Places in protecting housing per 100 000 inhabitants from 1990 to 2012, Western Europe

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How has the extent of institutional mental healthcare changed in Western Europe? Analysis of data since 1990.

Chow WS¹, Priebe S¹.

¹Unit for Social and Community Psychiatry (WHO Collaborating Centre for Mental Health Services Development), Queen Mary University of London, London, UK.

BMJ Open. 2016 Apr 29;6(4):e010188. doi: 10.1136/bmjopen-2015-010188.

Forensic beds per 100 000 inhabitants from 1990 to 2012, Western Europe

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How has the extent of institutional mental healthcare changed in Western Europe? Analysis of data since 1990.

Chow WS¹, Priebe S¹.

¹Unit for Social and Community Psychiatry (WHO Collaborating Centre for Mental Health Services Development), Queen Mary University of London, London, UK.

BMJ Open. 2016 Apr 29;6(4):e010188. doi: 10.1136/bmjopen-2015-010188.

Psychiatric hospital beds per 100 000 inhabitants from 1990 to 2012, Western Europe

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How has the extent of institutional mental healthcare changed in Western Europe? Analysis of data since 1990.

Chow WS¹, Priebe S¹.

¹Unit for Social and Community Psychiatry (WHO Collaborating Centre for Mental Health Services Development), Queen Mary University of London, London, UK.

BMJ Open. 2016 Apr 29;6(4):e010188. doi: 10.1136/bmjopen-2015-010188.

Mental Health and Medical Health Disparities in 5135 Transgender Veterans Receiving Healthcare in the Veterans Health Administration: A Case-Control Study

PURPOSE:

There are no large controlled studies of health disparities in transgender (TG) or gender dysphoric patients. The Veterans Health Administration (VHA) is the largest healthcare system in the United States and was an early adopter of electronic health records. We sought to determine whether medical and/or mental health disparities exist in VHA for clinically diagnosed TG veterans compared to matched veterans without a clinical diagnosis consistent with TG status.

METHODS:

Using four ICD-9-CM codes consistent with TG identification, a cohort of 5135 TG veterans treated in VHA between 1996 and 2013 was identified. Veterans without one of these diagnoses were matched 1:3 in a case-control design to determine if medical and/or mental health disparities exist in the TG veteran population.

RESULTS:

In 2013, the prevalence of TG veterans with a qualifying clinical diagnosis was 58/100,000 patients. Statistically significant disparities were present in the TG cohort for all 10 mental health conditions examined, including depression, suicidality, serious mental illnesses, and post-traumatic stress disorder. TG Veterans were more likely to have been homeless, to have reported sexual trauma while on active duty, and to have been incarcerated. Significant disparities in the prevalence of medical diagnoses for TG veterans were also detected for 16/17 diagnoses examined, with HIV disease representing the largest disparity between groups.

CONCLUSION:

This is the first study to examine a large cohort of clinically diagnosed TG patients for psychiatric and medical health outcome disparities using longitudinal, retrospective medical chart data with a matched control group. TG veterans were found to have global disparities in psychiatric and medical diagnoses compared to matched non-TG veterans. These findings have significant implications for policy, healthcare screening, and service delivery in VHA and potentially other healthcare systems.

Purchase full article at:   http://goo.gl/yZCiKY

By:  Brown GR1,2, Jones KT3.

• 1 Psychiatry Service, Mountain Home Veterans Affairs Medical Center , Johnson City, Tennessee.
• 2 Department of Psychiatry and Behavioral Sciences, Quillen College of Medicine, East Tennessee State University , Johnson City, Tennessee.
• 3 Office of Health Equity , Veterans Health Administration, Washington, District of Columbia.
• LGBT Health. 2016 Apr;3(2):122-31. doi: 10.1089/lgbt.2015.0058. Epub 2015 Dec 16. 

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The Use of a Brief Mental Health Screener to Enhance the Ability of Police Officers to Identify Persons with Serious Mental Disorders

Police agencies in Canada and elsewhere have received much criticism over how they respond to persons with serious mental disorders. The adequacy of training provided to police officers on mental health issues and in particular on recognizing indicators of serious mental disorders has been a major concern. 

