Milev Roumen V, Giacobbe Peter, Kennedy Sidney H, Blumberger Daniel M, Daskalakis Zafiris J, Downar Jonathan, Modirrousta Mandana, Patry Simon, Vila-Rodriguez Fidel, Lam Raymond W, MacQueen Glenda M, Parikh Sagar V, Ravindran Arun V
Department of Psychiatry, Queen's University, Kingston, Ontario
Department of Psychiatry, University of Toronto, Toronto, Ontario.
Can J Psychiatry. 2016 Sep;61(9):561-75. doi: 10.1177/0706743716660033. Epub 2016 Aug 2.
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.
加拿大情绪与焦虑治疗网络（CANMAT）通过更新证据和建议对2009年指南进行了修订。2016年指南的范围仍是成人重度抑郁症（MDD）的管理，目标受众为精神科医生和其他心理健康专业人员。
我们采用问答形式进行了系统的文献检索，重点关注系统评价和荟萃分析。证据根据CANMAT定义的证据水平标准进行分级。治疗方案的建议基于证据质量和临床专家共识。“神经刺激治疗”是2016年指南六个部分中的第四部分。
针对6种神经刺激方式的31个问题制定了基于证据的回答：1）经颅直流电刺激（tDCS），2）重复经颅磁刺激（rTMS），3）电休克治疗（ECT），4）磁惊厥治疗（MST），5）迷走神经刺激（VNS），以及6）深部脑刺激（DBS）。大多数神经刺激治疗已在不同程度治疗抵抗的患者中进行了研究。
越来越多的证据表明神经刺激治疗具有有效性、耐受性和安全性。rTMS现在是至少1种抗抑郁药治疗失败的MDD患者的一线推荐。ECT仍然是难治性抑郁症患者的二线治疗方法，尽管在某些情况下，它可能被视为一线治疗。三线推荐包括tDCS和VNS。MST和DBS仍被视为试验性治疗。
