1. Study suggests earlier school start times may increase risk of adolescent depression and anxiety

    October 13, 2017 by Ashley

    From the University of Rochester Medical Center press release:

    Teenagers who start high school before 8:30 a.m. are at higher risk of depression and anxiety, even if they’re doing everything else right to get a good night’s sleep, a recent study out of Rochester, N.Y., suggests.

    Led by University of Rochester Medical Center clinical assistant professor in Psychiatry Jack Peltz, Ph.D., the study, recently published in Sleep Health, not only reinforces the theorized link between sleep and adolescent mental health, but is among the first to demonstrate that school start times may have a critical impact on adolescent sleep and daily functioning. The findings provide additional evidence in the national debate over how school start times impact adolescent health.

    “Our study is consistent with a growing body of research demonstrating the close connection between sleep hygiene and adolescent mental health,” says Peltz, who is also on the faculty of Daemon College in Amherst, N.Y. “But ours is the first to really look at how school start times affect sleep quality, even when a teen is doing everything else right to get a good night’s sleep. While there are other variables that need to be explored, our findings show that earlier school start times seem to put more pressure on the sleep process and increase mental health symptoms, while later school start times appear to be a strong protective factor for teens.”

    Peltz is one of many investigators now exploring ways to address what has become a nationwide sleep epidemic among adolescents. About 90% of high-school-aged adolescents get insufficient sleep on school nights, or barely meet the required amount of sleep (8-10 hours) needed for healthy functioning. School start times, among other interventions (ie. limiting electronic use before bedtime), have become a critical point of interest. The research to date, however, has primarily focused on the academic benefits of delaying school start times for adolescents, rather than examining how earlier start times may disrupt sleep-related processes and affect mental health outcomes, says Peltz.

    “Looking at school start times as a larger contextual variable that may moderate sleep hygiene, sleep quality and adolescent functioning, fills an important gap in the literature,” he says.

    With the help of a grant from the National Sleep Foundation, Peltz’ and his co-authors used an online tool to collect data from 197 students across the country between the ages of 14 and 17. All children and parents completed a baseline survey that included questions about the child’s level of sleep hygiene, family socioeconomic status, their circadian chronotype (roughly, whether you are a “morning person” or “night person”), and their school start times. They were separated into two groups: those who started school before 8:30 a.m. and those who started after 8:30 a.m. (which is currently the recommended start time for high schoolers by the American Academy of Pediatricians).

    Over a period of seven days, the students were instructed to keep a sleep diary, in which they reported specifically on their daily sleep hygiene, levels of sleep quality and duration, and their depressive/anxiety symptoms.

    The results showed that good baseline sleep hygiene was directly associated with lower average daily depressive/anxiety symptoms across all students, and the levels were even lower in students with school start times after 8:30. However, students with good baseline sleep hygiene and earlier school start times had higher average daily depressive/anxiety symptoms.

    “Our results suggest that good sleep hygiene practices are advantageous to students no matter when they go to school,” says Peltz. “Maintaining a consistent bedtime, getting between 8 and 10 hours of sleep, limiting caffeine, turning off the TV, cell phone and video games before bed… these efforts will all benefit their quality of sleep and mental health. However, the fact that school start times showed a moderating effect on mental health symptoms, suggests that better sleep hygiene combined with later school start times would yield better outcomes.”

    Peltz says one possible explanation for the difference may be that “earlier starting students” have more pressure on them to get high quality sleep, or there may be other aspects of the school environment that vary by start time that may trigger their depression/anxiety symptoms. Peltz says there may be other lifestyle changes that coincide with earlier start times as well (for example, morning nutrition or exercise) that require closer scrutiny.

    “More studies are definitely needed, but our results help clarify the somewhat mixed findings with other sleep hygiene-focused interventions, by suggesting that school start times may be a very important contextual factor,” he says.

    Peltz hopes the evolving evidence in this area will help propel more concrete national sleep hygiene recommendations for children and teens, similar to what the American Dental Association recommends for oral health.

    “If we don’t sleep, eventually we will die…our brains will cease to function,” he says. “At the end of the day, sleep is fundamental to our survival. But if you have to cram for a test or have an important paper due, it’s one of the first things to go by the wayside, although that shouldn’t be.”


