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CC B
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C
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A
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Am
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Nn
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Dep
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co
m
1.
I
NT
RO
D
UCT
I
O
N
P
o
s
t
-
tr
au
m
atic
s
tr
ess
d
is
o
r
d
er
(
PTSD)
is
a
ch
r
o
n
ic,
s
ev
er
e,
an
d
in
ca
p
ac
itatin
g
p
s
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iatr
ic
co
n
d
itio
n
th
at
r
esu
lts
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r
o
m
in
d
iv
id
u
als’
ex
p
o
s
u
r
e
to
a
t
r
au
m
atic
ev
e
n
t,
wh
ich
lead
s
to
s
ev
er
al
ad
v
er
s
e
p
s
y
ch
o
lo
g
ical
ef
f
ec
ts
;
th
ese
ca
n
in
clu
d
e
a
n
in
cr
ea
s
ed
h
ig
h
p
r
o
b
ab
i
lity
o
f
co
-
o
cc
u
r
r
en
ce
with
o
th
er
r
el
ated
m
en
tal
h
ea
lth
p
r
o
b
lem
s
,
ac
ce
ler
ated
life
ex
p
ec
tan
cy
,
an
d
ea
r
ly
d
ea
th
[
1
]
,
[
2]
.
T
h
e
p
s
y
ch
o
l
o
g
ical
d
is
o
r
d
er
o
f
PTSD
is
ch
ar
ac
ter
is
ed
b
y
a
v
o
id
a
n
ce
,
m
o
o
d
s
witch
es
an
d
c
o
g
n
itio
n
,
an
d
h
y
p
er
a
r
o
u
s
al;
all
th
ese
s
y
m
p
to
m
s
p
e
r
s
is
t
f
o
r
s
o
m
e
tim
e,
s
o
m
e
f
o
r
wee
k
s
af
t
er
en
co
u
n
ter
in
g
a
tr
au
m
atic
in
cid
en
t
[
3
]
,
[
4]
.
R
esear
ch
h
as
id
en
tifie
d
ca
u
s
ativ
e
f
ac
to
r
s
th
at
ca
n
b
e
attr
ib
u
t
ed
to
PTSD
d
ev
elo
p
m
e
n
t:
a
p
r
e
-
ex
is
tin
g
h
is
to
r
y
o
f
s
u
b
s
tan
ce
a
b
u
s
e
an
d
f
am
ily
h
is
to
r
y
o
f
m
en
tal
d
is
o
r
d
er
;
tr
au
m
atic
e
x
p
o
s
u
r
e;
th
e
i
n
ten
s
ity
o
f
ex
p
o
s
u
r
e;
as
well
a
s
p
o
s
t
-
tr
au
m
atic
co
n
d
itio
n
s
lik
e
s
o
cial
a
s
s
i
s
tan
ce
[
5
]
,
[
6]
.
Peo
p
le
ca
n
d
ev
elo
p
PT
SD
d
u
e
to
in
h
er
ited
m
en
tal
d
is
o
r
d
er
s
a
n
d
d
i
r
ec
t
ex
p
o
s
u
r
e
to
t
h
r
ea
ten
in
g
cir
cu
m
s
t
an
ce
s
lik
e
s
ex
u
al
ab
u
s
e
a
n
d
te
r
r
o
r
is
m
as
well
as
co
n
s
is
ten
t
d
r
u
g
ab
u
s
e.
As
a
h
e
alth
is
s
u
e,
PS
T
D
h
as
b
ee
n
d
o
c
u
m
en
ted
a
m
o
n
g
co
n
f
lict
-
af
f
ec
t
ed
p
o
p
u
latio
n
s
s
u
c
h
as
in
s
u
r
g
en
cy
,
c
o
m
m
u
n
al
ar
m
ed
co
n
f
licts
,
an
d
war
s
lead
in
g
to
p
o
v
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ty
,
u
n
em
p
lo
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m
en
t,
a
n
d
ch
an
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in
s
o
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Evaluation Warning : The document was created with Spire.PDF for Python.
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I
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Sci
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Vo
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No
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1
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Ma
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20
2
5
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3
3
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342
334
d
y
n
am
ics
[
7]
.
Po
s
ttra
u
m
atic
s
tr
ess
d
is
o
r
d
er
is
est
im
ated
to
d
ev
elo
p
in
6
%
o
f
th
e
wo
r
ld
p
o
p
u
latio
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an
d
1
5
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4
%
o
f
h
ig
h
-
r
is
k
p
e
r
s
o
n
s
ex
p
o
s
ed
to
tr
au
m
a
[
7]
a
n
d
is
ass
ciate
d
with
later
-
life
p
h
y
s
ical
d
is
ab
ilit
y
,
in
ef
f
icien
cy
,
s
u
icid
al
th
o
u
g
h
ts
,
an
d
m
o
r
tality
[
8]
–
[
11]
.
R
esear
ch
er
s
an
d
p
s
y
ch
o
lo
g
is
ts
h
av
e
d
ev
elo
p
ed
s
ev
er
al
in
ter
v
en
tio
n
s
an
d
th
er
a
p
ies
to
ass
is
t
in
d
iv
id
u
als
in
r
ec
o
v
er
i
n
g
f
r
o
m
t
h
e
n
eg
ativ
e
im
p
ac
ts
o
f
PTSD.
So
m
e
o
f
th
ese
p
s
y
ch
o
lo
g
ical
i
n
ter
v
en
tio
n
s
i
d
en
tifie
d
in
th
e
PTSD
liter
atu
r
e
in
clu
d
e
ex
p
o
s
u
r
e,
co
g
n
itiv
e
-
b
eh
av
i
o
r
al
an
d
r
estru
ctu
r
in
g
t
h
er
ap
ies,
an
d
o
th
er
in
ter
v
en
tio
n
s
lik
e
ad
a
p
tiv
e,
b
io
p
s
y
ch
o
s
o
cial,
a
n
d
telem
ed
icin
e
-
b
ased
in
ter
v
en
tio
n
s
[
1
2
]
–
[
15]
.
T
h
e
PTSD
liter
atu
r
e
s
h
o
ws
th
at
th
ese
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
ar
e
ef
f
ec
tiv
e
in
th
e
tr
ea
tm
en
t
o
f
PTSD
am
o
n
g
th
e
g
en
er
al
p
o
p
u
latio
n
o
n
d
if
f
er
e
n
t
asp
ec
ts
o
f
tr
au
m
a
e
n
co
u
n
ter
s
,
s
u
ch
as
war
,
s
ex
u
al
ass
au
lt,
an
d
ac
cid
en
ts
am
o
n
g
o
th
er
s
[
1
6
]
.
So
m
e
o
f
th
ese
in
ter
v
e
n
tio
n
th
er
ap
ies
an
d
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
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av
e
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ee
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u
b
jecte
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n
o
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ic
ev
alu
atio
n
u
s
in
g
t
h
e
g
u
i
d
elin
es
an
d
p
r
o
t
o
co
l
o
u
tlin
e
d
b
y
W
ils
o
n
[
17]
to
ass
ess
th
e
co
s
t
an
d
o
u
tco
m
e
o
f
in
ter
v
en
tio
n
s
an
d
th
e
r
atio
n
al
ch
o
ice
am
id
v
a
r
i
o
u
s
in
ter
v
e
n
tio
n
s
.
T
h
e
ec
o
n
o
m
ic
ev
alu
ati
o
n
o
f
in
te
r
v
en
tio
n
s
tak
es
in
to
ac
co
u
n
t
th
e
co
s
ts
an
d
co
n
s
eq
u
e
n
ce
s
ass
o
ciate
d
with
alter
n
ativ
e
ap
p
r
o
ac
h
es
b
y
m
e
asu
r
in
g
,
ev
al
u
atin
g
,
an
d
co
m
p
a
r
in
g
th
e
ass
o
ciate
d
co
s
ts
an
d
b
en
ef
its
[
1
8
]
,
[
1
9
]
.
E
co
n
o
m
ic
ev
alu
atio
n
h
as
s
ev
er
al
ap
p
r
o
ac
h
es
f
o
r
ev
alu
atin
g
in
ter
v
e
n
tio
n
s
tu
d
ie
s
s
u
ch
as:
i)
c
o
s
t
-
ef
f
ec
tiv
en
ess
r
atio
u
s
in
g
in
cr
em
en
tal
co
s
t
-
ef
f
ec
tiv
en
ess
r
atio
(
I
C
E
R
)
to
m
ea
s
u
r
e
s
ev
er
al
o
u
t
co
m
es
o
f
th
e
in
ter
v
e
n
tio
n
in
n
atu
r
ally
o
cc
u
r
r
in
g
u
n
its
[
2
0
]
;
ii
)
c
o
s
t
-
u
tili
t
y
,
wh
ich
is
th
e
f
r
ac
tio
n
o
f
co
s
t
-
ef
f
ec
tiv
en
ess
in
wh
ich
th
e
u
tili
ty
o
f
t
h
e
in
ter
v
en
tio
n
is
m
ea
s
u
r
ed
u
s
i
n
g
q
u
ality
-
ad
ju
s
ted
life
y
ea
r
(
QAL
Y
)
[
21]
;
iii)
c
o
s
t
-
b
en
ef
it
an
aly
s
is
is
esti
m
ated
in
m
o
n
etar
y
ter
m
s
wh
ich
allo
ws
a
d
ir
ec
t
co
m
p
ar
is
o
n
o
f
s
tu
d
y
o
b
jectiv
e
s
o
f
d
if
f
er
en
t
in
te
r
v
en
tio
n
s
[
2
2
]
;
an
d
iv
)
c
o
s
t
-
m
i
n
i
m
i
z
a
t
i
o
n
a
n
a
l
y
s
i
s
w
h
i
c
h
t
a
k
e
s
i
n
t
o
a
c
c
o
u
n
t
t
h
e
a
c
t
u
a
l
c
o
s
t
o
f
a
l
t
e
r
n
a
t
i
v
e
i
n
t
e
r
v
e
n
t
i
o
n
o
p
t
i
o
n
s
[
2
3
]
,
[
24]
.
All
th
ese
ec
o
n
o
m
ic
ev
alu
atio
n
ap
p
r
o
ac
h
es
ar
e
d
esig
n
ed
t
o
estab
lis
h
th
e
ef
f
icac
y
,
ef
f
icien
cy
,
co
s
t
-
af
f
o
r
d
a
b
ilit
y
,
an
d
u
tili
za
tio
n
o
f
th
ese
in
ter
v
en
tio
n
p
r
o
g
r
am
m
e
s
f
o
r
PTSD
p
atien
ts
’
tr
ea
tm
en
ts
.
R
e
s
ea
r
ch
er
s
s
u
ch
as
[
1
8
]
,
[
1
9
]
r
ep
o
r
ted
t
h
at
ec
o
n
o
m
ic
ev
alu
ati
o
n
r
e
v
ea
ls
th
e
c
o
s
ts
ass
o
ciate
d
with
an
in
ter
v
e
n
tio
n
alo
n
g
with
it
s
ef
f
ec
tiv
en
ess
,
ef
f
icien
cy
,
an
d
af
f
o
r
d
a
b
ilit
y
in
th
e
tr
ea
tm
en
t
o
f
PTSD
s
y
m
p
to
m
s
.
An
ec
o
n
o
m
ic
ev
alu
atio
n
o
f
in
ter
v
en
tio
n
s
tu
d
ies
h
as
b
ee
n
co
n
d
u
cte
d
o
n
th
er
a
p
eu
tic
tr
ea
t
m
en
t
o
f
PTSD
p
atien
ts
[
1
5
]
,
[
2
5
]
,
[
2
6
]
.
Pre
v
io
u
s
r
ev
iews
co
n
d
u
cted
b
y
v
o
n
d
e
r
W
ar
th
et
a
l.
[
27]
o
n
ec
o
n
o
m
i
c
ev
alu
atio
n
an
d
co
s
t
a
n
aly
s
is
o
f
PTSD
id
en
tifie
d
k
ey
liter
atu
r
e
r
ev
iews
[
1
3
]
,
[
2
8
]
,
[
2
9
]
.
