1
|
Chauhan N, Chakrabarti S, Grover S. Identifying Poor Adherence in Outpatients with Bipolar Disorder: A Comparison of Different Measures. J Neurosci Rural Pract 2022; 13:12-22. [PMID: 35110916 PMCID: PMC8803505 DOI: 10.1055/s-0041-1736155] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Objective Unlike schizophrenia, comparisons of different methods of estimating inadequate adherence in bipolar disorder (BD) are scarce. This study compared four methods of identifying inadequate adherence among outpatients with BD. Materials and Methods Two self-reports, the Morisky Medication Adherence Questionnaire (MAQ) and the Drug Attitude Inventory (DAI-10), clinician ratings employing the Compliance Rating Scale (CRS), mood-stabilizer levels, and clinic-based pill counts were compared at intake in 106 outpatients with BD and after 6 months of follow-up ( n = 75). Statistical Analysis Rates of nonadherence were determined for each method. The ability to detect inadequate adherence was based on sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (LR positive and LR negative). Correlation coefficients and Cohen's kappa values were used to determine the agreement between measures. Correlation coefficients were also used to evaluate the determinants of inadequate adherence Results The MAQ and the DAI-10 (cut-off score of two) yielded higher rates of nonadherence (35-47%) than the other methods. They were better at detecting adherence (specificity, 34-42%; PPV, 40-44%; and LR negative, 0.70-0.96) than other measures and had moderate ability to identify nonadherence compared with them (sensitivity, 63-73%; NPV, 54-70%; and LR positive, 1.02-1.16). They were associated with several established predictors of nonadherence. The MAQ and DAI-10 scores and the MAQ and CRS scores were modestly correlated. Multivariate analysis showed that 20% of the variance in the DAI-10 scores was explained by the MAQ scores. Despite their low yield, serum levels had a high sensitivity (88%) and higher accuracy (55%) in identifying inadequate adherence. CRS ratings and pill counts had high sensitivity but low specificity to detect inadequate adherence. Conclusion Self-reports appeared to be the most efficient method of ascertaining inadequate adherence among outpatients with BD. However, since none of the measures were adequate by themselves, a combination of different measures is more likely to maximize the chances of identifying inadequate adherence among these patients.
Collapse
Affiliation(s)
- Nidhi Chauhan
- Department of Psychiatry, Postgraduate Institution of Medical Education and Research (PGIMER), Chandigarh, India
- Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
| | - Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institution of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institution of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
2
|
Pico AMP, Sánchez MJI, Tejedor FM, Acevedo RM. Toe Support Pattern as a New Predictive Factor Associated with Falls in Older People with Psychiatric Disorders. J Am Podiatr Med Assoc 2021; 111. [PMID: 34861691 DOI: 10.7547/20-135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Maintaining autonomy is one of the principal objectives for seniors and people with psychiatric disorders. Podiatric medical care can help them maintain autonomy. This work aimed to characterize and quantify the support of the toes in a psychiatric population by analyzing the influence of psychotropic medications and toe and foot support parameters on the prevalence of falls. METHODS We conducted a cross-sectional descriptive study in 67 participants (31 people with psychiatric disorders and 36 without diagnosed disorders [control population]). Toe support pattern was analyzed with a pressure platform. Variables were measured in static and dynamic loading and related to falls and psychotropic medication use. RESULTS The psychiatric population fell more than the control population and presented less toe-ground contact in static measurements, although it has more foot-ground contact time. Maximum toe pressure during toe-off is also less intensive in the psychiatric population and is related to people who take psychotropic medications. CONCLUSIONS Toe support pattern could be used as a predictive factor for falls and to improve stability in these populations.
