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Running Head: LONGITUDINAL … TRAUMA

Longitudinal Effects of Childhood Trauma

Ryan Florin Kelly

Immaculata University

Supervised by Dr. Martinson, PhD, LPC, LAC, CCS

Associate Professor of Psychology

Immaculata University
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Abstract

This independent study will focus on drawing relevant educational experiences tied to research

connected with the longitudinal effects of childhood trauma to the development of adult

psychopathology and pathology in general. This includes focusing on developing an integrative

understanding of the connection of past trauma and psychopathology and the implications of

these perceptions on a counselor’s work by looking into relevant research. Discussions will

address how better understanding of the development of implementing this research into

counselor education and clinical practice can inform a counselor’s work. A multitude of

scholarly journals and the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition

(DSM-5) was analyzed in order to complete my research (American Psychiatric Association,

2013; Centers for Disease Control and Prevention, 2015; Cohen, Scheid, and Gerson, 2014;

Corso, Edwards, Fang, and Mercy, 2008; Felitti, 2009; Gilbert, Breiding, Merrick, Thompson,

Ford, Dhingra, and Parks, 2015; Kruijshaar, Hoeymans, Spijker, Stouthard, and Essink-Bot,

2005; Merrick, Fortson, and Mercy, 2015; National Institute on Drug Abuse, 2008; Shonkoff,

Boyce, and McEwen, 2009; Venigalla, Mekala, Hassan M, et al., 2017). The goal was to

discover how childhood trauma contributes to the later development of psychopathology and

pathophysiology. The clinically relevant knowledge I gained has allowed me to create a literature

review that could later represent a future thesis or future research endeavors. That being said, it is

important that I highlight the major research limitations encountered. No official funding was

implemented in order to discover the outcome of my findings. My conclusion is that childhood

trauma can influence the later development of a mental-health disorder or can contribute to the

later onset of a physical illness that is associated with a plethora of physiological effects and

complications.
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Key Words
Biomarker - An attribute that is objectively measured and evaluated as an indicator of normal
biologic processes, pathologic processes, or biological responses to a therapeutic intervention.

Clinician – Represents either a scientist conducting research or describes the role of a health-
care worker that directly helps with the process of curing patients that suffer from either a
medically-related condition or a mental-health related issue. Examples: Physician, nurse,
therapist, dentist, social worker.

Complex Post-Traumatic Stress Disorder - When a person has experienced trauma on an

ongoing basis, or one prolonged event.

Counselor (therapist) – A person licensed to provide individual or group psychotherapy and

clinically trained to treat psychiatric disorder listed in the DSM-5 through talk-therapy.

Epidemiological – The study of the distribution (frequency, pattern) and determinants (causes,
risk factors) of health-related states and events (not just diseases) in specified populations
(neighborhood, school, city, state, country, global). The method used to find the causes of health
outcomes and diseases in populations.

Epigenetics - the study of heritable changes in gene expression (active versus inactive genes)
that do not involve changes to the underlying DNA sequence - a change in phenotype without a
change in genotype - which in turn affects how cells read the genes.

FMRI – Measures blood flow through the brain, telling doctors more about the activities of
neurons and show which brain regions are most active.

Neurobiology - a branch of the life sciences that deals with the anatomy, physiology, and
pathology of the nervous system
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Pathology - Describes conditions typically observed during a disease state. Describes the
abnormal or undesired condition. The study of the structural and functional changes produced
by them

Pathophysiology - The study of the disordered physiological processes that cause, result from,
or are otherwise associated with a disease or injury. This seeks to explain the functional changes
that are occurring within an individual due to a disease or pathologic state.

Post-Traumatic Stress Disorder - An anxiety disorder that develops following frightening,

stressful, or distressing life events. Characterized by intense fear, helplessness, and stress to the
point where it affects a person’s normal well-being and ability to function.

Psychopathology - The scientific study of mental disorders, including efforts to understand their
genetic, biological, psychological, and social causes; develop classification schemes which can
improve treatment planning and treatment outcomes; understand the course of psychiatric
illnesses across all stages of development; more fully understand the manifestations of mental
disorders; and investigate potentially effective treatments

Reliability - The extent to which the results can be reproduced when the research is repeated
under the same conditions. It is assessed by checking the consistency of results across time,
across different observers, and across parts of the test itself. A reliable measurement is not
always valid: the results might be reproducible, but they’re not necessarily correct.

