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LeBlanc MA, Gough A, Rideout AL, Dyack S, Singh K, MacNeil M. Atypical Neuropsychiatric Presentation of FTD-ALS Caused by a Pathogenic Repeat Expansion in C9orf72: A Case Report. J Geriatr Psychiatry Neurol 2024; 37:157-162. [PMID: 37548032 PMCID: PMC10802081 DOI: 10.1177/08919887231195337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
The case report describes the presentation of a 42-year-old male ultimately diagnosed with FTD-ALS caused by a genetic mutation, who initially presented with atypical psychiatric symptoms. Given that the initial clinical manifestations of FTD-ALS can be quite variable, the diagnosis is often challenging; the case report aims to highlight several key considerations in the diagnostic assessment, including genetic testing in order to guide clinicians in more timely diagnosis and ultimately improve patient care.
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Affiliation(s)
- Marissa A. LeBlanc
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health, Halifax, NS, Canada
| | - Amy Gough
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health, Halifax, NS, Canada
| | | | - Sarah Dyack
- Nova Scotia Health, Halifax, NS, Canada
- IWK Maritime Medical Genetics, Halifax, NS, Canada
| | - Kathleen Singh
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health, Halifax, NS, Canada
| | - Meagan MacNeil
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health, Halifax, NS, Canada
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Dratch L, Azage M, Baldwin A, Johnson K, Paul RA, Bardakjian TM, Michon SC, Amado DA, Baer M, Deik AF, Elman LB, Gonzalez-Alegre P, Guo MH, Hamedani AG, Irwin DJ, Lasker A, Orthmann-Murphy J, Quinn C, Tropea TF, Scherer SS, Ellis CA. Genetic testing in adults with neurologic disorders: indications, approach, and clinical impacts. J Neurol 2024; 271:733-747. [PMID: 37891417 PMCID: PMC11095966 DOI: 10.1007/s00415-023-12058-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
The role of genetic testing in neurologic clinical practice has increased dramatically in recent years, driven by research on genetic causes of neurologic disease and increased availability of genetic sequencing technology. Genetic testing is now indicated for adults with a wide range of common neurologic conditions. The potential clinical impacts of a genetic diagnosis are also rapidly expanding, with a growing list of gene-specific treatments and clinical trials, in addition to important implications for prognosis, surveillance, family planning, and diagnostic closure. The goals of this review are to provide practical guidance for clinicians about the role of genetics in their practice and to provide the neuroscience research community with a broad survey of current progress in this field. We aim to answer three questions for the neurologist in practice: Which of my patients need genetic testing? What testing should I order? And how will genetic testing help my patient? We focus on common neurologic disorders and presentations to the neurology clinic. For each condition, we review the most current guidelines and evidence regarding indications for genetic testing, expected diagnostic yield, and recommended testing approach. We also focus on clinical impacts of genetic diagnoses, highlighting a number of gene-specific therapies recently approved for clinical use, and a rapidly expanding landscape of gene-specific clinical trials, many using novel nucleotide-based therapeutic modalities like antisense oligonucleotides and gene transfer. We anticipate that more widespread use of genetic testing will help advance therapeutic development and improve the care, and outcomes, of patients with neurologic conditions.
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Affiliation(s)
- Laynie Dratch
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Meron Azage
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Aaron Baldwin
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Kelsey Johnson
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Rachel A Paul
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Tanya M Bardakjian
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
- Sarepta Therapeutics Inc, Cambridge, MA, 02142, USA
| | - Sara-Claude Michon
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Defne A Amado
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Michael Baer
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Andres F Deik
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Lauren B Elman
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Pedro Gonzalez-Alegre
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
- Spark Therapeutics Inc, Philadelphia, PA, 19104, USA
| | - Michael H Guo
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Ali G Hamedani
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - David J Irwin
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Aaron Lasker
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Jennifer Orthmann-Murphy
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Colin Quinn
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Thomas F Tropea
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Steven S Scherer
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Colin A Ellis
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA.
