Problem-Solving Therapy for Older Adults at Risk for Depression: A Qualitative Analysis of the Depression in Later Life Trial
Publication: American Journal of Psychotherapy
Abstract
Objective:
As a sequel to the Depression in Later Life trial of lay counselor–delivered problem-solving therapy for depression prevention among older adults in Goa, India, this qualitative study aimed to explore participant experiences to illuminate the reasons for the trial’s positive findings and implications for further efforts at depression prevention in low-resource settings.
Methods:
In-depth interviews were conducted with 19 participants (21% of those randomly assigned to the original intervention). Two independent raters coded the data and organized narratives according to broad themes.
Results:
Most participants valued their relationship with the lay counselor, learned self-care strategies to cope with illnesses, and increased engagement in pleasurable social and physical activities. Some participants reported needing assistance with managing financial strain and family conflicts.
Conclusions:
The lay-counselor–delivered intervention was well received. The relationship with the counselor and behavioral activation toward better self-care and more-pleasurable activities may have been keys to the intervention’s success.
Highlights
•
Problem-solving therapy delivered by lay counselors was a feasible and acceptable strategy for preventing depression in older adults in a low-resource setting.
•
Participants spoke about the relationship with the lay counselor, learning about strategies for better self-care, and increasing their participation in pleasurable activities as helpful strategies.
•
More help in relieving financial strain and reducing interpersonal conflict were suggested as ways to improve the intervention.
With the worldwide population aging, depression in older adults is a growing public health challenge, particularly in low- and middle-income countries (LMICs), because of scarce resources for treatment (1). Late-life depression is associated with increased risk for suicide and dementia, and it amplifies disability from comorbid medical conditions (1, 2). Many older adults have depressive symptoms that do not meet diagnostic criteria for major depression (3–5). Research from high-income countries has shown that indicated prevention (i.e., prevention focused on those with subsyndromal symptoms) of major depression in older persons is feasible and effective (6, 7). Until recently, however, there was no such evidence from LMICs. To bridge this evidence gap, we conducted the first (to our knowledge) randomized clinical trial, called Prevention of Depression in Late Life (DIL, which means “heart” in Hindi), to develop and test a model of depression prevention for low-resource settings (8). The study implemented risk-reduction strategies grounded in problem-solving therapy for primary care (PST-PC) by targeting persons with subsyndromal depressive symptoms, and it tested the effectiveness of delivering the intervention through task shifting and/or sharing with lay counselors (8, 9). PST-PC is a manualized intervention that teaches a positive problem orientation and active problem-solving skills in place of avoidant coping. By teaching active coping skills, PST-PC combats learned helplessness and includes specific behavioral activation components, such as engagement in pleasant daily activities. Thus, at every session (six to seven initial sessions, followed by three booster sessions across 9 to 10 months), the lay counselors asked about daily pleasant events and connected efforts at problem solving and engagement in pleasurable activities with changes in mood. Because of study participants’ limited literacy, the lay counselors used pictorial flip charts rather than work sheets or handouts to teach the basic steps of problem definition, brain storming, and goal setting. In addition to using strategies from PST-PC, and as a result of extensive formative work, the intervention also incorporated elements of brief behavioral treatment of insomnia (BBTI), instruction in self-management of common comorbid medical conditions (e.g., diabetes, hypertension, and arthritis), and practical assistance in accessing government-sponsored medical and social programs for older adults (9) in Goa. The primary outcome measure was incidence of major depressive episodes, as ascertained by administration of the Mini-International Neuropsychiatric Interview, version 6.0 (10). To provide further clinical context for the study, we also reported changes in symptoms of depression and anxiety over 12 months as measured by the self-report General Health Questionnaire (GHQ-12) (11) and changes in functional status (as measured by the World Health Organization Disability Assessment Schedule 2.0) (12), cognition (as measured by the Hindi Mini-Mental State Examination) (13), blood pressure, and body mass index.
As reported previously (8), we enrolled 181 participants: 91 into the intervention arm (DIL) and 90 into care as usual. Incident episodes of major depression were lower in the DIL arm than in the care-as-usual arm (4.4% versus 14.4%, log rank p=0.036, number needed to treat=9.95, 95% confidence interval [CI]=5.12–182.43). The 12-month Kaplan-Meier estimates of percent depression free were 95.1 (95% CI=90.5–99.9) in DIL versus 87.4 (95% CI=80.4–95.1) in care as usual. The incidence of depressive and anxiety symptoms (as measured by the GHQ-12) was also less in the intervention arm compared with the care-as-usual arm (group × time interaction, p<0.001).
