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International Journal of Emerging Issues of Social Science, Arts, and Humanities

Vol. 2 No. 2; April 2024; Page: 58-68



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Unveiling the Interplay of Depression, Antidepressants, and Cognitive Patterns: A Review of Silent Schemas in Mental Health Struggles



Lyu Shunchao1*, Pan Chunqiu2


1&2Faculty of Social Science, Arts & Humanities, Lincoln University College, Malaysia


*Corresponding author’s e-mail: lyushunchao006@outlook.com


ABSTRACT


This review examines the complex relationship between depression, medication, and cognitive processes, revealing implicit cognitive frameworks that affect depression. It examines how automatic thinking and cognitive schemas affect depression-related emotions and behaviors using the Dysfunctional Attitude Scale. We examine how antidepressants affect cognition and emotion, including automatic thinking, cognitive schemas, and emotional well-being. It stresses evidence- based depression treatment and the placebo effect. The study compares cognitive therapy's long-term benefits on patients' pessimism, self-view, and mood versus medication's, focusing on cognitive schema modification. The study examines pharmaceutical users' cognitive reactivity and relapse triggers using mood induction to understand depression relapse vulnerability better. Neuroimaging is also used to examine metabolic activity and brain areas after cognitive treatment and medication to determine how each treatment affects memory consolidation and cognitive functioning. This thorough study explains the complicated interaction between depression, pharmacological therapy, and cognitive processes, enhancing depression understanding and empirically supported mental health approaches.


Keywords: Dysfunctional Attitude Scale (DAS); Cognitive Schemas; Depression; Automatic Thought Questionnaire (ATQ)


Background


Depression is a complex and pervasive mental health disorder that affects millions of individuals worldwide. The treatment landscape for depression has seen significant advancements, with both cognitive and pharmaceutical interventions playing essential roles in alleviating symptoms and improving overall well-being. This comprehensive analysis seeks to compare the effects of these two approaches on individuals battling depression, focusing on their long-term impact on negative schema. Negative schema, deeply rooted and tenacious cognitive patterns, have been identified as central contributors to the perpetuation of depressive symptoms (Leavitt et al., 2020). This study aims to shed light on how cognitive and pharmaceutical interventions influence these schemas and their potential long-term effects.

  1. Cognitive Interventions and Negative Schema

    Cognitive interventions, including cognitive-behavioral therapy (CBT), have gained prominence in the treatment of depression due to their focus on identifying and challenging negative thought patterns (Alareqe et al., 2022). Research has demonstrated their effectiveness in modifying dysfunctional schemas and reducing depressive symptoms. When individuals receive cognitive treatment, there is a notable positive modification in their cognitive patterns over time (Price & Duman, 2020). These interventions equip patients with essential coping mechanisms and a renewed perspective on their thought processes, ultimately leading to improved mental health (Aljaberi et al., 2021).


  2. Pharmaceutical Interventions and Negative Schema

    Pharmaceutical interventions, such as antidepressant medications, are commonly prescribed to individuals with depression. These medications provide symptomatic relief by altering neurotransmitter levels in the brain. While they are effective at managing depressive symptoms, their influence on the negative schema is more nuanced. Antidepressants primarily target the biochemical underpinnings of depression, leaving the cognitive aspects relatively unaltered. As a result, a subset of the negative schema may persist even when overt depressive symptoms are in remission (Chin Fatt et al., 2020).


  3. Long-term Effects of Pharmaceutical Treatment

    This study delves into the long-term effects of pharmaceutical treatment on individuals with depression. Even after individuals no longer exhibit obvious signs of depression, they frequently retain emotionally concealed and inactive maladaptive schemas. These schemas can subtly but significantly influence their thoughts and behaviors. When exposed to stressors or mood-inducing situations, these residual dysfunctional schemata may resurface, impacting individuals' responses and decision-making (Ho et al., 2020). Additionally, the cessation of pharmaceutical interventions raises questions about their enduring effects on a negative schema. It is observed that discontinuation of medication can lead to the reactivation of dormant schemas, potentially contributing to the risk of relapse. This highlights the need for ongoing support and monitoring for individuals who have undergone pharmaceutical treatment for depression.


