Anxiety and Depression

Last Updated: April 4, 2023

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This clinical tool helps family physicians and primary care nurse practitioners identify and manage anxiety and depression in adult patients. The tool was developed to help guide conversations with patients and families over a series of visits, as needed.

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Screening and assessment

Guiding principles for the screening and assessment of anxiety and depression:

Avoid stigmatizing labels (e.g., “abnormal”, “unusual”). Ensure steps are taken to reduce stigma, discrimination and barriers for patients.
Talk about symptoms instead of disorders/diagnoses.
Ensure that patients feel comfortable establishing trust with you as their healthcare provider.
Ensure services are culturally appropriate or culturally adapted (e.g., language considerations/translators).
Provide various of methods to engage with patients (e.g., in-person, email, telephone, online or remote consultations).
Ensure that discussions occur in settings where confidentiality, privacy and dignity are respected.

Screen patient

Screen for risk factors^{1, 3}

Clinical factors:

Personal or family history of anxiety or depression
Psychosocial adversity (e.g., stressful life events, childhood trauma)
Chronic medical conditions (e.g., cardiovascular disease, diabetes, neurological disorders, chronic pain)
Other psychiatric conditions (e.g., bipolar disorder, schizophrenia, substance use disorder)
Perinatal/postpartum, premenstrual dysphoric disorder, menopause

Symptom factors:

Fatigue
Insomnia
Unexplained physical symptoms (e.g., unexplained aches and pains)
Significant and repeated worry
Frequent healthcare use due to any of the above

Complete a validated or recognized screening tool^3,4

Anxiety

If anxiety is suspected, proceed with the general anxiety or specific anxiety disorder screening tool for diagnosis and measurement of progress or responses to treatment.

General anxiety disorder (GAD): Generalized Anxiety Disorder 7 (GAD-7)
- Cut off points for minimal (≤4), mild (score 5-9), moderate (score 10-14) and severe anxiety (score ≥15)
Social anxiety disorder (SAD): Social Phobia Inventory (SPIN)
- Cut off points for minimal (score ≤20), mild (score 21-30), moderate (score 31-40), severe (score 41-50) and very severe social phobia (score ≥51)
Panic disorder: Panic Disorder Severity Scale (PDSS)
- Cut off points for none (score <9) and present panic disorder (score ≥9)
Specific phobia or agoraphobia: Severity Measure for Specific Phobia (SMSP)
- Cut off points for none (avg score of 0), mild (avg score of 1), moderate (avg score of 2), severe (avg score of 3) and extreme phobia (avg score of 4)

Screening special populations^3-5

Older adults

Generalized Anxiety Disorder 7 (GAD-7): Cut off points for minimal (≤4), mild (score 5-9), moderate (score 10-14) and severe anxiety (score ≥15)

Peri/postnatal

Perinatal Anxiety Screening Scale (PASS): Cut off points for none (score 0-20), mild (score 21-41) and severe anxiety (score 42-93)

Depression

If depression is suspected, proceed with the Patient Health Questionnaire 9 (PHQ-9) screening tool for diagnosis and measurement of progress or responses to treatment.

Major depression: Patient Health Questionnaire 9 (PHQ-9)
- Cut off points for minimal (≤4), mild (score 5-9), moderate (score 10-14) and severe depression (score ≥15)

Screening special populations^3-5

Older adults

Geriatric Depression Scale: Cut off points for does not suggest depression (score < 5), suggests depression (score 5-10) and almost always indicates depression (score ≥10)
Cornell Scale for Depression in Dementia: Cut off points for probably major depressive episode (score >10) and definite major depressive episode (score >18)

Peri/postnatal

Edinburgh Perinatal/Postnatal Depression Scale (EPDS): Cut off points for not likely (score < 8), possible (score 9-11), fairly high possibility (score 12-13), probable (score ≥ 14) and positive depression (score of 1, 2 or 3 on question 10). Pay close attention to question 10 as scores could indicate suicidality risk which requires further follow-up and intervention)

Guidance for screening for perinatal depression by Public Health Ontario

Assess findings

If ≥mild anxiety or depression, begin or schedule a time to conduct or complete a comprehensive assessment. Consider booking a longer appointment or schedule as the last patient of the day to ensure a less rushed and more relaxed appointment.

If minimal anxiety or depression, book a follow-up appointment or create a reminder to check in at patient’s next appointment to see if their scores change. Consider reevaluating the diagnosis if necessary, as symptoms could be related to something else.

Conduct a comprehensive assessment^{2-4, 6}

Collect clinical history

Onset, intensity and history of symptoms (including a snapshot of the last few weeks)
Past experiences of, and response(s) to, previous treatments

Understand individual patient-contributing factors

Recent or past stressful life events (e.g., work, school, divorce/breakups, bereavement)
Traumatic life events (e.g., adverse childhood events, abuse, trauma)
Personal and psychosocial support (e.g., family, friends, community)
Lifestyle (e.g., diet, physical activity, sleep, smoking, social isolation)
Total screen time (e.g., work, school, excessive social media use)
Drug and alcohol use
Social determinants of health (e.g., housing access, employment, food security and nutrition, income level, racial segregation, social support networks)
Perspectives about mental health (e.g., stigma, comfort with management strategies)
Provider-patient relationship (e.g., safe space)
Current and history of physical health conditions (e.g., endocrine disorders, anemia, thyroid dysfunction, nutrient and vitamin deficiencies, cardiovascular disease, diabetes, neurological disorders, pregnancy and postpartum, perimenopause, menopause, oncological disorders, dementia, Alzheimer’s, Parkinson’s)
Refer to the latest lab / test results of the following when appropriate:^5,7,8
- CBC, HBA1c, TSH, Ferritin, B-12, Vitamin D, Electrocardiogram (ECG), Urine Drug Screen (if warranted to rule out substance use disorders)

Community and social resources:

211Ontario: Regional community and support resources.

If individual patient factors that affect mental health are detected or suspected, support the patient to address and manage these first.
If a physical condition that affects mental health is detected or suspected, screen for and treat the condition while concurrently treating and monitoring mental health symptoms as appropriate.

Screen for risk of suicide or self-harm or harm others

“Sometimes when people feel the way you do right now, they start to have thoughts about self harm. Has this ever happened to you?”
“Do you have a plan for how you would engage in self-harm?”
“In the next 24-48 hours, how likely is it that you will act on your suicidal plan?” (rate on scale of 1 to 10, where 1 = very unlikely and 10 = certain)
“With the way you are currently feeling, have you had any thoughts of harming yourself or others?”

Screen for risk of suicide, self-harm or harm to others

When considering a patient’s mental health status consider:
- Risk factors
- Specific suicidal thoughts and methods
- Extent of planning and action
- Present and history
- Obtaining input from family and caregivers

If the patient is at risk, arrange appropriate help based on their level of need

Assess for adequate social support and awareness of resources
Advise the patient to create a safety plan and seek further help if the situation becomes worse
Let the patient know that we have a legal obligation to report if they are in danger (document that you have mentioned this to the patient)
If the patient is identified to be at high risk of harming themselves or others (have a clear intention to act in the next 24-48 hours on a suicide plan), advise them, their family, caregivers and friends to call 911 or go to the Emergency Department (ED)
If the patient refuses further assessment and is unwilling to go to the ED:
1. Communicate with the patient the importance of going to the ED
2. Complete a Form 1 (if the patient meets criteria) and a brief note to accompany the patient. Consult the CEP’s Keeping Your Patients Safe for tips on completing a Form 1.
3. Arrange for EMS/police transport of the patient to the ED

Emergency support and suicide prevention resources

For patients:

Good2Talk: 1-866-925-5454 (post-secondary students) open 24/7
Crisis Line: 1-866-996-0991 (all ages) open 24/7
Talk Suicide: 1-833-456-4566
Distress and Crisis Ontario: Provides a free, confidential chat program to support patients and offers self-management tips
My Safety Plan: For patients experiencing thoughts of suicide but are not in immediate crisis

For family and caregivers:

Canadian Association for Suicide Prevention: Tips on identifying suicidal thoughts and suggestions for the patient’s loved ones or caregivers

Provider resources:

Columbia-Suicide Severity Rating Scale (C-SSRS)

Identify any comorbid mental health conditions

Attention deficit hyperactivity disorder (ADHD)/attention-deficit disorder (ADD)
Post-traumatic stress disorder (PTSD)
Bipolar disorder
Psychosis
Obsessive compulsive disorder (OCD)
Panic disorder
Personality disorders
Adverse childhood experiences
Substance use and addictions disorders (e.g., alcohol, drugs, gambling, gaming and problematic screen time)
Other

If mental health comorbidities are suspected, consider referral to appropriate mental health services or an eConsult for further assessment and treatment
Comorbid mental health disorders significantly increase the risk of suicidal behaviour

Mental health screening tools

List of various mental health disorder screening tools

Communicate diagnosis to patients

Confirm and communicate a diagnosis to the patient as soon as possible to help with the patient’s understanding of the disorder and to start timely and effective treatment.²

To confirm diagnosis, use the DSM-V criteria (Anxiety / Depression)
Discuss with the patients how individual factors may affect the development, course and severity of their mental health (e.g., comorbidities, lifestyle, social determinants of health, etc.)

Management

Use your clinical judgement to move patients through the stepped-care approach. For the psychological and pharmacological management of anxiety and depression. Individualize therapy based on a patient’s symptom severity, concerns and preferences. This may involve skipping steps to achieve appropriate treatment for an individual patient. Routinely follow-up and monitor changes in the patient’s symptoms and quality of life. Empower patients to make decisions with you about their treatment plan.²

Guiding principles for the management of anxiety and depression:

Understand the patient’s context and life circumstances, such as:⁶
- Coverage options (e.g., access to extended health coverage, Non-insured health benefits program mental health counselling benefit, and Employee Assistance Plans)
- Potential barriers to treatment (e.g., disability, language or communication)
Cost considerations
- Reach out to drug companies to inquire about their compassionate use programs
- Connect patients with Ontario Works and the Ontario Disability Support Program for financial assistance with drug coverage
Account for how coexisting conditions may impact treatment options.

