Positive psychotic symptoms as a marker of clinical severity in a transdiagnostic sample of help-seeking adolescents.
Adolescence
Dimensional
Psychosis
Transdiagnostic
Youth
Journal
European child & adolescent psychiatry
ISSN: 1435-165X
Titre abrégé: Eur Child Adolesc Psychiatry
Pays: Germany
ID NLM: 9212296
Informations de publication
Date de publication:
30 Mar 2024
30 Mar 2024
Historique:
received:
18
08
2023
accepted:
10
03
2024
medline:
30
3
2024
pubmed:
30
3
2024
entrez:
30
3
2024
Statut:
aheadofprint
Résumé
The present study aimed to examine the association between the presence, number, and type of positive psychotic symptoms (PPS) and clinical severity in adolescent patients. Five hundred-six patients aged 11-17 years were assigned to either the noPPS (n = 341), the delusional beliefs only (del; n = 32), the hallucinations only (hall; n = 80), or the delusional beliefs and hallucinations (del&hall; n = 53) group. Generalized Structural Equation Modeling was applied to identify the best-fitting model representing clinical severity indicated by psychiatric diagnoses, depressivity, personality pathology, non-suicidal self-injury, suicide attempts, perceived stress, and psychosocial impairments, assessed by interviews and questionnaires. The groups were compared concerning the final model's factors. The final model consisted of three factors representing psychopathology and functional impairments, self-harming behavior, and perceived stress (BIC difference to reference model: 103.99). Participants with any PPS scored higher on all factors than the noPPS group (differences in SD: 0.49-1.48). Additionally, the del&hall group scored 1.31 SD higher on psychopathology and functional impairments than the hall group, and 1.16 SD higher on self-harming behavior compared to the del group. Finally, the hall group scored 0.84 SD higher on self-harming behavior than the del group, with no group differences in the other factors. In adolescent patients, the presence of PPS may represent a marker for a more severe form of mental disorder, with hallucinations being indicative of self-harming behavior. Early transdiagnostic assessment of PPS seems indicated as it may inform treatment in the context of clinical staging.
Identifiants
pubmed: 38553647
doi: 10.1007/s00787-024-02417-7
pii: 10.1007/s00787-024-02417-7
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
© 2024. The Author(s).
Références
Johns LC, Kompus K, Connell M et al (2014) Auditory verbal hallucinations in persons With and without a need for care. Schizophr Bull 40:S255–S264. https://doi.org/10.1093/schbul/sbu005
doi: 10.1093/schbul/sbu005
pubmed: 24936085
pmcid: 4141313
Moseley P, Powell A, Woods A et al (2022) Voice-hearing across the continuum: a phenomenology of spiritual voices. Schizophr Bull 48:1066–1074. https://doi.org/10.1093/schbul/sbac054
doi: 10.1093/schbul/sbac054
pubmed: 35733238
pmcid: 9434432
Stip E, Letourneau G (2009) Psychotic symptoms as a continuum between normality and pathology. Can J Psychiatry 54:140–151. https://doi.org/10.1177/070674370905400302
doi: 10.1177/070674370905400302
pubmed: 19321018
Verdoux H, van Os J (2002) Psychotic symptoms in non-clinical populations and the continuum of psychosis. Schizophr Res 54:59–65. https://doi.org/10.1016/S0920-9964(01)00352-8
doi: 10.1016/S0920-9964(01)00352-8
pubmed: 11853979
Kelleher I, Connor D, Clarke MC et al (2012) Prevalence of psychotic symptoms in childhood and adolescence: a systematic review and meta-analysis of population-based studies. Psychol Med 42:1857–1863. https://doi.org/10.1017/S0033291711002960
doi: 10.1017/S0033291711002960
pubmed: 22225730
Kelleher I, Keeley H, Corcoran P et al (2012) Clinicopathological significance of psychotic experiences in non-psychotic young people: evidence from four population-based studies. Br J Psychiatry 201:26–32. https://doi.org/10.1192/bjp.bp.111.101543
