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<front>
<journal-meta>
<journal-id journal-id-type="publisher-id">Front. Pharmacol.</journal-id>
<journal-title>Frontiers in Pharmacology</journal-title>
<abbrev-journal-title abbrev-type="pubmed">Front. Pharmacol.</abbrev-journal-title>
<issn pub-type="epub">1663-9812</issn>
<publisher>
<publisher-name>Frontiers Media S.A.</publisher-name>
</publisher>
</journal-meta>
<article-meta>
<article-id pub-id-type="doi">10.3389/fphar.2017.00269</article-id>
<article-categories>
<subj-group subj-group-type="heading">
<subject>Pharmacology</subject>
<subj-group>
<subject>Review</subject>
</subj-group>
</subj-group>
</article-categories>
<title-group>
<article-title>Plastic and Neuroprotective Mechanisms Involved in the Therapeutic Effects of Cannabidiol in Psychiatric Disorders</article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author" corresp="yes">
<name><surname>Campos</surname> <given-names>Alline C.</given-names></name>
<xref ref-type="aff" rid="aff1"><sup>1</sup></xref>
<xref ref-type="author-notes" rid="fn001"><sup>&#x0002A;</sup></xref>
<uri xlink:href="http://loop.frontiersin.org/people/115275/overview"/>
</contrib>
<contrib contrib-type="author">
<name><surname>Foga&#x000E7;a</surname> <given-names>Manoela V.</given-names></name>
<xref ref-type="aff" rid="aff1"><sup>1</sup></xref>
</contrib>
<contrib contrib-type="author">
<name><surname>Scarante</surname> <given-names>Franciele F.</given-names></name>
<xref ref-type="aff" rid="aff1"><sup>1</sup></xref>
<uri xlink:href="http://loop.frontiersin.org/people/380677/overview"/>
</contrib>
<contrib contrib-type="author">
<name><surname>Joca</surname> <given-names>S&#x000E2;mia R. L.</given-names></name>
<xref ref-type="aff" rid="aff2"><sup>2</sup></xref>
<uri xlink:href="http://loop.frontiersin.org/people/9892/overview"/>
</contrib>
<contrib contrib-type="author">
<name><surname>Sales</surname> <given-names>Amanda J.</given-names></name>
<xref ref-type="aff" rid="aff2"><sup>2</sup></xref>
</contrib>
<contrib contrib-type="author">
<name><surname>Gomes</surname> <given-names>Felipe V.</given-names></name>
<xref ref-type="aff" rid="aff3"><sup>3</sup></xref>
<uri xlink:href="http://loop.frontiersin.org/people/288792/overview"/>
</contrib>
<contrib contrib-type="author">
<name><surname>Sonego</surname> <given-names>Andreza B.</given-names></name>
<xref ref-type="aff" rid="aff1"><sup>1</sup></xref>
<uri xlink:href="http://loop.frontiersin.org/people/380689/overview"/>
</contrib>
<contrib contrib-type="author">
<name><surname>Rodrigues</surname> <given-names>Naielly S.</given-names></name>
<xref ref-type="aff" rid="aff1"><sup>1</sup></xref>
<uri xlink:href="http://loop.frontiersin.org/people/380680/overview"/>
</contrib>
<contrib contrib-type="author">
<name><surname>Galve-Roperh</surname> <given-names>Ismael</given-names></name>
<xref ref-type="aff" rid="aff4"><sup>4</sup></xref>
<xref ref-type="aff" rid="aff5"><sup>5</sup></xref>
<uri xlink:href="http://loop.frontiersin.org/people/68374/overview"/>
</contrib>
<contrib contrib-type="author">
<name><surname>Guimar&#x000E3;es</surname> <given-names>Francisco S.</given-names></name>
<xref ref-type="aff" rid="aff1"><sup>1</sup></xref>
<uri xlink:href="http://loop.frontiersin.org/people/40439/overview"/>
</contrib>
</contrib-group>
<aff id="aff1"><sup>1</sup><institution>Department of Pharmacology, Centre for Interdisciplinary Research on Applied Neurosciences (NAPNA), School of Medicine of Ribeir&#x000E3;o Preto, University of S&#x000E3;o Paulo</institution> <country>Ribeir&#x000E3;o Preto, Brazil</country></aff>
<aff id="aff2"><sup>2</sup><institution>Department of Physical and Chemical, School of Pharmaceutical Science of Ribeir&#x000E3;o Preto, University of S&#x000E3;o Paulo</institution> <country>Ribeir&#x000E3;o Preto, Brazil</country></aff>
<aff id="aff3"><sup>3</sup><institution>Department of Neuroscience, University of Pittsburgh</institution> <country>Pittsburgh, PA, United States</country></aff>
<aff id="aff4"><sup>4</sup><institution>Department of Biochemistry and Molecular Biology I, School of Biology, Complutense University</institution> <country>Madrid, Spain</country></aff>
<aff id="aff5"><sup>5</sup><institution>Centro de Investigaci&#x000F3;n Biom&#x000E9;dica en Red sobre Enfermedades Neurodegenerativas, Instituto de Universitario de Investigaci&#x000F3;n en Neuroqu&#x000ED;mica and Instituto Ram&#x000F3;n y Cajal de Investigaci&#x000F3;n Sanitaria</institution> <country>Madrid, Spain</country></aff>
<author-notes>
<fn fn-type="edited-by"><p>Edited by: Giuseppe Esposito, Sapienza University of Rome, Italy</p></fn>
<fn fn-type="edited-by"><p>Reviewed by: Benedict Green, Agricultural Research Service (USDA), United States; Anatol Manaenko, Universit&#x000E4;tsklinikum Erlangen, Germany</p></fn>
<fn fn-type="corresp" id="fn001"><p>&#x0002A;Correspondence: Alline C. Campos <email>allinecampos&#x00040;usp.br</email></p></fn>
<fn fn-type="other" id="fn002"><p>This article was submitted to Ethnopharmacology, a section of the journal Frontiers in Pharmacology</p></fn>
</author-notes>
<pub-date pub-type="epub">
<day>23</day>
<month>05</month>
<year>2017</year>
</pub-date>
<pub-date pub-type="collection">
<year>2017</year>
</pub-date>
<volume>8</volume>
<elocation-id>269</elocation-id>
<history>
<date date-type="received">
<day>14</day>
<month>10</month>
<year>2016</year>
</date>
<date date-type="accepted">
<day>01</day>
<month>05</month>
<year>2017</year>
</date>
</history>
<permissions>
<copyright-statement>Copyright &#x000A9; 2017 Campos, Foga&#x000E7;a, Scarante, Joca, Sales, Gomes, Sonego, Rodrigues, Galve-Roperh and Guimar&#x000E3;es.</copyright-statement>
<copyright-year>2017</copyright-year>
<copyright-holder>Campos, Foga&#x000E7;a, Scarante, Joca, Sales, Gomes, Sonego, Rodrigues, Galve-Roperh and Guimar&#x000E3;es</copyright-holder>
<license xlink:href="http://creativecommons.org/licenses/by/4.0/"><p>This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.</p></license>
</permissions>
<abstract>
<p>Beneficial effects of cannabidiol (CBD) have been described for a wide range of psychiatric disorders, including anxiety, psychosis, and depression. The mechanisms responsible for these effects, however, are still poorly understood. Similar to clinical antidepressant or atypical antipsychotic drugs, recent findings clearly indicate that CBD, either acutely or repeatedly administered, induces plastic changes. For example, CBD attenuates the decrease in hippocampal neurogenesis and dendrite spines density induced by chronic stress and prevents microglia activation and the decrease in the number of parvalbumin-positive GABA neurons in a pharmacological model of schizophrenia. More recently, it was found that CBD modulates cell fate regulatory pathways such as autophagy and others critical pathways for neuronal survival in neurodegenerative experimental models, suggesting the potential benefit of CBD treatment for psychiatric/cognitive symptoms associated with neurodegeneration. These changes and their possible association with CBD beneficial effects in psychiatric disorders are reviewed here.</p>
</abstract>
<kwd-group>
<kwd>cannabinoids</kwd>
<kwd>anxiety</kwd>
<kwd>depression</kwd>
<kwd>schizophrenia</kwd>
<kwd>neurogenesis</kwd>
<kwd>synaptic remodeling</kwd>
<kwd>autophagy</kwd>
</kwd-group>
<counts>
<fig-count count="1"/>
<table-count count="2"/>
<equation-count count="0"/>
<ref-count count="196"/>
<page-count count="18"/>
<word-count count="14631"/>
</counts>
</article-meta>
</front>
<body>
<sec sec-type="intro" id="s1">
<title>Introduction</title>
<p>Plasticity relates to the particular characteristic of a material that undergoes deformation under a load (Lubliner, <xref ref-type="bibr" rid="B121">2005</xref>). In neuroscience, the term neuroplasticity applies to the capacity of the brain to adapt and change in response to experience (Fuchs and Flugge, <xref ref-type="bibr" rid="B64">2014</xref>). William James was the first to propose this term in 1890, defending the idea that brain functions are not fixed during life (James, <xref ref-type="bibr" rid="B92">1890</xref>). Several neuroscientists denied this concept for decades. Santiago Ram&#x000F3;n y Cajal, however, used the term neuroplasticity to describe changes in the brain that were a consequence of, or related to, pathology. He also suggested that small protrusions in the dendrites of neurons stained with Golgi&#x00027;s method, which he later named as dendritic spines, are involved in synaptic connectivity and function (Stahnisch and Nitsch, <xref ref-type="bibr" rid="B177">2002</xref>). Nowadays, the idea that brain continually changes along our lifetime is well accepted. Notably, the concept of neuroplasticity has expanded to include not only changes at a morphological level but also biochemical and pharmacological adaptations (intracellular pathways, receptors, synaptic proteins), alterations in neuronal networks (changes in connectivity, dendritic remodeling, and number and morphology of dendritic spines), as well as the generation of new neurons (i.e., adult neurogenesis) (Fuchs and Flugge, <xref ref-type="bibr" rid="B64">2014</xref>). These neuroplastic modifications, moreover, can be either adaptive or maladaptive. Therefore, the mechanisms responsible for these changes may be a great window of opportunity for understanding the pathophysiology and treatment of mental illness (Kays et al., <xref ref-type="bibr" rid="B99">2012</xref>).</p>
<sec>
<title>Neuroplasticity and psychotropic drugs</title>
<p>Psychiatric disorders may result from significant neuroplastic changes that lead to new set points of brain functions (Pallanti, <xref ref-type="bibr" rid="B142">2016</xref>). For instance, several neuropsychiatric conditions have been associated with stress-induced changes in dendritic remodeling and decreased adult hippocampal neurogenesis (Bessa et al., <xref ref-type="bibr" rid="B8">2009</xref>; Campos et al., <xref ref-type="bibr" rid="B23">2013b</xref>). Corroborating this proposal, decreased hippocampal volume and reduced proliferative activity of neurogenic niches have been described in mood disorders, posttraumatic stress disorder (PTSD) and schizophrenia (Reif et al., <xref ref-type="bibr" rid="B153">2006</xref>; Dhikav and Anand, <xref ref-type="bibr" rid="B44">2007</xref>; Lucassen et al., <xref ref-type="bibr" rid="B122">2010</xref>).</p>
<p>The therapeutic effects of several psychotropic drugs usually need 2&#x02013;6 weeks to be clinically recognized. It suggests that time-dependent structural reorganization of neuronal circuits and biochemical synaptic changes are required for the pharmacological action of these drugs (Konradi and Heckers, <xref ref-type="bibr" rid="B106">2001</xref>; Foga&#x000E7;a et al., <xref ref-type="bibr" rid="B62">2013</xref>).</p>
<p>Antidepressants are probably the most studied class of medication associated with plastic brain changes. For example, chronic, but not acute, treatment with antidepressants such as serotonin selective uptake inhibitors (SSRIs) and tricyclics increases the expression of Brain-derived Neurotrophic Factor (BDNF) in the hippocampus and prefrontal cortex (PFC) (Castren et al., <xref ref-type="bibr" rid="B29">2007</xref>). Repeated antidepressant treatment also prevents stress-induced hippocampal dendritic atrophy (Bessa et al., <xref ref-type="bibr" rid="B8">2009</xref>) and facilitates adult hippocampal neurogenesis in rodents (Malberg et al., <xref ref-type="bibr" rid="B126">2000</xref>; Santarelli et al., <xref ref-type="bibr" rid="B163">2003</xref>). In addition to standard antidepressant drugs, the rapid and sustained antidepressant effects induced by ketamine also seem to depend on neuroplastic events (Duman et al., <xref ref-type="bibr" rid="B47">2016</xref>). Ketamine appears to act in the PFC and hippocampus modifying the number of dendritic spines and BDNF expression by facilitating mTOR (mechanistic Target of Rapamycin) intracellular pathway (Duman et al., <xref ref-type="bibr" rid="B47">2016</xref>).</p>
