Non-pharmacological treatments for insomnia
Article
First Online:
Received:
Accepted:
- 1.4k Downloads
- 34 Citations
Abstract
Insomnia is a common disorder effecting millions of people worldwide. Currently most individuals suffering from insomnia take medications to help them sleep. However, there are a variety of behavioral treatments, which have been shown to be effective in empirical studies that offer many advantages over medications. In addition, behavioral treatments have been shown to be more effective long-term than medication. This paper reviews the principles and practice of these behavioral treatments. At the end of the paper there is also a brief discussion of circadian rhythm disorders that can mimic insomnia.
Keywords
Insomnia Behavioral treatments Sleep restriction Stimulus control Sleep hygiene CBT-IReferences
- Adamson, J., & Burdick, J. A. (1973). Sleep of dry alcoholics. Archives of General Psychiatry, 28(1), 146–149.PubMedGoogle Scholar
- American Academy of Sleep Medicine. (2005). The international classification of sleep disorders: Diagnostic and coding manual (xviii, 297 pp). Westchester, IL: American Academy of Sleep Medicine.Google Scholar
- Ando, K., Kripke, D. F., & Ancoli-Israel, S. (1995). Estimated prevalence of delayed and advanced sleep phase syndromes. Sleep Research, 24, 509.Google Scholar
- Ando, K., Kripke, D. F., & Ancoli-Israel, S. (2002). Delayed and advanced sleep phase symptoms. The Israel Journal of Psychiatry and Related Sciences, 39(1), 11–18.PubMedGoogle Scholar
- Bastien, C. H., Vallieres, A., & Morin, C. M. (2004). Precipitating factors of insomnia. Behavioral Sleep Medicine, 2(1), 50–62. doi: 10.1207/s15402010bsm0201_5.PubMedCrossRefGoogle Scholar
- Benca, R. M., Obermeyer, W. H., Thisted, R. A., & Gillin, J. C. (1992). Sleep and psychiatric disorders. A meta-analysis. Archives of General Psychiatry, 49(8), 651–668. discussion 669–70.PubMedGoogle Scholar
- Boivin, D. B., Duffy, J. F., Kronauer, R. E., & Czeisler, C. A. (1996). Dose–response relationships for resetting of human circadian clock by light. Nature, 379(6565), 540–542. doi: 10.1038/379540a0.PubMedCrossRefGoogle Scholar
- Bootzin, R. R. (1972). A stimulus control treatment for insomnia. In Proceedings of the American Psychological Association (pp. 395–396).Google Scholar
- Bootzin, R. R., Epstein, D., & Wood, J. M. (1991). Stimulus control instructions. In P. Hauri (Ed.), Critical issues in psychiatry: Case studies in insomnia (pp. 19–28). New York: Plenum Medical Book.Google Scholar
- Breslau, N., Roth, T., Rosenthal, L., & Andreski, P. (1996). Sleep disturbance and psychiatric disorders: A longitudinal epidemiological study of young adults. Biological Psychiatry, 39(6), 411–418. doi: 10.1016/0006-3223(95)00188-3.PubMedCrossRefGoogle Scholar
- Coursey, R. D., Frankel, B. L., Gaarder, K. R., & Mott, D. E. (1980). A comparison of relaxation techniques with electrosleep therapy for chronic, sleep-onset insomnia a sleep-EEG study. Biofeedback and Self-Regulation, 5(1), 57–73. doi: 10.1007/BF00999064.PubMedCrossRefGoogle Scholar
- Czeisler, C. A., Buxton, O. M., & Khalsa, S. B. S. (2005). The human circadian timing system and sleep-wake regulation. In M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and practice of sleep medicine (4th ed., xxxiii, 1517 pp). Philadelphia, PA: Elsevier/Saunders.Google Scholar
- Czeisler, C. A., Richardson, G. S., Coleman, R. M., Zimmerman, J. C., Moore-Ede, M. C., Dement, W. C., et al. (1981). Chronotherapy: Resetting the circadian clocks of patients with delayed sleep phase insomnia. Sleep, 4(1), 1–21.PubMedGoogle Scholar
