1
|
de Graaf JA, Schepers VPM, Nijsse B, van Heugten CM, Post MWM, Visser-Meily JMA. The influence of psychological factors and mood on the course of participation up to four years after stroke. Disabil Rehabil 2020; 44:1855-1862. [DOI: 10.1080/09638288.2020.1808089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- J. A. de Graaf
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - V. P. M. Schepers
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
- Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, The Netherlands
| | - B. Nijsse
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - C. M. van Heugten
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
- Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht, The Netherlands
| | - M. W. M. Post
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
- University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - J. M. A. Visser-Meily
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
- Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, The Netherlands
| |
Collapse
|
2
|
Tóth-Vajna G, Tóth-Vajna Z, Balog P, Konkolÿ Thege B. Depressive symptomatology and personality traits in patients with symptomatic and asymptomatic peripheral arterial disease. BMC Cardiovasc Disord 2020; 20:304. [PMID: 32571227 PMCID: PMC7310261 DOI: 10.1186/s12872-020-01586-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 06/15/2020] [Indexed: 01/22/2023] Open
Abstract
Background The aim of this study was to examine the relationship of depressive symptomatology and personality traits with peripheral arterial disease (PAD). Methods The sample of this cross-sectional study comprised of 300 individuals (Mage = 65.3 ± 8.7 years, 61.0% female) recruited from the offices of 33 general practitioners. Based on at-rest ankle-brachial index (ABI) values and claudication symptoms, four subsamples were formed: clear PAD-positive, clear PAD-negative, ABI-negative but symptomatic, and a non-compressible-artery group. The concurrent role of depression (assessed by a shortened version of the Beck Depression Inventory) and personality traits (measured by the Big Five Inventory) in predicting PAD status was examined using multinomial logistic regression – controlled for sex, age, hypertonia, diabetes, smoking, hazardous drinking, and body mass index. Results Depressive symptomatology was significant in predicting peripheral arterial disease status even after controlling for both traditional risk factors and personality traits. Among the Big Five personality traits, neuroticism showed a significant, positive relationship with PAD – independently of depression. Conclusions Patients with PAD – even those with asymptomatic forms of the disease – are at higher risk for suffering from depression compared to individuals without PAD, independently of neuroticism, other Big Five personality dimensions or traditional risk factors for cardiovascular diseases.
Collapse
Affiliation(s)
- Gergely Tóth-Vajna
- Institute of Behavioral Sciences, Semmelweis University, Nagyvárad tér 4. XX. emelet, Budapest, 1089, Hungary.
| | - Zsombor Tóth-Vajna
- Heart and Vascular Center, Department of Vascular Surgery, Semmelweis University, Városmajor utca 68, Budapest, 1122, Hungary
| | - Piroska Balog
- Institute of Behavioral Sciences, Semmelweis University, Nagyvárad tér 4. XX. emelet, Budapest, 1089, Hungary.
