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UW Psychiatry and Behavioral Sciences Newsletter, March 2017
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Message from the Chair

 
Dear friends and colleagues,

Today more than ever, we need to pay attention to equity, diversity and inclusion. Paul Ramsey, MD, CEO of UW Medicine, recently wrote a letter to faculty and staff about the adverse impacts of institutional racism on UW Medicine’s ability to improve the health of the public. As part of Dean Ramsey’s commitment to address institutional racism, the School of Medicine has formed the Anti-Racism Action Committee (ARAC) led by Drs. Mark Snowden, Freddie Overstreet and Anne Eacker. By acknowledging the presence of institutional racism and identifying policies, practices and knowledge gaps that need to be changed, the ARAC – and all of us at UW Medicine -- hope to improve health equity and reduce disparities in health care and beyond.

As an immigrant to this country, I continue to be in awe of the tremendous potential that lies in our diversity and I will do what I can to commit our department to value, celebrate, and increase the diversity of our faculty and staff. You can read about some of our efforts in the December, 2016 newsletter, including the work of our Diversity Committee led by Mark Snowden, our diversity sub-internship program that helps medical students from underrepresented minority groups spend time working with our clinicians and teachers here at UW Medicine, and our efforts to educate faculty leaders on implicit bias as well as best practices regarding inclusive hiring.

UW Medicine’s work to improve health equity and reduce disparities is also embedded in the UW Medicine Initiative to Transform Care. Launched a year ago, the initiative is working to bring clinical practice transformation to care delivery with the goals of improving healthcare for individual patients, improving the health of the public, and controlling costs. A group of more than 300 UW Medicine Practice Innovators – including 17 faculty members from our department – are leading this effort under the direction of Dr. Carlos Pellegrini, Chief Medical Officer for UW Medicine. We have included an update on one initiative that we are heavily involved in, the Depression Path Project, in this month’s newsletter. Dr. Pellegrini will be giving a brief overview of the care transformation initiative to our department on Friday, June 2 as part of our Grand Rounds schedule. More information to come.

Earlier this month at a meeting of all clinical department chairs, I was pleasantly surprised to receive the “Employer of Choice Award” from UW Medicine, celebrating the fact that for the 3rd year in a row, Psychiatry and Behavioral Sciences was one of the top two clinical departments in terms of provider satisfaction with their clinical practice at UW Medicine. We have more than 200 psychiatrists and psychologists who practice here at UW Medicine, and in any given week, we hear about the many challenges and frustrations that our clinicians encounter during their clinical work, ranging from the electronic medical record to challenges with access to care for our patients. But it is rewarding to hear that overall, the majority of our clinically active faculty find their work here at UW Medicine satisfying and rewarding. I know that your work is valued by our colleagues in the other clinical specialties here at UW Medicine, and I want to take this time to thank every one of you for your outstanding contributions to our clinical programs. I also want to encourage you all to talk with each other, with your clinical service chiefs, and with me about how we can further improve our clinical work here at UW Medicine. That work is never done, and I am always happy to hear from you about how we can do better.

Lastly, please mark your calendars for our Annual Department Meeting on Monday, June 12 from 10:00 AM-12:00 PM in Hogness Auditorium. All faculty and staff are encouraged to attend. This is one of the few opportunities we have to come together as a department and I look forward to seeing you there. Associate and Full Professors will be asked to stay for our annual promotions meeting from 12 – 2 PM. New this year is a Staff Appreciation Event to be held after the annual department meeting. Details coming soon.

Jürgen


HR Team at Full Strength
For the first time in many months, we have a fully staffed Human Resources team! Rachel Reichert, MA, has been joined by Salyse Duckworth, our new Human Resources Coordinator, and Maureen Johnson, Assistant Director of Human Resources. Many of you know Maureen already; after a year being the administrator for the Sports Health and Safety Institute at Harborview, she's come back into our fold. She previously worked at the Fred Hutchinson Cancer Research Center and UW’s Department of Orthopedics and Sports Medicine.

Salyse is a graduate of the University of Washington. Her previous work experience includes serving as an Administrative Specialist for the UW Medicine Clinical Resource Management Department. She has a love for the theater and the arts, and likes to visits museums and watch new and old Hollywood films. Salyse will report directly to Rachel.