- Dahlitz, M., Alvarez, B., Vignau, J., English, J., Arendt, J., & Parkes, J. D. (1991). Delayed sleep phase syndrome response to melatonin. Lancet, 337(8750), 1121–1124. doi: 10.1016/0140-6736(91)92787-3.PubMedCrossRefGoogle Scholar
- Drake, C., Richardson, G., Roehrs, T., Scofield, H., & Roth, T. (2004). Vulnerability to stress-related sleep disturbance and hyperarousal. Sleep, 27(2), 285–291.PubMedGoogle Scholar
- Ebben, M. R., & Fine, L. (2009). Insomnia: A risk for future psychiatric illness. In S. R. Pandi-Peumal & M. Kramer (Eds.), Sleep and mental illness. Cambridge: Cambridge University Press (in press).Google Scholar
- Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001). Cognitive behavioral therapy for treatment of chronic primary insomnia: A randomized controlled trial. Journal of the American Medical Association, 285(14), 1856–1864. doi: 10.1001/jama.285.14.1856.PubMedCrossRefGoogle Scholar
- Engle-Friedman, M., Bootzin, R. R., Hazlewood, L., & Tsao, C. (1992). An evaluation of behavioral treatments for insomnia in the older adult. Journal of Clinical Psychology, 48(1), 77–90. doi:10.1002/1097-4679(199201)48:1<77::AID-JCLP2270480112>3.0.CO;2-J.PubMedCrossRefGoogle Scholar
- Espie, C. A., & Lindsay, W. R. (1985). Paradoxical intention in the treatment of chronic insomnia: Six case studies illustrating variability in therapeutic response. Behaviour Research and Therapy, 23(6), 703–709. doi: 10.1016/0005-7967(85)90070-1.PubMedCrossRefGoogle Scholar
- Espie, C. A., Lindsay, W. R., Brooks, D. N., Hood, E. M., & Turvey, T. (1989). A controlled comparative investigation of psychological treatments for chronic sleep-onset insomnia. Behaviour Research and Therapy, 27(1), 79–88. doi: 10.1016/0005-7967(89)90123-X.PubMedCrossRefGoogle Scholar
- Espie, C. A., Inglis, S. J., Tessier, S., & Harvey, L. (2001). The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: Implementation and evaluation of a sleep clinic in general medical practice. Behaviour Research and Therapy, 39(1), 45–60. doi: 10.1016/S0005-7967(99)00157-6.PubMedCrossRefGoogle Scholar
- Espie, C. A., Broomfield, N. M., MacMahon, K. M., Macphee, L. M., & Taylor, L. M. (2006). The attention-intention-effort pathway in the development of psychophysiologic insomnia: A theoretical review. Sleep Medicine Reviews, 10(4), 215–245. doi: 10.1016/j.smrv.2006.03.002.PubMedCrossRefGoogle Scholar
- Fava, M., McCall, W. V., Krystal, A., Wessel, T., Rubens, R., Caron, J., et al. (2006). Eszopiclone co-administered with fluoxetine in patients with insomnia coexisting with major depressive disorder. Biological Psychiatry, 59(11), 1052–1060. doi: 10.1016/j.biopsych.2006.01.016.PubMedCrossRefGoogle Scholar
- Ford, D. E., & Kamerow, D. B. (1989). Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? Journal of the American Medical Association, 262(11), 1479–1484. doi: 10.1001/jama.262.11.1479.PubMedCrossRefGoogle Scholar
- Freedman, R., & Papsdorf, J. D. (1976). Biofeedback and progressive relaxation treatment of sleep-onset insomnia: A controlled, all-night investigation. Biofeedback and Self-Regulation, 1(3), 253–271. doi: 10.1007/BF01001167.PubMedCrossRefGoogle Scholar
- Friedman, L., Bliwise, D. L., Yesavage, J. A., & Salom, S. R. (1991). A preliminary study comparing sleep restriction and relaxation treatments for insomnia in older adults. Journal of Gerontology, 46(1), 1–8.Google Scholar
