A two-year double-blind crossover trial of the prophylactic effect of methylene blue in manic-depressive psychosis

Prefrontal mechanisms in extinction of conditioned fear

Interest in the medial prefrontal cortex (mPFC) as a source of behavioral inhibition has increased with the mounting evidence for a functional role of the mPFC in extinction of conditioned fear. In fear extinction, a tone-conditioned stimulus (CS) previously paired with a footshock is presented repeatedly in the absence of footshock, causing fear responses to diminish. Here, we review converging evidence from different laboratories implicating the mPFC in memory circuits for fear extinction: (1) lesions of mPFC impair recall of extinction under various conditions, (2) extinction potentiates mPFC physiological responses to the CS, (3) mPFC potentiation is correlated with extinction behavior, and (4) stimulation of mPFC strengthens extinction memory. These findings support Pavlov's original notion that extinction is new learning, rather than erasure of conditioning. In people suffering from posttraumatic stress disorder (PTSD), homologous areas of ventral mPFC show morphological and functional abnormalities, suggesting that extinction circuits are compromised in PTSD. Strategies for augmenting prefrontal function for clinical benefit are discussed.

Methylene blue prevents neurodegeneration caused by rotenone in the retina

An experimental optic neuropathy model was used to test the hypothesis that methylene blue may protect the retinal ganglion cell layer from neurodegeneration caused by rotenone. Rotenone is a widely used pesticide that inhibits complex I, the first enzyme of the mitochondrial respiratory chain. Complex I dysfunction is linked to the degeneration of retinal ganglion cells in Leber's optic neuropathy. Methylene blue is a reduction-oxidation agent that can act as a powerful antioxidant and also as an enhancer of the electron transport chain, preventing formation of mitochondrial oxygen free radicals and promoting oxygen consumption. The neurodegeneration of the retina was studied in mice with intravitreal microinjection of rotenone alone, or in combination with increasing doses of methylene blue, in one eye, and the vehicle in the contralateral control eye. The effect of rotenone and rotenone plus methylene blue was investigated using two histological stains, complex I and Nissl, and two measurements, morphometric layer thickness and non-biased stereological cell counts. Rotenone induced neurodegeneration in the retinal ganglion cell layer 24 h after injection, as indicated by significant reductions in both the thickness and cell numbers of the retinal ganglion cell layer of eyes microinjected with rotenone as compared to the control eyes. This neurodegeneration was prevented in a dose dependent manner by the injection of methylene blue along with rotenone. It was concluded that rotenone-induced degeneration in the ganglion cell layer can be prevented by intravitreal injection of methylene blue. In vitro experiments showed that methylene blue is both a powerful antioxidant as well as an enhancer of cellular oxygen consumption and is able to reverse the oxidative stress and decrease in oxygen consumption induced by rotenone in brain homogenates. The findings suggest that methylene blue may be a promising neuroprotective agent in optic neuropathy and perhaps other neurodegenerative diseases caused by mitochondrial dysfunction.

Methylene blue photoinactivation abolishes West Nile virus infectivity in vivo

The prevalence of West Nile virus (WNV) infections and associated morbidity has accelerated in recent years. Of particular concern is the recent demonstration that this virus can be transmitted by blood products and can cause severe illness and mortality in transfusion recipients. We have evaluated methylene blue (MB)+light as a safe and cost-effective means to inactivate WNV in vitro. This regimen inactivated WNV with an IC50 of 0.10 microM. Up to 10(7)pfu/ml of WNV could be inactivated by MB+light with no residual infectivity. MB+light inactivated three primary WNV isolates from the years 1999, 2002 and 2003 and prevented mortality in a murine model for WNV infection. Since MB is already approved for human use at a dose of 100mg/kg/day, we conjecture that MB+light treatment of blood products for high-risk patients will be efficacious and suitable for use in resource-limited settings.

Memory facilitation by methylene blue: Dose-dependent effect on behavior and brain oxygen consumption

Methylene blue administered post-training improves memory retention in avoidance and appetitive tasks, and restores spatial memory impaired by an inhibitor of cytochrome oxidase. Methylene blue may improve memory retention by increasing brain oxygen utilization. We investigated which doses improve memory without nonspecific behavioral effects, and whether methylene blue enhances brain oxygen consumption. Different doses were evaluated 24 h after administration in wheel running, feeding, open field habituation and object recognition tests. The 1-10 mg/kg methylene blue-treated rats were not different from saline-treated rats in locomotion or feeding behavior. The 50-100 mg/kg doses decreased running wheel behavior. The 4 mg/kg dose improved behavioral habituation and object memory recognition. Dose-dependent effects of methylene blue on brain oxygen consumption revealed that low concentrations increased brain oxygen consumption in vitro and 24 h after in vivo administration. Therefore, methylene blue doses that increase brain oxygen consumption also facilitate memory retention.