  2. Study suggests exercise can help with depression prevention

    by Ashley

    From the University of New South Wales press release:

    A landmark study led by the Black Dog Institute has revealed that regular exercise of any intensity can prevent future depression — and just one hour can help.

    Published in the American Journal of Psychiatry, the results show even small amounts of exercise can protect against depression, with mental health benefits seen regardless of age or gender.

    In the largest and most extensive study of its kind, the analysis involved 33,908 Norwegian adults who had their levels of exercise and symptoms of depression and anxiety monitored over 11 years.

    The international research team found that 12 percent of cases of depression could have been prevented if participants undertook just one hour of physical activity each week.

    “We’ve known for some time that exercise has a role to play in treating symptoms of depression, but this is the first time we have been able to quantify the preventative potential of physical activity in terms of reducing future levels of depression,” said lead author Associate Professor Samuel Harvey from Black Dog Institute and UNSW.

    “These findings are exciting because they show that even relatively small amounts of exercise — from one hour per week — can deliver significant protection against depression.

    “We are still trying to determine exactly why exercise can have this protective effect, but we believe it is from the combined impact of the various physical and social benefits of physical activity.

    “These results highlight the great potential to integrate exercise into individual mental health plans and broader public health campaigns. If we can find ways to increase the population’s level of physical activity even by a small amount, then this is likely to bring substantial physical and mental health benefits.”

    The findings follow the Black Dog Institute’s recent Exercise Your Mood campaign, which ran throughout September and encouraged Australians to improve their physical and mental wellbeing through exercise.

    Researchers used data from the Health Study of Nord-Trøndelag County (HUNT study) — one of the largest and most comprehensive population-based health surveys ever undertaken — which was conducted between January 1984 and June 1997.

    A healthy cohort of participants was asked at baseline to report the frequency of exercise they participated in and at what intensity: without becoming breathless or sweating, becoming breathless and sweating, or exhausting themselves. At follow-up stage, they completed a self-report questionnaire (the Hospital Anxiety and Depression Scale) to indicate any emerging anxiety or depression.

    The research team also accounted for variables which might impact the association between exercise and common mental illness. These include socio-economic and demographic factors, substance use, body mass index, new onset physical illness and perceived social support.

    Results showed that people who reported doing no exercise at all at baseline had a 44% increased chance of developing depression compared to those who were exercising one to two hours a week.

    However, these benefits did not carry through to protecting against anxiety, with no association identified between level and intensity of exercise and the chances of developing the disorder.

    According to the Australian Health Survey, 20 percent of Australian adults do not undertake any regular physical activity, and more than a third spend less than 1.5 hours per week being physically active. At the same time, around 1 million Australians have depression, with one in five Australians aged 16-85 experiencing a mental illness in any year.

    “Most of the mental health benefits of exercise are realised within the first hour undertaken each week,” said Associate Professor Harvey.

    “With sedentary lifestyles becoming the norm worldwide, and rates of depression growing, these results are particularly pertinent as they highlight that even small lifestyle changes can reap significant mental health benefits.”


  3. Study suggests midlife depression may stem from tension with mothers and siblings

    September 30, 2017 by Ashley

    From the Iowa State University press release:

    Relationships with our mothers and siblings change as we become adults and start our own families, but the quality of those relationships still has an effect on our well-being, particularly at midlife.

    A new study led by Iowa State University researcher Megan Gilligan found that tension with our mothers and siblings, similar to our spouses, is associated with symptoms of depression. The research, published in the journal Social Sciences, found all three relationships have a similar effect and one is not stronger than another.

    “Family scholars have focused a lot on the relationship we have with our spouse,” said Gilligan, an assistant professor of human development and family studies. “There is this assumption that as you go through your life course, you leave these other relationships with your parents and siblings behind, but you don’t. You carry those with you.”

    The relationship between mothers and daughters is even more significant. The research shows tension between mothers and adult children was a stronger predictor of depression for daughters than it was for sons. However, gender did not make a difference in relationships with spouses and siblings. Gilligan says this makes sense based on her previous research.

    “We know that mothers and daughters in adulthood have the closest relationships and also the most conflictual. These are really intense relationships,” she said. “Later in life, adult children start providing more care to their parents, and daughters in particular are often caregivers for their mothers.”