Psychological treatment options

Anxiety^{2, 3, 9}

Depression^{1, 4, 5, 10}

Refer adult patients who are experiencing mild to moderate depression, anxiety, and anxiety-related problems to publicly funded, short-term, evidence-based services that are based on the treatment principles of cognitive behavioural therapy (CBT) through the Ontario Structured Psychotherapy (OSP) Program. Find your regional OSP network below.

OSP services follow a stepped-care approach. They include in-person or virtual self-help resources facilitated or guided by a mental health professional and one-on-one or group CBT sessions.

OSP Networks and Referral Process

Waypoint Centre for Mental Health Care

Submit online: referral form

CarePoint Health (Brampton, Halton, Mississauga)

Submit online: referral form
Ocean eReferral
Fax: one-Link referral form (Mississauga and Halton residents)

Canadian Mental Health Association – York and South Simcoe

Submit online: referral form

Centre for Addiction and Mental Health

Submit online: referral form
Fax: referral form

OSP West Region (St. Joseph’s Healthcare Hamilton and St. Joseph’s Health Care London)

Submit online: referral form
Email: referral form
Fax: referral form

The Royal Ottawa Mental Health Centre

AccessMHA through Ocean eReferral

Ontario Shores Centre for Mental Health Services

Ontario Shores Centre for Mental Health Services through Ocean eReferral

Health Sciences North

Fax/Mail: referral form

St. Joseph’s Care Group

Submit online: application

Resources for patients and caregivers⁹

Encourage patients to consider other options for care and support while they wait for a referral, such as internet-based CBT. Instead of waiting for a referral, patients can also find a psychologist through the Ontario Psychological Association, a counsellor or psychotherapist through the Canadian Counselling and Psychotherapy Association or College of Registered Psychotherapists of Ontario.

Free resources available for patients and their caregivers are listed below:

Community and social

Canadian Mental Health Association: 30 branches that provide community mental health services across Ontario.

ConnexOntario: Mental health system navigation and information. Mental health: 1-800-531-2600 | Addictions: 1-800-565-8603

eMentalHealth.ca: Directory of publicly-funded regional service coordination and case management services.

Hope for Wellness: Mental health counselling and community-based cultural and emotional support for Indigenous people. 1-855-242-3310

Ontario Caregiver Organization: Support for caregivers to improve their caregiving experience.

Talk4Healing: 24/7 talk, text, and chat to support Indigenous women by Indigenous women. 1-888-200-9997

thehealthline.ca: Regional mental health organizations, clinics, workshops, conferences and support groups.

Wellness Together Canada: Resources for mental health and substance use support.

Educational supports for patients and caregivers

Ontario Health Anxiety Disorders Patient Guide

Ontario Health Depression Patient Guide

Online app and resources

Anxiety Canada mindfulness exercises: Non-facilitated self-help virtual resources on mindfulness and relaxation.

Be Safe: Safety plan app. Available on App Store and Google Play.

BounceBack Ontario: Available through the OSP Program. Guided self-led resources to support adults and youth manage low mood, mild to moderate depression and anxiety, stress or worry. Delivered by phone with a coach and through online videos.

MindShift CBT App: CBT-based tools for worry, panic, perfectionism, social anxiety and phobias. Available on the App Store and Google Play.

My Anxiety Plan (MAP): Virtual, individual non-facilitated and facilitated self-help program for adults with mild to moderate anxiety.

Greenspace: Matches patients to therapists in the GTA. Matching is free. Therapy fees apply.

PocketWell: Free app for tracking mood from Wellness Together Canada.

Antidepressant Skills Workbook: A self-care guide for depression (to be used in combination with depression treatments).

Non-pharmacological complementary treatment options

Talk to patients about complementary therapies (lifestyle changes) that can help alleviate symptoms of anxiety and depression in addition to other treatment options.^1,4,5

Exercise
- First-line monotherapy for mild to moderate depression.
- Second-line adjunctive therapy for moderate to severe depression.
- Typical or studied dose and duration: at least 30 minutes of moderate-intensity exercise at least 3 times weekly for a minimum of 9 weeks is considered effective.
Yoga
- Second-line adjunctive therapy for mild to moderate depression.
- Typical or studied dose and duration: at least 2 to 4 sessions a week over 2 to 3 months.
Sleep hygiene
- Recommended habits and practices of maintaining a regular sleep schedule; avoiding excess eating, drinking, or smoking before going to sleep and establishing a proper sleep environment.
Nutrition
- Maintaining a healthy, balanced diet and correcting any nutritional deficiencies.

Pharmacological treatment options

Factors to consider when choosing a medication^{1, 5}

Patient factors:

Previous experience with antidepressants (e.g., response, side effects). Consider a pharmacy review for information on the discontinuation of past medications.
Family history of a positive response to particular medication(s)
Clinical features/specifiers/dimensions
Comorbid conditions
Patient preference(s)
Other factors (e.g., age, pregnancy/breastfeeding, suicide risk)

Medication factors:

Comparative efficacy
Comparative tolerability, warnings, contraindications and precautions
Potential interactions with other medications
Simplicity of use
Cost and availability

Support from a pharmacist or mental health expert may be helpful in complex cases or if there is uncertainty.

Role of pharmacogenetic testing for medication selection¹

There is a paucity of large-scale randomized controlled trial (RCT) evidence for pharmacogenetic testing. Pharmacogenetic testing may be considered in specific cases, including a patient’s inability to tolerate multiple medications or repeated lack of response to high doses of medications.

First-line medication options^{1,3–5, 7, 9, 11–30}

The following medications are considered first-line in the CANMAT 2016 MDD Guidelines and 2014 Anxiety Guidelines.^1,7 Some international guidelines recommend all SSRIs and SNRIs broadly (+/- agents) as first-line for MDD, anxiety or both.^6,8,28 CANMAT classifies the SNRI levomilnacipran (Fetzima^®) as second-line for MDD due to lack of comparative and relapse-prevention data.¹ Other options (e.g., amitriptyline, trazodone) are not first-line in any of the reviewed guidelines due to side effects.

Available evidence for drug selection has many limitations, including limited head-to-head trials between drugs and potential for bias. If you have questions about drug selection, consult a pharmacist or specialist through eConsult.

Click to view first-line medication options in table format.

Selective Serotonin Reuptake Inhibitors (SSRI)

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Selective Serotonin Reuptake Inhibitors (SSRI)
Citalopram (Celexa®)

10 mg, 20 mg, 40 mg tablet

First-line for
- Major depressive disorder
- Panic disorder (+/- agoraphobia)
Coverage
- ODB ✓
- NIHB ✓
Cost for usual dose ($/100 days)
- $24-60
Overall tolerability*
- Well-tolerated
Activating or sedating
- Activating/sedating
Interaction risk
- + (CYP)
- Caution: combined QT-prolongation risk
Features**
- A preferred pharmacological options in pregnancy
View dosing, side effects, warning and contraindications
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Citalopram (Celexa®)

Dosing***

Initial: 10-20 mg daily (am/pm)

Usual: 20–40 mg daily

Max: 40 mg daily (20 mg in older adults, liver disease, concurrent CYP 2C19 inhibitors)

Side effects

CNS: headache, sleep disturbance, drowsiness, nervousness, dizziness, somnolence, fatigue

GI: nausea, vomiting, diarrhea

Anticholinergic: dry mouth, constipation, blurred vision, hyperhidrosis

CV: orthostatic hypotension, tachycardia

Urogenital: sexual dysfunction

Warnings and contraindications

QTc prolongation risk

Contraindicated in patients with known QT prolongation or congenital long QT syndrome

Anxiety/agitation may worsen initially (first 1-2 weeks)

GI bleeding (consider gastroprotective agent if high risk)

Hyponatremia (especially in elderly)

Fractures (especially in first 6 weeks)

Suicidal thinking and self-harm (patients 30 years and under)
Selective Serotonin Reuptake Inhibitors (SSRI)
Escitalopram (Cipralex®)

10 mg, 20 mg tablet

First-line for
- Major depressive disorder
- Generalized anxiety disorder
- Social anxiety disorder
- Panic disorder (+/- agoraphobia)
Coverage
- ODB ✓
- NIHB ✓
Cost for usual dose ($/100 days)
- $26-45
Overall tolerability*
- Very well-tolerated
Activating or sedating
- Activating/sedating
Interaction risk
- + (CYP)
- Caution: combined QT-prolongation risk
Features**
- A preferred pharmacological option in pregnancy
View dosing, side effects, warning and contraindications
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Escitalopram (Cipralex®)

Dosing***

Initial: 5-10 mg daily (am/pm)

Usual: 10-20 mg daily

Max: 20 mg daily (10 mg in older adults, liver disease, concurrent CYP 2C19 inhibitors)

Side effects

CNS: headache, sleep disturbance, drowsiness, nervousness, dizziness, somnolence, fatigue

GI: nausea, vomiting, diarrhea

Anticholinergic: dry mouth, constipation, blurred vision, hyperhidrosis

CV: orthostatic hypotension, tachycardia

Urogenital: sexual dysfunction

Warnings and contraindications

QTc prolongation risk

Contraindicated in patients with known QT prolongation or congenital long QT syndrome

Anxiety/agitation may worsen initially (first 1-2 weeks)

GI bleeding (consider gastroprotective agent if high risk)

Hyponatremia (especially in elderly)

