Skip to main content
Erschienen in: Social Psychiatry and Psychiatric Epidemiology 11/2014

01.11.2014 | Original Paper

The prevalence of metabolic syndrome in people with severe mental illness: a mediation analysis

verfasst von: Giuseppe Carrà, Francesco Bartoli, Daniele Carretta, Cristina Crocamo, Alberto Bozzetti, Massimo Clerici, Paul E. Bebbington

Erschienen in: Social Psychiatry and Psychiatric Epidemiology | Ausgabe 11/2014

Einloggen, um Zugang zu erhalten

Abstract

Background

People with severe mental illness (SMI) generally have high rates of metabolic syndrome (MetS). Proposed explanations remain conjectural. Relatively little is known about Mets in SMI in Southern Europe, an area with generally healthy dietary traditions.

Purpose

To establish prevalence rates of MetS in an Italian sample, and testing hypotheses about putative reasons for the excess in the SMI group.

Methods

We compared the prevalence and correlates of MetS in inpatients with SMI and controls randomly chosen from patients undergoing routine maxillofacial surgery. We employed formal tests of mediation.

Results

The MetS prevalence rate was 26.1 % in the SMI group and 15.9 % in the comparison group. After controlling for age, people with SMI were three times more likely to have MetS than their non-SMI counterparts. Smoking and a family history of cardiovascular disease were strongly related to MetS in both groups. However, these factors could not explain the excess of MetS in the SMI group, and we found no effect of antipsychotic dose.