Trauma – Occurs when a person experiences either an actual or threatened death, endures a
serious injury, or is a victim of sexual violence. (American Psychiatric Association, 2013)

Validity - The extent to which the results really measure what they are supposed to measure. It is
assessed by checking how well the results correspond to established theories and other measures
of the same concept. A valid measurement is generally reliable: if a test produces accurate
results, they should be reproducible.
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Longitudinal Effects of Childhood Trauma

Introduction

The National Institutes of Health (NIH) believes trauma affects more than two thirds of

American children; and estimate that one third experience multiple, often chronic, traumas such

as child maltreatment (child sexual, physical, or emotional abuse; child neglect; or domestic

violence). Yet widespread efforts to identify and effectively treat the potentially serious and

long-term negative impacts of these experiences lag far behind. Research connecting the

longitudinal effects of childhood trauma to the later development of adult pathology expands

across multiple professional disciplines. Simply exploring the elements of psychopathology,

pathophysiology, neuropathology, neurobiology, biochemistry, and epigenetics will provide

mental-health practitioners with at best, broad clinical interpretations. This poses the question of

how exactly negative health outcomes are linked to childhood adversities. A more complete

understanding of these issues is likely to lead to a better understanding of the relationship

between childhood adversities and disease burden. Therefore, in order to develop an integrative

understanding of the relationship between trauma and the later onset of pathology, clinicians can

obtain scholarly journals published by different professional organizations and around the globe.

Once a relationship can be established, outlining how the research can implicate and inform a

counselor’s work can be presented.

Trauma

The American Psychiatric Association (2013) indicates that psychological trauma

manifests when a person experiences either an actual or threatened death, endures a serious

injury, or is a victim of sexual violence in at least one of the following four ways: (a) directly
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encounters a threatening event; (b) physically witnesses an intrusive event occurring to others;

(c) learns that a close family member or friend experienced a troublesome event; or (d)

repetitively experiences aversive details across a series of particular events. It is important to

highlight that an actual or threatened death must occur in a violent or accidental manner; and

excludes any exposure through social media, television, movies or pictures, unless it is work-

related.

Adverse Childhood Events (ACE)

In 1990, Dr. Felitti presented his landmark ACE study showing research that links events

of childhood adversity and health outcomes. This would be the first study of its kind to introduce

the longitudinal effects of childhood trauma. The ACE study strongly established a dose-

response relationship, which is an important step towards demonstrating causality. Through his

research efforts, Dr. Felitti (2009) found that a person with a higher ACE score would become

more likely to later develop a cluster of diseases. Clinicians would become inspired to study just

how trauma over activates the body’s stress response; and many curious how it leads to a

person’s physical, emotional, and psychological dysfunction.

ACE: Anatomy & Physiology

Dr. Alan Guttmacher, head of the National Institute of Child Health and Human

Development, notions when adverse childhood experiences occur, the body has a series of stress

responses. Areas of the brain, such as the amygdala, prefrontal cortex, hypothalamic-pituitary-

adrenal (HPA) axis, sympatho-adrenomedullary (SAM) axis, noradrenergic nucleus in the locus

coeruleus, and hippocampus all rapidly react to the potentially threatening stimuli. Research
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indicates that when a child is overly exposed to a stressor, it can reduce the size of their

hippocampus by up to 4x its healthy developed state. MRI studies have indicated that when

children are chronically traumatized, their risk for dramatically enlarging their amygdalae

skyrockets. Research has shown that trauma can trigger chronic inflammation throughout the

body, alter how hormones functions for decades, and can alter how DNA is replicated and how

our body reads it. Other research using other brain-imaging tests have shown how trauma stunts

a child’s skeletal maturity. This indicates that when a child experiences trauma at a young age,

the child may continue to age in years but will show the muscular age and growth consistent of

their age when the trauma occurred. Overall, the consequences of toxic stress are neurologic,

hormonal, immunologic, compromise the health of telomeres, effect epigenetic markets and

transgenerational genetics.

Trauma’s Longitudinal Effects on Psychopathology & Pathophysiology

Corso et al. (2008) includes research suggesting that childhood adversities have an

independent effect on disease burden, apart from their effect on mental and general medical

disorders. These findings are in line with other research showing that childhood adversities are

associated with health outcomes in adulthood. Our study adds to this by showing that childhood

adversities have a strong impact on disease burden, through increasing the risk of mental and

general medical disorders, but also by an effect which is independent from these disorders.