Extinction memory improvement by the metabolic enhancer methylene blue

We investigated whether postextinction administration of methylene blue (MB) could enhance retention of an extinguished conditioned response. MB is a redox compound that at low doses elevates cytochrome oxidase activity, thereby improving brain energy production. Saline or MB (4 mg/kg intraperitoneally) were administered to rats for 5 d following extinction training of tone-footshock conditioning. Postextinction freezing was lower in rats receiving MB compared with saline, suggesting that MB improved retention of the extinction memory. The MB effect was specific to tone-evoked freezing because there were no differences in pretone freezing. Control subjects similarly injected with MB showed no evidence of nonspecific effects on measures of motor activity and fearfulness. MB-treated rats exhibited both greater retention of extinction and greater overall brain metabolic activity. Rats with higher retention of extinction also showed a relative increase in cytochrome oxidase activity in prefrontal cortical regions, especially anterior infralimbic cortex, dorsal and medial frontal cortex, and lateral orbital cortex. These regional metabolic increases were also correlated to the behavioral freezing index used to assess retention of extinction. It was concluded that MB administered postextinction could enhance retention of extinction memory through an increase in brain cytochrome oxidase activity.

Methylene blue photoinactivation of RNA viruses

We present a review of the current status of the use of methylene blue (MB) photoinactivation of viruses starting with the first early observations up to its current use to inactivate HIV-1 in blood products. Basic mechanism of action studies conducted with model bacteriophages indicate that MB-photomediated viral RNA-protein crosslinkage is a primary lesion and that oxygen, specifically singlet oxygen, is very important also. Basic studies on the mechanism of action with HIV are lacking; however, we do show new data illustrating that viral reverse transcriptase inactivation per se cannot account for MB-mediated photoinactivation. We also show data illustrating that MB photomediates the inactivation of West Nile Virus, a flavivirus, which poses a significant new threat to the continental US. MB photoinactivation of viruses show significant promise because the technology not only offers significant potency but the history of safe MB use in human therapy makes it attractive also.

Methylene blue, a nitric oxide inhibitor, prevents haemodialysis hypotension

BACKGROUND

Plasma nitric oxide (NO) levels have been found to be high in haemodialysis (HD) patients, especially in those prone to hypotension in dialysis. The aim of the study was to prevent dialysis hypotension episodes by i.v. administration of methylene blue (MB), an inhibitor of NO activity and/or production.

METHODS

MB was given i.v. in 18 stable HD patients with hypotensive episodes during almost every dialysis, in 18 HD patients without hypotension during dialyses, and in five healthy controls. MB was given as a bolus of 1 mg/kg bodyweight followed by a constant infusion of 0.1 mg/kg bodyweight lasting 210 min until the end of the dialysis session and only as a bolus on a non-dialysis day. Systolic and diastolic blood pressures (BP) were measured at 10-min intervals during HD sessions with or without MB and on a non-dialysis day with MB.

RESULTS

In hypotension-prone patients, MB completely prevented the hypotension during dialysis and increased both systolic and diastolic BP on non-dialysis days. In normotensive patients, MB increased BP during the first hour of dialysis and for 90 min on the non-dialysis day. The BP in the healthy controls remained unchanged. Plasma and platelet NO(2)+NO(3) (stable metabolites of NO) levels were determined. The NO(2)+NO(3) generation rate in the first post-dialysis day was calculated. The plasma and platelet NO(2)+NO(3) were higher in the hypotensive group than in the normotensive dialysis group. The generation rate of nitrates was higher (P<0.01) in the hypotensive group (1.21+/-0.13 micromol/min and 0.74+/-0.16 after MB) than in the normotensive patients (0.61+/-0.11 micromol/ min and 0.27+/-0.14 after MB). No side-effects were recorded.

CONCLUSIONS

MB is an efficient therapy in the prevention of dialysis hypotension.

Selective inhibition of Alzheimer disease-like tau aggregation by phenothiazines

In Alzheimer disease (AD) the microtubule-associated protein tau is redistributed exponentially into paired helical filaments (PHFs) forming neurofibrillary tangles, which correlate with pyramidal cell destruction and dementia. Amorphous neuronal deposits and PHFs in AD are characterized by aggregation through the repeat domain and C-terminal truncation at Glu-391 by endogenous proteases. We show that a similar proteolytically stable complex can be generated in vitro following the self-aggregation of tau protein through a high-affinity binding site in the repeat domain. Once started, tau capture can be propagated by seeding the further accumulation of truncated tau in the presence of proteases. We have identified a nonneuroleptic phenothiazine previously used in man (methylene blue, MB), which reverses the proteolytic stability of protease-resistant PHFs by blocking the tau-tau binding interaction through the repeat domain. Although MB is inhibitory at a higher concentration than may be achieved clinically, the tau-tau binding assay was used to identify desmethyl derivatives of MB that have Ki values in the nanomolar range. Neuroleptic phenothiazines are inactive. Tau aggregation inhibitors do not affect the tau-tubulin interaction, which also occurs through the repeat domain. Our findings demonstrate that biologically selective pharmaceutical agents could be developed to facilitate the proteolytic degradation of tau aggregates and prevent the further propagation of tau capture in AD.