Another change is that Marivic Ramirez, the department’s payroll analyst, will be returning fulltime to the department. Marivic has been working with the School of Medicine’s Shared Services team for the past year as part of a pilot project. She will report to Maureen and continue to provide payroll services, but will move over to join the rest of the department’s administrative team at UWMC beginning July 1, 2017.

With these new additions, the HR team has been restructured to better serve both academic and staff needs. In general, Maureen will serve as the staff HR lead and Rachel will serve as the academic HR lead, with Salyse supporting both areas, with some exceptions. For a full breakdown of who to contact for what, please refer to the HR Chart on our department wiki.

Welcome to Young Cho
Young Cho has joined the department finance team as our Fiscal Specialist and will be focusing efforts on purchasing, reimbursement processing, and process improvement. Young comes to our team with a very diverse background, ranging from banking to non-profit to the energy sector. He has an on-going interest in music and sports and is an avid board game player. Young will report to Nadia Khan and can be reached at ycho868@uw.edu.

Seeking Nominations for the Wayne J. Katon Outstanding Mentor Award
We are seeking nominations for the Wayne J. Katon Outstanding Mentor Award now through April 30. This prestigious award acknowledges the time, dedication, and attention that faculty members devote to foster the career development and academic success of colleagues and trainees in the areas of research, clinical practice and education. Through this award, we honor and celebrate the valuable efforts of faculty members who embody Dr. Katon’s spirit of mentoring. Any UW Psychiatry faculty member, postdoc, fellow, resident or student may submit a nomination and any faculty member in the department can be nominated. More information as well as nomination instructions can be found at https://catalyst.uw.edu/collectit/dropbox/rreicher/39704

Annual Faculty Teaching Retreat May 31
The annual faculty teaching retreat will be held the afternoon of Wednesday, May 31 (1-4:30 PM) at Wisteria Hall at the Arboretum. This year's retreat will feature a workshop by Tyra Fainstad, MD, from the UW Department of Medicine about novel ways of giving feedback, and a session on using technology in teaching and supervision. If you would like to attend this retreat, please RSVP to Charisa Lantin in the Education Office at charisam@uw.edu.

Reminder to Junior Faculty: Fill Out Your Individual Development Plan!
Every junior faculty member should meet with his/her department mentor at least every six months to complete their Individual Development Plan (IDP), located on the Mentorship Program page of the department intranet. Junior faculty members should fill out the IDP in advance of the meeting, provide comments at the end of the form, and submit the IDP to Rachel Reichert, MA, Assistant Director of Human Resources. IDPs are then reviewed by Drs. Unützer, Cowley, and the faculty member's Chief of Service. This will help all of us to make sure you are on track for promotion. If you have any questions, please contact Rachel at rreicher@uw.edu.


Fann, Hoffman Land $12.7 Million PCORI Award
Jesse Fann, MD, MPH, and Jeanne Hoffman, PhD, (UW professor of Rehabilitation Medicine) received $12.7 million from the Patient-Centered Outcomes Research Institute (PCORI), an independent nonprofit, nongovernmental organization, to conduct new research on Traumatic Brain Injury (TBI).

Each year, about 3.5 million people sustain a traumatic brain injury (TBI) in the United States, and at least 25 percent of these injuries are classified as moderate to severe. Nearly half of those hospitalized for TBI have long-term disability. Outcomes are affected by the type and severity of the TBI, but the timing and type of treatment someone with TBI receives is also important.

Inpatient rehabilitation professionals are currently told to give people with TBI information, reassurance, advice, and referral resources. Some promising ways of further helping people with TBI include using telephone and other mobile devices to reach out to patients after they leave the hospital, regularly assessing their individual needs and helping them coordinate their health care, and providing the information and resources that patients need. These strategies may lead to earlier return to activities and improved quality of life. This new study will compare the standard approach to discharge care with an approach that uses telecare delivered by a care manager to provide information and care coordination after discharge. Functioning and quality of life over a 12-month period will be compared among people randomized to the two groups.

Congratulations Dr. Fann!

STEPS Curriculum Brings Coping Strategies to the Classroom
The Seattle Children’s Department of Psychiatry and Behavioral Medicine is at the cutting edge of developing interventions to address the needs of adolescents who engage in high risk behaviors that reflect poor problem solving and emotional control. However, access to hospital and clinic-based mental health interventions is limited, and most youth who need such services do not get them. One effective way that faculty from Seattle Children’s address the problem of limited access is by taking their expertise into the community.