Fractures (especially in first 6 weeks)

Suicidal thinking and self-harm (patients 30 years and under)
Selective Serotonin Reuptake Inhibitors (SSRI)
Fluoxetine (Prozac®)

10 mg, 20 mg, 40 mg, 60 mg tablet
4 mg/mL oral solution

First-line for
- Major depressive disorder
- Panic disorder (+/- agoraphobia)
Coverage
- ODB ✓ (excludes 10mg tablet)
- NIHB ✓
Cost for usual dose ($/100 days)
- $45-152
Overall tolerability*
- Well-tolerated
Activating or sedating
- Activating
Interaction risk
- +++
Features**
- Easy to discontinue (self-taper)
View dosing, side effects, warning and contraindications
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Fluoxetine (Prozac®)

Dosing***

Initial: 10-20 mg daily (am)

Usual: 20 mg daily

Max: 80 mg daily (lower dose recommended for older adults)

Side effects

CNS: insomnia, headache, sleep disturbance, drowsiness, nervousness, dizziness, somnolence, fatigue

GI: nausea, vomiting, diarrhea

Anticholinergic: dry mouth, constipation, blurred vision, hyperhidrosis

CV: orthostatic hypotension, tachycardia

Urogenital: sexual dysfunction

Other: agitation, anorexia

Warnings and contraindications

Higher rates of confusion

QTc prolongation risk

Anxiety/agitation may worsen initially (first 1-2 weeks)

GI bleeding (consider gastroprotective agent if high risk)

Hyponatremia (especially in elderly)

Fractures (especially in first 6 weeks)

Suicidal thinking & self-harm (patients 30 years and under)
Selective Serotonin Reuptake Inhibitors (SSRI)
Fluvoxamine (Luvox®)

50 mg, 100 mg tablet

First-line for
- Major depressive disorder
- Social anxiety disorder
- Panic disorder (+/- agoraphobia)
Coverage
- ODB ✓
- NIHB ✓
Cost for usual dose ($/100 days)
- $55-132
Overall tolerability*
- Poorly-tolerated
Activating or sedating
- Sedating
Interaction risk
- +++
Features**
- No notable features
View dosing, side effects, warning and contraindications
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Fluvoxamine (Luvox®)

Dosing***

Initial: 25-50 mg daily (hs)

Usual: 100–200 mg daily

Max: 300 mg daily

Divide doses above 150 mg (max 150 mg at bedtime)

Hepatic/renal disease: increase dose slowly & monitor carefully

Side effects

CNS: headache, sleep disturbance, drowsiness, nervousness, dizziness, somnolence, fatigue

GI: severe GI upset, nausea, vomiting, diarrhea

Anticholinergic: anticholinergic potential, dry mouth, constipation, blurred vision, hyperhidrosis

CV: orthostatic hypotension, tachycardia

Urogenital: sexual dysfunction

Other: anorexia

Warnings and contraindications

Caution when using for older adults

Anxiety/agitation may worsen initially (first 1-2 weeks)

GI bleeding (consider gastroprotective agent if high risk)

Hyponatremia (especially in elderly)

Fractures (especially in first 6 weeks)

Suicidal thinking & self-harm (patients 30 years and under)
Selective Serotonin Reuptake Inhibitors (SSRI)
Paroxetine (Paxil®)

10 mg, 20 mg, 30 mg tablet
CR: 12.5 mg, 25 mg tablet

First-line for
- Major depressive disorder
- Generalized anxiety disorder
- Social anxiety disorder
- Panic disorder (+/- agoraphobia)
Coverage
- ODB ✓ (excludes 10mg and CR tablets)
- NIHB ✓ (excludes CR tablets)
Cost for usual dose ($/100 days)
- $27-125
- CR: $252 – 790
Overall tolerability*
- Poorly-tolerated
Activating or sedating
- Sedating
Interaction risk
- +++
Features**
- A preferred pharmacological options for breastfeeding
View dosing, side effects, warning and contraindications
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Paroxetine (Paxil®)

Dosing***

Initial: 10-20 mg daily (hs)

Usual: 20 mg daily (40 mg for GAD)

Max: 50 mg daily (40 mg for older adults/debilitated patients)

Dosing (CR)

Initial: 12.5-25 mg daily (hs)

Usual: 25 mg daily (50 mg for GAD)

Max: 62.5 daily (50 mg for older (adults/debilitated patients)

Side effects

CNS: headache, sleep disturbance, drowsiness, nervousness, dizziness, somnolence, fatigue

GI: nausea, vomiting, diarrhea

Anticholinergic: anticholinergic potential, dry mouth, constipation, blurred vision, hyperhidrosis

CV: orthostatic hypotension, tachycardia

Urogenital: sexual dysfunction

Other: weight gain, withdrawal effects

Warnings and contraindications

Avoid in older adults and pregnancy

Anxiety/agitation may worsen initially (first 1-2 weeks)

GI bleeding (consider gastroprotective agent if high risk)

Hyponatremia (especially in elderly)

Fractures (especially in first 6 weeks)

Suicidal thinking & self-harm (patients 30 years and under)
Selective Serotonin Reuptake Inhibitors (SSRI)
Sertraline (Zoloft®)

25 mg, 50 mg, 100 mg capsule

First-line for
- Major depressive disorder
- Generalized anxiety disorder
- Social anxiety disorder
- Panic disorder (+/- agoraphobia)
Coverage
- ODB ✓
- NIHB ✓
Cost for usual dose ($/100 days)
- $26-81
Overall tolerability*
- Very well-tolerated
Activating or sedating
- Activating
Interaction risk
- ++
Features**
- A preferred pharmacological option for older adults, pregnancy and breastfeeding
- May be a preferred option in CV disease
View dosing, side effects and warnings
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Sertraline (Zoloft®)

Dosing***

Initial: 25-50 mg daily (am/pm)

Usual:

MDD: 50-100 mg daily

GAD: 50-150 mg daily

SAD & panic: 50-200 mg daily

Max: 200 mg daily

Side effects

CNS: headache, sleep disturbance, drowsiness, nervousness, dizziness, somnolence, fatigue

GI: nausea, vomiting, diarrhea

Anticholinergic: dry mouth, constipation, blurred vision, hyperhidrosis

CV: orthostatic hypotension, tachycardia

Urogenital: sexual dysfunction

Warnings and contraindications

Anxiety/agitation may worsen initially (first 1-2 weeks)

GI bleeding (consider gastroprotective agent if high risk)

Hyponatremia (especially in elderly)

Fractures (especially in first 6 weeks)

Suicidal thinking & self-harm (patients 30 years and under)

_{*Overall tolerability is based on availability of evidence that primarily evaluates drop-out rates from trials. Specific drug side effects and patient factors may influence overall tolerability in practice.
** Consider in addition to other patient and medication factors
***Titration information:
Depression: for most agents – increase dose no more frequently than once a week.
Anxiety OR if sensitive to side effects, or has kidney disease, liver disease, advanced age, or other factors warranting caution: start with the lowest dose and increase every 1-2 weeks}

Serotonin Norepinephrine Reuptake Inhibitors (SNRI)

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Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
Desvenlafaxine (Pristiq®)

50 mg, 100 mg tablet

First-line for
- Major depressive disorder
Coverage
- ODB X
- NIHB X
Cost for usual dose ($/100 days)
- $268
Overall tolerability*
- Poorly tolerated
Activating or sedating
- Activating > sedating
Interaction risk
- +
Features**
- No notable features
View dosing, side effects, warning and contraindications
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Desvenlafaxine (Pristiq®)

Dosing***

Initial: 50 mg daily

Usual: 50 mg daily

Max: 100 mg daily

Side effects

CNS: headache, sleep disturbance, drowsiness, nervousness, dizziness, somnolence, fatigue

GI: nausea, vomiting, diarrhea, decreased appetite

Anticholinergic: dry mouth, constipation, blurred vision, hyperhidrosis

CV: increased blood pressure, orthostatic hypotension

Urogenital: sexual dysfunction

Warnings and contraindications

Anxiety/agitation may worsen initially (first 1-2 weeks)

Increased risk of bone fractures
Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
Duloxetine (Cymbalta®)

30 mg, 60 mg capsule

First-line for
- Major depressive disorder
- Generalized anxiety disorder
Coverage
- ODB ✓
- NIHB ✓
Cost for usual dose ($/100 days)
- $48-167
Overall tolerability*
- Neutral
Activating or sedating
- Activating > sedating
Interaction risk
- + +
Features**
- A preferred pharmacological option for older adults
- Helpful for some types of pain
View dosing, side effects, warning and contraindications
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Duloxetine (Cymbalta®)

Dosing***

Initial: 30 mg daily (may be considered for tolerability)

Usual: 60 mg daily

Max: 60 mg daily (120 mg daily for GAD)

Side effects

CNS: headache, sleep disturbance, drowsiness, nervousness, dizziness, somnolence, fatigue

GI: nausea, vomiting, diarrhea, decreased appetite

Anticholinergic: dry mouth, constipation, blurred vision, hyperhidrosis

CV: increased blood pressure, orthostatic hypotension

Urogenital: sexual dysfunction

Warnings and contraindications

Anxiety/agitation may worsen initially (first 1-2 weeks)

Increased risk of bone fracture
Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
Venlafaxine (Effexor®)

37.5 mg, 75 mg, 150 mg capsule

First-line for
- Major depressive disorder
- Generalized anxiety disorder
- Social anxiety disorder
- Panic disorder (+/- agoraphobia)
Coverage
- ODB ✓
- NIHB ✓
Cost for usual dose ($/100 days)
- $19-69
Overall tolerability*
- Poorly tolerated
Activating or sedating
- Activating > sedating
Interaction risk
- +
Features**
- Helpful for some types of pain
View dosing, side effects, warning and contraindications
Close
Venlafaxine (Effexor®)

