Dusunen Adam The Journal of Psychiatry and Neurological Sciences 2018;31:238-245 Research / Araştırma

DOI: 10.5350/DAJPN2018310301

The Effect of Heroin Use Melike Dissiz1

Disorder on the Sexual 1University of Health Sciences, Faculty of Nursing,

Department of Obstetrics and Gynecology Nursing,

Istanbul - Turkey

Functions of Women
ABSTRACT
The effect of heroin use disorder on the sexual functions of women
Objective: This study was conducted to evaluate the sexual functions of women with heroin use
disorder.
Method: This comparative-descriptive and cross-sectional study was carried out at the Research,
Treatment and Training Center for Alcohol and Substance Dependence (AMATEM) of Bakirkoy Training
and Research Hospital for Psychiatry Neurology and Neurosurgery. Included in the heroin use disorder
group were 57 women aged 18 years or above who presented to AMATEM between June 1, 2014 and
December 31, 2014 and received a diagnosis of substance use disorder according to DSM-5. Inclusion
criteria were the absence of psychiatric diseases, substance withdrawal symptoms, or mental retardation,
being sexually active, not being pregnant or puerperant, and having given consent to participate in the
study. Healthy female relatives of 79 female patients who presented to the Gynecology Clinic of the
same hospital during the same period were included in the healthy group. The data were collected
through an interview form was developed by researchers, Female Sexual Function Index (FSFI), and
Beck Depression Inventory (BDI).
Results: No difference was determined between the participants in both groups in terms of average
age, period of education, body mass index, or employment and economic situation (p>0.05). It was
determined that, in contrast with the healthy group, 70.4% of the women with heroin use disorder had
sexual problems and 71.9% of them were not satisfied with their sexual life. It was found that women
with heroin use disorder scored significantly lower than healthy controls in FSFI sub-dimensions such as
desire, arousal, lubrication, orgasm, satisfaction, and pain, as well as for the total scale, while scores
were higher on the BDI scale (p<0.05).
Conclusion: Among women with heroin use disorder, sexual functions are adversely affected and
depressive symptoms appear to be increased.
Keywords: Heroin use disorder, sexual function, woman

ÖZ
Eroin kullanım bozukluğunun kadınların cinsel işlevi üzerine etkisi How to cite this article: Dissiz M. The effect of
Amaç: Bu çalışma eroin kullanım bozukluğu olan kadınların cinsel işlevlerinin değerlendirilmesi amacıyla heroin use disorder on the sexual functions of
women. Dusunen Adam The Journal of Psychiatry
yapılmıştır. and Neurological Sciences 2018;31:238-245.
Yöntem: Karşılaştırmalı-tanımlayıcı ve kesitsel tipte planlanan çalışma Bakırköy Ruh Sağlığı ve Sinir https://doi.org/10.5350/DAJPN2018310301
Hastalıkları Eğitim ve Araştırma Hastanesi Alkol- Madde Araştırma, Tedavi, Eğitim Merkezinde (AMATEM)
yapıldı. Araştırmada eroin kullanım bozukluğu olan gruba; 1 Haziran 2014 - 31 Aralık 2014 tarihleri arasında
AMATEM’e başvuran ve DSM-5’e göre madde kullanım bozukluğu tanısı konmuş 18 yaş ve üzerinde, psikiyatrik
Address reprint requests to / Yazışma adresi:
hastalığı, madde yoksunluk bulgusu ve mental retardasyon bozukluğu olmayan, cinsel yönden aktif olan, Melike Dissiz,
gebe ya da lohusa olmayan, çalışmaya katılmayı kabul eden 57 kadın alınmıştır. Sağlıklı gruba aynı University of Health Sciences, Faculty of
Nursing, Department of Obstetrics and
tarihlerde, aynı hastanenin Jinekoloji Polikliniği’ne başvuran kadın hastaların 79 sağlıklı kadın akrabası dahil
Gynecology Nursing, Uskudar,
edilmiştir. Verilerin toplanmasında araştırmacı tarafından hazırlanan görüşme formu, Kadın Cinsel İşlev Istanbul, Turkey
Ölçeği (KCİÖ) ve Beck Depresyon Envanteri (BDE) kullanıldı. Phone / Telefon: +90-216-418-9616
Bulgular: Her iki grupta yer alan katılımcılar arasında yaş ortalaması, eğitim süresi, beden kitle indeksi,
E-mail address / Elektronik posta adresi:
çalışma ve ekonomik durum açısından fark saptanmadı (p>0.05). Sağlıklı gruba göre eroin kullanım melekd78@gmail.com
bozukluğu olan kadınların çoğunluğunun (%70.2) cinsel bir sorunu olduğu ve cinsel yaşamlarından memnun
Date of receipt / Geliş tarihi:
olmadıkları (%71.9) saptandı. Eroin kullanım bozukluğu olan kadınların sağlıklı gruba göre istek, uyarılma, March 31, 2018 / 31 Mart 2018
lubrikasyon, orgazm, memnuniyet, ağrı gibi KCİÖ ölçeğinin alt boyut ve toplamından anlamlı olarak daha Date of the first revision letter /
düşük, BDÖ ölçeğinden daha yüksek puanlar aldıkları belirlendi (p<0.05). İlk düzeltme öneri tarihi:
Sonuç: Eroin kullanım bozukluğu olan kadınların cinsel işlevlerinin olumsuz yönde etkilendiği ve depresif April 24, 2018 / 24 Nisan 2018

