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Pentz AB, Timpe CMF, Normann EM, Slapø NB, Melle I, Lagerberg TV, Steen NE, Westlye LT, Jönsson EG, Haukvik UK, Moberget T, Andreassen OA, Elvsåshagen T. Mismatch negativity in schizophrenia spectrum and bipolar disorders: Group and sex differences and associations with symptom severity. Schizophr Res 2023; 261:80-93. [PMID: 37716205 DOI: 10.1016/j.schres.2023.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/15/2023] [Accepted: 09/04/2023] [Indexed: 09/18/2023]
Abstract
OBJECTIVE Research increasingly implicates glutamatergic dysfunction in the pathophysiologies of psychotic disorders. Auditory mismatch negativity (MMN) is an electroencephalography (EEG) waveform linked to glutamatergic neurotransmission and is consistently attenuated in schizophrenia (SCZ). MMN consists of two subcomponents, the repetition positivity (RP) and deviant negativity (DN) possibly reflecting different neural mechanisms. However, whether MMN reduction is present across different psychotic disorders, linked to distinct symptom clusters, or related to sex remain to be clarified. METHODS Four hundred participants including healthy controls (HCs; n = 296) and individuals with SCZ (n = 39), bipolar disorder (BD) BD typeI (n = 35), or BD type II (n = 30) underwent a roving MMN paradigm and clinical evaluation. MMN, RP and DN as well their memory traces were recorded at the FCZ electrode. Analyses of variance and linear regression models were used both transdiagnostically and within clinical groups. RESULTS MMN was reduced in SCZ compared to BD (p = 0.006, d = 0.55) and to HCs (p < 0.001, d = 0.63). There was a significant group × sex interaction (p < 0.003) and the MMN impairment was only detected in males with SCZ. MMN amplitude correlated positively with Positive and Negative Syndrome Scale total score and negatively with Global Assessment of Functioning Scale score. The deviant negativity was impaired in males with SCZ. No group differences in memory trace indices of the MMN, DN, or RP. CONCLUSION MMN was attenuated in SCZ and correlated with greater severity of psychotic symptoms and lower level of functioning. Our results may indicate sex-dependent differences of glutamatergic function in SCZ.
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Affiliation(s)
- Atle Bråthen Pentz
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Norway.
| | - Clara Maria Fides Timpe
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Norway; Department of Psychology, University of Oslo, Oslo, Norway
| | | | - Nora Berz Slapø
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Norway
| | - Ingrid Melle
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Norway
| | - Trine Vik Lagerberg
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Norway
| | - Nils Eiel Steen
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Norway; Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Lars T Westlye
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Norway; Department of Psychology, University of Oslo, Oslo, Norway
| | - Erik G Jönsson
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Norway; Centre for Psychiatric Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Sciences, Stockholm Region, Stockholm, Sweden
| | - Unn K Haukvik
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Norway; Department of Adult Psychiatry, Institute of Clinical Medicine, University of Oslo, Norway; Department of Forensic Psychiatry Research, Oslo University Hospital, Norway
| | - Torgeir Moberget
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Norway; Department of Psychology, University of Oslo, Oslo, Norway
| | - Ole A Andreassen
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Norway
| | - Torbjørn Elvsåshagen
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Norway; Department of Neurology, Oslo University Hospital, Oslo, Norway.
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Wang F, Chen J, Guo L, Li Z, Li Z. Paliperidone long-acting injection in the treatment of an adolescent with schizophrenia with fluctuating mental symptoms during menstrual period: a case report. Front Psychiatry 2023; 14:1276983. [PMID: 37867775 PMCID: PMC10587406 DOI: 10.3389/fpsyt.2023.1276983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
Background The treatment of schizophrenia, a chronic disabling psychiatric disorder, mainly relies on antipsychotics to control the disease and improve clinical symptoms. Various medication options are available, and differences in treatment effects, even for the same medication, have been noted. Treatment efficacy is correlated with the patient's sex, age, and physical condition. When a drug fails to achieve the desired effect or the symptoms are unstable, the drug dose is often increased or a change in medication is advised according to the patient's situation. Case presentation We report the case of a 16 years-old girl with schizophrenia and apparent psychotic symptoms. According to the genetic testing results, the symptoms were effectively controlled, and she was discharged from the hospital with the prescription of paliperidone sustained-release tablets. During the follow-up, her symptoms fluctuated during menstrual period, causing her great distress. Furthermore, her compliance gradually declined during the following 2 years of treatment, and the medication was often discontinued. We changed the drug from an oral tablet to an injection preparation while maintaining the active ingredients of the drug. The patient's symptoms were significantly controlled, and no fluctuation of symptoms occurred during the menstrual cycle. Conclusion Long-acting antipsychotic injections can be administered to female adolescents with schizophrenia who experience fluctuating psychotic symptoms during menstruation. This technique can ensure both consistency of medication and improvement in clinical symptoms.
