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Archives of Women's Mental Health

, Volume 22, Issue 1, pp 105–114 | Cite as

Postpartum depression and social support in a racially and ethnically diverse population of women

  • Christine Pao
  • Jerry GuintivanoEmail author
  • Hudson Santos
  • Samantha Meltzer-Brody
Original Article

Abstract

Lack of social support is an important risk factor for postpartum depression (PPD), whereas the presence of social support can buffer against PPD. However, the relationship between social support and PPD in racial/ethnic minority women is still largely unknown. Our purpose was to examine the role of social support in a large, diverse population of PPD cases and controls. Participants (N = 1517) were recruited at the routine 6-week postpartum visit (± 1–2 weeks) from four different outpatient clinics in North Carolina. Case status was determined using the MINI International Neuropsychiatric Interview. Social support was measured using the Medical Outcomes Social (MOS) Support survey and the Baby’s Father Support Scale (DAD). We found that higher levels of social support had a strong protective association against PPD (MOS total score OR, 0.23; 95% CI, 0.19–0.27; p = 6.92E-90; DAD total score OR, 0.89; 95% CI, 0.88–0.92; p = 1.69E-29), and the effects of social support did not differ when accounting for race/ethnicity. Additionally, PPD symptom severity is significantly and negatively correlated with the degree of social support. Our findings suggest that multi-dimensional aspects of social support may be protective for racial/ethnic minority women. We believe this study is currently the largest and most robust characterizing PPD case status and its association with social support in a diverse cohort of mothers. Future work is required to understand how best to implement culturally sensitive interventions to increase social support in minority perinatal women.

Keywords

Postpartum depression Social support Paternal support Race Ethnicity 

Notes

Funding information

This work was supported by the National Institutes of Mental Health (S.M.B. grant no. 5R01MH095992-04) (J.G. grant no. 4T32MH093315-05).

Compliance with ethical standards

Conflict of interest

Author S.M.B. has received research support from Sage Therapeutics and Janssen. The other authors declare that they have no conflict of interest.

Supplementary material

737_2018_882_MOESM1_ESM.docx (23 kb)
ESM 1 (DOCX 23 kb)