Collapse
|
3
|
Attitudes to Medication-Treatment Among Patients and Caregivers: A Longitudinal Comparison of Bipolar Disorder and Schizophrenia From India. J Clin Psychopharmacol 2020; 40:18-29. [PMID: 31804452 DOI: 10.1097/jcp.0000000000001144] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Attitudes toward medication treatment are thought to significantly influence adherence in bipolar disorder (BD) and schizophrenia. However, the actual impact of patients' treatment attitudes on adherence and determinants of attitudes is still uncertain. METHODS A longitudinal examination of treatment attitudes and their correlates was conducted among patients with BD and their caregivers compared with those with schizophrenia. Structured assessments of symptom severity, functioning, insight, medication side effects, knowledge of illness, medication adherence, treatment attitudes, and treatment satisfaction were performed among 176 selected patients (106 with BD and 70 with schizophrenia) and their caregivers. Participants were reassessed on these parameters at 3 and 6 months. RESULTS Rates of nonadherence at baseline varied widely between self-reports, clinician ratings, and serum levels. Though symptoms and functioning improved with treatment, overall rates of nonadherence increased in the first 3 months because of early dropouts and remained stable thereafter. However, treatment attitudes and treatment satisfaction remained largely unchanged among patients and caregivers. Both positive and negative attitudes were commonly held and patients' attitudes did not differ between BD and schizophrenia. Patients' attitudes were significantly associated with adherence, insight, knowledge about illness, treatment satisfaction, symptom severity, social disadvantage, and side effects together with caregivers' knowledge, attitudes, and satisfaction. Caregivers of patients with schizophrenia were more knowledgeable and had more positive attitudes than patients. CONCLUSIONS Patients' attitudes to medication treatment are associated with adherence over time. They are relatively enduring and mainly associated with insight, knowledge of illness, and treatment satisfaction among patients and their caregivers. These findings could inform psychosocial interventions aiming to improve treatment attitudes and adherence in BD and schizophrenia.
Collapse
|
4
|
Chakrabarti S. Treatment Attitudes and Adherence Among Patients with Bipolar Disorder: A Systematic Review of Quantitative and Qualitative Studies. Harv Rev Psychiatry 2020; 27:290-302. [PMID: 31385812 DOI: 10.1097/hrp.0000000000000228] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Systematic reviews about treatment attitudes of patients influencing adherence in bipolar disorder (BD) are rare. METHODS A systematic review was conducted according to the PRISMA guidelines and principles of thematic synthesis. Selectively identified quantitative and qualitative studies were used to examine the attitude-adherence relationship in BD, the types and correlates of treatment attitudes, and the impact of psychosocial interventions on attitudes. RESULTS The final list of 163 articles included 114 observational reports (incorporating 21 psychosocial intervention trials), 45 qualitative/descriptive studies, and 4 patient surveys. A positive association between treatment attitudes and adherence was found in most quantitative and qualitative studies, though the strength of the relationship was unclear. Thematic analysis of qualitative studies suggested that patient attitudes influencing adherence were based on perceived advantages and disadvantages of treatment. The principal correlates of patients' attitudes were family attitudes, the clinician-patient alliance, social support, and patients' knowledge of BD. Though negative attitudes such as denial, concerns about adverse treatment consequences, and stigmatizing effects of treatment were common, many patients believed treatment to be beneficial and necessary. The limited data on the effect of psychosocial interventions indicated that treatments selectively targeting attitudes enhanced adherence. LIMITATIONS The studies were heterogeneous in design; the quality was uneven (fair to poor); and the risk of bias moderate to high. CONCLUSIONS Despite these flaws, awareness of the existing evidence on the attitude-adherence association and other aspects of treatment attitudes in BD can help in efforts to address nonadherence in BD.