- Greenblatt, D. J. (1992). Pharmacology of benzodiazepine hypnotics. The Journal of Clinical Psychiatry, 53(Suppl), 7–13.PubMedGoogle Scholar
- Guilleminault, C., Clerk, A., Black, J., Labanowski, M., Pelayo, R., & Claman, D. (1995). Nondrug treatment trials in psychophysiologic insomnia. Archives of Internal Medicine, 155(8), 838–844. doi: 10.1001/archinte.155.8.838.PubMedCrossRefGoogle Scholar
- Gustafson, R. (1992). Treating insomnia with a self-administered muscle relaxation training program: A follow-up. Psychological Reports, 70(1), 124–126. doi: 10.2466/PR0.70.1.124-126.PubMedCrossRefGoogle Scholar
- Harvey, A. G., Sharpley, A. L., Ree, M. J., Stinson, K., & Clark, D. M. (2007). An open trial of cognitive therapy for chronic insomnia. Behaviour Research and Therapy, 45(10), 2491–2501. doi: 10.1016/j.brat.2007.04.007.PubMedCrossRefGoogle Scholar
- Hauri, P. (1981). Treating psychophysiologic insomnia with biofeedback. Archives of General Psychiatry, 38(7), 752–758.PubMedGoogle Scholar
- Hauri, P. (1991). Sleep hygiene, relaxation therapy, and cognitive interventions. In P. Hauri (Ed.), Critical issues in psychiatry: Case studies in insomnia (pp. 65–84). New York: Plenum Medical Book.Google Scholar
- Hauri, P. J., Percy, L., Hellekson, C., Hartmann, E., & Russ, D. (1982). The treatment of psychophysiologic insomnia with biofeedback: A replication study. Biofeedback and Self-Regulation, 7(2), 223–235. doi: 10.1007/BF00998785.PubMedCrossRefGoogle Scholar
- Jacobs, G. D., Rosenberg, P. A., Friedman, R., Matheson, J., Peavy, G. M., Domar, A. D., et al. (1993). Multifactor behavioral treatment of chronic sleep-onset insomnia using stimulus control and the relaxation response. A preliminary study. Behavior Modification, 17(4), 498–509. doi: 10.1177/01454455930174005.PubMedCrossRefGoogle Scholar
- Jacobs, G. D., Pace-Schott, E. F., Stickgold, R., & Otto, M. W. (2004). Cognitive behavior therapy and pharmacotherapy for insomnia: A randomized controlled trial and direct comparison. Archives of Internal Medicine, 164(17), 1888–1896. doi: 10.1001/archinte.164.17.1888.PubMedCrossRefGoogle Scholar
- Johnson, L. C., & Chernik, D. A. (1982). Sedative-hypnotics and human performance. Psychopharmacology, 76(2), 101–113. doi: 10.1007/BF00435262.PubMedCrossRefGoogle Scholar
- Johnson, E. O., Roth, T., & Breslau, N. (2006). The association of insomnia with anxiety disorders and depression: Exploration of the direction of risk. Journal of Psychiatric Research, 40(8), 700–708. doi: 10.1016/j.jpsychires.2006.07.008.PubMedCrossRefGoogle Scholar
- Kales, A., & Kales, J. D. (1984). Evaluation and treatment of insomnia (xi, 324 pp). New York: Oxford University Press.Google Scholar
- Kales, A., Bixler, E. O., Tan, T. L., Scharf, M. B., & Kales, J. D. (1974). Chronic hypnotic-drug use. Ineffectiveness, drug-withdrawal insomnia, and dependence. Journal of the American Medical Association, 227(5), 513–517. doi: 10.1001/jama.227.5.513.PubMedCrossRefGoogle Scholar
- Karacan, I., Thornby, J. I., Anch, M., Booth, G. H., Williams, R. L., & Salis, P. J. (1976). Dose-related sleep disturbances induced by coffee and caffeine. Clinical Pharmacology and Therapeutics, 20(6), 682–689.PubMedGoogle Scholar
- Katz, D. A., & McHorney, C. A. (1998). Clinical correlates of insomnia in patients with chronic illness. Archives of Internal Medicine, 158(10), 1099–1107. doi: 10.1001/archinte.158.10.1099.PubMedCrossRefGoogle Scholar
