1
|
Liu CC, Hsieh MH, Chien YL, Liu CM, Lin YT, Hwang TJ, Hwu HG. Protocol of guided antipsychotic reduction to reach minimum effective dose (GARMED) in patients with remitted psychosis based on pragmatic design. Early Interv Psychiatry 2022; 16:178-185. [PMID: 33751764 DOI: 10.1111/eip.13144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 02/01/2021] [Accepted: 03/06/2021] [Indexed: 11/29/2022]
Abstract
AIMS Patients with psychosis intend to discontinue antipsychotic treatment for various reasons. As antipsychotic discontinuation involves a high risk of relapse, maintenance treatment is recommended by mainstream opinion even when remission is attained. To optimize the risk-to-benefit ratio of long-term antipsychotic treatment, we proposed an operationalized guided dose-reduction algorithm to serve as an intermediate approach as to achieve the lowest effective antipsychotic dose and better functioning for patients with remitted psychosis. METHODS Outpatients with a history of schizophrenia-related psychotic disorders currently under stable medications and symptoms are eligible to register in this protocol. Patients intending for dose reduction are randomized into 2:1, guided dose reduction group (GDR) versus maintenance treatment group (MTG1). Eligible patients who do not intend to reduce antipsychotics serve as naturalistic maintenance controls (MTG2). The GDR patients reduce no more than 25% of their baseline antipsychotic dose, with at least a 6-month stabilization period before reducing another 25% of their last dose. The timing of the next dose reduction will be determined by shared decision-making with the patient. Following a dose reduction, the patients will receive three consecutive monthly monitoring; otherwise, they receive treatment as usual. DISCUSSION By employing this pragmatic-based protocol, patients are empowered to evaluate their readiness for next dose reduction attempt. We would like to test in real-world situations if stable patients can reduce antipsychotics not at the expense of an increased risk of relapse, so as to optimize the balance between risk-to-benefit ratios of long-term antipsychotic treatment.
Collapse
Affiliation(s)
- Chen-Chung Liu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Psychiatry, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Ming H Hsieh
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Ling Chien
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Min Liu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Ting Lin
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tzung-Jeng Hwang
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hai-Gwo Hwu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| |
Collapse
|
2
|
Yen K, Liu CC, Lin YT, Chien YL, Hsieh MH, Liu CM, Hwang TJ, Liao WH, Hwu HG. Discontinuing Antipsychotic Medication After Remission from First-Episode Psychosis: A Survey of Psychiatrists' Attitudes in Taiwan. Neuropsychiatr Dis Treat 2022; 18:465-475. [PMID: 35261544 PMCID: PMC8898187 DOI: 10.2147/ndt.s339866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/26/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patients in remission after first-episode psychosis are inclined to discontinue antipsychotic treatment, which may lead to higher risk of relapse and unfavorable outcomes. Paradoxically, also there are evidences suggesting that certain patients may stay well in drug-free condition. Psychiatrists' views towards this dilemma might affect their approaches to these patients, and discrepant attitudes are noted between Western and Asian clinicians. This study aimed to examine psychiatrists' attitudes about discontinuing antipsychotic medications after remission from first-episode psychosis. METHODS Psychiatrists were recruited for this study using convenience sampling. A cross-sectional survey was conducted using a set of questionnaires comprising nine items for attitudes toward medication discontinuation, six vignettes for probing psychiatrists' practice in designated clinical scenarios, and a list of criteria that may affect their responses. RESULTS Responses were provided by 118 psychiatrists, two-thirds men, mean age 39.8 ± 10.1 years and mean experience 12.7 ± 9.7 years. Half of the participants endorsed that fewer than 20% of the remitted patients should stop medication completely; the majority advised that an observation period of 1 year or longer is necessary while discontinuing medication. The majority would not initiate discussion with patients about discontinuing medication. Responding to two case vignettes, those who endorsed that more patients could stop antipsychotics were also more inclined to discuss it with patients, but not consistently in response to the other four case vignettes. Taiwan psychiatrists expressed a wide range of decision-making considerations for discontinuing antipsychotics. CONCLUSION The majority of Taiwan psychiatrists thought it was not feasible to stop medications completely but were willing to consider this option. Once being presented with actual clinical scenarios, many participants hesitated to discontinue antipsychotic medications for various reasons. The proactive attitude of psychiatrists towards conducting clinical trials to test the feasibility of medication discontinuation may help to provide better reference for this clinical dilemma.
