- Email: [email protected]
Mental health after the Boston marathon bombing
Comment
into health-care and social-care education to increase the knowledge and expertise across the continent. Development of appropriate educational services for children with autism in Africa is urgently needed. Research on autism in Africa should be strengthened: development and validation of screening and diagnostic tools are key. Thereafter, epidemiological research is needed to assess the burden of autism spectrum disorder and define the clinical features of the disorder in Africa. We have an ethical duty to develop post-diagnostic interventions—from psychoeducation, to communitybased and specialist programmes. Linking educational, health-care, and social-care systems to generate coordinated knowledge, policies, and plans would ensure efficacy and cost-effectiveness of the programmes—an important consideration in resource-poor settings. The needs of Africa are substantial, but the world has much to learn from Africa in terms of the interplay between nature and nurture in the pathway to autism spectrum disorder and neurodevelopmental disorders, and in finding creative ways to meet the needs of individuals and families in low-cost, high-impact ways.
PJdV reports grants and personal fees from Novartis; is on the study steering committee of three trials sponsored by Novartis; is a co-principal investigator of two projects part-funded by Novartis; and is on the working committee of a project sponsored by Novartis, outside of the submitted work. AA has a consultancy agreement with Autism Speaks to develop open access screening and diagnostic tools, outside of the submitted work. DS and CRN declare no competing interests.
*Amina Abubakar, Derrick Ssewanyana, Petrus J de Vries, Charles R Newton
11
Neuroassessment Unit, Kenya-Medical Research Institute-Wellcome Trust Collaborative Programme, Kilifi, Kenya (AA, DS, CRN); Department of Psychiatry, University of Oxford, Oxford, United Kingdom (AA, CRN); and Division of Child & Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa (PJdV) [email protected]
12
1
2
3 4
5 6 7
8 9
10
Durkin MS, Elsabbagh M, Barbaro J, et al. Autism screening and diagnosis in low resource settings: Challenges and opportunities to enhance research and services worldwide. Autism Res 2015; 8: 473–76. Ruparelia K, Abubakar A, Badoe E, et al. Autism spectrum disorders in Africa: current challenges in identification, assessment, and treatment a report on the International Child Neurology Association meeting on ASD in Africa, Ghana, April 3–5, 2014. J Child Neurol 2016; 31: 1018–26. Elsabbagh M, Divan G, Koh YJ, et al. Global prevalence of autism and other pervasive developmental disorders. Autism Res 2012; 5: 160–79. Bakare MO, Munir KM, Bello-Mojeed MA. Public health and research funding for childhood neurodevelopmental disorders in Sub-Saharan Africa: a time to balance priorities. Healthc Low Resour Settings 2014; 2: 2014.1559. Wallace S, Fein D, Rosanoff M, et al. A global public health strategy for autism spectrum disorders. Autism Res 2012; 5: 211–17. Lotter V. Childhood autism in Africa. J Child Psychol Psychiatry 1978; 19: 231–44. Barnevik-Olsson M, Gillberg C, Fernell E. Prevalence of autism in children of Somali origin living in Stockholm: brief report of an at-risk population. Dev Med Child Neurol 2010; 52: 1167–68. Geschwind DH, State MW. Gene hunting in autism spectrum disorder: on the path to precision medicine. Lancet Neurol 2015; 14: 1109–20. Talkowski ME, Minikel EV, Gusella JF. Autism spectrum disorder genetics: diverse genes with diverse clinical outcomes. Harv Rev Psychiatry 2014; 22: 65–75. Betancur C. Etiological heterogeneity in autism spectrum disorders: more than 100 genetic and genomic disorders and still counting. Brain Res 2011; 1380: 42–77. Campbell MC, Hirbo JB, Townsend JP, Tishkoff SA. The peopling of the African continent and the diaspora into the new world. Curr Opin Genet Dev 2014; 29: 120–32. Gardener H, Spiegelman D, Buka SL. Perinatal and neonatal risk factors for autism: a comprehensive meta-analysis. Pediatrics 2011; 128: 344–55.
