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Brown AD, Ross N, Sangraula M, Laing A, Kohrt BA. Transforming mental healthcare in higher education through scalable mental health interventions. Glob Ment Health (Camb) 2023; 10:e33. [PMID: 37854434 PMCID: PMC10579693 DOI: 10.1017/gmh.2023.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 06/05/2023] [Accepted: 06/14/2023] [Indexed: 10/20/2023] Open
Abstract
A significant number of young people throughout the world are experiencing mental health concerns. Many young people will develop their first mental health concerns or will be managing their symptoms while enrolled in institutions of higher education. Although many colleges and universities are aware of the significant mental health needs among their students, the mental health and psychosocial needs of students often exceed the availability of resources and cultural and contextual barriers, such as stigma, may further impede access to care. Such gaps and barriers in mental health may lead to poor prognosis as well as negative educational and social outcomes. We propose that non-specialist delivered mental health and psychosocial interventions may play a critical role in reducing the gaps in care for students in higher education. In particular, non-specialist delivered care can complement existing specialized services to provide stepped models of care. Importantly, the adaptation and implementation of non-specialist delivered mental health and psychosocial support interventions in higher education may lead to innovative strategies for increasing access to care in this context, but may lead to adaptations that could apply to contexts outside of higher education as well.
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Affiliation(s)
- Adam D. Brown
- Department of Psychology, New School for Social Research, New York, NY, USA
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - Nicole Ross
- Department of Psychology, New School for Social Research, New York, NY, USA
| | - Manaswi Sangraula
- Department of Psychology, New School for Social Research, New York, NY, USA
| | - Andy Laing
- Department of Social Work, University of The Bahamas-North, Freeport, Bahamas
| | - Brandon A. Kohrt
- Division of Global Mental Health, Department of Psychiatry, George Washington University, Washington, DC, USA
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Berger M, Fernando S, Churchill A, Cornish P, Henderson J, Shah J, Tee K, Salmon A. Scoping review of stepped care interventions for mental health and substance use service delivery to youth and young adults. Early Interv Psychiatry 2022; 16:327-341. [PMID: 34018335 PMCID: PMC9292436 DOI: 10.1111/eip.13180] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 04/21/2021] [Accepted: 05/05/2021] [Indexed: 11/28/2022]
Abstract
AIMS Many young people with mental health and/or substance use concerns do not have access to timely, appropriate, and effective services. Within this context, stepped care models (SCMs) have emerged as a guiding framework for care delivery, inspiring service innovations across the globe. However, substantial gaps remain in the evidence for SCMs as a strategy to address the current systemic challenges in delivering services for young people. This scoping review aims to identify where these gaps in evidence exist, and the next steps for addressing them. METHODS A scoping review was conducted involving both peer-reviewed and grey literature. Eligible studies explored SCMs implemented in the various health care settings accessed by young people aged 12-24 seeking treatment for mental health and substance use challenges. After screening titles and abstracts, two reviewers examined full-text articles and extracted data to create a descriptive summary of the models. RESULTS Of the 656 studies that were retrieved, 51 studies were included and grouped by study team for a final yield of 43 studies. Almost half of the studies were focused on the adult population (i.e., 18 and over), and most did not specify interventions for young people. Among the SCMs, substantial variability was found in almost every aspect of the models. CONCLUSIONS Considering the current body of evidence, there is an urgent need for a consensus position on the definition, implementation, and outcome measures required for rigorously assessing the utility of SCMs for young people.
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Affiliation(s)
- Mai Berger
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Saranee Fernando
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - AnnMarie Churchill
- Student Wellness and Counseling Centre, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Peter Cornish
- Director of Counseling and Psychological Services, University of California, Berkeley, Berkeley, California, USA.,Honorary Research Professor, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Joanna Henderson
- Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Jai Shah
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, Quebec, Canada.,ACCESS Open Minds, Douglas Mental Health University Institute, Montreal, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Karen Tee
- Foundry, Vancouver, British Columbia, Canada
| | - Amy Salmon
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Assessing Implementation Strategy Reporting in the Mental Health Literature: A Narrative Review. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2021; 47:19-35. [PMID: 31482489 DOI: 10.1007/s10488-019-00965-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Inadequate implementation strategy reporting restricts research synthesis and replicability. We explored the implementation strategy reporting quality of a sample of mental health articles using Proctor et al.'s (Implement Sci 8:139, 2013) reporting recommendations. We conducted a narrative review to generate the sample of articles and assigned a reporting quality score to each article. The mean article reporting score was 54% (range 17-100%). The most reported domains were: name (100%), action (82%), target (80%), and actor (67%). The least reported domains included definition (6%), temporality (26%), justification (34%), and outcome (37%). We discuss limitations and provide recommendations to improve reporting.
