Helena C Kraemer

Stanford University, Palo Alto, California, United States

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Publications (483)2911.46 Total impact

  • Vyjeyanthi S Periyakoil · Eric Neri · Helena Kraemer ·
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    ABSTRACT: Objective: The study objective was to empirically identify barriers reported by multiethnic patients and families in receiving high-quality end-of-life care (EOLC). Methods: This cross-sectional, mixed-methods study in Burmese, English, Hindi, Mandarin, Tagalog, Spanish, and Vietnamese was held in multiethnic community centers in five California cities. Data were collected in 2013-2014. A snowball sampling technique was used to accrue 387 participants-261 women, 126 men, 133 Caucasian, 204 Asian Americans, 44 African Americans, and 6 Hispanic Americans. Measured were multiethnic patient-reported barriers to high-quality EOLC. A development cohort (72 participants) of responses was analyzed qualitatively using grounded theory to identify the six key barriers to high-quality EOLC. A new validation cohort (315 participants) of responses was transcribed, translated, and back-translated for verification. The codes were validated by analyses of responses from 50 randomly drawn subjects from the validation cohort. All the 315 validation cohort transcripts were coded for presence or absence of the six barriers. Results: In the validation cohort, 60.6% reported barriers to receiving high-quality EOLC for persons in their culture/ethnicity. Primary patient-reported barriers were (1) finance/health insurance barriers, (2) doctor behaviors, (3) communication chasm between doctors and patients, (4) family beliefs/behaviors, (5) health system barriers, and (6) cultural/religious barriers. Age (χ(2) = 9.15, DF = 1, p = 0.003); gender (χ(2) = 6.605, DF = 1, p = 0.01); and marital status (χ(2) = 16.11 DF = 3, p = 0.001) were associated with reporting barriers; and women <80 years were most likely to report barriers to receiving high-quality EOLC. Individual responses of reported barriers were analyzed and only the participant's level of education (Friedman statistic = 2.16, DF = 10, p = 0.02) significantly influenced choices. Conclusion: Multiethnic patients report that high-quality EOLC is important to them; but unfortunately, a majority state that they have encountered barriers to receiving such care. Efforts must be made to rapidly improve access to culturally competent EOLC for diverse populations.
    Journal of palliative medicine 11/2015; DOI:10.1089/jpm.2015.0403 · 1.91 Impact Factor
  • Helena Chmura Kraemer ·