In 2016, the Seattle Children’s Guild Association Executive Committee awarded Elizabeth McCauley, PhD, Molly Adrian, PhD, Mylien Duong, PhD, and Ann Vander Stoep, PhD, one of their three annual grants. The group proposed to test a new approach for teaching skills for dealing effectively with intense emotional experiences in Seattle-area high schools. They developed a curriculum called Skills Training for Emotion Problem Solving (STEPS) that is based on UW Professor Marcia Linehan’s Dialectical Behavioral Therapy. While these skills have proven effectiveness in decreasing self-harm and emotion dysregulation in youth at high risk of depression, suicide, and substance abuse, they are also healthy practices that all young people can employ to rebound from setbacks and cope with stress.

Last year, the STEPS team tested and evaluated a six-week stress management curriculum with 9th graders enrolled in health classes at Garfield High School. Based on what they learned in the Garfield pilot, the STEPS team modified the curriculum and recently launched a six-week series to teach interpersonal effectiveness, emotion regulation, distress tolerance, and mindfulness in health classes at Ingraham High School. The curriculum is lively and engages students in small group work to learn and practice skills, didactic sessions about the physiology of stress, and homework assignments to try out skills in situations where students experience distress.

There is an increasing demand for a wide range of school-based emotional health supports, including those that can be offered universally. Society recognizes that good emotional health is a critical ingredient to school success and healthy social relationships. In the US, schools are the number one place where children and adolescents receive mental health services. The STEPS team is comparing students in 9th grade health where they are offering their curriculum with students in classes where health teachers are giving 1-2 lectures on stress management. If the pilot evaluations show that STEPS has a positive impact on students’ stress levels and coping strategies, then the team will apply for funding to carry out a large scale implementation and evaluation project.

Analyst Spotlight Series: Robert Arao
Several members of our department have unique analytic skills that strengthen our department as a whole. We’ve previously highlighted the work of Joan Russo, PhD, and Michael Pullmann, PhD. This month, our spotlight is on Robert Arao.

Robert F. Arao, MPH, was hired six months ago as a data manger. He works on several projects with Joan Russo, PhD, including the Mental Health Integration Program (MHIP), Behavioral Integration Program (BHIP), Study to Promote Innovation in Rural Integrated Telepsychiatry (SPIRIT), and Partners in Care, to name a few. Robert’s tasks employ using various data science tools to identify problems and tell stories from within the data.

Robert has an extensive background in research. He worked as a biochemist performing bench science research in Canada and Utah before pursuing a career in Public Health. He obtained his Master’s degree in Public Health from the Oregon Health & Science University majoring in Biostatistics and Epidemiology whereby he authored his first major study titled “Physician Barriers in Recommending Flu Vaccine to Healthy Pregnant Women” in the Maternal and Child Health Journal. He worked as an outbreak investigation epidemiologist for the Oregon Health Authority as well as an analyst for a multi-hospital study employing antimicrobial stewardship. More recently, Robert worked at Group Health-Kaiser Permanente where he served as a biostatistician. He has co-authored several big data studies in breast cancer including “National Performance Benchmarks for Modern Diagnostic Digital Mammography” which was recently mentioned on CBS news. Robert’s interest in Population Health is driven by his passion to identify and protect vulnerable populations with the ultimate aim of improving quality of life and patient-centered care.

As an aside, Robert also has a passion for inventing and programming automated tasks. One of his inventions is a mobile robotic arm (MoRA) which is controlled wirelessly by both voice commands and hand gestures. His most recent invention, “The Alexa Mirror,” won a runner-up prize at an Amazon-based competition last year.


