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Espiritualidades.com.brAdvance Access Publication 25 August 2006 Healing by Gentle Touch Ameliorates Stress and OtherSymptoms in People Suffering with Mental Health Disordersor Psychological Stress Clare Weze1, Helen L. Leathard2, John Grange3, Peter Tiplady4 and Gretchen Stevens1 1The Centre for Complementary Care, Muncaster Chase, Ravenglass, Cumbria, CA18 1RD, 2Faculty of Health andSocial Care, St Martin’s College, Lancaster, Lancashire LA1 3JD, 3Centre for Infectious Diseases and InternationalHealth, Royal Free and University College Medical School, 46 Cleveland Street, London W1P 6DB and4Meadow Croft, Wetheral, Carlisle, Cumbria CA4 8JG, UK Previous studies on healing by gentle touch in clients with various illnesses indicated substantialimprovements in psychological well-being, suggesting that this form of treatment might be helpful forpeople with impaired quality of mental health. The purpose of this study was to evaluate theeffectiveness and safety of healing by gentle touch in subjects with self-reported impairments in theirpsychological well-being or mental health. One hundred and forty-seven clients who identifiedthemselves as having psychological problems received four treatment sessions. Pre- to post-treatmentchanges in psychological and physical functioning were assessed by self-completed questionnaireswhich included visual analogue scales (VAS) and the EuroQoL (EQ-5D). Participants recordedreductions in stress, anxiety and depression scores and increases in relaxation and ability to cope scores(all P < 0.0004). Improvements were greatest in those with the most severe symptoms initially. Thisopen study provides strong circumstantial evidence that healing by gentle touch is safe and effective inimproving psychological well-being in participants with self-reported psychological problems, and alsothat it safely complements standard medical treatment. Controlled trials are warranted.
Keywords: alleviation of symptoms – complements medical treatments – gentle touch – healing –psychological well-being – relaxation – stress frequently imperfect due to inadequacies in dosage and duration(6,7). Adherence to prescribed medication may be erratic (7,8) Anxiety and depression are among the most common mental due in part to adverse effects, which usually begin before the health disorders encountered in primary care (1), with episodes therapeutic effect is achieved (9) and medication is tolerated less of depression typically lasting for 12–20 weeks (2). Psycho- well by patients with mild to moderate depression (10). Poor logical stress resulting from bereavement, major life events or expectations of improvement are a consequence of the negative stressors in the external environment has been associated with cognitive set; namely, the tendency to view self, future and world depressive disorders in some individuals (3,4), and contributes in a negative manner (11), which is associated with depressive considerably to general morbidity and health care resource use disorders and which contributes to non-adherence (12). Further- more, many patients with major depression require long-term Although evidence of the efficacy of antidepressants is robust, maintenance therapy to prevent relapse or recurrence (13–15) and current pharmacotherapeutic management of depression is for these people adverse effects of medication are particularlyproblematic.
Depression is now conceptualized as a syndrome with For reprints and all correspondence: Clare Weze, St Martin’s College,Bowerham, Lancaster, Lancashire LA1 3JD, UK. Tel: þ44-1524-221718; biological, psychological and social influences (16), and is Ó 2006 The Author(s).
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License by-nc/2.0/uk/) which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.