    Medical Decision Making 08/2015; DOI:10.1177/0272989X15603984 · 3.24 Impact Factor
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    Vyjeyanthi S Periyakoil · Eric Neri · Helena Kraemer ·
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    ABSTRACT: Though most patients wish to discuss end-of-life (EOL) issues, doctors are reluctant to conduct end-of-life conversations. Little is known about the barriers doctors face in conducting effective EOL conversations with diverse patients. This mixed methods study was undertaken to empirically identify barriers faced by doctors (if any) in conducting effective EOL conversations with diverse patients and to determine if the doctors' age, gender, ethnicity and medical sub-specialty influenced the barriers reported. Mixed-methods study of multi-specialty doctors caring for diverse, seriously ill patients in two large academic medical centers at the end of the training; data were collected from 2010 to 2012. Doctor-reported barriers to EOL conversations with diverse patients. 1040 of 1234 potential subjects (84.3%) participated. 29 participants were designated as the development cohort for coding and grounded theory analyses to identify primary barriers. The codes were validated by analyses of responses from 50 randomly drawn subjects from the validation cohort (n= 996 doctors). Qualitative responses from the validation cohort were coded and analyzed using quantitative methods. Only 0.01 % doctors reported no barriers to conducting EOL conversations with patients. 99.99% doctors reported barriers with 85.7% finding it very challenging to conduct EOL conversations with all patients and especially so with patients whose ethnicity was different than their own. Asian-American doctors reported the most struggles (91.3%), followed by African Americans (85.3%), Caucasians (83.5%) and Hispanic Americans (79.3%) in conducting EOL conversations with their patients. The biggest doctor-reported barriers to effective EOL conversations are (i) language and medical interpretation issues, (ii) patient/family religio-spiritual beliefs about death and dying, (iii) doctors' ignorance of patients' cultural beliefs, values and practices, (iv) patient/family's cultural differences in truth handling and decision making, (v) patients' limited health literacy and (vi) patients' mistrust of doctors and the health care system. The doctors' ethnicity (Chi-Square = 12.77, DF = 4, p = 0.0125) and medical subspecialty (Chi-Square = 19.33, DF = 10, p =0.036) influenced their reported barriers. Friedman's test used to examine participants relative ranking of the barriers across sub-groups identified significant differences by age group (F statistic = 303.5, DF = 5, p < 0.0001) and medical sub-specialty (F statistic =163.7, DF = 5, p < 0.0001). Doctors report struggles with conducting effective EOL conversations with all patients and especially with those whose ethnicity is different from their own. It is vital to identify strategies to mitigate barriers doctors encounter in conducting effective EOL conversations with seriously ill patients and their families.
    PLoS ONE 04/2015; 10(4):e0122321. DOI:10.1371/journal.pone.0122321 · 3.23 Impact Factor
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    ABSTRACT: High levels of high-frequency heart rate variability (HF-HRV), related to parasympathetic-nervous-system functioning, have been associated with longer survival in patients with myocardial infarction and acute trauma and in patients undergoing palliative care. From animal studies linking higher vagal activity with better immune system functioning and reduced metastases, we hypothesized that higher HF-HRV would predict longer survival in patients with metastatic or recurrent breast cancer (MRBC). Eighty-seven patients with MRBC participated in a laboratory task including a 5-minute resting baseline electrocardiogram. HF-HRV was computed as the natural logarithm of the summed power spectral density of R-R intervals (0.15-0.50 Hz). In this secondary analysis of a study testing whether diurnal cortisol slope predicted survival, we tested the association between resting baseline HF-HRV on survival using Cox proportional hazards models. A total of 50 patients died during a median follow-up of 7.99 years. Higher baseline HF-HRV predicted significantly longer survival, with a hazard ratio of 0.75 (95% confidence interval = 0.60-0.92, p = .006). Visceral metastasis status and baseline heart rate were related to both HF-HRV and survival. However, a combination of HF-HRV and heart rate further improved survival prediction, with a hazard ratio of 0.64 (95% confidence interval = 0.48-0.85, p = .002). Vagal activity of patients with MRBC strongly predicted their survival, extending the known predictive window of HF-HRV in cancer beyond palliative care. Vagal activity can be altered by behavioral, pharmacological, and surgical interventions and may be a promising target for extending life expectancy in patients with metastasizing cancer.
    Psychosomatic Medicine 04/2015; 77(4). DOI:10.1097/PSY.0000000000000167 · 3.47 Impact Factor
  • Vyjeyanthi Periyakoil · Eric Neri · Helena Kraemer ·

    Journal of Pain and Symptom Management 02/2015; 49(2):446-447. DOI:10.1016/j.jpainsymman.2014.11.255 · 2.80 Impact Factor

