The history of the European Federation of Psychiatric Trainees (EFPT) started almost thirty years ago. During this time, EFPT has organized an annual forum with an ever-growing number of participating countries, from nine at the beginning to 59 during the 2020 Bucharest Virtual Forum. Although there were many problems along the way, work continued in a constant matter, including during the COVID-19 pandemic. This was achieved by the hard work of the 2019-2020 board of directors and the Romanian Association of Psychiatric Trainees that fully digitalized the event. The transition to the virtual environment involved transposing the events taking place at regular congresses, including social events, and at the same time, capturing and maintaining the attention of the participants during the forum. Over the years, an infrastructure has been created within the EFPT that has allowed several development and research projects to be carried out through working groups, the partnership with Union Européenne des Médecins Spécialistes (UEMS), and through the annual EFPT Country Surveys.
trainees, federation, pandemic, forum, virtual, working groups
Federaţia Europeană a Rezidenţilor în Psihiatrie (EFPT) are un istoric de aproape 30 de ani, timp în care, anual, a organizat Forumul Federaţiei, cu un număr de ţări participante într-o creştere constantă, de la 9 la prima ediţie la 59 de ţări participante în acest an. Deşi au existat numeroase probleme, ritmicitatea întâlnirilor a fost păstrată, inclusiv în perioada pandemiei, prin digitalizarea forumului organizat de Asociaţia Medicilor Rezidenţi în Psihiatrie din România, cu sprijinului consiliului director al EFPT. Această trecere în mediul virtual a presupus transpunerea evenimentelor care se desfăşoară la congresele obişnuite – inclusiv a evenimentelor sociale – şi, în acelaşi timp, captarea şi menţinerea atenţiei participanţilor pe parcursul forumului. De-a lungul anilor, în cadrul EFPT a fost creată o infrastructură care a permis derularea mai multor proiecte de dezvoltare şi cercetare prin intermediul grupurilor de lucru, al parteneriatului cu Union Européenne des Médecins Spécialistes (UEMS) şi al rapoartelor anuale de ţară EFPT.
The European Federation of Psychiatric Trainees Forum began in 1992 in London (United Kingdom), when 16 colleagues from 9 different countries got together to explore the similarities and the differences between their training programs. One year later, in Utrecht, the Federation was formally established.
It did not take much for our hard working colleagues to set the next meeting, this time in Cork (Republic of Ireland), in April 1994. At this time, the constitution was created and the plan to expand throughout Europe, in coming years, was set in motion. Since its inception, the Federation has managed to organize a forum every year, despite facing numerous hardships, and this is a feat in itself. The latest forum was organized by the Romanian Association and, due the unfortunate global events of 2020, it was fully digitalized.
The professionalism of the Federation was quickly noticed by international and national medical associations. By the time the third meeting took place in Copenhagen (Denmark), EFPT representatives were already working in partnership with the Union Européenne des Médecins Spécialistes (UEMS), as well as with the European Boards for Psychiatry and Child and Adolescent Psychiatry.
In the years that followed, each forum brought progress and expansion – numerous statements and projects were presented, such as: “Mental Health Promotion”, “Psychotherapy in Training”, “Evaluation of Knowledge” (in Tampere, Finland), “Experience in Research” and “Exchange of Trainees” (in Napoli).
In June 2002, the Forum was organized in Sinaia, Romania, and it was for the first time that the member countries presented each a poster with the theme “Status of Psychiatric Training”. A workgroup on satisfaction concerning the psychiatric training in Europe started its activities, and since then, multiple statements have been updated.
In the following years, the EFPT consolidated. Their work included the continuous improvement of the statements, the establishment and the promotion of the European Trainee Exchange Program, and the yearly country poster presentation sessions which were gaining popularity. During this time, the website was created (during the forum from Paris, France), marking the first steps towards the digitalization of EFPT.
Considering the reasonably fast expansion, many of the countries were unable to be represented because they did not have a national trainee association. A fundamental idea of our federation is that all psychiatric trainees should be represented by a national trainee organization. As such, the Maintaining and Establishing a National Trainees’ Association Working Group (MENTA) was established during the EFPT Forum in Cambridge (UK) in 2009. Over the years, MENTA was so successful that it helped create not only national associations but international ones, such as the World Network of Psychiatric Trainees (WNPT), while also engaging and promoting the EFPT across multiple continents.
