Fibromyalgia and bipolar disorder: Extent of comorbidity and therapeutic implications

Abstract

Fibromyalgia (FM) is a syndrome that affects muscles and soft tissues. Presenting symptoms include chronic muscle pain, fatigue, sleep problems and psychological symptoms, including depression and anxiety. There exists strong evidence of a comorbidity between FM and Bipolar Disorder (BD). In this study, papers from 2006 to February 2016 that examined the comorbidity and etiological similarities of FM and BD were reviewed, as well as the therapeutic implications of these findings. The reviewed articles showed that an adequate psychiatric screening for BD is recommended in FM patients with depressive symptoms, in order to decrease administration of antidepressants for BD, due to the lack of proven efficacy, and to limit antidepressant-induced mania. Alternative therapies, such as agomelatine, memantine and psychotherapic treatment should be considered.

Full text

;
&RS\ULJKWE\%,2/,)(VDV
7KLVSXEOLFDWLRQDQGRUDUWLFOHLVIRULQGLYLGXDOXVHRQO\DQGPD\QRWEHIXUWKHU
UHSURGXFHGZLWKRXWZULWWHQSHUPLVVLRQIURPWKHFRS\ULJKWKROGHU
8QDXWKRUL]HGUHSURGXFWLRQPD\UHVXOWLQ¿QDQFLDODQGRWKHUSHQDOWLHV
',6&/2685($//$87+2565(325712&21)/,&762)
,17(5(675(/(9$17727+,6$57,&/(

