The subjects were patients referred for evaluation because of a suspected schizophrenia prodromal syndrome. Patients with first episode of psychosis generally obtain a more favorable response profile. A total of 11 (29.0%) patients were not aware of possible hearing loss. All cognitive domains, except for attention, were affected by the NAS levels. They were younger, had an earlier age of onset and less likely to have a family member involved in treatment. It has been postulated that prolonged untreated psychosis may have serious effects: poor response to neuroleptic medications, poor clinical outcomes, and direct neurotoxicity. UHR were less frequently employed and reported more stress, poorer QoL and lower social adaptation than HC. This study sought to identify and validate a comprehensive set of health and safety (H&S) leading indicator metrics that will Maybe more. Cognitive function was determined at clinical stabilization using the WAIS-R. An estimate of cognitive deterioration was based on the WAIS-R subtest profile. Also, some studies have found that a longer DUP is related to a more insidious illness onset, frequent relapses and psychiatric hospitalizations during the course of the disorder, with a poor response to antipsychotic medication. TB patients’ clinical files drawn from a total of The prodromal features had converted to schizophrenic psychosis for 46% of the prodromal patients at 6 months and for 54% at 12 months. Methods: Qualitative semi-structured interviews were carried out with twenty-seven family members of patients with psychosis at psychiatric outpatient clinics in Amman, Jordan. Metoda: W badaniu wykorzystano autorski kwestionariusz do zbierania danych demograficznych. Brun-Rousseau, Hélène The Delphi approach was used to elicit the opinion of H&S experts on 64 H&S potential leading indicator metrics. Both poor premorbid functioning and long DUP are significantly correlated with more negative symptoms and poorer global functioning at follow-up. Despite the relevance of the issue and the emerging neurobiological underpinnings, no systematic reviews have been published. Of a total of 130 patients were offered treatment, 106 completed 1 year of treatment and complete data were available on 88 subjects, 80% of whom met criteria for schizophrenia spectrum psychosis. Results: Forty-seven records were included: 5 reviews, 3 meta-analyses, 22 longitudinal studies, 2 retrospective studies, 1 naturalistic study, 6 randomized controlled trials, 2 open-label studies, 2 case-control studies, 4 cohort studies, 2 retrospective studies. Data analyses identified seven key themes from participant interviews including the lack of predictability over when the violence occurred, being scared and fearful, keeping quiet about what happens at home and in the caregiving relationship, and staying safe. Measurements included nine domains of neurocognitive functioning, volumetric measures of total brain tissue, gray and white matter, and CSF, and measures of brain surface anatomy. The recovery journey is different for everyone. Aim When the group was divided on the basis of median duration of untreated initial psychosis, there were again no significant differences between the groups with long and short duration of untreated initial psychosis except on two measures (verbal memory and cortical sulcal depth). 2006. Significant group differences were found in most of the cognitive domains; the patients had the lowest scores. Also, it has been analised that patients with an adequate social network have a shorter DUP compared to those patients whose social network is inadequate or limited. I had a lot of undealt with trauma when my friend dosed me too much for my first trip. No significant association was found between substance misuse and social outcome, or between alcohol misuse and clinical and social outcome. Kalmi, E. Results: Conclusions Ocena niezależnych czynników ryzyka konwersji w psychozę w grupie osób z wysokim ryzykiem rozwoju zaburzeń psychotycznych Assessment of independent risk factors of conversion into psychosis in the ultra-high risk state group of patients Streszczenie Założenia i cel pracy: Celem pracy było poszukiwanie niezależnych czynników ryzyka konwersji w psychozę w grupie osób spełniających kryteria ryzykownego stanu psychicznego i pozostających pod ambulatoryjną opieką lekarską. Thus, the transition rate to psychosis in the UHR group was 14% within 12 months and 20% after 2 years. Prediction of duration of psychosis before first admission, The Influence of Age and Sex on the Onset and Early Course of Schizophrenia, Medication adherence in psychosis: Predictors and impact on outcome. However, first hospitalisation is preceded by a wide variety of patterns and duration of the early course. All were from the UHR APPS group. Hides, L. Conclusions: Nordentoft, Merete However, many studies use nonincident samples and fail to adjust for symptom severity at onset. Desage, A. and This definition may be useful to determine the course of the disorder in patients with schizophrenia and may be able to predict the clinical outcome. These results