Dosing***

Initial: 37.5 mg daily (75 mg daily for Panic)

MDD: if needed to adjust to the medication

GAD: for 4-7 days

SAD: for 7 days

Panic: for 4-7 days may be considered for tolerability

Titration: increase by ≤ 75 mg daily, as needed

MDD: at intervals of 4 days – 2 weeks

GAD & Panic: at interval of ≥ 4 days

SAD: at interval of ≥ 7 days

Usual: 75 mg daily

Max: 225 mg daily

Side effects

CNS: headache, sleep disturbance, drowsiness, nervousness, dizziness, somnolence, fatigue

GI: nausea, vomiting, diarrhea, decreased appetite

Anticholinergic: dry mouth, constipation, blurred vision, hyperhidrosis

CV: increased blood pressure, orthostatic hypotension

Urogenital: sexual dysfunction

Warnings and contraindications

Anxiety/agitation may worsen initially (first 1-2 weeks)

Increased risk of bone fracture

^{*Overall tolerability is based on availability of evidence that primarily evaluates drop-out rates from trials. Specific drug side effects and patient factors may influence overall tolerability in practice.}
^{**Consider in addition to other patient and medication factors}
^{***Titration information:}
^{Depression: for most agents – increase dose no more frequently than once a week.
Anxiety OR if sensitive to side effects, or has kidney disease, liver disease, advanced age, or other factors warranting caution: start with the lowest dose and increase every 1-2 weeks}

Other classes

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Norepinephrine Dopamine Reuptake Inhibitor (NDRI)
Bupropion (Wellbutrin®)

SR: 100 mg, 150 mg tablet
XL (ER): 150 mg, 300 mg capsule

First-line for
- Major depressive disorder
Coverage
- ODB ✓: LU 315
- NIHB ✓
Cost for usual dose ($/100 days)
- SR: $66-207
- XL: $41-72
Overall tolerability*
- Well tolerated
Activating or sedating
- Activating
Interaction risk
- ++
Features**
- Low risk of sexual dysfunction
- Low risk of hyponatremia
- Also indicated for smoking cessation
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Bupropion (Wellbutrin®)

Dosing (SR)***

Initial: 100-150 mg daily

Usual: 100-150 mg daily

Max: 300 mg daily (doses > 150 mg daily should be given BID with at least 8 hours between doses. A single dose should not exceed 150 mg)

Dosing (XL, given once daily)***

Initial: 150 mg daily

Usual: 150–300 mg daily

Max: 450 mg daily

Side effects

CNS: headache, sleep disturbance, nervousness, dizziness, fatigue

GI: nausea, vomiting, diarrhea, decreased appetite

Anticholinergic: dry mouth, constipation, blurred vision, hyperhidrosis

CV: Increased blood pressure, orthostatic hypotension

Warnings and contraindications

Contraindicated in patients with seizure disorder or at higher risk for seizures (e.g, anorexia nervosa or bulimia)
Noradrenergic and Specific Serotonergic Antidepressant (NaSSA)
Mirtazapine (Remeron®)

15 mg, 30 mg, 45 mg tablet
15 mg, 30 mg, 45 mg orally disintegrating tablet (ODT)

First-line for
- Major depressive disorder
Coverage
- ODB ✓ (excludes 15mg and 45mg tablets)
- NIHB ✓
Cost for usual dose ($/100 days)
- $26-134 (tablet)
- $54-143 (ODT)
Overall tolerability*
- Neutral
Activating or sedating
- Sedating
Interaction risk
- +
Features**
- Low risk of sexual dysfunction
- Can help increase appetite and weight
- May be helpful for insomnia (especially at lower doses)
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Mirtazapine (Remeron®)

Dosing***

Initial: 15 mg daily

Usual: 15–45 mg daily

Maximum: 45 mg daily

Side effects

CNS: headache, sleep disturbance, nervousness, dizziness, fatigue

GI: nausea, vomiting, diarrhea, increased appetite

Anticholinergic: dry mouth, constipation, blurred vision, hyperhidrosis

CV: orthostatic hypotension
Calcium Modulator, GABA Anxiolytic
Pregabalin (Lyrica®)

25 mg, 50 mg, 75 mg, 150 mg, 300 mg capsule

First-line for
- Generalized anxiety disorder
- Social anxiety disorder
Coverage
- ODB ✓
- NIHB ✓
Cost for usual dose ($/100 days)
- $25-99
Overall tolerability*
- Neutral
Activating or sedating
- Sedating
Interaction risk
- 0/+
Features**
- Helpful for some types of pain
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Pregabalin (Lyrica®)

Dosing***

Initial: 150 mg daily (75 mg BID or 50 mg TID)

some experts recommend 50 mg daily

Titration: Increase weekly

Usual:

GAD: 300 mg daily (150 mg BID)

SAD: 600 mg daily (300 mg BID)

Max: 600 mg daily (300 mg BID)

Side effects

CNS: headache, sleep disturbances, memory impairment, ataxia, diplopia, dizziness, somnolence, sedation, fatigue

GI: nausea, vomiting, diarrhea, weight gain

Anticholinergic: dry mouth, blurred vision

Other: skin rash, peripheral edema, weight gain

Warnings

Angioedema

Hypersensitivity reactions

Caution in renal impairment

New-onset congestive heart failure in CV-compromised adults

Reduced GI motility (caution with concurrent opioid use)
Serotonin Receptor Antagonist and Serotonin Reuptake Inhibitor (SARI)
Vortioxetine (Trintellix®)

5 mg, 10 mg, 20 mg tablet
No generic available

First-line for
- Major depressive disorder
Coverage
- ODB ✓
- NIHB ✓
Cost for usual dose ($/100 days)
- $320-363
Overall tolerability*
- Poorly tolerated
Activating or sedating
- Activating/sedating
Interaction risk
- ++
Features**
- No notable features
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Vortioxetine (Trintellix®)

Dosing***

Initial: 10 mg daily (5 mg daily in older adults; consider decreasing to 5 mg if higher dose is not tolerated)

Usual: 10–15 mg daily

Max: 20 mg daily

Side effects

CNS: headache, sleep disturbance, nervousness, dizziness, fatigue

GI: nausea, vomiting, diarrhea, abdominal pain, bloating, decreased appetite

Anticholinergic: dry mouth, constipation, hyperhydrosis

CV: orthostatic hypotension

Other: cough, flu-like symptoms, pruritus, joint and muscle pain

Warnings and contraindications

Anxiety/agitation may worsen initially (first 1-2 weeks)

Increased risk of bone fractures

Caution in narrow-angle glaucoma

Role of benzodiazepines for anxiety disorders^3,5,7

Benzodiazepines should not be routinely prescribed for anxiety disorders.

Benzodiazepines may be useful as an adjunctive therapy early in treatment for acute crises. Due to concerns about tolerance, dependency, sedation, cognitive impairment, and other side effects, benzodiazepines should be restricted to short-term use. They should be used with caution, especially with patients with a history of substance use disorder. Patients should also be warned about the safety risks of driving and using benzodiazepines (i.e. drowsiness, reduced concentration). Older adults may be at increased risk of falls and fractures and memory impairment with benzodiazepines. Except for alprazolam (which may be harder to discontinue), short-acting agents are preferable to long-acting agents.

Medication counselling

The idea of starting a medication can cause anxiety for some patients. This can be compounded by the fact that medication side effects can make patients feel worse before there is an expected benefit.¹ Options to address anxiety related to medications include:⁵

Provide information about the recommended treatment option(s) verbally and in writing.
- Understanding antidepressant medications, side effects, and managing patient expectations
Probe for questions or concerns.
If appropriate, the patient may want time to process the information before proceeding.
Provide choice (e.g., treatment type, initiation timing, follow-up timing). If the patient is struggling to make decisions due to their underlying condition, consider limiting the number of options and adjusting this approach based on clinical judgement.

Before starting a treatment, discuss the following with the patient, and if desired, their family or caregiver(s):¹^-5,9

Medication option(s)

Expected benefit(s) of the particular medication

Overall plan to “start low and go slow” to the “target” dose

Onset of action

Depression: 2-4 weeks¹
Anxiety: 2-8 weeks⁷

Full effect(s)

Depression: 4-8 weeks^4,5
Anxiety: 6-12 weeks or more^3,7
Older adults may take longer to respond⁹

Cost/coverage of the treatment

Understand your patient’s access to private health insurance
Reach out to drug companies to inquire about their compassionate use programs
Connect your patient with Ontario Works and Ontario Disability Support Program for financial assistance with drug coverage

Side effects/risks of treatment and how to manage

Common side effects that are likely to go away within a week or two of each dose change (e.g., GI upset, sedation, increased anxiety, sleeping difficulties). See Side effect management.
Serious side effects (e.g., serotonin syndrome, unmasking bipolar disorder, neuroleptic malignant syndrome, hyponatremia)

Follow-up and monitoring

Why regular monitoring is needed
Options for monitoring, as appropriate (i.e., phone call, virtual, in person, support staff)
Frequency of follow-up. See Follow-up/monitoring for the overall approach
How to self-monitor (e.g., keep track of symptoms and feelings in a mood diary)
Contingency plans if additional support is needed between appointments

Treatment duration

Depression: 6-9 months after symptom remission¹
Anxiety: 12-24 months⁷

Precautions

SSRIs have been associated with thoughts of suicide or self-harm early on in treatment for a small number of people under the age of 30. Discuss & create a safety plan.
Caution with driving until impact on the central nervous system (CNS) is known (e.g., sedation, cognitive impairment).
Caution with other CNS-active substances: alcohol, cannabinoids, over-the-counter (OTC) products, etc.
Ask a pharmacist to confirm any known interactions with herbal treatments.
Avoid abrupt discontinuation due to risk of withdrawal symptoms.

