Depression is a public health problem with U.S. population prevalence rates totaling over 11% for depressive disorders. Major depression alone has a lifetime prevalence estimate over 17% and causes substantial functional impairment and debilitates well-being. A 1990 estimate of the economic burden of depression was $44 billion, and this burden, as well as impact on functioning and well-being, is comparable to other major medical illnesses. Despite efficacious treatments such as pharmacotherapY and psychotherapy, the appropriateness and effectiveness of depression treatments are not as expected and need further exploration. Furthermore, key elements surrounding a depressed person's needs and wants are not well delineated -- elements which may directly affect the process of care, and hence, patient outcomes. This revised SDAC application is comprised of a career activities plan and research program to examine a specific individual component affecting the process of care -- what people think about, need and want regarding depression and its treatments. This plan focuses on an understudied area in mental health services research -- health state preference (utility) assessment -- and its application to depression outcomes which will include both positive and negative aspects of treatments. Measuring preferences for certain health states, or outcomes, is one approach to examining health related quality of life, and can be applied to other health services research such as cost-effectiveness and decision analyses. The career activities plan is comprised of preceptorship, on-site consultation team, off-site practical, didactic courses, tutorials, and conferences, and will thereby meet four clearly specified needs of the applicant to facilitate his scientific inquiry in this area. The research program is comprised of three projects which will yield preferences of depressed patients, their family members, and the """"""""general public"""""""" for depression outcomes. These preferences will be obtained using three standard methods (category rating, standard gamble, time trade-off) and a decomposed measurement design rooted in theory. Additionally, the research program will examine the comparative performance characteristicS (reliability, validity, feasibility) of the methods, as well as the impact of other individual characteristics such as sociodemographics, clinical status (including functional health status) and history, and two rarely studied domains -- attitudes/expectations and knowledge. Finally, the third project will be a basic (vs. applied) research study investigating preference elicitation using non-traditional/methods rooted in theory. This research, informed by the career activities plan, can have clinical, research and policy implications. This program will hopefully generate refined methods and """"""""utility"""""""" data for future cost-utility and decision analyses, guide innovative interventions to improve the effectiveness and appropriateness of depression care, and provide a synthetic conceptual framework within which to study preferences for other mental health outcomes. Finally, this SDAC will facilitate the applicant's development into a independent mental health services researcher studying multiple aspects, especially at the patient level. of the process of care.