belirtilerin arttığı belirlenmiştir. Date of acceptance / Kabul tarihi:

May 29, 2018 / 29 Mayıs 2018
Anahtar kelimeler: Eroin kullanım bozukluğu, cinsel işlev, kadın

238 Dusunen Adam The Journal of Psychiatry and Neurological Sciences, Volume 31, Number 3, September 2018
 Dissiz M

INTRODUCTION reduced sexual arousal, 68.0% to have lack of sexual

drive, and 60.0% to have orgasm problems; and they

T he term substance is used for any chemical

substance, taken by whichever route, that causes
changes in mood, perception, cognition, and other brain
further stated that in advanced stages of the substance
use disorder, their desire for sexuality gradually
decreased, even to the point that their sexual life
functions and may lead to substance use disorder (1). vanished (1,4,6).
It is generally used to achieve a euphoric effect on an Studies support the association of substance use
individual’s central nervous system. Substance use disorders not only with sexual dysfunction but also with
disorder is characterized by perseveration in the use of depression. However, the cause-and-effect relationship
the substance despite self-harm, failure to discontinue between the two disorders remains unclear (1,2,5).
the use, constant search for the substance, and gradual Nonetheless, depression often accompanies substance
escalation of the dose used (1,2). Substance use use disorders. Loss of interest, energy loss, low self-
disorder is a multidimensional chronic disease esteem, lack of enjoyment of life, and social isolation can
affecting the physical, psychological, social, and sexual damage the shape and continuity of interpersonal
health of the individual, that is becoming more relationships. These symptoms may harm their sexual life
prevalent every day in both sexes (2). Individuals with and relationships, leading to sexual dysfunction (1,2,5,7).
substance use disorder, especially women, face many Sexual problems among women with opioid use
social, economic, legal, and sexual health-related disorder, though being common, are often neglected.
problems due to substance use (3). A literature search showed a general tendency to
Sexuality, which is one of the important parameters investigate physical and psychological problems
of women’s quality of life, is adversely affected by caused by opioid use disorder (7). The number of
substance use disorder. It is a common habit to use studies on sexual problems arising from substance or
substances as an aphrodisiac to improve sexual opioid use disorder in Turkey is also very limited (5).
performance and pleasure in both genders. This study is one of the first in this country to disclose
Nevertheless, sexuality is unfavorably affected by the problems in female sexual functioning caused by
substance use disorder (4). The acute effects of opioid use disorder that is able to contribute to thinking
substances increase the levels of dopamine, about a solution by creating awareness on the subject.
norepinephrine, and serotonin, the neurotransmitters For this purpose, the study aimed to evaluate the sexual
associated with sexual activity. Heroin, which is a functions of women with substance use disorder.
semisynthetic form of morphine, when used acutely
suppresses the central nervous system (CNS) and METHOD
causes intense euphoria and relaxation by the
endorphin effect (1,5). Continuous use of the This cross-sectional study was performed at the
substance causes psychiatric disorders and decreased Research, Treatment and Training Center for Alcohol
interest in sexuality (2). Continuous use of opioids is and Substance Dependence of Bakirkoy Training and
reported to influence sexual functions negatively by Research Hospital for Psychiatry Neurology and
altering levels of neurotransmitters such as serotonin, Neurosurgery (AMATEM) after being approved by the
norepinephrine, and dopamine, by directly or local ethics committee (Ethics Committee no.
indirectly suppressing the release of various hormones 2014/57).
such as testosterone, estrogen, and progesterone, The study population consisted of 93 adult women
associated with sexual arousal, or by directly (>18 years of age) who presented to AMATEM between
disturbing blood flow in the genital organs and other June 1, 2014 and December 31, 2014 with a diagnosis
physiological mechanisms. Studies reported that of substance use disorder based on DSM-5 criteria.
60.0% of female chronic heroin users stated to have Generated by non-probability sampling method, the

