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
Scott B. Pattena,⁎, Sidney H. Kennedyb, Raymond W. Lamc, Claire O'Donovand, Marie J. Filteaue,
Sagar V. Parikhb, Arun V. Ravindranb
aUniversity of Calgary, Canada
bUniversity of Toronto, Canada
cUniversity of British Columbia, Canada
dDalhousie University, Canada
eUniversité Laval, Canada
a r t i c l ei n f oa b s t r a c t
Received 1 May 2009
Accepted 23 June 2009
Available online 12 August 2009
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 arechallenging tasks for bothclinicians andfor the health systems
in which they work.
Limitations: Epidemiologic and clinical data cannot be seamlesslylinked due toheterogeneity 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.
© 2009 Published by Elsevier B.V.
Major Depressive Disorder
Canadian Network for Mood and Anxiety
Principle of management
The Canadian Psychiatric Association and the Canadian
Network for Mood and Anxiety Treatments (CANMAT), a
not-for-profit scientific and educational organization,
collaborated on the publication in 2001 of evidence-
based Canadian clinical guidelines for the treatment of
depressive disorders (Kennedy and Lam, 2001). A revision
of these guidelines was undertaken by CANMAT in 2008–
2009 to update the recommendations based on new
evidence. The scope of these guidelines encompasses the
management of adults with unipolar major depressive
disorder (MDD). This section on classification, burden and
Journal of Affective Disorders 117 (2009) S5–S14
⁎ Corresponding author.
E-mail address: email@example.com (S.B. Patten).
0165-0327/$ – see front matter © 2009 Published by Elsevier B.V.
Contents lists available at ScienceDirect
Journal of Affective Disorders
journal homepage: www.elsevier.com/locate/jad
principles of treatment is one of 5 guideline articles. There
are separate CANMAT guidelines for Bipolar Disorder
(Yatham et al., 2009).
The current classification of depressive disorders is based
on the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV; American Psychiatric Association,
2000) or “Recurrent Depressive Episodes” in the ICD-10
Classification of Mental and Behavioral Disorders (http://
www.who.int/classifications/icd/en/). In neither case are
these diagnoses linked to etiopathology. MDD is associated
with a substantial health, psychosocial and financial burden
and is increasingly recognized as a target for chronic disease
management. While standardized diagnostic criteria are
available, clinical assessment must extend beyond application
of these criteria. It is important to consider the short term and
long-term components of management and these will be
expanded upon in subsequent sections of the guidelines,
dealing with psychotherapies, pharmacotherapies, neurosti-
mulation therapies and complementary and alternative
medicines. The recommendations are presented as guidance
for clinicians who should consider them in context of
individual patients, and not as standards of care.
The full methods have been described elsewhere (Kennedy
et al, 2009-this issue) but, in summary, relevant English
language publications from January 1, 2000 to December
31, 2008 were identified using computerized searches of
electronic databases (PubMed, PsychInfo, Cochrane Register
of Clinical Trials), inspection of bibliographies, and review
of other guidelines and major reports. The previous question–
answer format has been retained based on feedback from
clinicians. Recommendations for each Line of Treatment
1.1. What is a depressive disorder?
The DSM-IV provides a general definition for mental
disorder: “a clinically significant behavioral or psychological
syndrome or pattern that occurs in an individual and that is
associated with present distress or disability or with a
significantly increased risk of suffering death, pain, disability,
or an important loss of freedom.” In keeping with this
definition, depressive disorders are mental disorders that are
characterized predominantly by depressive features.
The DSM-IV concept of a depressive disorder adds
considerable specificity to otherwise non-specific terminol-
ogy such as “depression” which might otherwise imply a
depressed (or lowered) mood, a normal response to loss (i.e.
bereavement) or a maladaptive reaction to stress (i.e. an
adjustment disorder with depressed mood). Depression can
also be conceptualized as a dimension of symptomexpression
quantifiable using symptom rating scales. In clinical practice,
depressive symptom ratings have an important role to play in
case-finding (screening) and in monitoring outcomes.
