Sexual Side Effects of Antidepressant Medications: An InformedConsent Accountability Gap Ó Springer Science+Business Media, LLC 2008 Sexual side effects of antidepressant medica- in consultations with prescribing professionals regarding tions are far more common than initially reported, and their psychotropic medications, and discuss medication-related scope, quality, and duration remain poorly captured in the issues with their patients in individual psychotherapy literature. Antidepressant treatment emergent sexual dys- (VandenBos and Williams Barnett and Neel ) functions may decrease clients’ quality of life, complicate take the stance that knowledge about psychotropic medi- psychotherapy, and damage the treatment alliance. Poten- cation effects and side effects has become a necessary tial damage to the treatment alliance is greatest when professional competency and ethical obligation held by all clients have not been adequately informed of risks related psychologists who practice or supervise, and aids in our to sexual side effects. It had previously been assumed that ability to best meet patients’ needs, provide appropriate sexual side effects always resolve shortly after medications informed consent in the presentation of treatment alterna- are discontinued. Emerging evidence, however, suggests that in some individuals, sexual dysfunction side effects Antidepressants are currently the most commonly pre- may persist indefinitely. The authors argue that all psy- scribed class of medications of all (Burt et al. ), with chologists should be well-informed about sexual side recent estimates of one in eight adult American having effects risks of antidepressant medications, should rou- taken or taking an SSRI over the last ten years (Raz tinely conduct a pre-medication baseline assessment of and 11 million prescriptions written for children and ado- sexual functioning, and take an active role in the informed lescents during 2002 (Goode The present article is concerned with sexual side effects of antidepressant med-ications including the Selective Serotonin Reuptake Inhibitors fluoxetine (Prozac), paroxetine (Paxil), sertraline SSRIs Á Sexual dysfunction Á Iatrogenic Á Informed consent (Zoloft), citalopram (Celexa), escitalopram (Lexapro), andfluvoxamine (Luvox), and the Serotonin NorepinephrineReuptake Inhibitor (SNRI)1 venlafaxine (Effexor). Sexualdysfunctions associated with antidepressants are acknowl- Professional psychologists have long been involved, either edged as a significant treatment risk (Rivas-Vasquez et al.
directly or indirectly, in patients’ decision-making process ). Yet the existing literature, which is heavily focused regarding psychotropic medications. A recent survey on prevalence rates and treatment compliance, poorly indicated that approximately 43% of the clients of psy- captures the scope, quality, and potential impact of the chologists take psychotropic medications adjunctively to sexual side effects (Bahrick Bahrick ; Michels psychotherapy, and virtually all practicing psychologistsmake recommendations for medication evaluations, engage 1 SNRIs include venlafaxine (Effexor), desvenlafaxine (Pristiq) andduloxetine (Cymbalta). Sexual side effects of desvenlafaxine and A. S. Bahrick (&) Á M. M. Harris duloxetine are less well studied and are not a specific focus of the University Counseling Service, The University of Iowa, present article. However as desvenlafaxine is the major metabolite of 3223 Westlawn S., Iowa City, IA 52242-1100, USA venlafaxine, the medications are likely to prove to have similar sexual ). Little attention has been focused on the ways that Antidepressant-emergent sexual difficulties noted by the addition of a new sexual dysfunction to a client’s men include decreased nocturnal and morning erections, presenting problem may complicate and confuse the clin- difficulty achieving or maintaining an erection sufficient ical picture, exacerbate the client’s distress, destabilize for penetration, ejaculatory delay or anorgasmia, difficulty intimate relationships, weaken the treatment alliance, and with arousal, and decreased libido. Women report delayed create mistrust in mental health professionals, especially if orgasm or anorgasmia, difficulty with arousal, lubrication the client has not been adequately informed of sexual side problems, and decreased libido. Ejaculatory delay in men, effect risks. The current article explores these themes and and anorgasmia in woman are the problems believed to be seeks to raise clinicians’ awareness of client welfare issues unequivocally medication-induced (Balon ). Loss of related to antidepressant sexual side effects. Challenges are genital tactile sensitivity and diminished intensity of raised about the psychologists’ role in the informed consent orgasm, or pleasureless orgasm, are also not uncommon in process, and recommendations are made for training.
both men and women (Zajecka et al. ), but are oftenmissed by assessment instruments (Bahrick , Serotonergic medications are known to decrease genital sensitivity, probably by way of interference with nitricoxide function (Clayton and Montejo which is No clinically meaningful differences have been established integral to penile and clitoral tumescence. Genital anes- in the tendency of the various SSRIs and venlafaxine to thesia and pleasureless orgasm are not known in the cause sexual dysfunction (Montgomery et al. and no general population and are unassociated with the condi- reliable remedies established (Balon ). Because no tions for which the medications are prescribed, thus these clinically significant differences in efficacy are recognized symptoms provide a clear link to the treatment rather than among the medications (American Psychiatric Association the condition being treated (Bahrick ).