Depression Path Project aims to improve outcomes, patient experience
Starting this past November, our Psychiatric Consultation and Telepsychiatry Program (PCAT) led by Marc Avery, MD, and Denise Chang, MD, began a systematic quality improvement project to improve the depression treatment and outcomes for patients receiving care within the UW Medicine primary care network, and who are members of an identified UW Medicine Accountable Care Network contract. The project is initially focusing on Boeing ACO Contract members, but will eventually include PEBB and Premera Blue Cross contract members. Goals of the Depression Path Project include:
  • Improving the oversight of depression treatments for depressed patients receiving primary care at UW Medicine.
  • Improving identification of patients who are not improving as expected and engaging in appropriate levels of care.
  • Improving the tracking of patient depression treatment outcomes.
  • Increasing the use of evidence-based practices in depressed patients.
  • Improving Health Care Teams’ and Patient Experience of Care.
  • Identifying opportunities for improving depression care and achieving optimal clinical outcomes for primary care patients within UW Medicine program.
The project is overseen by David R Flum, MD, MPH and D.C. Dugdale, MD, FACP, with assistance from Van Chaudhari, FACHE, and Jason Chu. Simultaneously, UW Medicine is engaged in a system-wide Primary Care Innovations (PCI) Initiative A number of the PCI workgroups address key elements in the improvement of depression treatment across the network – representing a stepped-strategy approach to improving depression care across the entire network.

Addictions Team a Big Presence at National Conference
Our addictions team had a strong presence at the 19th Annual Fundamentals of Addiction Medicine Conference held earlier this month. Psychiatry Addiction Fellows Lauren Augello, MD, Matt Iles-Shih, MD and Mark Ellestad, MD gave the Fellowship Lecture on the challenges and promise of integrating addictions treatment with primary care. Courtesy faculty member and former UW psychiatry resident/community fellow Paul Grekin, MD, talked about the best way to integrate primary care into a federally licensed opioid treatment program, and courtesy faculty member and former UW psychiatry resident/geriatric fellow Chris Bundy, MD, MPH, talked about legalized marijuana in the context of healthcare professionals. Rounding out our presence was our addictions leadership faculty Richard Ries, MD, and Andrew Saxon, MD. The aim of the conference is to enhance the skills and performance of healthcare professionals who treat patients with substance abuse disorders through new scientific, best practices, treatment, tools, and modalities in all areas of addiction medicine. Over 300 people attended the conference including physicians, chemical dependency professionals, and medical students.

New Teleconsultation Program Helps Deliver CBTp
Sarah Kopelovich, PhD, launched two new teleconsultation clinics in February for community mental health providers in Cognitive Behavioral Therapy for psychosis (CBTp). The clinics follow the Project ECHO (Extension for Community Healthcare Outcomes) Model developed at the University of New Mexico. Using state-of-the-art telehealth technology and clinical management tools, the CBT ECHO clinics connect expertise within our department to community mental health providers from rural and underserved areas to enhance workforce capacities to deliver CBTp. In Washington State, these CBT ECHO Clinics will enable providers to build proficiency in individual and group-based CBTp more quickly, advancing efforts to enhance access to evidence-based treatments for individuals with Serious Mental Illness and create self-sustaining communities of practice among CBTp providers.

The CBT ECHO Clinic is the first ECHO program in the world focused on psychotic disorders and the first ECHO program to assist providers in developing competencies in group and individual evidence-based psychotherapeutic interventions.

Suicide Prevention Training Coming Your Way
For the past several months, our department has been working to create an online suicide prevention training course for medical providers that would meet the new state law requiring health professionals, including psychiatrists, to complete a one-time training in suicide assessment, treatment, and management as part of their continuing education, continuing competency, or recertification requirements. The team, led by Anna Ratzliff, MD, PhD, includes members from Forefront, Seattle Children’s, UW Family Medicine, and CoMotion. The training will be available not only to all UW providers, but to other providers in the state and perhaps the country as other states develop similar requirements.

The core content includes modules on risk, assessment, management and treatment. We also plan to include an innovative section to help providers think about the needs in their own system or practice in order to manage and treat beyond the acute presentation. Our goal is to have the suicide prevention training available starting in July, 2017, the date providers who are renewing their license are required to complete a training.


Psychiatry Residency Match Results
Results of the 2017 National Resident Matching Program (NRMP) were announced earlier this month. It was the largest match in history with 28,849 positions offered in the Match nationwide across all specialties. Our department had another successful Match this year thanks to the efforts of our team of faculty, residents, and staff. Our admissions committee (Drs Murray, Baldwin, Crawford, Curry, Duncan, Jenkins, Markman, Neumaier, Pascoe, Pascualy, Pellegrino, Poeschla and our recruitment chief Dr. Nicole Sussman) and our residency staff did their usual amazing job or organizing everything. We received over 1,361 applications and interviewed nearly 130 people for our 16 intern positions and our 3 PGY2 positions. We are thrilled to have an incredible group of residents join us this summer. Meet the incoming psychiatry residents!

