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Aino S, Saara M, Mishra Pashupati P, Leo-Pekka L, Binisha HM, Emma R, Nina M, Mika K, Olli R, Terho L, Liisa KJ. Early resilience and epigenetic ageing: Results from the prospective Young Finns Study with a 31-year follow-up. Aging Cell 2024:e14394. [PMID: 39460379 DOI: 10.1111/acel.14394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 10/04/2024] [Accepted: 10/10/2024] [Indexed: 10/28/2024] Open
Abstract
Evidence is accumulating on the connection of early adversities and harsh family environment with epigenetic ageing. We investigated whether early psychosocial resilience is associated with epigenetic ageing in adulthood. We used the population-based Young Finns data (n = 1593). Early psychosocial resilience was assessed in 1980-1989 across five broad domains: (1) index of psychological strength (self-esteem at home/in general/at school, perceived possibilities to influence at home, internal life control), (2) index of social satisfaction (perceived support from family/friends and life satisfaction), (3) index of leisure time activities (hobbies and physical fitness), (4) index of responsible health behaviors (infrequent smoking or alcohol consumption), and (5) index of school career (school grades and adaptation). Epigenetic ages were calculated for blood samples from 2011, and the analyses were performed with variables describing age deviation (AgeDevHannum, AgeDevHorvath, AgeDevPheno, AgeDevGrim) and DunedinPACE. Covariates included early family environment, polygenic risk scores for schizophrenia and major depression, adulthood education, and adulthood health behaviors. All of the early resilience indexes were associated with lower levels of epigenetic ageing in adulthood, most consistently with AgeDevGrim and DunedinPACE. The associations of psychological strength and social satisfaction, in particular, seemed to be non-linear. In a smaller subsample (n = 289), high early resilience was related to lower AgeDevGrim over a 25-year follow-up in those who had high "baseline" levels of AgeDevGrim. In conclusion, early resilience seems to associate with lower level of epigenetic ageing in adulthood. Our results tentatively suggest that early resilience may increase "equality in epigenetic ageing" in a general population.
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Affiliation(s)
- Saarinen Aino
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Marttila Saara
- Department of Molecular Epidemiology, Cardiovascular Research Center Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Gerontology Research Center, Tampere University, Tampere, Finland
| | - P Mishra Pashupati
- Department of Clinical Chemistry, Cardiovascular Research Center Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Clinical Chemistry, Fimlab Laboratories, Tampere, Finland
| | - Lyytikäinen Leo-Pekka
- Department of Clinical Chemistry, Cardiovascular Research Center Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Clinical Chemistry, Fimlab Laboratories, Tampere, Finland
| | - Hamal Mishra Binisha
- Department of Clinical Chemistry, Cardiovascular Research Center Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Raitoharju Emma
- Department of Molecular Epidemiology, Cardiovascular Research Center Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Mononen Nina
- Department of Clinical Chemistry, Cardiovascular Research Center Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Kähönen Mika
- Department of Clinical Physiology, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Raitakari Olli
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
- Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland
- Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland
| | - Lehtimäki Terho
- Department of Clinical Chemistry, Cardiovascular Research Center Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Clinical Chemistry, Fimlab Laboratories, Tampere, Finland
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Chen S, Tan Y, Tian L. Immunophenotypes in psychosis: is it a premature inflamm-aging disorder? Mol Psychiatry 2024; 29:2834-2848. [PMID: 38532012 PMCID: PMC11420084 DOI: 10.1038/s41380-024-02539-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 03/28/2024]
Abstract
Immunopsychiatric field has rapidly accumulated evidence demonstrating the involvement of both innate and adaptive immune components in psychotic disorders such as schizophrenia. Nevertheless, researchers are facing dilemmas of discrepant findings of immunophenotypes both outside and inside the brains of psychotic patients, as discovered by recent meta-analyses. These discrepancies make interpretations and interrogations on their roles in psychosis remain vague and even controversial, regarding whether certain immune cells are more activated or less so, and whether they are causal or consequential, or beneficial or harmful for psychosis. Addressing these issues for psychosis is not at all trivial, as immune cells either outside or inside the brain are an enormously heterogeneous and plastic cell population, falling into a vast range of lineages and subgroups, and functioning differently and malleably in context-dependent manners. This review aims to overview the currently known immunophenotypes of patients with psychosis, and provocatively suggest the premature immune "burnout" or inflamm-aging initiated since organ development as a potential primary mechanism behind these immunophenotypes and the pathogenesis of psychotic disorders.
