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ABSTRACT: Objective:There have been debates about the linkages between abortion and mental health. Few reviews have considered the extent to which abortion has therapeutic benefits that mitigate the mental health risks of abortion. The aim of this review was to conduct a re-appraisal of the evidence to examine the research hypothesis that abortion reduces rates of mental health problems in women having unwanted or unintended pregnancy.Methods:Analysis of recent reviews (Coleman, 2011; National Collaborating Centre for Mental Health, 2011) identified eight publications reporting 14 adjusted odds ratios (AORs) spanning five outcome domains: anxiety; depression; alcohol misuse; illicit drug use/misuse; and suicidal behaviour. For each outcome, pooled AORs were estimated using a random-effects model.Results:There was consistent evidence to show that abortion was not associated with a reduction in rates of mental health problems (p>0.75). Abortion was associated with small to moderate increases in risks of anxiety (AOR 1.28, 95% CI 0.97-1.70; p<0.08), alcohol misuse (AOR 2.34, 95% CI 1.05-5.21; p<0.05), illicit drug use/misuse (AOR 3.91, 95% CI 1.13-13.55; p<0.05), and suicidal behaviour (AOR 1.69, 95% CI 1.12-2.54; p<0.01).Conclusions:There is no available evidence to suggest that abortion has therapeutic effects in reducing the mental health risks of unwanted or unintended pregnancy. There is suggestive evidence that abortion may be associated with small to moderate increases in risks of some mental health problems.
Australian and New Zealand Journal of Psychiatry 04/2013; · 2.93 Impact Factor
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ABSTRACT: OBJECTIVE:To evaluate the extent to which a home-visitation program (Early Start) had benefits for child abuse, child behavior, and parental- and family-level benefits to the 9-year follow-up.METHODS:A randomized controlled trial in which 220 families receiving Early Start were contrasted with a control series of 223 families not receiving the program. Families were enrolled in the program for up to 5 years. Outcomes were assessed at 6 months, annually from 1 year to 6 years, and at 9 years after trial entry.RESULTS:Comparisons between the Early Start and control series showed that families in the Early Start program showed significant (P < .05) benefits in reduced risk of hospital attendance for unintentional injury, lower risk of parent-reported harsh punishment, lower levels of physical punishment, higher parenting competence scores, and more positive child behavioral adjustment scores. Effect sizes (Cohen's "d") ranged from 0.13 to 0.29 (median = 0.25). There were no significant differences (all P values > .05) between the Early Start and control series on a range of measures of parental behavior and family outcomes, including maternal depression, parental substance use, intimate partner violence, adverse economic outcomes, and life stress.CONCLUSIONS:The Early Start program was associated with small to moderate benefits in a range of areas relating to child abuse, physical punishment, child behavior, and parenting competence. There was little evidence to suggest that the Early Start program had benefits that extended to the level of parents or family overall.
PEDIATRICS 01/2013; · 4.47 Impact Factor
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ABSTRACT: BACKGROUND: This study examined the associations between measures of alcohol abuse/dependence (AAD) and several classifications of offending behaviour to age 30 in a New Zealand birth cohort. METHODS: Outcomes included: assault; use of a weapon; theft/burglary/vehicle conversion; property damage/vandalism/arson; and fraud/embezzlement/misappropriation of funds. The study also used measures of AAD symptoms; and time-dynamic covariate factors including life stress, other substance use, mental health status, peer and partner substance use and offending, and unemployment. Data were analysed using conditional fixed effects regression modelling augmented by time-dynamic covariate factors to control for confounding. RESULTS: Those with five or more AAD symptoms had unadjusted odds of offending that ranged from 6.23 to 21.25 times higher than those with no symptoms, with little evidence to suggest these associations varied with age. Adjustment for both unobserved fixed effects and time-dynamic covariate factors reduced the magnitude of the associations between AAD and offending, with those with five or more AAD symptoms having odds of offending that were 0.88-4.10 times higher than those with no symptoms. After adjustment, only the associations between AAD and: a) assault (OR=4.10; 95% CI=1.91-8.62; p<0.0001); and b) property damage/vandalism/arson (OR=3.87; 95% CI=1.30-11.39; p<0.0001); remained statistically significant. CONCLUSIONS: The results suggest a causal association between alcohol misuse and "impulsive" crimes such as assault and property damage/vandalism/arson, with estimates suggesting that AAD accounted for approximately 9.6-9.9% of these types of reported offending in the cohort.