  • Sleep Medicine 11/2014; 15(11). DOI:10.1016/j.sleep.2014.05.032 · 3.15 Impact Factor
  • Helena Chmura Kraemer ·
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    ABSTRACT: Does the McFarlane et al study1 provide a model for practical trials? Unfortunately, not. The methodological problems are here reviewed and used as a springboard to set out methodological criteria that might define such a model.
    Schizophrenia Bulletin 10/2014; 41(1). DOI:10.1093/schbul/sbu139 · 8.45 Impact Factor
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    ABSTRACT: Objective To compare the outcome of donepezil treatment in ethnically diverse Alzheimer Disease (AD) patients to ethnically diverse AD patients who did not receive donepezil. Design: Patients meeting NINCDS-ADRA criteria for probable or possible AD from a consortium of California sites were systematically followed for at least one year in this prospective, observational study. Their treatment regimens, including prescription of donepezil, were determined by their individual physician according to his or her usual criteria. Patients self-identified their ethnicity. Results: The 64 ethnically diverse AD patients who completed the study and received donepezil treatment had an average one year decline of 2.30 points (3.9 SD) on the 30-point MMSE compared with a 1.70 point (4.2 SD) decline in the 74 ethnically diverse completers who received no donepezil or other anti-AD drugs during the study period. This difference was not statistically significant. The overall Cohen effect size of this treatment-associated difference was estimated at – 0.15. After using propensity analyses and other techniques to assess factors that could bias prescribing decisions, the lack of benefits associated with donepezil treatment remained. The lack of donepezil benefits also remained when more traditional analyses were applied to these data. Conclusion: California ethnically diverse AD patients in this study apparently did not benefit from one year of donepezil treatment. These unpromising results are in contrast to modest benefits of donepezil treatment measured in a directly comparable California study involving white non-Latino AD patients.
    American Journal of Geriatric Psychiatry 09/2014; 23(4). DOI:10.1016/j.jagp.2014.09.007 · 4.24 Impact Factor
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    ABSTRACT: Separate bodies of literature report that elevated pro-inflammatory cytokines and cortisol negatively affect hippocampal structure and cognitive functioning, particularly in older adults. Although interactions between cytokines and cortisol occur through a variety of known mechanisms, few studies consider how their interactions affect brain structure. In this preliminary study, we assess the impact of interactions between circulating levels of IL-1Beta, IL-6, IL-8, IL-10, IL-12, TNF-alpha, and waking cortisol on hippocampal volume. Twenty-eight community-dwelling older adults underwent blood draws for quantification of circulating cytokines and saliva collections to quantify the cortisol awakening response. Hippocampal volume measurements were made using structural magnetic resonance imaging. Elevated levels of waking cortisol in conjunction with higher concentrations of IL-6 and TNF-alpha were associated with smaller hippocampal volumes. In addition, independent of cortisol, higher levels of IL-1beta and TNF-alpha were also associated with smaller hippocampal volumes. These data provide preliminary evidence that higher cortisol, in conjunction with higher IL-6 and TNF-alpha, are associated with smaller hippocampal volume in older adults. We suggest that the dynamic balance between the hypothalamic-pituitary adrenal axis and inflammation processes may explain hippocampal volume reductions in older adults better than either set of measures do in isolation.
    Frontiers in Aging Neuroscience 07/2014; 6:153. DOI:10.3389/fnagi.2014.00153 · 4.00 Impact Factor
  • Helena Chmura Kraemer ·
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    ABSTRACT: To understand the process by which a treatment (T) achieves an effect on outcome (O) and thus to improve the effect of T on O, it is vital to detect mediators, to compare the impact of different mediators, and to develop hypotheses about the causal factors (all mediators) linking T and O. An index is needed to facilitate interpretation of the potential clinical importance of a mediator (M) of choice of T on treatment O in randomized clinical trials (RCTs). Ideally such a mediator effect size should (1) be invariant under any rescaling of M and O consistent with the model used, and (2) reflect the difference between the overall observed effect of T on O and what the maximal effect of T on O could be were the association between T and M broken. A mediator effect size is derived first for the traditional linear model, and then more generally for any categorical (ordered or non-ordered) potential mediator. Issues such as the problem of multiple treatments, outcomes and mediators, and of causal inferences, and the correspondence between this approach and earlier ones, are discussed. Illustrations are given of the application of the approach. Copyright © 2014 John Wiley & Sons, Ltd.
    International Journal of Methods in Psychiatric Research 06/2014; 23(4). DOI:10.1002/mpr.1445 · 1.76 Impact Factor
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    Vyjeyanthi S Periyakoil · Eric Neri · Ann Fong · Helena Kraemer ·
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    ABSTRACT: High-intensity interventions are provided to seriously-ill patients in the last months of life by medical sub-specialists. This study was undertaken to determine if doctors' age, ethnicity, medical sub-specialty and personal resuscitation and organ donation preferences influenced their attitudes toward Advance Directives (AD) and to compare a cohort of 2013 doctors to a 1989 (one year before the Patient Self Determination Act in 1990) cohort to determine any changes in attitudes towards AD in the past 23 years.
    PLoS ONE 05/2014; 9(5):e98246. DOI:10.1371/journal.pone.0098246 · 3.23 Impact Factor
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    ABSTRACT: Background: Poor sleep, prevalent among cancer survivors, is associated with disrupted hormonal circadian rhythms and poor quality of life. Using a prospective research design, this study aimed to clarify the relationship between objective measures of sleep efficiency and sleep disruption with survival among women with advanced breast cancer. Method: We examined sleep quality and duration via wrist-worn actigraphy and sleep diaries for 3 days among 97 women in whom advanced breast cancer was diagnosed (age = 54.6 ± 9.8 years). Sleep efficiency was operationalized using actigraphy as the ratio of total sleep time to total sleep time plus wake after sleep onset. Results: As hypothesized, better sleep efficiency was found to predict a significant reduction in overall mortality (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.94-0.98; P < 0.001) at median 6 y follow-up. This relationship remained significant (HR, 0.94; 95% CI, 0.91-0.97; P < 0.001) even after adjusting for other known prognostic factors (age, estrogen receptor status, cancer treatment, metastatic spread, cortisol levels, and depression). Secondary hypotheses were also supported (after adjusting for baseline prognostic factors) showing that less wake after sleep onset (HR, 0.41; 95% CI, 0.25-0.67; P < 0.001), fewer wake episodes, (HR, 0.93; 95% CI, 0.88-0.98; P = 0.007); and shorter wake episode duration (HR, 0.29; 95% CI, 0.14-0.58; P < 0.001) also contributed to reductions in overall mortality. Conclusions: These findings show that better sleep efficiency and less sleep disruption are significant independent prognostic factors in women with advanced breast cancer. Further research is needed to determine whether treating sleep disruption with cognitive behavioral and/or pharmacologic therapy could improve survival in women with advanced breast cancer.
    Sleep 05/2014; 37(5):837-842. DOI:10.5665/sleep.3642 · 4.59 Impact Factor
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    Helena Chmura Kraemer · Robert Freedman ·