  4. Comparative Analysis

When comparing the two techniques, it becomes evident that cognitive interventions have a higher level of effectiveness and durability in inducing positive modifications in response to negative schema. Cognitive treatments equip individuals with the tools to identify, challenge, and reframe dysfunctional cognitive patterns. As a result, these interventions target the root causes of depressive symptoms, leading to sustainable improvements in mental health (Boschloo et al., 2019).


Research Problems and Gaps:

  1. Limited Longitudinal Studies: While there is extensive research on the short-term efficacy of both cognitive and pharmaceutical interventions for depression, there is a dearth of longitudinal studies examining their long-term effects on negative schema and overall well-being.

  2. Comparative Analysis: There is a lack of comprehensive comparative studies directly comparing the long-term impact of cognitive and pharmaceutical interventions on negative schema in individuals with depression.

  3. Mechanisms of Change: The specific mechanisms through which cognitive and pharmaceutical interventions affect negative schema and their sustainability over time remain poorly understood.


Research Questions:

  1. What are the long-term effects of cognitive interventions on negative schema in individuals with depression, and how do these effects compare to those of pharmaceutical interventions?

  2. How do cognitive and pharmaceutical interventions for depression differ in their mechanisms of altering negative schema, and what factors contribute to the sustainability of these changes over time?

  3. Are there distinct subgroups of individuals with depression who respond better to cognitive interventions versus pharmaceutical interventions in terms of modifying negative schema?

  4. What role do individual differences, such as cognitive flexibility and neurobiological factors, play in mediating the long-term effects of cognitive and pharmaceutical interventions on negative schema in depression?

  5. How can insights from this research inform the development of personalized treatment approaches that maximize the sustained reduction of negative schema and improve long-term outcomes for individuals with depression?


Literature Review


The therapeutic methods used to treat depression are thoroughly reviewed in this article. It examines cognitive and affective aspects, including depressed cognitions and cognitive schemas in depression. This study also analyzes how pharmaceutical therapy and cognitive interventions address persistent and maladaptive schemas associated with depression. This review tries to synthesize available literature to explain how various therapy techniques improve emotional well-being and provide persistent symptom alleviation in depressed people.


The review concludes that psychopharmacological interventions, while beneficial in treating depression, may hide or restrict some cognitive schemas' infectious traits. Pharmacological therapies may protect the emotions but not the cognitive components of depression (Törnblom & Drossman, 2021).


The importance of including cognitive and affective aspects of depression in therapeutic approaches is shown by this extensive literature review. Although drugs can relieve symptoms, cognitive therapies are more effective at correcting the underlying cognitive schemas that cause depressive affective symptoms and are resistant to treatment (Heifets & Malenka, 2019). Pharmacological

therapies may not properly treat the cognitive elements of depression, so a multidisciplinary approach may be needed to establish a more thorough treatment strategy.


Methods


Cognitive evaluation tools are designed to choose a subset of negative cognitions from a larger cognitive spectrum. These tools' endorsement evaluation methods go beyond 'present' or 'absent.' These surveys vary in their focus on aggregated symptoms or individual cognitions. Bowlby's theory of internal working models suggests that detecting thought clusters can reveal cognitive schemas and developmental traumas (Thompson, 2021). Analyzing cognition’s degree and substance is essential to understanding how medicine and cognitive therapy manage depressive symptoms. Due to these differences, depression patients are characterized as 'walking wounded.' They exhibit psychological tendencies akin to "walking pneumonia," allowing them to sustain cognitive function without disease-related deterioration. Consequently, people can avoid emotional suffering from their own cognitive patterns (Homme & Shults, 2020).