), the choice of which medication to prescribe is often The lack information about the impact of antidepressant based on the medication’s known side effect profile. The sexual side effects on the psychosexual development of current drug insert literature for all of the SSRIs includes adolescents and children is especially troubling. Yet little acknowledgement that the 2–16% listed rates of sexual side concern has been raised, and no studies have been con- effects may be an underestimate. Indeed, large prospective ducted with the aim of determining the impact and long studies in which participants report no sexual dysfunctions term outcome of SSRIs on adolescents’ and children’s at baseline, have shown that between 30 and 73% of adult psychosexual development. While adolescents may be patients experience SSRI and venlafaxine -emergent sexual presumed to experience sexual side effects at rates similar dysfunctions (Montejo-Gonzalez et al. Montejo et al.
to adults (Sharko and while the medications’ sexual side effects are intended as the primary therapeutic effect SSRIs and/or SNRIs are approved and considered first in off-label treatment of paraphilias in adolescents (e.g.
line treatments for depressive disorders, generalized anxiety Aguirre ; Galli et al. no age-appropriate disorder, panic disorder, social phobia, obsessive-compul- instruments have been developed to assess sexual side sive disorder, bulimia, premenstrual dysphoric disorder, post effects in adolescents, and the area remains ignored in traumatic stress disorder, and diabetic peripheral neuro- pathic pain: issues with which a large number of our clientspresent. Increasingly, the medications are also prescribedoff-label (Chen et al. ) to treat conditions such as peri- Post Medication Persistence of Sexual Side Effects menopausal hot flashes, chronic fatigue syndrome, chronicpain syndromes, premature ejaculation (i.e. see Waldinger Antidepressant sexual side effects persist in most individ- ) and paraphilias (i.e. see Kafka ). In the later two uals who experience them for at least as long as they take conditions, the sexual side effects are intended as the pri- the medications (Montejo et al. Landen et al. mary desirable therapeutic effect, with SSRIs reported to be The conventional wisdom holds that the side effects the most common first line treatment for premature ejacu- resolve shortly after discontinuing the medications. The lation among urologists (Shindel et al. Given the research literature, however, has failed to include system- frequency with which the medications are prescribed, and atic follow-up in support of this assumption. While it is the pervasiveness with which they may affect all phases of likely that sexual side effects resolve for most individuals, the sexual response cycle (Clayton et al. ; Clayton et al.
of particular concern to this inquiry are indications that for ; Montejo-Gonzalez et al. Montejo et al. some individuals, antidepressant-emergent sexual dys- psychologists should be well-informed about the potential functions do not always resolve upon discontinuation of the for the medications to impact sexual functioning.
medications, and may persist indefinitely (see Bahrick for a review). Signs from recent case reports (Bolton about SSRI/SNRI sexual side effects. These gaps may be of public health significance, particularly when they involve Kauffman and Murdock Internet based consumer iatrogenic sexual dysfunctions that persist beyond treat- ment discontinuation, and when the side effects impact the and findings of post SSRI persistence of ejaculation delay psychosexual development of adolescents and children. If in men treated for premature ejaculation (Arafa and post-medication aberrations of normal sexual response Shamloul ; Safarinejad ; Safarinejad and Hosse- persist even in a small number of people, such findings ini ), converge to point to an emergent problem.
should come to light (Kauffman The literature has In all the case reports noted above, the presenting failed to consider the ways in which medication-related problems have long resolved, however the antidepressant- sexual side effects may complicate the efforts of individ- emergent sexual dysfunctions have persisted for years uals who take them to improve their lives as well as their beyond medication discontinuation, and no alternative moods. Further, the literature appears to entirely miss the etiologies for the persistent symptoms could be found. The possibility that, in some cases, the treatment-emergent SSRIsex Internet group membership of over 1600 indi- sexual side effects may be worse than the condition for viduals has generated more than 12,000 postings of which treatment has been sought, and even become a cause consumer experiences of persistent post- antidepressant of long term anguish. Given limits of knowledge, psy- sexual side effects (accessed June 14, 2008). These post- chologists should be especially attentive to client-reported medication experiences as a credible and worthy source of information not capturable within current research para- information about the impact of antidepressant sexual side digms, and not encompassed by existing post market effects. Psychologists, by virtue of our frequent regular pharmacovigalence mechanisms. The present authors urge contact with patients, are in an optimal position to assess attentiveness to such signals of emerging problems.