| | - Barna Konkolÿ Thege
- Waypoint Research Institute, Waypoint Centre for Mental Health Care, 500 Church St, Penetanguishene, Ontario, Canada.,Department of Psychiatry, University of Toronto, 250 College St, Toronto, Ontario, Canada
| |
Collapse
|
3
|
Douven E, Staals J, Schievink SHJ, van Oostenbrugge RJ, Verhey FRJ, Wetzels-Meertens S, Köhler S, Aalten P. Personality traits and course of symptoms of depression and apathy after stroke: Results of the CASPER study. J Psychosom Res 2018; 111:69-75. [PMID: 29935757 DOI: 10.1016/j.jpsychores.2018.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 05/17/2018] [Accepted: 05/18/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Post-stroke depression (PSD) and post-stroke apathy (PSA) are both associated with adverse outcome after stroke. This study aimed to examine whether personality traits predict the course of PSD and PSA. METHODS In this prospective cohort study, 240 stroke patients completed the NEO Five Factor Inventory, Montgomery-Åsberg Depression Rating Scale, and Apathy Evaluation Scale at 3 months post-stroke. Neuropsychiatric assessment was repeated at 6- and 12-month follow-up after initial testing. RESULTS Linear mixed models showed that high neuroticism scores were associated with higher depression levels at baseline, and this association remained stable at follow-up. High extraversion scores and high conscientiousness scores were associated with lower apathy levels at baseline. For neuroticism, a significant interaction with time was found, with higher neuroticism scores at baseline being associated with an increase in apathy scores from 6-month to 12-month follow-up. Prospective analyses showed that high extraversion predicted low apathy levels at 6-month and 12-month follow-up independent of its relations with baseline depression and apathy. High neuroticism predicted high apathy levels at 12-month follow-up, whereas high agreeableness and high openness predicted high apathy levels and low apathy levels, respectively, at 6-month follow-up. None of the personality traits predicted depression scores at follow-up. CONCLUSION Personality traits are associated with the development and sustainability of PSD and PSA. The traits associated with PSD and PSA were different, providing support for the independence of these constructs. The findings highlight the importance to take personality traits into account as a potential vulnerability factor for PSD and PSA.
Collapse
Affiliation(s)
- Elles Douven
- Alzheimer Center Limburg and School for Mental Health and Neuroscience (MHeNs), Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, the Netherlands
| | - Julie Staals
- Cardiovascular Research Institute Maastricht (CARIM), Department of Neurology, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Syenna H J Schievink
- Alzheimer Center Limburg and School for Mental Health and Neuroscience (MHeNs), Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, the Netherlands
| | - Robert J van Oostenbrugge
- Cardiovascular Research Institute Maastricht (CARIM), Department of Neurology, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Frans R J Verhey
- Alzheimer Center Limburg and School for Mental Health and Neuroscience (MHeNs), Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, the Netherlands
| | | | - Sebastian Köhler
- Alzheimer Center Limburg and School for Mental Health and Neuroscience (MHeNs), Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, the Netherlands
| | - Pauline Aalten
- Alzheimer Center Limburg and School for Mental Health and Neuroscience (MHeNs), Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, the Netherlands.
| |
Collapse
|
4
|
Dwan T, Ownsworth T. The Big Five personality factors and psychological well-being following stroke: a systematic review. Disabil Rehabil 2017; 41:1119-1130. [PMID: 29272953 DOI: 10.1080/09638288.2017.1419382] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To identify and appraise studies investigating the relationship between the Big Five personality factors and psychological well-being following stroke and evidence for personality change. METHODS Systematic searches of six databases (PsychINFO, CINAHL, Ovid Medline, Cochrane, PubMed, and Web of Science) were conducted from inception to June 2017. Studies involving adult stroke samples that employed a validated measure of at least one of the Big Five personality factors were included. Two reviewers independently assessed the eligibility and methodological quality of studies. RESULTS Eleven studies were identified that assessed associations between personality and psychological well-being after stroke (nine studies) or post-stroke personality change (two studies). A consistent finding was that higher neuroticism was significantly related to poorer psychological well-being. The evidence for the other Big Five factors was mixed. In terms of personality change, two cross-sectional studies reported high rates of elevated neuroticism (38-48%) and low extraversion (33-40%) relative to normative data. Different questionnaires and approaches to measuring personality (i.e., self vs. informant ratings, premorbid personality vs. current personality) complicated comparisons between studies. CONCLUSIONS People high on neuroticism are at increased risk of poor psychological well-being after stroke. Prospective longitudinal studies are needed to address the limited research on post-stroke personality change. Implications for rehabilitation High neuroticism is associated with poorer psychological well-being after stroke. Assessing personality characteristics early after stroke may help to identify those at risk of poor psychological outcomes.
