2005-2023 Psych Central a Red Ventures Company. [3], Prognostic studies have been difficult due to the diagnostic challenges associated with schizoaffective disorder. 2006 Jan; [PubMed PMID: 16390898], Laursen TM,Munk-Olsen T,Nordentoft M,Bo Mortensen P, A comparison of selected risk factors for unipolar depressive disorder, bipolar affective disorder, schizoaffective disorder, and schizophrenia from a danish population-based cohort. Verywell Health's content is for informational and educational purposes only. Untreated mental disorders have more than just social and functional consequences. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have to also be ruled out. Phone: 650-931-2505 | Fax: 650-931-2506 [4], Although schizoaffective disorder is a diagnosis in the DSM-5, its validity as a diagnosis remains under debate. Most first and second-generation antipsychotics block dopamine receptors. It eventually became its own diagnosis despite a lack of evidence for unique differences in etiology or pathophysiology. What Are Disorganized Symptoms of Schizophrenia? Depression can make life so gray that you arent sure where the sunshine is hiding or if it will return.. There are limited studies on the prevalence of schizoaffective disorder. At least one of these must be from the first three below. Delusions or hallucinations for at least 2 weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness. Patients with MDD with PF do not meet criterion A of schizoaffective disorder. (2011). If your loved one can't provide his or her own food, clothing or shelter, or if the safety of your loved one or others is a concern, you may need to call 911 or other emergency responders for help so that your loved one can be evaluated by a mental health professional. Oct. 27, 2019. Consider the use of mood-stabilizers if the patient has a history of manic or hypomanic symptoms. Schizoaffective disorder can be difficult to diagnose because it has symptoms of both schizophrenia and either depression or bipolar disorder. To be diagnosed with schizoaffective disorder a person must have the following symptoms. Have symptoms been continuous or occasional? Schizoaffective disorder. An uninterrupted duration of illness during which there is a major mood episode (manic or 2012;38(6):1288-96. doi:10.1093/schbul/sbs068. According to the DSM-5, the lifetime prevalence of schizophrenia is approximately 0.3% to 0.7%. Accessed Sept. 19, 2019. Schizoaffective disorder: A review. What are the Types of Schizoaffective Disorder? Your symptoms and the duration of the episodes may vary. Delusions or hallucinations for two or more consecutive weeks without mood symptoms sometime When schizophrenia is active, symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation. These tools include: Severity scales are useful as they can plot a starting point when the schizoaffective disorder is first diagnosed and then track improvement throughout treatment. MentalHealth.gov. Accessed Sept. 5, 2019. If you are worried, take a self-test at home to see whether its time to reach out for help. Because of criteria that encompass both psychotic and mood symptoms, schizoaffective disorder is easy to mistake for other mental disorders. Signs and symptoms of schizoaffective disorder depend on the type bipolar or depressive type and may include, among others: If you think someone you know may have schizoaffective disorder symptoms, talk to that person about your concerns. Schizotypal personality disorder typically includes five or more of these signs and symptoms: Being a loner and lacking close friends outside of the immediate family Flat emotions or limited or inappropriate emotional responses Persistent and History-taking is an essential skill necessary for all clinicians; it is even more imperative in psychiatry. The schizoaffective DSM-IV-TR diagnostic criteria are the following: 1. How are you functioning in daily life are you eating regularly, bathing regularly, going to work, school or social activities? AskMayoExpert. Manic behavior. Duration of symptoms and effects. 5th ed. If you think you may have schizoaffective disorder or that your loved one may have it, take steps to prepare for the appointment, whether it's with a primary care doctor or a mental health professional, such as a psychiatrist. trustworthy health information: verify Delusions, which are false, fixed beliefs that are heldregardless of contradictoryevidence. The Journal of clinical psychiatry. What is schizophrenia? https://www.mentalhealth.gov/talk/friends-family-members. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Treatment varies, depending on the type and severity of symptoms and whether the disorder is the depressive or bipolar type. Harmful Skills on this podcast episode. Harrison, G., Hopper, K. I. M., Craig, T., Laska, E., Siegel, C., Wanderling, J. O. E., & Holmberg, S. K. (2001). Expert Review of Neurotherapeutics, 12(1), 1-3. Rape stories, Particularly when young, some people may ask, "How do I know if I am gay?" 2013 Oct; [PubMed PMID: 23800613], Vieta E, Developing an individualized treatment plan for patients with schizoaffective disorder: from pharmacotherapy to psychoeducation. 2007 Nov; [PubMed PMID: 18052560], Marneros A,Deister A,Rohde A, Psychopathological and social status of patients with affective, schizophrenic and schizoaffective disorders after long-term course. Schizoaffective disorder (adult). If a personhas been diagnosed with schizoaffective disorder:bipolar type they will experience feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania. https://www.nami.org/learn-more/mental-health-conditions/schizoaffective-disorder. Observe the criteria for each diagnosis carefully. These medications may include: In addition to medication, psychotherapy, also called talk therapy, may help. Mayo Clinic; 2019. MentalHealth.gov. The person must also exhibit a decreased level of functioning regarding work, interpersonal relationships, or self-care. WebThe DSM -5 describes Schizophrenia in terms of a severe, chronic, and potentially disabling thought disorder. With regard to schizoaffective diagnosis, the only significant revision considered for the DSM-5 is to make it explicitly a lifetime diagnosis, 45 and this is how the disorder was approached in the present study. Normal function aside from impact of delusions. The next step of evaluation is the objective and physical portion. If you are worried about a friend or family member, you can also use an online screening tool to determine whether you need to take action to help your loved one. Bipolar type is diagnosed when symptoms of schizophrenia overlap with symptoms of bipolar disorder, specifically manic episodes. Psychotic features of the disorder typically emerge between the mid-teens and mid-30s, with the peak age of onset of the first psychotic episode in the early to mid-20s for males and late 20s for females. The mainstay of most treatment regimens should include an antipsychotic, but the choice of treatment should be tailored to the individual. Acta Psychiatrica Scandinavica, 113(5), 369-371. Thus, there have been no large-scale studies on the epidemiology, incidence, or prevalence of schizoaffective disorder. Schizoaffective disorder. This is because when you look at the dominant symptoms, schizoaffective disorder may resemble schizophrenia more than it does depressive or bipolar disorders. Mr. Ando was diagnosed with. People with schizophrenia, however, do not experience predominant mood episodes. WebIndeed, such ratings have been proposed for the DSM-5. a schizoaffective disorder based on the DSM5/ICD10. Once the psychotic symptoms predominate the majority of the total duration of the illness, the diagnosis leans towards schizophrenia. (2008). Collegium antropologicum. On the other hand, schizophrenia primarily affects your cognition. The schizoaffective DSM-IV-TR diagnostic criteria are the following:1, In the DSM-IV-TR, criterion A for schizophrenia requires two of the following:2. Steven Gans, MD, is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital. The Journal of clinical psychiatry. Professional screenings are completed in the office of a credentialed mental health professional. Journal of clinical psychopharmacology. Selective-serotonin reuptake inhibitors (SSRIs) are preferred due to lower risk for adverse drug effects and tolerability when compared to tricyclic antidepressants and selective norepinephrine reuptake inhibitors. Schizoaffective disorder has its own diagnostic criteria and list of specific symptoms, even though its categorized under schizophrenia spectrum. Has anyone else in your family been diagnosed with or treated for mental illness? Genetics Home Reference. This activity describes limitations and challenges related to the diagnostic criteria and highlights the interprofessional team's role in caring for patients with psychiatric disorders. In young people who develop schizophrenia, this stage of the disorder is called the prodromal period. Please see the differential diagnoses and pearls sections below for more information. Additionally, the diagnostic entity of