Venigalla H, Mekala HM, Hassan M, et al. (2017) strongly assert that adverse trauma

negatively impacts a child’s short-and-long term mental well-being, biological systems, and its

structures. They leverage the work of others’ longitudinal research, qualitative-and-quantitative

studies, and meta-analyses to support why adverse childhood events increase a child’s risk of
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later developing a psychopathological disorder(s); such as various mood disorder(s), anxiety

disorder(s), alcohol problems, eating disorder(s), and psychotic symptoms. Their own research

has revealed childhood adversity being significantly associated with children becoming more

susceptible to later experiencing suicidal ideations and suicide attempts. Furthermore, their

research findings indicate that childhood trauma can increase a child’s risk for later developing

concurrent mental disorder(s), and include the risk of having severe interpersonal difficulties,

weight problems, and early retirement due to developing a disability.

Gilbert et al. (2015) illustrate a small sample size of research believes adverse childhood

events may be associated with increasing ones risk of later developing a pathophysiological

disorder(s); such as various auto-immune diseases, cancer, Alzheimer’s, sexually transmitted

infections, including HIV, delayed cognitive development, chronic obstructive pulmonary

disease, ischemic heart disease, liver disease, reproductive health problems, migraines, peptic

ulcers, arthritis, coronary heart disease, and diabetes. In addition, there is a growing body of

research that believes early childhood trauma cause damage to the nervous, endocrine,

circulatory, musculoskeletal, reproductive, respiratory, and immune systems. That being said,

despite research findings, clinicians do not have enough evidence to support all the correlations.

Clinically Detecting Trauma

Venigalla H, Mekala HM, Hassan M, et al. (2017) assert that different methodologies can

be used in order to explain and further support the relationship between childhood trauma and

being able to predict a person’s health status throughout adulthood. For example, there are

several studies that adequately portray how the onset of chronic stress, addiction, or depression at

a young age can severely effect a person’s quality of life later on in adulthood. A second way to
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explain the relationship can be performed by using statistical methods to predict a person’s

mortality rate. For instance, the proportional mortality method is a simple way of portraying the

burden of a specific disease within a population. Clinicians are also able to calculate how time a

person loses in terms of their quality of life, because of year(s) lived with a certain disease. For

example, Kruijshaar, Hoeymans, Spijker, Stouthard, & Essink-Bot (2005) estimated that of each

year lived with a major depressive disorder, 46% of the quality of life in this year is missed

because of the depressive disorder. Despite their being different equations to predict a person’s

mortality rate, the calculations have a low validity rate due to the limited research on the overall

impact of childhood adversities on disease burden on a population level. Without this data,

clinicians are unable to accurately calculate a patient’s mortality rate, which explains why its

clinical application has become obsolete in most clinical settings.

ACE Risk Factors

The Centers for Disease Control and Prevention (2015) point out that a child’s risk of

being exposed to adverse childhood-related events is influenced by a number of individual,

family, and environmental factors, all of which interact to increase or decrease risk over time and

within specific contexts. Obvious risk factors include a child’s age and if they have any special

needs may increase their vulnerability (e.g., developmental and intellectual disabilities, mental

health issues, and chronic physical illnesses). Additional risk factors include the age of the

parent(s) or caregiver(s), the number of children in the household, if there is any parental history

of abuse, neglect, substance abuse, or mental-health issues, if there is any history of intimate

partner or community violence, and concentrated neighborhood disadvantage (e.g., high poverty

and residential instability, high unemployment rates). Although risk factors provide information
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about who is most at risk for being a victim or a perpetrator of child abuse and neglect, they are

not direct causes and cannot predict who will be a victim or a perpetrator. Fortson and Mercy

have argued that no single factor tells the entire story about how and why adverse childhood

experiences occurs, nor outline the exact risk and protective factors.

