Protocol for a Nested Randomized Controlled Trial to Evaluate the Feasibility and Preliminary Efficacy of the Mindfulness Based Health Promotion Program on the Quality of Life of Older Adults Assisted in Primary Care-"The MBHP-Elderly Study"

Marcelo Vasconcelos Mapurunga, Solange Andreoni, Daniela Rodrigues de Oliveira, Vicente Sarubbi Jr, Ana Cláudia Bonilha, Vania D'Almeida, Luciana Tomita, Luiz Roberto Ramos, Marcelo Demarzo, Marcelo Vasconcelos Mapurunga, Solange Andreoni, Daniela Rodrigues de Oliveira, Vicente Sarubbi Jr, Ana Cláudia Bonilha, Vania D'Almeida, Luciana Tomita, Luiz Roberto Ramos, Marcelo Demarzo

Abstract

Introduction: Population aging is a global phenomenon that has grown rapidly and progressively all over the world. Interventions that promote health must be studied and implemented to make the aging process be with quality of life. Depression and anxiety are the most common mental health conditions that compromise the quality of life on the elderly and it can cause damage to the autonomy and activities of daily life. Mindfulness training has been shown to improve psychological health and quality of life on adults. Studies involving Mindfulness-Based Interventions (MBIs) with older people are scarce in the literature, but they have been increasing in recent years showing promising results for healthy aging. This trial will investigate the feasibility and preliminary efficacy of an MBI on the quality of life of elderly assisted in the Primary Care. Materials and Methods: A cohort-nested randomized controlled trial with 3 assessment points (baseline, post-intervention and 1-year follow up) will be conducted to compare a MBI program (Mindfulness-Based Health Promotion) to a cognitive stimulation control-group in a Primary Care facility. One-hundred and two older adults will be recruited from a cohort of this facility and they will be randomized and allocated into an intervention group (N = 76) and the control group (N = 76). The primary outcome evaluated will be the improvement of quality of life assessed by the WHOQOL-BREF and WHOQOL-OLD. The secondary outcomes will be cognitive function, psychological health, sleep quality, self-compassion, and religiosity. Qualitative data will be assessed by focus group and the word free evocation technique. The feasibility of the program will also be evaluated by adherence and unwanted effects questionnaires. Discussion: This cohort-nested clinical trial will be the first mixed-methods study with 3 assessment points which will study the feasibility and preliminary efficacy of a mindfulness-based program for older people in Latin America population. If the findings of this study confirm the effectiveness of this program in this population it will be possible to consider it as intervention that might be implemented as public policy addressed to older people in healthcare systems. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03048708. Registered retrospectively on October 11th 2018.

Keywords: MBHP; NHL); elderly; health promotion (source: MeSH NLM); mindfulness (MeSH; primary care (MeSH); quality of life.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2020 Mapurunga, Andreoni, de Oliveira, Sarubbi, Bonilha, D'Almeida, Tomita, Ramos and Demarzo.

Figures

Figure 1
Figure 1
Diagram of planned study flow of participants and study design.
Figure 2
Figure 2
Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) diagram. ADL, Activities of Daily Living Scale; CDR, Clinical Dementia Ratings; DASS-21, Depression Anxiety Stress Asessment-21; DUREL, Duke Religious Index; MAAS, Mindful Attention Awareness Assessment; MBHP, Mindfulness-Based Health Promotion; Active Control Group, Cognitive Stimulation; MoCA, Montreal Cognitive Assessment; PSQI, Pittsburgh Sleep Quality Index; SCS, Self-Compassion Scale; -T1, Screening and Recruitment; T0, Before Intervention; T1, Post-Intervention; T2, 1-year follow up; WGGA, Wide Geriatric and Gerontologic Assessment; WHOQOL-BREF, World Health Organization Quality of Life–BREF; WHOQOL-OLD, World Health Organization Quality of Life–OLD.

