Mental Health in Patients Requiring Pancreas and Visceral Transplantation

  • Catherine Crone
  • Jacqueline Posada


Patients with type I diabetes face lifelong insulin dependence and significant daily lifestyle adjustments along with the prospect of eventual complications and shortened life-span. A similar phenomenon exists for patients with intestinal failure who are dependent on parenteral nutrition. The psychological impact of life with these conditions, which significantly impacts day-to-day functioning and quality of life, is considerable and leads some to consider the possibility of transplantation. However, for transplant teams, awareness of the unique psychological issues that arise with each of these patient populations may allow for better understanding of their patients prior to transplant and enable more effective care planning.


Type 1 diabetes Diabetes distress Disordered eating behavior Fear of hypoglycemia Total parenteral nutrition Intestinal failure Anxiety Depression 


  1. 1.
    Roy T, Lloyd CE. Epidemiology of depression and diabetes: a systematic review. J Affect Disord. 2012;142(Suppl):S8–21.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Holt RIG, de Groot M, Lucki I, et al. NIDDK international conference report on diabetes and depression: current understanding and future directions. Diabetes Care. 2014;37:2067–77.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Buchberger B, Huppertz H, Krabbe L, et al. Symptoms of depression and anxiety in youth with type 1 diabetes: a systematic review and meta-analysis. Psychoneuroendocrinology. 2016;70:70–84.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Nouwen A, Nefs G, Caranlau I, et al. Prevalence of depression in individuals with impaired glucose metabolism or undiagnosed diabetes: a systematic review and meta-analysis of the European Depression in Diabetes (EDID) research consortium. Diabetes Care. 2011;34:752–62.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Lyoo IK, Yoon S, Jacobson AM, et al. Prefrontal cortical deficits in type 1 diabetes mellitus: brain correlates of comorbid depression. Arch Gen Psychiatry. 2012;69:1267–76.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Ho N, Sommers MS, Lucki I. Effects of diabetes on hippocampal neurogenesis: links to cognition and depression. Neurosci Biobehav Rev. 2013;37:1346–62.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Rustad JK, Musselman DL, Nemeroff CB. The relationship of depression and diabetes: pathophysiological and treatment implications. Psychoneuroendocrinology. 2011;36:1276–86.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Lustman PJ, Anderson RJ, Freedland KE, et al. Depression and poor glycemic control. Diabetes Care. 2000;23:934–42.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Reynolds KA, Helgeson VS. Children with diabetes compared to peers: depressed? Distressed? A meta-analytic review. Ann Behav Med. 2011;42:29–41.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    De Groot M, Anderson R, Freedland KE, et al. Association of depression and diabetes complications: a meta-analysis. Psychosom Med. 2001;63:619–30.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Molosankwe I, Patel A, Gagliardino J, et al. Economic aspects of the association between diabetes and depression: a systemic review. J Affect Disord. 2012;142:S42–55.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Park M, Katon WJ, Wolf FM. Depression and risk of mortality in individuals with diabetes: a meta-analysis and systemic review. Gen Hosp Psychiatry. 2013;35:217–25.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Katon W, Fan MY, Unutzer J, et al. Depression and diabetes: a potentially lethal combination. J Health Psychology. 2008;23:1571–5.Google Scholar
  14. 14.
    Stewart SM, Rao U, Emslie GJ, et al. Depressive symptoms predict hospitalization for adolescents with type 1 diabetes. Pediatrics. 2005;115:1315–9.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Ducat L, Rubenstein A, Philipson L, Anderson BJ. A review of the mental health issues of diabetes conference. Diabetes Care. 2015;38:333–8.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Petrak F, Baumeister H, Skinner TC, et al. Depression and diabetes: treatment and health-care delivery. Lancet Diabetes Endocrinol. 2015;3:472–485a.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Roy T, Lloyd CE, Pouwer F, et al. Screening tools used for measuring depression among people with type 1 and type 2 diabetes: a systematic review. Diabet Med. 2012;29:164–75.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Baumeister H, Hutter N, Bengel J. Psychological and pharmacological interventions for depression in patients with diabetes mellitus: an abridged Cochrane review. Diabet Med. 2014;31:773–86.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Petrak F, Herpertz S, Albus C, et al. Cognitive behavioral therapy versus sertraline in patient with depression and poorly controlled diabetes mellitus. Diabetes Care. 2015;38(5):767–75.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Simon GE, Katon WJ, Lin EHB, et al. Cost-effectiveness of systematic depression treatments among people with diabetes mellitus. Arch Gen Psychiatry. 2007;64:65–72.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Katon W, Russo J, Lin EH, et al. Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial. Arch Gen Psychiatry. 2012;69:506–14.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Fisher L, Gonzalez JS, Polonsky WH. The confusing tale of depression and distress in patients with diabetes: a call for greater clarity and precision. Diabet Med. 2014;31:764–72.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Gonzalez JS. Depression. In: Type 1 diabetes sourcebook. Alexandria: American Diabetes Association; 2013. p. 169–79.Google Scholar
  24. 24.
