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Yan H, Wu H, Cai Z, Du S, Li L, Xu B, Chang C, Wang N. The neural correlates of apathy in the context of aging and brain disorders: a meta-analysis of neuroimaging studies. Front Aging Neurosci 2023; 15:1181558. [PMID: 37396666 PMCID: PMC10311641 DOI: 10.3389/fnagi.2023.1181558] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Apathy is a prevalent mood disturbance that occurs in a wide range of populations, including those with normal cognitive aging, mental disorders, neurodegenerative disorders and traumatic brain injuries. Recently, neuroimaging technologies have been employed to elucidate the neural substrates underlying brain disorders accompanying apathy. However, the consistent neural correlates of apathy across normal aging and brain disorders are still unclear. Methods This paper first provides a brief review of the neural mechanism of apathy in healthy elderly individuals, those with mental disorders, neurodegenerative disorders, and traumatic brain injuries. Further, following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, the structural and functional neuroimaging meta-analysis using activation likelihood estimation method is performed on the apathy group with brain disorders and the healthy elderly, aiming at exploring the neural correlates of apathy. Results The structural neuroimaging meta-analysis showed that gray matter atrophy is associated with apathy in the bilateral precentral gyrus (BA 13/6), bilateral insula (BA 47), bilateral medial frontal gyrus (BA 11), bilateral inferior frontal gyrus, left caudate (putamen) and right anterior cingulate, while the functional neuroimaging meta-analysis suggested that the functional connectivity in putamen and lateral globus pallidus is correlated with apathy. Discussion Through the neuroimaging meta-analysis, this study has identified the potential neural locations of apathy in terms of brain structure and function, which may offer valuable pathophysiological insights for developing more effective therapeutic interventions for affected patients.
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Affiliation(s)
- Hongjie Yan
- Department of Neurology, Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Huijun Wu
- School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, China
- Department of Electrical and Electronic Engineering, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Zenglin Cai
- Department of Neurology, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou, China
- Department of Neurology, Gusu School, Suzhou Science and Technology Town Hospital, Nanjing Medical University, Suzhou, China
| | - Shouyun Du
- Department of Neurology, Guanyun People’s Hospital, Guanyun, China
| | - Lejun Li
- Department of Neurology, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Bingchao Xu
- Department of Neurology, Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Chunqi Chang
- School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, China
- Pengcheng Laboratory, Shenzhen, China
| | - Nizhuan Wang
- School of Biomedical Engineering, ShanghaiTech University, Shanghai, China
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Zakharova K, Arkusha I, Akzigitov R, Avedisova A. Transdiagnostic approach to negative symptoms. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:23-30. [DOI: 10.17116/jnevro202212201123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abdolalizadeh A, Ostadrahimi H, Ohadi MAD, Saneei SA, Bayani Ershadi AS. White matter microstructural associates of apathy-avolition in schizophrenia. J Psychiatr Res 2021; 142:110-116. [PMID: 34332375 DOI: 10.1016/j.jpsychires.2021.07.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 06/30/2021] [Accepted: 07/21/2021] [Indexed: 11/25/2022]
Abstract
Apathy is present at the onset in nearly half the patients with schizophrenia. Current therapies lack the efficiency to improve apathy in patients. The presence of apathy is also associated with poorer outcomes. Despite its clinical importance, the underlying mechanism of apathy in schizophrenia is unclear, but it seems frontostriatal connections play a role. In this study, we investigated whole-brain white matter microstructural properties associated with the severity of apathy-avolition in schizophrenia. We included 80 schizophrenia patients (60 Male, 20 Female) from the Mind Clinical Imaging Consortium database and associated Apathy-Avolition score of "Scale for Assessment of Negative Symptoms" with fiber integrity measures derived from diffusion-weighted imaging using Tract-Based Spatial Statistics (TBSS). We also did tractography on eight tracts, including bilateral superior longitudinal fasciculus, uncinate fasciculus, cingulum, genu and splenium of the corpus callosum. Age, gender, years of education, chlorpromazine equivalent cumulative dose, and acquisition site were inserted as covariates. We showed a widespread association between lower fiber integrity (by measures of increased mean diffusivity and decreased fractional anisotropy) and increased apathy-avolition in TBSS, which we also validated in tractography. Moreover, mean diffusivity, and not fractional anisotropy, was associated with apathy independent of disease severity. In conclusion, we propose diffuse white-matter pathology, within the corpus callosum, limbic system, and the frontostriatal circuit is involved in apathy-avolition in schizophrenia. Also, we suggest that diffuse neuroinflammatory processes may play a part in apathy-avolition, independent of disease severity.