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Assessing Implementation Strategy Reporting in the Mental Health Literature: A Narrative Review. ADMINISTRATION AND POLICY IN MENTAL HEALTH 2019. [PMID: 31482489 DOI: 10.1007/s10488‐019‐00965‐8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Inadequate implementation strategy reporting restricts research synthesis and replicability. We explored the implementation strategy reporting quality of a sample of mental health articles using Proctor et al.'s (Implement Sci 8:139, 2013) reporting recommendations. We conducted a narrative review to generate the sample of articles and assigned a reporting quality score to each article. The mean article reporting score was 54% (range 17-100%). The most reported domains were: name (100%), action (82%), target (80%), and actor (67%). The least reported domains included definition (6%), temporality (26%), justification (34%), and outcome (37%). We discuss limitations and provide recommendations to improve reporting.
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Sluiter RL, Kievit W, van der Wilt GJ, Schene AH, Teichert M, Coenen MJH, Schellekens A. Cost-Effectiveness Analysis of Genotype-Guided Treatment Allocation in Patients with Alcohol Use Disorders Using Naltrexone or Acamprosate, Using a Modeling Approach. Eur Addict Res 2018; 24:245-254. [PMID: 30384381 PMCID: PMC6492516 DOI: 10.1159/000494127] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/27/2018] [Indexed: 11/19/2022]
Abstract
Alcohol use disorders (AUD) are a major contributor to the global burden of disease, and have huge societal impact. Some studies show that AUD patients carrying the G-allele of the OPRM1 variant c.118A>G respond better to naltrexone, resulting in reduced relapse rates compared to carriers of the AA genotype. Genotype-guided treatment allocation of these patients carrying a G-allele to naltrexone could potentially improve the treatment outcome. However, cost-effectiveness of this strategy should be investigated before considering clinical implementation. We, therefore, evaluated costs and Quality-Adjusted Life-Years (QALYs), using a modelling approach, from an European perspective, of genotype-guided treatment allocation (G-allele carriers receiving naltrexone; AA homozygotes acamprosate or naltrexone) compared to standard care (random treatment allocation to acamprosate or naltrexone), by using a Markov model. Genotype-guided treatment allocation resulted in incremental costs of EUR 66 (95% CI -28 to 149) and incremental effects of 0.005 QALYs (95% CI 0.000-0.011) per patient (incremental cost-effectiveness ratio of EUR 13,350 per QALY). Sensitivity analyses showed that the risk ratio to relapse after treatment allocation had the largest impact on the cost-effectiveness. Depending on the willingness to pay for a gain of one QALY, probabilities that the intervention is cost-effective varies between 6 and 79%. In conclusion, pharmacogenetic treatment allocation of AUD patients to naltrexone, based on OPRM1 genotype, can be a cost-effective strategy, and could have potential individual and societal benefits. However, more evidence on the impact of genotype-guided treatment allocation on relapse is needed to substantiate these conclusions, as there is contradictory evidence about the effectiveness of OPRM1 genotyping.
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Affiliation(s)
- Reinier L Sluiter
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands,
| | - Wietske Kievit
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert Jan van der Wilt
- Department for Health Evidence, Donders Centre for Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Aart H Schene
- Department of Psychiatry, Donders Centre for Neuroscience, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Martina Teichert
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke J H Coenen
- Department of Human Genetics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arnt Schellekens
- Department of Psychiatry, Donders Centre for Neuroscience, Radboud University Medical Centre, Nijmegen Institute for Scientist Practitioners in Addiction, Nijmegen, The Netherlands
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Abstract
PURPOSE OF REVIEW To review the clinical practice guideline landscape for depression screening in pediatric primary care and to identify current gaps in knowledge. RECENT FINDINGS Various organizations have recommendations that support screening for depression in pediatric primary care, although some differ based on the age of the child. To date, guidelines have been made based on indirect evidence of efficacy. For example, indirect evidence shows that several screening tools exist for use in primary care, and various primary care-administered or referred treatments for childhood depression have some evidence of efficacy (particularly among adolescents). In addition to determining the applicability of this evidence to younger children, more research is needed on the direct net benefits of screening and to identify factors that facilitate its effective implementation. Indirect evidence supports the benefits of screening for depression in pediatric primary care; most organizations that publish screening guidelines recommend its use.
