Amy M Kilbourne

Concordia University–Ann Arbor, Ann Arbor, Michigan, United States

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Publications (187)574.37 Total impact

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    ABSTRACT: Background The mood stabilisers lithium and valproate might plausibly have differing associations with mortality because of differing effects on mental health and various physiological indicators. Aims To assess associations between lithium, valproate and non-suicide mortality. Method Intention-to-treat, propensity score-matched cohort study. Results Lithium was associated with significantly reduced non-suicide mortality in the intent-to-treat cohort over 0-90 days (hazard ratio (HR) = 0.67, 95% CI 0.51-0.87) but not longer. In secondary analyses, a sizeable reduction in mortality was observed during active treatment with lithium across all time periods studied (for example 365-day HR = 0.62, 95% CI 0.45-0.84), but significantly increased risks were observed among patients discontinuing lithium by 180 days (HR = 1.54, 95% CI 1.01-2.37). Conclusions Patients initiating lithium had lower non-suicide mortality over 0-90 days than patients initiating valproate and consistently lower non-suicide mortality among patients maintaining treatment, but elevated risk among patients discontinuing treatment by 180 days. Although residual confounding or selection effects cannot be excluded, this study suggests potential benefits to enhancing lithium treatment persistence and the monitoring of patients discontinuing lithium. There is a need for further research. © The Royal College of Psychiatrists 2015.
    The British journal of psychiatry: the journal of mental science 05/2015; DOI:10.1192/bjp.bp.113.138685 · 7.34 Impact Factor
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    ABSTRACT: To examine gender differences in prescribing of antipsychotic medications (APMs) according to their liability for weight gain and other metabolic side effects. We identified 4510 patients with schizophrenia or bipolar disorders receiving usual care in a Veterans Affairs (VA) health care network in the U.S. mid-Atlantic region who initiated treatment with an APM between October 2006 and September 2011. We used multivariable logistic regression to examine gender differences in the likelihood of incident prescription of APMs with low versus medium/high metabolic risk, adjusting for fiscal year of prescribing and selected Veteran demographic, mental health and physical health characteristics. Overall, 58% of women were prescribed an APM with a low risk of metabolic side effects compared to 45% of men (P<.001). In multivariable analysis, women Veterans were 1.47 times as likely as men to be prescribed a low-metabolic-risk APM (95% confidence interval: 1.26-1.73, P<.001). Several demographic and clinical covariates were also independently related to prescribing of APMs by level of metabolic risk. The results may suggest that prescribing choices for APMs by VA mental health prescribers and female Veterans reflect a growing awareness of the potential adverse health consequences of these treatments in women. Copyright © 2015. Published by Elsevier Inc.
    General Hospital Psychiatry 04/2015; DOI:10.1016/j.genhosppsych.2015.03.018 · 2.90 Impact Factor
  • Soham Rej, Martha Sajatovic, John Beyer, Amy M. Kilbourne
    American Journal of Geriatric Psychiatry 03/2015; 23(3):S30-S31. DOI:10.1016/j.jagp.2014.12.047 · 3.52 Impact Factor
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    ABSTRACT: Background Little is known about the demographic and clinical differences between early- and late-onset depressions (EOD and LOD, respectively) in Chinese patients. This study examined the demographic and clinical profile of EOD (<=25 years) compared to LOD (>25 years) in China. Methods A consecutively recruited sample of 1178 patients with MDD was assessed in 13 psychiatric hospitals or psychiatric units of general hospitals in China nationwide. The cross-sectional data of patients׳ demographic and clinical characteristics and prescriptions of psychotropic drugs including antidepressants, mood stabilizers, antipsychotics and benzodiazepines were recorded using a standardized protocol and data collection procedure. Results Two hundred and seventy five (23.3%) of the 1178 patients fulfilled criteria for EOD. In multiple logistic regression analyses, compared to LOD patients their EOD counterparts were more likely to be unmarried and unemployed, had more atypical and psychotic depressive episodes, had bipolar features, while they had more lifetime depressive episodes. Conclusions The demographic and more severe clinical features of EOD in Chinese patients were basically consistent with those found in Western populations. The association between socio-cultural factors and development of EOD warrants further studies.
