Depression
The INESSS protocol covers follow-up of a person already on an antidepressant.
Don't miss
- INESSS Institut national d'excellence en santé et services sociaux
- CANMAT Canadian Network for Mood and Anxiety Treatments
- CCSMH Canadian Coalition for Seniors' Mental Health
- 988 9-8-8 Suicide Crisis Helpline
| Decision | Guideline |
|---|---|
| Ask | Ask directly about suicidal ideation, intent and plan. |
| PHQ-9 item 9 | Score of 1 or more:Assess how, where and when, access to the means and its lethality. |
| High risk | Inpatient care is often warranted for suicidal ideation with intent to act, psychotic symptoms, or both. |
| Start and stop window | Higher risk in the month after starting and the month after stopping an antidepressant.Monitor more closely in the first 4 weeks after each. |
| Under 25 | Before starting, tell young adults about the risk of new suicidal thoughts. |
| Hypomanic switch | Reassess if mood turns expansive or the need for sleep drops, especially if a full response appears after a few days or a week.Outside the INESSS protocol. |
| Crisis line | 9-8-8, call or text, 24 hours a day. |
Diagnose
- INESSS Institut national d'excellence en santé et services sociaux
- CANMAT Canadian Network for Mood and Anxiety Treatments
- CTFPHC Canadian Task Force on Preventive Health Care
| Decision | Guideline |
|---|---|
| Diagnosis | A screen is not a diagnosis.Make it with a full assessment in a DSM-5 or ICD-11 framework, with collateral history when possible. |
| Rule out | Look for medical and psychiatric conditions that present with low mood.They can also coexist. |
| Severity | Mild, moderate or severe, rated on symptom severity and functional impairment, whichever is higher.Use a validated scale. |
| Safety risk | Rate it alongside severity.The initial treatment depends on both. |
| PHQ-9 bands | 0–4: no depression 5–9: mild 10–14: moderate 15–19: moderately severe 20–27: severe |
| Anxious distress | 2 or more of 5 symptoms, most days.The list is in the INESSS protocol. |
| Adults 18 and older | Do not screen with a questionnaire and a cut-off (strong, very low certainty).Stay alert to risk factors and symptoms, and assess when indicated. CTFPHC 2025 opens in a new tabCTFPHC 2025 guideline opens in a new tab |
| People with risk factors | Do not screen with a questionnaire, including adults at elevated risk. Screen with a validated scale if diagnosis and treatment are available.PHQ-2, then PHQ-9 if positive (PHQ-2 of 2 or more, PHQ-9 of 10 or more).
A positive screen needs a full diagnostic assessment. |
Investigate
- CANMAT Canadian Network for Mood and Anxiety Treatments
| Decision | Guideline |
|---|---|
| Routine | History and targeted exam.CBC and TSH: low-cost, to rule out anemia and thyroid causes, though direct evidence is thin. |
| Only if indicated | Other labs when history or exam suggests another cause, or in older adults, medical comorbidity or substance use. |
| ECG | Cardiovascular disease plus a QTc-prolonging drug. |
| Imaging | Neurologic signs, new or persistent cognitive impairment, sudden mood, behaviour or personality change.May be considered in new late-life depression. |
| Do not | No routine ECG, EEG or neuroimaging. |
Treat
- INESSS Institut national d'excellence en santé et services sociaux
- CANMAT Canadian Network for Mood and Anxiety Treatments
| Decision | Guideline |
|---|---|
| Stepped care | Psychosocial or psychotherapy first, especially for mild to moderate depression.Structured physical activity helps.
Antidepressants can be used at any severity and are usual for more severe depression. INESSS 2024 opens in a new tabCANMAT 2023 opens in a new tab |
| Mild, low safety risk | Psychotherapy is preferred if readily accessible.Psychotherapy and medication have similar benefit. Exercise or guided digital tools may be used alone. |
| Moderate, low-moderate safety risk | Choose medication or psychotherapy.The two together may be considered. |
| Severe, moderate to high safety risk | No psychotic features: antidepressant plus psychotherapy, started together or staggered. Psychotic features: antidepressant plus antipsychotic. Very severe or life-threatening: consider ECT. |
| First-line drugs | SSRI, SNRI, bupropion, mirtazapine, vilazodone, vortioxetine. |
| How long | Effect can start by 2 weeks. Allow up to 8 weeks at a therapeutic dose. 6–12 weeks at an optimal dose for remission and function. Hold the dose at least 3 months after functional recovery. |
| Titration | Use the smallest dose steps with:anxiety; age 65 and older; renal or hepatic impairment; side effects. |
| Risk and benefit | Weigh risk and benefit with the person.See the INESSS tool Major depressive disorder during pregnancy opens in a new tab. INESSS 2024 opens in a new tabINESSS pregnancy tool opens in a new tab |
Usual start doses from the INESSS protocol opens in a new tab (Annexe V). Steps, intervals and maximum doses are in the protocol.
| Drug | Start dose |
|---|---|
| Citalopram | 20 mg DIE |
| Escitalopram | 10 mg DIE |
| Fluoxetine | 20 mg DIE |
| Paroxetine | 20 mg DIE |
| Sertraline | 50 mg DIE |
| Desvenlafaxine | 50 mg DIE |
| Duloxetine | 30 mg DIE |
| Levomilnacipran | 20 mg DIE |
| Venlafaxine XR | 37.5 or 75 mg DIE |
| Bupropion XL | 150 mg DIE |
| Vortioxetine | 10 mg DIE |
| Vilazodone | 10 mg DIE |
| Mirtazapine | 15 mg DIE, bedtime |
Follow-up
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Visits | Every 2–4 weeks for the first 3 months, or until functional recovery.Closer by clinical judgment. |
| Measure | PHQ-9 for depression. GAD-7 if anxious. WSAS for function. |
| Targets | Remission: PHQ-9 under 5. Functional recovery: WSAS under 10. |
| Electrolytes | Over 65 with hyponatremia risk (female, low weight, diuretic): 2–4 weeks after the start, and after a dose increase if needed.Not for bupropion or quetiapine alone. |
| Quetiapine | Lipids and fasting glucose at 3 months. |
| Each visit | Check:suicidal ideation; hypomanic signs; side effects; serotonin toxicity; withdrawal symptoms; new drugs. |
| Anxious distress | Reassess treatment if it appears.Known before treatment: reassess if more than 2 symptoms persist past 4 weeks. |
| After recovery | Once a month for at least 3 months, for adherence and relapse prevention. |
Age 65 and older
- INESSS Institut national d'excellence en santé et services sociaux
- CCSMH Canadian Coalition for Seniors' Mental Health
| Decision | Guideline |
|---|---|
| First-line drugs | Sertraline or duloxetine.Citalopram or escitalopram as alternatives; QTc concern may keep their dose low. |
| Avoid | Fluoxetine (long half-life). Paroxetine (anticholinergic). |
| Severe | Antidepressant plus concurrent psychotherapy when services are available and neither is contraindicated. |
| ECT | First-line when the risk of a poor outcome is high:suicidal ideation or intent, severe physical illness, psychotic features. Also consider after a past good ECT response, or after 1 or more adequate antidepressant trials plus psychotherapy fail. |
| Start doses | Sertraline 25 mg DIE. Duloxetine 30 mg DIE. Citalopram 10 mg DIE. Escitalopram 5 mg DIE. |
Reviewed 17 October 2026 against the official sources below.
Sources
Blue square: Québec · red round: Canada. The code names the body; each section's key gives its full name.