    Fisher L, Polonsky WH, Hessler DM, et al. Understanding the sources of diabetes distress in adults with type 1 diabetes. J Diabetes Complicat. 2015;29:572–7.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Fisher L, Hessler D, Polonsky W, et al. Diabetes distress in adults with type 1 diabetes: prevalence, incidence and change over time. J Diabetes Complicat. 2016;30:1123–8.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Hessler DM, Fisher L, Polonsky WH, et al. Diabetes distress is linked with worsening diabetes management over time in adults with type 1 diabetes. Diabet Med. 2017; Scholar
  27. 27.
    Hessler D, Fisher L, Polonsky W, et al. Understanding the areas and correlates of diabetes-related distress in parents of teens with type 1 diabetes. J Ped Psychol. 2016;41:750–8.CrossRefGoogle Scholar
  28. 28.
    Weissberg-Bencehll J, Antisdel-Lomaglio J. Diabetes-specific emotional distress among adolescents: feasibility, reliability, and validity of the problem areas in diabetes-teen version. Pediatr Diabetes. 2011;12:341–4.CrossRefGoogle Scholar
  29. 29.
    Smith KJ, Beland M, Clyde M, et al. Association of diabetes with anxiety: a systematic review and meta-analysis. J Psychosom Res. 2013;74:89–99.CrossRefGoogle Scholar
  30. 30.
    De Groot M, Golden SH, Wagner J. Psychological condition in adults with diabetes. Am Psychol. 2016;71:552–62.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Cemeroglu AP, Can A, Davis AT, et al. Fear of needles in children with TID mellitus on multiple daily injections (MDI) and continuous subcutaneous insulin infusion (CSII). Endocr Pract. 2015;21:46–53.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Van Son J, Nyklicek I, Pop VJ, et al. The effects of a mindfulness-based intervention on emotional distress, quality of life, and HbA (1c) in outpatients with diabetes (DiaMind): a randomized controlled trial. Diabetes Care. 2013;36:823–30.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Hopkins D, Lawrence I, Mansell P, et al. Improved biomedical and psychological outcomes 1 year after structured education in flexible insulin therapy for people with type 1 diabetes: the UK DAFNE experience. Diabetes Care. 2012;35:1638–42.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Martyn-Nemeth P, Farabi SS, Mihailescu D, et al. Fear of hypoglycemia in adults with type 1 diabetes: impact of therapeutic advances and strategies for prevention: a review. J Diabetes Complicat. 2016;30:167–77.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Wild D, Von Maltzahn R, Brohan E, et al. A critical review of the literature on fear of hypoglycemia in diabetes: implications for diabetes management and patient education. Patient Educ Couns. 2007;68:10–5.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Anderbro T, Gonder-Frederick L, Bolinder J, et al. Fear of hypoglycemia: relationship to hypoglycemic risk and psychological factors. Acta Diabetol. 2015;52:581–9.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Anderbro T, Amsberg S, Adamson U, et al. Fear of hypoglycemia in adults with type 1 diabetes. Diabet Med. 2007;27:1151–8.CrossRefGoogle Scholar
  38. 38.
    Amsberg S, Anderbro T, Wredling R, et al. A cognitive behavioral therapy-based intervention among poorly controlled adult type 1 diabetes patients: a randomized controlled trial. Patient Educ Couns. 2009;77:72–80.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    George JT, Vadovinos AP, Russell I, et al. Clinical effectiveness of a brief educational intervention in type 1 diabetes: results from the BITES (Brief Intervention in Type I Diabetes. Education for Self-efficacy) trial. Diabet Med. 2008;25:1447–53.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Cox DJ, Gonder-Frederick L, Polonsky W, et al. Blood glucose awareness training (BGAT-2): long-term benefits. Diabetes Care. 2001;24:637–42.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Cox DJ, Ritterband L, Magee J, et al. Blood glucose awareness training delivered over the internet. Diabetes Care. 2008;31:1527–8.PubMedPubMedCentralCrossRefGoogle Scholar
  42. 42.
