Canadian Network For Mood And Anxiety Treatments Research Articles

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly.

The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals. Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. This section on "Special Populations" is the sixth of six guidelines articles. Recent studies inform the treatment of MDD in children and adolescents, pregnant and breastfeeding women, women in perimenopause or menopause, and the elderly. Evidence for efficacy of treatments in these populations is more limited than for the general adult population, however, and risks of treatment in these groups are often poorly studied and reported. Despite the limited evidence base, extant data and clinical experience suggest that each of these special populations can benefit from the systematic application of treatment guidelines for treatment of MDD.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments.

The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals. Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. "Pharmacological Treatments" is the third of six sections of the 2016 guidelines. With little new information on older medications, treatment recommendations focus on second-generation antidepressants. Evidence-informed responses are given for 21 questions under 4 broad categories: 1) principles of pharmacological management, including individualized assessment of patient and medication factors for antidepressant selection, regular and frequent monitoring, and assessing clinical and functional outcomes with measurement-based care; 2) comparative aspects of antidepressant medications based on efficacy, tolerability, and safety, including summaries of newly approved drugs since 2009; 3) practical approaches to pharmacological management, including drug-drug interactions and maintenance recommendations; and 4) managing inadequate response and treatment resistance, with a focus on switching antidepressants, applying adjunctive treatments, and new and emerging agents. Evidence-based pharmacological treatments are available for first-line treatment of MDD and for management of inadequate response. However, given the limitations of the evidence base, pharmacological management of MDD still depends on tailoring treatments to the patient.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 4. Neurostimulation Treatments.

The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals. Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. "Neurostimulation Treatments" is the fourth of six sections of the 2016 guidelines. Evidence-informed responses were developed for 31 questions for 6 neurostimulation modalities: 1) transcranial direct current stimulation (tDCS), 2) repetitive transcranial magnetic stimulation (rTMS), 3) electroconvulsive therapy (ECT), 4) magnetic seizure therapy (MST), 5) vagus nerve stimulation (VNS), and 6) deep brain stimulation (DBS). Most of the neurostimulation treatments have been investigated in patients with varying degrees of treatment resistance. There is increasing evidence for efficacy, tolerability, and safety of neurostimulation treatments. rTMS is now a first-line recommendation for patients with MDD who have failed at least 1 antidepressant. ECT remains a second-line treatment for patients with treatment-resistant depression, although in some situations, it may be considered first line. Third-line recommendations include tDCS and VNS. MST and DBS are still considered investigational treatments.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 5. Complementary and Alternative Medicine Treatments.

The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals. Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. "Complementary and Alternative Medicine Treatments" is the fifth of six sections of the 2016 guidelines. Evidence-informed responses were developed for 12 questions for 2 broad categories of complementary and alternative medicine (CAM) interventions: 1) physical and meditative treatments (light therapy, sleep deprivation, exercise, yoga, and acupuncture) and 2) natural health products (St. John's wort, omega-3 fatty acids; S-adenosyl-L-methionine [SAM-e], dehydroepiandrosterone, folate, Crocus sativus, and others). Recommendations were based on available data on efficacy, tolerability, and safety. For MDD of mild to moderate severity, exercise, light therapy, St. John's wort, omega-3 fatty acids, SAM-e, and yoga are recommended as first- or second-line treatments. Adjunctive exercise and adjunctive St. John's wort are second-line recommendations for moderate to severe MDD. Other physical treatments and natural health products have less evidence but may be considered as third-line treatments. CAM treatments are generally well tolerated. Caveats include methodological limitations of studies and paucity of data on long-term outcomes and drug interactions.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 1. Disease Burden and Principles of Care.

The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals. Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. This section is the first of six guidelines articles. In Canada, the annual and lifetime prevalence of MDD was 4.7% and 11.3%, respectively. MDD represents the second leading cause of global disability, with high occupational and economic impact mainly attributable to indirect costs. DSM-5 criteria for depressive disorders remain relatively unchanged, but other clinical dimensions (sleep, cognition, physical symptoms) may have implications for depression management. e-Mental health is increasingly used to support clinical and self-management of MDD. In the 2-phase (acute and maintenance) treatment model, specific goals address symptom remission, functional recovery, improved quality of life, and prevention of recurrence. The burden attributed to MDD remains high, whether from individual distress, functional and relationship impairment, reduced quality of life, or societal economic cost. Applying core principles of care, including comprehensive assessment, therapeutic alliance, support of self-management, evidence-informed treatment, and measurement-based care, will optimize clinical, quality of life, and functional outcomes in MDD.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Introduction and Methods.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Introduction and Methods.