To further inform the interpretation of the outcomes of the DIL trial, we initiated a qualitative study to elicit the perceptions of participants about their experiences with the DIL intervention. In this current study, we sought to understand what participants considered beneficial or not beneficial, together with the challenges and barriers that they (and the lay counselors) encountered in implementing the intervention. We sought this input to inform the development of future programs in depression prevention in low-resource settings.
Methods
The DIL intervention used an experiential, learning-based approach that was grounded in PST-PC (14) and BBTI (15). The intervention was adapted to the local environment to serve the needs of study participants. For example, pictorial flip charts were used to engage participants with little or no literacy (8, 9, 16). Every 2 weeks, teleconferences were held with supervisors in the United States (J.Q.M. and C.F.R.), an on-site supervisor (M.S.), and the four lay counselors to monitor the study’s progress and the fidelity of the intervention delivery. The meeting agenda addressed participant enrollment and retention, challenges faced while delivering the intervention, and strategies or tools developed to aid in delivery of the intervention. For example, one such strategy was for the lay counselors to work with the participants to identify people in the participants’ social networks who could consistently help them with their action plan, thereby facilitating the participants’ independence in the action plan (rather than relying on the counselor). Strategies to overcome potential barriers were discussed in detail during these teleconferences (see Appendix 1 in the online supplement for examples of challenges and how they were handled). Other challenges included participants’ difficulty in recalling the content of the previous session, skepticism on the part of family members as to the need for counseling, interruptions from family members and neighbors during home-based sessions, difficulties scheduling sessions, and session duration (because of the elders’ need to vent and sessions going beyond 60 minutes). Lay counselors developed flexible responses to these situations (see the online supplement) , which probably contributed to the study’s high retention rate of about 85% (8). Local supervisory sessions (conducted by M.S.) were also held every other week, alternating with those conducted via teleconference by the U.S.-based supervisors, to monitor and maintain the quality of the intervention, as measured by the therapy quality scale (17). A supportive learning-based collaborative emerged during this process, as the peer counselors often helped each other in implementing the DIL strategies with poor rural and urban Goan elders with limited or no literacy.
We conducted semistructured, in-depth interviews (see Appendix 2 in the online supplement ) with participants in the DIL intervention arm who had completed the final (12-month) outcome assessment. The semistructured interviews were designed to allow participants to express what they considered meaningful and valuable and also what they did not find helpful about the intervention. The objectives of these exit interviews were to understand the experiences of DIL participants who received the intervention, to explore the impact of the intervention, to identify key parts of the intervention the participants perceived as beneficial, and to understand the barriers and challenges to implementing action plans formulated through use of PST-PC (see Appendix 2 of the online supplement ). For the interviews, we named PST-PC “Saud,” which in the local Konkani language means “health.” We included several strategies to ensure rigor in our qualitative approach, including consulting with an advisory panel during the formative research preceding the randomized clinical trial to obtain diverse perspectives regarding the position of older adults in Goan society (18), using codes that were not mutually exclusive to reduce the chance of losing important ideas, analyzing negative cases (participants reporting no improvement in depressive and anxiety symptoms) to better understand participants’ priorities, maintaining variability in sampling (both men and women, rural and urban, “young old” and “old old”), and conducting the interviews in in a timely manner to reduce recall bias. We were no longer identifying new themes by the time we coded the 19th transcript. Although we did not interview the lay counselors, all four remained with the study throughout and reported satisfaction with their roles in shaping and implementing the DIL intervention.
Sample
Participants were asked at the completion of their 12-month outcome assessment whether they would be willing to be approached for participation in the exit qualitative study. The data manager randomly selected eligible participants in accordance with the recruitment ratio (i.e., urban-rural classification), and interviews were conducted by research assistants (not the lay counselors) who were blind to participant outcomes. After the data were unmasked, however, we observed that 14 of the 19 participants had reported reductions in GHQ-12 scores of depressive and anxiety symptoms. Therefore, a second-stage sampling (N=5) was done, in which the data manager purposely identified participants who reported increases in GHQ-12 scores (i.e., worsening of depressive and anxiety symptoms) during the study. Thus, participants (N=19; nine men, 10 women) of the current study included 14 DIL participants randomly selected without regard to GHQ-12 scores, along with five additional DIL participants who had experienced worsening symptoms during the intervention. The interviews ended after thematic saturation was achieved, based upon achievement of consensus of the two independent coders (F.A. and M.S.).