doi: 10.1192/bjp.bp.111.101543
pubmed: 22500011
Linscott RJ, van Os J (2013) An updated and conservative systematic review and meta-analysis of epidemiological evidence on psychotic experiences in children and adults: on the pathway from proneness to persistence to dimensional expression across mental disorders. Psychol Med 43:1133–1149. https://doi.org/10.1017/S0033291712001626
doi: 10.1017/S0033291712001626
pubmed: 22850401
Rubio JM, Sanjuán J, Flórez-Salamanca L, Cuesta MJ (2012) Examining the course of hallucinatory experiences in children and adolescents: a systematic review. Schizophr Res 138:248–254. https://doi.org/10.1016/j.schres.2012.03.012
doi: 10.1016/j.schres.2012.03.012
pubmed: 22464200
Staines L, Healy C, Murphy F et al (2023) Incidence and persistence of psychotic experiences in the general population: systematic review and meta-analysis. Schizophr Bull 49:1007–1021. https://doi.org/10.1093/schbul/sbad056
doi: 10.1093/schbul/sbad056
pubmed: 37402250
pmcid: 10318880
Healy C, Brannigan R, Dooley N et al (2019) Childhood and adolescent psychotic experiences and risk of mental disorder: a systematic review and meta-analysis. Psychol Med 49:1589–1599. https://doi.org/10.1017/S0033291719000485
doi: 10.1017/S0033291719000485
pubmed: 31088578
Healy C, Coughlan H, Clarke M et al (2020) What mediates the longitudinal relationship between psychotic experiences and psychopathology? J Abnorm Psychol 129:505–516. https://doi.org/10.1037/abn0000523
doi: 10.1037/abn0000523
pubmed: 32309957
McGrath JJ, Saha S, Al-Hamzawi A et al (2016) The bidirectional associations between psychotic experiences and DSM-IV mental disorders. Am J Psychiatry 173:997–1006. https://doi.org/10.1176/appi.ajp.2016.15101293
doi: 10.1176/appi.ajp.2016.15101293
pubmed: 26988628
pmcid: 5175400
Barragan M, Laurens KR, Navarro JB, Obiols JE (2011) Psychotic-like experiences and depressive symptoms in a community sample of adolescents. Eur Psychiatry 26:396–401. https://doi.org/10.1016/j.eurpsy.2010.12.007
doi: 10.1016/j.eurpsy.2010.12.007
pubmed: 21334860
Núñez D, Monjes P, Campos S, Wigman JTW (2021) Evidence for specific associations between depressive symptoms, psychotic experiences, and suicidal ideation in chilean adolescents from the general population. Front Psychiatry 11:552343. https://doi.org/10.3389/fpsyt.2020.552343
doi: 10.3389/fpsyt.2020.552343
pubmed: 33584356
pmcid: 7876080
Peters EM, Yates K, DeVylder J et al (2022) Understanding the inverse relationship between age and psychotic symptoms: the role of borderline personality traits. Acta Psychiatr Scand 146:484–491. https://doi.org/10.1111/acps.13475
doi: 10.1111/acps.13475
pubmed: 35821578
Turley D, Drake R, Killackey E, Yung AR (2019) Perceived stress and psychosis: the effect of perceived stress on psychotic-like experiences in a community sample of adolescents. Early Interv Psychiatry 13:1465–1469. https://doi.org/10.1111/eip.12795
doi: 10.1111/eip.12795
pubmed: 30712294
Carey E, Gillan D, Healy C et al (2021) Early adult mental health, functional and neuropsychological outcomes of young people who have reported psychotic experiences: a 10-year longitudinal study. Psychol Med 51:1861–1869. https://doi.org/10.1017/S0033291720000616
doi: 10.1017/S0033291720000616
pubmed: 32216843
Healy C, Campbell D, Coughlan H et al (2018) Childhood psychotic experiences are associated with poorer global functioning throughout adolescence and into early adulthood. Acta Psychiatr Scand 138:26–34. https://doi.org/10.1111/acps.12907
doi: 10.1111/acps.12907
pubmed: 29855047