Healing by gentle touch in mental health disorders perhaps, therefore, likely to respond to a multidimen- According to Dixon (39) this type of approach to healing sional treatment strategy. Favorable outcomes have already appears to trigger or enhance physiological healing processes, been associated with combinations of treatment modalities and this notion is consistent with our own understanding as (17,18), where synergistic effects are likely. The character- discussed in detail by Weze et al. (40). In a preliminary study, istic remit–recur cycle of depression (19–21) means that Tiplady (41) reported that healing at The Centre improved appropriate treatment approaches must be ongoing, safe, physical and psychological functioning in the majority of acceptable to patients and as free from adverse effects as 110 subjects with various ailments. A further study of 300 possible. Healing by gentle touch as described by MacMan- clients with a wide range of ailments has confirmed benefits to away and Turcan (22), and practiced at the Centre for both psychological and physical functioning (25). Analysis of Complementary Care in Cumbria (The Centre) and else- data from people with specific categories of ailments has where, meets these criteria and merits evaluation as a revealed psychological benefits of healing in people with treatment modality for people with mental health disorders musculoskeletal disorders (23) and with cancer (24). We have also identified a subgroup of 147 clients who attended TheCentre with psychological problems, identified as described Complementary Therapies and Mental Health Care below, occurring alone or as part of more complex illness, andthe analysis of their data is presented here. In describing this Although there is increasing use of various complementary work we will use the term ‘psychological problems’ to encompass the whole range of (often ill defined) mental health disorders (26–29), little published research focuses on health-related ailments reported by the clients and detailed the effects of touch therapies (which include Reiki and Therapeutic Touch), on such populations, or on healing suchas that carried out at The Centre. The safety of manycomplementary modalities is, however, an area lackingrobust investigation (30,31) particularly in relation to mental Table 1. Characteristics of the study population of 147 subjects with mental health disorders who completed entry and post-treatmentquestionnaires (percentages in parentheses) Interestingly, improved psychological functioning in both healthy participants and in those with a variety of ailments is a common outcome of many touch therapies (32–34). One study, using healthy participants and a single group repeated measures design, found that Reiki Touch significantly reduced a state of anxiety and increased IgA levels, indicating modulation of the stress response (35). Other workers have measured the effects of guided imagery, meditation, Homeop- athy, Ayurvedic medicine and Reiki, and found that subjects with serious mental illness (including schizophrenia, bipolardisorder and depressive disorder) reported improvements in emotional stability, well-being and concentration following treatment (36). Outcomes of such therapies for subjects with mental health problems are therefore worthy of Healing at The Centre for Complementary Care The Centre where the current evaluation was conducted has been serving an area of rural and urban social deprivation and poor health for 12 years and, functioning as a charity, has a history of treating all those who attend, regardless of their ability to pay. It is known as a place in which measurable, self- functioning are achieved regularly (23–25,37,38). Some of the clients visiting The Centre are referred formally by medical practitioners but most are self-referred, attending as a result of recommendations by either local health care professionals or The Centre’s principal therapeutic modality is healing by gentle touch, as described below. It is non-invasive, applicable to any health deficit and complementary to medical treatments.
this current or to change energy flows. The practitioner workson an intuitive level, trusting the body’s own self-healing mechanisms to re-establish balance, mentally, physically andpsychologically. The requirement for both client and practi- New clients with self-reported psychological problems attend- tioner is for openness and concentration rather than willed ing The Centre for treatment between 1995 and 2001 were results. ‘‘Getting our hands off the steering wheel’’ allows the invited to participate in the ongoing program of evaluation of body to do its own fine tuning. The gentle touch is like a healing. Inclusion criteria were as follows: willingness and battery charger that boosts the energy needed to do this, and ability to participate by filling in questionnaires, age at least 16 interestingly, the person relaxes ever more deeply as this years, notification of depression/anxiety/psychological stress/ other mental health problems on the questionnaire, completing This touch provides a point of contact between healer and a post-treatment questionnaire after four treatments that were client. By moving progressively around the body, from head to feet on one side and then feet to head along the other, the Exclusion criteria were as follows: previous treatment at The healer is attentive to each area of the person in turn. From a Centre, failure to complete the course of four sessions and client’s perspective, the touch enables awareness of the failure to complete both entry and post-treatment question- healer’s attentiveness to each area of their body in turn. The naires. The present study, as a continuation of that reported by lingering of the healer on places where disease has been Tiplady, (41) received ethical approval from the local Health reported by the client, or recognized by the healer, evidences Authority. Furthermore, the research process was consistent the especial attention being paid to those places.
with St Martin’s College ‘Ethical Principles and Guidelines for Informal conversation concerning the health and well-being Research Involving People’ (2002). The purpose and require- of the client, along with reports of any physical, mental, ments of the study were explained to each subject both emotional or spiritual changes since the previous session, verbally and in writing. Confidentiality, anonymity and take place while the treatment is occurring. Clients may also permission to withdraw from participation without any drowse, sleep or talk as they feel inclined. A 10 min rest detriment to treatment were assured, and consent was concludes the session. Although a simple, repeating pattern of evidenced through their completion of the questionnaires.
touch is followed by the therapist at each session, successfultreatment depends not upon an exact physical routine, but onsensitive response to the altering circumstances of the subject, concentration as in meditation or contemplative prayer, and The research participants received four 1 h healing sessions the ability to listen sympathetically both to the voice and the within a 4–6 week period, undertaken by either of two body of the client. Healing treatment is more truly defined therapists, although one treated 90% of the subjects in this study. The Centre’s standard practice commences with awelcoming and evaluative conversation during which the therapist ascertains the client’s views of the presentingproblem and describes what the treatment will involve.