In 2010, in Brussels (Belgium), the Federation was officially registered as a European NGO with 28 member countries. Four years later, the famous “Shaping the Future of Psychiatry” motto was launched in London (UK), alongside the EFPT Newsletter. The event hosted 100 national trainee association delegates, representing 31 countries. The forum was then one of the major events for psychiatrists in Europe.
In the following year, the 2015 Porto Forum managed to host the Professors’ Norman Sartorius famous Leadership and Professional Skills Pre-Forum Course. Several great works were presented at the Scientific Program under the motto of “Global Mental Health”, which was open to medical students and junior doctors from all specialties, making it a most memorable event. Among them, “The consequences of the financial crisis on the Greek health care system – a review of a Greek tragedy” was distinguished with the prize of the best poster award, which was duly cheered in several local social celebrations, in the days of the city’s patron, Saint John. The famous Porto Research Award was established after the forum – a yearly 1000 euro award aimed to encourage psychiatric trainees to conduct research in the upcoming years(1,2).
Soon after, one of the most important works to come out of the EFPT research working group was published – the “Brain Drain” study, a study on 2281 trainees from 33 countries that shed light on the reasoning behind workforce migration of junior mental health professionals. The countries with the highest number of immigrants were UK, Switzerland and Sweden. Approximately one in twenty trainees across Europe had the perception of feeling discriminated or not having the same opportunities as the native trainees, especially concerning the work opportunities. It has also been found that the reasons for a country to become attractive to migrants are related mostly to academic opportunities and to personal reasons. At the same time, the factors that tend to induce emigration were mainly connected to academic and financial reasons. It was also noted that trainees who wanted to leave the country were significantly more dissatisfied with their income(3-5).
Work continued, and through the Federation’s long standing partnership with the UEMS and the team behind the very successful 2016 Antwerp Forum, we have learned that only a small percentage of trainees were familiar with the European guidelines in accordance to the Charter on Training of Medical Specialist. We also learned that heterogeneity in training in Europe is high and that it leads to different knowledge and skills. The work of EFPT has to continue in order to assure the quality of (mental) health care across Europe(6) by always keeping in mind that all aspects of the training process should be taken into consideration. The training program must prepare the psychiatric trainee to fulfill the following seven roles: medical expert, health advocate, communicator, collaborator, scholar, manager, professional(7,8).
In more recent years, the forums in Istanbul, Bristol and Prague registered a continuous increase in represented countries and international organizations. So much so that in Bristol the delegations occupied almost the whole of the Bristol University Campus (luckily, it was summertime), and in 2019 the MENTA working group had to look to other continents in order to find new colleagues interested in participating in the EFPTs events. And that’s how the idea behind the overseas project was conceived, and trainees from five countries outside of the WHO European Region attended the event. The Prague event was also the first that welcomed over 40 country representatives (46, to be exact).
The 2020 Forum was supposed to take place in Bucharest, Romania. Preparations were well underway, when rumors about a coronavirus outbreak were starting to make the news. At the time, there was no reason to believe that it might affect the annual forum in any way, so the preparations continued according to the plan.
On the 30th of January 2020, the World Health Organization classified the disease as public health emergency of international concern, and on the 11th of March it declared and classified it as a pandemic. By the end of March, it was becoming obvious that travel restrictions will have an influence, but everyone was hopeful that by July everything will be back to normal. To add to our troubles, our longstanding partners The European Psychiatric Association (EPA), was forced to delay its annual congress and unfortunately the new date was overlapping with the EFPT Forum. “What a disaster” we thought at first. As time passed, it appeared that the forum would have to either be rescheduled/canceled because of the pandemic, or severely affected if the pandemic was to subside due to the overlap with the largest psychiatric event in Europe.
A significant number of EFPT country delegates, speakers and members were involved in the EPA congress in numerous capacities. Two of the keynote speakers of the Bucharest Forum were Dr. Julian Beezhold, former EFPT President and current General Secretary of EPA, and Dr. Mariana Pinto da Costa, former EFPT President and the current EPA Early Career Psychiatry Chair. We were stuck between a rock and a hard place.