Recurrent Major Depressive Disorder of a Young Woman.

Questions are presented at “consideration points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. At the end of the exercise, you will add up your points to obtain a total score.

Management Issues During Pregnancy in Women With Bipolar Disorder

Back to table of contents Previous article Next article Communications and UpdatesFull AccessManagement Issues During Pregnancy in Women With Bipolar DisorderVerinder Sharma, M.B.B.S., and Christina Sommerdyk, M.Sc.Verinder SharmaSearch for more papers by this author, M.B.B.S., and Christina SommerdykSearch for more papers by this author, M.Sc.Published Online:1 Mar 2014https://doi.org/10.1176/appi.ajp.2014.13111493AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: We read with interest the article by Clark et al. (1) on lamotrigine dosing in pregnant patients with bipolar I disorder. The authors report on the use of lamotrigine in eight patients with bipolar disorder, six of whom received concomitant psychotropic drugs including four women who were taking antidepressant drugs. Dosage adjustments of lamotrigine were made in response to hypomanic, manic, or depressive symptoms. It is not clear whether the dosages of concomitant psychotropic drugs remained the same during pregnancy. Of the three women requiring a dosage increase to manage symptoms, two were also taking antidepressants that can increase the recurrence of bipolar mood episodes both during and after pregnancy (2). There are no data suggesting that monitoring serum levels with corresponding adjustments to lamotrigine dosing will protect against antidepressant-led mood instability. Interestingly, the authors did not report a correlation between lamotrigine concentration and scores on rating scales for depression and mania. Thus, the conclusion that women with bipolar disorder who are treated with lamotrigine experience an increase in symptoms as a result of declining concentrations of this drug is not justified.While lamotrigine has a role in the management of bipolar disorder during pregnancy, no data on its effectiveness in the prevention of postpartum mood episodes are currently available. Moreover, lamotrigine is generally not recommended for the acute treatment of mania (3).Finally, the statement that pregnancy is a vulnerable period for recurrence of mood episodes is true for women treated at tertiary care centers with complex and often comorbid disorders and women who discontinue mood-stabilizing drugs. However, evidence from studies using nonclinical samples, retrospective studies, and studies on psychiatric hospitalization rates is suggestive of a positive effect of pregnancy on bipolar disorder (4).From the Departments of Psychiatry and Obstetrics & Gynecology, University of Western Ontario, London, Ontario, Canada; the Perinatal Clinic, London Health Sciences Centre, London, Ontario; and Regional Mental Health Care, London, Ontario.Professor Sharma has received grant support from, participated on scientific advisory boards for, or served on the speakers’ bureaus of AstraZeneca, Bristol-Myers Squibb, Cephalon, Eli Lilly, Janssen, Lundbeck, the Ontario Mental Health Foundation, Pfizer, Servier, and the Stanley Foundation. Ms. Sommerdyk reports no financial relationships with commercial interests.References1 Clark CT, Klein AM, Perel JM, Helsel J, Wisner KL: Lamotrigine dosing for pregnant patients with bipolar disorder. Am J Psychiatry 2013; 170:1240–1247Link, Google Scholar2 Viguera AC, Whitfield T, Baldessarini RJ, Newport DJ, Stowe Z, Reminick A, Zurick A, Cohen LS: Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. Am J Psychiatry 2007; 164:1817–1824Link, Google Scholar3 Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Beaulieu S, Alda M, O’Donovan C, Macqueen G, McIntyre RS, Sharma V, Ravindran A, Young LT, Milev R, Bond DJ, Frey BN, Goldstein BI, Lafer B, Birmaher B, Ha K, Nolen WA, Berk M: Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disord 2013; 15:1–44Crossref, Medline, Google Scholar4 Sharma V, Pope CJ: Pregnancy and bipolar disorder: a systematic review. J Clin Psychiatry 2012; 73:1447–1455Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited byRisk of Medication Exposures in Pregnancy and Lactation26 May 2021 Volume 171Issue 3 March 2014Pages 370-371 Metrics PDF download History Accepted 1 January 2014 Published online 1 March 2014 Published in print 1 March 2014