This paper describes the process that led to the development of a new brief mental health screener (interRAI Brief Mental Health Screener, BMHS) designed to assist police officers to better identify persons with serious mental disorders. The interRAI BMHS was developed in collaboration with interRAI, an international, not-for-profit consortium of researchers. The government of Ontario had previously partnered with interRAI to develop and implement the Resident Assessment Instrument for Mental Health (RAI-MH), the assessment system mandated for use on all persons admitted into inpatient psychiatric care in the province. Core items on the interRAI BMHS were obtained through analysis (N=41,019) of RAI-MH data together with input from representatives from health care, police services, and patient groups. 

Two police services in southwestern Ontario completed forms (N=235) on persons thought to have a mental disorder. Patient records were later accessed to determine patient disposition. The use of summary and inferential statistics revealed that the variables significantly associated with being taken to hospital by police included performing a self-injurious act in the past 30days, and others being concerned over the person's risk for self-injury. Variables significantly associated with being admitted included abnormal thought process, delusions, and hallucinations. 

The results of the study indicate that the 14-variable algorithm used to construct the interRAI BMHS is a good predictor of who was most likely to be taken to hospital by police officers and who was most likely to be admitted. The instrument is an effective means of capturing and standardizing police officer observations enabling them to provide more and better quality information to emergency department (ED) staff. 

Teaching police officers to use the form constitutes enhanced training on major indicators of serious mental disorders. Further, given that items on the interRAI BMHS are written in the language of the health system, language acts as common currency between police officers and ED staff laying the foundation for a more collaborative approach between the systems.

Full article at:   http://goo.gl/4FA5EB

By:  Hoffman R1, Hirdes J2, Brown GP3, Dubin JA4, Barbaree H5.

• 1Ministry of Community Safety and Correctional Services, Ontario Police College, 10716 Hacienda Road, Aylmer, Ontario N5H 2T2, Canada; Faculty of Applied and Professional Studies, School of Criminology and Criminal Justice, Nipissing University, 100 College Drive, Box 5002, North Bay, Ontario P1B 8L, Canada. Electronic address: Ron.Hoffman@sympatico.ca.
• 2School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada.
• 3Faculty of Applied and Professional Studies, School of Criminology and Criminal Justice, Nipissing University, 100 College Drive, Box 5002, North Bay, Ontario P1B 8L7, Canada.
• 4Department of Statistics and Actuarial Science, School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada.
• 5Division of Forensic Psychiatry, Department of Psychiatry, University of Toronto, Toronto, Ontario M5T 1R, Canada; Waypoint Centre for Mental Health Care, 500 Church Street, Penetanguishene, Ontario L9M 1G3, Canada. 
• Int J Law Psychiatry. 2016 Apr 1. pii: S0160-2527(16)30044-9. doi: 10.1016/j.ijlp.2016.02.031.

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Recidivism Following Mental Health Court Exit: Between & Within-Group Comparisons

Over the past decade, Mental Health Courts (MHCs) have spread rapidly across the U.S. These courts aim to reduce recidivism among adults with mental illnesses through diversion into community-based treatment. 

Extant research suggests that MHCs can be effective in reducing recidivism, but also demonstrates that effectiveness varies as a function of characteristics of the participants (e.g., criminal history) and the program (e.g., coercion). Less is known regarding the extent to which process-related factors (e.g., length of participation, time between referral and receipt of services) impact effectiveness. 

Prior research also is limited by a focus on recidivism during MHC as opposed to postexit. To address these knowledge gaps, we examined recidivism 1 year postexit for a group of MHC participants (n = 57) and offenders receiving treatment as usual (TAU; n = 40), total N = 97. We also investigated the influence of individual characteristics and process factors on changes in jail days 1 year preentry to 1 year postexit for MHC participants. 

Overall, results provide some evidence supporting the effectiveness of MHCs. MHC participants had significantly fewer jail days, but not charges or convictions, relative to TAU participants. Among MHC participants, graduation from the MHC, presence of co-occurring substance use, and longer length of MHC participation were associated with greater reductions in jail days. Other process factors were unrelated to reductions in recidivism. 

Findings suggest that MHCs may be particularly effective for high-risk participants and that time spent in a MHC has positive effects on recidivism, regardless of graduation status.

