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Published in final edited form as: J Subst Use Addict Treat. 2023 May 26;151:209085. doi: 10.1016/j.josat.2023.209085

Psychometric properties of the Treatment Effectiveness Assessment in methamphetamine use disorder

Hoa T Vo 1, Alexandra Kulikova 1, Taryn L Mayes 1, Thomas Carmody 1,2, Steve Shoptaw 3, Walter Ling 3, Joseph M Trombello 1, Madhukar H Trivedi 1
PMCID: PMC10977640  NIHMSID: NIHMS1970878  PMID: 37245855

Abstract

Introduction:

The ability for people living with stimulant use disorder to live meaningful lives requires not only abstinence from addictive substances, but also healthy engagement with their community, lifestyle practices, and overall health. The Treatment Effectiveness Assessment (TEA) assesses components of recovery consisting of four functional domains: substance use, health, lifestyle, and community. This secondary data analysis of 403 participants with severe methamphetamine use disorder tested the reliability and validity of the TEA.

Methods:

Participants were enrolled in the Accelerated Development of Additive Pharmacotherapy Treatment (ADAPT-2) for methamphetamine use disorder. The study used total TEA and domain scores at baseline to assess factor structure and internal consistency, as well as construct validity related to substance cravings (visual analog scale [VAS]), quality of life (quality-of-life assessment [QoL]), mental health (Patient Health Questionnaire-9 [PHQ-9], Concise Health Risk Tracking Scale Self-Report [CHRT-SR16]), and social support (CHRT-SR16).

Results:

Individual TEA items showed moderate to large correlations with each other (r=0.27–0.51; p<.001), and strong correlations to the total score (r=0.69–0.78; p<.001). Internal consistency was strong (coefficient α=0.73 [0.68–0.77]; coefficient ω=0.73 [0.69–0.78]). Construct validity was acceptable, with the strongest correlation between the TEA Health item and the general health status item on the QoL (r=0.53, p<.001).

Conclusions:

TEA has acceptable levels of reliability and validity supporting prior similar findings in a sample of participants with moderate to severe methamphetamine use disorder. Results from this study provide support for its use in assessing clinically meaningful changes beyond simply reduced substance use.

Keywords: Functioning, Methamphetamine use disorder, Stimulant use, Substance use disorder, Psychometric analysis

1. Introduction

Stimulant misuse is a global public health concern associated with a range of negative physical, psychiatric, and socioeconomic outcomes (Bazmi et al., 2017; Cai et al., 2020; McKetin et al., 2019). The rise in stimulant use, including methamphetamine use, in the United States necessitates the development of both successful treatments and psychometrically sound instruments to measure treatment outcomes (Ciccarone, 2021; Hedegaard et al., 2020).

Existing stimulant use research has primarily focused on evaluating the reduction in frequency of stimulant use, abstinence from stimulants during trial periods, and prevention of stimulant use relapse as successful treatment outcomes (Fishman et al., 2020). Although these are important measures of treatment outcome, they do not address other factors that should improve with treatments for stimulant use disorder. For example, measurable improvements in quality of life, physical and mental health, positive engagement with community, employment, and lifestyle practices are important areas (Hennessy, 2017; Ling et al., 2019; Molina Fernández et al., 2021). Many of the measures that examine these important domains are lengthy, and thus not feasible to implement clinically or in research (Ling et al., 2012). The Treatment Effectiveness Assessment (TEA) is a four-item patient-centered instrument developed to evaluate level of satisfaction with four domains of functioning that should be linked with treatment outcome in patients in addiction treatment: substance use, physical and mental health, lifestyle practices, and community involvement (Ling et al., 2012; Ling et al., 2019).