-2851$/2)%,2/2*,&$/5(*8/$7256+20(267$7,&$*(176 9ROQR
0DLOLQJDGGUHVV
'U0&'L7RPPDVR0RUULVRQ
/DNHVLGH$YH&UDQVWRQ
5,86$
7HO
HPDLOPDULDPRUULVRQ#VDOYHHGX
.H\ZRUGVHVRSKDJHDOFDQFHU%DUUHWW¶VHVRSKDJXV+HOLFREDFWHU3\ORUL%DUUHWW¶VDGHQRFDUFLQRPD
,Q RUGHU WR IXUWKHU LQYHVWLJDWH WKH FRPRUELGLW\
RI ¿EURP\DOJLD )0 DQG ELSRODU GLVRUGHU %'
SDSHUV ZHUH UHYLHZHG IURP  WR )HEUXDU\ 
XVLQJWKH1,+3XE0HG/LWHUDWXUH6HDUFK 6\VWHPWR
VHDUFK IRU UHOHYDQW DUWLFOHV ,QFOXVLRQ FULWHULD ZHUH
WKDW PDQXVFULSWV LEH SULPDU\ SHHUUHYLHZUHVHDUFK
DUWLFOHV LL FRQFLVHO\ H[SODLQHG RU LQYHVWLJDWHG
HWLRORJLFDOVLPLODULWLHVDQGWKHUDSHXWLFLPSOLFDWLRQVRI
)0DQG%3LLLEHSXEOLVKHGLQ(QJOLVK)RUVHOHFWHG
PDQXVFULSWV WKHVHFULWHULD ZHUHUHOD[HG WR DOORZ WKH
LQFOXVLRQRIVWXGLHVGHHPHGSDUWLFXODUO\XVHIXO
$ FKURQLF GLVHDVH )0 SUHVHQWV ZLWKRXW D
IXOO\NQRZQ HWLRORJ\ DQG SDWKRSK\VLRORJ\ 
&KDUDFWHUL]HG E\ FKURQLF ZLGHVSUHDG SDLQ IDWLJXH
DQGSV\FKRORJLFDOV\PSWRPVVXFKDVGHSUHVVLRQDQG
DQ[LHW\)0 FDQ EHDVHYHUHO\GHELOLWDWLQJGLVRUGHU
 ,Q DGGLWLRQ PDUNHUV VXFK DV F\WRNLQHV DQG
FKHPRNLQHV ZKLFK SOD\ D UROH LQ LQÀDPPDWRU\
GLVRUGHUVDUHDOVRLQYROYHGLQ)0DVVKRZQLQ
ELRSVLHVRIPXVFOH
2YHU WKH \HDUV WKHUH KDYH EHHQ FRXQWOHVV
SDSHUVUHSRUWLQJ RQ WKH DVVRFLDWLRQ RI )0 DQG %'
 7KH UHFRJQLWLRQ RI WKH SRRUO\ XQGHUVWRRG
SDWKRSK\VLRORJLFDOSURFHVVHVDQGV\PSWRPVEHWZHHQ
),%520<$/*,$$1'%,32/$5',625'(5
(;7(172)&2025%,',7<$1'7+(5$3(87,&,03/,&$7,216
0&',7200$620255,621)&$5,1&,*/(66,$1,(63,1$6
6..5,7$6*521&21,$O&$5$))$DQG3&217,
6DOYH5HJLQD8QLYHUVLW\1HZSRUW86$'HSDUWPHQWRI0RUSKRORJ\6XUJHU\DQG
([SHULPHQWDO0HGLFLQH8QLYHUVLW\RI)HUUDUD)HUUDUD,WDO\$QJLRORJ\8QLW0HGLFLQH
DQG*HULDWULF'HSDUWPHQW9LOOD6HUHQD+RVSLWDO,WDO\'HSDUWPHQWRI6XUJHU\DQG
2GRQWRVWRPDWRORJLFDO6FLHQFHV8QLYHUVLW\RI&DJOLDUL,WDO\'HSDUWPHQWRI0LFURELRORJ\
DQG,QIHFWLRXV'LVHDVHV6FKRRORI9HWHULQDU\0HGLFLQH$ULVWRWOH8QLYHUVLW\RI7KHVVDORQLNL
0DFHGRQLD*UHHFH826&OLQLFDGHL3D]LHQWLGHO7HUULWRULR3ROLFOLQLFR*HPHOOL5RPD,WDO\
'HSDUWPHQWRI3KDUPDFRORJ\8QLYHUVLW\RI3HUXJLD3HUXJLD,WDO\,PPXQRORJ\'LYLVLRQ
3RVWJUDGXDWH0HGLFDO6FKRRO8QLYHUVLW\RI&KLHWL3HVFDUD&KLHWL,WDO\
5HFHLYHG0DUFK$FFHSWHG)HEUXDU\
(',725,$/
)LEURP\DOJLD)0LVDV\QGURPHWKDWDIIHFWVPXVFOHVDQGVRIWWLVVXHV3UHVHQWLQJV\PSWRPVLQFOXGH
FKURQLF PXVFOH SDLQ IDWLJXH VOHHS SUREOHPV DQG SV\FKRORJLFDO V\PSWRPV LQFOXGLQJ GHSUHVVLRQ DQG
DQ[LHW\7KHUHH[LVWVVWURQJHYLGHQFHRIDFRPRUELGLW\EHWZHHQ)0DQG%LSRODU'LVRUGHU%',QWKLV
VWXG\SDSHUV IURPWR )HEUXDU\ WKDWH[DPLQHG WKH FRPRUELGLW\DQGHWLRORJLFDOVLPLODULWLHV
RI)0DQG %'ZHUHUHYLHZHG DVZHOODV WKH WKHUDSHXWLFLPSOLFDWLRQVRI WKHVH¿QGLQJV7KH UHYLHZHG
DUWLFOHV VKRZHG WKDW DQ DGHTXDWH SV\FKLDWULF VFUHHQLQJ IRU %' LV UHFRPPHQGHGLQ )0 SDWLHQWV ZLWK
GHSUHVVLYHV\PSWRPVLQRUGHUWRGHFUHDVHDGPLQLVWUDWLRQRIDQWLGHSUHVVDQWVIRU%'GXHWRWKHODFNRI
SURYHQHI¿FDF\DQGWROLPLWDQWLGHSUHVVDQWLQGXFHGPDQLD$OWHUQDWLYHWKHUDSLHVVXFKDVDJRPHODWLQH
PHPDQWLQHDQGSV\FKRWKHUDSLFWUHDWPHQWVKRXOGEHFRQVLGHUHG