Wladimir Bulgar/Science Photo Library
Mental health after the Boston marathon bombing
This online publication has been corrected. The corrected version first appeared at thelancet.com/psychiatry on September 28, 2016
802
In the 3 years since the Boston marathon bombing, the medical and media focus has largely remained on the physical health impact.1–3 Much less is known about the mental health response. Disaster events are known to cause increased emotional distress in the affected population, manifested as behavioural change, distress responses, and mental illness.4 Understanding the mental health response after the Boston bombing might help health-care providers and communities better prepare for their response to disasters. On the day of the bombing, after the initial triaging of 281 patients to hospitals to treat physical trauma, a mental health response was also mobilised within
hospitals and in the community in general. At the hospital level, at least three distinct types of organisational responses took place. First, multidisciplinary teams were established across departments to help patients cope with the events. For example, at Brigham and Women’s Hospital, a psychological response team consisting of staff from emergency medicine, psychiatry, chaplaincy, and patient-family services was created to provide mental health assistance to the injured victims, their families, and other affected individuals.5 Second, some institutions pursued a systematic strategy of screening every patient for potential needs related to the bombing. For instance, at Spaulding Hospital, every www.thelancet.com/psychiatry Vol 3 September 2016
Comment
patient who arrived for rehabilitation was screened for emotional issues, and families were asked about patients’ coping styles and psychosocial needs.6 Third, hospitals initiated programmes aimed at both educating and supporting clinicians. Brigham and Women’s Hospital, for example, instituted 1-h training sessions for psychiatrists and social workers on best practices for acute stress responses.7 Boston Medical Center created a “campaign of healing” that acknowledged the difficulty, and celebrated the resiliency, of the providers.6 Other hospitals also created support groups to target medical staff affected by the bombing. While hospitals initiated their mental health response, community-level initiatives were also established. First, support centres that welcomed people seeking care were created or activated by organisations in the weeks after the bombing. The Medical Intelligence Center, a multiagency centre for health-care organisations in the Boston area that coordinates the response in the face of a disaster, was activated the day of the marathon. The Center worked with many agencies including governmental (eg, Massachusetts Department of Mental Health and US Department of Health and Human Services) and non-governmental agencies (eg, American Red Cross and Salvation Army). Combined, these agencies spent over 600 hours providing mental health services to thousands of individuals.8 A short-term Community Support Center was set up on the evening of the bombing and remained open for 3 days, providing mental health counselling, shelter, and family reunification.8 Additionally, a longer-term Family Assistance Center was set up for months to provide support services to 118 bombing victims and their families.8 The most commonly requested service was a mental health referral, more so than help with financial services, legal assistance, or benefit information.8 Second, initiatives that actively sought to offer services to people in need were mobilised. Support groups for individuals affected by the bombing were set up through organisations such as the Boston Public Health Commission, the Beth Israel Deaconess Center for Violence Prevention and Recovery, and the Center for Homicide Bereavement.9 Several community sites offered free in-home and community-based counselling, such as the Community Violence Response Team at Boston Medical Center.9 Stay Strong Boston was created to provide individuals with access to a mental health self-assessment www.thelancet.com/psychiatry Vol 3 September 2016
tool, information on coping, and information on how to contact national hotlines.9 Multiple hotlines were made available to support members of the community. The Mayor’s Health Line, a free information and referral service, received 253 bombing-related calls, 88 of which were requests for mental health counselling.8 A Boston Recovery and Resource Guide was created by the Boston Public Health Commission with a list of all the mental health and crisis intervention services available and a list of books on trauma and healing.9 What can we learn from the Boston marathon events that might be applicable to other mental health disaster responses? At the health-care level, mental health disaster preparedness should be taught systematically. Training programmes for allied health professionals should include education about the mental health response to disasters.10 We recommend that all hospitals prepare