    Larranaga A, Docet MF, Garcia-Mayor RV. Disordered eating behaviors in type 1 diabetic patients. World J Diabetes. 2011;11:189–95.CrossRefGoogle Scholar
  43. 43.
    Goebbel-Fabbri AE, Fikkan J, Franko DL, et al. Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care. 2008;31:415–9.CrossRefGoogle Scholar
  44. 44.
    Gagnon C, Aime A, Belanger C. Predictors of comorbid eating disorders and diabetes in people with type 1 and type 2 diabetes. Can J Diabetes. 2017;41:52–7.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Racicka E, Brynska A. Eating disorders in children and adolescents with type 1 and type 2 diabetes- prevalence, risk factors, warning signs. Psychiatr Pol. 2015;49:1017–24.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Olmsted MP, Colton PA, Daneman D, et al. Prediction of the onset of disturbed eating behavior in adolescent girls with type 1 diabetes. Diabetes Care. 2008;31:1978–82.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Goebel-Fabbri AE. Disturbed eating behaviors and eating disorders in type 1 diabetes: clinical significance and treatment recommendations. Curr Diab Rep. 2009;9:133–9.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Gibbons CH, Goebel-Fabbri A. Microvascular complications associated with rapid improvement in glycemic control in diabetes. Curr Diab Rep. 2017;17:48. Scholar
  49. 49.
    Goncalves S, Barros V, Gomes AR. Eating disordered behavior in adolescents with type 1 diabetes. Can J Diabetes. 2016;40:152–7.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    Colton P, Olmsted M, Daneman D, et al. Eating disorders in girls and women with type1 diabetes: a longitudinal study of prevalence, onset, remission, and recurrence. Diabetes Care. 2015a;38:1212–7.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Pinhas-Hamiel O, Hamiel U, Levy-Shraga Y. Eating disorder in adolescents with type 1 diabetes: challenges in diagnosis and treatment. World J Diabetes. 2015;6:517–26.PubMedPubMedCentralCrossRefGoogle Scholar
  52. 52.
    Markowitz JT, Butler DA, Volkening LK, et al. Brief screening tool for disordered eating in diabetes: internal consistency and external validity in a contemporary sample of pediatric patients with type 1 diabetes. Diabetes Care. 2010;33:495–500.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Colton PA, Olmsted MP, Wong H, Rodin GM. Eating disorders in individuals with type 1 diabetes: case series and day hospital treatment outcome. Eur Eat Disord Rev. 2015b;23:312–7.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Custal N, Arcelus J, Aguera Z, et al. Treatment outcome of patients with comorbid type 1 diabetes and eating disorders. BMC Psychiatry. 2014;14:40. Scholar
  55. 55.
    Bharadwaj S, Tandon P, Gohel TD, et al. Current status of intestinal and multivisceral transplantation. Gastroenterol Rep (Oxf). 2017;5:20–8.Google Scholar
  56. 56.
    Pironi L, Goulet O, Buchman A, et al. Outcome on home parenteral nutrition for benign intestinal failure: a review of the literature and benchmarking with the European prospective survey of ESPEN. Clin Nutr. 2012;31:831–45.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Grant D, Abu-Elmagd K, Mazariegos G, et al. Intestinal transplant registry report: global activity and trends. Am J Transplant. 2015;15:210–9.CrossRefGoogle Scholar
  58. 58.
    Stenn PG, Lammens P, Houle L, Grant D. Psychiatric psychosocial and ethical aspects of small bowel transplantation. Transplant Proc. 1992;24:1251–2.PubMedPubMedCentralGoogle Scholar
  59. 59.
    Jeppesen PB, Langholz E, Mortensen PB. Quality of life in patients receiving home parenteral nutrition. Gut. 1999;44(6):844–52.PubMedPubMedCentralCrossRefGoogle Scholar
  60. 60.
    Winkler MF, Smith CE. Clinical, social, and economic impacts of home parenteral nutrition dependence in short bowel syndrome. JPEN J Parenter Enteral Nutr. 2014;38(1 Suppl):32S–7S.PubMedCrossRefPubMedCentralGoogle Scholar
  61. 61.