References

  1. Almeida LM, Costa-Santos C, Caldas JP, Dias S, Ayres-de-Campos D (2016) The impact of migration on women’s mental health in the postpartum period. Rev Saude Publica 50.  https://doi.org/10.1590/S1518-8787.2016050005617
  2. Bandyopadhyay M, Small R, Watson LF, Brown S (2010) Life with a new baby: how do immigrant and Australian-born women's experiences compare? Aust N Z J Public Health 34:412–421.  https://doi.org/10.1111/j.1753-6405.2010.00575.x CrossRefPubMedGoogle Scholar
  3. Baumel A, Schueller SM (2016) Adjusting an available online peer support platform in a program to supplement the treatment of perinatal depression and anxiety. JMIR Ment Health 3:e11.  https://doi.org/10.2196/mental.5335 CrossRefPubMedPubMedCentralGoogle Scholar
  4. Bécares L, Atatoa-Carr P (2016) The association between maternal and partner experienced racial discrimination and prenatal perceived stress, prenatal and postnatal depression: findings from the growing up in New Zealand cohort study. Int J Equity Health 15:1–12.  https://doi.org/10.1186/s12939-016-0443-4 CrossRefGoogle Scholar
  5. Beck CT (1998) The effects of postpartum depression on child development: a meta-analysis. Arch Psychiatr Nurs 12:12–20CrossRefGoogle Scholar
  6. Beck CT (2001) Predictors of postpartum depression: an update. Nurs Res 50:275–285CrossRefGoogle Scholar
  7. Beck CT (2006) Acculturation: implications for perinatal research. MCN Am J Matern Child Nurs 31:114–120CrossRefGoogle Scholar
  8. Boury JM, Larkin KT, Krummel DA (2004) Factors related to postpartum depressive symptoms in low-income women. Women Health 39:19–34.  https://doi.org/10.1300/J013v39n03_02 CrossRefPubMedGoogle Scholar
  9. Britton JR (2007) Postpartum anxiety and breast feeding. J Reprod Med 52:689–695PubMedGoogle Scholar
  10. Brown JD, Harris SK, Woods ER, Buman MP, Cox JE (2012) Longitudinal study of depressive symptoms and social support in adolescent mothers. Matern Child Health J 16:894–901.  https://doi.org/10.1007/s10995-011-0814-9 CrossRefPubMedGoogle Scholar
  11. Bullock LF, Browning C, Geden E (2002) Telephone social support for low-income pregnant women. J Obstet Gynecol Neonatal Nurs 31:658–664CrossRefGoogle Scholar
  12. Campbell-Grossman C, Hudson DB, Kupzyk KA, Brown SE, Hanna KM, Yates BC (2016) Low-income, African American, adolescent mothers’ depressive symptoms, perceived stress, and social support. J Child Fam Stud 25:2306–2314.  https://doi.org/10.1007/s10826-016-0386-9 CrossRefPubMedPubMedCentralGoogle Scholar
  13. Canady RB, Bullen BL, Holzman C, Broman C, Tian Y (2008) Discrimination and symptoms of depression in pregnancy among African American and White women. Womens Health Issues 18:292–300.  https://doi.org/10.1016/j.whi.2008.04.003 CrossRefPubMedPubMedCentralGoogle Scholar
  14. Chojenta C, Loxton D, Lucke J (2012) How do previous mental health, social support, and stressful life events contribute to postnatal depression in a representative sample of Australian women? J Midwifery Womens Health 57:145–150.  https://doi.org/10.1111/j.1542-2011.2011.00140.x CrossRefPubMedGoogle Scholar
  15. Coburn SS, Gonzales NA, Luecken LJ, Crnic KA (2016) Multiple domains of stress predict postpartum depressive symptoms in low-income Mexican American women: the moderating effect of social support. Arch Womens Ment Health 19:1009–1018.  https://doi.org/10.1007/s00737-016-0649-x CrossRefPubMedPubMedCentralGoogle Scholar
  16. Collins NL, Dunkel-Schetter C, Lobel M, Scrimshaw SC (1993) Social support in pregnancy: psychosocial correlates of birth outcomes and postpartum depression. J Pers Soc Psychol 65:1243–1258CrossRefGoogle Scholar
  17. Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 150:782–786CrossRefGoogle Scholar
  18. Davey HL, Tough SC, Adair CE, Benzies KM (2011) Risk factors for sub-clinical and major postpartum depression among a community cohort of Canadian women. Matern Child Health J 15:866–875.  https://doi.org/10.1007/s10995-008-0314-8 CrossRefPubMedGoogle Scholar