a psychological response team that would be available to provide mental health care to both patients and staff after a disaster. At the community level, a coordinated response should build on the framework of existing community agencies and programmes.11 The evidence-informed approach known as Psychological First Aid is a recognised guiding principle by which to address the needs of individuals affected by disaster.5 Its basic principles include establishing connection and engagement with community members, ensuring their safety and comfort, and providing them information to help cope with the psychological impact of disasters.5 In Boston, agencies worked well to create a coordinated response through centres, hotlines, and support groups, but a systematic method for analysing the effectiveness of these interventions is not available. It could prove beneficial for other cities to have a mental health preparedness system in place that not only uses the principles of psychological first aid, but also has a system to measure the effectiveness of the interventions implemented. As an adjunct to these on-the-ground efforts, the media can be a powerful and underrated force in promoting or preventing healing. The media can disseminate messages that include ways to obtain help, educate about the stages of grief, and provide information about common symptoms after disasters. However, reduction of the endless cycles of reporting on the event and, therefore, overexposure of the event to the public, might be beneficial.12 803
Comment
The response to the Boston marathon bombing showed that a well-coordinated response at the hospital and community level can offer meaningful methods to manage not only the physical, but also the mental, trauma that occurs after disasters. Yet the field of mental health disaster preparedness remains underdeveloped. Whereas the effect of the physical response in the Boston bombing was measured in terms of morbidity and mortality outcomes, the effect of the mental health response has received scant attention and its effectiveness remains unclear. Development of systems in cities to not only prepare for, but also to measure and analyse, the mental health response to a disaster is imperative to minimise both short-term and long-term sequelae from traumatic events. 21st century disaster planning must include mental health preparedness as a central component of disaster response. *Arvind von Keudell, Katherine A Koh, Sejal B Shah, Mitchel B Harris, Malcolm Smith, Edward K Rodriguez, George Dyer Harvard Orthopedic Trauma Initiative, Harvard Medical School, Boston, MA, USA (AvK, MBH, MS, EKR, GD); Department of Psychiatry (KAK, SBS), and Department of Orthopaedic Surgery (MS), Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA (MBH, GD); and Department of Orthopaedic Surgery, Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA, USA (EKR) [email protected]
804
We declare no competing interests. AvK and KAK contributed equally to this Comment. 1 2 3
4
5
6
7
8
9
10
11 12
Walls RM, Zinner MJ. The Boston Marathon response: why did it work so well? JAMA 2013; 309: 2441–42. Biddinger PD, Baggish A, Harrington L, et al. Be prepared—the Boston Marathon and mass-casualty events. N Engl J Med 2013; 368: 1958–60. Tobert D, von Keudell A, Rodriguez EK. Lessons from the Boston Marathon bombing: an orthopaedic perspective on preparing for high-volume trauma in an urban academic center. J Orthop Trauma 2015; 29 (suppl 10): S7–10. Katz CL. Psychiatric evaluation. In: Stoddard F, Pandya A, Katz CL (eds). Disaster psychiatry: readiness, evaluation, and treatment. Arlington, VA: American Psychiatric Publishing, 2011: 71–88. Oser M, Shah SB, Gitlin D. Psychiatry department response to the Boston Marathon bombings within a level-1 trauma center. Harv Rev Psychiatry 2015; 23: 195–200. Resnick L. JBJS-JOSPT Special Report. It takes a team—the 2013 Boston Marathon: preparing for and recovering from a mass-casualty event. March, 2014. http://sites.jbjs.org/ittakesateam/2014/report.pdf (accessed Dec 5, 2015). Steenen SA, van Westrhenen R, Olff M. Toward rational use of benzodiazepines in posttraumatic stress disorder. J Clin Psychiatry 2013; 74: 852. Boston Public Health Commission, Office of Public Health Preparedness. 2013 Boston Bombings: response & recovery infographic. https://delvalle. bphc.org/mod/page/view.php?id=610 (acessed Dec 15, 2015). Boston Public Health Commission. Resource and recovery guide Boston Marathon. http://www.bphc.org/whatwedo/mental-emotional-health/ trauma-response-and-recovery/Documents/Resource%20and%20 Recovery%20Guide%20Boson%20Marathon%20April%202014.pdf (acessed Feb 3, 2016). Tsai TC, Smink DS. Responding to the Boston Marathon bombing: the unheralded role of graduate medical education. J Surg Educ 2013; 70: 555–56. Yun K, Lurie N, Hyde PS. Moving mental health into the disaster-preparedness spotlight. N Engl J Med 2010; 363: 1193–95. Holman EA, Garfin DR, Silver RC. Media’s role in broadcasting acute stress following the Boston Marathon bombings. Proc Natl Acad Sci USA 2014; 111: 93–98.