    Journal of Affective Disorders 01/2015; 170:266–269. DOI:10.1016/j.jad.2014.09.008 · 3.71 Impact Factor
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    ABSTRACT: This study compared effectiveness of an enhanced versus standard implementation strategy (Replicating Effective Programs [REP]) on site-level uptake of Re-Engage, a national program for veterans with serious mental illness. Mental health providers at 158 Veterans Affairs (VA) facilities were given REP-based manuals and training in Re-Engage, which involved identifying veterans who had not been seen in VA care for at least one year, documenting their clinical status, and coordinating further health care. After six months, facilities not responding to REP (N=88) were randomized to receive six months of facilitation (enhanced REP) or continued standard REP. Site-level uptake was defined as percentage of patients (N=1,531) with updated documentation or with whom contact was attempted. Rate of Re-Engage uptake was greater for enhanced REP sites compared with standard REP sites (41% versus 31%, p=.01). Total REP facilitation time was 7.3 hours per site for six months. Added facilitation improved short-term uptake of a national mental health program.
    Psychiatric services (Washington, D.C.) 01/2015; 66(1):90-3. DOI:10.1176/appi.ps.201300497 · 1.99 Impact Factor
  • 01/2015; 13(1):85-93. DOI:10.1176/appi.focus.130114
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    ABSTRACT: Background Few implementation strategies have been empirically tested for their effectiveness in improving uptake of evidence-based treatments or programs. This study compared the effectiveness of an immediate versus delayed enhanced implementation strategy (Enhanced Replicating Effective Programs (REP)) for providers at Veterans Health Administration (VA) outpatient facilities (sites) on improved uptake of an outreach program (Re-Engage) among sites not initially responding to a standard implementation strategy.Methods One mental health provider from each U.S. VA site (N¿=¿158) was initially given a REP-based package and training program in Re-Engage. The Re-Engage program involved giving each site provider a list of patients with serious mental illness who had not been seen at their facility for at least a year, requesting that providers contact these patients, assessing patient clinical status, and where appropriate, facilitating appointments to VA health services. At month 6, sites considered non-responsive (N¿=¿89, total of 3,075 patients), defined as providers updating documentation for less than <80% of patients on their list, were randomized to two adaptive implementation interventions: Enhanced REP (provider coaching; N¿=¿40 sites) for 6 months followed by Standard REP for 6 months; versus continued Standard REP (N¿=¿49 sites) for 6 months followed by 6 months of Enhanced REP for sites still not responding. Outcomes included patient-level Re-Engage implementation and utilization.ResultsPatients from sites that were randomized to receive Enhanced REP immediately compared to Standard REP were more likely to have a completed contact (adjusted OR¿=¿2.13; 95% CI: 1.09¿4.19, P¿=¿0.02). There were no differences in patient-level utilization between Enhanced and Standard REP sites.Conclusions Enhanced REP was associated with greater Re-Engage program uptake (completed contacts) among sites not responding to a standard implementation strategy. Further research is needed to determine whether national implementation of Facilitation results in tangible changes in patient-level outcomes.Trial registrationISRCTN: ISRCTN21059161.
    Implementation Science 12/2014; 9(1):778. DOI:10.1186/s13012-014-0163-3 · 3.47 Impact Factor
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    ABSTRACT: Background Lithium has been reported in some, but not all, studies to be associated with reduced risk of suicide death or suicidal behavior. The objective of this nonrandomized cohort study was to examine whether lithium was associated with reduced risk of suicide death in comparison to the commonly-used alternative treatment, valproate.MethodsA propensity score-matched cohort study was conducted of Veterans Health Administration patients (n¿=¿21,194/treatment) initiating lithium or valproate from 1999¿2008.ResultsMatching produced lithium and valproate treatment groups that were highly similar in all 934 propensity score covariates, including indicators of recent suicidal behavior, but recent suicidal ideation was not able to be included. In the few individuals with recently diagnosed suicidal ideation, a significant imbalance existed with suicidal ideation more prevalent at baseline among individuals initiating lithium than valproate (odds ratio (OR) 1.30, 95% CI 1.09, 1.54; p¿=¿0.003). No significant differences in suicide death were observed over 0¿365 days in A) the primary intent-to-treat analysis (lithium/valproate conditional odds ratio (cOR) 1.22, 95% CI 0.82, 1.81; p¿=¿0.32); B) during receipt of initial lithium or valproate treatment (cOR 0.86, 0.46, 1.61; p¿=¿0.63); or C) after such treatment had been discontinued/modified (OR 1.51, 95% CI 0.91, 2.50; p¿=¿0.11). Significantly increased risks of suicide death were observed after the discontinuation/modification of lithium, compared to valproate, treatment over the first 180 days (OR 2.72, 95% CI 1.21, 6.11; p¿=¿0.015).Conclusions In this somewhat distinct sample (a predominantly male Veteran sample with a broad range of psychiatric diagnoses), no significant differences in associations with suicide death were observed between lithium and valproate treatment over 365 days. The only significant difference was observed over 0¿180 days: an increased risk of suicide death, among individuals discontinuing or modifying lithium, compared to valproate, treatment. This difference could reflect risks either related to lithium discontinuation or higher baseline risks among lithium recipients (i.e., confounding) that became more evident when treatment stopped. Our findings therefore support educating patients and providers about possible suicide-related risks of discontinuing lithium even shortly after treatment initiation, and the close monitoring of patients after lithium discontinuation, if feasible. If our findings include residual confounding biasing against lithium, however, as suggested by the differences observed in diagnosed suicidal ideation, then the degree of beneficial reduction in suicide death risk associated with lithium treatment would be underestimated. Further research is urgently needed, given the lack of interventions against suicide and the uncertainties concerning the degree to which lithium may reduce suicide risk during active treatment, increase risk upon discontinuation, or both.
    BMC Psychiatry 12/2014; 14(1):357. DOI:10.1186/s12888-014-0357-x · 2.24 Impact Factor
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    ABSTRACT: Mood disorders represent the most expensive mental disorders for employer-based commercial health plans. Collaborative care models are effective in treating chronic physical and mental illnesses at little to no net healthcare cost, but to date have primarily been implemented by larger healthcare organizations in facility-based models. The majority of practices providing commercially insured care are far too small to implement such models. Health plan-level collaborative care treatment can address this unmet need. The goal of this study is to implement at the national commercial health plan level a collaborative care model to improve outcomes for persons with mood disorders. A randomized controlled trial of a collaborative care model versus usual care will be conducted among beneficiaries of a large national health plan from across the country seen by primary care or behavioral health practices. At discharge 344 patients identified by health plan claims as hospitalized for unipolar depression or bipolar disorder will be randomized to receive collaborative care (patient phone-based self-management support, care management, and guideline dissemination to practices delivered by a plan-level care manager) or usual care from their provider. Primary outcomes are changes in mood symptoms and mental health-related quality of life at 12 months. Secondary outcomes include rehospitalization, receipt of guideline-concordant care, and work productivity. This study will determine whether a collaborative care model for mood disorders delivered at the national health plan level improves outcomes compared to usual care, and will inform a business case for collaborative care models for these settings that can reach patients wherever they receive treatment. ClinicalTrials.gov Identifier: NCT02041962; registered January 3, 2014.
    11/2014; 2(1):48. DOI:10.1186/s40359-014-0048-x
  • Amy M Kilbourne, David Atkins
    Journal of General Internal Medicine 10/2014; DOI:10.1007/s11606-014-3050-3 · 3.42 Impact Factor
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    ABSTRACT: This randomized controlled implementation study compared the effectiveness of a standard versus enhanced version of the replicating effective programs (REP) implementation strategy to improve the uptake of the life goals-collaborative care model (LG-CC) for bipolar disorder. Seven community-based practices (384 patient participants) were randomized to standard (manual/training) or enhanced REP (customized manual/training/facilitation) to promote LG-CC implementation. Participants from enhanced REP sites had no significant changes in primary outcomes (improved quality of life, reduced functioning or mood symptoms) by 24 months. Further research is needed to determine whether implementation strategies can lead to sustained, improved participant outcomes in addition to program uptake.
