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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 or drug allergies
- Significant risk of drug interactions
Augmentation
Consider an evidence-based psychotherapy (cognitive-behavioural therapy, interpersonal therapy or problem-solving therapy) as an augmentation strategy instead of medication.
Other non-medication augmentation options (second-line as per CANMAT 2016 guidelines) include:
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 2 mg po daily x 2 weeks. If less than 20% response increase to 5 mg po daily, OR
- for those sleeping poorly and who can tolerate weight gain quetiapine XR 50 mg po at supper x 1 week. If tolerated then increase it to 150 mg po q supper. If less than 20% response after 2 weeks and if tolerated then consider increase to 300 mg po q supper
- 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
* 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