Understanding the potential of digital therapies in implementing the standard of care for depression in Europe.

Depressive disorders represent the largest proportion of mental illnesses, and by 2030, they are expected to be the first cause of disability-adjusted life years [1]. The COVID-19 pandemic exacerbated prevalence and burden of depression and increased the occurrence of depressive symptoms in general population [2]. The urgency of implementing mental health services to address new barriers to care persuaded clinicians to use telemedicine to follow patients and stay in touch with them, and to explore digital therapeutics (DTx) as potential tools for clinical intervention [2]. The combination of antidepressants and psychotherapy is widely recommended for depression by international guidelines [3] but is less frequently applied in real-world practice. Commonly used treatments are pharmacological, but while being effective, some aspects such as adherence to the drug regimen, residual symptoms, resistance, lack of information, and stigma may hinder successful treatment. In case of less severe depression, standalone psychological therapies should be the first-line treatment option [3], but access to trained psychotherapists remains inequitable. DTx are evidence-based therapies driven by software programs to treat or complement treatment of a specific disease. DTx are classified as Medical Devices, and given their therapeutic purpose, they need to be validated through randomized controlled clinical trials, as for drug-based therapies. In the last 10 years, studies of digital interventions have proliferated; these studies demonstrate that digital interventions increase remission rates and lower the severity of depressive symptoms compared with waitlist, treatment as usual, and attention control conditions [4]. Despite the efficacy demonstrated in clinical trials, many of these tools never reach real-life patients; thus, it might be necessary to implement DTx in the public health system to expand access to valid treatment options. In this framework, DTx represent a good opportunity to help people with depression receive optimal psychotherapeutic care [5].

Polyploidy as a strategy to increase taxane production in yew cell cultures: Obtaining and characterizing a Taxus baccata tetraploid cell line.

Novel approaches to optimize the production of plant specialized metabolites are crucial to reach maximum productivity of plant biofactories. Plant polyploidization frequently enhances protein synthesis and thereby increases the biosynthesis of specialized metabolites. Paclitaxel is a valuable anticancer agent scarcely produced in nature. Therefore, plant biofactories represent a sustainable alternative source of this compound and related taxanes. With the aim of improving the productivity of Taxus spp. cell cultures, we induced polyploidy in vitro by treating immature embryos of Taxus baccata with colchicine. To obtain the polyploid cell lines, calli were induced from T. baccata plantlets previously treated with colchicine and ploidy levels were accurately identified using flow cytometry. In terms of cell morphology, tetraploid cells were about 3-fold bigger than the diploid cells. The expression of taxane pathway genes was higher in the tetraploid cell line compared to the diploid cells. Moreover, taxane production was 6.2-fold higher and the production peak was achieved 8 days earlier than in the diploid cell line, indicating a higher productivity. The obtained tetraploid cell line proved to be highly productive, constituting a step forward towards the development of a bio-sustainable production system for this chemotherapeutic drug.

Chronic Liver Disease and the Risk of Osteoporotic Fractures: A Meta-Analysis.

Introduction Chronic liver disease (CLD) causes more than 1 million deaths every year and remains a pandemic in the last decade affecting more than 600,000 patients in the United States. Previous studies found patients with CLD had increased risk of osteoporosis, so fractures were inferred to be complications of this condition. The aim of this meta-analysis is to summarize the best evidence that correlates CLD patients and the risk to develop osteoporotic fractures versus control patients without CLD. Methods A review of the literature using MEDLINE and EMBASE database was performed during December 2017. We included cross-sectional and cohort studies that reported relative risks (RR), odds ratios (OR) and hazard ratios (HR) comparing the risk of developing osteoporotic fractures among patients with CLD versus patients without CLD. Pooled OR and 95% confidence interval (CI) were calculated using generic inverse- variance method. The Newcastle-Ottawa scale was used to determine the quality of the studies. Effect estimates from the individual study were extracted and combined using the random-effect, generic inverse variance method of DerSimonian and Laird.  Results After the review of the literature, seven studies fulfilled the eligibility criteria established during the analysis. Significant association was found between CLD and osteoporotic fractures with a pooled OR of 2.13 (95% CI, 1.79 - 2.52). High heterogeneity among the studies was found (I2=88.5). No publication bias was found using Egger regression test (p=0.44). Conclusion We found a significant association between CLD and the risk of developing osteoporotic fractures. The calculated risk was 2.13 times higher for patients with CLD when compared with controls. The results showed high heterogeneity but no publication bias. More prospective studies are needed to fully understand the mechanisms involved in loss of bone density and osteoporotic fractures in order to improve the morbidity associated with this disease.

