1
|
Lin Y, Wei Q, Luo S, Ye X, Zheng F, Zheng L, Lu X, Li H, Wu S. The risk of suicidal intention in severe mental illness: An ecological perspective. Psychol Psychother 2023; 96:1044-1061. [PMID: 37668301 DOI: 10.1111/papt.12495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE Guided by the ecosystem theory model framework, we aimed to explore the influence of three ecological dimensions (social, family and psychological factors) on suicidal intention in people with severe mental illness (SMI). We hypothesized that three factors influence suicidal intention, and that psychological factors may play a mediating role in the influence of social and family factors on suicidal intention. METHODS We collected 994 patients with SMI aged 18 and above from May 2021 to March 2022 in the Fourth Hospital of Fuzhou City. We used logistic regression to analyse the association between social, family, psychological factors and suicidal intention. Furthermore, we explored the mediating effects among the influencing factors. RESULTS Younger male patients with schizophrenia were more likely to have suicidal intention due to psychosocial family factors (p < .05). Social factors (poor interpersonal relations, social retreat, social activities outside the home), family factors (parental functions, activities within the family, family functions), psychological factors (anxiety, depression, interest in the outside world, overt aggression, lack of accountability and planning) were all independent risk factors for suicidal intention in patients. Mediation analysis showed anxiety and depression mediated the role of social and family factors on suicidal intention (p < .05). CONCLUSION Social, family and psychological factors were important risk factors for suicidal intention, with anxiety and depression being partial mediators for suicidal intention. Therefore, interventions that enhance family and social functioning and reduce anxiety and depression may be effective in reducing suicidal intention in SMI.
Collapse
Affiliation(s)
- Yawen Lin
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China
| | - Qinfei Wei
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China
| | - Suping Luo
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China
| | - Xiaoying Ye
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China
| | - Fuhao Zheng
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China
- Department of Scientific Research Management, Fujian Provincial Hospital, Fujian Medical University, Fuzhou, China
| | - Liuyan Zheng
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China
| | - Xinyue Lu
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China
| | - Huangyuan Li
- Department of Preventive Medicine, Statistics, School of Public Health, Fujian Medical University, Fuzhou, China
| | - Siying Wu
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China
| |
Collapse
|
2
|
Midlife suicide: A systematic review and meta-analysis of socioeconomic, psychiatric and physical health risk factors. J Psychiatr Res 2022; 154:233-241. [PMID: 35961179 DOI: 10.1016/j.jpsychires.2022.07.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 07/09/2022] [Accepted: 07/20/2022] [Indexed: 10/16/2022]
Abstract
Suicide is an increasing contributing cause of mortality in middle-aged adults; however, knowledge to guide prevention is limited. This first systematic review and meta-analysis of studies on midlife suicide has provided an overview of published research on this issue and synthesized the evidence on socioeconomic and physical and mental health factors associated with this mortality. Using PRISMA guidelines MEDLINE, Embase, PsycINFO, Scopus and Web of Science were searched for English-language publications that involved persons aged 35 to 65, used individual-level data, and reported prevalence of exposure(s) or relative risks. The search identified 62 studies on midlife suicides and associated factors (28 for SES, 22 for psychiatric disorder and 23 for physical illness). All studies were from high income countries, and most (80.6%) used data from population registries. Meta-analyses showed that the pooled prevalence of exposure in suicide decedents was 57.8% for psychiatric disorder, 56.3% for low income, 43.2% for unemployment, and 27.3% for physical illness. The associated pooled risk ratio was 11.68 (95% confidence intervals: 5.82-23.47) for psychiatric illness of any type, 12.59 (8.29-19.12) for mood disorders, 3.91 (2.72-5.59) for unemployment, 3.18 (2.72-3.72) for being separated or divorced, 2.64 (2.26-3.10) for cancer, 2.50 (0.96-6.38) for central nervous system illness, and 2.26 (1.16-4.41) for low income. In conclusion, midlife suicide is strongly associated with socioeconomic difficulties and physical and psychiatric illnesses that are common in this age population. Future investigations should consider the interactions between risk factors, the intersectionality of sex and ethnicity, and include data from low- and middle-income countries.
