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Wood HJ, Jones N, Eack SM, Chengappa KNR, Prasad KM, Kelly C, Montrose D, Schooler NR, Ganguli R, Carter CS, Keshavan MS, Sarpal DK. Over 30 years of STEP: The Pittsburgh experience with first-episode psychosis. Early Interv Psychiatry 2024. [PMID: 38637133 DOI: 10.1111/eip.13536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 04/20/2024]
Abstract
AIMS For over 30 years, combined research and treatment settings in the US have been critical to conceptualizing care for first-episode psychosis (FEP). Here we describe an early example of such a context, the Services for the Treatment of Early Psychosis (STEP) clinic, which is affiliated with the University of Pittsburgh. METHODS We describe STEP's historical roots and establishment in the early 1990s; STEP's research and treatment contributions, alongside its growth and ongoing leadership. RESULTS Research-based clinics, like STEP, preceded and helped pave the way for the Recovery After an Initial Schizophrenia Episode project in the US and the ensuing Coordinated Specialty Care (CSC) approach, now widely adopted in the US. Early clinic-based research at STEP helped establish protocols for psychopharmacology, the relevance of effective early treatment, including psychosocial approaches, and highlighted disparities in treatment outcomes across race/ethnicity. Multidisciplinary collaboration and dialogue with consumers contributed to early treatment, combining psychosocial and pharmacological approaches. STEP adopted CSC and is situated within a bi-state Learning Health System. STEP has retained a relatively unique 5-year treatment model and exists within continuum of care ideally suited to studying psychotic illness and treatment outcomes. CONCLUSIONS STEP remains the largest academic FEP clinic in Pennsylvania. Academic FEP clinics like STEP will have a critical role within Learning Health Systems nationally to model participatory approaches, sustain early intervention treatment quality and ongoing treatment developments.
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Affiliation(s)
- Helen J Wood
- Services for the Treatment of Early Psychosis (STEP), UPMC Western Psychiatric Hospital, Pittsburgh, Pennsylvania, USA
| | - Nev Jones
- School of Social Work, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shaun M Eack
- School of Social Work, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - K N Roy Chengappa
- Services for the Treatment of Early Psychosis (STEP), UPMC Western Psychiatric Hospital, Pittsburgh, Pennsylvania, USA
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Konasale M Prasad
- Services for the Treatment of Early Psychosis (STEP), UPMC Western Psychiatric Hospital, Pittsburgh, Pennsylvania, USA
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christian Kelly
- Services for the Treatment of Early Psychosis (STEP), UPMC Western Psychiatric Hospital, Pittsburgh, Pennsylvania, USA
| | - Debra Montrose
- Services for the Treatment of Early Psychosis (STEP), UPMC Western Psychiatric Hospital, Pittsburgh, Pennsylvania, USA
| | - Nina R Schooler
- Department of Psychiatry and Behavioral Sciences, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Rohan Ganguli
- Services for the Treatment of Early Psychosis (STEP), UPMC Western Psychiatric Hospital, Pittsburgh, Pennsylvania, USA
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cameron S Carter
- Department of Psychiatry, University of California, Irvine, California, USA
| | - Matcheri S Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Massachusetts Mental Health Center Division of Public Psychiatry, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak K Sarpal
- Services for the Treatment of Early Psychosis (STEP), UPMC Western Psychiatric Hospital, Pittsburgh, Pennsylvania, USA
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Murphy SM, Flores AT, Wojtalik JA, Keshavan MS, Eack SM. Symptom contributors to quality of life in schizophrenia: Exploratory factor and network analyses. Schizophr Res 2024; 264:494-501. [PMID: 38281419 PMCID: PMC11005863 DOI: 10.1016/j.schres.2024.01.028] [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: 07/14/2023] [Revised: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 01/30/2024]
Abstract
Individuals with schizophrenia and other associated disorders experience significant disturbance to their quality of life (QoL) due to a multitude of co-occurring symptoms. Popular evidence-based practices (EBPs) devote significant effort to reduce positive symptomatology in order to prevent relapse, while emerging research posits that other symptoms (cognitive deficits, negative and affective symptoms) are more indicative of QoL disturbance. This study sought to examine the impact of symptom constructs on QoL and attempt to infer directionality of influence via network analysis. A total of 102 recovery phase adult outpatients with schizophrenia spectrum disorders were assessed on positive, negative, and affective symptomatology, in addition to QoL and cognitive abilities. Exploratory factor analysis and network analysis were performed to identify associations and infer directed influence between symptom constructs, and a directed acyclic graph was constructed to observe associations between symptom domains and QoL. Factor analysis results indicated that individual measures align with their respective symptom constructs. Strong factor correlations were found between QoL and the negative and affective symptom constructs, with weaker associations found between positive symptoms and cognition. Visualization of the network structure illustrated QoL as the central cluster of the network, and examination of the weighted edges found the strongest connectivity between QoL, negative symptomatology, and affective symptoms. More severe negative and affective symptoms were most directly linked with poorer QoL and may prove to be integral in attaining positive outcomes in schizophrenia treatment. Incorporation of psychosocial treatments in addition to pharmacotherapy may prove effective in targeting negative and affective symptoms.
