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If the patient is not yet responding, and if the maximum is not yet reached, consider increasing / optimizing the dosage, up to the recommended maximum dosage.
Note: Lower doses or less frequent dosage increase may be better for anxious or medically compromised patients.
Do not increase/maximize the antidepressant dose if:
- There are significant side effects (consider using FIBSER.pdf ) or drug allergies
- Significant risk of drug interactions
Consider an evidence-based psychotherapy as an augmentation strategy instead of medication.
- Click here for psychotherapy resources
- Other non-medication augmentation options (second-line as per CANMAT 2016 guidelines) include:
If using a medication for augmentation, consider this two step process:
- for those with insomnia and who can tolerate weight gain consider mirtazapine 30 mg po qhs x 2 weeks. If less than 20% response and tolerating it, consider increasing to 45 mg po qhs, OR
- for those without risk factors for seizures and who are lacking energy consider bupropion XL 150 mg po daily x 2 weeks. If less than 20% response, consider increase to 300 mg po daily**
- If on either bupropion or mirtazapine as an initial agent, consider augmenting with an SSRI or SNRI
If Step 1 interventions are ineffective or not tolerated, then proceed to Step 2…
- Aripiprazole starting at 1-2 mg p.o. daily. Titrate at more than 2 week intervals or longer in increments of 1-2 mg to a target dose range of 2-5 mg and a maximum dose of 10 mg
- for those sleeping poorly and who can tolerate weight gain quetiapine XR 50 mg po at supper x 1 week. If tolerated and not much improved increase by 50 mg per week to a target dose of 150 mg and a maximum dose of 300, as tolerated and as required. In more urgent situations the dose can be increased more quickly as follows: 50mg on Day 1, 100 mg on Day 2, 200mg on Day 3 and 300 mg on Day 4.
- Brexpiprazole is also approved for augmentation and can be started at 0.5 mg po daily (or at night) and increased in increased in increments of 0.5 mg every 2 weeks, based on response an tolerance, to a maximum dose of 2.0 mg as required
- While on antipsychotics need to check lipids, fasting glucose or HbA1c and weight at baseline, at 3 months, and periodically thereafter
- If no response to antipsychotic augmentation we suggest tapering and removing the antipsychotic over several weeks to avoid unnecessary side effects
- If there is a good response to antipsychotic augmentation try to taper and remove the antipsychotic gradually after 6-9 months to avoid unnecessary side effects
- if remains on antipsychotic for more than one year check for tardive dyskinesia annually using the Abnormal Involuntary Movement Scale AIMS.pdf
* Note: CANMAT recommends antipsychotics as first line augmentation options but due to side effect profile we have recommended them as second line options.
** If adding bupropion to vortioxetine may need to decrease dose of vortioxetine