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Increase or Augment

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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:

  • 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


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