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Abstract
Introduction: Anorexia nervosa (AN) is a severe psychiatric disorder that is difficult to treat and is associated with frequent relapses and high mortality rates. Psychiatric symptomatology (eg, depression, anxiety, obsessive-compulsive disorder/behaviors) are common comorbidities. This review provides current information about safety and efficacy of antidepressant therapy for management of AN in adults. Methods: A literature review of randomized controlled trials, open-label studies, and case reports with adults or adults/adolescents was conducted. PubMed and Medline were searched using anorexia management and treatment, antidepressants, selective serotonin reuptake inhibitors (SSRIs), fluoxetine, sertraline, citalopram, and mirtazapine in AN, relapse prevention in AN, and psychotropic medications in AN. Results: The role and utility of antidepressants in AN were published in double-blind, placebo-controlled studies; open-label trials; and a retrospective study. Antidepressants should not be used as sole therapy for AN although their use for confounding symptomatology makes discerning efficacy difficult as they are given together with other therapies. Neurobiological changes due to starvation and AN itself complicate results interpretation. For safety, tricyclic antidepressants and monoamine oxidase inhibitors are not recommended, and bupropion is contraindicated. Use of SSRIs during acute treatment lacks efficacy. Use of SSRIs—primarily fluoxetine and to some extent citalopram, sertraline, or mirtazapine—may aid in relapse prevention and improvement of psychiatric symptomatology in weight-restored anorexic patients. Discussion: Health care professionals should use clinical judgment regarding fluoxetine or possibly citalopram, sertraline or mirtazapine as adjunctive treatment to psychotherapy for relapse prevention, improvement of depressive and anxiety symptoms, and/or obsessive-compulsive behaviors unresolved with nutritional rehabilitation and psychotherapy.
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Affiliation(s)
- Marketa Marvanova
- Chair and Associate Professor, Department of Pharmacy Practice, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, North Dakota,
| | - Kirstin Gramith
- PGY-1 Resident, University of Minnesota, Postgraduate Pharmacy Residency Program, Minneapolis, Minnesota
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Dunican KC, DelDotto D. The Role of Olanzapine in the Treatment of Anorexia Nervosa. Ann Pharmacother 2016; 41:111-5. [PMID: 17190846 DOI: 10.1345/aph.1h297] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To evaluate the role of olanzapine in the treatment of anorexia nervosa. Data Sources: Literature was obtained through searches of MEDLINE (1966–December 2006), EMBASE (1980–4th Quarter 2006), and PsycINFO (1985–December 2006) and a bibliographic review of published articles. Key terms used in the searches included anorexia nervosa, antipsychotics, eating disorders, olanzapine, and Zyprexa. Study Selection And Data Extraction: All English language articles that were identified from the search were evaluated. All primary literature was included in the review. Data Synthesis: In several case reports and most clinical trials, patients with anorexia nervosa successfully gained weight while being treated with olanzapine. Moreover, many patients treated with olanzapine achieved a healthy body weight. Case reports and trials identified additional benefits of olanzapine, including reduction in delusional thinking; improvement in body image, sleep, depressive symptoms, adherence to treatment, and eating-disorder symptoms; and decreased agitation and premeal anxiety. Conclusions: Preliminary evidence supports the use of olanzapine for treatment of anorexia nervosa by demonstrating that olanzapine 2.5–15 mg daily promotes weight gain and has positive effects on associated psychological symptoms. Limitations of the reported data include small sample size, low completion rate in clinical trials, and open-label trial design. Although olanzapine appears to have a potential role in the treatment of anorexia nervosa that has been unresponsive to other therapy, randomized, placebo-controlled studies with larger sample sizes are necessary to establish its role in therapy.
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Affiliation(s)
- Kaelen C Dunican
- School of Pharmacy-Worcester, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA 01608, USA.