0'4 IRU %' )LEURP\DOJLD ,PSDFW 4XHVWLRQQDLUH
'LVDELOLW\ ,QGH[ (SZRUWK 6OHHSLQHVV 6FDOH IRU
GD\WLPHVOHHSLQHVVDQG%HFN'HSUHVVLRQ ,QYHQWRU\
IRU GHSUHVVLRQ  )URP WKLV  RI WKH )0
VXEMHFWVKDG DSRVLWLYHUHVXOW IRU%'ZHUH
FOLQLFDOO\ GHSUHVVHG  UHSRUWHG GD\WLPH
VOHHSLQHVV'HSUHVVLYHV\PSWRPVZHUHPRUHVHYHUH
LQ)0ZKHQ%'ZDVFRPRUELG
3URYHQ HIIHFWLYH WUHDWPHQWV RI SDWLHQWV ZLWK
)0 GHSUHVVLYH V\PSWRPV DUH VHURWRQLQ DQG
QRUHSLQHSKULQH UHXSWDNH LQKLELWRUV HVSHFLDOO\
GXOR[HWLQHDQGPLOQDFLSUDQKRZHYHUWKHVH
PD\FDXVHGHVWDELOL]DWLRQRIPRRGWKXV
:LONHHWDOFRQFOXGHGWKDWSDWLHQWVZLWK)0VKRXOG
EHV\VWHPDWLFDOO\VFUHHQHGIRU%'SULRUWRWUHDWPHQW
,Q D VWXG\ ZLWK WKH UHWXUQ WR FOLQLF WLPH RI RQH
\HDU&DUWD HWDODGYDQFHG WKHK\SRWKHVLVWKDW
615,DQWLGHSUHVVDQWVDUHQRWHIIHFWLYHLQORQJWHUP
WUHDWPHQWRI)0DWWKHHQGRIWKHRQH\HDUIROORZ
XSTXDOLW\RIOLIHDQGELSRODUV\PSWRPVZHUHZRUVH
LQWKHJURXSWUHDWHGZLWKDQWLGHSUHVVDQWVWKDQLQWKH
FRQWUROV 7KHVH UHVXOWV VKRXOG EH UHDG LQ WKH OLJKW
RI WKH KLJK )0%' FRPRUELGLW\ DQG RI WKH ZHOO
NQRZQSRRUUHVSRQVHRIELSRODUGHSUHVVLRQWR615,
DQWLGHSUHVVDQWV
6HYHUDO VWXGLHV VXJJHVWHG WKDW VRPH
SV\FKRWKHUDSLFWUHDWPHQWVDQG615,DQWLGHSUHVVDQWV
VKRZHG YLUWXDOO\ LGHQWLFDO UHVXOWV LQ )0  
7KXV&DUWDHWDOVXJJHVWHGWKDWSV\FKRWKHUDSLF
WUHDWPHQWV RI SURYHQ HI¿FDF\ LQ )0 VKRXOG
EH FRQVLGHUHG ¿UVW FKRLFH ZKHQ FRPSDUHG WR
DQWLGHSUHVVDQWV
,Q  &DODQGUH HW DO  DQG %UXQR HW DO
UHSRUWHGWKDWDJRPHODWLQHDPHODWRQLQDJRQLVW
VOLJKWO\LPSURYHGGHSUHVVLRQ DQ[LHW\DQGSDLQEXW
GLG QRW VLJQL¿FDWLYHO\ LPSURYH VOHHS TXDOLW\ DQG
H[HFXWLYHFRJQLWLYHV\PSWRPVDVVRFLDWHGZLWK)0
,QDFDVHUHSRUW6HUUDHWDOUHSRUWHG
WKH FDVH RI D \RXQJ ZRPDQ VXIIHULQJ IURP %' ,,
ZLWKDVVRFLDWHG)0LQZKRPPHPDQWLQHDQ10'$
DQWDJRQLVW VKRZHG SRVLWLYH HIIHFWV RQ ERWK %' DV
ZHOODVWKHDVVRFLDWHG)0V\QGURPH
&21&/86,21
&RPRUELGLW\ RI )0 DQG %' LV FOHDUO\ HYLGHQW
%' DQG )0 KDV UHOHYDQW FOLQLFDO DQG WKHUDSHXWLF
LPSOLFDWLRQV 7KHFURVVRYHUOLNHZLVHGHVHUYHV