Collapse
Affiliation(s)
- Subho Chakrabarti
- From the Department of Psychiatry, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh (India)
| |
Collapse
|
5
|
Godman B, Grobler C, Van-De-Lisle M, Wale J, Barbosa WB, Massele A, Opondo P, Petrova G, Tachkov K, Sefah I, Abdulsalim S, Alrasheedy AA, Unnikrishnan MK, Garuoliene K, Bamitale K, Kibuule D, Kalemeera F, Fadare J, Khan TA, Hussain S, Bochenek T, Kalungia AC, Mwanza J, Martin AP, Hill R, Barbui C. Pharmacotherapeutic interventions for bipolar disorder type II: addressing multiple symptoms and approaches with a particular emphasis on strategies in lower and middle-income countries. Expert Opin Pharmacother 2020; 20:2237-2255. [PMID: 31762343 DOI: 10.1080/14656566.2019.1684473] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Appropriately managing mental disorders is a growing priority across countries in view of the impact on morbidity and mortality. This includes patients with bipolar disorders (BD). Management of BD is a concern as this is a complex disease with often misdiagnosis, which is a major issue in lower and middle-income countries (LMICs) with typically a limited number of trained personnel and resources. This needs to be addressed.Areas covered: Medicines are the cornerstone of managing patients with Bipolar II across countries including LMICs. The choice of medicines, especially antipsychotics, is important in LMICs with high rates of diabetes and HIV. However, care is currently compromised in LMICs by issues such as the stigma, cultural beliefs, a limited number of trained professionals and high patient co-payments.Expert opinion: Encouragingly, some LMICs have introduced guidelines for patients with BD; however, this is very variable. Strategies for the future include addressing the lack of national guidelines for patients with BD, improving resources for mental disorders including personnel, improving medicine availability and patients' rights, and monitoring prescribing against agreed guidelines. A number of strategies have been identified to improve the treatment of patients with Bipolar II in LMICs, and will be followed up.
Collapse
Affiliation(s)
- Brian Godman
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedicial Sciences, University of Strathclyde, Glasgow, UK.,Division of Clinical Pharmacology, Karolinska, Karolinska Institutet, Stockholm, Sweden.,Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, South Africa.,Health Economics Centre, University of Liverpool Management School, Liverpool, UK
| | - Christoffel Grobler
- Elizabeth Donkin Hospital, Port Elizabeth, South Africa.,Walter Sisulu University, East London, South Africa.,Nelson Mandela University, Port Elizabeth, South Africa
| | | | - Janney Wale
- Independent consumer advocate, Brunswick, Australia
| | - Wallace Breno Barbosa
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Amos Massele
- Department of Biomedical Sciences, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Philip Opondo
- Department of Psychiatry, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Guenka Petrova
- Faculty of Pharmacy, Department of Social Pharmacy and Pharmacoeconomics, Medical University of Sofia, Sofia, Bulgaria
| | - Konstantin Tachkov
- Faculty of Pharmacy, Department of Social Pharmacy and Pharmacoeconomics, Medical University of Sofia, Sofia, Bulgaria
| | - Israel Sefah
- Department of Pharmacy, Keta Municipal Hospital, Ghana Health Service, Keta, Ghana
| | - Suhaj Abdulsalim
- Unaizah College of Pharmacy, Qassim University, Buraidah Saudi Arabia
| | | | | | - Kristina Garuoliene
- Department of Pathology, Forensic Medicine and Pharmacology, Faculty of Medicine, Vilnius University, Lithuania and Ministry of Health, Vilnius, Lithuania
| | - Kayode Bamitale
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Dan Kibuule
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Francis Kalemeera
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Joseph Fadare
- Department of Pharmacology and Therapeutics, College of Medicine, Ekiti State University, Ado-Ekiti, Nigeria
| | | | | | - Tomasz Bochenek
- Department of Drug Management, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | | | - James Mwanza
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Antony P Martin
- Health Economics Centre, University of Liverpool Management School, Liverpool, UK.,HCD Economics, The Innovation Centre, Daresbury, UK
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, Whelan Building, Liverpool University, Liverpool, UK
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona Italy
| |
Collapse
|
6
|
Drivenes K, Vederhus JK, Haaland VØ, Ruud T, Hauge YL, Regevik H, Falk RS, Tanum L. Enabling patients to cope with psychotropic medication in mental health care: Evaluation and reports of the new inventory MedSupport. Medicine (Baltimore) 2020; 99:e18635. [PMID: 31895824 PMCID: PMC6946431 DOI: 10.1097/md.0000000000018635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
This cross sectional study examined patients' perceptions of professional support regarding use of psychotropic medication in a specialist mental health care setting. The aims were to evaluate reliability and validity of the MedSupport inventory, and investigate possible associations between MedSupport scores and patient characteristics.A cross-sectional study was performed. The patients completed the MedSupport, a newly developed self-reported 6 item questionnaire on a Likert scale ranged 1 to 5 (1 = strongly disagree to 5 = strongly agree), and the Beliefs about Medicines Questionnaire. Diagnosis and treatment information were obtained at the clinical visits and from patient records.Among the 992 patients recruited, 567 patients (57%) used psychotropic medications, and 514 (91%) of these completed the MedSupport and were included in the study. The MedSupport showed an adequate internal consistency (Cronbach alpha.87; 95% CI.86-89) and a convergent validity toward the available variables. The MedSupport mean score was 3.8 (standard deviation.9, median 3.8). Increasing age and the experience of stronger needs for psychotropic medication were associated with perception of more support to cope with medication, whereas higher concern toward use of psychotropic medication was associated with perception of less support. Patients diagnosed with behavioral and emotional disorders, onset in childhood and adolescence perceived more support than patients with Mood disorders.The MedSupport inventory was suitable for assessing the patients' perceived support from health care service regarding their medication. Awareness of differences in patients' perceptions might enable the service to provide special measures for patients who perceive insufficient medication support.