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Affiliation(s)
- AmirHussein Abdolalizadeh
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran; Interdisciplinary Neuroscience Research Program, Tehran University of Medical Sciences, Tehran, Iran.
| | - Hamidreza Ostadrahimi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran; Interdisciplinary Neuroscience Research Program, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Dabbagh Ohadi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran; Interdisciplinary Neuroscience Research Program, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed AmirHussein Saneei
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran; Interdisciplinary Neuroscience Research Program, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Sasan Bayani Ershadi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran; Interdisciplinary Neuroscience Research Program, Tehran University of Medical Sciences, Tehran, Iran
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Kirschner M, Schmidt A, Hodzic-Santor B, Burrer A, Manoliu A, Zeighami Y, Yau Y, Abbasi N, Maatz A, Habermeyer B, Abivardi A, Avram M, Brandl F, Sorg C, Homan P, Riecher-Rössler A, Borgwardt S, Seifritz E, Dagher A, Kaiser S. Orbitofrontal-Striatal Structural Alterations Linked to Negative Symptoms at Different Stages of the Schizophrenia Spectrum. Schizophr Bull 2020; 47:849-863. [PMID: 33257954 PMCID: PMC8084448 DOI: 10.1093/schbul/sbaa169] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Negative symptoms such as anhedonia and apathy are among the most debilitating manifestations of schizophrenia (SZ). Imaging studies have linked these symptoms to morphometric abnormalities in 2 brain regions implicated in reward and motivation: the orbitofrontal cortex (OFC) and striatum. Higher negative symptoms are generally associated with reduced OFC thickness, while higher apathy specifically maps to reduced striatal volume. However, it remains unclear whether these tissue losses are a consequence of chronic illness and its treatment or an underlying phenotypic trait. Here, we use multicentre magnetic resonance imaging data to investigate orbitofrontal-striatal abnormalities across the SZ spectrum from healthy populations with high schizotypy to unmedicated and medicated first-episode psychosis (FEP), and patients with chronic SZ. Putamen, caudate, accumbens volume, and OFC thickness were estimated from T1-weighted images acquired in all 3 diagnostic groups and controls from 4 sites (n = 337). Results were first established in 1 discovery dataset and replicated in 3 independent samples. There was a negative correlation between apathy and putamen/accumbens volume only in healthy individuals with schizotypy; however, medicated patients exhibited larger putamen volume, which appears to be a consequence of antipsychotic medications. The negative association between reduced OFC thickness and total negative symptoms also appeared to vary along the SZ spectrum, being significant only in FEP patients. In schizotypy, there was increased OFC thickness relative to controls. Our findings suggest that negative symptoms are associated with a temporal continuum of orbitofrontal-striatal abnormalities that may predate the occurrence of SZ. Thicker OFC in schizotypy may represent either compensatory or pathological mechanisms prior to the disease onset.
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Affiliation(s)
- Matthias Kirschner
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada,Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland,To whom correspondence should be addressed; 3801 Rue University, Montréal QC, H3A 2B4 Canada; tel: +1 514-398-1726, fax: +1 514–398–8948, e-mail:
| | - André Schmidt
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | | | - Achim Burrer
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Andrei Manoliu
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland,Wellcome Centre for Human Neuroimaging, University College London, London, UK,Max Planck University College London Centre for Computational Psychiatry and Ageing Research, London, UK
| | - Yashar Zeighami
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Yvonne Yau
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Nooshin Abbasi
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Anke Maatz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | | | - Aslan Abivardi
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Mihai Avram
- Department of Neuroradiology and TUM-NIC Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany,Department of Psychiatry, Psychosomatics and Psychotherapy, Schleswig Holstein University Hospital, University Lübeck, Lübeck Germany
| | - Felix Brandl
- Department of Psychiatry and TUM-NIC Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Christian Sorg
- Department of Neuroradiology and TUM-NIC Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany,Department of Psychiatry and TUM-NIC Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Philipp Homan
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland,Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY,Division of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, New York, NY,Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY
| | | | - Stefan Borgwardt
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Alain Dagher
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Stefan Kaiser
- Department of Psychiatry, Division of Adult Psychiatry, Geneva University Hospitals, Geneva, Switzerland
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Kirschner M, Cathomas F, Manoliu A, Habermeyer B, Simon JJ, Seifritz E, Tobler PN, Kaiser S. Shared and dissociable features of apathy and reward system dysfunction in bipolar I disorder and schizophrenia. Psychol Med 2020; 50:936-947. [PMID: 30994080 DOI: 10.1017/s0033291719000801] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Bipolar disorder I (BD-I) is defined by episodes of mania, depression and euthymic states. These episodes are among other symptoms characterized by altered reward processing and negative symptoms (NS), in particular apathy. However, the neural correlates of these deficits are not well understood. METHODS We first assessed the severity of NS in 25 euthymic BD-I patients compared with 25 healthy controls (HC) and 27 patients with schizophrenia (SZ). Then, we investigated ventral (VS) and dorsal striatal (DS) activation during reward anticipation in a Monetary Incentive Delayed Task and its association with NS. RESULTS In BD-I patients NS were clearly present and the severity of apathy was comparable to SZ patients. Apathy scores in the BD-I group but not in the SZ group correlated with sub-syndromal depression scores. At the neural level, we found significant VS and DS activation in BD-I patients and no group differences with HC or SZ patients. In contrast to patients with SZ, apathy did not correlate with striatal activation during reward anticipation. Explorative whole-brain analyses revealed reduced extra-striatal activation in BD-I patients compared with HC and an association between reduced activation of the inferior frontal gyrus and apathy. CONCLUSION This study found that in BD-I patients apathy is present to an extent comparable to SZ, but is more strongly related to sub-syndromal depressive symptoms. The findings support the view of different pathophysiological mechanisms underlying apathy in the two disorders and suggest that extra-striatal dysfunction may contribute to impaired reward processing and apathy in BD-I.
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Affiliation(s)
- Matthias Kirschner
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032Zurich, Switzerland
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Flurin Cathomas
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032Zurich, Switzerland
| | - Andrei Manoliu
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032Zurich, Switzerland
- Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
- Max Planck University College London Centre for Computational Psychiatry and Ageing Research, London, United Kingdom
| | | | - Joe J Simon
- Department of General Internal Medicine and Psychosomatics, Centre for Psychosocial Medicine, Heidelberg, Germany
- Department of Psychosomatic Medicine and Psychotherapy, Medical Faculty, Heinrich-Heine-University Düsseldorf, Dusseldorf, Germany
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich, 8057Zurich, Switzerland
- Zurich Center for Integrative Human Physiology, University of Zurich, 8057Zurich, Switzerland
| | - Philippe N Tobler
- Neuroscience Center Zurich, University of Zurich, 8057Zurich, Switzerland
- Zurich Center for Integrative Human Physiology, University of Zurich, 8057Zurich, Switzerland
- Department of Economics, Laboratory for Social and Neural Systems Research, University of Zurich, 8006Zurich, Switzerland
| | - Stefan Kaiser
- Division of Adult Psychiatry, Department of Psychiatry, Geneva University Hospitals, Chemin du Petit-Bel-Air, 1225 Chêne-Bourg, Switzerland
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Palmisano S, Fasotti L, Bertens D. Neurobehavioral Initiation and Motivation Problems After Acquired Brain Injury. Front Neurol 2020; 11:23. [PMID: 32153486 PMCID: PMC7049782 DOI: 10.3389/fneur.2020.00023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 01/08/2020] [Indexed: 12/11/2022] Open
Abstract
Motivation is a primary and permanent source of human behavior and adaptation. Motivational deficits, along with deficiencies in initiation, frequently occur in individuals with acquired brain injury (ABI). These neurobehavioral problems are associated with consequences at the participation level: patients are reluctant to engage in rehabilitation, and their subsequent social reintegration is often at risk. The same problems may also become a heavy burden for the families of individuals with ABI. In the present paper, we will critically review both the current definitions and the instruments used to measure motivational disorders following ABI. We will also describe the neural system underlying motivation and its impairments. What emerges is the need to develop specific rehabilitative treatments, still absent at the moment, with the ultimate aim of ensuring a better quality of life for both the patients and their proxies.
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Affiliation(s)
- Simona Palmisano
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.,Rehabilitation Center Klimmendaal, Arnhem, Netherlands
| | - Luciano Fasotti
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.,Rehabilitation Center Klimmendaal, Arnhem, Netherlands
| | - Dirk Bertens
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.,Rehabilitation Center Klimmendaal, Arnhem, Netherlands
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Kim J, Iwata Y, Plitman E, Caravaggio F, Chung JK, Shah P, Blumberger DM, Pollock BG, Remington G, Graff-Guerrero A, Gerretsen P. A meta-analysis of transcranial direct current stimulation for schizophrenia: "Is more better?". J Psychiatr Res 2019; 110:117-126. [PMID: 30639917 DOI: 10.1016/j.jpsychires.2018.12.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 11/05/2018] [Accepted: 12/06/2018] [Indexed: 01/29/2023]
Abstract
Transcranial direct current stimulation (tDCS) has generated interest in recent years as a potential adjunctive treatment for patients with schizophrenia. The primary objective of this meta-analysis was to evaluate the efficacy of tDCS on positive symptoms, particularly auditory hallucinations, and negative symptoms. A literature search of randomized sham-controlled trials was conducted using the OVID database on October 9, 2018. The standardized mean differences (SMDs) were calculated to examine changes in symptom severity between active and sham groups for the following symptom domains: auditory hallucinations, positive symptoms (including auditory hallucinations), and negative symptoms. Moderator analyses were performed to examine the effects of study design and participant demographics. We identified 10 eligible studies. Main-analyses showed no effects of tDCS on auditory hallucinations (7 studies, n = 242), positive symptoms (9 studies, n = 313), or negative symptoms (9 studies, n = 313). Subgroup analyses of studies that applied twice-daily stimulation showed a significant reduction in the severity of auditory hallucinations (4 studies, n = 138, SMD = 1.04, p = 0.02). Studies that applied ≥10 stimulation sessions showed a reduction in both auditory hallucination (5 studies, n = 186, SMD = 0.86, p = 0.009) and negative symptom severity (7 studies, n = 257, SMD = 0.41, p = 0.04). Meta-regression analyses revealed a negative association between mean age and the SMDs for auditory hallucinations and negative symptoms, and a positive association between baseline negative symptom severity and the SMDs for negative symptoms. Our findings highlight the need to optimize tDCS parameters and suggest twice-daily or 10 or more stimulation sessions may be needed to improve clinical outcomes in patients with schizophrenia.
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Affiliation(s)
- Julia Kim
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Yusuke Iwata
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Eric Plitman
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Fernando Caravaggio
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Jun Ku Chung
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Parita Shah
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Daniel M Blumberger
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada; Temerty Centre for Therapeutic Brain Intervention, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Bruce G Pollock
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Gary Remington
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Ariel Graff-Guerrero
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Philip Gerretsen
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada.
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