We did our best to continue planning for the live event while also taking contingency measures. The Local Organizing Committee started working on a secret project – the Virtual Forum. While hopeful that we will still be able to welcome our colleagues to Romania, with each day passing this possibility was becoming more and more unrealistic. Eventually, the problem was brought up with the EFPT Board of Directors and the decision to transition to a fully virtual event was made. With about two months at our disposal to reorganize such a massive event, the Local Organizing Committee started working around the clock to remake and rethink each part.
How will we handle the poster sessions and the country reports? What about the speakers, will they be able to reschedule? How will we be able to truly inspire and motivate our colleagues, NTA presidents, country representatives to engage, network and wish to really shape the future of psychiatry? Will they even be interested or have the time to join a virtual event while also facing the pandemic? Remember that all participants were delegated trainees of their respective national trainees’ associations, and doctors with a lot of responsibilities. When we announced the virtual event, we had about 110 registered representatives, we were missing about 9 members countries and the overseas colleagues, but this was expected in the given timeframe. To add to the problem, a couple of delegations were forced to pull their delegation due to heavy traveling restrictions.
Fortunately, things started to turn around quickly. First of all, all of the speakers accepted the rescheduling – Prof. Eliot Sorel was the first to offer his full support to the event. His presentation “COVID-19: Stress Test of Global Health Systems & Social Contracts” was a huge success. The LOC is grateful for his help and encouragement.
The forum participants were able to attend lectures and workshops held by:
Prof. Celso Arango (Spain), ECNP Past President
Prof. Joseph Zohar (Israel), CINP Vice President
Prof. Eliot Sorel (USA), WASP, WPA Founder of Conflict Management Section
Dr. Julian Beezhold (UK), EPA General Secretary
Dr. Mariana Pinto da Costa (Portugal/UK), EPA ECP Chair
Dr. Marisa Casanova Dias (UK), UEMS Board member and Vice President for CME
Dr. Peter Deschamps (The Netherlands), UEMS-CAP
Dr. Bruno Fellisard (France), IACAPAP
Dr. Howard Ryland (UK) – EFPT Past President
Dr. Livia de Picker (Belgium) – EFPT Past President
Dr. Bernadka Dubicka (UK).
Secondly, we increased the number of available spots. Usually, the EFPT only allows a limited number of participants per country due to logistical limitations and economical constraints. The annual forums are organized without any corporate funding! Considering that the event was a virtual one, we decided to allow an increase in participation for both member countries and the overseas project. We continued the traditional EFPT events while also presenting new and innovative ideas. During the event, the participants were able to attend:
The EFPT International Movie – an NTA-generated movie that would promote the culture of each represented country. The delegates were asked to send a 2-3-minute video offering insight into their culture. The movie was streamed during the forum while attendees were able to join a small zoom meeting to discuss it live. This proved to be a good networking opportunity, as the vast majority of delegations were present.
Country posters – most of the delegations prepared a poster. The theme was “The 2020 – What will change?” Topics such as telemedicine, psychedelic treatments and coronavirus changes were described. Some of these posters will be published alongside this article.
The Virtual Museum – a fully digital, three-dimensional and explorable museum was created and launched. By walking through it, you could learn about the history of the Romanian National Trainee Association, the forum speakers, the EFPT board, the general managers and working groups, and you could also study the country posters. Currently, the Virtual Museum is open and free for anyone to explore.
Live Q&A sessions and breakout rooms – the main focus of all presentations were the Q&A sessions. We did our best to make sure that attendees gained the most from each presentation. We designed the program in a way that heavily emphasized the question and answer panels. Once the sessions were over, the attendees were randomly distributed in a breakout room of five-six participants where they discussed what they had just learned. The format proved to be a success. All the Q&A sessions lasted beyond the allocated program and the breakout rooms were lingering long after.
The EFPT Forum Manual and materials – meticulously detailed instructions on how the forum will work were prepared and distributed in advance. Rules, timelines, working group reports, opportunities, frequently asked questions on technical matters were included. We also prepared a troubleshoot e-mail and phone number just in case any problems occurred. During the five days of the forum, no one needed to use it. Fortunately, despite so many changes, everything went smoothly.
Networking and experience exchange with colleagues from other continents – the overseas program was heavily emphasized and outcomes were extremely positive. During the Prague Forum, the program was able to bring in representatives from five countries outside Europe; this year we were able to welcome representatives from all of the continents. We welcomed colleagues from Nepal, USA, Brazil, Egypt, El Salvador, Guatemala, India, Indonesia, Japan, Jordan, New Zealand, Nigeria, Pakistan, Palestine, Australia, Tunisia and others.