The main research tool was a questionnaire incorporating Although it is conceivable that some people might have visual analogue scales (VAS), and the EuroQoL (EQ-5D), an reservations about being touched by the therapist none has extensively used and validated generic state of health mea- been expressed by clients attending The Centre. After these sure (42–44). VAS were used to monitor clients’ subjective preliminaries the evaluation study is explained and the client is scores of their degrees of physical (pain, disability, immobi- invited to complete as much as they wish of the pre-treatment lity, sleep disturbances, reliance upon medication, ability to questionnaire. The treatment then involves lingering, firm but participate in usual activities) and psychological (stress, gentle, non-invasive touch on the head, chest, arms, legs and panic, fear, anger, relaxation, coping, depression/anxiety) feet for approximately 40 min, most usually while the client lies comfortably on a treatment bed, or while seated End point descriptors were used to help clients to locate their position on the scale, for example: 0 ¼ ‘no stress’ to 10 ¼ The touch is described by the Director of The Centre as ‘severe stress’; 0 ¼ ‘coping badly’ to 10 ¼ ‘coping well’.
follows: ‘Gentle Touch is not derived from the techniques of In the case of sleep disturbances, 0–3 ¼ ‘sleeping too much’, Reiki, Therapeutic Touch or Massage. It is a light touch, with 4–7 ¼ ‘sleeping well’ and 8–10 ¼ ‘sleeping badly’. Prior no greater pressure than one would exert in soothing a child’s expectation of treatment effect was assessed on a VAS where brow or laying a hand on a forehead to test temperature. The 0 ¼ ‘expect nothing’, 5 ¼ ‘see what happens’ and 10 ¼ ‘expect hands do touch the (clothed) body, sometimes with fingertips a lot’. The EQ-5D asked participants to choose statements that only and sometimes with the flat palm of the hand. There is no best described their state of health at that moment from self- manipulation, stroking or kneading. The length of time a hand care, usual activities, pain/discomfort and anxiety/depression is held in one place depends upon the response, which is felt as subscales. Finally, they indicated their general health status on a current or magnetic connection. There is no attempt to direct a VAS where 0 ¼ ‘worst possible state’ and 100 ¼ ‘best Healing by gentle touch in mental health disorders possible state’. The use of more than one scale to assess key variables provided a means of triangulation by whichconsistency and, therefore, reliability of the participants’ self-assessments could be monitored.
One hundred and forty-seven participants, of whom 66% were Additional factors that were monitored included demo- women, completed both entry and post-treatment question- graphic characteristics of participants, the duration of any naires. Sixteen percent were referred formally by local general medical condition that led to their attendance at The Centre, practitioners (GPs) and the remainder were self-referred medical history, prior expectation of treatment effect, post- following word of mouth recommendation by friends or health treatment satisfaction and previous experiences of comple- care professionals. Their characteristics are summarized in mentary therapies. Participants taking medication at entry Table 1, where it can be seen that anxiety, depression and were asked to circle statements indicating any or no changes psychological stress were the most common reasons for the in consumption of their medicines on the post-treatment participants attending The Centre. Although 41 participants (28%) failed to disclose the duration of their condition, 50% ofthe total study population had a duration of illness extending beyond 1 year, of which 23 (16%) had suffered for more than5 years.
