febriliankr/CANMAT_summary

## CANMAT_summary
The Canadian Network for Mood and Anxiety Treatments (CANMAT) published evidence-based clinical guidelines for the treatment of depressive disorders in 2009, with an updated version in 2016. The guidelines include recommendations for complementary and alternative medicine (CAM) treatments as part of the management of unipolar major depressive disorder in adults. The use of CAM treatments is popular among individuals with mental illness, including depression, but often lacks medical supervision and considers possible interactions with existing medications. The guidelines focus on physical and meditative forms of CAM treatments due to limited evidence on the efficacy of other therapies.

This article reviews various treatments and natural health products for depression, including light therapy, sleep deprivation, exercise, yoga, and acupuncture, as well as St. John’s wort, omega-3 fatty acids, and other supplements. The evidence for these treatments is limited, and the quality of research varies, making it challenging to determine their effectiveness. The article highlights the need for better-designed studies and more long-term data to evaluate the benefits of these alternative therapies for depression.

Systematic reviews and meta-analyses are recommended to provide a comprehensive overview of the literature on complementary and alternative medicine (CAM) treatments for major depressive disorder (MDD). Publication bias should be considered when evaluating CAM research. Evidence-based pharmacological and psychological treatments are typically preferred over CAM treatments due to a larger evidence base and better quality evidence for efficacy. It is important for clinicians to consider individual patient needs and potential interactions between CAM therapies and conventional treatments. Light therapy, or phototherapy, is a common CAM treatment for MDD that involves daily exposure to bright light. The standard protocol is 10,000 lux for 30 minutes per day during the early morning for up to 6 weeks, with response usually seen within 1 to 3 weeks. Proposed mechanisms of action include alteration of circadian rhythms and modulation of serotonin.

Light therapy is a well-tolerated treatment for seasonal depression, supported by meta-analyses and systematic reviews. It has also shown efficacy in nonseasonal major depressive disorder (MDD) as both monotherapy and in combination with medication. Cognitive-behavioral therapy (CBT) has also been found to be effective in treating seasonal depression, with long-term benefits. Sleep deprivation has shown rapid antidepressant effects in recent studies, with total sleep deprivation lasting up to 40 hours and partial sleep deprivation involving limited sleep per night.

Sleep deprivation (SD) is used as a treatment for moderate to severe Major Depressive Disorder (MDD) as an augmentation to antidepressants. It can be effective when combined with other strategies such as sleep-phase advance (SPA) and light therapy. SD should be used as a third-line adjunctive treatment for more severe and refractory forms of MDD. Some common side effects of SD include daytime sleepiness and panic attacks, but the risk of induced mania is low. Additionally, SD is contraindicated for individuals with epilepsy due to the high risk of seizure induction. Overall, the efficacy of SD in treating MDD is supported by Level 2 Evidence, but challenges in sustaining treatment and blinding make it a complex intervention.

Exercise has been shown to be an effective treatment for depression, with both cardiovascular and resistance exercise being beneficial. Recommendations for exercise include at least 30 minutes of supervised moderate-intensity exercise at least 3 times weekly for a minimum of 9 weeks. Recent studies have found that exercise is as effective as pharmacotherapy or psychotherapy for treating mild to moderate depression, and can be superior to control conditions for moderate to severe depression. Some methodological challenges exist, but exercise is generally well tolerated with few reported adverse events.

The effectiveness of exercise in treating Major Depressive Disorder (MDD) is supported by Level 1 Evidence, with recommendations for it to be used as a first-line monotherapy for mild to moderate MDD and as a second-line adjunctive treatment for moderate to severe MDD. There are limitations in the interpretation of results due to control conditions, blinding, and self-selection bias, as well as feasibility issues with supervised exercise. The long-term benefits of exercise for MDD are unclear, but it may help maintain early benefits and prevent the onset of depression. Further research is needed to assess the long-term effects of exercise for MDD. Yoga, as a complementary treatment for MDD, aims to achieve physical, mental, and spiritual balance through various practices. Proposed neurobiological mechanisms for the benefits of yoga include changes in brain chemistry, regulation of stress hormones, and normalization of heart rate variability. Yoga interventions typically involve 2 to 4 sessions per week over 2 to 3 months.

Yoga has shown moderate advantages compared to usual care but only modest benefits compared to relaxation and aerobic exercise. Integrated yoga forms that incorporate breath control and meditation may be more beneficial than focusing on postures alone. However, there are limitations in yoga studies such as low quality of research, variability in practice parameters, and lack of long-term efficacy and safety data. Side effects of yoga are rare, but there are case reports of serious adverse effects from excessive or incorrect practice. Yoga is recommended as a second-line adjunct therapy for mild to moderate depression. Acupuncture, involving the insertion of needles at specific points on the body, has been used for centuries in Asia for various health conditions. Electro-acupuncture and laser acupuncture have shown comparable efficacy to manual acupuncture. Acupuncture has been evaluated for its effectiveness in treating depression.