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Affiliation(s)
- Song Chen
- Peking University HuiLongGuan Clinical Medical School, Beijing Huilongguan Hospital, Beijing, PR China
| | - Yunlong Tan
- Peking University HuiLongGuan Clinical Medical School, Beijing Huilongguan Hospital, Beijing, PR China
| | - Li Tian
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
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Caspi A, Shireby G, Mill J, Moffitt TE, Sugden K, Hannon E. Accelerated Pace of Aging in Schizophrenia: Five Case-Control Studies. Biol Psychiatry 2024; 95:1038-1047. [PMID: 37924924 PMCID: PMC11063120 DOI: 10.1016/j.biopsych.2023.10.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/29/2023] [Accepted: 10/21/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Schizophrenia is associated with increased risk of developing multiple aging-related diseases, including metabolic, respiratory, and cardiovascular diseases, and Alzheimer's and related dementias, leading to the hypothesis that schizophrenia is accompanied by accelerated biological aging. This has been difficult to test because there is no widely accepted measure of biological aging. Epigenetic clocks are promising algorithms that are used to calculate biological age on the basis of information from combined cytosine-phosphate-guanine sites (CpGs) across the genome, but they have yielded inconsistent and often negative results about the association between schizophrenia and accelerated aging. Here, we tested the schizophrenia-aging hypothesis using a DNA methylation measure that is uniquely designed to predict an individual's rate of aging. METHODS We brought together 5 case-control datasets to calculate DunedinPACE (Pace of Aging Calculated from the Epigenome), a new measure trained on longitudinal data to detect differences between people in their pace of aging over time. Data were available from 1812 psychosis cases (schizophrenia or first-episode psychosis) and 1753 controls. Mean chronological age was 38.9 (SD = 13.6) years. RESULTS We observed consistent associations across datasets between schizophrenia and accelerated aging as measured by DunedinPACE. These associations were not attributable to tobacco smoking or clozapine medication. CONCLUSIONS Schizophrenia is accompanied by accelerated biological aging by midlife. This may explain the wide-ranging risk among people with schizophrenia for developing multiple different age-related physical diseases, including metabolic, respiratory, and cardiovascular diseases, and dementia. Measures of biological aging could prove valuable for assessing patients' risk for physical and cognitive decline and for evaluating intervention effectiveness.
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Affiliation(s)
- Avshalom Caspi
- Department of Psychology & Neuroscience, Duke University, Durham, North Carolina; Social, Genetic and Developmental Psychiatry, Institute of Psychiatry, Psychology, & Neuroscience, King's College London, London, United Kingdom; PROMENTA, Department of Psychology, University of Oslo, Oslo, Norway.
| | - Gemma Shireby
- Centre of Longitudinal Studies, University College London, Exeter, United Kingdom
| | - Jonathan Mill
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Terrie E Moffitt
- Department of Psychology & Neuroscience, Duke University, Durham, North Carolina; Social, Genetic and Developmental Psychiatry, Institute of Psychiatry, Psychology, & Neuroscience, King's College London, London, United Kingdom; PROMENTA, Department of Psychology, University of Oslo, Oslo, Norway
| | - Karen Sugden
- Department of Psychology & Neuroscience, Duke University, Durham, North Carolina
| | - Eilis Hannon
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
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Saarinen A, Marttila S, Mishra PP, Lyytikäinen L, Raitoharju E, Mononen N, Sormunen E, Kähönen M, Raitakari O, Hietala J, Keltikangas‐Järvinen L, Lehtimäki T. Polygenic risk for schizophrenia, social dispositions, and pace of epigenetic aging: Results from the Young Finns Study. Aging Cell 2024; 23:e14052. [PMID: 38031635 PMCID: PMC10928579 DOI: 10.1111/acel.14052] [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: 07/10/2023] [Revised: 10/26/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
Schizophrenia is often regarded as a disorder of premature aging. We investigated (a) whether polygenic risk for schizophrenia (PRSsch ) relates to pace of epigenetic aging and (b) whether personal dispositions toward active and emotionally close relationships protect against accelerated epigenetic aging in individuals with high PRSsch . The sample came from the population-based Young Finns Study (n = 1348). Epigenetic aging was measured with DNA methylation aging algorithms such as AgeAccelHannum , EEAAHannum , IEAAHannum , IEAAHorvath , AgeAccelHorvath , AgeAccelPheno , AgeAccelGrim , and DunedinPACE. A PRSsch was calculated using summary statistics from the most comprehensive genome-wide association study of schizophrenia to date. Social dispositions were assessed in terms of extraversion, sociability, reward dependence, cooperativeness, and attachment security. We found that PRSsch did not have a statistically significant effect on any studied indicator of epigenetic aging. Instead, PRSsch had a significant interaction with reward dependence (p = 0.001-0.004), cooperation (p = 0.009-0.020), extraversion (p = 0.019-0.041), sociability (p = 0.003-0.016), and attachment security (p = 0.007-0.014) in predicting AgeAccelHannum , EEAAHannum , or IEAAHannum . Specifically, participants with high PRSsch appeared to display accelerated epigenetic aging at higher (vs. lower) levels of extraversion, sociability, attachment security, reward dependence, and cooperativeness. A rather opposite pattern was evident for those with low PRSsch . No such interactions were evident when predicting the other indicators of epigenetic aging. In conclusion, against our hypothesis, frequent social interactions may relate to accelerated epigenetic aging in individuals at risk for psychosis. We speculate that this may be explained by social-cognitive impairments (perceiving social situations as overwhelming or excessively arousing) or ending up in less supportive or deviant social groups.
