CINXE.COM

<!DOCTYPE html><html lang="en-US"><head><title>Just a moment...</title><meta http-equiv="Content-Type" content="text/html; charset=UTF-8"><meta http-equiv="X-UA-Compatible" content="IE=Edge"><meta name="robots" content="noindex,nofollow"><meta name="viewport" content="width=device-width,initial-scale=1"><style>*{box-sizing:border-box;margin:0;padding:0}html{line-height:1.15;-webkit-text-size-adjust:100%;color:#313131;font-family:system-ui,-apple-system,BlinkMacSystemFont,Segoe UI,Roboto,Helvetica Neue,Arial,Noto Sans,sans-serif,Apple Color Emoji,Segoe UI Emoji,Segoe UI Symbol,Noto Color Emoji}body{display:flex;flex-direction:column;height:100vh;min-height:100vh}.main-content{margin:8rem auto;max-width:60rem;padding-left:1.5rem}@media (width <= 720px){.main-content{margin-top:4rem}}.h2{font-size:1.5rem;font-weight:500;line-height:2.25rem}@media (width <= 720px){.h2{font-size:1.25rem;line-height:1.5rem}}#challenge-error-text{background-image:url(data:image/svg+xml;base64,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);background-repeat:no-repeat;background-size:contain;padding-left:34px}@media (prefers-color-scheme:dark){body{background-color:#222;color:#d9d9d9}}</style><meta http-equiv="refresh" content="390"></head><body class="no-js"><div class="main-wrapper" role="main"><div class="main-content"><noscript><div class="h2"><span id="challenge-error-text">Enable JavaScript and cookies to continue</span></div></noscript></div></div><script>(function(){window._cf_chl_opt={cvId: '3',cZone: "www.biologicalpsychiatryjournal.com",cType: 'managed',cRay: '8e7262335f3a4484',cH: 'Pz6AoIwwHZ._k_WYpqfFjqwlxYuDTP9Injaud5bVgPk-1732377746-1.2.1.1-0RJ3IX4r7wS4gnafpH3ZaJcA7f74yr..AIi9Y_4IvD_NU.LBPoHvEaPEUPo6zXx7',cUPMDTk: "\/article\/S0006-3223(21)00033-0\/fulltext?__cf_chl_tk=bDhnKWqXB8wYW4yI28vI.7CO84kQEXi8nRsEMEPOs_4-1732377746-1.0.1.1-lsthXy_MgVmnD9hJmVsoTajnupc1TTo1m70ArqozCXs",cFPWv: 'g',cITimeS: '1732377746',cTTimeMs: '1000',cMTimeMs: '390000',cTplC: 0,cTplV: 5,cTplB: 'cf',cK: "",fa: "\/article\/S0006-3223(21)00033-0\/fulltext?