    Huisman-de Waal G, Schoonhoven L, Jansen J, Wanten G, van Achterberg T. The impact of home parenteral nutrition on daily life-a review. Clin Nutr. 2007;26:275–88.PubMedCrossRefPubMedCentralGoogle Scholar
  62. 62.
    Hofstetter S, Stern L, Willet J. Key issues in addressing the clinical and humanistic burden of short bowel syndrome in the US. Curr Med Res Opin. 2013;29:495–504.PubMedCrossRefPubMedCentralGoogle Scholar
  63. 63.
    Howard LJ. Length of life and quality of life on home parenteral nutrition. JPEN J Parenter Enteral Nutr. 2002;26(5 Suppl):S55–9.PubMedCrossRefPubMedCentralGoogle Scholar
  64. 64.
    Persoon A, Huisman-de Waal G, Naber TA, et al. Impact of long-term HPN on daily life in adults. Clin Nutr. 2005;24:304–13.PubMedCrossRefPubMedCentralGoogle Scholar
  65. 65.
    Winkler MF. Quality of life in adult home parenteral nutrition patients. JPEN J Parenter Enteral Nutr. 2005;29:162–70.PubMedCrossRefPubMedCentralGoogle Scholar
  66. 66.
    Kelly DG, Tappenden KA, Winkler MF. Short bowel syndrome: highlights of patient management, quality of life, and survival. JPEN J Parenter Enteral Nutr. 2014;38:427–37.PubMedCrossRefPubMedCentralGoogle Scholar
  67. 67.
    Stern J. Home parenteral nutrition and the psyche: psychological challenges for patient and family. Proc Nutr Soc. 2006;65:222–6.PubMedCrossRefPubMedCentralGoogle Scholar
  68. 68.
    Baxter JP, Fayers PM, McKinlay AW. The clinical and psychometric validation of a questionnaire to assess the quality of life of adult patients treated with long-term parenteral nutrition. JPEN J Parenter Enteral Nutr. 2010;34:131–42.PubMedCrossRefPubMedCentralGoogle Scholar
  69. 69.
    Stern JM, Jacyna N, Lloyd DA. Review article: psychological aspects of home parenteral nutrition, abnormal illness behaviour and risk of self-harm in patients with central venous catheters. Aliment Pharmacol Ther. 2008;27:910–8.PubMedCrossRefPubMedCentralGoogle Scholar
  70. 70.
    Huisman-de Waal G, Naber T, Schoonhoven L, et al. Problems experienced by patients receiving parenteral nutrition at home: results of an open interview study. JPEN J Parenter Enteral Nutr. 2006;30:215–21.PubMedCrossRefPubMedCentralGoogle Scholar
  71. 71.
    Huisman-de Waal G, Versleijen M, van Achterberg T, et al. Psychosocial complaints are associated with venous access-device related complications in patients on home parenteral nutrition. JPEN J Parenter Enteral Nutr. 2011;35:588–95.PubMedCrossRefPubMedCentralGoogle Scholar
  72. 72.
    Dew MA, Rosenberger EM, Myaskovsky L, et al. Depression and anxiety as risk factors for morbidity and mortality after organ trans-plantation: a systematic review and meta-analysis. Transplantation. 2015;100:988–1003.PubMedPubMedCentralCrossRefGoogle Scholar
  73. 73.
    Nishida S, Kato T, Levi D, Nery J, Madariaga J, Mittal N, et al. Intestinal transplantation for trauma patients. Transplant Proc. 2002;34:913.PubMedCrossRefPubMedCentralGoogle Scholar
  74. 74.
    McNally RJ. Special areas of interest: post traumatic stress disorder. In: Sadock BJ, Sadock VA, editors. Kaplan and Sadock’s comprehensive textbook of psychiatry. 9th ed. Philadelphia: LWW; 2009. p. 2654.Google Scholar
  75. 75.
    Davydow DS, Lease ED, Reyes JD. Posttraumatic stress disorder in organ transplant recipients: a systematic review. Gen Hosp Psychiatry. 2015;37(5):387–98.PubMedPubMedCentralCrossRefGoogle Scholar
  76. 76.
    Regueiro M, Greer JB, Szigethy E. Etiology and treatment of pain and psychosocial issues in patients with inflammatory bowel diseases. Gastroenterology. 2017;152:430–9.PubMedCrossRefPubMedCentralGoogle Scholar
  77. 77.
