title: Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 4. Neurostimulation Treatments.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Department of Psychiatry, Queen's University, Kingston, Ontario roumen.milev@queensu.ca.
authors.forename: Roumen V
authors.initials: RV
authors.lastname: Milev
authors.affiliation: Department of Psychiatry, University of Toronto, Toronto, Ontario.
authors.forename: Peter
authors.initials: P
authors.lastname: Giacobbe
authors.affiliation: Department of Psychiatry, University of Toronto, Toronto, Ontario.
authors.forename: Sidney H
authors.initials: SH
authors.lastname: Kennedy
authors.affiliation: Department of Psychiatry, University of Toronto, Toronto, Ontario.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Blumberger
authors.affiliation: Department of Psychiatry, University of Toronto, Toronto, Ontario.
authors.forename: Zafiris J
authors.initials: ZJ
authors.lastname: Daskalakis
authors.affiliation: Department of Psychiatry, University of Toronto, Toronto, Ontario.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Downar
authors.affiliation: Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba.
authors.forename: Mandana
authors.initials: M
authors.lastname: Modirrousta
authors.affiliation: Department of Psychiatry, L'Université Laval, Québec City, Québec.
authors.forename: Simon
authors.initials: S
authors.lastname: Patry
authors.affiliation: Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: Fidel
authors.initials: F
authors.lastname: Vila-Rodriguez
authors.affiliation: Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: Raymond W
authors.initials: RW
authors.lastname: Lam
authors.affiliation: Department of Psychiatry, University of Calgary, Calgary, Alberta.
authors.forename: Glenda M
authors.initials: GM
authors.lastname: MacQueen
authors.affiliation: Department of Psychiatry, University of Toronto, Toronto, Ontario Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.
authors.forename: Sagar V
authors.initials: SV
authors.lastname: Parikh
authors.affiliation: Department of Psychiatry, University of Toronto, Toronto, Ontario.
authors.forename: Arun V
authors.initials: AV
authors.lastname: Ravindran
mesh_terms: D002170:Canada; D046690:Deep Brain Stimulation / Q000379:methods / Q000592:standards*; D003865:Major Depressive Disorder / Q000628:therapy*; D004565:Electroconvulsive Therapy / Q000379:methods / Q000592:standards*; D019317:Evidence-Based Medicine / Q000592:standards*; D006801:Humans; D017410:Practice Guidelines as Topic / Q000592:standards*; D065908:Transcranial Direct Current Stimulation / Q000379:methods / Q000592:standards*; D050781:Transcranial Magnetic Stimulation / Q000379:methods / Q000592:standards*; D055536:Vagus Nerve Stimulation / Q000379:methods / Q000592:standards*
keywords: clinical practice guidelines; deep brain stimulation; electroconvulsive therapy; evidence-based medicine; major depressive disorder; meta-analysis; neurostimulation; repetitive transcranial magnetic stimulation; systematic reviews