schizoaffective disorder has very poor inter-rater reliability between clinicians. All rights reserved. [1]In fact, some researchers have proposed revisions to the diagnostic criteria, and others have suggested removing the diagnosis altogether from the DSM-5. This content does not have an English version. A single copy of these materials may be reprinted for noncommercial personal use only. frequent derailment or incoherence), Grossly disorganized or catatonic behavior, Negative symptoms such as a flattened affect, lack of speech, lack of motivation, Positive and Negative Symptom Scale for Schizophrenia [PANSS] rates positive symptoms like delusions, negative symptoms like emotional withdrawal and general psychopathology like, Hamilton depression scale rates the severity of depression symptoms like, Young mania scale rates the severity of mania symptoms like increased energy and sexual interest, Cut down, annoyed, guilty, and eye opener (CAGE) questionnaire regarding substance use and abuse. Michelle Pugle is an expert health writer with nearly a decade of experience contributing accurate and accessible health information to authority publications. One must tease out a 2 week or longer period of just psychotic symptoms in the patient's history. Schizoaffective disorder includes at least two of the above symptoms related to psychotic disorders and these DSM-5 criteria: A major mood episode (either major depression or mania) that lasts for an uninterrupted period of time. Although the development and course of schizoaffective disorder may vary, defining features include a major mood episode (depressed or manic mood) and at least a two-week period of psychotic symptoms when a major mood episode is not present. Schizoaffective disorder severity can also be measured using a variety of rating scales. Law Office of Gretchen J. Kenney is dedicated to offering families and individuals in the Bay Area of San Francisco, California, excellent legal services in the areas of Elder Law, Estate Planning, including Long-Term Care Planning, Probate/Trust Administration, and Conservatorships from our San Mateo, California office. Mr. Ando was diagnosed with. One study found that 50% of cases showed favourable outcomes (i.e. Accessed Sept. 19, 2019. Talk of suicide or suicidal behavior may occur in someone with schizoaffective disorder. Have you thought about or attempted suicide? In contrast, schizoaffective requires at least, Similar to depression with psychotic features, patients with bipolar disorder with psychotic features only experience psychotic symptoms (delusions and hallucinations) during a manic episode. [32]Research has shown that among all completedsuicides, ten percent are attributable to those with a psychotic illness.[33]. What is the Treatment for Schizoaffective Disorder? 2002 [PubMed PMID: 12153335], Baethge C,Gruschka P,Berghfer A,Bauer M,Mller-Oerlinghausen B,Bschor T,Smolka MN, Prophylaxis of schizoaffective disorder with lithium or carbamazepine: outcome after long-term follow-up. All Rights Reserved. Describe the pathophysiology of schizoaffective disorder. Inside Schizophrenia Podcast: Why are Some People with Schizophrenia Able to Live Alone While Others Cannot? Schizophrenia bulletin. These criteria must also be evident for a doctor to diagnose schizoaffective disorder: In sum, schizoaffective disorder affects your mood, thoughts, and behavior. Signs and symptoms that could indicate schizoaffective disorder include: Inability to sleep Sleeping too much Risk-taking behavior Extreme sadness Thinking Mental Health episode. 4301 Wilson Blvd., Suite 300 Is this condition likely temporary or long term? Symptoms that meet the criteria for mood episodes are present for a substantial portion of the total active and residual periods of illness. Ising HK, Veling W, Loewy RL, Rietveld MW, Rietdijk J, Dragt S, Klaassen RM, Nieman DH, Wunderink L, Linszen DH, van der Gaag M. The validity of the 16-item version of the Prodromal Questionnaire (PQ-16) to screen for ultra high risk of developing psychosis in the general help-seeking population. (2013). Signs of a Gay Husband, Rape Victim Stories: Real Stories of Being Raped, How Do I Know If I Am Gay? The Diagnostic and Statistical Manual of Mental Disorders, 5 th edition (DSM-5) has established the following criteria for diagnosing schizoaffective disorder Schizoaffective disorder (adult). if they have conflicting sexual feelings. Recovery from psychotic illness: a 15-and 25-year international follow-up study. Schizoaffective disorder affects about 0.3% of the general population. Our website services, content, and products are for informational purposes only. What are the side effects of the medication you're prescribing? The DSM-5 considers schizoaffective disorder a stand-alone diagnosis, although it appears in the chapter on schizophrenia spectrum and other psychotic Symptoms of psychosis, however, often require immediate medical intervention. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Book: Mayo Clinic Family Health Book, 5th Edition, Newsletter: Mayo Clinic Health Letter Digital Edition. Wy TJP, et al. With schizoaffective disorder, you experience a combination of symptoms that affect both your emotions and your thinking abilities. This podcast episode explore psychological resilience. 2000 Oct [PubMed PMID: 11001235], Dietrich DE,Kropp S,Emrich HM, [Oxcarbazepine in the treatment of affective and schizoaffective disorders]. [25]SSRIs include fluoxetine, sertraline, citalopram, escitalopram, paroxetine, and fluvoxamine. Holder SD, Wayhs A. Schizophrenia. This site complies with the HONcode standard for trustworthy health information: verify here. If you have this type of schizoaffective disorder, you may experience symptoms such as: Depressive type is diagnosed only if you mostly experience symptoms of major depression together with symptoms of schizophrenia. (1990). Sometimes, you might not have any dominant symptoms between episodes. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Schizoaffective disorder is among the most frequently misdiagnosed psychiatric disorders in clinical practice. The Journal of clinical psychiatry. Summarize the treatment options for patients with schizoaffective disorder. Schizoaffective disorder can be managed effectivelywith medication and therapy. [10] Researchers have also found reduced hippocampal volumes and distinct deformations in the medial and lateral thalamic regions in those with schizoaffective disorder in comparison to controls.[11][12]. Meltzer, H. Y., Arora, R. C., & Metz, J. In the psychiatric community, some experts also believe schizoaffective disorder should be considered a subtype of schizophrenia instead of a stand-alone psychotic disorder. Why Some People with Schizophrenia Can Live Alone and Others Cannot. Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline, Schizophrenia: overview and treatment options, The validity of the 16-item version of the Prodromal Questionnaire (PQ-16) to screen for ultra high risk of developing psychosis in the general help-seeking population, Bipolar disorder with psychotic or catatonic features, Autism spectrum disorder or communication disorders. Genetics Home Reference. Schizotypal, schizoid, or paranoid personality disorder. 2004 Dec [PubMed PMID: 15641867], Ciapparelli A,Dell'Osso L,Bandettini di Poggio A,Carmassi C,Cecconi D,Fenzi M,Chiavacci MC,Bottai M,Ramacciotti CE,Cassano GB, Clozapine in treatment-resistant patients with schizophrenia, schizoaffective disorder, or psychotic bipolar disorder: a naturalistic 48-month follow-up study. Veterans Pension Benefits (Aid & Attendance). American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. [14]A study that reported obtained data on treatment regimens for schizoaffective showed that 93% of patients received an antipsychotic. Accessed Sept. 19, 2019. Treatment can help manage symptoms and improve quality of life. Anyone who is worried about a friend or family member having schizophrenia can take a different version of this test. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms or (2) any mood episodes that have occurred during active-phase symptoms have been present for a This site complies with the HONcode standard for Psychotic features in bipolar disorder do not meet criterion A of schizoaffective disorder. Schizoaffective disorder criteria are defined in both the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and the International Classification of Diseases, Tenth Revision (ICD-10). European archives of psychiatry and clinical neuroscience. White matter integrity and lack of insight in schizophrenia and schizoaffective disorder. When someone is experiencing both psychotic and mood symptoms, it can be difficult to determine what he or she is truly experiencing. Schizoaffective disorder. When it comes down to it, there is no reliable "Am I Gay test", so the only way, Positive inspirational quotes are good for people with depression to have on-hand. Some studies show that as high as 50% of people with schizophrenia also have comorbid depression. Diagnosis of schizoaffective disorder involves ruling out other mental health disorders and concluding that symptoms are not due to substance use, medication or a medical condition. There are two changes in the criteria for bipolar I disorder in DSM-5. The first step in evaluation is obtaining a complete medical history while focusing on the diagnostic criteria for schizoaffective disorder. 