Collapse
Affiliation(s)
- Toni Dwan
- a School of Applied Psychology and Menzies Health Institute Queensland , Griffith University , Brisbane , Australia
| | - Tamara Ownsworth
- a School of Applied Psychology and Menzies Health Institute Queensland , Griffith University , Brisbane , Australia
| |
Collapse
|
5
|
Almas A, Moller J, Iqbal R, Forsell Y. Effect of neuroticism on risk of cardiovascular disease in depressed persons - a Swedish population-based cohort study. BMC Cardiovasc Disord 2017; 17:185. [PMID: 28697763 PMCID: PMC5504725 DOI: 10.1186/s12872-017-0604-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 06/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The relationship between neuroticism, depression and cardiovascular disease (CVD) is complex and has so far not been studied in depth. The aim of this study was to determine if neuroticism is an effect-modifier in the association between depression and CVD. Data derived from a longitudinal cohort study on mental health, work and relations among adults (20-64 years), including 10,443 individuals. Depression was assessed using the Major Depression Inventory (MDI) and neuroticism by the Swedish Scale of Personality (SSP). Outcomes of cardiovascular disease were register-based from the National inpatient register. RESULTS Both depression (OR 1.9 (95%CI 1.4, 2.5)) and high levels of neuroticism (OR 1.2 (95%CI 1.1-1.3)) were associated with increased risk of CVD. The combined effect of depression and neuroticism on the risk of CVD revealed HRs ranging from 1.0 to 1.9 after adjusting for age and gender, socioeconomic position, prevalent hypertension and diabetes. Almost similar associations were seen after further adjustment for lifestyle factors. CONCLUSION Neuroticism increased the risk of CVD in depressed persons. We found synergistic interaction between neuroticism and depression status in predicting future risk of CVD.
Collapse
Affiliation(s)
- Aysha Almas
- Department of Public Health Sciences, Karolinska Institutet, 171 77 Stockholm, Sweden
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Jette Moller
- Department of Public Health Sciences, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Romaina Iqbal
- Department of Medicine, Aga Khan University, Karachi, Pakistan
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Yvonne Forsell
- Department of Public Health Sciences, Karolinska Institutet, 171 77 Stockholm, Sweden
| |
Collapse
|
6
|
Abstract
BACKGROUND It is well recognized that an individual's personality characteristics influence their psychological adjustment after stroke. However, there is a lack of research on the reliability of personality inventories for stroke. This study primarily aimed to evaluate the reliability of the Neuroticism, Extroversion, Openness to Experience (NEO)-Five Factor Inventory (NEO-FFI) for assessing pre-morbid personality and personality changes after stroke. Further aims were to investigate changes in personality during the hospital-to-home transition period and examine associations between personality and mood. METHODS Forty participants with stroke (52.5% male, M age=65.55 years) were recruited at time of hospital discharge and completed the NEO-FFI, Centre for Epidemiologic Studies - Depression and Geriatric Anxiety Inventory. Significant others completed an informant version of the NEO-FFI. Stroke participants were re-assessed on the NEO-FFI at 1-month and 4-months post-discharge. Forty matched controls also completed the NEO-FFI. RESULTS Internal consistency was adequate for the NEO-FFI (α=0.57-0.86), although low for agreeableness. There was fair to excellent concordance between self-rated and informant versions of the NEO-FFI (ICC=0.58-0.78). Significant positive associations were found between neuroticism and mood (r=0.50-0.68), and significant negative associations were found between extraversion and mood (r=-0.33-0.36) and agreeableness and anxiety (r=-0.43). Self-ratings of stroke participants on the NEO-FFI at discharge did not significantly differ from matched controls. Extraversion levels significantly decreased, and agreeableness levels significantly increased between discharge and 1- and 4-months post-discharge. CONCLUSIONS Overall, the results support the reliability of the NEO-FFI for assessing personality characteristics in the context of stroke.