Ho
wev
er
,
v
o
n
d
er
W
ar
th
et
a
l.
[
27]
f
o
cu
s
ed
m
o
r
e
o
n
th
e
co
s
t
an
aly
s
es
o
f
PTSD
tr
ea
tm
en
ts
wh
ile
litt
le
was
d
o
n
e
o
n
th
e
c
o
s
t
-
ef
f
ec
tiv
en
ess
o
f
th
e
PTSD
in
ter
v
en
tio
n
p
r
o
g
r
am
.
T
h
e
latest
s
tu
d
y
r
ev
iewe
d
i
n
v
o
n
d
er
W
ar
th
et
a
l.
[
2
7
]
was
p
u
b
lis
h
ed
in
2
0
1
9
.
R
ec
en
tly
,
n
u
m
er
o
u
s
s
tu
d
ies
h
av
e
b
ee
n
p
u
b
lis
h
ed
o
n
t
h
e
ec
o
n
o
m
ic
ev
alu
atio
n
o
f
in
ter
v
e
n
tio
n
p
r
o
g
r
am
m
es
f
o
r
PTSD
p
atien
ts
,
wh
ich
h
av
e
d
e
m
o
n
s
t
r
a
t
e
d
t
h
e
i
r
f
e
a
s
i
b
i
l
i
t
y
c
o
n
c
e
r
n
i
n
g
c
o
s
t
-
e
f
f
e
c
t
i
v
e
n
e
s
s
a
n
d
Q
A
L
Y
s
.
D
u
e
t
o
t
h
i
s
r
e
c
e
n
t
u
p
s
u
r
g
e
i
n
a
r
t
i
c
l
e
s
p
u
b
l
i
s
h
e
d
,
t
h
e
r
e
i
s
a
n
e
e
d
f
o
r
a
n
u
p
d
a
t
e
d
r
e
v
i
e
w
o
f
t
h
e
e
c
o
n
o
m
i
c
e
v
a
l
u
a
t
i
o
n
o
f
i
n
t
e
r
v
e
n
t
i
o
n
s
t
u
d
i
e
s
o
n
P
T
S
D
p
a
t
i
e
n
t
s
.
Usi
n
g
a
s
co
p
in
g
r
ev
iew
ap
p
r
o
ac
h
,
we
aim
ed
to
u
n
v
eil
th
e
latest
d
ata
o
n
th
e
co
s
t
-
ef
f
ec
tiv
en
ess
o
f
th
ese
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
an
d
th
eir
ass
o
ciate
d
h
ea
lth
b
en
ef
its
.
Hen
ce
,
th
is
r
ev
iew
is
s
ig
n
if
ican
t
esp
ec
i
ally
in
th
is
cu
r
r
en
t
g
lo
b
al
ec
o
n
o
m
ic
cr
is
is
wh
er
e
m
an
y
co
u
n
tr
ies
ar
e
ex
p
er
ien
cin
g
b
u
d
g
et
d
e
f
icits
f
o
r
co
n
cu
r
r
en
t
ex
p
en
d
itu
r
e.
W
e
s
tr
o
n
g
ly
b
eliev
e
th
at
th
e
f
in
d
in
g
s
o
f
th
is
s
tu
d
y
will
g
u
id
e
th
e
r
ap
is
ts
,
clin
ician
s
,
p
s
y
ch
o
lo
g
is
ts
,
an
d
p
o
licy
m
ak
er
s
b
ec
a
u
s
e
it
will h
elp
th
em
m
ak
e
a
r
atio
n
al
c
h
o
ice
in
ad
o
p
tin
g
a
n
in
ter
v
e
n
tio
n
p
r
o
g
r
am
m
e
f
o
r
PTSD
th
at
i
s
af
f
o
r
d
ab
le
an
d
ef
f
ec
tiv
e
an
d
h
as r
o
b
u
s
t h
ea
lth
b
en
ef
its
.
I
t is ex
p
ec
ted
th
at
th
e
f
in
d
in
g
s
will a
s
s
i
s
t
in
th
e
allo
ca
tio
n
o
f
lim
ited
r
e
s
o
u
r
ce
s
th
at
will
b
e
d
ir
ec
ted
t
o
war
d
s
tr
ea
tin
g
th
e
ad
v
e
r
s
e
ef
f
ec
ts
o
f
PTSD.
W
e
b
eliev
e
th
at
o
u
r
r
esear
ch
f
in
d
i
n
g
s
will
f
ill
th
e
k
n
o
wled
g
e
g
a
p
in
th
e
liter
atu
r
e
an
d
p
r
o
v
id
e
in
s
ig
h
t
in
to
th
e
m
o
s
t
af
f
o
r
d
a
b
le,
co
s
t
-
ef
f
ec
tiv
e
,
an
d
r
o
b
u
s
t in
ter
v
e
n
tio
n
p
r
o
g
r
am
f
o
r
PTSD
p
atien
ts
.
R
ev
iew
q
u
esti
ons
−
Ar
e
all
PTSD
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es c
o
s
t
-
ef
f
ec
tiv
e?
−
W
h
at
ar
e
th
e
h
ea
lth
b
e
n
ef
its
ass
o
ciate
d
with
th
ese
PTSD
in
t
er
v
en
tio
n
p
r
o
g
r
am
m
es?
Po
s
t
-
tr
au
m
atic
Stre
s
s
Dis
o
r
d
er
(
PTSD)
in
ter
v
en
tio
n
p
r
o
g
r
a
m
m
es
ar
e
ass
o
ciate
d
with
ca
p
ital
-
in
ten
s
iv
e
tr
ea
tm
en
ts
.
T
h
is
s
tu
d
y
r
ev
ea
le
d
s
o
m
e
i
n
ter
v
en
tio
n
p
r
o
g
r
am
m
es
th
at
ar
e
c
o
s
t
-
ef
f
icien
t
a
n
d
h
av
e
r
o
b
u
s
t
h
ea
lth
b
en
ef
its
f
o
r
tr
ea
tin
g
PTSD
p
atien
ts
ac
r
o
s
s
th
e
g
lo
b
e.
Similar
ly
,
o
th
er
c
o
s
t
-
in
ef
f
ec
tiv
e
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
wer
e
also
h
ig
h
lig
h
ted
.
Fo
r
ef
f
ec
tiv
e
tr
ea
tm
en
t
o
f
PTSD,
f
u
t
u
r
e
r
esear
ch
er
s
,
th
er
a
p
is
ts
,
an
d
th
e
W
o
r
l
d
Hea
lth
Or
g
an
is
atio
n
s
h
o
u
ld
ad
o
p
t th
e
s
e
co
s
t
-
ef
f
ec
tiv
e
in
ter
v
en
t
io
n
s
.
2.
M
E
T
H
O
D
A
r
ig
o
r
o
u
s
p
r
elim
in
ar
y
s
ea
r
ch
f
o
r
a
s
co
p
in
g
r
ev
iew
was
co
n
d
u
cte
d
o
n
t
h
e
ec
o
n
o
m
ic
ev
alu
atio
n
o
f
in
ter
v
en
tio
n
s
f
o
r
PTSD
p
atie
n
ts
in
s
ev
er
al
o
n
lin
e
d
atab
ase
s
s
u
ch
as
Ps
y
cI
n
f
o
,
NHS
E
c
o
n
o
m
ic
E
v
alu
atio
n
,
Scien
ce
Dir
ec
t,
Natio
n
al
L
ib
r
ar
y
o
f
Me
d
icin
e,
a
n
d
Pu
b
Me
d
f
r
o
m
J
u
n
e
to
J
u
ly
2
0
2
3
.
T
h
e
r
e
was
n
o
ex
is
tin
g
r
ev
iew
o
f
th
is
ty
p
e
in
th
e
liter
a
tu
r
e.
I
n
co
n
d
u
ctin
g
th
is
s
tu
d
y
,
we
f
o
llo
wed
th
e
g
u
i
d
elin
es
f
o
r
p
r
ef
er
r
e
d
r
ep
o
r
tin
g
item
s
f
o
r
s
y
s
tem
atic
r
ev
iews
an
d
m
eta
-
a
n
aly
s
es
(
PR
I
SMA)
an
d
J
o
an
n
a
B
r
ig
g
s
I
n
s
titu
te
(
JBI
)
m
y
th
o
l
o
g
ical
f
r
am
ewo
r
k
[
3
0
]
,
[
31]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
A
s
co
p
in
g
r
ev
iew
o
f e
co
n
o
mic
ev
a
lu
a
tio
n
s
o
f
p
o
s
t
-
tr
a
u
ma
tic
s
tr
es
s
d
is
o
r
d
er …
(
V
ero
n
ica
Dw
a
r
ika
)
335
2
.
1
.
L
it
er
a
t
ure
s
ea
rc
h
A
s
co
p
in
g
r
e
v
iew
was
co
n
d
u
cted
o
n
o
n
lin
e
d
atab
ases
s
u
ch
as
th
e
NHS
E
co
n
o
m
ic
E
v
alu
atio
n
Data
b
ase,
Pu
b
Me
d
,
Ps
y
cI
n
f
o
,
E
co
n
L
it,
Hea
lth
Ma
n
ag
em
en
t
Data
b
ase,
an
d
Sco
p
u
s
.
W
e
f
o
r
m
u
lated
s
en
s
itiv
e
s
ea
r
ch
s
y
n
tax
with
th
e
ass
i
s
t
an
ce
o
f
d
ig
ital
lib
r
ar
ian
s
.
W
e
u
s
ed
th
e
f
o
llo
win
g
s
ea
r
ch
s
y
n
tax
:
“E
co
n
o
m
ic
ev
alu
atio
n
o
f
PTSD
in
ter
v
en
tio
n
p
r
o
g
r
am
”
,
“c
o
s
t
-
ef
f
ec
tiv
e
n
ess
an
aly
s
i
s
o
f
in
ter
v
en
tio
n
p
r
o
g
r
am
”,
“e
co
n
o
m
ic
ev
alu
atio
n
o
f
PTSD
in
ter
v
en
ti
o
n
”,
co
s
t
an
aly
s
is
o
f
PTSD
in
ter
v
en
tio
n
,
”
a
n
d
“c
o
s
t
-
b
en
e
f
it
an
aly
s
is
o
f
PTSD
in
ter
v
en
tio
n
p
r
o
g
r
am
”.
Mo
r
e
o
v
er
,
we
s
cr
ee
n
ed
th
e
r
ef
e
r
en
ce
lis
t
o
f
th
e
id
en
tifie
d
ar
ticles
f
o
r
ad
d
itio
n
al
s
tu
d
ies.
Ar
ticles we
r
e
n
o
t r
estricte
d
b
y
d
ate
o
f
p
u
b
licatio
n
.
2
.
2
.
E
lig
ibi
lity
o
f
s
t
ud
ies
Scr
ee
n
in
g
o
f
ar
ticles
was
co
n
d
u
cted
in
d
ep
e
n
d
en
tly
b
y
two
au
th
o
r
s
(
Dwa
r
ik
a
Ver
o
n
ica
(
DV)
an
d
Am
o
s
Nn
ae
m
ek
a
Am
ed
u
(
AN)
)
.
Pee
r
r
ev
iewe
d
ar
ticles
wer
e
an
al
y
ze
d
.
B
ased
o
n
th
e
r
esear
ch
q
u
esti
o
n
s
th
at
g
u
id
e
d
th
e
s
tu
d
y
,
o
n
ly
in
ter
v
e
n
tio
n
s
tu
d
ies
f
o
cu
s
ed
o
n
PTSD
we
r
e
co
n
s
id
er
ed
f
o
r
in
clu
s
io
n
.
Ar
ticles
d
is
cu
s
s
in
g
m
an
ag
em
en
t
c
o
s
ts
,
s
er
v
ice
co
s
ts
,
an
d
u
tili
za
tio
n
wer
e
ex
clu
d
ed
f
r
o
m
th
e
s
tu
d
y
.