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Affiliation(s)
- Aino Saarinen
- Department of Psychology and Logopedics, Faculty of MedicineUniversity of HelsinkiHelsinkiFinland
- Helsinki University Central HospitalAdolescent Psychiatry Outpatient ClinicHelsinkiFinland
| | - Saara Marttila
- Department of Molecular Epidemiology, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Gerontology Research CenterTampere UniversityTampereFinland
| | - Pashupati P. Mishra
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Department of Clinical ChemistryFimlab LaboratoriesTampereFinland
- Finnish Cardiovascular Research CenterTampereFinland
| | - Leo‐Pekka Lyytikäinen
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Department of Clinical ChemistryFimlab LaboratoriesTampereFinland
- Finnish Cardiovascular Research CenterTampereFinland
- Department of Cardiology, Heart CenterTampere University HospitalTampereFinland
| | - Emma Raitoharju
- Department of Molecular Epidemiology, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Cardiovascular Research Center Tampere, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Nina Mononen
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Department of Clinical ChemistryFimlab LaboratoriesTampereFinland
- Finnish Cardiovascular Research CenterTampereFinland
- Cardiovascular Research Center Tampere, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Elina Sormunen
- Department of PsychiatryUniversity of TurkuTurkuFinland
- Turku University HospitalTurkuFinland
| | - Mika Kähönen
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Department of Clinical PhysiologyTampere University HospitalTampereFinland
| | - Olli Raitakari
- Turku University HospitalTurkuFinland
- Research Centre of Applied and Preventive Cardiovascular MedicineUniversity of TurkuTurkuFinland
- Centre for Population Health ResearchUniversity of TurkuTurkuFinland
- Department of Clinical Physiology and Nuclear MedicineTurku University HospitalTurkuFinland
| | - Jarmo Hietala
- Department of PsychiatryUniversity of TurkuTurkuFinland
- Turku University HospitalTurkuFinland
- Department of MedicineUniversity of TurkuTurkuFinland
- Division of MedicineTurku University HospitalTurkuFinland
| | | | - Terho Lehtimäki
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Department of Clinical ChemistryFimlab LaboratoriesTampereFinland
- Finnish Cardiovascular Research CenterTampereFinland
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Segura AG, de la Serna E, Sugranyes G, Baeza I, Valli I, Díaz-Caneja C, Martín N, Moreno DM, Gassó P, Rodriguez N, Mas S, Castro-Fornieles J. Epigenetic age deacceleration in youth at familial risk for schizophrenia and bipolar disorder. Transl Psychiatry 2023; 13:155. [PMID: 37156786 PMCID: PMC10167217 DOI: 10.1038/s41398-023-02463-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/21/2023] [Accepted: 04/27/2023] [Indexed: 05/10/2023] Open
Abstract
Epigenetic modifications occur sequentially during the lifespan, but their pace can be altered by external stimuli. The onset of schizophrenia and bipolar disorder is critically modulated by stressors that may alter the epigenetic pattern, a putative signature marker of exposure to environmental risk factors. In this study, we estimated the age-related epigenetic modifications to assess the differences between young individuals at familial high risk (FHR) and controls and their association with environmental stressors. The sample included 117 individuals (6-17 years) at FHR (45%) and a control group (55%). Blood and saliva samples were used estimate the epigenetic age with six epigenetic clocks through methylation data. Environmental risk was measured with obstetric complications, socioeconomic statuses and recent stressful life events data. Epigenetic age was correlated with chronological age. FHR individuals showed epigenetic age deacceleration of Horvath and Hannum epigenetic clocks compared to controls. No effect of the environmental risk factors on the epigenetic age acceleration could be detected. Epigenetic age acceleration adjusted by cell counts showed that the FHR group was deaccelerated also with the PedBE epigenetic clock. Epigenetic age asynchronicities were found in the young at high risk, suggesting that offspring of affected parents follow a slower pace of biological aging than the control group. It still remains unclear which environmental stressors orchestrate the changes in the methylation pattern. Further studies are needed to better characterize the molecular impact of environmental stressors before illness onset, which could be critical in the development of tools for personalized psychiatry.