- Khalsa, S. B., Jewett, M. E., Cajochen, C., & Czeisler, C. A. (2003). A phase response curve to single bright light pulses in human subjects. The Journal of Physiology, 549(Pt 3), 945–952. doi: 10.1113/jphysiol.2003.040477.PubMedCrossRefGoogle Scholar
- Kuppermann, M., Lubeck, D. P., Mazonson, P. D., Patrick, D. L., Stewart, A. L., Buesching, D. P., et al. (1995). Sleep problems and their correlates in a working population. Journal of General Internal Medicine, 10(1), 25–32. doi: 10.1007/BF02599573.PubMedCrossRefGoogle Scholar
- Lacks, P., Bertelson, A. D., Sugerman, J., & Kunkel, J. (1983). The treatment of sleep-maintenance insomnia with stimulus-control techniques. Behaviour Research and Therapy, 21(3), 291–295. doi: 10.1016/0005-7967(83)90211-5.PubMedCrossRefGoogle Scholar
- Ladouceur, R., & Gros-Louis, Y. (1986). Paradoxical intention vs stimulus control in the treatment of severe insomnia. Journal of Behavior Therapy and Experimental Psychiatry, 17(4), 267–269. doi: 10.1016/0005-7916(86)90062-5.PubMedCrossRefGoogle Scholar
- Lichstein, K. L., & Johnson, R. S. (1993). Relaxation for insomnia and hypnotic medication use in older women. Psychology and Aging, 8(1), 103–111. doi: 10.1037/0882-7974.8.1.103.PubMedCrossRefGoogle Scholar
- Lick, J. R., & Heffler, D. (1977). Relaxation training and attention placebo in the treatment of severe insomnia. Journal of Consulting and Clinical Psychology, 45(2), 153–161. doi: 10.1037/0022-006X.45.2.153.PubMedCrossRefGoogle Scholar
- McClusky, H. Y., Milby, J. B., Switzer, P. K., Williams, V., & Wooten, V. (1991). Efficacy of behavioral versus triazolam treatment in persistent sleep-onset insomnia. The American Journal of Psychiatry, 148(1), 121–126.PubMedGoogle Scholar
- Mitchell, K. R. (1979). Behavioral treatment of presleep tension and intrusive cognitions in patients with severe predormital insomnia. Journal of Behavioral Medicine, 2(1), 57–69. doi: 10.1007/BF00846563.PubMedCrossRefGoogle Scholar
- Morgenthaler, T., Kramer, M., Alessi, C., Friedman, L., Boehlecke, B., Brown, T., et al. (2006). Practice parameters for the psychological and behavioral treatment of insomnia: An update. An american academy of sleep medicine report. Sleep, 29(11), 1415–1419.PubMedGoogle Scholar
- Morgenthaler, T. I., Lee-Chiong, T., Alessi, C., Friedman, L., Aurora, R. N., Boehlecke, B., et al. (2007). Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report. Sleep, 30(11), 1445–1459.PubMedGoogle Scholar
- Morin, C. M. (1993). Cognitive therapy Component. Insomnia: Psychological assessment and management. Treatment manuals for practitioners (pp. 126–144). Guilford Press: New York.Google Scholar
- Morin, C. M., & Azrin, N. H. (1987). Stimulus control and imagery training in treating sleep-maintenance insomnia. Journal of Consulting and Clinical Psychology, 55(2), 260–262. doi: 10.1037/0022-006X.55.2.260.PubMedCrossRefGoogle Scholar
- Morin, C. M., Gaulier, B., Barry, T., & Kowatch, R. A. (1992). Patients’ acceptance of psychological and pharmacological therapies for insomnia. Sleep, 15(4), 302–305.PubMedGoogle Scholar
- Morin, C. M., Kowatch, R. A., Barry, T., & Walton, E. (1993a). Cognitive-behavior therapy for late-life insomnia. Journal of Consulting and Clinical Psychology, 61(1), 137–146. doi: 10.1037/0022-006X.61.1.137.PubMedCrossRefGoogle Scholar
- Morin, C. M., Stone, J., Trinkle, D., Mercer, J., & Remsberg, S. (1993b). Dysfunctional beliefs and attitudes about sleep among older adults with and without insomnia complaints. Psychology and Aging, 8(3), 463–467. doi: 10.1037/0882-7974.8.3.463.PubMedCrossRefGoogle Scholar