Differentiating, evaluating, and classifying three quinoa ecotypes by washing, cooking and germination treatments, using 1H NMR-based metabolomic approach.

We processed three quinoa ecotypes as they are commonly consumed in a daily diet. For the treatments, quinoa seeds were washed, cooked, and/or germinated. Following treated, we used 1H NMR-based metabolomic profiling to explore differences between the ecotypes. Then, for a non-targeted and targeted food fingerprint analysis of samples, we performed multivariable data analyses, including principal component analysis (PCA), orthogonal partial least squares discriminant analysis (OPLS-DA), and hierarchical cluster analysis. From our study, we were able to discriminate each quinoa ecotype regardless of treatment based on its metabolomic profiling. Additionally, we were able to identify 30 metabolites that were useful to determine the effect of each treatment on nutritional composition. Germination increased the content of most metabolites irrespective of ecotype. In general, ecotype CQE_03 was different from ecotypes CQE_01 and CQE_02. Our phytochemical analysis revealed the effects of washing, cooking, and/or germination, particularly on saponins content.

Celiac Disease and Risk of Atrial Fibrillation: A Meta-analysis and Systematic Review.

Introduction Several studies have found celiac disease may be associated with a variety of cardiac manifestations. Atrial fibrillation (AF) is one of the most common arrhythmias that can cause significant morbidity. However, the risk of atrial fibrillation in patients with celiac disease according to epidemiological studies remains unclear. The aim of this meta-analysis study is to assess the risk of atrial fibrillation in patients diagnosed with celiac disease compared to controls. Methods A systematic literature review was conducted in MEDLINE, EMBASE, Cochrane databases from inception through December 2017 to identify studies that evaluated the risk of atrial fibrillation in patients with celiac disease. We included randomized controlled trial, cross sectional and cohort studies that reported the odds ratio, relative risk, hazard ratio, and standardized incidence ratio comparing the risk of developing atrial fibrillation among patients with celiac disease, versus patients without celiac disease as control. The Newcastle-Ottawa scale was used to determine the quality of the studies. Effect estimates from individual studies were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird. Results Celiac disease is an autoimmune condition. This inflammatory state predisposes patients to develop AF. After a review of the literature, four observational studies with a total of 64,397 participants were enrolled. The association between celiac disease and increased risk of atrial fibrillation was significant, with a pooled OR of 1.38 (95% CI: 1.01-1.88). No publication bias as assessed by the funnel plots and Egger's regression asymmetry test with p = 0.54. However, the heterogeneity of the included studies was high (I2 = 96). Conclusion A significant association between celiac disease and risk of atrial fibrillation was reported in this study. There is a 38% increased risk of atrial fibrillation. Additional studies are needed to clarify the mechanistic link between atrial fibrillation and celiac disease. Some of the limitations of this study are that all were observational studies, some were medical registry-based and there was high heterogeneity between studies.

Validity, reliability, and psychometric properties of a computerized, cognitive assessment test (Cognivue®).

BACKGROUND: Cognitive issues such as Alzheimer's disease and other dementias confer a substantial negative impact. Problems relating to sensitivity, subjectivity, and inherent bias can limit the usefulness of many traditional methods of assessing cognitive impairment. AIM: To determine cut-off scores for classification of cognitive impairment, and assess Cognivue® safety and efficacy in a large validation study. METHODS: Adults (age 55-95 years) at risk for age-related cognitive decline or dementia were invited via posters and email to participate in two cohort studies conducted at various outpatient clinics and assisted- and independent-living facilities. In the cut-off score determination study (n = 92), optimization analyses by positive percent agreement (PPA) and negative percent agreement (NPA), and by accuracy and error bias were conducted. In the clinical validation study (n = 401), regression, rank linear regression, and factor analyses were conducted. Participants in the clinical validation study also completed other neuropsychological tests. RESULTS: For the cut-off score determination study, 92 participants completed St. Louis University Mental Status (SLUMS, reference standard) and Cognivue® tests. Analyses showed that SLUMS cut-off scores of < 21 (impairment) and > 26 (no impairment) corresponded to Cognivue® scores of 54.5 (NPA = 0.92; PPA = 0.64) and 78.5 (NPA = 0.5; PPA = 0.79), respectively. Therefore, conservatively, Cognivue® scores of 55-64 corresponded to impairment, and 74-79 to no impairment. For the clinical validation study, 401 participants completed ≥ 1 testing session, and 358 completed 2 sessions 1-2 wk apart. Cognivue® classification scores were validated, demonstrating good agreement with SLUMS scores (weighted κ 0.57; 95%CI: 0.50-0.63). Reliability analyses showed similar scores across repeated testing for Cognivue® (R 2 = 0.81; r = 0.90) and SLUMS (R 2 = 0.67; r = 0.82). Psychometric validity of Cognivue® was demonstrated vs. traditional neuropsychological tests. Scores were most closely correlated with measures of verbal processing, manual dexterity/speed, visual contrast sensitivity, visuospatial/executive function, and speed/sequencing. CONCLUSION: Cognivue® scores ≤ 50 avoid misclassification of impairment, and scores ≥ 75 avoid misclassification of unimpairment. The validation study demonstrates good agreement between Cognivue® and SLUMS; superior reliability; and good psychometric validity.