__cf_chl_f_tk=bDhnKWqXB8wYW4yI28vI.7CO84kQEXi8nRsEMEPOs_4-1732377746-1.0.1.1-lsthXy_MgVmnD9hJmVsoTajnupc1TTo1m70ArqozCXs",md: "z9si0nFGfaw8JhTujEuj39UTzUZxwWKcKiLZ43R9ROU-1732377746-1.2.1.1-ypifvZqlNSwlqX99NzTP6uX8ejiHYHSToHnNrYP2zwsE48S7gzJyp96cZ0dCpT0RRz57kLp83qXP3AX_yeJyBNoCp2iKU0cJyAg0J6S7rkYnVOHPkVx0bo4ov1_DT4sb9_bV4yMBwzj47j3UnY8WNYRwsyb8EOYF0h89BJjym_J0Veh7DyYoolduBlczBHkcL1rpu7sfO7uq92cY_gAH5vtqLnQdWucUl90S16LaXTjASOLLtAqbb3sDXr3fdLnzO3dDYO.yy6v5pd5ZX7P5aqUKblnx49fxBAMu9dLkDxie5uPCuLTRjevCQQ9Y7m5RQHO1cByszAoXpwg5sRFmgWc.coS7MuTg9_dhbzDEimY6F_Lnm_5v4PHpdK2mR5VXV_XlqomXHnY611BwSYESTuSQBc7FK7y5wwtw0R4aKauEK9U3QrX0g3B7WBXe2lgTGbXKsjqxhjKFba9428FTboO1lKq3CBK0nVb6nWMl_sim4..hFNP8x_ICz7DeueluVYEZeL0f1aT9dfGDuz2NXeDK6bTUxoV4X1.twBBIWjwV3ZS11EGjCNJNa4zrT957mncY6JR0wvXjOBt07FRW9e3dyyJh1dHAVLzo2qHoQSXmz9YJE9vo_t23ww8b9_EE0_yVMvR0tYidazKNRcQWpzHZNjcbAm8Ni4rRcNVTR0Iqoj0_6J767fm7zpeLp92rj6sNukSSYxLnsAW1Gmlp4iLI8vv_E5_uixuQRJAgMNTqaSJnJP8JbmbRy2yrKbyo8hEgbL96X073TRR5EgiVDWJFk9ZfgTj041eB4sI4xB34y54hWiEOcFoGZK812Yl96eCPCdDQv0h73Tv87B9kVHPPIWBidMt7fVT1fkFRtySGLNQjOA3HEo_aGg4voAlbwu.E00.83bhQIdii0YwjZyggiXi.EpL6RUvF3O8zhzbN0pHSNi1d7XHRgcQvI_EQanZMMt5WCRRR2ZFtA564mMIBznjrELg6QVDaNPJzx.Q1l9WUNRUWFW86HZwrRsIRNhagx_1Rzw6iahqAcaoYv8i0sBP6J39sT5uF1Az5OxU6ja3zHxx4anMPrZRo6leY.cUAPs9f9RNVlWjfhBvTtylEypHgQSyTd0.oy1cgcg3nKdWXi69Kk.elPUy01eh2Cr2msqABj9okmZOaInjOcD1zD354dVCRYAgZj1WhVj5O2gEWNBR97oZR3ea9PyAifbS6HXFm9gQvPxIIWopp4fn4yRmd8X2T7_5GWATNNbKtbolfyqgtsakXPFRoJ90cPqygh4Gsr002cFa000oyRGxkNLxKnXpyPf1reyprgurQPoPOa3e0vsKxsskePfdTkraY9NyCEdyWOeM.OPPQf41HCCUQTZHMg9AaBjkCFu5m5GXG23AXPJo_800DbxZMqMIA9fkVdBiOB7YxBxsE3sC505AjvWk5CJUz60PTnlAFNpzG0_NmltvTq7tQrDHxvUNKmpP6Cm2pW97vKGXe1YqkW3QWDVk7YnRl273rzvGP6XfVOoxG_tMOQDo.R7EuYgQo2Pl9rWDZvH2Yw7ueyNoCrAyETJYO0u4S7lLAPrIjYJRAjVeGJAktLucwfFW5vALSHKb_RWvrbT0m_t0LfI8XrgAhOZWmijPwiSN8MoeDPeetqctJqO_GkXG1Jsab8CGApNp5.8XDcmFltoqh4DQH1XFGmKVmXJLYsr2jNpGlxiiWM_WxdPOODh6LqPPxciTZRLkHvzCz.vRyTq8_XyRph6wmw8s07HW7qjng9Cx8A2KdEZn1wXNylbsvg4HC6APFOjlsevjpRxMeChYjsxw.jFHFx44hdX_ieuk5nu2r7rP67PJmxHLEXQ_R9N0Sh02d_R3XhMko7JCfQ1qW0mm5DkDONaVSfDEtv6wf4fVI3_7W_26RCWX7cZCPOIP2