February 2012

Vol. 24. No. 1


Why are there no treatment guidelines for mood disorders and comorbidities?

Raymond W. Lam, MD | Sidney H. Kennedy, MD | Jitender Sareen, MD, FRCPC | Lakshmi N. Yatham, MBBS, FRCPC, MRCPsych (UK)

Mood disorders, including major depressive disorder (MDD) and bipolar disorder (BD), are among the most prevalent and burdensome medical conditions. In a World Mental Health Survey sponsored by the World Health Organization, the lifetime and 12-month prevalence rates for these 2 disorders in 17 developed and developing countries1 were 12.5% and 5.6% for major depressive episodes, respectively, and 1% and 0.7% for BD, respectively.2 A recent commentary on challenges in global mental health identified depression as the third leading contributor to the global disease burden; unipolar depressive disorders and BD, respectively, were ranked first and fourth in an evaluation of the global burden across all mental, neurological, and substance use disorders. 3 Previous studies have highlighted the enormous unmet need for treatment among persons with mood disorders…



The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid conditions

Roger S. McIntyre, MD, FRCPC | Ayal Schaffer, MD, FRCPC | Serge Beaulieu, MD, PhD, FRCPC

Results from epidemiological and clinical studies indicate that psychiatric and medical comorbidity occurs at a high rate among individuals with major depressive disorder (MDD) and bipolar disorder (BD). Comorbidity in mood disorders has diagnostic, prognostic, therapeutic, and conceptual implications. For example, comorbid substance use may obscure an underlying mood disorder, delay initiation of treatment, alter the determination of the most appropriate therapy, and challenge the clinician’s development of an etiological understanding of the patient’s condition. Moreover, an association between comorbid conditions and more complicated mood disorder presentations has been documented, with evidence of increased rates of chronicity, nonrecovery, suicidality, and premature ] mortality in comorbid patients. From a treatment perspective, the probability of achieving full recovery from an index affective episode is significantly decreased in the presence of comorbidity, and in many cases, treating a comorbid condition could inadvertently disrupt management of the mood disorder (eg, using antidepressants to treat an anxiety disorder in an adult with bipolar I disorder)…



The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid anxiety disorders

Ayal Schaffer, MD, FRCPC | Diane McIntosh, MD, FRCPC | Benjamin I. Goldstein, MD, PhD, FRCPC | Neil A. Rector, PhD, CPsych | Roger S. McIntyre, MD, FRCPC | Serge Beaulieu, MD, PhD, FRCPC | Richard Swinson, MD, FRCPC | Lakshmi N. Yatham, MBBS, FRCPC, MRCPsych (UK)

BACKGROUND: Comorbid mood and anxiety disorders are commonly seen in clinical practice. The goal of this article is to review the available literature on the epidemiologic, etiologic, clinical, and management aspects of this comorbidity and formulate a set of evidence- and consensus-based recommendations. This article is part of a set of Canadian Network for Mood and Anxiety Treatments (CANMAT) Comorbidity Task Force papers.

METHODS: We conducted a PubMed search of all English-language articles published between January 1966 and November 2010. The search terms were bipolar disorder and major depressive disorder, cross-referenced with anxiety disorders/symptoms, panic disorder, agoraphobia, generalized anxiety disorder, social phobia, obsessive-compulsive disorder, and posttraumatic stress disorder. Levels of evidence for specific interventions were assigned based on a priori determined criteria, and recommendations were developed by integrating the level of evidence and clinical opinion of the authors.

RESULTS: Comorbid anxiety symptoms and disorders have a significant impact on the clinical presentation and treatment approach for patients with mood disorders. A set of recommendations are provided for the management of bipolar disorder (BD) with comorbid anxiety and major depressive disorder (MDD) with comorbid anxiety with a focus on comorbid posttraumatic stress disorder, use of cognitive-behavioral therapy across mood and anxiety disorders, and youth with mood and anxiety disorders.

CONCLUSIONS: Careful attention should be given to correctly identifying anxiety comorbidities in patients with BD or MDD. Consideration of evidence- or consensus-based treatment recommendations for the management of both mood and anxiety symptoms is warranted.