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Affiliation(s)
- Feng Wang
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing, Sichuan University, Chengdu, China
| | - Juan Chen
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing, Sichuan University, Chengdu, China
| | - Linglin Guo
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing, Sichuan University, Chengdu, China
| | - Zhixiong Li
- The Third Department of Clinical Psychology, Karamay Municipal People’s Hospital, Karamay, China
| | - Zhe Li
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Clinical Medical Research Center for Mental Disorders, Chengdu, China
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Natividad M, Seeman MV, Paolini JP, Balagué A, Román E, Bagué N, Izquierdo E, Salvador M, Vallet A, Pérez A, Monreal JA, González-Rodríguez A. Monitoring the Effectiveness of Treatment in Women with Schizophrenia: New Specialized Cooperative Approaches. Brain Sci 2023; 13:1238. [PMID: 37759839 PMCID: PMC10526759 DOI: 10.3390/brainsci13091238] [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: 07/19/2023] [Revised: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023] Open
Abstract
Women with schizophrenia have specific health needs that differ from those of men and that change through successive life stages. We aimed to review the biopsychosocial literature on schizophrenia that addresses clinically important questions related to the treatment of women, including somatic morbi-mortality, hyperprolactinemia, comorbid substance use disorders, social risk factors, and medication effectiveness/safety. Data search terms were as follows: (Morbidity AND mortality) OR hyperprolactinemia OR ("substance use disorders" OR addictions) OR ("social risk factors") OR ("drug safety" OR prescription) AND women AND schizophrenia. A secondary aim was to describe a method of monitoring and interdisciplinary staff strategies. Schizophrenia patients show an increased risk of premature death from cardiovascular/respiratory disease and cancer compared to the general population. The literature suggests that close liaisons with primary care and the introduction of physical exercise groups reduce comorbidity. Various strategies for lowering prolactin levels diminish the negative long-term effects of hyperprolactinemia. Abstinence programs reduce the risk of victimization and trauma in women. Stigma associated with women who have serious psychiatric illness is often linked to reproductive functions. The safety and effectiveness of antipsychotic drug choice and dose differ between men and women and change over a woman's life cycle. Monitoring needs to be multidisciplinary, knowledgeable, and regular.
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Affiliation(s)
- Mentxu Natividad
- Department of Mental Health, Mutua Terrassa University Hospital, Fundació Docència i Recerca Mutua Terrassa, University of Barcelona, 08221 Terrassa, Spain; (M.N.); (J.P.P.); (E.R.); (N.B.); (E.I.); (M.S.); (A.V.); (A.P.)
| | - Mary V. Seeman
- Department of Psychiatry, University of Toronto, Toronto, ON M5P 3L6, Canada;
| | - Jennipher Paola Paolini
- Department of Mental Health, Mutua Terrassa University Hospital, Fundació Docència i Recerca Mutua Terrassa, University of Barcelona, 08221 Terrassa, Spain; (M.N.); (J.P.P.); (E.R.); (N.B.); (E.I.); (M.S.); (A.V.); (A.P.)
| | - Ariadna Balagué
- Department of Mental Health, Mutua Terrassa University Hospital, Fundació Docència i Recerca Mutua Terrassa, University of Barcelona, 08221 Terrassa, Spain; (M.N.); (J.P.P.); (E.R.); (N.B.); (E.I.); (M.S.); (A.V.); (A.P.)