Collapse
Affiliation(s)
- Ko Yen
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Chen-Chung Liu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Psychiatry, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Yi-Ting Lin
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Ling Chien
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming H Hsieh
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Min Liu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tzung-Jeng Hwang
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei-Hsiang Liao
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hai-Gwo Hwu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| |
Collapse
|
3
|
Seppälä A, Pylvänäinen J, Lehtiniemi H, Hirvonen N, Corripio I, Koponen H, Seppälä J, Ahmed A, Isohanni M, Miettunen J, Jääskeläinen E. Predictors of response to pharmacological treatments in treatment-resistant schizophrenia - A systematic review and meta-analysis. Schizophr Res 2021; 236:123-134. [PMID: 34496316 DOI: 10.1016/j.schres.2021.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 06/30/2021] [Accepted: 08/04/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND As the burden of treatment-resistant schizophrenia (TRS) on patients and society is high it is important to identify predictors of response to medications in TRS. The aim was to analyse whether baseline patient and study characteristics predict treatment response in TRS in drug trials. METHODS A comprehensive search strategy completed in PubMed, Cochrane and Web of Science helped identify relevant studies. The studies had to meet the following criteria: English language clinical trial of pharmacological treatment of TRS, clear definition of TRS and response, percentage of response reported, at least one baseline characteristic presented, and total sample size of at least 15. Meta-regression techniques served to explore whether baseline characteristics predict response to medication in TRS. RESULTS 77 articles were included in the systematic review. The overall sample included 7546 patients, of which 41% achieved response. Higher positive symptom score at baseline predicted higher response percentage. None of the other baseline patient or study characteristics achieved statistical significance at predicting response. When analysed in groups divided by antipsychotic drugs, studies of clozapine and other atypical antipsychotics produced the highest response rate. CONCLUSIONS This meta-analytic review identified surprisingly few baseline characteristics that predicted treatment response. However, higher positive symptoms and the use of atypical antipsychotics - particularly clozapine -was associated with the greatest likelihood of response. The difficulty involved in the prediction of medication response in TRS necessitates careful monitoring and personalised medication management. There is a need for more investigations of the predictors of treatment response in TRS.
Collapse
Affiliation(s)
- Annika Seppälä
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.
| | - Jenni Pylvänäinen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Heli Lehtiniemi
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Arctic Biobank, Infrastructure for Population Studies, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Noora Hirvonen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Information Studies, Faculty of Humanities, University of Oulu, Oulu, Finland
| | - Iluminada Corripio
- Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, CIBERSAM G21, U.A.B (Autonomous University of Barcelona), Barcelona, Spain
| | - Hannu Koponen
- University of Helsinki and Helsinki University Hospital, Psychiatry, Helsinki, Finland
| | - Jussi Seppälä
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Department of Mental Health and Substance Use Disorders, South Carelia Social and Health Care District, Lappeenranta, Finland
| | - Anthony Ahmed
- Department of Psychiatry, Weill Cornell Medicine, Cornell University, White Plains, USA
| | - Matti Isohanni
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Jouko Miettunen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Erika Jääskeläinen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Department of Psychiatry, University Hospital of Oulu, Finland
| |
Collapse
|
4
|
Liu CC, Liu CM, Chien YL, Lin YT, Hsieh MH, Hwang TJ, Hwu HG. Challenging the Minimum Effective Antipsychotic Dose During Maintenance: Implications From 10-Year Follow-Up of First Episode Psychosis. Front Psychiatry 2021; 12:714878. [PMID: 34557119 PMCID: PMC8453020 DOI: 10.3389/fpsyt.2021.714878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Contradictory messages regarding the necessity of long-term antipsychotic treatment after first episode psychosis arouse deliberations in clinical practice. We explored if there is an alternative beyond the dichotomy of maintenance treatment and discontinuation of medications. Methods: We conducted a retrospective observational study by reviewing medical records at the study hospital of a cohort of patients since their participation in an early psychosis study starting from 2006, with special interests in patients able to maintain good functioning under treatment with a low antipsychotic dose. Results: Of the 81 patients with first-episode psychosis, 55 patients (67.9%) had follow-up information for longer than 5 years. The majority (n = 46, 83.6%) had non-affective psychosis, 20 patients (36.4%) had full-time employment/education by the time of their latest visit; among them, 15 patients received dosage of antipsychotics no more than the minimum effective dose [chlorpromazine equivalent (CPZE) dose, 200 mg/day]. Besides, 10 of 55 patients (18.2%) only received very low dose antipsychotics (CPZE < 50 mg/day) during maintenance, which was significantly correlated to good functioning. Being male, having a history of hospitalization, and being on clozapine therapy were correlated to poorer functioning. Antipsychotic-free status was achieved only in two non-psychotic patients. Conclusions: A substantial proportion of patients could achieve good functioning under low-dose antipsychotic maintenance after first-episode psychosis, even if they could not completely withdraw antipsychotics in the long term. Optimizing the balance between preventing relapse and preserving functioning by fine-tuning antipsychotic dosage during maintenance is a challenge warranting more clinical attention.