Reducing stigma toward people with bipolar disorder: Impact of a filmed theatrical intervention based on a personal narrative

Stigma toward people with bipolar disorder (BD) is pervasive and can have many negative repercussions. Common approaches to stigma reduction include education and intergroup contact. From this perspective, the Collaborative RESearch Team to study psychosocial issues in Bipolar Disorder (CREST.BD) and Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to develop an intervention to combat stigma. The result is a personal narrative intervention that combines contact, education and drama to educate audiences and dispel the myths that drive stigma. This study reports on the impact of the CREST.BD-CANMAT stigma-reduction intervention in filmed format. A sample of 137 participants was recruited to view the film, including health-care service providers, university students in a health-care-related course, people with BD and their friends and family members and the general public. Participants were evaluated for stigmatizing attitudes and the desire for social distance before and after the intervention and 1 month later. For health-care service providers, the intervention was associated with statistically significant improvements in several categories of stigmatizing attitudes, with maintenance 1 month later. The impact was more modest for the other subsamples. Students demonstrated progressive, significant improvements in the desire for (less) social distance. Some improvements were observed among members of the BD community and the general public, but these were limited and eroded over time. This study demonstrated that a filmed dramatic intervention based on the lived experience of BD has statistically significant, sustainable stigma-reduction impacts for health-care service providers and more limited impacts for other target groups. This intervention can be considered an effective tool for use in stigma-reduction campaigns specifically targeting members of the health-care sector. Results are discussed in the context of multi-component stigma-reduction campaigns and the potential needs of target groups.

Use of antidepressants during pregnancy: a better choice for some.

Mood disorders such as depression are more common among women, especially among pregnant women. Some population-based studies report a 20% prevalence of depression among pregnant women.[1],[2] Given this relatively high prevalence, the use of antidepressant medication during pregnancy is not uncommon. A study in the United States reported that at least 10% of pregnant women used antidepressants during pregnancy.[3] However, antidepressants may interfere with fetal growth so there is an ongoing debate about whether or not antidepressants should be used during pregnancy. Like all medications, antidepressants should be used with caution during pregnancy. The use of anti-depressants during pregnancy has been linked to various negative outcomes including miscarriage, pre-term birth, and low birth weight. One study found that within the two weeks of birth, newborns of mothers who used antidepressants during pregnancy were more likely to develop poor neonatal adaptation syndrome (OR=5.07, 95% CI=3.25-7.90), a condition which is characterized by poor temperature control, hypoglycemia, tachypnoea, respiratory distress, nasal congestion or cyanosis and seizures.[4] A systematic review reported a higher risk of developing congenital heart defects among newborns of mothers who used paroxetine during pregnancy (OR=1.36, 95% CI=1.08-1.71); however, this study did not find evidence of an overall association between the use of antidepressants and neonatal birth defects.[5] Untreated depression during pregnancy has been linked to more pre-term births and less breast-feeding.[6] Depression during pregnancy has also been associated with asthma in newborns, and the severity of depression was positively correlated with the severity of asthma (a dose-response relationship).[7] Moreover, the distress experienced by women with depression who are pregnant is similar to that experienced by women with depression who are not pregnant; the decline in their quality of life, impairment in their social functioning, and their risk of suicide are the same.[8] Therefore, treatment of depression during pregnancy is important for both the mother and the child. Psychotherapy, specifically interpersonal psycho-therapy,[9] has been shown to ameliorate depressive mood in pregnant women. However, this has only been studied among pregnant women with mild to moderate depression, not among those with severe depression for whom antidepressant treatment may be necessary. To date, there has been limited evidence about the effectiveness and safety of antidepressant use during pregnancy. Some experts have reached a consensus that antidepressants should be used to treat severe depression during pregnancy.[10] The Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults suggest weighing the adverse effects of antidepressants on the fetus (which occur at a low frequency) against the benefits of treatment. The guidelines list fluoxetine and other selective serotonin re-uptake antidepressants (SSRIs) as first-line antidepressants for use during pregnancy, but they also warn of possible neonatal heart defects after the use of fluoxetine.[11] A small-sample prospective study compared neonatal outcomes between 35 pregnant women who used antidepressants (mainly SSRI) with 23 pregnant women who did not. This study found no differences in cognitive functioning, language, and mobility in the babies at 18 months of age.[12] Another case report found no anomalies in the physical or mental development of a nine-month-old infant born to a mother who had taken duloxetine.[13] We believe that the benefits of antidepressant treatment of pregnant women with depression out-weigh the possible risk to the fetus: (a) if the depression is severe (that is, with suicidal ideation or behavior, psychotic symptoms, or a complete loss of appetite), (b) if there is a family history of re-occurring mental disorders, (c) if the individual lacks family or social support, or (d) if moderate depression persists despite psychotherapeutic treatment. Antidepressant use should be considered for the treatment of pregnant women who meet any of these criteria. The pros and cons of antidepressant treatment should be discussed with the individuals and their family members before obtaining their informed consent. Currently, most guidelines recommend the use of SSRIs (e.g., fluoxetine and citalopram) or tricyclic antidepressants (e.g., nortriptyline) for depression during pregnancy. Psychiatrists should ensure that the depressed woman and her family members are aware of the potential risks and immediately report any related symptoms. Psychiatrists treating pregnant women also need to coordinate their treatment with the responsible obstetrician to ensure the timely prevention of possible negative outcomes.