| | - Eloïsa Román
- Department of Mental Health, Mutua Terrassa University Hospital, Fundació Docència i Recerca Mutua Terrassa, University of Barcelona, 08221 Terrassa, Spain; (M.N.); (J.P.P.); (E.R.); (N.B.); (E.I.); (M.S.); (A.V.); (A.P.)
| | - Noelia Bagué
- Department of Mental Health, Mutua Terrassa University Hospital, Fundació Docència i Recerca Mutua Terrassa, University of Barcelona, 08221 Terrassa, Spain; (M.N.); (J.P.P.); (E.R.); (N.B.); (E.I.); (M.S.); (A.V.); (A.P.)
| | - Eduard Izquierdo
- Department of Mental Health, Mutua Terrassa University Hospital, Fundació Docència i Recerca Mutua Terrassa, University of Barcelona, 08221 Terrassa, Spain; (M.N.); (J.P.P.); (E.R.); (N.B.); (E.I.); (M.S.); (A.V.); (A.P.)
| | - Mireia Salvador
- Department of Mental Health, Mutua Terrassa University Hospital, Fundació Docència i Recerca Mutua Terrassa, University of Barcelona, 08221 Terrassa, Spain; (M.N.); (J.P.P.); (E.R.); (N.B.); (E.I.); (M.S.); (A.V.); (A.P.)
| | - Anna Vallet
- Department of Mental Health, Mutua Terrassa University Hospital, Fundació Docència i Recerca Mutua Terrassa, University of Barcelona, 08221 Terrassa, Spain; (M.N.); (J.P.P.); (E.R.); (N.B.); (E.I.); (M.S.); (A.V.); (A.P.)
| | - Anabel Pérez
- Department of Mental Health, Mutua Terrassa University Hospital, Fundació Docència i Recerca Mutua Terrassa, University of Barcelona, 08221 Terrassa, Spain; (M.N.); (J.P.P.); (E.R.); (N.B.); (E.I.); (M.S.); (A.V.); (A.P.)
| | - José A. Monreal
- Department of Mental Health, Mutua Terrassa University Hospital, Fundació Docència i Recerca Mutua Terrassa, University of Barcelona, 08221 Terrassa, Spain; (M.N.); (J.P.P.); (E.R.); (N.B.); (E.I.); (M.S.); (A.V.); (A.P.)
- Institut de Neurociències, Universitat Autònoma de Barcelona (UAB), 08221 Terrassa, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), 28029 Madrid, Spain
| | - Alexandre González-Rodríguez
- Department of Mental Health, Mutua Terrassa University Hospital, Fundació Docència i Recerca Mutua Terrassa, University of Barcelona, 08221 Terrassa, Spain; (M.N.); (J.P.P.); (E.R.); (N.B.); (E.I.); (M.S.); (A.V.); (A.P.)
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), 28029 Madrid, Spain
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Petersen E, Holm S, Ganz M, Feragen A. The path toward equal performance in medical machine learning. PATTERNS (NEW YORK, N.Y.) 2023; 4:100790. [PMID: 37521051 PMCID: PMC10382979 DOI: 10.1016/j.patter.2023.100790] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
To ensure equitable quality of care, differences in machine learning model performance between patient groups must be addressed. Here, we argue that two separate mechanisms can cause performance differences between groups. First, model performance may be worse than theoretically achievable in a given group. This can occur due to a combination of group underrepresentation, modeling choices, and the characteristics of the prediction task at hand. We examine scenarios in which underrepresentation leads to underperformance, scenarios in which it does not, and the differences between them. Second, the optimal achievable performance may also differ between groups due to differences in the intrinsic difficulty of the prediction task. We discuss several possible causes of such differences in task difficulty. In addition, challenges such as label biases and selection biases may confound both learning and performance evaluation. We highlight consequences for the path toward equal performance, and we emphasize that leveling up model performance may require gathering not only more data from underperforming groups but also better data. Throughout, we ground our discussion in real-world medical phenomena and case studies while also referencing relevant statistical theory.