<p>Neuroplastic changes have also been associated with the effects of antipsychotic drugs. Haloperidol modifies the number/shape of dendritic spines and synaptic strength and increases expression of synaptic proteins (Eastwood et al., <xref ref-type="bibr" rid="B48">1997</xref>; Harris, <xref ref-type="bibr" rid="B83">1999</xref>; Matus, <xref ref-type="bibr" rid="B130">1999</xref>; Nakahara et al., <xref ref-type="bibr" rid="B139">1999</xref>). Regarding adult hippocampal neurogenesis, the results are contradictory. Whereas Malberg et al. (<xref ref-type="bibr" rid="B126">2000</xref>) found no changes in haloperidol-treated adult rats, in gerbils haloperidol seems to facilitate neurogenesis (Dawirs et al., <xref ref-type="bibr" rid="B38">1998</xref>). In the case of atypical antipsychotic drugs, clozapine induces proliferation in the subgranular zone of the rodent dentate gyrus 24-h after the treatment (Halim et al., <xref ref-type="bibr" rid="B80">2004</xref>) and prevents the phencyclidine-induced decrease in hippocampal neurogenesis (Maeda et al., <xref ref-type="bibr" rid="B123">2007</xref>).</p>
</sec>
<sec>
<title>Cannabidiol effects in psychiatric disorders</title>
<p>Cannabidiol (CBD) is one of the most abundant components among more than 100 compounds called cannabinoids present in the <italic>Cannabis sativa</italic> plant. CBD differs from it&#x00027;s the main psychoactive component, delta-9-tetrahydrocannabinol (THC), CBD does not cause psychotomimetic and anxiogenic effects or induce dependence after repeated use (for review, see Ligresti et al., <xref ref-type="bibr" rid="B116">2016</xref>). In addition, it has a better safety profile compared to other cannabinoids, such as THC. For instance, high doses of CBD (up to 1,500 mg/day) are well tolerated in animals and humans.</p>
<p>Nowadays, CBD is one of the phytocannabinoid with the widest range of potential therapeutic actions (Izzo et al., <xref ref-type="bibr" rid="B91">2009</xref>; Ligresti et al., <xref ref-type="bibr" rid="B116">2016</xref>). There are a considerable number of clinical trials using CBD alone or in combination with other cannabinoids in progress (Campos et al., <xref ref-type="bibr" rid="B19">2016</xref>). CBD has attracted considerable interest recently, as marihuana extracts enriched in CBD have been reported to exert a significant reduction in seizure number and severity in Dravet and Gaston-Leroux patients (Devinsky et al., <xref ref-type="bibr" rid="B43">2014</xref>). Of note, the Food and Drug Administration and, the European Medicines Agency approved the use of CBD (Epidiolex, GW) for the treatment of this conditions. Additionaly, CBD exhibits a broad spectrum of other possible therapeutic actions, which include anxiolytic, antipsychotic, antidepressive, and neuroprotective effects over a large range of psychiatric and neurodegenerative disorders (Campos et al., <xref ref-type="bibr" rid="B19">2016</xref>; Ligresti et al., <xref ref-type="bibr" rid="B116">2016</xref>). Although most of these putative therapeutic properties were initially described in animal models, clinical studies have supported the beneficial effects of CBD in anxiety, schizophrenia, epilepsy, and multiple sclerosis (Bergamaschi et al., <xref ref-type="bibr" rid="B6">2011a</xref>; Leweke et al., <xref ref-type="bibr" rid="B113">2012</xref>; Ligresti et al., <xref ref-type="bibr" rid="B116">2016</xref>; Table <xref ref-type="table" rid="T1">1</xref>). Corroborating these findings, neuroimaging studies clearly demonstrated that CBD affects brain areas involved in the neurobiology of psychiatric disorders. Crippa et al. (<xref ref-type="bibr" rid="B33">2004</xref>) showed that a single dose of CBD, administered orally in healthy volunteers, alters the resting activity in limbic and paralimbic brain areas while decreasing subjective anxiety associated with the scanning procedure. CBD reduced the activity of the left amygdala-hippocampal complex, hypothalamus, and posterior cingulated cortex while increasing the activity of the left parahippocampal gyrus compared with placebo. In healthy volunteers treated with CBD and submitted to a presentation of fearful faces, a decreasing of the amygdala and anterior and posterior cingulate cortex activities and a disruption in the amygdala-anterior cingulated cortex connectivity have also been observed (Fusar-Poli et al., <xref ref-type="bibr" rid="B66">2009</xref>, <xref ref-type="bibr" rid="B65">2010</xref>). Furhter imaging studies also demonstrated that CBD changes activity in other brain areas involved in neuropsychiatric disorders such as the medial and left temporal and prefrontal cortex and insula (Borgwardt et al., <xref ref-type="bibr" rid="B13">2008</xref>; Bhattacharyya et al., <xref ref-type="bibr" rid="B10">2010</xref>; Table <xref ref-type="table" rid="T1">1</xref>).</p>
<table-wrap position="float" id="T1">
<label>Table 1</label>
<caption><p><bold>CBD effects in psychiatric disorders</bold>.</p></caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th valign="top" align="left"><bold>Behavioral effect</bold></th>
<th valign="top" align="left"><bold>Model</bold></th>
<th valign="top" align="left"><bold>CBD dose/concentration range</bold></th>
<th valign="top" align="left"><bold>Route of administration/schedule</bold></th>
<th valign="top" align="left"><bold>Species/Strain</bold></th>
<th valign="top" align="left"><bold>Mechanisms investigated</bold></th>
<th valign="top" align="left"><bold>References</bold></th>
</tr>
</thead>
<tbody>
<tr style="background-color:#bbbdc0">
<td valign="top" align="left" colspan="7"><bold>PRECLINICAL STUDIES</bold></td>
</tr>
<tr>
<td valign="top" align="left">Antidepressant-like</td>
<td valign="top" align="left">Forced Swimming Test (FST)</td>
<td valign="top" align="left">30 mg/kg</td>
<td valign="top" align="left">Acute, i.p.</td>
<td valign="top" align="left">Swiss mice</td>
<td valign="top" align="left">5HT<sub>1A</sub></td>
<td valign="top" align="left">Zanelati et al., <xref ref-type="bibr" rid="B192">2010</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">FST and Tail Suspension Test (TST)</td>
<td valign="top" align="left">200 mg/kg</td>
<td valign="top" align="left">Acute, i.p.</td>
<td valign="top" align="left">Swiss Webster mice (FST) DBA/2 mice (TST)</td>
<td valign="top" align="left">Not determinated</td>
<td valign="top" align="left">El-Alfya et al., <xref ref-type="bibr" rid="B49">2010</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">FST</td>
<td valign="top" align="left">30 mg/kg</td>
<td valign="top" align="left">Acute and chronic, i.p.</td>
<td valign="top" align="left">Wistar rats</td>
<td valign="top" align="left">&#x02013;</td>
<td valign="top" align="left">R&#x000E9;us et al., <xref ref-type="bibr" rid="B156">2011</xref></td>
</tr>
<tr style="border-top: thin solid #000000;">
<td valign="top" align="left">Antidepressant-/Anxiolytic-like</td>
<td valign="top" align="left">Chronic Unpredictable Stress</td>
<td valign="top" align="left">30 mg/kg</td>
<td valign="top" align="left">Chronic, i.p.</td>
<td valign="top" align="left">GFAP-thymidine kinase (GFAP-TK) transgenic mice</td>
<td valign="top" align="left">CB1, increased neurogenesis and anandamide levels</td>
<td valign="top" align="left">Campos et al., <xref ref-type="bibr" rid="B23">2013b</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">Novelty Suppressed Feeding</td>
<td/>
<td/>
<td valign="top" align="left">C57BL6 mice</td>
<td/>
<td/>
</tr>
<tr>
<td/>
<td valign="top" align="left">Elevated Plus Maze (EPM)</td>
<td/>
<td/>
<td/>
<td/>
<td/>
</tr>
<tr style="border-top: thin solid #000000;">
<td valign="top" align="left">Antidepressant-like</td>
<td valign="top" align="left">FST and TST</td>
<td valign="top" align="left">3 and 30 mg/kg</td>
<td valign="top" align="left">Acute and chronic, i.p.</td>
<td valign="top" align="left">Swiss mice</td>
<td valign="top" align="left">Increased neurogenesis</td>
<td valign="top" align="left">Schiavon et al., <xref ref-type="bibr" rid="B166">2016</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">Olfactory bulbectomy</td>
<td valign="top" align="left">50 mg/kg</td>
<td valign="top" align="left">Acute and chronic, i.p.</td>
<td valign="top" align="left">C57BL6 mice</td>
<td valign="top" align="left">5HT<sub>1A</sub></td>
<td valign="top" align="left">Linge et al., <xref ref-type="bibr" rid="B117">2016</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">FST</td>
<td/>
<td valign="top" align="left">Intracerebral (mPFC), acute</td>
<td valign="top" align="left">Wistar rats</td>
<td valign="top" align="left">5HT<sub>1A</sub></td>
<td valign="top" align="left">Sartim et al., <xref ref-type="bibr" rid="B165">2016</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">FST</td>
<td valign="top" align="left">30 mg/kg</td>
<td valign="top" align="left">Acute, i.p.</td>
<td valign="top" align="left">Swiss mice</td>
<td valign="top" align="left">Not determinated</td>
<td valign="top" align="left">Breuer et al., <xref ref-type="bibr" rid="B15">2016</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">Saccharin consumption test</td>
<td valign="top" align="left">30 mg/kg</td>
<td valign="top" align="left">Oral, acute</td>
<td valign="top" align="left">Wistar-Kyoto (WKY) rat</td>
<td valign="top" align="left">Not determinated</td>
<td valign="top" align="left">Shoval et al., <xref ref-type="bibr" rid="B173">2016</xref></td>
</tr>
<tr style="border-top: thin solid #000000;">
<td valign="top" align="left">Antipsychotic</td>
<td valign="top" align="left">Repeated administration of the NMDA receptor antagonist MK-801</td>
<td valign="top" align="left">15&#x02013;60 mg/kg</td>
<td valign="top" align="left">14 days, i.p.</td>
<td valign="top" align="left">C57BL6/J mice</td>
<td valign="top" align="left">Attenuated parvalbumin loss and glial activation in the mPFC,</td>
<td valign="top" align="left">Gomes et al., <xref ref-type="bibr" rid="B69">2015a</xref>,<xref ref-type="bibr" rid="B70">b</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">Amphetamine sensitization model Prepulse inhibition (PPI)</td>
<td valign="top" align="left">100 ng/0.5 &#x003BC;L</td>
<td valign="top" align="left">Intra-NAc shell/acute</td>
<td valign="top" align="left">Sprague Dawley rats</td>
<td valign="top" align="left">Attenuated PPI disruption and increased dopamine system activity via a mTOR/p70S6Kinase signaling pathway</td>
<td valign="top" align="left">Renard et al., <xref ref-type="bibr" rid="B154">2016</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">Acute administration of the NMDA receptor antagonist MK-801</td>
<td valign="top" align="left">5 mg/kg</td>
<td valign="top" align="left">Acute, i.p.</td>
<td valign="top" align="left">Swiss mice</td>
<td valign="top" align="left">TRPV1 receptors</td>
<td valign="top" align="left">Long et al., <xref ref-type="bibr" rid="B119">2006</xref></td>
</tr>
<tr style="border-top: thin solid #000000;">
<td valign="top" align="left">Anxiolytic-like</td>
<td valign="top" align="left">EPM Vogel&#x02018;s conflict test</td>
<td valign="top" align="left">30 nmol</td>
