Dysthymia

Jump to navigation Jump to search

WikiDoc Resources for Dysthymia

Articles

Most recent articles on Dysthymia

Most cited articles on Dysthymia

Review articles on Dysthymia

Articles on Dysthymia in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Dysthymia

Images of Dysthymia

Photos of Dysthymia

Podcasts & MP3s on Dysthymia

Videos on Dysthymia

Evidence Based Medicine

Cochrane Collaboration on Dysthymia

Bandolier on Dysthymia

TRIP on Dysthymia

Clinical Trials

Ongoing Trials on Dysthymia at Clinical Trials.gov

Trial results on Dysthymia

Clinical Trials on Dysthymia at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Dysthymia

NICE Guidance on Dysthymia

NHS PRODIGY Guidance

FDA on Dysthymia

CDC on Dysthymia

Books

Books on Dysthymia

News

Dysthymia in the news

Be alerted to news on Dysthymia

News trends on Dysthymia

Commentary

Blogs on Dysthymia

Definitions

Definitions of Dysthymia

Patient Resources / Community

Patient resources on Dysthymia

Discussion groups on Dysthymia

Patient Handouts on Dysthymia

Directions to Hospitals Treating Dysthymia

Risk calculators and risk factors for Dysthymia

Healthcare Provider Resources

Symptoms of Dysthymia

Causes & Risk Factors for Dysthymia

Diagnostic studies for Dysthymia

Treatment of Dysthymia

Continuing Medical Education (CME)

CME Programs on Dysthymia

International

Dysthymia en Espanol

Dysthymia en Francais

Business

Dysthymia in the Marketplace

Patents on Dysthymia

Experimental / Informatics

List of terms related to Dysthymia

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vatsala Sharma; M.B.B.S[2]

Synonyms and Keywords: Dysthymic disorder; persistent depressive disorder; double depression

Overview

Dysthymia is a mood disorder that falls on the depression spectrum. It is characterized by the lack of enjoyment or pleasure, clinically referred to as anhedonia, that continues for an extended period. Dysthymia differs from major depression in that it is both longer-lasting and not as distressing. The symptoms of dysthymia are often underestimated by the patients and misdiagnosed by clinicians. Dysthymia can have a substantial impact on an individual's life by preventing effective functioning, disrupting sleep patterns, and interfering with activities of daily living (ADLs). It usually presents with mild symptoms on a day-to-day basis. Progressively, the disorder may take a more severe form, resulting in work impairment, social isolation, and high rates of suicide. Due to its chronicity and lesser severity, most of the patients suffering from dysthymia believe that it is a part of their character and do not seek treatment until it gets extremely disabling.

Historical Perspective

  • The historical origin of the term 'dysthymia' is Greek.
  • In 1844, dysthymia was used first in psychiatry by C.F. Flemming. [1]
  • In 1882, dysthymia was further described by Kahlbaum, and he differentiated it from the fluctuating mood of cyclothymia.[2]
  • In the Diagnostic and Statistical Manual of Mental Disorders (DSM), dysthymia as a clinical entity has undergone complex evolution from being considered a personality disorder to an affective disorder.


Classification

  • DSM-IV has classified chronic depression into dysthymic disorder and major depressive disorder, chronic type.
  • Based on the age of onset, DSM-IV has divided dysthymic disorders into early (before 21 years) and late-onset (after 21 years) subtypes. [5]
  • Early-onset dysthymic disorder is related to a higher familial burden of mood disorders and childhood adverse conditions. On the other hand, late-onset has an association with health issues and major losses.[5]
  • In DSM-IV, individuals having underlying dysthymic disorder who develop major depressive episodes are diagnosed as having both dysthymic disorder and major depressive disorder. So, DSM-IV has categorized dysthymic disorder and major depressive episodes as separate diagnoses instead of phases of a single disorder that fluctuates in severity over time.[6]
  • In spite of minor differences in the definitions of dysthymic disorder in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) and International Classification of Diseases Tenth Edition (ICD-l0), both the systems are competent to establish the diagnosis.[7]
  • Dysthymia and chronic major depression are both included under the new term 'persistent depressive disorder' in DSM-5.[8]
  • Since the introduction in DSM-III, the diagnostic validity of dysthymia is questioned. It is a heterogeneous diagnosis including various depressive and anxiety conditions. As persistent depressive disorder includes dysthymia as a component, the former is more likely to represent a heterogeneous domain diagnosis. It limits the identification of the preferred treatment options. [9]