Inflammatory Bowel Disease and Risk of Osteoporotic Fractures: A Meta-Analysis.

Introduction Inflammatory bowel disease (IBD) and its complications have been well-established. The literature shows an association between IBD and decreased bone mineral density in the adult population. However, most studies have reported an association between IBD and osteoporosis, while the risk of fractures has not been well-studied. The aim of this meta-analysis is to summarize the best available evidence regarding IBS and osteoporotic fractures. Methods A review of the literature using the MEDLINE and EMBASE databases was performed during November 2017. We included cross-sectional and cohort studies that reported the relative risks, odds ratios, and hazard ratios comparing the risk of developing osteoporotic fractures among patients with IBD patients, both ulcerative colitis (UC) and Crohn's disease (CD), versus patients without IBD as controls. The pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using the generic inverse-variance method. Results After a review of the literature, seven studies fulfilled the eligibility criteria established during the analysis. A significant association was found between IBD and osteoporosis, with a pooled OR of 1.32 (95% CI, 1.2 - 1.4). Low heterogeneity among the studies was found, I2=42.3. No publication bias was found using the Egger regression test p=0.18. Sensitivity analysis showed that the inclusion of data on children by Kappelman et al. (2007) did not change the results. Conclusion A significant association between IBD and the risk of developing osteoporotic fractures was observed in this study. There is a 32% increased risk, which is consistent with different cohort studies previously done.

Biotechnological Production of Pharmaceuticals and Biopharmaceuticals in Plant Cell and Organ Cultures.

BACKGROUND: Plant biofactories are biotechnological platforms based on plant cell and organ cultures used for the production of pharmaceuticals and biopharmaceuticals, although to date only a few of these systems have successfully been implemented at an industrial level. Metabolic engineering is possibly the most straightforward strategy to boost pharmaceutical production in plant biofactories, but social opposition to the use of GMOs means empirical approaches are still being used. Plant secondary metabolism involves thousands of different enzymes, some of which catalyze specific reactions, giving one product from a particular substrate, whereas others can yield multiple products from the same substrate. This trait opens plant cell biofactories to new applications, in which the natural metabolic machinery of plants can be harnessed for the bioconversion of phytochemicals or even the production of new bioactive compounds. Synthetic biological pipelines involving the bioconversion of natural substrates into products with a high market value may be established by the heterologous expression of target metabolic genes in model plants. OBJECTIVE: To summarize the state of the art of plant biofactories and their applications for the pipeline production of cosme-, pharma- and biopharmaceuticals. RESULTS: In order to demonstrate the great potential of plant biofactories for multiple applications in the biotechnological production of pharmaceuticals and biopharmaceuticals, this review broadly covers the following: plant biofactories based on cell and hairy root cultures; secondary metabolite production; biotransformation reactions; metabolic engineering tools applied in plant biofactories; and biopharmaceutical production.

Extracellular chromone derivatives in cell cultures of Pimpinella anisum. Influence of elicitation with methyl jasmonate and 2ß-methyl cyclodextrins.

