Newberg AR, Catapano LA, Zarate CA, Manji HK. The scope of these guidelines remains the management of adults with unipolar major depressive disorder (MDD) with a target audience of psychiatrists and other mental health professionals. Response and side effects during previous use of antidepressants, Comparative tolerability (potential side effects), Potential interactions with other medications, Use an antidepressant with efficacy in generalized anxiety disorder (Level 4), No differences in efficacy between SSRIs, SNRIs, and bupropion (Level 2), No specific antidepressants have demonstrated superiority (Level 2), Older studies found MAO inhibitors superior to TCAs, Use antipsychotic and antidepressant cotreatment (Level 1), Few studies involved atypical antipsychotics, No specific antidepressants have demonstrated superiority (Level 2 and 3), SSRIs, agomelatine, bupropion, and moclobemide have been studied, Limited data available on cognitive effects of other antidepressants and on comparative differences in efficacy, Beneficial effects on sleep must be balanced against potential for side effects (e.g., daytime sedation), Few antidepressants have been studied for somatic symptoms other than pain, Few comparative antidepressant studies for pain and other somatic symptoms, Antiepileptics (diazepam, phenytoin, phenobarbital), Codeine and other opioids (reduces effect), Antihistamines (astemizole, chlorpheniramine), Calcium channel antagonists (e.g., diltiazem, verapamil), Immune modulators (cyclosporine, tacrolimus), Macrolide antibacterials (clarithromycin, erythromycin), Severe episodes (psychosis, severe impairment, suicidality), Presence of comorbid psychiatric or other medical conditions. In summary, given the limited evidence, a pharmacologic approach for TRD would include diagnostic reevaluation, consideration of previous medication trials (including degree of response and tolerability), rational use of adjunctive medications, discontinuation of medications that have not been beneficial, and careful monitoring of symptoms, side effects, and functioning to evaluate outcomes. Phenomenal showing for #psychiatry! 2018 May;20(3):275-276. doi: 10.1111/bdi.12647. BDI, bipolar disorder type, Lamotrigine as a secondline agent for bipolar II depression: Summary of evidence BDI,, Treatments for pediatric bipolar depression:, Treatments for pediatric bipolar depression: Summary of evidence [Colour figure can be viewed, What is the role of primary treatments for anxiety disorders in treating comorbid, MeSH major depressive disorder, pharmacotherapy, clinical practice guidelines, antidepressants, evidence-based medicine, meta-analysis, antipsychotics, clinical trials, randomized controlled trial, Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. Results from a CANMAT-led research study comparing the effectiveness of a brief psychoeducation group intervention to a more time- and resource-intensive cognitive-behavioral therapy intervention in patients with bipolar disorder. Cipriani A, Santilli C, Furukawa TA, et al. 7 Lessons . Provides case-specific recommendations and real-time feedback on patient management. 2016 Depression Guidelines. Only one randomised trial to date has compared one-to-one sessions of psychoeducation plus routine care against routine care alone (Reference Perry, Tarrier and Morriss Perry 1999).In this study of 69 people with bipolar disorder, the intervention was The foundations of effective management of bipolar disorder. Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Beaulieu S, Alda M, ODonovan C, Macqueen G, McIntyre RS, Sharma V, et al. Hsu TW, Thompson T, Solmi M, Vieta E, Yang FC, Tseng PT, Hsu CW, Tu YK, Yu CL, Tsai CK, Liang CS, Carvalho AF. Abbreviation: EPS = extrapyramidal symptoms. Abbreviation: RCT = randomized controlled trial. Weisler RH, Montgomery SA, Earley WR, Szamosi J, Lazarus A. Efficacy of extended release quetiapine fumarate monotherapy in patients with major depressive disorder: a pooled analysis of two 6-week, double-blind, placebo-controlled studies. Gonzlez-Pinto A, Aldama A, Mosquera F, et al. Ng F, Mammen OK, Wilting I, et al. Hirschfeld RM, Williams JB, Spitzer RL, et al. 2. Santaguida PL, MacQueen G, Kashavarz H, et al. Sexual dysfunction associated with second-generation antidepressants in patients with major depressive disorder: results from a systematic review with network meta-analysis, Summary of findings from the FDA regulatory science forum on measuring sexual dysfunction in depression