Purchase full article at:   http://goo.gl/SO2t2i

By:  Lowder EM1, Desmarais SL1, Baucom DJ1.

• 1Department of Psychology, North Carolina State University. 
• Law Hum Behav. 2016 Apr;40(2):118-27. doi: 10.1037/lhb0000168. Epub 2015 Nov 23.

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Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: A retrospective, descriptive study

Objectives

To identify patterns in euthanasia requests and practices relating to psychiatric patients; to generate recommendations for future research.

Design

Retrospective analysis of data obtained through medical file review.

Setting

Outpatient psychiatric clinical setting in the Dutch-speaking region of Belgium, between October 2007 and December 2011; follow-up at the end of December 2012.

Participants

100 consecutive psychiatric patients requesting euthanasia based on psychological suffering associated with psychiatric disorders (77 women, 23 men; mean age 47 years; age range 21–80 years).

Main outcome measures

Patient sociodemographic characteristics; diagnoses; decisions on euthanasia requests; circumstances of euthanasia procedures; patient outcomes at follow-up.

Results

Most patients had been referred for psychiatric counselling by their physician (n=55) or by LEIF (Life End Information Forum) (n=36). 90 patients had >1 disorder; the most frequent diagnoses were depression (n=58) and personality disorder (n=50). 38 patients required further testing and/or treatment, including 13 specifically tested for autism spectrum disorder (ASD); 12 received an ASD diagnosis (all Asperger syndrome). In total, 48 of the euthanasia requests were accepted and 35 were carried out. Of the 13 remaining patients whose requests were accepted, 8 postponed or cancelled the procedure, because simply having this option gave them enough peace of mind to continue living. In December 2012, 43 patients had died, including 35 by euthanasia; others died by suicide (6), palliative sedation (1) and anorexia nervosa (1).

Conclusions

Depression and personality disorders are the most common diagnoses in psychiatric patients requesting euthanasia, with Asperger syndrome representing a neglected disease burden. Further research is needed, especially prospective quantitative and qualitative studies, to obtain a better understanding of patients with psychiatric disorders who request euthanasia due to unbearable psychological suffering.

Below:  Frequency of age in 100 psychiatric patients who requested euthanasia, by gender

Full article at:   http://goo.gl/6fSQex

By:  Lieve Thienpont,1 Monica Verhofstadt,2 Tony Van Loon,3 Wim Distelmans,3 Kurt Audenaert,4 and Peter P De Deyn5,6,7

¹University Hospital Brussels, Brussels, Belgium

2MSc student at the Open University of the Netherlands, Heerlen, The Netherlands

3Free University of Brussels, Brussels, Belgium

4Department of Psychiatry, Ghent University Hospital, Ghent, Belgium

5University of Antwerp, Institute Born-Bunge, Wilrijk, Belgium

6University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

7

²MSc student at the Open University of the Netherlands, Heerlen, The Netherlands

³Free University of Brussels, Brussels, Belgium

⁴Department of Psychiatry, Ghent University Hospital, Ghent, Belgium

⁵University of Antwerp, Institute Born-Bunge, Wilrijk, Belgium

⁶University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

⁷Middelheim General Hospital, ZNA, Antwerp, Belgium

1University Hospital Brussels, Brussels, Belgium

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Pathways Through Care of Severely Mentally Ill Individuals Experiencing Multiple Public Crisis Events

BACKGROUND:

Patients experiencing severe mental illnesses (SMI) need continuing support and remain vulnerable in many domains. Crisis interventions and compulsory admissions are common, causing a huge burden on police, health workers, the community and patients. The aim of this retrospective case-file study is to determine profiles of SMI-patients and their pathways through care among those experiencing multiple public crisis events.

METHODS:

Data from a larger study of 323 SMI-patients in Amsterdam were used. These data were linked to data of the public mental health care (PMHC) in order to identify persons that experienced crisis interventions (CI's) between January 2004 and November 2012. The cut-off point for inclusion in the study population was set on three CI's, resulting in a group of 47 SMI-patients. PMHC and mental health care (MHC) data were linked in order to identify profiles in patterns of care. Qualitative content analysis was used to gather and analyze chronological timelines.