<td valign="top" align="left">Intra-periqueductal gray matter</td>
<td valign="top" align="left">Wistar rats</td>
<td valign="top" align="left">5HT<sub>1A</sub></td>
<td valign="top" align="left">Campos and Guimar&#x000E3;es, <xref ref-type="bibr" rid="B20">2008</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">EPM</td>
<td valign="top" align="left">60 nmol</td>
<td valign="top" align="left">Intra-periqueductal gray matter</td>
<td valign="top" align="left">Wistar rats</td>
<td valign="top" align="left">TRPV1</td>
<td valign="top" align="left">Campos and Guimar&#x000E3;es, <xref ref-type="bibr" rid="B21">2009</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">Predator threat-induced long lasting behavioral alterations</td>
<td valign="top" align="left">5 mg/kg</td>
<td valign="top" align="left">7 days, i.p.</td>
<td valign="top" align="left">Wistar rats</td>
<td valign="top" align="left">5HT<sub>1A</sub></td>
<td valign="top" align="left">Campos et al., <xref ref-type="bibr" rid="B18">2012a</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">Elevated T-Maze</td>
<td valign="top" align="left">5 mg/kg</td>
<td valign="top" align="left">21 days, i.p.</td>
<td valign="top" align="left">Wistar rats</td>
<td valign="top" align="left">5HT<sub>1A</sub></td>
<td valign="top" align="left">Campos et al., <xref ref-type="bibr" rid="B17">2013a</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">Marble burying</td>
<td valign="top" align="left">15&#x02013;60 mg/kg</td>
<td valign="top" align="left">Acute, i.p.</td>
<td valign="top" align="left">Swiss mice</td>
<td valign="top" align="left">CB1</td>
<td valign="top" align="left">Casarotto et al., <xref ref-type="bibr" rid="B27">2010</xref></td>
</tr>
<tr style="border-top: thin solid #000000;">
<td valign="top" align="left">Anxiogenic-like</td>
<td valign="top" align="left">Contextual Fear conditioning</td>
<td valign="top" align="left">10 mg/kg</td>
<td valign="top" align="left">14 days, i.p.</td>
<td valign="top" align="left">Lister-hooded rats</td>
<td valign="top" align="left">Decreased levels of the phosphorylated form of ERK1/2 in the PFC</td>
<td valign="top" align="left">ElBatsh et al., <xref ref-type="bibr" rid="B50">2012</xref></td>
</tr>
<tr style="background-color:#bbbdc0">
<td valign="top" align="left" colspan="7"><bold>CLINICAL STUDIES</bold></td>
</tr>
<tr>
<td valign="top" align="left">Antipsychotic</td>
<td valign="top" align="left">Double blind controlled clinical trial</td>
<td valign="top" align="left">600&#x02013;800 mg</td>
<td valign="top" align="left">28 days, oral</td>
<td valign="top" align="left">Schizophrenia patients</td>
<td valign="top" align="left">Reduces psychotic symptoms similar to amisulpride</td>
<td valign="top" align="left">Leweke et al., <xref ref-type="bibr" rid="B113">2012</xref></td>
</tr>
<tr>
<td/>
<td valign="top" align="left">Placebo-controlled clinical trial</td>
<td valign="top" align="left">Not informed</td>
<td valign="top" align="left">Oral</td>
<td valign="top" align="left">Schizophrenia patients</td>
<td valign="top" align="left">Reduces psychotic symptoms in patients that have previously failed to respond adequately to first line anti-psychotic medications</td>
<td valign="top" align="left">GW Pharmaceuticals, <xref ref-type="bibr" rid="B78">2015</xref></td>
</tr>
<tr style="border-top: thin solid #000000;">
<td valign="top" align="left">Anxiolytic</td>
<td/>
<td valign="top" align="left">400 mg</td>
<td valign="top" align="left">Acute, oral</td>
<td/>
<td valign="top" align="left">&#x02193; Subjective anxiety and &#x02191; mental sedation.</td>
<td valign="top" align="left">Crippa et al., <xref ref-type="bibr" rid="B33">2004</xref></td>
</tr>
<tr>
<td/>
<td/>
<td/>
<td/>
<td/>
<td valign="top" align="left">&#x02193; Blood Flow in posterior cingulated cortex and Amygdala/Bed nucleus of stria terminalis and &#x02191; in left parahippocampal gyrus</td>
<td/>
</tr>
<tr>
<td/>
<td/>
<td valign="top" align="left">600 mg</td>
<td valign="top" align="left">Acute, oral</td>
<td/>
<td valign="top" align="left">&#x02193; Blood-oxygen-level dependent contrast imaging (BOLD) of amydala signal and amygdala-anterior cingulated connectivity during fearful faces presentations</td>
<td valign="top" align="left">Fusar-Poli et al., <xref ref-type="bibr" rid="B66">2009</xref>, <xref ref-type="bibr" rid="B65">2010</xref></td>
</tr>
<tr>
<td/>
<td/>
<td valign="top" align="left">600 mg</td>
<td valign="top" align="left">Acute, oral</td>
<td/>
<td valign="top" align="left">&#x02193; Activation left temporal and insular cortex during motor inhibition task</td>
<td valign="top" align="left">Borgwardt et al., <xref ref-type="bibr" rid="B13">2008</xref></td>
</tr>
</tbody>
</table>
<table-wrap-foot>
<p><italic>i.p., intraperitoneal; mPFC, medial prefrontal c&#x000F3;rtex; &#x02193;, decreases; &#x02191;, increases</italic>.</p>
</table-wrap-foot>
</table-wrap>
</sec>
</sec>
<sec id="s2">
<title>Mechanisms of CBD effects in neuropsychiatric disorders</title>
<p>The mechanism of action of CBD remains controversial and is yet unclear. Numerous signaling pathways have been proposed as candidates to mediate its neuroplastic effects (Izzo et al., <xref ref-type="bibr" rid="B91">2009</xref>; Fern&#x000E1;ndez-Ruiz et al., <xref ref-type="bibr" rid="B59">2013</xref>). The possible targets of CBD action have been extensively examined recently (Ibeas Bih et al., <xref ref-type="bibr" rid="B88">2015</xref>; Ligresti et al., <xref ref-type="bibr" rid="B116">2016</xref>). The present review will focus on mechanisms more closely associated with the neuropsychiatric effects of CBD, particularly those related to its neuroplastic effects.</p>
<p>Although several CBD actions are not directly mediated by canonical metabotropic CB<sub>1</sub>/CB<sub>2</sub> receptors, CBD can influence endocannabinoid (ECB) levels (Izzo et al., <xref ref-type="bibr" rid="B91">2009</xref>). While there are contradictory results, it was suggested that CBD exerts an antagonist or negative modulatory action, but with a low affinity, at CB<sub>1</sub> and CB<sub>2</sub> receptors (Thomas et al., <xref ref-type="bibr" rid="B182">2007</xref>; Laprairie et al., <xref ref-type="bibr" rid="B110">2015</xref>; McPartland et al., <xref ref-type="bibr" rid="B132">2015</xref>). At high concentrations, CBD can facilitate ECB-mediated actions <italic>in vitro</italic>, including CB<sub>1</sub>-neuromodulation by decreasing their hydrolysis mediated by Fatty acid amide hydrolase (FAAH) and Monoacylglycerol lipase (MAGL) or re-uptake (Bisogno et al., <xref ref-type="bibr" rid="B11">2001</xref>; De Petrocellis et al., <xref ref-type="bibr" rid="B41">2011</xref>). Another possible mechanism by which CBD decreases anandamide uptake/metabolism in humans, but not rodents, could be the binding to fatty acid binding proteins (FABPs), which is necessary for the transport of this ECB from the membrane to intracellular FAAH (Elmes et al., <xref ref-type="bibr" rid="B51">2015</xref>). The interaction of plant-derived cannabinoids with the ECB metabolism enzymes explains partially why some of the anxiolytic effects of CBD are mediated by CB<sub>1</sub> receptors (Casarotto et al., <xref ref-type="bibr" rid="B27">2010</xref>; Campos et al., <xref ref-type="bibr" rid="B17">2013a</xref>).</p>
<p>Like other cannabinoids, CBD produces bell-shaped dose-response curves and can act by different mechanisms accordingly to its concentration or the simultaneous presence of other cannabinoid-ligands (Campos et al., <xref ref-type="bibr" rid="B22">2012b</xref>; Ligresti et al., <xref ref-type="bibr" rid="B116">2016</xref>). CBD can regulate, directly or indirectly, the activity of peroxisome proliferator-activated receptor gamma (PPAR&#x003B3;), serotonin 5HT<sub>1A</sub> receptor, adenosine transporter, members of the TRPV family, and the metabotropic CB<sub>1</sub> and CB<sub>2</sub> receptors (Campos et al., <xref ref-type="bibr" rid="B22">2012b</xref>; Ligresti et al., <xref ref-type="bibr" rid="B116">2016</xref>).</p>
<sec>
<title>5HT<sub>1A</sub> receptors and the effects of CBD</title>
<p>The acute anxiolytic and antidepressive actions of acute CBD are proposed to be mediated by serotonin 5HT<sub>1A</sub> receptors. The crosstalk between cannabinoids and serotoninergic signaling, however, is complex. In rats, CBD administration into the dorsal portions of periaqueductal gray matter (dPAG) produces anti-aversive effects in the elevated plus maze and flight-induced by local electric stimulation. These effects were prevented by WAY-100635, a 5HT<sub>1A</sub> antagonist (Campos and Guimar&#x000E3;es, <xref ref-type="bibr" rid="B20">2008</xref>; Soares et al., <xref ref-type="bibr" rid="B175">2010</xref>). Other brain regions, such as the basal ganglia (Espejo-Porras et al., <xref ref-type="bibr" rid="B53">2013</xref>), the bed nucleus of stria terminallis (Gomes et al., <xref ref-type="bibr" rid="B71">2011</xref>), the prelimbic PFC (Foga&#x000E7;a et al., <xref ref-type="bibr" rid="B63">2014</xref>) and the dorsal raphe nucleus (Rock et al., <xref ref-type="bibr" rid="B157">2012</xref>; Katsidoni et al., <xref ref-type="bibr" rid="B96">2013</xref>), also seem to mediate CBD effects via 5HT<sub>1A</sub> receptors. Similarly, a 5HT<sub>1A</sub> antagonist prevented the anxiolytic, antistress, and antidepressive-like effects of acute, subchronic (7 days) (Resstel et al., <xref ref-type="bibr" rid="B155">2009</xref>; Zanelati et al., <xref ref-type="bibr" rid="B192">2010</xref>; Campos et al., <xref ref-type="bibr" rid="B18">2012a</xref>; Twardowschy et al., <xref ref-type="bibr" rid="B186">2013</xref>), or chronic (14 days) systemic administration of CBD (Campos et al., <xref ref-type="bibr" rid="B23">2013b</xref>).</p>
<p>The molecular mechanism by which CBD facilitates 5HT<sub>1A</sub> receptor activation remains unclear. Evidence suggests that it may involve allosteric modulation of this receptor, promoting 5HT<sub>1A</sub> agonist-related stimulation of [35S]GTP&#x003B3;S binding (Russo et al., <xref ref-type="bibr" rid="B158">2005</xref>; Rock et al., <xref ref-type="bibr" rid="B157">2012</xref>), increase in 5-HT release and/or reuptake inhibition (Linge et al., <xref ref-type="bibr" rid="B117">2016</xref>) or the indirect formation of heterodimers consisting of 5HT<sub>1A</sub> and other receptors, such as CB<sub>1</sub> (Mato et al., <xref ref-type="bibr" rid="B129">2010</xref>).</p>
</sec>
<sec>
<title>TRPV1 and the effects of CBD</title>
<p>CBD and other non-psychotomimetic phytocannabinoids can also act, at least in some cases, via the transient receptor potential vanilloid (TRPV) ion channel receptor family. CBD and cannabidivarin (CBDV) activate and desensitize TRPV1 <italic>in vitro</italic> (Iannotti et al., <xref ref-type="bibr" rid="B87">2014</xref>). TRPV1 receptors activation contributes to the bell-shaped dose-response curve of the anxiolytic action of CBD. The lack of effects observed with high doses of CBD was prevented when the animals were treated with a TRPV1 antagonist (Campos and Guimar&#x000E3;es, <xref ref-type="bibr" rid="B21">2009</xref>). TRPV1 also seem to participate in the antihyperalgesic effects of CBD (Costa et al., <xref ref-type="bibr" rid="B32">2004</xref>) as well as in the CBD effects on the sensorimotor gating disruption induced by NMDA antagonists (Long et al., <xref ref-type="bibr" rid="B119">2006</xref>).</p>
</sec>
<sec>
<title>Neuroplasticity and CBD effects in chronic stress</title>