References

    1. Alves JED. Transição demográfica, envelhecimento e a reforma da previdência. Cadernos Adenauer Xix. (2018) 2:79–101.
    1. Paskulin LMG, Córdova FPCR, Costa FMD, Vianna LAC. Percepção de pessoas idosas sobre qualidade de vida. Acta Paul Enferm. (2010) 2:101–7. 10.1590/S0103-21002010000100016
    1. The WHOQOL Group . The world health organization quality of life assessment (WHOQOL): position paper from the world health organization. Soc Sci Med. (1995) 41:1403–9. 10.1016/0277-9536(95)00112-K
    1. García LMR, Navarro JMR. The impact of quality of life on the health of older people from a multidimensional perspective. J Aging Res. (2018) 2018:4086294. 10.1155/2018/4086294
    1. Duarte YADO, Andrade CLd, Lebrão ML. O Índex de Katz na avaliação da funcionalidade dos idosos. Revista da Escola de Enfermagem da USP. (2007) 41:317–25. 10.1590/S0080-62342007000200021
    1. Castilho-Weinert LV, Takeda SYM, Guimarães ATB, Gonçalves AM, Zanini LM, Cavalcanti AI, et al. Functional performance and quality of life in institutionalized elderly individuals. Top Geriatr Rehabil. (2014) 30:270–5. 10.1097/TGR.0000000000000036
    1. Giebel CM, Sutcliffe C, Challis D. Activities of daily living and quality of life across different stages of dementia: a UK study. Aging Ment Health. (2015) 19:63–71. 10.1080/13607863.2014.915920
    1. Millan-Calenti JC, Tubio J, Pita-Fernandez S, González-Abraldes I, Lorenzo T, Fernandéz-Arruty T, et al. . Prevalence of functional disability in activities of daily living (ADL), instrumental activities of daily living (IADL) and associated factors, as predictors of morbidity and mortality. Arch Gerontol Geriatr. (2010) 50:306–10. 10.1016/j.archger.2009.04.017
    1. Mlinac ME, Feng MC. Assessment of activities of daily living, self-care, and independence. Arch Clin Neuropsychol. (2016) 31:506–16. 10.1093/arclin/acw049
    1. Wong WP, Coles J, Chambers R, Wu DB, Hassed C. The effects of mindfulness on older adults with mild cognitive impairment. J Alzheimers Dis Rep. (2017) 1:181–93. 10.3233/ADR-170031
    1. Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clin Psychol Sci Pract. (2003) 10:144–56. 10.1093/clipsy.bpg016
    1. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry. (1982) 4:33–47. 10.1016/0163-8343(82)90026-3
    1. Demarzo MM, Andreoni S, Sanches N, Perez S, Fortes S, Garcia-Campayo J. Mindfulness-based stress reduction (MBSR) in perceived stress and quality of life: an open, uncontrolled study in a Brazilian healthy sample. Explore. (2014) 10:118–20. 10.1016/j.explore.2013.12.005
    1. Grossman P, Kappos L, Gensicke H, D'Souza M, Mohr DC, Penner IK, et al. . MS quality of life, depression, and fatigue improve after mindfulness training: a randomized trial. Neurology. (2010) 75:1141–9. 10.1212/WNL.0b013e3181f4d80d
    1. Hölzel BK, Carmody J, Vangel M, Congleton C, Yerramsetti SM, Gard T, et al. . Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Res. (2011) 191:36–43. 10.1016/j.pscychresns.2010.08.006
    1. Nyklicek I, Kuijpers KF. Effects of mindfulness-based stress reduction intervention on psychological well-being and quality of life: is increased mindfulness indeed the mechanism? Ann Behav Med. (2008) 35:331–40. 10.1007/s12160-008-9030-2
    1. Ruskin D, Harris L, Stinson J, Kohut SA, Walker K, McCarthy E. “I learned to let go of my pain”. The effects of mindfulness meditation on adolescents with chronic pain: an analysis of participants' treatment experience. Children. (2017) 4:110. 10.3390/children4120110
