Increase or Augment

Increase

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

Augmentation

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:
  • exercise pdf
  • light therapy pdf

If using a medication for augmentation, consider this two step process:

Step 1* 

Choose:

• 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…

Step 2 

Choose:

• 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

          OR

• 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
• Note: 
  • 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