T
h
e
r
ef
o
r
e
,
o
n
ly
a
r
ticles
th
at
d
is
cu
s
s
ed
th
e
co
s
t
o
f
in
ter
v
e
n
tio
n
wh
ich
in
clu
d
ed
eith
e
r
co
s
t
-
ef
f
ec
tiv
en
ess
,
co
s
t
-
b
en
e
f
it,
o
r
co
s
t
-
u
tili
ty
an
aly
s
is
wer
e
in
clu
d
ed
.
A
b
o
o
k
o
f
ab
s
t
r
ac
ts
th
at
co
n
tain
ed
all
th
e
n
ec
ess
ar
y
d
ata
was in
clu
d
ed
.
On
ly
ar
ticles p
u
b
lis
h
ed
in
th
e
E
n
g
lis
h
lan
g
u
ag
e
wer
e
elig
ib
le
an
d
ar
ticles
p
u
b
lis
h
ed
in
f
o
r
eig
n
lan
g
u
ag
es
wer
e
ex
clu
d
ed
.
All
p
ar
ticip
an
ts
wer
e
in
clu
d
ed
,
as
th
er
e
was n
o
ag
e
r
estrictio
n
.
S
tu
d
ies p
u
b
lis
h
ed
b
elo
w
2
0
1
5
wer
e
ex
clu
d
ed
f
r
o
m
th
e
s
tu
d
y
.
2
.
3
.
Da
t
a
e
x
t
ra
ct
i
o
n
T
h
e
r
atio
n
ale
f
o
r
d
ata
ex
tr
ac
t
io
n
was
f
o
r
m
u
lated
b
y
th
e
t
wo
au
th
o
r
s
(
DV)
an
d
(
AN)
.
Data
wer
e
ex
tr
ac
ted
b
y
o
n
e
o
f
th
e
r
ev
iew
er
s
(
AN)
an
d
r
ev
is
ed
b
y
a
s
ec
o
n
d
r
e
v
iewe
r
(
DV)
.
C
o
n
s
en
s
u
s
was
u
s
ed
to
r
eso
lv
e
am
b
ig
u
o
u
s
d
ata
p
o
i
n
ts
.
A
s
u
m
m
ar
y
o
f
th
e
d
ata
co
llected
i
n
clu
d
ed
t
h
e
f
ir
s
t
au
th
o
r
’
s
n
am
e,
in
ter
v
en
tio
n
ty
p
e
,
co
u
n
tr
y
,
s
am
p
le
s
ize,
p
r
im
ar
y
o
u
tco
m
e
,
an
d
th
e
f
in
d
in
g
s
.
T
h
e
f
in
d
i
n
g
s
o
f
th
e
s
tu
d
y
wer
e
f
u
r
th
er
ca
teg
o
r
ize
d
in
to
co
s
t
o
f
in
ter
v
en
tio
n
p
er
p
a
tien
t,
in
cr
em
en
tal
co
s
t
-
ef
f
ec
tiv
en
ess
r
atio
(
I
C
E
R
)
,
am
o
u
n
t
o
f
QAL
Y,
an
d
QAL
Y
g
ain
ed
.
C
o
s
ts
m
ea
s
u
r
ed
in
o
th
er
f
o
r
eig
n
cu
r
r
en
cies w
er
e
co
n
v
er
ted
to
USD
u
s
in
g
th
e
p
u
b
licatio
n
d
ate.
3.
RE
SU
L
T
S
T
h
e
s
ea
r
ch
r
esu
lts
p
r
o
d
u
ce
d
6
2
8
r
ec
o
r
d
s
(
m
a
n
u
al
s
ea
r
ch
=5
; d
atab
ase=2
2
3
)
; h
o
wev
er
,
1
6
a
r
ticles
m
et
th
e
cr
iter
ia
f
o
r
in
clu
s
io
n
in
t
h
e
s
co
p
in
g
r
ev
iew
(
[
1
4
]
,
[
1
5
]
,
[
2
3
]
,
[
2
4
]
,
[
32]
–
[
44
]
.
Am
o
n
g
th
e
ex
clu
d
e
d
r
ec
o
r
d
s
,
8
.
2
8
%
o
f
th
e
id
en
tifie
d
r
ec
o
r
d
s
(
5
2
ar
ticles)
m
et
all
th
e
cr
i
ter
ia
ex
ce
p
t
th
at
th
e
in
te
r
v
en
ti
o
n
co
s
t
a
n
d
QAL
Y
wer
e
n
o
t sp
ec
if
ie
d
.
Fu
r
t
h
er
m
o
r
e,
3
5
.
1
9
%
(
2
2
1
ar
ticles)
o
f
th
e
r
ec
o
r
d
s
wer
e
ex
cl
u
d
ed
b
ec
au
s
e
th
e
ar
ticles d
ea
lt
with
o
n
ly
p
h
ar
m
ac
eu
tical
an
d
clin
ical
co
s
ts
o
f
tr
ea
tin
g
P
T
SD
p
atien
ts
wh
ile
5
3
.
9
%
r
e
co
r
d
s
(
3
3
9
ar
ticles)
co
n
s
titu
ted
d
u
p
licates w
h
ich
wer
e
r
em
o
v
e
d
(
Fig
u
r
e
1
)
.
-
Featu
r
es o
f
in
clu
d
ed
s
tu
d
ies
T
h
e
ea
r
lies
t e
co
n
o
m
ic
e
v
alu
ati
o
n
(
E
E
)
s
tu
d
y
s
elec
ted
was
p
u
b
lis
h
ed
in
2
0
1
5
[
41]
an
d
th
e
m
o
s
t r
ec
en
t
E
E
was p
u
b
lis
h
ed
in
2
0
2
3
[
3
3
]
.
I
n
th
is
r
ev
iew,
n
i
n
e
s
tu
d
ies
wer
e
co
n
d
u
cted
in
No
r
th
Am
e
r
ica
[
1
4
]
,
[
2
3
]
,
[
2
4
]
,
[
3
2
]
,
[
3
4
]
,
[
3
5
]
,
[
3
9
]
,
[
4
0
]
,
[
42]
,
s
ix
wer
e
co
n
d
u
cted
in
E
u
r
o
p
e
[
1
5
]
,
[
3
3
]
,
[
3
6
]
–
[
3
8
]
,
[
44]
,
an
d
o
n
e
was
co
n
d
u
cte
d
in
Au
s
tr
alia
[
4
1
]
.
T
h
e
s
elec
ted
s
tu
d
ies
s
am
p
le
s
ize
r
an
g
e
d
f
r
o
m
N=
3
1
[
15]
(
1
8
)
t
o
N=
2
6
4
2
7
1
3
[
4
0
]
.
So
m
e
o
f
th
e
s
tu
d
ies
d
ea
lt
wit
h
p
s
y
ch
o
lo
g
ical
tr
ea
tm
en
ts
s
u
ch
as
T
F
-
C
B
T
v
s
T
F
-
C
B
T
+
SS
R
I
s
[
41]
.
TF
-
C
B
T
v
s
s
tan
d
ar
d
ca
r
e
[
4
2
]
,
co
g
n
itiv
e
b
eh
a
v
io
r
al
th
er
a
p
y
(
CBT
)
v
s
b
r
ief
in
ter
v
en
tio
n
(
B
R
F)
[
23]
p
r
o
lo
n
g
ed
ex
p
o
s
u
r
e
th
er
a
p
y
v
s
p
h
ar
m
ac
o
th
er
ap
y
[
13]
,
p
r
o
lo
n
g
e
d
ex
p
o
s
u
r
e
(
PE)
v
s
i
-
PE
v
s
Sk
ills
T
r
ain
in
g
in
A
f
f
ec
tiv
e
an
d
I
n
ter
p
er
s
o
n
al
R
eg
u
latio
n
+
Pro
lo
n
g
ed
e
x
p
o
s
u
r
e
(
STAI
R
+
PE)
,
[
32]
an
d
b
io
p
s
y
c
h
o
s
o
cial
in
ter
v
en
tio
n
v
s
waitin
g
lis
t,
[
15]
.
Fu
r
th
er
m
o
r
e
,
o
th
er
s
tu
d
ies th
at
f
o
cu
s
ed
o
n
th
e
in
ter
v
en
tio
n
ca
r
es we
r
e
s
tep
p
ed
ca
r
e
v
s
u
s
u
al
ca
r
e
[
39]
,
s
m
o
k
in
g
ce
s
s
atio
n
v
s
s
tan
d
ar
d
ca
r
e
[
3
9
]
,
telem
ed
icin
e
-
b
ased
co
llab
o
r
ativ
e
ca
r
e
v
s
ed
u
ca
tio
n
o
n
ly
[
14]
,
ev
i
d
en
ce
-
b
ased
telem
ed
icin
e
v
s
s
tan
d
ar
d
tr
ea
tm
en
t;
[
35]
,
telep
h
o
n
e
-
b
ased
co
n
cu
s
s
io
n
m
an
ag
em
en
t
p
r
o
b
lem
s
o
lv
in
g
th
er
ap
y
v
s
e
d
u
ca
tio
n
o
n
l
y
[
24]
,
ce
n
tr
ally
ass
is
ted
co
lla
b
o
r
ativ
e
telec
ar
e
v
s
o
p
tim
ized
u
s
u
al
ca
r
e
[
3
5
]
,
s
cr
ee
n
a
n
d
tr
ea
t
in
t
er
v
en
tio
n
v
s
en
h
an
ce
d
u
s
u
al
c
ar
e
[
3
6
]
tr
a
n
s
m
u
r
al
t
r
au
m
a
ca
r
e
m
o
d
el
v
s
r
eg
u
lar
ca
r
e
[
2
3
]
an
d
MD
MA
-
AT
[
3
4
]
,
[
4
1
]
.
3.
1
.
M
a
in
o
utc
o
m
e
T
h
e
f
o
u
r
m
ajo
r
o
u
tco
m
e
v
a
r
ia
b
les o
f
th
is
s
tu
d
y
in
cl
u
d
ed
co
s
t p
er
p
atien
t,
QAL
Ys,
QAL
Y
g
ain
ed
an
d
I
C
E
R
.
B
a
s
ed
o
n
th
e
r
esu
lts
o
f
th
e
s
elec
ted
liter
atu
r
e,
th
e
co
s
t
-
ef
f
ec
tiv
en
ess
o
f
th
e
in
ter
v
en
tio
n
p
r
o
g
r
am
p
e
r
p
atien
t
was
r
ep
o
r
ted
in
all
s
tu
d
ies
ex
ce
p
t
o
n
e
[
42]
.
QAL
Ys
g
ain
ed
d
u
e
to
in
ter
v
en
tio
n
wa
s
also
e
s
tab
lis
h
ed
in
m
o
s
t
o
f
th
e
s
tu
d
ies,
ex
ce
p
t
i
n
f
iv
e
[
1
4
]
,
[
2
3
]
,
[
3
5
]
,
[
37]
.
Fu
r
th
er
m
o
r
e
,
in
cr
em
e
n
tal
QAL
Ys
g
ain
ed
d
u
e
to
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
wer
e
n
o
t
r
ep
o
r
te
d
in
eig
h
t
s
tu
d
ies
[
3
2
]
,
[
3
4
]
,
[
35]
,
[
3
8
]
,
[
4
2
]
.
T
h
er
e
was
n
o
m
en
tio
n
o
f
I
C
E
R
s
in
th
ese
s
tu
d
ies
[
1
3
]
,
[
3
2
]
,
[
3
5
]
,
[
3
7
]
,
[
4
2
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
1
4
,
No
.
1
,
Ma
r
ch
20
2
5
:
3
3
3
-
342
336
Fig
u
r
e
1
.
PR
I
SMA
f
lo
w
ch
ar
t
3.
2
.
F
ind
ing
s
3.
2
.
1
.