  19. Davila M, McFall SL, Cheng D (2009) Acculturation and depressive symptoms among pregnant and postpartum Latinas. Matern Child Health J 13:318–325.  https://doi.org/10.1007/s10995-008-0385-6 CrossRefPubMedGoogle Scholar
  20. Dennis CL, Brown HK, Wanigaratne S, Vigod SN, Grigoriadis S, Fung K, Marini F, Brennenstuhl S (2017a) Determinants of comorbid depression and anxiety postnatally: a longitudinal cohort study of Chinese-Canadian women. J Affect Disord 227:24–30.  https://doi.org/10.1016/j.jad.2017.09.033 CrossRefPubMedGoogle Scholar
  21. Dennis CL, Merry L, Gagnon AJ (2017b) Postpartum depression risk factors among recent refugee, asylum-seeking, non-refugee immigrant, and Canadian-born women: results from a prospective cohort study. Soc Psychiatry Psychiatr Epidemiol 52:411–422.  https://doi.org/10.1007/s00127-017-1353-5 CrossRefPubMedGoogle Scholar
  22. Dennis CL, Merry L, Stewart D, Gagnon AJ (2016) Prevalence, continuation, and identification of postpartum depressive symptomatology among refugee, asylum-seeking, non-refugee immigrant, and Canadian-born women: results from a prospective cohort study. Arch Womens Ment Health 19:959–967.  https://doi.org/10.1007/s00737-016-0633-5 CrossRefPubMedGoogle Scholar
  23. Dickerson SS, Zoccola PM, Hooker E (2009) Toward a biology of social support. In: The Oxford handbook of positive psychologyGoogle Scholar
  24. Eastwood JG, Phung H, Barnett B (2011) Postnatal depression and socio-demographic risk: factors associated with Edinburgh Depression Scale scores in a metropolitan area of New South Wales, Australia. Aust N Z J Psychiatry 45:1040–1046.  https://doi.org/10.3109/00048674.2011.619160 CrossRefPubMedGoogle Scholar
  25. Edwards RC, Thullen MJ, Isarowong N, Shiu CS, Henson L, Hans SL (2012) Supportive relationships and the trajectory of depressive symptoms among young. African Am Mothers J Fam Psychol 26:585–594.  https://doi.org/10.1037/a0029053 CrossRefGoogle Scholar
  26. Evans M, Donelle L, Hume-Loveland L (2012) Social support and online postpartum depression discussion groups: a content analysis. Patient Educ Couns 87:405–410.  https://doi.org/10.1016/j.pec.2011.09.011 CrossRefPubMedGoogle Scholar
  27. Falah-Hassani K, Shiri R, Dennis CL (2016) Prevalence and risk factors for comorbid postpartum depressive symptomatology and anxiety. J Affect Disord 198:142–147.  https://doi.org/10.1016/j.jad.2016.03.010 CrossRefPubMedGoogle Scholar
  28. Flynn HA, Davis M, Marcus SM, Cunningham R, Blow FC (2004) Rates of maternal depression in pediatric emergency department and relationship to child service utilization. Gen Hosp Psychiatry 26:316–322.  https://doi.org/10.1016/j.genhosppsych.2004.03.009 CrossRefPubMedGoogle Scholar
  29. Fonseca A, Canavarro MC (2017) Women's intentions of informal and formal help-seeking for mental health problems during the perinatal period: the role of perceived encouragement from the partner. Midwifery 50:78–85.  https://doi.org/10.1016/j.midw.2017.04.001 CrossRefPubMedGoogle Scholar
  30. Gaillard A, Le Strat Y, Mandelbrot L, Keita H, Dubertret C (2014) Predictors of postpartum depression: prospective study of 264 women followed during pregnancy and postpartum. Psychiatry Res 215:341–346.  https://doi.org/10.1016/j.psychres.2013.10.003 CrossRefPubMedGoogle Scholar
  31. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T (2005) Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol 106:1071–1083.  https://doi.org/10.1097/01.AOG.0000183597.31630.db CrossRefPubMedGoogle Scholar
  32. Gaynes BN et al. (2005) Perinatal depression: prevalence, screening accuracy, And screening outcomes evidence reports/technology assessments:1–8Google Scholar