Joining a working group – the working groups continued their projects and were able to recruit new members. Feedback was positive and the foundations of EFPT’s future projects were set. Considering our newly established relations to the CINP (International College of Neuropsychopharmacology), EFPT also created a new working group – Neuropsychopharmacology. More information on EFPT working groups and how to join them can be found on our site, efpt.eu.
In order to fulfill our mission, we heavily rely on information gathered from the delegate countries. We achieve this by conducting yearly country surveys. This way, EFPT is updated on the status of psychiatric training in Europe. At the current time, data were gathered from delegations of 31 member countries
What we learned this year is that the average training program is 4.5 years, varying between 2 and 6 years. In some cases, the training program can be extended over the 6-year period.
When being asked if the recruitment of junior doctors into psychiatry is a concern in their country, 55% of respondents stated that recruitment was a problem.
When asked to identify the most important issues of psychiatric training in their country, working conditions except salary (working hours, vacations/leaves, night shifts), the implementation of new training programs, low salary and the lack of psychotherapy training were the highest rated, in that order. The lowest rated reasons were the stigmatization of psychiatrists and the waiting list to start residency.
We asked how many working hours a week (on call included) are officially mandatory in the training. The average time was around 40 hours, although when asked how many hours they perform on average in reality, the number increased by an average of 25%. Multiple delegates reported work hours up to 60 hours per week.
We have covered a lot about the forum so far, but in order to get the full view of the event, we have invited colleagues, partners and speakers to share some of their thoughts on the forum. We would like to extend our heartfelt thank you to all of them for being by our side.
Dr. Mariana Pinto da Costa, EFPT Past President, EPA and WPA ECP Chair, Unit for Social and Community Psychiatry (WHO Collaborating Center for Mental Health Services Development), Queen Mary University of London, London, United Kingdom
“The EFPT Virtual Forum 2020, hosted from a wifi router in Bucharest in Romania, was a memorable event. Not only was it the 10th forum I have attended, but it was the first one that took place virtually. I was excited to see through the video cameras the sparkling eyes of many trainees: some newcomers to the EFPT Forum, and friendly faces of old friends and colleagues – while I presented an overview of opportunities for psychiatric trainees from the European Psychiatric Association (EPA) and the World Psychiatric Association (WPA).
George Stercu and the EFPT team were swift to rearrange the Forum to a virtual format, and surprised us all by launching the EFPT Virtual Museum. While I was very pleased to hear about the research conducted by Lucy Stirland from the UK, winner of the EFPT Porto Research Award 2020, I am already waiting to revisit the Virtual Museum and look up for the past edition winners (Irina Frankova from Ukraine, Daniel Linqvist from Sweden, Adrian Chrobak from Poland) to hear more about their research.
Every forum finishes with a general assembly that includes the election of the new President-Elect. Surely, Asilay Seker will be setting many precedents, not only for being the first president elected through electronic voting, but for stepping from her former role and solid experience representing Child and Adolescent Psychiatry in the EFPT Board to the unique task and challenge of in less than one year becoming the EFPT President.
These strange times that we are all living in the current pandemic call for joining forces and to unite efforts. I wish Charlotte Migchels and the rest of the EFPT board every success, continuing to shape the future of psychiatry.”
Dr. Shevonne Matheiken, Psychiatric Trainees’ Committee (PTC) of the Royal College of Psychiatrists (RCPsych), UKdelegate
“The COVID-19 pandemic has impacted us all in many ways, in our personal and professional lives. When the annual EFPT forum had to go virtual as well, as an observer, I was humbled and amazed at the efforts the local organizing committee in Romania had gone to. A sneak peek into the Virtual Museum during one of the pre-conference meetings impressed me immensely, as I had seen nothing like it in the UK with regard to virtual conferences during the pandemic.
As an international Indian-trained doctor doing psychiatry in the UK, I have always found the multicultural multilingual EFPT family very welcoming, tolerant and curious to learn about each of our differences and strengths. The events ran very smoothly, and to the over 180 delegates from 59 countries, we remained oblivious to the immense efforts behind the scenes as the team made it look effortless.