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Affiliation(s)
- Eike Petersen
- DTU Compute, Technical University of Denmark, Richard Pedersens Plads, 2800 Kgs. Lyngby, Denmark
- Pioneer Centre for AI, Øster Voldgade 3, 1350 Copenhagen, Denmark
| | - Sune Holm
- Pioneer Centre for AI, Øster Voldgade 3, 1350 Copenhagen, Denmark
- Department of Food and Resource Economics, University of Copenhagen, Rolighedsvej 23, 1958 Frederiksberg C., Denmark
| | - Melanie Ganz
- Pioneer Centre for AI, Øster Voldgade 3, 1350 Copenhagen, Denmark
- Department of Computer Science, University of Copenhagen, Universitetsparken 1, 2100 Copenhagen, Denmark
- Neurobiology Research Unit, Rigshospitalet, Inge Lehmanns Vej 6–8, 2100 Copenhagen, Denmark
| | - Aasa Feragen
- DTU Compute, Technical University of Denmark, Richard Pedersens Plads, 2800 Kgs. Lyngby, Denmark
- Pioneer Centre for AI, Øster Voldgade 3, 1350 Copenhagen, Denmark
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Review of Male and Female Care Needs in Schizophrenia: A New Specialized Clinical Unit for Women. WOMEN 2023. [DOI: 10.3390/women3010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Women with schizophrenia require health interventions that differ, in many ways, from those of men. The aim of this paper is to review male and female care needs and describe a newly established care unit for the treatment of women with schizophrenia. After reviewing the literature on the differentiated needs of men and women with schizophrenia, we describe the new unit’s assessment, intervention, and evaluation measures. The program consists of (1) individual/group patient/family therapy, (2) therapeutic drug monitoring and adherence checks, (3) perinatal mental health, (4) medical liaison, (5) suicide prevention/intervention, (6) social services with special focus on parenting, domestic abuse, and sexual exploitation, (7) home-based services, (8) peer support, (9) occupational therapies (physical activity and leisure programs), and (10) psychoeducation for both patients and families. Still in the planning stage are quality evaluation of diagnostic assessment, personalized care, drug optimization, health screening (reproductive health, metabolic syndrome, cardiovascular health, cancer, menopausal status), and patient and family satisfaction with services provided. Woman-specific care represents an important resource that promises to deliver state-of-the-art treatment to women and, ideally, prevent mental illness in their offspring.
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The Effect of Menopause on Antipsychotic Response. Brain Sci 2022; 12:brainsci12101342. [PMID: 36291276 PMCID: PMC9599119 DOI: 10.3390/brainsci12101342] [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: 07/25/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 11/17/2022] Open
Abstract
Background: It has been hypothesized that, whenever estrogen levels decline, psychosis symptoms in women increase. At menopause, this can happen in two main ways: (a) the loss of estrogen (mainly estradiol) can directly affect central neurotransmission, leading to increase in schizophrenia-related symptoms, and (b) the loss of estrogen can decrease the synthesis of enzymes that metabolize antipsychotic drugs, thus weakening their efficacy. Aims and Methods: The aim of this narrative review was to investigate the second possibility by searching PubMed and ClinicalTrials.gov for studies over the last two decades that investigated the metabolism of antipsychotics and their efficacy before and after menopause in women or that studied systemic and local estrogen level effects on the pharmacokinetics and pharmacodynamics of individual antipsychotic drugs. Results: The evidence suggests that symptom level in women with schizophrenia rises after menopause for many reasons beyond hormones but, importantly, there is an estrogen-dependent loss of efficacy related to antipsychotic treatment. Conclusion: Effective clinical intervention is challenging; nevertheless, several promising routes forward are suggested.
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7
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Seeman MV. Sex/Gender differences in schizophrenia: Thinking back and thinking forward. Psychiatry Res 2022; 316:114738. [PMID: 35905691 DOI: 10.1016/j.psychres.2022.114738] [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: 05/26/2022] [Revised: 07/17/2022] [Accepted: 07/21/2022] [Indexed: 10/16/2022]
Abstract
This commentary summarizes my view of my life's work in psychiatry, which has mainly been devoted to my obsessive interest in sex and gender differences in schizophrenia. I summarize the influences that guided my research and I take the opportunity to make some personal recommendations to future researchers.
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Affiliation(s)
- Mary V Seeman
- Professor Emerita, Department of Psychiatry, University of Toronto, #605 260 Heath Street West, Toronto, Ontario, Canada, M5P 3L6.
