Beyond Medication: Developing Coping Skills in Treatment for Major Depression
When you are struggling with major depression, it is tempting to believe that medication will provide complete relief from your illness. However, researchers are learning more about the limits of medication and looking beyond pharmacotherapy to create better outcomes. Therapies that support the development of meaningful coping skills are now recognized as essential for creating comprehensive treatment experiences, leading to better outcomes.
Medication for depression is nothing new. Tofranil (imipramine), the first drug designed specifically to treat depression, was released in the late 1950s. Tofranil fundamentally changed the way depression was treated and understood by the medical community and the public alike. Hailed as a “miracle cure,” it quickly gained dozens of tricyclic rivals as pharmaceutical companies sought to stake out their place in the market. While the drugs were effective, helping 60-80% of patients find relief from symptoms, they also had serious drawbacks—weight gain, lethargy, and even risk of overdose. In other words, there was plenty of room for improvement.
That improvement came in the late 1980s in the form of a new class of antidepressants: SSRIs. Prozac became the first FDA approved SSRI in 1987 and by the next year, 2,469,000 Prozac prescriptions had been dispensed in the United States. Four years later, Elizabeth Wurtzel would tell millions of Prozac Nation readers about how this new generation of miracle drugs changed her life. Before being medicated, she was suicidal and felt she was living in “a computer program of total negativity … an absence of affect, absence of feeling, absence of response, absence of interest.” That changed when she began taking Prozac. “One morning I woke up and really did want to live … It was as if the miasma of depression had lifted off me, in the same way that the fog in San Francisco rises as the day wears on. Was it the Prozac? No doubt.” Her book raised the profile of Prozac like no drug advertisement ever could, and by 2002, the number of Prozac prescriptions written each year totaled over 33 million. Today, antidepressants are the second most commonly prescribed medication type in America, taken by 13% of the population.
Prozac, of course, isn’t alone—there is Zoloft, Paxil, Lexapro, Celexa. There are also new antidepressant types, offering options for people who didn’t respond to SSRIs. And, of course, there are other medications that are not antidepressants but can be used to treat depression or augment antidepressant treatment. And while this plethora of medication options has undoubtedly opened up avenues for healing for countless people struggling with major depression, it also reflects a widespread belief that medication can be the central—and often, only—focus in depression treatment. But empirical data does not support this conclusion. Rather, antidepressant treatment must be coupled with psychotherapeutic approaches that help you develop meaningful coping skills in order to achieve true recovery from major depression.
The Limits of Medication
Antidepressants and other types of medications used to treat depression have revolutionized the field of mental health treatment. They have improved and even saved the lives of millions of people, pulling them back from the abyss and restoring their sense of self. When they work, it is hard to overstate the value these medications have for people struggling with major depression.
However, medication doesn’t work for everyone equally; for example, meta-reviews have consistently found that people with severe depression show a greater response to SSRIs than people with mild to moderate depression. Additionally, as Elizabeth Penn and Derek. K. Tracy point out, “[I]t is well-recognized that there is significant individual variation in response to different medications.” Studies suggest that 10-30% of people with major depression do not improve with antidepressant treatment or show only a partial response while remaining in a general state of severe depression. Many of those who generally respond well to antidepressant treatment still experience residual symptoms to various degrees. Others are successfully treated for a time, then relapse due to an external trigger or because the medication appears to stop working. Tolerability issues may also interfere with medication adherence, compromising outcomes.
In all, medication on its own often fails to provide complete, durable relief from depressive symptoms and alleviate functional deficits. This, however, doesn’t necessarily mean that the medication is failing to do its job. While it was once believed that major depression was the result of a chemical imbalance that could be remediated with the right pharmacological intervention, that theory has failed to find empirical support. The fact is that we do not fully understand the causes of major depression, but we do know that it is a complex illness with emotional, cognitive, behavioral, and environmental components. Simply modifying brain chemistry does not address many of the factors at play; medication doesn’t automatically disrupt destructive and deeply held beliefs, it doesn’t make your trauma disappear, it doesn’t imbue you with the skills to form meaningful relationships or maintain a healthy lifestyle that reduces your risk of relapse. So while medication may be addressing the neurochemical part of the puzzle, it is not a panacea. Rather, it is one piece—often, a critical piece—in a larger project of healing.
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Looking Beyond Pharmacotherapy
Although medication has taken center stage in discourse surrounding the treatment of major depression in recent decades, a significant body of research has also emerged showing that specific psychotherapeutic modalities can produce similar short-term outcomes to antidepressant therapy. Furthermore, evidence suggests that the gains made through psychotherapeutic interventions are longer-lasting than antidepressant treatment.