IXWXUH UHVHDUFK FRQVLGHUDWLRQ ,Q D PHWDDQDO\VLV
VWXG\ .XGORZ HW DO  DLPHG WR LQYHVWLJDWH WKH
DVVRFLDWLRQ EHWZHHQ %' DQG )0 DQG QLQH VWXGLHV
ZHUH LQFOXGHG  7KH UDWH RI %' FRPRUELGLW\ LQ
VDPSOHVRI)0SDWLHQWV ZDV Q WKHUDWH
RI%'LQWKHJHQHUDOSRSXODWLRQLV
)XUWKHU XQHTXLYRFDO HYLGHQFH RI )0%'
DVVRFLDWLRQ ZDV VKRZQ E\ $UQROG HW DO  LQ D
VWXG\FRQGXFWHGIURP6HSWHPEHUWR$SULO
7KHVWXG\LQFOXGHG)0SDWLHQWVDQGRIWKHLU
UHODWLYHV7KHRGGVUDWLRIRU%'LQLQGLYLGXDOVZLWK
YHUVXVWKRVHZLWKRXW)0ZDV&, WR
SDQGWKHKLJKHVWDPRQJRWKHUFRPRUELG
GLVRUGHUVPDMRUGHSUHVVLRQVFKL]RSKUHQLDDQ[LHW\
VXEVWDQFHXVHGLVRUGHUHWF
0RUHRYHUDFFRUGLQJWR*RWDHWDOLQFUHDVLQJ
OHYHOV RI GHSUHVVLRQ VHYHULW\ DV ZHOO DV D SRVLWLYH
VFUHHQ IRU %' ZHUH VLJQL¿FDQWO\ DVVRFLDWHG ZLWK
LQFUHDVLQJSUHYDOHQFHDQGVHYHULW\RI)0V\PSWRPV
,Q$OFLDWLHWDOVXSSRVHGWKDWLQFUHDVH
LQDFWLYLW\RISDWLHQWVZLWK)0LVOLQNHGWRWKHPDQLF
K\SRPDQLF VWDWHV DVVRFLDWHG ZLWK ELSRODU VSHFWUXP
GLVRUGHUV 8VLQJ WKH '60,9 DQG =XULFK FULWHULD
HOHYDWHG LQFLGHQFH RI ELSRODU VSHFWUXP GLVRUGHUV
ZHUH IRXQG LQ SDWLHQWV ZLWK )0  DQG 
UHVSHFWLYHO\  RI VXEMHFWV ZLWK )0 VFRUHG
 WKUHVKROG IRU K\SRPDQLD RU DERYH 7KHVH
UHVXOWVVXJJHVWHGWKDW)0LV VWURQJO\ UHODWHG WR WKH
K\SRPDQLDRYHUDFWLYLW\FRPSRQHQWRI%'
6RPH UHFHQW SDSHUV IXUWKHU LQYHVWLJDWHG WKH
ZHOONQRZQDVVRFLDWLRQRI)0ZLWK%'DWDJHQHWLF
OHYHO ,QD UHWURVSHFWLYHFDVHFRQWURO
6FKPHFKHO DQG (GZDUGV  GHPRQVWUDWHG DQ
DVVRFLDWLRQ RI ¿EURP\DOJLD V\QGURPH )06
DQG $$7 LQ D FRQVHFXWLYH VHULHV RI SDWLHQWV
)XUWKHUPRUH SDWLHQWV ZLWK DQ[LHW\ GLVRUGHUV %'
,%',, RU376'VKRZHGLQFUHDVHG SURSRUWLRQRI
$$7 SRO\PRUSKLVPV DQG VLJQL¿FDQW RYHUODS ZLWK
)06SKHQRW\SHDQG³,&(LQWHQVHFUHDWLYHHQHUJ\´
DFRPSOH[EHKDYLRUDOWUDLW
,QRUGHUWRVFUHHQSDWLHQWVZLWK)0IRU%'DQGWR
GHWHUPLQHZKHWKHUWKHUHDUHFOLQLFDOPHWKRGVRWKHU
WKDQ WKH 0RRG 'LVRUGHUV 4XHVWLRQQDLUH 0'4
:LONH HW DO  VFUHHQHG  )0 SDWLHQWV XVLQJ
0&',7200$620255,621(7$/