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Gynecological Health Concerns in Women with Schizophrenia and Related Disorders: A Narrative Review of Recent Studies. WOMEN 2022. [DOI: 10.3390/women2010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Sex and age are important factors influencing physical and mental health in schizophrenia. Our goal was to review the recent literature for associations between gynecological conditions and psychotic illness and to propose integrated strategies for their management in order to improve overall health outcomes in women. We addressed the following questions: What are the prevalence and risk factors of gynecological disorders in women with schizophrenia or delusional disorder (DD)? What are the rates of uptake of gynecological cancer screening and mortality in this population? What role does menopause play? We found an increased incidence of breast cancer in women with schizophrenia. Other gynecological comorbidities were less frequent, but the field has been understudied. Low rates of breast and cervical cancer screening characterize women with schizophrenia. Menopause, because of endocrine changes, aging effects, and resultant comorbidity is associated with high rates of aggressive breast cancer in this population. Uterine and ovarian cancers have been less investigated. Psychosocial determinants of health play an important role in cancer survival. The findings lead to the recommendation that primary care, psychiatry, gynecology, oncology, and endocrinology collaborate in early case finding, in research into etiological links, and in improvement of prevention and treatment.
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Yan J, Chen Y, Ju P, Gao J, Zhang L, Li J, Wang K, Zhang J, Li C, Xia Q, Zhu C, Zhang X. Network Association of Biochemical and Inflammatory Abnormalities With Psychiatric Symptoms in First-Episode Schizophrenia Patients. Front Psychiatry 2022; 13:834539. [PMID: 35273531 PMCID: PMC8901486 DOI: 10.3389/fpsyt.2022.834539] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/25/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) risk factors such as dyslipidemia and systemic aberrant inflammatory processes may occur in patients with psychotic disorders, which may cause increased mortality. The interplay between immune and metabolic markers and its contribution to the clinical symptoms of schizophrenia (SCZ) remain unclear. This study aimed to examine the association of a series of inflammatory factors, plasma biochemical indicators, and SCZ clinical symptomatology with the severity of SCZ symptoms. METHODS A total of 115 participants, including 79 first-episode drug-naïve patients with SCZ and 36 healthy controls, were enrolled in this study. Semi-structured interviews were used to collect sociodemographic data, family history of SCZ, and medical and psychiatric history. The Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS) were administered by a clinical psychiatrist to evaluate the symptom severity of patients with SCZ. Plasma inflammatory cytokines were measured by a fully automated electrochemiluminescent immunoassay (Meso Scale Discovery). RESULTS Blood routine, biochemical, and inflammation cytokine test results showed that the levels of white blood cell count, neutrophil count, natrium, CRP, IL-8, IL-6, IL-13, and IL-16 significantly increased in the case group than in the healthy controls (p < 0.05), whereas levels of red blood cell count, hemoglobin concentration, mean corpuscular hemoglobin concentration, total protein, albumin, total bile acid, high-density lipoprotein (HDL), apolipoprotein A1, blood urea nitrogen, kalium and IL-15 were lower than in the healthy controls (p < 0.05). Correlation network analysis results shown that the natrium, HDL and red blood cell count were the top 3 factors closely to with BPRS and PANSS related clinical symptoms among of correlation network (degree = 4). ROC curve analysis explored the IL-16, IL-8, IL-13, IL-15, natrium, and HDL had highly sensitivity and specificity to the predictive validity and effectiveness for SCZ symptoms. CONCLUSION Our study revealed a complex interactive network correlation among the cardiovascular risk factors, biological immunity profiles, and psychotic symptoms in first-episode patients. Abnormal inflammatory factors and CVD risk factors had high sensitivity and specificity for predicting SCZ symptoms. Generally, our study provided novel information on the immune-related mechanisms involved in early CVD risk in patients with psychotic disorders.
