SOAP RESPONSES
Respond at least 2 times each, 1.5 pages to each response to all colleagues who presented this week (should be 2-3 presenters each week). The goal is for the discussion forum to function as robust clinical conferences on the patients. Provide a response to 1 of the 3 discussion prompts that your colleagues provided in SOAP. Also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient. Responses exhibit synthesis, critical thinking, and application to practice settings…. Responses provide clear, concise opinions and ideas that are supported by at least two scholarly sources…. Responses demonstrate synthesis and understanding of Learning Objectives…. Communication is professional and respectful to colleagues…. Presenters’ prompts/questions posed in the case presentations are thoroughly addressed…. Responses are effectively written in standard, edited English. Meets requirements for participation by responding at least twice to each colleague who presented this week. Responses are carried out over multiple days between Days 4 and 7. Student 1 SOAP Week 9: Special Considerations Related to Prescribing to Older Adults Courtney Whitaker, RN College of Nursing-PMHNP, Walden University PRAC 6675: PMHNP Care Across the Lifespan II Dr. Brown January 24, 2024 Subjective: CC (chief complaint): “I’ve been a little down and more anxious lately.” HPI: The patient is an 81-year-old Caucasian male with GAD, MDD, and PTSD presenting for follow-up. He reports multiple stressors over the last three months, with the death of his brotherin-law, his wife’s declining health, being a full-time caregiver to his spouse, and having to take on all of the household chores. He reports a depressed mood, daytime somnolence, increased anxiety, and memory issues, stating, “I sometimes can’t find the words.” He states he has been using Lorazepam more frequently due to his recent stressors and feeling like he is going to have a panic attack at various times for unknown reasons. He reports feeling guilty and helpless because he cannot spend time with his sister and recognizing that he is in the “last chapter” of his life. He reports broken sleep with middle-of-the-night awakenings and trouble going back to sleep. He reports that before his recent stressors, he slept through the night and felt rested upon awakening with the supplemental oxygen ordered at bedtime by his primary care physician. He states he tried over-the-counter melatonin once, which was effective, but he had some anxiety about interaction with his other medications. He currently denies suicidal ideations, homicidal ideations, intrusive thoughts, nightmares, flashbacks, auditory or visual hallucinations, and mania symptoms. He reports that his appetite is good. Past psychiatric hx: Per chart review: The patient reports that he began outpatient behavioral health services in 2014 when he divorced his wife of 39 years; he reports experiencing increased anxiety, frequent panic attacks, depressed mood, feelings of hopelessness, and insomnia. He reported a history of nightmares and flashbacks of trauma experienced while working at a manufacturing job he had over 60 years ago and has had ego dystonic intrusive homicidal ideations towards former coworkers. He was started on Paxil for depressive symptoms, Clonazepam, and eventually Lorazepam for panic attacks and insomnia by a former psychiatrist who retired. He continued these medications for many years with his PCP. He denies any inpatient hospitalizations or behavioral health services prior to 2014. He denies suicidal ideations, suicide attempts, selfinjurious behaviors, auditory and visual hallucinations, and mania. His therapist referred him to his current PMHNP office for medication management one year ago. Psychotherapy: Currently participates in biweekly therapy since 2014. Psychosocial Hx: Per chart review: The patient is a retired heterosexual male living with his current spouse and adult stepson for nine years. He has no biological children; he adopted a child with his first wife. He completed high school. He denies any family substance use. His mother (deceased) had a history of hypertension (HTN). His father (deceased) had a history of CVA and prostate cancer. He had one brother (deceased) with HTN and MI and one younger sister with HTN. He reports that his son (adopted) has an alcohol use disorder (AUD) and bipolar disorder (BPD), Substance Current Use: He denies any current or prior illicit substance, tobacco, nicotine, or vaping. He reports being a social drinker in the past. He states that he quit drinking alcohol in 1980. Medical History: Coronary Artery disease (CAD), Chronic kidney disease (CKD)-Moderate, Gastric polyps, Gastroesophageal reflux disease (GERD), Hypertension (HTN), Hyperlipidemia, Sensorineural hearing loss-Bilateral Current Medications: Paroxetine 40mg 1 tab daily- MDD,GAD, Lorazepam 0.25 mg 1 tab daily prn panic attacks, Atenolol 50mg 1 tab daily HTN, Pantoprazole 40mg 1 daily GERD, Atorvastatin 20mg 1 tab at bedtime-Cholesterol, Metoclopramide 10mg 1 tab daily GERD, Sucralfate 1 g/10mL QID (with meals and at bedtime) GERD, Clopidogrel 75mg 1 tab daily, Calcium with Vit D 1 daily, Oxygen @1-2L at bedtime prn, Ondansetron 4mg 1 q 4hr, prn N/V, Melatonin 5mg OTC prn insomnia Medication trials- Zoloft- reported GI upset, nausea/vomiting, Lexapro- reported increased anxiety, Clonazepam-tapered off when Lorazepam initiated Allergies: Codeine- hives, itching, Adhesive bandages Reproductive Hx: No reported symptoms, per chart review. PT met all developmental milestones; PT has no biological children. ROS: • • • • • GENERAL: Denies weight loss, fever, weakness HEENT: Head: no complaints. Eyes: No visual loss, blurred vision, double vision, yellow sclerae observed; hx of amaurosis fugax. Ears: Bilateral hearing aids, no observed changes in hearing. Nose, Throat: No sneezing, congestion, runny nose, or sore throat. SKIN: No rash was noted on the exposed skin. CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations; hx of hypertension, coronary artery stent. RESPIRATORY: No shortness of breath, respirations even and unlabored, use of supplemental oxygen at bedtime as needed • • • • • • • GASTROINTESTINAL: No abdominal pain, anorexia, diarrhea, nausea, vomiting, hx of GERD, appendectomy, cholecystectomy, partial gastrectomy, hernia repair. GENITOURINARY: No enuresis, no burning on urination, urgency, hesitancy; hx of prostate cancer, prostatectomy. NEUROLOGICAL: No headaches, no dizziness, syncope. MUSCULOSKELETAL: No muscle or back pain, joint pain, or stiffness. HEMATOLOGIC: No anemia, bleeding, or bruising noted to exposed skin; low platelets per recent laboratory results. LYMPHATICS: No enlarged nodes were observed; no complaints were voiced. ENDOCRINOLOGIC: No polyuria or polydipsia. Objective: BP 128/73 P- 72, R- 20 Temp. 36.8 SpO2: 94% Wt: 59.42 kg; 131 lbs Ht: 160.02 cm; 5ft 3 in. BMI: 22.91 Diagnostic results: Laboratory results completed by PCP 11/2023 CBC- This is utilized for screening or evaluating disease situations and determining if the patient’s symptoms can be attributed to a medical condition (Pagana et al., 2017). This patient’s Platelets are 133,000 per microliter. Adults’ normal platelet count ranges between 150,000 and 450,000 per microliter (Pagana et al., 2017). The 133,000 is indeed below the normal range but not severely low. He has a history of gastric polyps and GERD, which could cause ulcers. CMP- This is utilized for screening or evaluating disease situations to see if the disease can account for the patient’s symptoms (Pagana et al., 2017). The patient’s results showed a Creatinine Level of 1.5 HIGH. Creatinine levels typically rise slightly with age as muscle mass naturally decreases. Consistently elevated creatinine levels are consistent with his CKD. This patient has GFR 48 LOW. He has a diagnosis of moderate CKD. Generally, it would fall within the 45-59 ml/min/1.73 m² range, aligning with the eGFR range for stage 3a CKD. Lipids- The procedure aims to identify patients who may be at risk for coronary and vascular disease (Pagana et al., 2017). He is currently taking medication for hyperlipidemia and has a family history of cardiovascular issues. This testing is important to assist in making medication choices; certain antipsychotic medications have the potential to increase lipid levels. Regular monitoring of lipid levels is crucial when prescribing antipsychotic medications, as it helps to identify potential risks. The patient’s results were within normal range. Total Cholesterol 104, Triglycerides- 81, HDL-36, LDL-52 Vit D – Vitamin D can influence the production and activity of neurotransmitters like serotonin and dopamine, which are crucial for mood regulation. This patient’s vitamin D levels are acceptable at 36.0ng/mL. Urinalysis- This test can detect issues such as urinary tract infections or conditions beyond the kidneys (Pagana et al., 2017). The patient results are within an acceptable range. GAD7: 10- A score of 10 on the GAD-7 suggests moderate anxiety. Screen tools are reliable and efficient instruments for identifying anxiety in older adults (Carlucci et al., 2021). PHQ9: 5- A score of 5 on the PHQ-9 suggests mild depression. Screening tools help identify bothersome