Dusunen Adam The Journal of Psychiatry and Neurological Sciences, Volume 31, Number 3, September 2018 239
 The effect of heroin use disorder on the sexual functions of women

case population included 57 women with use disorder Beck Depression Inventory (BDI): BDI is a self-
who had no additional psychiatric disorders, report scale developed by Beck (11) in 1961 to measure
withdrawal signs, or mental retardation disorder and emotional, cognitive, somatic, and motivational
had been sexually active during the last three months. components of depression. It consists of 21 items
Informed consent was given. The reasons for the which are answered on four-level Likert-type scales
exclusion of potential subjects were as follows: eighteen which are graded between ‘0’ and ‘3’. The lowest and
women did not agree to participate in the study; nine highest scores that can be achieved at the completion
others had not performed regular sexual activity within of scale are 0 and 63, respectively. Higher scores
last three months; six patients had a severe psychotic indicate increased level of depression symptoms. Cut-
disorder; three had signs of withdrawal. The healthy off point is usually accepted as 17. The study was
control group consisted of 79 women who presented to validated for Turkey by Hisli (12).
the gynecology department of the same hospital as
outpatients during the same period, meeting the Procedure
following criteria: no alcohol or other substance use
disorder, no chronic disease, no medication use, not Data were collected through three forms filled in as
being in the perimenopausal, postpartum, lactation, or a self-report at the same time. Both verbal and written
pregnancy period; and giving consent to participate in information about the study was given to the
the study. participants, who then gave informed consent.

Measures Statistical Analysis

Data were collected by Personal Information Form, The collected data were analyzed using the SPSS
Female Sexual Function Index (FSFI) and Beck (Version 21.0) software package. Chi-square test was
Depression Inventory (BDI). used to compare the categorical variables and
Student’s t-test to compare parametric variables
Personal Information Form: The form consists between the study groups; Pearson correlation was
of 35 questions about participants’ sociodemographic used to analyze the association for normally
characteristics, chronic diseases, persistent drug and distributed variables. The results were accepted as
substance use, and sexual health. statistically significant if p-value was <0.05 for a 95%
confidence interval.
Female Sexual Function Index (FSFI): The FSFI
was developed by Rosen et al. (8) in 2000 to assess the RESULTS
sexual function of women over the last four weeks. The
index is a multidimensional measure consisting of six There was no difference between the two groups
subdivisions (desire, arousal, lubrication, orgasm, in terms of mean age, duration of education, body
saturation, and pain) and 19 items. Items 1 and 2 are five- mass index, employment, and economic status
level Likert-type (1-5 points), and the others are six-level (p>0.05), except for smoking status, where the rate of
Likert-type questions (0-5 points). The highest score to non-smokers in the control group was found to be
be reached on the scale is 36 and the lowest score is 2. higher (69.6%) (Table 1).
The reliability and validity for Turkey was confirmed by Heroin-related characteristics of the case group
the Turkish Society of Andrology and Aygin-Aslan in showed age at onset of the substance use to be
2005 (9). The cut-off point for the scale was 26.55, where 19.57±5.20 years (range: 10-40 years), the duration of
subjects with a score of ≤26.55 are assumed to have a intensive heroin use was 3.36±2.26 years (range: 1-10
negative alteration in sexual function (10). years), and the daily dose 3.17±1.99g (range: 1-7g).