Acupuncture is a treatment option for depression, with sessions typically ranging from 10 to 30 and decreasing in frequency over time. Studies have shown mixed results on its efficacy, with methodological issues being a contributing factor. Adverse effects are generally mild. Acupuncture is recommended as a third-line treatment for mild to moderate MDD. St. John's Wort is a natural health product that has been used for centuries as a herbal remedy for depression.

St. John's Wort (SJW) is a popular herbal remedy for mild to moderate major depressive disorder (MDD) with comparable efficacy to antidepressants and superior to placebo. The recommended dose range is 500 to 1800 mg/day for 4 to 12 weeks. SJW is well-tolerated but can have side effects such as gastrointestinal upset and headaches. It is recommended as first-line monotherapy for mild to moderate MDD and as a second-line adjunctive treatment for moderate to severe MDD. High potency extracts may interfere with the metabolism of other medications and can potentially cause serotonin syndrome or hypomania when used with antidepressants. Omega-3 fatty acids, found in fish and certain nuts and seeds, have been studied for the treatment of MDD with varying formulations such as EPA and DHA.

Omega-3 fatty acids are commonly used in the treatment of Major Depressive Disorder (MDD), with a typical dose range of 3 to 9 g/day. Studies have provided conflicting results on the efficacy of omega-3 fatty acids, with some showing positive outcomes as monotherapy or adjunctive therapy. The most recent meta-analysis found large effect sizes for the efficacy of omega-3 fatty acids in DSM-defined MDD. EPA-dominant formulations were found to be superior for alleviating depressive symptoms. Omega-3 supplements are generally well tolerated with mild side effects, but patients on certain medications may require additional monitoring. Omega-3 fatty acids are recommended as second-line monotherapy for mild to moderate MDD and adjunctive to antidepressants for moderate to severe MDD.

SAM-e is a supplement used for the treatment of MDD, prescribed in Europe and available over-the-counter in the US and Canada. It is effective as a monotherapy or adjunctive treatment for mild to moderate MDD, but there are concerns about trial methodologies and lack of data on maintenance therapy. Common side effects include gastrointestinal upset, insomnia, sweating, headache, and anxiety. DHEA, a hormone produced by the adrenal cortex, has also been used for the treatment of MDD, but no new evidence on its efficacy has been found since 2009. Side effects of DHEA include hirsutism, acne, and hypertension.

The use of DHEA as a treatment for depression is recommended as a third-line option, with potential for adverse effects at higher doses. Tryptophan, despite being a precursor of serotonin, does not have clear evidence supporting its effectiveness as an adjunctive treatment for depression. Other natural health products such as folate preparations, inositol, and saffron have been evaluated, with mixed results regarding their efficacy in treating depression.

Various natural supplements, such as L-methylfolate, saffron, lavender, and roseroot, have been studied for their effectiveness in treating mild to moderate depression. L-methylfolate may be effective as monotherapy or adjunct to antidepressants, while saffron and lavender have shown comparable efficacy to antidepressants in treating depression. Lavender combined with citalopram was found to be more effective than citalopram alone. Roseroot did not show significant differences from placebo in one study. These supplements are generally well-tolerated, with mild and infrequent side effects reported. More research is needed to establish standard dose regimens for roseroot.

The study recommends acetyl-L-carnitine and C. sativus as third-line monotherapy for mild to moderate depression, with folate and Lavandula recommended as adjunctive treatments. Inositol and R. rosea are not recommended. Exercise, St. John's wort, and light therapy have the most robust evidence for treating depression. CAM treatments can be effective for mild to moderate depression and should be considered when patient preference or adherence to traditional treatments is a concern. More education for physicians on CAM treatments is needed.

The CANMAT guidelines for evidence-based treatment options for patients with depression were funded internally and not endorsed by the Canadian Psychiatric Association. The organization is governed by volunteer advisory board members and has a conflict of interest policy in place. Some authors of the guidelines disclosed potential conflicts of interest with pharmaceutical companies.