1.2. How are depressive disorders classified?
The two most important depressive disorders are MDD and
Dysthymic Disorder. The essential feature of MDD is the
occurrence of one or more Major Depressive Episodes. In turn,
2 weeks characterized either by depressed mood (most of the
day, nearly every day) and/or markedly diminished interest or
pleasure in all, or almost all, activities (most of the day, nearly
every day).Intotal, duringthesame2-week period,there must
be five or more symptoms drawn from the list presented in
Table 2. Major Depressive Episodes are also the predominant
form of mood disturbance in Bipolar Disorder. These disorders
are not discussed further here because CANMAT has produced
separate Canadian guidelines for Bipolar Disorders (Yatham
et al., 2009). Dysthymic Disorder is characterized by a
chronically depressed mood that occurs most of the day, more
days than not, for at least 2 years. While depressed mood is
present there must be at least two additional depressive
symptoms. Treatment of Dysthymic Disorder is not a focus of
these guidelines. In addition to MDD, Bipolar Disorder and
Dysthymic Disorder, DSM-IV contains a category fordepressive
episodes caused by the use of, or withdrawal from, a drug:
Substance-Induced Mood Disorder, with Depressive Features.
DSM-IV also recognizes depression caused by the direct
physiological consequences of a general medical condition:
Mood Disorder Due to a General Medical Condition, with
Depressive Features. Finally, DSM-IV contains a residual
category called Depressive Disorder Not Otherwise Specified.
1.3. What are the important subtypes of major depressive
disorder and Dysthymic Disorder?
DSM-IV includes subtypes (specifiers) that can be used to
Criteria for Level of Evidenceaand Line of Treatment.b
• At least 2 RCTs with adequate sample sizes,
preferably placebo-controlled, and/or
meta-analysis with narrow confidence intervals
• At least 1 RCT with adequate sample size and/or
meta-analysis with wide confidence intervals.
• Non-randomized, controlled prospective studies
or case series or high quality retrospective studies.
• Expert opinion/consensus.
Line of TreatmentCriteria
• Level 1 or Level 2 evidence, plus clinical supportc
• Level 3 evidence or higher, plus clinical supportc
• Level 4 evidence or higher, plus clinical supportc
aNote that Level 1 and 2 evidence refer specifically to treatment studies in
which randomized comparisons are available. Recommendations involving
epidemiological or risk factors primarily arise from observational studies,
hence the highest Level of Evidence is usually Level 3. Higher order
recommendations (e.g., principles of care) reflect higher level judgment of
the strength of evidence from various data sources, and therefore are
primarily Level 4 evidence.
bA first-line treatment represents a balance of efficacy, tolerability and
clinical support. Second-line and third-line treatments are reserved for
situations where first-line treatments are not indicated or cannot be used, or
when first-line treatments have not worked.
cClinical support refers to application of expert opinion of the CANMAT
committees to ensure that evidence-supported interventions are realistic in
clinical practice. Therefore, treatments with higher levels of evidence may be
downgraded to lower Lines of Treatment due to clinical issues such as side
effect or safety profile.
S.B. Patten et al. / Journal of Affective Disorders 117 (2009) S5–S14
a current episode, these specifiers refer to this episode.
Otherwise, they are applied to the most recent episode. Some
of the specifiers refer to severity: major depressive episodes can
be classified as mild, moderate or severe. Within the severe
category, the disorder may or may not be characterized by
psychotic symptoms. Additional specifiers refer to clinical
features, as presented in Table 3. Specifiers can also be used to
describe partial or full remission of symptoms. Course specifiers
for Dysthymic Disorder refer to early onset (before age 21), late
onset, and the presence of atypical features.
1.4. How common are depressive disorders?
The prevalence of depressive disorders is usually reported
on a lifetime or annual basis. Lifetime prevalence is the
proportion of the population meeting diagnostic criteria for a
disorder at any time during their lives prior to the time of
assessment. Annual prevalence is the proportion meeting
diagnostic criteria during the preceding year. One month
prevalence is less commonly reported and represents the
proportion meeting diagnostic criteria during the month
preceding an assessment interview. Lifetime prevalence
estimates should be interpreted with caution. Measurement
of lifetime prevalence using typical epidemiologic research
instruments requires respondents to recall specific symptoms
that may have occurred many years prior to the actual
assessment interview. Long-term follow-up studies suggest
that such symptoms are often not recalled so that diagnostic
instruments may fail to detect prior episodes (Andrews et al.,
1999). For this reason, available estimates of lifetime pre-
valence are probably underestimates (Andrews et al., 2005).