<p>Several studies have addressed the effects of CBD administration in different models of stress. Among these models, chronic unpredictable stress (CUS) produces anxiety and depression-like behaviors and cognitive impairment, which are accompanied by reduced levels of neurotrophins (i.e., BDNF and others important for neuronal survival), impaired hippocampal neurogenesis and dendritic arborization, and neuroinflammatory response (microgliosis and astrogliosis; Farooq et al., <xref ref-type="bibr" rid="B58">2012</xref>; Campos et al., <xref ref-type="bibr" rid="B23">2013b</xref>). Chronic CBD administration counteracts the behavioral and neuroplastic consequences of CUS in adult mice by a complex interplay of different mechanisms (Campos et al., <xref ref-type="bibr" rid="B23">2013b</xref>).</p>
<sec>
<title>CBD and hippocampal adult neurogenesis</title>
<p>Adult neurogenesis is a complex process that involves division, survival (not all cells that divide will survive), migration, and differentiation of new cells (Kempermann, <xref ref-type="bibr" rid="B100">2008</xref>; Suh et al., <xref ref-type="bibr" rid="B179">2009</xref>; Deng et al., <xref ref-type="bibr" rid="B40">2010</xref>). Although, neuronal proliferative capacity has been reported in different brain regions (Chaker et al., <xref ref-type="bibr" rid="B31">2016</xref>), it is well accepted that two areas have an effective neurogenic potential under physiological conditions: the subventricular zone (SVZ), comprising the lateral walls of the lateral ventricle, and the subgranular zone (SGZ) of the dentate gyrus of the hippocampus (Kempermann et al., <xref ref-type="bibr" rid="B102">2004</xref>). Both regions have a small population of neural stem/progenitor cells that originate neurons, astrocytes, and oligodendrocytes (Kempermann and Gage, <xref ref-type="bibr" rid="B101">2000</xref>).</p>
<p>Hippocampal neurogenesis is necessary for at least some forms of learning and memory (Kempermann and Gage, <xref ref-type="bibr" rid="B101">2000</xref>). In addition, decreased adult hippocampal neurogenesis has been associated with psychiatric disorders such as anxiety, schizophrenia, and mood disorders. Disturbed adult hippocampal neurogenesis may be one of the contributors to the loss of hippocampal volume reported in patients suffering from these disorders (Sheline et al., <xref ref-type="bibr" rid="B172">1996</xref>). In animal models, exposure to chronic stress induces both depressive and anxiogenic-like behavior and an impairment of the dentate gyrus subgranular zone (SGZ) neurogenesis (Gould et al., <xref ref-type="bibr" rid="B74">1997</xref>; Goul et al., <xref ref-type="bibr" rid="B73">1998</xref>; Tanapat et al., <xref ref-type="bibr" rid="B181">1998</xref>). Snyder et al. (<xref ref-type="bibr" rid="B174">2011</xref>) showed that neurogenesis-deficient mice presented a heightened stress-induced depressive-like behavior and impaired hypothalamus-pituitary-adrenal axis response to stress. Interestingly, classical antidepressants increase neurogenesis in a time span similar to the latency required for their therapeutic effects (Malberg et al., <xref ref-type="bibr" rid="B126">2000</xref>; Manev et al., <xref ref-type="bibr" rid="B127">2001</xref>). Additionally, when neurogenesis is blocked, some behavioral effects of fluoxetine and imipramine disappear (Santarelli et al., <xref ref-type="bibr" rid="B163">2003</xref>; Airan et al., <xref ref-type="bibr" rid="B1">2007</xref>; David et al., <xref ref-type="bibr" rid="B37">2009</xref>).</p>
<p>Although several reports have investigated the potential use <italic>C. sativa</italic> derivatives in mood and anxiolytic disorders, the effects of cannabinoids on hippocampal neurogenesis was an unexplored issue until the mid-2000&#x00027;s. Jiang et al. (<xref ref-type="bibr" rid="B95">2005</xref>) observed that chronic treatment with the synthetic cannabinoid HU210 enhanced neurogenesis in rats. Wolf et al. (<xref ref-type="bibr" rid="B190">2010</xref>) investigated the effect of a 6 weeks treatment with a CBD-rich diet in mice and reported an increased number of cells positive for the thymidine analog bromodeoxyuridine (BrdU) in the hippocampus, reflecting increased neural progenitor cell proliferation. This facilitation of hippocampal neurogenesis seemed to depend on CB<sub>1</sub> receptors since it was absent in animals lacking this cannabinoid receptor. Another report showed that repeated CBD administration prevented the reduction in neurogenesis in a murine model of Alzheimer&#x00027;s disease through a PPAR&#x003B3;-dependent mechanism (Esposito et al., <xref ref-type="bibr" rid="B56">2011</xref>).</p>
<p>The first study to directly investigate if the behavioral effects of repeated CBD administration are mediated by its pro-neurogenic action was performed by Campos et al. (<xref ref-type="bibr" rid="B17">2013a</xref>). They showed that CBD reversed the anxiogenic effect and decreased neurogenesis in CUS-exposed wild-type mice. Interestingly, reforcing the pro-neurogenic effects of CBD, the anti-stress effect of CBD was not observed in transgenic GFAP/thymidine kinase mice where neurogenesis was abolished. CBD effects were also prevented by pharmacological antagonism of CB<sub>1</sub> and CB<sub>2</sub> receptors, suggesting that the anti-stress effects CBD depend on facilitation of hippocampal neurogenesis through a mechanism that involves increased ECB levels (Campos et al., <xref ref-type="bibr" rid="B17">2013a</xref>). Interestingly, Demirakca et al. (<xref ref-type="bibr" rid="B39">2011</xref>) suggested that in chronic heavy Cannabis users, higher THC and lower CBD concentrations were associated with diminished hippocampal gray matter and low cognitive performance, while higher CBD concentrations in the consumed <italic>Cannabis</italic> samples prevented THC-induced neurotoxic effects. To explain these findings, the authors suggested that the CBD neuroprotective effects would occur through a mechanism that facilitates hippocampal neurogenesis (Demirakca et al., <xref ref-type="bibr" rid="B39">2011</xref>). However, as will be discussed bellow, the role of neurogenesis in CBD effects is complex and may depend on the stress level (Schiavon et al., <xref ref-type="bibr" rid="B166">2016</xref>).</p>
</sec>
<sec>
<title>CBD and synaptic remodeling</title>
<p>Synaptic plasticity could be a major target to treat mental disorders. Indeed, besides modulating neurogenesis, pre-clinical findings suggest that usual (SSRIs) and rapid-acting antidepressants, such as ketamine, may increase or restore the synaptic function impaired by chronic stress through a modulation of plastic changes. These effects may involve dendritic spines density, dendritic length and branches, neurotrophic factors (BNDF) and synaptic proteins such as synapsin, synaptophysin, post-synaptic density protein 95 (PSD95) and metabotropic glutamate receptors (mGluR), in the hippocampus and PFC (Li et al., <xref ref-type="bibr" rid="B115">2010</xref>; Duman et al., <xref ref-type="bibr" rid="B47">2016</xref>). These effects are mediated by several intracellular pathways that control neuronal plasticity, protection and survival, including protein kinase B (Akt), extracellular-signal regulated kinases (Erk1/2), glycogen synthase kinase 3&#x003B2; (GSK3&#x003B2;) and mammalian target of rapamycin (mTOR, Bockaert and Marin, <xref ref-type="bibr" rid="B12">2015</xref>; Duman et al., <xref ref-type="bibr" rid="B47">2016</xref>).</p>
<p>Evidence suggests that CBD can interfere with stress-induced synaptic remodeling. CBD normalized synaptophysin levels in rats submitted to a brain damage by iron overload (da Silva et al., <xref ref-type="bibr" rid="B36">2014</xref>) and produced a neuritogenic effect in PC12 cells, increasing the expression of synaptophysin and synapsin I. These effects were inhibited by a TrkA antagonist (Santos et al., <xref ref-type="bibr" rid="B164">2015</xref>). In addition, CBD can modulate intracellular pathways directly related to synaptic remodeling, such as Erk1/2 and Akt, in different types of cancer cell lines (McAllister et al., <xref ref-type="bibr" rid="B131">2011</xref>; Solinas et al., <xref ref-type="bibr" rid="B176">2013</xref>). Its precise effects in different brain regions, however, are still unclear. For example, repeated CBD administration (14 days) enhanced contextual conditioned fear responses and decreased phosphorylated forms of Erk1/2 levels in the PFC (ElBatsh et al., <xref ref-type="bibr" rid="B50">2012</xref>). Since fear acquisition took place under treatment with CBD, learning/memory facilitation could also explain/contribute to this finding.</p>
<p>In chronically stressed mice, repeated CBD treatment also promoted dendritic remodeling and increased the expression of PSD95, Synapsin I/II, and p-GSK3&#x003B2; in the hippocampus of animals submitted to CUS (Foga&#x000E7;a, <xref ref-type="bibr" rid="B61">2016</xref>).</p>
</sec>
</sec>
<sec>
<title>CBD and antidepressant effects</title>
<p>The first experimental evidence indicating that CBD induces antidepressant-like effects is based on its ability to attenuate autonomic and behavioral responses induced by previously inescapable stress exposure in rats (Resstel et al., <xref ref-type="bibr" rid="B155">2009</xref>). These CBD effects were blocked by pre-treatment with WAY100635, a 5HT<sub>1A</sub> antagonist. Following this study, our group investigated CBD effects in animals submitted to the forced swimming test (FST) (Zanelati et al., <xref ref-type="bibr" rid="B192">2010</xref>) a widely used animal model predictive of antidepressant effects (Cryan et al., <xref ref-type="bibr" rid="B34">2002</xref>). Systemic CBD treatment reduced immobility time in mice, as did the prototype tricyclic antidepressant imipramine (Zanelati et al., <xref ref-type="bibr" rid="B192">2010</xref>). Similar results were shown in mice submitted to the FST or the tail suspension test (TST) (El-Alfya et al., <xref ref-type="bibr" rid="B49">2010</xref>; R&#x000E9;us et al., <xref ref-type="bibr" rid="B156">2011</xref>; Schiavon et al., <xref ref-type="bibr" rid="B166">2016</xref>). More recently, the antidepressant-like effect of CBD was detected in the olfactory bulbectomy (Linge et al., <xref ref-type="bibr" rid="B117">2016</xref>) and learned helplessness models (Pereira et al., <xref ref-type="bibr" rid="B147">2016</xref>). CBD was also effective in rat strains that naturally express &#x0201C;depressive-like behaviors,&#x0201D; such as the Wistar-Kyoto (Shoval et al., <xref ref-type="bibr" rid="B173">2016</xref>). Altogether, this data strengthen the possibility that CBD can induce antidepressant effects. However, the mechanisms involved in this effect have only recently started to be investigated. As discussed above, similar to the acute anxiolytic effects, the acute antidepressant effect of CBD seems to depend on facilitation of 5HT<sub>1A</sub> receptor-mediated neurotransmission (Zanelati et al., <xref ref-type="bibr" rid="B192">2010</xref>).</p>