    Administration and Policy in Mental Health and Mental Health Services Research 10/2014; DOI:10.1007/s10488-014-0598-5 · 3.44 Impact Factor
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    ABSTRACT: Background Despite the availability of psychosocial evidence-based practices (EBPs), treatment and outcomes for persons with mental disorders remain suboptimal. Replicating Effective Programs (REP), an effective implementation strategy, still resulted in less than half of sites using an EBP. The primary aim of this cluster randomized trial is to determine, among sites not initially responding to REP, the effect of adaptive implementation strategies that begin with an External Facilitator (EF) or with an External Facilitator plus an Internal Facilitator (IF) on improved EBP use and patient outcomes in 12 months.Methods/DesignThis study employs a sequential multiple assignment randomized trial (SMART) design to build an adaptive implementation strategy. The EBP to be implemented is life goals (LG) for patients with mood disorders across 80 community-based outpatient clinics (N¿=¿1,600 patients) from different U.S. regions. Sites not initially responding to REP (defined as <50% patients receiving ¿3 EBP sessions) will be randomized to receive additional support from an EF or both EF/IF. Additionally, sites randomized to EF and still not responsive will be randomized to continue with EF alone or to receive EF/IF. The EF provides technical expertise in adapting LG in routine practice, whereas the on-site IF has direct reporting relationships to site leadership to support LG use in routine practice. The primary outcome is mental health-related quality of life; secondary outcomes include receipt of LG sessions, mood symptoms, implementation costs, and organizational change.DiscussionThis study design will determine whether an off-site EF alone versus the addition of an on-site IF improves EBP uptake and patient outcomes among sites that do not respond initially to REP. It will also examine the value of delaying the provision of EF/IF for sites that continue to not respond despite EF.Trial registrationClinicalTrials.gov identifier: NCT02151331.
    Implementation Science 09/2014; 9(1):132. DOI:10.1186/s13012-014-0132-x · 3.47 Impact Factor
  • Carol A Janney, Mark S Bauer, Amy M Kilbourne
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    ABSTRACT: This review provides clinicians and individuals with bipolar disorder (BD) with an overview of evidence-based skills shown to be effective in BD and amenable to self-management including psychoeducation; monitoring moods, medications, and social function; sleep hygiene; setting goals and relapse plans; and healthy lifestyles (physical activity, healthy eating, weight loss and management, medical comorbidities). Currently available self-management resources for BD are summarized by mode of delivery (workbooks, mobile technologies, internet, and peer-led interventions). Regardless of the self-management intervention/topic, the research suggests that personally tailored interventions of longer duration and greater frequency may be necessary to achieve the maximal benefit among individuals with BD. Means to support these self-management interventions as self-sustaining identities are critically needed. Hopefully, the recent investment in patient-centered research and care will result in best practices for the self-management of BD by mode of delivery. Since self-management of BD should complement rather than replace medical care, clinicians need to partner with their patients to incorporate and support advances in self-management for individuals with BD.
    Current Psychiatry Reports 09/2014; 16(9):485. DOI:10.1007/s11920-014-0485-5 · 3.05 Impact Factor
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    ABSTRACT: Background Persons with serious mental illnesses (SMI) are more likely to die earlier than the general population, primarily due to increased medical burden, particularly from cardiovascular disease (CVD). Life Goals Collaborative Care (LG-CC) is designed to improve health outcomes in SMI through self-management, care management, and provider support. This single-blind randomized controlled effectiveness study will determine whether patients with SMI receiving LG-CC compared to usual care (UC) experience improved physical health in 12 months. Methods Patients diagnosed with SMI and at least one CVD risk factor receiving care at a VA mental health clinic were randomized to LG-CC or UC. LG-CC included five self-management sessions covering mental health symptom management reinforced through health behavior change; care coordination and health monitoring via a registry, and provider feedback. The primary outcome is change in physical health-related quality of life score (VR-12) from baseline to 12 months. Secondary outcomes include changes in mental health-related quality of life, CVD risk factors (blood pressure, BMI), and physical activity from baseline to 12 months later. Results Out of 304 enrolled, 139 were randomized to LG-CC and 145 to UC. Among patients completing baseline assessments (N = 284); the mean age was 55.2 (SD = 10.9; range 28–75 years), 15.6% were women, the majority (62%) were diagnosed with depression, and the majority (63%) were diagnosed with hypertension or were overweight (BMI mean ± SD = 33.3 ± 6.3). Baseline VR-12 physical health component score was below population norms (50.0 ± SD = 10) at 33.4 ± 11.0. Conclusions Findings from this trial may inform initiatives to improve physical health for SMI patient populations.