While prevalence reflects the frequency of depressive
disorders in a population, it does not reflect the risk of
developing a disorder: incidence. Assessment of incidence
requires that a population at risk be identified (i.e. those who
DSM-IV criteria for a Major Depressive Episode.
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of
the symptoms is either depressed mood or markedly diminished interest or pleasure.
(1) Depressed mood mostof the day, nearlyeveryday,as indicatedbyeither subjectivereport(e.g., feels sad orempty) orobservation made byothers(e.g., appears
tearful). Note: In children and adolescents, can be irritable mood.
(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or
observation made by others). Additional criteria are derived from the following symptoms:
(3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly
every day. Note: In children, consider failure to make expected weight gains.
(4) Insomnia or hypersomnia nearly every day
(5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
(6) Fatigue or loss of energy nearly every day
(7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
(9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.
DSM-IV (American Psychiatric Association, 2000).
Prevalence studies of MDD in general populations.
Location (study)Criteria Current/1 month 12 monthsLifetime
Netherland (NEMESIS) DSM-III-R
Modified from Lam and Mok (2008).
DSM-IV-TR subtypes of MDD (Lam and Mok, 2008).
Non-reactive mood, anhedonia,
weight loss, guilt, psychomotor
retardation or agitation,
morning worsening of mood,
early morning awakening and
excessive or inappropriate guilt.
Reactive mood, over-sleeping,
over-eating, leaden paralysis,
Hallucinations or delusions
Catalepsy (waxy flexibility),
negativism or mutism,
mannerisms or stereotypes,
echolalia or echopraxia
(uncommon in clinical practice)
Chronic patternTwo years or more with
full criteria for MDE
Seasonal pattern Regular onset and remission
of depressive episodes
during a particular season
(usually fall/winter onset)
Onset of depressive episode
within 4 weeks postpartum
S.B. Patten et al. / Journal of Affective Disorders 117 (2009) S5–S14
do not already have a depressive disorder), and that new cases
emerging over a defined time interval be identified. Also,
prevalence estimates do not fully reflect the burden of
not only on prevalence, but also on the amount of time spent in
the depressed state, the extent of associated disability and the
often quantified using composite parameters that combine
information about prevalence, course, impairment and pre-
mature mortality, for example the Disability Adjusted Life Year,
DiseaseProject (Ayuso-Mateos, 2003;Murrayand Lopez,1996).
Early estimates of depressive disorder prevalence in
Canada were derived from studies conducted in Edmonton
(Bland et al., 1988a,b) and in the province of Ontario (Offord
et al.,1996). National estimates became available in 1994 with
the first interview cycle of the National Population Health
Survey (NPHS) (Beaudet, 1996). The NPHS included a brief
version of the major depression module of the Composite
International Diagnostic Interview (CIDI) (Kessler et al.,
1998). As a longitudinal study, the NPHS also provided
national incidence estimates (Beaudet, 1999; Patten, 2000;
Patten and Lee, 2004). The first national estimates of
prevalence based on the full version of the CIDI interview
were produced by the Canadian Community Health Survey,
Mental Health and Wellbeing (CCHS 1.2) conducted by
Statistics Canada in 2002 (Gravel and Béland, 2005). Table 4
presents a summary of international prevalence estimates.
Canada is 10.8%. Annual and one month prevalence estimates
et al., 2005b). These estimates are lower than in the US where
estimates of 16.2% lifetime and 6.6% annual prevalence were
reported by Kessler et al. (2003). Canadian estimates more
closely resemble recent European prevalence rates of 12.8%
lifetime and 3.9% annual (Alonso et al., 2004). However, a
telephone survey conducted jointly in Canada and the US did
not find a difference in prevalence between the two countries
and in younger age groups, although this sex difference
diminishes with increasing age in Canada (Patten et al.,
2005a,b), a pattern that was previously reported in the United
overall annual incidence of major depressive episodes is 3.1%
(Patten and Lee, 2004). However, the incidence is higher in
women and also tends to decline with age (Patten, 2000).