trials, Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration, Suicidal thoughts and behavior with antidepressant treatment: reanalysis of the randomized placebo-controlled studies of fluoxetine and venlafaxine, Meta-analysis of efficacy and treatment-emergent suicidality in adults by psychiatric indication and age subgroup following initiation of paroxetine therapy: a complete set of randomized placebo-controlled trials, Selective serotonin reuptake inhibitors and risk of suicide: a systematic review of observational studies, Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 6. special populations: youth, women, and the elderly. A Randomized, placebo-controlled, crossover pilot trial of the oral selective NR2B antagonist MK-0657 in patients with treatment-resistant major depressive disorder, Randomized proof of concept trial of GLYX-13, an N-methyl-D-aspartate receptor glycine site partial agonist, in major depressive disorder nonresponsive to a previous antidepressant agent, P.2.f.027. Tables S1 and S2). Parikh SV, Zaretsky A, Beaulieu S, et al. Extended-release divalproex in bipolar and other psychiatric disorders: a comprehensive review. Psychoeducation focusing on recognition of early warning signs of relapse is an effective adjunct to medication management and should be offered to all patients with bipolar disorder.48 More intensive psychotherapies (cognitive-behavioral therapy, family focused therapy, interpersonal and social rhythm therapy) have also demonstrated benefit as adjuncts to improve both symptoms and function and should be considered when available and financially feasible4951 (Table 7). Disclosures: The guidelines process and publication were funded entirely by internal CANMAT funds; no external support was sought or received. Medications for Bipolar Disorder in Pregnancya. Data sources and references are available in Supplemental Table S3. Pharmacological Treatments . Perry A, Tarrier N, Morriss R, McCarthy E, Limb K. Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. Sienaert P, Lambrichts L, Dols A, De FJ. Figure 1 shows a summary algorithm. Mahableshwarkar AR, Zajecka J, Jacobson W, et al. Drug and psychotherapy trials have largely proceeded independently of one another. Bipolar disorders; 2013; 15 (1):144. Validating hard and soft phenotypes within the bipolar spectrum: continuity or discontinuity? Bopp JM, Miklowitz DJ, Goodwin GM, Stevens W, Rendell JM, Geddes JR. ClinicalTrials Web site. It's free! A pooled analysis of 2 placebo-controlled 18-month trials of lamotrigine and lithium maintenance in bipolar I disorder. Hieronymus F, Emilsson JF, Nilsson S, et al. Perlis RH, Ostacher MJ, Patel JK, et al. There is less time to wait for a response (more severe, more functional impairment). While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. The neurobiology of bipolar disorder: identifying targets for specific agents and synergies for combination treatment. Discontinuation symptoms, described by the FINISH mnemonic (flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, hyperarousal), may be experienced by up to 40% of patients when antidepressants are stopped abruptly.87,88 These are generally mild and transient, but more severe symptoms have been described. The 2009 guidelines recommended that patients maintain treatment with antidepressants for 6 to 9 months after achieving symptomatic remission, while those with risk factors for recurrence extend antidepressant treatment to 2 years or more.82 New evidence continues to support this recommendation for antidepressant maintenance. Valproic acid, valproate and divalproex in the maintenance treatment of bipolar disorder. Increased prevalence of type 2 diabetes mellitus among psychiatric inpatients with bipolar I affective and schizoaffective disorders independent of psychotropic drug use. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2009. An interactive online tool full of up-to-date information designed for health care providers who are adjusting their patients psychotropic treatment regimens. Brain Sci. Accessibility Reinares M, Colom F, Snchez-Moreno J, et al. Although neither study showed reductions in relapses, patients in systematic care had fewer weeks in manic episodes than did those in usual care. Despite earlier reports questioning the efficacy of antidepressants,5 subsequent meta-analyses have continued to support the efficacy of antidepressants in MDD.6 The 2009 CANMAT guidelines identified most second-generation antidepressants as first-line treatments