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Zamperoni G, Tan EJ, Sumner PJ, Rossell SL. Exploring the conceptualisation, measurement, clinical utility and treatment of formal thought disorder in psychosis: A Delphi study. Schizophr Res 2024; 270:486-493. [PMID: 39002286 DOI: 10.1016/j.schres.2024.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/09/2024] [Accepted: 06/22/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Formal Thought Disorder (FTD) is a recognised psychiatric symptom, yet its characterisation remains debated. This is problematic because it contributes to poor efficiency and heterogeneity in psychiatric research, with salient clinical impact. OBJECTIVE This study aimed to investigate expert opinion on the concept, measurement and clinical utility of FTD using the Delphi technique. METHOD Across three rounds, experts were queried on their definitions of FTD, methods for the assessment and measurement of FTD, associated clinical outcomes and treatment options. RESULTS Responses were obtained from 56 experts, demonstrating varying levels of consensus across different aspects of FTD. While consensus (>80 %) was reached for some aspects on the concept of FTD, including its definition and associated symptomology and mechanisms, others remained less clear. Overall, the universal importance attributed to the clinical understanding, measurement and treatment of FTD was clear, although consensus was infrequent as to the reasons behind and methods for doing so. CONCLUSIONS Our results contribute to the still elusive formal definition of FTD. The multitude of interpretations regarding these topics highlights the need for further clarity with this phenomenon. Our findings emphasised that the measurement and clinical utility of FTD are closely tied to the concept; hence, until there is agreement on the concept of FTD, difficulties with measuring and understanding its clinical usefulness to inform treatment interventions will persist. Future FTD research should focus on clarifying the factor structure and dimensionality to determine the latent structure and elucidate the core clinical phenotype.
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Affiliation(s)
- Georgia Zamperoni
- Centre for Mental Health and Brain Sciences, School of Health Sciences, Swinburne University of Technology, Melbourne, VIC 3122, Australia.
| | - Eric J Tan
- Centre for Mental Health and Brain Sciences, School of Health Sciences, Swinburne University of Technology, Melbourne, VIC 3122, Australia; Memory Ageing & Cognition Centre, National University Health System, Singapore; Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Philip J Sumner
- Centre for Mental Health and Brain Sciences, School of Health Sciences, Swinburne University of Technology, Melbourne, VIC 3122, Australia
| | - Susan L Rossell
- Centre for Mental Health and Brain Sciences, School of Health Sciences, Swinburne University of Technology, Melbourne, VIC 3122, Australia; Department of Psychiatry, St Vincent's Hospital, Melbourne, VIC 3065, Australia
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2
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Tortorella A. We Should Improve Personalization of Management in Patients with a Diagnosis of Schizophrenia. J Clin Med 2021; 11:jcm11010184. [PMID: 35011925 PMCID: PMC8745754 DOI: 10.3390/jcm11010184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/17/2021] [Accepted: 12/29/2021] [Indexed: 12/23/2022] Open
Abstract
The current management of patients with schizophrenia is marked by a lack of personalization. After the diagnosis is made, a second-generation antipsychotic is usually prescribed based on the current clinician’s preferences, sometimes accompanied by a psychosocial intervention which is typically not evidence-based and not targeted to the specific needs of the individual patient. In this opinion paper, some steps are outlined that could be taken in order to address this lack of personalization. A special emphasis is laid on the clinical characterization of the patient who has received a diagnosis of schizophrenia. Considerations are put forward concerning the assessment of the negative dimension in ordinary clinical practice, which is often neglected; the evaluation of cognitive functioning using a simple test battery which requires limited professional training and takes no more than 15 min to administer; the evaluation of social functioning using a validated instrument focusing on personal care skills, interpersonal relationships, social acceptability, activities, and work skills; and the assessment of the unmet needs of the person (including practical, social, and emotional needs, and existential or personal recovery). The implications of the assessment of these domains for the formulation of the management plan are discussed.