www.thelancet.com/psychiatry Vol 3 September 2016
into health-care and social-care education to increase the knowledge and expertise across the continent. Development of appropriate educational services for children with autism in Africa is urgently needed. Research on autism in Africa should be strengthened: development and validation of screening and diagnostic tools are key. Thereafter, epidemiological research is needed to assess the burden of autism spectrum disorder and define the clinical features of the disorder in Africa. We have an ethical duty to develop post-diagnostic interventions—from psychoeducation, to communitybased and specialist programmes. Linking educational, health-care, and social-care systems to generate coordinated knowledge, policies, and plans would ensure efficacy and cost-effectiveness of the programmes—an important consideration in resource-poor settings. The needs of Africa are substantial, but the world has much to learn from Africa in terms of the interplay between nature and nurture in the pathway to autism spectrum disorder and neurodevelopmental disorders, and in finding creative ways to meet the needs of individuals and families in low-cost, high-impact ways.
PJdV reports grants and personal fees from Novartis; is on the study steering committee of three trials sponsored by Novartis; is a co-principal investigator of two projects part-funded by Novartis; and is on the working committee of a project sponsored by Novartis, outside of the submitted work. AA has a consultancy agreement with Autism Speaks to develop open access screening and diagnostic tools, outside of the submitted work. DS and CRN declare no competing interests.
*Amina Abubakar, Derrick Ssewanyana, Petrus J de Vries, Charles R Newton
11
Neuroassessment Unit, Kenya-Medical Research Institute-Wellcome Trust Collaborative Programme, Kilifi, Kenya (AA, DS, CRN); Department of Psychiatry, University of Oxford, Oxford, United Kingdom (AA, CRN); and Division of Child & Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa (PJdV) [email protected]
12
1
2
3 4
5 6 7
8 9
10
Durkin MS, Elsabbagh M, Barbaro J, et al. Autism screening and diagnosis in low resource settings: Challenges and opportunities to enhance research and services worldwide. Autism Res 2015; 8: 473–76. Ruparelia K, Abubakar A, Badoe E, et al. Autism spectrum disorders in Africa: current challenges in identification, assessment, and treatment a report on the International Child Neurology Association meeting on ASD in Africa, Ghana, April 3–5, 2014. J Child Neurol 2016; 31: 1018–26. Elsabbagh M, Divan G, Koh YJ, et al. Global prevalence of autism and other pervasive developmental disorders. Autism Res 2012; 5: 160–79. Bakare MO, Munir KM, Bello-Mojeed MA. Public health and research funding for childhood neurodevelopmental disorders in Sub-Saharan Africa: a time to balance priorities. Healthc Low Resour Settings 2014; 2: 2014.1559. Wallace S, Fein D, Rosanoff M, et al. A global public health strategy for autism spectrum disorders. Autism Res 2012; 5: 211–17. Lotter V. Childhood autism in Africa. J Child Psychol Psychiatry 1978; 19: 231–44. Barnevik-Olsson M, Gillberg C, Fernell E. Prevalence of autism in children of Somali origin living in Stockholm: brief report of an at-risk population. Dev Med Child Neurol 2010; 52: 1167–68. Geschwind DH, State MW. Gene hunting in autism spectrum disorder: on the path to precision medicine. Lancet Neurol 2015; 14: 1109–20. Talkowski ME, Minikel EV, Gusella JF. Autism spectrum disorder genetics: diverse genes with diverse clinical outcomes. Harv Rev Psychiatry 2014; 22: 65–75. Betancur C. Etiological heterogeneity in autism spectrum disorders: more than 100 genetic and genomic disorders and still counting. Brain Res 2011; 1380: 42–77. Campbell MC, Hirbo JB, Townsend JP, Tishkoff SA. The peopling of the African continent and the diaspora into the new world. Curr Opin Genet Dev 2014; 29: 120–32. Gardener H, Spiegelman D, Buka SL. Perinatal and neonatal risk factors for autism: a comprehensive meta-analysis. Pediatrics 2011; 128: 344–55.
