Research report
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

https://doi.org/10.1016/j.jad.2009.06.044Get rights and content

Abstract

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 are challenging tasks for both clinicians and for the health systems in which they work.

Limitations

Epidemiologic and clinical data cannot be seamlessly linked due to heterogeneity 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.

Introduction

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 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, neurostimulation 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.

Section snippets

Methods

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

Conclusion

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 received.

SBP is on Speaker/Advisory Boards for, or has received research funds from: 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.,

Acknowledgements

CANMAT thanks the external reviewers: Alain LeSage, MD, FRCPC (University of Montreal), and Jitender Sareen, MD, FRCPC (University of Manitoba).

References (92)

  • J. Alonso et al.

    Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta. Psychiatrica. Scandinavica

    Supplementum

    (2004)
  • Diagnostic and Statistical Manual of Mental Disorders

    (2000)
  • G. Andrews

    Should depression be managed as a chronic disease?

    Br. Med. J.

    (2001)
  • G. Andrews et al.

    Recall of depressive episode 25 years previously

    Psychol. Med.

    (1999)
  • G. Andrews et al.

    Lifetime risk of depression: restricted to a minority or waiting for most?

    Br. J. Psychiatry

    (2005)
  • A.R. Aro et al.

    Psychosocial predictors of first attendance for organised mammography screening

    J. Med. Screen

    (1999)
  • J.L. Ayuso-Mateos

    Global Burden of Unipolar Depressive Disorders in the Year 2000

    (2003)
  • M.P. Beaudet

    Depression

    Health Rep.

    (1996)
  • M.P. Beaudet

    Psychological health — depression

    Health Rep.

    (1999)
  • P.E. Bebbington et al.

    The influence of age and sex on the prevalence of depressive conditions: report from the National Survey of Psychiatric Morbidity

    Psychol. Med.

    (1998)
  • A.T. Beck et al.

    An inventory for measuring depression

    Arch. Gen. Psychiatry

    (1961)
  • D. Bilsker et al.

    Health service patterns indicate potential benefit of supported self-management for depression in primary care

    Can. J. Psychiatry

    (2007)
  • D. Blacker et al.

    Contested boundaries of bipolar disorder and the limits of categorical diagnosis in psychiatry

    Am. J. Psychiatry

    (1992)
  • R.C. Bland et al.

    Period prevalence of psychiatric disorders in Edmonton

    Acta. Psychiatr. Scand.

    (1988)
  • R.C. Bland et al.

    Lifetime prevalence of psychiatric disorders in Edmonton

    Acta. Psychiatr. Scand.

    (1988)
  • L.C. Brown et al.

    History of depression increases risk of type 2 diabetes in younger adults

    Diabetes Care

    (2005)
  • T.S. Brughta et al.

    Trends in service use and treatment for mental disorders in adults through Great Britain

    Br. J. Psychiatry

    (2004)
  • Public Use Microdata File Guide

    Statistics Canada, Ottawa. September 9, 2004.

    (2004)
  • M. Cepoiu et al.

    Recognition of depression by non-psychiatric physicians—a systematic literature review and meta-analysis

    J. Gen. Intern. Med.

    (2008)
  • P.S. Ciechanowski et al.

    Depression and diabetes. Impact of depressive symptoms on adherence, function, and costs

    Arch. Intern. Med.

    (2000)
  • S. Dave et al.

    Major paternal depression and child consultation for development and behavioural problems

    Br. J. Gen. Pract.

    (2009)
  • L. Elinson et al.

    Depression and the ability to work

    Psychiatr. Serv.

    (2004)
  • L. Gask et al.

    Improving the psychiatric skills of the general practice trainee: an evaluation of a group training course

    Med. Educ.

    (1988)
  • S. Gilbody et al.

    Screening and case finding instruments for depression

    Cochrane Database Syst. Rev.

    (2005)
  • H. Gilmour

    Depression and risk of heart disease

    Health Rep.

    (2008)
  • R. Gravel et al.

    The Canadian Community Health Survey: Mental Health and Wellbeing

    Can. J. Psychiatry

    (2005)
  • M. Hamilton

    A rating scale for depression

    J. Neurol. Neurosurg. Psychiatry

    (1960)
  • C.W. Hoge et al.

    Mental disorders among U.S. military personnel in the 1990s: association with high levels of health care utilization and early military attrition

    Am. J. Psychiatry

    (2002)
  • N. Kates

    Shared mental health care. The way ahead

    Can. Fam. Physician

    (2002)
  • N. Kates et al.

    Chronic disease management for depression in primary care: a summary of the current literature and implications for practice

    Can. J. Psychiatry

    (2007)
  • S.H. Kennedy et al.

    Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the treatment of management of major depressive disorder in adults

    J Affect Disord

    (2009)
  • R.C. Kessler et al.

    The World Health Organization Composite International Diagnostic Interview Short-Form (CIDI-SF)

    Int. J. Methods Psychiatr. Res.

    (1998)
  • R.C. Kessler et al.

    The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R)

    JAMA

    (2003)
  • R.C. Kessler et al.

    Prevalence and treatment of mental disorders, 1990–2003

    NEJM

    (2005)
  • K. Kroenke et al.

    The PHQ-9. Validity of a brief depression severity measure

    J. Gen. Intern. Med.

    (2001)
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