A study published in the Nature Reviews Neuroscience comparing cognitive therapy (CT) to antidepressant medication (ADM) found that while CT and ADM had similar short-term effects, 54% of patients who received only ADM experienced recurrence of depression when withdrawn from ADM compared with only 17% of those who had received CT prior to ADM discontinuation. The authors note that:
These findings, which are consistent with the pattern observed in previous studies, indicate that CT has an enduring effect that is not found with ADM. This suggests that, whereas the acute responses to CT and ADM might be due to changes in similar mechanisms, CT can be assumed to also produce changes that ADM does not.
In other words, cognitive therapy offered not only comparable alleviation of acute systems, but enhanced protection against re-emergence of symptoms in the future. So what accounts for this difference in efficacy? While more research is necessary to more fully understand the mechanisms at play, most experts in the mental health community believe it comes down to coping skills.
Creating Meaningful Coping Skills
Coping is a something we all do throughout our lives to deal with internal or external stressors. When you experience major depression, however, your ability to cope is often diminished and you must learn new—and fortify existing—coping skills in order to regain emotional harmony. This is particularly important to protect you from harmful coping methods, such as substance use, which are unfortunately common for people with major depression.
Some coping skills are general in nature. Exercise, yoga, meditation, good sleep practices, a healthy diet, and engaging in meaningful social contact can all be basic building blocks to support mental health and are broadly applicable to virtually anyone struggling with major depression. Some coping skills, however, will be specific to your situation. This includes learning how to identify your individual challenges, such any harmful thoughts and beliefs, unresolved conflict, and traumatic memories you may be holding that prevent you from moving forward. With the guidance of an experienced therapist, you can deeply investigate the roots of these challenges, understand how they impact your emotional state, and develop the skills to overcome them. Cognitive therapy is often particularly effective for gaining both the insight and skills necessary to create meaningful emotional and behavioral change. As the Nature Reviews Neuroscience study explains:
(Cognitive therapy) therapists aim to help patients acquire the abilities to, first, identify the thoughts and images that accompany and precede the experience of upsetting emotions; second, distance themselves from the beliefs embedded in, or implied by, these thoughts and images; third, question, often through experiments, the validity of their beliefs (for example: What is the evidence for this belief? Are there alternative explanations for the event that triggered the beliefs?); and fourth, identify the themes in the content of the thoughts and images that occur across a range of situations.
Through this process, you and your therapist will create strategies for coping with both internal and external stressors in positive ways. In doing so, you can break through damaging patterns of thought and replace destructive ways of being with healthy alternatives, strengthening your resilience and self-determination even in the face of overwhelming triggers.
Of course, cognitive therapy is only one possible modality for developing coping skills. Psychodynamic, somatic, and holistic therapies all address major depression in a variety of ways and give you a multitude of ways to cope with psychological distress, both generally and in specific scenarios. This is vital for handling acute phases of major depression as well as preventing recurrence. These durable skills can stay with you throughout your life—even if your medication diminishes in efficacy or you need to switch medications, you can turn to your coping skills to buoy you through changes in pharmacotherapy, reducing the likelihood of slipping back into a deep state of depression. Additionally, you can develop specific skills to cope with any side effects of medication, increasing the likelihood that you will stick with and benefit from pharmacological treatment.
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Creating Comprehensive Treatment Experiences
The best treatment for major depression typically draws on both pharmacotherapy and therapeutic modalities designed to enhance insight and skill development to create a well-rounded treatment experience. As Dr. David Mintz writes, “Numerous studies have shown that combined treatment for depression to have many benefits over single-modality treatment.” As such, connecting with a treatment program that offers a broad array of therapies as well as expertly designed medication strategies is vital to creating lasting recovery.
For many, residential treatment programs are an ideal space for engaging in a truly comprehensive healing process. Removed from the stressors of everyday life, you are given the opportunity to rapidly find medication that works for you while participating in a full range of therapeutic practices. As you develop the coping skills necessary to nurture your emotional and behavior health, you also have the opportunity to practice these skills in a safe environment with the support of compassionate clinicians and peers. This helps you integrate positive coping in your life until it becomes a natural part of your everyday experience.
Residential treatment programs can also offer dedicated family program, such as family and couples therapy, to help you resolve interpersonal conflict and develop both individual and collective coping skills. This is often an essential part of the recovery process and ensures that each member of your family has the tools they need to break through damaging patterns and create more harmonious relationships. In doing so, you can grow stronger and learn how to nurture your bonds while dismantling unhealthy dynamics that interfere with your healing.
Major depression can be a deeply painful experience, but today we have more effective treatments than ever before. By engaging in comprehensive treatment, you can create true and lasting transformation and a more stable, purposeful, and joyful life.
Bridges to Recovery offers comprehensive treatment for people struggling with mental health disorders as well as co-occurring substance use disorders. Contact us to learn more about our renowned Los Angeles and San Diego-based programs and how we can help you or your loved one start on the path to lasting wellness.
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