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Affiliation(s)
- Samuel M Murphy
- School of Social Work, University of Pittsburgh, United States of America; Department of Psychiatry, University of Pittsburgh School of Medicine, United States of America.
| | - Ana T Flores
- School of Social Work, University of Pittsburgh, United States of America; Department of Psychiatry, University of Pittsburgh School of Medicine, United States of America
| | - Jessica A Wojtalik
- Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, United States of America
| | - Matcheri S Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Massachusetts Mental Health Center Division of Public Psychiatry, United States of America
| | - Shaun M Eack
- School of Social Work, University of Pittsburgh, United States of America; Department of Psychiatry, University of Pittsburgh School of Medicine, United States of America
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Ruffalo ML. The Psychotherapy of Schizophrenia: A Review of the Evidence for Psychodynamic and Nonpsychodynamic Treatments. PSYCHIAT CLIN PSYCH 2023; 33:222-228. [PMID: 38765312 PMCID: PMC11082629 DOI: 10.5152/pcp.2023.23627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/19/2023] [Indexed: 05/22/2024] Open
Abstract
Following the discovery of chlorpromazine's effectiveness as a treatment for schizophrenia in the 1950s, a gradual shift away from psychotherapeutic and toward biological methods of investigation has ensued. Nevertheless, psychological approaches to schizophrenia have a long history and continue to represent an important component of schizophrenia treatment. In the past 2 decades, there has been renewed interest in psychotherapy for schizophrenia among some clinicians and researchers. This article examines the current evidence for both psychodynamic and nonpsychodynamic (cognitive-behavioral, cognitive enhancement, and psychoeducational) therapies for schizophrenic illness. There is evidence to support the use of both types of therapies though these orientations generally differ in their views on the role of psychological factors in the etiology of schizophrenia. It is argued that a pluralistic or biopsychosocial model of schizophrenia is necessary to account for the complexity of the disease and to provide the most effective treatment.