Chief Residents Selected
The 2017-18 Psychiatry Chief Residents have been selected! We look forward to working with this talented group of incoming chief residents.
  • HMC Inpatient: Megan Riddle, MD, PhD, MS
  • HMC Oupt/CL: Bob Sise, MD, MPH, MBA
  • UPOC: David Zacharias, MD, MPH
  • UWMC inpatient: Stephanie Chang, MD
  • VA Medical Center: Justin Stamschror, MD
  • Child and Adolescent: Nayla Khoury, MD, MPH, and Roberto Montenegro, MD, PhD
  • Recruitment Chief: Joe Baldwin, MD
  • Call Chief: Kate Jenkins, MD
  • Idaho Chiefs: Jonathan DeHaan, MD, and Leo Velez, MD
Heidi Combs Steps Down, Paul Borghesani and Anne Rich Step Up!
After 11 years in the position, Heidi Combs, MD, is stepping down as our medical student Psychiatry Clerkship Director and transitioning to taking on educational projects in the Dean's Office related to the new medical school curriculum. Heidi has done a wonderful job, winning multiple School of Medicine Distinguished Teaching awards and rare recognition as a Superior Teacher in Perpetuity. We are delighted to welcome Paul Borghesani, MD, PhD, currently the Associate Psychiatry Clerkship Director, as our new Psychiatry Clerkship Director! Paul has made major contributions to the clerkship, especially in the areas of evaluation and grading, and has directly overseen rotation sites in Washington and Wyoming. We are also excited that Anne Rich, MD, will be stepping into the Associate Clerkship Director role. She is a graduate of our Psychiatry Residency and Psychosomatic Medicine fellowship, served as Director of Medical Student Education in Psychiatry at the University of Vermont, and now practices in Bozeman, Montana, where she is the Psychiatry Clerkship Site Director.

UW at the AADPRT Meeting
Seventeen faculty members, trainees, and staff from our department and affiliated residencies attended the annual meeting of the American Association of Directors of Psychiatric Residency Training (AADPRT) in San Francisco. Presentations by our faculty and trainees covered a wide range of topics in psychiatric education, including peer mentoring for mutual care (Suzanne Murray, MD), developing a faculty mentoring program (Jesse Markman, MBA, MD and Deb Cowley, MD), substance use disorder education (Andy Saxon, MD, FASAM), collaborative care education (Anna Ratzliff, MD, PhD), how to have difficult conversations with residents about adversity in the workplace (Roberto Montenegro, MD), and resident scholarly activity (Tanya Keeble, MD).

Soliciting Nominations for the Gary J. Tucker Career Teaching Award
We invite you to nominate one of our academic or clinical faculty members for the Gary J. Tucker Career Teaching Award. Established in recognition of Gary J. Tucker, MD, Chair of our Department from 1985 through 1997, the Tucker Award recognizes exceptional career achievement in teaching and education within the Department of Psychiatry and Behavioral Sciences and honors Dr. Tucker's significant contributions to our academic programs, his leadership and dedication as a teacher, clinician, and scholar, his love of teaching, and his ability to inspire and encourage trainees.

The award is given to a member of the academic or clinical faculty who has demonstrated, throughout his or her career, outstanding skills as a teacher and dedication to education. To date, the following members of our faculty have received this award: Jack Carr, PhD, Johan Verhulst, MD, Chris Varley, MD, Joan Romano, PhD, Deb Cowley, MD, Dick Miyoshi, RPh, and Marcella Pascualy, MD.

If you would like to nominate someone for this award, please send his/her name and a paragraph about why you are nominating him/her to Deb Cowley by Monday, May 1.

Save the Date! Graduation Ceremony June 23
The Department's annual Graduation ceremony will be on Friday, June 23 beginning at 5:30 PM at the Center for Urban Horticulture. This ceremony will honor the graduates of our many educational programs.


