Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults: Réseau canadien pour les traitements de l'humeur et de l'anxiété (CANMAT) 2023 : Mise à jour des lignes directrices cliniques pour la prise en charge du trouble dépressif majeur chez les adultes

BACKGROUND

The Canadian Network for Mood and Anxiety Treatments (CANMAT) last published clinical guidelines for the management of major depressive disorder (MDD) in 2016. Owing to advances in the field, an update was needed to incorporate new evidence and provide new and revised recommendations for the assessment and management of MDD in adults.

METHODS

CANMAT convened a guidelines editorial group comprised of academic clinicians and patient partners. A systematic literature review was conducted, focusing on systematic reviews and meta-analyses published since the 2016 guidelines. Recommendations were organized by lines of treatment, which were informed by CANMAT-defined levels of evidence and supplemented by clinical support (consisting of expert consensus on safety, tolerability, and feasibility). Drafts were revised based on review by patient partners, expert peer review, and a defined expert consensus process.

RESULTS

The updated guidelines comprise eight primary topics, in a question-and-answer format, that map a patient care journey from assessment to selection of evidence-based treatments, prevention of recurrence, and strategies for inadequate response. The guidelines adopt a personalized care approach that emphasizes shared decision-making that reflects the values, preferences, and treatment history of the patient with MDD. Tables provide new and updated recommendations for psychological, pharmacological, lifestyle, complementary and alternative medicine, digital health, and neuromodulation treatments. Caveats and limitations of the evidence are highlighted.

CONCLUSIONS

The CANMAT 2023 updated guidelines provide evidence-informed recommendations for the management of MDD, in a clinician-friendly format. These updated guidelines emphasize a collaborative, personalized, and systematic management approach that will help optimize outcomes for adults with MDD.

Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force Report: A Systematic Review and Recommendations of Cannabis use in Bipolar Disorder and Major Depressive Disorder

BACKGROUND

Given the increasing acceptability and legalization of cannabis in some jurisdictions, clinicians need to improve their understanding of the effect of cannabis use on mood disorders.

OBJECTIVE

The purpose of this task force report is to examine the association between cannabis use and incidence, presentation, course and treatment of bipolar disorder and major depressive disorder, and the treatment of comorbid cannabis use disorder.

METHODS

We conducted a systematic literature review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching PubMed, Embase, PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials from inception to October 2020 focusing on cannabis use and bipolar disorder or major depressive disorder, and treatment of comorbid cannabis use disorder. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of evidence and clinical considerations were integrated to generate Canadian Network for Mood and Anxiety Treatments recommendations.

RESULTS

Of 12,691 publications, 56 met the criteria: 23 on bipolar disorder, 21 on major depressive disorder, 11 on both diagnoses and 1 on treatment of comorbid cannabis use disorder and major depressive disorder. Of 2,479,640 participants, 12,502 were comparison participants, 73,891 had bipolar disorder and 408,223 major depressive disorder without cannabis use. Of those with cannabis use, 2,761 had bipolar disorder and 5,044 major depressive disorder. The lifetime prevalence of cannabis use was 52%-71% and 6%-50% in bipolar disorder and major depressive disorder, respectively. Cannabis use was associated with worsening course and symptoms of both mood disorders, with more consistent associations in bipolar disorder than major depressive disorder: increased severity of depressive, manic and psychotic symptoms in bipolar disorder and depressive symptoms in major depressive disorder. Cannabis use was associated with increased suicidality and decreased functioning in both bipolar disorder and major depressive disorder. Treatment of comorbid cannabis use disorder and major depressive disorder did not show significant results.

CONCLUSION

The data indicate that cannabis use is associated with worsened course and functioning of bipolar disorder and major depressive disorder. Future studies should include more accurate determinations of type, amount and frequency of cannabis use and select comparison groups which allow to control for underlying common factors.

The effect of lowering plasma tryptophan on food selection in normal males

The effects of a tryptophan deficient amino acid mixture on food selection were studied using a double-blind counterbalanced crossover design in normal male subjects. The subjects ingested tryptophan deficient or nutritionally balanced amino acid mixtures in the morning after an overnight fast. Five hours after the tryptophan deficient amino acid mixture plasma tryptophan was only 19% of the level found five hours after the nutritionally balanced amino acid mixture. After both mixtures subjects were allowed to select lunch from a buffet. The tryptophan-deficient mixture was associated with a modest but significant decline in protein selection with no significant alteration in selection of carbohydrate, fat or total kcal. Our results suggest that 5-hydroxytryptamine is involved in the control of protein selection in humans.

Verapamil in refractory schizophrenia: a case report

Verapamil, a papaverine calcium channel blocker, has been used effectively and safely in the treatment of angina pectoris and auricular arrhythmias, and more recently in the treatment of mania. Many antipsychotic drugs show calcium channel blocking effects similar to verapamil's. A 41 year old male schizophrenic, only partially responsive to haloperidol decanoate and oral haloperidol, was given increasing doses of verapamil concomitantly, and monitored clinically and by the BPRS, electrocardiogramme, and other laboratory measures. The patient's total BPRS score dropped from 79 to 41 and remained stable, after initial worsening at lower doses, at verapamil 80 mg po qid. Mild fatigue was the only side effect. Further investigation of verapamil in the treatment of schizophrenia is warranted.

Prediction of alexithymic characteristics from physiological, personality, and subjective measures

Noting concerns for a comprehensive conceptualization of alexithymic characteristics, the present study examines the potential utility of considering these characteristics as manifestations of deficits in cognitive schemata. Research guided by this conceptualization has identified physiological, subjective, and personality features of alexithymic characteristics. It is reasoned that if this conceptualization has merit, it should be possible to predict the presence of alexithymic characteristics from these features. Results of the present study indicate that a combination of physiological, subjective, and personality variables significantly predicts the presence of alexithymic characteristics as measured by the Schalling-Sifneos Personality Scale. These results are discussed in terms of their implications for a more comprehensive description of alexithymia and the value of the cognitive schema conceptualization.