The CCHS 1.2 did not assess the prevalence of Dysthymic
Disorder, so national Canadian prevalence estimates are not
available. The Edmonton study, which used DSM-III diagnos-
tic criteria, reported 3.7% lifetime prevalence (Bland et al.,
1988a,b),closelyresemblingrecent Europeanestimates based
on DSM-IV criteria, 4.1% lifetime (Alonso et al., 2004).
Notably, the annual European prevalence was 1.1%, which
also resembled the 0.8% annual prevalence estimate from the
Mental Health Supplement of the Ontario Health Survey,
based on DSM-III-R criteria (Offord et al., 1996).
1.5. What is the long-term course of MDD?
In the CCHS 1.2, the reported duration of initial Major
Depressive Episodes was 2 weeks in 16% of episodes and one
month or less in 30% of episodes (Patten, 2006). At the other
extreme,13.7% of the subjects reported that their first episode
lasted 5 years or longer. The percentage of respondents
according to episode duration among those experiencing a
past year major depressive episode is shown in Table 5.
Mathematical modeling studies provide an explanation for
these results: the probability of recovery appears to decline
with increasingepisode duration (Patten and Lee, 2004). Mean
episode duration in the NPHS was 17 weeks (Patten and Lee,
2004), but the mean duration obscures both the brief nature of
some episodes and the protracted nature of others. Prevalence
is a product of incidence and duration, such that reducing the
duration of episodes (for example, through treatment), in the
absence of other changes, will reduce the prevalence in the
population. Unfortunately, despite recent increases in treat-
ment provision (Patten and Beck, 2004), a reduction in
prevalence has not yet been discernable in those countries
where before–after comparisons have been feasible (Brugha
et al., 2004; Kessler et al., 2005). Many new-onset episodes
occurring in the general population are brief, but longer
episodes accumulate to a greater extent and predominate as
prevalent cases in the population (Patten, 2006; Patten, 2007).
The Netherlands Mental Health Survey and Incidence Study
DSM-III-R defined MDD. This study retrospectively assessed
episode duration in community residents with new-onset
episodes. Consistent with Canadian data, a sizable proportion of
However, the recovery rate flattened over time, and the authors
estimated that approximately 20% would have chronic episodes
persisting longer than 24 months (Spijker et al., 2002).
MDD is often a recurrent condition. In the CCHS 1.2,
respondents with lifetime MDD reported a single episode
56.0% of the time, 2 episodes 28.6% of the time and 3 or more
lifetime episodes 15.4% of the time (CCHS 1.2, Public Use
Microdata File). Given the potential role of recall bias (see
above), it is likely that these are underestimates of the
frequency of recurrent episodes.
1.6. What is the impact of depressive disorders on
6.1. How substantial is the disease burden associated with MDD?
According to the Global Burden of Disease Study, MDD is
one of the world's leading causes of disability (Murray and
Lopez, 1996; The World Health Report 2001, 2001). Because
cognitive symptoms are prominent, the ongoing transition to
impact of MDD on occupational functioning (The Standing
Senate Committee on Social Affairs Science and Technology,
ing suicide risk. In a study of 102 suicides in New Brunswick,
Number of weeks depressed (past year) in CCHS 1.2 respondents with past-
year Major Depressive Episodes.
b 6 weeks
7 to 12 weeks
13 to 26 weeks
27 to 52 weeks
Canadian Community Health Survey 1.2, Public Use Microdata File.
S.B. Patten et al. / Journal of Affective Disorders 117 (2009) S5–S14
almost 70% of victims had an affective disorder, usually
comorbid with addictive or personality disorders (Seguin
et al., 2006). Data from NEMESIS demonstrated that comorbid
anxiety disorders amplify the risk of suicide attempt in
individuals with mood disorders (Sareen et al., 2005). Depres-
sive disorders also have a major impact on quality of life (QOL).