E
co
no
m
ic
co
s
t
-
e
f
f
ec
t
iv
eness
o
f
P
T
SD i
nte
rv
ent
io
n pro
g
ra
mm
es
T
h
is
r
ev
iew
ex
p
lo
r
ed
th
e
ec
o
n
o
m
ic
co
s
t
-
ef
f
ec
tiv
en
ess
o
f
in
te
r
v
en
tio
n
p
r
o
g
r
am
m
es f
o
r
tr
ea
t
in
g
PTSD
p
atien
ts
.
W
e
f
o
u
n
d
s
tr
o
n
g
e
v
id
en
ce
t
h
at
s
o
m
e
o
f
th
ese
PTS
D
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
a
r
e
co
s
t
-
ef
f
ec
tiv
e
in
tr
ea
tin
g
p
atien
ts
with
PTSD.
T
o
b
e
m
o
r
e
p
r
ec
is
e,
we
f
o
u
n
d
t
h
at
1
9
PTSD
s
tu
d
ies o
n
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
r
ep
o
r
ted
co
s
t
-
ef
f
ec
ti
v
en
ess
p
er
p
atien
t.
Am
o
n
g
th
e
liter
atu
r
e
th
at
m
et
o
u
r
in
clu
s
io
n
cr
iter
ia,
telem
ed
icin
e
r
ated
th
e
h
ig
h
est.
T
h
e
r
e
wer
e
f
o
u
r
s
tu
d
ies
th
at
ev
alu
ated
th
e
co
s
t
-
ef
f
ec
tiv
en
ess
o
f
telem
ed
icin
e
in
ter
v
en
tio
n
s
f
o
r
PTSD
p
atien
ts
.
Pain
ter
et
a
l.
[
14]
estab
lis
h
ed
t
h
at
telem
ed
ici
n
e
was
r
elativ
ely
ex
p
en
s
iv
e
co
m
p
ar
ed
to
t
h
e
co
s
t
o
f
en
h
an
c
ed
u
s
u
al
ca
r
e.
R
ich
ar
d
s
o
n
et
a
l.
[
24]
r
e
v
ea
led
th
at
telep
h
o
n
ic
ed
u
ca
tio
n
was
m
o
r
e
co
s
tly
th
an
ed
u
ca
tio
n
alo
n
e
.
I
n
o
t
h
er
wo
r
d
s
,
ed
u
ca
tio
n
o
n
ly
is
m
o
r
e
e
co
n
o
m
ically
co
s
t
-
ef
f
ec
ti
v
e
th
an
telep
h
o
n
e
-
b
ased
co
n
cu
s
s
io
n
m
an
ag
e
m
en
t
p
r
o
b
l
em
s
o
lv
in
g
th
er
ap
y
(
PS
T
)
.
T
h
i
s
f
in
d
in
g
v
alid
ated
th
e
r
ep
o
r
t
o
f
Pain
ter
et
a
l.
[
14]
wh
o
r
ev
ea
led
th
at
telem
ed
icin
e
is
r
elativ
ely
ex
p
en
s
iv
e
c
o
m
p
ar
ed
to
u
s
u
al
ca
r
e
b
ec
a
u
s
e
o
f
th
e
ass
o
ciate
d
tr
ain
in
g
co
s
ts
an
d
in
h
er
en
t c
ap
ital
-
in
te
n
s
iv
e
n
atu
r
e
o
f
th
e
i
n
ter
v
en
tio
n
.
W
o
n
g
et
a
l.
[
3
5
]
f
o
u
n
d
th
at
ce
n
tr
alize
d
ass
is
ted
co
llab
o
r
ati
v
e
telec
ar
e
(
C
AC
T
)
ap
p
ea
r
ed
to
b
e
co
s
t
-
ef
f
ec
tiv
e
r
elate
d
to
o
p
tim
ized
u
s
u
al
ca
r
e
(
OUC)
ev
en
th
o
u
g
h
C
AC
T
was
ass
o
ciate
d
w
ith
a
h
ig
h
co
s
t
o
f
im
p
lem
en
tatio
n
.
T
h
is
f
in
d
in
g
p
ar
tially
ag
r
ee
d
wit
h
p
r
ev
io
u
s
f
in
d
i
n
g
s
in
ter
m
s
o
f
ca
p
ital
in
ten
s
iv
en
ess
as
s
o
ciate
d
wit
h
telem
ed
ici
n
e,
Pain
ter
et
a
l.
[
14]
a
n
d
R
ich
ar
d
s
o
n
et
a
l.
[
24]
h
o
wev
er
,
it
r
e
v
ea
led
th
at
C
AC
T
wh
ich
is
p
ar
t
o
f
telem
ed
icin
e
is
co
s
t
-
ef
f
ec
tiv
e.
W
o
n
g
et
a
l
.
[
35]
r
ep
o
r
ted
th
at
ev
id
en
ce
-
b
ased
telem
ed
icin
e
was
co
s
t
-
ef
f
ec
tiv
e
co
m
p
ar
ed
to
s
tan
d
ar
d
ca
r
e.
W
o
n
g
’
s
f
i
n
d
in
g
s
u
p
p
o
r
te
d
th
e
r
ep
o
r
t
o
f
W
o
n
g
et
a
l.
[
35]
w
h
ich
r
ev
ea
led
th
at
C
AC
T
is
a
co
s
t
-
ef
f
ec
tiv
e
in
ter
v
e
n
tio
n
.
Ho
we
v
er
,
W
o
n
g
’
s
f
in
d
i
n
g
co
u
n
ter
s
th
e
f
in
d
i
n
g
s
o
f
th
e
p
r
ev
io
u
s
r
esear
ch
es
[
1
4
]
,
[
2
4
]
,
[
35]
wh
ich
r
e
p
o
r
ted
th
at
th
e
tel
em
ed
icin
e
ap
p
r
o
ac
h
is
n
o
t c
o
s
t
-
ef
f
ec
tiv
e
d
u
e
to
th
e
ca
p
ital
-
in
ten
s
iv
e
n
atu
r
e
o
f
th
e
im
p
lem
en
tatio
n
.
T
wo
s
tu
d
ies
ex
p
lo
r
ed
th
e
co
s
t
-
ef
f
ec
tiv
en
ess
o
f
MD
MA
-
AT
in
tr
ea
tin
g
PTSD
p
atien
ts
.
A
s
tu
d
y
r
ev
ea
led
th
at
MD
MA
-
AT
was
m
o
r
e
co
s
t
-
ef
f
ec
tiv
e
b
ec
a
u
s
e
it
g
en
er
ated
m
o
r
e
n
et
s
av
in
g
s
an
d
av
er
ted
p
r
e
m
atu
r
e
d
ea
th
[
3
2
]
.
T
h
e
MD
MA
-
AT
h
ad
a
b
r
ea
k
ev
e
n
p
o
in
t
at
3
.
8
y
ea
r
s
,
m
ea
n
in
g
it
was
n
o
t
e
co
n
o
m
ically
c
o
s
t
-
in
ef
f
icien
t
f
r
o
m
1
to
3
.
7
y
ea
r
s
.
Fu
r
th
er
m
o
r
e
,
Av
an
ce
ñ
a
et
a
l
.
[
34]
f
o
u
n
d
th
at
at
a
co
s
t
-
ef
f
e
ctiv
en
ess
th
r
esh
o
ld
o
f
$
1
0
0
,
0
0
0
p
e
r
QAL
Y
g
ain
e
d
,
th
e
th
r
ee
MD
MA
-
AT
(
2
5
%,
5
0
%
an
d
7
5
%)
wer
e
c
o
s
t
-
ef
f
ec
tiv
e
an
d
co
s
t
s
av
in
g
co
m
p
ar
ed
t
o
s
tan
d
ar
d
ca
r
e
.
T
h
is
f
in
d
in
g
alig
n
e
d
with
Ma
r
s
eille
et
a
l.
[
32]
wh
o
r
e
v
ea
led
th
at
MD
MA
T
-
AT
s
av
es
liv
es
an
d
en
h
an
ce
s
th
e
h
ea
lth
o
f
p
atien
ts
with
s
ev
er
e
PTSD.
W
h
en
th
e
ef
f
ec
tiv
en
ess
o
f
PE,
in
ten
s
if
ied
PE
(
i
-
PE)
an
d
s
k
ills
tr
ain
in
g
in
af
f
ec
tiv
e
an
d
in
ter
p
er
s
o
n
al
r
eg
u
latio
n
(
STAI
R
+PE
)
wer
e
co
m
p
ar
e
d
,
th
er
e
was
n
o
s
ig
n
if
ican
t
d
if
f
er
en
ce
d
u
e
to
th
e
th
r
ee
tr
ea
tm
e
n
t
co
n
d
itio
n
s
[
3
2
]
.
Ho
wev
er
,
s
in
ce
th
e
in
d
iv
id
u
al
p
atien
t’
s
co
s
t
-
ef
f
ec
tiv
en
ess
r
atio
was
b
elo
w
th
e
QAL
Y
th
r
esh
o
l
d
,
t
h
e
p
r
o
b
ab
ilit
y
o
f
ea
ch
o
f
th
ese
p
r
o
g
r
am
m
es
b
ein
g
co
s
t
-
ef
f
ec
tiv
e
was e
s
tab
lis
h
ed
at
3
2
% f
o
r
PE,
2
8
%
f
o
r
i
-
PE
a
n
d
4
0
% f
o
r
STAI
R
-
PE
r
esp
ec
t
iv
ely
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
A
s
co
p
in
g
r
ev
iew
o
f e
co
n
o
mic
ev
a
lu
a
tio
n
s
o
f
p
o
s
t
-
tr
a
u
ma
tic
s
tr
es
s
d
is
o
r
d
er …
(
V
ero
n
ica
Dw
a
r
ika
)
337
Fu
r
th
er
m
o
r
e
,
we
id
en
tifie
d
two
s
tu
d
ies
th
at
ex
p
lo
r
ed
th
e
co
s
t
-
ef
f
ec
tiv
en
ess
o
f
CBT
in
ter
v
en
tio
n
in
th
e
tr
ea
tm
en
t
o
f
in
d
iv
id
u
als
with
PTSD.
Slad
e
et
a
l.
[
23]
f
o
u
n
d
th
at
C
B
T
was
n
o
t
m
o
r
e
co
s
t
-
ef
f
ec
tiv
e
th
an
B
R
F
s
in
ce
co
s
ts
a
s
s
o
ciate
d
with
C
B
T
wer
e
s
tat
is
tical
ly
n
o
n
-
s
ig
n
if
ican
t
co
m
p
ar
ed
with
B
R
F
in
ter
v
en
tio
n
.
Seco
n
d
,
Sh
ea
r
er
et
a
l.
[
38]
r
ev
ea
led
th
at
C
B
T
was
f
o
u
n
d
to
b
e
at
6
9
%
p
r
o
b
a
b
ilit
y
o
f
b
ein
g
co
s
t
-
ef
f
ec
tiv
e
co
m
p
ar
ed
to
u
s
u
al
ca
r
e
at
th
e
UK
QAL
Y
d
ec
is
io
n
th
r
esh
o
ld
.
Mih
alo
p
o
u
lo
s
et
a
l.
[
41]
f
o
u
n
d
th
at
T
F
-
C
B
T
was
co
s
t
-
ef
f
ec
tiv
e
f
o
r
b
o
th
ch
ild
r
en
a
n
d
ad
u
lts
co
m
p
ar
ed
to
SS
R
I
s
at
cu
r
r
en
t
p
r
i
ce
s
.
Hen
ce
,
Mih
alo
p
o
u
lo
s
et
a
l
.
[
4
1
]
r
ec
o
m
m
en
d
e
d
th
at
th
e
f
u
ll
im
p
lem
en
tatio
n
g
u
id
elin
e
ev
alu
ated
in
t
h
e
s
tu
d
y
wo
u
ld
lead
to
th
e
ec
o
n
o
m
ic
ef
f
icien
cy
in
th
e
tr
ea
tm
en
t o
f
PTSD.
T
h
is
r
ev
iew
id
en
tifie
d
s
ix
o
th
er
in
ter
v
en
t
io
n
s
tu
d
ies
th
at
co
m
p
ar
ed
two
i
n
ter
v
en
tio
n
p
r
o
g
r
am
m
es
o
r
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
with
u
s
u
al
ca
r
e.