Cognitive processes are assessed using many tools in mood disorder research. The Personal Beliefs Inventory, Cognitions Questionnaire, Cognitive Errors Questionnaire, Beck's Depression Inventory- II, Attributional Style Questionnaire, Ways of Responding Questionnaire, Automatic Thoughts Questionnaire, Hopelessness Scale, Sociotropy-Autonomy Scale, and Schema Questionnaire are included. The Dysfunctional Attitudes Scale (DAS) is less sensitive and specific for depression in a wide range of clinical groups than the Alternative Thoughts Questionnaire (ATQ). Thus, the ATQ is commonly used in both domains. The Depression Assessment Scale (DAS) can distinguish between groups with various depression levels, although the Automatic Thought Questionnaire (ATQ) is more sensitive. However, the DAS produces a high rate of false-positive results (Jalenques et al., 2021). Participants rate their agreement with negative ideas on Likert scales in the ATQ and DAS (Ruiz et al., 2020). Most researchers use cumulative scores for evaluation, but some use item analysis to uncover cluster response patterns. The ATQ is responsive to depression, but its diagnostic accuracy is limited. However, the Dysfunctional Attitude Scale (DAS) has lower sensitivity and more diagnostic mistakes. Both assessments offer great insights into depression symptoms and treatment efficacy (Kürümlüoğlugil & Tanrıverdi, 2022).


Discussion


Cognitive Schemas

Schemas—cognitive constructs used to make sense of reality and interpret experiences—explain, perceive, and direct behavior. Many believe these schemas are generated from nuclear family experiences and integrated into an individual's self-concept, influencing perceptions and symptoms. Shaping established schema patterns often faces resistance. Contextual signals can activate cognitive schemas regardless of drug status. Despite their potential drawbacks, schemas provide regularity and comfort (Calvete et al., 2019). Schemas are thought to arise from repeating early childhood events. Template schemas filter and process data and maintain it. The perceptual field is restricted to help the brain process sensory input. Selective input helps reinforce schema patterns (Bredicean et al., 2020).


Schemas, defined by advanced and comprehensive cognitions, are linked to more stimuli or situations that can trigger them. Schemas are thought to evolve in response to unmet demands such as interpersonal connection, autonomy, independence, impulsivity, and self-regulation (Tariq, Reid, & Chan, 2021). The extent to which genetic predispositions affect an individual's schema preference in different contexts is unclear. Wilde & Dozois (2019) state schemas are inactive during symptom absence but activate and affect cognitive processing when prompted. Latency implies inaction, although the exact influence of dormant schemas on cognitive processes and actions is unknown. Negative schemas can influence people through communication and behavior even when they are dormant, especially if they are coupled with mood problems. Schema deactivation reduces

symptoms, particularly low mood, without changing schemas unless more advanced therapeutic techniques are used.


Hope as a Cognitive Schema ‌

When schemas alter, hope influences treatment outcomes. The hope of early cognitive development supports adaptive information processing. The absence of hope suggests self-sustaining aberrations. According to Erikson, hope is a virtue when people resolve their initial trust and mistrust issues. By internalizing a mother figure, a trustworthy caregiver's availability is perceived. Erikson's early emergent patterns reflect primordial schemas and resist change (Sekowski, 2022). Big reductions in pessimism suggest increased adaptability, which may improve other cognitive deficits. Previous studies have shown that depressed patients with high despair levels are more likely to abandon therapy and have poor outcomes. Some people still have depression after extensive therapy (Schachter, 2018; Sekowski, 2022). This is crucial because reductions in despair in the first month of therapy improve treatment results. Hope inspires change. Hope is changeable therapeutically. People with personality disorders may feel despondent and reluctant to change (Mohammed et al., 2023). Self-destruction, emotional attachment, and identification with problems are common among these people.