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Abstract
The aim of this review was to summarize evidence from research on psychopharmacological options for adult patients with anorexia nervosa (AN). Database searches of MEDLINE and PsycINFO (from January 1966 to January 2014) were performed, and original articles published as full papers, brief reports, case reports, or case series were included. Forty-one papers were screened in detail, and salient characteristics of pharmacological options for AN were summarized for drug classes. The body of evidence for the efficacy of pharmacotherapy in AN was unsatisfactory, the quality of observations was questionable (eg, the majority were not blinded), and sample size was often small. More trials are needed, while considering that nonresponse and nonremission are typical of patients with AN.
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Abstract
It is estimated that between 60 and 80% of those with major depressive disorder do not achieve full symptomatic remission from first-line antidepressant monotherapy. Residual depressive symptoms substantially impair quality of life and add to the risk of recurrence. It is now clear that depression would benefit from more vigorous treatment, in order to ameliorate its disease burden. While there are established algorithms in situations of treatment resistance, the use of combination pharmacotherapy in unipolar depression is a relatively under-investigated area of treatment and may be an effective and tolerable strategy that maximizes the available resources. This paper reviews the current evidence for combination pharmacotherapy in unipolar depression and discusses its clinical applications.
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Affiliation(s)
- Felicity Ng
- University of Melbourne, Department of Clinical and Biomedical Sciences: Barwon Health, PO Box 281, Geelong, Victoria, Australia.
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Antipsychotic agents in the treatment of anorexia nervosa: neuropsychopharmacologic rationale and evidence from controlled trials. Curr Psychiatry Rep 2012; 14:398-405. [PMID: 22628000 DOI: 10.1007/s11920-012-0287-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The search for an effective psychopharmacologic strategy in the treatment of anorexia nervosa (AN) has been elusive for decades and has run the gamut from reserpine to typical antipsychotics, to lithium, to tetrahydrocannabinol, to growth hormone, to anticonvulsants, to antidepressants, to atypical antipsychotics. Only recently has there arisen a potential "diamond in the rough" in the form of the atypical antipsychotic agent, olanzapine, which, in four randomized clinical trials, has shown superiority to placebo (two studies), chlorpromazine (one study), and aripiprazole (one study) in terms of weight gain and/or reduction in obsessional symptoms. The pharmacologic profile of olanzapine and other antipsychotic medications is discussed in light of the known pathophysiology of AN involving serotonin and dopamine systems, as well as brain-derived neurotrophic factor.
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Duvvuri V, Cromley T, Klabunde M, Boutelle K, Kaye WH. Differential weight restoration on olanzapine versus fluoxetine in identical twins with anorexia nervosa. Int J Eat Disord 2012; 45:294-7. [PMID: 21344468 PMCID: PMC3579522 DOI: 10.1002/eat.20917] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2010] [Indexed: 11/08/2022]
Abstract
OBJECTIVE No studies have compared the response to selective serotonin reuptake inhibitors and atypical antipsychotics in anorexia nervosa. This case study examines such a comparison. METHOD This report describes a case of 12-year-old identical twins with anorexia nervosa, one of whom was treated with olanzapine and the other with fluoxetine, while undergoing family therapy. RESULTS Twin A treated with fluoxetine went from 75 to 84.4% ideal body weight, while Twin B treated with olanzapine went from 72 to 99.9% ideal body weight over the course of 9 months. DISCUSSION This case supports the need for adequately powered, controlled clinical trials to test the efficacy of olanzapine in adolescents presenting with anorexia nervosa.