symptoms reported by the patient. A comprehensive assessment is required to diagnose (Carlart, 2017). Assessment: Mental Status Examination: He is an 81-year-old Caucasian male who looks the stated age. He presents himself politely and pleasantly, appropriately dressed and groomed for the occasion. The individual demonstrates a cooperative and polite demeanor, although there are indications of unease through fidgeting and limited eye contact, which may suggest an underlying anxiety. He exhibited a variety of emotions, ranging from tearful concern to anxious unease, fueled by his worries about his wife’s deteriorating health and his realization of mortality. The individual’s thoughts are wellstructured; however, there seems to be a slight tendency towards distraction. This is evident in his occasional difficulty maintaining focus and expressing his thoughts, which can be observed in delayed speech. He seems restless, as evidenced by his rocking in his chair. However, there are no indications of delusions or hallucinations, and no signs of self-harm or suicidal thoughts were observed during the interview. Diagnostic Impression: 1. F41.1 Generalized Anxiety Disorder (GAD)- GAD was considered due to the supporting evidence of excessive worry, difficulty focusing, irritability, sleep problems, and somatic complaints. DSM-5-TR criteria for GAD that are met include excessive worry, difficulty controlling worry, and significant distress and impairment. Pertinent positives: Excessive worry, impending doom, distractability, and sleep problems. A GAD-7 score of 10 suggests moderate anxiety and was taken into consideration and used in conjunction with an assessment to confirm GAD. His current symptoms and generalized worry about various issues align with GAD. 2. F32.2 Major Depressive Disorder (MDD): MDD was taken into consideration. In order to receive a diagnosis of depression, according to the DSM-5-TR, an individual must experience five symptoms that persist for a minimum of two weeks and significantly impact their normal functioning. One may experience feelings of sadness or a loss of interest/pleasure. Common signs of depression include experiencing daily sadness or emptiness, frequent crying, and a decrease in overall activity level. Other symptoms may include a loss of enjoyment in most activities, sudden weight gain or loss, changes in appetite, excessive sleepiness, noticeable anxiety or slowed movement, persistent fatigue, feelings of worthlessness or excessive shame, difficulty with concentration or focus, frequent thoughts of death or suicide attempts, significant distress or impairment in daily life. It is important to note that these symptoms should not be caused by drugs, medical conditions, or grief alone, as these factors may contribute to some symptoms but cannot fully explain them (APA, 2022). There was no indication of psychosis or bipolar disorder, and no signs of mania or hypomania were present (APA, 2022). There are indications of potential Major Depressive Disorder based on sleep issues and feelings of sadness, guilt, and helplessness. This patient’s presentation suggests a lower likelihood of Major Depressive Disorder, as the predominant theme appears to be anxiety and lack of anhedonia, with only some depressive symptoms present. 3. F51.01 Insomnia- The DSM-5-TR criteria for diagnosing insomnia states a predominant complaint of dissatisfaction with sleep quantity or quality (APA, 2022). One may experience challenges in falling asleep, staying asleep throughout the night, and waking up early in the morning without being able to fall back asleep. A consistent pattern of sleep disturbance is happening regularly, occurring at least three nights per week for at least three months. The sleep disturbance results in significant distress or impairment in social, occupational, or other important areas of functioning. These symptoms may manifest as excessive daytime sleepiness or fatigue, impaired concentration or memory, and decreased motivation or productivity. Experiencing mood disturbances such as irritability or anxiety, facing challenges in social or occupational functioning, and finding it difficult to maintain relationships. The sleep disturbance is not caused by any other medical condition or mental disorder (APA, 2022). The key factor that currently rules out this diagnosis as the primary is that his sleep disturbance could be related to other factors, and this patient’s sleep issues have not been occurring for the required three months. 