Increase or Augment

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

Suggest considering an evidence-based psychotherapy, if available, as an augmentation strategy instead of medication.

• Click here for psychotherapy resources

The evidence for augmentation with medications in anxiety disorders is not well developed. The following are some suggestions that can be tried for which there may be some evidence:

For Generalized Anxiety disorder consider:

1. Pregabalin starting slowly at 25-50 mg po qhs and if tolerated  increasing in increments of 25-50 mg weekly in divided doses aiming for a target dose of 150 mg. Doses up to 600 mg have found effective for some patients. If too sedated try to consolidate the entire dose at night.
2. Buspirone beginning at 5 mg po tid and titrating it up weekly by 5 mg, based on tolerance and response to a maximum dose of 60 mg in divided dose if necessary
3. If above augmentation options are not successful or not tolerated consider trial of quetiapine XR beginning at a dose 50 mg at supper. The dose can be increased every 1-2 weeks, based on response and tolerance to a maximum dose of 150 mg.
   Note:
   • While on antipsychotic medication need to check lipids, fasting glucose or HbA1c and weight at baseline, at 3 months, and periodically thereafter
   • If no response to antipsychotic augmentation  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
   • if remains on antipsychotic for more than one year check for tardive dyskinesia annually using the  Abnormal Involuntary Movement Scale AIMS.pdf
   • Note that this  is considered an off-label use of this medication and side effects including metabolic and risk of tardive dyskinesia needs to be carefully discussed with the patient and consent obtained
4. Low dose benzodiazepines can sometimes be used in very resistant cases under strict conditions (see below)

For Social Anxiety Disorder consider:

1. Pregabalin starting slowly at 25-50 mg po qhs and if tolerated  increasing in increments of 25-50 mg weekly in divided doses aiming for a target dose of 150 -300 mg. Doses up to 600 mg have found effective in some studies. If too sedated try to consolidate the entire dose at night.
2. Gabapentin starting at a dose of 50 mg po bid and increasing by 100 mg weekly, as tolerated and as required, to a target of between 600-900 in divided doses.
3. Low dose benzodiazepines can sometimes be used in very resistant cases under strict conditions (see below)

For Panic Disorder consider:

1. Mirtazapine  starting at a dose of 15 mg po qhs X 1 week to be then increased to 30 mg if tolerated and if no response. The maximum dose is 45 mg po qhs.
2. Pregabalin starting slowly at 25-50 mg po qhs and if tolerated  increasing in increments of 25-50 mg weekly in divided doses aiming for a target dose of 150 -300 mg. Doses up to 600 mg have found effective in some studies. If too sedated try to consolidate the entire dose at night.
3. Gabapentin starting at a dose of 50 mg po bid and increasing by 100 mg weekly, as tolerated and as required, to a target of between 600-900 in divided doses.
4. Low dose benzodiazepines can sometimes be used in very resistant cases under strict conditions (see below). They can also occasionally be used at initiation of treatment for severe panic symptoms with frequent panic attacks  in the short term until the antidepressant starts to take effect

For Posttraumatic Stress Disorder consider:

1. Starting risperidone beginning at a dose of 0.25-0.5 mg po qhs and increasing the dose in increments of 0.25-0.5 mg weekly to a maximum dose of 3 mg po qhs based on tolerance and response
   Note: 
   • While on antipsychotic medication need to check lipids, fasting glucose or HbA1c and weight at baseline, at 3 months, and periodically thereafter
   • If no response to antipsychotic augmentation  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
   • if remains on antipsychotic for more than one year check for tardive dyskinesia annually using the  Abnormal Involuntary Movement Scale AIMS.pdf
   • Note that this  is considered an off-label use of this medication and side effects including metabolic and risk of tardive dyskinesia needs to be carefully discussed with the patient and consent obtained
2. For nightmares using prazosin beginning at a dose of 1 mg po qhs and increasing in increments of 1 mg weekly based on response and tolerance to a maximum dose of 15 mg if required. Caution required in patients prone to hypotension. Avoid sudden discontinuation as this can lead to rebound hypertension
3. For insomnia consider adding Trazadone 25-50 mg  po qhs with dosage increase gradually up to 150-200 mg qhs as required or mirtazapine starting at 7.5 mg po qhs gradual dose increase up to 15-30 mg po qhs as required, based on response and tolerance.

For Obsessive-Compulsive Disorder consider:

1. After at least 8 weeks at the maximally tolerated dose of antidepressant and CBT not effective or not available consider augmentation with risperidone. It can be started at a dose of 0.25-0.5 mg po qhs and increased weekly in increments of 0.25-0.5 mg, based on response and tolerance, to a maximum dose of 3.0 mg po qhs.
   Note: 
   • While on antipsychotic medication need to check lipids, fasting glucose or HbA1c and weight at baseline, at 3 months, and periodically thereafter
   • If no response to antipsychotic augmentation after 4 weeks at the maximally tolerated dose 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
   • if remains on antipsychotic for more than one year check for tardive dyskinesia annually using the  Abnormal Involuntary Movement Scale AIMS.pdf
   • Note that this  is considered an off-label use of this medication and side effects including metabolic and risk of tardive dyskinesia needs to be carefully discussed with the patient and consent obtained

Benzodiazepines

• Do not use in patients with a history of substance abuse or in elderly patients
• Not indicated for patients with PTSD or OCD
• For some patients with Panic Disorder who have frequent and debilitating panic attacks benzodiazepines could be used in the short term (6-8 weeks) to assist with adjustment to side effects of SSRI or SNRI and temporary reduction in panic attacks until the antidepressant takes effect, at which point they can be tapered off gradually (over 1-2 months)
• For patients with chronic GAD and Social Anxiety Disorder, minimal depressive symptoms, no history of substance abuse and no response to CBT or other medication treatments (see above) longer term maintenance treatment could be considered in rare cases. This strategy needs to be assessed regularly for response, tolerance and abuse, with efforts made to decrease the dose and consider alternatives whenever possible.
• If using a benzodiazepine suggest starting with clonazepam 0.25 mg po qhs or bid and increasing the dose gradually in increments of 0.25-0.5 mg to a maximum dose of 2.0 mg if required. Patients should be instructed not to combine it with alcohol or other sedating drugs, and to avoid driving if sedated.