In a study of QOL impairment in depressive and anxiety
disorders, 63% of respondents with MDD had severe impair-
mentin QOL,while 85% of thosewith double depression (MDD
and Dysthymic Disorder) and 56% of those with Dysthymic
Disorder had QOL impairment in the severe range (Rapaport
et al., 2005).
1.7. What is the occupational impact?
Depression profoundly affects occupational functioning,
both through absenteeism and presenteeism (loss of produc-
tivity while attending work when unwell) (Sanderson et al.,
2007). A longitudinal study found that depressed workers
had significantly greater performance deficits than control
workers (who had rheumatoid arthritis) with regard to
performing mental interpersonal tasks, time management,
output tasks and physical tasks (Adler et al., 2006). Even after
18 months of follow-up, clinical improvement did not result
in full recovery of job performance.
In a comparison of 6 ‘depressed-at work’ and ‘depressed-
not at work’ populations, the depressed workers were more
likely to be young, better educated, white collar and of better
overall health status than the non-working depressed group
(Elinson et al., 2004). Depressed employees are also more
likely to become unemployed or miss time at work than
physically ill employees (Hoge et al., 2002). When depressed
workers were compared to controls and workers with
rheumatoid arthritis, the depressed employees became
unemployed five times more frequently than the other 2
groups (Lerner et al., 2004).
1.8. What is the impact of MDD on other functional domains?
While occupational impairment has received the most
attention, depressive disorders also negatively affect func-
tioning in non-occupational tasks. In fact, the National
Comorbidity Survey Replication study in the US found that
role impairment in people with MDD was lowest in the
occupational domain and highest in the social domain
(Kessler et al., 2003). In this survey, 59.3% of respondents
with past-year major depressive episodes reported severe or
very severe role impairment. Depression in women may also
have a negative effect on the development of their children
and on family dynamics (Toney, 2007). Treatmentof maternal
depression to remission in the STAR*D child study was
associated with decreased psychiatric symptoms and
improved functioning in the offspring (Pilowsky et al.,
2008). There is also evidence of increased consultation for
developmental and behavioral problems in the children of
fathers who meet criteria for major depressive disorder (Dave
et al., 2009). Such intergenerational effects may magnify the
impactof depression onpopulation health (Ramchandaniand
1.9. What is the impact of MDD on physical health?
MDD or depressive symptoms can negatively affect
physical health by reducing adherence to medical treatment
(Ciechanowski et al., 2000), reducing participation in pre-
ventive activities (Aro et al., 1999), and altering risk factors
such as obesity (McIntyre et al., 2006), smoking (Murphy
et al., 2003) and sedentary lifestyles (van Gool et al., 2003).
Depressed patients with or without diabetes have a higher
incidence of obesity, metabolic disorders, higher insulin
(Linetal.,2004). Thereisevidencefrom SaskatchewanHealth
data, that depressive disorders increase the risk of Type II
diabetes (Brown et al., 2005). A growing body of evidence
suggests that MDD is also associated with immune dysfunc-
tion (Corcos et al., 2002; Kop et al., 2002; Musselman et al.,
2001; Penninxet al., 2003), and, in the case of recurrent MDD,
with coronary and aortic calcification in middle aged women
(Agatisa et al., 2005). Depression is increasingly recognized as
an independent risk factor for cardiovascular disease and an
independent predictor of mortality (Kop, 2003; Taylor et al.,
the ENRICHED investigators, 2003). Statistics Canada recently
reported MDD to be predictive of new-onset heart disease in
the Canadian general population (Gilmour, 2008) and a
Science Advisory Statement by the American Heart Associa-
tion (endorsed by the American Psychiatric Association)
recommended routine screening for depression in patients
with coronary heart disease (Lichtman et al., 2008). In addi-
tion to these specific examples, MDD appears to be associated
with a general increase in chronic disease incidence (Patten
et al., 2008) and there is a joint effect of depression and these
While there has been much interest in the relationship
between MDD and chronic medical conditions such as heart
disease and diabetes, the conditions most strongly associated
with MDD in the Canadian population are neurological
conditions and conditions related to pain and inflammation
1.10. How do patients with MDD typically present in
Depressive disorders, as currently defined by DSM-IV, are
largely symptom-based diagnostic entities. These disorders
are associated with a very broad range of clinical presenta-
tions, which must be understood in a biopsychosocial context.
