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Restrepo A, Smith KE, Silver EM, Norman G. Ambiguity potentiates effects of loneliness on feelings of rejection. Cogn Emot 2024:1-11. [PMID: 39093061 DOI: 10.1080/02699931.2024.2385006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 07/21/2024] [Accepted: 07/22/2024] [Indexed: 08/04/2024]
Abstract
For social species, having strong and high-quality social relationships is an important safety cue. Loneliness occurs when an individual perceives they have insufficient relationships resulting in feelings of lack of safety. States of perceived unsafety are linked to an increased tendency to construe ambiguous information - information lacking a unique clear interpretation - as threatening. Here, we explore whether the ambiguity of social cues of interpersonal rejection moderates effects of loneliness on feelings of rejection while undergoing social exclusion. Data were collected in 2021; 144 adults completed a progressive social exclusion paradigm where they were randomly assigned to be equally included, excluded, or over-included. Social exclusion/inclusion cues became more pronounced over the course of multiple rounds of a ball-tossing game (Cyberball) resulting in a scenario where ambiguity was highest in earlier rounds and decreased over time. Participants reported feelings of loneliness prior to the task and feelings of rejection throughout the task. Results demonstrated that higher loneliness predicted increased feelings of rejection regardless of exclusion condition. Notably, this positive relationship was strongest during earlier rounds when social cues were most ambiguous. These findings contribute to our understanding of how loneliness modulates social perception to enable organisms to adequately adapt to changing circumstances.
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Affiliation(s)
- Anita Restrepo
- Department of Psychology, University of Chicago, Chicago, IL, USA
| | - Karen E Smith
- Department of Psychology, Rutgers University, Newark, NJ, USA
| | - Emily M Silver
- Department of Psychology, University of Chicago, Chicago, IL, USA
| | - Greg Norman
- Department of Psychology, University of Chicago, Chicago, IL, USA
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2
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Wu Y, Guo Z, Zhang D, Wang Y, Wang S. Sleep Quality and Suicidal Ideation in Adolescent Depression: A Chain Mediation Effect of Perceived Social Support and Resilience. Clin Psychol Psychother 2024; 31:e2990. [PMID: 38659274 DOI: 10.1002/cpp.2990] [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: 03/23/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND The prevalence of suicide is high among major depressive adolescents. Poor sleep quality has been documented as a significant risk factor for suicide, influencing perceived social support. Enhanced social support acts as a buffer against suicidal ideation and positively impacts resilience, reducing the prevalence of suicidal ideation. This reciprocal relationship between sleep quality, social support and resilience forms the basis for understanding the mechanisms contributing to suicidal ideation in major depressive adolescents. METHODS A total of 585 major depressive adolescents aged 11 to 24 years was conducted to explore these associations. Assessments included the Pittsburgh Sleep Quality Index, Multidimensional Scale of Perceived Social Support, Connor-Davidson Resilience Scale and Beck Scale for Suicide Ideation. Pearson correlation and Model 6 in the SPSS program were employed for chain mediating tests. RESULTS Better sleep quality positively predicted decreased suicide ideation (β = 0.207, p < 0.01) and predicted lower perceived social support (β = -0.226, p < 0.01) and resilience (β = -0.355, p < 0.01). Perceived social support positively predicted increased resilience (β = 0.422, p < 0.01) and negatively predicted suicide ideation (β = -0.288, p < 0.01). Resilience negatively predicted suicide ideation (β = -0.187, p < 0.01). Sleep quality indirectly predicted suicide ideation through perceived social support and resilience, with a mediation value of 0.0678 (95% CI [0.0359, 0.1060]), constituting 10.65% of the total effect. CONCLUSIONS This study establishes that sleep quality indirectly predicts suicide ideation in major depressive adolescents, mediated independently by perceived social support and resilience.