    American Journal of Psychiatry 02/2014; 171(2):134-6. DOI:10.1176/appi.ajp.2013.13111458 · 12.30 Impact Factor
  • Helena Chmura Kraemer ·

    Statistical Methods in Medical Research 02/2014; 23(1):111-3. DOI:10.1177/0962280213515776 · 4.47 Impact Factor
  • Helena Chmura Kraemer ·
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    ABSTRACT: Reliability of clinical diagnosis is essential for good clinical decision making as well as productive clinical research. The current review emphasizes the distinction between a disorder and a diagnosis and between validity and reliability of diagnoses, and the relationships that exist between them. What is crucial is that reliable diagnoses are essential to establishing valid diagnoses. The present review discusses the theoretical background underlying the evaluation of diagnoses, possible designs of reliability studies, estimation of the reliability coefficient, the standards for assessment of reliability, and strategies for improving reliability without compromising validity. Expected final online publication date for the Annual Review of Clinical Psychology Volume 10 is March 20, 2014. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.
    Annual Review of Clinical Psychology 01/2014; 10(1). DOI:10.1146/annurev-clinpsy-032813-153739 · 12.67 Impact Factor
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    ABSTRACT: Despite depressive disorders being very common there has been little research to guide primary care physicians on the choice of treatment for patients with mild to moderate depression. To evaluate the efficacy of interpersonal counselling compared with selective serotonin reuptake inhibitors (SSRIs), in primary care attenders with major depression and to identify moderators of treatment outcome. A randomised controlled trial in nine centres (DEPICS, Australian New Zealand Clinical Trials Registry number: ACTRN12608000479303). The primary outcome was remission of the depressive episode (defined as a Hamilton Rating Scale for Depression score ≤7 at 2 months). Daily functioning was assessed using the Work and Social Adjustment Scale. Logistic regression models were used to identify moderators of treatment outcome. The percentage of patients who achieved remission at 2 months was significantly higher in the interpersonal counselling group compared with the SSRI group (58.7% v. 45.1%, P = 0.021). Five moderators of treatment outcome were found: depression severity, functional impairment, anxiety comorbidity, previous depressive episodes and smoking habit. We identified some patient characteristics predicting a differential outcome with pharmacological and psychological interventions. Should our results be confirmed in future studies, these characteristics will help clinicians to define criteria for first-line treatment of depression targeted to patients' characteristics.
    The British journal of psychiatry: the journal of mental science 12/2013; 204(2). DOI:10.1192/bjp.bp.112.122663 · 7.99 Impact Factor
  • Meredith L Wallace · Ellen Frank · Helena C Kraemer ·
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    ABSTRACT: IMPORTANCE Identifying treatment moderators may help mental health practitioners arrive at more precise treatment selection for individual patients and can focus clinical research on subpopulations that differ in treatment response. OBJECTIVE To demonstrate a novel exploratory approach to moderation analysis in randomized clinical trials. DESIGN, SETTING, AND PARTICIPANTS A total of 291 adults from a randomized clinical trial that compared an empirically supported psychotherapy with selective serotonin reuptake inhibitor (SSRI) pharmacotherapy as treatments for depression. MAIN OUTCOMES AND MEASURES We selected 8 relatively independent individual moderators out of 32 possible variables. A combined moderator, M*, was developed as a weighted combination of the 8 selected individual moderators. M* was then used to identify individuals for whom psychotherapy may be preferred to SSRI pharmacotherapy or vice versa. RESULTS Among individual moderators, psychomotor activation had the largest moderator effect size (0.12; 95% CI, <.01 to 0.24). The combined moderator, M*, had a larger moderator effect size than any individual moderator (0.31; 95% CI, 0.15 to 0.46). Although the original analyses demonstrated no overall difference in treatment response, M* divided the study population into 2 subpopulations, with each showing a clinically significant difference in response to psychotherapy vs SSRI pharmacotherapy. CONCLUSIONS AND RELEVANCE Our results suggest that the strongest determinations for personalized treatment selection will likely require simultaneous consideration of multiple moderators, emphasizing the value of the methods presented here. After validation in a randomized clinical trial, a mental health practitioner could input a patient's relevant baseline values into a handheld computer programmed with the weights needed to calculate M*. The device could then output the patient's M* value and suggested treatment, thereby allowing the mental health practitioner to select the treatment that would offer the greatest likelihood of success for each patient.
