years, scientists and neurologists were convinced that neurons in the brain only formed during early development, and after that it was simply impossible for new neurons to be formed.  More recent work, however, has shown this to be largely untrue, since several regions of the brain possess resident stem cell populations that can divide to replenished damaged neurons and even augment learning and memory.  The capacity of neural stem cell populations to regenerate the central nervous system is a continuing field of intense research, and scientists at the National Institutes of Health (NIH) have reported one region of the central nervous system that can form new brain cells; the mouse olfactory system, which processes smells.  This work appeared in the October 8 issue of the Journal of Neuroscience.

“This is a surprising new role for brain stem cells and changes the way we view them,” said Leonardo Belluscio, Ph.D., a scientist at NIH’s National Institute of Neurological Disorders and Stroke (NINDS) and lead author of the study.

The olfactory bulb is at the front of the brain (shown as “A” in he picture below), and is rather small in humans, but somewhat larger in other animals.  This structure receives information directly from the nose about volatile odors.  Neurons in the olfactory bulb sort through this smelly information and relay neural signals to the rest of the brain.  This is the point at which we become aware of the smells in our surroundings.  The loss of the sense of smell is sometimes an early symptom in a variety of neurological disorders, including Alzheimer’s and Parkinson’s diseases.

Olfactory lobes in brain


Neurogenesis is the process by which neuroprogenitor cells are produced in the subventricular zone deep in the brain.  After birth, these cells migrate to the olfactory bulb, which becomes the final location of these cells.  Once they arrive at the olfactory bulb. the neuroprogenitor cells divide, differentiate, and form connections with existing cells to become integrated into the neural circuitry in the olfactory bulb and elsewhere.

Dr. Belluscio studies the olfactory system, and for this study, he collaborated with Heather Cameron, Ph.D., a neurogenesis researcher at the NIH’s National Institute of Mental Health.  The goal of this study was to better understand how the continuous addition of new neurons affects the neural organization of the olfactory bulb.  They used two different types of genetically engineered laboratory mice that had specifically genes knocked out.  Consequently, these mice lacked the specific stem cell populations that generate the new neurons during adulthood, without affecting the other olfactory bulb cells.  Previously, this remarkable level of specificity had not been achieved.

Belluscio and his coworkers had previously shown that plugging the nostrils of the animals so that they are not subject to olfactory stimulation causes the axonal extensions of the olfactory neurons to dramatically spread out and lose the precise network of connections with other cells that are normally observed under normal conditions.  They also showed that this widespread disrupted circuitry could re-organize itself and restore its original precision once the sensory deprivation was reversed.  Therefore, Belluscio and his team temporarily plugged a nostril in their lab animals to block olfactory sensory information from entering the brain.  However, if laboratory animals that do not produce new neuroprogenitors are subjected to this type of manipulation, once the nose is unblocked, new neurons are prevented from forming and entering the olfactory bulb, and, therefore, the neural circuits remain in disarray. “We found that without the introduction of the new neurons, the system could not recover from its disrupted state,” said Dr. Belluscio.

Further examination showed that elimination of the formation of adult-born neurons in mice that did not experience sensory deprivation also caused the organization of the olfactory bulb organization began to degenerate, eventually resembling the pattern observed in animals prevented from receiving sensory information from the nose.  Belluscio and his team also noticed that the extent of stem cell loss was directly proportional to the degree of disorganization in the olfactory bulb.

According to Belluscio, circuits of the adult brain are thought to be rather stable and that introducing new neurons alters the existing circuitry, causing it to re-organize. “However, in this case, the circuitry appears to be inherently unstable requiring a constant supply of new neurons not only to recover its organization following disruption but also to maintain or stabilize its mature structure. It’s actually quite amazing that despite the continuous replacement of cells within this olfactory bulb circuit, under normal circumstances its organization does not change,” he said.

Dr. Belluscio and his colleagues think that these new neurons in the olfactory bulb are important for the maintenance of activity-dependent changes in the brain, which help animals adapt to a constantly varying environment.