OBJECTIVES: To explore the potentiality of undifferentiated Pimpinella anisum L. cell cultures for the production of secondary metabolites by means of elicitation. RESULTS: Two chromone compounds were secreted to the medium of undifferentiated cultures of P. anisum: 4-methoxyfuro[3,2-g]chromen-7-one, known as bergapten, which is constitutive to anise, and 5-hydroxy-7-methoxy-2-methylchromen-4-one, the rare chromone eugenin, not yet described in P. anisum. Caffeoyl quinic acid species were also identified in the biomass. Elicitation with methyl jasmonate enhanced chromone accumulation in the medium and stimulated phenolic acid metabolism in the biomass (11 mg caffeoyl quinic acids g-1 DW cells). The application of 2,6-dimethyl-ß-cyclodextrins to cultures led to an intense accumulation of chromones, with nearly 10 mg l-1 bergapten and 150 mg l-1 eugenin being accumulated extracellularly after optimal elicitation conditions. CONCLUSIONS: The significant amounts of eugenin obtained in the anise cultures and the stability of production over long periods of time can be of interest for its biotechnological production and for future studies on biosynthesis regulation.

Tailoring tobacco hairy root metabolism for the production of stilbenes.

Tobacco hairy root (HR) cultures, which have been widely used for the heterologous production of target compounds, have an innate capacity to bioconvert exogenous t-resveratrol (t-R) into t-piceatannol (t-Pn) and t-pterostilbene (t-Pt). We established genetically engineered HR carrying the gene encoding stilbene synthase (STS) from Vitis vinifera and/or the transcription factor (TF) AtMYB12 from Arabidopsis thaliana, in order to generate a holistic response in the phenylpropanoid pathway and coordinate the up-regulation of multiple metabolic steps. Additionally, an artificial microRNA for chalcone synthase (amiRNA CHS) was utilized to arrest the normal flux through the endogenous chalcone synthase (CHS) enzyme, which would otherwise compete for precursors with the STS enzyme imported for the flux deviation. The transgenic HR were able to biosynthesize the target stilbenes, achieving a production of 40 µg L-1 of t-R, which was partially metabolized into t-Pn and t-Pt (up to 2.2 µg L-1 and 86.4 µg L-1, respectively), as well as its glucoside piceid (up to 339.7 µg L-1). Major metabolic perturbations were caused by the TF AtMYB12, affecting both primary and secondary metabolism, which confirms the complexity of biotechnological systems based on seed plant in vitro cultures for the heterologous production of high-value molecules.

Biotechnological production of recombinant tissue plasminogen activator protein (reteplase) from transplastomic tobacco cell cultures.

Transplastomic plants are a system of choice for the mass production of biopharmaceuticals due to the polyploidy of the plastid genome and the low risk of pollen-mediated outcrossing because of maternal inheritance. However, as field-grown plants, they can suffer contamination by agrochemicals and fertilizers, as well as fluctuations in yield due to climatic changes and infections. Tissue-type plasminogen activator (tPA), a protein used to treat heart attacks, converts plasminogen into plasmine, which digests fibrin and induces the dissolution of fibrin clots. Recently, we obtained transplastomic tobacco plants carrying the K2S gene encoding truncated human tPA (reteplase) with improved biological activity, and confirmed the presence of the target protein in the transgenic plant leaves. Considering the advantages of plant cell cultures for biopharmaceutical production, we established a cell line derived from the K2S tobacco plants. The active form of reteplase was quantified in cultures grown in light or darkness, with production 3-fold higher in light.

Bioconversion of stilbenes in genetically engineered root and cell cultures of tobacco.

It is currently possible to transfer a biosynthetic pathway from a plant to another organism. This system has been exploited to transfer the metabolic richness of certain plant species to other plants or even to more simple metabolic organisms such as yeast or bacteria for the production of high added value plant compounds. Another application is to bioconvert substrates into scarcer or biologically more interesting compounds, such as piceatannol and pterostilbene. These two resveratrol-derived stilbenes, which have very promising pharmacological activities, are found in plants only in small amounts. By transferring the human cytochrome P450 hydroxylase 1B1 (HsCYP1B1) gene to tobacco hairy roots and cell cultures, we developed a system able to bioconvert exogenous t-resveratrol into piceatannol in quantities near to mg L-1. Similarly, after heterologous expression of resveratrol O-methyltransferase from Vitis vinifera (VvROMT) in tobacco hairy roots, the exogenous t-resveratrol was bioconverted into pterostilbene. We also observed that both bioconversions can take place in tobacco wild type hairy roots (pRiA4, without any transgene), showing that unspecific tobacco P450 hydroxylases and methyltransferases can perform the bioconversion of t-resveratrol to give the target compounds, albeit at a lower rate than transgenic roots.