Drug and alcohol dependence 08/2012; · 3.60 Impact Factor
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ABSTRACT: To examine the role of ethnicity and cultural identity in alcohol use and misuse in a birth cohort of over 1000 young people.
Data on ethnicity, cultural identification, alcohol use, alcohol abuse/dependence (AAD), socio-economic factors and childhood adversity were gathered as part of a longitudinal study of a New Zealand birth cohort (the Christchurch Health and Development Study).
Those reporting Māori ethnicity had rates of alcohol use and AAD that were 1.47-1.63 times higher than the rates found in the non-Māori people. However, there was little evidence to suggest that rates of alcohol use and AAD differed according to Māori cultural identity. Generalized estimating equation regression analyses adjusting for socio-economic disadvantage and childhood adversity slightly reduced the magnitude of these associations, but they remained statistically significant [AAD: odds ratio = 1.52; 95% confidence interval (CI): 1.11-2.10; consumption: incidence rate ratio = 1.31; 95% CI: 1.13-1.52].
(a) Māori ethnicity was found to be associated with modestly increased risks of alcohol use and AAD (b) the higher rates of alcohol use and AAD among the Māori members of the cohort could not be explained by a combination of socio-economic factors and greater exposure to environmental factors known to influence the risk of alcohol use and misuse.
Alcohol and Alcoholism 06/2012; 47(5):591-6. · 2.95 Impact Factor
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ABSTRACT: This paper examines the developmental antecedents of interpartner violence (IPV) victimization and perpetration in a New Zealand
birth cohort (n = 828). The study found: (a) IPV occurred in 70% of relationships, with conflict ranging from minor psychological abuse to
severe assault; (b) men and women reported similar experiences of victimization and perpetration of IPV; (c) exposure to abuse
in childhood, family dysfunction and adversity, childhood and adolescent conduct problems, and alcohol abuse/dependence were
significant predictors of IPV victimization and perpetration at age 25; and (d) the antecedents of IPV were largely the same
for males and females, although the specific effects of these risk factors differed according to gender. Conduct disorder
was more strongly predictive of IPV for females, whereas family adversity was more strongly predictive of IPV victimisation
for males.
Journal of Family Violence 04/2012; 23(8):737-753. · 1.17 Impact Factor
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ABSTRACT: This study examined the associations between the transition to parenthood and substance use disorders from ages 18 to 30 in a New Zealand birth cohort.
Outcomes included: DSM-IV criteria for: (a) alcohol abuse/dependence (AAD) and (b) illicit substance abuse/dependence. The study also used measures transition to parenthood during the period 18-30 years; and observed covariate factors including: family socio-economic status; family functioning; childhood abuse exposure; childhood personal and behavioural characteristics; and psychosocial adjustment in adolescence. Data were analysed using repeated measures Generalised Estimating Equation models, and conditional fixed effects regression modelling to control for confounding. Gender interactions were examined using moderated regression analyses.
Those who became parents had unadjusted odds of substance use disorder outcomes that were approximately 50% lower than those who had not become parents. Adjustment of the associations for both: (a) observed confounding factors and (b) non-observed fixed effects; strengthened the associations between parenthood status and substance use disorders. Custodial parents had odds of substance use disorders that were 57-78% lower than those who did not become parents after adjusting for non-observed fixed effects. Additional analyses suggested these effects were confined to custodial parents only. There was also evidence for gender×parenthood status interactions for AAD, with the effects of parenthood on AAD being stronger for females.
The results suggest that the transition to custodial parenthood may result in reduced risks of substance use disorder, particularly amongst female cohort members.
Drug and alcohol dependence 04/2012; 125(3):295-300. · 3.60 Impact Factor
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ABSTRACT: Recent studies have examined gene×environment (G×E) interactions involving the monoamine oxidase A (MAOA) gene in moderating the associations between exposure to adversity and antisocial behaviour. The present study examined a novel method for assessing interactions between a single gene and multiple risk factors related to environmental and personal adversity.
To test the hypothesis that the presence of the low-activity MAOA genotype was associated with an increased response to a series of risk factors.