“It’s very exciting to find that new neurons affect the precise connections between neurons in the olfactory bulb. Because new neurons throughout the brain share many features, it seems likely that neurogenesis in other regions, such as the hippocampus, which is involved in memory, also produce similar changes in connectivity,” said Dr. Cameron.

The underlying basis of the connection between neurological disease and changes in the olfactory system is also unknown but may come from a better understanding of how the sense of smell works. “This is an exciting area of science,” said Dr. Belluscio, “I believe the olfactory system is very sensitive to changes in neural activity and given its connection to other brain regions, it could lend insight into the relationship between olfactory loss and many brain disorders.”

Fat-Based Stem Cells Support New Brain Cell Growth in Alzheimer’s Disease Mice

Alzheimer’s disease (AD) causes progressive death of brain cells and dementia. The loss of memory, coordination, and eventually motor function is relentless and horrific, and causes extensive suffering, financial pressures and loss. Stem cell treatments have been proposed as a treatment for AD, but such treatments have met resistance because of the complex pathology of AD. Introducing new neurons into the brain will do little good if cells are normally dying. However, some work with laboratory animals has suggested that stem cell treatments can benefit animals with conditions that approximately AD (see Kim S, et al., PLoS One. 2012;7(9):e45757; Bae JS, et al., Curr Alzheimer Res. 2013 Jun;10(5):524-31). However there are few studies that examine the therapeutic effect of mesenchymal stem cells from fat tissue or “adipose-derived stem cells” on mice with AD, and the effect of these cells on the oxidative injury that tends to accompany AD, and if these stem cells stimulate the generation of new neurons in the brains of AD mice.

Now we have evidence that transplantation of mesenchymal stem cells can stimulate for formation of new brain cells in adult rat or mouse models of AD and improve tissue structure and function after a stroke. Dr. Yufang Yan and her team from the School of Life Sciences at Tsinghua University, China transplanted adipose-derived stromal cells (ADSCs) into a part of the brain known as the hippocampus of mice that express the APP/PS1 transgene. Such mice show an AD-like disease, with memory loss and amyloid plaques that form in the brain.

Transplantation of ADSCs in these AD model mice decreased oxidative stress and promoted the growth of new neurons and glial cells in the subgranular and subventricular zones of the hippocampus, and, consequently improved the cognitive impairment in APP/PS1 transgenic AD mice.

These findings were published in Neural Regeneration Research (Vol. 9, No. 8, 2014), and provide theoretical and experimental evidence that ADSCs can be used to treat AD patients.

A Molecular Switch that Determines Stem Cell Or Neuron

A University of California, San Diego School of Medicine research team has provided new information about a well-known protein that provides the switch for cells to become neurons. This protein is part of a regulatory circuit that can push an immature neural cell to become a functional neuron.

Postdoctoral fellow Chih-Hong Lou and his colleagues worked with principal investigator Miles F. Wilkinson, who is a professor in the Department of Reproductive Medicine, and is also a member of the UC San Diego Institute for Genomic Medicine. These data were published in the February 13 online issue of the journal Cell Reports. These data may also elucidate a still poorly understood process – neuron specification – and might significantly accelerate the development of new therapies for specific neurological disorders, such as autism and schizophrenia.

Wilkinson, Lou and others discovered that the conversion of immature cells to neurons is controlled by a protein called UPF1. UPF1 works in a pathway called the “nonsense-mediated RNA decay” or NMD pathway. The NMD pathway provides a quality control mechanism that eliminates faulty messenger RNA (mRNA) molecules.

mRNA molecules are synthesized from DNA in the nucleus of cells and are exported to the cytoplasm where they are translated by ribosomes into protein. All proteins are encoded by stretches of DNA known as genes and the synthesis of an RNA copy of this stretch of DNA is called transcription. After the transcription of a messenger RNA molecule, is goes to the cytoplasm and is used as the template for the synthesis of a specific protein. Occasionally, mistakes are made in the transcription of mRNAs, and such aberrant mRNAs will either be translated into junk protein, or are so damaged that they cannot be recognized by ribosomes. Such junk mRNAs will gum up the protein synthesis machinery, but cells have the NMD pathway that degrades junk mRNAs to prevent the collapse of the protein synthesis machinery.