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Affiliation(s)
- Yan Wu
- Beijing Hui-Long-Guan Hospital, Peking University, Beijing, China
| | - Zixuan Guo
- Beijing Hui-Long-Guan Hospital, Peking University, Beijing, China
| | - Dawei Zhang
- Beijing Hui-Long-Guan Hospital, Peking University, Beijing, China
| | - Yongna Wang
- Beijing Hui-Long-Guan Hospital, Peking University, Beijing, China
| | - Shufen Wang
- Beijing Hui-Long-Guan Hospital, Peking University, Beijing, China
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3
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Yu X, Du H, Li D, Sun P, Pi S. The Influence of Social Exclusion on High School Students' Depression: A Moderated Mediation Model. Psychol Res Behav Manag 2023; 16:4725-4735. [PMID: 38024658 PMCID: PMC10676663 DOI: 10.2147/prbm.s431622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose High school students face various pressures such as academic and interpersonal relationships, which can easily lead to depression. Social exclusion is one of the important influencing factors for adolescent depression, but there is still limited research on the mechanisms of the impact that social exclusion has on depression. Therefore, this study aimed to explore the effect of social exclusion on depression among high school students, as well as the mediating role of thwarted belongingness and the moderating role of cognitive reappraisal. Methods Researchers assessed 1041 high school students using the Center for Epidemiologic Studies Depression Scale (CES-D), Adolescent Social Exclusion Scale, Interpersonal Needs Scale, and Emotion Regulation Scale. Results (1) Social exclusion was negatively associated with cognitive reappraisal (r = -0.224, p < 0.001), and positively associated with thwarted belongingness and depression (r = 0.657, 0.490, p <0.001). Thwarted belongingness was positively associated with depression (r = 0.617, p <0.001), and negatively associated with cognitive reappraisal (r = -0.325, p <0.001). Cognitive reappraisal was negatively associated with depression (r = -0.280, p < 0.01). (2) Social exclusion could directly predict depression, 95% CI [0.08, 0.21]. Thwarted belongingness played a partial mediating role between social exclusion and depression, 95% CI [0.30, 0.40]. (3) Cognitive reappraisal moderated the predictive effect of thwarted belongingness on depression. Conclusion Social exclusion can influence depression through thwarted belongingness and cognitive reappraisal, and educators can reduce depression by decreasing thwarted belongingness and promoting the use of cognitive reappraisal strategies by high school students.
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Affiliation(s)
- Xinxin Yu
- Department of Psychology, Guangxi Normal University, Guilin, 541004, People’s Republic of China
| | - Haixin Du
- Department of Psychology, Guangxi Normal University, Guilin, 541004, People’s Republic of China
| | - Dongyan Li
- Department of Psychology, Guangxi Normal University, Guilin, 541004, People’s Republic of China
| | - Peizhen Sun
- Department of Psychology, Jiangsu Normal University, Xuzhou, 221116, People’s Republic of China
| | - Shiyi Pi
- Department of Psychology, Guangxi Normal University, Guilin, 541004, People’s Republic of China
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Bard HA, O'Driscoll C, Miller CB, Henry AL, Cape J, Espie CA. Insomnia, depression, and anxiety symptoms interact and individually impact functioning: A network and relative importance analysis in the context of insomnia. Sleep Med 2023; 101:505-514. [PMID: 36527942 DOI: 10.1016/j.sleep.2022.12.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/25/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVES Insomnia, depression, and anxiety show high rates of comorbidity and functional impairment. Transdiagnostic symptom interactions may be implicated in this comorbidity. This network analysis sought to assess how symptoms of insomnia, depression, and anxiety may interact and individually predict impairment across several domains for individuals with insomnia. METHODS Baseline psychometric data from a randomised controlled trial were analysed (N = 1711). A regularized partial correlation network was estimated from the symptom data. Centrality (symptom connectivity), community structure (symptom clustering), and bridging (inter-community connectivity) were assessed. The replicability of the network model was assessed via confirmatory analyses in a holdout sample. Separately, Shapley values were estimated to determine the relative importance of each symptom in predicting functioning (i.e., psychological wellbeing, psychosocial functioning, and physical health impairment). RESULTS The most connected nodes were uncontrollable worrying; trouble relaxing; and depressed mood/hopelessness. Five communities were identified with trouble relaxing identified as the bridge symptom between communities. The model showed good fit in the holdout sample. Low energy and depressive affect symptoms (feelings of failure/guilt; depressed mood/hopelessness; anhedonia) were key predictors in the relative importance analysis across multiple domains of impairment. CONCLUSION Trouble relaxing may be of clinical and transdiagnostic significance in the context of insomnia. In terms of how symptoms relate to functioning, it was clear that, while low energy and feelings of failure/guilt were prominent predictors, a range of symptoms are associated with functional impairment. Consideration of both symptoms and functional impairment across domains may be useful in determining targets for treatment. CLINICAL TRIAL REGISTRATION This is a secondary analysis of an original clinical trial. TRIAL REGISTRATION NUMBER ISRCTN60530898. Registry URL: https://www.isrctn.com/ISRCTN60530898.