MDD canpresent at anyage but the peak prevalence occurs in
those between the ages of 15 and 45 years (Patten et al.,
2005b). Consequently, MDD has a disproportionately large
impact on education, work productivity, relationships and
Medical conditions strongly associated with MDD in the Canadian
Medical conditionOdds ratio Medical condition Odds ratio
Estimates derive from the Canadian Community.
Health Survey 1.1, Patten et al. (2005a).
S.B. Patten et al. / Journal of Affective Disorders 117 (2009) S5–S14
parenting, all of which may appear to be the presenting
problem. While many of those with depression never present
to their primary care physician, up to 50% who do visit the
office are not recognized as depressed and as many as two
thirds present with somatic symptoms only (Cepoiu et al.,
2008). Clinician training in communication and emotive skills
may improve detection and management of depression in
primary care (Gask et al., 1988; Roter et al., 1995).
The simplest approach to case-finding in clinical practice
is a quick 2-question screen: “In the last month, have you
been bothered by little interest or pleasure in doing things?”
and “In the last month, have you been feeling down,
depressed or hopeless?” (Kroenke et al., 2003). This 2-
question screening approach is recommended for routine
practice by the US Preventive Services Task Force in settings
where resources exist to confirm diagnoses and provide
effective treatment and follow-up (US Preventive Services
Task Force, 2002). An answer of “yes” to either question
requires a more detailed assessment and consideration of
other possible causes of depressive symptoms (Whooley
et al., 1997). Despite the Task Force recommendations, the
value of screening remains controversial (Palmer and Coyne,
2003) and available evidence does not confirm that screening
activities in isolation lead to better outcomes (Gilbody et al.,
2005). One concern is the low predictive value of screening
instruments and approaches. This can be increased by
restricting screening to high risk groups identified either
using clinical groups or symptom presentations (Table 7).
1.11. What are the basic principles of clinical assessment?
DSM-IV provides valuable sets of diagnostic criteria but
the nosology is not intended to supplant clinical judgment.
Successful treatment depends on an accurate diagnosis, but
an accurate diagnosis does not provide a sufficient basis for
clinical management. The diagnosis of MDD is always a
provisional diagnosis since the occurrence of hypomanic,
manic or mixed episodes trigger a revision of the diagnosis
(Blacker and Tsuang, 1992). As such, working diagnoses may
evolve over time. Nevertheless, an accurate diagnosis is the
most important starting point for clinical management. The
goals of assessment include: assessment of safety, establish-
ment of rapport and a therapeutic alliance, assessment of
comorbidity, patient education, and obtaining informed
consent to proceed with treatment.
In situations where clinicians choose to use a measure-
ment instrument for case-finding, screening or monitoring,
several tools are available (see Table 8), and there were no
major differences between these (and other) instruments in a
comparative study (Williams et al., 2002). However, many
clinicians find the PHQ-9 or the QIDS-SR to be attractive
options because of their brevity and strong alignment with
In the assessment of depressed patients, clinicians should
evaluate suicide risk. Suicide risk is an important considera-
tion in determining the need for hospitalization. Clinicians
should ensure that patients are aware of locally available
sources of help and patients should be advised to seek help if
their situation deteriorates. Physical health, psychosocial
status (including social and interpersonal relationships) and
psychiatric comorbidity should also be assessed. Assessment
of past response to treatment can provide valuable guidance
for treatment decisions. Information from supplemental
sources such as health records andknowledgeable informants
is often a key component of assessment.
The spectrum of depressive morbidity encountered by
primary care physicians is broad. As such, “stepped care”
strategies have an important role. In primary care, the range
of interventions offered may extend from close monitoring
of mild episodes without immediate treatment (so-called
“watchful waiting”), through guided self-management
(Bilsker et al., 2007), brief psychological or behavioral
interventions, pharmacological management and, if needed,
referral to more specialized services or hospital admission. A
decision about where to start on this continuum is initially
made, and a lack of response leads to stepped-up care. A
stepped care approach is advocated by the NICE guidelines
in the UK (National Institute for Health and Clinical
Excellence, 2004), and is an intrinsic component of most
disease management approaches for MDD. The stepped care
approach has implications for assessment of patients
presenting with depression — a clinician must form a judg-
ment not only about the correct diagnosis, but also about
where a particular patient falls on the continuum of care.