  33. Gibson J, McKenzie-McHarg K, Shakespeare J, Price J, Gray R (2009) A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women. Acta Psychiatr Scand 119:350–364.  https://doi.org/10.1111/j.1600-0447.2009.01363.x CrossRefPubMedGoogle Scholar
  34. Giurgescu C, Misra DP, Sealy-Jefferson S, Caldwell CH, Templin TN, Slaughter-Acey JC, Osypuk TL (2015) The impact of neighborhood quality, perceived stress, and social support on depressive symptoms during pregnancy in African American women. Soc Sci Med 130:172–180.  https://doi.org/10.1016/j.socscimed.2015.02.006 CrossRefPubMedPubMedCentralGoogle Scholar
  35. Gray NS, Amankwaa LC, Frank DI (2000) Social support and postpartum African American women. ABNF J 11:64–68PubMedGoogle Scholar
  36. Guintivano J, Manuck T, Meltzer-Brody S (2018) Predictors of postpartum depression: a comprehensive review of the last decade of evidence Clin Obstet Gynecol doi: https://doi.org/10.1097/GRF.0000000000000368
  37. Guintivano J, Sullivan PF, Stuebe AM, Penders T, Thorp J, Rubinow DR, Meltzer-Brody S (2017) Adverse life events, psychiatric history, and biological predictors of postpartum depression in an ethnically diverse sample of postpartum women. Psychol Med 48:1–14.  https://doi.org/10.1017/S0033291717002641 CrossRefGoogle Scholar
  38. Junge C, Garthus-Niegel S, Slinning K, Polte C, Simonsen TB, Eberhard-Gran M (2017) The impact of perinatal depression on children’s social-emotional development: a longitudinal study. Matern Child Health J 21:607–615.  https://doi.org/10.1007/s10995-016-2146-2 CrossRefPubMedGoogle Scholar
  39. Kim TH, Connolly JA, Tamim H (2014) The effect of social support around pregnancy on postpartum depression among Canadian teen mothers and adult mothers in the maternity experiences survey. BMC Pregnancy Childbirth 14:162.  https://doi.org/10.1186/1471-2393-14-162 CrossRefPubMedPubMedCentralGoogle Scholar
  40. Leahy-Warren P, McCarthy G, Corcoran P (2011) Postnatal depression in first-time mothers: prevalence and relationships between functional and structural social support at 6 and 12 weeks postpartum. Arch Psychiatr Nurs 25:174–184.  https://doi.org/10.1016/j.apnu.2010.08.005 CrossRefPubMedGoogle Scholar
  41. Leung BM, Letourneau NL, Giesbrecht GF, Ntanda H, Hart M, Team AP (2017) Predictors of postpartum depression in partnered mothers and fathers from a longitudinal cohort. Community Ment Health J 53:420–431.  https://doi.org/10.1007/s10597-016-0060-0 CrossRefPubMedGoogle Scholar
  42. Lindahl V, Pearson JL, Colpe L (2005) Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health 8:77–87.  https://doi.org/10.1007/s00737-005-0080-1 CrossRefPubMedGoogle Scholar
  43. Logsdon MC, Usui W (2001) Psychosocial predictors of postpartum depression in diverse groups of women. West J Nurs Res 23:563–574.  https://doi.org/10.1177/019394590102300603 CrossRefPubMedGoogle Scholar
  44. Lovejoy MC, Graczyk PA, O'Hare E, Neuman G (2000) Maternal depression and parenting behavior: a meta-analytic review. Clin Psychol Rev 20:561–592CrossRefGoogle Scholar
  45. Lucero NB, Beckstrand RL, Callister LC, Sanchez Birkhead AC (2012) Prevalence of postpartum depression among Hispanic immigrant women. J Am Acad Nurse Pract 24:726–734.  https://doi.org/10.1111/j.1745-7599.2012.00744.x CrossRefPubMedGoogle Scholar
  46. Luecken LJ, Lin B, Coburn SS, MacKinnon DP, Gonzales NA, Crnic KA (2013) Prenatal stress, partner support, and infant cortisol reactivity in low-income Mexican American families. Psychoneuroendocrinology 38:3092–3101.  https://doi.org/10.1016/j.psyneuen.2013.09.006 CrossRefPubMedGoogle Scholar
  47. Martinez I, Kershaw TS, Keene D, Perez-Escamilla R, Lewis JB, Tobin JN, Ickovics JR (2017) Acculturation and syndemic risk: longitudinal evaluation of risk factors among pregnant Latina adolescents in New York City Ann Behav Med doi: https://doi.org/10.1007/s12160-017-9924-y
