Kennedy Sidney H, Milev Roumen, Giacobbe Peter, Ramasubbu Rajamannar, Lam Raymond W, Parikh Sagar V, Patten Scott B, Ravindran Arun V
University of Toronto, Canada.
J Affect Disord. 2009 Oct;117 Suppl 1:S44-53. doi: 10.1016/j.jad.2009.06.039. Epub 2009 Aug 5.
In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. There is renewed interest in refined approaches to brain stimulation, particularly for treatment resistant major depressive disorder (MDD).
The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included evidence and expert clinical support. This section on "Neurostimulation Therapies" is one of 5 guidelines articles.
Among the four forms of neurostimulation reviewed in this section, electroconvulsive therapy (ECT) has the most extensive evidence, spanning seven decades. Repetitive transcranial magnetic (rTMS) and vagus nerve stimulation (VNS) have been approved to treat depressed adults in both Canada and the United States with a much smaller evidence base. There is also emerging evidence that deep brain stimulation (DBS) is effective for otherwise treatment resistant depression, but this is an investigational approach in 2009.
Compared to other modalities for the treatment of MDD, the data based is limited by the relatively small numbers of randomized controlled trials (RCTs) and small sample sizes.
There is most evidence to support ECT as a first-line treatment under specific circumstances and rTMS as a second-line treatment. Evidence to support VNS is less robust and DBS remains an investigational treatment.
2001年，加拿大精神病学协会与加拿大情绪与焦虑治疗网络（CANMAT）合作制定了抑郁症治疗的循证临床指南。CANMAT在2008 - 2009年对这些指南进行了修订，以反映该领域的进展。人们对改进脑刺激方法重新产生了兴趣，特别是对于难治性重度抑郁症（MDD）。
CANMAT指南采用问答形式，以提高临床医生的可及性。使用循证形式，对文献进行了更新的系统评价，并根据证据水平使用预定义标准对建议进行分级。根据包括证据和专家临床支持在内的标准确定治疗方案。“神经刺激疗法”这一部分是5篇指南文章之一。
在本节中回顾的四种神经刺激形式中，电休克疗法（ECT）有最广泛的证据，跨越了七十年。重复经颅磁刺激（rTMS）和迷走神经刺激（VNS）在加拿大和美国均已被批准用于治疗成年抑郁症患者，但其证据基础要小得多。也有新出现的证据表明，深部脑刺激（DBS）对难治性抑郁症有效，但在2009年这还是一种研究性方法。
与治疗MDD的其他方式相比，数据基础受到相对较少的随机对照试验（RCT）数量和小样本量的限制。
有最多的证据支持在特定情况下将ECT作为一线治疗方法，将rTMS作为二线治疗方法。支持VNS的证据不太充分，而DBS仍然是一种研究性治疗方法。