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Affiliation(s)
- Mark L. Ruffalo
- Department of Psychiatry, University of Central Florida College of Medicine, Orlando, FL, USA; Tufts University School of Medicine, Boston, MA, USA
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Wojtalik JA, Brown WJ, Mesholam-Gately RI, Kotwani A, Keshavan MS, Eack SM. Predictors of treatment discontinuation during an 18-month multi-site randomized trial of Cognitive Enhancement Therapy for early course schizophrenia. Psychiatry Res 2023; 326:115254. [PMID: 37267670 PMCID: PMC10527356 DOI: 10.1016/j.psychres.2023.115254] [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: 01/23/2023] [Revised: 05/14/2023] [Accepted: 05/15/2023] [Indexed: 06/04/2023]
Abstract
Treatment discontinuation during clinical trials in schizophrenia is a critical challenge, especially for longer-term interventions in the early course. This research explored predictors of treatment discontinuation in an outpatient early course schizophrenia sample (N = 102) during an 18-month multi-site trial of Cognitive Enhancement Therapy (n = 58) and Enriched Supportive Therapy (n = 44). Fifty-three (52%) participants discontinued, with no significant difference between the treatment groups in discontinuation rate. Univariate and multivariate binary logistic regression models explored differences in key demographic and cognitive and behavioral outcomes between participants who completed and discontinued treatment. Significant multivariate predictors of discontinuation included IQ (linear) and problem solving (curvilinear). The concave shape of the problem solving prediction demonstrated that initially as scores were increasing the probability of non-completion was increasing. However, after a score of 41 (below average problem solving), the probability of being a non-completer decreased as performance increased. Non-completers had significantly lower IQ scores compared to completers. Post-hoc analyses indicated that participants who discontinued prior to mid-treatment exhibited the greatest intellectual challenges, with comparisons moderate-to-large in strength. IQ and problem solving are likely important factors to assess at pre-treatment in early course schizophrenia trials to identify those most vulnerable to discontinuation.
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Affiliation(s)
- Jessica A Wojtalik
- Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, USA.
| | - Wilson J Brown
- Department of Psychology, School of Humanities and Social Sciences, Pennsylvania State University, The Behrend College, Erie, PA, USA
| | - Raquelle I Mesholam-Gately
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Massachusetts Mental Health Center Division of Public Psychiatry, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Anju Kotwani
- Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Matcheri S Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Massachusetts Mental Health Center Division of Public Psychiatry, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Shaun M Eack
- School of Social Work, University of Pittsburgh, Pittsburgh, PA, USW; Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Harris A. Approach to schizophrenia. Intern Med J 2023; 53:473-480. [PMID: 37070777 DOI: 10.1111/imj.16068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/30/2023] [Indexed: 04/19/2023]
Abstract
Schizophrenia is the most common of a group of psychotic disorders that occur in approximately 3% of the population over the lifespan. It has clear genetic antecedents, which are shared across the spectrum of psychotic disorders; however, a range of other biological and social factors influence the onset and treatment of the disorder. Schizophrenia is diagnosed by a characteristic set of symptoms (positive, negative, disorganisation, cognitive and affective) accompanied by a functional decline. Investigations are used to exclude other organic causes of psychosis and to provide a baseline for the negative effects of pharmacological treatments. Treatment requires a combination of pharmacological and psychosocial interventions. Physical health is poor in this group of people and this is not helped by inconsistent care from health services. Although earlier intervention has improved the immediate outcomes, the longer-term outcome has not significantly shifted.
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Affiliation(s)
- Anthony Harris
- Specialty of Psychiatry, Sydney Medical School, Faculty of Medicine and Health Sciences, University of Sydney, Sydney, New South Wales, Australia
- Brain Dynamics Centre, Westmead Institute for Medical Research, Sydney, New South Wales, Australia
- Prevention Early Intervention and Recovery Service, Western Sydney Local Health District, Sydney, New South Wales, Australia
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Schutt RK, Xi H, Mueser KT, Killam MA, Delman J, Eack SM, Mesholam-Gately R, Pratt SI, Sandoval L, Santos MM, Golden LR, Keshavan MS. Cognitive Enhancement Therapy vs social skills training in schizophrenia: a cluster randomized comparative effectiveness evaluation. BMC Psychiatry 2022; 22:583. [PMID: 36050663 PMCID: PMC9434502 DOI: 10.1186/s12888-022-04149-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/19/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Schizophrenia and related disorders are highly disabling and create substantial burdens for families, communities, and health care systems. Although pharmacological treatments can often lessen the psychotic symptoms that are a hallmark of schizophrenia, they do not lessen the social and cognitive deficits that create the greatest impediments