Collapse
Affiliation(s)
- Chen-Chung Liu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Psychiatry, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Chih-Min Liu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Ling Chien
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Ting Lin
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming H Hsieh
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tzung-Jeng Hwang
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hai-Gwo Hwu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| |
Collapse
|
5
|
Isohanni M, Jääskeläinen E, Miller BJ, Hulkko A, Tiihonen J, Möller H, Hartikainen S, Huhtaniska S, Lieslehto J. Medication management of antipsychotic treatment in schizophrenia—A narrative review. Hum Psychopharmacol 2020. [DOI: 10.1002/hup.2765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Matti Isohanni
- Center for Life Course Health Research University of Oulu Oulu Finland
| | | | - Brian J. Miller
- Department of Psychiatry Augusta University Augusta Georgia USA
| | - Anja Hulkko
- Center for Life Course Health Research University of Oulu Oulu Finland
| | - Jari Tiihonen
- Karolinska Institutet Stockholm Sweden
- University of Eastern Finland Kuopio Finland
| | | | - Sirpa Hartikainen
- Kuopio Research Center of Geriatric Care School of Pharmacy University of Eastern Finland Kuopio Finland
| | - Sanna Huhtaniska
- Center for Life Course Health Research University of Oulu Oulu Finland
| | | |
Collapse
|
6
|
Achieving the Lowest Effective Antipsychotic Dose for Patients with Remitted Psychosis: A Proposed Guided Dose-Reduction Algorithm. CNS Drugs 2020; 34:117-126. [PMID: 31741178 DOI: 10.1007/s40263-019-00682-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Continuing antipsychotic treatment in patients with schizophrenia under clinical remission remains controversial. Even though the mainstream opinion declares an outweighed balance against medication discontinuation, recent reviews and critiques suggest that some patients may remain symptom free and well functioning after stopping antipsychotics, but few predictors can identify who can try medication discontinuation, whilst no guidelines exist for reducing medication to reach the lowest effective dose safely. Analyzing the findings from studies employing different methodologies, adopting evidence from pharmacodynamic research, and observing dose reduction in stable patients, as well as taking inspiration from the metaphor of the Cantor set in natural philosophy, we introduce an alternative solution and propose a guided dose-reduction algorithm that follows a set of clear precautions and instructions. The algorithm recommends only a fraction (no more than 25%) of the dosage to be reduced at a time, with at least a 6-month stabilization period required before reducing another 25% of the dose. Patients are empowered to actively participate in decision making when they are ready for further dose tapering, or should they retreat to a previous dosage if warning signs of a relapse re-emerge. An intermittent or irregular dosing schedule can be used to adapt this algorithm to real-world practice. Our preliminary findings suggest that patients with remitted psychosis can do well along this path. We anticipate that this approach can help optimize the risk-benefit ratio and instill a hope in patients with schizophrenia that they can maintain in stable remission under a lower antipsychotic dose without an increased risk of relapse.