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Colijn MA, Ismail Z. Presenilin Gene Mutation-associated Psychosis: Phenotypic Characteristics and Clinical Implications. Alzheimer Dis Assoc Disord 2024; 38:101-106. [PMID: 38227890 DOI: 10.1097/wad.0000000000000599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/18/2023] [Indexed: 01/18/2024]
Abstract
Although psychotic symptoms have been described in association with rare presenilin ( PSEN ) gene mutations underlying early-onset Alzheimer disease (AD), no contemporary reviews on this topic exist. The purpose of this review is to characterize the psychiatric phenotype (specifically with respect to psychosis) of PSEN1 and PSEN2 variant-associated AD. A PubMed search was completed in July 2023. Only articles that described individuals harboring a PSEN1 or PSEN2 mutation who experienced symptoms of psychosis were included in the review. Thirty-three articles describing 52 individuals were included in the review, as well as one other study that provided limited information pertaining to an additional 21 cases. While visual hallucinations were the most common psychotic symptom, followed by persecutory delusions, auditory hallucinations occurred in ~17% of individuals. In ~33% of the reviewed cases psychotic symptoms were present at or near disease onset, and 9 of these individuals experienced auditory hallucinations and/or delusions in the absence of visual hallucinations (~17% of all cases). In many cases, symptoms developed at a relatively young age. As presenilin gene variant-associated psychosis may resemble a primary psychotic disorder, clinicians should be vigilant with respect to screening for signs/symptoms suggestive of neurodegeneration in first-episode psychosis.
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Affiliation(s)
- Mark A Colijn
- Department of Psychiatry, Hotchkiss Brain Institute, Mathison Centre for Mental Health Research and Education, University of Calgary
| | - Zahinoor Ismail
- Departments of Psychiatry, Clinical Neurosciences, Community Health Sciences, and Pathology, Hotchkiss Brain Institute and O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Clinical and Biomedical Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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Poulton A, Curnow L, Eratne D, Sexton A. Family Communication about Diagnostic Genetic Testing for Younger-Onset Dementia. J Pers Med 2023; 13:jpm13040621. [PMID: 37109007 PMCID: PMC10144767 DOI: 10.3390/jpm13040621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
Younger-onset dementia (YOD) refers to onset before 65 years of age and may be associated with a genetic cause. Family communication surrounding any genetic risk is complex, and this process may be further complicated in a YOD context due to its effects on cognition, behaviour, and associated psychosocial consequences. This study aimed to investigate how individuals experience family communication about potential genetic risk and testing for YOD. Thematic analysis was performed on verbatim transcripts of nine semi-structured interviews undertaken with family members who attended a neurogenetics clinic due to a relative diagnosed with YOD. The interviews explored the participants’ experiences of learning that YOD might be inherited and the ensuing family communication about genetic testing. Four key themes emerged: (1) a clinical diagnostic odyssey was common and could be a motivator for genomic testing, (2) pre-existing family tension and/or disconnection was a common barrier, (3) family members’ autonomy was considered, and (4) avoidant coping strategies influenced communication. Communication regarding potential YOD genetic risk is a complicated process and may be influenced by pre-existing family dynamics, individual coping mechanisms, and a desire to promote autonomy in relatives. To promote effective risk communication, genetic counsellors should pre-emptively address family tensions that may be exacerbated in the context of genetic testing for YOD, with awareness that family strain during a preceding period of diagnostic odyssey is common. Genetic counsellors can offer psychosocial support to facilitate coping with this tension in an adaptive way. The findings also indicated the importance of extending genetic counselling support to relatives.