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3
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Maj M, van Os J, De Hert M, Gaebel W, Galderisi S, Green MF, Guloksuz S, Harvey PD, Jones PB, Malaspina D, McGorry P, Miettunen J, Murray RM, Nuechterlein KH, Peralta V, Thornicroft G, van Winkel R, Ventura J. The clinical characterization of the patient with primary psychosis aimed at personalization of management. World Psychiatry 2021; 20:4-33. [PMID: 33432763 PMCID: PMC7801854 DOI: 10.1002/wps.20809] [Citation(s) in RCA: 138] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The current management of patients with primary psychosis worldwide is often remarkably stereotyped. In almost all cases an antipsychotic medica-tion is prescribed, with second-generation antipsychotics usually preferred to first-generation ones. Cognitive behavioral therapy is rarely used in the vast majority of countries, although there is evidence to support its efficacy. Psychosocial interventions are often provided, especially in chronic cases, but those applied are frequently not validated by research. Evidence-based family interventions and supported employment programs are seldom implemented in ordinary practice. Although the notion that patients with primary psychosis are at increased risk for cardiovascular diseases and diabetes mellitus is widely shared, it is not frequent that appropriate measures be implemented to address this problem. The view that the management of the patient with primary psychosis should be personalized is endorsed by the vast majority of clinicians, but this personalization is lacking or inadequate in most clinical contexts. Although many mental health services would declare themselves "recovery-oriented", it is not common that a focus on empowerment, identity, meaning and resilience is ensured in ordinary practice. The present paper aims to address this situation. It describes systematically the salient domains that should be considered in the characterization of the individual patient with primary psychosis aimed at personalization of management. These include positive and negative symptom dimensions, other psychopathological components, onset and course, neurocognition and social cognition, neurodevelopmental indicators; social functioning, quality of life and unmet needs; clinical staging, antecedent and concomitant psychiatric conditions, physical comorbidities, family history, history of obstetric complications, early and recent environmental exposures, protective factors and resilience, and internalized stigma. For each domain, simple assessment instruments are identified that could be considered for use in clinical practice and included in standardized decision tools. A management of primary psychosis is encouraged which takes into account all the available treatment modalities whose efficacy is supported by research evidence, selects and modulates them in the individual patient on the basis of the clinical characterization, addresses the patient's needs in terms of employment, housing, self-care, social relationships and education, and offers a focus on identity, meaning and resilience.
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Affiliation(s)
- Mario Maj
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Jim van Os
- Department of Psychiatry, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Marc De Hert
- University Psychiatric Centre KU Leuven, Kortenberg, Belgium
- Antwerp Health Law and Ethics Chair, University of Antwerp, Antwerp, Belgium
| | - Wolfgang Gaebel
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University Düsseldorf, LVR-Klinikum Düsseldorf, and WHO Collaborating Center on Quality Assurance and Empowerment in Mental Health, Düsseldorf, Germany
| | - Silvana Galderisi
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Michael F Green
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
- Department of Veterans Affairs, Desert Pacific Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, USA
| | - Sinan Guloksuz
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Philip D Harvey
- Division of Psychology, Department of Psychiatry, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Peter B Jones
- Department of Psychiatry, University of Cambridge and Cambridgeshire & Peterborough NHS Foundation Trust, Cambridge, UK
| | - Dolores Malaspina
- Department of Psychiatry and Neuroscience, Ichan Medical School at Mount Sinai, New York, NY, USA
| | - Patrick McGorry
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Jouko Miettunen
- Centre for Life Course Health Research, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Robin M Murray
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Keith H Nuechterlein
- Semel Institute for Neuroscience and Human Behavior, Geffen School of Medicine, and Department of Psychology, University of California Los Angeles, Los Angeles, CA, USA
| | - Victor Peralta
- Mental Health Department, Servicio Navarro de Salud, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Graham Thornicroft
- Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Ruud van Winkel
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
- Antwerp Health Law and Ethics Chair, University of Antwerp, Antwerp, Belgium
- University Psychiatric Center KU Leuven, Leuven, Belgium
| | - Joseph Ventura
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
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Wood L, Williams C, Billings J, Johnson S. A systematic review and meta-analysis of cognitive behavioural informed psychological interventions for psychiatric inpatients with psychosis. Schizophr Res 2020; 222:133-144. [PMID: 32586627 DOI: 10.1016/j.schres.2020.03.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 03/11/2020] [Accepted: 03/21/2020] [Indexed: 01/09/2023]
Abstract
Psychological interventions such as Cognitive Behavioural Therapy for psychosis (CBTp) are recommended by the National Institute of Health and Care Excellence (NICE) for delivery in the acute phase of people's mental health difficulties. However, the effectiveness of cognitive behavioural informed psychological therapies for psychiatric inpatients is unknown. The aim of this review is to examine the type, quality and efficacy of cognitive behavioural informed psychological interventions for psychiatric inpatients experiencing psychosis. A systematic review and meta-analysis was conducted of randomised controlled trials examining the efficacy of cognitive behavioural informed psychological interventions offered to acute psychiatric inpatients with psychosis on primary (positive symptoms) and secondary outcomes of interest. A total of 23 studies were identified reporting on 18 trials of interventions such as CBTp, Acceptance and Commitment Therapy (ACT) and Metacognitive Therapy (MCT). Cognitive behavioural informed psychological interventions were found not be effective in reducing positive symptoms (primary outcome) at post-therapy and at follow-up but when a one study removed analysis was conducted a positive effect was found at both time points. In regard to secondary outcomes, cognitive behavioural informed psychological interventions demonstrated a significant favourable effect on negative symptoms (post-therapy), total symptoms (post-therapy and follow-up), functioning (post-therapy and follow-up) and readmission (follow-up). These psychological interventions may have potential to be effective for those admitted to psychiatric inpatient care and in acute crisis. However, findings are equivocal with evidence that these interventions have effect on some symptom measures but not others. Further examination of inpatient adapted cognitive behavioural informed psychological interventions is required.