The analysis presented is based on data that is collected as The Most subjects had received medical or related treatments, Centre’s normal means of monitoring the effectiveness of its and of those who had been prescribed medication 11% named provision. The data set extracted for the present statistical an antidepressant, with fluoxetine being most common.
analysis was simply of a group of clients who were relatively Responses did not distinguish reliably between current and homogeneous in having attended for four sessions of healing former use of medication. Twelve percent had used a within 4–6 weeks and completed their follow-up question- combination of medication and counselling/psychotherapy.
naire at that time. Four sessions is the usual minimum Fifty-seven percent had previous experience of a complement- number of sessions attended by clients. The experience of the ary therapy, of which massage and aromatherapy were most Director attests to this number providing the clearest indi- common. Nineteen percent of participants reported comorbid cation of whether or not people are benefiting from their visits, conditions, which included asthma, headache, skin disorders, and therefore whether or not there is any point in them gastrointestinal disorders, high blood pressure, musculo- skeletal pain, throat problems, exhaustion and extreme The participants completed the full questionnaire provided tension. Data relating specifically to these are not presented for all clients of The Centre but the present analysis will focus specifically on psychological and related (pain, sleep)parameters. Subjects completed the questionnaire beforetheir first treatment and completed a second one after their fourth treatment. Questionnaires were anonymized by mark-ing each with a unique number allocated at the start of the Differences between entry and post-treatment scores were Pre- and post-treatment scores are summarized as median (interquartile ranges) in Table 2, which shows changes matched pairs and signed ranks test for paired data. The EQ- that were highly significant statistically (all P < 0.0004) 5D data were analyzed by assigning each category (no towards improvement during the study period. Before treat- problems, moderate problems, severe problems) a score from ment, stress was the most severe symptom, with a median 1 to 3, respectively, and using pre- to post-treatment score of 8, which fell to 4 after treatment. Median scores for differences in category choice for each subject as the basis of panic, fear, anger and pain were moderate before treatment and fell by 2–3 points. Sleep scores improved only a little In separate analyses, participants were subdivided according but the change was consistent. The ability of participants to to baseline (at entry) severity of stress, pain, panic, fear, anger, relax and to cope showed improvements of 4 and 3 points, sleep disturbance and coping ability. Changes after treatment respectively. Median general health improved by 24 points.
were assessed comparatively in order to determine whether or Most Severe Symptoms Showed Greatest Improvement not the degree of benefit they experienced was influenced bythe initial extent of their distress, discomfort or other disease.
Table 3 shows the results of a separate analysis in which Data collected on subjects’ prior use of complementary participants were subdivided according to severity of stress, therapies were analyzed via subgroup comparisons, to deter- pain, panic, fear, anger, sleep disturbance and coping mine any effect of prior experience on outcomes.
ability at the time of entry. Following treatment, the most The Statistical Package for Social Sciences (SPSS Chicago, substantial improvement was seen in those with scores IL, USA, 1998) version 9.0 for Windows was used for all indicating the greatest severity at entry, in all symptom categories, with severe stress, panic, fear, anger and inability Table 2. Median scores on entry and change (all improvements) following to cope showing the greatest improvement (P < 0.004).
four healing sessions (interquartile ranges in parentheses) There were no statistically significant changes in thosesymptoms with mild entry scores (Table 3). Median expecta- tions of treatment did not exceed 6 (‘see what happens’) for any group, regardless of the severity of symptoms at the time Severity of Quality of Life Impairments is Reduced by The Fig. 1 shows the number of participants responding in each EuroQoL (EQ-5D) questionnaire category before and after treatment. Anxiety and/or depression showed the most substantial improvements following treatment, with the number of participants reporting no problems increasing from 3 to 42, and the number of participants experiencing severe #The numbers are less than 147 because some participants did not complete all problems fell from 58 to 14. By contrast those reporting moderate problems increased from 75 to 80 but this was *Wilcoxon matched pairs, signed ranks test for paired data.
because some downgraded from the severe to moderate rating.
Changes in anxiety/depression, pain and ability to carry out Table 3. Median change following four healing sessions for participants usual activities all proved highly statistically significant (P < with mild, moderate and severe entry levels of stress, pain, sleep 0.0004) when paired entry and post-treatment scores were disturbances and coping ability (interquartile ranges in parentheses) compared for all individuals. The most impressive improve- ment in pain rating was shown by the number of participants reporting severe pain falling from 25 to 11. Improvements in ability to carry out usual activities after treatment are indicative of a substantial resumption of functioning by many participants. It is of interest that there was also statistically significant improvement (P ¼ 0.001) in self caring ability,even though most participants also reported no problems There were no reports of adverse effects of the healing sessions. Of those taking medication at the time of entry (n ¼ 73), 16% ceased taking their medication, 37% reduced, 40% maintained and 7% increased their usage of medication.