to community engagement and functional recovery. This study builds on prior research on psychosocial rehabilitation by comparing the effectiveness of two treatments demonstrated as efficacious in improving social and community functioning, Cognitive Enhancement Therapy (CET) and a version of Social Skills Training (HOPES/SST). METHODS The study uses a randomized cluster design in which a pair of clinicians at community- and hospital-based mental service centers deliver either CET or HOPES to at least one group of 6-8 eligible clients for 12 months. Clinicians are trained and then supervised weekly, with ongoing process measurement of treatment fidelity, attendance, satisfaction, and retention, and use of other services. Measures administered at baseline and at 6 and 12 months while in treatment, and then at 18 and 24 months after treatment include social adjustment, quality of life, social skills, positive and negative symptoms, and neuro- and social cognition. We hypothesize that CET will be associated with greater improvements than SST in both the primary outcome of community functioning and the secondary outcomes of neuro- and social cognition and social skills. Secondarily, we hypothesize that more cognitive impairment at baseline and younger age will predict more benefit from CET compared to HOPES. DISCUSSION Resource shortages endemic in mental health services and exacerbated by the pandemic highlight the importance of identifying the most effective approach to improving social and community functioning. We aim to improve understanding of the impact of two efficacious psychosocial treatments and to improve clinicians' ability to refer to both treatments the individuals who are most likely to benefit from them. We expect the result to be programmatic improvements that improve the magnitude and durability of gains in community functioning. TRIAL REGISTRATION ClinicalTrial.gov NCT04321759 , registered March 25, 2020.
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Affiliation(s)
- Russell K. Schutt
- grid.239395.70000 0000 9011 8547Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA ,grid.266685.90000 0004 0386 3207University of Massachusetts Boston, Boston, USA
| | - Haiyi Xi
- grid.254880.30000 0001 2179 2404Dartmouth College, Hanover, USA
| | - Kim T. Mueser
- grid.189504.10000 0004 1936 7558Boston University, Boston, USA
| | - Matthew A. Killam
- grid.239395.70000 0000 9011 8547Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Jonathan Delman
- grid.168645.80000 0001 0742 0364University of Massachusetts Medical School, Worcester, USA
| | - Shaun M. Eack
- grid.21925.3d0000 0004 1936 9000University of Pittsburgh, Pittsburgh, USA
| | - Raquelle Mesholam-Gately
- grid.239395.70000 0000 9011 8547Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Sarah I. Pratt
- grid.254880.30000 0001 2179 2404Geisel School of Medicine at Dartmouth, Hanover, USA
| | - Luis Sandoval
- grid.239395.70000 0000 9011 8547Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Meghan M. Santos
- grid.254880.30000 0001 2179 2404Geisel School of Medicine at Dartmouth, Hanover, USA
| | - Laura R. Golden
- grid.239395.70000 0000 9011 8547Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA ,grid.266685.90000 0004 0386 3207University of Massachusetts Boston, Boston, USA
| | - Matcheri S. Keshavan
- grid.239395.70000 0000 9011 8547Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
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Wojtalik JA, Flores AT, Keshavan MS, Eack SM. Premorbid Sociality Moderates Social Adjustment Change during Cognitive Enhancement Therapy for Adults with Early Schizophrenia. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2022; 51:312-322. [PMID: 35044886 PMCID: PMC9177526 DOI: 10.1080/15374416.2022.2025599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Cognitive remediation approaches for early course schizophrenia are promising interventions for improving social adjustment. Premorbid sociality is a potentially important moderator of social adjustment response to cognitive remediation and may serve to personalize such interventions. METHOD Eighty-eight early course schizophrenia outpatients with premorbid sociality scores were included in this preliminary investigation. Secondary data came from a recent 18-month multi-site confirmatory trial of Cognitive Enhancement Therapy (CET) compared to Enriched Supportive Therapy (EST). Intent-to-treat mixed effects models examined the moderating effect of premorbid sociality assessed at baseline on differential social adjustment change between CET and EST assessed at baseline, 9, and 18 months. RESULTS Premorbid sociality significantly moderated the differential effect of CET vs. EST on overall social adjustment change at 18 months, such that CET was particularly effective for patients with high premorbid sociality and EST for low premorbid sociality. This significant group x time x premorbid sociality interaction was also observed for 18-month change in interpersonal anguish, self-care, and sexual relations. Again, CET was largely favorable for higher premorbid sociality patients and EST for lower premorbid sociality for these sub-scales. CONCLUSIONS The results provide initial evidence that premorbid sociality moderates differential social adjustment change during cognitive remediation in early course schizophrenia. In many, but not all cases, better social functioning prior to the development of schizophrenia was associated with a significantly better social adjustment response to CET. Data on social functioning during childhood and adolescence is possibly useful for personalizing treatment planning in the early course of schizophrenia.
