From the Editor

What’s new in depression treatment?

The new guidelines

This week, we look at the new CANMAT guidelines. Published in September in The Canadian Journal of Psychiatry, the papers – six in all – speak to the latest in depression management.

What should you think about the new antidepressants? What alternatives are there to CBT? What to do when everything else fails? Spoiler alert: this week’s Reading answers all these questions and more.


Depression and Its Management

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

The Canadian Journal of Psychiatry, September 2016

The Canadian Network for Mood and Anxiety Treatments (CANMAT) is a not-for-profit scientific and educational organization founded in 1995. In 2015, the CANMAT Depression Work Group began the process of producing new guidelines for the treatment of major depressive disorder (MDD), to update the previous 2009 guidelines. The scope of the guidelines remains the management of adults with unipolar MDD with an identified target audience of community-based psychiatrists and mental health professionals. CANMAT, in collaboration with the International Society for Bipolar Disorders, has published separate guidelines for bipolar disorder.

The editorial group defined 6 sections for inclusion in the CANMAT 2016 Depression Guidelines: (1) Disease Burden and Principles of Care, (2) Psychological Treatments, (3) Pharmacological Treatments, (4) Neurostimulation Treatments, (5) Complementary and Alternative Medicine Treatments, and (6) Special Populations (children/adolescents, women, elderly). Treatment recommendations for patients with MDD and psychiatric/medical comorbidities were published by a CANMAT task force in 2012.

The methods used were similar to the previous CANMAT guidelines that have been well regarded by clinicians. In contrast to other guidelines that use highly formalized evidence summaries that may be less accessible to users, we chose a clinically useful method that balances systematic evidence review with consensus expert opinion by experienced clinicians. Expert panels were established for each of the 6 sections. Members represented content experts from the fields of psychiatry, pharmacy, and psychology. The familiar question-answer format from previous editions was retained because feedback from clinicians affirmed the clinical practicality and ease of use.

Dr. Raymond Lam, CANMAT Executive Chair

So begins the first section of the new CANMAT depression guidelines, published in The Canadian Journal of Psychiatry.

Here’s what they did:

· The authors provide the first major update since 2009.

· There are a total of 6 papers, as well as an editorial by Dr. Scott Patten, the editor of The CJP.

· The guidelines are written in a question-and-answer format – making them readable if, as Dr. Patten notes, slightly unconventional as compared to other national guidelines.

It’s difficult to summarize these documents. Let me instead draw attention to several key tables and graphs.

On the illness experience:

Drawing on the work of Patten et al., the authors note the treatment – and lack of treatment – of MDD and its comorbidities.

On medication management:

It’s striking that the list of medications with level 1 evidence is short and – with the exception of Agomelatin (which isn’t available in Canada) – all off patent.

Also note that, with two exceptions, the antidepressants are all SRIs. So, after all these years, we still live in the age of Prozac, at least from a pharmacological perspective.

Careful here: the guidelines do make specific recommendations about sub-types of depression.

On psychotherapy:

Of course, we aren’t in the age of Prozac – we are in the age of multimodality treatment plans.

CBT remains first line for acute treatment. It’s not alone. And while several therapies have level 1 evidence in the acute phase, the authors comment on relapse prevention – showing strong evidence for CBT and MBCT. It’s a clear recognition that Major Depressive Disorder is a chronic episodic illness for many people.

On complementary treatments:

One of the biggest changes from 2009: the bigger recognition of the role of exercise. Note that it has first line evidence for mild to moderate MDD and second line evidence for moderate to severe. Summarizing the exercise recommendation, the National Post ran a story with the headline: “For mild depression, try jogging, yoga, or any form of aerobic exercise before drugs, psychiatrists say.” The article quotes CAMH’s Dr. Arun Ravindran: “There is a paradigm shift.” (I’ll be picky and note the error in the headline: yoga is adjunctive, even for mild depression.)

On alternative medications:

More and more patients are turning to alternative medications. It’s striking that these meds have migrated from health food stores to grocery stores and pharmacies. One of the most common questions I’m asked is the evidence for the use of alternative meds – to bolster prescription drugs or in lieu of them.

But for your patients who want something “natural,” there isn’t that much evidence for that much, with the exception of St. John’s wort, which is ultimately an SSRI.

On neurostimulation:

Much research has been done in the area of neurostimulation. As our understanding of the brain has evolved, so have our treatments. But the super-cutting edge treatments – think VNS and DBS – still don’t rival ECT. Regardless of the stigma, ECT is first line for both acute and maintenance phases of the illness.

Here’s a quick summary:

New isn’t better: There are new medications but they aren’t necessarily better.

Talking works: CBT is still the gold standard of psychotherapies, but there is a role for other evidence-based therapies too.

Don’t forget about exercise: exercise has level 1 evidence for mild and moderate depression.

Alternative meds aren’t ideal: there is limited evidence for much of everything except for St. John’s wort.

If all else fails… rTMS, ECT.

A few thoughts:

1. This is a major update from the 2009 guidelines.

2. The guidelines consider medication management – and much more. The guidelines have grown richer and more complete with each update.

3. Following up on this last point, my summary is crude at best. The new guidelines are detailed and worth a careful read.

4. My notes and observations are that of a journeyman clinician. I’ve benefited from conversations with CAMH’s Dr. David Goldbloom and UHN’s Dr. Jodi Lofchy. Over the coming months, the authors of these guidelines will be speaking. No doubt they will have further observations and thoughts.

If you are in Toronto, you could consider attending the University of Toronto’s Psychopharmacology Update, which will partly focus on the CANMAT guidelines. (I’m bringing my team from The Scarborough Hospital to present at this conference – though not on the guidelines.)

5. I marvel how evolved this field has become. When I entered my residency in psychiatry, there were no published Canadian guidelines for depression. Today’s guidelines are clear and thoughtful.

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