There has been a shift towards a conceptualization of MDD
as a chronic disease (Andrews, 2001), resulting in the
emergence of disease management strategies resembling
those employed for other chronic medical conditions such as
depression typically includes several elements: (1) active
efforts to detect depression using screening questions or
rating scales, (2) delivery of evidence-based care, including
Case-finding and monitoring instruments for depression.
Instrument nameNumber of items
Brief Patient Health Questionnaire
(PHQ-9) (Kroenke et al., 2001)
Quick Inventory of Depressive Symptomatology,
Self-Rated (QIDS-SR) (Rush et al, 2003)
Beck Depression Inventory (BDI-I or BDI-II)
(Beck et al., 1961)
Zung Self-Rating Depression Scale (Zung, 1965)
Center for Epidemiologic Studies Depression
Rating Scale (CES-D) (Radloff, 1977)
16 (only 9 scored)
aThe BDI-II has 21 items.
High risk groups and symptomatic presentation of MDD.
High risk clinical groups High risk symptom presentations
Past history of depression
Family history of depression
High users of the medical system
Chronic medical conditions
(especially cardiovascular disease,
diabetes, conditions involving chronic
pain and neurological disorders)
Other psychiatric conditions
Times of hormonal challenge
Unexplained physical symptoms
Pain, including chronic pain
S.B. Patten et al. / Journal of Affective Disorders 117 (2009) S5–S14
management in a collaborative context with “stepped” care
options, (4) patient education about depression and self-
management of depression and (5) process measurement
such as monitoring of the timeliness and quality of care in
randomized controlled trials found robust evidence of
the effectiveness of disease management for depression
(Neumeyer-Gromen et al., 2004).
In the Canadian context, most treatment for depressive
disorders occurs in fee for service primary care practices,
where disease management strategies are challenging to
implement. For example, fee for service funding arrange-
ments do not generally provide support for case-manage-
ment, which is a component of most disease management
strategies. This situation may change in the future as
primary care reform leads to a greater emphasis on chronic
disease management. Nevertheless, collaborative care mod-
els have been a focus of interest in Canada for many years
(Kates, 2002). When shared or collaborative care arrange-
ments are in place, the professionals involved must main-
tain a clear awareness of their responsibilities within those
1.12. What are the phases of treatment?
into two phases: acute and maintenance (Table 9). The aim of
acute treatment is to eliminate symptoms of depression and
restore psychosocial functioning. The aim of maintenance
treatment is to ensure a return to baseline function and quality
of life and to prevent recurrence of symptoms.
1.13. What are the basic principles of treatment?
Although approaches to management differ depending on
the context of care delivery, many of the basic principles
remain the same. Trends in collaborative MDD management
that incorporate “stepped care” and disease management
have common elements, most of which (the exception being
case-management) are applicable to other treatment settings
(see Table 10). These elements include systematic monitoring
of patient outcomes, treatment decisions that are evidence-
based and responsive to therapeutic goals. The systematic
progression through available treatment options is consistent
with the CANMAT concept of “Lines of Treatment” which are
elaborated in subsequent sections of these guidelines.
Because MDD in itself may reduce treatment adherence, this
should be discussed at an early stage and should be
monitored frequently during treatment in an open manner
(Trivedi et al., 2007).
1.14. What are the goals of acute treatment?
The target goal for acute treatment should be remission: a
resolution of depressive symptoms. “Response” to treatment
(a reduction in symptom levels) is not an adequate outcome
because residual depressive symptoms are risk factors for
relapse and negative predictors of long-term outcome
(McIntyre and O'Donovan, 2004). Monitoring of symptom
levels during treatment is an essential metric of outcome.
