Welcome to PsychED, the educational psychiatry podcast for medical learners, by medical learners.

This episode covers the approach to treating Major Depressive Disorder, as described by the CANMAT (Canadian Network for Mood and Anxiety Treatments) Guidelines. We discuss with Dr. Sid Kennedy, the founding chair of CANMAT, the past president of International Society for Affective Disorders, as well as a staff psychiatrist and scientist at Toronto Western and St. Michael’s Hospitals in Toronto.

In this episode, Dr. Kennedy discusses the origins of the CANMAT and how the guidelines are structured and constructed. We talk briefly about consideration of specifiers and symptoms in tailoring treatment. We then approach psychotherapy, pharmacotherapy, electrostimulation, and complementary and alternative therapies as treatment options, using the case from the previous episode on the diagnosis of depression.

Evidence-based psychotherapies for depression include cognitive behavioral therapy (CBT), interpersonal therapy (IPT), and mindfulness-based cognitive therapy (MBCT). We explain briefly the theoretical underpinnings of each. Patient suitability and availability of quality therapy are considered. Some evidence demonstrate a superiority of combining psychotherapy with pharmacotherapy (Cuijpers 2009).

The first-line pharmacotherapy includes antidepressant classes SSRI (selective serotonin reuptake inhibitor), SNRI (serotonin and norepinephrine reuptake inhibitor), NDRI (norepinephrine and dopamine reuptake inhibitor), and NaSSA (norepinephrine and specific serotonergic antidepressant). We discuss side effects with a focus on SSRIs, and understanding them from serotonin receptor profiles. We talk about the delayed onset of antidepressants, using validated tools to measure improvement, and strategies to optimize dosage, or using adjuncts with partial responses. We explore results from STAR*D (Trivedi et al, 2006) regarding response rates to medications.We touch briefly on antidepressant selection and the limited evidence of superiority of one medication/class over another (Cipriani et al 2009).

Brain stimulation includes electro-convulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and Deep Brain Stimulation (DBS). Dr. Kennedy discusses the cultural origins of misconceptions around ECT and explores the current practice of ECT today, which includes general anesthesia for the comfort of patients. We explain briefly the practice of rTMS and DBS.

Complementary and alternative therapies are briefly explored, including light therapy which has increasing evidence not only for seasonal patterns of depression. Dr. Kennedy discusses the limited evidence available to support any complementary therapies including nutraceuticals and exercise.

The Learning Objectives for this episode are as follows. By the end of this episode, the listener will be able to:

1. Demonstrate an approach to the treatment of depression based on severity of illness and other clinical features

2. Apply the CANMAT Guidelines in discussing treatment options for MDD

3. Identify psychotherapy, pharmacotherapy, brain stimulation, and complementary and alternative therapies as treatment options for MDD

4. Psychotherapy

   • Identify CBT, IPT, and MBCT as evidence-based psychotherapies for depression

   • Explain factors for choosing psychotherapy versus pharmacotherapy as first-line treatment

   • Describe the efficacy of psychotherapy in relation to pharmacotherapy

5. Pharmacotherapy

   • Identify SSRI, SNRI, NDRI, and NaSSA as classes of antidepressants that are first-line for depression

   • Explain the time of onset and side effect profile of SSRIs

   • Apply the guideline to either optimize, switch, or add adjunctive therapies with limited or partial responses to medication

   • Identify some factors to consider in choice of antidepressants

6. Brain Stimulation

   • Identify ECT, rTMS, and DBS as brain stimulation treatments for depression

   • Criticize the cultural origins of stigma around ECT

   • Describe the current practice of ECT, rTMS, and DBS

7. Complementary and Alternative Therapies

   • Describe Light Therapy as the only evidence-based complementary treatment strategy

   • Recognize the limited data in support of other therapies including nutraceuticals and exercise

Guest Staff Psychiatrist: Dr. Sid Kennedy (Toronto Western Hospital and St. Michael’s Hospital, Toronto)

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