RESULTS:

Three profiles were identified: SMI-patients with CI's during continuous MHC, SMI-patients with CI's after discharge and SMI-patients with CI's during unstable MHC. For each profile events prior to, during and after a CI were identified.

CONCLUSIONS:

PMHC and MHC can possibly identify cases with a high risk of CI's and predict these events based on the results of this study. CI's seem inevitable for a group of SMI-patients in care but they do not only require acute psychiatric care. The collaboration between MHC, PMHC and police could be further developed in a quick and effective triage in order to tackle the complexity of problems of the SMI-patients.

Full article at:   http://goo.gl/AJeLo0

By:  Hensen MJ1, de Mooij LD2, Theunissen J3, Dekker J2, Willemsen M4, Zoeteman J5, Peen J2, de Wit MA6.

• 1Public Health Service Amsterdam, Department of Epidemiology, Health Promotion, and Care Innovation, Amsterdam, The Netherlands.
• 2Arkin Mental Health Care, Research department, Amsterdam, The Netherlands.
• 3GGZ Ingeest Mental Health Care, Amsterdam, The Netherlands.
• 4Public Health Service Amsterdam, Department of Public Mental Health Care, Amsterdam, The Netherlands.
• 5Arkin Mental Health Care, Department of Emergency Psychiatry, Amsterdam, The Netherlands.
• 6Public Health Service Amsterdam, Department of Epidemiology, Health Promotion, and Care Innovation, Amsterdam, The Netherlands. mdwit@ggd.amsterdam.nl. 
• BMC Psychiatry. 2016 Apr 1;16(1):84.

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Criminal Justice System Contact & Mortality among Offenders with Mental Illness in British Columbia

BACKGROUND:

Persons with mental illness are over-represented in prison populations around the world. They are more vulnerable to arrest and more likely to experience repeated encounters with the criminal justice system. Whether criminal justice involvement, in and of itself, is associated with higher mortality, particularly among offenders with mental illness, is unknown.

METHODS:

The authors conducted a mediation analysis of mortality rates in a cohort of 79,088 offenders from British Columbia using administrative records spanning 2001-2010, where the mediating variable was the individual-level rate of criminal sentencing.

RESULTS:

During 339,506 person-years of follow-up, there were 1841 deaths. The diagnosis of mental illness had no direct association with higher mortality after adjustment for confounders (HR=0.98, 95% CI 0.86 to 1.06). However, mental illness had an indirect association with mortality that was mediated through more frequent criminal justice involvement (HR=1.02, 95% CI 1.01 to 1.04).

CONCLUSIONS:

These findings support the hypothesis that offenders with mental illness experience higher mortality that is mediated by higher rates of criminal justice contact. The results of our study indicate that criminal justice diversion programmes are further warranted because they may contribute to the prevention of mortality among offenders with mental illness.

Purchase full article at:   http://goo.gl/QheVNV

By:  McCandless LC1, Stewart LC1, Rempel ES1, Venners SA1, Somers JM1.

• 1Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada. 

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Trajectories of Recovery among Formerly Homeless Adults with Serious Mental Illness

OBJECTIVE:

Recovery from mental illness is possible, but individuals with co-occurring disorders and homelessness face challenges. Although a nonlinear recovery course is assumed, few studies have analyzed recovery over time. This mixed-methods study examined recovery trajectories over 18 months after enrollment in supportive housing programs of 38 participants with DSM axis I diagnoses.

METHODS:

Qualitative interview data were quantified through consensual ratings to generate a recovery score for four waves of data collection based on eight recovery domains culled from the literature. Case study analyses were conducted of participants whose scores varied by one standard deviation or more between baseline and 18 months to identify which domains were important.

RESULTS:

Most of the 38 participants (N=23) had no significant change in recovery; seven had a negative trajectory, and eight had a positive trajectory. Case studies of these 15 participants indicated domains that contributed to change: significant-other relationships (N=9), engagement in meaningful activities (N=9), mental health (N=7), family relationships (N=6), general medical health (N=5), housing satisfaction (N=5), employment (N=2), and substance use (N=1). Except for mental health and substance use (which contributed only to negative trajectories), the influence of domains was both positive and negative. Domains were intertwined; for example, variation in relationships was linked to changes in meaningful activities.