We had lively panel sessions with experts, academic sessions and networking sessions. The international night was one to remember, with each country’s 4 minutes video being compiled into a 2-3-hour long video which was live streamed; it truly was a magical transportation across the globe which I cannot express in words. The social part of the night had various breakout rooms to give as close an experience as a conference party with attention to details, such as DJing and even a breakout room called ‘queue to the toilet’. And the grand finale was the general assembly, and live voting was all done via live polls and zoom, which was a massive feat to pull off.
All in all, a virtual event could never be the same as a face-to-face event, but I think the team did a pretty awesome job at making that a questionable statement.”
Dr. Howard Ryland, EFPT Past President, Honorary Consultant Forensic Psychiatrist, Oxford Health NHS Foundation Trust
“Necessity is the mother of invention, runs an old English proverb, and the local organizing committee in Bucharest rose to the occasion with aplomb, to deliver a hugely innovative online annual European Federation of Psychiatric Trainees (EFPT) Forum in 2020. COVID-19 has turned all our worlds upside down and forced us to think differently about almost every aspect of our lives, including our professional networks. EFPT has always thrived on personal contact between individual psychiatrists in training from the myriad of countries that make up the European region. The annual forum is the central fulcrum of the organization that brings together representatives of all the Federation’s members to develop plans for the forthcoming year. I was intrigued to see how this would translate to the virtual format and what opportunities and challenges this might bring. With skillful facilitation by the president, Dr. George Stercu, the online discussions amongst alumni were free flowing and conversational, which I greatly enjoyed. I was very impressed by the large and varied turnout for the event, which showed how democratic and accessible a virtual event could be. This has the potential to remove some of the barriers, such as cost and the need to travel, that have always threatened comprehensive participation. Another highlight was the Virtual Museum, which benefited from an intuitive and realistic interface. I really appreciated moving between the rooms to learn about the speakers, the history of EFPT, and to get a sense of the wonderful host country Romania, even though I could not physically be there. Although I am sure that some aspects of a live forum could not be exactly replicated with our current technology, there were clearly many unanticipated benefits to the virtual approach. I hope that one day a return to a live format will be possible, but that future forums incorporate all the learning from this year’s successful adventure in cyberspace.”
Dr. Sharad Philip and Dr. Thomas Gregor Issac, Indian delegateswriting for the EFPT Newsletter:
“We made friends, we made connections, we dreamt dreams of being able to go on exchange programs too! As we went to the international night, we were even more amazed at how industriously and meticulously things were put together to empower a most striking display of diversity, cuisine, costume and color! It was indeed an enriching experience […] We express our heartfelt gratitude and sincere thanks to the EFPT leadership for having us over and for opening our eyes to vistas on collaborations and unlocking realms of possibility. Personally, we felt enriched to realize how much we could actually give back to the system and how that could start even as trainees.”
Dr. Dipesh Bhattarai – Nepal delegatewriting for the EFPT Newsletter:
“I was fortunate to be selected as an overseas awardee for this year’s 28th EFPT virtual forum in Bucharest. Sharing this stage of EFPT has been a dream come true. The virtual forum this year had its own prospects and challenges. Time zones, internet connections and regular duties were some of the challenges I faced. Despite all the obstacles, a global connection was made. […] I together with other trainees have already started steps towards forming an NTA in Nepal. I have already begun advocacy towards global research through the connection I made during the forum.”
Dr. Victor Pereira-Sanchez, WNPT Chair (World Network of Psychiatry Trainees), former EFPT MENTA Chair, Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine
“The World Network of Psychiatric Trainees (WNPT) was born in 2018 as an online framework of communication and collaboration among colleagues in different countries across the world. It emerged through a growing collaboration of the EFPT Maintaining and Establishing a National Trainees’ Association (MENTA) Working Group with trainees outside of Europe, with a priority aim of promoting and strengthening national trainees’ associations (NTAs) globally. The WNPT grew rapidly in the academic year 2019-2020, boosted by collaborations with the EFPT and by the COVID-19 pandemic.