    Midlife is key to findings

    Midlife is often characterized as stable and uneventful, but in reality, it is a time of change and transition for many people, Gilligan said. For example, adult children may be leaving the house and aging parents start requiring more care. Additionally, researchers know that midlife adults often react more strongly to family conflict than older adults do.

    While there is a great deal of research on young families and family dynamics later in life, there is a gap at midlife, Gilligan said. Given the potential for greater conflict with mothers or siblings related to these midlife changes, it is important to understand the consequences of negative relationships on our psychological well-being.

    “Midlife is a time when siblings are often coming back together as they prepare and navigate care for parents,” she said. “For that reason, it’s a pivotal time when these family relationships might be experiencing more tension, more strain, more discord.”

    Professionals should consider whole family

    The research team used data collected through the Within-Family Differences Study. Their analysis included 495 adult children within 254 families. For a majority of families, multiple siblings participated in the study. Researchers measured depressive symptoms and tension among family members through survey questions. They controlled for race, gender and education.

    In the paper, Gilligan and her colleagues explained that they expected all three relationships would predict depressive symptoms, but the effect would vary depending on the salience of the relationship. The fact that they found no significant difference between spouses, mothers and siblings is important to note, especially for practitioners. Gilligan says instead of focusing solely on a romantic partner or spouse, marriage and family therapists should ask about other sources of family stress.

    “These findings show that we are navigating other family relationships at the same time and we’re not experiencing them in isolation; we’re experiencing them simultaneously,” Gilligan said. “The stress people are experiencing may be the result of a romantic partner or spouse. However, it could also be that they’re fighting with their siblings or they’re experiencing a lot of tension with their mother even though they are 50 years old.”


  4. Study suggests you can ‘pick up’ a good or bad mood from your friends

    September 29, 2017 by Ashley

    From the University of Warwick press release:

    New research suggests that both good and bad moods can be ‘picked up’ from friends, but depression can’t.

    A team led by the University of Warwick has examined whether friends’ moods can affect an individual therefore implying that moods may spread across friendship networks.

    The team analysed data from the National Longitudinal Study of Adolescent to Adult Health which incorporates the moods and friendship networks of US adolescents in schools. Their paper Spreading of components of mood in adolescent social networks has been published in the journal Royal Society Open Science. The team’s findings imply that mood does spread over friendship networks, as do various different symptoms of depression such as helplessness and loss of interest. However they also found that they also found that the effect from lower or worse mood friends was not strong enough to push the other friends into depression.

    Using mathematical modelling they found that having more friends who suffer worse moods is associated with a higher probability of an individual experiencing low moods and a decreased probability of improving. They found the opposite applied to adolescents who had a more positive social circle.

    Public health statistics researcher Rob Eyre led the study. He said: “We investigated whether there is evidence for the individual components of mood (such as appetite, tiredness and sleep) spreading through US adolescent friendship networks while adjusting for confounding by modelling the transition probabilities of changing mood state over time.

    “Evidence suggests mood may spread from person to person via a process known as social contagion.

    “Previous studies have found social support and befriending to be beneficial to mood disorders in adolescents while recent experiments suggest that an individual’s emotional state can be affected by exposure to the emotional expressions of social contacts.

    “Clearly, a greater understanding of how changes in the mood of adolescents are affected by the mood of their friends would be beneficial in informing interventions tackling adolescent depression.”

    The World Health Organisation has estimated that depression affects 350 million people across the world, impacting on individual’s abilities to work and socialise and at worse leading to suicide. This study’s findings emphasise the need to also consider those who exhibit levels of depressive symptoms just below those needed for a diagnosis of actual depression when designing public health interventions.

    The study also helps confirm that there is more to depression than simply low mood. At the individual level, these findings imply that following the evidence-based advice for improving mood, e.g. exercise, sleeping well, and managing stress, can help a teenager’s friends as well as themselves. Whilst for depression, friends do not put an individual at risk of illness so a recommended course of action would be to show them support.

    Their conclusions link in to current policy discussions on the importance of sub-threshold levels of depressive symptoms and could help inform interventions against depression in senior schools

    Co-author, professor Frances Griffiths of Warwick Medical School said: “The results found here can inform public health policy and the design of interventions against depression in adolescents. Sub-threshold levels of depressive symptoms in adolescents is an issue of great current concern as they have been found to be very common, to cause a reduced quality of life and to lead to greater risk of depression later on in life than having no symptoms at all.