Conclusions

SMI remained prominent in increasing the likelihood of MetS in this low prevalence population, and putative determinants of MetS were common to people with SMI and to controls. Explanations for high MetS rates in SMI may lie in health behaviours other than smoking.
Literatur
1.
Zurück zum Zitat Saha S, Chant D, McGrath J (2007) A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry 64:1123–1131PubMedCrossRef Saha S, Chant D, McGrath J (2007) A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry 64:1123–1131PubMedCrossRef
2.
Zurück zum Zitat Tiihonen J, Lonnqvist J, Wahlbeck K, Klaukka T, Niskanen L, Tanskanen A et al (2009) 11-year follow-up of mortality in patients with schizophrenia: a population based cohort study (FIN11 study). Lancet 374:620–627PubMedCrossRef Tiihonen J, Lonnqvist J, Wahlbeck K, Klaukka T, Niskanen L, Tanskanen A et al (2009) 11-year follow-up of mortality in patients with schizophrenia: a population based cohort study (FIN11 study). Lancet 374:620–627PubMedCrossRef
3.
Zurück zum Zitat Lahti M, Tiihonen J, Wildgust H, Beary M, Hodgson R, Kajantie E et al (2012) Cardiovascular morbidity, mortality and pharmacotherapy in patients with schizophrenia. Psychol Med 42:2275–2285PubMedCrossRef Lahti M, Tiihonen J, Wildgust H, Beary M, Hodgson R, Kajantie E et al (2012) Cardiovascular morbidity, mortality and pharmacotherapy in patients with schizophrenia. Psychol Med 42:2275–2285PubMedCrossRef
4.
Zurück zum Zitat Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F et al (2004) Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case–control study. Lancet 364:937–952PubMedCrossRef Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F et al (2004) Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case–control study. Lancet 364:937–952PubMedCrossRef
5.
Zurück zum Zitat Galassi A, Reynolds K, He J (2006) Metabolic syndrome and risk of cardiovascular disease: a meta-analysis. Am J Med 119:812–819PubMedCrossRef Galassi A, Reynolds K, He J (2006) Metabolic syndrome and risk of cardiovascular disease: a meta-analysis. Am J Med 119:812–819PubMedCrossRef
6.
Zurück zum Zitat Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (2001) Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 285:2486–2497CrossRef Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (2001) Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 285:2486–2497CrossRef
7.
Zurück zum Zitat McEvoy JP, Meyer JM, Goff DC, Nasrallah HA, Davis SM, Sullivan L et al (2005) Prevalence of the metabolic syndrome in patients with schizophrenia: baseline results from the clinical antipsychotic trials of intervention effectiveness (CATIE) schizophrenia trial and comparison with national estimates from NHANES III. Schizophr Res 80:19–32PubMedCrossRef McEvoy JP, Meyer JM, Goff DC, Nasrallah HA, Davis SM, Sullivan L et al (2005) Prevalence of the metabolic syndrome in patients with schizophrenia: baseline results from the clinical antipsychotic trials of intervention effectiveness (CATIE) schizophrenia trial and comparison with national estimates from NHANES III. Schizophr Res 80:19–32PubMedCrossRef
8.
Zurück zum Zitat Mitchell AJ, Vancampfort D, Sweers K, Van Winkel R, Yu W, De Hert M (2013) Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders—a systematic review and meta-analysis. Schizophr Bull 39:306–318PubMedCrossRefPubMedCentral Mitchell AJ, Vancampfort D, Sweers K, Van Winkel R, Yu W, De Hert M (2013) Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders—a systematic review and meta-analysis. Schizophr Bull 39:306–318PubMedCrossRefPubMedCentral
9.
Zurück zum Zitat Mulder H, Cohen D, Scheffer H, Gispen-de Wied C, Arends J, Wilmink FW et al (2009) HTR2C gene polymorphisms and the metabolic syndrome in patients with schizophrenia: a replication study. J Clin Psychopharmacol 29:16–20PubMedCrossRef Mulder H, Cohen D, Scheffer H, Gispen-de Wied C, Arends J, Wilmink FW et al (2009) HTR2C gene polymorphisms and the metabolic syndrome in patients with schizophrenia: a replication study. J Clin Psychopharmacol 29:16–20PubMedCrossRef
10.
Zurück zum Zitat De Hert M, Correll CU, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I et al (2011) Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 10:52–77 De Hert M, Correll CU, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I et al (2011) Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 10:52–77
11.
Zurück zum Zitat Manu P, Correll CU, Van Winkel R, Wampers M, De Hert M (2012) Prediabetes in patients treated with antipsychotic drugs. J Clin Psychiatry 73:460–466PubMedCrossRef Manu P, Correll CU, Van Winkel R, Wampers M, De Hert M (2012) Prediabetes in patients treated with antipsychotic drugs. J Clin Psychiatry 73:460–466PubMedCrossRef
12.