Participants were 399 males from the Christchurch Health and Development Study who had complete data on: (a) MAOA promoter region variable number tandem repeat genotype; (b) antisocial behaviour (criminal offending) to age 30 and convictions to age 21; and (c) maternal smoking during pregnancy, IQ, childhood maltreatment and school failure.
Poisson regression models were fitted to three antisocial behaviour outcomes (property/violent offending ages 15-30; and convictions ages 17-21), using measures of exposure to adverse childhood circumstances. The analyses revealed consistent evidence of G x E interactions, such that those with the low-activity MAOA variant who were exposed to adversity in childhood were significantly more likely to report offending in late adolescence and early adulthood.
The present findings add to the evidence suggesting that there is a stable G x E interaction involving MAOA, a range of adverse environmental and personal factors, and antisocial behaviour across the life course. These analyses also demonstrate the utility of using multiple environmental/personal exposures to test G×E interactions.
The British journal of psychiatry: the journal of mental science 02/2012; 200(2):116-23. · 6.62 Impact Factor
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ABSTRACT: This study examined the associations between measures of alcohol abuse/dependence (AAD) and violent offending and intimate partner violence (IPV) to age 30 in a New Zealand birth cohort.
Outcomes included: measures of violent offending, violence victimization, and physical IPV perpetration and victimization. The study also used measures of AAD symptoms; and time-dynamic covariate factors including life stress, other substance use, mental health status, peer and partner substance use and offending, and unemployment. Data were analysed using conditional fixed effects regression modelling augmented by time-dynamic covariate factors to control for confounding.
Those with five or more AAD symptoms had unadjusted rates of violence outcomes that ranged from 4.10 to 11.85 times higher than those with no symptoms, but these associations did not differ by gender. Adjustment of the associations for both unobserved fixed effects and time-dynamic covariate factors reduced the magnitude of the associations for violent offending, violence victimization and IPV perpetration, with those with five or more AAD symptoms having rates of violence outcomes that were 1.91-3.58 times higher than those with no symptoms. However, control for both fixed effects and time-dynamic covariate factors reduced the associations between AAD symptoms and physical IPV victimization to statistical non-significance (IRR=0.73, 95% CI: 0.51-1.06).
The results suggest a causal association between alcohol misuse and violent offending/victimization and IPV perpetration, with estimates suggesting that alcohol use disorder accounted for approximately 4.6-9.3% of the reported violent offending/victimization and IPV perpetration in the cohort.
Drug and alcohol dependence 10/2011; 122(1-2):135-41. · 3.60 Impact Factor
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ABSTRACT: The present study examined the associations between internalizing disorders and substance use disorders using structural equation models to examine the relative contributions of common fixed confounding factors and direct causal pathways, and to determine the direction of causality.
Data were gathered during the course of the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children (n = 953). Measures included DSM-IV symptom criteria for major depression, anxiety disorders, alcohol abuse/dependence, nicotine dependence, and illicit drug abuse/dependence, ages 18, 21, and 25.
Structural equation modeling showed that for depression and substance use disorder, the best-fitting model was the one in which the associations were explained by a combination of common fixed factors and direct causal pathways from substance use to depression. A similar pattern emerged for anxiety disorders and (1) nicotine dependence, and (2) illicit drug abuse/dependence. The comorbidity of anxiety disorder and alcohol abuse/dependence was best explained by a model that included common fixed factors and a reciprocal pathway between these disorders. Decomposition of the correlations between internalizing disorders and substance use disorders showed that most of the correlation arose from direct causal pathways between disorders.
The findings suggest that the comorbidity between internalizing disorders and substance use disorders can be attributed to both common fixed factors and direct causal pathways between substance use disorder and internalizing disorder. The evidence suggests that, in most cases, the most plausible explanation of causality is the one in which substance use disorder increases the risk of internalizing disorder.
Social Psychiatry 10/2011; 46(10):933-42. · 2.05 Impact Factor
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ABSTRACT: The present study examined errors of reporting, including unreliability and recall bias, in retrospective reports of childhood maltreatment. Data were gathered on retrospective reports of childhood sexual and physical abuse and current mental health in a birth cohort of over 980 participants studied at ages 18 and 21. A structural equation model was developed to estimate the contributions of test unreliability and recall bias to reporting variation. Retrospective abuse reports were of modest test-retest reliability (r(tt) = 0.50 approximately). Recall bias accounted for <1% of report variance. As a consequence the observed correlations between maltreatment and mental health closely approximated the corresponding estimated true correlations. The results of the study suggested that, for this cohort, errors of measurement in reports of childhood maltreatment did not pose a significant threat to study validity.