    JAMA Psychiatry 09/2013; 70(11). DOI:10.1001/jamapsychiatry.2013.1960 · 12.01 Impact Factor
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    ABSTRACT: Objective: This article captures the proceedings of a meeting aimed at defining clinically meaningful effects for use in randomized controlled trials for psychopharmacological agents. Design: Experts from a variety of disciplines defined clinically meaningful effects from their perspectives along with viewpoints about how to design and interpret randomized controlled trials. Setting: The article offers relevant, practical, and sometimes anecdotal information about clinically meaningful effects and how to interpret them. Participants: The concept for this session was the work of co-chairs Richard Keefe and the late Andy Leon. Faculty included Richard Keefe, PhD; James McNulty, AbScB; Robert S. Epstein, MD, MS; Shelby D. Reed, PhD; Juan Sanchez, MD; Ginger Haynes, PhD; Andrew C. Leon, PhD; Helena Chmura Kraemer, PhD; Ellen Frank, PhD, and Kenneth L. Davis, MD. Results: The term clinically meaningful effect is an important aspect of designing and interpreting randomized controlled trials but can be particularly difficult in the setting of psychopharmacology where effect size may be modest, particularly over the short term, because of a strong response to placebo. Payers, regulators, patients, and clinicians have different concerns about clinically meaningful effects and may describe these terms differently. The use of moderators in success rate differences may help better delineate clinically meaningful effects. Conclusion: There is no clear consensus on a single definition for clinically meaningful differences in randomized controlled trials, and investigators must be sensitive to specific concerns of stakeholders in psychopharmacology in order to design and execute appropriate clinical trials.
    Innovations in Clinical Neuroscience 07/2013; 10(5-6 Suppl A):4S-19S.
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    ABSTRACT: Objective: This article describes the clinical utility and feasibility of proposed DSM-5 criteria and measures as tested in the DSM-5 Field Trials in Routine Clinical Practice Settings (RCP). METHODS RCP data were collected online for six months (October 2011 to March 2012). Participants included psychiatrists, licensed clinical psychologists, clinical social workers, advanced practice psychiatric-mental health nurses, licensed counselors, and licensed marriage and family therapists. Clinicians received staged, online training and enrolled at least one patient. Patients completed self-assessments of cross-cutting symptom domains, disability measures, and an evaluation of these measures. Clinicians conducted diagnostic interviews and completed DSM-5 and related assessments and a clinical utility questionnaire. Results: A total of 621 clinicians provided data for 1,269 patients. Large proportions of clinicians reported that the DSM-5 approach was generally very or extremely easy for assessment of both pediatric (51%) and adult (46%) patients and very or extremely useful in routine clinical practice for pediatric (48%) and adult (46%) patients. Clinicians considered the DSM-5 approach to be better (57%) or much better (18%) than that of DSM-IV. Patients, including children age 11 to 17 (47%), parents of children age six to ten (64%), parents of adolescents age 11 to 17 (72%), and adult patients (52%), reported that the cross-cutting measures would help their clinicians better understand their symptoms. Similar patterns in evaluations of feasibility and clinical utility were observed among clinicians from various disciplines. Conclusions: The DSM-5 approach was feasible and clinically useful in a wide range of routine practice settings and favorably received by both clinicians and patients.
    Psychiatric services (Washington, D.C.) 07/2013; 64(10). DOI:10.1176/appi.ps.201300098 · 2.41 Impact Factor
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    ABSTRACT: Objective: Additional treatments with persisting benefit are needed for ADHD. Because ADHD often shows excessive theta electroencephalogram (EEG) power, low beta, and excessive theta-beta ratio (TBR), a promising treatment is neurofeedback (NF) downtraining TBR. Although several nonblind randomized clinical trials (RCTs) show a medium-large benefit for NF, a well-blinded, sham-controlled RCT is needed to differentiate specific from nonspecific effects. Method: Experts in NF, ADHD, clinical trials, and statistics collaborated to design a double-blind multisite RCT. Results/Conclusion: At four sites, 180 children aged 7 to 10 years with rigorously diagnosed ADHD and TBR ≥ 5 will be randomized to active TBR-NF versus sham NF of equal duration, intensity, and appearance. Sham, utilizing prerecorded EEGs with participant artifacts superimposed, will keep participants and staff blind. Treatment fidelity will be trained/monitored by acknowledged NF leaders. Multidomain assessments before, during, and after treatment (follow-up to 2 years) will also include tests of blinding and sham inertness.
    Journal of Attention Disorders 07/2013; 17(5):420-426. DOI:10.1177/1087054713482580 · 3.78 Impact Factor