Wladimir Bulgar/Science Photo Library
Mental health after the Boston marathon bombing
This online publication has been corrected. The corrected version first appeared at thelancet.com/psychiatry on September 28, 2016
802
In the 3 years since the Boston marathon bombing, the medical and media focus has largely remained on the physical health impact.1–3 Much less is known about the mental health response. Disaster events are known to cause increased emotional distress in the affected population, manifested as behavioural change, distress responses, and mental illness.4 Understanding the mental health response after the Boston bombing might help health-care providers and communities better prepare for their response to disasters. On the day of the bombing, after the initial triaging of 281 patients to hospitals to treat physical trauma, a mental health response was also mobilised within
hospitals and in the community in general. At the hospital level, at least three distinct types of organisational responses took place. First, multidisciplinary teams were established across departments to help patients cope with the events. For example, at Brigham and Women’s Hospital, a psychological response team consisting of staff from emergency medicine, psychiatry, chaplaincy, and patient-family services was created to provide mental health assistance to the injured victims, their families, and other affected individuals.5 Second, some institutions pursued a systematic strategy of screening every patient for potential needs related to the bombing. For instance, at Spaulding Hospital, every www.thelancet.com/psychiatry Vol 3 September 2016
Comment
patient who arrived for rehabilitation was screened for emotional issues, and families were asked about patients’ coping styles and psychosocial needs.6 Third, hospitals initiated programmes aimed at both educating and supporting clinicians. Brigham and Women’s Hospital, for example, instituted 1-h training sessions for psychiatrists and social workers on best practices for acute stress responses.7 Boston Medical Center created a “campaign of healing” that acknowledged the difficulty, and celebrated the resiliency, of the providers.6 Other hospitals also created support groups to target medical staff affected by the bombing. While hospitals initiated their mental health response, community-level initiatives were also established. First, support centres that welcomed people seeking care were created or activated by organisations in the weeks after the bombing. The Medical Intelligence Center, a multiagency centre for health-care organisations in the Boston area that coordinates the response in the face of a disaster, was activated the day of the marathon. The Center worked with many agencies including governmental (eg, Massachusetts Department of Mental Health and US Department of Health and Human Services) and non-governmental agencies (eg, American Red Cross and Salvation Army). Combined, these agencies spent over 600 hours providing mental health services to thousands of individuals.8 A short-term Community Support Center was set up on the evening of the bombing and remained open for 3 days, providing mental health counselling, shelter, and family reunification.8 Additionally, a longer-term Family Assistance Center was set up for months to provide support services to 118 bombing victims and their families.8 The most commonly requested service was a mental health referral, more so than help with financial services, legal assistance, or benefit information.8 Second, initiatives that actively sought to offer services to people in need were mobilised. Support groups for individuals affected by the bombing were set up through organisations such as the Boston Public Health Commission, the Beth Israel Deaconess Center for Violence Prevention and Recovery, and the Center for Homicide Bereavement.9 Several community sites offered free in-home and community-based counselling, such as the Community Violence Response Team at Boston Medical Center.9 Stay Strong Boston was created to provide individuals with access to a mental health self-assessment www.thelancet.com/psychiatry Vol 3 September 2016
tool, information on coping, and information on how to contact national hotlines.9 Multiple hotlines were made available to support members of the community. The Mayor’s Health Line, a free information and referral service, received 253 bombing-related calls, 88 of which were requests for mental health counselling.8 A Boston Recovery and Resource Guide was created by the Boston Public Health Commission with a list of all the mental health and crisis intervention services available and a list of books on trauma and healing.9 What can we learn from the Boston marathon events that might be applicable to other mental health disaster responses? At the health-care level, mental health disaster preparedness should be taught systematically. Training programmes for allied health professionals should include education about the mental health response to disasters.10 We recommend that all hospitals prepare a psychological response