240 Dusunen Adam The Journal of Psychiatry and Neurological Sciences, Volume 31, Number 3, September 2018
 Dissiz M

The mean duration of heroin use of was 6.66±4.43 Obstetric/gynecological comparison of the
years. It was mostly taken by nasal route (68.4%), groups showed that the heroin group had a
while the remaining patients used it intravenously significantly lower mean age at both onset of sexual
(31.6%). intercourse and pregnancy compared to the control

Table 1: Comparison of the study groups by their demographic characteristics

Heroin Group Control Group
(n=57) (n=79)

Mean SD Min. Max. Mean SD Min. Max. t p

Age 26.22 6.64 18 44 27.21 2.00 20 32 -1.238 0.218

Education status (years) 9.29 2.95 5 15 8.98 2.98 5 17 0.601 0.549

n % n % χ2 p

BMI (kg/m2)
18.49< underweight 17 29.8 11 13.9
18.49-24.99 36 63.2 57 72.2 5.890 0.053
25> overweight 4 7.0 11 13.9
Employment status
Employed 23 40.4 37 46.8 0.565 0.452
Unemployed 34 59.6 42 53.2
Economic status
Income<expenses 24 42.1 37 46.8 0.300 0.584
Income≥expenses 33 57.9 42 53.2
Smoking status
Smoker 57 100.0 24 30.4 66.629 <0.001
Non-smoker - - 55 69.6
t: Student’s t test, χ2: Chi-square test, SD: Standard deviation, BMI: Body mass index

Table 2: Comparison of the study groups by their sexual and obstetrical-gynecological parameters
Heroin Group Control Group
(n=57) (n=79)

Mean SD Mean SD t p
Age at the first sexual intercourse 17.35 2.51 22.59 3.11 -10.832 <0.001
Number of sexual intercourses (per week) 2.19 1.30 2.86 1.19 -3.096 0.002
Age at first pregnancy 19.41 2.97 23.69 3.31 -5.950 <0.001
Number of pregnancies 2.55 2.10 1.60 0.91 2.509 0.016
Number of deliveries 1.31 0.56 1.25 0.55 0.453 0.652
Number of abortions 1.38 1.74 0.27 0.66 3.556 <0.001
n % n % χ2 p

Sexual partners
Single 37 64.9 78 98.7 29.008 <0.001
Multiple 20 35.1 1 1.3
Satisfaction with sex life
Satisfied 16 28.1 77 97.5 73.754 <0.001
Dissatisfied 41 71.9 2 2.5
Current family planning method
Effective method 27 47.4 65 82.3 18.437 <0.001
Ineffective method 30 52.6 14 17.7
Menstrual cycles
Regular 13 22.8 78 98.7 86.215 <0.001
Irregular 44 77.2 1 1.3
t: Student’s t test, χ2: Chi-square test, SD: Standard deviation

Dusunen Adam The Journal of Psychiatry and Neurological Sciences, Volume 31, Number 3, September 2018 241
 The effect of heroin use disorder on the sexual functions of women

Table 3: Comparison of the study groups by mean FSFI and BDI scores
Heroin Group Control Group
(n=57) (n=79)

Mean SD Mean SD t p

Desire 2.26 1.18 4.09 0.79 -10.134 <0.001

Arousal 2.20 1.07 4.38 0.90 -12.803 <0.001
Lubrication 2.94 1.43 4.98 0.74 -9.821 <0.001
Orgasm 2.40 1.18 4.72 0.91 -12.394 <0.001
Satisfaction 2.76 1.36 5.12 0.83 -14.574 <0.001
Pain 4.67 1.47 5.22 0.95 -2.447 0.016
Total FSFI 17.25 6.05 28.54 3.94 -12.319 <0.001
BDI 30.56 10.29 6.00 6.99 15.603 <0.001
t: Student’s t test, SD: Standard deviation, FSFI: Female Sexual Function Inventory, BDI: Beck Depression Inventory

Table 4: Correlation of BDI score to total FSFI and its subdomains among women with heroin use disorder (n=57)
Desire Arousal Lubrication Orgasm Satisfaction Pain Total FSFI

r p r p r p r p r p r p r p

BDI -0.260 0.110 -0.161 0.327 -0.097 0.556 -0.056 0.734 -0.036 0.826 -0.062 0.709 -0.143 0.417
r: Pearson correlation, FSFI: Female Sexual Function Inventory, BDI: Beck Depression Inventory