    Contemporary Clinical Trials 09/2014; 39(1). DOI:10.1016/j.cct.2014.07.007 · 1.99 Impact Factor
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    ABSTRACT: Objective: This evaluation compared the effectiveness of MOVE!, a U.S. Veterans Health Administration (VHA) weight management program, among veterans with post-traumatic stress disorder (PTSD), other mental conditions, or no mental health diagnoses. Methods: YHA administrative data from 2008 to 2012 were used to estimate adjusted six- and 12-month weight change and >= 5% weight loss among 20,819 veterans with "intense and sustained" MOVE! participation (14% of 148,963 MOVE! participants, regardless of mental health status). Results: Compared with veterans with no mental health diagnoses, veterans with PTSD lost significantly less weight at six and 12 months (p<.05) and were less likely to lose 5(70 body weight at six months (OR =.89, p<.05). At six months, those with other mental conditions lost significantly less weight than those with no mental health diagnoses (p<.05). Conclusions: MOVE! may need adaptation to increase overall engagement and enhance weight loss for veterans with mental conditions, especially PTSD.
    Psychiatric services (Washington, D.C.) 08/2014; 65(11). DOI:10.1176/appi.ps.201300404 · 1.99 Impact Factor
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    ABSTRACT: People with bipolar disorders report a lower quality of life than the general population does, and few mutable factors associated with health-related quality of life (HRQoL) among people with bipolar disorders have been identified. Using a cross-sectional design, these analyses examined whether self-efficacy was associated with mental and physical HRQoL in a sample of 141 patients with bipolar disorder who completed baseline assessments for two randomized controlled trials. Multiple linear regression analyses indicated that higher levels of self-efficacy were associated with higher mental and physical HRQoL, after controlling for demographic factors and clinical factors (including mood symptoms, comorbid medical conditions, and substance use). Future research should examine whether targeted treatments that aim to improve self-efficacy (such as self-management interventions) lead to improvements in HRQoL among people with bipolar disorder and other serious mental illnesses.
    Journal of Nervous & Mental Disease 07/2014; 202(8). DOI:10.1097/NMD.0000000000000165 · 1.81 Impact Factor
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    ABSTRACT: The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) posttraumatic stress disorder (PTSD) module is widely used in epidemiological studies of PTSD, yet relatively few data attest to the instrument's diagnostic utility. The current study evaluated the diagnostic utility of the CIDI 3.0 PTSD module with U. S. women Vietnam-era veterans. The CIDI and the Clinician-Administered PTSD Scale (CAPS) were independently administered to a stratified sample of 160 women, oversampled for current PTSD. Both lifetime PTSD and recent (past year) PTSD were assessed within a 3-week interval. Forty-five percent of the sample met criteria for a CAPS diagnosis of lifetime PTSD, and 21.9% of the sample met criteria for a CAPS diagnosis of past-year PTSD. Using CAPS as the diagnostic criterion, the CIDI correctly classified 78.8% of cases for lifetime PTSD (κ = .56) and 82.0% of past year PTSD cases (κ = .51). Estimates of diagnostic performance for the CIDI were sensitivity of .61 and specificity of .91 for lifetime PTSD and sensitivity of .71 and specificity of .85 for past-year PTSD. Results suggest that the CIDI has good utility for identifying PTSD, though it is a somewhat conservative indicator of lifetime PTSD as compared to the CAPS.Traditional and Simplified Chinese Abstracts by AsianSTSS標題:女越南戰事退役軍中綜合國際診斷會見(CIDI 3.0) 的診斷準確性撮要:世界衛生組織(WHO)綜合國際診斷會見(CIDI)創傷後壓力症(PTSD)單元被廣泛應用於PTSD流行學研究,但只有少數研究其相關診斷效用。本研究在女性越南戰事退役軍中評定CIDI 3.0 PTSD單元的診斷效能。這是160名女士的分層和過度採樣現有PTSD的樣本,然後獨立地施行CIDI 和醫生施行PTSD量表(CAPS)。在三週內使用評估其終生PTSD和現有(過去一年)PTSD。總數45.0%符合CAPS終生PTSD診斷準則,和21.9%為CAPS過去一年PTSD診斷準則。