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Dardas LA, Silva SG, Smoski MJ, Noonan D, Simmons LA. Adolescent Depression in Jordan: Symptoms Profile, Gender Differences, and the Role of Social Context. J Psychosoc Nurs Ment Health Serv 2018; 56:44-55. [DOI: 10.3928/02793695-20171027-04] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 08/24/2017] [Indexed: 11/20/2022]
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Withers MC, Reynolds JE, Reed K, Holtrop K. Dissemination and Implementation Research in Marriage and Family Therapy: An Introduction and Call to the Field. JOURNAL OF MARITAL AND FAMILY THERAPY 2017; 43:183-197. [PMID: 27701773 DOI: 10.1111/jmft.12196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Despite the considerable resources allocated to research to promote public health, interventions capable of benefiting individuals and families are not finding their way into regular practice. An important avenue for addressing this problem is through dissemination and implementation (D&I) science, a burgeoning research area focusing on translating empirical knowledge into everyday practice. This article begins by suggesting ways in which MFTs are uniquely equipped to contribute to and benefit from D&I research. We will then provide an overview of D&I research, outlines key D&I models, and highlight examples of family intervention research relevant to MFTs using the key models. Finally, we conclude by providing the field with important next steps to advance the presence of MFT research within D&I scholarship.
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Winder R, Richards SH, Campbell JL, Richards DA, Dickens C, Gandhi M, Wright C, Turner K. Development and refinement of a complex intervention within cardiac rehabilitation services: experiences from the CADENCE feasibility study. Pilot Feasibility Stud 2017; 3:9. [PMID: 28289547 PMCID: PMC5304389 DOI: 10.1186/s40814-017-0123-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 01/09/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients who experience a cardiac event are at higher risk of developing depression than the general population. Despite this, cardiac rehabilitation (CR) programmes do not provide a systematic approach to psychological care for depression. The CADENCE study aimed to develop and pilot an enhanced psychological care (EPC) intervention consisting of behavioural activation (BA) and mental health care coordination. Following original research commissioning guidance, the intervention was planned to be embedded in routine care and delivered by CR nurses to patients with depression attending CR. This paper describes how qualitative methods were used to develop, embed and refine the intervention. METHODS This feasibility study involved three CR teams. Observations were made of CR nurses delivering usual care, of EPC training given to nurses, and of supervision sessions provided to the CR nurses. Four nurses were interviewed shortly after their EPC training, and three were interviewed again 6-7 months later having delivered EPC to patients. All nine patients recruited to receive EPC were interviewed. Analyses of the observation notes and interview transcripts focused on how the intervention could be improved in terms of its acceptability and implementation. RESULTS Variations were found between the CR teams regarding patient waiting list times, how CR was delivered, what facilities were available and how many CR sessions were offered to patients. EPC was acceptable to both nurses and patients. However, nurses struggled to provide this additional care within their existing workload and resources, and patients' disrupted progression through the CR programme affected EPC delivery. Limited time and availability of private space meant nurses also delivered EPC by telephone, which was viewed as a pragmatic solution but less preferable than face-to-face. Nurses indicated that patients struggled with some of the written materials. Findings were used to revise the intervention to become a protocol of care coordination which included guided self-help BA. CONCLUSIONS Insights gained through conducting interviews and observations enabled us to identify barriers to the implementation of EPC, and to modify the intervention to facilitate its delivery within existing services whilst remaining acceptable to both nurses and patients. The multiple method, iterative approach used was key to the success of this qualitative study. TRIAL REGISTRATION ISRCTN34701576 Registered 29/05/2014.
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Affiliation(s)
- Rachel Winder
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - Suzanne H. Richards
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - John L. Campbell
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - David A. Richards
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - Chris Dickens
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - Manish Gandhi
- Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW UK
| | - Christine Wright
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - Katrina Turner
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Whatley Road, Bristol, BS8 2PS UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Silverstone PH, Rittenbach K, Suen VYM, Moretzsohn A, Cribben I, Bercov M, Allen A, Pryce C, Hamza DM, Trew M. Depression Outcomes in Adults Attending Family Practice Were Not Improved by Screening, Stepped-Care, or Online CBT during a 12-Week Study when Compared to Controls in a Randomized Trial. Front Psychiatry 2017; 8:32. [PMID: 28373846 PMCID: PMC5357781 DOI: 10.3389/fpsyt.2017.00032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 02/15/2017] [Indexed: 11/13/2022] Open
Abstract
There is uncertainty regarding possible benefits of screening for depression in family practice, as well as the most effective treatment approach when depression is identified. Here, we examined whether screening patients for depression in primary care, and then treating them with different modalities, was better than treatment-as-usual (TAU) alone. Screening was carried out for depression using the 9-item Patient Health Questionnaire (PHQ-9), with a score of ≥10 indicating significant depressive symptoms. PHQ-9 scores were given to family physicians prior to patients being seen (except for the Control group). Patients (n = 1,489) were randomized to one of four groups. Group #1 were controls (n = 432) in which PHQ-9 was administered, but results were not shared. Group #2 was screening followed by TAU (n = 426). Group #3 was screening followed by both TAU and the opportunity to use an online cognitive behavioral therapy (CBT) treatment program (n = 440). Group #4 utilized an evidence-based Stepped-care pathway for depression (n = 191, note that this was not available at all clinics). Of the study sample 889 (60%) completed a second PHQ-9 rating at 12 weeks. There were no statistically significant differences in baseline PHQ-9 scores between these groups. Compared to baseline, mean PHQ-9 scores decreased significantly in the depressed patients over 12 weeks, but there were no statistically significant differences between any groups at 12 weeks. Thus, for those who were depressed at baseline Control group (Group #1) scores decreased from 15.3 ± 4.2 to 4.0 ± 2.6 (p < 0.001), Screening group (Group #2) scores decreased from 15.5 ± 3.9 to 4.6 ± 3.0 (p < 0.001), Online CBT group (Group #3) scores decreased from 15.4 ± 3.8 to 3.4 ± 2.7 (p < 0.01), and the Stepped-care pathway group (Group #4) scores decreased from 15.3 ± 3.6 to 5.4 ± 2.8 (p < 0.05). In conclusion, these findings from this controlled randomized study do not suggest that using depression screening tools in family practice improves outcomes. They also suggest that much of the depression seen in primary care spontaneously resolves and do not support suggestions that more complex treatment programs or pathways improve depression outcomes in primary care. Replication studies are required due to study limitations.