Side effect management^{1, 5}

Medication side effects can lead to significant distress and treatment discontinuation. In extreme cases, these negative experiences may impact a patient’s consideration of another medication or their relationship with their healthcare provider and the healthcare system. Side effects should be discussed with patients before treatment initiation. Consider booking a follow-up appointment within 2 weeks of initiation to discuss side effect management.

Troubleshooting side effects^{1, 5}

Consider whether the symptom is a side effect vs the underlying condition or improvement of the condition being treated
Switch the time of day taken
Consider taking the medication with food
Treat the side effect if short-term
Titrate more slowly (and do so in the future too)
Lower the dose
Consider drug interactions
Switch medications (see first-line medications options table)
Consult a pharmacist or expert as needed
Pharmacogenetic testing (if available) may be considered if patients have severe side effects to multiple medications.

Specific side effect management for symptoms^{1, 5}

Short-term or long-term: usually short-term

Management:

Take with food
Consider alternate dose timing
Eat smaller, more frequent meals
Drink plenty of fluids
Switch to another medication or use a long-acting formulation
Short-term use of OTC antacids or antinauseants

Short-term or long-term: usually short-term

Management:

Take with food
Ensure hydration
Consider alternate dose timing
Short-term use of loperamide

Short-term or long-term: usually short-term

Management:

Ensure hydration
Regular exercise
Dietary fibre and laxatives may be used

Short-term or long-term: long-term

Management:

Confirm not due to increased appetite with treatment of mental health condition
Diet and exercise
Switch medication if not manageable

Short-term or long-term: Usually short-term

Management:

Consider dosing at bedtime
Brief nap during the day
Dose reduction
Switch medication if not manageable

Short-term or long-term: Usually short-term

Management:

Consider dosing at morning
Avoid caffeinated food or drinks later in the day
Regular exercise several hours before bedtime
Sleep hygiene
Switch medication if not manageable

Management:

Consider dosing at morning

Short-term or long-term: usually short-term

Management:

Consider dosing in morning
If agitation/anxiety occur further dose increases should be done with caution
If agitation/anxiety are bothersome or not resolving, consider alternative agents
The risks & benefits of short-term benzodiazepines may be considered for SSRI-related activation in select patients with anxiety.⁷ See “role of benzodiazepines for anxiety disorders”. Consider consulting an expert

Short-term or long-term: short or long-term

Management:

Confirm not due to underlying condition(s)
Wait and watch for improvement
Take a once-daily dose after sexual activity
Lower the dose
Switch medication if not manageable (switch to bupropion or mirtazapine)
Conflicting evidence for adjunct bupropion

Short-term or long-term: usually short-term

Management:

Consider switching dose timing

Short-term or long-term: long-term

Management:

Ensure hydration
Reduce dose or consider switching medications

Short-term or long-term: short or long-term

Management:

Exercise and outdoor activities
Diet and exercise
Work with a therapist
Reduce dose or consider switching medications

Short-term or long-term: short or long-term

Management:

Provide education on how to identify and manage
Keep a glass of water at the bedside to drink when waking
Get up gradually from sitting or lying down
Perform leg pumps before getting up
Reduce dose or consider switching medications³¹

Short-term or long-term: short-term

Management:

Sip water regularly
Chew sugarless gum or suck on sugarless candy/ice
Avoid tobacco, alcohol and caffeinated beverages
Breathe through nose
Dental hygiene
Reduce dose or switch medication if not manageable
Use an OTC artificial saliva product

Warnings and precautions

An association with falls and fractures has been noted for patients taking SSRIs long-term. The risk of fractures has been noted to be elevated in the first 6 weeks of treatment.¹

Management: Provide education and strategies to lower the general risk as relevant for the patient.⁵

SSRIs have been associated with an increased risk of upper GI bleeding, especially in older adults, patients with a history of GI bleeding and patients taking other agents that may increase risk (e.g., non-steroidal anti-inflammatory drugs, steroids).

Management: Educate regarding this potential side effect and consider a gastroprotective agent if an SSRI is chosen for these patients.^{1, 2}

Older adults may be at a higher risk of hyponatremia with SSRIs.¹

Management: Caution when using with older adults and in patients taking other agents that lower sodium. Consider baseline serum sodium levels and repeat at 2-4 weeks. Thereafter repeat yearly or as appropriate.⁵

In the absence of known risk factors, the risk of Torsades de Pointes (TdP) is very low.¹ However, when other risk factors exist, the risk of TdP may occur at even low therapeutic doses of antidepressants and has even occurred with QTc intervals within the normal range.¹

Management: For QT-prolonging antidepressants, request an ECG if the patient has risk factors, such as a history of Tdp, arrhythmias, chronic kidney disease and age.⁵

While serotonin syndrome is rare, it can occur in cases of overdose or when multiple serotonergic agents are used (e.g., SSRIs, SNRIs, TCAs, tramadol, OTC products).¹

Serotonin Syndrome Patient handout from UWaterloo Pharmacy 5-in5

Management: Particular caution should be taken when changing or adding another serotonergic agent, especially if the agent being discontinued has a long half-life (e.g., fluoxetine).⁸ Educate the patient and monitor for signs and symptoms.⁵

SSRIs have been associated with thoughts of suicide or self harm early on in treatment in a small number of people under the age of 30. Weekly monitoring should be employed with treatment initiation until the condition has stabilized.. Discuss and create a safety plan.¹ See “Emergency Support and Suicide Prevention” in the Assessment section.

Special populations

Peri/post natal

This section pertains to patients who develop depression or anxiety while trying to conceive or who are pregnant or breastfeeding. This section excludes patients who have postpartum depression. At the time of pregnancy, all medications should be reviewed (i.e., by a peripartum psychiatrist). Patients who are already receiving SSRI treatment should not be taken off of their treatment medication(s) when they become pregnant.⁵ A shared decision-making approach should consider the risks and benefits of pharmacological management, including the risks of not treating. In cases of high risk or uncertainty, there should be a low threshold for referral to an expert for support (OTN eConsult).

Psychological management

Anxiety

Despite the lack of data on the efficacy of psychological interventions in perinatal patients with anxiety disorders, CBT or behavioural therapy are considered safe alternatives during pregnancy.⁷

Depression (excluding postpartum depression)

For patients who wish to become pregnant, are pregnant, or are breastfeeding, depression-focused psychological interventions alone are recommended. Depending on the severity of symptoms, depression-focused psychological interventions should be considered the first-line treatment.
First-line treatment for mild to moderate antenatal depression: CBT or IPT.¹

Pharmacological management

Anxiety and Depression (excluding postpartum depression)

Before prescribing medication, weigh the risks of pharmacological treatment to the fetus and newborn against the potential risks of untreated anxiety and depression.^1,7 Refer to the LactMed® database for information on exposure to medications and during lactation. Refer to Medicines in Pregnancy for information on exposure to medications during pregnancy.

Special considerations:

In pregnant patients, if pharmacological treatment is indicated, citalopram, escitalopram, and sertraline are preferred second-line treatments after CBT or IPT.¹ Valproate and paroxetine must not be used.^7,10
Empower patients and encourage them to think about their treatment as an important element of their health and wellness and their child’s.⁵
In breastfeeding patients, if pharmacological treatment is indicated, sertraline or paroxetine are preferred. Despite the limited evidence, the excretion of such prescription medication in breast milk results in very low amounts being transferred to the baby and few isolated instances of adverse events.⁷
Refer to the pharmacy with a prescription, noting that the patient is breastfeeding and request that they be counselled.⁵
St. John’s Wort must not be used in pregnant and breastfeeding women.¹⁰

Depression (excluding postpartum depression)

First-line treatment for severe antenatal depression: pharmacological treatment, either alone or in combination with CBT or IPT.¹

Older adults

Depression and anxiety disorders are commonly present simultaneously present among patients aged 65 or older.⁷ Determine the onset of depression. Late-onset depression is more chronic with a higher relapse rate and higher levels of medical comorbidity, cognitive impairment and mortality.¹ Monitor cognition at the initial assessment and over time. Late-onset depression might be an early symptom of dementia.¹

Medications and risks
Before prescribing medication, weigh the risks associated with antidepressant use against their potential benefits.