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Affiliation(s)
- Lisa Wood
- North East London NHS Foundation Trust, Acute and Rehabilitation Directorate, Goodmayes Hospital, Barley Lane, Ilford, Essex IG3 8XJ, United Kingdom of Great Britain and Northern Ireland; University College London, Division of Psychiatry, Maple House, 149 Tottenham Court Road, London W1T 7BN, United Kingdom of Great Britain and Northern Ireland.
| | - Claire Williams
- North East London NHS Foundation Trust, Acute and Rehabilitation Directorate, Goodmayes Hospital, Barley Lane, Ilford, Essex IG3 8XJ, United Kingdom of Great Britain and Northern Ireland
| | - Jo Billings
- University College London, Division of Psychiatry, Maple House, 149 Tottenham Court Road, London W1T 7BN, United Kingdom of Great Britain and Northern Ireland
| | - Sonia Johnson
- University College London, Division of Psychiatry, Maple House, 149 Tottenham Court Road, London W1T 7BN, United Kingdom of Great Britain and Northern Ireland
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Shryane N, Drake R, Morrison AP, Palmier-Claus J. Is cognitive behavioural therapy effective for individuals experiencing thought disorder? Psychiatry Res 2020; 285:112806. [PMID: 32007658 DOI: 10.1016/j.psychres.2020.112806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 12/16/2019] [Accepted: 01/20/2020] [Indexed: 10/25/2022]
Abstract
Various clinical guidelines recommend cognitive behavioural therapy (CBT) to treat psychosis without reference to patients' thought disorder. However, there is a risk that disorganized thinking hampers CBT. We tested the prediction that thought disorder would interfere with the effectiveness of CBT for hallucinations and delusions, compared to treatment as usual and supportive counselling, in secondary data from two large, single blind randomised controlled trials. We fitted latent growth curve models separately for the development of frequency and distress of symptoms. CBT was significantly more successful than counselling in reducing delusional frequency in the short term and hallucinatory distress at any point, even in those with relatively high thought disorder. We found little evidence that clinicians should restrict CBT in this subgroup of patients. Nevertheless, the findings highlight the importance of effective initial treatment of thought disorder in maximising the benefit of CBT for psychosis, particularly for reducing distress from hallucinations.
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Affiliation(s)
- Nick Shryane
- Department of Social Statistics, University of Manchester, Manchester M13 9PL, UK
| | - Richard Drake
- Division of Clinical Psychology and Mental Health, University of Manchester, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Anthony P Morrison
- Division of Clinical Psychology and Mental Health, University of Manchester, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Jasper Palmier-Claus
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancashire, UK; Lancashire & South Cumbria NHS Foundation Trust, Lancashire, UK.
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6
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Palmier-Claus J, Wright K, Mansell W, Bowe S, Lobban F, Tyler E, Lodge C, Jones S. A guide to behavioural experiments in bipolar disorder. Clin Psychol Psychother 2019; 27:159-167. [PMID: 31830342 DOI: 10.1002/cpp.2415] [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: 10/14/2019] [Accepted: 12/05/2019] [Indexed: 11/08/2022]
Abstract
Behavioural experiments are an important component of cognitive-behavioural therapy. However, there exists little up-to-date guidance on how to conduct these in people with a diagnosis of bipolar disorder. This paper provides recommendations on how to conduct behavioural experiments in this population. The aim is to upskill and empower clinicians to conduct behavioural experiments. The paper combines the expertise of senior clinicians working in the United Kingdom. The article starts by providing general advice on conducting behavioural experiments in people with bipolar disorder. It then offers specific examples of behavioural experiments targeting cognitions around the uncontrollability and danger of affective states, and related behavioural strategies, which have been implicated in the maintenance of bipolar mood swings. The article finishes by providing examples of behavioural experiments for non-mood related difficulties that commonly occur with bipolar experiences including perfectionistic thinking, need for approval, and intrusive memories. Behavioural experiments offer a useful therapeutic technique for instigating cognitive and behavioural change in bipolar disorder. Conducted sensitively and collaboratively, in line with people's recovery-focused goals, behavioural experiments can be used to overcome mood- and non-mood related difficulties.
