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Review
. 2016 Sep;61(9):561-75.
doi: 10.1177/0706743716660033. Epub 2016 Aug 2.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 4. Neurostimulation Treatments

Roumen V Milev  1 , Peter Giacobbe  2 , Sidney H Kennedy  2 , Daniel M Blumberger  2 , Zafiris J Daskalakis  2 , Jonathan Downar  2 , Mandana Modirrousta  3 , Simon Patry  4 , Fidel Vila-Rodriguez  5 , Raymond W Lam  5 , Glenda M MacQueen  6 , Sagar V Parikh  7 , Arun V Ravindran  2 ; CANMAT Depression Work Group
Affiliations
Review

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 4. Neurostimulation Treatments

Roumen V Milev et al. Can J Psychiatry. 2016 Sep.

Abstract

Background: The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals.

Methods: Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. "Neurostimulation Treatments" is the fourth of six sections of the 2016 guidelines.

Results: Evidence-informed responses were developed for 31 questions for 6 neurostimulation modalities: 1) transcranial direct current stimulation (tDCS), 2) repetitive transcranial magnetic stimulation (rTMS), 3) electroconvulsive therapy (ECT), 4) magnetic seizure therapy (MST), 5) vagus nerve stimulation (VNS), and 6) deep brain stimulation (DBS). Most of the neurostimulation treatments have been investigated in patients with varying degrees of treatment resistance.

Conclusions: There is increasing evidence for efficacy, tolerability, and safety of neurostimulation treatments. rTMS is now a first-line recommendation for patients with MDD who have failed at least 1 antidepressant. ECT remains a second-line treatment for patients with treatment-resistant depression, although in some situations, it may be considered first line. Third-line recommendations include tDCS and VNS. MST and DBS are still considered investigational treatments.

Keywords: clinical practice guidelines; deep brain stimulation; electroconvulsive therapy; evidence-based medicine; major depressive disorder; meta-analysis; neurostimulation; repetitive transcranial magnetic stimulation; systematic reviews.

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Conflict of interest statement

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RVM has received speaker and consultant honoraria or research funds from Allergan, Bristol-Myers Squibb, Canadian Institutes of Health Research, Canadian Network for Mood and Anxiety Treatments, Canadian Psychiatric Association, Eli Lilly, Johnson & Johnson, Lallemand, Lundbeck, Merck, Ontario Brain Institute, Ontario Mental Health Foundation, Otsuka, Paladin, Pfizer, Queen’s University, Sunovion, Takeda, the University Health Network Foundation, and Valeant. PG has received speaker and consultant honoraria or research funds from Brain & Behavior Research Foundation, Bristol-Myers Squibb, Canadian Institutes of Health Research, Lundbeck, National Institute of Health, and St. Jude Medical. SHK has received honoraria for ad hoc speaking or advising/consulting or research funds from Allergan, Brain Canada, Bristol Myers Squibb, Canadian Institutes of Health Research, Canadian Network for Mood and Anxiety Treatments, Janssen, Johnson & Johnson, Lundbeck, Lundbeck Institute, Medscape, Ontario Brain Institute, Pfizer, Servier, St. Jude Medical, Sunovion, and Takeda. DMB has received research funds/support from Brain Canada, Brain Research and Development Ltd., Brainsway Inc., CAMH Foundation, Campbell Institute, Canadian Institutes of Health Research, National Institutes of Health, Tonika/Magventure, and Invidior. ZJD has received honoraria for ad hoc speaking or advising/consulting or received research funds from Brain and Behavior Research Foundation, Brainsway Inc., CAMH Foundation, Campbell Institute, Canadian Institutes of Health Research, Eli Lilly, Hoffmann-La Roche Limited, Merck, Ontario Mental Health Foundation, and Sunovion, JD has received research support or honoraria from ANT Neuro, Canadian Institutes of Health Research, Brain Canada, Edgestone Foundation, Klarman Family Foundation, Lundbeck, MagVenture, National Institutes of Health, and Toronto General and Western Hospital Foundation. MM and SP have no disclosures. FVR has received grant funding from Brain Canada and the Canadian Institutes of Health Research. RWL has received honoraria for ad hoc speaking or advising/consulting or received research funds from Asia-Pacific Economic Cooperation, AstraZeneca, Brain Canada, Bristol-Myers Squibb, Canadian Institutes of Health Research, Canadian Depression Research and Intervention Network, Canadian Network for Mood and Anxiety Treatments, Canadian Psychiatric Association, Coast Capital Savings, Johnson & Johnson, Lundbeck, Lundbeck Institute, Medscape, Pfizer, St. Jude Medical, Takeda, University Health Network Foundation, and Vancouver Coastal Health Research Institute. GMM has been on advisory board or speaker for Janssen, Lilly, Lundbeck, and Pfizer. SVP has been a consultant to Bristol Myers Squibb, Lundbeck, and Takeda; has had a research contract with Assurex; and has equity in Mensante. AVR has received speaker and consultant honoraria or research funds from Bristol-Myers Squibb, Canadian Depression Research and Intervention Network, Canadian Foundation for Innovation and the Ministry of Economic Development and Innovation, Canadian Institutes of Health Research, Grand Challenges Canada, Janssen, Lundbeck, Ontario Mental Health Foundation, Pfizer, and Sunovion.

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