P282 Management Of Patients With Bipolar Disorder: An Adapted Clinical Practice Guideline >From King Saud University, King Khalid University Hospital, Clinical Practice Guidelines Committee, Faculty Of Medicine, Department Of Psychiatry

ObjectivesAdaptation of CPGs for Treatment of Bipolar disorder in King Khalid University Hospital, Psychiatry DepartmentMethodsThe ADAPTE process for CPGs adaptation. Results: the final decision of the panel after full assessments...

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013

The Canadian Network for Mood and Anxiety Treatments published guidelines for the management of bipolar disorder in 2005, with updates in 2007 and 2009. This third update, in conjunction with the International Society for Bipolar Disorders, reviews new evidence and is designed to be used in conjunction with the previous publications.The recommendations for the management of acute mania remain largely unchanged. Lithium, valproate, and several atypical antipsychotic agents continue to be first-line treatments for acute mania. Monotherapy with asenapine, paliperidone extended release (ER), and divalproex ER, as well as adjunctive asenapine, have been added as first-line options.For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, as well as olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. Lurasidone monotherapy and the combination of lurasidone or lamotrigine plus lithium or divalproex have been added as a second-line options. Ziprasidone alone or as adjunctive therapy, and adjunctive levetiracetam have been added as not-recommended options for the treatment of bipolar depression. Lithium, lamotrigine, valproate, olanzapine, quetiapine, aripiprazole, risperidone long-acting injection, and adjunctive ziprasidone continue to be first-line options for maintenance treatment of bipolar disorder. Asenapine alone or as adjunctive therapy have been added as third-line options.

Ethnic Disparities in Antipsychotic Drug Use in British Columbia: A Cross-Sectional Retrospective Study

Ethnic Disparities in Antipsychotic Drug Use in British Columbia: A Cross-Sectional Retrospective Study