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Affiliation(s)
- Alice Poulton
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3051, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, VIC 3051, Australia
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia
- Monash IVF Group Ltd., Cremorne, VIC 3121, Australia
| | - Lisette Curnow
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia
- Victorian Clinical Genetics Services, Royal Children’s Hospital, Parkville, VIC 3010, Australia
| | - Dhamidhu Eratne
- Neuropsychiatry, Royal Melbourne Hospital, Parkville, VIC 3051, Australia
- Melbourne Neuropsychiarty Centre, The University of Melbourne, Parkville, VIC 3051, Australia
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC 3051, Australia
- Walter and Elize Hall Institue of Medical Research, The University of Melbourne, Parkville, VIC 3051, Australia
| | - Adrienne Sexton
- Genomic Medicine, The Royal Melbourne Hospital, Grattan St, Parkville, VIC 3050, Australia
- Department of Medicine-Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC 3052, Australia
- Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Ultimo, NSW 2007, Australia
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Loi SM, Cations M, Velakoulis D. Young-onset dementia diagnosis, management and care: a narrative review. Med J Aust 2023; 218:182-189. [PMID: 36807325 PMCID: PMC10952480 DOI: 10.5694/mja2.51849] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 02/21/2023]
Abstract
Young-onset dementia comprises a heterogeneous range of dementias, with onset at less than 65 years of age. These include primary dementias such as Alzheimer disease, frontotemporal and vascular dementias; genetic/familial dementias; metabolic disorders; and secondary dementias such as those that result from alcohol use disorder, traumatic brain injury, and infections. The presentation of young-onset dementia is varied and may include cognitive, psychiatric and neurological symptoms. Diagnostic delay is common, with a frequent diagnostic conundrum being, "Is this young-onset dementia or is this psychiatric?". For assessment and accurate diagnosis, a thorough screen is recommended, such as collateral history and investigations such as neuroimaging, lumbar puncture, neuropsychology, and genetic testing. The management of young-onset dementia needs to be age-appropriate and multidisciplinary, with timely access to services and consideration of the family (including children).
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Affiliation(s)
- Samantha M Loi
- University of MelbourneMelbourneVIC
- Royal Melbourne HospitalMelbourneVIC
| | | | - Dennis Velakoulis
- University of MelbourneMelbourneVIC
- Royal Melbourne HospitalMelbourneVIC
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Wiggins M, McEwen A, Sexton A. Young-onset dementia: A systematic review of the psychological and social impact on relatives. PATIENT EDUCATION AND COUNSELING 2023; 107:107585. [PMID: 36516659 DOI: 10.1016/j.pec.2022.107585] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Young-onset dementia (YOD) has significant impact for the affected person, but also has far-reaching effects on the family. Additionally, biological relatives have an increased genetic risk of developing the condition themselves. This review aimed to identify the psychological and social impacts of YOD in the family, for asymptomatic relatives. METHODS A systematic review of key databases for empirical studies about the lived experience of biological relatives at risk for YOD was performed. Data was collated and interpreted via narrative synthesis. RESULTS The majority of the nineteen included studies were qualitative and explored the experiences of children with a parent with YOD. Five themes were developed: (1) Onset of YOD disrupts family functioning (2) Emotional impact is significant and varied (3) Uncertain future (due to uncertainty of diagnosis, care-giving responsibilities, and their own increased genetic risk) (4) Lack of visibility in health care and society (5) Coping strategies include physical/cognitive distancing, and emotion-focused coping. CONCLUSION Our findings demonstrate a diagnosis of YOD significantly impacts the lives of relatives, yet their experiences and needs often go unnoticed. PRACTICE IMPLICATIONS We present a practical framework of questions and strategies for care of relatives, mapped to the self-regulation model of genetic counselling.