The flagship collaboration between WNPT and EFPT is the EFPT-MENTA Overseas Program, which since 2018 has invited selected non-European psychiatric trainees to join the EFPT Annual Forum. Previous experiences have been quite successful in participants’ satisfaction, in EFPT-WNPT network expansion, and in the establishment of new NTAs in Latin America and East Asia. The current pandemic made it impossible to gather trainees together in Bucharest last July, but instead it enabled a virtual venue that allowed the participation of more than thirty overseas awardees from all world regions. there were admirable the interest and engagement they showed during the forum – some of them, in countries very distant to Europe (as far as New Zealand), stayed awake late in the night to participate in live activities!
EFPT-WNPT is also collaborating on scientific projects, as they are ideal frameworks to assemble international research groups and to spread worldwide surveys. An example is the Violence Against Psychiatric Trainees (VAPT) international study, which was started at the EFPT Research Working group in 2017, and is gathering, analyzing and sending for submission data on the extent and consequences of workplace violence suffered by colleagues worldwide. The survey has collected so far more than 1,400 responses from all over the world. The European data showed compelling results, which were highlighted by medical press outlets after their presentation at the annual congress of the European Psychiatric Association (https://www.medscape.com/viewarticle/933924) and have recently been submitted to a scientific journal. Now we are analyzing East Asian data and collecting responses from other world regions. On the other hand, WNPT and EFPT members have started to collaborate with other early career psychiatrists in the World Psychiatric Association (WPA) Early Career Psychiatrists’ Section’s COVID-19 and Mental Health international research group and think tank, with several publications in international journals so far(9-11).
Both the EFPT working groups and the WNPT are ever open to new members (current psychiatric trainees in any country); for more information, consult our social media. We very much look forward to working together to shape the future of psychiatry.”
This was the story of the European Federation of Psychiatric Trainees 2020 Bucharest Forum. When everything settled, over 180 country representatives from 59 different countries attended.
I never mentioned the name of the forum because long before all of this, we named it “Empowering the Trainee”, and I’d like to think that the Romanian National Trainee Association managed just that.
European Federation of Psychiatric Trainees; efpt.eu.
Pinto da Costa M; https://efptporto2015.wordpress.com/
Pinto da Costa M, Bischof E, Giurgiuca A, Kaaja J, Kilic O, Mogren T, Stoyanova M, Banjac V, Tomori S. Should I stay or should I go? Mobility and migration among psychiatric trainees in Europe – EFPT Brain Drain Survey. European Psychiatry. 2016; 33. S176. 10.1016/j.eurpsy.2016.01.375.
Tomori S, Pinto Da Costa M, Tove Mogren T. Migratory Trends of Psychiatric Residents in Albania – EFPT Brain Drain Project. American Journal of Psychiatry and Neuroscience. Special Issue: “In and out of Your Mind”. Abstracts of the 1st Eastern European Conference of Mental Health. 2017; Vol. 5, No. 6-1, 58-58. doi: 10.11648/j.ajpn.s.2017050601.68
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De Picker L, Nobels A. Heterogeneity in psychiatry training in Europe: competition or collaboration? Tijdschrift voor Psychiatrie. 2019; 61(3), 175-181.
Brittlebank A, Hermans M, Bhugra D, Pinto da Costa M, Kuzman M, Fiorillo A, Kurimay T, Hanon C, Wasserman D, Gaag R. Training in psychiatry throughout Europe. European Archives of Psychiatry and Clinical Neuroscience. 2016; 266. 10.1007/s00406-016-0679-4.
UEMS Section for Psychiatry. Charter on training of medical specialists in the EU: requirements for the specialty of psychiatry. Eur Arch Psychiatry Clin Neurosci. 1997; 247:S45–S47
Pereira-Sanchez V, Adiukwu F, El Hayek S, et al. COVID-19 effect on mental health: patients and workforce. Lancet Psychiatry. 2020; 7(6):e29-e30.
Ransing R, Ramalho R, de Filippis R, et al. Infectious Disease Outbreak Related Stigma and Discrimination during the COVID-19 Pandemic: Drivers, Facilitators, Manifestations, and Outcomes across the World [published online ahead of print, 2020 Jul 27]. Brain Behav Immun. 2020; S0889-1591(20)31693-7. doi:10.1016/j.bbi.2020.07.033.
Ransing R, Adiukwu F, Pereira-Sanchez V, et al. Mental Health Interventions during the COVID-19 Pandemic: A Conceptual Framework by Early Career Psychiatrists. Asian J Psychiatr. 2020; 51:102085. doi:10.1016/j.ajp.2020.102085.