and monitor emergent medication effects and to help cli- Empirical evidence of the persistence of SSRI-emergent ents formulate a response to concerns in this area of sexual side effects well beyond medication discontinuation is found in the literature related to premature ejaculation(PE). Three, random assignment, placebo controlled stud-ies of healthy men treated for PE (Arafa and Shamloul ; Safarinejad ; Safarinejad and Hosseini with sertraline (n = 147), escitalopram (n = 276), and The doctrine of informed consent requires that health citalopram (n = 58) respectively, all found robust evidence professionals provide sufficient information so that a rea- of continuation of the benefit of medication-emergent sonable person may decide whether or not to accept the delayed ejaculation over a six month post-treatment treatment in question. While (non-prescribing) psycholo- assessment period. Yet none of the researchers raised gists function primarily in an advisory and referral role concerns about medication-induced delayed ejaculation in with regards to medication decisions, they hold responsi- men being treated for reasons other than PE and for whom bility for protecting client welfare. Clients must trust delayed ejaculation may not be a desirable treatment or psychologists to protect their best interests and to ensure post-treatment effect. Neither were questions raised about that all risks for harm are minimized (Barnett The possible post-treatment persistence of other sexual side amount and type of information deemed adequate to con- effects that both men and women may find far less desir- stitute full disclosure is a matter of some debate, however able. When SSRIs are used to treat premature ejaculation, it the process of providing ongoing and current information is an irony that in this instance it is advantageous to relevant to the client’s situation is the critical aspect of industry to acknowledge the robustness of treatment informed consent to which psychologists must aspire induced sexual side effects, and also to emphasize a lasting (Johnson-Greene Moreover, research involving psychiatric residents (Rutherford et al. and psychi- Given the lack of qualitative information in the litera- atric nurses (Higgins et al. indicates that informed ture, the absence of systematic follow-up, the limited scope consent is often inadequate, particularly with regards to and aims of current research paradigms, the lack of sexual side effects (Higgins et al. and that patients inclusiveness of consumer voices in the post market are specifically dissatisfied with the information they pharmacovigalence system, and the many ways in which receive about the impact of medications on sexual func- industry financial and marketing motives result in mis- leading information regarding risks vs. benefits (i.e.
Higgins et al. ) studied how psychiatric nurses Antonuccio et al. Pachter et al. ), it is not sur- approached providing information about possible sexual prising that there remain significant gaps in knowledge side effects in the informed consent process with patients.
These registered nurses acknowledged that their responsi- provided among residents based on year of residency.
bilities included providing education about and monitoring While Rutherford et al. note that the degree to which of medication effects, and that this commitment was in adequate informed consent occurs in the community is keeping with the rights of consumers to make informed unclear, they question how psychiatrists would learn to treatment decisions. The researchers found that despite obtain informed consent, if not during residency.
positive aspirations regarding informed consent, in prac- Adults are presumed capable of making informed con- tice, information about drug-related sexual side effects was sent decisions if given reliable and understandable relegated to the bottom of a hierarchy of information, information upon which to base a decision. Adults may rarely proactively verbally disclosed at drug initiation, and have a clear appreciation of sexual changes and losses rarely directly inquired about once patients were taking the associated with medication use, and therefore are capable medications. This hierarchy was based on nurses’ percep- of weighing potential risks against possible therapeutic tion that disclosure about possible sexual side effects could benefits in their treatment decisions. Indications are that lead to a high risk of medication non-compliance, their only a small minority of antidepressant-treated patients personal unease talking about sexual side effects, as well as (3% of 5356 patients surveyed) consider sexual functioning their (mis)perception of the prevalence of sexual side not at all important, and that the vast majority of patients are willing to talk about sexual functioning (Clayton et al.