-RXUQDORI%LRORJLFDO5HJXODWRUV+RPHRVWDWLF$JHQWV
0HGLFDO FRPRUELGLW\ DPRQJ \RXWK GLDJQRVHG ZLWK
ELSRODUGLVRUGHULQWKH8QLWHG6WDWHV-&OLQ3V\FKLDWU\

 :LONH :6*RWD &( 0X]LQD '- )LEURP\DOJLD DQG
ELSRODUGLVRUGHUDSRWHQWLDOSUREOHP"%LSRODU'LVRUG

 .XGORZ 3$ 5RVHQEODW -' :HLVVPDQ &5 HW DO
3UHYDOHQFH RI ¿EURP\DOJLD DQG FRPRUELG ELSRODU
GLVRUGHU $ V\VWHPDWLF UHYLHZ DQG PHWDDQDO\VLV -
$IIHFW'LVRUG
 $UQROG /0 +XGVRQ -, .HFN 3($XFKHQEDFK 0%
-DYDUDV .1 +HVV (9 &RPRUELGLW\ RI ¿EURP\DOJLD
DQG SV\FKLDWULF GLVRUGHUV - &OLQ 3V\FKLDWU\ 

 *RWD&(.DRXN6:LONH:67KHLPSDFWRIGHSUHVVLYH
DQGELSRODUV\PSWRPVRQVRFLRHFRQRPLFVWDWXVFRUH
V\PSWRPVIXQFWLRQDQGVHYHULW\RI ¿EURP\DOJLD,QW
- 5KHXP 'LV  GRL ;
>(SXEDKHDGRISULQW@
 $OFLDWL $ 6DU]L3XWWLQL 3 %DWWLFFLRWWR $ HW DO
2YHUDFWLYH OLIHVW\OH LQ SDWLHQWV ZLWK ¿EURP\DOJLD DV
DFRUHIHDWXUHRIELSRODUVSHFWUXPGLVRUGHU&OLQ([S
5KHXPDWRO6XSSO6
 $QGHUVRQ * 0DHV 0/RFDO PHODWRQLQ UHJXODWHV
LQÀDPPDWLRQ UHVROXWLRQ D FRPPRQ IDFWRU LQ
QHXURGHJHQHUDWLYH SV\FKLDWULF DQG V\VWHPLF
LQÀDPPDWRU\ GLVRUGHUV &16 1HXURO 'LVRUG 'UXJ
7DUJHWV
 6FKPHFKHO '( (GZDUGV &/ )LEURP\DOJLD PRRG
GLVRUGHUV DQG LQWHQVH FUHDWLYH HQHUJ\ $$7
SRO\PRUSKLVPVDUHQRWDOZD\VVLOHQW1HXURWR[LFRORJ\

 &RUGLQJ 0 'HUU\ 6 3KLOOLSV 7 0RRUH 5$:LIIHQ
3- 0LOQDFLSUDQ IRU SDLQ LQ ¿EURP\DOJLD LQ DGXOWV
&RFKUDQH 'DWDEDVH 6\VW 5HY  &'
GRL&'SXE
 &ODUN * (YLGHQFHEDVHG SKDUPDFRORJLF DSSURDFKHV
IRU FKURQLF RURIDFLDOSDLQ - &DOLI 'HQW$VVRF