International journal of methods in psychiatric research. 06/2011; 20(2):93-104.
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ABSTRACT: Recent studies have raised issues concerning the replicability of gene × environment (G × E) interactions involving the monoamine oxidase A (MAOA) gene in moderating the associations between abuse or maltreatment exposure and antisocial behaviour. This study attempted to replicate the findings in this area using a 30-year longitudinal study that has strong resemblance to the original research cohort.
To test the hypothesis that the presence of the low-activity MAOA genotype was associated with an increased response to abuse exposure.
Participants were 398 males from the Christchurch Health and Development Study who had complete data on: MAOA promoter region variable number tandem repeat genotype; antisocial behaviour to age 30; and exposure to childhood sexual and physical abuse.
Regression models were fitted to five antisocial behaviour outcomes (self-reported property offending; self-reported violent offending; convictions for property/violent offending; conduct problems; hostility) observed from age 16 to 30, using measures of childhood exposure to sexual and physical abuse. The analyses revealed consistent evidence of G × E interactions, with those having the low-activity MAOA variant and who were exposed to abuse in childhood being significantly more likely to report later offending, conduct problems and hostility. These interactions remained statistically significant after control for a range of potentially confounding factors. Findings for convictions data were somewhat weaker.
The present findings add to the evidence suggesting that there is a stable G × E interaction involving MAOA, abuse exposure and antisocial behaviour across the life course.
The British journal of psychiatry: the journal of mental science 06/2011; 198(6):457-63. · 6.62 Impact Factor
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ABSTRACT: To examine the literature on the associations between alcohol use disorders (AUD) and major depression (MD), and to evaluate the evidence for the existence of a causal relationship between the disorders.
PsycInfo; PubMed; Embase; Scopus; ISI Web of Science database searches for studies pertaining to AUD and MD from the 1980 to the present. Random-effects models were used to derive estimates of the pooled adjusted odds ratios (AOR) for the links between AUD and MD among studies reporting an AOR.
The analysis revealed that the presence of either disorder doubled the risks of the second disorder, with pooled AORs ranging from 2.00 to 2.09. Epidemiological data suggest that the linkages between the disorders cannot be accounted for fully by common factors that influence both AUD and MD, and that the disorders appear to be linked in a causal manner. Further evidence suggests that the most plausible causal association between AUD and MD is one in which AUD increases the risk of MD, rather than vice versa. Potential mechanisms underlying these causal linkages include neurophysiological and metabolic changes resulting from exposure to alcohol. The need for further research examining mechanisms of linkage, gender differences in associations between AUD and MD and classification issues was identified.
The current state of the literature suggests a causal linkage between alcohol use disorders and major depression, such that increasing involvement with alcohol increases risk of depression. Further research is needed in order to clarify the nature of this causal link, in order to develop effective intervention and treatment approaches.
Addiction 03/2011; 106(5):906-14. · 4.31 Impact Factor
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ABSTRACT: This study examined associations between age of menarche and psychosocial outcomes in early adulthood, including sexual behavior, mental health, criminal behavior, and education/employment, to identify the possible causal role of earlier age of menarche in increasing risks of adverse outcomes.
Data were gathered from 497 female members of a New Zealand longitudinal birth cohort. Outcome measures (to age 18 years) were as follows: pregnancy; sexually transmitted infection (STI); DSM-IV major depression, anxiety disorder, alcohol dependence and conduct disorder/ASPD; self-reported crime; convictions; leaving school without qualifications; and unemployment. Associations between age of menarche and outcome measures were then adjusted for confounding factors spanning family background, family functioning, and individual factors. Additional analyses examined sexual behavior outcomes to age 21, and all other outcomes to age 30 years.
Analyses showed that sexual behavior outcomes (pregnancy, STI) were significantly associated with age of menarche, even after controlling for confounding factors. Anxiety disorder was marginally (p < .10) associated with age of menarche. In addition, pregnancy during ages 18 to 21 years was significantly associated with age of menarche. There were no significant associations between age of menarche and outcomes at any other age (to age 30).