以CAPS為診斷標準,CIDI 正確判別78.8% 終生PTSD個案(K= .56)和82.0% 過去一年PTSD 個案(K= .51) 。利用CAPS為標準估計CIDI的診斷表現,終生PTSD的靈敏度為.61和特異性為.091,而過往一年PTSD的靈敏度是.71 和特異性是.85。結果確認CIDI對辨識PTSD有高效用,但對比CAPS在終生PTSD方面卻是較保守的指標。标题:女越南战事退役军中综合国际诊断会见(CIDI 3.0) 的诊断准确性撮要:世界卫生组织(WHO)综合国际诊断会见(CIDI)创伤后压力症(PTSD)单元被广泛应用于PTSD流行学研究,但只有少数研究其相关诊断效用。本研究在女性越南战事退役军中评定CIDI 3.0 PTSD单元的诊断效能。这是160名女士的分层和过度采样现有PTSD的样本,然后独立地施行CIDI 和医生施行PTSD量表(CAPS)。在三周内使用评估其终生PTSD和现有(过去一年)PTSD。总数45.0%符合CAPS终生PTSD诊断准则,和21.9%为CAPS过去一年PTSD诊断准则。以CAPS为诊断标准,CIDI 正确判别78.8% 终生PTSD个案(K= .56)和82.0% 过去一年PTSD 个案(K= .51) 。利用CAPS为标准估计CIDI的诊断表现,终生PTSD的灵敏度为.61和特异性为.091,而过往一年PTSD的灵敏度是.71 和特异性是.85。结果确认CIDI对辨识PTSD有高效用,但比对CAPS在终生PTSD方面却是较保守的指标。
    Journal of Traumatic Stress 04/2014; 27(2). DOI:10.1002/jts.21905 · 2.72 Impact Factor
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    ABSTRACT: To assess the efficacy of collaborative care for behavior problems, attention-deficit/hyperactivity disorder (ADHD), and anxiety in pediatric primary care (Doctor Office Collaborative Care; DOCC). Children and their caregivers participated from 8 pediatric practices that were cluster randomized to DOCC (n = 161) or enhanced usual care (EUC; n = 160). In DOCC, a care manager delivered a personalized, evidence-based intervention. EUC patients received psychoeducation and a facilitated specialty care referral. Care processes measures were collected after the 6-month intervention period. Family outcome measures included the Vanderbilt ADHD Diagnostic Parent Rating Scale, Parenting Stress Index-Short Form, Individualized Goal Attainment Ratings, and Clinical Global Impression-Improvement Scale. Most measures were collected at baseline, and 6-, 12-, and 18-month assessments. Provider outcome measures examined perceived treatment change, efficacy, and obstacles, and practice climate. DOCC (versus EUC) was associated with higher rates of treatment initiation (99.4% vs 54.2%; P < .001) and completion (76.6% vs 11.6%, P < .001), improvement in behavior problems, hyperactivity, and internalizing problems (P < .05 to .01), and parental stress (P < .05-.001), remission in behavior and internalizing problems (P < .01, .05), goal improvement (P < .05 to .001), treatment response (P < .05), and consumer satisfaction (P < .05). DOCC pediatricians reported greater perceived practice change, efficacy, and skill use to treat ADHD (P < .05 to .01). Implementing a collaborative care intervention for behavior problems in community pediatric practices is feasible and broadly effective, supporting the utility of integrated behavioral health care services.
    PEDIATRICS 03/2014; 133(4). DOI:10.1542/peds.2013-2516 · 5.30 Impact Factor
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Publication Stats

3k Citations
574.37 Total Impact Points

Institutions

  • 2010–2015
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
    • University of Arkansas at Little Rock
      Little Rock, Arkansas, United States
  • 2007–2014
    • University of Michigan
      • Department of Psychiatry
      Ann Arbor, Michigan, United States
  • 2009–2012
    • Harvard University
      Cambridge, Massachusetts, United States
    • University of Texas Health Science Center at San Antonio
      • Department of Psychiatry
      San Antonio, TX, United States
    • Geisel School of Medicine at Dartmouth
      • Department of Community and Family Medicine
      Hanover, New Hampshire, United States
  • 2004–2010
    • U.S. Department of Veterans Affairs
      • Center for Health Equity Research and Promotion (CHERP)
      Washington, Washington, D.C., United States
  • 2008
    • Alpert Medical School - Brown University
      Providence, Rhode Island, United States
  • 2000–2008
    • University of Pittsburgh
      • • Department of Psychiatry
      • • Department of Medicine
      • • Division of General Internal Medicine
      Pittsburgh, Pennsylvania, United States
  • 2006
    • Columbia University
      New York, New York, United States
  • 2003
    • University of California, Los Angeles
      • Division of General Internal Medicine and Health Services Research
      Los Angeles, CA, United States