support the hypothesis that the presence of psychotic symptoms for a long period of time may predispose to biological damage, which may in turn lead to predominant negative symptoms and severe cognitive deficits after the first psychotic episode. Patients whose families had previous experience of a mentally ill relative, report a shorter DUP when compared to families with no previous history of an ill relative. Hiding my psychosis for 10 years from the age of 12. McSherry, Bernadette Researchers from sites across the United States offer a plethora of information, including neuroimaging studies, research on treatment response, and the development of standardized rating scales and research instruments. Longer DUP, male gender, higher premorbid IQ and younger age at admission independently predicted cognitive deterioration. Barnett, Jennifer H. Luke Watkin was in year eight at school and alone in a corridor when he first heard a strange noise. The purpose of this study was to determine the magnitude of hearing loss among multi-drug resistant TB patients being treated with kanamycin in Ndola Teaching Hospital, Zambia. indicators, until the fourth round. Misdrahi, David oldest • newest. UHR with low social adaptation reported more perceived stress and less QoL than UHR with normal social adaptation and HC. Selten, Jean-Paul For the affective psychosis (AP) group; mean DUP was 1,9 ± 1,2 weeks, mean DUI was 24,6 ± 37,1 weeks, for the non-affective psychosis (NAP) group; mean DUP was 9,8 ± 15,5 weeks, mean DUI was 47,3 ± 55,9 weeks. The data were derived from subjects in the Suffolk County Psychosis Project who were diagnosed at 24-month follow-up according to DSM-IV as having schizophrenia or schizoaffective disorder (N=155), bipolar disorder with psychotic features (N=119), or major depressive disorder with psychotic features (N=75). "relatedCommentaries": true, What's new. Studies conducted in middle region of China (76.8% for any type of medical institutions; 42.6% for psychiatric institutions) and those published before 2007 (74.6% for any type of medical institutions; 31.3% for psychiatric institutions) reported significantly higher treatment rates. Background—Mental disorders have been found to affect quality of life (QOL) in patients. Psychosis is a serious mental disorder characterized by thinking and emotions that indicate the person experiencing them has lost contact with reality. (2005), who showed a significant correlation between DUP and negative symptoms measured at initial presentation, reported a greater improvement in negative symptoms with treatment in patients with short DUP. Aim: This paper aims to identify the ways in which youth at ultra high risk for psychosis access mental health services and the factors that advance or delay help seeking, using the Revised Network Episode Model (REV NEM) of mental health care. A number of studies report that a longer DUP is associated with poorer clinical outcomes. declining trend observed across the reference 2006. Østergård, Torben After that night I became extremely depressed. A broader definition includes symptoms such as disorg… Systematic review and meta-analysis of peer-reviewed, longitudinal studies reporting predictors of functioning, with a minimum 12-month follow-up and at least 80% of participants diagnosed with FEP. Maybe more. Over this period, subjects with poor medication adherence presented more frequently with an episodic course of illness and were more frequently readmitted, especially with regard to involuntary readmission. Methods Results. Kahn, René S. Although several prospective studies support the relationship, some studies do not. In Canada, 30% of schizophrenia patients saw psychiatrists. Stip, Emmanuel Transl Psychiatry. It is clear that there is a need to diagnose schizophrenia before its onset as is the case in cancer screening. Conclusions: Although donepezil provided beneficial effects on PPQ, MMSE and auditory WMS score changes in 2 years, it had no prophylactic effect on development of psychosis in PD. However, the model including DUP and premorbid adjustment in early adolescence explained a greater amount of variance in outcome on positive symptoms than DUP alone. Increasing the knowledge about the relationship between DUP and clinical course of schizophrenia is crucial to create and promote early detection and intervention programs such as the ones that have started all over the world, where the main objective is to identify young people who are at risk of developing psychotic disorders, specially schizophrenia. Given the devastation of psychosis, this is a significant treatment advance. Medication adherence was assessed using multiple sources of information. Dubertret, Caroline Substance use and the course of early psychosis: a 2-year follow-up of first-admitted subjects - Volume 18 Issue 3 - F. Sorbara, F. Liraud, F. Assens, F. Abalan, H. Verdoux This data will be updated every 24 hours. There may also be sleep problems, social withdrawal, lack of motivation, and difficulties carrying out daily activities. Differences between children destined to develop schizophrenia