group (p<0.05). In addition, the mean number of DISCUSSION

pregnancies and abortion and rates of
promiscuousness, dissatisfaction with sexual life, Substance use disorder is a multidimensional
menstrual irregularity, and use of ineffective chronic disorder. Substance use disorder developed by
contraception methods were significantly higher in the abuse of substances also affects the physical,
the heroin group than in the healthy controls mental, social, and sexual aspects of women’s life, and
(p<0.05, Table 2). these effects change over time. Several studies reported
In the heroin group, mean scores for desire, substance use disorder to cause sexual problems and
arousal, lubrication, orgasm, satisfaction, and pain sexual dissatisfaction among women (4,5,13). In fact,
subdomains of FSFI and total FSFI were detected to sexual dysfunction caused by substance use has been
be significantly lower compared to those in the described in a separate section of the DSM-5 as a
control group (p<0.05, Table 3). The cut-off point for situation where “clinically significant sexual
FSFI showed negatively altered sexual activity in dysfunction that results in marked distress or
30.4% of healthy women and in 91.2% of women in interpersonal difficulty predominates in the clinical
the heroin group. The mean BDI score was picture” (13). Substance use disorder, which negatively
significantly higher in the heroin group, and affects quality of life and sexual health, is perceived as
depressive symptoms were found in 87.7% of heroin- a serious health problem that is becoming increasingly
addicted women compared with 10.1% of healthy widespread throughout the world. A limited number
controls, as determined by the BDI cut-off point of studies performed in recent years suggests the
(p<0.001, Table 3). problem to be more common among men; however, a
No significant association was found in the case rapid increase of substance use disorder is also found
group between BDI scores and scores on the FSFI for among young women in many countries, including
the total scale or any of the FSFI subdomains (p>0.05, Turkey (14). Sociodemographic characteristics such as
Table 4). age, gender, employment status, economic level, and

242 Dusunen Adam The Journal of Psychiatry and Neurological Sciences, Volume 31, Number 3, September 2018
 Dissiz M

educational status were also evaluated as risk factors are under the influence of a substance (20-22). Repeated
in substance use disorder studies, especially in substance use can also lead to economic hardship in
treatment-focused studies. Sociodemographic women’s lives. Therefore, women may perform risky
characteristics were also compared in the current sexual acts such as having multiple partners or
study, and it was determined that both groups were engaging in unprotected sexual intercourse aimed at
similar. The similarity of socio-demographic money or substance exchange to supply the substance
characteristics of women with and without heroin use they abuse (21-23). In consistence with the literature,
disorder is positive in terms of comparison of sexual our study showed heroin users to be more likely to
function and depression levels. In this study, women have their first sexual intercourse under the age of 18,
with heroin use disorder were more likely to smoke a higher number of pregnancies or abortions, earlier
than the non-addicted group. Smoking has been age at their first pregnancy, and higher rates of
suggested as a transition in the substance substance ineffective birth control method usage and menstrual
use disorder continuum (15). In accordance with our irregularities.
findings, Karsidag et al. (16) reported that smokers Substance abuse may decrease the quality of life
were 3-4 times more likely to drink alcohol and 5 and cause sexual dysfunction by affecting a person’s
times more likely to use other substances than those social life, emotional health, human relations, and
who did not smoke. school/work performance (7). A small number of
Studies revealed that the first substance use is available studies reported that continuous use of a
usually observed during youth. As the dose and substance led to sexual dysfunction and decreased
duration of the substance used increased, the negative sexual desire (2,24). In fact, though substance-induced
effects experienced were more prominent among sexual dysfunction is discussed in separate sections
women compared to their male counterparts, given both in ICD-10 and in DSM-5, it has been less studied
women’s more sensitive physiological nature due to in women. A limited number of studies among
lower body lipid/water ratio or higher variability of addicted men and women reported a decrease in
their hormones according to the phase of their arousal, orgasm, vaginal intercourse, and sexual desire
menstrual cycle (17). In this study, it was found that the after starting heroin use (6,20,25). Human and animal
age of starting substance use was 19.57±5.20 years and studies with opioids reported that these drugs
the mean duration of heroin use was 6.66±4.43 years. suppressed the secretion of luteinizing hormone-
Moreover, the period between intensive substance use releasing hormone and gonadotropin, resulting in
and seeking medical help was very short. This might be decreased testosterone levels and abnormal menstrual
explained by the possibility of a relatively early start of function. In fact, this was described as opioid-induced
negative effects of substance use disorder on general androgen dysfunction (24,25). Gonadal dysfunction
health level, quality of life, and sexual life (18,19). associated with substance use disorder may lead to
Studies on substance use disorder in females decreased libido, sexual dysfunction, amenorrhea,
frequently reported that, under the influence of the oligomenorrhea, fatigue, depression, and osteoporosis
substance used, especially adolescents experienced in women (3,6,13). Another theory that explains the
sexuality at an early age, had unprotected sexual effects of opioids on sexual functioning involves
intercourse, and went through more pregnancies and mesolimbic pathways, i.e. the dopaminergic reward
abortions at an early age (20,21). Women in all system. This system encourages behavior and actions
societies are expected to have high moral values in the that benefit the individual. Substances, including
social and sociocultural context (21). Women who use heroin, have been reported to elicit sexual dysfunction
substances have been considered as “weak-willed, easily by causing a rapid deterioration of behaviors that are
available” the society and are frequently exposed to any normally rewarding, like sex (6,13).
kind of sexual trauma like harassment or rape when they Substance women with use disorder often find it

