About Contact Print
  • Home
  • Algorithm Content
  • Medications
  • Instructional Video
  • Medications Video
  • Email this page
  • About
  • Contact

Increase or Augment

Email this page
Click the algorithm buttons for more info.
Enlarge Shrink Hide Show Algorithm

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 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



Mental Health Algorithms © 2021 Copyright. All Rights Reserved. Web Policy Site Map Admin Login

Instructional Video

Medications Video

Email this page:

Instructions:
  • Email this page to your colleague or client.
  • Select the first option to send the entire page or select specific links and PDFs from this page to include in your email.
  • Click 'Send Email' below when ready.
Cancel
The from address of the sent email is: do-not-reply@ottawadepressionalgorithm.ca.
The transmission of the email is secured with 256-bit SSL encryption.