Collapse
Affiliation(s)
- Karin Drivenes
- Division of Mental Health and Addiction Services Sørlandet Hospital
- South Eastern Norway Hospital Pharmacy Enterprise, Kristiansand
| | | | - Vegard Øksendal Haaland
- Addiction Unit, Sørlandet Hospital
- Clinical Neuroscience Research Group, Department of Psychology, The Faculty of Social Sciences
| | - Torleif Ruud
- Clinic for Health Services Research and Psychiatry, Institute of clinical medicine, University of Oslo
- Department of R&D in Mental health service, Akershus university hospital
| | - Yina Luk Hauge
- South Eastern Norway Hospital Pharmacy Enterprise, Kristiansand
| | - Hilde Regevik
- Division of Mental Health and Addiction Services Sørlandet Hospital
| | - Ragnhild Sørum Falk
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo
| | - Lars Tanum
- Department of R&D in Mental health service, Akershus university hospital
- Department of Nursing and Health Promotion, Oslo Metropolitan University, Norway
| |
Collapse
|
7
|
Grover S, Mehra A, Chakrabarti S, Avasthi A. Attitude toward psychotropic medications: A comparison of the elderly and adult patients with affective and psychotic disorders. JOURNAL OF GERIATRIC MENTAL HEALTH 2019. [DOI: 10.4103/jgmh.jgmh_36_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
8
|
Attitude towards Antipsychotic Medications in Patients Diagnosed with Schizophrenia: A Cross-Sectional Study at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia. SCHIZOPHRENIA RESEARCH AND TREATMENT 2019; 2019:5094017. [PMID: 31263597 PMCID: PMC6556305 DOI: 10.1155/2019/5094017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/06/2019] [Accepted: 05/15/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Poor attitude towards antipsychotic drugs is high, and it is a factor for non-adherence to treatment. This increases the risk of relapse, associated healthcare utilization, and costs. This study aimed to assess attitude towards antipsychotic medication among patients with schizophrenia. OBJECTIVES The aim of this institution based cross-sectional study was to assess attitude towards antipsychotic medications and associated factors among patients with schizophrenia who attend the outpatient clinics at Amanuel Mental Specialized Hospital, 2018. METHODS In a cross-sectional study, 393 schizophrenic patients from Amanuel Mental Specialized Hospital were recruited by a systematic random sampling technique. Drug Attitude Inventory (DAI-10) was used to assess attitude, experience, and belief about antipsychotics. Glasgow antipsychotic side effect scale modified version, positive and negative syndrome scale, and Birch wood's insight scale for psychosis were the instruments used to assess the associated factors. Simple and multiple linear regression analysis models were fitted, and the adjusted unstandardized beta (β) coefficient at 95% confidence interval was used. RESULTS The mean score of attitude towards antipsychotic medications was 6.51 with standard deviation (SD) of 2.22. In multiple linear regression, positive symptoms (β= -0.07, 95% CI: (-0.09, -0.05)), negative symptoms (β= -0.04, 95% CI: (-0.06,-0.02)), shorter (≤5 years) duration of illness (β= -0.39, 95% CI: (-0.63, -0.15)), first generation antipsychotics (β = -0.35, 95% CI: (-0.55,-0.14)), having sedation (β= -0.28, 95% CI: (-0.52, -0.02)), and extra-pyramidal side effects (β= -0.34, 95% CI: (-0.59,-0.09)) were factors negatively associated with attitude towards antipsychotic medication treatment. Insight to illness (β= 0.24, 95% CI: (0.20, 0.27) was a factor positively associated with attitude towards antipsychotic medications. CONCLUSION The result suggests that the mean score of participants' attitude towards antipsychotic medications was good. Prevention of side effects particularly due to first generation antipsychotics is necessary.