Visual inspection of responses relating to ‘prior expectations of outcome’ (median 6; interquartile range 5–8, ‘see what happens’) and ‘previous experiences of complementary therapies’ revealed no indication of relationship to outcome measures and no statistical analysis was attempted.
This evaluation demonstrates that healing by gentle touch,when used alone or in addition to any conventional medical treatment, is a safe and effective method of improving psychological well-being in people with psychological pro- blems of the varieties encountered at The Centre. Although the treatment is referred to as ‘healing by gentle touch’, the relative contributions to benefit provided by the touch per se, the attentive presence of the healer and the pleasant, caring *Wilcoxon matched pairs, signed ranks test for paired data.
ambience of The Centre cannot be discerned and they may Healing by gentle touch in mental health disorders Anxiety/depression (N = 136)
Pain/discomfort (N = 127)
Self care (N = 127)
Usual activities (N = 131)
Figure 1. The number of participants with Mental Health Disorders responding in each EuroQoL (EQ-5D) questionnaire category. Numbers of participants (N)with ‘severe problems’ decreased and numbers of participants with ‘no problems’ increased after healing, while changes in the numbers of participants with ‘someproblems’ represents the balance between numbers moving in from the ‘severe’ category or out into the ‘no problems’ group. For anxiety/depression and pain/discomfort the numbers of participants with ‘some problems’ increased because the numbers changing from ‘severe’ to ‘some’ problems exceeded the numbersmoving from ‘some’ to ‘no’ problems. Statistical significance of post-treatment changes, using Wilcoxon matched pairs, signed ranks test for paired data: anxiety/depression, P < 0.0004; pain/discomfort, P < 0.0004; self-care, P < 0.001; usual activities, P < 0.0004.
well synergize. The substantial post-treatment reductions in measures has provided a more comprehensive picture than subjective ratings of the predominant symptoms of the would have been supplied by depression/anxiety measures majority of participants (stress, anxiety and depression) in alone, and has enabled participants to indicate the factors of this study are consistent with the findings of the earlier most importance to them. No concurrent controls were used so, analysis made by the local Health Authority (41), and with although there was clearly a strong association between the findings of research on similar treatment modalities participants experiencing the healing sessions and improve- ment in their reported symptoms, causality regarding the The recorded improvements in sleep patterns (particularly apparent beneficial effects of healing by gentle touch cannot in the subgroup with severe problems) are highly relevant be established definitively. Furthermore, the episodic, remit- since depression and anxiety in particular are characterized ting and recurring nature of depressive disorders and their by sleep disturbance (45). Improved sleep is likely to have characteristic acute response to treatment (21) also limits had a profound effect on other dimensions with consequent increases in energy which probably improved their ability Nevertheless, strong circumstantial evidence of benefit is to cope, and this in turn enhancing self-esteem, thereby provided by the findings that a high proportion of people with further reducing stress and increasing the ability to relax.
an illness duration exceeding 1 year reported substantial Furthermore, the fact that substantial benefits were recor- benefits after only four healing sessions over 4–6 weeks, and ded by a population of participants, at least 50% of which those with the most severe symptoms at the time of entry had experienced their symptoms for more than a year, is showed the greatest improvements. Interestingly, in placebo strongly indicative of the ability of healing by gentle touch controlled trials of antidepressants, participants with mild to engender changes in refractory or chronic ill health.
depression typically showed higher responses to placebo than Demonstration of the greatest benefit in participants with those with severe symptoms (46). Although the present study the most severe symptoms is also of considerable interest, was not placebo controlled, the lack of statistically significant particularly as evidence against a simple placebo effect as changes following treatment in participants reporting mild stress, pain, panic, fear, anger, sleep disturbances and copingdifficulties is contrary to those observations. Therefore,the improvements recorded in the present study can be differentiated from placebo responses.