- Morin, C. M., Culbert, J. P., & Schwartz, S. M. (1994). Nonpharmacological interventions for insomnia: A meta-analysis of treatment efficacy. The American Journal of Psychiatry, 151(8), 1172–1180.PubMedGoogle Scholar
- Morin, C. M., Colecchi, C., Stone, J., Sood, R., & Brink, D. (1999a). Behavioral and pharmacological therapies for late-life insomnia: A randomized controlled trial. Journal of the American Medical Association, 281(11), 991–999. doi: 10.1001/jama.281.11.991.PubMedCrossRefGoogle Scholar
- Morin, C. M., Hauri, P. J., Espie, C. A., Spielman, A. J., Buysse, D. J., & Bootzin, R. R. (1999b). Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review. Sleep, 22(8), 1134–1156.PubMedGoogle Scholar
- Murtagh, D. R., & Greenwood, K. M. (1995). Identifying effective psychological treatments for insomnia: A meta-analysis. Journal of Consulting and Clinical Psychology, 63(1), 79–89. doi: 10.1037/0022-006X.63.1.79.PubMedCrossRefGoogle Scholar
- Nagtegaal, J. E., Kerkhof, G. A., Smits, M. G., Swart, A. C., & Van Der Meer, Y. G. (1998). Delayed sleep phase syndrome: A placebo-controlled cross-over study on the effects of melatonin administered five hours before the individual dim light melatonin onset. Journal of Sleep Research, 7(2), 135–143. doi: 10.1046/j.1365-2869.1998.00102.x.PubMedCrossRefGoogle Scholar
- Nicassio, P., & Bootzin, R. (1974). A comparison of progressive relaxation and autogenic training as treatments for insomnia. Journal of Abnormal Psychology, 83(3), 253–260. doi: 10.1037/h0036729.PubMedCrossRefGoogle Scholar
- Nicassio, P. M., Boylan, M. B., & McCabe, T. G. (1982). Progressive relaxation, EMG biofeedback and biofeedback placebo in the treatment of sleep-onset insomnia. The British Journal of Medical Psychology, 55(Pt 2), 159–166.PubMedGoogle Scholar
- Nierenberg, A. A., Keefe, B. R., Leslie, V. C., Alpert, J. E., Pava, J. A., Worthington, J. J., III, et al. (1999). Residual symptoms in depressed patients who respond acutely to fluoxetine. The Journal of Clinical Psychiatry, 60(4), 221–225.PubMedGoogle Scholar
- NIH State-of-the-Science Conference Statement on manifestations and management of chronic insomnia in adults. NIH Consensus and State-of-the-Science Statements, 22(2), 1–30 (2005).Google Scholar
- Ohayon, M. M. (1997). Prevalence of DSM-IV diagnostic criteria of insomnia: Distinguishing insomnia related to mental disorders from sleep disorders. Journal of Psychiatric Research, 31(3), 333–346. doi: 10.1016/S0022-3956(97)00002-2.PubMedCrossRefGoogle Scholar
- Ohayon, M. M. (2007). Prevalence and comorbidity of sleep disorders in general population. La Revue du Praticien, 57(14), 1521–1528.PubMedGoogle Scholar
- Ohayon, M. M., & Roth, T. (2003). Place of chronic insomnia in the course of depressive and anxiety disorders. Journal of Psychiatric Research, 37(1), 9–15. doi: 10.1016/S0022-3956(02)00052-3.PubMedCrossRefGoogle Scholar
- Ohayon, M. M., Shapiro, C. M., & Kennedy, S. H. (2000). Differentiating DSM-IV anxiety and depressive disorders in the general population: Comorbidity and treatment consequences. Canadian Journal of Psychiatry, 45(2), 166–172.Google Scholar
- Oldani, A., Ferini-Strambi, L., Zucconi, M., Stankov, B., Fraschini, F., & Smirne, S. (1994). Melatonin and delayed sleep phase syndrome: Ambulatory polygraphic evaluation. NeuroReport, 6(1), 132–134.PubMedCrossRefGoogle Scholar
