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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EA study of Dutch subjects [Cohen D et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2006] found previously undiagnosed diabetes in 14.5% of subjects with severe mental illness versus 1.5% in the general population. This and other studies have also found a high frequency of impaired glucose tolerance among the severely mentally ill. This article discusses the role of antipsychotic drugs, the management of metabolic issues in psychiatric patients, and diabetes and depression.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ediabetes mellitus\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiometabolic disorder\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Emood disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eschizophrenia\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003EA recent study of Dutch subjects [Cohen D et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2006] found previously undiagnosed diabetes in 14.5% of subjects with severe mental illness versus 1.5% in the general population. This and other studies have also found a high frequency of impaired glucose tolerance among the severely mentally ill.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EThis association is likely multifactorial and involves not only antipsychotic agents but also unhealthy lifestyles and genetics. A family history of type 2 diabetes has been found in up to 30% of patients with schizophrenia. Regions of the human genome that overlap diabetes and schizophrenia have also been identified, as well as overlaps in the regulatory enzymes for glycolysis and schizophrenia. It has also been shown that beta-cell function and insulin resistance improve as psychosis improves [Shiloah E et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2003].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EJogin H. Thakore, PhD, St. Vincent\u0027s Hospital, Dublin, Ireland, discussed possible mechanisms for these associations. He reported that patients having a first episode of schizophrenia have three times as much intra-abdominal fat as matched controls and that impaired glucose tolerance is found in 15% of patients with schizophrenia and in 18% of their first-degree relatives. These patients also have increased expression of a surface-bound platelet glycoprotein that is critical for platelet aggregation. \u201cThis may partly explain the increased predisposition of the severe mentally ill to cardiac events,\u201d Dr. Thakore suggested.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003ECoronary heart disease is now the leading cause of death among persons with severe mental illness (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Osborn DP et al. \u003Cem\u003EArch Gen Psychiatry\u003C\/em\u003E 2007] suggesting that persons with schizophrenia and their relatives may benefit from cardiovascular screening.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/6\/16\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Rates of Coronary Heart Disease in Patients with Severe Mental Illness.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1243496339\u0022 data-figure-caption=\u0022Rates of Coronary Heart Disease in Patients with Severe Mental Illness.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/6\/16\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/6\/16\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/6\/16\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/10828\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003ERates of Coronary Heart Disease in Patients with Severe Mental Illness.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ERole of Antipsychotic Drugs\u003C\/h2\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EType 2 diabetes has been reported to develop during treatment for schizophrenia. The role of second-generation antipsychotic agents in worsening glucose tolerance has been actively explored. Leslie Citrome, MD, New York University School of Medicine, New York, United States, presented the results of a recent study that showed that the second-generation antipsychotics were associated with a range of 53 more cases of diabetes to 46 fewer cases of diabetes per 1,000 patients (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Citrome LL et al. \u003Cem\u003EAnn Pharmacother\u003C\/em\u003E 2007].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/6\/16\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Risk of Diabetes Attributable to First- and Second-Generation Antipsychotic Agents.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1243496339\u0022 data-figure-caption=\u0022Risk of Diabetes Attributable to First- and Second-Generation Antipsychotic Agents.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/6\/16\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/6\/16\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/6\/16\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/10830\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003ERisk of Diabetes Attributable to First- and Second-Generation Antipsychotic Agents.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-9\u0022\u003E\u201cThere was little observable difference between individual second-generation antipsychotics versus first-generation antipsychotics\u201d Dr. Citrome said. Few studies, however, controlled for confounding factors such as body weight, family history and physical activity, he added. \u201cProlonged exposure to an individual agent can cause problems, though the attributable risk remains unknown. The choice of antipsychotic cannot predict who will develop type 2 diabetes.\u201d Differences among the antipsychotics regarding weight gain and lipid alterations must be balanced with the need to provide for more efficacious psychiatric treatment, he said.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPractical Management of Metabolic Issues in Psychiatric Patients\u003C\/h2\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EPersons with severe mental illness have triple the mortality rate of the general population and die 10\u201320 years earlier. For 33- 60%, death is due to cardiovascular disease. An increased prevalence of diabetes and the metabolic syndrome may explain this, said Richard Holt, MD, University of Southampton, UK.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EThe Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study found that over 85% of schizophrenic patients had at least one feature of the metabolic syndrome [McEvoy JP et al. \u003Cem\u003ESchizophr Res\u003C\/em\u003E 2005]. \u201cThe management of metabolic predictors in patients with severe mental illness is a neglected area,\u201d Dr. Holt said. \u201cYou should consider this problem from the first day a patient is diagnosed with mental illness.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EDr. Holt recommended that patients should be screened for the metabolic syndrome and cardiovascular risk prior to starting antipsychotic therapy. They should undergo a fasting blood glucose test, or at least a random blood glucose screen. After 3\u20134 months of treatment, the test should be repeated to identify treatment-emergent diabetes, and then repeated annually. Standard risk factors should be assessed annually and treated. Dr. Holt said that he had been successful with lifestyle intervention programs in people with mental illness.