Collapse
|
3
|
Wasserman D, Carli V, Iosue M, Javed A, Herrman H. Suicide prevention in childhood and adolescence: a narrative review of current knowledge on risk and protective factors and effectiveness of interventions. Asia Pac Psychiatry 2021; 13:e12452. [PMID: 33646646 DOI: 10.1111/appy.12452] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/28/2021] [Accepted: 02/15/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Suicide is a global mental health problem for people of all ages. While rates of suicide in children and adolescents are reported as lower than those in older populations worldwide, they represent the third leading cause of death in 15-19-year-olds. The rates are higher among boys than girls worldwide, though the death rates for girls exceed those for boys in Bangladesh, China, India, and Nepal. There has been a general decrease in adolescent suicide rates over recent decades. However, increases are reported in South East Asia as well as South America over the same time period. METHODS A narrative review method has been used to summarize current knowledge about risk and protective factors for suicide among children and adolescents and to discuss evidence-based strategy for suicide prevention in this age group. RESULTS Identified suicide risk and protective factors for children and adolescents largely overlap with those for adults. Nevertheless, developmental characteristics may strengthen the impact of some factors, such as decision-making style, coping strategies, family and peer relationships, and victimization. The implementation of evidence-based suicide preventive strategies is needed. Restricting access to lethal means, school-based awareness and skill training programs, and interventions delivered in clinical and community settings have been proven effective. The effectiveness of gatekeeper training and screening programs in reducing suicidal ideation and behavior is unproven but widely examined in selected settings. DISCUSSION Since most studies have been conducted in western countries, future research should assess the effectiveness of these promising strategies in different cultural contexts. The use of more rigorous study designs, the use of both short- and long-term follow-up evaluations, the larger inclusion of individuals belonging to vulnerable groups, the evaluation of online intervention, and the analysis of programs' cost-effectiveness are also required.
Collapse
Affiliation(s)
- Danuta Wasserman
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden.,Section on Suicidology, World Psychiatric Association (WPA), Geneva, Switzerland
| | - Vladimir Carli
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden.,Section on Suicidology, World Psychiatric Association (WPA), Geneva, Switzerland
| | - Miriam Iosue
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden.,Section on Suicidology, World Psychiatric Association (WPA), Geneva, Switzerland
| | - Afzal Javed
- Coventry and Warwickshire Partnership NHS Trust, Coventry, UK
| | - Helen Herrman
- Orygen and Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| |
Collapse
|
4
|
Suicide attempts and deaths in older persons in Ghana: A media surveillance approach. CURRENT PSYCHOLOGY 2021. [DOI: 10.1007/s12144-018-9932-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
5
|
Does physical ill-health increase the risk of suicide? A census-based follow-up study of over 1 million people. Epidemiol Psychiatr Sci 2020; 29:e140. [PMID: 32635966 PMCID: PMC7372180 DOI: 10.1017/s2045796020000529] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AIMS Mental ill-health is a known risk factor for suicide mortality. However, the relationship between physical ill-health and suicide is less clear. This study examined the relationship between different aspects of physical ill-health and the risk of suicide death. METHODS Data for 1 196 364 adults (aged 18 years and over) were identified from the 2011 Northern Ireland Census and linked to death registrations until the end of 2015. Multivariate logistic regression was used to construct models to test associations with likelihood ratio tests for interactions. RESULTS Over one in eight individuals (13.7%) reported multimorbidity (⩾2 physical health conditions) and one in four (25.4%) identified having limitation of daily activities. During follow-up, 51 672 individuals died; 877 due to suicide. The gradient in suicide risk by number of physical conditions disappeared following adjustment for activity limitation. Individuals with a lot of activity limitation were over three times more likely to die by suicide (OR = 3.13, 95% CI 2.50-3.93) compared to those with no limitations though this was reduced to OR = 1.72 (95% CI 1.35-2.20) with adjustment for poor mental health. The relationship between activity limitation and suicide was most pronounced at younger ages (18-34 years). CONCLUSIONS This study suggests that it is the effect that physical illness has on a person's life, in terms of disruption to daily activity, rather than the number of conditions that predicts suicide risk, especially at younger ages. Improved awareness and better management of mental wellbeing of individuals with physical health conditions may help to reduce suicides, especially in younger people.