B
ar
n
ett
et
a
l.
[
3
9
]
f
o
u
n
d
t
h
at
ev
en
th
o
u
g
h
th
e
c
o
s
ts
ass
o
ciate
d
with
s
m
o
k
in
g
ce
s
s
atio
n
was
h
ig
h
,
it
was
8
6
%
lik
ely
to
b
e
co
s
t
-
ef
f
ec
tiv
e
co
m
p
ar
e
d
to
u
s
u
al
ca
r
e
at
a
th
r
esh
o
ld
o
f
$
1
0
0
,
0
0
0
/QAL
Y.
B
ar
n
ett
et
a
l
.
[
39]
r
ev
ea
led
th
at
s
tep
p
e
d
ca
r
e
is
m
o
r
e
co
s
t
-
ef
f
ec
tiv
e
th
an
u
s
u
al
ca
r
e
an
d
with
in
th
e
r
ea
ch
o
f
ac
ce
p
ta
b
ilit
y
o
f
b
e
in
g
co
s
t
-
ef
f
ec
tiv
e
f
o
r
in
d
iv
i
d
u
als
with
PT
SD.
C
h
an
g
et
a
l.
[
15]
r
ev
ea
led
th
at
th
e
im
p
lem
en
tatio
n
c
o
s
t
o
f
b
io
p
s
y
ch
o
s
o
cial
in
ter
v
en
tio
n
was
h
ig
h
an
d
ab
o
v
e
th
e
W
o
r
ld
He
alth
Or
g
an
izatio
n
’
s
(
W
HO
)
co
s
t
-
ef
f
ec
tiv
en
ess
t
h
r
e
s
h
o
l
d
.
S
c
r
e
e
n
a
n
d
t
r
e
a
t
w
a
s
f
o
u
n
d
c
o
s
t
-
e
f
f
e
c
t
i
v
e
a
t
8
8
%
c
o
m
p
a
r
e
d
t
o
u
s
u
a
l
c
a
r
e
a
m
o
n
g
a
d
u
l
t
v
i
c
t
i
m
s
o
f
t
e
r
r
o
r
i
s
m
[
35]
.
T
r
a
n
s
m
u
r
a
l
t
r
a
u
m
a
c
a
r
e
m
o
d
e
l
(
T
T
C
M
)
w
a
s
f
o
u
n
d
c
o
s
t
-
e
f
f
e
c
t
i
v
e
w
h
e
n
c
o
m
p
a
r
e
d
w
i
t
h
r
e
g
u
l
a
r
c
a
r
e
[
37]
.
3.
2
.
2
.
H
ea
lt
h benef
it
a
s
s
o
cia
t
ed
wit
h t
he
P
T
SD i
nte
rv
ent
io
n pro
g
ra
m
T
h
e
ex
ten
t
th
ese
in
te
r
v
en
tio
n
p
r
o
g
r
a
m
m
es
p
r
o
d
u
ce
d
QAL
Y
v
ar
ied
ac
r
o
s
s
1
5
s
tu
d
ies.
Stu
d
ies
with
a
lo
n
g
er
p
e
r
io
d
o
f
in
ter
v
en
tio
n
y
ield
ed
m
o
r
e
am
o
u
n
t
o
f
QAL
Ys
[
3
2
]
,
[
3
4
]
.
Ho
wev
er
,
s
tu
d
i
es
th
a
t
last
ed
f
o
r
a
s
h
o
r
t
p
er
io
d
y
ield
e
d
lo
wer
QAL
Ys
p
er
p
atien
t
[
2
4
]
,
[
3
7
]
.
L
ik
ewise,
h
ig
h
er
QAL
Y
g
ai
n
s
wer
e
p
o
s
itiv
ely
co
r
r
elate
d
with
a
lo
n
g
er
p
er
io
d
o
f
in
te
r
v
en
tio
n
[
3
2
]
,
[
34]
.
I
C
E
R
s
h
o
ws
th
at
in
ter
v
en
tio
n
s
t
h
at
p
r
o
d
u
ce
d
h
ig
h
e
r
QAL
Y
g
ain
s
wer
e
d
o
m
in
an
t
[
3
2
]
,
[
34]
wh
ile
lo
wer
QAL
Y
g
ain
s
wer
e
ass
o
ciate
d
wi
th
h
ig
h
er
I
C
E
R
[
1
4
]
,
[
2
3
]
,
[
42]
.
T
h
e
h
ig
h
est
am
o
u
n
t
o
f
QAL
Y
at
a
p
er
io
d
o
f
3
0
y
ea
r
s
was
MD
MA
-
AT
[
32]
.
T
h
e
am
o
u
n
t
o
f
QAL
Ys
g
ain
ed
was n
o
t a
s
s
o
ciate
d
with
th
e
p
er
io
d
o
f
in
ter
v
en
tio
n
r
ath
er
it wa
s
ass
o
ciate
d
with
th
e
ef
f
ec
tiv
en
ess
o
f
th
e
two
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
co
m
p
ar
ed
.
T
h
e
two
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
th
at
p
r
o
d
u
ce
d
s
i
m
ilar
QAL
Ys
wer
e
ass
o
ciate
d
with
lo
wer
QAL
Y
g
ain
ed
o
r
ze
r
o
QAL
Y
g
ain
ed
[
3
5
]
,
[
4
1
]
,
[
4
2
]
.
3.
3
.
Dis
cus
s
io
n
T
h
is
r
ev
iew
aim
ed
to
r
e
v
ea
l
th
e
m
o
s
t
co
s
t
-
ef
f
ec
tiv
e
in
ter
v
en
tio
n
p
r
o
g
r
am
f
o
r
tr
ea
tm
en
t
o
f
PTSD
p
atien
ts
an
d
f
o
u
n
d
th
at
T
F
-
C
B
T
was
th
e
m
o
s
t
co
s
t
-
ef
f
ec
tiv
e.
T
F
-
C
B
T
h
as
b
ee
n
p
r
o
v
e
n
c
o
s
t
-
ef
f
ec
tiv
e
b
o
th
in
is
o
latio
n
o
r
co
m
b
in
ed
with
o
th
er
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
s
u
ch
as
T
F+C
B
T
+S
SR
I
s
[
41]
.
T
h
is
m
ea
n
s
th
at
T
F
-
C
B
T
is
m
o
r
e
co
s
t
-
ef
f
ec
tiv
e
wh
en
c
o
m
p
ar
e
d
with
o
th
er
in
te
r
v
en
tio
n
p
r
o
g
r
am
m
es
b
ec
au
s
e
it
o
f
f
s
ets
th
e
co
s
ts
ac
cr
u
ed
f
r
o
m
o
th
er
m
e
d
ical
ca
r
e
s
er
v
ices.
T
F
-
C
B
T
is
a
ls
o
co
s
t
-
ef
f
ec
tiv
e
in
th
e
tr
ea
tm
en
t
o
f
b
o
th
ch
ild
r
en
a
n
d
ad
u
lts
[
4
2
]
.
T
F
-
C
B
T
+SS
R
I
s
is
am
o
n
g
t
h
e
lis
t
o
f
f
ir
s
t
-
lin
e
tr
e
atm
en
ts
r
ec
o
m
m
e
n
d
ed
b
y
in
te
r
n
atio
n
al
g
u
id
elin
es
wh
er
e
it
h
as
b
ee
n
f
o
u
n
d
to
b
e
h
ig
h
ly
e
f
f
ec
tiv
e
f
o
r
a
d
u
lts
o
n
l
y
[
4
5
]
.
Fu
r
th
er
m
o
r
e,
PET
was
f
o
u
n
d
co
s
t
-
ef
f
ec
tiv
e
in
tr
ea
tin
g
PTSD
p
atien
ts
[
32]
.
T
h
is
co
u
ld
b
e
as
a
r
esu
lt
o
f
PE
b
ei
n
g
less
ex
p
en
s
iv
e
in
ter
m
s
o
f
im
p
lem
en
tatio
n
wh
en
co
m
p
a
r
ed
to
o
th
er
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es.
Als
o
,
it
co
u
ld
b
e
ass
o
ciate
d
with
PE’
s
f
ea
tu
r
e
th
at
g
r
ad
u
ally
ex
p
o
s
es
p
atien
ts
to
an
ev
en
t
th
at
ca
u
s
ed
th
e
PTSD
in
a
s
a
f
e
co
n
tr
o
lled
en
v
ir
o
n
m
en
t
with
th
e
in
ten
tio
n
o
f
r
ed
u
cin
g
p
atien
ts
’
f
ea
r
a
n
d
a
n
x
iety
.
Als
o
,
MD
MA
-
AT
wa
s
f
o
u
n
d
to
b
e
co
s
t
-
ef
f
ec
tiv
e
in
th
e
tr
ea
tm
en
t
o
f
PTSD
p
atien
ts
[
3
2
]
,
[
34]
.
T
h
e
co
s
t
-
ef
f
ec
tiv
en
ess
o
f
MD
MA
-
AT
b
r
o
k
e
ev
e
n
af
ter
a
p
e
r
io
d
o
f
3
.
7
y
ea
r
s
o
f
co
n
s
is
ten
t
im
p
le
m
en
tatio
n
[
3
2
]
.
T
h
is
co
u
ld
b
e
as
r
esu
lt
o
f
m
o
r
e
n
et
s
av
in
g
s
it
g
en
er
ated
af
ter
3
.
7
y
ea
r
s
;
co
s
ts
ass
o
ciate
d
w
ith
im
p
lem
en
tatio
n
r
em
ain
ed
c
o
n
s
tan
t
d
esp
ite
an
in
cr
ea
s
e
in
QAL
Y
g
ain
ed
.
T
h
is
m
ea
n
t
t
h
at
MD
MA
-
AT
in
ter
v
en
tio
n
wa
s
n
o
t
co
s
t
-
ef
f
ec
tiv
e
with
in
3
.
7
y
ea
r
s
o
f
im
p
lem
en
tatio
n
,
h
en
ce
,
it
is
s
u
i
tab
le
f
o
r
in
ter
v
e
n
tio
n
th
at
wo
u
ld
last
f
o
r
a
m
in
im
u
m
o
f
f
iv
e
y
ea
r
s
.
T
h
r
ee
o
th
er
in
te
r
v
en
tio
n
s
tu
d
ies
s
u
ch
as
s
tep
p
e
d
ca
r
e,
s
cr
ee
n
an
d
tr
ea
t,
a
n
d
T
T
C
M
wer
e
all
f
o
u
n
d
co
s
t
-
ef
f
ec
tiv
e
[
3
5
]
,
[
3
7
]
,
[
39]
.
C
o
s
t
-
ef
f
ec
tiv
en
ess
o
f
th
ese
in
t
er
v
en
tio
n
wer
e
ev
alu
ate
d
b
ase
d
o
n
t
h
e
s
tr
en
g
th
o
f
th
e
u
s
u
al
ca
r
e
wh
ich
v
ar
ies f
r
o
m
co
u
n
tr
y
to
c
o
u
n
tr
y
.
Ho
wev
er
,
s
o
m
e
in
ter
v
en
tio
n
s
wer
e
f
o
u
n
d
to
b
e
co
s
t
-
in
e
f
f
ec
tiv
e
co
m
p
ar
ed
to
u
s
u
al
ca
r
e
o
r
o
th
er
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es.
T
h
e
liter
atu
r
e
s
h
o
wed
th
at
telem
ed
icin
e
in
ter
v
en
tio
n
was
p
o
p
u
lar
am
o
n
g
r
esear
c
h
er
s
,
h
o
wev
er
,
it
was
ass
o
ciate
d
with
a
h
ig
h
co
s
t
o
f
im
p
lem
en
tatio
n
an
d
f
o
u
n
d
to
b
e
co
s
t
-
in
ef
f
ec
tiv
e
[
1
4
]
,
[
2
4
]
,
[
35]
.