Consider pharmacokinetic changes with aging and patient factors such as hepatic and renal function and body mass. Also consider comorbidities and the use of other medications which could increase the risk of side effects (e.g., anticholinergic, sedation, orthostatic hypotension, and neurological effects).^{1, 7, 30}

Due to these pharmacokinetic changes, including an increased risk of impaired balance and falls early in treatment, initiate older adults at a low dose and increase doses slowly with regular follow-up.³⁰

When prescribing an SSRI or SNRI, patients should be screened for hyponatremia. A serum level should be obtained before starting medication if there is a positive history. In general, a serum sodium level should be done within 2-4 weeks of initiating an SSRI or SNRI.³²

Risks:

Increased susceptibility to adverse drug events and drug-drug interactions⁷
Increased risk of impaired balance and falls early in treatment³⁰
Increased risk of fractures⁷
Increased risk of mortality in older patients with dementia⁷
Increased risk of rare side effects such as bone loss, serotonin syndrome, extrapyramidal side effects, and neuroleptic malignant syndrome¹

Psychological management

Anxiety (the efficacy of psychological and pharmacological treatments is similar)⁷

Relaxation training
CBT (with learning- and memory-aids)
Supportive therapy
Cognitive therapy
Exercise for prevention⁷

Depression

Problem-solving theray: discrete, time-limited, structured psychological intervention that focuses on learning to cope with specific problem areas and where therapist and patient work collaboratively to identify and prioritize key problem areas.¹⁰
Interventions that reduce social isolation and loneliness (e.g., reminiscence therapy, physical exercise programs, video conferences with family, horticultural therapy and gender-based social groups)³²
Social prescribing (referring patients with social, emotional and practical needs to local, non-clinical services typically from the voluntary or community sectors)³²
Increased physical activity (e.g., Fountain of Health)³²

Pharmacological management

Anxiety (efficacy of psychological and pharmacological treatments is similar)²⁸

Medication has similar effectiveness as in younger adults.⁷

For GAD: pregabalin (significant improvements), duloxetine, venlafaxine, citalopram, escitalopram, sertraline (more effective than CBT at 1-year follow-up), buspirone, fluvoxamine.⁷
For panic disorder: paroxetine (as effective as CBT), citalopram, escitalopram, fluvoxamine, and mirtazapine (for older adults with major depressive disorder).⁷

Depression

First-step: duloxetine, mirtazapine, sertraline, venlafaxine, and vortioxetine.¹ Of these agents, sertraline and duloxteine are preferred. Escitalopram and citalopram are useful options as well, but must be balanced with concerns around QTc prolongation.³²
Second-step (if multiple first-step treatments are ineffective): switch to bupropion, fluoxetine, paroxetine,or quetiapine.¹

Follow-up/monitoring

Depression

Overall approach

Follow-up frequency for patients using pharmacological treatment:⁴

First 6 weeks OR until response and tolerability are established: at least every 2 weeks
After 6 weeks OR after response and tolerability are confirmed: every 4 weeks

Ongoing treatment options

Treatment response:
At least a 50% reduction in the patient’s baseline score on a validated depression rating scale indicates early improvement/response to antidepressant treatment. The evidence is mixed regarding the benefits of switching at 2-4 weeks for non-response to the first antidepressant tried.¹ Whereas symptom remission is when the patient’s score is in the nondepressed range.¹

Partial or non-response:^{1, 5, 28}
Ask: Is the treatment being taken as prescribed?

No: explore reasons why not and provide support. Adjust treatment plan if needed
Yes:
- Consider:
  Is the diagnosis correct?
  
  Factors that may complicate response (e.g., social factors, comorbid conditions, drug interactions)
- Consider increasing the dose of medication if:
  The target dose has not been reached
  
  The medication is being tolerated well
  
  This is not the first medication tried
  
  Functional deficit and symptoms are mild (no urgency for effect)
  
  The patient is comfortable with increasing the dose
- Note: less frequent dose increases may be preferable for patients who are anxious or medically compromised
- Review opportunities to switch to, intensify, or add non-pharmacological treatment, including psychological interventions, exercise and light therapy. See Psychological treatment options for depression.
- If the above options not preferred, an adjunctive medication or medication switch can be considered as follows:^1,5

Adjunct

When to consider:

Not the first antidepressant tried
Tolerated well
>25% improvement on symptom scale
Urgency for efficacy (severe symptoms)
Additional symptoms that could be addressed by an additional drug
The patient prefers to add-on

Advantages

Fast onset for effectiveness
More convenient to start
Easier for a provider to implement
Able to target symptoms not fully addressed

Disadvantages

Higher CNS load
Risk of additive side effects
High interaction risk
Likely less convenient overall (2 drugs)
Possibly higher cost
Less certainty of effect
Harder to discontinue (2 drugs)

Switch

When to consider:

First antidepressant tried
Bothersome side effects
<25% improvement on symptom scale
No urgency for efficacy
No additional symptoms being targeted
The patient prefers to switch

Advantages

Lower overall CNS load
Low interaction risk (high to start)
Likely more convenient overall (1 drug)
Possibly lower cost
More certainty of effect
Easier to discontinue (1 drug)

Disadvantages

Slow onset for effectiveness
Risk of additive side effects
Risk of withdrawal
Less convenient to start
Harder for a provider to implement

_{*For the initial antidepressant trial. In subsequent trials, lack of response (<25% improvement) may not be a factor for choosing between switch and adjunctive strategies}

First-line adjunctive medications options for depression^{1,27,29,33-35}

The evidence and recommendations for adjunctive treatment strategies are mixed and must be balanced with the risk of adding an additional medication.^1,28 The following medications are considered first-line adjunctive agents in the CANMAT 2016 MDD Guidelines.¹ Other options include an alternative class of antidepressant.^6,28 Consider patient and medication factors in the approach to adjunct medication selection. If you have questions about adjunctive medications, consult a pharmacist or specialist through eConsult.

The evidence and recommendations for augmentation strategies are mixed and must be balanced with the risk of adding an additional medication.^{1, 28} Consider patient and medication factors in the approach to adjunct medication selection.

Atypical antipsychotics¹^,5,33–35

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Atypical antipsychotics
Aripiprazole (Abilify®)

2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg tablet

Coverage
- ODB ✓
- NIHB ✓
Cost for usual dose ($/100 days)
- $96-146
Overall tolerability*
- Neutral
Activating or sedating
- Activating > sedating
Interaction risk
- ++
Features**
- Useful is there is comorbid psychosis
View dosing, side effects and warnings
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Aripiprazole (Abilify®)

Dosing

Initial: 2-5 mg daily

Titration: Increase gradually by ≤ 5 mg daily, at intervals of ≥ 1 week

Usual: 5-15 mg daily

Max: 15 mg daily

Common side effects

CNS: akathisia, restlessness, fatigues, insomnia, somnolence

Anticholinergic: blurred vision, constipation

Warnings

Increased mortality, cerebrovascular events, dysphagia and other treatment-emergent side effects in older adults with dementia.

Caution in older adults due to changes in pharmacodynamic response.

Caution in patients who have Parkinson’s Disease or Dementia with Lewy Bodies.

General: disruption of body temperature regulation, falls, carcinogenicity (animal models), fertility impairment (animal models), dependence/tolerance

Cardiovascular: orthostatic hypotension (especially in elderly), tachycardia, syncope, arrhythmias including 1st-degree AV block, hypotension, QT prolongation

Endocrine and metabolism: hyperglycemia and Diabetes Mellitus, dyslipidemia, weight gain (lower risk than quetiapine and risperidone)

Genitourinary: priapism

Hematologic: leukopenia, neutropenia and agranulocytosis, venous thromboembolism

Neurologic: Extrapyramidal symptoms, Neuroleptic Malignant Syndrome, potential effect on cognitive and motor performance, seizures, tardive dyskinesia

Psychiatric: suicide, pathological gambling and other impulse-control disorders

Skin: Severe cutaneous adverse events
Atypical antipsychotics
Quetiapine (Seroquel®)

IR: 25 mg, 100 mg, 150 mg, 200 mg, 300 mg tablet
XR: 50 mg, 150 mg, 200 mg, 300 mg, 400 mg tablet

Coverage
- ODB ✓
- NIHB ✓
Cost for usual dose ($/100 days)
- $40-115 (IR)
- $62-114 (XR)
Overall tolerability*
- Poorly tolerated
Activating or sedating
- Sedating
Interaction risk
- +++
Features**
- Useful is there is comorbid psychosis
- May be helpful for insomnia (balance with risk of daytime sedation)
View dosing, side effects and warnings
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Quetiapine (Seroquel®)

Dosing

Initial: 50 mg daily

Titration: Initial dose may be doubled daily until usual/max dose achieved

Usual: 150-300 mg per day

Max: 300 mg daily

(BID for IR and once daily for XR)

Common side effects

CNS: somnolence, sedation, dizziness

GI: xerostomia

Anticholinergic: constipation

Warnings

Increased mortality, cerebrovascular events, dysphagia and other treatment-emergent side effects in older adults with dementia.

Caution in older adults due to changes in pharmacodynamic response.

Caution in patients who have Parkinson’s Disease or Dementia with Lewy Bodies.

General: disruption of body temperature regulation, falls dependence/tolerance, acute withdrawal (discontinuation) symptoms

Cardiovascular: hypotension and syncope (including orthostatic hypotension), QT prolongation, cardiomyopathy and myocarditis

Endocrine & metabolism: hyperglycemia and Diabetes Mellitus, cholesterol and triglyceride events, weight gain, hyperprolactinemia, hypothyroidism

Gastrointestinal: antiemetic effect may mask overdose toxicity, dysphagia and aspiration pneumonia, intestinal obstruction

Genitourinary: priapism, urinary hesitation and retention

Hematologic: leukopenia, neutropenia and agranulocytosis, venous thromboembolism

Hepatic/pancreatic: LFT elevations, pancreatitis. Caution in patients with hepatic disease due to reduced clearance.

Neurologic: Extrapyramidal symptoms, Neuroleptic Malignant Syndrome, potential effect on cognitive and motor performance, seizures, tardive dyskinesia, sleep apnea

Ophthalmologic: cataracts

Psychiatric: suicide
Atypical antipsychotics
Risperidone (Risperdal®)

0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg tablet
1 mg/mL oral solution
0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg orally disintegrating tablet (ODT)

Coverage
- ODB ✓
- NIHB ✓
Cost for usual dose ($/100 days)
- $30-74 (tablets)
- $85-238 (oral solution)
- $64-172 (ODT)
Overall tolerability*
- Neutral
Activating or sedating
- Activating/sedating
Interaction risk
- ++
Features**
- Useful is there is comorbid psychosis
View dosing, side effects and warnings
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Risperidone (Risperdal®)

Dosing

Initial: 0.5 mg/day

Titration: Increase over 3 weeks to target 1-2mg daily. May be increased to 3 mg if response to 2 mg is inadequate.

Usual: 1-3 mg daily

Max: 3 mg daily

Common side effects

CNS: insomnia, agitation, anxiety, dizziness, headache, somnolence

Anticholinergic: constipation

Neurologic: extrapyramidal symptoms, hyperkinesia, tremor, dystonia

Warnings

Increased mortality, cerebrovascular events, dysphagia and other treatment-emergent side effects in older adults with dementia.