Collapse
|
6
|
O'Neill S, O'Connor RC. Suicide in Northern Ireland: epidemiology, risk factors, and prevention. Lancet Psychiatry 2020; 7:538-546. [PMID: 32006466 DOI: 10.1016/s2215-0366(19)30525-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/20/2019] [Accepted: 12/21/2019] [Indexed: 12/13/2022]
Abstract
The rates of suicide and self-harm in Northern Ireland are high, and have increased from 143 registered suicides in 1996 to 313 in 2010 and 318 in 2015. This Review summarises the epidemiology of suicidal behaviour, as well as the evidence from a small number of studies that have identified risk factors associated with high suicide rates in Northern Ireland. These risk factors were mental illness, trauma, exposure to the conflict known as the Troubles, deprivation, relationship problems, employment difficulties, financial difficulties, being LGBT, childhood adversities, and alcohol or drug use. We highlight the key challenges and opportunities for suicide prevention, emphasising a so-called lifespan approach. More needs to be done to address the relationship between substance misuse and suicide. Future research and prevention efforts should also focus on the transgenerational effect of the conflict, youth suicide, suicide prevention in minority groups, and the criminal justice context. The provision of and access to suicide-specific psychosocial interventions need to be prioritised, more support for people in crisis is required, as well as interventions for mental illness. Protect Life 2, the national suicide prevention strategy, needs to be implemented in full. Given the legacy of conflict in Northern Ireland, all suicide prevention efforts should be trauma informed.
Collapse
Affiliation(s)
- Siobhan O'Neill
- School of Psychology, Ulster University, County Londonderry, Ulster, UK.
| | - Rory C O'Connor
- Suicidal Behaviour Research Laboratory, Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| |
Collapse
|
7
|
Beringuel BM, Costa HVVD, Silva APDSC, Bonfim CVD. Mortality by suicide in the State of Pernambuco, Brazil (1996-2015). Rev Bras Enferm 2020; 73 Suppl 1:e20180270. [DOI: 10.1590/0034-7167-2018-0270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 03/02/2019] [Indexed: 12/26/2022] Open
Abstract
ABSTRACT Objective: To describe the epidemiological characteristics of suicide mortality in the state of Pernambuco, from 1996 to 2015. Method: Study with data from the Sistema de Informações sobre Mortalidade. The simple linear regression model was used to verify the trend in the period analyzed. Results: There were 6,229 suicides, of which 3,390 (54.4%) occurred in the second decade of study. The mortality rate was 4.7 per 100,000 inhabitants. The temporal trend presented a decrease of 23.5% (p=0.031). For the male sex and the age range between 20 and 39 years, there was a decline in self-inflicted death of 23.8% (p=0.018) and 26.1% (p=0.046), respectively. Conclusion: The temporal analysis revealed a reduction in suicide mortality coefficients. This observation may contribute to better targeting of health interventions, optimizing resources and efforts, especially in suicide prevention.
Collapse
|
8
|
Abstract
Although recent years have seen large decreases in the overall global rate of suicide fatalities, this trend is not reflected everywhere. Suicide and suicidal behaviour continue to present key challenges for public policy and health services, with increasing suicide deaths in some countries such as the USA. The development of suicide risk is complex, involving contributions from biological (including genetics), psychological (such as certain personality traits), clinical (such as comorbid psychiatric illness), social and environmental factors. The involvement of multiple risk factors in conveying risk of suicide means that determining an individual's risk of suicide is challenging. Improving risk assessment, for example, by using computer testing and genetic screening, is an area of ongoing research. Prevention is key to reduce the number of suicide deaths and prevention efforts include universal, selective and indicated interventions, although these interventions are often delivered in combination. These interventions, combined with psychological (such as cognitive behavioural therapy, caring contacts and safety planning) and pharmacological treatments (for example, clozapine and ketamine) along with coordinated social and public health initiatives, should continue to improve the management of individuals who are suicidal and decrease suicide-associated morbidity.