Several researchers and professionals in the field of mental health have received honoraria, consulting fees, research funds, or speaker fees from various pharmaceutical companies and organizations, including AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Pfizer, and Johnson & Johnson, among others. This includes involvement in advisory boards, speaking engagements, and research collaborations related to mental health treatments and interventions.
	The Canadian Network for Mood and Anxiety Treatments (CANMAT) published evidence-based clinical guidelines for the treatment of depressive disorders in 2009, with an updated version in 2016. The guidelines include recommendations for complementary and alternative medicine (CAM) treatments as part of the management of unipolar major depressive disorder in adults. The use of CAM treatments is popular among individuals with mental illness, including depression, but often lacks medical supervision and considers possible interactions with existing medications. The guidelines focus on physical and meditative forms of CAM treatments due to limited evidence on the efficacy of other therapies.

	This article reviews various treatments and natural health products for depression, including light therapy, sleep deprivation, exercise, yoga, and acupuncture, as well as St. John’s wort, omega-3 fatty acids, and other supplements. The evidence for these treatments is limited, and the quality of research varies, making it challenging to determine their effectiveness. The article highlights the need for better-designed studies and more long-term data to evaluate the benefits of these alternative therapies for depression.

	Systematic reviews and meta-analyses are recommended to provide a comprehensive overview of the literature on complementary and alternative medicine (CAM) treatments for major depressive disorder (MDD). Publication bias should be considered when evaluating CAM research. Evidence-based pharmacological and psychological treatments are typically preferred over CAM treatments due to a larger evidence base and better quality evidence for efficacy. It is important for clinicians to consider individual patient needs and potential interactions between CAM therapies and conventional treatments. Light therapy, or phototherapy, is a common CAM treatment for MDD that involves daily exposure to bright light. The standard protocol is 10,000 lux for 30 minutes per day during the early morning for up to 6 weeks, with response usually seen within 1 to 3 weeks. Proposed mechanisms of action include alteration of circadian rhythms and modulation of serotonin.

	Light therapy is a well-tolerated treatment for seasonal depression, supported by meta-analyses and systematic reviews. It has also shown efficacy in nonseasonal major depressive disorder (MDD) as both monotherapy and in combination with medication. Cognitive-behavioral therapy (CBT) has also been found to be effective in treating seasonal depression, with long-term benefits. Sleep deprivation has shown rapid antidepressant effects in recent studies, with total sleep deprivation lasting up to 40 hours and partial sleep deprivation involving limited sleep per night.

	Sleep deprivation (SD) is used as a treatment for moderate to severe Major Depressive Disorder (MDD) as an augmentation to antidepressants. It can be effective when combined with other strategies such as sleep-phase advance (SPA) and light therapy. SD should be used as a third-line adjunctive treatment for more severe and refractory forms of MDD. Some common side effects of SD include daytime sleepiness and panic attacks, but the risk of induced mania is low. Additionally, SD is contraindicated for individuals with epilepsy due to the high risk of seizure induction. Overall, the efficacy of SD in treating MDD is supported by Level 2 Evidence, but challenges in sustaining treatment and blinding make it a complex intervention.

	Exercise has been shown to be an effective treatment for depression, with both cardiovascular and resistance exercise being beneficial. Recommendations for exercise include at least 30 minutes of supervised moderate-intensity exercise at least 3 times weekly for a minimum of 9 weeks. Recent studies have found that exercise is as effective as pharmacotherapy or psychotherapy for treating mild to moderate depression, and can be superior to control conditions for moderate to severe depression. Some methodological challenges exist, but exercise is generally well tolerated with few reported adverse events.

	The effectiveness of exercise in treating Major Depressive Disorder (MDD) is supported by Level 1 Evidence, with recommendations for it to be used as a first-line monotherapy for mild to moderate MDD and as a second-line adjunctive treatment for moderate to severe MDD. There are limitations in the interpretation of results due to control conditions, blinding, and self-selection bias, as well as feasibility issues with supervised exercise. The long-term benefits of exercise for MDD are unclear, but it may help maintain early benefits and prevent the onset of depression. Further research is needed to assess the long-term effects of exercise for MDD. Yoga, as a complementary treatment for MDD, aims to achieve physical, mental, and spiritual balance through various practices. Proposed neurobiological mechanisms for the benefits of yoga include changes in brain chemistry, regulation of stress hormones, and normalization of heart rate variability. Yoga interventions typically involve 2 to 4 sessions per week over 2 to 3 months.

	Yoga has shown moderate advantages compared to usual care but only modest benefits compared to relaxation and aerobic exercise. Integrated yoga forms that incorporate breath control and meditation may be more beneficial than focusing on postures alone. However, there are limitations in yoga studies such as low quality of research, variability in practice parameters, and lack of long-term efficacy and safety data. Side effects of yoga are rare, but there are case reports of serious adverse effects from excessive or incorrect practice. Yoga is recommended as a second-line adjunct therapy for mild to moderate depression. Acupuncture, involving the insertion of needles at specific points on the body, has been used for centuries in Asia for various health conditions. Electro-acupuncture and laser acupuncture have shown comparable efficacy to manual acupuncture. Acupuncture has been evaluated for its effectiveness in treating depression.