Collapse
|
7
|
Trends in the incidence and DALYs of schizophrenia at the global, regional and national levels: results from the Global Burden of Disease Study 2017. Epidemiol Psychiatr Sci 2020; 29:e91. [PMID: 31928566 PMCID: PMC7214712 DOI: 10.1017/s2045796019000891] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIM Schizophrenia is a serious health problem worldwide. This systematic analysis aims to quantify the burden of schizophrenia at the global, regional and national levels using the Global Burden of Disease Study 2017 (GBD 2017). METHODS We collected detailed information on the number of incidence cases, disability-adjusted life years (DALYs) and age-standardised incidence rate (ASIR) and age-standardised rate of DALYs (ASDR) during 1990-2017 from GBD 2017. The estimated annual percentage changes (EAPCs) in the ASIR and in the ASDR were calculated to quantify the temporal trends in the ASIR and ASDR of schizophrenia. RESULTS Globally there were 1.13 million (95% uncertainty interval [UI] = 1.00 to 1.28) incident schizophrenia cases and 12.66 million (95% UI = 9.48 to 15.56) DALYs due to schizophrenia in 2017. The global ASIR decreased slightly from 1990 to 2017 (EAPC = -0.124, 95% UI = -0.114 to -0.135), while the ASDR was stable. The number of incident cases, DALYs, ASIR and ASDR were higher for males than for females. The incident rate and DALYs rate were highest among those aged 20-29 and 30-54 years, respectively. ASIR and ASDR were highest in East Asia in 2017, at 19.66 (95% UI = 17.72 to 22.00) and 205.23 (95% UI = 153.13 to 253.34), respectively. In 2017, the ASIR was highest in countries with a high-moderate sociodemographic index (SDI) and the ASDR was highest in high-SDI countries. We also found that the EAPC in ASDR was negatively correlated with the ASDR in 1990 (P = 0.001, ρ = -0.23). CONCLUSION The global burden of schizophrenia remains large and continues to increase, thereby increasing the burden on health-care systems. The reported findings should be useful for resource allocation and health services planning for the increasing numbers of patients with schizophrenia in ageing societies.
Collapse
|
8
|
Fiorillo A, Barlati S, Bellomo A, Corrivetti G, Nicolò G, Sampogna G, Stanga V, Veltro F, Maina G, Vita A. The role of shared decision-making in improving adherence to pharmacological treatments in patients with schizophrenia: a clinical review. Ann Gen Psychiatry 2020; 19:43. [PMID: 32774442 PMCID: PMC7409631 DOI: 10.1186/s12991-020-00293-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 07/16/2020] [Indexed: 12/11/2022] Open
Abstract
Shared decision-making (SDM) is a process in which the doctor provides clear and complete medical information to patients about their treatment, and patients provide information on his/her preferences. Patients and clinicians bring different, but equally important, knowledge to the decision-making process. Through the adoption of SDM, it should be possible to overcome the barriers that hinder the acceptance of long-acting injectable antipsychotics (LAIs) by patients, and often also by psychiatrists. The present paper is a critical appraisal of recent literature on the impact of SDM in improving adherence to pharmacological treatments and in implementing the use of LAIs in the treatment of patients with schizophrenia. SDM is recognized as a promising strategy to improve collaboration between clinicians and patients in achieving recovery. When considering drug treatments, clinicians must evaluate the patient's preferences, expectations and concerns towards the development of a personalized treatment strategy. Moreover, an active involvement in the decision process could reduce the patient's perception of being coerced into the use of LAIs. Involving patients in the choice of therapy is not sufficient to increase pharmacological adherence if, at the same time, there is no constant work of comparison and communication with the reference psychiatric team. SDM can be particularly effective for LAI prescription, since patient can have prejudices and unjustified fears related to the LAI formulation, which the doctor must resolve.
Collapse
Affiliation(s)
- Andrea Fiorillo
- Department of Psychiatry, University of Campania "L. Vanvitelli, Largo Madonna delle Grazie, Naples, Italy
| | - Stefano Barlati
- Department of Mental Health and Addiction Services, ASST Spedali Civili, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Antonello Bellomo
- Department of Clinical and Experimental Medicine, Psychiatric Unit, University of Foggia, Foggia, Italy
| | | | - Giuseppe Nicolò
- Department of Mental Health Colleferro, ASL Roma G, Tivoli, Italy
| | - Gaia Sampogna
- Department of Psychiatry, University of Campania "L. Vanvitelli, Largo Madonna delle Grazie, Naples, Italy
| | - Valentina Stanga
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Franco Veltro
- Mental Health Department of Campobasso, Campobasso, Italy
| | - Giuseppe Maina
- Department of Neuroscience, University of Torino, Turin, Italy
| | - Antonio Vita
- Department of Mental Health and Addiction Services, ASST Spedali Civili, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| |
Collapse
|