    1. Sanada K, Alda Díez M, Salas Valero M, Pérez-Yus MC, Demarzo MMP, Montero-Marín J, et al. . Effects of mindfulness-based interventions on biomarkers in healthy and cancer populations: a systematic review. BMC Complement Alternat Med. (2017) 17:125. 10.1186/s12906-017-1638-y
    1. Chiesa A, Serretti A. Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. J Altern Complement Med. (2009) 15:593–600. 10.1089/acm.2008.0495
    1. Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol. (2010) 78:169–83. 10.1037/a0018555
    1. Kuyken W, Warren FC, Taylor RS, Whalley B, Crane C, Bondolfi G, et al. . Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: an individual patient data meta-analysis from randomized trials. JAMA Psychiatry. (2016) 73:565–74. 10.1001/jamapsychiatry.2016.0076
    1. Demarzo MM, Cebolla A, Garcia-Campayo J. The implementation of mindfulness in healthcare systems: a theoretical analysis. Gen Hosp Psychiatry. (2015) 37:166–71. 10.1016/j.genhosppsych.2014.11.013
    1. Salvo VLMAd, Souza ÉLd, Loyola VT, Oliveira MBd, Hirayama MS, Favarato ML, et al. Ambulatório de mindfulness e promoção da saúde: relato de experiência. Mindfulness Compassion. (2016) 1:94–100. 10.1016/j.mincom.2016.10.002
    1. Creswell JD, Irwin MR, Burklund LJ, Lieberman MD, Arevalo JMG, MA J, et al. . Mindfulness-based stress reduction training reduces loneliness and pro-inflammatory gene expression in older adults: a small randomized controlled trial. Brain Behav Immun. (2012) 26:1095–101. 10.1016/j.bbi.2012.07.006
    1. Foulk MA, Ingersoll-Dayton B, Kavanagh J, Robinson E, Kales HC. Mindfulness-based cognitive therapy with older adults: an exploratory study. J Gerontol Soc Work. (2014) 57:498–520. 10.1080/01634372.2013.869787
    1. Gallegos AM, Hoerger M, Talbot NL, Moynihan JA, Duberstein PR. Emotional benefits of mindfulness-based stress reduction in older adults: the moderating roles of age and depressive symptom severity. Aging Ment Health. (2013) 17:823–9. 10.1080/13607863.2013.799118
    1. Morone NE, Lynch CS, Greco CM, Tindle HA, Weiner DK. “I felt like a new person.” The effects of mindfulness meditation on older adults with chronic pain: qualitative narrative analysis of diary entries. J Pain. (2008) 9:841–8. 10.1016/j.jpain.2008.04.003
    1. Paller KA, Creery JD, Florczak SM, Weintraub S, Mesulam MM, Reber PJ, et al. . Benefits of mindfulness training for patients with progressive cognitive decline and their caregivers. Am J Alzheimer's Dis Other Dementias. (2015) 30:257–67. 10.1177/1533317514545377
    1. Helmes E, Ward BG. Mindfulness-based cognitive therapy for anxiety symptoms in older adults in residential care. Aging Ment Health. (2017) 21:272–8. 10.1080/13607863.2015.1111862
    1. Morone NE, Greco CM, Moore CG, Rollman BL, Lane B, Morrow LA, et al. . A mind-body program for older adults with chronic low back pain: a randomized clinical trial. JAMA Intern Med. (2016) 176:329–37. 10.1001/jamainternmed.2015.8033
    1. Wetherell JL, Hershey T, Hickman S, Tate SR, Dixon D, Bower ES, et al. . Mindfulness-based stress reduction for older adults with stress disorders and neurocognitive difficulties: a randomized controlled trial. J Clin Psychiatry. (2017) 78:e734–43. 10.4088/JCP.16m10947
    1. Bishop SR, Lau M, Shapiro S, Carlson L, Anderson ND, Carmody J, et al. Mindfulness: a proposed operational definition. Clin Psychol. (2004) 11:230–41. 10.1093/clipsy.bph077
    1. Cebolla A, Demarzo M. O que é Mindfulness? In: Kato DS, editors. Trans. Mindfulness e Ciência: Da Tradição à Modernidade. Vol 1. 1 ed. São Paulo: Palas Athena; (2016). p. 19–35.