Information about the goals of the interview was provided, confidentiality and anonymity were explained, and participants were asked if they voluntarily and freely consented to be interviewed and recorded using a digital tape recorder. Participants were informed that no financial incentive would be provided. Of the 19 participants approached, all consented to be interviewed.
Ethical approval for this study was obtained from research ethics boards at all associated institutions: University of Pittsburgh; London School of Hygiene and Tropical Medicine; Sangath, Goa, India; and Goa Medical College, India.
Interview
An interview guide (see Appendix 2 in the online supplement ) was developed by the study team in collaboration with key stakeholders (9, 16). As noted above, the guide addressed participants’ experiences while engaging with the lay counselors, content of the intervention, and perceived impact of the intervention on the participants’ lives.
The interview guide was translated into Konkani (the local language of Goa). All interviews were conducted in Konkani and took place in the participants’ homes. Interviews lasted an average of 30–45 minutes. The interviews were audio recorded and then translated and transcribed into English for review by study coauthors (F.A., M.S., A.C., V.P., and C.F.R.). The interview guide was translated by individuals fluent in Konkani and English. The research team reviewed all the transcripts for accuracy.
Data Analysis
We used a framework analysis approach, as described by Cohen et al. (18), to generate themes from the raw data using the interview guide as the overall framework for coding and delineating the themes. Two independent raters (F.A. and M.S.) read and familiarized themselves with the transcripts. Next, the two raters randomly selected several interviews to read and systematically generated initial codes. Subsequently, by using the coded data and interview guide as a basis, the two raters defined and collated the codes into potential themes and finalized the code book. The final coding scheme was achieved by the two raters reaching consensus. The two raters coded the entire data set independently, one of them directly coding into NVivo data analysis software and the other into a Microsoft Word document. Agreement between the raters was tested by double-coding all the interview transcripts. The codes were then compared and reconciled in a consensus process that involved the senior authors (A.C., A.D., J.Q.M., V.P., A.D., C.F.R.) as needed for resolving any differences in how the codes were applied; thus, the final NVivo file for analysis was created. Finally, simple frequencies were counted for the selected themes, as reported in the Results section below, and illustrative examples of narrative related to themes of the interviews were selected and analyzed.
Results
To better integrate our qualitative findings with the previously reported quantitative findings, we have presented the qualitative results organized thematically and within the framework of self-reported symptoms of depression and anxiety on the GHQ-12 (which was the primary clinical, contextual outcome measure, along with incidence of major depressive episodes).
Participant Perceptions of the Psychoeducation and Active Coping Strategies
Of the 19 (nine male, 10 female) participants (mean age=68.6 years) interviewed (21% of those randomized to the intervention), 14 (74%) showed decreasing (i.e., improving) depressive and anxiety symptoms, and five (26%) showed increasing (i.e., worsening) symptoms. The mean baseline GHQ-12 score of those whose scores improved was 6.4, compared with 5.4 for those whose scores worsened. The mean GHQ score at the 12-month outcome for those whose symptoms improved was 2.4, and for those whose symptoms worsened, it was 7.6 (Table 1).
| GHQ-12 score | |||||
|---|---|---|---|---|---|
| Participant age (years)/sex | Baseline | 3 months | 6 months | 12 months | PST-PC strategy recall |
| 69/M | 6 | 1 | 1 | 2 | Remembered well |
| 62/F | 5 | 3 | 1 | 3 | Remembered well |
| 65/M | 4 | 2 | 0 | 0 | Partially remembered |
| 70/F | 6 | 2 | 3 | 4 | Could not remember well |
| 65/F | 8 | 4 | 3 | 3 | Could not remember well |
| 79/M | 6 | 3 | 5 | 1 | Remembered well |
| 71/M | 5 | 3 | 3 | 1 | Remembered well |
| 74/M | 8 | 2 | 3 | 5 | Remembered well |
| 70/F | 6 | 2 | 3 | 0 | Could not remember well |
| 72/F | 9 | 6 | 10 | 3 | Could not remember well |
| 67/M | 6 | 0 | 1 | 1 | Could not remember well |
| 64/F | 9 | 5 | 4 | 1 | Could not remember well |
| 72/M | 8 | 5 | 8 | 7 | Remembered well |
| 73M | 4 | 6 | 3 | 3 | Partially remembered |
| 62/F | 7 | 6 | 6 | 9 | Could not remember well |
| 75/F | 5 | 2 | 4 | 8 | Could not remember well |
| 62/F | 6 | 6 | 4 | 8 | Partially remembered |
| 70/F | 5 | 8 | 5 | 6 | Remembered well |
| 61/M | 4 | 4 | 2 | 7 | Could not remember well |
a
GHQ-12, 12-item General Health Questionnaire. Possible scores range from 0 to 12, with higher scores indicating more symptoms of depression and anxiety. F, female; M, male; PST-PC, problem-solving therapy for primary care.