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Affiliation(s)
- Jessica A. Wojtalik
- Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, USA
- Correspondence: Jessica A. Wojtalik, PhD, Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH, 44106,
| | - Ana T. Flores
- School of Social Work, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matcheri S. Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Massachusetts Mental Health Center Division of Public Psychiatry, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Shaun M. Eack
- School of Social Work, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Harris AWF, Kightley M, Williams J, Ma C, Dodds C. Does Adding Social Cognitive Remediation Therapy to Neurocognitive Remediation Therapy Improve Outcomes in Young People With a Severe Mental Illness?-The Advantage Trial. Front Psychiatry 2021; 12:789628. [PMID: 35368729 PMCID: PMC8964396 DOI: 10.3389/fpsyt.2021.789628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/10/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Cognitive impairments are a common and significant issue for young people with a severe mental illness. Young people with schizophrenia, bipolar disorder and major depression all experience significant cognitive problems that impede their ability to return to work or study. These neurocognitive problems are frequently exacerbated by social cognitive deficits that interfere with their ability to integrate into the community and understand the social and emotional nuances about them. This study aimed to assess if the addition of a social cognitive remediation treatment to a neurocognitive remediation therapy improved functional outcome. METHODS Five youth mental health services were trained in both the Neuropsychological Educational Approach to Remediation (NEAR) and the Social Cognition and Interaction Training (SCIT) treatments. Participants were randomised between receiving either NEAR + SCIT or NEAR + treatment as usual (TAU) over a 20-week period, with all participants receiving the NEAR treatment first. Symptoms, neurocognition, social cognition and functioning were examined at baseline, end of treatment and at 3 months follow-up and compared between the two arms of the study. The primary outcome was function. RESULTS Thirty-nine participants were randomised to treatment (Schizophrenia spectrum = 28, Bipolar disorder = 7, Major Depression = 2). The trial was curtailed by Covid-related service restrictions. There was an overall significant improvement in function over time with a trend towards a greater improvement in the NEAR + SCIT arm. No changes in symptoms, neurocognitive or social cognitive measures were seen. While 74% completed treatment only 49% agreed to follow up at 3 months affecting our ability to interpret the findings. Attrition did not differ by arm. CONCLUSIONS In a pragmatic, service-based research project, treatment aimed at improving cognition enhanced functional outcome in young people with a range of severe mental illnesses. There was a trend towards improved function in young people who had a combined NEAR + SCIT approach. CLINICAL TRIAL REGISTRATION Identifier: ACTRN12622000192785.
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Affiliation(s)
- Anthony W F Harris
- Specialty of Psychiatry, University of Sydney School of Medicine, The University of Sydney, Sydney, NSW, Australia.,Brain Dynamics Centre, The Westmead Institute for Medical Research, The University of Sydney, Sydney, NSW, Australia.,Child and Youth Mental Health Service, Western Sydney Local Health District, North Parramatta, NSW, Australia
| | - Michelle Kightley
- Child and Youth Mental Health Service, Western Sydney Local Health District, North Parramatta, NSW, Australia
| | - Joanna Williams
- Child and Youth Mental Health Service, Western Sydney Local Health District, North Parramatta, NSW, Australia
| | - Cassandra Ma
- Child and Youth Mental Health Service, Western Sydney Local Health District, North Parramatta, NSW, Australia
| | - Carlie Dodds
- Brain Dynamics Centre, The Westmead Institute for Medical Research, The University of Sydney, Sydney, NSW, Australia
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