If the patient is not yet responding, and if the maximum is not yet reached, consider increasing / optimizing the dose.
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
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)
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).
For Obsessive-Compulsive disorder consider switching to clomipramineif 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.
If unable to tolerate SSRI or SNRI consider Psychotherapy or for GAD and Social Anxiety Disorder a trial of pregabalin