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Affiliation(s)
- Junwei Yan
- Affiliated Psychological Hospital of Anhui Medical University, Hefei, China.,Department of Medical Education and Research, Hefei Fourth People's Hospital, Hefei, China.,Department of Medical Education and Research, Anhui Mental Health Center, Hefei, China.,Department of Medical Education and Research, Anhui Clinical Center for Mental and Psychological Diseases, Hefei, China
| | - Yuanyuan Chen
- Affiliated Psychological Hospital of Anhui Medical University, Hefei, China.,Department of Medical Education and Research, Hefei Fourth People's Hospital, Hefei, China.,Department of Medical Education and Research, Anhui Mental Health Center, Hefei, China.,Department of Medical Education and Research, Anhui Clinical Center for Mental and Psychological Diseases, Hefei, China
| | - Peijun Ju
- Department of Psychiatry, Shanghai Mental Health Center, Shanghai, China.,Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Psychiatry, Shanghai Key Laboratory of Psychotic Disorders, Shanghai, China
| | - Jianliang Gao
- Affiliated Psychological Hospital of Anhui Medical University, Hefei, China.,Department of Medical Education and Research, Hefei Fourth People's Hospital, Hefei, China.,Department of Medical Education and Research, Anhui Mental Health Center, Hefei, China.,Department of Medical Education and Research, Anhui Clinical Center for Mental and Psychological Diseases, Hefei, China
| | - Loufeng Zhang
- Affiliated Psychological Hospital of Anhui Medical University, Hefei, China.,Department of Medical Education and Research, Hefei Fourth People's Hospital, Hefei, China.,Department of Medical Education and Research, Anhui Mental Health Center, Hefei, China.,Department of Medical Education and Research, Anhui Clinical Center for Mental and Psychological Diseases, Hefei, China
| | - Jingwei Li
- Affiliated Psychological Hospital of Anhui Medical University, Hefei, China.,Department of Medical Education and Research, Hefei Fourth People's Hospital, Hefei, China.,Department of Medical Education and Research, Anhui Mental Health Center, Hefei, China.,Department of Medical Education and Research, Anhui Clinical Center for Mental and Psychological Diseases, Hefei, China
| | - Keming Wang
- Affiliated Psychological Hospital of Anhui Medical University, Hefei, China.,Department of Medical Education and Research, Hefei Fourth People's Hospital, Hefei, China.,Department of Medical Education and Research, Anhui Mental Health Center, Hefei, China.,Department of Medical Education and Research, Anhui Clinical Center for Mental and Psychological Diseases, Hefei, China
| | - Jie Zhang
- Affiliated Psychological Hospital of Anhui Medical University, Hefei, China.,Department of Medical Education and Research, Hefei Fourth People's Hospital, Hefei, China.,Department of Medical Education and Research, Anhui Mental Health Center, Hefei, China.,Department of Medical Education and Research, Anhui Clinical Center for Mental and Psychological Diseases, Hefei, China
| | - Chao Li
- Affiliated Psychological Hospital of Anhui Medical University, Hefei, China.,Department of Medical Education and Research, Hefei Fourth People's Hospital, Hefei, China.,Department of Medical Education and Research, Anhui Mental Health Center, Hefei, China.,Department of Medical Education and Research, Anhui Clinical Center for Mental and Psychological Diseases, Hefei, China
| | - Qingrong Xia
- Affiliated Psychological Hospital of Anhui Medical University, Hefei, China.,Department of Medical Education and Research, Hefei Fourth People's Hospital, Hefei, China.,Department of Medical Education and Research, Anhui Mental Health Center, Hefei, China.,Department of Medical Education and Research, Anhui Clinical Center for Mental and Psychological Diseases, Hefei, China
| | - Cuizhen Zhu
- Affiliated Psychological Hospital of Anhui Medical University, Hefei, China.,Department of Medical Education and Research, Hefei Fourth People's Hospital, Hefei, China.,Department of Medical Education and Research, Anhui Mental Health Center, Hefei, China.,Department of Medical Education and Research, Anhui Clinical Center for Mental and Psychological Diseases, Hefei, China
| | - Xulai Zhang
- Affiliated Psychological Hospital of Anhui Medical University, Hefei, China.,Department of Medical Education and Research, Hefei Fourth People's Hospital, Hefei, China.,Department of Medical Education and Research, Anhui Mental Health Center, Hefei, China.,Department of Medical Education and Research, Anhui Clinical Center for Mental and Psychological Diseases, Hefei, China
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