Pathophysiology

Clinical Features

  • The main features of dysthymia are
  • Dysthymia as compared to major depression, tends to be less intense and persists for a longer duration.
  • Other than the variation in magnitude of severity, both these conditions exhibit similar symptomatology.
  • To diagnose major depressive disorder, the symptoms should be present for a minimum duration of 14 days (2 weeks) whereas, dysthymia symptoms should be present for at least 2 years.
  • The symptoms of dysthymia can grow into a full-blown episode of major depression. The intense episode often exists with the underlying feelings of low mood and this resulting condition is called "double depression"[15]
  • As compared to the general population, the people with dysthymia have a greater-than-average chance of developing major depression.
  • While major depressive disorder mostly occurs in episodes, dysthymia lasts for longer periods, is consistent, and sometimes begins in childhood. Therefore, persons with dysthymia tend to consider depression as a part of their character.
  • Dysthymia and major depression, both are inheritable.
  • Some individuals describe dysthymia as being under chronic stress.
  • When treating cases, it is often difficult to distinguish if these people are actually under unusually high environmental stress or if the dysthymia causes them to be more psychologically stressed in a standard environment.

Differential Diagnosis

The differential diagnosis of dysthymia includes the following: [16]

Epidemiology and Demographics

Prevalence

  • The 12-month prevalence of dysthymia is approximately 500 per 100,000 (0.5%) of the overall population.[17]

Age

  • Individuals of all age groups may develop dysthymia.
  • Based on the age of onset, the etiology of dysthymia varies.
  • The individuals with early onset dysthymia often have a history of physical or sexual abuse. They have also been found to have poor relationships with both the parents.[18]
  • Compared to adolescents, children display lesser variability in the symptoms of dysthymia.
  • 'Anhedonia' is a common characteristic in adolescents with dysthymia. [19]
  • In younger adults, dysthymia is related to the abnormalities of personality whereas, the elderly have a strong association with losses in life and other health-related issues. [20]

Gender

  • Dysthymia affects both men and women.
  • The prevalence of dysthymia is more in women compared to men.[21]
  • The symptomatic profile is similar in males and females of the adolescent population. While comparing the symptoms of dysthymia in both genders, no specific symptom predominance has been noticed. [22]
  • Gender differences have been noted in the elderly population.
  • In elderly men, dysthymia is more related to lower educational levels and in those receiving nursing home/ institutional care. No relation has been found based on occupation or marital status.[23]
  • As opposed to this, in elderly females, dysthymia is predominant in older individuals (70 years +), married, and in those with higher education levels. It is not related to marital status, occupation, or form of health care received. [24]

Race

  • Dysthymia has a higher lifetime prevalence in individuals of Mexican American and African American backgrounds. This can be explained by a number of factors dominating these populations: [25]
    • Lower education level
    • Poverty
    • Hesitancy in seeking help
    • Lesser utilization of mental health services
    • Failure to comply with treatment
    • Various cultural beliefs

Risk Factors

Common risk factors in the development of dysthymia are:[17][26]

Natural History, Complications, and Prognosis

Prognosis

Overall, dysthymia has a worse prognosis than major depressive disorder. [31]

Poor prognostic factors related to dysthymia are: [17][32]

Diagnostic Criteria

DSM-5 Diagnostic Criteria for Dysthymia

  • Persistent Depressive Disorder (Dysthymia) is diagnosed using DSM-5 Criteria.[17]
DSM-5 DIAGNOSTIC CRITERIA FOR DYSTHYMIA SPECIFIERS
The following criteria should be fulfilled-



A. For at least 2 years, depression for most of the day as observed by the individual himself/herself or others. Irritable mood lasting at least 1 year for adolescents and children.