Publication Stats

31k Citations
2,911.46 Total Impact Points


  • 1963-2015
    • Stanford University
      • • Department of Psychiatry and Behavioral Sciences
      • • Stanford Prevention Research Center
      • • Department of Medicine
      Palo Alto, California, United States
  • 2003-2014
    • University of Pittsburgh
      • Department of Psychiatry
      Pittsburgh, Pennsylvania, United States
  • 2012
    • Norfolk and Norwich University Hospitals NHS Foundation Trust
      Norwich, England, United Kingdom
  • 2002-2011
    • Washington University in St. Louis
      • Department of Psychiatry
      San Luis, Missouri, United States
    • University of California, Los Angeles
      • Department of Family Medicine
      Los Angeles, CA, United States
    • Loyola University Maryland
      • Department of Psychology
      Baltimore, Maryland, United States
  • 2010
    • University of Chicago
      • Department of Psychiatry and Behavioral Neuroscience
      Chicago, IL, United States
  • 2009
    • University of California, San Francisco
      • Department of Anthropology, History and Social Medicine
      San Francisco, CA, United States
  • 1975-2009
    • Stanford Medicine
      • • Division of Cardiovascular Medicine
      • • Department of Psychiatry and Behavioral Sciences
      • • Department of Medicine
      • • Laboratory for the Study of Behavioral Medicine
      • • Stanford School of Medicine
      Stanford, California, United States
  • 2007
    • University of Rochester
      • Department of Radiation Oncology
      Rochester, New York, United States
    • Johns Hopkins University
      Baltimore, Maryland, United States
  • 2003-2007
    • Columbia University
      • Department of Psychiatry
      New York, New York, United States
  • 2006
    • University of Louisville
      • Department of Psychological and Brain Sciences
      Louisville, Kentucky, United States
    • Tel Aviv University
      Tell Afif, Tel Aviv, Israel
    • Palo Alto University
      Palo Alto, California, United States
  • 2004
    • University of South Florida
      • School of Aging Studies
      Tampa, Florida, United States
  • 2002-2003
    • University of Wisconsin, Madison
      • Department of Psychiatry
      Madison, MS, United States
  • 2001
    • Pennsylvania Mental Health and Justice Center of Excellence
      Philadelphia, Pennsylvania, United States
  • 2000
    • University of Oregon
      Eugene, Oregon, United States
    • Cornell University
      • Department of Psychiatry
      Итак, New York, United States
  • 1999-2000
    • Harvard University
      Cambridge, Massachusetts, United States
    • University of Texas Southwestern Medical Center
      • Department of Psychiatry
      Dallas, Texas, United States
    • University of Waterloo
      Waterloo, Ontario, Canada
  • 1997
    • Yale University
      • Department of Psychology
      New Haven, Connecticut, United States
  • 1994
    • Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
      Torrance, California, United States
  • 1992
    • University of Newcastle
      • School of Psychology
      Newcastle, New South Wales, Australia
  • 1991
    • Johns Hopkins Bloomberg School of Public Health
      Baltimore, Maryland, United States
  • 1989-1991
    • University of Arkansas at Little Rock
      Little Rock, Arkansas, United States
  • 1986
    • Santa Clara Valley Medical Center
      San Jose, California, United States

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