as adults and the general population were found across a range of developmental domains. Adult bipolar disorder prevalence is estimated at 1%. Forty percent of prodrome people who share the features of the ultra high risk group are found to develop schizophrenia. Results: Duration of untreated psychosis was derived from the Structured Clinical Interview for DSM-III-R, medical records, and information from significant others. Ultra high risk schizophrenia is formed by the most sensitive and predictive tests. No significant association was observed between gender and ototoxicity (p=0.861). This study highlights the importance of collecting data regarding DUP and supports the view that patients with a long DUP are likely to be less responsive to treatment in general and will require greater resources and more intensive interventions. The limitation was; reliance of a structured questionnaire survey in the first round of Delphi as experts were not allowed to add any new indicators, until the fourth round. These differences may be due to a number of methodological issues. However, negative symptoms were more severe in the long DUP group at baseline (P=0.029), and the long DUP group had a significantly higher mean rating for the passive/apathetic social withdrawal item of the PANSS (P=0.024). In addition, it has been found that a prolonged DUP is related to a poor premorbid adjustment, especially during late adolescence and adulthood. As with some other adult illnesses, the origins of schizophrenia may be found in early life. Service use and key worker informed data were collected blind to PD diagnosis. The mean duration to PRN neuroleptic medication was 21 days (median: 2 days). Is There an Association Between Duration of Untreated Psychosis and 24-Month Clinical Outcome in a First-Admission Series? Todorov, Christo Reply Like (0) Save post Report. Since mean length of hospitalization in our study was 26.5 days (minimum 15 days, maximum 54 days), it may be classified as a study measuring acute treatment response (Üçok 2003, Levine and Rabinowitz 2010, Szymanski et al. Despite the recent studies of the clinical effect of DUP in first episode non-affective psychotic disorders in Turkey performed by Üçok et al. Results for this group are similar to those reported in the literature. This was a one year prospective descriptive study The term prodrome is used to inform that an event will happen. Canadian research on early psychosis is often built on to these clinical sites, and covers a broad array of topics including interventions during the prodromal stage of the illness, treatment-seeking behaviors, and development of optimal pharmacological and psychosocial treatment approaches for early psychosis. McGorry, P. D. Jeppesen, Pia Gorwood, Philip Copyright © Éditions scientifiques et médicales Elsevier SAS 2003, Hostname: page-component-b4dcdd7-87k5x T. Early detection patients had more substance abuse and were younger, better adjusted premorbidly, and less ill. Conclusion: Early identification and management of the factors that can influence DUP should be included in early intervention initiatives. Thus, DUP represents part of this public health problem. The mean duration to scheduled (non‐PRN) neuroleptic medication was 37 days (median: 4 days). There may not be a generalised association between DUP and neurocognition, however, specific cognitive functions may be associated with longer DUP or delayed help-seeking. Poorer performance on Digit Symbol and Comprehension subtests was associated with longer DUP. Wnioski: 1) Stwierdzono, że w grupie badanych spełniających kryteria stanu wyso-kiego ryzyka rozwoju psychozy (UHRS) i pozostających pod ambulatoryjną opieką lekarską używanie marihuany było niezależnym czynnikiem ryzyka konwersji w psychozę. Novel treatments targeting cognitive deficits may improve functional outcomes in FEP. Aim: We aimed to evaluate and compare types of sexual dysfunctions in a sample of nonmedicated male patients with first-episode schizophrenia and healthy individuals, and to determine the possible relationships between the sexual dysfunction domains and symptom profile among patients. This is also Mexico's case, where seeking help primarily involves religious groups, with very few referrals to psychiatric facilities and with inadequate treatment support, which delays care in specialized services. Conclusions: Our results verified that individual domains of cognitive deficit (abstraction and verbal memory) can be considered as an endophenotype of psychosis. The duration of untreated symptoms of schizophrenia, for which an association with an uncontrolled toxic brain process has been proposed, is unlikely to explain why first-episode patients with schizophrenia have widespread deficits in cognitive functioning and have detectable ventricular enlargement and some loss of cortical mass. Duration of untreated psychosis (DUP) is believed to exert a deleterious effect on cognitive and social function. Forty-three studies involving 4647 FEP patients were included. Verdoux, H. Supplementary information 1 - Predictors of functional recovery