<p>Preclinical and clinical studies indicate that forebrain 5HT<sub>1A</sub> receptors are important targets of antidepressant drugs (Samuels et al., <xref ref-type="bibr" rid="B162">2015</xref>; Kaufman et al., <xref ref-type="bibr" rid="B97">2016</xref>). The mechanisms of this effect are still unclear, but these receptors interfere in neuroplastic events that have been associated with antidepressant action such as BDNF release and neurogenesis (Mahar et al., <xref ref-type="bibr" rid="B125">2014</xref>; Serafini et al., <xref ref-type="bibr" rid="B170">2014</xref>; Samuels et al., <xref ref-type="bibr" rid="B162">2015</xref>; Zhang et al., <xref ref-type="bibr" rid="B193">2016</xref>). However, acute or sub-chronic CBD treatment failed to change hippocampal BDNF levels (Zanelati et al., <xref ref-type="bibr" rid="B192">2010</xref>; Campos et al., <xref ref-type="bibr" rid="B18">2012a</xref>). R&#x000E9;us et al. (<xref ref-type="bibr" rid="B156">2011</xref>) reported similar results in three brain regions (PFC, hippocampus, and amygdala) after acute treatment with doses that induced antidepressant-like effects in rats submitted to the FST. Despite these negative results, BDNF involvement in the plastic changes induced by CBD cannot be ruled out. Methodological issues such as measurement of the whole BDNF content (not distinguishing stored and released pools), problems with the punching method, and the possibility that CBD increases BDNF release in specific subregions (Fanselow and Dong, <xref ref-type="bibr" rid="B57">2010</xref>; O&#x00027;Leary and Cryan, <xref ref-type="bibr" rid="B141">2014</xref>; Suzuki et al., <xref ref-type="bibr" rid="B180">2016</xref>) indicate that additional research on this topic is needed.</p>
<p>Another possibility to explain CBD-induced acute antidepressant effects would be the fast modulation of the neurochemical environment in limbic brain regions. In a recent work by Linge et al. (<xref ref-type="bibr" rid="B117">2016</xref>), a single CBD injection induced rapid antidepressant-like effect in the olfactory bulbectomy mouse model. This effect was associated with increased extracellular 5-HT and glutamate levels in the ventromedial prefrontal cortex (vmPFC). The 5HT<sub>1A</sub>-receptor antagonist WAY100635 prevented the behavioral and neurochemical effects of CBD. To explain these results, the authors suggested that CBD acute effects would be mediated by disinhibition of 5-HT and glutamatergic neurotransmission in the vmPFC through the modulation of 5HT<sub>1A</sub> receptor (Linge et al., <xref ref-type="bibr" rid="B117">2016</xref>). In agreement with this proposal, bilateral microinjections of CBD into the vmPFC induced antidepressant-like effect in rats submitted to the FST. This effect was blocked by pre-treatment with WAY100635 or by the CB<sub>1</sub> antagonist AM251 (Sartim et al., <xref ref-type="bibr" rid="B165">2016</xref>). Since the antidepressant-like effect induced by the endogenous cannabinoid anandamide was also blocked by 5HT<sub>1A</sub> receptor antagonist, it was hypothesized that CBD effects on 5HT<sub>1A</sub> receptors would be due to indirect modulation of local 5-HT levels via CB<sub>1</sub> activation. Therefore, this data support the hypothesis that acute CBD effects could involve rapid neurochemical changes, such as in the ECB and serotonergic systems, in the vmPFC. CBD effects in other brain regions remain to be examined.</p>
<p>Repeated administration of CBD can prevent the impairment in neurogenesis induced by CUS (Campos et al., <xref ref-type="bibr" rid="B23">2013b</xref>). At a lower dose, CBD decreased depressive-like behaviors in non-stressed Swiss mice in the TST and increased the number of Ki67, BrdU, and doublecortin-positive cells, reflecting an enhanced SGZ neurogenesis (Schiavon et al., <xref ref-type="bibr" rid="B166">2016</xref>). In this study, however, a higher CBD dose, despite still displaying an antidepressant-like effect, decreased the number of positive cell markers for the neurogenesis in the hippocampus (Schiavon et al., <xref ref-type="bibr" rid="B166">2016</xref>). More studies, therefore, are needed to unveil an involvement of hippocampal neurogenesis in the antidepressive-like effects of CBD. Additionally, as discussed above, the participation of rapid plastic changes such as synaptic remodeling in acute CBD effects needs to be further investigated.</p>
<p>Epigenetics mechanisms could also be involved in the antidepressant effects of CBD. Psychiatric disorders are thought to originate from a complex interplay between genetic predisposition and environmental factors such as stress exposure. These factors may also modulate gene expression through interference with epigenetic mechanisms (Tsankova et al., <xref ref-type="bibr" rid="B185">2007</xref>; Borrelli et al., <xref ref-type="bibr" rid="B14">2008</xref>). They include covalent DNA modifications (e.g., DNA methylation), post-translational modifications of histone tails (e.g., methylation, acetylation, phosphorylation, and ubiquitination), as well as non-translational gene silencing mechanisms (e.g., micro-RNAs, ribonucleic acid; Krishnan and Nestler, <xref ref-type="bibr" rid="B109">2008</xref>; Kim et al., <xref ref-type="bibr" rid="B103">2009</xref>). Epigenetic changes have been related to the neurobiology of various neuropsychiatric disorders, including depression (Tsankova et al., <xref ref-type="bibr" rid="B185">2007</xref>; Klengel et al., <xref ref-type="bibr" rid="B104">2014</xref>), and antidepressant drugs can interfere with these changes. For example, antidepressants decrease the activity of DNA methyltransferases <italic>in vitro</italic> (Zimmermann et al., <xref ref-type="bibr" rid="B194">2012</xref>) and alter gene transcription via epigenetic mechanisms in different brain structures associated with depression (Toffoli et al., <xref ref-type="bibr" rid="B183">2014</xref>). Consistent with the idea that decreasing stress-induced DNA methylation could induce antidepressant effects, administration of DNMT inhibitors (Sales et al., <xref ref-type="bibr" rid="B161">2011</xref>) as well as DNMT1 knockout (Morris et al., <xref ref-type="bibr" rid="B138">2016</xref>) induced antidepressant-like effects in the FST.</p>
<p>A recent work by Pucci et al. (<xref ref-type="bibr" rid="B150">2013</xref>) demonstrated that CBD could also modulate epigenetic mechanisms by reducing global DNA methylation in human keratinocytes cells. Since stress appears to increase DNA methylation, this finding raised the possibility that the antidepressant-like effects of CBD involve epigenetic mechanism, such as DNA methylation.</p>
</sec>
<sec>
<title>CBD and antipsychotic effects</title>
<p>Preclinical and clinical studies indicate that CBD also has a potential therapeutic role in schizophrenia. CBD attenuates schizophrenia-related behavioral abnormalities (i.e., psychostimulant-induced hyperlocomotion, decreased sensorimotor gating, deficits in cognitive function, and decreased social interaction) in pharmacological, genetic, and neurodevelopmental animal models (Moreira and Guimar&#x000E3;es, <xref ref-type="bibr" rid="B136">2005</xref>; Gururajan et al., <xref ref-type="bibr" rid="B77">2012</xref>; Long et al., <xref ref-type="bibr" rid="B118">2012</xref>; Levin et al., <xref ref-type="bibr" rid="B112">2014</xref>; Gomes et al., <xref ref-type="bibr" rid="B69">2015a</xref>,<xref ref-type="bibr" rid="B70">b</xref>; Pedrazzi et al., <xref ref-type="bibr" rid="B145">2015</xref>; Renard et al., <xref ref-type="bibr" rid="B154">2016</xref>) with a profile similar to atypical antipsychotics (Zuardi et al., <xref ref-type="bibr" rid="B196">1991</xref>, <xref ref-type="bibr" rid="B195">1995</xref>; Guimar&#x000E3;es et al., <xref ref-type="bibr" rid="B76">2004</xref>). In humans, the antipsychotic properties of CBD were confirmed in a double-blind clinical trial where CBD reduced psychotic symptoms with a similar efficacy to the atypical antipsychotic amisulpride, but with significantly fewer side effects (Leweke et al., <xref ref-type="bibr" rid="B113">2012</xref>). More recently, a placebo-controlled clinical trial with 88 schizophrenia patients who remained on their antipsychotic medication and were randomized to receive CBD or placebo as adjunct therapy also showed that it was consistently superior to placebo in alleviating psychotic symptoms (GW Pharmaceuticals, <xref ref-type="bibr" rid="B78">2015</xref>). In this study, CBD also tended to improve negative and cognitive symptoms. Current antipsychotics show limited effectiveness in targeting these symptoms (Elvevag and Goldberg, <xref ref-type="bibr" rid="B52">2000</xref>; Hanson et al., <xref ref-type="bibr" rid="B82">2010</xref>).</p>
<p>The mechanisms by which CBD exert its antipsychotic effects are currently unknown. Leweke et al. showed that the alleviation of psychotic symptoms in patients treated with CBD was significantly associated with an increase in serum AEA levels (Leweke et al., <xref ref-type="bibr" rid="B113">2012</xref>). In the same study, they confirmed that CBD inhibited FAAH activity <italic>in vitro</italic> (Leweke et al., <xref ref-type="bibr" rid="B113">2012</xref>). Thus, by indirectly activating CB<sub>1</sub> receptors via increased AEA levels, CBD could potentially modulate other neurotransmitters systems (Campos et al., <xref ref-type="bibr" rid="B22">2012b</xref>). Additionally, a recent study using amphetamine sensitization model of schizophrenia suggest that its antipsychotic actions are dependent on the mTOR signaling pathway (Renard et al., <xref ref-type="bibr" rid="B154">2016</xref>). However, other mechanisms such as anti-inflammatory and neuroprotective could also contribute to the beneficial effects of CBD in schizophrenia (Gomes et al., <xref ref-type="bibr" rid="B70">2015b</xref>; Campos et al., <xref ref-type="bibr" rid="B19">2016</xref>). The CBD antipsychotic effects may also involve parvalbumin-positive GABA neurons. These neurons are fast-spiking GABAergic interneurons, which synapse on the cell body or the axon initial segment of pyramidal neurons, promoting synchronization and temporal control of the information flow through the pyramidal neurons (Lewis et al., <xref ref-type="bibr" rid="B114">2005</xref>). Parvalbumin-positive GABA neurons are selectively altered in schizophrenia patients (Lewis et al., <xref ref-type="bibr" rid="B114">2005</xref>) and can account for abnormal circuit synchrony and cognitive deficits in this disorder (Gonzalez-Burgos and Lewis, <xref ref-type="bibr" rid="B72">2012</xref>). Similar to patients, different rodent models of schizophrenia show deficits in the function of these cells (Penschuck et al., <xref ref-type="bibr" rid="B146">2006</xref>; Gomes et al., <xref ref-type="bibr" rid="B69">2015a</xref>; Canetta et al., <xref ref-type="bibr" rid="B24">2016</xref>).</p>
<p>Recently, we observed that CBD attenuated the decreased number of parvalbumin-positive cells in the mPFC induced by repeated administration of the NMDA receptor antagonist MK-801 in mice (Gomes et al., <xref ref-type="bibr" rid="B69">2015a</xref>). Parvalbumin loss induced by NMDA antagonists has been associated with increased oxidative stress (Behrens et al., <xref ref-type="bibr" rid="B5">2007</xref>). The high-energy demands of parvalbumin interneurons make them particularly vulnerable to this process (Steullet et al., <xref ref-type="bibr" rid="B178">2016</xref>). Impairment in antioxidant systems can lead to a diffusion of excessive reactive oxygen species outside the parvalbumin cell and induce glial activation (Morishita et al., <xref ref-type="bibr" rid="B137">2015</xref>). However, glial changes could also be a consequence of high local levels of glutamate due to parvalbumin interneuron dysfunction, which leads to disinhibition of glutamate release from pyramidal neurons targeted by those interneurons (Nakazawa et al., <xref ref-type="bibr" rid="B140">2012</xref>). Given that glial cells have a pivotal role in glutamate homeostasis (Bezzi et al., <xref ref-type="bibr" rid="B9">1999</xref>; Shaked et al., <xref ref-type="bibr" rid="B171">2005</xref>), changes in their activity may result from a compensatory mechanism in an attempt to normalize, for example, glutamate levels.</p>
