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

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


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.

Publication types

  • Meta-Analysis
  • Review
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Canada
  • Deep Brain Stimulation / methods
  • Deep Brain Stimulation / standards*
  • Depressive Disorder, Major / therapy*
  • Electroconvulsive Therapy / methods
  • Electroconvulsive Therapy / standards*
  • Evidence-Based Medicine / standards*
  • Humans
  • Practice Guidelines as Topic / standards*
  • Transcranial Direct Current Stimulation / methods
  • Transcranial Direct Current Stimulation / standards*
  • Transcranial Magnetic Stimulation / methods
  • Transcranial Magnetic Stimulation / standards*
  • Vagus Nerve Stimulation / methods
  • Vagus Nerve Stimulation / standards*