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Affiliation(s)
- H Ariel Bard
- Centre for Outcomes Research & Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London (UCL), London, UK
| | - Ciarán O'Driscoll
- Centre for Outcomes Research & Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London (UCL), London, UK.
| | - Christopher B Miller
- Sir Jules Thorn Sleep & Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Big Health Inc, San Francisco, CA, USA & London, UK
| | - Alasdair L Henry
- Sir Jules Thorn Sleep & Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Big Health Inc, San Francisco, CA, USA & London, UK
| | - John Cape
- Centre for Outcomes Research & Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London (UCL), London, UK
| | - Colin A Espie
- Sir Jules Thorn Sleep & Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Big Health Inc, San Francisco, CA, USA & London, UK
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Gao M, Li X, Lee CY, Ma H, Chen T, Zhang S, Chiang YC. Sleep duration and depression among adolescents: Mediation effect of collective integration. Front Psychol 2022; 13:1015089. [PMID: 36518962 PMCID: PMC9744325 DOI: 10.3389/fpsyg.2022.1015089] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/02/2022] [Indexed: 11/10/2023] Open
Abstract
Adolescence is a time of dramatic physical and mental change when adolescents are extremely vulnerable to various mental health problems. Depression and poor sleep duration are increasingly common among adolescents. This study is mainly aimed to verify the important mediating role of collective integration on sleep duration and depression and examine the interrelationship between sleep duration and depression in adolescents longitudinally. The data were obtained from the Wave 1 (in 2013-2014) and Wave 2 (in 2014-2015) longitudinal surveys of China Education Panel Survey (CEPS). The analytic sample in the present study included 8,829 seventh-grade students aged about 14 years (51.50% boys and 48.50% girls). A structural equation modeling (SEM) was used to investigate parent-child/teacher factors affecting adolescent sleep duration and depression, and Monte Carlo resampling with R was employed to confirm the significance of the mediation effects of collective integration. An autoregressive cross-lagged model was employed to analyze the interrelationship between adolescent sleep duration and depression. The findings were as follows. Firstly, collective integration strongly mediated the relationships among academic self-efficacy, parental involvement, teacher praise/criticism, sleep duration, and depression. Secondly, sleep duration and depression were found to have enduring effects and have effects on each other. Thirdly, parental involvement and teacher praise were positively associated with sleep quality and negatively associated with depression. Teacher criticism was negatively associated with sleep quality and positively associated with depression. Compared with teacher praise, teacher criticism has stronger effects on youth sleep duration and depression. In conclusion, improving sleep problems and depression in adolescents as early as possible can stop the persistent and long-term consequences of these problems. Increasing teacher praise, decreasing teacher criticism, and increasing adolescents' collective integration were effective ways to improve adolescents' sleep duration and mediate depression.