Collapse
|
9
|
Sajatovic M, Ross R, Legacy SN, Correll CU, Kane JM, DiBiasi F, Fitzgerald H, Byerly M. Identifying patients and clinical scenarios for use of long-acting injectable antipsychotics - expert consensus survey part 1. Neuropsychiatr Dis Treat 2018; 14:1463-1474. [PMID: 29922062 PMCID: PMC5997124 DOI: 10.2147/ndt.s167394] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To assess expert consensus on barriers and facilitators for long-acting injectable antipsychotic (LAI) use and provide clinical recommendations on issues where clinical evidence is lacking, including identifying appropriate clinical situations for LAI use. METHODS A 50-question survey comprising 916 response options was distributed to 42 research experts and high prescribers with extensive LAI experience. Respondents rated options on relative appropriateness/importance using a 9-point scale. Consensus was determined using chi-square test of score distributions. Mean (standard deviation) ratings were calculated. Responses to 29 questions (577 options) relating to appropriate patients and clinical scenarios for LAI use are reported. RESULTS Recommendations aligned with research on risk factors for nonadherence and poor outcomes for patients with schizophrenia/schizoaffective or bipolar disorder. Findings suggested, contrary to general practice patterns, that LAI use may be appropriate earlier in the disease course and in younger patients. Results for bipolar disorder were similar to those for schizophrenia but with less consensus. Numerous facilitators of LAI prescribing were considered important, particularly that LAIs may reduce relapses and improve outcomes. CONCLUSION Findings support wider use of LAIs in patients with schizophrenia/schizoaffective and bipolar disorders beyond the setting of poor adherence and earlier use in the disease course.
Collapse
Affiliation(s)
- Martha Sajatovic
- Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Departments of Psychiatry and Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ruth Ross
- Ross Editorial, Port Townsend, WA, USA
| | - Susan N Legacy
- US Medical Affairs Neuroscience, Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA
| | - Christoph U Correll
- Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, USA
- Psychiatry, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Glen Oaks, NY, USA
| | - John M Kane
- Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, USA
- Psychiatry, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Glen Oaks, NY, USA
| | - Faith DiBiasi
- Scientific Communications, Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, MD, USA
| | | | - Matthew Byerly
- Cell Biology and Neuroscience, Center for Mental Health Research and Recovery, Montana State University, Bozeman, MT, USA
| |
Collapse
|
10
|
Karadağ H, Kokurcan A, Güriz SO, Atmar M, Örsel S. Assessing the treatment adherence and clinical correlates of low adherence among bipolar disorder outpatients: a cross-sectional study. PSYCHIAT CLIN PSYCH 2018. [DOI: 10.1080/24750573.2018.1480082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
- Hasan Karadağ
- Department of Psychiatry, Faculty of Medicine, Health Sciences Univercity Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
| | - Ahmet Kokurcan
- Department of Psychiatry, Faculty of Medicine, Health Sciences Univercity Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
| | - Seher Olga Güriz
- Department of Psychiatry, Faculty of Medicine, Health Sciences Univercity Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
| | - Mehlika Atmar
- Omer Halisdemir Research and Training Hospital Psychiatry Clinic, Nigde, Turkey
| | - Sibel Örsel
- Department of Psychiatry, Faculty of Medicine, Health Sciences Univercity Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
| |
Collapse
|