    “Understanding that these components of mood can spread socially suggests that while the primary target of social interventions should be to increase friendships because of its benefits in reducing of the risk of depression, a secondary aim could be to reduce spreading of negative mood.”


  5. Feeling bad about feeling bad can make you feel worse

    August 27, 2017 by Ashley

    From the University of California – Berkeley press release:

    Pressure to feel upbeat can make you feel downbeat, while embracing your darker moods can actually make you feel better in the long run, according to new UC Berkeley research.

    “We found that people who habitually accept their negative emotions experience fewer negative emotions, which adds up to better psychological health,” said study senior author Iris Mauss, an associate professor of psychology at UC Berkeley.

    At this point, researchers can only speculate on why accepting your joyless emotions can defuse them, like dark clouds passing swiftly in front of the sun and out of sight.

    Maybe if you have an accepting attitude toward negative emotions, you’re not giving them as much attention,” Mauss said. “And perhaps, if you’re constantly judging your emotions, the negativity can pile up.”

    The study, conducted at UC Berkeley and published in the Journal of Personality and Social Psychology, tested the link between emotional acceptance and psychological health in more than 1,300 adults in the San Francisco Bay Area and the Denver, Co., metropolitan area.

    The results suggest that people who commonly resist acknowledging their darkest emotions, or judge them harshly, can end up feeling more psychologically stressed.

    By contrast, those who generally allow such bleak feelings as sadness, disappointment and resentment to run their course reported fewer mood disorder symptoms than those who critique them or push them away, even after six months.

    “It turns out that how we approach our own negative emotional reactions is really important for our overall well-being,” said study lead author Brett Ford, an assistant professor of psychology at the University of Toronto. “People who accept these emotions without judging or trying to change them are able to cope with their stress more successfully.”

    Three separate studies were conducted on various groups both in the lab and online, and factored in age, gender, socio-economic status and other demographic variables.

    “It’s easier to have an accepting attitude if you lead a pampered life, which is why we ruled out socio-economic status and major life stressors that could bias the results,” Mauss said.

    In the first study, more than 1,000 participants filled out surveys rating how strongly they agreed with such statements as “I tell myself I shouldn’t be feeling the way that I’m feeling.” Those who, as a rule, did not feel bad about feeling bad showed higher levels of well-being than their less accepting peers.

    Then, in a laboratory setting, more than 150 participants were tasked with delivering a three-minute videotaped speech to a panel of judges as part of a mock job application, touting their communication skills and other relevant qualifications. They were given two minutes to prepare.

    After completing the task, participants rated their emotions about the ordeal. As expected, the group that typically avoids negative feelings reported more distress than their more accepting peers.

    In the final study, more than 200 people journaled about their most taxing experiences over a two-week period. When surveyed about their psychological health six months later, the diarists who typically avoided negative emotions reported more mood disorder symptoms than their nonjudgmental peers.

    Next, researchers plan to look into such factors as culture and upbringing to better understand why some people are more accepting of emotional ups and downs than others.

    “By asking parents about their attitudes about their children’s emotions, we may be able to predict how their children feel about their emotions, and how that might affect their children’s mental health,” Mauss said.

    In addition to Mauss and Ford, Oliver John at UC Berkeley and Phoebe Lam of Northwestern University are co-authors on the paper. The research was funded by the National Institute on Aging.


  6. Day-to-day experiences affect awareness of aging, mood

    August 8, 2017 by Ashley

    From the North Carolina State University press release:

    A study of older adults finds an individual’s awareness of aging is not as static as previously thought, and that day-to-day experiences and one’s attitude toward aging can affect an individual’s awareness of age-related change (AARC) — and how that awareness affects one’s mood.

    “People tend to have an overall attitude toward aging, good or bad, but we wanted to know whether their awareness of their own aging — or AARC — fluctuated over time in response to their everyday experiences,” says Shevaun Neupert, an associate professor of psychology at North Carolina State University and lead author of a paper on the study.

    For the study, researchers enrolled 116 participants between the ages of 60 and 90. Each participant took a survey to establish baseline attitudes toward aging. For the following eight days, participants kept a log of daily stressors (such as having an argument), completed a daily evaluation of age-related experiences (such as “I am becoming wiser” or “I am more slow in my thinking”), and reported on their affect, or mood.