In cases where patients spontaneously initiated com- ). As evidenced by the large discrepancy, up to 60% plaints about the medication’s effect on sexual functioning, (Balon ), between sexual side effect rates obtained by Higgins et al. (describe the nurses as acting out their spontaneous patient report vs. via direct inquiry, it cannot role in relation to medication in paternalistic and compli- be assumed that patients experiencing them, and who are ance terms: that is by providing their professional willing to discuss them, will initiate such discussion.
perspective regarding the importance of remaining on the The question of SSRI informed consent for adolescents medication, a disinclination to hear about the quality-of- and children is considerably more problematic. From what life impact of the sexual problems, and a desire to achieve basis may adolescents and children, or their parents in their the predetermined outcome of medication compliance.
behalf, evaluate the current or potential future meaning and Nurses’ assumptions about the impact of sexual side effects impact of medication induced changes in sexual function- differed depending on gender of the patient. Male patients ing? As previously noted, sexual side effects can be tended to initiate complaints about medication-induced expected to occur in adolescents at rates similar to those in sexual dysfunction more often than women and were adults (Sharko With little or no stable baseline from viewed as more concerned about performance and the erect which to assess sexual changes, how would children, penis as a center of male sexual expressiveness. Women adolescents, their parents, or prescribing professionals were viewed as being less concerned with sexual perfor- become aware of the medications having an impact on mance and therefore assumed to be more willing to silently sexual functioning or development? Case reports of per- sistent post-medication sexual dysfunction, evidence of Are problems with informed consent and the compli- SSRI-linked growth suppression in children (Weintraub ance-based interactions described by Higgins et al. ( et al. and animal studies in which early exposure to reflective more generally of prescribing practices beyond SSRIs persistently negatively impacts adolescent and adult this community? The authors indicate that that the nurses sexual behavior (deJong et al. ; Maciag et al. ; veiling of sexual side effects information mirrors their Gouveˆa et al. raise concern that antidepressants training, role-modeling, and socialization into the culture could alter pubertal development in adolescents. As noted of psychiatry and psychiatric nursing practice, where if and by Antonuccio ) children are essentially ‘‘involuntary when sexual side effects were mentioned, they were ‘‘quite patients’’ who are compelled by parents to take their medicine. Thus he argues that treatment decisions should A recent study of the informed consent practices of be guided by a stringent ‘‘first do no harm’’ approach.
psychiatric residents would seem as well to support and Given the indications of potential harm along with the extend Higgins’ et al.’s ) conclusions. Rutherford inestimable value of future sexual health, it is the present et al. ) found that psychiatric residents failed to authors’ position that until reliable long-term safety data appreciate that it is the physicians’ responsibility to initiate become available, neither children nor adolescents are an informed consent discussion. Instead of initiating capable of providing informed consent for treatment with informed consent discussions with hypothetical patients, SSRIs, nor can their parents provide it competently in their residents reported that they would provide appropriate information when asked by the patient. No significant Based on the above discussion, and in the context of differences were found in the adequacy of information continued underestimation of sexual side effects by psychiatrists (Osvath et al. primary care physicians destabilizing an important intimate partnership and (Clayton et al. Hu et al. ), and psychiatric nurses major source of support, and leading to new and (Higgins et al. there are reasonable grounds for unexpected relational conflict, stress, or even loss. Her asking questions about the degree to which patients con- mood, previously buoyed by the medication, begins to sidering taking antidepressant medications are being gradually return to near baseline levels of distress.
adequately informed about the known risk of sexual side Session time that had been devoted to focusing on her effects. Beyond the more easily remediable underestima- depressive symptoms now gradually begins to shift tion by prescribing professionals of sexual dysfunction toward a focus on emergent relationship concerns.
rates are process issues more challenging to address. These Some of the previously made gains in therapy are lost, may include: discomfort with initiating discussion about and confusion is added regarding the meaning of the sexual functioning; presumption of patient discomfort; lack absence of physical longing or sexual interest in her of professional training in sexuality issues; assumption that sexual functioning is unimportant due to client level of A socially anxious young man’s anxiety has prohibited distress or other client variables such as age, gender or him from meeting potential romantic partners. His partner status; lack of awareness that initiating such a frustration and loneliness finally motivate him to discussion is the prescribing professional’s responsibility; endure the social discomfort of psychotherapy itself.