Dusunen Adam The Journal of Psychiatry and Neurological Sciences, Volume 31, Number 3, September 2018 243
 The effect of heroin use disorder on the sexual functions of women

problematic to establish a close and harmonious role in the diagnosis and treatment of female and male
relationship with a partner or spouse, while the status sexual dysfunction. The definitive diagnosis of such
of psychological well-being and the ability to establish disorders requires completion of a detailed medical
close relationships are important determinants of history, physical examination, and laboratory tests
healthy sexuality (24). Women with substance use and as well as a multidisciplinary evaluation. As the
disorders are reported to have many physical, study was conducted in an treatment center for
behavioral, and social problems that negatively substance use disorder, no comprehensive evaluation
influence sexual functions (19). Sexuality, shaped by by a multidisciplinary team could be performed.
the interaction of psychological, social, and biological Furthermore, the study was performed in a single
variables, may lose functioning as a result of the center, which could be seen as another limitation.
inhibition of any of these components (25). In line In conclusion, the study shows that in women
with similar research, our study showed that 91.2% of with heroin use disorder, sexual functioning is
women with substance use disorder had negatively adversely affected and depressive symptoms are
altered sexual functions, and the mean scores for increased. This study is the first to evaluate sexual
desire, arousal, lubrication, orgasm, satisfaction, pain functions among woman with heroin use disorder in
and total FSFI were significantly lower in the heroin comparison with a control group. Despite some
group. limitations, it provides important insights and clues to
It has been reported that substance use disorder the field thanks to its comparative and descriptive
frequently causes psychological problems, which may structure. There are only a few studies regarding the
further adversely affect the mood and sexual life of the effects of substance use disorder on the sexual
individual (27,28). Our study did not include subjects functions of women in Turkey. The study findings
with comorbid psychiatric disorders. However, need to be confirmed and supported by further
depressive symptoms were found to increase in the comprehensive and multicenter prospective studies.
heroin group. Besides, no correlation was detected
between depression level and sexual functioning in Contribution Categories Author Initials

the heroin group. This suggests that female sexual Concept/Design M.D.

dysfunction is not only related to psychological Category 1 Data acquisition M.D.

factors, but rather constitutes a complex process Data analysis/Interpretation M.D.

involving pharmacological, physical, social, and Drafting manuscript M.D.

Category 2
Critical revision of manuscript M.D.
cultural components.
Category 3 Final approval and accountability M.D.
This study has several limitations, the most
Technical or material support N/A
important one being the low sample size, which was
Other Supervision N/A
partly due to the low number of presenting female
Securing funding (if applicable) N/A
heroin use disorder patients who were followed by
the treatment center and partly due to our relatively
strict participant selection criteria, including patients Informed Consent: Written consent was obtained from the
with an active sexual life and excluding those with participants.
depression or additional substance use. In addition,
the evaluation of the level of relationship and sexual Peer-review: Externally peer-reviewed.
intimacy of the participants were based on their own
statements; their partners were not included in the Conflict of Interest: Author declared no conflict of interest.
study. Another limitation is that sexual function-
related questionnaires play merely a complementary Financial Disclosure: Author declared no financial support.

244 Dusunen Adam The Journal of Psychiatry and Neurological Sciences, Volume 31, Number 3, September 2018
 Dissiz M

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