T
h
e
h
ig
h
c
o
s
t
o
f
im
p
lem
en
tat
io
n
co
u
ld
b
e
attr
ib
u
ted
to
th
e
f
ac
ilit
ies
an
d
p
e
r
s
o
n
n
el
th
at
wer
e
h
ir
ed
f
o
r
th
e
in
ter
v
en
tio
n
.
Ho
we
v
er
,
a
r
ec
e
n
t stu
d
y
b
y
W
o
n
g
et
a
l.
[
3
5
]
e
s
tab
lis
h
ed
th
at
telem
ed
icin
e
is
m
o
r
e
co
s
t
-
ef
f
ec
tiv
e
wh
en
u
s
in
g
d
escr
ip
tiv
e
an
al
y
s
is
in
s
tead
o
f
p
o
p
u
latio
n
-
le
v
el
co
s
t
-
ef
f
ec
tiv
en
ess
an
aly
s
i
s
u
s
ed
b
y
p
r
ev
io
u
s
s
tu
d
ies.
Als
o
,
C
B
T
an
d
in
d
iv
id
u
alize
d
th
er
ap
y
we
r
e
ca
p
ital
-
in
ten
s
iv
e
an
d
co
s
t
-
in
ef
f
ec
tiv
e
.
T
h
is
was
p
ar
am
o
u
n
t
wh
en
C
B
T
an
d
in
d
i
v
id
u
alize
d
th
er
ap
y
i
n
ter
v
en
tio
n
s
wer
e
co
m
p
ar
ed
with
o
th
er
in
ter
v
e
n
tio
n
s
[
23]
.
I
n
ad
d
itio
n
,
th
e
im
p
lem
en
tatio
n
co
s
t
o
f
th
e
b
io
p
s
y
ch
o
s
o
cial
in
ter
v
e
n
tio
n
was
h
ig
h
an
d
was
eq
u
ally
h
ig
h
er
th
an
th
e
W
HO
co
s
t
-
ef
f
ec
tiv
e
th
r
esh
o
ld
.
T
h
is
im
p
lies
th
at
th
e
b
io
p
s
y
ch
o
s
o
ci
al
in
ter
v
en
tio
n
is
n
o
t e
co
n
o
m
i
ca
lly
co
s
t
-
ef
f
ec
tiv
e.
Ho
wev
er
,
th
e
co
s
ts
o
f
im
p
lem
en
tatio
n
o
f
i
n
ter
v
en
tio
n
s
tu
d
ie
s
v
ar
y
f
r
o
m
co
u
n
tr
y
t
o
co
u
n
tr
y
d
u
e
to
s
tan
d
ar
d
o
f
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
1
4
,
No
.
1
,
Ma
r
ch
20
2
5
:
3
3
3
-
342
338
liv
in
g
an
d
wag
e
v
ar
ia
b
ilit
y
.
So
m
e
o
f
th
e
in
ter
v
en
tio
n
s
th
at
wer
e
f
o
u
n
d
to
b
e
in
e
f
f
ec
ti
v
e
co
u
ld
h
av
e
b
ee
n
ef
f
ec
tiv
e
if
t
h
ey
wer
e
im
p
lem
e
n
ted
in
lo
w
-
in
c
o
m
e
co
u
n
tr
ies.
As
a
r
esu
lt o
f
t
h
is
s
tu
d
y
,
it h
as
b
ee
n
estab
lis
h
ed
t
h
at
T
F
-
CBT
-
SS
R
I
s
an
d
PET
a
r
e
ec
o
n
o
m
ically
co
s
t
-
ef
f
ec
tiv
e
f
o
r
a
s
h
o
r
t
p
er
i
o
d
o
f
p
s
y
ch
o
lo
g
ical
i
n
ter
v
en
tio
n
s
,
wh
er
ea
s
PE
an
d
MD
MA
-
AT
ar
e
co
s
t
-
ef
f
ec
tiv
e
f
o
r
a
lo
n
g
p
er
i
o
d
o
f
p
s
y
ch
o
lo
g
ica
l
in
ter
v
en
tio
n
s
.
I
n
g
en
er
al,
s
o
m
e
o
f
th
ese
in
ter
v
e
n
tio
n
s
th
at
wer
e
f
o
u
n
d
to
b
e
in
ef
f
ec
tiv
e
d
u
e
to
h
ig
h
co
s
t
o
f
im
p
lem
en
tatio
n
m
ay
b
e
t
h
e
r
esu
lt
o
f
a
s
h
o
r
t
p
er
io
d
o
f
i
m
p
lem
en
tatio
n
.
Fo
r
in
s
tan
ce
,
MD
MA
-
AT
was
f
o
u
n
d
in
e
f
f
ec
tiv
e
f
o
r
3
.
7
y
ea
r
s
b
e
f
o
r
e
b
r
ea
k
in
g
e
v
en
a
n
d
was
f
o
u
n
d
co
s
t
-
ef
f
ec
tiv
e
f
o
r
2
6
.
3
y
ea
r
s
.
h
er
e
f
o
r
e,
wh
eth
er
an
in
ter
v
e
n
tio
n
is
co
s
t
-
in
ef
f
ec
tiv
e
o
r
n
o
t
d
ep
en
d
s
o
n
h
o
w
it
is
d
esig
n
ed
to
ac
co
m
p
lis
h
a
s
h
o
r
t
-
ter
m
o
r
lo
n
g
-
ter
m
g
o
al.
Als
o
,
th
e
co
s
t
-
e
f
f
ec
tiv
en
ess
o
f
th
e
in
te
r
v
en
t
io
n
d
e
p
en
d
s
o
n
h
o
w
ef
f
ec
tiv
e
th
e
u
s
u
al
ca
r
e
o
r
s
tan
d
ar
d
ca
r
e
is
at
th
e
tim
e
o
f
i
n
ter
v
en
tio
n
im
p
lem
e
n
tatio
n
.
I
n
a
c
o
u
n
tr
y
w
h
er
e
u
s
u
al
ca
r
e
is
n
o
t
g
e
n
er
ally
ef
f
ec
tiv
e,
th
er
e
is
a
h
ig
h
ch
an
ce
th
at
an
y
PTSD
in
ter
v
e
n
tio
n
wo
u
ld
b
e
co
s
t
-
ef
f
ec
tiv
e,
b
u
t
wh
en
u
s
u
al
ca
r
e
is
co
s
t
-
ef
f
ec
tiv
e,
it
wo
u
ld
b
e
v
e
r
y
r
a
r
e
to
f
in
d
in
te
r
v
en
tio
n
s
tu
d
ies
th
at
ar
e
co
s
t
-
ef
f
ec
tiv
e
,
esp
ec
ially
wh
en
co
m
p
ar
ed
with
cu
r
r
en
t
p
r
ac
tices.
Fu
r
th
er
m
o
r
e,
it
is
s
ig
n
if
ican
t
to
em
p
h
asis
e
th
at
th
e
b
en
ch
m
ar
k
f
o
r
estab
lis
h
in
g
th
e
co
s
t
-
ef
f
ec
tiv
en
ess
o
f
s
o
m
e
o
f
th
ese
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
was
b
ased
o
n
co
m
p
ar
in
g
th
e
cu
r
r
en
t
p
r
ac
ti
ce
o
f
co
s
t
-
ef
f
ec
tiv
e
n
ess
to
th
e
ef
f
ec
tiv
en
ess
o
f
i
n
ter
v
en
ti
o
n
p
r
o
g
r
a
m
m
es
o
r
in
ter
v
en
tio
n
s
v
s
.
an
o
th
er
in
ter
v
en
tio
n
[
1
4
]
,
[
2
3
]
,
[
42]
.
T
h
e
r
ef
o
r
e,
if
th
e
co
s
t
-
ef
f
ec
tiv
en
ess
r
a
tio
o
f
s
o
m
e
o
f
th
ese
in
ter
v
en
tio
n
s
wer
e
co
m
p
ar
ed
t
o
th
e
W
o
r
ld
Hea
lth
Or
g
an
is
atio
n
’
s
co
s
t
-
ef
f
ec
tiv
e
th
r
esh
o
ld
,
s
o
m
e
in
ter
v
en
tio
n
s
wo
u
ld
b
e
f
o
u
n
d
co
s
t
-
ef
f
ec
tiv
e.
T
h
e
h
ea
lth
b
en
ef
its
ass
o
ciate
d
with
th
ese
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
wer
e
m
ea
s
u
r
ed
in
QAL
Ys.
T
h
u
s
,
th
e
g
r
ea
ter
t
h
e
n
u
m
b
er
o
f
QAL
Ys
ass
o
ciate
d
with
an
in
ter
v
en
tio
n
,
th
e
g
r
ea
ter
th
e
am
o
u
n
t
o
f
h
ea
lth
b
e
n
ef
it
a
p
atien
t
g
ain
f
r
o
m
p
a
r
ticip
atin
g
in
th
e
i
n
ter
v
en
tio
n
.
T
h
is
r
ev
iew
s
h
o
we
d
th
at
QAL
Y
s
v
ar
ied
ac
r
o
s
s
th
e
in
ter
v
en
tio
n
s
tu
d
ies.
As
s
h
o
wn
in
T
a
b
le
1
,
lo
n
g
er
-
ter
m
in
ter
v
en
tio
n
s
wer
e
ass
o
ciate
d
with
a
h
ig
h
e
r
n
u
m
b
er
o
f
QAL
Ys
[
3
4
]
,
[
41]
.
T
h
is
m
ea
n
s
th
at
in
ter
v
en
tio
n
s
th
at
las
ted
lo
n
g
er
h
ad
a
h
ig
h
e
r
n
u
m
b
e
r
o
f
QAL
Ys,
s
in
ce
an
in
cr
ea
s
e
in
t
h
e
n
u
m
b
e
r
o
f
QA
L
Ys
in
d
icate
s
th
e
co
s
t
-
ef
f
ec
tiv
en
ess
o
f
th
e
in
ter
v
en
tio
n
.
T
h
is
r
ev
iew
h
as
r
ev
ea
led
th
at
QAL
Ys
g
ain
ed
wer
e
n
o
t c
o
r
r
elate
d
with
a
lo
n
g
er
p
er
io
d
o
f
in
ter
v
e
n
tio
n
b
ec
au
s
e
s
o
m
e
s
tu
d
ies
estab
lis
h
ed
th
e
co
s
t
-
ef
f
ec
tiv
e
n
ess
o
f
two
i
n
ter
v
en
tio
n
p
r
o
g
r
a
m
m
es.
Hen
ce
,
th
e
QAL
Y
ass
o
ciate
d
with
th
e
two
p
r
o
g
r
am
m
es
co
u
ld
b
e
h
ig
h
,
b
u
t
th
e
d
if
f
er
e
n
ce
in
th
e
QAL
Y
g
ain
ed
co
u
l
d
b
e
v
er
y
s
m
all.
Fo
r
in
s
tan
ce
,
th
e
QAL
Y
g
ain
ed
f
r
o
m
th
e
co
m
p
ar
is
o
n
o
f
C
AC
T
an
d
o
p
tim
is
ed
u
s
u
al
ca
r
e
was
s
m
all
d
esp
ite
th
e
h
ig
h
er
QAL
Y
ass
o
ciate
d
wi
th
ea
ch
in
ter
v
en
tio
n
[
42]
.
T
h
is
m
ea
n
s
th
at
wh
en
two
in
ter
v
en
tio
n
s
p
r
o
d
u
ce
th
e
s
am
e
n
u
m
b
er
o
f
QAL
Ys,
th
e
QAL
Ys
g
ain
ed
will
b
e
ze
r
o
s
in
ce
th
er
e
is
n
o
s
ig
n
if
ican
t
d
if
f
er
en
ce
in
th
e
QAL
Ys
ass
o
ciate
d
with
th
e
in
ter
v
en
tio
n
s
[
40]
.
3.
4
.