    1. Boss L, Kang DH, Branson S. Loneliness and cognitive function in the older adult: a systematic review. Int Psychogeriatr. (2015) 27:541–53. 10.1017/S1041610214002749
    1. Donovan NJ, Wu Q, Rentz DM, Sperling RA, Marshall GA, Glymour MM. Loneliness, depression and cognitive function in older U.S. adults. Int J Geriatr Psychiatry. (2017) 32:564–73. 10.1002/gps.4495
    1. Shrestha S, Stanley MA, Wilson NL, Cully JA. Predictors of change in quality of life in older adults with generalized anxiety disorder. Int Psychogeriatr. (2015) 27:1207–15. 10.1017/S1041610214002567
    1. Sivertsen H, Bjorklof GH, Engedal K, Selbaek G, Helvik AS. Depression and quality of life in older persons: a review. Dement Geriatr Cogn Disord. (2015) 40:311–39. 10.1159/000437299
    1. Krug RDR, Silva AQAd, Schneider IJC, Ramos LR, d'Orsi E, Xavier AJ. Cognitive cooperation groups mediated by computers and internet present significant improvement of cognitive status in older adults with memory complaints: a controlled prospective study. Arquivos de Neuro-Psiquiatria. (2017) 75:228–33. 10.1590/0004-282x20170021
    1. Demarzo M, Campayo JG. Manual Prático Mindfulness: Curiosidade e Aceitação. 2 Edn. São Paulo: Palas Athena; (2015).
    1. Smith A, Graham L, Senthinathan S. Mindfulness-based cognitive therapy for recurring depression in older people: a qualitative study. Aging Ment Health. (2007) 11:346–57. 10.1080/13607860601086256
    1. Splevins K, Smith A, Simpson J. Do improvements in emotional distress correlate with becoming more mindful? A study of older adults. Aging Ment Health. (2009) 13:328–35. 10.1080/13607860802459807
    1. Young LA, Baime MJ. Mindfulness-based stress reduction: effect on emotional distress in older adults. Complement Health Pract Rev. (2010) 15:59–64. 10.1177/1533210110387687
    1. Berk L, van Boxtel M, van Os J. Can mindfulness-based interventions influence cognitive functioning in older adults? A review and considerations for future research. Aging Ment Health. (2017) 21:1113–20. 10.1080/13607863.2016.1247423
    1. Schulz KF, Altman DG, Moher D. CONSORT 2010. Statement: updated guidelines for reporting parallel group randomised trials. BMJ. (2010) 340:c332. 10.1136/bmj.c332
    1. Chan AW, Tetzlaff JM, Altman DG, Laupacis A, Gotzsche PC, A-Jeric K, et al. . SPIRIT 2013 statement: defining standard protocol items for clinical trials. Am J Public Health. (2015) 38:506–14. 10.7326/0003-4819-158-3-201302050-00583
    1. Ramos LR, Andreoni S, Coelho-Filho JM, Lima-Costa MF, Matos DL, Rebouças M, et al. . Perguntas mínimas para rastrear dependência em atividades da vida diária em idosos. Revista de Saúde Pública. (2013) 47:506–13. 10.1590/S0034-8910.2013047004325
    1. Morris JC. The clinical dementia rating (CDR): current version and scoring rules. Neurology. (1993) 43:2412–14. 10.1212/WNL.43.11.2412-a
    1. Montaño MMBM, Ramos LR. Validade da versão em português da clinical dementia rating. Revista de Saúde Pública. (2005) 39:912–17. 10.1590/S0034-89102005000600007
    1. Almeida OP, Almeida SA. Confiabilidade da versão brasileira da escala de depressão em geriatria (GDS) versão reduzida. Arquivos de Neuro-Psiquiatria. (1999) 57:421–6. 10.1590/S0004-282X1999000300013
    1. Sheikh JI, Yesavage JA. Geriatric depression scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. (1986) 5:165–73. 10.1300/J018v05n01_09
    1. Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. (1982) 17:37–49. 10.1016/0022-3956(82)90033-4
    1. Hughes CP, Berg L, Danziger WL, Coben LA, Martin RL. A new clinical scale for the staging of dementia. Br J Psychiatry. (1982) 140:566–72. 10.1192/bjp.140.6.566
    1. UK Network for Mindfulness Teacher Training Organizations Good Practice Guidance for Teachers. (2015). Available online at: (accessed January 20, 2019).