This research continues work by our group to develop valid and reliable self-report measures to evaluate improvements during treatments for stimulant use disorder. A recent article provided evidence of acceptable reliability and validity of TEA in a sample of participants with opioid use disorder (OUD) (Ling et al., 2019). The current article investigates the psychometric properties of TEA in a multi-site sample of adults who participated in an outpatient clinical trial investigating the efficacy of extended-release naltrexone in combination with high dose oral bupropion versus placebo for methamphetamine use disorder (MUD) (Trivedi et al., 2021). Specifically, we address the following questions:

  1. Does the factor structure of the TEA found in patients with OUD replicate in patients with MUD?

  2. Does the scale demonstrate adequate internal consistency in a sample of moderate-to-severe methamphetamine users?

  3. Does evidence exist of construct validity for the scale?

2. Methods

This article reports on ad hoc analyses using data obtained in the Accelerated Development of Additive Pharmacotherapy Treatment (ADAPT-2) for Methamphetamine Use Disorder clinical trial. The study team carried out the study in accordance with the Declaration of Helsinki, and a central Institutional Review Board and four sites’ Institutional Review Boards approved the study. All participants provided a written informed consent prior to initiating any study procedures.

2.1. Participants

Participants (n=403) were outpatients, ages 18–65 years, with moderate to severe MUD based on the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and reported methamphetamine use at least 18 out of 30 days on the Timeline Follow-Back prior to study enrollment (American Psychiatric Association, 2013). Participants undergoing substance use treatment, needing opioid medications during the study, or having other contraindicated medical conditions were excluded from the study. Additional details about inclusion and exclusion criteria are available in Trivedi et al. (2021).

2.2. Design

ADAPT-2 was a randomized, double-blind trial, comparing the efficacy and safety of extended-release injectable naltrexone (380 mg every 3 weeks) combined with once-daily oral extended-release bupropion (450 mg per day) compared with matching injectable and oral placebo. The study was a 12-week study that used a sequential parallel comparison design, in which the study randomized participants in a 0.26:0.74 ratio of active treatment to placebo during the first 6 weeks; the study then re-randomized nonresponders to placebo in the first stage in a 1:1 ratio of active treatment to placebo for an additional 6 weeks (Trivedi et al., 2021). Thus, for the analyses of the baseline data of the study, 26% were randomized to active treatment of injectable naltrexone plus oral bupropion, and 74% were randomized to placebo.

2.3. Measures

Participants completed all measures several times during the study. For these analyses, we use measures completed at baseline.

2.3.1. Treatment Effectiveness Assessment (TEA)

The TEA evaluates four domains of functioning: substance use, health, lifestyle, and community, and creates a global index of outcomes for individuals engaged in treatment for stimulant use disorder (Ling et al., 2012; Ling et al., 2019), and has demonstrated acceptable psychometric properties in adults with OUD (Ling et al., 2019). Specific questions include:

  1. Substance Use: How much better are you with drug and alcohol use? Consider the frequency and amount of use, money spent on drugs, amount of drug craving, time spent being loaded, being sick, in trouble and in other drug-using activities, etc.?

  2. Health: Has your health improved? In what way and how much? Think about your physical and mental health: Are you eating and sleeping properly, exercising, taking care of health problems or dental problems, feeling better about yourself, etc.?

  3. Lifestyle: How much better are you in taking care of personal responsibilities? Think about your living conditions, family situation, employment, relationships: Are you paying your bills? Following through with your personal or professional commitments?

  4. Community: Are you a better member of the community? Think about things like obeying laws and meeting your responsibilities to society: Do your actions have positive or negative impacts on other people?

The measure includes the following instructions for rating each item:

“The TEA asks you to express the extent of changes for the better from your involvement in the program to this point (or how things are if it’s your first TEA or baseline) in four areas: substance use, health, lifestyle, and community. For each area, think about how things have become better and circle the results on the scale below: the more you have improved, the higher the number – from 1 (not better at all) to 10 (very much better).” Thus, higher scores indicate better or improved functioning.

The study used other measures to monitor clinical symptoms, and we used them to examine construct validity. We discuss these measures below.

2.3.2. Cravings

The study assessed substance craving using the Visual Analogue Scale (VAS) (McHugh et al., 2014). The VAS ranges from 0 (no craving) to 100 (most intense craving possible).

2.3.3. Quality of Life

We assessed quality of life (QoL) using items from the PhenX Core Tier 1. (Hamilton et al., 2011) Participants were asked to provide a rating of general health on a scale from 1 (“Excellent”) to 5 (“Poor”). Participants also rated the number of days in the past 30 in which their physical health and mental health were “not good” and the number of days in which bad physical or mental health kept them from “usual activities, such as self-care, work, or recreation”. The study summed these three ratings to create a total score. Higher scores indicate poorer quality of life.