Participants whose symptoms improved (N=14) had a positive view of the intervention and the psychoeducational tools used to deliver it, such as pictorial flipcharts.
The pictures which they showed me, made me realize that she is showing the correct things. Then I took a step forward and started following it. That is why I feel good now. (male, age 69)She has taught us something which no one used to tell us: on how you do not get sickness. I will keep worrying on the problem. But if I work on it, I will stop worrying. My worry becomes less when I work on it. (female, age 62)
In contrast to participants whose symptoms worsened, those whose symptoms improved adopted a self-help approach and actively followed the steps of the intervention, including engaging in pleasurable activities, to reduce “tension” (the word used in Konkani to denote dysphoric states). For example, one participant said,
When I am at home, I get tension. Then I go out for an hour or so. I walk or take my cycle. I go out and speak to people, old persons or children, then I feel good. It was useful all that she [the counselor] told me. (male, age 71)
Interestingly, the proportion of participants able to recall the steps of PST-PC did not appear to differ among those reporting overall improvement or absence of improvement. This finding may suggest that other, nonspecific treatment factors were at play in addition to the active techniques of PST-PC.
Engagement With the Lay Counselor
Almost universally, the participants reported that they liked meeting with the lay counselor; they felt that having someone take time to inquire about them reduced feelings of social isolation and loneliness and was helpful in itself, irrespective of the content of the intervention. The interaction with the counselors, particularly at participants’ homes, was viewed as an added benefit to the strategies of engaging in pleasurable activities and learning skills to cope with prevalent issues and comorbid medical conditions. Although nine participants (47%) reported difficulty recalling specific topics discussed during the sessions, the majority (N=12, 63%) of the participants reported perceived improvement in their quality of life, with greater satisfaction and sense of control resulting from the use of behavioral activation to reduce “tension” and of active coping strategies to manage health-related concerns (rather than passive acceptance or simply giving up).
I liked that he inquired about me. I liked that he cares, means you come because of us. You come from afar and spend time with us. I appreciate it. We learn a lot on healthy living activities, about health. (male, age 74)It will be good if someone like the counselor can come and visit us every month and check on us. I feel good if this happens. (male, age 73)She told me not to take tension. If you take tension, you start thinking. I have improved a lot talking to her. I talk to my friends, and I have no time to think. (male, age 61)
Coping with Physical Health Issues
All 19 participants reported having at least one chronic physical illness (such as diabetes, hypertension, or arthritis) that they had discussed during visits with the lay counselor. Participants associated taking a more active role in managing their physical health conditions with lessening of depressive and anxiety symptoms. Those who reported not feeling better physically or not having more confidence in self-care reported no lessening of depressive and anxiety symptoms. Lay counselors encouraged adherence to prescribed treatments, taught simple exercises for pain management, and occasionally provided instrumental assistance to facilitate access to primary and specialty medical care.
I have high blood pressure, because of which I used to keep on worrying. My diabetes would rise because of this worrying. Now I am free: no tension. (male, age 61)The advice on seizures and hypertension has worked: it has helped me. I am completely all right. (female, age 62)Now I am bored with my life in this world. I feel if I had died then it would have been better. I feel like my world is over because of my health problems. (female, age 62)I did not do anything [that] he had told me. I cannot remember very well. (female, age 75)
Engaging in More Pleasurable Activities
Increased activity was found to be useful by 13 of 19 (68%) participants, with the majority incorporating more physical and social activity into their daily routines, in addition to taking a greater role in self-management of chronic health conditions, particularly diabetes, hypertension, arthritis, and chronic pain.