 &DODQGUH(35LFR9LOODGHPRURV)6OLP0$QXSGDWH
RQSKDUPDFRWKHUDS\IRUWKHWUHDWPHQWRI¿EURP\DOJLD
([SHUW2SLQ3KDUPDFRWKHU
 /XFLDQR -9 '¶$PLFR ) &HUGj/DIRQW 0 HW DO
&RVWXWLOLW\ RI FRJQLWLYH EHKDYLRUDO WKHUDS\ YHUVXV
86 )RRG DQG 'UXJ $GPLQLVWUDWLRQ UHFRPPHQGHG
GUXJVDQGXVXDOFDUHLQWKHWUHDWPHQWRISDWLHQWVZLWK
WKHUHIRUH DGHTXDWH SV\FKLDWULF VFUHHQLQJ IRU
%' LV UHFRPPHQGHG LQ )0 SDWLHQWV SULRU WR
DGPLQLVWUDWLRQ RI DQWLGHSUHVVDQWV RU VOHHS DLGV LQ
WKH OLJKW RI WKH ZHOONQRZQ SRRU UHVSRQVH RI WKH
PRRG V\PSWRPV WR DQWLGHSUHVVDQWV LQ %'  7KLV
DSSURDFK ZRXOG DOVR OLPLW DQWLGHSUHVVDQWLQGXFHG
PDQLDDZHOONQRZQFRPSOLFDWLRQRISDWLHQWVZLWK
GHSUHVVLYH %' V\PSWRPV  $OWHUQDWLYH WKHUDSLHV
VXFKDVDJRPHODWLQHPHPDQWLQHDQGSV\FKRWKHUDSLF
WUHDWPHQWVRISURYHQHI¿FDF\VKRXOGEHFRQVLGHUHG
5()(5(1&(6
 0DOHWLF 9 5DLVRQ &/ 1HXURELRORJ\ RI GHSUHVVLRQ
¿EURP\DOJLDDQGQHXURSDWKLFSDLQ)URQW%LRVFL

 %RUWRODWR % %HUN 0 0DHV 0 0F,QW\UH 56
&DUYDOKR $) )LEURP\DOJLD DQG ELSRODU GLVRUGHU
HPHUJLQJ HSLGHPLRORJLFDO DVVRFLDWLRQV DQG VKDUHG
SDWKRSK\VLRORJ\&XUU0RO0HG
 /LQ - 3DQJ / /LX ;/ ;LQJ - 5ROH RI
YLWDFDPSKRUH LQ LPSURYLQJ FHQWUDO SUR
LQÀDPPDWRU\ F\WRNLQHV IROORZLQJ WUDQVLHQW JOREDO
LVFKHPLD - %LRO 5HJXO +RPHRVW $JHQWV 

 $XWHQVKO\XV$, $UNKLSRY 6$ .XQWV 7$ 0DULQNLQ
,2 0LNKDLORYD (6 .DUSXNKLQD ;9 9DUDNVLQ 1$
&\WRNLQH SUR¿OHV RI WXPRU VXSHUQDWDQWV LQ LQYDVLYH
GXFWDO FDQFHU DQG ¿EURDGHQRPD RI WKH EUHDVW DQG
LWV UHODWLRQVKLS ZLWK 9(*)$ H[SUHVVLRQ LQ WKH
WXPRUV ,QW - ,PPXQRSDWKRO 3KDUPDFRO  GRL
>(SXEDKHDGRISULQW@
 <DQJ / 7LQJ < 6KHQ < :DQJ / DQG =KXDQJ =
ȕHVWUDGLRO PRGXODWHV WKH YLDELOLW\ SKHQRW\SH
HQGRF\WRVLV DQG LQÀDPPDWRU\ F\WRNLQH H[SUHVVLRQ RI
5$:PDFURSKDJHV(XU-,QÀDPP
 6FKHIIHU5(/LQGHQ6&RQFXUUHQWPHGLFDOFRQGLWLRQV
ZLWKSHGLDWULF ELSRODUGLVRUGHU &XUU 2SLQ3V\FKLDWU\

 3HUURQ %( +RZDUG 02 1LHQKXLV -. %DXHU 06
:RRGZDUG$7.LOERXUQH$03UHYDOHQFHDQGEXUGHQ
RIJHQHUDOPHGLFDOFRQGLWLRQVDPRQJDGXOWVZLWKELSRODU
, GLVRUGHU UHVXOWV IURP WKH 1DWLRQDO (SLGHPLRORJLF
6XUYH\ RQ $OFRKRO DQG 5HODWHG &RQGLWLRQV - &OLQ
3V\FKLDWU\
 (YDQV/DFNR6(=HEHU-(*RQ]DOH]-02OYHUD5/


