From the Editor

Much has changed in the past eight years. In 2016, singer Olivia Rodrigo was starting high school. Quarterback Tom Brady seemed ageless. And none of us were talking about pandemics. 2016 was also the year when the last Canadian Network for Mood and Anxiety Treatments (CANMAT) depression guidelines were released. Well, it’s 2024 and the update has just been published in The Canadian Journal of Psychiatry

How has depression management changed over these past eight years, and how should you adjust your clinical practice? In the first selection, we look at seven takeaways and a commentary.

Melancholia (from the Wellcome Library)

In this week’s other selection, Dr. Nathan Houchens (of the University of Michigan) and his co-authors consider telemedicine video backgrounds in a new research letter from JAMA Network Open. They asked patients to rate different backgrounds and in various medical circumstances; they report on survey results of more than 1 200 patients. “In this study, two-thirds of participants preferred a traditional health care setting background for video visits with any physician type, with physician office displaying diplomas rated highest.”


Selection 1: “Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults”
Raymond W. Lam, Sidney H. Kennedy, Camelia Adams, et al

The Canadian Journal of Psychiatry, 6 May 2024  Online First

Depressive illnesses such as major depressive disorder (MDD) are common mental health conditions that significantly impact a person’s quality of life and increase their risk of developing other health problems. Despite international calls to prioritize the recognition and treatment of MDD, only 20% of individuals with MDD will receive adequate treatment. Clinical guidelines are one tool for standardizing treatments to improve clinical care.

The Canadian Network for Mood and Anxiety Treatments (CANMAT) last published evidence-based guidelines for managing MDD in 2016 (previous iterations were published in 2001 and 2009). Since then, new research has emerged and new and updated treatment options for MDD are available. This 2023 update provides healthcare professionals with the latest evidence-informed recommendations for assessing and managing MDD…

So begins the new update by Lam and Kennedy et al.

Here’s what they did:

  • The authors provide the first major update since 2016.
  • They answered eight clinically relevant questions, representing different aspects of a patient’s journey.
  • The update covers everything from psychotherapy to apps.

It’s difficult to summarize this paper, so let me instead draw attention to several key tables with seven takeaways.

Takeaway 1: Many meds work.

The update recommends several antidepressants as first-line agents, a significantly expanded list from 2016. Note that the vast majority are off patent.

Takeaway 2: Augmentation is important – and has been re-thought.

What should be done when meds help but the patient is still struggling? The update puts an emphasis on augmentation (now termed adjunctive), and the recommendations are very different from 2016.

First-line agents: aripiprazole and brexpiprazole. Old favourites – think lithium and thyroid – remain out of favour. In my recent podcast interview with Dr. Raymond Lam, he suggested that the augmentation recommendations are the biggest single change in the update.

Takeaway 3: It’s not just about the meds.

As was the case in 2016, the authors emphasize the importance of non-pharmacological interventions. Exercise, in particular, is evidenced and first line; note, though, the importance of supervision.

Takeaway 4: Digital interventions are popular – but not necessarily backed by evidence.

Approximately 80% of the world’s population has a smart phone. Not surprisingly, there are apps and other digital interventions to help people with depression. The authors offer a cautionary note: only those that are therapist guided are recommended as first line.

Some examples follow.

Takeaway 5: Complementary and alternative meds are popular – but not necessarily backed by evidence.

Our patients are increasingly interested in complementary and alternative medications. That said, there remains only one first-line treatment and it’s for mild-severity depression. 

Takeaway 6: Therapy works.

Psychotherapy is backed by evidence, and three are first line – which doesn’t represent a significant change from 2016.

Takeaway 7: Neuromodulation works when other treatments don’t.

Despite the passage of time and the advances with pharmacology and therapy, neuromodulation is appropriate for some patients, with the most evidence favouring rTMS and ECT. 