    “We found that people’s AARC, as reflected in their daily evaluations, varied significantly from day to day,” says Jennifer Bellingtier, a recent Ph.D. graduate from NC State and co-author of the paper. “We also found that people whose baseline attitudes toward aging were positive also tended to report more positive affect, or better moods.”

    People with positive attitudes toward aging were also less likely to report ‘losses,’ or negative experiences, in their daily aging evaluations,” Neupert says.

    “However, when people with positive attitudes did report losses, it had a much more significant impact on their affect that day,” Neupert says. “In other words, negative aging experiences had a bigger adverse impact on mood for people who normally had a positive attitude about aging.”

    The study expands on previous work that found having a positive attitude about aging makes older adults more resilient when faced with stressful situations.


  7. Study links rude customers to workers’ shopping binges

    August 5, 2017 by Ashley

    From the Michigan State University press release:

    Service workers who face verbal abuse from customers during the workday are more likely to go on unnecessary shopping sprees in the evening, indicates new research co-authored by a Michigan State University business expert.

    The study of 94 call-center workers at a large bank in China found that customer mistreatment (e.g., customers who yelled, argued, swore, etc.) put the employees in a bad mood after work. This, in turn, led to damaging thoughts (ruminating about the mistreatment) and behaviors (impulse shopping).

    “Thus, stress from customers spills over to spoil people’s experiences outside of work,” said Russell Johnson, MSU associate professor of management.

    The findings from Johnson and colleagues — who surveyed employees multiple times per day for 15 consecutive workdays — are published online in the Academy of Management Journal.

    The researchers also tested two interventions and found a potential solution to the problem.

    On days when workers who thought about a recent incident where they helped customers (a “recall of prosocial action intervention”) or thought about an interaction from the customer’s viewpoint (a “perspective-taking intervention”) before starting work, it reduced their perceptions of mistreatment, reduced their negative mood and led to less rumination and impulse shopping.

    Becoming more prosocial shifts attention away from the self and reduces impulsive and individualistic acts, according to the study.

    “These recall and perspective-taking interventions are quick and easy exercises that customer-service employees can do prior to beginning the workday to reduce the stress from rude customers,” Johnson said.


  8. Study suggests association between gut bacteria and emotion

    July 19, 2017 by Ashley

    From the University of California – Los Angeles Health Sciences press release:

    Researchers have identified gut microbiota that interact with brain regions associated with mood and behavior. This may be the first time that behavioral and neurobiological differences associated with microbial composition in healthy humans have been identified.

    Brain-gut-microbiota interactions may play an important role in human health and behavior. Previous research suggests that microbiota, a community of microorganisms in the gut, can influence behavior and emotion. Rodent models have demonstrated the effects of gut microbiota on emotional and social behaviors, such as anxiety and depression. There is, however, little evidence of this in humans.

    For this study the researchers sought to identify brain and behavioral characteristics of healthy women clustered by gut microbiota profiles.

    Forty women supplied fecal samples for profiling, and magnetic resonance images were taken of their brains as they viewed images of individuals, activities or things that evoked emotional responses. The women were divided by their gut bacteria composition into two groups: 33 had more of a bacterium called Bacteroides; the remaining seven had more of the Prevotella bacteria. The Bacteroides group showed greater thickness of the gray matter in the frontal cortex and insula, brain regions involved with complex processing of information. They also had larger volumes of the hippocampus, a region involved in memory processing. The Prevotella group, by contrast, showed more connections between emotional, attentional and sensory brain regions and lower brain volumes in several regions, such as the hippocampus. This group’s hippocampus was less active while the women were viewing negative images. They also rated higher levels of negative feelings such as anxiety, distress and irritability after looking at photos with negative images than did the Bacteroides group.

    These results support the concept of brain-gut-microbiota interactions in healthy humans. Researchers do not yet know whether bacteria in the gut influence the development of the brain and its activity when unpleasant emotional content is encountered, or if existing differences in the brain influence the type of bacteria that reside in the gut. Both possibilities, however, could lead to important changes in how one thinks about human emotions.


  9. Study suggests cycling can help reduce stress, improve work performance

    July 9, 2017 by Ashley

    From the Concordia University press release:

    New research from Concordia’s John Molson School of Business (JMSB) has found that cycling can help reduce stress and improve your work performance.

