Unlike efficacy trials, where specially trained clinicians carry out state-of-the-art assessment and treatment, public health trials are carried out in settings of usual practice where there is a broad and variable range

of clinician expertise and experience with the disorder under study. Outcome measures will necessarily extend beyond symptomatology to include function, disability, morbidity, mortality, health care and other resource use, family burden, institutionalization, Inhibitors,research,lifescience,medical and quality of life. Public health studies are not simply secondary analyses of administrative data collected in large and naturalistic databases, but are treatment trials that are broadly representative of clinical, family, and organizational factors.19 Types of intervention research We begin with the assumption that the mental disorders of late life are chronic, recurring conditions. Within this broad perspective, three types of studies would seem to be appropriate. First arc treatment Inhibitors,research,lifescience,medical trials including both short-term and long-term studies directed toward management of symptoms, optimization of function, and learn more minimization of disability. Treatment trials of this kind are common and well recognized in

the field. The methodology of these trials is well established and accepted by all those involved in clinical care. However, the conceptualization Inhibitors,research,lifescience,medical of the nature of treatment response is broader in public health trials than in regulatory trials. Rather than focusing exclusively on response as a dichotomous variable, ie, responder or nonresponder, a public health Inhibitors,research,lifescience,medical approach requires in addition that attention be paid to speed of response, completeness of response, and durability of response. An intervention directed at the speed of response fits within an overall conceptualization Inhibitors,research,lifescience,medical of treatment. The question is how can we accelerate the response to treatment and how early in the treatment process

can we know when an approach to treatment is likely to fail? A related question concerns the management of treatment-resistant cases. Regardless of how treatment response is defined, we know that invariably a subset of patients show incomplete responses Thiamine-diphosphate kinase or nonresponse to any given treatment intervention. Under the regulatory model, the management of nonresponders and partial responders receives relatively little attention. Yet treatment-resistant patients make up a significant portion of actual clinical practice and they account for a major share of the mortality, morbidity, and cost of mental illness. Therefore, a public health orientation requires that the management of treatment resistance be a priority for investigation. An intervention directed at the completeness of response is considered rehabilitative.