DQG FRJQLWLYHEHKDYLRUDO WKHUDS\ IRU V\PSWRP
V\QGURPHV&166SHFWU
 )ULHGEHUJ)-DVRQ/$&KURQLFIDWLJXHVLQGURPHDQG
¿EURP\DOJLDFOLQLFDODVVHVVPHQWDQGWUHDWPHQW-&OLQ
3V\FKRO
 &DUWD 0* &DUGLD & 0DQQX ) HW DO 7KH KLJK
IUHTXHQF\ RI PDQLF V\PSWRPV LQ ¿EURP\DOJLD GRHV
LQÀXHQFHWKHFKRLFHRIWUHDWPHQW"&OLQ3UDFW(SLGHPRO
0HQW+HDOWK
 &DODQGUH (3 6OLP 0 *DUFLD/HLYD -0 5RGULJXH]
/RSH]&07RUUHV35LFR9LOODGHPRURV)$JRPHODWLQH
IRU WKH WUHDWPHQW RI SDWLHQWV ZLWK ¿EURP\DOJLD DQG
GHSUHVVLYH V\PSWRPDWRORJ\ $Q XQFRQWUROOHG 
ZHHNSLORWVWXG\3KDUPDFRSV\FKLDWU\
 %UXQR $ 0LFz 8 /RUXVVR 6 HW DO $JRPHODWLQH
LQ WKH WUHDWPHQW RI ¿EURP\DOJLD $ ZHHN
RSHQODEHOXQFRQWUROOHG SUHOLPLQDU\ VWXG\ - &OLQ
3V\FKRSKDUPDFRO
 6HUUD*'(&KLDUD/.RXNRSRXORV$(.RXNRSRXORV
$ 6HUUD* .DKQ '$ 0HPDQWLQH LQ WKH WUHDWPHQW
DQGSURSK\OD[LVRIELSRODU ,,GLVRUGHUDQGFRPRUELG
¿EURP\DOJLD D FDVH UHSRUW - 3V\FKLDWU 3UDFW 

¿EURP\DOJLD DQ HFRQRPLF HYDOXDWLRQ DORQJVLGH D
PRQWK UDQGRPL]HG FRQWUROOHG WULDO $UWKULWLV 5HV
7KHU
 +lXVHU : :DOLWW % )LW]FKDUOHV 0$ 6RPPHU &
5HYLHZRISKDUPDFRORJLFDOWKHUDSLHVLQ ¿EURP\DOJLD
V\QGURPH$UWKULWLV5HV7KHU
 +lXVHU : 8UU~WLD * 7RUW 6 8oH\OHU 1 :DOLWW %
6HURWRQLQ DQG QRUDGUHQDOLQH UHXSWDNH LQKLELWRUV
615,V IRU ¿EURP\DOJLD V\QGURPH &RFKUDQH
'DWDEDVH6\VW5HY&'
 3HULWRJLDQQLV 9 $QWRQLRX . 0RXND 9 0DYUHDV 9
+\SKDQWLV 71 'XOR[HWLQHLQGXFHG K\SRPDQLD FDVH
UHSRUW DQG EULHI UHYLHZ RI WKH OLWHUDWXUH RQ 615,V
LQGXFHG PRRG VZLWFKLQJ - 3V\FKRSKDUPDFRO 

 'H'LRV& (]TXLDJD(0DQLFVZLWFKLQJLQSDWLHQWV
UHFHLYLQJ GXOR[HWLQH $P - 3V\FKLDWU\ 

 &DUWD0*5XJJLHUR96DQFDVVLDQL)HWDO7KHXVHRI
DQWLGHSUHVVDQWVLQWKHORQJWHUPWUHDWPHQWVKRXOGQRW
LPSURYHWKHLPSDFWRI¿EURP\DOJLDRQTXDOLW\RIOLIH
&OLQ3UDFW(SLGHPLRO0HQW+HDOWK
 -DFNVRQ-/2¶0DOOH\3*.URHQNH.$QWLGHSUHVVDQWV
0&',7200$620255,621(7$/