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Factors to consider in choosing between switching vs. augmenting*:
According to 2016 CANMAT guidelines consider switching antidepressants when:
- it is the first antidepressant
- there are poorly tolerated side effects to the first antidepressant
- no response to (<25% improvement to the first antidepressant
- there is more time to wait for a response (less severe, less functional impairment)
- patient prefers to switch
CANMAT recommends considering adjunctive medication when:
- there have been 2 or more antidepressant trials
- the initial antidepressant is well tolerated
- there is a partial response (>25% improvement) to the initial antidepressant
- there are specific residual symptoms or side effects to the original antidepressant that can be targeted
- there is less time to wait for a response (more severe, more functional impairment)
- patient prefers to add on another medication
Augmentation
Note: Consider an evidence-based psychotherapy (cognitive-behavioural therapy, interpersonal therapy or problem-solving therapy) as an augmentation strategy first instead of medication.
Other non-medication augmentation strategies 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 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 with no risk factors for seizure bupropion XL 150 mg po daily x 2 weeks. If less than 20% response and tolerating it, 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 with insomnia 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 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
Switching
If considering switching CANMAT 2016 guidelines recommend switching to an antidepressant with evidence of superior efficacy (escitalopram, sertraline, venlafaxine or mirtazapine)
If you decide to switch from one medication to another, please go to SwitchRx for assistance
* 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