    1. Trombka M, Demarzo M, Bacas DC, Antonio SB, Cicuto K, Salvo V, et al. . Study protocol of a multicenter randomized controlled trial of mindfulness training to reduce burnout and promote quality of life in police officers: the POLICE study. BMC Psychiatry. (2018) 18:151. 10.1186/s12888-018-1726-7
    1. Cebolla A, Demarzo M, Martins P, Soler J, Garcia-Campayo J. Unwanted effects: Is there a negative side of meditation? A multicentre survey. PLoS ONE. (2017) 12:e0183137. 10.1371/journal.pone.0183137
    1. Zellner Keller B, Singh NN, Winton AS. Mindfulness-based cognitive approach for seniors (MBCAS): program development and implementation. Mindfulness. (2014) 5:453–9. 10.1007/s12671-013-0262-2
    1. McBee L. Mindfulness-Based Elder Care: a CAM Model for Frail Elders and Their Caregivers. New York: Springer Pub; (2008). 10.1007/978-0-387-09593-6_24
    1. Xavier A, Ramos L, dos Santos L, Sigulem D. Oficina da Lembrança: Ambiente de Inclusão Digital e Tele-Reabilitação Cognitiva para Idosos, Portadores de Doença de Alzheimer e Outros. São Paulo.
    1. Development of the World Health Organization WHOQOL-BREF quality of life assessment The WHOQOL Group. Psychol Med. (1998) 28:551–8. 10.1017/S0033291798006667
    1. Fleck MP, Chachamovich E, Trentini C. Development and validation of the portuguese version of the WHOQOL-OLD module. Revista de Saúde Pública. (2006) 40:785–91. 10.1590/S0034-89102006000600007
    1. Fleck MP, Louzada S, Xavier M, Chachamovich E, Vieira G, Santos L, et al. . Aplicação da versão em português do instrumento abreviado de avaliação da qualidade de vida “WHOQOL-bref”. Revista de Saúde Pública. (2000) 34:178–83. 10.1590/S0034-89102000000200012
    1. Power M, Quinn K, Schmidt S. Development of the WHOQOL-old module. Qual Life Res. (2005) 14:2197–214. 10.1007/s11136-005-7380-9
    1. Memoria CM, Yassuda MS, Nakano EY, Forlenza OV. Brief screening for mild cognitive impairment: validation of the Brazilian version of the montreal cognitive assessment. Int J Geriatr Psychiatry. (2013) 28:34–40. 10.1002/gps.3787
    1. Nasreddine ZS, Phillips NA, Bedirian V, Charbonneau S, Whitehead V, Collin I, et al. The montreal cognitive assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. (2005) 53:695–9. 10.1111/j.1532-5415.2005.53221.x
    1. Barros VVD, Kozasa EH, Souza ICWD, Ronzani TM. Validity evidence of the brazilian version of the mindful attention awareness scale (MAAS). Psicologia. (2015) 28:87–95. 10.1590/1678-7153.201528110
    1. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol. (2003) 84:822–48. 10.1037/0022-3514.84.4.822
    1. Neff KD. The development and validation of a scale to measure self-compassion. Self Identity. (2003) 2:223–50. 10.1080/15298860309027
    1. Souza LKd, Hutz CS. Adaptation of the self-compassion scale for use in Brazil: evidences of construct validity. Temas Psicol. (2016) 24:159–72. 10.9788/TP2016.1-11
    1. Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the depression anxiety stress scales (DASS) with the beck depression and anxiety inventories. Behav Res Ther. (1995) 33:335–43. 10.1016/0005-7967(94)00075-U
    1. Vignola RC, Tucci AM. Adaptation and validation of the depression, anxiety and stress scale (DASS) to Brazilian Portuguese. J Affect Disord. (2014) 155:104–9. 10.1016/j.jad.2013.10.031