Kelleher I, Wigman JTW, Harley M et al (2015) Psychotic experiences in the population: association with functioning and mental distress. Schizophr Res 165:9–14. https://doi.org/10.1016/j.schres.2015.03.020
doi: 10.1016/j.schres.2015.03.020
pubmed: 25868930
Bromet EJ, Nock MK, Saha S et al (2017) Association between psychotic experiences and subsequent suicidal thoughts and behaviors: A cross-national analysis from the world health organization world mental health surveys. JAMA Psychiat 74:1136. https://doi.org/10.1001/jamapsychiatry.2017.2647
doi: 10.1001/jamapsychiatry.2017.2647
Hielscher E, Connell M, Lawrence D et al (2019) Association between psychotic experiences and non-accidental self-injury: results from a nationally representative survey of adolescents. Soc Psychiatry Psychiatr Epidemiol 54:321–330. https://doi.org/10.1007/s00127-018-1629-4
doi: 10.1007/s00127-018-1629-4
pubmed: 30478528
Hielscher E, DeVylder J, Hasking P et al (2021) Mediators of the association between psychotic experiences and future non-suicidal self-injury and suicide attempts: results from a three-wave, prospective adolescent cohort study. Eur Child Adolesc Psychiatry 30:1351–1365. https://doi.org/10.1007/s00787-020-01593-6
doi: 10.1007/s00787-020-01593-6
pubmed: 32712716
Kelleher I, Ramsay H, DeVylder J (2017) Psychotic experiences and suicide attempt risk in common mental disorders and borderline personality disorder. Acta Psychiatr Scand 135:212–218. https://doi.org/10.1111/acps.12693
doi: 10.1111/acps.12693
pubmed: 28185269
Steenkamp LR, De Neve-Enthoven NGM, João AM et al (2023) Psychotic experiences, suicidality and non-suicidal self-injury in adolescents: independent findings from two cohorts. Schizophr Res 257:50–57. https://doi.org/10.1016/j.schres.2023.05.006
doi: 10.1016/j.schres.2023.05.006
pubmed: 37285715
Honings S, Drukker M, Groen R, van Os J (2016) Psychotic experiences and risk of self-injurious behaviour in the general population: a systematic review and meta-analysis. Psychol Med 46:237–251. https://doi.org/10.1017/S0033291715001841
doi: 10.1017/S0033291715001841
pubmed: 26419206
Yates K, Lång U, Cederlöf M et al (2019) Association of psychotic experiences with subsequent risk of suicidal ideation, suicide attempts, and suicide deaths: a systematic review and meta-analysis of longitudinal population studies. JAMA Psychiat 76:180. https://doi.org/10.1001/jamapsychiatry.2018.3514
doi: 10.1001/jamapsychiatry.2018.3514
Sharifi V, Eaton WW, Wu LT et al (2015) Psychotic experiences and risk of death in the general population: 24–27 year follow-up of the epidemiologic catchment area study. Br J Psychiatry 207:30–36. https://doi.org/10.1192/bjp.bp.113.143198
doi: 10.1192/bjp.bp.113.143198
pubmed: 25953893
pmcid: 4486819
Capra C, Kavanagh DJ, Hides L, Scott JG (2015) Subtypes of psychotic-like experiences are differentially associated with suicidal ideation, plans and attempts in young adults. Psychiatry Res 228:894–898. https://doi.org/10.1016/j.psychres.2015.05.002
doi: 10.1016/j.psychres.2015.05.002
pubmed: 26050011
van Os J, Reininghaus U (2016) Psychosis as a transdiagnostic and extended phenotype in the general population. World Psychiatry 15:118–124. https://doi.org/10.1002/wps.20310
doi: 10.1002/wps.20310
pubmed: 27265696
pmcid: 4911787
Wigman JTW, van Nierop M, Vollebergh WAM et al (2012) Evidence that psychotic symptoms are prevalent in disorders of anxiety and depression, impacting on illness onset, risk, and severity-implications for diagnosis and ultra-high risk research. Schizophr Bull 38:247–257. https://doi.org/10.1093/schbul/sbr196
doi: 10.1093/schbul/sbr196
pubmed: 22258882
pmcid: 3283146
Schultze-Lutter F, Renner F, Paruch J et al (2014) Self-reported psychotic-like experiences are a poor estimate of clinician-rated attenuated and frank delusions and hallucinations. Psychopathology 47:194–201. https://doi.org/10.1159/000355554
