Updated Canadian guidelines for management of depression in adults

Revised guidelines from the Canadian Network for Mood and Anxiety Treatments (CANMAT) provide evidence-informed recommendations for the management of major depressive disorder in adults, updating those last published in 2016. The 47-page guidelines use a personalized care approach, emphasizing shared decision-making that reflects the values, preferences and treatment history of the patient. The importance of the guidelines is highlighted by the fact that only 20% of individuals with depression receive adequate treatment; clinical guidelines are one tool for standardizing treatments to improve clinical care. The updated guidelines map a patient care journey from patient assessment to selection of evidence-based treatments, prevention of recurrence and strategies for managing inadequate response.The depression guidelines are organized into eight main topics, as described below. 1. Important issues for assessment and diagnosisThis section covers the following key topics:Risk factors for major depressive disorder (nonmodifiable and potentially modifiable)Screening and screening toolsImportant factors in assessment and diagnosis2. Principles for depression managementThis segment deals with several issues:Phases and objectives of treatmentWhy symptom remission is importantManagement of suicide and safety risks Effective lifestyle interventions3. Treatment selectionThis section consists of the following topics:Initial treatment selectionWhen pharmacotherapy and psychotherapy should be combinedSelection of psychological treatment Selection of pharmacological treatment, with three key tables: 1. First-, second- and third-line antidepressant treatments and doses; 2. Summary of the frequency of adverse effects of specific antidepressants; and 3. Comparative favourability ratings for first-line antidepressant efficacy, acceptability, drug interactions, discontinuation effects and tolerability issues.Factors that influence medication selectionAntidepressants and risk of suicideAntidepressant safety concerns and drug interactionsPharmacogenetic testing Complementary and alternative medicine treatmentsManagement of comorbid conditions 4. Role of digital health interventions (DHIs)This portion of the guidelines discusses the use of computers, smartphones, tablet devices, wearables (e.g., activity trackers), digital phenotyping, text or SMS messaging and virtual care videoconferencing for depression screening, monitoring, treatment and preventing recurrence. It discusses:Best practices for evaluating DHIsGuided and unguided DHIs5. Treatment monitoringThis section describes measurement-based care, an evidence-based practice that uses routine outcome measurement and feedback to guide clinical decisions. It encompasses:Definitions for improvement, response and remissionHow to implement measurement-based careLab tests that should be monitored during treatment6. What to do when a patient is betterThis section examines:How to maintain remission, including a table of recommendations for maintenance antidepressant treatmentHow to prevent recurrence, including a table outlining risk factors for recurrenceWhich patients need longer-term antidepressant treatmentHow antidepressant treatment should be discontinued, with a table of antidepressants and their risk of discontinuation symptoms7. What to do when a patient is not betterThis section describes:Contributors to a poor response to treatmentThe difference between treatment-resistant depression and difficult-to-treat depressionSequenced strategies when there is a poor response to initial antidepressant treatment, with an algorithm for sequential treatment after suboptimal response to initial antidepressant medicationWhen and how antidepressants should be switchedBenefits and drawbacks of adding an adjunctive medicationAdjunctive medication selection, including a table of first-, second- and third-line adjunctive medications and dosesRisks and benefits of specific adjunctive medications8. Neuromodulation (neurostimulation) treatmentsThis section discusses noninvasive neuromodulation treatments (e.g., electroconvulsive therapy [ECT], magnetic seizure therapy [MST], repetitive transcranial magnetic stimulation [rTMS], transcranial direct current stimulation [tDCS]) and treatments that involve surgical placement of electrodes (e.g., vagus nerve stimulation [VNS], deep brain stimulation [DBS]).SummaryThe updated CANMAT depression guidelines provide a comprehensive and evidence-informed framework for managing depression in adults. Healthcare providers can usethe guidelines to collaboratively guide patients through their care journey, with the overall aim of optimizing their personal, functional and quality-of-life outcomes.Reference1. Lam RW, Kennedy SH, Adams C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 update on clinical guidelines for management of major depressive disorder in adults. Can J Psychiatry 2024; May 6:7067437241245384. Published online ahead of print. (accessed May 15, 2024).

Updated Canadian guidelines for management of depression in adults

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