Which therapy is suitable, what do the different antidepressants do and what if the treatment does not help enough? Here you will find an explanation on how to make choices together with your clinician.
There is no treatment that works the same for everyone. This page explains treatment options: from conversations and activities to medications and specialist care. Discuss in advance what you want to improve, which disadvantages are important to you and when you will evaluate together.
Zorgfuik provides general information and does not make a diagnosis. Discuss personal symptoms, treatment and medication with a qualified healthcare provider.
Sources checked for . General information for adults; no personal treatment or dosage advice.
A treatment plan starts with more than the diagnosis. What no longer works in your daily life? How serious and how long are the symptoms? What helped in previous periods, and what did not? Sleep, physical health, other medications, alcohol or drugs and your personal circumstances also count.
The basis consists of explanation, feasible daily structure, activities and regular contact. In the case of depression without serious limitations, guidance or psychological treatment may first be appropriate. In case of more severe symptoms, a lot of suffering or other psychological problems, more intensive treatment is needed faster. In specialist care, a combination of psychotherapy and medication is usually recommended for moderately severe or severe depression. Your preference and previous experiences are part of that decision.
The GP and mental health practice assistant can provide guidance and refer if necessary. A psychologist or psychotherapist provides psychological treatment; a psychiatrist can assess complex diagnostics and medication. During a waiting period, ask who will continue to monitor you and who you can call if things deteriorate.
Sources: NHG Standard Depression and Dutch treatment guideline. Also read who does what in your care process.
Psychotherapy is a targeted treatment with appointments, exercises and evaluation. Different approaches can help. The Dutch guideline takes into account the preference, availability and expertise of the clinician. CBT has a large research base; that does not automatically make it the best choice for everyone.
You investigate how thoughts, feelings and behaviour influence each other. For example: the thought 'I am a burden to everyone' can lead to you avoiding contact and feeling increasingly lonely. Together with your therapist, you test such thoughts and practice different behaviour. It is not an assignment to just 'think positive'. You often also work on small, agreed-upon assignments between appointments.
With depression you can do less and less, while withdrawing can maintain the symptoms. Behavioural activation helps to gradually bring back activities that can provide meaning, contact or satisfaction. You don't have to be motivated first. The structure is adapted to what is feasible; it is not advice to force yourself.
IPT focuses on the connection between depression and relationships or changes in your life. Think of a loss, conflict or new role as a parent. You investigate how those events affect you and practice communication, asking for support and dealing with changes.
ACT, mindfulness-based cognitive therapy (MBCT), problem-solving therapy and psychodynamic therapy can also be considered. They place different emphasis, such as dealing with thoughts, recurring patterns or concrete problems. Ask why the proposed method suits your symptoms. Read how ACT works or watch it overview of treatments.
Sources: guideline on psychotherapy and UMCG: treatment of depression.
Antidepressants can reduce depressive symptoms, but do not work the same for everyone. The groups differ in their influence on signal transmission in the brain, side effects, interactions and the ease with which you can stop. 'Newer' or 'stronger' does not automatically mean better.
Below are the most important groups and examples of active substances used in Dutch healthcare. It is not a complete leaflet or selection list to start with yourself. Some drugs are also used for anxiety, compulsion or pain: a prescription for an antidepressant does not always mean that you have depression.
The usual first choice is not the only good choice. If medication is appropriate for an adult, the NHG lists citalopram, escitalopram, fluoxetine and sertraline as preferred drugs. Another drug that previously helped and was well tolerated does not therefore need to be replaced. Discuss the reason for your choice with the prescriber.
Sources: Pharmacotherapeutic Compass: depression and guideline on medication choice.
Examples: citalopram, escitalopram, fluoxetine, sertraline, paroxetine and fluvoxamine.
For what and how? They inhibit the reuptake of serotonin. They are used for depression and, depending on the drug, also for anxiety or obsessive-compulsive disorders. Paroxetine and fluvoxamine are not preferred drugs for a new treatment of depression in the general practice guideline.
NB: nausea, restlessness, changes in sleep and sexual symptoms may occur. With citalopram and escitalopram, the heart rhythm is sometimes an additional point of attention. Paroxetine can be difficult to reduce. Good effect on mood is not the only measure: side effects on sexuality or daily functioning also deserve attention.
Examples: venlafaxine and duloxetine.
For what and how? They influence the reuptake of serotonin and norepinephrine and can be a next step in depression. Both also have applications in certain anxiety disorders. Duloxetine is also used for nerve pain due to diabetes. That doesn't mean it's suitable for every type of pain.
NB: including nausea, sweating, sexual symptoms and increased blood pressure. Blood pressure should be monitored with venlafaxine; liver and kidney problems also count with duloxetine. Especially with venlafaxine, a missed dose or tapering too quickly can cause withdrawal symptoms.
More about venlafaxine Compass: venlafaxine and duloxetine
Examples: amitriptyline, nortriptyline, clomipramine, imipramine and dosulepine.