Caution in older adults due to reduced clearance and changes in pharmacodynamic response.

Caution in patients who have Parkinson’s Disease or Dementia with Lewy Bodies.

General: disruption of body temperature regulation, falls, carcinogenicity (animal models), fertility impairment (animal models)

Cardiovascular: orthostatic hypotension (especially in elderly), tachycardia, syncope, arrhythmias including 1st-degree AV block, hypotension, QT prolongation

Endocrine & metabolism: hyperglycemia & Diabetes Mellitus, weight gain, hyperprolactinemia

Gastrointestinal: antiemetic effect may mask overdose toxicity of other drugs, dysphagia

Genitourinary: priapism

Hematologic: leukopenia, neutropenia and agranulocytosis, venous thromboembolism

Hepatic: Caution in patients with hepatic disease due to reduced clearance.

Neurologic: Neuroleptic Malignant Syndrome, potential effect on cognitive and motor performance, seizures, tardive dyskinesia.

Ophthalmologic: intraoperative floppy iris syndrome

Renal: caution in patients who have kidney disease due to reduced clearance.

Psychiatric: suicide

Skin: Severe cutaneous adverse events

Guidance for switching medications

Drug selection:

There is a paucity of evidence to guide whether to switch to an alternate first-line drug within the same class versus switching to a different class of first-line medication after the first medication is tried.¹

Consider:

Reasons for switching (e.g., tolerability or lack of effect)
Specific features of alternate options as they pertain to your patient’s clinical picture

Cross-tapering:

Due to the risk of additive side effects, serotonin syndrome, withdrawal effects and drug interactions, consider asking a pharmacist or clinical expert for support with cross-tapers.⁵

The Switchrx.com website offers some general medication-related guidance. See first-line medications table.

Cross-tapers may occur over weeks or months depending on several factors, including:⁵

How long has the patient been taking the medication?
Urgency of completing the cross taper (e.g., severity of mental health condition and side effects)?
What is the risk of destabilizing the mental health condition with changes based on the patient’s clinical factors?
What is the half-life of the drug involved?
What is the propensity for withdrawal effects with the medications involved?
What is the risk of side effects with the new medication?
What drug interactions may impact the taper?
What is the patient’s preference?

Putting it into practice:⁵

Develop a plan with the patient. Consider including an expert in pharmacological treatment options (e.g., pharmacist, mental health expert).
Discuss the risks and benefits of the plan with the patient
Provide the cross-taper plan in writing.
Provide guidance for side effect management of the new medication and any potential withdrawal effects of the medication being stopped (see discontinuation and withdrawal symptoms) if relevant.
Discuss serotonin syndrome symptoms if multiple serotonergic medications are involved in the cross-taper (see warnings and precautions: serotonin syndrome under side effect management).
Follow-up within 1 week of each dose change to review side effects and symptoms.

Anxiety

Overall approach

Ongoing treatment options

Treatment response:

A 25-50% reduction in the patient’s score on a validated disorder-specific rating scale indicates response to treatment. Whereas symptom remission is when the patient loses diagnostic status and has no functional impairment.⁷

Partial or non-response:^{3, 5, 7}

Ask: Is the treatment being taken as prescribed?

No: explore reasons why not and provide support. Adjust treatment plan if needed
Yes:
- Review options for intensifying psychological treatment
- Consider increasing the dose of medication to condition-related target* if:
  The target dose has not been reached
  
  The medication is being tolerated well
  
  This is not the first medication tried
  
  Functional deficit and symptoms are mild (no urgency for effect)
  
  The patient is comfortable with increasing the dose
- If increasing is not preferred, switching to an alternate medication is recommended (see guidance for switching medications).

*While initial medication dosing for anxiety is often lower than dosing for depression, the usual and maximum doses for anxiety are sometimes higher than those used for depression (see drug cards).

Adjunctive treatment is generally reserved for second-line management after multiple first-line agents have been tried.⁷ A clinical expert should be consulted in cases where second-line treatment or second-line adjunctive therapy is being considered.³

Duration of pharmacological treatment

Anxiety¹⁷

GAD: Treatment should be continued for at least one to two years to maintain symptom remission and prevent relapse.
Panic Disorder: Review with the patient every 8-12 weeks.²
- Optimal treatment duration is not well defined⁸
- Consider a minimum continuation for 6 months after remission and up to a year. Avoidance behaviour should be resolved before the medication is withdrawn and relapse of avoidance behaviours should be monitored.
- Long-term treatment can be considered – weighing the risks and benefits.

Discontinuation guidance

Due to the risk of withdrawal symptoms, the dose of medication should generally be gradually reduced over an extended period. This may be weeks or months, depending on the duration of treatment, the medication involved, and patient factors.⁵

If a medication is being stopped to switch to another antidepressant due to lack of effectiveness or side effects, dose reductions may be done more quickly (e.g., over days). Symptoms emerging during the transition period may be due to either discontinuation/withdrawal effects OR side effects to the new medication.

A pharmacist or mental health expert can be helpful in providing guidance as it relates to the individual drug and patient.

The website Medstopper.com offers advice regarding tapering plans and possible withdrawal symptoms.

Putting it into practice:⁵

Develop a plan with the patient. Consider including an expert in pharmacological treatment options (e.g., pharmacist, mental health expert).
Discuss the risks and benefits of the plan with the patient.
Provide the plan and withdrawal symptom management information in writing.
Follow-up within 1-2 weeks of each dose change to review withdrawal effects and emerging mental health symptoms.

Discontinuation & withdrawal symptoms for anxiety and depression

Discontinuation & withdrawal symptoms⁸

Symptoms²⁹

Flu-like symptoms (e.g., malaise, headache, fatigue, chills, sweating, tremor, loss of appetite)

Management⁵

Provide reassurance and support to patients, including but not limited to:

Symptom management
Additional follow-up
Pause, adjust, or stop the tapering plan according to patient preference
Arranging contingency plans for subsequent dose reductions

In some cases, it may be helpful to:

Increase the dose of the medication
Consult an expert for further advice (e.g., cross-taper, managing discontinuation symptoms, etc.)

Symptoms²⁹

“Electric shock sensations” (especially with SNRIs), paresthesias, numbness, blurred vision, palinopsia, auditory disturbances

Management⁵

Provide reassurance and support to patients, including but not limited to:

Symptom management
Additional follow-up
Pause, adjust, or stop the tapering plan according to patient preference
Arranging contingency plans for subsequent dose reductions

In some cases, it may be helpful to:

Increase the dose of the medication
Consult an expert for further advice (i.e., cross-taper, managing discontinuation symptoms, etc.)

Symptoms²⁹

Light-headedness, dizziness, vertigo

Management⁵

Provide reassurance and support to patients, including but not limited to:

Symptom management
Additional follow-up
Pause, adjust, or stop the tapering plan according to patient preference
Arranging contingency plans for subsequent dose reductions

In some cases, it may be helpful to:

Increase the dose of the medication
Consult an expert for further advice (i.e., cross-taper, managing discontinuation symptoms, etc.)

Symptoms²⁹

Nausea, vomiting, diarrhea

Management⁵

Provide reassurance and support to patients, including but not limited to:

Symptom management
Additional follow-up
Pause, adjust, or stop the tapering plan according to patient preference
Arranging contingency plans for subsequent dose reductions

In some cases, it may be helpful to:

Increase the dose of the medication
Consult an expert for further advice (i.e., cross-taper, managing discontinuation symptoms, etc.)

Symptoms²⁹

Insomnia, nightmares, excessive dreaming

Management⁵

Provide reassurance and support to patients, including but not limited to:

Symptom management
Additional follow-up
Pause, adjust, or stop the tapering plan according to patient preference
Arranging contingency plans for subsequent dose reductions

In some cases, it may be helpful to:

Increase the dose of the medication
Consult an expert for further advice (i.e., cross-taper, managing discontinuation symptoms, etc.)

Appendix: alternative therapies and natural health products

Alternative therapies

Light Therapy
- First-line monotherapy for seasonal depression
- Second-line adjunctive therapy or monotherapy for moderate to severe depression
- Typical or studied dose and duration: standard protocol is 10,000 lux (light intensity) for 30 minutes per day during the early morning for up to 6 weeks. A response is usually seen within 1 to 3 weeks
Acupuncture
- Third-line adjunctive therapy for mild to moderate depression
- Typical or studied dose and duration: typically 20 to 30 minutes in session duration, and ranging from 10 to 30 sessions, decreasing in frequency over time from daily to weekly intervals

Natural health products (NHPs)^{1, 36}

Considerations for NHPs:
A pharmacist can support you and patients in navigating herbal treatments. Some general considerations include the following:

Is it a quality product?
- Does it have an NPN (Natural Product Number)?
Is there a potential for harm?
- Risk of bleeding and liver damage are the most common warnings for herbal products.
Is there a potential for drug interactions? (e.g., St. John’s Wort)
How many ingredients are listed?
- Products with more than one ingredient have a higher risk of interactions and side effects.
How much does the product cost?
Is there evidence of the product’s efficacy?

The National Institute for Health (NIH) National Center for Complementary and Integrative Health has information about evidence, potential harms and drug interaction risks for various modalities.

Click to view natural health products in table format.