An optimized biotechnological system for the production of centellosides based on elicitation and bioconversion of Centella asiatica cell cultures.

Centella asiatica is a herbaceous plant of Asian traditional medicine. Besides wound healing, this plant is recommended for the treatment or care of various skin conditions such as dry skin, leprosy, varicose ulcers, eczema, and/or psoriasis. Triterpene saponins, known as centellosides, are the main metabolites associated with these beneficial effects. Considering the interest in these high value active compounds, there is a need to develop biosustainable and economically viable processes to produce them. Previous work using C. asiatica plant cell culture technology demonstrated the efficient conversion of amyrin derivatives into centellosides, opening a new way to access these biomolecules. The current study was aimed at increasing the production of centellosides in C. asiatica plant cell cultures. Herein, we report the application of a new elicitor, coronatine, combined with the addition of amyrin-enriched resins as potential sustainable precursors in the centelloside pathway, for a positive synergistic effect on centelloside production. Our results show that coronatine is a powerful elicitor for increasing centelloside production and that treatments with sustainable natural sources of amyrins enhance centelloside yields. This process can be scaled up to an orbitally shaken CellBag, thereby increasing the capacity of the system for producing biomass and centellosides.

Silybum marianum cell cultures stably transformed with Vitis vinifera stilbene synthase accumulate t-resveratrol in the extracellular medium after elicitation with methyl jasmonate or methylated ß-cyclodextrins.

The growing demand for t-resveratrol for industrial uses has generated considerable interest in its production. Heterologous resveratrol production in plant cell suspensions, apart from requiring the introduction of only one or two genes, has the advantage of high biomass yield and a short cultivation time, and thus could be an option for large-scale production. Silybum marianum is the source of the flavonolignan silymarin. Phenylpropanoid synthesis in cultures of this species can be activated by elicitation with methyl jasmonate and methylated ß-cyclodextrins, with products of the pathway (coniferyl alcohol and some isomers of the silymarin complex) being released into the medium. Given that stilbene synthase shares the same key precursors involved in flavonoid and /or monolignol biosynthesis, we explored the potential of metabolically engineered S. marianum cultures for t-resveratrol production. Cell suspensions were stably transformed with Vitis vinifera stilbene synthase 3 and the expression of the transgene led to extracellular t-resveratrol accumulation at the level of milligrams per litre under elicitation. Resveratrol synthesis occurred at the expense of coniferyl alcohol. Production of silymarin was less affected in the transgenic cultures, since the flavonoid pathway is limiting for its synthesis, due to the preferred supply of precursors for the monolignol branch. The fact that the expressed STS gene took excessively produced precursors of non-bioactive compounds (coniferyl alcohol), while keeping the metabolic flow for target secondary compounds (i.e. silymarin) unaltered, opens a way to extend the applications of plant cell cultures for the simultaneous production of both constitutive and foreign valuable metabolites.

Elicitation, an Effective Strategy for the Biotechnological Production of Bioactive High-Added Value Compounds in Plant Cell Factories.

Plant in vitro cultures represent an attractive and cost-effective alternative to classical approaches to plant secondary metabolite (PSM) production (the "Plant Cell Factory" concept). Among other advantages, they constitute the only sustainable and eco-friendly system to obtain complex chemical structures biosynthesized by rare or endangered plant species that resist domestication. For successful results, the biotechnological production of PSM requires an optimized system, for which elicitation has proved one of the most effective strategies. In plant cell cultures, an elicitor can be defined as a compound introduced in small concentrations to a living system to promote the biosynthesis of the target metabolite. Traditionally, elicitors have been classified in two types, abiotic or biotic, according to their chemical nature and exogenous or endogenous origin, and notably include yeast extract, methyl jasmonate, salicylic acid, vanadyl sulphate and chitosan. In this review, we summarize the enhancing effects of elicitors on the production of high-added value plant compounds such as taxanes, ginsenosides, aryltetralin lignans and other types of polyphenols, focusing particularly on the use of a new generation of elicitors such as coronatine and cyclodextrins.

Antipsychotic switching in schizoaffective disorder: A systematic review.