time pressures; and, in a misconstrual of the doctrine of Treated with an SSRI, his anxiety decreases but he informed consent, apparently also the concern that the develops medication-induced anorgasmia and erectile information may lead to medication non-compliance. An dysfunction. These symptoms create new anxieties and accountability gap arises from the inadequacies inherent in vulnerability about adequacy to engage in a romantic the literature, the unevenness with which prescribers pro- partnership, perhaps contributing as well to perceived actively inform patients about the possibility of sexual side sexual failure experiences if attempted. In turn, such effects, along with the failure of manufacturers to update experiences raise new, potentially even more challeng- SSRI/SNRI product information. How do psychologists ing anxieties which further entrench his avoidant best proceed when there is reason to believe that clients are behavior as his concerns about adequacy grow even inadequately informed of sexual dysfunction risks of anti- A young man seeks counseling with depressive symp-toms related to a lack of meaningful intimacy. Whileclear about same sex attractions, internalized homo- Case Scenarios and Implications for Psychotherapy phobia and concern about family disapproval have beenbarriers to acting on his attractions. An SSRI has a When clients are not proactively informed about sexual side positive impact on depressive symptoms, and psycho- effects, treatment emergent sexual dysfunctions may be therapy helps him to affirm a more positive gay identity.
poorly understood as medication-related by both patients He experiences increased energy to pursue a longstand- and prescribers (Osvath et al. This is especially true ing same sex attraction. Once with a potential partner, if no baseline assessment of sexual functioning was con- however, he finds the physical arousal is difficult to ducted. Consider the following three hypothetical but in our maintain, leading him to confusion and return to earlier own clinical experience, not uncommon case scenarios. In sexual identity questions he believed he had resolved.
each, psychotherapy clients’ medication-emergent sexual In all the scenarios noted, it is preferable for psycholo- side effects create new difficulties which may be chal- gists to be in a position of having proactively discussed the lenging to interpret in light of presenting issues, and that possibility of sexual dysfunction directly with clients as a may even work in direct opposition to the goals the client psychotherapy treatment issue, rather than to assume that came in to address in psychotherapy. In each scenario, the accurate or complete information was provided by the psychologists’ role may vary from having urged the client prescribing professional. Providing information or con- to consider pharmacotherapy, to having suggested phar- firming that the client is aware of the possibility of sexual macotherapy as one of several viable options, to the client side effects signals openness to addressing the concern having initiated pharmacotherapy outside of the psycho- collaboratively with the client if it arises, is likely to pre- serve the psychotherapy treatment alliance, and increases A depressed, albeit sexually active and sexually the likelihood that symptoms may be accurately inter- functional young woman begins SSRI treatment. She preted. It should be emphasized that ongoing and feels better on the medication, but develops sexual side transparent collaboration with the prescribing professional effects that lead to sexual disinterest and withdrawal, regarding medication concerns is equally essential to promote client welfare, and that clients should of course be decision-making that the long term impact of this class of encouraged to raise concerns regarding medication effects medications on sexual functioning is unknown and has not directly with prescribers. When appropriate, and with client been studied systematically. While most individuals who permission, psychologists’ roles may also include advo- experience sexual side effects return to baseline sexual cating for our clients about possible changes to a functioning shortly after discontinuing the medications, a medication regimen based on concerns about observed small number of reports have surfaced suggesting this is not Sorting out the meaning of new, treatment-emergent It is of course possible that some clients may be sug- sexual dysfunctions with clients can be challenging and gestible regarding sexual side effects as a result of such delicate. This task is facilitated by ensuring an adequate information, that anxiety may be raised, and that clients and ongoing informed consent process, and by routinely may elect non-drug treatments. These possibilities, while attending to baseline sexual functioning and history at the real and significant, must be weighed against the potential outset of treatment. Our role is to raise the possibilities, and for new-onset sexual dysfunctions to confound therapy, in collaboration with the client hypothesize about the rel- create confusion and distress in intimate relationships, ative impact of contributing factors. In the first case, libido damage the working alliance, and diminish client auton- was not affected at baseline during the depressive episode, omy to choose treatment options based on accurate thus, the medication may be suspected as having impacted information, the hallmark of a truly informed consent. As libido. The relational conflict itself, however, may con- argued by Wise (if our agenda is to seek client tribute to lowered libido and sexual withdrawal, leaving a agreement with our treatment plan rather than to genuinely puzzling circularity. In the second and third cases, medi- engage in collaborative decision-making ‘‘we are arguably cation rather than a psychological basis for the sexual engaging in risk management rather than truly meeting the changes may be strongly suspected if the individual is also aspirational goal of informed consent’’ (p. 183).
newly unable to masturbate to satisfaction, as few indi- An adequate informed consent for antidepressants and other psychotropic medications goes far beyond the pro- masturbating. Initiating exploration regarding the emer- vision of information about sexual side effects, and is gence of ‘‘markers’’ of medication exposure (Bahrick beyond the scope of the present article. Informing patients ), including decreased genital sensitivity or genital about risks and benefits of medications has become a major anesthesia, and decreased orgasmic intensity or pleasure- challenge for health care providers (Berry ). The less orgasm may provide further support for clarifying the present authors have chosen to highlight sexual side effects contribution of medication vs. psychological factors.