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Affiliation(s)
- Vikas Duvvuri
- Department of Psychiatry, University of California San Diego, La Jolla, CA
| | - Taya Cromley
- Department of Psychology, University of California Los Angeles, Los Angeles, CA
| | - Megan Klabunde
- Department of Psychiatry, University of California San Diego, La Jolla, CA
| | - Kerri Boutelle
- Department of Psychiatry, University of California San Diego, La Jolla, CA
| | - Walter H. Kaye
- Department of Psychiatry, University of California San Diego, La Jolla, CA
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Trunko ME, Schwartz TA, Duvvuri V, Kaye WH. Aripiprazole in anorexia nervosa and low-weight bulimia nervosa: case reports. Int J Eat Disord 2011; 44:269-75. [PMID: 20186719 DOI: 10.1002/eat.20807] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE There has been much interest in the use of atypical antipsychotics in anorexia nervosa (AN). However, newer, more weight-neutral medications have not been studied in AN, and there are no reports of the use of antipsychotics in bulimia nervosa (BN). METHOD We report on the treatment of eight patients (five with AN and three with BN) with aripiprazole for time periods of four months to more than three years. RESULTS All individuals had reduced distress around eating, fewer obsessional thoughts about food, weight and body image, significant lessening of eating-disordered behaviors, and gradual weight restoration where appropriate. Depression, generalized anxiety, and cognitive flexibility improved as well. DISCUSSION In summary, these findings support the need to perform controlled trials of aripiprazole in AN and BN.
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Affiliation(s)
- Mary Ellen Trunko
- Department of Psychiatry, University of California San Diego, San Diego, California, USA
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Safer DL, Darcy AM, Lock J. Use of mirtazapine in an adult with refractory anorexia nervosa and comorbid depression: a case report. Int J Eat Disord 2011; 44:178-81. [PMID: 20127940 DOI: 10.1002/eat.20793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The objective of this report was to describe an efficacious treatment of an adult with long-standing anorexia nervosa (AN). A 50-year-old woman with an over 7-year history of AN and comorbid major depression had been treated unsuccessfully with numerous psychotropic medications, manualized cognitive behavior therapy, and an intensive outpatient treatment program before referral. After treatment with mirtazapine, she gained weight and her depression improved. A 9-month follow-up revealed a maintenance of these benefits. Mirtazapine may be useful for older, chronically ill patients presenting with AN and comorbid depression.
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Affiliation(s)
- Debra L Safer
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California 94305, USA
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McKnight RF, Park RJ. Atypical antipsychotics and anorexia nervosa: a review. EUROPEAN EATING DISORDERS REVIEW 2010; 18:10-21. [PMID: 20054875 DOI: 10.1002/erv.988] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is currently mixed opinion regarding the value of using atypical antipsychotics to treat anorexia nervosa (AN). AIMS To evaluate the literature on the use of atypical antipsychotics in AN. METHOD A review of all studies and clinical guidelines published before September 2009 involving use of an atypical antipsychotic in patients with AN. Analysis is by narrative synthesis. RESULTS Forty-three publications or study protocols were found, including four randomized-controlled trials, five open-label trials and 26 case reports. The most studied drugs were olanzapine, quetiapine and risperidone. Atypical antipsychotics appear safe and there is some evidence of positive effects on depression, anxiety and core eating disordered psychopathology in patients with anorexia nervosa. Currently there is insufficient evidence to confirm atypical antipsychotics enhance weight gain in this setting. CONCLUSIONS Further high quality evidence is needed in this area in order to provide practical guidance to clinicians. However, the main challenge is to persuade adequate numbers of AN patients to participate in research trials.
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Affiliation(s)
- Rebecca F McKnight
- Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, UK.
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Kovalchik S. Comparative study of rate of weight loss among premorbid and healthy restrictive eaters. Eat Weight Disord 2008; 13:176-82. [PMID: 19169073 DOI: 10.1007/bf03327504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Initial body mass index (BMI) and rate of weight loss are compared between cohorts of pathological and healthy dieters. The eating disordered sample consists of young adults reported in case studies in the past ten years with a primary diagnosis of anorexia nervosa (AN). The healthy dieters were adolescents who participated in the National Longitudinal Survey of Adolescent Health and indicated at the time of study enrollment that they were trying to lose weight. At diet initiation, the anorexic sample had a mean BMI (kg/m2) of 20.5 while the healthy dieters had a mean of 24.8. The median rate of weight loss was -1.87 kg per month (1 pound per week) for individuals later diagnosed with AN, while the median weight change was 0.24 kg per month for the Add Health dieters, reflecting an actual gain of 0.13 pounds per week. These findings suggest that measurable physiological characteristics during the early phase of a diet could be predictive of pathological food restriction.
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Affiliation(s)
- S Kovalchik
- University of California Los Angeles - UCLA, Department of Biostatistics, UCLA School of Publich Health, Los Angeles, CA, USA.
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Nature against nurture: calcification in the right thalamus in a young man with anorexia nervosa and obsessive-compulsive personality disorder. CNS Spectr 2008; 13:906-10. [PMID: 18955946 DOI: 10.1017/s1092852900017016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This report describes the case of a young man with a large calcification in the right thalamus that was first diagnosed at 9 years of age. Case history reveals specific eating rituals and other obsessive-compulsive personality traits during the patient's childhood and adolescence, fulfilling diagnostic criteria of obsessive-compulsive personality disorder. After a critical life event the patient develops anorexia nervosa. We suggest that our case and further literature provide evidence for an involvement of specific thalamic structures, such as the dorsomedial nucleus, in the development of anorexia nervosa. Furthermore, the treatment of the patient by a combined psychotherapeutic and pharmacotherapeutic approach is described. We focus on the beneficial effect of the atypical antipsychotic olanzapine, which can induce weight gain by an increase of leptin levels.
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Storch CH, Nikendei C, Schild S, Haefeli WE, Weiss J, Herzog W. Expression and activity of P-glycoprotein (MDR1/ABCB1) in peripheral blood mononuclear cells from patients with anorexia nervosa compared with healthy controls. Int J Eat Disord 2008; 41:432-8. [PMID: 18348284 DOI: 10.1002/eat.20519] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Pharmacotherapeutic strategies for treatment of anorexia nervosa (AN) are characterized by limited success. Some drugs used (antipsychotics, selective serotonin reuptake inhibitors) are transported by P-glycoprotein (P-gp), a transporter with major impact on pharmacokinetics of substrate drugs. Biochemical alterations seen in AN patients could lead to increased expression and/or activity of P-gp and therefore to diminished access of drugs to the brain. The aim of our study was to investigate expression and activity levels of P-gp in peripheral blood mononuclear cells (PBMCs) in AN patients. METHOD PBMCs of 16 AN patients and 16 controls were isolated. Activity of P-gp was determined by flow cytometry and expression was quantified by reverse-transcriptase-real-time-polymerase-chain-reaction. RESULTS Neither a significant difference in P-gp expression (AN: 0.00154 +/- 0.00088 [MDR1/beta2 mg], control: 0.00244 +/- 0.0013 [MDR1/beta2 mg], p = .138) nor a difference in P-gp activity (rhodamine 123 ratio AN: 1.79 +/- 0.73, control: 2.03 +/- 0.42, p = .20) between AN patients and healthy controls could be detected. In contrast to previous studies, expression and activity of P-gp correlated significantly (p = .0031). CONCLUSION Failure in pharmacotherapy with P-gp substrates in AN patients are probably neither caused by different P-gp expression nor activity levels.