    Researchers Stéphane Brutus, Roshan Javadian and Alexandra Panaccio compared how different modes of commuting — cycling, driving a car and taking public transport — affected stress and mood at work. The study was published in the International Journal of Workplace Health Management.

    Its results indicate that cycling to work is a good way to have a good day, says Brutus, the lead author. “Employees who cycled to work showed significantly lower levels of stress within the first 45 minutes of work than those who travelled by car,” he says.

    The study did not, however, find any difference in the effect on mood.

    The research team collected data from 123 employees at Autodesk, an information technology company in Old Montreal, using a web-based survey. Respondents replied to questions about their mood, perceived commuting stress and mode of travel.

    The survey differentiated between perceived stress and mood, a more transient state affected by personality traits and emotions.

    The study only assessed answers from respondents who had completed the questionnaire within 45 minutes of arriving at work. This was done to get a more ‘in-the-moment’ assessment of employees’ stress and mood.

    Brutus notes that this time specification was the study’s major innovation.

    “Recent research has shown that early morning stress and mood are strong predictors of their effect later in the day,” he explains. “They can shape how subsequent events are perceived, interpreted and acted upon for the rest of the day.”

    He adds that the time specification ensured a more precise picture of stress upon arrival at work. Retrospective assessments can be coloured by stressors that occur later in the workday.

    The advantages of cycling

    “There are relatively few studies that compare the affective experiences of cyclists with those of car and public transport users,” says Brutus, an avid cyclist himself. “Our study was an attempt to address that gap.”

    At the same time, the team confirmed previous research that found that cyclists perceived their commute as being less stressful than those who travelled by car.

    Cycling has been shown to be a relatively inexpensive mode of transportation and a good form of physical activity. A 2015 study from the Institute for Transportation and Development Policy found that cycling could help reduce CO2 emissions from urban passenger transportation by 11 per cent by 2050. It could also save society US$24 trillion globally between 2015 and 2050.

    Brutus points out that 6 per cent of Canadians cycled to work in 2011 and the number is only growing. However, Canada still lags behind many European countries.

    There is potential for public policy makers to seize on this, he adds.

    “With growing concerns about traffic congestion and pollution, governments are increasingly promoting non-motorized alternative modes of transport, such as walking and cycling. I can only hope that further studies will follow our lead and develop more precise and deliberate research into this phenomenon.”


  10. Probiotic use linked to improved symptoms of depression

    June 8, 2017 by Ashley

    From the McMaster University press release:

    Probiotics may relieve symptoms of depression, as well as help gastrointestinal upset, research from McMaster University has found.

    In a study published in the medical journal Gastroenterology, researchers of the Farncombe Family Digestive Health Research Institute found that twice as many adults with irritable bowel syndrome (IBS) reported improvements from co-existing depression when they took a specific probiotic than adults with IBS who took a placebo.

    The study provides further evidence of the microbiota environment in the intestines being in direct communication with the brain said senior author Dr. Premysl Bercik, an associate professor of medicine at McMaster and a gastroenterologist for Hamilton Health Sciences.

    “This study shows that consumption of a specific probiotic can improve both gut symptoms and psychological issues in IBS. This opens new avenues not only for the treatment of patients with functional bowel disorders but also for patients with primary psychiatric diseases,” he said.

    IBS is the most common gastrointestinal disorder in the world, and is highly prevalent in Canada. It affects the large intestine and patients suffer from abdominal pain and altered bowel habits like diarrhea and constipation. They are also frequently affected by chronic anxiety or depression.

    The pilot study involved 44 adults with IBS and mild to moderate anxiety or depression. They were followed for 10 weeks, as half took a daily dose of the probiotic Bifidobacterium longum NCC3001, while the others had a placebo.

    At six weeks, 14 of 22, or 64%, of the patients taking the probiotic had decreased depression scores, compared to seven of 22 (or 32%) of patients given placebo.

    Functional Magnetic Resonance Imaging (fMRI) showed that the improvement in depression scores was associated with changes in multiple brain areas involved in mood control.

    “This is the result of a decade long journey — from identifying the probiotic, testing it in preclinical models and investigating the pathways through which the signals from the gut reach the brain,” said Bercik.

    “The results of this pilot study are very promising but they have to be confirmed in a future, larger scale trial,” said Dr. Maria Pinto Sanchez, the first author and a McMaster clinical research fellow.