Epidemiology

Merrick, Fortson, & Mercy (2015) concluded that a child’s risk of being exposed to a

trauma-related event varies across several epidemiological factors, such as a person’s race,

ethnicity, and family income. The research indicates that younger children are most likely to

experience a fatal-related traumatic event while teens are most likely to experience a non-fatal

traumatic incident. According to data from child protective services, African American children

experience abuse and neglect at rates that are nearly double those for white children. Children

living in families with a low socioeconomic status (SES) have rates of child abuse and neglect

that are five times higher than those of children living in families with a higher SES. These

differences are generally attributed to various community and societal factors, including poverty

as well as differences in reporting and investigation. Irrespective of data source, definitions, and

measures, the true magnitude of child abuse and neglect is likely underestimated. As a result,

these numbers should be considered to be on the lower end of the spectrum. Although risk

factors continue to provide practitioners and public officials with information correlating who is

most at risk for being a victim of child abuse and neglect, they are not direct causes. Therefore,

clinicians are unable to precisely predict who will become a victim. This is can best be explained

because correlation does not mean causation.

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Biomarkers & Neuroimaging

Venigalla H, Mekala HM, Hassan M, et al. (2017) define a biomarker as an attribute that

is “objectively measured and evaluated as an indicator of normal biologic processes, pathologic

processes, or biological responses to a therapeutic intervention. A biomarker can be a gene or a

group of genes, proteins, or other biomolecules… and can be used to confirm the presence of a

specific disease” (472). Psychiatrists aim to use biomarker testing to measure a patient’s

biological response before and after any pharmacological interventions are made. In addition,

psychiatrist would utilize biomarker testing during a patient’s follow-up appointment in order to

assess the overarching pathological process. This kind of strategic approach and systematic

process would produce objective data for psychiatrist to use to enhance their ability to make an

accurate diagnosis, form a reliable prognosis, and improve the patient’s outcomes.

Venigalla H, Mekala HM, Hassan M, et al. (2017) state that despite the past two decades

of research centered around biomarkers, clinicians have not been able to identify the etiology of

most psychiatric disorders. That being said, the current research literature introduces a set of

anatomical and physiological biomarkers that clinicians believe to correlate with the onset of

certain psychopathology. For example, Young et al. (2016) theorizes the biomarker “C-reactive

protein, Interleukin-6, Tumor necrosis factor- α” influences the onset of clinical depression

(474).

Venigalla H, Mekala HM, Hassan M, et al. (2017) indicated that despite any correlations,

biomarker testing is not openly available for clinicians to use throughout the diagnostic and

intervention process for psychiatric disorders due to its heterogeneous expression. As a result,

until research can precisely pinpoint the root cause that explains why a particular psychiatric

disorder develops, any clinical application of biomarkers to treat mental-health related disorders
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will remain in its early stages. To see more examples, refer to “Table-1: Various Studies

Proposing Different Biomarkers for Different Psychiatric Diagnoses” on page 16-17 and “Table-

2: Various Studies Proposing Genetic and Preteomic Biomarkers for Different Psychiatric

Diagnoses” on page 17..

Shonkoff, Boyce, and McEwen (2009) exemplify how the medical community has seen

massive technological advances that have allowed clinicians to observe and study the brain like

never before. Recent developments in neuroimaging have just began to unravel the existing

relationship between psychological trauma and pathophysiology, neurobiology, and

psychopathology. Further research is necessary in order to understand how structural brain

dysfunction, neuro-hemodynamics, neurobiology, and neurophysiology influence the

development of various psychiatric disorders. Such newfound research could guide psychiatrist

to establish a reliable set of clinically applicable biomarkers. Until that happens though,

clinicians are not able to rely on biomarker testing to predict the longitudinal effects of childhood

trauma, nor are they able to better understand how a person’s biological and pathological

processes have responded to previous trauma.

Treatment

According to Cohen, Scheid, and Gerson (2014) research study, there are no evidence-

based psychopharmacologic treatments available because clinical trials have generally failed to

demonstrate its effectiveness in any medication for improving pediatric PTSD (p. 11). Since not

all problems respond positively to psychopharmacologic interventions, and for traumatized

children in particular, the most effective intervention is evidence-based trauma-focused

psychotherapy. When feeling emotionally, behaviorally, or psychologically dysregulated from

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trauma-induced symptoms, using breathings techniques and incorporating mindfulness exercises

can help calm the body’s stress response. When balancing dysregulation pathways by

incorporating exercise, maintaining a balanced diet, developing healthy sleep habits, and

improving upon interpersonal relationships are all ways to negate the longitudinal effects of

adverse childhood trauma. For adults who have not overcome their early-childhood trauma, they

can attend therapy/counseling to help improve their quality of life. In order for treatment to be

successful, a person must work through intense emotional, mental, and psychological tasks

throughout the course of therapy. People may join social support groups, local club, or turn to

religion as ways to improve their quality of life.

Counselor’s Future Work

In theory, if the Counsel for Accreditation of Counseling and Related Educational

Programs (CACREP) were to adopt a science-based approach throughout their respective

graduate curriculums and was to adopt a greater emphasis that acknowledges the longitudinal

effects of childhood trauma, then the traditional biopsychosocial approach that counselors are

trained to practice, would then drastically shift to a clinical approach that largely embodies one

similar to the medical-model. This would significantly effect a counselor’s role and scope of

practice within the entire health-care system. For instance, it would foster more leadership-type

roles in clinical settings for counselors to earn within the mental-health profession and allow

counselors to command greater respect from the general public. Moreover, it may help

destigmatize the public’s misconception that attending counseling is scary or that it is ineffective.

If counselors became equipped to incorporate bio-related intervention tactics, it would

help guild their clinical practices and could significantly enhance treatment outcomes. Generally,
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when more efficient and effective interventions are implemented in clinical settings, it will drive

down the overall cost for treatment and save people tax dollars. For example, the National

Institute on Drug Abuse (2008) reported that the average cost for 1 year of methadone

maintenance treatment is approximately $4,700 per patient, whereas 1 year of imprisonment

costs approximately $24,000 per person. As one can see, when someone is incarcerated, the costs

becomes 5x more than the more efficient, effective treatment route. This historical example

adequately depicts how new and improved treatment options could systematically open up doors

that allow people to have better access to mental-health services in underserved, rural, poor

communities.

I believe if counselors were to adopt a greater emphasis that acknowledges the

longitudinal effects of childhood trauma, it would unify the counseling community by shortening

the amount of theoretical orientations that they practice. This is important because other health-

care professions argue that the counseling community cannot agree to use just one theory in

clinical practice. Although most counselors use cognitive-behavioral therapy (CBT) techniques

and strategies, they do so at the expense that insurance companies will generally deny covering

treatments that primarily incorporate other theoretical models. This ideological split within the

counseling community largely explains why clients may have struggled in the past with finding

the right counselor for them or have trouble obtaining mental-health services. Unifying the

counseling community could theoretically change these problems.

If counselors were to adopt a greater emphasis that acknowledges the longitudinal effects

of childhood trauma, it could shorten the amount of times and extend the length of time that

people would attend counseling. That being said, the opposite could occur where it may increase
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the amount of times and extend the length of time that people would attend counseling. While

this can be considered a drawback, it may lead to better treatment outcomes.

Research Methods

In order to successfully complete my independent study, I had to access of a wide array

of resources. The interlibrary loan system at Immaculata University played a pivotal role for this

study. The platform offered global access to scholarly journals and doctoral dissertations that I

otherwise would not have access to as a general visitor of the University. My supervisor, Dr.

Martinson, played a significant role during the semester long independent study. Throughout our

meetings, he provided a different perspective on clinically relevant content as a way to help me

navigate the direction of my research efforts. In addition, he would answer questions with rich

insight, would recommend scholarly article that was published in different professional journals,

and provided a list of 104 different scholarly publications that may enhance my research

findings. Lastly, he would offer guidance in order to help me navigate and facilitate the overall

direction of the independent study.

Limitations

Throughout the process of successfully completing my independent study, I encountered

a number of limitations that are worth mentioning. Although I was given 15-weeks to complete

my study, there are time-related factors that affect the quality-and-amount of content gathered.

Had I been provided additional time or a support staff to help me gather research, it is plausible

that the quality of content would improve. A second limitation occurred when I was asked to pay

in order to access certain publications of research literature. Financial constraints restricted my

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access to some clinically related publications. By narrowing my research efforts only towards

free resources, then I can argue that the overall quality of content I could collect would become

limited. A third limitation relates to all of my held or hidden biases’. This complex phenomenon

effected what direction I took throughout the research process. This could lead readers to

question the reliability of my research findings due to events like information bias or research

bias.

Conclusion

There is a large body of research literature that connects the longitudinal effects of

childhood trauma to the later development of adult psychopathology and pathophysiology.