2.3.4. Depression

The 9-item Patient Health Questionnaire (PHQ-9) assessed the extent to which participants have been affected by the nine symptoms of a major depressive episode over the last two weeks, with item-level responses ranging from 0 (“not at all”) to 3 (“nearly every day”) and the total score ranging from 0 to 27, with higher scores indicating greater depression severity (Kroenke et al., 2001).

2.3.5. Suicidality and lack of social support

The 16-item Concise Health Risk Tracking Self-Report (CHRT-SR16) examined suicidal risk, and the study used two items from the CHRT-SR16 to examine social support: Item 5 (“There is no one I can depend on”) and Item 6 (“The people I care the most for are gone”). All items are rated on a 5-point scale from 0 (“strongly disagree”) to 4 (“strongly agree”), where higher scores indicate greater suicidal risk (total score) and poorer social support (social support subscale). The CHRT-SR has demonstrated reliability and validity in adults with depression, bipolar disorder, suicidality, and stimulant use disorder (Ostacher et al., 2015; Reilly-Harrington et al., 2016; Sanchez et al., 2018; Trivedi et al., 2011; Villegas et al., 2018).

2.4. Statistical analyses

A confirmatory factor analysis (CFA) tested TEA as a global measure of recovery from substance use under a single-factor CFA framework. The CFA model was fit using a diagonally weighted least squares (WLSMV) estimator with robust standard errors given the ordinal-level item responses and nonnormal item distributions. (Li, 2016; Suh, 2015) The team evaluated the model fit using root mean square error of approximation (RMSEA) ≤ 0.06 (90% CI ≤ 0.08), standardized root mean square residual (SRMR) ≤ 0.08, comparative fit index (CFI) ≥ 0.95, Tucker-Lewis Index (TLI) ≥ 0.95, and the weighted root mean square residual (WRMR) ≤ 1.00 (Brown, 2015; DiStefano et al., 2018; Hu & Bentler, 1999). We also evaluated standardized factor loadings to detect item misfit.

The study team evaluated the internal consistency reliability of TEA using coefficients alpha (α) and omega (ω). Acceptable reliability was indicated by coefficient values ≥ 0.70. (Hair et al., 2010) Coefficient ω does not assume equal factor loadings (essential tau equivalence), making it a more general estimator of reliability (Hayes & Coutts, 2020).

We evaluated construct validity by assessing the Spearman ρ correlation coefficient among TEA total score, its subscales, and quality of life measures, PHQ-9 total score, CHRT-SR16 Total score and Social Support subscale, and VAS at baseline. We hypothesized that the TEA would have negative correlations with each of these measures.

The study team conducted all statistical analyses using R statistical software (version 4.1.1) or SAS version 9.4, with CFA fitted using R package lavaan, and we obtained reliability and validity estimates using R package psych (Revelle, 2017; Rosseel, 2012).

3. Results

This analysis of baseline data included all randomized participants (N = 403), who were primarily male (n = 277, 68.7%), middle-aged (M: 41.0 years, SD: 10.1 years), and White (n = 287, 71.2%), with 55 participants (13.6%) of Hispanic or Latino ethnicity. Only about a third of the sample was employed. Table 1 provides the demographic and clinical characteristics of the sample.

Table 1.

Baseline Demographic and Clinical Characteristics (n=403)

N (%)
Males 277 (68.7%)
Hispanic/Latino 55 (13.6%)
Race
White 287 (71.2%)
Black 48 (11.9%)
Other 68 (16.9%)
Employed 156 (38.7%)
Most frequent route of methamphetamine use
Smoking 293 (72.7%)
Intravenous 77 (19.1%)
Nasal or Oral 33 (8.2%)
Mean SD
Age (years) 40.8 10.1
Days methamphetamine use (in 30 days before consent) 26.7 4.1
TEA Total 18.3 7.2
Substance Use 3.6 2.4
Health 4.4 2.2
Lifestyle 4.5 2.6
Community 5.8 2.5
VAS Total 66.1 22.3
QoL Total 34.0 22.9
Days Physical Health Not Good 7.1 9.6
Days Mental Health Not Good 15.4 10.7
Days Activities Restricted 9.9 9.5
PHQ-9 Total 10.9 6.5
CHRT-SR Total 38.8 11.6
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Individual TEA items showed moderate-to-large positive correlations with each other, with the weakest correlation between the substance use and the lifestyle items (ρ = 0.27, p < .001) and the strongest correlation between the community and lifestyle items (ρ =0.51, p < .001). All correlation coefficients were statistically significant at p < 0.001 (Table 2).