doi: 10.1159/000355554
pubmed: 24192655
Shah JL, Scott J, McGorry PD et al (2020) Transdiagnostic clinical staging in youth mental health: a first international consensus statement. World Psychiatry 19:233–242. https://doi.org/10.1002/wps.20745
doi: 10.1002/wps.20745
pubmed: 32394576
pmcid: 7215079
Sheehan DV, Sheehan KH, Shytle RD et al (2010) Reliability and validity of the mini international neuropsychiatric interview for children and adolescents (MINI-KID). J Clin Psychiatry 71:313–326. https://doi.org/10.4088/JCP.09m05305whi
doi: 10.4088/JCP.09m05305whi
pubmed: 20331933
Chanen AM, Jovev M, Djaja D et al (2008) Screening for borderline personality disorder in outpatient youth. J Personal Disord 22:353–364. https://doi.org/10.1521/pedi.2008.22.4.353
doi: 10.1521/pedi.2008.22.4.353
First MB, Gibbon M (2004) The structured clinical interview for DSM-IV Axis I disorders (SCID-I) and the structured clinical interview for DSM-IV Axis II disorders (SCID-II). Comprehensive handbook of psychological assessment, Vol 2: personality assessment. John Wiley & Sons Inc., Hoboken, NJ, US, pp 134–143
Hutsebaut J, Berghuis H, De Saeger H, et al (2014) Semi-Structured Interview for Personality Functioning DSM-5 (STiP 5.1). Podium DSM-5 Res Group Neth Cent Expert Personal Disord Utrecht Neth Trimbos Inst 15 198 207
Association AP, Association AP (2013) Diagnostic and statistical manual of mental disorders: DSM-5, 5th edn. American Psychiatric Association, Washington, D.C.
doi: 10.1176/appi.books.9780890425596
Bender DS, Morey LC, Skodol AE (2011) Toward a model for assessing level of personality functioning in DSM–5, part I: a review of theory and methods. J Pers Assess 93:332–346. https://doi.org/10.1080/00223891.2011.583808
doi: 10.1080/00223891.2011.583808
pubmed: 22804672
Poznanski EO, Mokros HB (1996) Children’s depression rating scale, revised (CDRS-R). West Psychol Serv Los Angel
Goldman HH, Skodol AE, Lave TR (1992) Revising axis V for DSM-IV: a review of measures of social functioning. Am J Psychiatry 149:9
Shaffer D (1983) A children’s global assessment scale (CGAS). Arch Gen Psychiatry 40:1228. https://doi.org/10.1001/archpsyc.1983.01790100074010
doi: 10.1001/archpsyc.1983.01790100074010
pubmed: 6639293
Cohen S, Kamarck T, Mermelstein R (1983) A global measure of perceived stress. J Health Soc Behav 24:385. https://doi.org/10.2307/2136404
doi: 10.2307/2136404
pubmed: 6668417
Fischer G, Ameis N, Parzer P et al (2014) The German version of the self-injurious thoughts and behaviors interview (SITBI-G): a tool to assess non-suicidal self-injury and suicidal behavior disorder. BMC Psychiatry 14:265. https://doi.org/10.1186/s12888-014-0265-0
doi: 10.1186/s12888-014-0265-0
pubmed: 25230931
pmcid: 4174267
Boomsma A (2000) Reporting analyses of covariance structures. Struct Equ Model Multidiscip J 7:461–483. https://doi.org/10.1207/S15328007SEM0703_6
doi: 10.1207/S15328007SEM0703_6
Muthén B (1984) A general structural equation model with dichotomous, ordered categorical, and continuous latent variable indicators. Psychometrika 49:115–132. https://doi.org/10.1007/BF02294210
doi: 10.1007/BF02294210
Draak THP, De Greef BTA, Faber CG et al (2019) The minimum clinically important difference: which direction to take. Eur J Neurol 26:850–855. https://doi.org/10.1111/ene.13941
doi: 10.1111/ene.13941
pubmed: 30793428
pmcid: 6593833
Norman GR, Sloan JA, Wyrwich KW (2003) Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care 41:582–592. https://doi.org/10.1097/01.MLR.0000062554.74615.4C
doi: 10.1097/01.MLR.0000062554.74615.4C
pubmed: 12719681
StataCorp (2021) Stata Statistical Software: Release 17. StataCorp LLC, College Station, TX
