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Aafjes-van Doorn K, Spina DS, Horne SJ, Békés V. The association between quality of therapeutic alliance and treatment outcomes in teletherapy: A systematic review and meta-analysis. Clin Psychol Rev 2024; 110:102430. [PMID: 38636207 DOI: 10.1016/j.cpr.2024.102430] [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: 08/22/2023] [Revised: 11/28/2023] [Accepted: 04/08/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE The strength of the therapeutic alliance is widely understood to impact treatment outcomes, however, the alliance-outcome relationship in teletherapy has remained relatively unexamined. The aim of this meta-analysis is to systematically summarize the relationship between therapeutic alliance and treatment outcomes in teletherapy with adult patients conducted via videoconferencing or telephone. METHODS We conducted a systematic search of the databases PsycINFO, PsycARTICLES, ProQuest Dissertation Databases, EMBASE, The Cochrane Library, MEDLINE, Google Scholar, and PubMed for studies published before June 26, 2023. We identified 31 studies with 34 independent samples (4862 participants). RESULTS The average weighted effect size was 0.15, p = .001, 95% CI [0.07, 0.24], k = 34. reflecting a small effect of therapeutic alliance on mental health outcomes. There was significant heterogeneity in the effect sizes, which was driven by between-study differences in the alliance-outcome correlation. The alliance-outcome effect was larger when the alliance was measured late in treatment and when the outcome was measured from the patient's perspective. CONCLUSION Very few teletherapy treatment studies were identified that initially reported on alliance-outcome associations, underlining that this is an under-researched area. The association between alliance-teletherapy outcomes in this meta-analysis was small but significant, and somewhat weaker than the alliance-outcome associations reported for in-person treatments and other online interventions. This might indicate that there are other processes at play in teletherapy that explain variance of treatment outcomes, or that the therapist (and the relationship) has less influence on the treatment outcomes than in in-person therapy.
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Affiliation(s)
| | - Daniel S Spina
- Pennsylvania State University, Psychology Department, PA, USA
| | - Sarah J Horne
- Yeshiva University, Ferkauf Graduate School of Psychology, New York, USA
| | - Vera Békés
- Yeshiva University, Ferkauf Graduate School of Psychology, New York, USA
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2
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Chen Y, Markowitz JC, Blanco C, Hershman DL, Zhang JT, Hellerstein DJ. Geographical distance predicts psychiatric treatment retention for Hispanic women with comorbid major depression and breast cancer. Breast Cancer Res Treat 2024; 205:249-256. [PMID: 38376796 DOI: 10.1007/s10549-024-07250-9] [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: 05/09/2023] [Accepted: 01/05/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE Depression is among the most common comorbid psychiatric disorders of patients with breast cancer. Depression decreases patient quality of life and, if untreated, can adversely affect cancer treatment. We sought to identify treatment barriers for women with breast cancer receiving psychotherapy for depression. Findings may help policy makers and researchers determine funding and design of future studies involving this population, especially in communities with high rates of health disparities. METHODS We used data from a randomized trial for women with breast cancer and current DSM-IV non-psychotic unipolar major depressive disorder (MDD). Patients were randomly assigned to 12 weeks of one of three psychotherapies and attrition was assessed by whether subjects completed 12 weekly treatment sessions. We used descriptive analyses and logistic regression to identify treatment barriers. R shiny was used to determine study patient residences. RESULTS Of 134 randomized patients, 84 (62.7%) were Hispanic. Fifty-nine patients (44%) either did not start or dropped out of treatment, 49 (83.1%) of them being Hispanic. Being a Hispanic woman, less educated, and geographically distant from treatment significantly predicted attrition. Single Hispanic mothers had significantly higher attrition risk than married and/or childless women. CONCLUSION Identifying barriers to treatment is important to improve treatment adherence for patients with concurrent diagnoses of breast cancer and MDD, especially for traditionally underserved minorities. Additional support such as affordable tele-medicine, multi-language assistance, financial aid for transportation and child-care, and allocation of more funds to address some identified barriers deserve consideration to improve treatment adherence and outcomes.