	Acupuncture is a treatment option for depression, with sessions typically ranging from 10 to 30 and decreasing in frequency over time. Studies have shown mixed results on its efficacy, with methodological issues being a contributing factor. Adverse effects are generally mild. Acupuncture is recommended as a third-line treatment for mild to moderate MDD. St. John's Wort is a natural health product that has been used for centuries as a herbal remedy for depression.

	St. John's Wort (SJW) is a popular herbal remedy for mild to moderate major depressive disorder (MDD) with comparable efficacy to antidepressants and superior to placebo. The recommended dose range is 500 to 1800 mg/day for 4 to 12 weeks. SJW is well-tolerated but can have side effects such as gastrointestinal upset and headaches. It is recommended as first-line monotherapy for mild to moderate MDD and as a second-line adjunctive treatment for moderate to severe MDD. High potency extracts may interfere with the metabolism of other medications and can potentially cause serotonin syndrome or hypomania when used with antidepressants. Omega-3 fatty acids, found in fish and certain nuts and seeds, have been studied for the treatment of MDD with varying formulations such as EPA and DHA.

	Omega-3 fatty acids are commonly used in the treatment of Major Depressive Disorder (MDD), with a typical dose range of 3 to 9 g/day. Studies have provided conflicting results on the efficacy of omega-3 fatty acids, with some showing positive outcomes as monotherapy or adjunctive therapy. The most recent meta-analysis found large effect sizes for the efficacy of omega-3 fatty acids in DSM-defined MDD. EPA-dominant formulations were found to be superior for alleviating depressive symptoms. Omega-3 supplements are generally well tolerated with mild side effects, but patients on certain medications may require additional monitoring. Omega-3 fatty acids are recommended as second-line monotherapy for mild to moderate MDD and adjunctive to antidepressants for moderate to severe MDD.

	SAM-e is a supplement used for the treatment of MDD, prescribed in Europe and available over-the-counter in the US and Canada. It is effective as a monotherapy or adjunctive treatment for mild to moderate MDD, but there are concerns about trial methodologies and lack of data on maintenance therapy. Common side effects include gastrointestinal upset, insomnia, sweating, headache, and anxiety. DHEA, a hormone produced by the adrenal cortex, has also been used for the treatment of MDD, but no new evidence on its efficacy has been found since 2009. Side effects of DHEA include hirsutism, acne, and hypertension.

	The use of DHEA as a treatment for depression is recommended as a third-line option, with potential for adverse effects at higher doses. Tryptophan, despite being a precursor of serotonin, does not have clear evidence supporting its effectiveness as an adjunctive treatment for depression. Other natural health products such as folate preparations, inositol, and saffron have been evaluated, with mixed results regarding their efficacy in treating depression.

	Various natural supplements, such as L-methylfolate, saffron, lavender, and roseroot, have been studied for their effectiveness in treating mild to moderate depression. L-methylfolate may be effective as monotherapy or adjunct to antidepressants, while saffron and lavender have shown comparable efficacy to antidepressants in treating depression. Lavender combined with citalopram was found to be more effective than citalopram alone. Roseroot did not show significant differences from placebo in one study. These supplements are generally well-tolerated, with mild and infrequent side effects reported. More research is needed to establish standard dose regimens for roseroot.

	The study recommends acetyl-L-carnitine and C. sativus as third-line monotherapy for mild to moderate depression, with folate and Lavandula recommended as adjunctive treatments. Inositol and R. rosea are not recommended. Exercise, St. John's wort, and light therapy have the most robust evidence for treating depression. CAM treatments can be effective for mild to moderate depression and should be considered when patient preference or adherence to traditional treatments is a concern. More education for physicians on CAM treatments is needed.

	The CANMAT guidelines for evidence-based treatment options for patients with depression were funded internally and not endorsed by the Canadian Psychiatric Association. The organization is governed by volunteer advisory board members and has a conflict of interest policy in place. Some authors of the guidelines disclosed potential conflicts of interest with pharmaceutical companies.

	Several researchers and professionals in the field of mental health have received honoraria, consulting fees, research funds, or speaker fees from various pharmaceutical companies and organizations, including AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Pfizer, and Johnson & Johnson, among others. This includes involvement in advisory boards, speaking engagements, and research collaborations related to mental health treatments and interventions.