<p>In our study, besides the changes in parvalbumin expression, the MK-801 treatment increased the expression of astrocytic and microglial cell markers in the mPFC (Gomes et al., <xref ref-type="bibr" rid="B70">2015b</xref>), similar to what has been observed in <italic>post-mortem</italic> brain of schizophrenia patients (Radewicz et al., <xref ref-type="bibr" rid="B151">2000</xref>; Catts et al., <xref ref-type="bibr" rid="B30">2014</xref>). These effects were also attenuated by repeated CBD treatment (Gomes et al., <xref ref-type="bibr" rid="B70">2015b</xref>) by mechanisms that are now under investigation. Suitable candidates are its antioxidant properties, activation of PPAR&#x003B3; or CB<sub>1</sub> and/or CB<sub>2</sub> receptors by the indirect increase in AEA levels (Campos et al., <xref ref-type="bibr" rid="B22">2012b</xref>). These mechanisms can also be involved in the attenuation of increased glial reactivity by CBD in animal models related to other neuropathological conditions (Mecha et al., <xref ref-type="bibr" rid="B133">2013</xref>; Perez et al., <xref ref-type="bibr" rid="B148">2013</xref>; Schiavon et al., <xref ref-type="bibr" rid="B167">2014</xref>).</p>
</sec>
<sec>
<title>CBD and neuroprotective mechanisms</title>
<p>Neuroprotection constitutes an important mechanism of neuropsychiatric drugs&#x00027; action to preserve structure and function of neural cells, promoting a protection against oxidative stress, iron, excitotoxicity, protein aggregation, organelles damage, and inflammation (Kaur and Ling, <xref ref-type="bibr" rid="B98">2008</xref>; Filipovi&#x00107; et al., <xref ref-type="bibr" rid="B60">2017</xref>). An imbalance in these processes are found in animal models of depression, anxiety, stroke and neurodegenerative diseases such as Alzheimer&#x00027;s, Huntington&#x00027;s, Parkinson&#x00027;s, and multiple sclerosis (Kaur and Ling, <xref ref-type="bibr" rid="B98">2008</xref>; Filipovi&#x00107; et al., <xref ref-type="bibr" rid="B60">2017</xref>).</p>
<p>Antioxidants compounds act against oxidative stress, a condition characterized by an exacerbation of reactive oxygen/nitrogen species (ROS/RNS) production and, consequently, peroxidation of polyunsaturated fatty acids, DNA oxidation, and nitration/carbonylation of proteins, leading to cell damage or death (Pisoschi and Pop, <xref ref-type="bibr" rid="B149">2015</xref>). One of the first studies relating CBD to neuroprotection showed that it acts as an antioxidant, preventing NMDA- and kainate receptor-mediated neurotoxicity and hydroperoxide-induced oxidative damage in rat cortical neuron culture, through a mechanism independent of cannabinoid receptors (Hampson et al., <xref ref-type="bibr" rid="B81">1998</xref>). In these assays, CBD demonstrated a superior neuroprotective activity than other known antioxidants such as alpha-tocopherol and ascorbate (Hampson et al., <xref ref-type="bibr" rid="B81">1998</xref>). Other studies have shown that neuroprotective effects of CBD are associated with its antioxidant properties (Table <xref ref-type="table" rid="T2">2</xref>). CBD decreases the neuronal damage promoted by &#x003B2;-amyloid protein deposit (Iuvone et al., <xref ref-type="bibr" rid="B90">2004</xref>; Esposito et al., <xref ref-type="bibr" rid="B54">2006</xref>, <xref ref-type="bibr" rid="B56">2011</xref>; Sagredo et al., <xref ref-type="bibr" rid="B160">2007</xref>; Harvey et al., <xref ref-type="bibr" rid="B84">2012</xref>; Janefjord et al., <xref ref-type="bibr" rid="B93">2014</xref>; Scuderi et al., <xref ref-type="bibr" rid="B169">2014</xref>) and attenuates the depletion of tyrosine hydroxylase, dopamine, and GABA levels by modulating the expression of the inducible isoform of nitric oxide synthase and reducing the production of ROS-generating NADPH oxidases (Esposito et al., <xref ref-type="bibr" rid="B54">2006</xref>, <xref ref-type="bibr" rid="B55">2007</xref>; Garcia-Arencibia et al., <xref ref-type="bibr" rid="B67">2007</xref>; Sagredo et al., <xref ref-type="bibr" rid="B160">2007</xref>, <xref ref-type="bibr" rid="B159">2011</xref>; Pan et al., <xref ref-type="bibr" rid="B143">2009</xref>). These effects seem to occur, in part, by activation of PPAR&#x003B3; receptors (Esposito et al., <xref ref-type="bibr" rid="B56">2011</xref>; Scuderi et al., <xref ref-type="bibr" rid="B169">2014</xref>) and ubiquitination of amyloid precursor protein (Scuderi et al., <xref ref-type="bibr" rid="B169">2014</xref>). CBD protective responses were also accompanied by an increase in cell survival through inhibition of ROS/RNS production, a decrease in malondialdehyde and caspase-3 levels, inhibition of DNA fragmentation (Iuvone et al., <xref ref-type="bibr" rid="B90">2004</xref>), and reduces de activity of NF-&#x003BA;B (Kozela et al., <xref ref-type="bibr" rid="B108">2010</xref>). In addition, CBD exerts antioxidant activities against toxicity and/or oxidative stress produced by H<sub>2</sub>O<sub>2</sub>, tertbutyl hydroperoxide, and amphetamine (Valvassori et al., <xref ref-type="bibr" rid="B189">2011</xref>; Harvey et al., <xref ref-type="bibr" rid="B84">2012</xref>; Mecha et al., <xref ref-type="bibr" rid="B134">2012</xref>). Moreover, CBD pre-treatment attenuates high-glucose-induced mitochondrial superoxide generation and NF-&#x003BA;B activation, along with the expression of the adhesion molecules ICAM-1 and VCAM-1 (Rajesh et al., <xref ref-type="bibr" rid="B152">2007</xref>).</p>
<table-wrap position="float" id="T2">
<label>Table 2</label>
<caption><p><bold>CBD and neuroprotective mechanisms</bold>.</p></caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th valign="top" align="left"><bold>Main effect of CBD</bold></th>
<th valign="top" align="left"><bold>Model</bold></th>
<th valign="top" align="left"><bold>CBD Dose/concentration range</bold></th>
<th valign="top" align="left"><bold>Route of administration</bold></th>
<th valign="top" align="left"><bold>Species/Strain</bold></th>
<th valign="top" align="left"><bold>Possible mechanism of action</bold></th>
<th valign="top" align="left"><bold>References</bold></th>
</tr>
</thead>
<tbody>
<tr>
<td valign="top" align="left">Prevents NMDA receptor-induced excitoxicity</td>
<td valign="top" align="left">E17 cortical neurons culture</td>
<td valign="top" align="left">EC50 &#x0003D; 3.7 &#x003BC;M</td>
<td valign="top" align="left"><italic>In vitro</italic></td>
<td valign="top" align="left">Wistar rat</td>
<td valign="top" align="left">Effect independent of cannabinoid receptors.</td>
<td valign="top" align="left">Hampson et al., <xref ref-type="bibr" rid="B81">1998</xref></td>
</tr>
<tr>
<td valign="top" align="left">&#x02193;Phosphorylated form of p38/MAP kinase, &#x02193;Caspase 3 levels, and NF&#x003BA;-b activation</td>
<td valign="top" align="left">&#x003B2; amyloid-induced neurotoxicity in PC12 cells</td>
<td valign="top" align="left">10 &#x003BC;M</td>
<td valign="top" align="left"><italic>In vitro</italic></td>
<td valign="top" align="left">PC12 cells</td>
<td valign="top" align="left">Antioxidant</td>
<td valign="top" align="left">Esposito et al., <xref ref-type="bibr" rid="B54">2006</xref></td>
</tr>
<tr>
<td valign="top" align="left">Prevented gliosis, neuronal death and &#x02191; hippocampal neurogenesis</td>
<td valign="top" align="left">Genetic model of Alzheimer&#x00027;s Disease</td>
<td valign="top" align="left">10 mg/kg</td>
<td valign="top" align="left">15 days</td>
<td valign="top" align="left">C57BL6 mice</td>
<td valign="top" align="left">PPAR&#x003B3;</td>
<td valign="top" align="left">Esposito et al., <xref ref-type="bibr" rid="B56">2011</xref></td>
</tr>
<tr>
<td valign="top" align="left">&#x02193;A&#x003B2; cell viability and &#x02193;LPS (conditioned media) induced microglia activation</td>
<td valign="top" align="left">&#x003B2; amyloid -induced neuronal toxicity in neuroblastoma cells. LPS-induced microglial-activation</td>
<td valign="top" align="left">10 &#x003BC;M</td>
<td valign="top" align="left"><italic>In vitro</italic></td>
<td valign="top" align="left">Neuroblastoma (SH-SY5Y) cells/Microglial (BV-2) cells</td>
<td valign="top" align="left">Not determinated</td>
<td valign="top" align="left">Janefjord et al., <xref ref-type="bibr" rid="B93">2014</xref></td>
</tr>
<tr>
<td valign="top" align="left">Improved cell viability</td>
<td valign="top" align="left">Amyloid &#x003B2; -induced toxicity and tert-butyl hydroperoxide-induced oxidative stress</td>
<td valign="top" align="left">0.01&#x02013;10 &#x003BC;M</td>
<td valign="top" align="left">15 min pre-incubation before A&#x003B2; or sA&#x003B2; addition/ 24-h incubation for oxidative stress analysis</td>
<td valign="top" align="left">PC12 and Neuroblastoma (SH-SYS5) cells</td>
<td valign="top" align="left">Not determinated</td>
<td valign="top" align="left">Harvey et al., <xref ref-type="bibr" rid="B84">2012</xref></td>
</tr>
<tr>
<td valign="top" align="left">&#x02193; Amyloid- &#x003B2; production</td>
<td valign="top" align="left">Amyloid &#x003B2; -induced neurotoxicity</td>
<td valign="top" align="left">100 nM</td>
<td valign="top" align="left">24 h</td>
<td valign="top" align="left">SHSY5Y (APP&#x0002B;) neurons</td>
<td valign="top" align="left">PPAR&#x003B3;</td>
<td valign="top" align="left">Scuderi et al., <xref ref-type="bibr" rid="B169">2014</xref></td>
</tr>
<tr>
<td valign="top" align="left">Reversed 3-nitropropionic acid&#x02014;induced &#x02193; GABA contents, &#x02193; substance P, &#x02193; neuronal-specific enolase and superoxide dismutase(SOD)-2</td>
<td valign="top" align="left">(10 mg/kg) 3-nitropropionic acid-induced) striatal lesions</td>
<td valign="top" align="left">5 mg/kg</td>
<td valign="top" align="left">5 days, i.p.</td>
<td valign="top" align="left">Sprague-Dawley rats</td>
<td valign="top" align="left">Independent of CB<sub>1</sub>, TRPV<sub>1</sub> and A<sub>2A</sub> receptors</td>
<td valign="top" align="left">Sagredo et al., <xref ref-type="bibr" rid="B160">2007</xref></td>
</tr>
<tr>
<td valign="top" align="left">&#x02193; Levels of IL-1beta, GFAP and iNOS</td>
<td valign="top" align="left">Amyloid &#x003B2; -induced neurotoxicity</td>
<td valign="top" align="left">10 mg/kg</td>
<td valign="top" align="left">i.p.</td>
<td valign="top" align="left">C57BL6 mice</td>
<td valign="top" align="left">Not determinated</td>
<td valign="top" align="left">Esposito et al., <xref ref-type="bibr" rid="B55">2007</xref></td>
</tr>
<tr>
<td valign="top" align="left">Reduced dopamine depletion and &#x02191;mRNA levels of SOD in the substantia nigra</td>
<td valign="top" align="left">6-hydroxydopamine toxicity</td>
<td valign="top" align="left">3 mg/kg</td>
<td valign="top" align="left">14 days, i.p.</td>
<td valign="top" align="left">Sprague-Dawley rats</td>
<td valign="top" align="left">Antioxidant</td>
<td valign="top" align="left">Garcia-Arencibia et al., <xref ref-type="bibr" rid="B67">2007</xref></td>
</tr>
<tr>
<td valign="top" align="left">&#x02193;Cell death</td>
<td valign="top" align="left">H<sub>2</sub>O<sub>2</sub>-inducedoxidative stress in Oligodendrocyte progenitor cells</td>
<td valign="top" align="left">1 &#x003BC;M</td>
<td valign="top" align="left"><italic>In vitro</italic></td>
<td valign="top" align="left">Oligodendrocyte progenitor cells</td>
<td valign="top" align="left">Not determinated</td>
<td valign="top" align="left">Mecha et al., <xref ref-type="bibr" rid="B134">2012</xref></td>
</tr>
<tr>
<td valign="top" align="left">&#x02193;of carbonyl groups and prevents the decrease in BDNF expression</td>
<td valign="top" align="left">Amphetamine-induced oxidative stress</td>