because of their pervasiveness, underestimation in the Well-informed psychologists are aware of the perva- product literature and by prescribing professionals, poten- tial to confound therapy and decrease quality of life, and medications, and given this awareness, cannot then ethically emerging indications that the side effects do not always justify withholding the information from clients. Instead, resolve for all patients. Sorting out the responsibility of they must grapple with tone and content of delivery, and psychologists to respond to broader inadequacies of with consideration for an existing treatment alliance with a informed consent for psychotherapy patients who are tak- prescribing professional when one is already in place. Such ing or considering taking psychotropic medications is a conversations with clients require that psychologists be highly challenging task and will require a dialog among knowledgable about medication side effects as well as psychologists. The reader is referred to Cohen and Jacobs’ competent in exploring and addressing sexuality issues.
) model consent form for psychotropic drug treat- Information about sexual side effects to share with adult ment. This consent form highlights the limits of knowledge clients contemplating taking antidepressant medications regarding the use of psychotropic medications, and pre- might be provided as follows: ‘‘You may already be aware sents easily comprehensible information regarding somatic that the medication you are considering taking is associated and psychological effects of drug use and drug withdrawal.
with a considerably higher level of sexual side effects than The content may serve as a stimulus to help psychologists was known at the time of marketing and which are listed in clarify a better-informed stance regarding participation in the product leaflet. Prior to your starting the medication, I medication recommendations and referrals.
would like for us to explore your current sexual functioningand history of any sexual problems and concerns, so that ifyou do begin to notice sexual changes once on the medica- tion, you and I, in collaboration with your prescriber, canmore confidently attribute them to medication vs. psycho- Psychologists’ training must keep pace with the changing logical factors. I would like for you to be aware in your demands of practice. Given the numbers of clients taking psychotropic medications and our frequent influence in patient’s decision-making regarding medication usage, allpsychologists need to be well-informed about medication Sexual side effects occurring in response to taking anti- main effects and common side effects. Sexual side effects depressant medications are more common than previously are only one of many potential adverse drug effects that reported and may not always resolve once the medication clients under our care may experience; awareness about the has been discontinued. Informed consent regarding the use impacts, side effects, and interactions among a range of of these medications is most effectively accomplished common medications and substances is also necessary. The when all professionals responsible for a patient’s care are American Psychological Association (APA) has endorsed educated about these side effects and work collaboratively basic knowledge in psychopharmacology as imperative for to educate patients, thus increasing their ability to make an all providers in psychology (American Psychological informed choice. The frequency with which the medica- Association board of Educational Affairs , p. ii).
tions are prescribed, the evidence that sexual side effects Barnett and Neel ) argue that that Level 1 training in have been underestimated, and the deleterious effects that psychopharmacology is the minimum requirement neces- such medication side effects may have on treatment and sary to meet the standard of care and avoid doing harm.
patient functioning make it imperative that psychologists Many graduate programs have already incorporated such educate themselves in order to best help those whom they training, and a basic curriculum for professional psychol- serve. This entails a necessary expansion of psychologists’ ogy internships was proposed by Dunivin and Southwell knowledge base and scope of practice. Current efforts at (). Practicing psychologists should seek out training informed consent are most likely inadequate, particularly opportunities available as continuing education courses or for the treatment of children and adolescents, and leave a void that psychologists, given our often more frequent Basic, Level I training in psychopharmacology is not contact with patients, are particularly suited to fill.
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los materiales impresos proponen. Y si el trabajo puede iniciarse supo-niendo que la tradicionalización de un romance de ciego ha de estu-diarse comparando un original con las versiones recogidas de la tradi-ción oral para documentar estados múltiples de cambio diacrónico, nadade esto obliga a asumir que la moral predicada, “el mensaje que coneste tipo de ‘fábulas’ se trata de transmiti

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CURRICULUM VITAE Name: António Braz da Silva Parreira Qualifications: Diploma in Medicine - Lisbon University School of Medicine - 1972. Haematology Board Certificate - Lisbon University School of Medicine, Santa Maria Hospital - 1979. PhD in Haematology - Lisbon University School of Medicine - 1989. Positions held: Junior Assistant of Pharmacology - 1969-72. Internship in Internal Medicine - 197

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