Updated National Guidelines on Depression

March 2022 blog post written by Dr. David Conn, Vice-President of Education and inaugural Director of the Centre for Education & Knowledge Exchange at Baycrest.

National guidelines on depression among older adults were recently updated by the Canadian Coalition for Seniors Mental Health (CCSMH). The updated document, which now includes recommendations on the prevention, assessment and treatment of depression, can be found at: www.ccsmh.ca\projects\depression. The original guidelines were developed in 2006 and this is the first update since then. The document includes two sections the first of which highlights new recommendations and those with major modifications. The second section compares the original guideline document to the new updated version. It includes all recommendations. For the first time the guidelines include a section on prevention. Other sections focus on assessment and screening, psychosocial interventions and psychotherapy, pharmacological treatments, somatic treatments, subtypes of depression, special populations and models of care. Funding for the guidelines project was originally provided by the Public Health Agency of Canada.

The new guidelines emphasize that there is promising evidence for exercise and mind-body interventions such as tai chi, yoga and mindfulness-based stress reduction in reducing depressive symptoms, either alone or in combination with other therapies. Physical activity in the form of exercise is an important non-pharmacological approach to improving depression in older adults. Although many psychotherapies have been shown to be effective in older adults the best evidence is for cognitive behavioural therapy (CBT) and problem-solving therapy (PST). Internet delivered therapies may be comparable to face-to-face treatment and may improve access to services for individuals in underserviced areas and those with mobility issues. The guidelines include some modifications to pharmacological treatments and recommend that sertraline and duloxetine be considered optimal first-line antidepressant treatments. For the first time repetitive transcranial magnetic stimulation (rTMS) is included as a treatment for people with unipolar depression who have failed to respond to at least one adequate trial of an antidepressant.

Healthcare systems have historically underfunded prevention approaches especially in the mental health field. The updated guidelines include a section on the prevention of depression. Although the research on prevention is in its infancy, it may be an alternative strategy to reduce the disease burden of depression, which has been described as a global public health priority. There was not enough evidence to recommend the use of antidepressants for people at high risk of depression. The prevention recommendations highlight a number of interventions for which there is some evidence. A variety of interventions focused on reducing social isolation and / or loneliness in older adults have demonstrated an associated reduction in depressive symptoms. These interventions have been primarily group-based and in long-term care settings. They include reminiscence therapy, physical exercise programs, video conferences with family, horticultural therapy and gender-based social groups. Social prescribing, which is defined as “a means of enabling primary care services to refer patients with social, emotional or practical needs to a range of local non-clinical services, often provided by the voluntary and community sector” may result in reduced depressive symptoms among older adults, who have experienced mild to moderate symptoms of depression, social isolation or loneliness.  Higher levels of physical activity are consistently associated with lower odds of developing future depression. A stepped-care approach, which includes bibliotherapy as an early intervention, can reduce the incidence of depressive and anxiety disorders in community dwelling older adults with sub-threshold symptoms. Finally, clinicians are encouraged to utilize the instilling of hope and positive thinking as important therapeutic tools in the prevention of depression and in supporting individuals with depressive symptoms or disorders.