Wider, Faster, More: Reenvisioning Depression Treatment Research in the United States

Depression is among the top 10 leading causes of disability in the United States and worldwide. Although there are effective interventions, the burden of disability attributable to depression is not decreasing and has not decreased even in places where treatment availability has increased. Contemporary research efforts have a focus on treatment development and the identification of biomarkers of psychophysiology or treatment response. These potential solutions are not scalable because depression is more common than usually appreciated, and there are substantial disparities in access to mental health care. Improving the dissemination of individual interventions may also be of limited value given data suggesting that high rates of symptom remission can only be achieved with multiple (e.g., 4-10) treatment steps. The logic of stepped care approaches for depression is well supported by these data, but "stepping up" should occur more quickly than usually done in most trials and treatment needs to include both low-intensity (e.g., self-guided app) as well as very high-intensity treatments (e.g., electroconvulsive therapy or ECT). Efforts that promise to make an impact in the public health burden of depression need to consider its high prevalence and the heterogeneity in the level of care needed as well as the different mechanisms that treatments may need to engage. A model of research by lone principal investigators or small teams is unlikely to make a substantial impact on the public health burden of depression because no individual is likely to have the expertise to study radically different treatments like self-guided apps and ECT. Clinical Impact Statement Depression is a heterogeneous distress reaction that affects a large and diverse group of individuals, and it has a highly variable prognosis. Practitioners and researchers should be skeptical of proposed solutions like developing novel treatments or using biomarkers and should consider practical solutions to treating depression, such as stepped care, low-intensity treatments, and rapidly augmenting treatment.