Zurück zum Zitat Buhagiar K, Parsonage L, Osborn DP (2011) Physical health behaviours and health locus of control in people with schizophrenia-spectrum disorder and bipolar disorder: a cross-sectional comparative study with people with non-psychotic mental illness. BMC Psychiatry 11:104PubMedCrossRefPubMedCentral Buhagiar K, Parsonage L, Osborn DP (2011) Physical health behaviours and health locus of control in people with schizophrenia-spectrum disorder and bipolar disorder: a cross-sectional comparative study with people with non-psychotic mental illness. BMC Psychiatry 11:104PubMedCrossRefPubMedCentral
13.
Zurück zum Zitat Kokkinos P, Panagiotakos DB, Polychronopoulos E (2005) Dietary influences on blood pressure: the effect of the Mediterranean diet on the prevalence of hypertension. J Clin Hypertens 7:165–170CrossRef Kokkinos P, Panagiotakos DB, Polychronopoulos E (2005) Dietary influences on blood pressure: the effect of the Mediterranean diet on the prevalence of hypertension. J Clin Hypertens 7:165–170CrossRef
14.
Zurück zum Zitat Salvi V, Albert U, Chiarle A, Soreca I, Bogetto F, Maina G (2008) Metabolic syndrome in Italian patients with bipolar disorder. Gen Hosp Psychiatry 30:318–323PubMedCrossRef Salvi V, Albert U, Chiarle A, Soreca I, Bogetto F, Maina G (2008) Metabolic syndrome in Italian patients with bipolar disorder. Gen Hosp Psychiatry 30:318–323PubMedCrossRef
15.
Zurück zum Zitat Bernardo M, Cañas F, Banegas JR, Casademont J, Riesgo Y, Varela C, RICAVA Study Group (2009) Prevalence and awareness of cardiovascular risk factors in patients with schizophrenia: a cross-sectional study in a low cardiovascular disease risk geographical area. Eur Psychiatry 24:431–441PubMedCrossRef Bernardo M, Cañas F, Banegas JR, Casademont J, Riesgo Y, Varela C, RICAVA Study Group (2009) Prevalence and awareness of cardiovascular risk factors in patients with schizophrenia: a cross-sectional study in a low cardiovascular disease risk geographical area. Eur Psychiatry 24:431–441PubMedCrossRef
16.
Zurück zum Zitat Yazici MK, Anil Yağcioğlu AE, Ertuğrul A, Eni N, Karahan S, Karaağaoğlu E et al (2011) The prevalence and clinical correlates of metabolic syndrome in patients with schizophrenia: findings from a cohort in Turkey. Eur Arch Psychiatry Clin Neurosci 261:69–78PubMedCrossRef Yazici MK, Anil Yağcioğlu AE, Ertuğrul A, Eni N, Karahan S, Karaağaoğlu E et al (2011) The prevalence and clinical correlates of metabolic syndrome in patients with schizophrenia: findings from a cohort in Turkey. Eur Arch Psychiatry Clin Neurosci 261:69–78PubMedCrossRef
17.
Zurück zum Zitat Sicras-Mainar A, Blanca-Tamayo M, Rejas-Gutiérrez J (2008) Metabolic syndrome in outpatients receiving antipsychotic therapy in routine clinical practice: a cross-sectional assessment of a primary health care database. Eur Psychiatry 23:100–108PubMedCrossRef Sicras-Mainar A, Blanca-Tamayo M, Rejas-Gutiérrez J (2008) Metabolic syndrome in outpatients receiving antipsychotic therapy in routine clinical practice: a cross-sectional assessment of a primary health care database. Eur Psychiatry 23:100–108PubMedCrossRef
18.
Zurück zum Zitat Carrà G, Sciarini P, Segagni-Lusignani G, Clerici M, Montomoli C, Kessler RC (2011) Do they actually work across borders? Evaluation of two measures of psychological distress as screening instruments in a non Anglo-Saxon country. Eur Psychiatry 26:122–127PubMedCrossRef Carrà G, Sciarini P, Segagni-Lusignani G, Clerici M, Montomoli C, Kessler RC (2011) Do they actually work across borders? Evaluation of two measures of psychological distress as screening instruments in a non Anglo-Saxon country. Eur Psychiatry 26:122–127PubMedCrossRef
19.
Zurück zum Zitat Spitzer RL, Williams JB, Gibbon M, First MB (1992) The structured clinical interview for DSM-III-R (SCID). I: History, rationale, and description. Arch Gen Psychiatry 49:624–629PubMedCrossRef Spitzer RL, Williams JB, Gibbon M, First MB (1992) The structured clinical interview for DSM-III-R (SCID). I: History, rationale, and description. Arch Gen Psychiatry 49:624–629PubMedCrossRef
20.
Zurück zum Zitat Rejas J, Bobes J, Arango C, Aranda P, Carmena R, Garcia-Garcia M (2008) Concordance of standard and modified NCEP ATP III criteria for identification of metabolic syndrome in outpatients with schizophrenia treated with antipsychotics: a corollary from the CLAMORS study. Schizophr Res 99:23–28PubMedCrossRef Rejas J, Bobes J, Arango C, Aranda P, Carmena R, Garcia-Garcia M (2008) Concordance of standard and modified NCEP ATP III criteria for identification of metabolic syndrome in outpatients with schizophrenia treated with antipsychotics: a corollary from the CLAMORS study. Schizophr Res 99:23–28PubMedCrossRef
21.
Zurück zum Zitat Atkins M, Burgess A, Bottomley C, Riccio M (1997) Chlorpromazine equivalents: a consensus of opinion for both clinical and research applications. Psychiatr Bull 21:224–226CrossRef Atkins M, Burgess A, Bottomley C, Riccio M (1997) Chlorpromazine equivalents: a consensus of opinion for both clinical and research applications. Psychiatr Bull 21:224–226CrossRef