for patients with a major depressive episode (MDE) of moderate or greater severity (as determined by symptom scales and/or functional impairment), and this recommendation is unchanged. In a trial of patients with bipolar disorder types I and II in the euthymic phase of illness, patients were randomly assigned to pharmacotherapy and 21 sessions of structured group psychoeducation or 21 sessions of an unstructured support group. AVR has received honoraria for ad hoc speaking or advising/consulting or received research funds from Bristol Myers Squibb, Canadian Depression Research and Intervention Network, Canadian Foundation for Innovation and the Ministry of Economic Development and Innovation, Canadian Institutes of Health Research, Grand Challenges Canada, Janssen, Lundbeck, Ontario Mental Health Foundation, Pfizer, and Sunovion. Phillips ML, Kupfer MJ. Finally, an overview of issues related to safety and monitoring is provided. Evidence-based clinical guidelines developed by CANMAT and the International Society for Bipolar Disorder (ISBD) for the diagnosis and treatment of Bipolar Disorders, designed for use by community-based psychiatrists and mental health professionals. SVT has received honoraria for ad hoc speaking or advising/consulting or received research funds from Bristol-Myers Squibb, Eli Lilly, Janssen, Lundbeck, Otsuka, Pfizer, Purdue, Shire, Sunovion, and Valeant. Kennedy SH, Lam RW, Mcintyre RS, et al. separate guidelines for bipolar disorder.2 This section on Pharmacological Treatments is 1 of 6 CANMAT guide-lines articles; other sections of the. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) recommendations for the management of patients with bipolar disorder with mixed presentations. Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhancement Program. Long-term management focuses on maintenance of euthymia, requires ongoing medication, and may benefit from adjunctive psychotherapy. Impact of caregiver group psychoeducation on the course and outcome of bipolar patients in remission: a randomized controlled trial. Clinically relevant drug-drug interactions are usually caused by agents that are potent CYP inhibitors, including fluoxetine (CYP2D6), paroxetine (CYP2D6), and fluvoxamine (CYP1A2, 2C19, and 3A4). : Start Course. Adjunctive atypical antipsychotic treatment for major depressive disorder: a meta-analysis of depression, quality of life, and safety outcomes, Meta-analysis on the efficacy and tolerability of the augmentation of antidepressants with atypical antipsychotics in patients with major depressive disorder, Atypical antipsychotic augmentation for treatment-resistant depression: a systematic review and network meta-analysis, Efficacy and safety of adjunctive brexpiprazole 2 mg in major depressive disorder: a phase 3, randomized, placebo-controlled study in patients with inadequate response to antidepressants, Adjunctive brexpiprazole 1 and 3 mg for patients with major depressive disorder following inadequate response to antidepressants: a phase 3, randomized, double-blind study, Ziprasidone augmentation of escitalopram for major depressive disorder: efficacy results from a randomized, double-blind, placebo-controlled study, Combination of antidepressants in the treatment of major depressive disorder: a systematic review and meta-analysis. 2022 Canadian Network for Mood and Anxiety Treatments. Flu-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbances, and Hyperarousal (anxiety/agitation), Withdrawal symptoms after selective serotonin reuptake inhibitor discontinuation: a systematic review, Selective serotonin reuptake inhibitor antidepressant treatment discontinuation syndrome: a review of the clinical evidence and the possible mechanisms involved, Definition, assessment, and staging of treatment-resistant refractory major depression: a review of current concepts and methods. Benedetti F, Serretti A, Colombo C, et al. The family physician plays a vital role in mitigating these risks by careful monitoring of a number of health parameters (Table 8).52, . The role of electroconvulsive therapy (ECT) in bipolar disorder: effectiveness in 522 patients with bipolar depression, mixed-state, mania and catatonic features. Geddes JR, Goodwin GM, Rendell J, et al. Among the SGAs, olanzapine and aripiprazole have demonstrated efficacy in preventing relapse among acute responders, and quetiapine and ziprasidone have some evidence as adjuncts to divalproex or lithium.4045 Most recently, a long-acting injectable preparation of