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Affiliation(s)
- Maddison Wiggins
- Graduate School of Health, University of Technology Sydney, Ultimo, NSW, Australia.
| | - Alison McEwen
- Graduate School of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Adrienne Sexton
- Graduate School of Health, University of Technology Sydney, Ultimo, NSW, Australia; Genomic Medicine Department, The Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Medicine Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
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Huq AJ, Thompson B, Bennett MF, Bournazos A, Bommireddipalli S, Gorelik A, Schultz J, Sexton A, Purvis R, West K, Cotter M, Valente G, Hughes A, Riaz M, Walsh M, Farrand S, Loi SM, Kilpatrick T, Brodtmann A, Darby D, Eratne D, Walterfang M, Delatycki MB, Storey E, Fahey M, Cooper S, Lacaze P, Masters CL, Velakoulis D, Bahlo M, James PA, Winship I. Clinical impact of whole-genome sequencing in patients with early-onset dementia. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2021-328146. [PMID: 35906014 DOI: 10.1136/jnnp-2021-328146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 06/07/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND In the clinical setting, identification of the genetic cause in patients with early-onset dementia (EOD) is challenging due to multiple types of genetic tests required to arrive at a diagnosis. Whole-genome sequencing (WGS) has the potential to serve as a single diagnostic platform, due to its superior ability to detect common, rare and structural genetic variation. METHODS WGS analysis was performed in 50 patients with EOD. Point mutations, small insertions/deletions, as well as structural variants (SVs) and short tandem repeats (STRs), were analysed. An Alzheimer's disease (AD)-related polygenic risk score (PRS) was calculated in patients with AD. RESULTS Clinical genetic diagnosis was achieved in 7 of 50 (14%) of the patients, with a further 8 patients (16%) found to have established risk factors which may have contributed to their EOD. Two pathogenic variants were identified through SV analysis. No expanded STRs were found in this study cohort, but a blinded analysis with a positive control identified a C9orf72 expansion accurately. Approximately 37% (7 of 19) of patients with AD had a PRS equivalent to >90th percentile risk. DISCUSSION WGS acts as a single genetic test to identify different types of clinically relevant genetic variations in patients with EOD. WGS, if used as a first-line clinical diagnostic test, has the potential to increase the diagnostic yield and reduce time to diagnosis for EOD.
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Affiliation(s)
- Aamira J Huq
- Department of Genomic Medicine, Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
- Department of Clinical Genetics, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Bryony Thompson
- Department of Genomic Medicine, Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
- Department of Pathology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Mark F Bennett
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| | - Adam Bournazos
- Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - Shobhana Bommireddipalli
- Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Gorelik
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Joshua Schultz
- Department of Genomic Medicine, Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
| | - Adrienne Sexton
- Department of Genomic Medicine, Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
| | - Rebecca Purvis
- Department of Genomic Medicine, Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
| | - Kirsty West
- Department of Genomic Medicine, Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
| | - Megan Cotter
- Department of Clinical Genetics, Austin Health, Heidelberg, Victoria, Australia
| | - Giulia Valente
- Department of Clinical Genetics, Austin Health, Heidelberg, Victoria, Australia
| | - Andrew Hughes
- Department of Clinical Genetics, Austin Health, Heidelberg, Victoria, Australia
| | - Moeen Riaz
- Public Health and Preventative Medicine, Monash University Faculty of Medicine, Nursing and Health Sciences, Melbourne, Victoria, Australia
| | - Maie Walsh
- Department of Genomic Medicine, Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
| | - Sarah Farrand
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Samantha M Loi
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Trevor Kilpatrick
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Amy Brodtmann
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Victoria, Australia
- Florey Neurosciences Institutes, University of Melbourne, Carlton South, Victoria, Australia
| | - David Darby
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Victoria, Australia
- Mental Health Research Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Dhamidhu Eratne
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Mark Walterfang
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | | | - Elsdon Storey
- Department of Genomic Medicine, Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
- Neuroscience, Alfred Health, Melbourne, Victoria, Australia
| | - Michael Fahey
- Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
| | - Sandra Cooper
- Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - Paul Lacaze
- Public Health and Preventative Medicine, Monash University Faculty of Medicine, Nursing and Health Sciences, Melbourne, Victoria, Australia
| | - Colin L Masters
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Dennis Velakoulis
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Melanie Bahlo
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| | - Paul A James
- Department of Genomic Medicine, Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
| | - Ingrid Winship
- Department of Genomic Medicine, Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
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