Increase, Augment or Switch

Increase

If the patient is not yet responding, and if the maximum is not yet reached, consider increasing / optimizing the dose.

Note: 

• Need to consider severity of the illness when deciding to increase the dose. For patients with  mild illness consider waiting longer for response to avoid unnecessary side effects.
• lower doses or less frequent dosage increase may be better for very somatically preoccupied or medically compromised patients
• for patients who develop treatment-emergent anxiety may need to drop the dose and go more slowly
• consider allowing the anxious patient, who is worried about side effects, some control as to when he or she feels comfortable increasing the dose
• for patients with obsessive-compulsive disorder it is recommended to try to increase the medication to the maximum tolerable dose and maintain that dose for at least eight weeks before considering switching or augmenting (unless augmenting with psychotherapy)

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
• If side effects are intolerable go Choosing an Antidepressant for assistance with switching

Augmentation or Switching

There are no clear guidelines to provide guidance when considering switching medication for anxiety. It is reasonable to consider recommendations for depression. Factors to consider in choosing between switching vs. augmenting for depression are as follows:

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

• Please go here

Switching

1. If side effects are intolerable  go to  Choosing an Antidepressant
2. If initial medication was an SSRI, and non-response (not side effects) is the reason to switch, consider switching instead to an SNRI such as Venlafaxine  and attempt to gradually dose to 225 mg if tolerated in order to see if patient needs noradrenergic effects seen at this dose (it is mostly a serotonergic medication at lower doses).
3. For Obsessive-Compulsive disorder consider switching to clomipramine if patient did not respond to adequate trials of an SSRI at higher doses and venlafaxine, for  at least 8 weeks each, at the maximum tolerable dose.
4. If unable to tolerate SSRI or SNRI consider Psychotherapy or  for GAD and Social Anxiety Disorder a trial of pregabalin