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Affiliation(s)
- Min Gao
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, Xiamen, China
| | - Xian Li
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, Xiamen, China
| | - Chun-Yang Lee
- School of International Business, Xiamen University Tan Kah Kee College, Zhangzhou, China
| | - Honghao Ma
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, Xiamen, China
| | - Tianmu Chen
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, Xiamen, China
| | | | - Yi-Chen Chiang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, Xiamen, China
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Otsuka Y, Itani O, Matsumoto Y, Kaneita Y. Associations between coping strategies and insomnia: a longitudinal study of Japanese workers. Sleep 2022; 45:zsab244. [PMID: 34585730 PMCID: PMC8842145 DOI: 10.1093/sleep/zsab244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 09/18/2021] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES Coping with stress is important because stress disturbs sleep. However, only a few longitudinal studies have investigated the association between coping and insomnia. We examined whether individuals with insomnia symptoms used more maladaptive coping strategies than individuals without insomnia symptoms, and evaluated the association between insomnia symptoms and coping strategies. METHODS In this prospective cohort study, Japanese workers were enrolled and observed over a 2-year period. During both years, self-administered questionnaires on coping and insomnia symptoms were administered. Coping was assessed using the Brief-Coping Orientation to Problems Experienced, and insomnia symptoms were examined using the Athens Insomnia Scale. Generalized estimating equation modeling identified the effects of coping strategies on insomnia severity. RESULTS In total, 1358 of 1855 workers at baseline were followed up. Individuals with insomnia symptoms showed a higher use of maladaptive coping strategies and less use of humor and instrumental support than individuals without insomnia symptoms. Active coping, humor, emotional support, and instrumental support were negatively associated with insomnia severity. In contrast, venting, substance use, behavioral disengagement, and self-blame were positively associated with insomnia severity. CONCLUSIONS This study showed that individuals with insomnia symptoms use both adaptive and maladaptive coping strategies and are more likely to use maladaptive strategies than individuals without insomnia symptoms. In the future, interventions focused on educating people about adaptive coping strategies should be conducted to determine whether coping strategies may prevent insomnia symptoms.
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Affiliation(s)
- Yuichiro Otsuka
- Division of Public Health, Department of Social Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Osamu Itani
- Division of Public Health, Department of Social Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yuuki Matsumoto
- Division of Public Health, Department of Social Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshitaka Kaneita
- Division of Public Health, Department of Social Medicine, Nihon University School of Medicine, Tokyo, Japan
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McCallum SM, Calear AL, Cherbuin N, Farrer LM, Gulliver A, Shou Y, Dawel A, Batterham PJ. Associations of loneliness, belongingness and health behaviors with psychological distress and wellbeing during COVID-19. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2021; 6:100214. [PMID: 34494016 PMCID: PMC8411686 DOI: 10.1016/j.jadr.2021.100214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The aim of this study was to assess the effects of loneliness, belongingness and other modifiable factors on psychological distress and wellbeing and whether the effects of COVID-19 modulated these relationships. METHODS The current study reported on 1217 participants aged 18 years or older who completed an online survey from 28 to 31 March 2020. Survey measures included demographic characteristics; exposure to COVID-19; impact of COVID-19 on employment, finance, and work and social adjustment; loneliness, thwarted belongingness, and health behavior changes as modifiable factors. Outcome measures were psychological distress and wellbeing. RESULTS Linear regression models revealed that COVID-19 related work and social adjustment difficulties, financial distress, loneliness, thwarted belongingness, eating a less healthy diet poorer sleep and being female were all associated with increased psychological distress and reduced wellbeing (p < 0.05). Psychological distress was more elevated for those with high difficulties adjusting to COVID-19 and high levels of thwarted belongingness (p < 0.005). Similarly, as COVID-19 related work and social adjustment difficulties increased, wellbeing reduced. This was more pronounced in those who felt lower levels of loneliness (p < 0.0001). Other interactions between COVID-19 impacts were observed with gender and poorer diet for psychological distress and cigarette use, age and gender for wellbeing (p < 0.05). LIMITATIONS The study was cross-sectional, preventing causal interpretation of the relationships. CONCLUSION Modifiable factors, age and gender had significant impacts on psychological distress and wellbeing. Public health and policy approaches to improving social, economic and lifestyle factors may mitigate the negative mental health effects of the pandemic and its restrictions.