B. With depressed mood, presence of two or more of-

1.Reduced appetite or overeating

2. Fatigue or less energy

3.Low self-esteem

4.Indecisiveness or low concentration

5.Hyper or insomnia

6.Hopelessness


C. The person has never been without the symptoms mentioned in Criteria A and B for greater than 2 months at a time.


D. Criteria for major depressive disorder may be present continuously for two years.


E. Criteria have never been met for Cyclothymia and there has never been a hypomanic or manic episode.


F. The condition can not be explained by schizophrenia, delusional disorder, schizoaffective disorder, or other schizophrenia spectrum disorder.


G. The symptomatology is not secondary to the effects of a substance or other medical condition.


H. Presence of clinically significant impairment in occupational, social, and other domains of functioning.

Specify if-

With anxious distress

With mixed features

With atypical features

With mood-incongruent psychotic features

With mood-congruent psychotic features

With melancholic features

With peripartum onset

Specify if-

In partial remission

In full remission

Specify if-

Early-onset (before 21 years)

Late-onset (at or after 21 years)

Specify if-

With pure dysthymic syndrome

With persistent major depressive episode

With intermittent major depressive episodes, with current episode

With intermittent major depressive episodes, without an ent episode

Specify if-

Mild

Moderate

Severe


Treatment

Medications

Selective Serotonin Reuptake Inhibitors (SSRI)

Side Effects of SSRI

Other medications

Psychotherapy

  • Evidence suggests the combination of pharmacotherapy and psychotherapy provides the greatest improvement in dysthymia. [42]
  • On the contrary, some studies point towards the inferiority of psychotherapy in treating dysthymia.[43]
  • There are different types of psychotherapies. The type of therapy chosen depends upon a number of factors like the nature of any stressful events, the availability of family and other social support, and personal preference.
  • Psychotherapy focuses mainly on education about the disease model, correcting the underlying cognitive distortions, and building up support.
  • Cognitive-behavioral therapy is designed to examine and help correct the faulty, self-critical thought patterns and correct the cognitive distortions that persons with mood disorders commonly experience.[44]
  • Psychodynamic, insight-oriented, or interpersonal psychotherapy (IPT) can find out the origin of the symptoms, address them appropriately, and explore the conflicts in important relationships which are further deteriorating the illness.[45]
  • IPT emphasizes resolving the conflict in current relationships that are exacerbating the depressive symptoms.[46]
  • Both CBT and IPT are effective for adolescents. Psychoeducation and psychosocial support provided to the parents of adolescents with dysthymia plays a very important role in the early and satisfactory response to these therapies.[47]
  • An adapted version for IPT is used for adolescents because they are in conflict with their parents as well as peers, limiting the outlet options for their emotional burden.[48]

