In the coming decades, medicine will face a new primary task: maximizing function and quality of life for those wit chronic disease. A new """"""""population-based medicine"""""""" which integrates preventive and rehabilitative interventions with curative interventions is already taking shape in managed care settings. This provides a unique opportunity for innovation in the integration of biomedical and psychosocial health services. This Scientist Development Award will prepare me to help lead psychiatry as it contributes to this innovation. The proposed 5-year plan of study of course work, seminars, and supervised research in epidemiology and health services will permit me to switch from controlled clinical research to population-based research. Three studies of health status and service use in coronary artery disease are proposed. FIRST, a longitudinal, observational study of patients' functional status and quality of life following coronary catheterization. 232 patients have already had extensive baseline biomedical and psychosocial assessments and one year of follow-up. This grant will allow assessments at 5 and 7 years after catheterization and an expansion of outcome measures to include more domains of health-related quality of life. SECOND, an experimental study of the role of depression in cardiac function, functional status, and quality of life conducted as part of a randomized controlled trial of sertraline in patients with a recent myocardial infarction and major depression. 80 depressed post-MI patients will be randomized to placebo or sertraline for 12 weeks. These patients and 50 non-depressed post-MI patients will be followed for a year with extensive assessments of functional status and quality of life at intake 12, 24, and 52 weeks. THIRD, participation in the data analysis in a series of three Dutch cohort studies following the functional status and quality of life of 150 patients each following development of depression, heart failure, and myocardial infarction. These cohort studies track enrollees from a cross- sectional study of 5000 who subsequently experiment a selected major event. The incident cases are interviewed at four weeks, three and eight months after the index event. These studies provide exposure to longitudinal, experimental, and cohort designs as ways of providing training in understanding biomedical vs psychosocial causation of functional status and quality of life.