CONCLUSIONS:

This study showed little change in recovery over time for most participants and a decline in mental health for a small minority. Findings underscore the importance of social relationships and meaningful activities among individuals with serious mental illness, who experience complex challenges.

Purchase full article at:   http://goo.gl/prHa2G

By:  Padgett DK1, Smith BT1, Choy-Brown M1, Tiderington E1, Mercado M1.

• 1Dr. Padgett, Ms. Choy-Brown, and Dr. Mercado are with the Silver School of Social Work, New York University, New York City (e-mail: dkp1@nyu.edu ). Ms. Smith is with the School of Social Service Administration, University of Chicago, Chicago, Illinois. Dr. Tiderington is with the School of Social Work, Rutgers University, New Brunswick, New Jersey. 
• Psychiatr Serv. 2016 Feb 14:appips201500126. 

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From Punishment to Treatment: The "Clinical Alternative to Punitive Segregation" (CAPS) Program in New York City Jails

The proliferation of jails and prisons as places of institutionalization for persons with serious mental illness (SMI) has resulted in many of these patients receiving jail-based punishments, including solitary confinement. 

Starting in 2013, the New York City (NYC) jail system developed a new treatment unit for persons with SMI who were judged to have violated jail rules (and previously would have been punished with solitary confinement) called the Clinical Alternative to Punitive Segregation (CAPS) unit. CAPS is designed to offer a full range of therapeutic activities and interventions for these patients, including individual and group therapy, art therapy, medication counseling and community meetings. 

Each CAPS unit requires approximately $1.5 million more investment per year, largely in additional staff as compared to existing mental health units, and can house approximately 30 patients. Patients with less serious mental illness who received infractions were housed on units that combined solitary confinement with some clinical programming, called Restrictive Housing Units (RHU). 

Between 1 December 2013 and 31 March 2015, a total of 195 and 1433 patients passed through the CAPS and RHU units, respectively. A small cohort of patients experienced both CAPS and RHU (n = 90). For these patients, their rates of self-harm and injury were significantly lower while on the CAPS unit than when on the RHU units. Improvements in clinical outcomes are possible for incarcerated patients with mental illness with investment in new alternatives to solitary confinement. We have started to adapt the CAPS approach to existing mental health units as a means to promote better clinical outcomes and also help prevent jail-based infractions. 

The cost of these programs and the dramatic differences in length of stay for patients who earn these jail-based infractions highlight the need for alternatives to incarceration, some of which have recently been announced in NYC.

Full article at:   http://goo.gl/jCSAJB

By:  Glowa-Kollisch S1, Kaba F2, Waters A3, Leung YJ4, Ford E5, Venters H6.

• 1Correctional Health Services, New York City Health + Hospitals, New York, NY 11101, USA. sglowakollisch@nychhc.org.
• 2Correctional Health Services, New York City Health + Hospitals, New York, NY 11101, USA. fkaba@nychhc.org.
• 3Correctional Health Services, New York City Health + Hospitals, New York, NY 11101, USA. awaters1@nychhc.org.
• 4Correctional Health Services, New York City Health + Hospitals, New York, NY 11101, USA. yleung2@nychhc.org.
• 5Correctional Health Services, New York City Health + Hospitals, New York, NY 11101, USA. eford@nychhc.org.
• 6Correctional Health Services, New York City Health + Hospitals, New York, NY 11101, USA. hventer1@nychhc.org. 
• Int J Environ Res Public Health. 2016 Feb 2;13(2). pii: E182. doi: 10.3390/ijerph13020182

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Mental Illness & Reduction of Gun Violence & Suicide: Bringing Epidemiologic Research to Policy

PURPOSE:

This article describes epidemiologic evidence concerning risk of gun violence and suicide linked to psychiatric disorders, in contrast to media-fueled public perceptions of the dangerousness of mentally ill individuals, and evaluates effectiveness of policies and laws designed to prevent firearms injury and mortality associated with serious mental illnesses and substance use disorders.

METHODS:

Research concerning public attitudes toward persons with mental illness is reviewed and juxtaposed with evidence from benchmark epidemiologic and clinical studies of violence and mental illness and of the accuracy of psychiatrists' risk assessments. Selected policies and laws designed to reduce gun violence in relation to mental illness are critically evaluated; evidence-based policy recommendations are presented.