Muthén LK, Muthén B (2017) Mplus user’s guide: Statistical analysis with latent variables, User’s guide (Version 8). Muthén & Muthén, Los Angeles, CA
Hu L, Bentler PM (1999) Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model Multidiscip J 6:1–55. https://doi.org/10.1080/10705519909540118
doi: 10.1080/10705519909540118
Hu L, Bentler PM (1998) Fit indices in covariance structure modeling: sensitivity to underparameterized model misspecification. Psychol Methods 3:424–453. https://doi.org/10.1037/1082-989X.3.4.424
doi: 10.1037/1082-989X.3.4.424
Neath AA, Cavanaugh JE (2012) The bayesian information criterion: background, derivation, and applications. WIREs Comput Stat 4:199–203. https://doi.org/10.1002/wics.199
doi: 10.1002/wics.199
Raftery AE (1995) Bayesian model selection in social research. Sociol Methodol 25:111. https://doi.org/10.2307/271063
doi: 10.2307/271063
Caspi A, Moffitt TE (2018) All for one and one for all: mental disorders in one dimension. Am J Psychiatry 175:831–844. https://doi.org/10.1176/appi.ajp.2018.17121383
doi: 10.1176/appi.ajp.2018.17121383
pubmed: 29621902
pmcid: 6120790
Haltigan JD, Aitken M, Skilling T et al (2018) “P” and “DP:” examining symptom-level bifactor models of psychopathology and dysregulation in clinically referred children and adolescents. J Am Acad Child Adolesc Psychiatry 57:384–396. https://doi.org/10.1016/j.jaac.2018.03.010
doi: 10.1016/j.jaac.2018.03.010
pubmed: 29859554
Murray AL, Eisner M, Ribeaud D (2016) The development of the general factor of psychopathology ‘p factor’ through childhood and adolescence. J Abnorm Child Psychol 44:1573–1586. https://doi.org/10.1007/s10802-016-0132-1
doi: 10.1007/s10802-016-0132-1
pubmed: 26846993
Ronald A (2019) Editorial: The psychopathology p factor: will it revolutionise the science and practice of child and adolescent psychiatry? J Child Psychol Psychiatry 60:497–499. https://doi.org/10.1111/jcpp.13063
doi: 10.1111/jcpp.13063
pubmed: 30968422
Shields AN, Giljen M, España RA, Tackett JL (2021) The p factor and dimensional structural models of youth personality pathology and psychopathology. Curr Opin Psychol 37:21–25. https://doi.org/10.1016/j.copsyc.2020.06.005
doi: 10.1016/j.copsyc.2020.06.005
pubmed: 32682314
Kaess M (2022) Self-harm: a transdiagnostic marker of psychopathology and suicide risk during the COVID-19 pandemic? Eur Child Adolesc Psychiatry 31:1–3. https://doi.org/10.1007/s00787-022-02044-0
doi: 10.1007/s00787-022-02044-0
pubmed: 35819728
pmcid: 9343285
Maciejewski DF, Creemers HE, Lynskey MT et al (2014) Overlapping genetic and environmental influences on nonsuicidal self-injury and suicidal ideation: different outcomes, same etiology? JAMA Psychiat 71:699. https://doi.org/10.1001/jamapsychiatry.2014.89
doi: 10.1001/jamapsychiatry.2014.89
Bowling A (2005) Mode of questionnaire administration can have serious effects on data quality. J Public Health 27:281–291. https://doi.org/10.1093/pubmed/fdi031
doi: 10.1093/pubmed/fdi031
Nuevo R, Van Os J, Arango C et al (2013) Evidence for the early clinical relevance of hallucinatory-delusional states in the general population: hallucinatory-delusional states. Acta Psychiatr Scand 127:482–493. https://doi.org/10.1111/acps.12010
doi: 10.1111/acps.12010
pubmed: 22943634
Smeets F, Lataster T, van Winkel R et al (2013) Testing the hypothesis that psychotic illness begins when subthreshold hallucinations combine with delusional ideation: hallucinations, delusions and psychosis vulnerability. Acta Psychiatr Scand 127:34–47. https://doi.org/10.1111/j.1600-0447.2012.01888.x
doi: 10.1111/j.1600-0447.2012.01888.x
pubmed: 22676336
Smeets F, Lataster T, Viechtbauer W, Delespaul P (2015) Evidence that environmental and genetic risks for psychotic disorder may operate by impacting on connections between core symptoms of perceptual alteration and delusional ideation. Schizophr Bull 41:687–697. https://doi.org/10.1093/schbul/sbu122
