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

University of British Columbia, Canada.
Journal of Affective Disorders (Impact Factor: 3.38). 09/2009; 117 Suppl 1:S26-43. DOI: 10.1016/j.jad.2009.06.041
Source: PubMed


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.
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.
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.
Most of the evidence is based on trials for registration and may not reflect real-world effectiveness.
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.

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    • "ncomplete . This conclusion contrasts sharply with abundant evidence of short - term efficacy of antimanic , antidepressant , and mood - stabilizing medical and psychosocial treatments for mood - disorder patients , and grow - ing evidence of long - term effectiveness as well ( Baldessarini , 2013 ; Cipriani et al . , 2009 ; Garay et al . , 2014 ; Lam et al . , 2009 ; Selle et al . , 2014 ; Tondo et al . , 2013 ; Undurraga and Baldessarini , 2012 ; Vázquez et al . , 2011 ; Yatham et al . , 2013 ; Yildiz et al . , 2014"
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    ABSTRACT: BACKGROUND: Long-term symptomatic status in persons with major depressive and bipolar disorders treated clinically is not well established, although mood disorders are leading causes of disability worldwide. AIMS: To pool data on long-term morbidity, by type and as a proportion of time-at-risk, based on published studies and previously unreported data. METHODS: We carried out systematic, computerized literature searches for information on percentage of time in specific morbid states in persons treated clinically and diagnosed with recurrent major depressive or bipolar I or II disorders, and incorporated new data from one of our centers. RESULTS: We analyzed data from 25 samples involving 2479 unipolar depressive and 3936 bipolar disorder subjects (total N=6415) treated clinically for 9.4 years. Proportions of time ill were surprisingly and similarly high across diagnoses: unipolar depressive (46.0%), bipolar I (43.7%), and bipolar II (43.2%) disorders, and morbidity was predominantly depressive: unipolar (100%), bipolar-II (81.2%), bipolar-I (69.6%). Percent-time-ill did not differ between UP and BD subjects, but declined significantly with longer exposure times. CONCLUSIONS: The findings indicate that depressive components of all major affective disorders accounted for 86% of the 43-46% of time in affective morbidity that occurred despite availability of effective treatments. These results encourage redoubled efforts to improve treatments for depression and adherence to their long-term use
    Journal of Affective Disorders 03/2015; 3(178):71-78. DOI:10.1016/j.jad.2015.02.011. · 3.38 Impact Factor
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    • "The mechanisms of action of intermittent or continuous HF and LF rTMS applied over the DLFPC are unclear, which limits the comparison of these approaches. The selection of venlafaxine as an antidepressant is based on studies reporting the efficacy of venlafaxine as a second line treatment after failure of an SSRI [32] [40] [41]. It could be hypothesized that the venlafaxine dosage (150 vs 225 mg/day) could have influenced the susceptibility of the brain to rTMS and subsequently the treatment efficacy. "
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    ABSTRACT: Context The aim of this study was to assess whether the combination of low frequency repetitive transcranial magnetic stimulation (rTMS) and venlafaxine (150-225 mg/day) is effective and safe for treatment-resistant unipolar depression (TRD). Method In a multicenter (18 centers) randomized double blind controlled trial with three arms, 170 patients were allocated to receive active rTMS combined with active venlafaxine (n= 55), active rTMS combined with placebo venlafaxine (n= 60) or sham rTMS combined with active venlafaxine (n= 55). The patients received once daily sessions of active or sham 1Hz rTMS applied over the right dorsolateral prefrontal cortex (360 pulses/day delivered at 120% of the resting motor threshold) for two to six weeks; rTMS was combined with active or sham venlafaxine (mean dose: 179.0 ± 36.6 mg/day). The primary outcome was the number of patients who achieved remission, which was defined as an HDRS-17 score < 8. Results We reported a similar significant antidepressant effect in the 3 groups (p< 10-6), with a comparable delay of action and a comparable number of remitters at the endpoint (28% in the combination group, 41% in the rTMS group and 43% in the venlafaxine group; p= 0.59). Conclusion Low frequency rTMS appears to be as effective as venlafaxine and as effective as the combination of both treatments for TRD. Because of its short session duration (the duration of one session was 8.5 minutes) and its safety, slow rTMS might be a useful alternative treatment for patients with TRD.
    Brain Stimulation 11/2014; 7(6). DOI:10.1016/j.brs.2014.07.040 · 4.40 Impact Factor
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    • "The CANMAT, BAP, APA, and Korean Society for Depressive and Bipolar Disorders and Korean College of Neuropsychopharmacology guidelines have described modafinil as having a low possibility of causing dependency and cardiovascular side effects (13, 16, 17, 27). In addition, modafinil is described as being helpful with residual symptoms such as fatigue and sedation (84, 85). "
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    ABSTRACT: This paper aims to introduce, summarize, and emphasize the importance of the 'Evidence-Based, Pharmacological Treatment Guideline for Depression in Korea, Revised Edition'. The guideline broadly covers most aspects of the pharmacological treatment of patients in Korea diagnosed with moderate to severe major depression according to the DSM-IV TR. The guideline establishment process involved determining and answering a number of key questions, searching and selecting publications, evaluating recommendations, preparing guideline drafts, undergoing external expert reviews, and obtaining approval. A guideline adaptation process was conducted for the revised edition. The guideline strongly recommends pharmacological treatment considered appropriate to the current clinical situation in Korea, and should be considered helpful when selecting the appropriate pharmacological treatment of patients diagnosed with major depressive disorder. Therefore, the wide distribution of this guideline is recommended.
    Journal of Korean Medical Science 04/2014; 29(4):468-484. DOI:10.3346/jkms.2014.29.4.468 · 1.27 Impact Factor
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