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

Summary & key facts

The Canadian Network for Mood and Anxiety Treatments updated its 2016 guidelines for treating major depression in adults. A team looked over existing high-quality reviews and answered about 30 clinical questions about brain-based treatments. They covered six types of stimulation to the brain and rated how well each one works and how safe it appears. The guidelines say one of these treatments, repetitive transcranial magnetic stimulation, can be offered earlier for people who did not get better after trying at least one antidepressant. Other options are placed later or are still considered experimental.

Key facts:

• The 2016 update reviewed high-quality summaries of research to answer about 30 clinical questions about brain-stimulation treatments for adult major depression.
• The report focused on six neurostimulation methods: transcranial direct current stimulation, repetitive transcranial magnetic stimulation, electroconvulsive therapy, magnetic seizure therapy, vagus nerve stimulation, and deep brain stimulation.
• The guidelines judged that evidence for these brain-stimulation treatments is growing for both how well they work and how tolerable and safe they are.
• Repetitive transcranial magnetic stimulation (rTMS) was recommended as a first-line neurostimulation option for people who did not improve after trying at least one antidepressant.
• Electroconvulsive therapy (ECT) was kept as a second-line option for treatment-resistant depression, though the guidelines note it may be used as a first option in some situations.
• Transcranial direct current stimulation (tDCS) and vagus nerve stimulation (VNS) were listed as third-line options, while magnetic seizure therapy (MST) and deep brain stimulation (DBS) were still described as investigational, meaning more research is needed.

Abstract

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Topics

Electroconvulsive Therapy Studies Neurological disorders and treatments Transcranial Magnetic Stimulation Studies

Categories

Life Sciences Neurology Neuroscience

Tags

Adverse effect Anxiety Clinical psychology Cognition Deep brain stimulation Deep transcranial magnetic stimulation Depression (economics) Disease Economics Electroconvulsive therapy Internal medicine Macroeconomics Major depressive disorder Major depressive episode Medicine Mood Neuroscience Neurostimulation Parkinson's disease Psychiatry Psychology Stimulation Tolerability Transcranial magnetic stimulation Vagus nerve Vagus nerve stimulation

Conditions & symptoms

Anxiety Sadness or low mood