Celebrating Progress, but Challenges Remain

With their early age of onset, high prevalence, chronicity, and pervasive impact on multiple domains of functioning, the burden of mood disorders exceeds that of virtually all medical conditions in the US and globally in terms of disability, cost, and suffering.

My long-term clinical and research interest in mood disorders has two primary sources. First, having a parent with a recurrent mood disorder taught me that vulnerability to depression can freely coexist with notable resilience and strength in many other areas, and that depression can be treated. Second, as a psychiatrist-in-training, I learned that mood disorders may be treatable for some but are barely treatable for far too many others. The field continues to evolve, but the challenges I first learned as a trainee largely remain.

Nevertheless, we have seen major advances over the past decade, including:

• Implementation of routine screening for depression in primary care and some sub-specialty care settings;

• Increasing adoption of measurement-based care;

• Greater emphasis on chronic disease management approaches for those with persistent or recurrent illness;

• A growing range of evidence-based psychotherapies and neuromodulation strategies;

• The quite preliminary yet promising emergence of combinatorial pharmacogenomics and other biomarkers that may augment clinical judgment;

• The FDA approval in 2019 of two rapidly acting antidepressants leveraging novel neural mechanisms; and

• An expanding range of big data approaches that promise to extend the reach of patient-oriented science well beyond traditional clinical trials.

The increased interest in the health and treatment of individuals traditionally under-represented in mood disorders research-including ethnically, culturally, and racially diverse individuals and individuals from sexual and gender minority groups-is also quite encouraging.

As we celebrate progress, we also appreciate the magnitude of the remaining obstacles. The considerable heterogeneity across patients in presentation, course, and treatment responsiveness continues to beg the question of whether the current nosology of mood disorders is meaningful. It remains quite possible that major depressive disorder is a non-specific manifestation of multiple pathophysiological entities. Along with high placebo response rates in depression studies, the potential inclusion of individuals whose symptoms reflect quite distinct etiologies means that the signal of promising treatments is almost certainly often lost amidst the noise of multiple subgroups with diverse responses.

Special patient populations with mood disorders, such as pediatric, geriatric, or peripartum, have been remarkably under-studied. And, access to expert care for individuals in these groups is often limited. As we welcome the burgeoning number of treatments and treatment modalities, we lack adequate research devoted to their optimal combination and sequencing.

In this Special Report, we have tried to target these important challenges with articles on the integration of psychotherapy and pharmacotherapy in the treatment of major depressive disorder and on diagnostic and treatment challenges in pediatric bipolar disorder.

The profound impact of mood disorders in health care settings and on society is widely acknowledged by clinicians, administrators, and policy makers. Government and health care leaders increasingly understand the value of greater investment in mood disorders. With increasingly sophisticated research approaches and evidence informed treatments, we have reason to look forward to meaningfully improved outcomes for the hundreds of millions of individuals who suffer from mood disorders during their lifetime.

Disclosures:

Dr Alpert is Dorothy and Marty Silverman Chair, Department of Psychiatry and Behavioral Sciences, and Professor of Psychiatry, Neuroscience and Pediatrics, Montefiore Medical Center and Albert Einstein College of Medicine, New York. He reports no conflicts of interest concerning the subject matter of this Special Report.