Negative Beliefs Cause Depression‌

Depression is believed to stem from enduring negative thought patterns, referred to as schemas, which give rise to the appearance of depressive symptoms. This concept incorporates both the substance and the mental processes of cognition, including underlying negative patterns of thought that can be awakened or triggered by significant adverse life events. Often seen as superficial manifestations, automatic thoughts can offer insights into their underlying cognitive schema origins. The literature has solidly established a link between clinical depression and negative cognitive processes, including their onset and duration. However, the exact connection between neurochemistry, genetic predispositions, and depressive schemas is still unclear. Depression includes both emotional experiences and negative thinking patterns (Aljaberi et al., 2022), which can be measured with assessment tools like the Depression Anxiety Stress Scale (DAS) and the Automatic Thoughts Questionnaire (ATQ). Typically, there is a direct correlation between higher scores on the DAS (Depression Anxiety Stress Scale) and less positive outcomes in treatments that largely utilize medication (Ruiz et al., 2020). This indicates the need to incorporate additional therapy methods. The effectiveness of pharmaceutical therapies in reducing symptoms may be limited when significant negative cognitive networks are present (Yapan, Türkçapar, & Boysan, 2022).


Once the treatment's effectiveness is confirmed, it is expected that the main symptoms of depression will decrease. Various symptoms, such as the apprehension of criticism, anxiety about rejection, and an inclination for connection, were identified as significant areas that displayed alterations during the therapy process for participants who attained favorable therapeutic results. The aforementioned indicators of depression exhibited a decline in magnitude as time progressed (Demir & Ercan, 2022). However, there was no discernible variation in these three fundamental categories among those who did not display a reaction to the treatment. The emotional symptoms of non-responsive individuals were significantly influenced by enduring negative beliefs, in addition to the expected impact of medication on mood.


Antidepressants and Euphoria

According to Read & Moncrieff (2022), there is insufficient conclusive data to support the usefulness of antidepressants in treating depression. They also question the idea that depression is solely caused by a malfunctioning brain that requires medication. Alternatively, the authors suggest that antidepressants induce an abnormal neurophysiological condition, leading to different effects such as drowsiness, cognitive decline, and increased alertness. The subjective experience of stimulation caused by these medicines might vary significantly, depending on individual differences, resulting in either feelings of pleasure or agitation. Moreover, the application of moderate levels of stimulation has the capacity to enhance attention and focus. Conversely, the use of antidepressants might

potentially cause sleepiness, which can help reduce the discomfort often felt during times of increased alertness.


Several commonly prescribed antidepressant medications, such as Paxil, Prozac, Celexa, and Effexor, have been found to have harmful effects on the central nervous system, including the occurrence of euphoria. The anticipated positive result has the capacity to alleviate depression symptoms that may emerge from persisting or underlying maladaptive attitudes or beliefs. While pharmacological interventions have been shown to alleviate specific symptoms commonly associated with depression effectively, it is important to recognize that certain underlying negative thoughts may still persist in a temporarily weakened state, which may not be completely resolved by the euphoric effects induced by medication (Carey, 2019).


Medication and Autonomic Thoughts‌

Automatic thoughts may reveal a deeper cognitive paradigm. A person's head constantly flows with pleasant and negative thoughts without conscious knowledge. Automatic schema notions produce unconscious behavioral and emotional responses. Stress increases automatic thoughts, making them more visible and accessible (Hu et al., 2019). Consider placebo effects when taking depression medicine. Medication significantly reduces symptoms compared to placebo. This reduces the placebo effect (Heifets & Malenka, 2019). However, evidence-based treatment suggests pharmaceutical outcomes may indicate psychological therapy. When using pharmaceuticals to treat symptoms, therapeutic professional aid may be essential. This aspect affects medication the most. Due to professional ties, prescriptions may influence cognitive schema patterns more than medication alone. A reduced Dysfunctional Attitude Scale (DAS) for depression was used to assess pre- and post- medication automatic thoughts in a typical investigation. Some negative thoughts or automatic thinking were greatly reduced by tricyclic antidepressants (Brown, Delgadillo, & Golino, 2023). This DAS investigation showed a subset of sad beliefs that remained statistically significant after one year of symptom remission in the medication-treated group. Subgroup support of intractable concepts reflects a shared schema or cognitive organizing style that enhances and exhausts environmental investigation. Depression was associated with pessimism, resilience, efficacy, and self-dependence. They desired ultimate control, appreciated others' opinions, and addressed interpersonal conflicts swiftly. Hypomania is linked to these cognitive tendencies (Qin et al., 2020).