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Affiliation(s)
- Jasper Palmier-Claus
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK.,Lancashire & South Cumbria NHS Foundation Trust, Lancashire, UK
| | - Kim Wright
- School of Psychology, University of Exeter, Exeter, UK
| | - Warren Mansell
- Division of Psychology and Mental Health Research, University of Manchester, Manchester, UK
| | - Samantha Bowe
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Fiona Lobban
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
| | - Elizabeth Tyler
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
| | - Christopher Lodge
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
| | - Steve Jones
- Spectrum Centre for Mental Health Research, Division of Health Research, Lancaster University, Lancaster, UK
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7
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de Sousa P, Sellwood W, Eldridge A, Bentall RP. The role of social isolation and social cognition in thought disorder. Psychiatry Res 2018; 269:56-63. [PMID: 30145302 DOI: 10.1016/j.psychres.2018.08.048] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 12/19/2022]
Abstract
A better understanding of how social factors relate to the psychological processes in thought disorder (TD) is necessary for the development of effective psychological interventions. Sixty-eight participants diagnosed with psychosis (18-65; 47.1% female) were recruited and evaluated on social cognition (Hinting Task, HT; and reading the mind in the eyes test, RMET), social isolation (size of social network, frequency and quality of contact), psychotic symptoms (Positive and Negative Syndrome Scale, PANSS) and TD (Thought, Language and Communication Disorders Scale, TLC). A mediation model was tested with isolation as the predictor, TD as the outcome, and performance on HT and RMET as the mediators. The final model, with adjustment for comorbid symptoms (i.e. delusions, suspiciousness, hallucinations, and negative symptoms), supported full mediation and explained a significant amount of the observed variance (60%). Performance on the HT was a significant mediator of the relationship between social isolation and TD. From the covariates, delusions contributed independently and significantly to TD. The implications of the findings for psychological practice, and TD-specific interventions, are discussed as well as the limitations of the study. Further avenues for symptom-specific research are discussed, in particular with reference to more complex psychosocial models.
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Affiliation(s)
- Paulo de Sousa
- Department of Clinical Psychology, University of Liverpool, Whelan Building, The Quadrangle, Brownlow Hill, Liverpool L69 3GB, United Kingdom.
| | - William Sellwood
- Division of Health Research, Faculty of Health and Medicine, Furness Building, Lancaster University, Lancaster LA1 4YG, United Kingdom
| | - Alaw Eldridge
- Resettle, Merseycare NHS Foundation Trust, Liverpool, L24 8RN, United Kingdom
| | - Richard P Bentall
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Cathedral Court, 1 Vicar Lane, Sheffield, S1 2L, United Kingdom
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Sumner PJ, Bell IH, Rossell SL. A systematic review of task-based functional neuroimaging studies investigating language, semantic and executive processes in thought disorder. Neurosci Biobehav Rev 2018; 94:59-75. [PMID: 30142368 DOI: 10.1016/j.neubiorev.2018.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 05/16/2018] [Accepted: 08/09/2018] [Indexed: 01/30/2023]
Abstract
The aim of the current systematic review was to synthesise the research that has investigated thought disorder (TD) using task-based functional neuroimaging techniques to target executive, language, or semantic functions. Thirty-five pertinent studies were identified from January 1990 to August 2016. Functional correlates of TD included the superior and middle temporal, fusiform, and inferior frontal gyri bilaterally, as well as the left and right cingulate cortex, the right caudate nucleus, and the cerebellum. TD-related increases and decreases in activation were both evident in most of these regions. However, the specificity of these correlates from general clinical and cognitive influences is unknown. The cortical regions implicated overlap with those thought to contribute to language and semantic systems. Cortico-striatal circuitry may also play a role in some aspects of TD through aberrant salience representation and inappropriate attentional prioritisation. To advance the field further, greater integration across structural, functional, and behavioural measures is required, in addition to non-unitary considerations of TD.
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Affiliation(s)
- Philip J Sumner
- Centre for Mental Health, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, VIC, Australia; Monash Alfred Psychiatry Research Centre (MAPrc), Central Clinical School, Monash University and The Alfred Hospital, Melbourne, VIC, Australia.
| | - Imogen H Bell
- Centre for Mental Health, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, VIC, Australia; Monash Alfred Psychiatry Research Centre (MAPrc), Central Clinical School, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Susan L Rossell
- Centre for Mental Health, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, VIC, Australia; Monash Alfred Psychiatry Research Centre (MAPrc), Central Clinical School, Monash University and The Alfred Hospital, Melbourne, VIC, Australia; Psychiatry, St Vincent's Hospital, Melbourne, VIC, Australia
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