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Affiliation(s)
- Sonia M McCallum
- Centre for Mental Health Research, Research School of Population Health, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Alison L Calear
- Centre for Mental Health Research, Research School of Population Health, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Nicolas Cherbuin
- Centre for Research on Ageing, Health and Wellbeing, Research School of Population Health, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Louise M Farrer
- Centre for Mental Health Research, Research School of Population Health, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Amelia Gulliver
- Centre for Mental Health Research, Research School of Population Health, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Yiyun Shou
- Research School of Psychology, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Amy Dawel
- Research School of Psychology, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Philip J Batterham
- Centre for Mental Health Research, Research School of Population Health, The Australian National University, Canberra, Australian Capital Territory, Australia
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Perceived burdensomeness and neural responses to ostracism in the Cyberball task. J Psychiatr Res 2020; 130:1-8. [PMID: 32763557 PMCID: PMC7554229 DOI: 10.1016/j.jpsychires.2020.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/09/2020] [Accepted: 06/22/2020] [Indexed: 12/23/2022]
Abstract
Previous studies have identified the brain correlates of social pain processing during ostracism. However, the affective response to ostracism may vary according to individual differences in interpersonal needs and subsequent social actions. Despite this relationship, how the neural processes underlying ostracism may be modulated by interpersonal needs to regulate prosocial behaviors remains unknown. Here, in an fMRI study of 64 adults performing the Cyberball task, we quantified ball catching and tossing response time (RT) as a behavioral measure of participants' willingness to seek and reciprocate social interactions. Neural activations to social exclusion were identified and characterized in relation to individual differences in behavioral performance and perceived burdensomeness (PB), a measure of interpersonal needs. The results showed that social exclusion elicited activity in the anterior insula, middle frontal gyrus, postcentral gyrus, and dorsomedial prefrontal cortex, replicating previous studies on ostracism. Importantly, those with higher PB also exhibited greater brain activations to exclusion as well as reduced prosocial behaviors, as reflected by slower ball catching and tossing RT in the Cyberball task. Taken together, these findings suggest that emotional distress in ostracism may increase with PB, resulting in stronger neural responses to social pain and behavioral avoidance of social interactions.
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Huang X, Funsch KM, Park EC, Franklin JC. Anticipated consequences as the primary causes of suicidal behavior: Evidence from a laboratory study. Behav Res Ther 2020; 134:103726. [PMID: 32979678 DOI: 10.1016/j.brat.2020.103726] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/24/2020] [Accepted: 09/08/2020] [Indexed: 01/30/2023]
Abstract
Due to the limitations of conducting experimental studies on suicide, little is known about its causes. Based on basic behavioral research, we hypothesized that the anticipated consequences of suicidal behavior (e.g., stress relief) are the primary causes of suicidal behavior, and experienced antecedents (e.g., stress) are secondary causes. We evaluated this general hypothesis by testing the causal effects of these two broad phenomena on virtual reality (VR) suicide in 497 participants across five groups. On their own, experienced antecedent manipulations (i.e., stress and rejection) did not significantly increase VR suicide rates relative to the control group. On its own, the anticipated consequence manipulation (i.e., instruction that engaging in VR suicide would allow one to avoid a future stressor) caused a large increase in the VR suicide rate. In the context of an experienced antecedent manipulation (i.e., stress), this anticipated consequence manipulation caused an even larger increase in the VR suicide rate. These findings suggest that the anticipated consequences of suicidal behavior (e.g., avoidance or escape from something unpleasant, attaining something pleasant) are the primary causes of suicidal behavior, and that experienced antecedents (e.g., stress) serve as secondary causes when they make an anticipated consequence of suicidal behavior seem more appealing.
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Affiliation(s)
- Xieyining Huang
- Florida State University, Department of Psychology, 1107 W Call St, Tallahassee, FL, 32304, USA.
| | - Kensie M Funsch
- Florida State University, Department of Psychology, 1107 W Call St, Tallahassee, FL, 32304, USA
| | - Esther C Park
- Florida State University, Department of Psychology, 1107 W Call St, Tallahassee, FL, 32304, USA
| | - Joseph C Franklin
- Florida State University, Department of Psychology, 1107 W Call St, Tallahassee, FL, 32304, USA
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Roach M, Juday T, Tuly R, Chou JW, Jena AB, Doghramji PP. Challenges and opportunities in insomnia disorder. Int J Neurosci 2020; 131:1058-1065. [PMID: 32449423 DOI: 10.1080/00207454.2020.1773460] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
| | | | | | | | - Anupam B. Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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