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Affiliation(s)
- Ying Chen
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA.
- Columbia University Irving Medical Center (CUIMC), New York, NY, 10032, USA.
| | - John C Markowitz
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- Columbia University Irving Medical Center (CUIMC), New York, NY, 10032, USA
| | - Carlos Blanco
- Division of Epidemiology, Services and Prevention Research, National Institute on Drug Abuse (NIDA), Gaithersburg, MD, 20892, USA
| | - Dawn L Hershman
- Columbia University Irving Medical Center (CUIMC), New York, NY, 10032, USA
| | - Joy T Zhang
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- University of Virginia, Charlottesville, VA, 22904, USA
| | - David J Hellerstein
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- Columbia University Irving Medical Center (CUIMC), New York, NY, 10032, USA
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Moring JC, Peterson AL, Straud CL, Ortman J, Mintz J, Young-McCaughan S, McGeary CA, McGeary DD, Litz BT, Macdonald A, Roache JD, Resick PA. The interactions between patient preferences, expectancies, and stigma contribute to posttraumatic stress disorder treatment outcomes. J Trauma Stress 2023; 36:1126-1137. [PMID: 37883128 PMCID: PMC10771265 DOI: 10.1002/jts.22982] [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: 03/06/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 10/27/2023]
Abstract
Cognitive processing therapy (CPT) is an effective treatment for posttraumatic stress disorder (PTSD); however, some patients do not improve to the same extent as others. It is important to understand potential factors that can be modified for better patient outcomes. This clinical trial implemented a three-arm, equipoise-stratified randomization design to allow for the accommodation of patient preference before randomization to one of three CPT treatment modalities: in-home, in-office, or telehealth. This study examined whether satisfaction with the modality, perceived stigma, expectations of therapy, and credibility of the therapist differed between modalities and whether these factors impacted treatment outcomes. We hypothesized that the contributions of these variables would depend upon whether participants opted out of any treatment arms and that these factors would predict treatment outcomes. Participants who endorsed less perceived stigma demonstrated larger reductions in PTSD symptom severity than those with similar levels of perceived stigma in the telehealth and in-office conditions, η2 = .12-.18. Participants who endorsed lower satisfaction with their treatment modality and were assigned to the in-home condition experienced larger PTSD symptom reductions than those with similar dissatisfaction in the telehealth and in-office conditions, η2 = .20. The results show the robustness of evidence-based therapies for PTSD given that dissatisfaction did not impede treatment success. In addition, they demonstrate that it is important for clinicians to address stigma before initiating evidence-based therapies for PTSD. Strategies to address these factors are discussed.
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Affiliation(s)
- John C. Moring
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Alan L. Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- South Texas Veterans Health Care System, San Antonio, Texas, USA
- Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, USA
| | - Casey L. Straud
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- South Texas Veterans Health Care System, San Antonio, Texas, USA
- Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, USA
| | - Jordan Ortman
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Cindy A. McGeary
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Donald D. McGeary
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- South Texas Veterans Health Care System, San Antonio, Texas, USA
- Department of Rehabilitation Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Brett T. Litz
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts, USA
| | - Alexandra Macdonald
- The Citadel, Military College of South Carolina, Charleston, South Carolina, USA
| | - John D. Roache
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Patricia A. Resick
- Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, North Carolina, USA
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Chen PV, Helm A, Caloudas SG, Ecker A, Day G, Hogan J, Lindsay J. Evidence of Phone vs Video-Conferencing for Mental Health Treatments: A Review of the Literature. Curr Psychiatry Rep 2022; 24:529-539. [PMID: 36053400 PMCID: PMC9437398 DOI: 10.1007/s11920-022-01359-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW The goal of this paper is to provide a comparative review of using phone (audio-only) or video for mental health treatments. Our review includes evidence of phone and video's effectiveness in terms of reduced symptomology, retention, satisfaction, therapeutic alliance, and other outcomes of interest. This review also discusses how patients and providers' experiences and attitudes differ between these two modalities. Finally, we present information on different usage rates of phone and video across patient populations and mental health provider types, and different implementation strategies. RECENT FINDINGS Treatments through phone and video are both able to reduce symptoms related to mental health conditions and have both been found to be non-inferior to in-person care. Both phone and video are more convenient to patients. Video offers important visual information that can be important to diagnosing mental health conditions. Phone, however, is more broadly accessible and may come with fewer technological issues. In the context of mental health care, where non-verbal cues are tied to symptomology and diagnosing, and a strong relationship between patient and provider can enhance treatment, we encourage the use of video, especially for psychotherapeutic services. However, as phone is more accessible, we ultimately recommend an accommodating approach, one that flexibly makes use of both phone and video. Future studies on telehealth should focus on direct, head-to-head comparisons between phone and video and conduct more rigorous testing on whether clinical differences exist.