In another trial, mild depression patients received six weeks of psychopharmacological treatment. Negative perceptions dropped significantly, supporting physiological factors affecting cognitive dysfunction. This study used the Dysfunctional Attitude Scale (DAS) without analyzing cognitions or schemas. Although qualitative cognitive data was not examined, several drugs lowered negative thoughts (Brown, Delgadillo, & Golino, 2023). DAS analysis demonstrates mood causes maladaptive attitudes. Phenotypic effects in the therapy group confirmed residual illness. Interestingly, exogenous depression patients had higher initial DAS scores than endogenous patients. Additionally, exogenous patients exhibited more disordered thoughts. In both cohorts, higher baseline DAS scores predicted worse treatment outcomes. Beck and Dozois (year) say stress triggers behavior or conditions based on vulnerability and strength. If the inclination is strong, less stress can produce disease. In contrast, lower vulnerability demands increased stress before sickness (Brown, Delgadillo, & Golino, 2023; Qin et al., 2020).


Another study found that medicine and cognitive therapy treated depression similarly. Treatment cohorts differed significantly. Cognitive therapy improved pessimism, self-view, and mood, which boosted motivation and activity (Beadle et al., 2020). Instead, medicated patients revealed no trends. Regular schema and mood changes inspire cognitive therapy patients. Depression and other stressors might produce recurring symptoms in medication recipients with a weak basic framework. Self-paced slide displays of the sad facial expressions of others were employed to produce a sad mood in the study. Medicine enhanced dysfunctional attitudes during sad mood induction, one study found. Cognitive treatment patients did not increase reactivity, and only the drug group had depressed recurrence in the following years. Medication seems to inactivate cognitive reactivity until sad

emotions are aroused. Most studies that revealed no difference between pharmaceutical and cognitive therapy overlooked reactive thoughts and depression relapses (Sedikides, 2021).


Participants might read unpleasant thoughts or relive painful events using the slide show induction technique to create melancholy. Sad mood induction in the lab can reveal concealed negative thoughts in medication-treated patients. According to studies, drug therapy patients' symptom reduction is hierarchical. Pharmacotherapy minimizes negative thinking by treating emotions. This effect is weaker and shorter-lasting than cognitive treatment. Emotions and cognition interact like semi-permeable membranes (Beadle et al., 2020). Alterations in cognitive patterns, especially deep schemas, alter emotions. Pharmacological interventions cause affective alterations that cause cognitive adjustments, although less so.


Cognitive and pharmaceutical treatments for unipolar depression differ biologically. The metabolic activity of two treatments differs. Medication affected limbic-cortical networks, while cognitive treatment altered cortical-limbic pathways. Cognitive therapy boosted the hippocampus and decreased the frontal cortex. Medication changed outcomes by lowering hippocampus activity and enhancing frontal brain activity (Price & Duman, 2020).


Cognitive reconstructions may boost hippocampus activation by consolidating short-term memories into long-term ones. The frontal cortex governs planning, initiative, personality, and creativity and helps learn and recall by communicating with other brain regions. The frontal brain stores long-term memories; therefore, schema-based cognitive treatment may require suppressing preexisting schema. Medication patients can benefit from euphoric effects rather than new learning pathways. Pharmacological treatment or unknown interactions may boost frontal brain activity in this group (Tao et al., 2020).


Cognitive Therapy as an Adjunct to Other Treatments

Numerous studies show that cognitive therapy reduces depressive symptoms in the early phases, with a focus on cognitive schema identification and adjustment as treatment progresses. Lack of a shift from a basic evaluation and adjustment method to a global perspective leads to treatment outcomes similar to those of pharmaceutical patients. This increases recidivism. Cognitive therapy has increasingly examined core beliefs to sustain recovery (Brown, Delgadillo, & Golino, 2023). While most cognitive therapy approaches have focused on acute phase states, pre-morbid fundamental beliefs are becoming more important.