doi: 10.1093/schbul/sbu122
pubmed: 25217481
Hielscher E, DeVylder J, Hasking P et al (2021) Can’t get you out of my head: persistence and remission of psychotic experiences in adolescents and its association with self-injury and suicide attempts. Schizophr Res 229:63–72. https://doi.org/10.1016/j.schres.2020.11.019
doi: 10.1016/j.schres.2020.11.019
pubmed: 33248885
Rogers P, Watt A, Gray NS et al (2002) Content of command hallucinations predicts self-harm but not violence in a medium secure unit. J Forensic Psychiatry 13:251–262. https://doi.org/10.1080/09585180210150096
doi: 10.1080/09585180210150096
de Boer JN, Corona Hernández H, Gerritse F et al (2022) Negative content in auditory verbal hallucinations: a natural language processing approach. Cognit Neuropsychiatry 27:139–149. https://doi.org/10.1080/13546805.2021.1941831
doi: 10.1080/13546805.2021.1941831
DeVylder J, Yamasaki S, Ando S et al (2023) Attributes of auditory hallucinations that are associated with self-harm: a prospective cohort study. Schizophr Res 251:30–36. https://doi.org/10.1016/j.schres.2022.12.008
doi: 10.1016/j.schres.2022.12.008
pubmed: 36529105
Shawyer F, Mackinnon A, Farhall J et al (2003) Command hallucinations and violence: implications for detention and treatment. Psychiatry Psychol Law 10:97–107. https://doi.org/10.1375/pplt.2003.10.1.97
doi: 10.1375/pplt.2003.10.1.97
World Health Organization (2024) Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders. World Health Organization, Geneva
Tyrer P (2022) Debate: young people with personality disorder should be recognised and appropriately managed. Child Adolesc Ment Health. https://doi.org/10.1111/camh.12551
doi: 10.1111/camh.12551
pubmed: 35842921
Ring D, Lawn S (2019) Stigma perpetuation at the interface of mental health care: a review to compare patient and clinician perspectives of stigma and borderline personality disorder. J Ment Health. https://doi.org/10.1080/09638237.2019.1581337
doi: 10.1080/09638237.2019.1581337
pubmed: 30862201
Cavelti M, Sharp C, Chanen AM, Kaess M (2023) Commentary: commentary on the twitter comments evoked by the may 2022 debate on diagnosing personality disorders in adolescents. Child Adolesc Ment Health 28:186–191. https://doi.org/10.1111/camh.12618
doi: 10.1111/camh.12618
pubmed: 36478638
Chanen AM, Nicol K, Nicol K et al (2020) Diagnosis and treatment of borderline personality disorder in young people. Curr Psychiatry Rep 22:1–8. https://doi.org/10.1007/s11920-020-01144-5
doi: 10.1007/s11920-020-01144-5
Chanen AM, Sharp C, Hoffman P, Alliance G, for Prevention and Early Intervention for Borderline Personality Disorder, (2017) Prevention and early intervention for borderline personality disorder: a novel public health priority. World Psychiatry 16:215–216. https://doi.org/10.1002/wps.20429
doi: 10.1002/wps.20429
pubmed: 28498598
pmcid: 5428197
Winsper C, Lereya ST, Marwaha S et al (2016) The aetiological and psychopathological validity of borderline personality disorder in youth: a systematic review and meta-analysis. Clin Psychol Rev 44:13–24. https://doi.org/10.1016/j.cpr.2015.12.001
doi: 10.1016/j.cpr.2015.12.001
pubmed: 26709502
Burnham KP, Anderson DR (2004) Multimodel inference: understanding AIC and BIC in model selection. Sociol Methods Res 33:261–304. https://doi.org/10.1177/0049124104268644
doi: 10.1177/0049124104268644
Shah JL, Jones N, van Os J et al (2022) Early intervention service systems for youth mental health: integrating pluripotentiality, clinical staging, and transdiagnostic lessons from early psychosis. Lancet Psychiatry 9:413–422. https://doi.org/10.1016/S2215-0366(21)00467-3
doi: 10.1016/S2215-0366(21)00467-3
pubmed: 35430004