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Affiliation(s)
- Patricia V Chen
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.
- Margaret M. and Albert B Alkek Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Ashley Helm
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- VA South Central Mental Illness Research, Houston, TX, USA
| | - Steve G Caloudas
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Anthony Ecker
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
- VA South Central Mental Illness Research, Houston, TX, USA
| | - Giselle Day
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- VA South Central Mental Illness Research, Houston, TX, USA
| | - Julianna Hogan
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
- VA South Central Mental Illness Research, Houston, TX, USA
| | - Jan Lindsay
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
- VA South Central Mental Illness Research, Houston, TX, USA
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Classen B, Tudor K, du Preez E, Day E, Ioane J, Rodgers B. An Integrative Review of Contemporary Perspectives on Videoconference-Based Therapy-Prioritising Indigenous and Ethnic Minority Populations in the Global South. ACTA ACUST UNITED AC 2021; 6:545-558. [PMID: 33898737 PMCID: PMC8058578 DOI: 10.1007/s41347-021-00209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/14/2021] [Accepted: 04/15/2021] [Indexed: 11/25/2022]
Abstract
An integrative literature review was undertaken as a means of drawing together contemporary perspectives on the outcomes and affordances of videoconference-based therapy. This review was conducted in a way which placed emphasis on the need for mental healthcare strategies which are mindful of the cultural and social needs of indigenous and ethnic minority populations, particularly those situated in the Global South. The review was undertaken using an inverse funnelling approach which sought to prioritise literature on videoconference-based therapy literature which specifically focused on indigenous and ethnic minority populations. A series of general and population specific searches across relevant health databases were supplemented by a simultaneous search of Google Scholar. The PICOS search tool was used in developing the search terms, and data was processed using an inductive approach to thematic analysis. A final dataset of 43 articles were included in the review. This body of literature encompassed an international range of studies and included perspectives informed by quantitative, qualitative and mixed methods research. Four key themes were identified across the reviewed literature: indigenous and ethnic minority populations, therapeutic relationships, clinical outcomes and technical and logistical considerations. Based on our findings, there is reason to believe that videoconference-based therapy can be made to be just as effective as offline, face-to-face modes of delivery. However, research into the efficacy, impact and cultural implications of this technology in relation to indigenous and ethnic minority populations represents a significant gap within contemporary literature.