Table 2.

TEA Spearman Correlation Matrix

N = 403 Substance Use Health Lifestyle Community
Health 0.46
Lifestyle 0.27 0.42
Community 0.34 0.42 0.51
TEA Total 0.69 0.75 0.75 0.78
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Note. All correlation coefficients are statistically significant at p < .001.

3.1. TEA factor structure

The one-factor model of TEA as a global recovery index yielded mixed findings with respect to model fit based on the goodness-of-fit indices (RMSEA = 0.151 [90% CI .096–.213]; CFI = 0.930; TFI = 0.791; SRMR = 0.039; WRMR = 0.739). The standardized loadings on the global TEA recovery index ranged from 0.525 for the Substance Use item to 0.693 for the Community item.

3.2. TEA internal consistency

Both coefficients α and ω were 0.73 for TEA, suggesting acceptable internal consistency. The “coefficient α if item deleted” was the lowest when the community and the health items were held out (0.64 for both) and the highest when the substance use item was held out from analysis (0.71). Table 3 provides a summary of reliability coefficients for TEA.

Table 3.

Coefficients Alpha and Omega (Internal Consistency)

N α [95% CI] ω [95% CI]
TEA Total 403 0.73 [.68–.77] .73 [.69–.78]
α if Substance Use item is deleted 0.71
α if Health item is deleted 0.64
α if Lifestyle item is deleted 0.67
α if Community item is deleted 0.64
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3.3. TEA construct validity

The TEA scale and its individual domains exhibited acceptable construct validity. The total TEA score and individual items also showed a moderate negative correlation across all QoL measures (ρ = −0.14 to −0.53, all p < 0.01), including general health, physical and mental health, the activity limitation item (“During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?”), and the QoL total score. The strongest negative correlation was seen between the TEA Health item and the general health status item on the quality-of-life measure (“Would you say that in general your health is”) (ρ = −0.53, p < .001). Compared to other TEA items, the Substance Use item had the weakest correlations with all QoL items (ρ= −0.14 to −0.26, all p < 0.01); however, all correlations were statistically significant. The TEA Substance Use item had a weak negative correlation with craving, as measured by VAS (ρ = −0.17, p < .001), suggesting greater recovery on the substance use domain is associated with lower craving. The TEA total score and all items also demonstrated acceptable construct validity with the PHQ-9 total score (ρ = −0.18 to −0.40, all p < .001). Finally, both the CHRT-SR16 total score and the social support score (higher values indicate a lack of social support) on CHRT-SR16 showed a weak negative correlation and a moderate negative correlation with TEA social support score (ρ = −0.05 to −0.20) and total score (ρ = −0.12 to −0.37, all p < 0.05), respectively. Table 4 shows the TEA scale and item correlations with VAS, quality of life, and CHRT-SR16 measures.

Table 4.

TEA Construct Validity. Correlation Coefficients (Spearman ρ) for each domain of TEA

QoL Items CHRT-SR16
VAS PHQ-9 QOL Total Score Physical Health Mental R Health A Restricted Activities QoL General Health Lack of Social Support Total
Substance Use −0.17*** −0.18*** −0.23*** −0.14** −0.22*** −0.20*** −0.26*** −0.05 −0.12*
Health −0.02 −0.32*** −0.43*** −0.36*** −0.34*** −0.35*** −0.53*** −0.09 −0.23***
Lifestyle −0.10* −0.36*** −0.42*** −0.28*** −0.32*** −0.41*** −0.31*** −0.20*** −0.37***
Community −0.13** −0.32*** −0.33*** −0.21*** −0.28*** −0.33*** −0.28*** −0.15** −0.31***
TEA Total −0.14*** −0.40*** −0.46*** −0.30*** −0.39*** −0.44*** −0.46*** −0.16** −0.34***
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Note.

*

Statistically significant p < 0.05;

**

Statistically significant at p < 0.01;

***

Statistically significant at p < .001.