Now I get up early, water all the plants. I can pass my time like that. I grow some plants, and I keep on doing something or the other. I do this to make my tension less. Otherwise I go and sit with my neighbors. (female, age 70)After taking part in the program, I am feeling better. I am interested in whatever I do. [A year ago], I did not have any interest. I feel interest in working. Before I did not like to go to the market, now I like to go. I feel nice when I go out. I am better than before, not much, now we are grown old. Not perfect, but better. (male, age 72)Although I knew that I get relaxed by going out, I used to just sit at home. Then I used to think about various things. Then when I started cycling, it became good. (male, age 69)
Improving Sleep Quality
Fifteen participants (79%) reported having sleep problems. Among four participants, BBTI was perceived to be helpful in recovering a stable sleep routine and reducing dysphoric arousal and in attaining greater daytime alertness and energy. Two others with midcycle awakening problems seemed to have found the intervention not as helpful. Another participant who had had a sleep problem for more than 10 years suggested that the intervention should have included prescribed sleep medication to be more effective.
What he had told me is that if I get tension, to sit on a chair and to think whatever I want, not to go on the bed and think. (male, age 74)
Using Strategies to Reduce “Tension”
Participants found information about “tension” and worry helpful, especially the connection between stress, poor sleep quality, and chronic illnesses. Such information was provided through the use of flip charts illustrating the steps of PST-PC and BBTI (16). For example, participants recalled concrete, specific strategies to stop from worrying and practiced them regularly. A male participant narrated the strategy he used to deal with worry, called the “worry-chair” technique:
Come on time and sit there [on his worry chair]. When you sit there, you do your worrying for 15 minutes. When you finish worrying, watch TV and concentrate on the program. When you are watching TV, you should not think [about that which worries you]. (male, age 74)
Where the DIL Intervention Was Not Perceived to Be Helpful
Of the five participants with worsening symptoms, only one was able to recollect the specific steps of the DIL intervention. Two of the participants with worsening symptoms perceived the PST-PC and BBTI as not useful, whereas the three others described these components as potentially beneficial to others, despite not feeling better themselves. Three of the participants with worsening symptoms perceived no improvement in physical health, and the two others did not comment on physical health. Participants without symptom improvement as measured by the GHQ-12 conveyed a negative view of the intervention, expressing a wish for medication, greater assistance in resolving financial stressors, and help in resolving family disputes instead of the counseling provided.
He had showed me the pictures, but I’m telling you truly that I can’t remember anything [that] he had told me. It is not his fault. It is my fault. I have forgotten what he had taught me. (female, age 75)
Nonetheless, three of the five participants without symptom improvement continued to follow components of the intervention, such as engagement with managing their own health through attention to diet, physical activity, and sleep. This continuing engagement seemed to reflect a positive relationship with the lay counselor and, perhaps, a hope for eventual benefit.
Participant Recommendations
Seventeen of the 19 participants provided suggestions for improving the program. The most common suggestion was to continue sending the counselors at least once a month to provide not only counseling services and social support, but also to check blood sugar and blood pressure during fasting and to provide reminders about healthful practices (N=6).
You have to do this. Now you come to visit us, you have to check our diabetes and pressure, ask us if we are feeling better than before. You must inquire about all this. Like that, you will also improve. (female, age 70)You should come regularly. When you come after a year, our memory fades. We forget if it is a long time. We get some knowledge also if you come often. (male, age 65)
Those whose symptoms failed to improve were not satisfied with the “talking treatment” and thought that the intervention would be more effective if medicines were prescribed (N=2), in addition to the counseling services. One participant with financial difficulties thought that counseling would be effective only if the counselor helped the participants overcome their financial burdens. Other participants expressed distress about ongoing family conflicts, wishing for more attention to role conflicts and to isolation and loneliness.