    1. Bertolazi AN, Fagondes SC, Hoff LS, Dartora EG, Miozzo ICdS, Barba MEFd, et al. . Validation of the Brazilian Portuguese version of the pittsburgh sleep quality index. Sleep Med. (2011) 12:70–75. 10.1016/j.sleep.2010.04.020
    1. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. (1989) 28:193–213. 10.1016/0165-1781(89)90047-4
    1. Taunay TCDE, Gondim FDAA, Macêdo DS, Moreira-Almeida A, Gurgel LDA, Andrade LMS, et al. Validação da versão brasileira da escala de religiosidade de Duke (DUREL). Arch Clin Psychiatry. (2012) 39:130–35. 10.1590/S0101-60832012000400003
    1. Koenig H, Parkerson GR, Jr, Meador KG. Religion index for psychiatric research. Am J Psychiatry. (1997) 154:885–6. 10.1176/ajp.154.6.885b
    1. Ramos LR, Goihman S. Geographical stratification by socio-economic status: methodology from a household survey with elderly people in S. Paulo, Brazil. Revista de Saúde Pública. (1989) 23:478–92. 10.1590/S0034-89101989000600006
    1. Blay SL, Ramos LR, Mari Jde J. Validity of a Brazilian version of the Older Americans resources and services (OARS) mental health screening questionnaire. J Am Geriatr Soc. (1988) 36:687–92. 10.1111/j.1532-5415.1988.tb07169.x
    1. Bertolucci PHF, Brucki SMD, Campacci SR, Juliano Y. O Mini-exame do estado mental em uma população geral: impacto da escolaridade. Arquivos de Neuro-Psiquiatria. (1994) 52:01–07. 10.1590/S0004-282X1994000100001
    1. Souza LKD, Hutz CS. Self-compassion in relation to self-esteem, self-efficacy and demographical aspects. Paidéia. (2016) 26:181–8. 10.1590/1982-43272664201604
    1. Gloster AT, Rhoades HM, Novy D, Klotsche J, Senior A, Kunik M, et al. . Psychometric properties of the depression anxiety and stress scale-21 in older primary care patients. J Affect Disord. (2008) 110:248–59. 10.1016/j.jad.2008.01.023
    1. Araujo PABD, Sties SW, Wittkopf PG, Netto AS, Gonzáles AI, Lima DP, et al. Índice da qualidade do sono de pittsburgh para uso na reabilitação cardiopulmonar e metabólica. Revista Brasil Med Esporte. (2015) 21:472–5. 10.1590/1517-869220152106147561
    1. Koenig HG, Büssing A. The duke university religion index (DUREL): a five-item measure for use in epidemological studies. Religions. (2010) 1:78–85. 10.3390/rel1010078
    1. Wachelke J, Wolter R. Critérios de construção e relato da análise prototípica para representações sociais. Psicologia. (2011) 27:521–6. 10.1590/S0102-37722011000400017
    1. Ensemble de programmes permettant l'analyse des evocations - EVOC (2005). [computer program]. Version June 2006. Paris.
    1. Bardin L. Análise de Conteúdo. São Paulo: Edições; (1979) p. 70.
    1. Berk L, Hotterbeekx R, van Os J, van Boxtel M. Mindfulness-based stress reduction in middle-aged and older adults with memory complaints: a mixed-methods study. Aging Ment Health. (2017) 22:1107–14 10.1080/13607863.2017.1347142
    1. Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosomatic Med. (2003) 65:571–81. 10.1097/01.PSY.0000074003.35911.41
    1. Hart T, Fann JR, Novack TA. The dilemma of the control condition in experience-based cognitive and behavioural treatment research. Neuropsychol Rehabil. (2008) 18:1–21. 10.1080/09602010601082359

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel