Using digital monitoring alongside psychosocial interventions in patients who self-harm
Intended for healthcare professionals
Evidence and practice    

Using digital monitoring alongside psychosocial interventions in patients who self-harm

Fiona Brand Research nurse, Oxford Health Emergency Department Psychiatric Service, John Radcliffe Hospital, Oxford, England
Keith Hawton Professor of psychiatry and director, Centre for Suicide Research, University of Oxford, Oxford Health NHS Foundation Trust, Oxford, England

Why you should read this article
  • To understand the current provision of self-harm services in England

  • To learn about how digital technologies could support patients who self-harm

  • To develop ideas for improving your service offering to patients who self-harm

With more than 200,000 presentations to hospital for self-harm each year in England, there is a clear requirement to reduce self-harm and improve well-being in this population. This service evaluation examined the potential for digital self-monitoring of patients’ well-being as an adjunct to psychological supportive therapy. The evaluation used a series of questionnaires to investigate patients’ use of digital technology to self-monitor their mood, suicidality and self-harm behaviour. The authors also collected questionnaire feedback from patients and clinicians about their experience of using the digital technology. Patients who used the digital self-monitoring technology mostly found it useful and easy to use, as did the clinicians. This method of recording patients’ progress has now been incorporated into routine clinical care.

Mental Health Practice. doi: 10.7748/mhp.2021.e1526

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

fiona.brand@oxfordhealth.nhs.uk

Conflict of interest

This research was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Oxford at Oxford Health NHS Foundation Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care

Brand F, Hawton K (2021) Using digital monitoring alongside psychosocial interventions in patients who self-harm. Mental Health Practice. doi: 10.7748/mhp.2021.e1526

Acknowledgement

The authors would like to thank Nic Walnes from the information technology department at Oxford Health NHS Foundation Trust, who assisted with the True Colours data, and the nursing team who recruited patients to the study

Published online: 30 March 2021

Background

Self-harm represents a major public health concern. It has been estimated that there are more than 200,000 general hospital presentations for self-harm in England each year (Tsiachristas et al 2017). In addition, just over 20% will re-present to hospital within 12 months following further episodes of self-harm (Geulayov et al 2016). Patients who self-harm have a significantly increased risk of suicide in the future compared with the general population, especially during the first few months after leaving hospital (Geulayov et al 2019). Patients who self-harm are also at greater risk of premature death than the general population, often due to issues relating to their physical health and lifestyle choices (Bergen et al 2012). The National Institute for Health and Care Excellence (2004, 2011) recommends that all patients who attend a general hospital following an episode of self-harm should be offered a psychosocial assessment and that subsequent interventions should be tailored to their needs, including psychological and other issues that may have led to them self-harming.

There has been considerable research into the factors that can reduce self-harm and improve well-being in this patient group. For example, brief psychological interventions represent a pragmatic and effective approach for reducing self-harm, depression, hopelessness and suicidal ideation (Hawton et al 2016). There is also evidence from Denmark that providing psychological interventions, such as elements of cognitive behavioural therapy (CBT) and/or dialectical behaviour therapy, can be effective in routine clinical care (Erlangsen et al 2015).

With significant numbers of patients presenting with self-harm to hospitals in England and a shortage of clinicians to provide psychological therapies following discharge, the authors contend that treatment for some patients after discharge from hospital should be provided by members of the hospital self-harm service who undertook the initial psychosocial assessment. This would have the advantage of providing continuity of clinical care.

Key points

  • Self-harm services in England are typically multidisciplinary and available seven days a week, with most involving nurses undertaking a psychosocial assessment of patients

  • Digital health technologies can support patients and clinicians to monitor symptoms using text, email and the internet

  • This service evaluation suggests that both patients and nurses found a digital self-management tool useful to monitor patients’ mood, thoughts of self-harm and suicidality alongside psychological therapy sessions

  • If digital health technologies are implemented, it is important that clinicians have access to appropriate training to ensure that they feel able to use them

Self-harm services

Self-harm services in England are typically multidisciplinary and available seven days a week, often for 24 hours a day. Most services involve nurses undertaking a psychosocial patient assessment. In an early study, Catalan et al (1980) showed that with specific training nurses could undertake such assessments as efficiently as psychiatrists. Recently, Pitman et al (2020) found no difference in patients’ subsequent rates of repetition of self-harm following assessment by nurses or psychiatrists. In addition, qualitative research has suggested that psychiatric nurses may use a particularly collaborative approach in their assessments (Hunter et al 2013).

One such self-harm service is the Emergency Department Psychiatric Service (EDPS) in Oxford, England. The EDPS is based in a large general teaching hospital and is staffed by band 7 mental health nurses, junior doctors and consultant psychiatrists. The EDPS offers psychosocial assessment to anyone aged over 13 years who presents to a hospital emergency department (ED) following an episode of self-harm or any other mental health issue. The ED staff contact the EDPS when a patient who has self-harmed attends the department. Following assessment, a discharge plan is formulated in collaboration with the patient. Any patient who does not meet the criteria for referral to secondary mental health services but who requires more than non-statutory services or primary care may be offered follow-up with the Brief Interventions for people at Risk of further Self Harm (BIRSH) programme, which is provided by the EDPS team.

BIRSH is a nurse-led service that is delivered by nurses in the EDPS team. Wand et al (2011) supported the value of mental health nurses delivering follow-up interventions after patients had presented to the ED, particularly when the interventions were delivered using a solution-focused therapeutic approach, which seeks to identify solutions rather than focusing on the patient’s ‘problem’. The BIRSH programme consists of a maximum of six sessions of therapy with the assessing nurse, following the patient’s discharge from hospital. These sessions are undertaken in outpatient rooms at the general hospital or via an online application such as Skype.

The therapy content of the BIRSH sessions is patient-led and focuses on any issues they have, but specifically covers issues relating to repetitive self-harm, alcohol misuse, bereavement, anxiety and depression. The underpinning value of the BIRSH programme is of validation with an emphasis on problem-solving. Curran and Brooker (2007) noted the skills nurses have in delivering problem-solving interventions, together with the value of the mix of interventions that can be provided by experienced nurses. This might include self-mapping, CBT-based techniques and/or short-term interventions for alcohol misuse.

The BIRSH intervention has been shown to be a contributory factor in reducing self-harming behaviour (Brand and Lascelles 2017). For example, all patients who attended two or more follow-up BIRSH sessions after an initial self-harm presentation to the ED experienced a reduction in presentations to the ED in the six-month period after the BIRSH sessions, compared with the previous six-month period (Brand and Lascelles 2017). This indicated the potential value of the BIRSH sessions in reducing self-harm presentations.

Digital health technologies

Digital health technologies are another potentially valuable method of transforming mental healthcare by connecting patients to services and health data. Online digital and mobile applications can offer patients greater access to information and enhance clinical management and early intervention through access to real-time patient data, for example mobile applications that enable patients to track their symptoms (Hollis et al 2015). One example of how digital health technologies can support patients and clinicians is the online self-assessment system True Colours. This system allows patients to monitor their symptoms using text, email and the internet (Goodday et al 2020). Using True Colours, the patient develops an online record of their mood and mental state, which they can monitor over time to assess their progress and to flag any unusual trends.

The authors wanted to explore the possible benefits of adding this digital self-monitoring component to the BIRSH programme, since there is minimal evidence that digital self-monitoring has been used in this patient population. As a result, the authors worked alongside the True Colours team to devise a questionnaire that collected weekly digital data directly from patients. The aim of this was to monitor patients’ mood, mental state, episodes of self-harm and any suicidal thoughts and/or behaviours. The data, which were accessible online to both the individual patient and their nurse, were then available for exploration with patients during therapy sessions. The authors wanted to explore whether the True Colours self-monitoring system was acceptable to patients and clinicians, and if it was feasible to implement it alongside the established BIRSH programme of therapy sessions, for example by using the True Colours data to inform the BIRSH therapy sessions.

Service evaluation

Aim

To ascertain the usefulness for patients and clinicians of a digital self-monitoring system alongside outpatient follow-up after patients had presented to a general hospital with self-harm.

Method

The pilot evaluation was conducted in a large general hospital in Oxford over a 12-month period in a nurse-led programme (BIRSH) for patients who had experienced self-harm. The aim was for the participating patients to complete a True Colours online questionnaire on a weekly basis, so that their mood, suicidality and self-harm behaviour could be monitored and explored during therapy sessions by clinicians and the patients themselves by examining the online data. Email reminders to complete the online True Colours questionnaire were sent to participants each week, irrespective of whether they continued to attend BIRSH therapy sessions.

The nurses leading the BIRSH service invited any patient who had agreed to attend BIRSH therapy sessions to complete a baseline True Colours questionnaire, following a psychosocial assessment in the ED. Patients could attend up to six BIRSH therapy sessions, usually one per fortnight. The purpose of the baseline True Colours questionnaire was to provide the nurse and patient with an initial baseline measurement of symptoms, which could then be benchmarked against the True Colours questionnaire results from subsequent weeks. Completing the baseline True Colours questionnaire also allowed the patients to become familiar with how to use the True Colours system.

The True Colours questionnaire used in this service evaluation comprised a series of items taken from the modified Patient Health Questionnaire (PHQ-9) (Kroenke et al 2001), which is designed to assess a patient’s depression, as well as positive anxiety items taken from the Hospital Anxiety and Depression Scale (HADS) (Spitzer et al 2006). The modified PHQ-9 element of the True Colours questionnaire included four additional questions formulated by the authors which focused on patients’ thoughts concerning self-harm and actual episodes of self-harm, and thoughts concerning suicide and any plans they had made for suicide. For example, patients completing the True Colours questionnaire were asked to rate on a scale of 0 (‘Not at all’) to 3 (‘Nearly every day’) whether they had experienced any of the following:

  • Suboptimal appetite or overeating.

  • Little interest or pleasure in activities.

  • Feeling ‘down’, depressed, or hopeless.

  • Trouble falling or staying asleep, or sleeping too much.

  • Feeling tired, or having little energy.

  • Feeling bad about themselves, or that they were a failure or had ‘let themselves or their family down’.

  • Issues with concentrating, such as on reading the newspaper or watching television.

  • Moving or speaking so slowly that other people could have noticed. Or the opposite, being so restless that they have been moving around a lot more than usual.

  • Thoughts of harming themselves in any way.

It was also possible to use the True Colours online system to record a patient’s medicines profile, any therapy sessions, self-harm episodes and major life events. For example, if a patient responded ‘Yes’ to the ‘Have you made any preparations to end your life?’ question, this brought up a box prompting the participant to seek assistance from either their GP or the Samaritans.

Five nurses who had substantive posts in the EDPS team were recruited as participants in the evaluation. Their role was to recruit patients to the study with whom they had conducted a psychosocial assessment while in hospital following self-harm, and with whom they had agreed to provide BIRSH therapy sessions following discharge from hospital. Patients were recruited to the evaluation if they were eligible for BIRSH follow-up therapy sessions, which meant that convenience sampling was used. All eligible patients were invited to join the pilot.

A target recruitment of between six and ten patients was deemed suitable for the evaluation. In the event, 12 patients were recruited.

Data collection

In addition to the regular True Colours questionnaires, paper questionnaires were distributed to patients at the end of their six BIRSH sessions to obtain feedback on their experiences of using True Colours. This paper questionnaire contained six questions, which included a mixture of Likert-scale questions, binary questions and open-ended questions. Patients who were not able to attend their final BIRSH therapy session were sent the questionnaire by post, with a stamped, addressed envelope enclosed for its return.

The authors also collected feedback via a questionnaire from the nurses who delivered the BIRSH therapy sessions and True Colours during the evaluation period. This comprised five questions, a mixture of Likert-scale questions, binary questions and open-ended questions. All the nurses who had delivered BIRSH therapy sessions alongside the True Colours system completed one of these feedback questionnaires.

Data analysis

Descriptive statistics were used to analyse the data. In addition, questionnaire responses were thematically analysed. Microsoft Excel was used as a data management tool. The analysis was primarily undertaken by the evaluation lead (FB).

Ethical approval

The evaluation was conducted as a clinical audit of a service development, so ethical approval was not necessary.

Findings

During the evaluation, 15 patients were offered BIRSH therapy sessions alongside monitoring with the True Colours system. Two patients declined to take part because they did not have the technology required to access the True Colours system, and another declined as they did not want the pressure of the weekly email prompting them to complete a questionnaire. The remaining 12 patients accepted the BIRSH therapy sessions, with nine also accepting the True Colours self-monitoring.

Most of the participants were female (n=10; 83%) and aged between 18 and 35 years (n=10; 83%). All but one of the participants had engaged in self-harm previously (n=11; 92%). The characteristics of the 12 evaluation participants are shown in Table 1.

Table 1.

Characteristics of the 12 evaluation participants

Characteristic n %
Gender Female1083
Male217
Age 18-351083
36-5418
55+18
Previous self-harm Yes1192
Method of self-harm Self-injury325
Self-poisoning975
Number of sessions attended 0433
1-200
3-5217
6650

Overall, eight (67%) of the participants attended three or more BIRSH therapy sessions. Four attended no BIRSH therapy sessions, but one of these still used the True Colours system.

Patients’ use of the True Colours system

A total of nine patients used the True Colours system. Two examples of participants’ True Colours’ results are shown in Figures 1 and 2, and demonstrate the BIRSH therapy period and any repeat episodes of self-harm. In terms of the PHQ-9 and HADS scores, the higher the score the more the patient’s mood or anxiety had deteriorated. Significant life events such as loss of employment or relationship breakdown are also shown in Figures 1 and 2.

Figure 1.

Example of True Colours system monitoring – participant 1

mhp.2021.e1526_0001.jpg
Figure 2.

Example of True Colours system monitoring – participant 4

mhp.2021.e1526_0002.jpg

The period detailed in Figure 1 shows when this participant was actively engaged in BIRSH therapy sessions, which were associated with improvements in their mood and anxiety scores from baseline. The patient lost their job during week nine, which was followed by a deterioration in their mental state for a short period of time and a repeat episode of self-harm. After their series of BIRSH therapy sessions ended – at week 14 – their mood and anxiety fluctuated, with their ratings indicating generally suboptimal levels compared with the therapy period.

The patient shown in Figure 2 engaged in further self-harm before therapy began, and in the first few weeks after it started. Then in week 7 they experienced a relationship breakdown, which was followed by an increase in anxiety scores but a decrease in depression, reflected in the figure.

Both patients continued using the True Colours system for many months after their BIRSH therapy sessions had ended.

Participants’ feedback on use of True Colours

All the participants who attended more than two BIRSH sessions (n=8) found the weekly True Colours questionnaires easy to use. One participant stated that:

… it was really easy to use, the questions and options were very clear and understandable. Keeping track of my mood made me more conscious of how I was feeling and my emotions, which was useful – especially looking back over the weeks. The graph with reference points visually demonstrated was very useful and interesting. It enabled me to better understand myself and recognise patterns in my mood.’ (Participant 2)

All these eight participants reported finding it useful to be able to review their responses (all participants had access to their online records). Seven of the participants reported that they experienced no issues when completing their weekly True Colours questionnaires. All eight participants said they would recommend True Colours to others in a similar situation. One participant stated:

[It was] really helpful to be able to see how I’m doing each week, easy way to keep a record of progress and problems. Easy to use, I’d like to carry on!’ (Participant 4)

Two participants made suggestions on how the True Colours system could be improved, with one stating:

… it would be really useful to get an overall rating from the system to see if you are improving.’ (Participant 5)

One participant commented that some of the scales used in the digital monitoring were repetitive, and that they would have liked more open-ended questions.

Nurses’ feedback on use of True Colours

Four of the five nurses who participated in the evaluation stated that they found it easy to recruit patients and explain the benefits of True Colours to them. The remaining nurse found registering a patient onto the True Colours system challenging. All the nurses who used True Colours during the BIRSH sessions found it useful. Examples of nurses’ comments on using True Colours were:

I found [True Colours] to be beneficial as it showed stages, improved areas for support and future input and allowed patients to see how far they had come.’ (Nurse participant 2)

… participants who engaged well with [True Colours] and had been preparing and reflecting ahead of the session.’ (Nurse participant 4)

Discussion

The findings from this evaluation suggested that both patients and nurses found it useful to use a digital self-management tool to monitor patients’ mood, thoughts of self-harm and suicidality alongside psychological therapy sessions. From the feedback questionnaire, it was clear that the nurse participants were able to use the real-time True Colours data in the BIRSH therapy sessions. These data provided a structure to the BIRSH therapy sessions because the nurses were able to ask the patients why they had felt more or less suicidal that week, for example. It also gave the patient participants a sense of ownership and responsibility about recording their data. The True Colours data also enabled the nurses and patients to monitor changes in the patients’ mood and suicidality over time, and to recognise how these changes related to life events or treatment modifications, for example.

One of the nurses related how they found registering patients on the True Colours online system challenging. This shows the value of ensuring clinicians have access to appropriate training to ensure that they feel able to use innovative technology such as the True Colours system. Fetter (2009) stated that although evidence links information technology with improved patient safety, nurses should be competent in using the information technology, which further indicates the need for adequate training in the True Colours system.

Shan et al (2019) noted that patient engagement with technology influenced the outcomes of any digital health intervention. Also, while numerous types of digital health interventions are available to patients and members of the public, many factors affect their ability to engage with these interventions (O’Connor et al 2016). Some potential participants in this evaluation were excluded from engaging with the True Colours system because they could not reliably self-monitor their mood and mental state, for example because of their mental health issues, or the possible ‘triggering’ nature of some of the questions. In addition, some patients lacked the technology required to operate the True Colours system, such as a mobile phone.

Although the results of this evaluation could not be generalised to the overall population of people who self-harm, due to the relatively small size of the sample, they did provide preliminary findings concerning the usefulness of the True Colours system when used as an adjunct to outpatient follow-up.

The findings of this evaluation should be developed in future research by testing the True Colours system in a larger population group to ascertain if it should be offered to all patients who self-harm and who require follow-up.

In terms of the True Colours measures used in this evaluation, the authors considered that the PHQ-9, with added questions about self-harm, was instrumental in eliciting the required information.

While this evaluation used items concerning anxiety extracted from the HADS scale, on reflection it might have been preferable to use a complete scale for this purpose, such as the General Anxiety Disorder-7 (GAD-7) (Spitzer et al 2006). This is because the evaluation only used the ‘anxiety’ element of HADS. Using a full anxiety scale might have been an improvement. Also, the GAD-7 is shorter, which would have meant fewer questions for participants to complete.

In this evaluation, participants were emailed a reminder to undertake their True Colours ratings weekly. However, because participants’ situations can often change rapidly, on reflection the authors believe that twice-weekly ratings would have been preferable.

Limitations

The main limitation of this pilot evaluation was the small sample size, but the authors hope their results will stimulate further research on the use of such digital technology in other mental health centres.

Another limitation was that the True Colours system itself is not monitored or regularly checked, except when the nurse examines a patient’s recordings before a face-to-face therapy session. Therefore, because some of the questions are sensitive and concern suicide, it is important that the patient understands that if their risk increases, they have a responsibility to seek further support. Simply answering ‘Yes’ to questions concerning suicidal ideation in the True Colours system, for example, would not trigger contact with a healthcare professional. However, if a patient responds ‘Yes’ to the question, ‘Have you made any preparations to end your life?’ then the True Colours system brings up a box prompting the patient to seek assistance from either their GP or the Samaritans.

Conclusion

The use of a digital, real-time method of monitoring mood, thoughts of self-harm and suicidality alongside a psychological intervention was found to be acceptable and useful to both patients and nurses. While it requires evaluation on a larger scale, the authors suggest that innovations such as the True Colours system could enhance the aftercare of people who self-harm.

References

  1. Bergen H, Hawton K, Waters K et al (2012) Premature death after self-harm: a multicentre cohort study. The Lancet. 380, 9853, 1568-1574. doi: 10.1016/S0140-6736(12)61141-6
  2. Brand F, Lascelles K (2017) Developing, implementing and evaluating a model for an outpatient self-harm service. Nursing Standard. 31, 37, 46-54. doi: 10.7748/ns.2017.e10229
  3. Catalan J, Marsack P, Hawton KE et al (1980) Comparison of doctors and nurses in the assessment of deliberate self-poisoning patients. Psychological Medicine. 10, 3, 483-491. doi: 10.1017/S0033291700047371
  4. Curran J, Brooker C (2007) Systematic review of interventions delivered by UK mental health nurses. International Journal of Nursing Studies. 44, 3, 479-509. doi: 10.1016/j.ijnurstu.2006.11.005
  5. Erlangsen A, Lind BD, Stuart EA et al (2015) Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching. The Lancet Psychiatry. 2, 1, 49-58. doi: 10.1016/S2215-0366(14)00083-2
  6. Fetter MS (2009) Improving information technology competencies: implications for psychiatric mental health nursing. Issues in Mental Health Nursing. 30, 1, 3-13. doi: 10.1080/01612840802555208
  7. Geulayov G, Kapur N, Turnbull P et al (2016) Epidemiology and trends in non-fatal self-harm in three centres in England, 2000-2012: findings from the Multicentre Study of Self-harm in England. BMJ Open. 6, 4, e010538. doi: 10.1136/bmjopen-2015-010538
  8. Geulayov G, Casey D, Bale L et al (2019) Suicide following presentation to hospital for non-fatal self-harm in the Multicentre Study of Self-Harm: a long-term follow-up study. The Lancet Psychiatry. 6, 12, 1021-1030. doi: 10.1016/S2215-0366(19)30402-X
  9. Goodday SM, Atkinson L, Goodwin G et al (2020) The True Colours remote symptom monitoring system: a decade of evolution. Journal of Medical Internet Research. 22, 1, e15188. doi: 10.2196/15188
  10. Hawton K, Witt KG, Taylor Salisbury TL et al (2016) Psychosocial interventions following self-harm in adults: a systematic review and meta-analysis. The Lancet Psychiatry. 3, 8, 740-750. doi: 10.1016/S2215-0366(16)30070-0
  11. Hollis C, Morriss R, Martin J et al (2015) Technological innovations in mental healthcare: harnessing the digital revolution. British Journal of Psychiatry. 206, 4, 263-265. doi: 10.1192/bjp.bp.113.142612
  12. Hunter C, Chantler K, Kapur N et al (2013) Service user perspectives on psychosocial assessment following self-harm and its impact on further help-seeking: a qualitative study. Journal of Affective Disorders. 145, 3, 315-323. doi: 10.1016/j.jad.2012.08.009
  13. Kroenke K, Spitzer RL, Williams JB (2001) The PHQ-9. Validity of a brief depression severity measure. Journal of General Internal Medicine. 16, 9, 606-613. doi: 10.1046/j.1525-1497.2001.016009606.x
  14. National Institute for Health and Care Excellence (2004) Self-Harm in Over 8s: Short-Term Management and Prevention of Recurrence. Clinical guideline No. 16. NICE, London.
  15. National Institute for Health and Care Excellence (2011) Self-Harm in Over 8s: Long-Term Management. Clinical guideline No. 133. NICE, London.
  16. O’Connor S, Hanlon P, O’Donnell CA et al (2016) Understanding factors affecting patient and public engagement and recruitment to digital health interventions: a systematic review of qualitative studies. BMC Medical Informatics and Decision Making. 16, 1, 120. doi: 10.1186/s12911-016-0359-3
  17. Pitman A, Tsiachristas A, Casey D et al (2020) Comparing short-term risk of repeat self-harm after psychosocial assessment of patients who self-harm by psychiatrists or psychiatric nurses in a general hospital: cohort study. Journal of Affective Disorders. 272, 158-165. doi: 10.1016/j.jad.2020.03.180
  18. Shan R, Sarkar S, Martin SS (2019) Digital health technology and mobile devices for the management of diabetes mellitus: state of the art. Diabetologia. 62, 6, 877-887. doi: 10.1007/s00125-019-4864-7
  19. Spitzer RL, Kroenke K, Williams JB et al (2006) A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine. 166, 10, 1092-1097. doi: 10.1001/archinte.166.10.1092
  20. Tsiachristas A, McDaid D, Casey D et al (2017) General hospital costs in England of medical and psychiatric care for patients who self-harm: a retrospective analysis. The Lancet Psychiatry. 4, 10, 759-767. doi: 10.1016/S2215-0366(17)30367-X
  21. Wand T, White K, Patching J et al (2011) An emergency department‐based mental health nurse practitioner outpatient service: part 1, participant evaluation. International Journal of Mental Health Nursing. 20, 6, 392-400. doi: 10.1111/j.1447-0349.2011.00744.x

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