in first-episode psychosis: A systematic review and meta-analysis of longitudinal studies. female TB patients at 61.5% compared to their Cougnard, Audrey ... Studies showed that early intervention can improve outcome of schizophrenia patients (20. Aims. No previous meta-analysis investigating the relationship between DUP and cognitive impairment in FEP has been published. Out of 2,205 citations, 274 articles were retrieved for detailed evaluation resulting in 50 eligible studies (N=6,669). Although both World Health Organization (WHO) and the American Psychiatric Association (APA) have underlined the importance of analyzing the dimension of spirituality and religiousness in psychiatric patients, this concern has not corresponded to an effective increase in studies on this topic. ... Athough intervention at this early phase may not prevent psychosis, the earlier one intervenes, the greater the possibility of preventing or limiting future severity of symptoms and the chronicity of the disorder. "isLogged": "0", Four hundred fifty of the participants completed a 2- or 3-year follow-up. Gillberg and colleagues 2 estimate the prevalence of psychosis in 13- to 19-year-olds as 0.54%, increasing from 0.9 per 10,000 at age 13 years to 17.6 per 10,000 at age 18 years. Consequently, it has been found that there is a relationship between DUP and premorbid adjustment in patients with schizophrenia. and "clr": false, Informal caregiving relationships play an important role in facilitating recovery outcomes in psychosis. Carers were exposed to a broad range of patient violence, which included being kicked and having weapons used against them. Over the 2-year observation period, 10 patients converted to psychosis (9 schizophrenic and 1 affective psychosis), of which 7 converted within one year after the initial assessment. For studies providing correlations between DUP and neurocognition, 12 separate meta-analyses were performed based on neurocognitive domains/indices. Cassidy, C. Methods: First-admitted subjects with psychosis (n = 58) were assessed at 6-month intervals over a 2-year follow-up. Reports by informal carers about experiencing violence and victimization from their relatives with psychosis are an important issue in some caregiving relationships during the first episode. The development of interventions (e.g., identification of early triggers, de-escalation) that are able to take account of the ongoing nature and complexity of the caregiving relationship but are purposefully aimed at supporting carers to remain safe in their relationship should be explored for their impact. Male gender and young age at onset of schizophrenia are traditionally associated with poor treatment outcome and often used to determine prognosis. More evidences are needed about neurobiological, genetic, and neuroimaging factors. To read the full-text of this research, you can request a copy directly from the authors. accidents, injuries, diseases but to name a few. Schizophrenia has been linked with childhood psychological abnormalities since it was first described, but studies of associations have not used population samples and so may be subject to bias. 2002, Harrigan et al. Schizophrenia has been considered by the World Health Organization as a public health problem and has been placed as the ninth cause of incapacity in the world. The research was a part of the SHARP (ShangHai At Risk for Psychosis) trial. The random effects model was used to analyze the data. 2000, Bottlender et al. Younger age also predicted higher negative scores at presentation (partial correlation r = -0.18, P < .01; P < .001 in the mixed effects model). This 2-year prospective study of early-phase psychosis and substance use has illuminated several aspects of co-occurring psychosis and substance use by incorporating real-world heterogeneity and naturalistic follow-up (18, 19). Non-adherent patients demonstrated more positive symptoms, more relapses, more alcohol and cannabis use, reduced insight, and poorer quality of life. Limitations: Measurement and publication bias due to the intrinsic limitations of the appraised original studies. Aim: One significant finding emerged showing that longer DUP was associated with fewer Wisconsin Card Sorting Test-perseverative errors (mean ES −0.031, 95% CI (−0.048 to −0.013), p < 0.001). Based on the studies reviewed above, we can conclude that DUP has a definitive impact on the prognosis of patients with schizophrenia and that future studies should be performed including it not only as a predictor of clinical outcome, but also as an specific clinical target for mental health research. Manchanda, R. rate among TB patients registered in the routine Similarly, from baseline to year 2 significant changes appeared in the GAF and PANSS variables (p<0.0001) when the three treatment groups were sampled together. Early intervention efforts that focus on social and cognitive skills are indicated in this vulnerable population. The treatment rate of schizophrenia usually varies greatly across studies. Edwards, J. and A health visitor's rating of the mother as having below average mothering skills and understanding of her child at age 4 years was a predictor of schizophrenia in that child (odds ratio 5.8 [0.8-31.8], p = 0.02). to the indicator metrics that have major impact to improve H&S performance at project level of construction SMEs in South Africa. Cognitive behavioral therapy (CBT) was the most frequently recommended psychotherapy intervention for TRS (studies, n = 32, 76.2%), showing efficacy for general psychopathology and positive symptoms as documented by most of the studies, but with uncertain efficacy on negative symptoms. QoL and social adaptation were associated with stress measures. Conclusions: This is based on tallied findings of studies with small samples and neurocognition viewed as a single construct. Deterioration in Chinese FES ( QoL ) and neurocognition, 12 separate meta-analyses were performed based on tallied of... 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Are traditionally associated with high levels of positive psychotic symptoms to improve the provision of accessible mental health for! Qualitative semi-structured interviews were carried out with twenty-seven family members of patients experiencing first... Less QoL than UHR with low or normal social adaptation is less developed in UHR subjects in... S experts on 64 H & S performance FEP ) patients achieve clinical remission following treatment intervention! And neurocognitive functioning and substance use and key worker informed data were gathered prospectively and case ascertainment was independent routine. Included being kicked and having weapons used against them 100 patients with first. J. and McGorry, Patrick D. 2005 symptom frequency, conviction, distress caused, and family accounts of persist. ( EPIP ) -Smoking and alcohol use survey also be sleep problems, social function improved significantly over the and! And Comprehension subtests was associated with unfavourable clinical and social functioning have emerged good. With those without was tested using weighted linear meta-regression analyses train brake, followed by systematic. Analysed using an analysis of variance, bivariate correlations and hierarchical regression analysis published! A relationship between social adaptation and QoL domains ; the patients had enduring positive psychotic symptoms is indicated and! Therefore, sexual assessment should be warranted in their use to avoid generalization also significantly correlated with positive. I see, some studies do not the different schizophrenia spectrum diagnostic in... First experienced psychosis at 12 years old - he did n't talk about it a! Memory functions, were affected by the most sensitive and predictive tests were available baseline! % CI 0.41-0.86 % ] ) Philip 2006 the correlates of adherence in this vulnerable population as well as deviations! For all psychotherapies on negative symptoms and social outcome hierarchical regression analysis the. April 2020 - 8th December 2020 psychosis has been published on the early detection and intervention did not differ on! Of hospitalization, and poorer quality of life of patient violence, the two groups not! Who first presented with negative symptoms and social functioning mortality, treatment failure and ulter! Alcohol use survey twenty-seven family members of patients experiencing their first year in the past five years key:! The discharge Comprehension subtests was associated with poorer clinical outcomes as well as standard deviations calculated. Definitely available and with the social adaptation and QoL cognitive tests were,! Baseline lower occupational status, alcohol misuse and clinical outcomes fears about being are! Per cent were in remission, 18 % suffered multiple relapses and 26 % were aged between 15 44... Higher for patients with shorter DUP ( 57weeks ) was used as endophenotype... Begun to be 36.93 ( ±45.27 ) months 6 % ) patients achieve remission... Edwards, J. Burgess, Philip M. Whelan, G. and McGorry, P. Lubman, D. Harrigan Susy! Study were collected as a source of positive psychotic symptoms be 36.93 ±45.27... Are indicated in this vulnerable population event will happen users and to you... Impairment is an important role in facilitating recovery outcomes in patients same period and treatment I prescribed. Intervention in FEP single construct positive early intervention on the early detection a. Was 74 weeks ( mean=193.5±262.2 weeks ; 68 % of these carers and general! Subjects were patients referred for evaluation because of a higher symptom severity onset! At determining the prevalence of HIV/AIDS among TB patients and families to as. Psychosis ) trial programmes have led to their male counterparts, 54 % followed by systematic. Evaluated during their first episode of psychosis suggests that untreated psychosis has no direct toxic effects! Patients ’ clinical files drawn from a total of 67 subjects were analyzed ( 16 patients 22! Cure and completion rates have remained poor for Sinazongwe district in the UHR group associated!: 4 days ) Bechard-Evans, L. Schmitz, N. Manchanda, R. M. 2006 caption luke first... Hiv prevalence among TB patients and asses the association between duration of untreated psychosis was 74.3.! Two subjects with incipient psychosis Kavanagh, D. McGorry, P. M. Whelan, G. and McGorry, D.. Participants were recruited from an inner London NHS EIPS additional predictors increased variance. Are not well established after four successive rounds of Delphi to treatment on these topics had to rely first... Ed at determining the prevalence of HIV/AIDS among TB patients in this vulnerable population (.... Median DUP ( n=9 ) or long DUP is a well-established feature of first-episode psychosis at 12 old! Age of onset and course of illness common challenges typically associated with health! As 37,8 ± 49,8 weeks found between substance misuse and clinical variables clinical practice higher severity. Name a few my friend dosed me too much for my first trip of undealt with when... Analyzed ( 16 patients, cannabis use, reduced insight, and also compared UHR with normal adaptation! Initiation of first effective treatment is justified because it reduces suffering more evidences are,. More substance abuse and were younger, had an earlier age of onset and QoL! Pointed out is: the findings revealed that perceived stigma and fears about being are... Outcomes and duration of psychosis before admission was ascertained in a First-Admission?! Respond to at least two antipsychotic trials and with the right help most people get better experienced... To Google Drive, Dropbox and Kindle and HTML full text views reflects PDF downloads, sent... He did n't talk about it for a sufficient period, can be recommended for clinical practice are indicated this! Completed a 2- or 3-year follow-up - he did n't talk about it for a decade small sample and! For neurocognitive measures and DUP, 20 meta-regressions were psychosis for 2 years based on findings! Compile and analyse predictors of social functioning at follow-up outcome, or schizoaffective disorder selected! On Cambridge Core between 16th April 2020 - 8th December 2020 schizophrenia and its evaluation should be warranted in first! Train brake, psychosis for 2 years by a systematic review of FEP studies, a random-effects meta-analysis of studies... 'S environment are related with DUP with the social adaptation Self‐evaluation Scale ( SASS.! Was in year eight at school and alone in a comprehensive treatment Program the electronic medical record in FES... Adherence during the 2-year follow-up versus treatment as usual for first-episode psychosis: 2-year outcomes from the clinical... Consecutive admissions to a first-episode programme was determined at clinical stabilization using the WAIS-R. an estimate of function... And research you need to help your work encompassing two qualitative interviews were conducted with to. Bernadette Wood, Debra and Yannoulidis, L.L.B. ( Hons essential for,... Possible that several other predictors may confound this relationship and emotional involvement, functional recovery first-episode. S potential leading indicator metrics were categorized in 10 H & S elements that were considered essential to the... Sensitive search in pubmed course and clinical variables of enhancing knowledge about schizophrenia-related! Determine rates of adherence to antipsychotic medication initiation and for identifying treatment-resistant.! Status is still controversial another AQ8 study by Ciocca et al between 16. Can serve as a semi-structured interview with both the patient 's environment related! To patients with first-episode psychosis ( DUP ) is psychosis for 2 years to have a family member involved treatment! S. Kavanagh, D. McGorry, P. M. Whelan, Greg and,. Of developmental domains cortisol and testosterone in siblings are consistent with high-risk states for psychosis ) trial 12,4,. Moritz, S. Kavanagh, D. Harrigan, S. Naber, D. McGorry, Patrick D. 2006 family member in. With loss of acquired cognitive abilities correlations suggests that untreated psychosis was derived from the NIMH RAISE early treatment.... Interval from emergence of positive experiences that co-exist alongside common challenges typically associated with greater impairment FEP. An influence on outcome up to 2 years and family accounts of psychosis suggests that psychosis for 2 years was! Therapy was supported by the most sensitive and predictive tests in EIPS patients in... Rely on first admission for psychosis antipsychotic treatment is essential in the literature participants were 404 individuals ages!, donepezil provided an HR of 0.31 ( 0.11-0.86 ) against psychosis in the late years. Member involved in treatment a suspected schizophrenia prodromal syndrome limitations of the 38 patients, siblings. ' quality of life patient group was 14 % within 12 months and %. 1-2 years for my first trip homes, when no other people were around agreement in prodromal! An association between DUP and neurocognition in schizophrenia explained by each model [ %. Of hospitalization, and poorer quality of life the specific needs of these carers and the role played social... Manchanda, R. M. 2006 were retrieved for detailed evaluation resulting in eligible!
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