  48. Martinez-Schallmoser L, Telleen S, MacMullen NJ (2003) The effect of social support and acculturation on postpartum depression in Mexican American women. J Transcult Nurs 14:329–338.  https://doi.org/10.1177/1043659603257162 CrossRefPubMedGoogle Scholar
  49. Matthey S, Kavanagh DJ, Howie P, Barnett B, Charles M (2004) Prevention of postnatal distress or depression: an evaluation of an intervention at preparation for parenthood classes. J Affect Disord 79:113–126.  https://doi.org/10.1016/S0165-0327(02)00362-2 CrossRefPubMedGoogle Scholar
  50. McCall-Hosenfeld JS, Phiri K, Schaefer E, Zhu J, Kjerulff K (2016) Trajectories of depressive symptoms throughout the peri- and postpartum period: results from the first baby study. J Women's Health 25:1112–1121.  https://doi.org/10.1089/jwh.2015.5310 CrossRefGoogle Scholar
  51. McLeish J, Redshaw M (2017) Mothers’ accounts of the impact on emotional wellbeing of organised peer support in pregnancy and early parenthood: a qualitative study. BMC Pregnancy Childbirth 17:28.  https://doi.org/10.1186/s12884-017-1220-0 CrossRefPubMedPubMedCentralGoogle Scholar
  52. Meltzer-Brody S, Bledsoe-Mansori SE, Johnson N, Killian C, Hamer RM, Jackson C, Wessel J, Thorp J (2013) A prospective study of perinatal depression and trauma history in pregnant minority adolescents. Am J Obstet Gynecol 208 211:e211–e217.  https://doi.org/10.1016/j.ajog.2012.12.020 CrossRefGoogle Scholar
  53. Murray L, Cooper PJ (2009) The impact of postpartum depression on child development. Int Rev Psychiatry 8:55–63.  https://doi.org/10.3109/09540269609037817 CrossRefGoogle Scholar
  54. Norhayati MN, Hazlina NH, Asrenee AR, Emilin WM (2015) Magnitude and risk factors for postpartum symptoms: a literature review. J Affect Disord 175:34–52.  https://doi.org/10.1016/j.jad.2014.12.041 CrossRefPubMedGoogle Scholar
  55. O'Hara MW, McCabe JE (2013) Postpartum depression: current status and future directions. Annu Rev Clin Psychol 9:379–407.  https://doi.org/10.1146/annurev-clinpsy-050212-185612 CrossRefPubMedGoogle Scholar
  56. Orsolini L, Valchera A, Vecchiotti R, Tomasetti C, Iasevoli F, Fornaro M, de Berardis D, Perna G, Pompili M, Bellantuono C (2016) Suicide during perinatal period: epidemiology, risk factors, and clinical correlates. Front Psychiatry 7:138.  https://doi.org/10.3389/fpsyt.2016.00138 CrossRefPubMedPubMedCentralGoogle Scholar
  57. Otsubo T et al (2005) Reliability and validity of Japanese version of the Mini-International Neuropsychiatric Interview. Psychiatry Clin Neurosci 59:517–526.  https://doi.org/10.1111/j.1440-1819.2005.01408.x CrossRefPubMedGoogle Scholar
  58. Paulson JF, Dauber S, Leiferman JA (2006) Individual and combined effects of postpartum depression in mothers and fathers on parenting behavior. Pediatrics 118:659–668.  https://doi.org/10.1542/peds.2005-2948 CrossRefPubMedGoogle Scholar
  59. Ramos-Marcuse F, Oberlander SE, Papas MA, McNary SW, Hurley KM, Black MM (2010) Stability of maternal depressive symptoms among urban, low-income, African American adolescent mothers. J Affect Disord 122:68–75.  https://doi.org/10.1016/j.jad.2009.06.018 CrossRefPubMedGoogle Scholar
  60. Rich-Edwards JW, Kleinman K, Abrams A, Harlow BL, McLaughlin TJ, Joffe H, Gillman MW (2006) Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice. J Epidemiol Community Health 60:221–227.  https://doi.org/10.1136/jech.2005.039370 CrossRefPubMedPubMedCentralGoogle Scholar
  61. Robertson E, Grace S, Wallington T, Stewart DE (2004) Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry 26:289–295.  https://doi.org/10.1016/j.genhosppsych.2004.02.006 CrossRefPubMedGoogle Scholar
  62. Robitaille A, Orpana H, McIntosh CN (2011) Psychometric properties, factorial structure, and measurement invariance of the English and French versions of the Medical Outcomes Study Social Support scale. Health Rep 22:33–40PubMedGoogle Scholar