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Affiliation(s)
- Caroline Henrike Storch
- Department of Internal Medicine VI, Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, D-69120 Heidelberg, Germany
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Brown RF, Bartrop R, Birmingham CL. Immunological disturbance and infectious disease in anorexia nervosa: a review. Acta Neuropsychiatr 2008; 20:117-28. [PMID: 26951035 DOI: 10.1111/j.1601-5215.2008.00286.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Severely malnourished patients with anorexia nervosa (AN) are reported to show fewer symptomatic viral infections and a poorer response to bacterial infection than controls. They are also reported to show mild immune system changes, although the relevance of these to altered infection disease presentation in AN and AN pathophysiology is unknown. Thus, in this paper, we suggest a range of immune system changes that might underpin these altered responses to common pathogens, and review a number of recent infectious disease findings for their utility in explaining the pathophysiology of AN. METHODS A systematic review of the literature pertaining to immunity and infectious disease in AN was performed. RESULTS AN is associated with leucopenia, and the increased spontaneous and stimulated levels of proinflammatory cytokines [i.e. interleukin (IL)-1β, IL-6 and tumour necrosis factor α). A range of less consistent findings are also reviewed. Most of these data were not controlled for length of illness, degree of malnutrition, micronutrient or vitamin deficiencies or recent refeeding and starvation. CONCLUSION Cytokine disturbances have been suggested to be causally related to AN symptomatology and pathophysiology of AN, although the evidence supporting this assertion is lacking. Immune and cytokine changes in AN do, however, occur in association with a decreased incidence of symptomatic viral infection, decreased clinical response to bacterial infection leading to delayed diagnosis and increased morbidity and mortality associated with the infections.
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Affiliation(s)
- Rhonda F Brown
- 1School of Behavioural, Cognitive and Social Sciences, University of New England, Armidale, New South Wales, Australia
| | - Roger Bartrop
- 2Department of Psychological Medicine, Royal North Shore Hospital, University of Sydney, New South Wales, Australia
| | - C Laird Birmingham
- 3Eating Disorders Program, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
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Hrdlicka M, Beranova I, Zamecnikova R, Urbanek T. Mirtazapine in the treatment of adolescent anorexia nervosa. Case-control study. Eur Child Adolesc Psychiatry 2008; 17:187-9. [PMID: 18357426 DOI: 10.1007/s00787-007-0670-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2007] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Anorexia nervosa (AN) is a serious and potentially life-threatening psychiatric disorder. Pharmacotherapeutic possibilities still remain limited. We sought to determine if there was a positive effect on body weight and body mass index (BMI) in AN patients being treated for depression or anxiety with mirtazapine. METHODS Using a case-control design, we found nine female patients with AN who had been treated with mirtazapine for depression or anxiety during hospitalization in our department. We also found nine female controls with AN, who had not received any pharmacotherapy. The two groups of patients were matched according to age and BMI. Case and control groups did not differ significantly in age (15.2 +/- 1.9 Vs. 14.7 +/- 1.7 years; P = 0.549), or in BMI (15.6 +/- 2.3 Vs. 15.6 +/- 2.1; P = 0.946) at baseline. Weight and BMI were evaluated at baseline and again after the patients had completed 1, 2, 3 and 4 weeks of treatment. RESULTS The mean dose of mirtazapine was 21.7 +/- 1.8 mg at the end of week 4. Using ANOVA Repeated Measures, we found no significant differences between cases and controls with regard to weight (P = 0.981) or BMI (P = 0.576). However, there was a non-significant trend in patients which had been treated with mirtazapine which showed slightly more improvement, in the measured parameters, at the end of weeks 1, 2 and 3, compared to controls. CONCLUSION Results are limited by small sample size. However, the use of mirtazapine could be useful in the treatment of AN in adolescence.
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Affiliation(s)
- Michal Hrdlicka
- Department of Child Psychiatry, 2nd Medical School, Charles University, V Uvalu 84, 15006 Prague, Czech Republic.
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Abstract
OBJECTIVE To report the use of Mirtazapine in the treatment of anorexia nervosa with depression primarily regarding its propensity for weight gain. METHOD We present an outpatient case report of anorexia nervosa with depression. The patient's subsequent progress was recorded. RESULTS The patient gained 2.5 kg within 3 months to eventually attain a body mass index of 15 after 5 months. Her depression achieved full remission at 6 weeks of treatment. CONCLUSIONS Mirtazapine is the choice medication in this case. However, treating depression requires caution, given these patients' physical vulnerability. Controlled trials of Mirtazapine for anorexia nervosa are needed.
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Affiliation(s)
- Nik Ruzyanei Nik Jaafar
- Department of Psychiatry, Faculty of Medicine, Hospital Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur, Cheras, Malaysia.
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