Collapse
|
9
|
O'Neill S, Graham B, Ennis E. Emergency department and hospital care prior to suicide: A population based case control study. J Affect Disord 2019; 249:366-370. [PMID: 30807938 DOI: 10.1016/j.jad.2019.02.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 01/15/2019] [Accepted: 02/19/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND High proportions of those who die by suicide in Northern Ireland (NI) are not known to mental health services, making it important to understand contact with the wider health services. Previous research has not examined the patterns of emergency department (ED) attendance and hospital admissions amongst those who have died by suicide in NI. OBJECTIVES The study objectives are to examine the relationships between ED attendances, hospital admissions, and death by suicide. METHODS A case control methodology was used, drawing on routinely collected administrative data on all deaths by suicide in Northern Ireland between 1/1/2012 and 31/12/2015. Each death was matched to 5 live controls, based on age and gender (n = 6630). RESULTS Death by suicide is associated with a recent ED attendance, with the highest odds for those who attended within the past three months (odds = 3.2, 95% CI = 2.5-4.2). Death by suicide is also associated with recent hospital admission, with the highest odds of death for admission within the past three months (odds = 6.6, 95% CI = 5.2-8.3). The odds of suicide are also higher for those living in a more deprived or urban area. LIMITATIONS The study is limited to administrative data. CONCLUSIONS Staff in EDs and hospitals may have a role in suicide prevention. These findings again support the importance of addressing economic deprivation and other area level factors, such as contagion in suicide prevention strategies.
Collapse
Affiliation(s)
- S O'Neill
- Psychology Research Institute, Ulster University, Coleraine Campus BT52 1SA
| | - B Graham
- Queen's Management School, Queen's University Belfast, BT9 5EE
| | - E Ennis
- Psychology Research Institute, Ulster University, Coleraine Campus BT52 1SA.
| |
Collapse
|
10
|
Carrasco-Farfan CA, Alvarez-Cutipa D, Vilchez-Cornejo J, Lizana-Medrano M, Durand-Anahua PA, Rengifo-Sanchez JA, Rebatta-Acuña A, Cubas WS, Arroyo-Hernandez H, Toro-Huamanchumo CJ. Alcohol consumption and suicide risk in medical internship: A Peruvian multicentric study. Drug Alcohol Rev 2019; 38:201-208. [PMID: 30681212 DOI: 10.1111/dar.12897] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND AIM Suicide and harmful alcohol consumption are major health problems, especially in medical students. This study aimed to evaluate the association between risk for alcohol abuse and suicide risk in medical interns of Peruvian hospitals. DESIGN AND METHODS We conducted a multicentre cross-sectional study in medical interns from 18 Peruvian hospitals. We measured suicide risk, risk for alcohol abuse, depression and self-esteem using the Plutchik Suicide Risk Scale, CAGE, Zung Self-Rating Depression Scale and Rosenberg Self-Esteem Scale, respectively. We used χ2 and Student t-tests for descriptive analysis. To evaluate the association between risk for alcohol abuse and suicide risk we generated crude and adjusted Poisson regression models with robust variance and estimated prevalence ratios with 95% confidence intervals. RESULTS We surveyed 433 medical interns. The prevalence of suicide risk and risk for alcohol abuse was 19.6% and 27.5%, respectively. We found significant differences in suicide risk according to age (P < 0.001), region of origin (P = 0.002), with whom the participant lived (P < 0.001), university of origin (P = 0.040), type of hospital (P = 0.042), family history of attempted suicide (P = 0.043), self-esteem level (P < 0.001) and alcohol consumption (P < 0.001). In the adjusted model, age (PRa: 1.11, 95% confidence interval 1.05-1.17) and risk for alcohol abuse (PRa: 7.60, 95% confidence interval 4.46-12, 96) were associated with suicide risk. DISCUSSION AND CONCLUSIONS Two out of 10 medical interns had a positive screening for suicide risk. Age and especially risk for alcohol abuse were the associated variables.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Wildor S Cubas
- School of Medicine, Universidad Nacional de San Martin, Tarapoto, Peru
| | | | - Carlos J Toro-Huamanchumo
- Universidad San Ignacio de Loyola, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru
| |
Collapse
|
11
|
Clapperton A, Newstead S, Bugeja L, Pirkis J. Differences in Characteristics and Exposure to Stressors Between Persons With and Without Diagnosed Mental Illness Who Died by Suicide in Victoria, Australia. CRISIS 2018; 40:231-239. [PMID: 30311798 DOI: 10.1027/0227-5910/a000553] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Mental illness is an established risk factor for suicide. To develop effective prevention interventions and strategies, the demographic characteristics and stressors (other than, or in addition to, mental illness) that can influence a person's decision to die by suicide need to be identified. Aim: To examine cases of suicide by the presence or absence of a diagnosed mental illness (mental illness status) to identify differences in factors associated with suicide in the groups. Method: Logistic regression analyses were used to investigate mental illness status and exposure to stressors among 2,839 persons who died by suicide in Victoria, Australia (2009-2013), using the Victorian Suicide Register. Results: Females, metropolitan residents, persons treated for physical illness/injury, those exposed to stressors related to isolation, family, work, education, and substance use and those who had made a previous suicide attempt had increased odds of having a diagnosed mental illness. Employed persons had decreased odds of having a diagnosed mental illness. Limitations: The retrospectivity of data collection as well as the validity and reliability of some of the data may be questionable owing to the potential for recall bias. Conclusion: The point of intervention for suicide prevention cannot always be a mental health professional; some people who die by suicide either do not have a mental illness or have not sought help.