Collapse
|
7
|
Lau CG, Tang WK, Liu XX, Liang HJ, Liang Y, Mok V, Wong A, Ungvari GS, Kutlubaev MA, Wong KS. Neuroticism and Fatigue 3 Months After Ischemic Stroke. Arch Phys Med Rehabil 2017; 98:716-721. [DOI: 10.1016/j.apmr.2016.08.480] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 08/10/2016] [Indexed: 02/05/2023]
|
8
|
Kootker JA, van Mierlo ML, Hendriks JC, Sparidans J, Rasquin SM, de Kort PL, Visser-Meily JM, Geurts AC. Risk Factors for Symptoms of Depression and Anxiety One Year Poststroke: A Longitudinal Study. Arch Phys Med Rehabil 2016; 97:919-28. [PMID: 26869287 DOI: 10.1016/j.apmr.2016.01.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 01/09/2016] [Accepted: 01/17/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To estimate the relative contribution of psychological factors next to sociodemographic and premorbid/stroke-related factors to the risk of developing symptoms of depression and anxiety after stroke. DESIGN Multicenter, longitudinal cohort study. SETTING Patients after stroke from 6 general hospitals. PARTICIPANTS Patients (N=331) were included at stroke onset and followed up 2 and 12 months after stroke. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Sociodemographic and premorbid/stroke-related information was recorded during hospital admission, whereas psychological characteristics were determined with postal questionnaires 2 months poststroke. Symptoms of depression and anxiety were assessed with the Hospital Anxiety and Depression Scale (HADS) 2 and 12 months poststroke. Multivariable logistic analysis was performed to analyze the influence of sociodemographic, premorbid/stroke-related, and psychological characteristics on depressive symptoms (depression subscale of HADS >7) and symptoms of anxiety (anxiety subscale of HADS >7) 1 year after stroke. RESULTS Early depression, stroke severity, posterior cerebral artery stroke, and neuroticism independently explained the variance of depressive symptoms 1 year poststroke (discriminative power, 83%; adjusted R(2) value, 36%). Neuroticism and early anxiety independently explained the variance of symptoms of anxiety 1 year poststroke (discriminative power, 88%; adjusted R(2) value, 44%). Based on these predictive models, nomograms were constructed to visually reflect the individual contribution of each risk factor to the development of long-term mood disorders after stroke. CONCLUSIONS Psychological characteristics are important risk factors for poststroke symptoms of depression and anxiety.
Collapse
Affiliation(s)
- Joyce A Kootker
- Radboud University Medical Center, Donders Center for Neuroscience, Department of Rehabilitation, Nijmegen, The Netherlands.
| | - Maria L van Mierlo
- University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Brain Center Rudolf Magnus and Center of Excellence for Rehabilitation Medicine, Utrecht, The Netherlands
| | - Jan C Hendriks
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department for Health Evidence, Nijmegen, The Netherlands
| | - Judith Sparidans
- Radboud University Medical Center, Donders Center for Neuroscience, Department of Rehabilitation, Nijmegen, The Netherlands
| | - Sascha M Rasquin
- Adelante Rehabilitation Clinic, Hoensbroek, The Netherlands; Maastricht University Medical Center, CAPHRI, Department of Rehabilitation Medicine, Maastricht, The Netherlands
| | - Paul L de Kort
- St. Elisabeth Hospital, Department of Neurology, Tilburg, The Netherlands
| | - Johanna M Visser-Meily
- University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Brain Center Rudolf Magnus and Center of Excellence for Rehabilitation Medicine, Utrecht, The Netherlands
| | - Alexander C Geurts
- Radboud University Medical Center, Donders Center for Neuroscience, Department of Rehabilitation, Nijmegen, The Netherlands
| |
Collapse
|
9
|