The study showed that females reaching menarche at an earlier age were at increased risk of early pregnancy, and STI by age 18. The present study found little evidence to suggest that age of menarche was related to mental health, criminal behavior, or education/employment outcomes for this cohort.
Journal of the American Academy of Child and Adolescent Psychiatry 02/2011; 50(2):132-140.e5. · 4.98 Impact Factor
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ABSTRACT: The present study examined the associations between involvement with alcohol and risks of sexually transmitted infection (STI) during adolescence and early adulthood.
A 30-year prospective longitudinal study of the health, development, and adjustment of a birth cohort of 1265 New Zealand-born individuals. Measures included repeated assessments of frequency of alcohol use and number of symptoms of alcohol disorder from ages 15 to 30 and rates of STI from ages 14 to 30. Conditional fixed effects regression models augmented by observed time-dynamic covariate factors were used to control for non-observed confounding in the associations between alcohol and STI risk.
There were clear and consistent trends for increasing involvement with alcohol to be linked with increased risk of STI diagnoses. Adjustment of the associations for sources of non-observed confounding and time-dynamic covariate factors reduced the magnitude of these associations, but they remained statistically significant (p < .05).
The results of the current study support the notion of the existence of a causal pathway in which increasing levels of alcohol use and symptoms of alcohol abuse/dependence led to increased risks of STI exposure. There was little evidence to suggest that the links between alcohol involvement and STI risk could be fully explained by an underlying predisposing factor that increased the risks of both alcohol involvement and STI.
Drug and alcohol dependence 01/2011; 113(2-3):200-6. · 3.60 Impact Factor
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ABSTRACT: The present study examined issues relating to the measurement and discriminant validity of Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria for behavior disorders in adolescence (conduct disorder [CD], oppositional defiant disorder [ODD], attention-deficit/hyperactivity disorder [ADHD]). Data were obtained from a birth cohort of 995 New Zealand-born individuals studied to the age of 25 years and modeled associations between behavior disorder from ages 14 to 16 years and later outcomes including crime, substance use, mental health, parenthood and partnership outcomes, and education and employment outcomes to age 25 years. The associations between behavior disorders and outcomes were adjusted for both comorbid behavior disorders and a range of confounding factors. The results suggested that (a) dimensional measures of behavior disorder were more strongly correlated with outcomes than categorical (DSM) measures; (b) CD, ODD, and ADHD each had a distinctive pattern of associations with longer term consequences; and (c) there was no evidence to suggest that the developmental consequences of CD, ODD, and ADHD differed by gender. In general, the results supported the validity of DSM diagnostic domains but also highlighted the importance of including in DSM-V methods for both recognizing the severity of disorder and addressing subclinical symptom levels.
Journal of Abnormal Psychology 11/2010; 119(4):699-712. · 4.86 Impact Factor
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ABSTRACT: To examine the social, family background, and individual antecedents of conduct disorder (CD) and oppositional defiant disorder (ODD), the extent to which CD and ODD symptoms were predicted by common environmental risk factors, and the extent to which the antecedents of CD and ODD accounted for the comorbidity between the two disorders.
Data were gathered from 926 members of a New Zealand longitudinal birth cohort. The outcome measures were DSM-IV symptom count measures of CD and ODD at age 14 to 16 years. Predictors measured during the period from 0 to 14 years included the following: maternal smoking during pregnancy; exposure to socioeconomic adversity; parental maladaptive behavior; childhood exposure to abuse and interparental violence; gender; cognitive ability; and affiliation with deviant peers in early adolescence. Associations between the predictors and outcome measures were modeled using structural equation modeling.
The analyses showed that each of the predictors was significantly (p < .05) associated with CD and ODD, with the exception of gender and ODD. After model fitting, the profile of risk factors that predicted CD and ODD were largely similar. The analyses revealed that approximately 40% of the comorbidity between disorders could be accounted for by common factors.
The data showed that CD and ODD had largely similar social and environmental antecedents. One implication of this finding is that treatment and prevention approaches that are developed for use with a particular behavior disorder may in fact reduce the incidence of both disorders.
Journal of the American Academy of Child and Adolescent Psychiatry 11/2010; 49(11):1125-33. · 4.98 Impact Factor
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ABSTRACT: Research on the comorbidity between cigarette smoking and major depression has not elucidated the pathways by which smoking is associated with depression.