  63. Santos H Jr, Fried EI, Asafu-Adjei J, Ruiz RJ (2017) Network structure of perinatal depressive symptoms in Latinas: relationship to stress and reproductive biomarkers. Res Nurs Health 40:218–228.  https://doi.org/10.1002/nur.21784 CrossRefPubMedPubMedCentralGoogle Scholar
  64. Schiller CE, Meltzer-Brody S, Rubinow DR (2015) The role of reproductive hormones in postpartum depression. CNS Spectr 20:48–59.  https://doi.org/10.1017/S1092852914000480 CrossRefPubMedGoogle Scholar
  65. Scholle SH, Kelleher K (2003) Preferences for depression advice among low-income women. Matern Child Health J 7:95–102CrossRefGoogle Scholar
  66. Serati M, Redaelli M, Buoli M, Altamura AC (2016) Perinatal major depression biomarkers: a systematic review. J Affect Disord 193:391–404.  https://doi.org/10.1016/j.jad.2016.01.027 CrossRefPubMedGoogle Scholar
  67. Sheehan DV et al (1998) The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59(Suppl 20):22–33 quiz 34–57PubMedGoogle Scholar
  68. Sherbourne CD, Stewart AL (1991) The MOS Social Support survey. Soc Sci Med 32:705–714CrossRefGoogle Scholar
  69. Stein A, Pearson RM, Goodman SH, Rapa E, Rahman A, McCallum M, Howard LM, Pariante CM (2014) Effects of perinatal mental disorders on the fetus and child. Lancet 384:1800–1819.  https://doi.org/10.1016/S0140-6736(14)61277-0 CrossRefPubMedGoogle Scholar
  70. Stuchbery M, Matthey S, Barnett B (1998) Postnatal depression and social supports in Vietnamese, Arabic and Anglo-Celtic mothers. Soc Psychiatry Psychiatr Epidemiol 33:483–490CrossRefGoogle Scholar
  71. Turan B, Stringer KL, Onono M, Bukusi EA, Weiser SD, Cohen CR, Turan JM (2014) Linkage to HIV care, postpartum depression, and HIV-related stigma in newly diagnosed pregnant women living with HIV in Kenya: a longitudinal observational study. BMC Pregnancy Childbirth 14:400.  https://doi.org/10.1186/s12884-014-0400-4 CrossRefPubMedPubMedCentralGoogle Scholar
  72. Uchino BN, Cacioppo JT, Kiecolt-Glaser JK (1996) The relationship between social support and physiological processes: a review with emphasis on underlying mechanisms and implications for health. Psychol Bull 119:488–531CrossRefGoogle Scholar
  73. Ugarriza DN (2006) Social support unique to African American mothers. J Afr Am Stud 10:19–31CrossRefGoogle Scholar
  74. Westdahl C, Milan S, Magriples U, Kershaw TS, Rising SS, Ickovics JR (2007) Social support and social conflict as predictors of prenatal depression. Obstet Gynecol 110:134–140.  https://doi.org/10.1097/01.AOG.0000265352.61822.1b CrossRefPubMedPubMedCentralGoogle Scholar
  75. Wisner KL, Parry BL, Piontek CM (2002) Clinical practice. Postpartum Depression N Engl J Med 347:194–199.  https://doi.org/10.1056/NEJMcp011542 CrossRefPubMedGoogle Scholar
  76. Xie RH, He G, Koszycki D, Walker M, Wen SW (2009) Prenatal social support, postnatal social support, and postpartum depression. Ann Epidemiol 19:637–643.  https://doi.org/10.1016/j.annepidem.2009.03.008 CrossRefPubMedGoogle Scholar
  77. Xie RH, Yang J, Liao S, Xie H, Walker M, Wen SW (2010) Prenatal family support, postnatal family support and postpartum depression. Aust N Z J Obstet Gynaecol 50:340–345.  https://doi.org/10.1111/j.1479-828X.2010.01185.x CrossRefPubMedGoogle Scholar
  78. Yim IS, Tanner Stapleton LR, Guardino CM, Hahn-Holbrook J, Dunkel Schetter C (2015) Biological and psychosocial predictors of postpartum depression: systematic review and call for integration. Annu Rev Clin Psychol 11:99–137.  https://doi.org/10.1146/annurev-clinpsy-101414-020426 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  • Christine Pao
    • 1
  • Jerry Guintivano
    • 1
    Email author
  • Hudson Santos
    • 2
  • Samantha Meltzer-Brody
    • 1
  1. 1.Department of PsychiatryUniversity of North Carolina at Chapel HillChapel HillUSA
  2. 2.School of NursingUniversity of North Carolina at Chapel HillChapel HillUSA

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