UPF1 mechanism

A second function for the NMD pathway is to degrade a specific group of normal mRNAs to prevent the production of particular proteins. This NMD function is physiologically important, but until now it had not been clear why it is important.

Wilkinson and others have discovered that UPF1, in combination with a particular class of microRNAs, acts as a molecular switch to determine when immature (non-functional) neural cells take the plunge and differentiate into non-dividing (functional) neurons. In particular, UPF1 directs the degradation of a specific mRNA that encodes for a protein in the TGF-beta signaling pathway, which promotes neural differentiation. The destruction of this mRNA prevents the proper functioning of the TGF-beta signaling pathway and neural differentiation fails to occur. Therefore, Wilkinson, Lou and co-workers identified, for the first time, a molecular pathway in which NMD drives a normal biological response.

NMD also promotes the decay of mRNAs that encode proliferation inhibitors, which Wilkinson said might explain why NMD stimulates the proliferative state characteristic of stem cells. There are many potential clinical ramifications for these findings,” Wilkinson said. “One is that by promoting the stem-like state, NMD may be useful for reprogramming differentiated cells into stem cells more efficiently.

Wilkinson continued: “Another implication follows from the finding that NMD is vital to the normal development of the brain in diverse species, including humans. Humans with deficiencies in NMD have intellectual disability and often also have schizophrenia and autism. Therapies to enhance NMD in affected individuals could be useful in restoring the correct balance of stem cells and differentiated neurons and thereby help restore normal brain function.”

Co-authors on this paper include Ada Shao, Eleen Y. Shum, Josh L. Espinoza and Rachid Karam, from the UCSD Department of Reproductive Medicine; and Lulu Huang, from Isis Pharmaceuticals.

Funding for this research came, in part, from National Institutes of Health (grant GM-58595) and the California Institute for Regenerative Medicine.

Teaching Old Neural Stem Cells New Tricks

In our brains, cells called neurons produce nerve impulses and are responsible for thinking, learning memory, reasoning, and so on. Neurons do not exist in isolation, but in combination with cells called glial cells that support the neurons, nourish them, and protects them from stress damage. Neurons and glial cells are replenished by brain-specific neural stem cell populations in the brain.

Unfortunately, the neural stem cell population in our brains tends to produce far fewer neurons as they age. This deficit of new neurons can play a role in the onset of neurodegenerative diseases such as Alzheimer’s disease and Parkinson’s disease. Also, our own “senior moments” when we forget where we placed our iPod or car keys comes from a loss of neurons as we age.

Fortunately, some recent research might change this trend. A team from Japan’s Keio University, and the Riken national research institute, has reported the discovery of a small RNA molecule (micro-RNA) that controls neuron production in young mice. When this micro-RNA was manipulated in older mice, their neural stem cells started to make neurons again. The Japanese team also has reasons to believe that the same mechanism is at work in human brains as well. This research was reported in the journal Proceedings of the National Academies of Science. The mechanism is believed to exist in humans as well.

Senior Author Hideyuki Okano said, “We observed the neurogenic-to-gliogenic switching in developing NSCs.” Translation: Okano and his team examined embryonic mouse brains and their neural stem cell (NSC) populations. They found what many other groups have previously observed: that the developing embryonic brain NSCs create neurons first, then switch over to making glial cells later. Okano’s team also discovered the microRNA-17/106-p38 axis that is responsible for this initial neuron-to-glial cell switch during embryonic development.

When they manipulated this embryonic microRNA-17/106-p38 pathway in older, post-natal NSCs in culture, these older post-natal NSCs switched from making glial cells to producing neurons.

In culture, NSCs are difficult to control, since getting large supplies of neurons from cell cultures that various research groups call NSCs is very difficult.

Nevertheless, “there is general agreement that neurogenesis (make neurons) largely precedes gliogenesis (making glial cells) during CNS development in vertebrates,” Okano explained. And adult NSCs, according to Okano, clearly can produce neurons in the body, “whereas they exhibit strong gliogenic characteristics under culture conditions in vitro (that is, in the laboratory).”