<td valign="top" align="left">60 mg/kg</td>
<td valign="top" align="left">2 weeks, i.p.</td>
<td valign="top" align="left">Wistar rats</td>
<td valign="top" align="left">Not determinated</td>
<td valign="top" align="left">Valvassori et al., <xref ref-type="bibr" rid="B189">2011</xref></td>
</tr>
<tr>
<td valign="top" align="left">&#x02193; NF&#x003BA;-B, &#x02193; ICAM-1 and VACAM-1</td>
<td valign="top" align="left">High glucose-induced mithocondrial superoxide generation</td>
<td valign="top" align="left">4 &#x003BC;M</td>
<td valign="top" align="left"><italic>In vitro</italic></td>
<td valign="top" align="left">Human coronary artery endothelial cells</td>
<td valign="top" align="left">Independent from CB1 and CB2 receptors</td>
<td valign="top" align="left">Rajesh et al., <xref ref-type="bibr" rid="B152">2007</xref></td>
</tr>
<tr>
<td valign="top" align="left">Prevented A&#x003B2;-induced cognitive deficits, &#x02193; microglia activation, &#x02193; IL-6 mRNA expression Inhibited NO generation and ATP-induced intracellular Ca2&#x0002B; levels</td>
<td valign="top" align="left">Rat primary cortical cultures, N13 and BV-2 microglial cells Morris water maze</td>
<td valign="top" align="left">10&#x02013;1,000 nM</td>
<td valign="top" align="left"><italic>In vitro</italic> 3 weeks: first week treated daily; second and third weeks treated 3 times/week, i.p.</td>
<td valign="top" align="left">Rat primary cortical cultures, N13 and BV-2 microglial cells C57BL6 mice</td>
<td valign="top" align="left">Some of the <italic>in vitro</italic> effects were mediated by A<sub>2A</sub>, CB<sub>1</sub>, and CB<sub>2</sub> receptors</td>
<td valign="top" align="left">Mart&#x000ED;n-Moreno et al., <xref ref-type="bibr" rid="B128">2011</xref></td>
</tr>
<tr>
<td valign="top" align="left">Blocked LPS-induced STAT1 activation</td>
<td valign="top" align="left">LPS-induced BV-2 activation</td>
<td valign="top" align="left">10 &#x003BC;M</td>
<td valign="top" align="left"><italic>In vitro</italic></td>
<td valign="top" align="left">BV-2 microglial cells</td>
<td valign="top" align="left">Not determinated</td>
<td valign="top" align="left">Kozela et al., <xref ref-type="bibr" rid="B108">2010</xref></td>
</tr>
<tr>
<td valign="top" align="left">&#x02193;Apoptosis; &#x02193;Excitotoxicty and neuroinflamation</td>
<td valign="top" align="left">Newborn hypoxic-ischemic brain damage</td>
<td valign="top" align="left">0.1&#x02013;1,000 &#x003BC;M</td>
<td valign="top" align="left"><italic>Ex vivo</italic></td>
<td valign="top" align="left">Brain slices from C57BL6 mice</td>
<td valign="top" align="left">CB<sub>2</sub> and A<sub>2A</sub> receptors</td>
<td valign="top" align="left">Castillo et al., <xref ref-type="bibr" rid="B28">2010</xref></td>
</tr>
<tr>
<td valign="top" align="left">Protects against the reduction in tyrosine hydroxylase activity</td>
<td valign="top" align="left">6-hydroxydopamine-induced toxicity in the striatum and substantia nigra</td>
<td valign="top" align="left">3 mg/kg</td>
<td valign="top" align="left">14 days, i.p.</td>
<td valign="top" align="left">Sprague-Dawley rats</td>
<td valign="top" align="left">Not determinated</td>
<td valign="top" align="left">Lastres-Becker et al., <xref ref-type="bibr" rid="B111">2005</xref></td>
</tr>
<tr>
<td valign="top" align="left">&#x02191; Viable neurons and &#x02193; excitoxicity, oxidative stress, and inflammation</td>
<td valign="top" align="left">Newborn hypoxic-ischemic brain damage (HI)</td>
<td valign="top" align="left">1 mg/kg</td>
<td valign="top" align="left">30 min after HI, i.p.</td>
<td valign="top" align="left">Newborn pigs</td>
<td valign="top" align="left">CB<sub>2</sub> and 5HT<sub>1A</sub> receptors</td>
<td valign="top" align="left">Pazos et al., <xref ref-type="bibr" rid="B144">2013</xref></td>
</tr>
<tr>
<td valign="top" align="left">Improve of cognition and motor activity. Restores BDNF levels</td>
<td valign="top" align="left">Encephalopathy (bile duct ligation)</td>
<td valign="top" align="left">5 mg/kg</td>
<td valign="top" align="left">28 days, i.p.</td>
<td valign="top" align="left">C57BL6 mice</td>
<td valign="top" align="left">5HT<sub>1A</sub></td>
<td valign="top" align="left">Magen et al., <xref ref-type="bibr" rid="B124">2010</xref></td>
</tr>
<tr>
<td valign="top" align="left">Improvments od liver function, normalizes 5-HT levels, and improves brain pathology</td>
<td valign="top" align="left">Encephalopathy (thioacetamide)</td>
<td valign="top" align="left">5 mg/kg</td>
<td valign="top" align="left">Single dose</td>
<td valign="top" align="left">C57BL6 mice</td>
<td valign="top" align="left">5HT-dependent mechanism</td>
<td valign="top" align="left">Avraham et al., <xref ref-type="bibr" rid="B4">2011</xref></td>
</tr>
<tr>
<td valign="top" align="left">Faciltates autophagic flux and decrease oxidative stress</td>
<td valign="top" align="left">Pilocarpine-Induced Seizure</td>
<td valign="top" align="left">100 ng</td>
<td valign="top" align="left">Intracerebroventricular</td>
<td valign="top" align="left">Wistar rats</td>
<td valign="top" align="left">Induction of autophagy pathway</td>
<td valign="top" align="left">Hosseinzadeh et al., <xref ref-type="bibr" rid="B86">2016</xref></td>
</tr>
<tr>
<td valign="top" align="left">Suppresses the transcription proinflammatory genes</td>
<td valign="top" align="left">MOG35-55-specific T cell in the presence of spleen-derived antigen presenting cells</td>
<td valign="top" align="left">5 &#x003BC;M</td>
<td valign="top" align="left"><italic>In vitro</italic></td>
<td valign="top" align="left">MOG35-55- and APCs isolated from spleens of C57BL6</td>
<td valign="top" align="left">Not determinated</td>
<td valign="top" align="left">Kozela et al., <xref ref-type="bibr" rid="B107">2016</xref></td>
</tr>
<tr>
<td valign="top" align="left">Attenuates TNF-&#x003B1; production and &#x02193; adenosine transport</td>
<td valign="top" align="left">murine microglia and RAW264.7 macrophages LPS-treated mice</td>
<td valign="top" align="left">500 nM or 1 mg/kg</td>
<td valign="top" align="left"><italic>In vitro</italic></td>
<td valign="top" align="left">Murine microglia</td>
<td valign="top" align="left">A<sub>2A</sub> adenosine receptor</td>
<td valign="top" align="left">Carrier et al., <xref ref-type="bibr" rid="B25">2006</xref></td>
</tr>
<tr>
<td/>
<td/>
<td/>
<td valign="top" align="left"><italic>In vivo</italic> (1 h before LPS injection, i.p.)</td>
<td valign="top" align="left">RAW264.7 macrophages C57BL6 mice</td>
<td/>
<td/>
</tr>
<tr>
<td valign="top" align="left">Improves motor deficits in the chronic phase; &#x02193; microglial activation and Il-beta and TNF-&#x003B1; production</td>
<td valign="top" align="left">Viral model of multiple sclerosis</td>
<td valign="top" align="left">5 mg/kg</td>
<td valign="top" align="left">7 days, i.p</td>
<td valign="top" align="left">SJL/J mice</td>
<td valign="top" align="left">A<sub>2A</sub> adenosine receptor</td>
<td valign="top" align="left">Carrier et al., <xref ref-type="bibr" rid="B25">2006</xref></td>
</tr>
<tr>
<td valign="top" align="left">Normalizes synaptophyisin and caspase 3 expression</td>
<td valign="top" align="left">Brain damage induced by iron overload during neonatal period</td>
<td valign="top" align="left">Not informed</td>
<td valign="top" align="left">14 day, i.p.</td>
<td valign="top" align="left">Wistar rats</td>
<td valign="top" align="left">Not determinated</td>
<td valign="top" align="left">da Silva et al., <xref ref-type="bibr" rid="B36">2014</xref></td>
</tr>
<tr>
<td valign="top" align="left">Prevented MPP-induced toxicity and induces neurite growth</td>
<td valign="top" align="left">MPP-induced toxicity in PC12 cells and SH-SY5Y</td>
<td valign="top" align="left">1 &#x003BC;M</td>
<td valign="top" align="left"><italic>In vitro</italic></td>
<td valign="top" align="left">PC12 and SH-SY5Y cells</td>
<td valign="top" align="left">TRKA</td>
<td valign="top" align="left">Santos et al., <xref ref-type="bibr" rid="B164">2015</xref></td>
</tr>
<tr>
<td valign="top" align="left">Prevents cognitive and anxiogenic effects, &#x02193; TNF-&#x003B1; and IL-6 &#x02191; BDNF levels</td>
<td valign="top" align="left">Murine model of cerebral Malaria</td>
<td valign="top" align="left">30 mg/kg</td>
<td valign="top" align="left">10 days, i.p.</td>
<td valign="top" align="left">C57BL6 mice</td>
<td valign="top" align="left">Not determinated</td>
<td valign="top" align="left">Campos et al., <xref ref-type="bibr" rid="B16">2015</xref></td>
</tr>
</tbody>
</table>
<table-wrap-foot>
<p><italic>i.p., intra peritoneal; &#x02193;, decreases; &#x02191;, increases</italic>.</p>
</table-wrap-foot>
</table-wrap>
<p>In models based on lipopolysaccharide (LPS) media activation, CBD increased microglial viability and migration as well as inhibited nitric oxide generation and STAT1 activation induced by LPS (Kozela et al., <xref ref-type="bibr" rid="B108">2010</xref>; Mart&#x000ED;n-Moreno et al., <xref ref-type="bibr" rid="B128">2011</xref>; Janefjord et al., <xref ref-type="bibr" rid="B93">2014</xref>). Some of these effects were mediated by adenosine A<sub>2A</sub>, CB<sub>1</sub>, and/or CB<sub>2</sub> receptors. In addition, CBD demonstrated neuroprotection in forebrain slices from newborn mice that underwent hypoxic-ischemic brain damage, reducing glutamate, IL-6 levels, and the expression of TNFalpha, COX-2, and iNOS via activation of CB<sub>2</sub> and adenosine A<sub>2A</sub> receptors (Castillo et al., <xref ref-type="bibr" rid="B28">2010</xref>). In accordance with these <italic>in vitro</italic> results, CBD was also neuroprotective <italic>in vivo</italic> after acute or chronic treatment in animal models of neurodegenerative diseases (Lastres-Becker et al., <xref ref-type="bibr" rid="B111">2005</xref>; Alzheimer&#x00027;s and Parkinson&#x00027;s, Esposito et al., <xref ref-type="bibr" rid="B55">2007</xref>, <xref ref-type="bibr" rid="B56">2011</xref>; Garcia-Arencibia et al., <xref ref-type="bibr" rid="B67">2007</xref>; Sagredo et al., <xref ref-type="bibr" rid="B160">2007</xref>), ischemia (Pazos et al., <xref ref-type="bibr" rid="B144">2013</xref>) and encephalopathy (Magen et al., <xref ref-type="bibr" rid="B124">2010</xref>; Avraham et al., <xref ref-type="bibr" rid="B4">2011</xref>). In a model of &#x003B2;-amyloid hippocampal inoculation, CBD decreased IL-1beta, GFAP, and iNOS levels (Esposito et al., <xref ref-type="bibr" rid="B55">2007</xref>). In models of Parkinson&#x00027;s disease, CBD reversed the reduction of tyrosine hydroxylase activity and the dopamine depletion in the substantia nigra and striatum after 6-hydroxydopamine microinjection (Lastres-Becker et al., <xref ref-type="bibr" rid="B111">2005</xref>; Garcia-Arencibia et al., <xref ref-type="bibr" rid="B67">2007</xref>) and upregulated superoxide dismutase (SOD) mRNA levels in the substantia nigra (Garcia-Arencibia et al., <xref ref-type="bibr" rid="B67">2007</xref>). In this same direction, CBD also reversed 3-nitropropionic acid-induced reductions in GABA contents and mRNA levels for substance P, neuronal specific enolase and superoxide dismutase 2, effects that were independent of CB<sub>1</sub>, TRPV1, and A<sub>2A</sub> receptors (Sagredo et al., <xref ref-type="bibr" rid="B160">2007</xref>).</p>