1900 S. Norfolk St., Suite 350, San Mateo, CA 94403 https://ghr.nlm.nih.gov/condition/schizoaffective-disorder. The Journal of clinical psychiatry. The specific DSM-5-TR criteria for delusional disorder are as follows: Delusions in schizophrenia and schizoaffective disorder are often bizarre in nature, and thematically-associated hallucinations are common. 2003 May; [PubMed PMID: 12740757], Leucht S,McGrath J,White P,Kissling W, Carbamazepine for schizophrenia and schizoaffective psychoses. 2008 Dec [PubMed PMID: 19337453], Azorin JM,Kaladjian A,Fakra E, [Current issues on schizoaffective disorder]. Schizoaffective disorder. Men and women experience schizoaffective disorder at the same rate, but men often develop the illness at an earlier age. 2001 Jun; [PubMed PMID: 11388966], Hor K,Taylor M, Suicide and schizophrenia: a systematic review of rates and risk factors. Call 911 or your local emergency number immediately. MentalHealth.gov. Michelle is the author of Ana, Mia & Me: A Memoir From an Anorexic Teen Mind. According to the fifth edition of the DSM, text revision (DSM-5-TR), in order for a diagnosis of bipolar I to be made, a person must have at least one manic episode that isnt better explained by schizoaffective disorder. Research shows that 30% of cases occur between the ages of 25 and 35,and it occurs more frequently in women. Signs You Are Gay, Positive Inspirational Quotes for People with Depression, HONcode standard for Supportive group programs can also help if the patient has been in social isolation and provides a sense of shared experiences among participants. Lab tests they will perform include: While you can only receive an official diagnosis of schizophrenia through a professional screening with a mental health professional, you can take an online screening test to better understand if you should be concerned about schizophrenia and take the initiative to seek professional help. Physical health conditions also can present in similar ways as schizophrenia. 2011 Jan; [PubMed PMID: 21648342], Smith MJ,Wang L,Cronenwett W,Mamah D,Barch DM,Csernansky JG, Thalamic morphology in schizophrenia and schizoaffective disorder. Accessed Sept. 19, 2019. Make a donation. 2003 [PubMed PMID: 14583908], Phutane VH,Thirthalli J,Kesavan M,Kumar NC,Gangadhar BN, Why do we prescribe ECT to schizophrenia patients? [21][22][23][24], Antidepressants: Used to target depressive symptoms in schizoaffective disorder. Individual therapy: This type of treatment aims to normalize thought processes and better help the patient understand the disorder and reduce symptoms. Make a donation. What are the alternatives to the primary approach you're suggesting? [34]An ideal treatment course to improve outcomes around patient-centered care may include: It is critical to determine if the patient is competent to make healthcare decisions independently; otherwise, a proxy must be a consideration. Accessed Sept. 19, 2019. It has a robust genetic component, tends to appear during young adulthood, and is typically marked by periods of remission and relapse throughout the lifespan. DSM-5 Schizoaffective Disorder considers the entire illness course In DSM-5, Schizoaffective Disorder is a lifetime diagnosis that considers the time from the onset of the psychosis up to the current episode, rather than only defining a single episode with co-morbid psychotic and mood syndromes. Neuropsychiatric Disease and Treatment. Patel KR, Cherian J, Gohil K, Atkinson D. Schizophrenia: overview and treatment options. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. It is not enough to symptoms of schizophrenia while meeting the criteria for a major mood episode. All Rights Reserved. Site last updated March 4, 2023. The disturbance is not attributable to the effects of a substance (e.g. Fortschritte der Neurologie-Psychiatrie. Do not trust tests provided or supported by a pharmaceutical company. Maier, W. (2006). For people with mental health problems. WebDSM-5 Criteria: Major Depressive Disorder Major Depressive Episode: F Five (or more) of the following symptoms have been present during the same schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. Inside Schizophrenia Podcast: Managing Family Dynamics. Schizophrenia is a complex illness with a range of symptoms and severity, so self-checks (which may be misleading due to the subjective nature of how you interpret the questions) should not be your only way of seeking help. Participants with schizophrenia met DSM-IV/DSM-5 criteria for schizophrenia or schizoaffective disorder, were psychiatrically stable at the time of the interview (total Positive and Negative Syndrome Scale for Schizophrenia [PANSS] score <70), had no hospitalizations in the 3 months before enrollment, and were maintained on https://www.mentalhealth.gov/talk/friends-family-members. Understand Schizophrenia Coping Techniques and Learning Helpful vs. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Laboratory studies are tailored to the patients history, especially for those who have an atypical presentation. BBC Documentary producer and historian Victoria Shepherd on how delusions have manifested throughout history on this episode of Inside Mental Health. Disorganized thinking. [7] There are also cultural/stigma effects that have been noted, with clinicians preferring to use the diagnosis of schizoaffective disorder over schizophrenia.[8]. Mayo Clinic; 2019. The two types of schizoaffective disorder both of which include some symptoms of schizophrenia are: Schizoaffective disorder may run a unique course in each affected person. Schizophrenia Medications: Types, Side Effects, Effectiveness. Merck Manual Professional Version. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have to also be ruled out. Psychosis vs. Schizophrenia: What's the Difference? Heckers, S. (2012). Determining a diagnosis of schizoaffective disorder may include: People with schizoaffective disorder generally respond best to a combination of medications, psychotherapy and life skills training. It is vital to rule out bipolar disorder before starting an antidepressant due to the risk of exacerbating a manic episode.[26]. Read on to learn more about what it takes to diagnose schizophrenia. [Level 5] Pharmacotherapy, psychotherapy, skills training, and vocational training work in tandem to create a holistic treatment plan. 5th ed. Schizophrenia bulletin, 10(1), 49-70. Also, schizophrenia requires 6 months of prodromal or residual symptoms; schizoaffective disorder does not require this criterion. If a person has been diagnosed with schizoaffective disorder depressive type they will experience feelings of sadness, emptiness, feelings of worthlessness or other symptoms of depression. In other words, schizoaffective disorder presents as depression or bipolar disorder layered on schizophrenia symptoms. Schizophrenia research. MindWise also offers an online screening for psychosis, which is a modified version of the Prodromal Questionnaire 16 and was developed to bring about the implementation of routine screening for psychosis risk. In fact, a set criterion to receive this diagnosis is that you must have two or more symptoms of psychosis, which are typical of schizophrenia. Symptoms of schizophrenia usually first appear in early adulthood. This content does not have an Arabic version. 2011 May; [PubMed PMID: 21429714], Radoni E,Rados M,Kalember P,Bajs-Janovi M,Folnegovi-Smalc V,Henigsberg N, Comparison of hippocampal volumes in schizophrenia, schizoaffective and bipolar disorder. All other programs and services are trademarks of their respective owners. Many people with schizoaffective disorder are often incorrectly diagnosed at first with bipolar disorder or schizophrenia. WebIndeed, such ratings have been proposed for the DSM-5. Do schizoaffective disorders exist at all?. These must have been present for at least one month. Because schizoaffective disorder is less well-studied than the other two conditions, many interventions are borrowed from their treatment approaches. Disorganized speech (e.g. (1984). MICROGEN IMAGES / SCIENCE PHOTO LIBRARY / Getty Images. Grossly disorganized or catatonic behavior, Negative symptoms (i.e., diminished emotional expression or avolition. 171 0 obj <>stream Accessed Sept. 5, 2019. However, a major mood episode (depression or mania) is present for the majority of the total duration of the illness. 155. Participants with schizophrenia met DSM-IV/DSM-5 criteria for schizophrenia or schizoaffective disorder, were psychiatrically stable at the time of the interview (total Positive and Negative Syndrome Scale for Schizophrenia [PANSS] score <70), had no hospitalizations in the 3 months before enrollment, and were maintained on
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