- Ree, M. J., & Harvey, A. G. (2004). Investigating Safety Behaviours in Insomnia: The Development of the Sleep-related Behaviours Questionnaire (SRBQ). Behaviour Change, 21, 26–36. doi: 10.1375/bech.21.1.26.35971.CrossRefGoogle Scholar
- Riedel, B. W., Lichstein, K. L., & Dwyer, W. O. (1995). Sleep compression and sleep education for older insomniacs: Self-help versus therapist guidance. Psychology and Aging, 10(1), 54–63. doi: 10.1037/0882-7974.10.1.54.PubMedCrossRefGoogle Scholar
- Sanavio, E. (1988). Pre-sleep cognitive intrusions and treatment of onset-insomnia. Behaviour Research and Therapy, 26(6), 451–459. doi: 10.1016/0005-7967(88)90139-8.PubMedCrossRefGoogle Scholar
- Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Evaluation and management of chronic insomnia in adults: An American Academy of Sleep Medicine clinical guideline. Journal of Clinical Sleep Medicine, in press.Google Scholar
- Simon, G. E., & VonKorff, M. (1997). Prevalence, burden, and treatment of insomnia in primary care. The American Journal of Psychiatry, 154(10), 1417–1423.PubMedGoogle Scholar
- Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J., Giles, D. E., et al. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. The American Journal of Psychiatry, 159(1), 5–11. doi: 10.1176/appi.ajp.159.1.5.PubMedCrossRefGoogle Scholar
- Spielman, A. J., Caruso, L. S., & Glovinsky, P. B. (1987a). A behavioral perspective on insomnia treatment. The Psychiatric Clinics of North America, 10(4), 541–553.PubMedGoogle Scholar
- Spielman, A. J., Saskin, P., & Thorpy, M. J. (1987b). Treatment of chronic insomnia by restriction of time in bed. Sleep, 10(1), 45–56.PubMedGoogle Scholar
- Stanton, H. E. (1989). Hypnotic relaxation and the reduction of sleep onset insomnia. International Journal of Psychosomatics, 36(1–4), 64–68.PubMedGoogle Scholar
- Taylor, D. J., Lichstein, K. L., Durrence, H. H., Reidel, B. W., & Bush, A. J. (2005). Epidemiology of insomnia, depression, and anxiety. Sleep, 28(11), 1457–1464.PubMedGoogle Scholar
- Turner, R. M., & Ascher, L. M. (1979). Controlled comparison of progressive relaxation, stimulus control, and paradoxical intention therapies for insomnia. Journal of Consulting and Clinical Psychology, 47(3), 500–508. doi: 10.1037/0022-006X.47.3.500.PubMedCrossRefGoogle Scholar
- Turner, R. M., & Ascher, L. M. (1982). Therapist factor in the treatment of insomnia. Behaviour Research and Therapy, 20(1), 33–40. doi: 10.1016/0005-7967(82)90006-7.PubMedCrossRefGoogle Scholar
- Walsh, J. K., & Schweitzer, P. K. (1999). Ten-year trends in the pharmacological treatment of insomnia. Sleep, 22(3), 371–375.PubMedGoogle Scholar
- Weissman, M. M., Bland, R. C., Canino, G. J., Faravelli, C., Greenwald, S., Hwu, H. G., et al. (1996). Cross-national epidemiology of major depression and bipolar disorder. Journal of the American Medical Association, 276(4), 293–299. doi: 10.1001/jama.276.4.293.PubMedCrossRefGoogle Scholar
- Woolfolk, R. L., & McNulty, T. F. (1983). Relaxation treatment for insomnia: A component analysis. Journal of Consulting and Clinical Psychology, 51(4), 495–503. doi: 10.1037/0022-006X.51.4.495.PubMedCrossRefGoogle Scholar
- Yang, C. M., Spielman, A. J., & Glovinsky, P. (2006). Nonpharmacologic strategies in the management of insomnia. The Psychiatric Clinics of North America, 29(4), 895–919. doi: 10.1016/j.psc.2006.09.005. abstract viii.PubMedCrossRefGoogle Scholar
- Zee, P. C. (2006). Circadian rhythm sleep disorders. Primary Psychiatry, 13(8), 58–67.Google Scholar
Copyright information
© Springer Science+Business Media, LLC 2009