OBJECTIVES: To systematically review the evidence about the switching of antipsychotics in SZA in acute and maintenance treatment. METHODS: A systematic review following the PRISMA statement identifying studies specifically conducted on, or including, SZA patients. RESULTS: One analysis considered uniquely a SZA population, 13 more studies including an adequate SZA subsample were considered. Most of the studies were aimed at switching antipsychotic treatments to improve tolerability issues. Despite the absolute lack of trials specifically conducted on SZA populations, we found limited evidence on the use of aripiprazole, lurasidone, and, to a lesser extent, risperidone and ziprasidone as possible agents to substitute previous treatments whereas efficacy or, more frequently, tolerability issues arise. Evidence supports also the switch to risperidone long-acting injectable when the adherence to oral treatment may be a concern. CONCLUSIONS: Antipsychotic switching in SZA is a neglected topic that would need better profiling. Clinicians should keep in mind the receptor binding characteristics of drugs in order to optimize transitions. Evidence supports the switch to aripiprazole and lurasidone, less strongly to risperidone and ziprasidone. The switch to risperidone long-acting injectable is supported, especially in patients with limited treatment adherence to oral therapy.

Management of adverse effects of mood stabilizers.

Mood stabilizers such as lithium and anticonvulsants are still standard-of-care for the acute and long-term treatment of bipolar disorder (BD). This systematic review aimed to assess the prevalence of their adverse effects (AEs) and to provide recommendations on their clinical management. We performed a systematic research for studies reporting the prevalence of AEs with lithium, valproate, lamotrigine, and carbamazepine/oxcarbazepine. Management recommendations were then developed. Mood stabilizers have different tolerability profiles and are eventually associated to cognitive, dermatological, endocrine, gastrointestinal, immunological, metabolic, nephrogenic, neurologic, sexual, and teratogenic AEs. Most of those can be transient or dose-related and can be managed by optimizing drug doses to the lowest effective dose. Some rare AEs can be serious and potentially lethal, and require abrupt discontinuation of medication. Integrated medical attention is warranted for complex somatic AEs. Functional remediation and psychoeducation may help to promote awareness on BD and better medication management.

Prophylactic antidepressant treatment of interferon-induced depression in chronic hepatitis C: a systematic review and meta-analysis.

OBJECTIVE: To assess the utility of prophylactic administration of antidepressants in preventing a major depressive episode during antiviral treatment for chronic hepatitis C. DATA SOURCES: A computerized literature search was conducted in MEDLINE, PsycINFO, EMBASE, the Cochrane Library, and ClinicalTrials.gov to locate articles published in any language from the earliest available online year until October 2012, using the following phrase and Boolean logic algorithm: "hepatitis and c and (interferon-alpha OR peginterferon OR (pegylated and interferon)) and (depression OR mood) and (prevention OR prophylactic OR prophylaxis OR antidepressant)." STUDY SELECTION: Double-blind, randomized, placebo-controlled trials using antidepressants prophylactically before starting antiviral therapy for chronic hepatitis C were included. At baseline, none of the patients in the trials presented depression (DSM-IV-TR criteria). Using keywords and cross-referenced bibliographies, 144 studies were identified and examined in depth. 137 articles were rejected because inclusion criteria were not met. Finally, 7 studies were included. DATA EXTRACTION: Data were extracted independently by 2 investigators. The primary outcome measure was the onset of a major depressive episode during the antiviral treatment. Depressive symptoms, other side effects, and sustained virologic response were also examined. A full review and meta-analysis were performed. Odds ratios (ORs), mean differences, and estimated numbers needed to treat (NNTs) with 95% confidence intervals (CIs) were calculated. RESULTS: 591 patients were randomly assigned to antiviral treatment and another intervention: escitalopram (n = 197), paroxetine (n = 42), citalopram (n = 53), or placebo (n = 299). Selective serotonin reuptake inhibitors (SSRIs), as a group, reduced the incidence of a major depressive episode during antiviral treatment (OR = 0.53; 95% CI, 0.33 to 0.84). The NNT was 12 (95% CI, 7.0 to 37.9). SSRIs reduced depressive symptoms at 24 weeks of treatment (mean difference -2.18; 95% CI, -4.25 to -0.10). With regard to side effects, only dizziness was associated with administration of antidepressants (OR = 2.65; 95% CI, 1.46 to 4.80). There were no differences in sustained virologic response (OR = 1.22; 95% CI, 0.58 to 2.57). CONCLUSIONS: Administration of SSRIs before starting antiviral treatment reduces the incidence of interferon-induced depression, with a relatively moderate prophylactic impact and good tolerability.