4. F43.1 Post-traumatic Stress Disorder (PTSD) Experiencing the loss of a loved one can be a highly traumatic event that meets the criteria for PTSD (Unterhitzenberger et al., 2020). PTSD was considered due to this supporting evidence: Pt has a history of nightmares and flashbacks of his previous job. One notable aspect of PTSD is the disturbance of sleep, often caused by recurring memories or dreams (APA, 2022). This patient is not reporting flashbacks, hypervigilance, or nightmares that would support PTSD; therefore, it is ruled out at this time. Reflections: If I could conduct this session again, I would spend more time building rapport. Given his age and complex medical conditions, establishing a strong therapeutic alliance might have taken more time than initially allotted. Building trust and rapport could have allowed for a deeper exploration of his difficulties and, potentially, better intervention engagement. I would also want to focus more on coping skills for sleep difficulties. While we discussed general stress management, specific sleep hygiene strategies and relaxation techniques might have been more helpful for his immediate sleep concerns (Wuthrich et al., 2024). (Zhao et al., 2019). The interaction between symptoms of insomnia and depression has a significant impact on the quality of life (Zhao et al., 2019). Case Formulation and Treatment Plan Reviewed laboratory results from PCP. The risks and side effects of medications are discussed, including the black box warning of increased suicidal thoughts and potential side effects, GI upset, nausea, vomiting, increased anxiety, highly anticholinergic, sedating, and orthostatic hypotension and currently being at maximum dosing for renal impaired patients for Paroxetine (American Geriatrics Society, 2023). Discussed taking Paroxetine at bedtime due to this possibly causing hypersomnolence. Potential for increased cognitive impairment and dependency with benzodiazepines (American Geriatrics Society, 2023). Informed client not to stop the medication abruptly due to withdrawal syndrome of headaches, vomiting, and weakness without discussing it with the provider. Instructed to call and report any adverse reactions. He voiced understanding of the discussion and agreed to the course of the treatment plan. Continue current medications: Paroxetine 40mg 1 tab at bedtime for MDD, GAD Melatonin 5mg 1 tab at bedtime as needed for insomnia Lorazepam 0.25mg 1 tab daily as needed for panic attacks Provided supportive psychotherapy and discussed how current stressors can contribute to anxiety, depressive symptoms, and sleep disturbance. Encouraged the use of guided breathing exercises as an alternative intervention for anxiety and sleep disturbances to reduce the use of Lorazepam for anxiety. Low-intensity psychological interventions (LIPI) offer a valuable alternative or starting point for managing mental health problems (Wuthrich et al., 2024). They are particularly beneficial for individuals with mild to moderate symptoms who desire accessible, evidence-based, and empowering interventions. Considering his age and capabilities, gentle exercises like guided chair yoga or breathing exercises could have been incorporated into the session to address his physical and emotional well-being simultaneously (Wuthrich et al., 2024). There is a need to prioritize elderly symptoms of sleep disturbance and depression to improve their quality of life (Zhao et al., 2019). Continue with biweekly psychotherapy with his therapist. Continue to follow up with PCP management of CAD, CKD, HTN, Hyperlipidemia, GERD Return to clinic in 1 month or sooner if needed. PRECEPTOR VERIFICATION: I confirm that the patient used for this assignment is seen and managed by the student at their Meditrek-approved clinical site during this quarter’s learning course. Preceptor signature: ____________________________Date: ________________________ Objectives: 1. Colleagues will be able to analyze the complex correlation of comorbid conditions in an older adult, considering potential medication interactions and exacerbating factors. 2. Colleagues will be able to critically evaluate the effectiveness of the patient’s current medication regimen in light of his presenting symptoms and comorbidities. 3. Colleagues will be able to develop a comprehensive interdisciplinary treatment plan for the patient, incorporating pharmacological and non-pharmacological interventions tailored to his specific needs and geriatric considerations. 4. Colleagues will be able to propose evidence-based strategies for addressing ethical considerations and potential barriers to treatment adherence in older adults with complex mental health presentations. Discussion Prompts 1. Given the patient’s multiple comorbidities and potential medication interactions, what alternative or adjunctive medication options might be considered to address his primary mental health symptoms while minimizing risks and side effects? 