References

  1. Brieger, Peter; Marneros, Andreas (1997). "Dysthymia and cyclothymia: historical origins and contemporary development". Journal of Affective Disorders. 45 (3): 117–126. doi:10.1016/S0165-0327(97)00053-0. ISSN 0165-0327.
  2. Freeman HL (1994). "Historical and nosological aspects of dysthymia". Acta Psychiatr Scand Suppl. 383: 7–11. doi:10.1111/j.1600-0447.1994.tb05877.x. PMID 7942068.
  3. Freeman, H. L. (1994). "Historical and nosological aspects of dysthymia". Acta Psychiatrica Scandinavica. 89 (s383): 7–11. doi:10.1111/j.1600-0447.1994.tb05877.x. ISSN 0001-690X.
  4. Freeman, H. L. (1994). "Historical and nosological aspects of dysthymia". Acta Psychiatrica Scandinavica. 89 (s383): 7–11. doi:10.1111/j.1600-0447.1994.tb05877.x. ISSN 0001-690X.
  5. 5.0 5.1 Klein DN, Santiago NJ (2003) Dysthymia and chronic depression: introduction, classification, risk factors, and course. J Clin Psychol 59 (8):807-16. DOI:10.1002/jclp.10174 PMID: 12858423
  6. Klein DN, Santiago NJ (2003) Dysthymia and chronic depression: introduction, classification, risk factors, and course. J Clin Psychol 59 (8):807-16. DOI:10.1002/jclp.10174 PMID: 12858423
  7. Lopez Ibor, J. J.; Frances, A.; Jones, C. (1994). "Dysthymic disorder: a comparison of DSM-IV and ICD-10 and issues in differential diagnosis". Acta Psychiatrica Scandinavica. 89 (s383): 12–18. doi:10.1111/j.1600-0447.1994.tb05878.x. ISSN 0001-690X.
  8. "StatPearls". 2020. PMID 31082096.
  9. Rhebergen D, Graham R (2014). "The re-labelling of dysthymic disorder to persistent depressive disorder in DSM-5: old wine in new bottles?". Curr Opin Psychiatry. 27 (1): 27–31. doi:10.1097/YCO.0000000000000022. PMID 24270481.
  10. Cao G, Harris KM (2012) Developmental regulation of the late phase of long-term potentiation (L-LTP) and metaplasticity in hippocampal area CA1 of the rat. J Neurophysiol 107 (3):902-12. DOI:10.1152/jn.00780.2011 PMID: 22114158
  11. Yoshimura R, Umene-Nakano W, Hoshuyama T, Ikenouchi-Sugita A, Hori H, Katsuki A; et al. (2010). "Plasma levels of brain-derived neurotrophic factor and interleukin-6 in patients with dysthymic disorder: comparison with age- and sex-matched major depressed patients and healthy controls". Hum Psychopharmacol. 25 (7–8): 566–9. doi:10.1002/hup.1155. PMID 21312291.
  12. Yoshimura R, Umene-Nakano W, Hoshuyama T, Ikenouchi-Sugita A, Hori H, Katsuki A; et al. (2010). "Plasma levels of brain-derived neurotrophic factor and interleukin-6 in patients with dysthymic disorder: comparison with age- and sex-matched major depressed patients and healthy controls". Hum Psychopharmacol. 25 (7–8): 566–9. doi:10.1002/hup.1155. PMID 21312291.
  13. Lopez Ibor, J. J.; Frances, A.; Jones, C. (1994). "Dysthymic disorder: a comparison of DSM-IV and ICD-10 and issues in differential diagnosis". Acta Psychiatrica Scandinavica. 89 (s383): 12–18. doi:10.1111/j.1600-0447.1994.tb05878.x. ISSN 0001-690X.
  14. Brunello, N.; Akiskal, H.; Boyer, P.; Gessa, G.L.; Howland, R.H.; Langer, S.Z.; Mendlewicz, J.; Paes de Souza, M.; Placidi, G.F.; Racagni, G.; Wessely, S. (1999). "Dysthymia: clinical picture, extent of overlap with chronic fatigue syndrome, neuropharmacological considerations, and new therapeutic vistas". Journal of Affective Disorders. 52 (1–3): 275–290. doi:10.1016/S0165-0327(98)00163-3. ISSN 0165-0327.
  15. Double Depression: Hopelessness Key Component Of Mood Disorder retrieved July 17, 2008,
  16. Lopez Ibor, J. J.; Frances, A.; Jones, C. (1994). "Dysthymic disorder: a comparison of DSM-IV and ICD-10 and issues in differential diagnosis". Acta Psychiatrica Scandinavica. 89 (s383): 12–18. doi:10.1111/j.1600-0447.1994.tb05878.x. ISSN 0001-690X.