UW Psychiatrists Among Seattle Magazine’s Top Docs
This year’s Top Doctors report, put out annually by Seattle Magazine, features a number of our faculty and courtesy faculty members. This yearly list recognizes some of the best physicians in our region. Each doctor is nominated by a colleague and then evaluated by an outside health care research firm for inclusion. Congratulations to faculty members Andrew Saxon, MD (Addiction Psychiatry), Jesse Fann, MD (Psychiatry), Murray Raskind, MD, (Psychiatry), Hower Kwon, MD, (Child & Adolescent Psychiatry), Kathleen M. Myers, MD (Child & Adolescent Psychiatry), Mark Snowden, MD (Geriatric Psychiatry), Richard Veith, MD (Geriatric Psychiatry) and courtesy faculty member Kenneth Melman, MD (psychiatry).

UW Ranked in Top Ten for Drug and Alcohol Abuse Program
The UW was once again named a top medical school for its drug and alcohol abuse program, coming in at #8 in the nation. The ranking is complex and incorporates medical school teaching, clinical services, academics (journal articles and books), and funded research. Multiple people, Institutes and Centers affiliated with our department contribute to the culture of collaboration and excellence of the program. Over 50 faculty members contribute to our addictions activities and bring in a sizable amount of our research portfolio. Below is a sample of our major addiction research and training centers:
  • The UW Psychiatry and Addictions Case Conference (UW PACC) series has been offered since July, 2016. Run by Mark Duncan, MD, and Rick Ries, MD, the series has provided over 1,200 hours of training to 160 individuals from 15 counties in Washington.
  • The Alcohol and Drug Abuse Institute, with Dennis Donovan, PhD, as the Principal Investigator, is in its 16th year of funding as the Pacific Northwest Node and Regional Research and Training Center of the National Institute on Drug Abuse National Drug Abuse Treatment Clinical Trials Network.
  • Our Addictions Track directed by Rick Ries, MD -- the only such entry track in the country -- recruits residents to our department prior to and in their initial year. Our ACGME Addictions Psychiatry Fellowship directed by Andrew Saxon, MD, remains a top program in the country. Graduates from both programs function as clinical and research faculty at our various departmental sites and occupy key positions in regional hospitals and treatment centers.
  • The T32 Psychology in Alcohol Research Training Grant, directed by Mary Larimer, PhD, provides pre- and post-doctoral support for fellows interested in pursuing a career in alcohol research, with an emphasis on the etiology and prevention of problem drinking and alcohol dependence.
  • Mary Larimer, PhD, also directs the Center for the Study of Health and Risk Behaviors (CSHRB), dedicated to eradicating the harm caused by engagement in a variety of health risk behaviors through the development and implementation of novel prevention and treatment approaches.
  • The Fetal Alcohol and Drug Unit (FADU) directed by Therese Grant, PhD, studies fetal alcohol syndrome (FAS) and fetal alcohol spectrum disorders (FASD) across the life span, disseminates research information, provides consultation for individuals affected by prenatal exposure to alcohol, and intervenes with high-risk mothers to prevent future births of children with fetal alcohol and drug effects.
  • The Harm Reduction Research and Treatment (HaRRT) Center directed by Susan Collins, PhD, and Seema Clifasefi, PhD, works collaboratively with substance users, community members and organizations to develop, conduct, evaluate and disseminate evidence-based interventions that help to reduce substance-related harm and improve quality of life for affected individuals and their communities.
  • Translational research efforts at the Mental Illness Research, Education and Clinical Center (MIRECC), directed by Murray Raskind, MD, focuses on treatment for PTSD and its substance abuse comorbidities (alcohol and tobacco)..
  • The Mental Health and Addictions Services at Harborview directed by Rick Ries, MD, is one of the most innovative in the country, provides integrated chemical dependency, mental health and medical primary care treatment in an outpatient setting to assist people with chemical abuse and dependency problems..
  • Our psychiatric neurosciences division led by John Neumaier, PhD, MD, conducts a broad range of addictions-related basic research.
Again, this is just a sample of our addictions work and many more people and projects contribute to our robust program. A lot of work goes into a nation-wide top ten ranking – thank you to all of our addictions researchers, clinicians and educators who contribute to the effort, and a big thank you to Rick Ries, MD, the director of our Addictions Division!
For upcoming events, please visit the Department calendar .
Copyright © 2017 Department of Psychiatry and Behavioral Sciences, University of Washington. All rights reserved.
 
University of Washington
Department of Psychiatry and Behavioral Sciences
1959 NE Pacific Street, Box 356560
Seattle, WA 98195

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