If she had [some medicine to give] because of this problem, it would have been helpful. They used to talk and go. It was of no use. (female, age 64)Whatever you people have told us, is never in our thoughts. If we follow, then the tension can be forgotten; this can reduce the stress. But in addition, the house situation should be good. Then [the counseling] will be more beneficial. Otherwise, if the house situation is not good, then people get frustrated and it is a problem. Then I have to ask people for money. This is a problem. For the last 3 months, I have not received my finance scheme [government pension]. This is a tension for me. (male, age 79)
Discussion
In keeping with the goal of illuminating the quantitative findings of the DIL trial (8), in the current qualitative study, we explored the experiences of DIL participants and their perceptions of what parts of the intervention contributed to positive change or worsening of their depressive and anxiety symptoms. The study also identified opportunities for further development of the lay-counselor intervention to make it more broadly acceptable and potentially scalable in diverse low-resource settings.
In an earlier study by Cohen et al. (18), we reported that physical health conditions are perceived by older Goans as vital to their well-being, an emphasis that was again reflected in the current study, wherein a majority of the participants discussed physical health concerns. The components of the DIL intervention, particularly basic education about prevalent conditions such as diabetes, hypertension, and arthritis; nutritional advice; encouragement for engaging in physical activity; and a focus on improved self-management of chronic diseases and insomnia, appeared to motivate and empower participants to take better care of their health. This engagement, which was reinforced during follow-up booster sessions every 3 months, was associated with lessening of depressive and anxiety symptoms as measured by the GHQ-12.
The DIL intervention enabled greater active coping by participants and engagement in managing their own health. Participants reported and displayed improved confidence to carry out action plans developed with the lay counselors (even when, as was typical, they had difficulty recalling the steps of PST-PC). This improvement was reflected in the significantly increased rates of hospitalization in the intervention arm, which were primarily a manifestation of help-seeking behavior (8). Participants also learned about the positive impact on their mood (described as decreasing levels of “tension”) from increasing social and physical activities. The participants valued the relationship and personal attention provided by the lay counselor and wished that these could continue, thus underscoring the importance of the therapeutic relationship to the participants as a source of emotional support and encouragement to continue improved self-care.
As previously described by Cohen et al. (18), interpersonal conflicts and financial strain had key roles in the participants’ well-being, in addition to concerns about physical health. Concerns with interpersonal relationships within the family (particularly regarding in-laws) were on occasion deeply preoccupying and sometimes inhibited participants from actively engaging in self-care and pleasurable activities. In addition, and also replicating the findings of Cohen et al. (18), some participants mentioned that financial insecurity was the major cause for their “tension” and that, unless that problem was resolved actively, the intervention could not be useful to them. In the current study and in the previous report by Cohen et al. (18), these interpersonal and financial concerns reflected perceived threats to the participants’ safety, independence, and dignity. These concerns represent important opportunities for culturally sensitive adaptations of DIL to better meet the needs of older adults in Goan society.
Sleep problems, a known risk factor for depression, were highly prevalent among these participants. Those whose sleep quality was improved through the use of BBTI reported benefiting more generally, and they continued to use BBTI strategies after exiting the study. Overall, however, use of strategies to improve sleep quality were less prominent in discussions of helpful interventions than were becoming more active in protecting and improving health, engaging in more-frequent physical and social activity, and having a positive relationship with the lay counselor.
Conclusions
DIL is a multicomponent intervention, the foundation of which is engagement with lay counselors who use psychoeducational strategies to teach active coping (particularly in regard to health-related concerns), more-effective ways of dealing with worry (described as “tension” in the Konkani language), and increased scheduling of pleasurable activities. These techniques are consistent with a recent systematic review and meta-analysis of behavioral activation for depression in older adults (19), but to our knowledge, this was the first such study of behavioral activation in a low-resource setting. Behavioral activation components are integral to PST-PC. The DIL intervention supports the development of resilience in the form of active coping skills, particularly for dealing with health problems and their attendant threat to safety and independence, and enhanced engagement with life, thus combatting the learned helplessness that can lead to clinical depression. Jeste et al. (20) have shown that resilience can counter the adverse effects of depression on self-rated measures of health and quality of life. Further attention to training lay counselors in mitigating intrafamilial conflicts and in accessing financial and material resources, if available and feasible, could represent useful, culturally sensitive avenues to further develop methods of depression prevention in this population and in other low-resource settings.
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Information & Authors
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History
Received: 17 February 2019
Revision received: 25 June 2019
Revision received: 26 August 2019
Revision received: 27 October 2019
Accepted: 6 November 2019
Published in print: December 01, 2019
Published online: 9 December 2019
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Authors
Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
This research was funded by the U.S. National Institute of Mental Health (grants R34-MH-096997 and P30-MH-90333).
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