2. Considering his physical health limitations and geriatric factors, How can we effectively integrate non-pharmacological interventions into this patient’s care plan? 3. What ethical considerations arise when treating an older adult with PTSD symptoms related to a past traumatic event, and how can we ensure culturally competent and patient-centered care in this context? References American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. (2023). Journal of the American Geriatrics Society, 71(7), 2052–2081. https://doi.org/10.1111/jgs.18372 Carlat, D.J. (2017). The psychiatric interview. (4th ed.). Wolters Kluwer. Carlucci, L., Balestrieri, M., Maso, E., Marini, A., Conte, N., & Balsamo, M. (2021). Psychometric properties and diagnostic accuracy of the short form of the geriatric anxiety scale (GAS-10). BMC Geriatrics, 21(1), 401. https://doi.org/10.1186/s12877-021-023503 Pagana, K.D., Pagana, T.J., Pagana, T.N. (2017). Mosby’s diagnostic and laboratory test reference. (13th ed.). Elsevier. Wuthrich, V. M., Dickson, S. J., Pehlivan, M., Chen, J. T.-H., Zagic, D., Ghai, I., Neelakandan, A., & Johnco, C. (2024). Efficacy of low intensity interventions for geriatric depression and anxiety – A systematic review and meta-analysis. Journal of Affective Disorders, 344, 592–599. https://doi.org/10.1016/j.jad.2023.10.093 Unterhitzenberger, J., Sachser, C., & Rosner, R. (2020). Posttraumatic stress disorder and childhood traumatic loss: A secondary analysis of symptom severity and treatment outcome. Journal of Traumatic Stress, 33(3), 208–217. https://doi.org/10.1002/jts.22499. Zhao, X., Zhang, D., Wu, M., Yang, Y., Xie, H., Jia, J., Li, Y., & Su, Y. (2019). Depressive symptoms mediate the association between insomnia symptoms and health‐related quality of life and synergistically interact with insomnia symptoms in older adults in nursing homes. Psychogeriatrics, 19(6), 584–590. https://doi.org/10.1111/psyg.12441 Student 2 SOAP Week 9: Complex Case Study Presentation Maryann Bate College of Nursing-PMHNP, Walden University PRAC 6675: PMHNP Care Across the Lifespan I Clinical Faculty 1/24/24 Complex Case Study Presentation Subjective: CC (chief complaint): “I feel sad”. HPI: Patient is a 25 y/o Caucasian female who presents for her follow up after initial evaluation. She was diagnosed with Major Depressive Disorder, Bipolar I, and Substance Use Disorder. She started experiencing the depressive symptoms three years ago when she lost her father. She was close to him and thus experienced a hard time getting over the death. The Bipolar was diagnosed two years ago when she started to feel hopeless and sad most of the time. She lost interest in her daily chores and experienced self-doubt. She started drinking heavily and smoking marijuana frequently. She is currently taking Lexapro and lithium. Sleeps for less than 4 hours a day. Denies suicidal ideation. Substance Current Use: Drinks beer and/or wine on a daily basis. Smokes marijuana on a daily basis. Medical History: • Current Medications: Lexapro 10 mg 1 tablet by mouth every night. Lithium 10 mL 2 times a day. • Allergies: KNA • Reproductive Hx: Sexually active. No child. Last period two weeks ago. ROS: • GENERAL: Denies weight loss, change in appetite, fever, weakness, chills or fatigue. • HEENT: Denies blurred vision, double vision, visual loss, yellow sclerae, or recent eye exam. Denies hearing loss or ear pain. Denies nasal congestion, sneezing, or runny nose. Denies sore throat. • SKIN: Denies rash or itching. • CARDIOVASCULAR: Denies chest pain, chest discomfort, or chest pressure. Denies edema or palpilations. • RESPIRATORY: Denies shortness of breath, cough or sputum. • GASTROINTESTINAL: Denies anorexia, diarrhea, nausea, or vomiting. • GENITOURINARY: Denies burning on urination, hesitancy, urgency, odor, or odd color. • NEUROLOGICAL: Denies dizziness, headache, paralysis, numbness, ataxia, or tingling in the extremeties. • MUSCULOSKELETAL: Denies back pain, muscle pain, joint pain, or stiffness. • HEMATOLOGIC: Denies anemia, bruising, or bleeding. • LYMPHATICS: Denies enlarged nodes or history of splenectomy. • ENDOCRINOLOGIC: Denies sweating, cold or heat intolerance. Denies polydipsia or polyuria. Objective: Diagnostic results: Not ordered. Assessment: Mental Status Examination: Patient is a 25 y/o Caucasian female who looks her age. She is cooperative during the questioning. Can easily name objects. Appropriately dressed. Inappropriate mood. Inappropriate affect. Short attention span. Signs of withdrawal and intoxication present. Evidene of bizarre behavior. Intact cognitive functioning. Denies suicidal ideation. Diagnostic Impression: 1. Major Depressive Disorder (MDD). Patients with MDD get to experience a depressed mood that impairs their daily life functioning. The condition also leads to both physical and behavioral symptoms, such as changed sleeping patterns and energy levels. One can also experience irritability, restlessness, agitation, slowing speech and ongoing feelings of worthelessness (Karrouri et al., 2021). 