risperidone was approved by the FDA to prevent relapse on the basis of 2 positive, randomized trials.46,47 For many patients, maintenance therapy will be the medication to which they responded acutely; this should be borne in mind when selecting an acute agent. Patients with bipolar disorder have high rates of medical, psychiatric, and substance abuse disorders, which contribute to reduced life expectancy and lower quality of life.6 A majority meet criteria for at least 1 other mental disorder; anxiety and substance abuse disorders are most common, with a 40% to 60% lifetime prevalence.710 Compared to the general population, patients with bipolar disorder have higher rates of diabetes mellitus and liver and cardiovascular disease and experience increased disability and mortality from these illnesses.11,12 The family physician has a valuable opportunity to improve outcomes by aggressive screening for, and maintenance of, these comorbid conditions. Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. A systematic review identified only 3 RCTs (N = 495), all of which investigated adjunctive strategies as the primary aim but included conditions for switching to a new antidepressant and continuing on the original antidepressant.99 There were no differences in response or remission rates between switch and continuing strategies and no consistent evidence of differential efficacy between switching within class (e.g., from one SSRI to another SSRI) or across classes of antidepressants.99. The DSM-5 has added a new diagnosis of persistent depressive disorder (PDD) that subsumes the DSM-IV diagnoses of dysthymic disorder and chronic MDD (see Section 13). Substantial progress has been made in the past decade in understanding of the role of psychotherapy in bipolar disorder. Gitlin MJ, Swendsen J, Heller TL, Hammen C. Relapse and impairment in bipolar disorder. Consensus Group of the British Association for Psychopharmacology. and transmitted securely. For example, clarification of the mechanisms by which different mood stabilisers and atypical antipsychotics affect sleep and circadian rhythms and their relation with daily mood fluctuations is likely to help with the treatment selection for individual patients. Grskovic M, Javaherian A, Strulovici B, Daley GQ. Individual psychoeducation. Author Michael J Gitlin 1 Affiliation 1 Department of Psychiatry, Geffen School of Medicine at UCLA, Los Angeles, CA, Group psychoeducation was estimated to cost US$180 per patient, whereas cognitive-behavioural therapy was estimated to cost $1200 per patient. Before 2013 May 11; 381(9878): 10.1016/S0140-6736(13)60857-0. MAO, monoamine oxidase; SNRI, serotonin and noradrenaline reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant. In one randomised controlled trial,68 remitted patients whose relatives attended psychoeducation groups had longer intervals before manic and hypomanic episodes than did those whose relatives did not attend groups. government site. It is one of the safest anesthetics, as, in contrast with opiates, ether, and propofol, it suppresses neither respiration nor heart rate.Ketamine is also simple to administer and highly tolerable compared to drugs with similar effects which are Cipriani A, Rendell J, Geddes JR. Olanzapine in the long-term treatment of bipolar disorder: a systematic review and meta-analysis. RU has received research funds from European Commission Framework 6. 8600 Rockville Pike Hence, selecting an antidepressant involves an individualized needs assessment for each patient. (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. All existing forms of psychotherapy for bipolar disorder include psychoeducation, although which didactic ingredients lead to the most clinical change is not clear (panel). Comparative efficacy and risk of harms of immediate- versus extended-release second-generation antidepressants: a systematic review with network meta-analysis, Rational use of generic psychotropic drugs, Withdrawal of generic budeprion for nonbioequivalence, Influence of CYP2D6 and CYP2C19 gene variants on antidepressant response in obsessive-compulsive disorder, Clinically significant drug interactions with newer antidepressants, Interactions between antidepressants and P-glycoprotein at the blood-brain barrier: clinical significance of in vitro and in vivo findings, Clinically significant drug interactions with atypical antipsychotics, Serotonin syndrome: analysis of cases registered in the French Pharmacovigilance