van Mierlo ML, van Heugten CM, Post MW, de Kort PL, Visser-Meily JM. Psychological factors determine depressive symptomatology after stroke. Arch Phys Med Rehabil 2015; 96:1064-70. [PMID: 25681672 DOI: 10.1016/j.apmr.2015.01.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 01/26/2015] [Accepted: 01/27/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify psychological factors related to poststroke depressive symptoms. DESIGN Cross-sectional study, with patients assessed at 2 months poststroke. SETTING Patients with stroke from 6 general hospitals. PARTICIPANTS Stroke patients (N=344; mean age ± SD, 66.9±12.3y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The presence of clinical depressive symptoms was determined with the depression subscale of the Hospital Anxiety and Depression Scale 2 months poststroke. Psychological factors assessed were extraversion, neuroticism, optimism, pessimism, self-efficacy, helplessness, acceptance, perceiving benefits, proactive coping, and passive coping. RESULTS Bivariate correlations and multivariate backward logistic regression were used to analyze associations between psychological factors and poststroke depressive symptoms, accounting for demographic and stroke-related factors. More neuroticism, pessimism, passive coping, and helplessness, and less extraversion, optimism, self-efficacy, acceptance, perceived benefits, and proactive coping were bivariately associated with the presence of depressive symptoms. Multivariate logistic regression analysis showed that more helplessness (odds ratio [OR]=1.17) and passive coping (OR=1.19) and less acceptance (OR=.89) and perceived benefits (OR=.89) were independently significantly associated with the presence of poststroke depressive symptoms (Nagelkerke R(2)=.49). CONCLUSIONS We found a relationship between psychological variables and the presence of depressive symptoms 2 months poststroke. It is important to take these factors into account during poststroke rehabilitation.
Collapse
Affiliation(s)
- Maria L van Mierlo
- Brain Center Rudolf Magnus and Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Caroline M van Heugten
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands; Department of Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, The Netherlands
| | - Marcel W Post
- Department of Rehabilitation Medicine, Center for Rehabilitation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul L de Kort
- Department of Neurology, St. Elisabeth Hospital, Tilburg, The Netherlands
| | - Johanna M Visser-Meily
- Brain Center Rudolf Magnus and Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands.
| |
Collapse
|
10
|
Personality as a predictor of depression symptoms in burn patients: A follow-up study. Burns 2015; 41:25-32. [DOI: 10.1016/j.burns.2014.07.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 07/15/2014] [Accepted: 07/30/2014] [Indexed: 11/19/2022]
|
11
|
Personality type as a predictor for depressive symptoms and reduction in quality of life among stroke survivals. Am J Geriatr Psychiatry 2013; 21:832-9. [PMID: 23871119 DOI: 10.1016/j.jagp.2013.04.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 04/23/2013] [Accepted: 04/24/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Although poststroke depression (PSD) and reduction in quality of life (QOL) are prevalent among stroke patients, little is known about the contribution of personality traits to such impairments. This study examines whether particular personality traits predict PSD symptoms (PSDS) and reduction in QOL among stroke survivals using Cloninger's biopsychosocial personality model. We hypothesized that harm avoidance (HA), expressing the tendency to respond intensely to adverse stimuli, characterizes stroke survivors at risk for PSDS and reduction in QOL. METHODS Hospitalized stroke patients (N = 84, age 63.5 ± 9.7 years) prospectively completed Cloninger's Tridimensional Personality Questionnaire, defining HA dominancy by scoring the three personality dimensions: reward dependence, novelty seeking, and HA. The level of neurologic deficit was evaluated by the National Institutes of Health Stroke Scale. At the 3-month follow-up visit, depressive symptoms and QOL scores were assessed using the Beck Depression Inventory and the Stroke Specific Quality of Life questionnaire. RESULTS Regression analyses revealed that higher HA scores independently predicted PSDS and reduction in QOL. After controlling for the relative contribution of stroke type and health-related variables, HA and neurologic deficit were significant risk factors for poststroke negative outcomes. CONCLUSION Our findings emphasize the relevance of Cloninger's theory (manifested by individual HA behavior) as a distinctive means to identifying patients at risk for PSDS and lower QOL after stroke. The role of specific psychological and neurologic aspects involved in the mechanism of PSD should be further explored using biopsychosocial models.
Collapse
|