  17. 17.0 17.1 17.2 17.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  18. Lizardi, Humberto; Klein, Daniel N.; Ouimette, Paige Crosby; Riso, Lawrence P.; Anderson, Rochelle L.; Donaldson, Shauna K. (1995). "Reports of the childhood home environment in early-onset dysthymia and episodic major depression". Journal of Abnormal Psychology. 104 (1): 132–139. doi:10.1037/0021-843X.104.1.132. ISSN 1939-1846.
  19. Masi, Gabriele; Favilla, Letizia; Mucci, Maria; Poli, Paola; Romano, Roberta (2001). "Depressive Symptoms in Children and Adolescents with Dysthymic Disorder". Psychopathology. 34 (1): 29–35. doi:10.1159/000049277. ISSN 0254-4962.
  20. Bellino, Silvio; Patria, Luca; Ziero, Simona; Rocca, Giuseppe; Bogetto, Filippo (2001). "Clinical features of dysthymia and age: a clinical investigation". Psychiatry Research. 103 (2–3): 219–228. doi:10.1016/S0165-1781(01)00274-8. ISSN 0165-1781.
  21. Beekman, A.T.F.; Deeg, D.J.H.; Smit, J.H.; Comijs, H.C.; Braam, A.W.; de Beurs, E.; van Tilburg, W. (2004). "Dysthymia in later life: a study in the community". Journal of Affective Disorders. 81 (3): 191–199. doi:10.1016/S0165-0327(03)00138-1. ISSN 0165-0327.
  22. Masi, Gabriele; Favilla, Letizia; Mucci, Maria; Poli, Paola; Romano, Roberta (2001). "Depressive Symptoms in Children and Adolescents with Dysthymic Disorder". Psychopathology. 34 (1): 29–35. doi:10.1159/000049277. ISSN 0254-4962.
  23. Kivelä, Sirkka-Liisa; Pahkala, Kimmo (1989). "Dysthymic disorder in the aged in the community". Social Psychiatry and Psychiatric Epidemiology. 24 (2): 77–83. doi:10.1007/BF01788630. ISSN 0933-7954.
  24. Kivelä, Sirkka-Liisa; Pahkala, Kimmo (1989). "Dysthymic disorder in the aged in the community". Social Psychiatry and Psychiatric Epidemiology. 24 (2): 77–83. doi:10.1007/BF01788630. ISSN 0933-7954.
  25. Riolo SA, Nguyen TA, Greden JF, King CA (2005). [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15914823 "Prevalence of depression by race/ethnicity: findings from the National Health and Nutrition Examination Survey III"] Check |url= value (help). Am J Public Health. 95 (6): 998–1000. doi:10.2105/AJPH.2004.047225. PMC 1449298. PMID 15914823. line feed character in |url= at position 54 (help)
  26. Hölzel, Lars; Härter, Martin; Reese, Christina; Kriston, Levente (2011). "Risk factors for chronic depression — A systematic review". Journal of Affective Disorders. 129 (1–3): 1–13. doi:10.1016/j.jad.2010.03.025. ISSN 0165-0327.
  27. Keller, M. B. (1994). "Course, outcome and impact on the community". Acta Psychiatrica Scandinavica. 89 (s383): 24–34. doi:10.1111/j.1600-0447.1994.tb05880.x. ISSN 0001-690X.
  28. Keller, M. B. (1994). "Course, outcome and impact on the community". Acta Psychiatrica Scandinavica. 89 (s383): 24–34. doi:10.1111/j.1600-0447.1994.tb05880.x. ISSN 0001-690X.
  29. Keller, M. B. (1994). "Course, outcome and impact on the community". Acta Psychiatrica Scandinavica. 89 (s383): 24–34. doi:10.1111/j.1600-0447.1994.tb05880.x. ISSN 0001-690X.
  30. Gureje, Oye (2011). "Dysthymia in a cross-cultural perspective". Current Opinion in Psychiatry. 24 (1): 67–71. doi:10.1097/YCO.0b013e32834136a5. ISSN 0951-7367.
  31. Gureje, Oye (2011). "Dysthymia in a cross-cultural perspective". Current Opinion in Psychiatry. 24 (1): 67–71. doi:10.1097/YCO.0b013e32834136a5. ISSN 0951-7367.
  32. Beekman, A.T.F.; Deeg, D.J.H.; Smit, J.H.; Comijs, H.C.; Braam, A.W.; de Beurs, E.; van Tilburg, W. (2004). "Dysthymia in later life: a study in the community". Journal of Affective Disorders. 81 (3): 191–199. doi:10.1016/S0165-0327(03)00138-1. ISSN 0165-0327.