ZAzAOCRyKhaZYBXXhTPA5u4QneFdXt2OD6lA1KLyf6j.OqfnsNWGT8zwrFOCActqtpGUvpNz0PN.j1oL5NXLkj3izjkjX7EFi7JYuiLyWNRNNFBIZxWp8NhJ0l9QOzFKI0TKYsp2uE8i3kkcTP..pa9ONAMWwNS5h9FUaxQL225t3UKaVIAU00oGVrVqa2htjm1pLg3xBvvl2samM_iqeERcuYF_7_glshKyRDt54OysAmwurSXuCpapidz7rKtZmJGmTaXVqURzRUzvj._eH8yjNHGcvH8qlFwsZ0ObnyaZekqtb9LIw51_CiA64J7fTCGyXFJDUcZSeXOolCazLHTKHL_sILOXm6IDbAWEYor3bQGYrq2EbjQ_zfnOJrby5LauJwtR7mCFsKVlyrWKpd40xm9ziaC4DA3mU7.a4TrSk0UigdLFEXDqm1Ucl.YJbdZMts5rcjuAu1sFPhYCvBxcn5cT1EouU4aqA76boNsHj7iym.jLb4OyQ0FOWgeCCK5gltvK309O9FZFXhTie_8hwAVqOOXetU7vEVeLNEp8RBEwDq8MrVmQKmI3WAW99ZStYAaLR5cTVyFHFEYyxfh7Btcm1JvPuEbpd_ti_cmeaUKW3Mf.XjGbWBBzQmvFOcKj9fuDFfE9aYZVg429BHKslpf3c5I0jhCfFpjl1FrHWWpsoqJPYmDbzdje2CZ.dgLGETVjqUx1DtJqnmUYn3W.XFS1Syi6nzCz5x7fmzxtxgE0QhxMQLb.yQMv2l9MU1WdLTHwyjeJS0Zt3uSjWQVmzXmerWzfgWQQsrjiHVJMQ1xllp_m_5sbfcjojhuk2O1IYYrBfkxCPjI8OOwjbie72ji0zNMLX6A1gODxnbm49lJiM1M9fH6mDDCjNKtgBszqVuHig.UvSSV5Ljax.og23iJ8yclPS5AyHOlLmkkonZn54aCfNj88u_BNJTJ7WJZcGsHU6FwtOIk01ruVwPUs0CfCoMXKXUfxb3HfHDuOpBFseMPUW9GJd8o.3vhAI_ThVemHYCwiREjJ_uh0CwtB6ZKcNsaJPG2uML51eWIASbmzehYh98s4U6w3QGTtxhdfpMtazb5wLI3nhnh_XxRFfjXFHJF7y7QhfkPZ62U",mdrd: "8wptWeo2AdLuW67GWMhDol6u7H_H.z8TbKex0f9gZR0-1732377746-1.2.1.1-YAQth1TdtC3Z_IIpfxJJZ3bmz7jVNOGA5nbiius8Y_SQBZEsoeNvk9RAMzPC1.dSESZCjqfzPvAC_5Uv2w54ZxZvfxpIMI2ijLc5S89Bbn_XCBgMJaOPl3Bthtr1ei7rsCVZOT4IVqPsoVKXOHYBP3_y29Vn5rgxRV3VFmIWGrpOKmRPCTMmEEwzPml9UZVa_y9iZUIh92YXT9j5qkbjM_9EX0lgYUBFKAaheHcxKIJpLcHep3vCm3xtVxkbyqm.XtN5ISu27otSfKyjdBvIu0dV49fCbWgP.FGvVzjHdexpsnV3sNkAHaA7qfU.3d62v61RS2451_IbNqFuty7t9ux1Wn8JIk7peLc36adPwXXwsVj6M8_ZvrwZmSzCr8py62hyXQ26BnIq3saOdAN9BrdSvnW4STkdorplhgBWX0VSW4.W.27rltq64mWXDeWEPo6o6rAB2kb1ldLvQOS73.kP2PABUsb5gztTnbfv2gZROajJV9m7uj8gUBUqgAtjfX0D.HGwCiP.elTrTAfVqj9hYoK_ipEHB.HNSs3sWuVF39HLplHKej3GqbTjXL1MI07maXCpBrOkuaEZa.Fr4t2UD.MyckvQIjG8bLFjE3jHmcJULcImHhTe7H6QbGm4itotMzH8V2YzETpgFpykW5lQ7JxOjf9geGek46JjkCSh2rLNhAslVonRt2ZFz0sa4cMGNKF5pDsimh3T_V.ldKu7IZY_QGhpUJgvgB5P0wrvUb9Ram5h8xiRPdAylnOy6g33c1SvtxBFwgDJRmhI6TNMiJEjUDc.YTaUIDjadbX2KrA2VBUtJh1mHZPJSnW12iTZNz..PVJlKILn.ja_GOhtLkRgcia.yEB8iQsh0HvCOzmSTfeI62wQdx1ok9BAztrSF6i_83dtSPNW2LaXq05XZ_MtzKz5rEXziqnlOE_Dt2tPpmv7gSQlFYHU_QnHTqe_pM3qfhKwykuHx1h9f1KEg0r7IDu19FmtIBrzuBGCn7Z.tmRCZWrS3GEikJ7zAp2zAplfeuUyku0YfW4nbNht82ScYt0PjOf_12Rl924nlC6vqlvkXrNWnJp9oTBMpGjElBtLASxo.eqCdRlLgVwKlw5XkPBLMXLtUwv5P2Lj2z5uOjwkWFgrIGhgA3NNl4snbt93I9qe.M7bgpWl2.4oHFv1.HQs03im4UwPw8VZXc.7OCPaNcBLHmGYTqqUnRlSKp09qkrLmo.FyzPI.1Qvw.B59yYsfvNBP6p_MvRn8DOILCN.3bBGVfeUl6q_SivraxlXJg2ADU0JKbwAgbjEoK5GwkXbNWh3jsE4NdwE7Triu5Yax7R16HVOZOEMMoodmpr1mn4uIuxKA0mJrrTyWa0Q4dxCBQLmmlkUJ3cpB04J13WL77y_eRkhpwx_jY33yyQ9Oydcpow5ta5k8fjVm.C.OdGznBCqCSrWZWDNb5loaklU6llKI9iD1Nje6RXbeuVugwCHIc64crq0ulEYXufQ06EGl612f_Hwet9U7QoErHZuZxsYw9tgzqVB3ZbRc9iFhdkmPrSBB_AD4gP.DY377KvvX74j0JlF7sLvomgQGZpQhVLZfxFdHQJ8GCNp.xPNeOlLXAW9cseR87Hz8P_eew2BR3Ztd.Dd43KpsBvM97JYuHmYFInHNdrnuAOHDZoIt77C9JmZe6K0eFvbh3R362z2fPilYdJAW6Falan6xwAUPEd0pE5wY3sPuSp92Udl6P0lSNFqLWr9_CDqXQ75boxhafHZuBBS5ZN1T04Cff0gCErVYy_bz7Rrx32I.TgdPP6u4sCyIk_vQd5C.ky2giqNZUvNqCA0TH_P_1LTzM9kkG7DuZs6haZ1jXUf5_N8IKZaaJB5uX1P_FsqPVneZOCQP_swBbKZXofaLUS2acxSwbFBAyQvIcU5iA0ECmlI.F_mzZ3PRmRzHKpTxwsGHRXnXT5g4CNcgXfJi9rHJwFwsNDy3R.2TUGSvg0ce9zadpCGnbla..HTPN_OCqqYOBL1YAzY80eGjGw"};var cpo = document.createElement('script');cpo.src = '/cdn-cgi/challenge-platform/h/g/orchestrate/chl_page/v1?ray=8e7262335f3a4484';window._cf_chl_opt.cOgUHash = location.hash === '' && location.href.indexOf('#') !== -1 ? '#' : location.hash;window._cf_chl_opt.cOgUQuery = location.search === '' && location.href.slice(0, location.href.length - window._cf_chl_opt.cOgUHash.length).indexOf('?') !== -1 ? '?' : location.search;if (window.history && window.history.replaceState) {var ogU = location.pathname + window._cf_chl_opt.cOgUQuery + window._cf_chl_opt.cOgUHash;history.replaceState(null, null, "\/article\/S0006-3223(21)00033-0\/fulltext?__cf_chl_rt_tk=bDhnKWqXB8wYW4yI28vI.7CO84kQEXi8nRsEMEPOs_4-1732377746-1.0.1.1-lsthXy_MgVmnD9hJmVsoTajnupc1TTo1m70ArqozCXs" + window._cf_chl_opt.cOgUHash);cpo.onload = function() {history.replaceState(null, null, ogU);}}document.getElementsByTagName('head')[0].appendChild(cpo);}());</script></body></html>