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Affiliation(s)
- Ben Classen
- Auckland University of Technology, Auckland, New Zealand
| | - Keith Tudor
- Auckland University of Technology, Auckland, New Zealand
| | | | - Elizabeth Day
- Auckland University of Technology, Auckland, New Zealand
| | - Julia Ioane
- Auckland University of Technology, Auckland, New Zealand
| | - Brian Rodgers
- Auckland University of Technology, Auckland, New Zealand
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Lobban J, Murphy D. Military museum collections and art therapy as mental health resources for veterans with PTSD. INTERNATIONAL JOURNAL OF ART THERAPY 2020. [DOI: 10.1080/17454832.2020.1845220] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Jones C, Miguel-Cruz A, Smith-MacDonald L, Cruikshank E, Baghoori D, Kaur Chohan A, Laidlaw A, White A, Cao B, Agyapong V, Burback L, Winkler O, Sevigny PR, Dennett L, Ferguson-Pell M, Greenshaw A, Brémault-Phillips S. Virtual Trauma-Focused Therapy for Military Members, Veterans, and Public Safety Personnel With Posttraumatic Stress Injury: Systematic Scoping Review. JMIR Mhealth Uhealth 2020; 8:e22079. [PMID: 32955456 PMCID: PMC7536597 DOI: 10.2196/22079] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/28/2020] [Accepted: 08/01/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND A necessary shift from in-person to remote delivery of psychotherapy (eg, teletherapy, eHealth, videoconferencing) has occurred because of the COVID-19 pandemic. A corollary benefit is a potential fit in terms of the need for equitable and timely access to mental health services in remote and rural locations. Owing to COVID-19, there may be an increase in the demand for timely, virtual delivery of services among trauma-affected populations, including public safety personnel (PSP; eg, paramedics, police, fire, correctional officers), military members, and veterans. There is a lack of evidence on the question of whether digital delivery of trauma-therapies for military members, veterans, and PSP leads to similar outcomes to in-person delivery. Information on barriers and facilitators and recommendations regarding digital-delivery is also scarce. OBJECTIVE This study aims to evaluate the scope and quality of peer-reviewed literature on psychotherapeutic digital health interventions delivered remotely to military members, veterans, and PSP and synthesize the knowledge of needs, gaps, barriers to, and facilitators for virtual assessment of and virtual interventions for posttraumatic stress injury. METHODS Relevant studies were identified using MEDLINE (Medical Literature Analysis and Retrieval System Online), EMBASE (Excerpta Medica dataBASE), APA (American Psychological Association) PsycINFO, CINAHL (Cumulative Index of Nursing and Allied Health Literature) Plus with Full Text, and Military & Government Collection. For collation, analysis, summarizing, and reporting of results, we used the CASP (Critical Skills Appraisal Program) qualitative checklist, PEDro (Physiotherapy Evidence Database) scale, level of evidence hierarchy, PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews), and narrative synthesis. RESULTS A total of 38 studies were included in this review. Evidence for the effectiveness of digital delivery of prolonged exposure therapy, cognitive processing therapy, behavioral activation treatment with therapeutic exposure to military members, veterans, and PSP was rated level 1a, whereas evidence for cognitive behavioral therapy was conflicting. The narrative synthesis indicated that virtual delivery of these therapies can be as effective as in-person delivery but may reduce stigma and cost while increasing access to therapy. Issues of risk, safety, potential harm (ie, suicidality, enabling avoidance), privacy, security, and the match among the therapist, modality, and patient warrant further consideration. There is a lack of studies on the influences of gender, racial, and cultural factors that may result in differential outcomes, preferences, and/or needs. An investigation into other therapies that may be suitable for digital delivery is needed. CONCLUSIONS Digital delivery of trauma therapies for military members, veterans, and PSP is a critical area for further research. Although promising evidence exists regarding the effectiveness of digital health within these populations, many questions remain, and a cautious approach to more widespread implementation is warranted.
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Affiliation(s)
- Chelsea Jones
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,1 Field Ambulance Physical Rehabilitation Department, Canadian Armed Forces Health Services, Department of National Defense, Edmonton, AB, Canada
| | - Antonio Miguel-Cruz
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Glenrose Rehabilitation Hospital Research Innovation and Technology (GRRIT), Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Lorraine Smith-MacDonald
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Emily Cruikshank
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Educational Psychology, Faculty of Education, University of Alberta, Edmonton, AB, Canada
| | - Delaram Baghoori
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Rehabilitation Science, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Avneet Kaur Chohan
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Alexa Laidlaw
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Allison White
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Bo Cao
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Vincent Agyapong
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Lisa Burback
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Olga Winkler
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Phillip R Sevigny
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Educational Psychology, Faculty of Education, University of Alberta, Edmonton, AB, Canada
| | - Liz Dennett
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Martin Ferguson-Pell
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Rehabilitation Science, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Andrew Greenshaw
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Suzette Brémault-Phillips
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
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