NHPs not recommended:¹

Inositol
Tryptophan
Rhodiola rosea (roseroot)

References New

[1]

Canadian Network for Mood and Anxiety Treatments (CANMAT) Depression Work Group. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder. Can J Psychiatry Rev Can Psychiatr. 2016 Sep;61(9):510–603.
[2]

NICE. Generalised anxiety disorder and panic disorder in adults: management | Guidance | NICE [Internet]. NICE; 2011 [cited 2023 Feb 10]. Available from: https://www.nice.org.uk/guidance/cg113
[3]

Anxiety Disorders – Health Quality Ontario (HQO) [Internet]. [cited 2022 Nov 16]. Available from: https://www.hqontario.ca/evidence-to-improve-care/quality-standards/view-all-quality-standards/anxiety-disorders
[4]

Major Depression – Health Quality Ontario (HQO) [Internet]. [cited 2022 Nov 16]. Available from: https://www.hqontario.ca/evidence-to-improve-care/quality-standards/view-all-quality-standards/major-depression
[5]

Expert opinion.
[6]

NICE. Depression in adults: treatment and management | Guidance | NICE [Internet]. NICE; 2022 [cited 2023 Feb 10]. Available from: https://www.nice.org.uk/guidance/ng222
[7]

Katzman MA, Bleau P, Blier P, Chokka P, Kjernisted K, Van Ameringen M, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014 Jul 2;14(1):S1.
[8]

Andrews G. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Aust N Z J Psychiatry. 2018;52(12):1109–72.
[9]

Bandelow B, Allgulander C, Baldwin DS, Costa DL da C, Denys D, Dilbaz N, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders – Version 3. Part I: Anxiety disorders. World J Biol Psychiatry Off J World Fed Soc Biol Psychiatry. 2023 Feb;24(2):79–117.
[10]

Management of Major Depressive Disorder (MDD) (2022) – VA/DoD Clinical Practice Guidelines [Internet]. [cited 2022 Sep 23]. Available from: https://www.healthquality.va.gov/guidelines/MH/mdd/
[11]

Bandelow B, Werner AM, Kopp I, Rudolf S, Wiltink J, Beutel ME. The German Guidelines for the treatment of anxiety disorders: first revision. Eur Arch Psychiatry Clin Neurosci. 2022 Jun 1;272(4):571–82.
[12]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) [product monograph] [Internet]. 2019 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[13]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. ESCITALOPRAM [product monograph] [Internet]. 2018 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[14]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. Paroxetine [product monograph] [Internet]. 2017 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[15]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. CYMBALTA: Duloxetine [product monograph] [Internet]. 2021 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[16]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. EFFEXOR XR: Venlafaxine [product monograph] [Internet]. 2020 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[17]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. PREGABALIN [product monograph] [Internet]. 2017 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[18]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. BUSPIRONE [product monograph] [Internet]. 2018 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[19]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. ZOLOFT: Sertraline [product monograph] [Internet]. 2020 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[20]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. CITALOPRAM [product monograph [Internet]. 2018 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[21]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. WELLBUTRIN XL: Buproprion [product monograph] [Internet]. 2017 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[22]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. TRINTELLIX: Vortioxetine [product monograph] [Internet]. 2021 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[23]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. PRISTIQ: Desvenlafaxine Succinate [product monograph] [Internet]. 2018 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[24]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. PROZAC: Fluoxetine [product monograph] [Internet]. 2021 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[25]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. LUVOX: Fluvoxamine Maleate [product monograph] [Internet]. 2021 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[26]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. MIRTAZAPINE [product monograph] [Internet]. 2018 [cited 2022 Nov 10]. Available from: http://www.e-therapeutics.ca
[27]

Government of Ontario M of H. Formulary Search [Internet]. Ontario Drug Benefit Formulary/Comparative Drug Index. 2023 [cited 2023 Feb 10]. Available from: https://www.formulary.health.gov.on.ca/formulary/
[28]

Qaseem A, Owens DK, Etxeandia-Ikobaltzeta I, Tufte J, Cross JT, Wilt TJ. Nonpharmacologic and Pharmacologic Treatments of Adults in the Acute Phase of Major Depressive Disorder: A Living Clinical Guideline From the American College of Physicians. Ann Intern Med [Internet]. 2023 Jan 24 [cited 2023 Feb 10]; Available from: https://www.acpjournals.org/doi/10.7326/M22-2056
[29]

Indigenous Services Canada. Non-insured health benefits, First Nations and Inuit Health Branch: Drug benefit list [Internet]. 2020. Available from: https://nihb-ssna.express-scripts.ca/en/0205140506092019/16/160407
[30]

American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Apr;67(4):674–94.
[31]

Centre for Effective Practice. Falls Prevention [Internet]. 2021 [cited 2023 Mar 17]. Available from: https://cep.health/clinical-products/falls-prevention/
[32]

Canadian Coalition for Senior’s Mental Health. Canadian Guidelines on Prevention, Assessment and Treatment of Depression Among Older Adults [Internet]. 2021. Available from: https://ccsmh.ca/wp-content/uploads/2021/06/CCSMH_Depression_Guidelines_FINAL_EN.pdf
[33]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. Aripiprazole [product monograph]. 2021.
[34]

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association. Quetiapine [product monograph]. 2017.
[35]

Mahmoud RA, Pandina GJ, Turkoz I, Kosik-Gonzalez C, Canuso CM, Kujawa MJ, et al. Risperidone for treatment-refractory major depressive disorder: a randomized trial. Ann Intern Med. 2007 Nov 6;147(9):593–602.
[36]

Canada H. About Natural Health Products [Internet]. 2016 [cited 2023 Feb 10]. Available from: https://www.canada.ca/en/health-canada/services/drugs-health-products/natural-non-prescription/regulation/about-products.html
[37]

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Acknowledgment and legal

The Managing Patients with Anxiety and Depression in Primary Care Tool was developed using the Centre for Effective Practice’s (CEP’s) integrated knowledge translation approach. This approach ensures that providers are engaged throughout the development processes through the application of user-centered design methodology. Clinical leadership of the resource was provided by Dr. Sharon Bal. End users and clinical experts were also engaged to provide feedback.

The tool is one of several clinical tools developed as part of the Knowledge Translation in Primary Care Initiative. This tool has been endorsed by Ontario College of Family Physicians (OCFP) and Nurse Practitioners’ Association of Ontario (NPAO). Funded by the Ministry of Health, this initiative supports primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative (KTinPC).

This Tool is a product of the Centre for Effective Practice. Permission to use, copy, and distribute this material is for all noncommercial and research purposes is granted, provided the above disclaimer, this paragraph and the following paragraphs, and appropriate citations appear in all copies, modifications, and distributions. Use of this Tool for commercial purposes or any modifications of the Tool are subject to charge and must be negotiated with the Centre for Effective Practice (info@cep.health).

For statistical and bibliographic purposes, please notify the Centre for Effective Practice (info@cep.health) of any use or reprinting of the Tool. Please use the following citation when referencing the Tool: Reprinted with Permission from Centre for Effective Practice. (March 2023). Managing Patients with Anxiety and Depression in Primary Care: Ontario. Toronto: Centre for Effective Practice.

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Anxiety and Depression

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Screening and assessment

Jump to:

Guiding principles for the screening and assessment of anxiety and depression:

Screen patient

Screen for risk factors1, 3

Clinical factors:

Symptom factors:

Complete a validated or recognized screening tool3,4

Anxiety

Screening special populations3-5

Depression

Screening special populations3-5

Assess findings

Conduct a comprehensive assessment2-4, 6

Collect clinical history

Understand individual patient-contributing factors

Screen for risk of suicide or self-harm or harm others

Identify any comorbid mental health conditions

Communicate diagnosis to patients

Talking tips

Talking tips2,5,6

Management

Jump to:

Talking tips

Talking tips

Guiding principles for the management of anxiety and depression:

Psychological treatment options

Anxiety2, 3, 9

Depression1, 4, 5, 10

OSP Networks and Referral Process

Central Region

Toronto Region

West Region

East Region

North East Region

North West Region

Resources for patients and caregivers9

Free resources available for patients and their caregivers are listed below:

Community and social

Educational supports for patients and caregivers

Online app and resources

Non-pharmacological complementary treatment options

Pharmacological treatment options

Factors to consider when choosing a medication1, 5

Patient factors:

Medication factors:

Talking tip5

Talking tip

Role of pharmacogenetic testing for medication selection1

First-line medication options1,3–5, 7, 9, 11–30

Selective Serotonin Reuptake Inhibitors (SSRI)

Scroll (left-right) for details

Citalopram (Celexa®)

Citalopram (Celexa®)

Dosing***

Side effects

Warnings and contraindications

Escitalopram (Cipralex®)

Escitalopram (Cipralex®)

Dosing***

Side effects

Warnings and contraindications

Fluoxetine (Prozac®)

Fluoxetine (Prozac®)

Dosing***

Side effects

Warnings and contraindications

Fluvoxamine (Luvox®)

Fluvoxamine (Luvox®)

Dosing***

Side effects

Warnings and contraindications

Paroxetine (Paxil®)

Paroxetine (Paxil®)

Dosing***

Dosing (CR)

Side effects

Warnings and contraindications

Screen for risk factors^{1, 3}

Complete a validated or recognized screening tool^3,4

Screening special populations^3-5

Screening special populations^3-5

Conduct a comprehensive assessment^{2-4, 6}

Talking tips^2,5,6

Anxiety^{2, 3, 9}

Depression^{1, 4, 5, 10}

Resources for patients and caregivers⁹

Factors to consider when choosing a medication^{1, 5}

Talking tip⁵

Role of pharmacogenetic testing for medication selection¹

First-line medication options^{1,3–5, 7, 9, 11–30}

Role of benzodiazepines for anxiety disorders^3,5,7

Talking tips⁵

Before starting a treatment, discuss the following with the patient, and if desired, their family or caregiver(s):¹^-5,9

Talking tips^3,5

Side effect management^{1, 5}

Troubleshooting side effects^{1, 5}

Talking tips⁵

Specific side effect management for symptoms^{1, 5}