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Affiliation(s)
- Alex G Segura
- Department of Clinical Foundations, Pharmacology Unit, University of Barcelona, Barcelona, Spain
| | - Elena de la Serna
- Child and Adolescent Psychiatry and Psychology Department, 2021SGR01319, Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain
- Department of Medicine, Institute of Neuroscience, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Gisela Sugranyes
- Child and Adolescent Psychiatry and Psychology Department, 2021SGR01319, Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain
- Department of Medicine, Institute of Neuroscience, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Inmaculada Baeza
- Child and Adolescent Psychiatry and Psychology Department, 2021SGR01319, Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain
- Department of Medicine, Institute of Neuroscience, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Isabel Valli
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Covadonga Díaz-Caneja
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
- Department of Child and Adolescent Psychiatry, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Nuria Martín
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
- Department of Child and Adolescent Psychiatry, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Dolores M Moreno
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
- Adolescent Inpatient Unit, Department of Psychiatry, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Psychiatry Department, Universidad Complutense de Madrid, Madrid, Spain
| | - Patricia Gassó
- Department of Clinical Foundations, Pharmacology Unit, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Natalia Rodriguez
- Department of Clinical Foundations, Pharmacology Unit, University of Barcelona, Barcelona, Spain
| | - Sergi Mas
- Department of Clinical Foundations, Pharmacology Unit, University of Barcelona, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain.
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
| | - Josefina Castro-Fornieles
- Child and Adolescent Psychiatry and Psychology Department, 2021SGR01319, Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain
- Department of Medicine, Institute of Neuroscience, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Martínez-Magaña JJ, Krystal JH, Girgenti MJ, Núnez-Ríos DL, Nagamatsu ST, Andrade-Brito DE, Montalvo-Ortiz JL. Decoding the role of transcriptomic clocks in the human prefrontal cortex. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.19.23288765. [PMID: 37163025 PMCID: PMC10168432 DOI: 10.1101/2023.04.19.23288765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Aging is a complex process with interindividual variability, which can be measured by aging biological clocks. Aging clocks are machine-learning algorithms guided by biological information and associated with mortality risk and a wide range of health outcomes. One of these aging clocks are transcriptomic clocks, which uses gene expression data to predict biological age; however, their functional role is unknown. Here, we profiled two transcriptomic clocks (RNAAgeCalc and knowledge-based deep neural network clock) in a large dataset of human postmortem prefrontal cortex (PFC) samples. We identified that deep-learning transcriptomic clock outperforms RNAAgeCalc to predict transcriptomic age in the human PFC. We identified associations of transcriptomic clocks with psychiatric-related traits. Further, we applied system biology algorithms to identify common gene networks among both clocks and performed pathways enrichment analyses to assess its functionality and prioritize genes involved in the aging processes. Identified gene networks showed enrichment for diseases of signal transduction by growth factor receptors and second messenger pathways. We also observed enrichment of genome-wide signals of mental and physical health outcomes and identified genes previously associated with human brain aging. Our findings suggest a link between transcriptomic aging and health disorders, including psychiatric traits. Further, it reveals functional genes within the human PFC that may play an important role in aging and health risk.
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Affiliation(s)
- José J. Martínez-Magaña
- Division of Human Genetics, Department of Psychiatry, Yale University School of Medicine, New Haven
- National Center for PTSD, US Department of Veterans Affairs, West Haven, CT, USA
| | - John H. Krystal
- Division of Human Genetics, Department of Psychiatry, Yale University School of Medicine, New Haven
- National Center for PTSD, US Department of Veterans Affairs, West Haven, CT, USA
- Psychiatry Service, VA Connecticut Health Care System, West Haven, CT, USA
| | - Matthew J. Girgenti
- Division of Human Genetics, Department of Psychiatry, Yale University School of Medicine, New Haven
- National Center for PTSD, US Department of Veterans Affairs, West Haven, CT, USA
| | - Diana L. Núnez-Ríos
- Division of Human Genetics, Department of Psychiatry, Yale University School of Medicine, New Haven
- National Center for PTSD, US Department of Veterans Affairs, West Haven, CT, USA
| | - Sheila T. Nagamatsu
- Division of Human Genetics, Department of Psychiatry, Yale University School of Medicine, New Haven
- National Center for PTSD, US Department of Veterans Affairs, West Haven, CT, USA
| | - Diego E. Andrade-Brito
- Division of Human Genetics, Department of Psychiatry, Yale University School of Medicine, New Haven
- National Center for PTSD, US Department of Veterans Affairs, West Haven, CT, USA
| | | | - Janitza L. Montalvo-Ortiz
- Division of Human Genetics, Department of Psychiatry, Yale University School of Medicine, New Haven
- National Center for PTSD, US Department of Veterans Affairs, West Haven, CT, USA
- Psychiatry Service, VA Connecticut Health Care System, West Haven, CT, USA
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