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Affiliation(s)
- Peter H Silverstone
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada; Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services, Edmonton, AB, Canada; Department of Finance and Statistical Analysis, University of Alberta, Edmonton, AB, Canada
| | - Katherine Rittenbach
- Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services , Edmonton, AB , Canada
| | - Victoria Y M Suen
- Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services , Edmonton, AB , Canada
| | | | - Ivor Cribben
- Department of Finance and Statistical Analysis, University of Alberta , Edmonton, AB , Canada
| | - Marni Bercov
- Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services , Edmonton, AB , Canada
| | - Andrea Allen
- Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services , Edmonton, AB , Canada
| | - Catherine Pryce
- Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services , Edmonton, AB , Canada
| | - Deena M Hamza
- Department of Psychiatry, University of Alberta , Edmonton, AB , Canada
| | - Michael Trew
- Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services , Edmonton, AB , Canada
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de Vries YA, de Jonge P, Kalverdijk L, Bos JHJ, Schuiling-Veninga CCM, Hak E. Poor guideline adherence in the initiation of antidepressant treatment in children and adolescents in the Netherlands: choice of antidepressant and dose. Eur Child Adolesc Psychiatry 2016; 25:1161-1170. [PMID: 26988978 PMCID: PMC5083767 DOI: 10.1007/s00787-016-0836-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 02/28/2016] [Indexed: 11/03/2022]
Abstract
The Dutch guideline for the treatment of depression in young people recommends initiating antidepressant treatment with fluoxetine, as the evidence for its efficacy is strongest and the risk of suicidality may be lower than with other antidepressants. Furthermore, low starting doses are recommended. We aimed to determine whether antidepressant prescriptions are in accord with guidelines. A cohort of young people aged between 6 and 17 at the time of antidepressant initiation was selected from IABD, a Dutch pharmacy prescription database. The percentage of prescriptions for each antidepressant was determined. Starting and maintenance doses were determined and compared with recommendations for citalopram, fluoxetine, fluvoxamine, and sertraline. During the study period, 2942 patients initiated antidepressant treatment. The proportion of these young people who were prescribed fluoxetine increased from 10.1 % in 1994-2003 to 19.7 % in 2010-2014. However, the most commonly prescribed antidepressants were paroxetine in 1994-2003 and citalopram in 2004-2014. The median starting and maintenance doses were ≤0.5 DDD/day for tricyclic antidepressants and 0.5-1 DDD/day for SSRIs and other antidepressants. Starting doses were guideline-concordant 58 % of the time for children, 31 % for preteens, and 16 % for teens. Sixty percent of teens were prescribed an adult starting dose. In conclusion, guideline adherence was poor. Physicians preferred citalopram over fluoxetine, in contrast to the recommendations. Furthermore, although children were prescribed a low starting dose relatively frequently, teens were often prescribed an adult starting dose. These results suggest that dedicated effort may be necessary to improve guideline adherence.
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Affiliation(s)
- Ymkje Anna de Vries
- Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Peter de Jonge
- Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Luuk Kalverdijk
- Department of Psychiatry, University Medical Center Groningen, Groningen, The Netherlands
| | - Jens H J Bos
- Unit PharmacoEpidemiology and PharmacoEconomics (PE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Catharina C M Schuiling-Veninga
- Unit PharmacoEpidemiology and PharmacoEconomics (PE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Eelko Hak
- Unit PharmacoEpidemiology and PharmacoEconomics (PE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
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