<p>Moreover, in hypoxic-ischemic animals, CBD prevented the decrease in the number of viable neurons and the increase in excitotoxicity, oxidative stress, and inflammation through mechanisms involving CB2 and 5HT<sub>1A</sub> receptors (Pazos et al., <xref ref-type="bibr" rid="B144">2013</xref>). In the middle cerebral artery occlusion, a method used to evaluate ischemia-reperfusion injury, CBD suppressed the decrease in cerebral blood flow after reperfusion, inhibited myeloperoxidase (MPO) activity in neutrophils, and reduced the number of MPO immunopositive cells. In addition, in animal models of encephalopathy, CBD improved cognition, motor activity, and restored 5-HT and BDNF levels via 5HT<sub>1A</sub> receptor activation (Magen et al., <xref ref-type="bibr" rid="B124">2010</xref>; Avraham et al., <xref ref-type="bibr" rid="B4">2011</xref>).</p>
<p>Besides these proposed mechanisms, neuroprotection can also be promoted by an enhancement in the autophagic function. Autophagy, more specifically macroautophagy, is a lysosomal degradation pathway essential to recycle damaged organelles and promote cell survival, protecting the cell malfunction or death under stress conditions (Jia and Le, <xref ref-type="bibr" rid="B94">2015</xref>). In fact, some SSRIs and mood stabilizers such as lithium increase autophagy in the brain (Heiseke et al., <xref ref-type="bibr" rid="B85">2009</xref>; Gassen et al., <xref ref-type="bibr" rid="B68">2014</xref>; Jia and Le, <xref ref-type="bibr" rid="B94">2015</xref>). Although there are few studies relating CBD to autophagy in neuropsychiatric disorders, CBD can modulate this process (Koay et al., <xref ref-type="bibr" rid="B105">2014</xref>; Yang et al., <xref ref-type="bibr" rid="B191">2014</xref>; Hosseinzadeh et al., <xref ref-type="bibr" rid="B86">2016</xref>). Specifically in the brain, CBD produced anticonvulsant effects concomitant to an activation of hippocampal autophagy pathway in the chronic phase of pilocarpine-induced seizure (Hosseinzadeh et al., <xref ref-type="bibr" rid="B86">2016</xref>). In a genetic model of tauopathy, used to evaluate frontotemporal dementia, parkinsonism, and motor neuron disease, 1-month daily injections of Sativex&#x000AE;, a 1:1 mixture combination of CBD and THC, increased the ratio of reduced/oxidized glutathione and promoted autophagy in the brain (Casarejos et al., <xref ref-type="bibr" rid="B26">2013</xref>). In this same study, Sativex&#x000AE; attenuated the abnormal behaviors and reduced free radicals produced during the metabolism of dopamine, iNOS levels and deposition of tau in the hippocampus and cortex (Casarejos et al., <xref ref-type="bibr" rid="B26">2013</xref>). In this context, recent findings from our group suggest that chronic CBD treatment increase autophagy in animals submitted to CUS, as revealed by its impact in phosphorylated form of mTOR, Beclin-1 and LC3, signaling proteins involved in autophagy induction (Foga&#x000E7;a, <xref ref-type="bibr" rid="B61">2016</xref>).</p>
<p>The CBD neuroprotective effects could also involve neuroinflammatory mechanisms. CBD administration counteracts the deleterious consequences of neuroinflammation reducing adaptive immune cell Th2 phenotype and microglial/macrophage innate immunity (Kozela et al., <xref ref-type="bibr" rid="B107">2016</xref>).</p>
<p>CBD inhibits adenosine transporter activity in a microglial cell line, thus resulting in increased A<sub>2A</sub> receptor signaling, and attenuation of TNF-&#x003B1; cytokine production (Carrier et al., <xref ref-type="bibr" rid="B25">2006</xref>). Likewise, adenosine 2A receptor signaling is involved in the protective effects of CBD in the Theiler virus model of multiple sclerosis preventing both leukocyte and microglial-mediated actions (Mecha et al., <xref ref-type="bibr" rid="B133">2013</xref>). On the other hand, CBD protects oligodendrocyte progenitor cells in CB<sub>1</sub>, CB<sub>2</sub>, PPAR&#x003B3;, and TRPV1 independent manner (Mecha et al., <xref ref-type="bibr" rid="B134">2012</xref>).</p>
</sec>
</sec>
<sec sec-type="conclusions" id="s3">
<title>Conclusions</title>
<p>In addition to CBD-only actions, considerable interest is also derived from its ability to modulate the psychoactive effects of THC. CBD tempers the detrimental (cognitive impairment, psychosis) consequences of THC (Curran et al., <xref ref-type="bibr" rid="B35">2016</xref>), while preserving its beneficial actions. For example, administration of a THC: CBD mixture 1:1 (the similar composition to Sativex) in the APPxPS1 exhibits a better therapeutic profile than each cannabis component alone (Aso et al., <xref ref-type="bibr" rid="B3">2015</xref>). Similarly THC:CBD combination is neuroprotective actions in toxin-induced striatal neurodegeneration (Valdeolivas et al., <xref ref-type="bibr" rid="B188">2012</xref>). In a recent double-blind crossover pilot clinical trial, Sativex administration in Huntington&#x00027;s disease patients was shown to be safe and well tolerated, while no significant effects or biomarker changes could be evidenced (L&#x000F3;pez-Send&#x000F3;n et al., <xref ref-type="bibr" rid="B120">2016</xref>). Similarly to CBD, other non-psychotomimetic phytocannabinoids exert significant neuroplasticity adaptations of therapeutic interest by this mechanism. Cannabigerol (CBG) a non-CB<sub>1</sub>/CB<sub>2</sub> receptor acting cannabinoid shares with CBD its ability to activate PPAR&#x003B3; and has been evaluated in preclinical models of neurodegeneration (Valdeolivas et al., <xref ref-type="bibr" rid="B187">2015</xref>). New molecules derived from the CBG structure have been tested in multiple sclerosis and Huntington&#x00027;s disease models (toxin- and mutant huntingtin-induced striatal neurodegeneration, Granja et al., <xref ref-type="bibr" rid="B75">2012</xref>; D&#x000ED;az-Alonso et al., <xref ref-type="bibr" rid="B46">2016</xref>). Characterization of the neuroprotective actions of VCE3.2 compound indicates that it acts as a PPAR&#x003B3; modulator without the secondary actions of full PPAR&#x003B3; agonists, thus highlighting the translational implications offered by non-psychotomimetic cannabinoids.</p>
<p>The pre-clinical and clinical studies available so far indicate that CBD has a good safety record (Bergamaschi et al., <xref ref-type="bibr" rid="B7">2011b</xref>). CBD or other non-psychotomimetic phytocannabinoids effects in brain development, however, have not yet been extensively investigated. This lack of studies is a significant point given that endogenous cannabinoid system regulates important steps of the nervous system development (Diaz-Alonso et al., <xref ref-type="bibr" rid="B45">2012</xref>). The deleterious consequences in brain development and psychiatric implications in the adulthood induced by psychoactive THC exposure have been widely studied (Tortoriello et al., <xref ref-type="bibr" rid="B184">2014</xref>; Alp&#x000E1;r et al., <xref ref-type="bibr" rid="B2">2015</xref>; de Salas-Quiroga et al., <xref ref-type="bibr" rid="B42">2015</xref>). Recent evidence indicates that while CBD in the adult brain is safe and lacks undesired side effects, in the differentiating neurons it may increase their sensitivity to future oxidative insults (Sch&#x000F6;nhofen et al., <xref ref-type="bibr" rid="B168">2015</xref>). Clearly, research on CBD safety during brain development is essential.</p>
<p>Even with this unanswered question, however, CBD ability to reduce inflammation-associated neurodegeneration and its antioxidant properties, lack of psychoactivity and a broad range of potentially beneficial effects indicates that this drug could be a useful new approach to treat several neuropsychiatric disorders. Actually, new CBD-derived molecules aimed at improving the efficacy and/or potency of natural phytocannabinoids have been recently developed (Haj et al., <xref ref-type="bibr" rid="B79">2015</xref>; Breuer et al., <xref ref-type="bibr" rid="B15">2016</xref>).</p>
<p>As discussed above, different mechanisms appear to be involved in CBD effects (Figure <xref ref-type="fig" rid="F1">1</xref>). The evidence available so far indicates that, in addition to its better described acute mechanisms (such as interaction with 5HT<sub>1A</sub>-mediated neurotransmission, TRPV1 receptors, and inhibition of anandamide metabolism), plastic changes take place over time and contribute to CBD-induced behavioral effects in response to chronic treatment. Even if the number of studies investigating these chronic effects is still sparse, it is clear that no single mechanism will explain the remarkable pharmacological profile of CBD. In this way, it joins a club of multi-target drugs that includes, for example, clozapine. These drugs challenge our familiar concept that acting in a single pharmacological target is always desirable (Imming et al., <xref ref-type="bibr" rid="B89">2006</xref>) and agree with the observation made by Mencher and Wang (<xref ref-type="bibr" rid="B135">2005</xref>) that, sometimes, promiscuity could be a virtue.</p>
<fig id="F1" position="float">
<label>Figure 1</label>
<caption><p><bold>Multiple mechanisms proposed to explain CBD effect in neuropsychiatric disorders</bold>. CBD seems to interact with numerous different targets. It can act as a positive modulator of 5HT<sub>1A</sub>-mediated neurotransmission or as an agonist at TRPV1 and PPAR&#x003B3; receptors. In addition, CBD can facilitate anandamide (AEA)-mediated neurotransmission (by inhibiting FAAH) and induce antioxidant actions. CBD also promotes a complex set of changes in crucial intra-cellular pathways such as mTOR, autophagy and GSK3&#x003B2;, resulting in neuroprotection, decreased proinflammatory responses and facilitation of neuroplastic events. Taken together, these mechanisms would lead to an overall beneficial effect of CBD in neuropsychiatric disorders. <sup>&#x0002A;</sup>Little is known about the contribution of TRPV1 and 5HT1A for the effects of CBD on glial reactivity and on adult hippocampal neurogenesis. <sup>&#x0002A;&#x0002A;</sup>CBD effects in reducing glial cell reactictivity and preventing stress-induced or amyloid-&#x003B2;-induced decreased adult hippocampal neurogenesis seem to depend on activation of CB1/CB2 (indirectly) and PPAR&#x003B3;. Because CB1 and CB2 are expressed in both neural precursor cells (NPCs) and glial cells, CBD effects on adult hippocampal neurogenesis could be a result of its actions on NPCs and/or attenuation of glial reactivity. BDNF, Brain derived neurotrophic factor; PSD95, postsynaptic density protein 95; mTOR, mechanistic target of rapamycin; GSK3&#x003B2;, Glycogen synthase kinase 3-beta.</p></caption>
<graphic xlink:href="fphar-08-00269-g0001.tif"/>
</fig>
</sec>
<sec id="s4">
<title>Author contributions</title>
<p>AC, MF, FS, SJ, AJS, FVG, ABS, NR, and IG participated in the writing process of the first draft of the manuscript. AC design the Figure <xref ref-type="fig" rid="F1">1</xref>. FSG, AC, and IG revised the final version of the manuscript.</p>
<sec>
<title>Conflict of interest statement</title>
<p>FG is co-inventor of the patent &#x0201C;Fluorinated CBD compounds, compositions and uses thereof.&#x0201D; Pub. No.: WO/2014/108899. International Application No.: PCT/IL2014/050023. The other authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.</p>
</sec>
</sec>
</body>
<back>
<ack><p>We thank CNPq, Capes, and Fapesp for their financial support. Research in IG lab is supported by Instituto de Salud Carlos III (PI15-00310) and Ministerio de Econom&#x000ED;a y Competitividad (RTC-2015-3364-1) and Regional Madrid Government S2010/BMD-2336 cofinanced by Fondo Europeo de Desarrollo Regional (FEDER) &#x0201C;Una manera de hacer Europa.&#x0201D; Illustrations were designed in Mind the Graph tool (<ext-link ext-link-type="uri" xlink:href="http://www.mindthegraph.com">www.mindthegraph.com</ext-link>).</p>
</ack>
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