Special Populations, Emerging Treatments and Persistent Challenges

October 1, 2004

Over the past quarter-century, new treatments for depression have emerged that are as effective as original pharmacotherapies but have fewer side effects. Yet, full remission and access to care remain out of reach for so many people. In this introduction to our Depressive Disorders Special Report, Dr. Golden encourages readers to see the glass as half-full.

Our progress in the treatment of depressive disorders, like the proverbial half-filled glass of water, can be viewed either as a partial success or a partial failure. Over the past quarter-century, many new treatments have emerged that are at least as effective as the original pharmacotherapies, yet have fewer and milder side effects. The majority of patients respond to their initial course of treatment. Our investment in basic and translational neurobiology should yield further advances in our armamentarium over the next several years. Massive public education efforts have begun to break down some of the stigma and lack of awareness that discourages people from obtaining treatment. Yet we still continue to see patients in our offices, clinics and hospitals who do not achieve an adequate response to treatment, and people throughout our communities continue to suffer without ready access to state-of-the-art care.

In this Special Report, some of the most challenging and, in many ways, most important clinical populations are highlighted. Women suffer disproportionately from depression and, in many instances, an underlying vulnerability breaks through during pregnancy and the postpartum period. This is especially poignant considering depressive illness in such instances attacks two patients, as the important mother-infant bonding process may be substantially disrupted. Rita Suri, M.D., and Lori L. Altshuler, M.D., provide an important overview of postpartum depression, including a synopsis of potential hormonal influences, the risks of untreated depression and our evolving evidence base for considering treatment options.

The obesity epidemic in this country is receiving increased attention, and thus, it is most timely to review the interplay between depression and this condition. In this month's continuing medical education article, Albert Stunkard, M.D., and colleagues provide a thoughtful synopsis of the diagnosis and pathogenesis of obesity and review the moderators and mediators that affect the complex relationship between these common syndromes.

The treatment of depression in the elderly remains an enigma. Several years ago, a task force highlighted the important role that psychotherapy should play in the treatment of depression in older patients. However, in many settings, psychotherapy is not incorporated into treatment planning as often as one might expect. Francesca Antognini, Ph.D., and James M. Ellison, M.D., highlight some of the possible root causes of this dilemma and summarize the emerging evidence base regarding the efficacy of psychotherapy and combined therapy in this important and growing subset of patients.

Light therapy (or phototherapy, as it was originally referred to) has a fascinating history. As Leo Sher, M.D., points out, the origins of light therapy can be traced to antiquity, although the modern chapter in its evolving story is intertwined with the identification of seasonal affective disorder (SAD) by Rosenthal and colleagues two decades ago. In his review, Sher highlights the practical clinical aspects of light therapy, along with the emerging evidence base for its use. Those readers who remember the ad campaign for orange juice that declared, " It's not just for breakfast anymore!" may see that light therapy may " not just be for SAD anymore," based on the summary of studies in nonseasonal depression.

New treatments for depression are on the horizon, but this offers limited solace for patients who are suffering from refractory depression today. We must take full advantage of all of our currently available therapies, including thoughtful combinations of medications that demonstrate efficacy and safety in controlled trials. The use of atypical antipsychotics in refractory nonpsychotic depression is reviewed by Richard C. Shelton, M.D., a pioneer in this area. This developing story reminds us of the limitations that may be imposed inadvertently by the initial application of a label to a new class of medication. Just as certain " anti-epileptics" could be described as " mood-stabilizing agents," it appears that the " atypical antipsychotics" may merit the descriptor " antidepressants" in certain situations. We hope that Shelton's paper, along with the other reports in this special section, will help guide our collective efforts to " fill the glass completely" in the treatment of depression.

It is with much gratitude that Psychiatric Times acknowledges Robert N. Golden, M.D., for his extensive contribution in planning and reviewing this special report. Dr. Golden is professor and chair of psychiatry and vice dean at the University of North Carolina at the Chapel Hill School of Medicine.