G
a
ps
identif
ied in t
he
li
t
er
a
t
ure
Stu
d
ies
o
n
c
o
s
t
-
b
e
n
e
f
i
t
a
n
a
l
y
s
is
o
f
i
n
t
e
r
v
e
n
t
i
o
n
s
t
u
d
i
e
s
o
n
P
T
S
D
p
a
t
ie
n
t
s
a
r
e
s
c
a
r
c
e
.
O
n
l
y
a
f
e
w
s
t
u
d
i
es
h
a
v
e
b
e
e
n
c
o
n
d
u
c
t
e
d
u
s
i
n
g
c
o
s
t
-
b
e
n
e
f
i
t
a
n
al
y
s
is
,
w
h
i
l
e
o
t
h
e
r
s
u
s
e
d
c
o
s
t
-
e
f
f
e
ct
i
v
e
n
es
s
a
n
a
l
y
s
i
s
.
T
h
e
r
e
f
o
r
e
,
t
h
e
r
e
w
a
s
a
n
e
e
d
t
o
i
n
v
e
s
t
i
g
at
e
P
T
SD
i
n
t
e
r
v
e
n
t
i
o
n
s
t
u
d
i
es
u
s
i
n
g
c
o
s
t
-
b
e
n
e
f
i
t
a
p
p
r
o
a
c
h
e
s
.
I
n
a
d
d
i
t
i
o
n
,
t
h
e
r
e
a
r
e
v
e
r
y
f
e
w
s
t
u
d
i
es
f
o
c
u
s
i
n
g
o
n
t
h
e
c
h
i
l
d
r
e
n
’
s
p
o
p
u
l
a
t
i
o
n
.
T
h
u
s
,
t
h
e
c
o
s
t
-
e
f
f
e
c
t
i
v
e
n
es
s
a
n
d
h
e
a
l
t
h
b
e
n
e
f
it
s
o
f
s
o
m
e
o
f
t
h
e
s
e
i
n
t
e
r
v
e
n
t
i
o
n
s
t
u
d
i
es
h
a
v
e
n
o
t
b
e
e
n
e
s
ta
b
l
is
h
e
d
f
o
r
c
h
il
d
r
e
n
.
F
u
r
t
h
e
r
m
o
r
e
,
t
h
is
s
c
o
p
i
n
g
r
e
v
ie
w
w
as
c
o
n
d
u
c
t
e
d
w
i
t
h
o
u
t
r
e
g
i
o
n
al
li
m
i
t
at
i
o
n
s
,
h
o
w
e
v
e
r
,
t
h
e
r
e
w
a
s
n
o
s
i
n
g
l
e
s
t
u
d
y
o
n
t
h
e
e
c
o
n
o
m
i
c
e
v
a
l
u
a
ti
o
n
o
f
i
n
t
e
r
v
e
n
ti
o
n
s
t
u
d
i
es
f
o
r
P
T
S
D
p
at
i
e
n
ts
f
r
o
m
S
o
u
t
h
A
m
e
r
i
ca
n
,
A
f
r
i
c
a
n
,
a
n
d
A
s
i
a
n
c
o
u
n
t
r
i
e
s
,
d
e
s
p
it
e
t
h
e
f
r
eq
u
e
n
c
y
o
f
t
r
a
u
m
a
t
i
c
ev
e
n
t
s
r
e
c
o
r
d
e
d
o
n
t
h
es
e
c
o
n
tin
e
n
t
s
.
F
o
r
i
n
s
ta
n
c
e
,
i
n
C
h
i
n
a
,
a
s
t
u
d
y
r
e
v
e
a
l
e
d
t
h
a
t
t
h
e
i
n
c
i
d
e
n
c
e
o
f
P
T
S
D
a
m
o
n
g
C
O
V
I
D
-
19
p
a
t
i
e
n
t
s
w
as
2
0
% a
m
o
n
g
p
a
t
i
e
n
t
s
h
o
s
p
i
ta
l
i
ze
d
,
t
r
ea
t
e
d
,
a
n
d
d
is
c
h
a
r
g
e
d
[
46]
.
Al
s
o
,
i
n
L
a
ti
n
A
m
e
r
i
c
a
,
a
s
t
u
d
y
f
o
u
n
d
t
h
a
t
P
T
S
D
a
f
f
e
c
te
d
a
q
u
a
r
t
e
r
o
f
P
i
s
c
o
’
s
p
o
p
u
l
a
t
io
n
a
n
d
i
t
s
i
m
p
a
c
t
s
r
a
n
g
e
d
f
r
o
m
m
o
d
e
r
a
t
e
t
o
s
e
v
e
r
e
i
n
c
o
m
p
a
r
i
s
o
n
w
it
h
o
t
h
e
r
d
i
s
as
t
e
r
s
i
n
L
a
ti
n
A
m
e
r
i
c
a
[
47]
.
Al
s
o
,
s
u
b
-
S
a
h
a
r
a
n
A
f
r
i
c
a
h
a
s
an
8
%
p
r
e
v
a
le
n
c
e
o
f
PTSD
in
co
n
f
lict
-
u
n
ex
p
o
s
ed
r
eg
io
n
s
an
d
3
0
%
in
co
n
f
lict
-
ex
p
o
s
ed
r
e
g
io
n
s
[
4
8
]
.
T
h
u
s
,
t
h
er
e
is
a
n
ee
d
to
c
o
n
d
u
ct
an
ec
o
n
o
m
ic
ev
alu
atio
n
o
f
in
t
er
v
en
tio
n
s
tu
d
ies o
n
PTSD
tr
ea
tm
en
t o
n
th
ese
co
n
tin
en
ts
.
3.
5
.
Str
eng
t
hs
a
nd
lim
it
a
t
io
ns
PTSD
is
a
g
lo
b
al
p
s
y
ch
o
lo
g
i
ca
l
p
r
o
b
lem
,
an
d
th
er
e
is
n
o
cu
r
r
en
t
liter
atu
r
e
th
at
r
ev
iews
th
e
co
s
t
-
ef
f
ec
tiv
en
ess
o
f
th
e
ec
o
n
o
m
ic
ev
alu
atio
n
o
f
t
h
ese
in
ter
v
e
n
tio
n
p
r
o
g
r
am
m
es
an
d
th
e
ass
o
ciate
d
h
ea
lth
b
en
ef
its
in
th
e
tr
ea
tm
en
t
o
f
PTSD
p
atien
ts
.
Fo
r
th
e
p
u
r
p
o
s
e
o
f
en
s
u
r
i
n
g
a
q
u
ality
r
ep
o
r
t,
we
s
tr
ictly
f
o
llo
wed
th
e
cu
r
r
en
t
g
u
id
elin
es
f
o
r
h
ea
lth
ec
o
n
o
m
i
cs
r
ev
iews
[
1
7
]
.
T
h
is
s
tu
d
y
is
th
e
f
ir
s
t
o
f
its
k
in
d
to
p
ar
ticu
la
r
ly
r
e
v
iew
th
e
c
o
s
t
-
ef
f
ec
tiv
en
ess
an
d
b
en
ef
its
ass
o
ciate
d
with
th
e
ec
o
n
o
m
ic
ev
a
lu
atio
n
o
f
in
ter
v
e
n
tio
n
s
tu
d
ies
f
o
r
PTSD
p
atien
ts
.
First,
th
is
r
ev
iew
h
as
in
h
er
en
t
s
h
o
r
tco
m
in
g
s
th
at
ar
e
im
b
ed
d
e
d
in
a
s
co
p
in
g
r
ev
iew,
lik
e
s
en
s
itiv
e
s
ea
r
ch
ter
m
s
,
s
cr
ee
n
in
g
cr
iter
ia,
an
d
ass
ess
m
en
t
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4.
CO
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ev
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F+C
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in
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I
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er
io
d
.
I
n
ad
d
itio
n
,
th
is
r
e
v
iew
r
ev
ea
led
th
at
th
e
h
ea
lth
b
en
ef
its
o
f
th
ese
in
ter
v
en
tio
n
s
,
as
m
ea
s
u
r
e
d
b
y
QAL
Y,
wer
e
p
o
s
itiv
ely
co
r
r
elate
d
with
in
ter
v
en
tio
n
s
o
f
lo
n
g
er
d
u
r
atio
n
s
,
a
n
d
th
e
QAL
Y
g
ain
ed
d
u
e
to
in
t
er
v
en
tio
n
s
was
n
o
t
ass
o
ciate
d
with
th
e
len
g
th
o
f
th
e
p
er
io
d
.
T
h
is
r
esu
lt
h
as
s
u
b
s
tan
tial
p
r
ac
tical
im
p
licati
o
n
s
f
o
r
th
er
a
p
is
ts
,
clin
ician
s
,
p
s
y
ch
o
lo
g
is
ts
,
an
d
p
o
licy
m
ak
er
s
.
Ad
o
p
tio
n
o
f
t
h
ese
co
s
t
-
ef
f
ec
tiv
e
in
ter
v
en
ti
o
n
p
r
o
g
r
am
m
es
f
o
r
PTSD
tr
ea
tm
en
t
wo
u
ld
b
e
p
r
o
f
itab
le
b
ec
au
s
e
it
wo
u
ld
lead
t
o
h
ig
h
n
et
s
av
in
g
s
an
d
b
en
ef
it
s
to
th
e
p
atien
ts
as
well
as
s
o
ciety
,
with
s
h
o
r
t
p
ay
b
ac
k
p
e
r
io
d
s
.
Ho
wev
e
r
,
ad
o
p
tio
n
o
f
th
ese
id
en
tifie
d
in
ter
v
en
tio
n
p
r
o
g
r
am
m
es
s
h
o
u
ld
b
e
d
o
n
e
with
ca
u
tio
n
s
in
ce
th
e
e
f
f
icac
y
o
f
s
o
m
e
o
f
t
h
ese
p
r
o
g
r
a
m
m
es
h
as
n
o
t
b
ee
n
estab
lis
h
ed
in
th
e
ch
ild
r
en
’
s
p
o
p
u
latio
n
o
r
o
n
o
th
er
co
n
tin
e
n
ts
s
u
ch
as So
u
th
Am
er
ica,
Asi
a,
an
d
Af
r
ica.
RE
F
E
R
E
NC
E
S
[
1]
W
.
L
i
e
t
a
l
.
,
“
P
o
s
t
-
t
r
a
u
m
a
t
i
c
s
t
r
e
s
s
d
i
s
o
r
d
e
r
a
n
d
t
r
a
u
ma
t
i
c
e
v
e
n
t
s
i
n
C
h
i
n
a
:
A
n
a
t
i
o
n
a
l
l
y
r
e
p
r
e
se
n
t
a
t
i
v
e
c
r
o
ss
-
sec
t
i
o
n
a
l
e
p
i
d
e
mi
o
l
o
g
i
c
a
l
st
u
d
y
,
”
Psy
c
h
i
a
t
ry
R
e
se
a
rc
h
,
v
o
l
.
3
2
6
,
A
u
g
.
2
0
2
3
,
d
o
i
:
1
0
.
1
0
1
6
/
j
.
p
sy
c
h
r
e
s.
2
0
2
3
.
1
1
5
2
8
2
.
[
2]
M
.
W
.
M
i
l
l
e
r
a
n
d
N
.
S
a
d
e
h
,
“
Tr
a
u
mat
i
c
st
r
e
ss,
o
x
i
d
a
t
i
v
e
st
r
e
ss
a
n
d
p
o
st
-
t
r
a
u
ma
t
i
c
st
r
e
ss
d
i
so
r
d
e
r
:
n
e
u
r
o
d
e
g
e
n
e
r
a
t
i
o
n
a
n
d
t
h
e
a
c
c
e
l
e
r
a
t
e
d
-
a
g
i
n
g
h
y
p
o
t
h
e
si
s,
”
Mo
l
e
c
u
l
a
r P
syc
h
i
a
t
ry
,
v
o
l
.
1
9
,
n
o
.
1
1
,
p
p
.
1
1
5
6
–
1
1
6
2
,
N
o
v
.
2
0
1
4
,
d
o
i
:
1
0
.
1
0
3
8
/
m
p
.
2
0
1
4
.