team that would be available to provide mental health care to both patients and staff after a disaster. At the community level, a coordinated response should build on the framework of existing community agencies and programmes.11 The evidence-informed approach known as Psychological First Aid is a recognised guiding principle by which to address the needs of individuals affected by disaster.5 Its basic principles include establishing connection and engagement with community members, ensuring their safety and comfort, and providing them information to help cope with the psychological impact of disasters.5 In Boston, agencies worked well to create a coordinated response through centres, hotlines, and support groups, but a systematic method for analysing the effectiveness of these interventions is not available. It could prove beneficial for other cities to have a mental health preparedness system in place that not only uses the principles of psychological first aid, but also has a system to measure the effectiveness of the interventions implemented. As an adjunct to these on-the-ground efforts, the media can be a powerful and underrated force in promoting or preventing healing. The media can disseminate messages that include ways to obtain help, educate about the stages of grief, and provide information about common symptoms after disasters. However, reduction of the endless cycles of reporting on the event and, therefore, overexposure of the event to the public, might be beneficial.12 803
Comment
The response to the Boston marathon bombing showed that a well-coordinated response at the hospital and community level can offer meaningful methods to manage not only the physical, but also the mental, trauma that occurs after disasters. Yet the field of mental health disaster preparedness remains underdeveloped. Whereas the effect of the physical response in the Boston bombing was measured in terms of morbidity and mortality outcomes, the effect of the mental health response has received scant attention and its effectiveness remains unclear. Development of systems in cities to not only prepare for, but also to measure and analyse, the mental health response to a disaster is imperative to minimise both short-term and long-term sequelae from traumatic events. 21st century disaster planning must include mental health preparedness as a central component of disaster response. *Arvind von Keudell, Katherine A Koh, Sejal B Shah, Mitchel B Harris, Malcolm Smith, Edward K Rodriguez, George Dyer Harvard Orthopedic Trauma Initiative, Harvard Medical School, Boston, MA, USA (AvK, MBH, MS, EKR, GD); Department of Psychiatry (KAK, SBS), and Department of Orthopaedic Surgery (MS), Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA (MBH, GD); and Department of Orthopaedic Surgery, Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA, USA (EKR) [email protected]
804
We declare no competing interests. AvK and KAK contributed equally to this Comment. 1 2 3
4
5
6
7
8
9
10
11 12
Walls RM, Zinner MJ. The Boston Marathon response: why did it work so well? JAMA 2013; 309: 2441–42. Biddinger PD, Baggish A, Harrington L, et al. Be prepared—the Boston Marathon and mass-casualty events. N Engl J Med 2013; 368: 1958–60. Tobert D, von Keudell A, Rodriguez EK. Lessons from the Boston Marathon bombing: an orthopaedic perspective on preparing for high-volume trauma in an urban academic center. J Orthop Trauma 2015; 29 (suppl 10): S7–10. Katz CL. Psychiatric evaluation. In: Stoddard F, Pandya A, Katz CL (eds). Disaster psychiatry: readiness, evaluation, and treatment. Arlington, VA: American Psychiatric Publishing, 2011: 71–88. Oser M, Shah SB, Gitlin D. Psychiatry department response to the Boston Marathon bombings within a level-1 trauma center. Harv Rev Psychiatry 2015; 23: 195–200. Resnick L. JBJS-JOSPT Special Report. It takes a team—the 2013 Boston Marathon: preparing for and recovering from a mass-casualty event. March, 2014. http://sites.jbjs.org/ittakesateam/2014/report.pdf (accessed Dec 5, 2015). Steenen SA, van Westrhenen R, Olff M. Toward rational use of benzodiazepines in posttraumatic stress disorder. J Clin Psychiatry 2013; 74: 852. Boston Public Health Commission, Office of Public Health Preparedness. 2013 Boston Bombings: response & recovery infographic. https://delvalle. bphc.org/mod/page/view.php?id=610 (acessed Dec 15, 2015). Boston Public Health Commission. Resource and recovery guide Boston Marathon. http://www.bphc.org/whatwedo/mental-emotional-health/ trauma-response-and-recovery/Documents/Resource%20and%20 Recovery%20Guide%20Boson%20Marathon%20April%202014.pdf (acessed Feb 3, 2016). Tsai TC, Smink DS. Responding to the Boston Marathon bombing: the unheralded role of graduate medical education. J Surg Educ 2013; 70: 555–56. Yun K, Lurie N, Hyde PS. Moving mental health into the disaster-preparedness spotlight. N Engl J Med 2010; 363: 1193–95. Holman EA, Garfin DR, Silver RC. Media’s role in broadcasting acute stress following the Boston Marathon bombings. Proc Natl Acad Sci USA 2014; 111: 93–98.
www.thelancet.com/psychiatry Vol 3 September 2016