RESULTS:

Media accounts of mass shootings by disturbed individuals galvanize public attention and reinforce popular belief that mental illness often results in violence. Epidemiologic studies show that the large majority of people with serious mental illnesses are never violent. However, mental illness is strongly associated with increased risk of suicide, which accounts for over half of US firearms-related fatalities.

CONCLUSIONS:

Policymaking at the interface of gun violence prevention and mental illness should be based on epidemiologic data concerning risk to improve the effectiveness, feasibility, and fairness of policy initiatives.

Below:  Average prevalence of minor to serious violence among persons with serious mental illness by setting of study: meta-analysis

Below:  Violence risk varies among people with serious mental illness who are involuntarily committed: characteristics of violent behavior in 4 months before involuntary hospital admission (Duke Mental Health Study; n = 331).

Below:  Accumulation of MH records in National Instant Check System

Below:  Mean monthly predicted probabilities of first violent crime for persons with serious mental illness with and without a gun-disqualifying mental health record, before and after NICS reporting began in Connecticut (n = 23,282). Note: analysis excludes persons with disqualifying criminal records.

Full article at:   http://goo.gl/YYm7wQ

By:   Jeffrey W. Swanson, PhD,a,∗ E. Elizabeth McGinty, PhD, MS,b Seena Fazel, MBChB, MD, FRCPsych,c and Vickie M. Mays, PhD, MSPHd,e

^aDepartment of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC

^bDepartment of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

^cDepartment of Psychiatry, University of Oxford, Oxford, England

^dDepartment of Psychology, University of California at Los Angeles, Los Angeles, CA

^eDepartment of Health Policy and Management, University of California at Los Angeles, Los Angeles, CA

Jeffrey W. Swanson: ude.ekud@nosnaws.yerffej

^∗Corresponding author. Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, DUMC Box 3071, Durham, NC.Email: ude.ekud@nosnaws.yerffej

Ann Epidemiol. 2015 May; 25(5): 366–376.

doi:  10.1016/j.annepidem.2014.03.004 

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Factors Influencing the Delivery of HIV-Related Services to Severely Mentally Ill Individuals: The Provider's Perspective

BACKGROUND:

Individuals with severe mental illnesses (SMI) are disproportionately vulnerable to HIV infection but are not consistently engaged in HIV-related services.

OBJECTIVE:

To understand factors influencing implementation of HIV-related services to individuals with SMI, we conducted a series of focus groups with multidisciplinary clinicians and staff serving individuals with SMI in outpatient, emergency, acute inpatient, and chronic inpatient levels of care.

METHOD:

Six focus groups with 30 participants were conducted, audiotaped, and transcribed. Our qualitative analysis drew on Grounded Theory. Using NVivo Version 9, coding was conducted by the first and senior authors; interrater reliability was verified by running Coding Comparison queries.

RESULTS:

The providers' narratives highlighted (1) patient-related factors, (2) stigma, and (3) administrative factors as themes particularly relevant to the delivery of HIV-related services to individuals with SMI. The reported relevance of these factors ranged across levels of care, from creating multiple barriers in the outpatient care to relatively seamless and effective delivery of full continuum of HIV-related services in the chronic inpatient environment, where adequate structural support is provided.

CONCLUSION:

Providers' narratives suggest that effective delivery of HIV-related services for individuals with SMI requires sustained structural support that is coordinated across levels of psychiatric care and tailored to individual patient's needs. The narratives also suggest that such support is currently not available.

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By:   Biradavolu M1, Jia Y2, Withers K3, Kapetanovic S4.

• 1Department of Sociology, American University, Washington, DC.
• 2Washington DC HIV/AIDS, Hepatitis, STD and TB Administration, Washington, DC.
• 3National Institutes of Health, National Institute of Mental Health, Bethesda, MD.
• 4National Institutes of Health, National Institute of Mental Health, Bethesda, MD; Department of Psychiatry and The Behavioral Sciences, University of Southern California Keck School of Medicine, Los Angeles, CA. Electronic address: kapetano@usc.edu. 

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