22.
Zurück zum Zitat Lehman AF, Steinwachs DM (1998) Translating research into practice: the schizophrenia patient outcomes research team (PORT) treatment recommendations. Schizophr Bull 24:1–10PubMedCrossRef Lehman AF, Steinwachs DM (1998) Translating research into practice: the schizophrenia patient outcomes research team (PORT) treatment recommendations. Schizophr Bull 24:1–10PubMedCrossRef
23.
Zurück zum Zitat Woods SW (2003) Chlorpromazine equivalent doses for the newer atypical antipsychotics. J Clin Psychiatry 64:663–667PubMedCrossRef Woods SW (2003) Chlorpromazine equivalent doses for the newer atypical antipsychotics. J Clin Psychiatry 64:663–667PubMedCrossRef
24.
Zurück zum Zitat Kroken RA, Johnsen E, Ruud T, Wentzel-Larsen T, Jørgensen HA (2009) Treatment of schizophrenia with antipsychotics in Norwegian emergency wards, a cross-sectional national study. BMC Psychiatry 9:24PubMedCrossRefPubMedCentral Kroken RA, Johnsen E, Ruud T, Wentzel-Larsen T, Jørgensen HA (2009) Treatment of schizophrenia with antipsychotics in Norwegian emergency wards, a cross-sectional national study. BMC Psychiatry 9:24PubMedCrossRefPubMedCentral
26.
Zurück zum Zitat Miccoli R, Bianchi C, Odoguardi L, Penno G, Caricato F, Giovannitti MG et al (2005) Prevalence of the metabolic syndrome among Italian adults according to ATP III definition. Nutr Metab Cardiovasc Dis 15:250–254PubMedCrossRef Miccoli R, Bianchi C, Odoguardi L, Penno G, Caricato F, Giovannitti MG et al (2005) Prevalence of the metabolic syndrome among Italian adults according to ATP III definition. Nutr Metab Cardiovasc Dis 15:250–254PubMedCrossRef
27.
Zurück zum Zitat Osborn DPJ, Wright CA, Levy G, King MB, Deo R, Nazareth I (2008) Relative risk of diabetes, dyslipidaemia, hypertension and the metabolic syndrome in people with severe mental illnesses: systematic review and metaanalysis. BMC Psychiatry 8:84PubMedCrossRefPubMedCentral Osborn DPJ, Wright CA, Levy G, King MB, Deo R, Nazareth I (2008) Relative risk of diabetes, dyslipidaemia, hypertension and the metabolic syndrome in people with severe mental illnesses: systematic review and metaanalysis. BMC Psychiatry 8:84PubMedCrossRefPubMedCentral
28.
Zurück zum Zitat Mancia G, Bombelli M, Corrao G, Facchetti R, Madotto F, Giannattasio C et al (2007) Metabolic syndrome in the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) study: daily life blood pressure, cardiac damage, and prognosis. Hypertension 49:40–47PubMedCrossRef Mancia G, Bombelli M, Corrao G, Facchetti R, Madotto F, Giannattasio C et al (2007) Metabolic syndrome in the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) study: daily life blood pressure, cardiac damage, and prognosis. Hypertension 49:40–47PubMedCrossRef
29.
Zurück zum Zitat Graham I, Atar D, Borch-Johnsen K, Boysen G, Burell G, Cifkova R et al (2007) Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice. European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Eur Heart J 28:2375–2414PubMedCrossRef Graham I, Atar D, Borch-Johnsen K, Boysen G, Burell G, Cifkova R et al (2007) Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice. European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Eur Heart J 28:2375–2414PubMedCrossRef
30.
Zurück zum Zitat Ford ES, Giles WH, Dietz WH (2002) Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA 287:356–359PubMedCrossRef Ford ES, Giles WH, Dietz WH (2002) Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA 287:356–359PubMedCrossRef
31.
Zurück zum Zitat Masulli M, Riccardi G, Galasso R, Vaccaro O (2006) Relationship between smoking habits and the features of the metabolic syndrome in a non-diabetic population. Nutr Metab Cardiovasc Dis 16:364–370PubMedCrossRef Masulli M, Riccardi G, Galasso R, Vaccaro O (2006) Relationship between smoking habits and the features of the metabolic syndrome in a non-diabetic population. Nutr Metab Cardiovasc Dis 16:364–370PubMedCrossRef
32.
Zurück zum Zitat Fernandez-Egea E, Bernardo M, Donner T, Conget I, Parellada E, Justicia A et al (2009) Metabolic profile of antipsychotic-naive individuals with non-affective psychosis. Br J Psychiatry 194:434–438PubMedCrossRefPubMedCentral Fernandez-Egea E, Bernardo M, Donner T, Conget I, Parellada E, Justicia A et al (2009) Metabolic profile of antipsychotic-naive individuals with non-affective psychosis. Br J Psychiatry 194:434–438PubMedCrossRefPubMedCentral
33.
Zurück zum Zitat Ripke S, O’Dushlaine C, Chambert K, Moran JL, Kähler AK, Akterin S et al (2013) Genome-wide association analysis identifies 13 new risk loci for schizophrenia. Nat Genet 45:1150–1159PubMedCrossRef Ripke S, O’Dushlaine C, Chambert K, Moran JL, Kähler AK, Akterin S et al (2013) Genome-wide association analysis identifies 13 new risk loci for schizophrenia. Nat Genet 45:1150–1159PubMedCrossRef