For what and how? These are older antidepressants that affect multiple signaling systems. They can be used for depression if other choices are insufficient or have not helped previously. Some, such as amitriptyline, are also used for nerve pain; Pain treatment is not the same as depression treatment.
NB: dry mouth, constipation, drowsiness, dizziness when standing up and difficulty urinating. Heart rhythm and safety in the event of overdose are also taken into account. The doctor may consider an ECG or blood level check necessary. In general practice, TCAs are not the standard first choice.
Source: Compass: TCAs
Group: often referred to as NaSSA; influences noradrenergic and serotonergic signals via receptors.
For what? Depression, for example if another choice does not help enough or is not well tolerated. Sleepiness and increased appetite can be taken into account in the choice, but do not automatically make it the best treatment for someone who sleeps poorly or eats little.
NB: drowsiness, dry mouth and weight gain occur. Getting drowsy can happen quickly; that is not the same as recovery from depression. Also discuss the influence on driving, work and combination with alcohol or other narcotics.
Source: Compass: mirtazapine
Group: reuptake inhibitor of norepinephrine and dopamine, often called NDRI.
For what? A possible next step for depression. A different registration and product name are used when quitting smoking. These applications are not simply interchangeable.
NB: insomnia, restlessness, dry mouth and increased blood pressure may occur. Due to the risk of epileptic seizures, it is unsuitable for epilepsy or a history of anorexia or bulimia. Abruptly stopping a lot of alcohol or benzodiazepines is also an important risk to discuss with the doctor.
Source: Compass: bupropion
Group: an antidepressant that affects both the reuptake and certain receptors of serotonin.
For what? Depression in adults, usually when other preferred medicines are insufficiently appropriate. It is not automatically a better choice because it works differently.
NB: especially nausea, but also dizziness and gastrointestinal symptoms. Sexual side effects cannot be ruled out. As with other serotonergic agents, the pharmacist must check for dangerous combinations.
Source: Compass: vortioxetine
For what and how? Agomelatine works on melatonin receptors and certain serotonin receptors. It can be considered for depression after inadequate results from a preferred drug. It is not the same as a melatonin supplement or a regular sleep aid.
NB: there is a risk of liver damage. Therefore, blood checks are necessary before and during treatment. It is not suitable for liver disease. Discuss new jaundice, dark urine or unexplained severe fatigue with a doctor immediately.
Source: Compass: agomelatine
For what and how? Trazodone affects serotonin via receptors and reuptake. It is an antidepressant, but not a preferred drug for a new treatment in general practice. Use for insomnia alone may be off-label: outside the registered use. Then discuss the purpose and substantiation.
NB: drowsiness, dizziness, drop in blood pressure when standing up and cardiac arrhythmias. A rare but urgent side effect is a persistent, painful erection; seek immediate medical attention. A sleep-promoting effect does not prove that depression is being adequately treated.
Source: Compass: trazodone
Examples: tranylcypromine and moclobemide.
For what and how? They inhibit an enzyme that breaks down signaling substances. Tranylcypromine may be an option for depression that does not respond sufficiently to other treatments. Moclobemide is a reversible MAO-A inhibitor, but according to the Kompas it has no place in the Dutch depression guidelines. The properties and precautions differ.
NB: there are important interactions with other medications. Tranylcypromine requires strict, personal dietary advice due to tyramine and the risk of a dangerous increase in blood pressure. Do not use those dietary rules as a general rule for every MAOI. Switching requires a careful plan and sometimes a waiting period between medicines.
Compass: tranylcypromine and moclobemide
You may also come across older or less commonly used agents, such as mianserin and maprotiline. Classifications vary: some are called tetracyclic or discussed together with related older antidepressants. A group name alone does not say enough about operation or safety.
Mianserin can be used for depression when other medicines do not help enough. Drowsiness and weight gain are areas of concern; Fever, sore throat or blisters in the mouth may indicate rare blood abnormalities and require consultation with the doctor. If the name is unknown, always ask for the active substance, the treatment goal and your own package leaflet.
Sources: Apotheek.nl: mianserin and Compass: older antidepressants
Side effects may be noticeable before improvement. You and your clinician often discuss how the drug is tolerated after one to two weeks and usually assess the effect after four to six weeks. Sometimes more time is needed for partial improvement. In case of deterioration or unsafe conditions, do not wait for that evaluation date.
Measure more than just your mood. Does getting up, eating or maintaining contact work better? Does anxiety decrease? Are work, studies or self-care becoming more feasible? A questionnaire can provide support, but does not replace the conversation. Also agree on what is an unacceptable side effect for you.
Source: guideline: evaluating treatment.
Have the pharmacist check your complete medication list, including over-the-counter medications, herbs and supplements. Combinations with other serotonergic agents, such as tramadol, certain antidepressants or St. John's wort, can be especially dangerous. Blood thinners, anti-inflammatory painkillers and narcotics can also cause additional risk. Ask for advice before adding anything.
Some substances affect the ability to drive. Ask the pharmacist about the rules for your product, dose and situation; do not drive if you are drowsy, dizzy or less alert. Alcohol can increase side effects.