4. Discussion

We examined the psychometric properties of the TEA, a 4-item self-report scale assessing treatment outcome in four life domains that define recovery, in a cohort with moderate to severe MUD. The results showed that the TEA, as a global index of recovery, has acceptable reliability and validity, affirming prior findings in patients recovering from OUD and extending its use to patients recovering from MUD (Ling et al., 2019).

We examined the TEA factor structure with four items representing a single latent global recovery index. The TEA single-factor model demonstrated poor-to-average model fit. Given the small number of items on the scale and their moderate inter-item correlations, the development of additional items may improve the global model fit. However, the TEA’s simplicity and ease of administration are its special strengths; users should balance the cost/benefit ratio of adding new items to the scale.

The TEA demonstrated acceptable internal consistency and construct validity. Its reliability without the community and health items showed the largest decrease, suggesting the relative importance of these items to recovery.

The global TEA score exhibited moderate negative correlations with all the quality of life measures, including the number of “not good” physical and mental health days in the past month, suggesting that overall methamphetamine use recovery is associated with a greater number of good quality of life days, as well as fewer days that limit activities. Among individual TEA items, the substance use item had the weakest association with all QoL domains, while the health and lifestyle TEA items showed the strongest relationship, perhaps suggesting that the health and lifestyle aspects of recovery are more strongly associated with improvements in QoL. Given that most clinical trials focus on the change in symptom severity, the findings here underscore the importance of functional improvements and quality of life (Laudet, 2011; Ling et al., 2012; Tiffany et al., 2012).

The study has some limitations. The sample had a relatively low representation of women, although the ratio is consistent with ratios of methamphetamine use in the US population. In addition, we are unable to use intraclass correlations (ICCs) to calculate the test-retest reliability of the measure because the TEA was only completed at baseline and week 6 of the ADAPT-2 study. Test-retest reliability using ICCs should be assessed over a short period of time where we would not expect any real change in the measure. Since the TEA is only assessed at baseline and week 6, real changes in the TEA could occur, which would be confounded with measurement error. A limitation of the scale is that it may be confusing for administration at baseline (or prior to treatment initiation). The intent of the scale is to evaluate treatment effectiveness, and therefore the questions are framed in a way that suggest potential improvement, which is unlikely before starting treatment. For research, the instructions clarify to respond, “how things are going if it’s your first TEA or baseline”, yet the overall instructions refer to “the extent of changes for the better” and “think about how things have become better”, which all lead to possibly differential interpretation of items for each participant. Thus, the psychometric properties of the scale at baseline could be affected. Finally, we are uncertain as to why the Community score worsened over time. The Community item asks about obeying laws, meeting responsibilities to society, and impact of actions on others. Participants who were reducing their substance use may became more cognizant of their impact on society or that they were limiting exposure with friends who were still using, thereby increasing their awareness or perception of their personal negative impact on the community, but we cannot know for certain why this item worsened over time.

Despite these limitations, the overarching purpose of the TEA was to provide a brief, easy-to-administer measure that is patient-oriented and allows patients to express their perception of overall improvement (or lack thereof) in areas most important to them: substance use, health, lifestyle, and community (Ling et al., 2012). Equally important was to create a measure that could be easily incorporated into clinical care. Although some measures have items assessing each distinct aspect of functioning, these measures are often long and therefore not feasible for use in clinical settings. The TEA is a psychometrically sound and practical measure that assesses meaningful life change during substance use recovery from the patient’s perspective.

5. Conclusion

Clinically useful and psychometrically sound measures are needed to quantify substance use recovery and enable clinicians to evaluate meaningful life changes during recovery from the patients’ perspective. This study demonstrated acceptable internal consistency and reliability and construct validity of the TEA in a sample of outpatient adults with moderate to severe MUD, extending the previous findings in OUD, suggesting that the TEA can potentially be a useful tool to efficiently evaluate gains in recovery in individuals with MUD (Ling et al., 2019). Furthermore, the TEA evaluates important functional domains and recovery outcomes beyond reductions in substance use, while also reducing assessment burden.

HIGHLIGHTS.

  • TEA is psychometrically sound among methamphetamine use disorder patients.

  • TEA can be a useful tool to evaluate gains in recovery in individuals with MUD.