Collapse
Affiliation(s)
- Angela Clapperton
- 1 Monash University Accident Research Centre, Monash University, Melbourne, VIC, Australia
| | - Stuart Newstead
- 1 Monash University Accident Research Centre, Monash University, Melbourne, VIC, Australia
| | - Lyndal Bugeja
- 2 Department of Forensic Medicine, Monash University, Melbourne, VIC, Australia
| | - Jane Pirkis
- 3 Melbourne School of Population and Global Health, The University of Melbourne, VIC, Australia
| |
Collapse
|
12
|
González-Castro TB, Tovilla-Zárate CA, Hernández-Díaz Y, Juárez-Rojop IE, León-Garibay AG, Guzmán-Priego CG, López-Narváez L, Frésan A. Characteristics of Mexican children and adolescents who died by suicide: A study of psychological autopsies. J Forensic Leg Med 2017; 52:236-240. [PMID: 29035840 DOI: 10.1016/j.jflm.2017.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 10/02/2017] [Accepted: 10/03/2017] [Indexed: 01/04/2023]
Abstract
OBJECTIVE In recent years, suicide in children and adolescents has increased considerably, becoming the second cause of death in this age group. Therefore, the aim of this study was to identify characteristics and factors that could precipitate deaths by suicide in children and adolescents. METHODS Using the psychological autopsy method, we studied 28 suicide cases of children and adolescents between 10 and 17 years old. Socio-demographic factors, characteristics of the suicide and family history were documented. RESULTS The proportion of deaths by suicide was the same in females and males (50% each). Most of the suicides were performed at the child/adolescent's home (78.6%) and no history of previous suicide attempts were registered (85.7%). Also, the majority of suicidal individuals came from a dysfunctional family (60.7%). CONCLUSIONS Our results identified characteristics of children and adolescents that had died by suicide, such as dying at their homes and coming from dysfunctional families. Knowing the characteristics of children and adolescents that had ended their lives by suicide should be considered in future studies to help developing preventive programs and strategies for treating suicidal behaviors in Mexican children and adolescents.
Collapse
Affiliation(s)
- Thelma Beatriz González-Castro
- Universidad Juárez Autónoma de Tabasco, División Académica Multidisciplinaria de Jalpa de Méndez, Jalpa de Méndez, Tabasco, Mexico
| | - Carlos Alfonso Tovilla-Zárate
- Universidad Juárez Autónoma de Tabasco, División Académica Multidisciplinaria de Comalcalco, Comalcalco, Tabasco, Mexico.
| | - Yazmín Hernández-Díaz
- Universidad Juárez Autónoma de Tabasco, División Académica Multidisciplinaria de Jalpa de Méndez, Jalpa de Méndez, Tabasco, Mexico
| | - Isela E Juárez-Rojop
- Universidad Juárez Autónoma de Tabasco, División Académica de Ciencias de la Salud, Villahermosa, Tabasco, Mexico
| | | | | | | | - Ana Frésan
- Subdirección de Investigaciones Clínicas, Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Ciudad de México, Mexico
| |
Collapse
|