Adult NSCs in two regions of the brain—the subventricular zone and hippocampus—also “make neurons, even though transplant studies have shown us that the adult CNS is a gliogenic environment.”

Subventricular Zone

So it seems clear that old NSCs can make neurons, at least under certain conditions. However, it is very difficult to determine the age at which NSCs begin making substantially more glial cells than neurons. According to Okano, “It is difficult to clearly explain the association between total glial cell number and changes in NSC abilities. Moreover, there is less evidence about gliogenic ability of aged NSCs because most of studies about NSCs have mainly focused on the neurogenic ability. “

Still, Okano says: “There are some reports about decline of neurogenesis ability of NSCs with age. These reports indicate that reduction in paracrine Wnt3 factors, and increase of (chemokine) CCL11 concentration in blood, impaired adult neurogenesis in the hippocampus, for example.”

Could the group’s microRNA approach improve memory in humans? Okano believes so, but says more work needs to be done.

“We observed the neurogenic effect by overexpression of miR-17 in primary cultured neurospheres” – spheres of a variety of cells, including NSCs—“derived from the SVZ at postnatal day 30. Similar phenomenon by overexpression of miR-106b-25 cluster has been reported by another group.”

Okano also warns that his approach has only been attempted in cultured cells. He cautioned, “There is no evidence using knock-out mice. Therefore, the functions of them in adult neurogenesis and learning/memory functions are still unclear.”

Next, Okano’s group will develop “a useful method for precise manipulation of cytogenesis from NSCs. “

However, he says, “we think that further understanding of basic molecular mechanisms underlying the neural development is also an important issue.” He will study the ways in which his microRNA system interacts with other glia-producing genes. He wants to fully understand the mechanisms underlying “the end of neurogenic competence and acquisition of gliogenic competence.”

Finally, the group will “examine the significance of miR-17/p38 pathway in various somatic stem cells other than NSCs,” he says.

How Neural Stem Cells Become Neurons and Glia

How do neural stem cells differentiate into neurons or glia? A new paper from researchers at the University of California, Los Angeles (UCLA) seeks to explain this very phenomenon.

Neurons serve as the conductive cells of the nervous system. They transmit electrochemical signals from one neuron to another and provide signals to muscles, glands, and so on. They are responsible for consciousness, thought, learning and memory, and personality.

Despite their immense utility, neurons are not the only cells in the nervous system. Glial cells or just glia support neurons, hold them in place, and supply neurons with oxygen and nutrients and protect them from pathogens.

Glial Cells

When mouse neural stem cells were grown in culture, Wange Lu, associate professor of biochemistry and molecular biology at the Keck School of Medicine, and his colleagues came upon a protein called SMEK1 that promotes the differentiation of neural stem and progenitor cells. SMEK1 also keeps neural stem cells in check by preventing them from dividing uncontrollably.

When Lu and others took a more detailed look at the role of SMEK1, they discovered that it does not work alone, but in concert with a protein called Protein Phosphatase 4 (PP4) to suppress the function of a third protein called PAR3. PAR3 discourages the birth of new neurons (neurogenesis), and PAR3 inhibition leads to the differentiation of neural stem progenitor cells into neurons and glia.

“These studies reveal the mechanisms of how the brain keeps the balance of stem cells and neurons when the brain is formed,” said Wange. “If this process goes wrong, it leads to cancer, or mental retardation or other neurological diseases.”

Neural stem and progenitor cells offer tremendous promise as a future treatment for neurodegenerative disorders, and understanding their differentiation is the first step towards co-opting the therapeutic potential of these cells. This could offer new treatments for patients who suffer from Alzheimer’s, Parkinson’s and many other currently incurable diseases.

This work is interesting. It was published in Cell Reports 5, 593–600, November 14, 2013. My only criticism of some of the thinking in this paper is that neural stem cell lines are usually made from aborted fetuses. I realize that some of these neural stem cell lines come from medical abortions in which the baby had already died, but many of them come from aborted babies. If we are going to use neural stem cells for therapeutic purposes, then we should make them from induced pluripotent stem cells and take them from aborted babies.