Outcome assessment can be conducted using validated
interviewer-rated scales, e.g., the Hamilton Depression Rating
Scale (HDRS, Hamilton, 1960) or the Montgomery Åsberg
Depression Rating Scale (MADRS, Montgomery and Åsberg,
1979). A seven-item version of the HDRS is a suitable tool for
clinical practice because of its brevity and validity (McIntyre
et al., 2002). Busy clinicians also may find that the self-report
scales listed in Table 8 are efficient tools to monitor progress
and outcome. Response is usually defined as N50% reduction
in scores on these scales, while remission is defined as a score
within the normal range.
1.15. What are the goals of maintenance treatment?
The terms relapse (return of symptoms during a current
episode) and recurrence (return of symptoms owing to a new
episode) are not functionally useful because there are no
methods to determine when an episode ends. Hence, once
patients are treated in the acute phase and are well (i.e., in
symptom remission), the critical questions are: how can they
stay well and how long do treatments need to be maintained?
The goals of this maintenance phase include resolving any
residual symptoms, treating comorbid conditions, returning
to full pre-morbid functioning and preventing return of
symptoms (Table 10), Clinicians should focus on healthy life
strategies, personality vulnerabilities, long-term self-manage-
ment and clinical strategies to reduce recurrence (Rafanelli
treatments have a role in the prevention of recurrence:
supporting evidence is evaluated in subsequent sections of
Phases of treatment for MDD.
• Remission of
• Restore function
• Establish therapeutic
• Select and use
• Monitor progress
• Return to full
quality of life
• Prevention of
• Treat comorbidities
• Monitor for recurrence
Chronic disease management strategiesafor MDD.
Active efforts to detect depression
Delivery of evidence-based care
Patient education about depression
Process measurement and systematic outcome assessment
aAdapted from Kates and Mach, 2007.
S.B. Patten et al. / Journal of Affective Disorders 117 (2009) S5–S14
Depressive disorders are among the most common and
burdensome conditions afflicting the Canadian population.
Evidence-based management can reduce their burden in
afflicted individuals and ultimately in society as a whole. By
summarizing an updated evidence base, the aim of these
revised CANMAT guidelines is to link the best available
evidence to the best possible care of depressed patients.
Conflict of interest
No conflict declared.
Role of funding sources
These guidelines were entirely funded with funding from the Canadian
Network for Mood and Anxiety Treatments; no external funds were sought or
Cipher Pharmaceuticals, Canadian Institutes of Health Research, Canadian
Network for Mood and Anxiety Treatments, Norlein Foundation, and Servier.
SHK is on Speaker/Advisory Boards for, or has received research funds
from: Advanced Neuromodulation Systems Inc., AstraZeneca, Biovail,
Boehringer-Ingelheim, Brain Cells Inc., Canadian Network for Mood and
Anxiety Treatments, Eli Lilly, GlaxoSmithKline, Janssen-Ortho, Lundbeck,
Lundbeck Institute, Merck Frost, Servier and Wyeth.
RWL is on Speaker/Advisory Boards for, or has received research funds
from: Advanced Neuromodulation Systems Inc., AstraZeneca, BrainCells Inc.,
Anxiety Treatments, Canadian Psychiatric Research Foundation, Eli Lilly,
Janssen, Litebook Company Ltd., Lundbeck, Lundbeck Institute, Mathematics
of Informatics Technology and Advanced Computing Systems, Michael Smith
Coast Capital Savings, and Wyeth.
CO is on Speaker/Advisory Boards for, or has received research funds from
Biovail Inc., Wyeth, Servier and Astra Zeneca.
MJF is on Speaker/Advisory Boards for, or has received research funds
from: AstraZeneca, Biovail, Bristol-Myers-Squibb, Canadian Network for
Mood and Anxiety Treatments, Eli Lilly, Janssen Ortho, Lundbeck, Pfizer,
Servier, and Wyeth.
and Anxiety Treatments, GlaxoSmithKline, Janssen, Lilly, Lundbeck, Novartis,
Pfizer, and Wyeth.
AstraZeneca, Canadian Network for Mood and Anxiety Treatments, Cephalon,
Eli Lilly, GlaxoSmithKline, Janssen-Ortho, Lundbeck, Pfizer, Roche, Servier and
CANMAT thanks the external reviewers: Alain LeSage, MD,
FRCPC (University of Montreal), and Jitender Sareen, MD,
FRCPC (University of Manitoba).
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