  33. Sangkuhl, Katrin; Klein, Teri E.; Altman, Russ B. (2009). "Selective serotonin reuptake inhibitors pathway". Pharmacogenetics and Genomics. 19 (11): 907–909. doi:10.1097/FPC.0b013e32833132cb. ISSN 1744-6872.
  34. Sangkuhl, Katrin; Klein, Teri E.; Altman, Russ B. (2009). "Selective serotonin reuptake inhibitors pathway". Pharmacogenetics and Genomics. 19 (11): 907–909. doi:10.1097/FPC.0b013e32833132cb. ISSN 1744-6872.
  35. National Institute of Mental Health
  36. Ferguson, James M. (2001). "SSRI Antidepressant Medications". The Primary Care Companion to The Journal of Clinical Psychiatry. 03 (01): 22–27. doi:10.4088/PCC.v03n0105. ISSN 1523-5998.
  37. Ferguson, James M. (2001). "SSRI Antidepressant Medications". The Primary Care Companion to The Journal of Clinical Psychiatry. 03 (01): 22–27. doi:10.4088/PCC.v03n0105. ISSN 1523-5998.
  38. Stahl, Stephen M. (1998). "Mechanism of action of serotonin selective reuptake inhibitors". Journal of Affective Disorders. 51 (3): 215–235. doi:10.1016/S0165-0327(98)00221-3. ISSN 0165-0327.
  39. Malik, A.; Junglee, N. (2015). "A Case of the Serotonin Syndrome Secondary to Phenelzine Monotherapy at Therapeutic Dosing". Case Reports in Medicine. 2015: 1–4. doi:10.1155/2015/931963. ISSN 1687-9627.
  40. Keltner, Norm (2009). "Serotonin Syndrome: A Case of Fatal SSRI/MAOI Interaction". Perspectives in Psychiatric Care. 30 (4): 26–31. doi:10.1111/j.1744-6163.1994.tb00446.x. ISSN 0031-5990.
  41. Gury C, Cousin F (1999). "[Pharmacokinetics of SSRI antidepressants: half-life and clinical applicability]". Encephale. 25 (5): 470–6. PMID 10598311.
  42. Browne, Gina; Steiner, Meir; Roberts, Jacqueline; Gafni, Amiram; Byrne, Carolyn; Dunn, Edward; Bell, Barbara; Mills, Michael; Chalklin, Lori; Wallik, David; Kraemer, James (2002). "Sertraline and/or interpersonal psychotherapy for patients with dysthymic disorder in primary care: 6-month comparison with longitudinal 2-year follow-up of effectiveness and costs". Journal of Affective Disorders. 68 (2–3): 317–330. doi:10.1016/S0165-0327(01)00343-3. ISSN 0165-0327.
  43. Cuijpers, Pim; van Straten, Annemieke; Schuurmans, Josien; van Oppen, Patricia; Hollon, Steven D.; Andersson, Gerhard (2010). "Psychotherapy for chronic major depression and dysthymia: A meta-analysis". Clinical Psychology Review. 30 (1): 51–62. doi:10.1016/j.cpr.2009.09.003. ISSN 0272-7358.
  44. Cuijpers, Pim; van Straten, Annemieke; Schuurmans, Josien; van Oppen, Patricia; Hollon, Steven D.; Andersson, Gerhard (2010). "Psychotherapy for chronic major depression and dysthymia: A meta-analysis". Clinical Psychology Review. 30 (1): 51–62. doi:10.1016/j.cpr.2009.09.003. ISSN 0272-7358.
  45. Schramm, Elisabeth; Zobel, Ingo; Dykierek, Petra; Kech, Sabine; Brakemeier, Eva-Lotta; Külz, Anne; Berger, Mathias (2011). "Cognitive behavioral analysis system of psychotherapy versus interpersonal psychotherapy for early-onset chronic depression: A randomized pilot study". Journal of Affective Disorders. 129 (1–3): 109–116. doi:10.1016/j.jad.2010.08.003. ISSN 0165-0327.
  46. "Psychotherapy of dysthymia". American Journal of Psychiatry. 151 (8): 1114–1121. 1994. doi:10.1176/ajp.151.8.1114. ISSN 0002-953X.
  47. Nobile, Maria; Cataldo, Giulia M; Marino, Cecilia; Molteni, Massimo (2003). "Diagnosis and Treatment of Dysthymia in Children and Adolescents". CNS Drugs. 17 (13): 927–946. doi:10.2165/00023210-200317130-00001. ISSN 1172-7047.
  48. Mufson, Laura; Fairbanks, Janet (1996). "Interpersonal Psychotherapy for Depressed Adolescents: A One-Year Naturalistic Follow-up Study". Journal of the American Academy of Child & Adolescent Psychiatry. 35 (9): 1145–1155. doi:10.1097/00004583-199609000-00012. ISSN 0890-8567.

Mental and behavioral disorders