    Sherwin E, Rea K, Dinan TG, Cryan JF. A gut (microbiome) feeling about the brain. Curr Opin Gastroenterol. 2016;32:96–102.PubMedCrossRefPubMedCentralGoogle Scholar
  78. 78.
    Nyabanga C, Kochhar G, Costa G, et al. Management of Crohn’s disease in the new era of gut rehabilitation and intestinal transplantation. Inflamm Bowel Dis. 2016;22:1763–76.PubMedCrossRefPubMedCentralGoogle Scholar
  79. 79.
    Mikocka-Walus A, Knowles SR, Keefer L, Graff L. Controversies revisited: a systematic review of the comorbidity of depression and anxiety with inflammatory bowel diseases. Inflamm Bowel Dis. 2016;22:752–62.PubMedCrossRefPubMedCentralGoogle Scholar
  80. 80.
    Villoria A, Garcia V, Dosal A, et al. Fatigue in out-patients with inflammatory bowel disease: prevalence and predictive factors. PLoS One. 2017;12(4):e0181435.PubMedPubMedCentralCrossRefGoogle Scholar
  81. 81.
    Targownik LE, Nugent Z, Singh H, et al. The prevalence and predictors of opioid use in inflammatory bowel disease: a population-based analysis. Am J Gastroenterol. 2014;109(10):1613–20.PubMedCrossRefPubMedCentralGoogle Scholar
  82. 82.
    Mayer EA, Tillisch K. The brain-gut axis in abdominal pain syndromes. Annu Rev Med. 2011;62:381–96.PubMedCrossRefPubMedCentralGoogle Scholar
  83. 83.
    Halpin SJ, Ford AC. Prevalence of symptoms meeting criteria for irritable bowel syndrome in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol. 2012;107:1474–82.PubMedCrossRefPubMedCentralGoogle Scholar
  84. 84.
    Rogal S, Mankaney G, Udawatta V, et al. Association between opioid use and readmission following liver transplantation. Clin Transpl. 2016;30(10):1222–9.CrossRefGoogle Scholar
  85. 85.
    Siniscalchi A, Begliomini B, De Pietri L, et al. Pain management after small bowel/multivisceral transplantation. Transplant Proc. 2002;34:969–70.PubMedCrossRefPubMedCentralGoogle Scholar
  86. 86.
    Marazziti D, Mungai F, Vivarelli L, et al. Pain and psychiatry: a critical analysis and pharmacological review. Clin Pract Epidemiol Ment Health. 2006;2:31.PubMedPubMedCentralCrossRefGoogle Scholar
  87. 87.
    Ward N. The impact of intestinal failure on oral drug absorption: a review. J Gastrointest Surg. 2010;14:1045–51.PubMedCrossRefPubMedCentralGoogle Scholar
  88. 88.
    Lloret-Linares C, Bellivier F, Heron K, Besson M. Treating mood disorders in patients with a history of intestinal surgery: a systematic review. Int Clin Psychopharmacol. 2015;30:119–28.PubMedCrossRefPubMedCentralGoogle Scholar
  89. 89.
    Faye E, Corcos O, Lancelin F, et al. Antidepressant agents in short bowel syndrome. Clin Ther. 2014;36:2033.e3.CrossRefGoogle Scholar
  90. 90.
    Owen JA, Crouse EL. Alternative route of drug administration. In: Levenson JL, Ferrando S, editors. Clinical manual of psychopharmacology in the medically ill. 2nd ed. Arlington: American Psychiatric Association Publishing; 2017. p. 101–25.Google Scholar
  91. 91.
    Robbins B, Reiss RA. Amitriptyline absorption in a patient with short bowel syndrome. Am J Gastroenterol. 1999;94:2302–4.PubMedCrossRefPubMedCentralGoogle Scholar
  92. 92.
    DiMartini A, Fitzgerald MG, Magill J, et al. Psychiatric evaluations of small intestine transplantation patients. Gen Hosp Psychiatry. 1996;18(6 Suppl):25S–9S.PubMedCrossRefPubMedCentralGoogle Scholar
  93. 93.
    Crone CC, Gabriel GM. Treatment of anxiety and depression in transplant patients: pharmacokinetic considerations. Clin Pharmacokinet. 2004;43(6):361–94.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of PsychiatryInova Fairfax HospitalFalls ChurchUSA
  2. 2.Department of PsychiatryVirginia Commonwealth University School of MedicineRichmondUSA
  3. 3.Department of PsychiatryGeorge Washington University School of MedicineWashington, DCUSA

Personalised recommendations