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003E\u201cJust reliably measuring cardiovascular risk factors and treating these patients as you would treat the general public would be a great leap forward,\u201d he said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003ECertainly, there are special issues in managing this patient population. \u201cThese patients are challenging at best,\u201d he observed. There should be liaisons between the diabetes and psychiatric services. Most importantly, adequate mental treatment should be maintained and the antipsychotic drug should only be stopped if it is the major cause of the diabetes.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EDiabetes and Depression\u003C\/h2\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EDiabetes is also associated with other mental illness. Major depressive disorder occurs in 10% of diabetics, and subclinical symptoms occur in another 10\u201340%. For reasons that are unclear, depression also increases the odds of developing type 2 diabetes, and when both conditions are present, diabetic outcomes are worsened, said Patrick J. Lustman, MD, Washington University, St. Louis, Missouri, United States.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EDepression also seems to increase the risk of developing diabetes. In the prospective Stockholm Diabetes Prevention Program which comprised 5,500 subjects, men (although not women) with the highest level of depressive symptoms had a nearly four-fold risk for type 2 diabetes and a nearly two-fold risk for a prediabetic state, compared with the least depressed, reported Claes-G\u00f6ran \u00d6stenson, MD, Karolinska Institute, Stockholm, Sweden.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EDepressed patients actually have an increased risk for virtually all factors of the metabolic syndrome except hyperlipidemia. Compared to non-depressed diabetic patients, patients who have both diabetes and depression have poorer glycemic control, a higher risk of multiple morbidities and mortality, increased functional impairment, and poorer adherence to diet, exercise and self-management strategies, said Professor Norbert Hermanns, Research Institute of the Diabetes Academy Mergentheim, Bad Mergentheim, Germany.\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EFrans Pouwer, PhD, VU Medical Center, Amsterdam, the Netherlands, added that all of the complications of diabetes are associated with increased scores on depression instruments, most likely because of \u201cthe hardship and chronic stress\u201d of having diabetes and its complications. He pointed to the results of a recent study that showed that persons with type 1 or type 2 diabetes were more likely to have attempted suicide than the general Dutch population (6.4% vs 2.7%). Those with previous suicide attempts tended to have higher HbA1c levels, more diabetic complications, and more erectile dysfunction. Not surprisingly, 94% of these subjects scored high on measures of depression, compared with 24% of non-suicidal diabetic subjects [Pouwer F et al. EASD 2007].\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EIn another report, Mirjana Pibernik-Okanovic, PhD, Vuk Vrhovac University Clinic, Zagreb, Croatia, examined patterns of glycemic control in \u201cemotionally burdened\u201d subgroups versus symptom-free individuals. The study of 470 type 2 diabetics found that 44% had severe depressive symptoms, high levels of \u201cdiabetes-related distress,\u201d or the combination of symptoms. Depressive symptoms combined with diabetes-related distress most adversely affected glycemic control. These levels improved at 1 year in the \u201cdistressed\u201d group but not in the depressed groups.\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EBehaviors that accompany depression may be partly to blame for such adverse outcomes, Prof. Pouwer said, noting that depressed patients are less likely to adhere to diet, exercise, and glucose self-monitoring. There are also numerous biochemical factors linking impaired glucose metabolism with depression, especially those related to the human stress response (\u003Ca id=\u0022xref-fig-3-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F3\u0022\u003EFigure 3\u003C\/a\u003E), he added.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F3\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/6\/16\/F3.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Factors Underlying Poor Glycemic Control in Depressed Patients.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1243496339\u0022 data-figure-caption=\u0022Factors Underlying Poor Glycemic Control in Depressed Patients.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 3.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/6\/16\/F3.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/6\/16\/F3.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 3.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/6\/16\/F3.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/10831\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 3.\u003C\/span\u003E \n               \u003Cp id=\u0022p-21\u0022 class=\u0022first-child\u0022\u003EFactors Underlying Poor Glycemic Control in Depressed Patients.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-22\u0022\u003E\u201cDepression in diabetes has to be taken seriously,\u201d emphasized Prof. Hermanns. Recent results of the World Health Survey [Moussavi S et al. \u003Cem\u003ELancet\u003C\/em\u003E 2007] show that combination of diabetes and depression has the most negative impact on health among a dozen or so serious medical conditions. Unfortunately, studies show that depression remains undetected and thus untreated in 50\u201375% of diabetics who have it.\u003C\/p\u003E\n         \u003Cp id=\u0022p-23\u0022\u003EAdequate treatment of depression seems to impact the prognosis of diabetes as well. Dr. Lustman and colleagues have shown that treatment with the dual norepinephrine and dopamine reuptake inhibitor bupropion not only improves depression but also improves glycemic control. The same may be true with the selective serotonin reuptake inhibitors, but not with nortriptyline, a norepinephrine reuptake inhibitor [Lustman PJ et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2007].\u003C\/p\u003E\n         \u003Cp id=\u0022p-24\u0022\u003ERichard Rubin, PhD, Johns Hopkins University, Maryland, United States, encouraged the use of antidepressant medications in diabetic patients, but said that counseling, especially cognitive behavioral therapy, is also important for patients with poorly controlled glycemia. Since depression often recurs, careful monitoring is important with some patients requiring chronic long-term treatment.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2007 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/7\/6\/16.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzm821\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzm821\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}