This study resembles Phase 2 clinical trials in that it was open Moreover, prior expectation of treatment effect was not in design. The utilization of health-related quality of life particularly high (median score 6—‘see what happens’), a finding that is consistent with findings for other subgroups of associated with tension, headache, skin and gastrointestinal clients of The Centre (23,24,40), which indicates that out- disorders and exhaustion. These improvements in somatic comes were not greatly influenced by anticipation of benefit.
comorbidities indicate that benefits of healing by gentle touch This finding is encouraging, since if anticipation was central to extend beyond the temporary psychological ‘boost’ which may the mechanism of action, healing would, theoretically, not be accompany relaxation. The contention that physical changes applicable to depression, because hopelessness and low also occur during healing is supported by the biochemical expectations of treatment effect are common features of the and autonomic nervous system changes following treat- ment with Reiki reported respectively by Wardell and Chronic depression is more resistant to treatment than acute Engebretson (35) and Mackay et al. (54). Other relaxation illness, is less responsive to single therapies (47) and placebo response-based interventions have also shown physiological (48) and is less likely to remit spontaneously (13). The number of participants with chronic illness of various types yet A further strength of the study relates to the client population showing improvement in the present study is, therefore, from which the research participants were drawn. Zollman and noteworthy, as is the reduction in medicines usage by more Vickers (56) found that complementary medicine users were than half the participants during the study period because these typically highly educated with favorable socioeconomic ancilliary observations reinforce the improvements discerned backgrounds. In contrast, the participants recruited to the present study were typical of local West Cumbrian people,many of whom are economically disadvantaged. The diversity Possible Contribution of the Relaxation Response of the research participants in this respect increases the The mechanism of action of healing remains to be elucidatedfully. It is, nevertheless, conceivable that the intensely caring nature of treatment, engendering a relaxation response (49), The present findings provide strong evidence that a short series could effectively facilitate processes responsible for initiating of healing sessions is associated with significant improve- recovery, possibly by reversing the hypothalamo–pituitary– ments in a wide range of parameters of psychological well- adrenal (HPA) hyperarousal processes involved in depression being. Notwithstanding the desirability of further randomized, (50,51). Reid and Stewart (52) have proposed interactions controlled studies, the quality of evidence presented above is between stress and the neurobiology of depression involving equivalent to or better than that which currently underpins a alterations in the plasticity of neural networks, which results in number of conventional and complementary therapies. There cognitive and emotional disturbances and, in some cases, is, therefore, a strong case for carefully monitored, funded neural damage and neuroanatomical change.
referrals of patients with significant psychological health Depression is frequently characterized by abnormal regula- deficits for healing as an adjunct to conventional treatments.
tion of glucocorticoids, which are released during stress and While the mechanism of action of ‘healing’ remains to be strongly influence processes in the hippocampus (52,53).
established, it seems appropriately cautious to restrict such Although the extent to which stress is linked to depression referrals to centers that can provide evidence of the safety and appears to differ greatly between individuals and is currently effectiveness of their interventions.
under debate (4), the physiological outcomes of stress The evidence presented in this report indicates that heal- reduction are clearly important in mental health (3,51).
ing is likely to be helpful in treating people with anxietyor depression and/or ‘psychological stress’. It might be of Considerations of Diagnoses and the Study Population particular benefit for people with chronic illness who are It is both a strength and a weakness of the study that the unwilling or unable to take long-term pharmacotherapy, for diagnostic distinction between various categories of psycho- those for whom pharmacotherapy has yielded inadequate logical problems cannot be drawn more precisely, nor can the benefit or undesirable side-effects, and for those with participants’ data be analyzed in discrete subgroups: a comorbid conditions in which antidepressants are contra- weakness because it does not align with prevailing medical indicated. It could be particularly useful as adjunctive therapy models but a strength because healing from the holistic during the slow onset of clinical benefit of antidepressants, perspective has been shown to be effective in people with a when easing of symptoms could enhance patients’ adherence range of diagnostic labels, providing evidence that it can be used without need to establish a definitive diagnosis in a Furthermore, as symptoms decrease in severity and cogni- clinical area where clear distinctions are rare.
tive and physical functioning recover, synergistic effects of Nevertheless, the comprehensive nature of the standard healing with other treatments are conceivable, particularly questionnaire from which the data for this paper have been with psychotherapeutic modalities, which frequently require drawn was valuable because several participants reported active participation. The manifold dysfunctions and remit– improvements in the problems they had been experiencing in relapse tendencies associated with depressive disorders (57) various physical dimensions, including musculoskeletal pain commonly require multiple treatment approaches. Future Healing by gentle touch in mental health disorders treatment strategies could be based on a combination of 14. Hirschfeld RMA, Schatzberg AF. Long-term management of depression.
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Received February 19, 2006; accepted June 28, 2006
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