Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments

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. "Pharmacological Treatments" is the third of six sections of the 2016 guidelines. With little new information on older medications, treatment recommendations focus on second-generation antidepressants.

Results: Evidence-informed responses are given for 21 questions under 4 broad categories: 1) principles of pharmacological management, including individualized assessment of patient and medication factors for antidepressant selection, regular and frequent monitoring, and assessing clinical and functional outcomes with measurement-based care; 2) comparative aspects of antidepressant medications based on efficacy, tolerability, and safety, including summaries of newly approved drugs since 2009; 3) practical approaches to pharmacological management, including drug-drug interactions and maintenance recommendations; and 4) managing inadequate response and treatment resistance, with a focus on switching antidepressants, applying adjunctive treatments, and new and emerging agents.

Conclusions: Evidence-based pharmacological treatments are available for first-line treatment of MDD and for management of inadequate response. However, given the limitations of the evidence base, pharmacological management of MDD still depends on tailoring treatments to the patient.

Keywords: antidepressants; antipsychotics; clinical practice guidelines; clinical trials; evidence-based medicine; major depressive disorder; meta-analysis; pharmacotherapy; randomized controlled trial.

Figure 1.

Summary algorithm for selecting an antidepressant.

Figure 2.

Summary algorithm for managing inadequate response to an antidepressant. (1) Monitor outcomes using measurement-based care. (2) Depending on tolerability, first optimize antidepressant by increasing dose. (3) For early treatment resistance, consider adjunctive use of psychological and neurostimulation treatments. (4) After failure of 1 or more antidepressants, consider switch to a second-line or third-line antidepressant. (5) For more resistant depressions, consider longer evaluation periods for improvement. (6) Depending on tolerability, increase dose if not at maximal doses. (7) For more chronic and resistant depressions, consider a chronic disease management approach, with less emphasis on symptom remission and more emphasis on improvement in functioning and quality of life.