Management of Major Depressive Disorder in Adults: Guidelines From CANMAT

Although major depressive disorder is common and has significant effects on quality of life, only an estimated 20% of patients with the disorder receive adequate treatment. The Canadian Network for Mood and Anxiety Treatments (CANMAT) has published updated guidelines on management of major depressive disorder in adults.

While the US Preventive Services Task Force recommends routine depression screening for all individuals 12 years and older, CANMAT recommends screening only for adult patients with risk factors, provided that resources and systems are available for diagnosis and treatment. Benefits of screening include increased remission of depression, whereas potential harms include stigmatization, effects on occupational or insurance status, and unnecessary pharmacologic or psychological treatment. CANMAT recommends using a validated screening tool such as the 2-item Patient Health Questionnaire (PHQ).

Risk factors for major depressive disorder include a family history of mood disorders, female sex, history of adverse childhood events, chronic illness, substance use disorders, insomnia, gender dysphoria, and stressful life events.

Diagnosis of major depressive disorder should consist of a comprehensive assessment that incorporates a diagnostic framework, such as the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revision, while recognizing cultural diversity and social factors. Laboratory tests should be considered only if the history and physical examination suggest contributing medical conditions. There is no supporting evidence for routine electrocardiography, electroencephalography, or neuroimaging in diagnosis.

Objectives of treatment include symptom remission, recovery of function, ensuring patient safety, restoring quality of life, and preventing recurrence.

Lifestyle Interventions

Supervised low- to moderate-intensity exercise for 30 to 40 minutes three to four times per week for a minimum of 9 weeks is a first-line monotherapy for mild depression. This is also a second-line adjunctive therapy for moderate depression. Improvements in diet, smoking cessation, and sleep hygiene may be beneficial. Light therapy with 10,000-lux white light for 30 minutes daily is a first-line treatment for seasonal depression. It also is effective as an adjunctive therapy for nonseasonal moderate depression.

Psychotherapy

Based on a balance of benefits and risks, psychotherapy should be tried before medication for mild depression. For moderate to severe depression, the combination of psychotherapy and pharmacotherapy is more effective than either therapy alone and decreases recurrence.

Cognitive behavior therapy, interpersonal therapy, and behavioral activation are first-line psychotherapies. Psychological treatments with less consistent evidence of benefit include cognitive behavioral analysis system of psychotherapy, mindfulness-based cognitive therapy, and problem-solving therapy. For most patients, the optimal amount of psychotherapy is 12 to 16 sessions. Twice-weekly sessions are associated with better outcomes than sessions once weekly or less.