1
1
1
.
[
3]
G
.
N
.
M
a
r
sh
a
l
l
,
“
M
e
n
t
a
l
h
e
a
l
t
h
o
f
c
a
mb
o
d
i
a
n
r
e
f
u
g
e
e
s
2
d
e
c
a
d
e
s
a
f
t
e
r
r
e
s
e
t
t
l
e
m
e
n
t
i
n
t
h
e
U
n
i
t
e
d
S
t
a
t
e
s
,
”
J
AM
A
,
v
o
l
.
2
9
4
,
n
o
.
5
,
p
p
.
5
7
1
–
5
7
9
,
A
u
g
.
2
0
0
5
,
d
o
i
:
1
0
.
1
0
0
1
/
j
a
ma.
2
9
4
.
5
.
5
7
1
.
[
4]
B
.
R
o
b
e
r
t
s
a
n
d
J
.
B
r
o
w
n
e
,
“
A
s
y
s
t
e
m
a
t
i
c
r
e
v
i
e
w
o
f
f
a
c
t
o
r
s
i
n
f
l
u
e
n
c
i
n
g
t
h
e
p
s
y
c
h
o
l
o
g
i
c
a
l
h
e
a
l
t
h
o
f
c
o
n
f
l
i
c
t
-
a
f
f
e
c
t
e
d
p
o
p
u
l
a
t
i
o
n
s
i
n
l
o
w
-
a
n
d
m
i
d
d
le
-
i
n
c
o
m
e
c
o
u
n
t
r
i
e
s
,
”
G
l
o
b
a
l
P
u
b
l
i
c
H
e
a
l
t
h
,
v
o
l
.
6
,
n
o
.
8
,
p
p
.
8
1
4
–
8
2
9
,
D
e
c
.
2
0
1
1
,
d
o
i
:
1
0
.
1
0
8
0
/
1
7
4
4
1
6
9
2
.
2
0
1
0
.
5
1
1
6
2
5
.
[
5]
T.
A
n
b
e
saw
,
Y
.
Ze
n
e
b
e
,
A
.
A
sm
a
ma
w
,
M
.
S
h
e
g
a
w
,
a
n
d
N
.
B
i
r
r
u
,
“
P
o
st
-
t
r
a
u
ma
t
i
c
st
r
e
ss
d
i
s
o
r
d
e
r
a
n
d
a
s
so
c
i
a
t
e
d
f
a
c
t
o
r
s
a
mo
n
g
p
e
o
p
l
e
w
h
o
e
x
p
e
r
i
e
n
c
e
d
t
r
a
u
ma
t
i
c
e
v
e
n
t
s
i
n
D
e
ssi
e
t
o
w
n
,
Et
h
i
o
p
i
a
,
2
0
2
2
:
A
c
o
mm
u
n
i
t
y
b
a
s
e
d
st
u
d
y
,
”
Fr
o
n
t
i
e
rs
i
n
Psy
c
h
i
a
t
r
y
,
v
o
l
.
1
3
,
O
c
t
.
2
0
2
2
,
d
o
i
:
1
0
.
3
3
8
9
/
f
p
sy
t
.
2
0
2
2
.
1
0
2
6
8
7
8
.
[
6]
I
.
E
.
F
.
K
h
si
m
,
M
.
M
.
R
o
d
r
í
g
u
e
z
,
B
.
R
.
G
a
l
l
e
g
o
,
R
.
A
.
C
.
G
o
n
z
a
l
e
z
,
a
n
d
C
.
A
.
P
r
i
e
t
o
,
“
R
i
s
k
f
a
c
t
o
r
s
f
o
r
p
o
st
-
t
r
a
u
m
a
t
i
c
st
r
e
ss
d
i
s
o
r
d
e
r
a
f
t
e
r
c
h
i
l
d
b
i
r
t
h
:
A
s
y
st
e
ma
t
i
c
r
e
v
i
e
w
,
”
D
i
a
g
n
o
st
i
c
s
,
v
o
l
.
1
2
,
n
o
.
1
1
,
O
c
t
.
2
0
2
2
,
d
o
i
:
1
0
.
3
3
9
0
/
d
i
a
g
n
o
st
i
c
s
1
2
1
1
2
5
9
8
.
[
7]
A
.
L.
H
a
y
c
r
a
f
t
,
“
T
h
e
f
u
t
u
r
e
f
o
r
p
s
y
c
h
e
d
e
l
i
c
a
g
e
n
t
s
i
n
t
h
e
t
r
e
a
t
me
n
t
o
f
p
o
s
t
t
r
a
u
m
a
t
i
c
st
r
e
ss
d
i
s
o
r
d
e
r
,
”
T
h
e
J
o
u
r
n
a
l
f
o
r
N
u
r
se
Pra
c
t
i
t
i
o
n
e
rs
,
v
o
l
.
1
9
,
n
o
.
5
,
M
a
y
2
0
2
3
,
d
o
i
:
1
0
.
1
0
1
6
/
j
.
n
u
r
p
r
a
.
2
0
2
3
.
1
0
4
5
8
6
.
[
8]
D
.
A
.
A
d
l
e
r
e
t
a
l
.
,
“
P
sy
c
h
i
a
t
r
i
c
st
a
t
u
s
a
n
d
w
o
r
k
p
e
r
f
o
r
m
a
n
c
e
o
f
v
e
t
e
r
a
n
s
o
f
o
p
e
r
a
t
i
o
n
s
e
n
d
u
r
i
n
g
f
r
e
e
d
o
m
a
n
d
I
r
a
q
i
f
r
e
e
d
o
m,
”
Psy
c
h
i
a
t
r
i
c
S
e
rv
i
c
e
s
,
v
o
l
.
6
2
,
n
o
.
1
,
p
p
.
3
9
–
4
6
,
J
a
n
.
2
0
1
1
,
d
o
i
:
1
0
.
1
1
7
6
/
p
s.
6
2
.
1
.
p
ss6
2
0
1
_
0
0
3
9
.
[
9]
V
.
S
.
G
u
e
r
r
a
a
n
d
P
.
S
.
C
a
l
h
o
u
n
,
“
Ex
a
mi
n
i
n
g
t
h
e
r
e
l
a
t
i
o
n
b
e
t
w
e
e
n
p
o
s
t
t
r
a
u
mat
i
c
st
r
e
ss
d
i
s
o
r
d
e
r
a
n
d
s
u
i
c
i
d
a
l
i
d
e
a
t
i
o
n
i
n
a
n
O
EF
/
O
I
F
v
e
t
e
r
a
n
s
a
mp
l
e
,
”
J
o
u
r
n
a
l
o
f
A
n
x
i
e
t
y
D
i
so
r
d
e
rs
,
v
o
l
.
2
5
,
n
o
.
1
,
p
p
.
1
2
–
1
8
,
Ja
n
.
2
0
1
1
,
d
o
i
:
1
0
.
1
0
1
6
/
j
.
j
a
n
x
d
i
s
.
2
0
1
0
.
0
6
.
0
2
5
.
[
10]
V
.
O
’
C
o
n
n
o
r
,
J
.
A
.
R
o
w
l
a
n
d
,
J.
C
.
N
a
y
l
o
r
,
A
.
T.
M
a
g
n
a
n
t
e
,
K
.
M
.
C
r
a
i
g
,
a
n
d
H
.
M
.
M
i
sk
e
y
,
“
T
i
me
d
o
e
s
n
’
t
h
e
a
l
a
l
l
:
P
TSD
sy
m
p
t
o
m
s
e
x
a
c
e
r
b
a
t
e
t
h
e
r
e
l
a
t
i
o
n
s
h
i
p
b
e
t
w
e
e
n
a
g
e
a
n
d
p
a
i
n
i
n
t
e
n
s
i
t
y
,
”
Fr
o
n
t
i
e
rs
i
n
Ps
y
c
h
i
a
t
r
y
,
v
o
l
.
1
4
,
Ju
l
.
2
0
2
3
,
d
o
i
:
1
0
.
3
3
8
9
/
f
p
s
y
t
.
2
0
2
3
.
1
2
2
1
7
6
2
.
[
11]
D
.
N
i
l
a
w
e
e
r
a
e
t
a
l
.
,
“
Li
f
e
t
i
m
e
p
o
s
t
t
r
a
u
m
a
t
i
c
st
r
e
ss
d
i
so
r
d
e
r
a
s
a
p
r
e
d
i
c
t
o
r
o
f
m
o
r
t
a
l
i
t
y
:
a
s
y
st
e
ma
t
i
c
r
e
v
i
e
w
a
n
d
met
a
-
a
n
a
l
y
s
i
s,
”
BM
C
Psy
c
h
i
a
t
ry
,
v
o
l
.
2
3
,
n
o
.
1
,
A
p
r
.
2
0
2
3
,
d
o
i
:
1
0
.
1
1
8
6
/
s1
2
8
8
8
-
0
2
3
-
0
4
7
1
6
-
w.
[
12]
K
.
T.
M
u
e
ser
e
t
a
l
.
,
“
E
v
a
l
u
a
t
i
o
n
o
f
c
o
g
n
i
t
i
v
e
r
e
s
t
r
u
c
t
u
r
i
n
g
f
o
r
p
o
s
t
-
t
r
a
u
m
a
t
i
c
st
r
e
ss
d
i
s
o
r
d
e
r
i
n
p
e
o
p
l
e
w
i
t
h
se
v
e
r
e
men
t
a
l
i
l
l
n
e
ss,”
Bri
t
i
sh
J
o
u
rn
a
l
o
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Evaluation Warning : The document was created with Spire.PDF for Python.
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341
[
26]
E.
M
a
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J.
G
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K
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.
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o
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,
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t
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0
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9
9
9
7
.
[
27]
R
.
v
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r
W
a
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t
h
,
J
.
D
a
ms,
T.
G
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.
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.
K
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g
,
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Ec
o
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a
l
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a
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a
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d
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o
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y
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p
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r
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d
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:
a
sy
s
t
e
mat
i
c
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,
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Eu
r
o
p
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a
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.
[
28]
E.
G
o
s
p
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d
a
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e
v
sk
a
y
a
a
n
d
L.
S
e
g
a
l
,
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C
o
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A
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.
[
29]
L.
A
.
M
o
r
l
a
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d
e
t
a
l
.
,
“
T
e
l
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me
d
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c
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e
:
A
c
o
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a
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w
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h
P
TSD
,
”
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.
[
30]
A
.
C
.
Tr
i
c
c
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t
a
l
.
,
“
P
R
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S
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A
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x
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(
P
R
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M
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)
:
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n
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.
[
31]
M
.
D
.
J.
P
e
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s
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t
a
l
.
,
“
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sco
p
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v
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w
s,”
J
BI
Ev
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[
32]
E.
M
a
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s
e
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l
l
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,
J
.
M
.
M
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t
c
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l
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,
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J.
G
.
K
a
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,
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.
[
33]
M.
-
L.
J.
K
u
l
l
b
e
r
g
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t
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l
.
,
“
Ex
p
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b
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d
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s
:
a
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u
ro
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6
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[
34]
A
.
L.
V
.
A
v
a
n
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ñ
a
,
J.
G
.
K
a
h
n
,
a
n
d
E.
M
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s
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l
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e
,
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t
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se
v
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TSD
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t
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U
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:
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mo
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l
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g
s
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l
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[
35]
E.
S
.
W
o
n
g
e
t
a
l
.
,
“
E
c
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o
mi
c
c
o
st
s
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m
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d
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d
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c
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V
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p
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[
36]
N
.
H
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g
a
n
,
M
.
K
n
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p
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D
.
M
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D
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,
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d
C
.
R
.
B
r
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w
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,
“
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o
f
‘
scr
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MJ
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.
[
37]
S
.
H
.
W
i
e
r
t
se
ma
e
t
a
l
.
,
“
C
o
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v
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Tr
a
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sm
u
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a
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t
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a
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a
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mo
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(
TT
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)
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Assessm
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[
38]
J.
S
h
e
a
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t
a
l
.
,
“
C
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