2. Bipolar I with most recent/current episode Manic, severe w/ psychotic features. This condition makes the individual experience mood swings ranging from depressive lows to manic highs (Mousavi et al., 2021). Therefore, one can report sadness, difficulty focusing, hallucinations, and constant worry. 3. Substance Use Disorder (SUD). Symptoms include the need to use alcohol or drugs on a daily basis, intense urges for alcohol or drug, consuming larger amounts of drugs or alcohol, not meeting daily life obligations, continual use of the drug or alcohol, and much more (Kalin, 2020). Reflections: I agree with the receptor’s and my assessment of the patient presented in this case. The patient was diagnosed with Major Depressive Disorder, Bipolar I, and Substance Use Disorder. The patient should continue with the medication she is taking for the different disorders. However, there is a need to help her change her lifestyle that pushes her to take alcohol and marijuana. The first line of action can be psychotherapy to also teach her healthy coping mechanisms. Cognitive Behavioral Therapy (CBT) is a structured and goal-oriented psychotherapy that can help the person look into the thought patterns that determine behavior. Through CBT, the person can unlearn the negative thoughts and behaviors and instead follow healthier ones. The therapy can help patients with SUD by motivating them to change and also beign educated on how to prevent relapse. Case Formulation and Treatment Plan: Continue with current medication. Lexapro 10 mg 1 tablet by mouth every night. Lithium 10 mL 2 times a day. Start psychotherapy. CBT is a structured and goal-oriented psychotherapy that can help her look into the thought patterns that determine behavior. Through CBT, she can unlearn the negative thoughts and behaviors and instead follow healthier ones. The therapy can help her deal with alcohol and marijuana by motivating them to change and also beign educated on how to prevent relapse. She will be taugh coping strategies. Patient received education on tbe benefits of adhering to medication and therapy. Patient also educated to monitor suicidal thoughts and side effects of medication, including nausea, increased heart rate, dry mouth, or difficulty sleeping. Talked about the risk and negative effect of mixing medications and alcohol or drugs. The patient given emergeny numbers to dial in case of issues that may arise suddenly. Given time to ask questions abuot the conditions she has and the treatment plan. Verbalized understanding of the discussion and promised to stick to the treatment regimen. Return to clinic after 4 weeks. Questions: 1. Is there any other diagnosis that may have been left out? 2. What would you do with a patient presenting with comorbidities? 3. How should we encourage lifestyle change for people who have SUD given the risks involved? 4. What education or coping strategies would you present to the patient? PRECEPTOR VERFICIATION: I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning. Preceptor signature: ________________________________________________________ Date: ________________________ References Kabade, A. S., & Mutalik, N. R. (2022). Neurological soft signs in patients with psychotic symptoms and without psychotic symptoms: A direct comparison. Journal of Psychiatry Spectrum, 1(2), 84-88. Kalin, N.H. (2020). Substance use disorders and addiction: Mechanisms, trends, and treatment implications. The American Journal of Psychiatry, 177(11), 1015-1018. Karrouri, R., Hammani, Z., Benjelloun, R., & Otheman, Y. (2021). Major depressive disorder: Validated treatments and future challenges. World Journal of Clinical Cases, 9(31), 9350-9350. Mousavi, N., Norozpour, M., Taherifar, Z., Naserbakht, M., & Shabani, A. (2021). Bipolar I disorder: A qualitative study of the viewpoints of the family members of patients on the nature of the disorder and pharmacological treatment non-adherence. BMC Psychiatry, 21(83).
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