Adjunctive Medication Strategies for Treatment- Resistant Depression

Abbreviations AD antidepressant CANMAT Canadian Network for Mood and Anxiety Treatments MDD major depressive disorder TRD treatment-resistant depression Depression is a serious illness. Numerous studies show that major depressive disorder (MDD) is associated with significant personal distress and burden of disability.1 The good news is that there are many effective treatments available to treat MDD. The bad news is that not everyone experiences a full response to treatment. For example, the Sequenced Treatment Alternatives to Relieve Depression (commonly known by its acronym, STAR*D) effectiveness study found that, in the real world, remission outcomes are modest, with only 33% of patients with MDD achieving full remission of symptoms after the first antidepressant (AD) and only 67% after 1 year of treatment involving up to 4 treatment steps.2 Thus a significant percentage of patients will have a treatment-resistant depression (TRD), regardless of how treatment-resistant is defined.3 It is also clear that TRD is associated with poor outcomes and a disproportionate amount of the burden associated with MDD.4,5 Although TRD is often used in the literature as if it were a distinct entity, there is considerable variability in how TRD is defined and there is no consensus definition.6 For example, a commonly applied definition for TRD is failure of 2 or more ADs, preferably from different classes. However, some studies define resistant depression as failure of one AD, while others attempt to stage resistance by incorporating responses to other treatments (including older medications, such as tricyclic ADs or monoamine oxidase inhibitors, and somatic treatments, such as electroconvulsive therapy).7 Moreover, the definition of failure also varies considerably from study to study. Some TRD studies include patients with treatment failure by history, while others define failure prospectively. These diagnostic issues contribute to significant heterogeneity in TRD samples, which makes it difficult to compare treatment studies of TRD. In the context of modest success rates with AD monotherapy for MDD, how can we optimize outcomes for the large proportion of patients with TRD? We practice in an evidence-based medicine climate, so it is important to first consider evidence-based treatment approaches. However, we need to remember to differentiate between evidence of lack of efficacy and lack of evidence of efficacy. The latter is much more representative of the evidence landscape in psychiatry than the former. While there is reasonable evidence to support choices for initial pharmacotherapy of MDD, there is still only limited evidence for many important clinical questions, including how to manage poor or incomplete response to an initial AD. To further complicate the issue, the terminology for treatment strategies for TRD is changing. Augmentation and combination have been used in the literature to describe distinct strategies when adding another medication to an AD. Augmentation referred to adding a medication that was not considered an AD (for example, lithium or triiodothyronine), while combination referred to the practice of adding a second AD (for example, desipramine or bupropion). However, the definition of an AD is blurring and some medications that were considered augmentation agents may be effective ADs on their own. For example, older studies indicated that lithium may have acute AD effects for unipolar depression,8 and more recent studies show that some atypical antipsychotics (for example, quetiapine extended release9) are effective as monotherapy for nonpsychotic MDD. For this reason, some authors have suggested that the terms augmentation and combination be replaced by add-on or adjunctive, which do not infer the type of medication added.10 The 2009 revision of the Canadian Network for Mood and Anxiety Treatments (CANMAT) depression guidelines summarizes the evidence for pharmacologic strategies for TRD. …

Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication

Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication

B2 Complementary and alternative treatments for depression

Introduction: In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. There is renewed interest in refined approaches to brain stimulation, particularly for treatment resistant major depressive disorder (MDD). Methods: PubMed, PsycInfo and the Cochrane database were searched for all publications relating to the use of neurostimulation approaches for depression, from January 2000 to December 2008. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included evidence and expert clinical support. Results: Among the four forms of neurostimulation reviewed in this section, electroconvulsive therapy (ECT) has the most extensive evidence, spanning seven decades. Repetitive transcranial magnetic (rTMS) and vagus nerve stimulation (VNS) have been approved to treat depressed adults in both Canada and the United States with a much smaller evidence base. There is also emerging evidence that deep brain stimulation (DBS) is effective for otherwise treatment resistant depression, but this is an investigational approach in 2009. Compared to other modalities for the treatment of MDD, the data on the neurostimulation approaches to depression is limited by the relatively small numbers of randomized controlled trials (RCTs) and small sample sizes. Conclusions: There is most evidence to support ECT as a first-line treatment under specific circumstances and rTMS as a second-line treatment. Evidence to support VNS is less robust and DBS remains an investigational treatment.

Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication

Background In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008–2009 to reflect advances in the field. This article, one of five in the series, reviews new studies of psychotherapy in the acute and maintenance phase of MDD, including computer-based and telephone-delivered psychotherapy. Methods The CANMAT guidelines are based on a question–answer format to enhance accessibility to clinicians. Evidence-based responses are based on updated systematic reviews of the literature and recommendations are graded according to the Level of Evidence, using pre-defined criteria. Lines of Treatment are identified based on criteria that included evidence and expert clinical support. Results Cognitive-Behavioural Therapy (CBT) and Interpersonal Therapy (IPT) continue to have the most evidence for efficacy, both in acute and maintenance phases of MDD, and have been studied in combination with antidepressants. CBT is well studied in conjunction with computer-delivered methods and bibliotherapy. Behavioural Activation and Cognitive-Behavioural Analysis System of Psychotherapy have significant evidence, but need replication. Newer psychotherapies including Acceptance and Commitment Therapy, Motivational Interviewing, and Mindfulness-Based Cognitive Therapy do not yet have significant evidence as acute treatments; nor does psychodynamic therapy. Limitations Although many forms of psychotherapy have been studied, relatively few types have been evaluated for MDD in randomized controlled trials. Evidence about the combination of different types of psychotherapy and antidepressant medication is also limited despite widespread use of these therapies concomitantly. Conclusions CBT and IPT are the only first-line treatment recommendations for acute MDD and remain highly recommended for maintenance. Both computer-based and telephone-delivered psychotherapy—primarily studied with CBT and IPT—are useful second-line recommendations. Where feasible, combined antidepressant and CBT or IPT are recommended as first-line treatments for acute MDD.

Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults

Abstract Background In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008–2009 to reflect advances in the field. There is widespread interest in complementary and alternative medicine (CAM) therapies in the treatment of major depressive disorder (MDD). Methods The CANMAT guidelines are based on a question–answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included evidence and expert clinical support. This section on Complementary and Alternative Medicine Treatments is one of 5 guideline articles. Results There is Level 1 evidence to support light therapy in seasonal MDD and St. John's wort in mild to moderate MDD. There is also some evidence for the use of exercise, yoga and sleep deprivation, as well as for omega-3 fatty acids and SAM-e . Support for other natural health products and therapies is still limited. Limitations The evidence base remains limited and studies often have methodological problems, including small samples, variability in dose, short duration of treatment, unknown quality of the agent and limited long-term data. Safety data are also sparse with little information about drug interactions. Conclusions Some CAM treatments have evidence of benefit in MDD. However, problems with standardization and safety concerns may limit their applicability in clinical practice.

Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical Guidelines for the Management of Major Depressive Disorder in Adults. I. Classification, Burden and Principles of Management

Background Major depressive disorder (MDD) is one of the most burdensome illnesses in Canada. The purpose of this introductory section of the 2009 revised CANMAT guidelines is to provide definitions of the depressive disorders (with an emphasis on MDD), summarize Canadian data concerning their epidemiology and describe overarching principles of managing these conditions. This section on “Classification, Burden and Principles of Management” is one of 5 guideline articles in the 2009 CANMAT guidelines. Methods The CANMAT guidelines are based on a question–answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to the Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included evidence and expert clinical support. Results Epidemiologic data indicate that MDD afflicts 11% of Canadians at some time in their lives, and approximately 4% during any given year. MDD has a detrimental impact on overall health, role functioning and quality of life. Detection of MDD, accurate diagnosis and provision of evidence-based treatment are challenging tasks for both clinicians and for the health systems in which they work. Limitations Epidemiologic and clinical data cannot be seamlessly linked due to heterogeneity of syndromes within the population. Conclusions In the eight years since the last CANMAT Guidelines for Treatment of Depressive Disorders were published, progress has been made in understanding the epidemiology and treatment of these disorders. Evidence supporting specific therapeutic interventions is summarized and evaluated in subsequent sections.

Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults.: III. Pharmacotherapy

Background In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008–2009 to reflect advances in the field. Methods The CANMAT guidelines are based on a question–answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included Levels of Evidence and expert clinical support. This section on “Pharmacotherapy” is one of 5 guideline articles. Results Despite emerging data on efficacy and tolerability differences amongst newer antidepressants, variability in patient response precludes identification of specific first choice medications for all patients. All second-generation antidepressants have Level 1 evidence to support efficacy and tolerability and most are considered first-line treatments for MDD. First-generation tricyclic and monoamine oxidase inhibitor antidepressants are not the focus of these guidelines but generally are considered second- or third-line treatments. For inadequate or incomplete response, there is Level 1 evidence for switching strategies and for add-on strategies including lithium and atypical antipsychotics. Limitations Most of the evidence is based on trials for registration and may not reflect real-world effectiveness. Conclusions Second-generation antidepressants are safe, effective and well tolerated treatments for MDD in adults. Evidence-based switching and add-on strategies can be used to optimize response in MDD that is inadequately responsive to monotherapy.