  • Results support using TEA to assess changes beyond simply reduced substance use

ACKNOWLEDGEMENTS

We thank the study participants, without whom this research would not have been possible. We also thank the staff at the following participating study sites for their collaboration and diligent work conducting CTN-0068 ADAPT-2: Behavioral Health Services of Pickens County, SC; CODA, Inc., Portland, OR; Hennepin County Medical Center - Berman Center for Research, Minneapolis, MN; New York State Psychiatric Institute - Substance Use Research Center, New York, NY; Substance Use Research Unit at the San Francisco Department of Public Health, San Francisco, CA; University of California Los Angeles Center for Behavioral Addiction Medicine, Los Angeles, CA; University of Texas Health Center for Neurobehavioral Research on Addiction, Houston, TX; University of Texas Southwestern Medical Center, Dallas, TX. Most importantly, we thank the individuals who volunteered to participate in the study. In addition, we thank our collaborators during the study: the Clinical Coordinating Center at The Emmes Company, particularly Matthew Wright and Eve Jelstrom; the Data and Statistics Center at The Emmes Company, particularly Catherine Mudrick, Ashley Case, and Jacquie King; AiCure, particularly Brien Hawley, Laura Schafner, and Gordon Kessler; Angela Casey-Willingham for her assistance monitoring study implementation. We thank Kathryn Forbes for her administrative assistance.

PRIMARY FUNDING

Support provided through the National Institute on Drug Abuse of the National Institutes of Health under Award Numbers UG1DA020024 (PI: Madhukar H. Trivedi), UG1DA013035 (PIs: Edward V. Nunes, John Rotrosen), UG1DA040316 (PIs: Gavin Bart, Anne Joseph), UG1DA013727 (PI: Kathleen T. Brady), UG1DA015815 (PIs: James L. Sorensen, Dennis McCarty). Support also provided through the Department of Health and Human Services under Contract No. HHSN271201500065C (Clinical Coordinating Center, The Emmes Company, PI: Robert Lindblad) and HHSN271201400028C (Data and Statistics Center, The Emmes Company, PI: Paul Van Veldhuisen). Alkermes, Inc. provided VIVITROL® (naltrexone for extended-release injectable suspension) and matched placebo free of charge for use in this study under a written agreement with NIDA. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Alkermes, Inc.

Footnotes

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DECLARATIONS OF COMPETING INTEREST

In the last 36 months, Dr. Carmody has served as a consultant for Alkermes. Dr. Trombello was a paid consultant for Alto Neuroscience; and currently owns stock in Merck. Dr. Shoptaw has served as a consultant or advisor for Alkermes, Inc., Gilead Services, Inc., and Indivior, Inc. Dr. Trivedi has served as a consultant or advisor for Acadia Pharmaceuticals Inc., Akili Interactive, Alkermes Inc, Allergan Sales LLC, Alto Neuroscience, Inc., Applied Clinical Intelligence, LLC (ACI), Axome Therapeutics, Boehringer Ingelheim, Engage Health Media, Gh Research, GreenLight VitalSign6, Inc., Heading Health, Inc., Health Care Global Village, Janssen – Cilag.SA, Janssen Research and Development, LLC (Adv Committee Esketamine), Janssen Research and Development, LLC (panel for study design for MDD relapse), Janssen - ORBIT, Legion Health, Jazz Pharmaceuticals, LUNDBECK RESEARCH U.S.A, Medscape, LLC, Merck Sharp & Dohme Corp., Mind Medicine (MindMed) Inc., Myriad Neuroscience, Neurocrine Biosciences Inc, Navitor, Pharmaceuticals, Inc., Noema Pharma AG, Orexo US Inc., Otsuka Pharmaceutical Development & Commercialization, Inc. (PsychU, MDD Section Advisor), Otsuka America Pharmaceutical, Inc. (MDD expert), Pax Neuroscience, Perception Neuroscience Holdings, Inc., Pharmerit International, LP, Policy Analysis Inc., Sage, Therapeutics, Rexahn Pharmaceuticals, Inc., Sage Therapeutics, Signant Health, SK Life Science, Inc., Takeda Development Center Americas, Inc., The Baldwin Group, Inc., and Titan Pharmaceuticals, Inc. Dr. Trivedi also received editorial compensation from Oxford University Press. Other authors have no conflicts to disclose.

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