The update runs with a commentary by Michael Berk (of Deakin University) et al. They begin:

“The Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines remain one of the eminent guidelines influencing clinical care worldwide, and these revisions thoughtfully update the literature influencing clinical care.”

Michael Berk

They make several points, including the importance of lifestyle interventions – “such as exercise, light therapy, improved dietary habits, tobacco (and other substances) cessation, and sleep hygiene.” They reference other guidelines:

“This is broadly concordant with other recent guidelines such as the RANZCP guidelines, which now place lifestyle modification as a foundational element of care. Furthermore, other lifestyle interventions, such as activity scheduling, volunteering, yoga, or tai chi, might also be effective in selected populations. Diet is given a third-line recommendation in these guidelines, based on only 1 identified trial. However, there are now several trials, and a 2019 meta-analysis of 15 clinical trials mostly in nonclinical populations, showing an aggregate positive effect on depressive symptoms with dietary interventions. A more recent meta-analysis of clinical populations using a Mediterranean diet also showed beneficial effects. The ketogenic dietary pattern is attracting significant interest, but data are to date inadequate to make any clinical recommendations. Nevertheless, based on potential utility for commonly comorbid medical conditions and the precautionary principle, lifestyle modification should arguably not be considered as an alternative step but rather as a normative practice alongside other therapies, providing a platform on which other therapies can be – potentially more successfully –employed.”

The CJP commentary can be found here:

Last week’s Reading included a summary of the interview with first co-author Dr. Raymond Lam (of the University of British Columbia). You can find it here:

The full CJP paper can be found here:

Selection 2: “Patient Preferences for Telemedicine Video Backgrounds”

Nathan Houchens, Sanjay Saint, Latoya Kuhn, et al.

JAMA Network Open, 15 May 2024

The COVID-19 pandemic prompted rapid adoption of telemedicine. Most physicians had no training on effective webside manner, including their physical environment. Strategies for optimal visual elements during telemedicine visits have been based on professional expertise and not empirical data. The preferred environment from which a physician conducts video visits remains unknown. Thus, we assessed patient preferences for various visual backgrounds during video visits.

So begins a research letter by Houchens et al.

Here’s what they did:

  • They conducted a cross-sectional study where a random sample of adults who had completed an in-person or virtual outpatient visit within the prior year and were invited to do a survey.
  • “Paper and electronic surveys included photographs of a model physician in different environments. Patients selected their preferred environment, and a composite score was calculated across 6 domains (how knowledgeable, trustworthy, caring, approachable, and professional the physician appeared, and how comfortable the physician made the respondent feel). Scores ranged from 1 to 10, with higher scores indicating greater preference.”
  • “Mean composite score differences were assessed using linear regression, with a solid color background as the reference category. Differences in preferred environment for all physician types were assessed using multinomial logistic regression.”

Here’s what they found:

  • A total of 1 213 patients responded; the response rates varied: university paper survey was 30%; veteran paper survey, 27%; university electronic survey, unknown. 
  • Demographics. The majority of patients were 65 and older (54.1%); 53.3% identified as female and 84.7% as White.
  • Ratings. The physician office displaying diplomas was rated highest across five domains (7.8) with lower mean scores for the bedroom (7.2) and kitchen (7.0) environments.
  • Preferences. “Considering all physician types together (a single respondent could choose a different preferred background for different physician types) and comparing with a solid color background (14.4%), respondents significantly preferred physician office (18.4%…) and physician office displaying diplomas (34.7%…) but significantly fewer preferred the bedroom (3.5%…) and kitchen (2.0%…) backgrounds.”

A few thoughts:

1. This is a fun research letter. 

2. The main finding in a sentence: patients preferred a traditional health care setting background.

3. “Webside manner” is a great phrase – one I intend to plagiarize.

4. The authors make a good and important point about backgrounds: “Numerous studies have found nonverbal communication to be a modifiable determinant of patient trust and satisfaction.”

The full JAMA Netw Open research letter can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.