Contact your clinician promptly if there is any clear deterioration. Examples include new thoughts of self-harm, severe restlessness, or needing noticeably less sleep while having much more energy or becoming disinhibited. Fever with confusion, heavy sweating, muscle stiffness or shaking can signal a serious medicine-related problem. Seek immediate medical assessment; call 112 if there is an immediate danger to life.
Drug specific information: Apotheek.nl: uses, interactions and side effects. Also read how to keep an overview of long-term medication use.
If the drug helps and the depression has recovered, treatment is often continued for at least six months to help prevent a recurrence. In the case of previous episodes, residual symptoms or other risks, continuing longer may be appropriate. With long-term use, have it regularly assessed whether the benefits still outweigh the disadvantages.
Don't stop suddenly on your own initiative. Together with your doctor and pharmacist, make a plan that suits the drug, the duration of use, previous previous tapering attempts and your symptoms. Tapering can take shorter or longer; there is no universal scheme. Some people need smaller steps and more time.
Dizziness, nausea, flu-like symptoms, restlessness or electric shocks can be withdrawal symptoms. They do not automatically mean that the depression has returned. Distinguishing from relapse is sometimes difficult and requires assessment. Report symptoms after a reduction, so that you can adjust the plan together. Withdrawal is real and does not mean that you are not trying hard enough.
Sources: Thuisarts: stop taking antidepressants and guideline: tapering, with the multidisciplinary tapering documents.
Inadequate results are a reason to reconsider the plan, not to label you as 'finished'. Is the diagnosis correct? Was the treatment long enough and feasible? Are there side effects, other conditions or social problems that hinder recovery? A next step can be: adjusting therapy, changing medication or specialist treatment. Combining substances yourself is not safe.
A psychiatrist can sometimes add lithium or a certain antipsychotic to an antidepressant. This is called augmentation. It is not an ordinary additional antidepressant group and does not mean that you automatically have a psychosis or bipolar disorder. Additional checks are required, depending on the drug, for example on blood levels, kidney function, weight or metabolism.
With repetitive transcranial magnetic stimulation, magnetic pulses are delivered via a coil on the head. It can be considered for depression without psychotic features after insufficient effect of previous treatments, or sometimes earlier in case of serious medication side effects. It requires several sessions; headache or local discomfort may occur. It is not the same as ECT.
Source: guideline: rTMS
Electroconvulsive therapy is a hospital treatment under short anesthesia in which an epileptic seizure is induced in a controlled manner. It can help with severe or treatment-resistant depression, and is needed more quickly, for example, with psychotic features or when rapid improvement is medically necessary. Discuss the possible benefits and memory problems, temporary confusion and other side effects with the treatment team.
Sources: UMCG: ECT and guideline: location of ECT
Esketamine works differently than usual antidepressants, via the glutamate system. It can be used under specific conditions for treatment-resistant depression, together with an oral antidepressant. Administration is done under direct professional supervision with observation, partly due to increased blood pressure, drowsiness and dissociation: a changed sense of yourself or your environment. It is not a home remedy or guarantee of recovery.
Source: Compass: esketamine nasal
This page is about adults. Treatment under the age of 18 requires individual consideration and guidelines. Other doses, checks or choices may also be necessary in the elderly.
At home you can support the treatment with a feasible daily structure, small activities and contact with someone you trust. Relaxation can temporarily reduce tension, but is not a substitute for depression treatment. Look at practical exercises and small steps for at home. Ask for help if those steps feel too big.
Help in times of crisis. Call in case of immediate danger 112. In case of new psychotic symptoms, sharply increasing suicidal thoughts or severe deterioration, contact your GP, out-of-hours GP service or your treatment team immediately. If you have thoughts of suicide you can call day or night 113 or 0800-0113, or chat via 113 Suicide Prevention. Don't leave someone alone if it is unsafe.
No. Counseling and psychotherapy may be appropriate without medication. For more severe symptoms, a combination is often discussed. The choice also depends on your preference, functioning and previous treatment.
Important groups are SSRIs, SNRIs, tricyclic antidepressants and MAOIs. In addition, there are drugs with other effects, such as mirtazapine, bupropion, vortioxetine and agomelatine. Medicines within a group differ in applications and risks.
There is no single best antidepressant for everyone. The choice is tailored to the previous effect, side effects, other medications and your health. A drug that helps well does not need to be replaced because it is not a common first choice.
CBT examines the connection between thoughts, feelings and behaviour. IPT focuses on relationships, loss, conflict and role changes associated with depression. Discuss which approach suits your situation.
Side effects are usually discussed in the first weeks. The effect is often assessed after four to six weeks; sometimes more time is needed. In case of severe deterioration, contact your clinician immediately and do not wait for the appointment.
Not automatically. After reducing a dose, withdrawal symptoms may arise that sometimes resemble a relapse. Discuss new symptoms with the prescriber and adjust the tapering plan together.
No. Some combinations are dangerous and switching may require a waiting period. Have your clinician and pharmacist make a plan and also include supplements and self-care products in the medication overview.