Database, Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2D6 and CYP2C19 genotypes and dosing of selective serotonin reuptake inhibitors, Pharmacogenomic testing for neuropsychiatric drugs: current status of drug labeling, guidelines for using genetic information, and test options, Early switching strategies in antidepressant non-responders: current evidence and future research directions, Is switching antidepressants following early nonresponse more beneficial in acute-phase treatment of depression? The https:// ensures that you are connecting to the Curr Neuropharmacol 2017;15: 359-371. CANMAT's evidence-based clinical guidelines for the diagnosis and treatment of adults with Major Depressive Disorder (MDD), designed for use by community-based psychiatrists and mental health professionals. official website and that any information you provide is encrypted : Start Course. However, an effectiveness trial (n=252) comparing cognitive-behavioural therapy with treatment as usual in five UK community care centres found no advantage for cognitive-behavioural therapy over 18 months, except among patients with fewer than 12 previous episodes.73. Would you like email updates of new search results? official website and that any information you provide is encrypted There is partial response (>25% improvement) to the initial antidepressant. An adjunctive strategy refers to the addition of a second medication to an initial medication. In subsequent trials, lack of response (<25% improvement) may not be a factor for choosing between switch and adjunctive strategies. Although considered small effects, 5% to 6% differences in response rate may be clinically relevant from a population basis. @UBC_Psychiatry @Psycholod @DMCBrainHealth @EMBEDstudy @GovCanHealth @CANMAT_org @CANBIND @APEC bAlso metabolized through the uridine diphosphate glucuronosyltransferase (UGT) pathway. Careers. 7 Lessons . While these agents are all effective as monotherapy, results of meta-analysis suggest that a combination of an SGA and either lithium or divalproex is the most effective treatment of acute mania or mixed states, though combination treatment significantly increases adverse effect burden.31, First-Line Agents for Acute Manic or Mixed Episodea. Front Psychiatry. Laughren TP, Gobburu J, Temple RJ, et al. Kirsch I, Deacon BJ, Huedo-Medina TB, et al. As such, patients should be cautioned to not stop their medications abruptly, and when a medication must be discontinued, if possible, it should be slowly tapered. There are no published meta-analyses for levomilnacipran, but a pooled analysis of 5 placebo-controlled RCTs (N = 2598) confirmed its efficacy for response and remission.7 One relapse-prevention study did not show significant differences between levomilnacipran and placebo.8 There are no comparison studies of levomilnacipran with other antidepressants. Miklowitz DJ, Goodwin GM, Bauer M, Geddes JR. Common and specific elements of psychosocial treatments for bipolar disorder: a survey of clinicians participating in randomized trials. In studies that used standardized rating scales or interviews, which are more likely to reliably detect sexual side effects, agomelatine, bupropion, mirtazapine, vilazodone, and vortioxetine demonstrated lower risk.54, Suicidal ideation and acts are important risks associated with MDD and require diligent assessment, monitoring and management during psychiatric treatment (see Section 13). Cipriani and colleagues45 examined 12 second-generation antidepressants in a network meta-analysis and found superior response for escitalopram, mirtazapine, sertraline, and venlafaxine. Fourth Edition, Text Revision. The most recent US guidelines are that of the Texas Implementation of Medication Algorithms project, last updated in 2005. In 2009, the Canadian Network for Mood and Anxiety Treatments (CANMAT), a not-for-profit scientific and educational organization, published a revision of evidence-based clinical guidelines for the treatment of depressive disorders. Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Epub 2018 Mar 30. Cipriani A, Barbui C, Salanti G, et al. Anxiety disorders include generalized and social anxiety and panic. Mental imagery as an emotional amplifier: Application to bipolar disorder. @CANMAT_org @CMHA_NTL @ProfDiCrone @simon_rosenbaum @UBCKin https://twitter.com/csep_scpe/status/1430549289999249413, Hot off the press! Learn the latest research to improve your clinical care for mood and anxiety treatments.
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