To examine the causal relationships between smoking and depression via fixed-effects regression and structural equation modelling.
Data were gathered on nicotine-dependence symptoms and depressive symptoms in early adulthood using a birth cohort of over 1000 individuals.
Adjustment for confounding factors revealed persistent significant (P<0.05) associations between nicotine-dependence symptoms and depressive symptoms. Structural equation modelling suggested that the best-fitting causal model was one in which nicotine dependence led to increased risk of depression. The findings suggest that the comorbidity between smoking and depression arises from two routes; the first involving common or correlated risk factors and the second a direct path in which smoking increases the risk of depression.
This evidence is consistent with the conclusion that there is a cause and effect relationship between smoking and depression in which cigarette smoking increases the risk of symptoms of depression.
The British journal of psychiatry: the journal of mental science 06/2010; 196(6):440-6. · 6.62 Impact Factor
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ABSTRACT: The present study examined the role of socioeconomic status and cultural identity in the association between ethnicity and nicotine dependence, in a birth cohort of >1000 methods young people studied to age 30.
Data were gathered on ethnicity, cultural identification, nicotine dependence, and socioeconomic factors, as part of a longitudinal study of a New Zealand birth cohort (the Christchurch Health and Development Study).
Those reporting Māori identity had rates of nicotine dependence that were significantly higher (p < 0.05) than rates for non-Māori. Control for socioeconomic factors reduced the associations between ethnic identity and nicotine dependence to statistical non-significance. In addition, there was no evidence of a statistically significant association between Māori cultural identity and nicotine dependence, nor was there evidence of gender differences in the association between ethnic identity and nicotine dependence, after controlling for socioeconomic factors.
The higher rates of nicotine dependence observed among Māori appear to be attributable to differences in socioeconomic status. Efforts to improve the socioeconomic standing of Māori should therefore help to reduce rates of nicotine dependence in this population.
Australian and New Zealand Journal of Psychiatry 04/2010; 44(4):378-83. · 2.93 Impact Factor
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ABSTRACT: The present study examined the associations between the experience of sexual abuse in childhood (CSA) and the number of abortions in adolescence and early adulthood.
A 25-year prospective longitudinal study of the health, development, and adjustment of a birth cohort of 1,265 New Zealand children (630 females). Measures included assessments of experience of CSA using retrospective data gathered at ages 18 and 21, self-reported abortions from ages 15 to 25, measures of childhood socio-economic disadvantage, family stability, family functioning, experience of childhood physical abuse, and pregnancy in adolescence and early adulthood.
Severity of CSA experience was significantly (p<.01) associated with an increasing rate of abortions during ages 15-25. Adjustment of the association for potentially confounding factors from childhood reduced the magnitude of the association, but it remained marginally statistically significant (p<.10). However, controlling for the mediating effects of pregnancy risk in adolescence and early adulthood reduced the association between experience of CSA and abortion to statistical non-significance (p>.70).
The current study suggested that the association between experience of CSA and increased rates of abortion was mediated by the increased rates of pregnancy associated with CSA experiences. The results suggest a causal chain in which experience of CSA leads to increased rates of pregnancy, which in turn leads to increased rates of abortion.
Child abuse & neglect 11/2009; 33(12):870-6. · 2.34 Impact Factor
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ABSTRACT: There has been continued interest in the extent to which women have positive and negative reactions to abortion.
To document emotional reactions to abortion, and to examine the links between reactions to abortion and subsequent mental health outcomes.
Data were gathered on the pregnancy and mental health history of a birth cohort of over 500 women studied to the age of 30.
Abortion was associated with high rates of both positive and negative emotional reactions; however, nearly 90% of respondents believed that the abortion was the right decision. Analyses showed that the number of negative responses to the abortion was associated with increased levels of subsequent mental health disorders (P<0.05). Further analyses suggested that, after adjustment for confounding, those having an abortion and reporting negative reactions had rates of mental health disorders that were approximately 1.4-1.8 times higher than those not having an abortion.
Abortion was associated with both positive and negative emotional reactions. The extent of negative emotional reactions appeared to modify the links between abortion and subsequent mental health problems.
The British journal of psychiatry: the journal of mental science 11/2009; 195(5):420-6. · 6.62 Impact Factor