Treatment-resistant bipolar depression

Patients with treatment-resistant bipolar depression require careful management, which takes into account the life-threatening potential of their depression and the risk of iatrogenic mania. Because there are few data specific to treatment of bipolar depression, much of the approach to bipolar depression is derived from experience with unipolar depression. There are, however, important differences between these two illnesses. Compared with patients with unipolar illness, patients with bipolar depression more likely experience antidepressant benefit from mood-stabilizing medication and, therefore, avoid the risks of antidepressant medication. Treatment of comorbid anxiety and substance abuse improves response. The risk of treating bipolar patients can be reduced but not avoided. Improved outcome may be achieved by careful assessment, prospective mood charting, and attempts to taper antidepressant medications after an appropriate continuation phase.

Non-lithium pharmacological treatment of manic depression: a review

Objectives:To examine the reasons why manic-depressive patients often fail to respond to lithium and, the chief purpose of this paper, to review the present state of knowledge concerning alternative pharmacotherapies to lithium in this disorder.Method:Literature review.Findings:Lithium produces a clinically useful effect in 70-80% of cases. Factors such as non-compliance, side-effects, serum levels, and enduring psychosocial influences on the patient must be considered before treatment failure is diagnosed. Carbamazepine is the most studied alternative drug to date, and the most likely predictors of response to this agent are rapid-cycling, absence of a family history of affective disorder, mania, severe illness, and non-response to lithium.Conclusions:In view of the 20-25% of patients who do not respond to lithium, and the increased likelihood that lithium-responders may fail to respond again once the drug has been stopped for a period, further research is needed to find better and safer prophylactics against depression in bipolar disorders and to refine our knowledge of the indications for use of those already available.

No evidence for neoantigens in human plasma after photochemical virus inactivation

Photodynamic virus inactivation of human fresh plasma mediated by visible light in the presence of the phenothiazine dyes methylene blue or toluidine blue was investigated to determine whether it influences functional, structural, and immunological properties of plasma proteins. The activities of the coagulation factors I, VIII, IX, X, and XI were affected to a certain degree, while those of most other plasma proteins were not. The elution profiles obtained by ion exchange chromatography of untreated and photodynamically treated plasma were almost identical. Using a number of antisera against human plasma and single plasma proteins, different immunochemical techniques revealed identical patterns for untreated and treated plasma. Thus, there was no indication that the photodynamic virus inactivation procedure applied considerably influences the properties of plasma proteins.

An overview of investigational antidepressants

This article provides a brief overview for the clinician of investigational antidepressant compounds. In the last decade, there have been a large number of compounds introduced, and many of these, some identified only by a compound number, are still in research and development. The present overview is not meant to be exhaustive, but focuses on the major classes of newer antidepressant drugs.

Antidepressants and metabolites that block GABAA receptors coupled to 35S-t-butylbicyclophosphorothionate binding sites in rat brain

Twenty-three clinically effective antidepressants and 9 metabolites of antidepressants (together, about 50% of all antidepressants tested) were found to, fully or partially, reverse the inhibitory action of 1 microM GABA on 35S-TBPS binding. Amoxapine, the most potent of the complete reversers, is a strong convulsant in overdosage while mianserin, the most potent of the partial reversers and a pro-convulsant, almost never produces convulsions in humans, even after massive overdosage. Convulsant side effects, a pervasive property of antidepressants, can probably be attributed to GABA antagonism, perhaps at a subset of GABAA receptors. Further, the structures of the antidepressants, as well as the criteria used to select them for clinical trials, are diverse, raising the possibility that GABA antagonism, perhaps at another subset of GABAA receptors, could be also involved in clinical antidepressant action. We speculate that selective blockade of excessive GABAergic inhibition of reward systems may contribute to the clinical effects of many antidepressants, in some cases via active metabolites.

A controlled trial of methylene blue in severe depressive illness

Methylene blue, 15 mg/day, was compared with placebo in treatment of severe depressive illness. The 3-week trial was designed to avoid bias by placebo response and also to avoid observer bias. Improvement in patients receiving methylene blue was significantly greater than in those receiving placebo. Methylene blue at a dose of 15 mg/day appears to be a potent antidepressant, and further clinical evaluation is essential.