Differences in study analysis may make the results seem ambiguous in studies comparing medical and cognitive therapy. When measuring excessive automatic thinking responses approved by individuals, cognitive treatment improves pharmaceutical therapy. Many studies show that cognitive treatment reduces relapse rates more than medicine (Beadle et al., 2018). A persistent depression group responded well to schema-focused cognitive treatment. The technique included an introduction, a bonding phase, and up to sixty schema therapy sessions. The six-month follow-up showed that the Hamilton Rating Scale for Depression reduced symptoms significantly and persistently.


According to research, medicine can improve depression symptoms by elevating mood, inducing euphoria, and suppressing certain sad or dysfunctional thoughts, which can relieve some bodily symptoms. However, residual, or unanalyzed, negative schemas remain fully integrated even with medicine. Schemas' bodily effects are hidden until stress triggers those (Hu et al., 2019). The creation of stress and a sad mood can reveal or activate underlying schema, but it does not inevitably engage particular systems. Other environmental cues may have a similar causal effect but have not been properly examined. Cognitive therapy produces the most widespread and lasting change and prevents relapse better than medicine (Carey, 2019; Van Tongeren et al., 2021). What happens when life circumstances activate specific cognitive frameworks, revealing depressive symptoms? Does time increase or decrease latency's impact on unfavorable cognitive patterns? Language imagery impacts and unanswered questions require further study.

Psychological trauma survivors may have hidden maladaptive schemas that medicine suppresses. Stress can bring back these schemas as outmoded symptoms (Aljaberi et al., 2023). Medicated people who are emotionally insulated from symptoms have mildly negative cognitive schemas (Boschloo et al., 2019). Even when dormant, schemas limit perceptions, attributions, actions, and decisions throughout an individual's lifespan, especially in stressful situations. Research suggests that these schemas may impact those not using medicine and those experiencing psychological distress (Price & Duman, 2020; Kürümlüoğlugil & Tanrıverdi, 2022).


Contrary to medication, cognitive therapy focuses on resolving negative cognitive schemas that cause persistent causal links in depression. Medication generally alters surface-level cognitions related to depressive symptoms, whereas underlying negative conceptions still impact life choices and activities (Kriesche et al., 2023).


Conclusion


The study promotes depression management theory and practice. Its major breakdown is:


Integration of Cognitive and Pharmacological Therapies: This study highlights the importance of adding cognitive and pharmaceutical depression treatments. By admitting both ways' efficacy, the study gives clinicians and researchers a solid foundation to develop better treatments. Depression is complex; thus, cognitive processes and symptoms must be addressed for efficacy.


Addressing Fundamental Cognitive Processes: Cognitive therapies to modify negative schema and depression-causing cognitive processes are crucial. This implies that remedies should address the root rather than just the symptoms. Interventions targeting these cognitive biases can prolong mental health and well-being.


According to the study, pharmacologically treated patients need cognitive support to prevent relapse. Preventing hidden negative cognitive frameworks reduces relapse risk. Adding cognitive support to treatment can boost long-term effects and help patients progress. Recognizing the complicated relationship between cognitive and pharmacological therapies allows for better and more customized depression treatments. Clinicians can tailor cognitive and pharmacological therapy to each patient's presentation and response. Personalization may improve treatment outcomes and patient satisfaction.


Depression cripples’ individuals, families, and societies worldwide. Better treatment methods from the study could help millions of depressed people. Improved therapy can reduce the condition's impact on individuals and society, boosting productivity, healthcare costs, and well-being. Cognitive and pharmacological therapy for depression is an important study finding. The findings inform theory and practice, paving the way for more effective and tailored treatment methods that benefit individuals and society.


Declarations


Ethics Approval & Consent to Participate: The current investigation was conducted after obtaining appropriate authorization from the institution for data collection.


Conflict of Interest: The authors state that they do not have any personal conflicts of interest.


Acknowledgement: The authors express their gratitude to the institutions for their support in the accomplishment of this study.



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