34.
Zurück zum Zitat Chen CC, Li TC, Chang PC, Liu CS, Lin WY, Wu MT et al (2008) Association among cigarette smoking, metabolic syndrome, and its individual components: the metabolic syndrome study in Taiwan. Metabolism 57:544–548PubMedCrossRef Chen CC, Li TC, Chang PC, Liu CS, Lin WY, Wu MT et al (2008) Association among cigarette smoking, metabolic syndrome, and its individual components: the metabolic syndrome study in Taiwan. Metabolism 57:544–548PubMedCrossRef
35.
Zurück zum Zitat Parks J, Radke AQ (2008) Obesity reduction and prevention strategies for individuals with serious mental illness. Alexandria: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council Parks J, Radke AQ (2008) Obesity reduction and prevention strategies for individuals with serious mental illness. Alexandria: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council
36.
Zurück zum Zitat American Diabetes Association (2004) Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 27:596–601CrossRef American Diabetes Association (2004) Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 27:596–601CrossRef
37.
Zurück zum Zitat Nielsen J, Skadhede S, Correll CU (2010) Antipsychotics associated with the development of type 2 diabetes in antipsychotic-naïve schizophrenia patients. Neuropsychopharmacology 35:1997–2004PubMedCrossRefPubMedCentral Nielsen J, Skadhede S, Correll CU (2010) Antipsychotics associated with the development of type 2 diabetes in antipsychotic-naïve schizophrenia patients. Neuropsychopharmacology 35:1997–2004PubMedCrossRefPubMedCentral
38.
Zurück zum Zitat Foley DL, Morley KI (2011) Systematic review of early cardiometabolic outcomes of the first treated episode of psychosis. Arch Gen Psychiatry 68:609–616PubMedCrossRef Foley DL, Morley KI (2011) Systematic review of early cardiometabolic outcomes of the first treated episode of psychosis. Arch Gen Psychiatry 68:609–616PubMedCrossRef
39.
Zurück zum Zitat Ray WA, Chung CP, Murray KT, Hall K, Stein CM (2009) Atypical antipsychotic drugs and the risk of sudden cardiac death. N Engl J Med 360:225–235PubMedCrossRefPubMedCentral Ray WA, Chung CP, Murray KT, Hall K, Stein CM (2009) Atypical antipsychotic drugs and the risk of sudden cardiac death. N Engl J Med 360:225–235PubMedCrossRefPubMedCentral
40.
Zurück zum Zitat Carrà G, Johnson S (2009) Variations in rates of comorbid substance use in psychosis between geographical areas and mental health settings in the UK. Soc Psychiatry Psychiatr Epidemiol 44:429–447PubMedCrossRef Carrà G, Johnson S (2009) Variations in rates of comorbid substance use in psychosis between geographical areas and mental health settings in the UK. Soc Psychiatry Psychiatr Epidemiol 44:429–447PubMedCrossRef
41.
Zurück zum Zitat Carrà G, Johnson S, Bebbington P, Angermeyer MC, Heider D, Brugha T et al (2012) The lifetime and past-year prevalence of dual diagnosis in people with schizophrenia across Europe: findings from the European Schizophrenia Cohort (EuroSC). Eur Arch Psychiatry Clin Neurosci 262:607–616PubMedCrossRef Carrà G, Johnson S, Bebbington P, Angermeyer MC, Heider D, Brugha T et al (2012) The lifetime and past-year prevalence of dual diagnosis in people with schizophrenia across Europe: findings from the European Schizophrenia Cohort (EuroSC). Eur Arch Psychiatry Clin Neurosci 262:607–616PubMedCrossRef
42.
Zurück zum Zitat Bartoli F, Carrà G, Crocamo C, Carretta D, Clerici M (2013) Bipolar disorder, schizophrenia and metabolic syndrome. Am J Psychiatry 170:927–928PubMedCrossRef Bartoli F, Carrà G, Crocamo C, Carretta D, Clerici M (2013) Bipolar disorder, schizophrenia and metabolic syndrome. Am J Psychiatry 170:927–928PubMedCrossRef
43.
Zurück zum Zitat Bartoli F, Carrà G, Crocamo C, Carretta D, Clerici M (2013) Metabolic syndrome in people suffering from posttraumatic stress disorder: a systematic review and meta-analysis. Metab Syndr Relat Disord 11:301–308PubMedCrossRef Bartoli F, Carrà G, Crocamo C, Carretta D, Clerici M (2013) Metabolic syndrome in people suffering from posttraumatic stress disorder: a systematic review and meta-analysis. Metab Syndr Relat Disord 11:301–308PubMedCrossRef
Metadaten
Titel
The prevalence of metabolic syndrome in people with severe mental illness: a mediation analysis
verfasst von
Giuseppe Carrà
Francesco Bartoli
Daniele Carretta
Cristina Crocamo
Alberto Bozzetti
Massimo Clerici
Paul E. Bebbington
Publikationsdatum
01.11.2014
Verlag
Springer Berlin Heidelberg
Erschienen in
Social Psychiatry and Psychiatric Epidemiology / Ausgabe 11/2014
Print ISSN: 0933-7954
Elektronische ISSN: 1433-9285
DOI
https://doi.org/10.1007/s00127-014-0835-y

Weitere Artikel der Ausgabe 11/2014

Social Psychiatry and Psychiatric Epidemiology 11/2014 Zur Ausgabe

Update Psychiatrie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.