Clinicians have identified that an association exists between the two, but the amount of

participants included in these studies is too small to prove that their findings yield a direct cause-

and-effect. Although certain anatomical and physiological biomarkers are directly linked with

the onset of certain psychopathology, there is not enough evidence to support anything more than

a correlation exists.

As neuroimaging techniques become more affordable and accessible to clinicians,

researchers hope to one day unveil the true relationship between psychological trauma and

psychopathology, pathophysiology, and neurobiology. As neuroimaging technology

continuously develops, neuroscientists would like to use optogenetics on human brains because it

would allow them to map the brain’s neural circuitry, ultimately revealing secrets about how the

brain processes information and drives human behavior. This breakthrough could allow

clinicians to improve treatment outcomes and enhance a patient’s access to effective, affordable
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care. These improvements may uncover the “how” and “why” trauma causes longitudinal

damage.

No matter a person’s geographic location, ethnicity, and socioeconomic background, we

all are effected by ACEs in similar ways. Although a child can experience many adverse events

or be exposed to severely traumatic incidents, they can forgo to live a happy, healthy life as long

as a positive, nurturing support system is in place. The long-term impacts of childhood adversity

are not all related to suffering. Adversity can foster perseverance, deepen empathy, strengthen

the resolve to protect, and becomes a part of who we are.

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Table 1: Various Studies Proposing Different Biomarkers for Different Psychiatric Diagnoses
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Table 1: Various Studies Proposing Different Biomarkers for Different Psychiatric Diagnoses
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Table 2: Various Studies Proposing Genetic and Preteomic Biomarkers for Different Psychiatric
Diagnoses
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Works Cited

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Arlington, VA: American Psychiatric Publishing.

Centers for Disease Control and Prevention. (2015). Child maltreatment: Risk and protective

factors. National Center for Injury Prevention and Control, Division of Violence

Prevention. Retrieved from

http://www.cdc.gov/violenceprevention/childmaltreatment/riskprotective factors.html.

Cohen, J.A., Scheid, J., Gerson, R. (2014). Transforming Trajectories for Traumatized Children.

Journal of the American Academy of Child & Adolescent Psychiatry, 53(1), 9-13.

Corso, P.S., Edwards, V.J., Fang, X., Mercy, J.A. (2008). Health-Related Quality of Life Among

Adults Who Experienced Maltreatment During Childhood. American Journal of Public

Health, 98(6), 1094-1100. doi: 10.2105/AJPH.2007.119826

Felitti V. (2009). Adverse childhood experiences and adult health. Academic Pediatrics, 9, 131-

132.

Gilbert, L. K., Breiding, M. J., Merrick, M. T., Thompson, W. W., Ford, D. C., Dhingra, S. S., &

Parks, S. E. (2015). Childhood adversity and adult chronic disease. An update from ten

states and the District of Columbia. American Journal of Preventive Medicine, 48(3),

345-349. Retrieved from: https://doi.org/10.1016/j.amepre.2014.09.006

Kruijshaar, M.E., Hoeymans, N., Spijker, J., Stouthard, M.E., Essink-Bot, M.L. (2005), Has the

burden of depression been overestimated? Bull World Health Organ, 83(6), 443-448.

doi:/S0042-96862005000600012

Merrick, M. T., Fortson, B. L., & Mercy, J. A. (2015). The epidemiology of child maltreatment.
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In P. D. Donnelly & C. L. Ward (Eds.), Oxford textbooks in public health – Violence: A

global health priority. Oxford, UK: Oxford University Press.

National Institute on Drug Abuse (2008). National Institute of Health. Retrieved from:

https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-

based-guide-third-edition/frequently-asked-questions/drug-addiction-treatment-worth-its-

cost

Shonkoff, J.P., Boyce, W.T., McEwen, B.S. (2009). Neuroscience, Molecular Biology, and the

Childhood Roots of Health Disparities: Building a New Framework for Health Promotion

and Disease Prevention. JAMA. 301(21), 2252–2259. doi:10.1001/jama.2009.754

Venigalla H, Mekala H.M, Hassan M, et al. (2017), An Update on Biomarkers in Psychiatric

Disorders - Are we aware, Do we use in our clinical practice? Mental Health in Family

Medicine 13, 471-479.