The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid attention-deficit/hyperactivity disorder

David J. Bond, MD, FRCPC | George Hadjipavlou, MD, FRCPC | Raymond W. Lam, MD | Roger S. McIntyre, MD, FRCPC | Serge Beaulieu, MD, PhD, FRCPC | Ayal Schaffer, MD, FRCPC | Margaret Weiss, MD, PhD, FRCPC

BACKGROUND: Patients with bipolar disorder (BD) and major depressive disorder (MDD) experience adult attention deficit/hyperactivity disorder (ADHD) at rates substantially greater than the general population. Nonetheless, ADHD frequently goes untreated in this population.

METHODS: We reviewed the literature regarding the management of adult ADHD in patients with mood disorders. Because a limited number of studies have been conducted in adults, our treatment recommendations also are partly informed by research in children and adolescents with BD+ADHD or MDD+ADHD, adults with ADHD, and our clinical experience.

RESULTS: In individuals with mood disorders, ADHD is best diagnosed when typical symptoms persist during periods of sustained euthymia. Individuals with BD+ADHD, particularly those with bipolar I disorder (BD I), are at risk for mood destabilization with many ADHD treatments, and should be prescribed mood-stabilizing medications before initiating ADHD therapies. Bupropion is a reasonable first-line treatment for BD+ADHD, while mixed amphetamine salts and methylphenidate also may be considered in patients determined to be at low risk for manic switch. Modafinil and cognitive- behavioral therapy (CBT) are second-line choices. In patients with MDD+ADHD and moderate to severe depression, MDD should be the treatment priority, whereas in mildly depressed or euthymic patients the order may be reversed. First-line treatments for MDD+ADHD include bupropion, an antidepressant plus a long-acting stimulant, or an antidepressant plus CBT. Desipramine, nortriptyline, and venlafaxine are second-line options.

CONCLUSIONS: Clinicians should be vigilant in screening for comorbid ADHD in mood disorder patients. ADHD symptoms can respond to appropriately chosen treatments.


The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid substance use disorders

Serge Beaulieu, MD, PhD, FRCPC | Sybille Saury, DESS | Jitender Sareen, MD, FRCPC | Jacques Tremblay, MD, MSc | Christian G. Schütz, MD, PhD, MPH | Roger S. McIntyre, MD, FRCPC | Ayal Schaffer, MD, FRCPC

BACKGROUND: Mood disorders, especially bipolar disorder (BD), frequently are associated with substance use disorders (SUDs). There are well-designed trials for the treatment of SUDs in the absence of a comorbid condition. However, one cannot generalize these study results to individuals with comorbid mood disorders, because therapeutic efficacy and/or safety and tolerability profiles may differ with the presence of the comorbid disorder. Therefore, a review of the available evidence is needed to provide guidance to clinicians facing the challenges of treating patients with comorbid mood disorders and SUDs.

METHODS: We reviewed the literature published between January 1966 and November 2010 by using the following search strategies on PubMed. Search terms were bipolar disorder or depressive disorder, major (to exclude depression, postpartum; dysthymic disorder; cyclothymic disorder; and seasonal affective disorder) cross-referenced with alcohol or drug or substance and abuse or dependence or disorder. When possible, a level of evidence was determined for each treatment using the framework of previous Canadian Network for Mood and Anxiety Treatments recommendations. The lack of evidence-based literature limited the authors’ ability to generate treatment recommendations that were strictly evidence based, and as such, recommendations were often based on the authors’ opinion.

RESULTS: Even though a large number of treatments were investigated for alcohol use disorder (AUD), none have been sufficiently studied to justify the attribution of level 1 evidence in comorbid AUD with major depressive disorder (MDD) or BD. The available data allows us to generate firstchoice recommendations for AUD comorbid with MDD and only thirdchoice recommendations for cocaine, heroin, and opiate SUD comorbid with MDD. No recommendations were possible for cannabis, amphet-amines, methamphetamines, or polysubstance SUD comorbid with MDD. First-choice recommendations were possible for alcohol, cannabis, and cocaine SUD comorbid with BD and only second-choice recommendations for heroin, amphetamine, methamphetamine, and polysubstance SUD comorbid with BD. No recommendations were possible for opiate SUD comorbid with BD. Finally, psychotherapies certainly are considered an essential component of the overall treatment of SUDs comorbid with mood disorders. However, further welldesigned studies are needed in order to properly assess their potential role in specific SUDs comorbid with a mood disorder.

CONCLUSIONS: Although certain treatments show promise in the management of mood disorders comorbid with SUDs, additional well designed studies are needed to properly assess their potential role in specific SUDs comorbid with a mood disorder.