Untreated Mental Illness Research Articles

In Case You Haven't Heard…

Actress and activist Ashley Judd is supporting mental health initiatives on behalf of herself and her late mother Naomi Judd, USA Today reported April 24. Nearly two years after the country music legend's death by suicide, her daughter Ashley Judd appeared on a panel at the White House on April 23 to back the Biden administration's newly formed National Strategy for Suicide Prevention (see related story on page one). “I'm here because I am my beloved mother's daughter and on the day she died, which will be the two‐year anniversary in one week, the disease of mental illness was lying to her, and with great terror convinced her that it would never get better,” the “Someone Like You” actress said. Naomi Judd died in April 2022 at age 76. The country singer's daughters Ashley Judd, 56, and Wynonna Judd, 59, shared the news, saying, “We lost our beautiful mother to the disease of mental illness.” Judd said her mother “lived most of her life with an untreated and undiagnosed mental illness that lied to her and stole from her. It stole from our family, and she deserved better,” she added. “I know the feeling of not wanting to be here, but I had a different experience because I went to treatment in 2006,” Ashley Judd shared. “I've been in good recovery for 18 years and I've had a different outcome than my mother. I carry a message of hope and recovery.”

STEP-Home transdiagnostic group reintegration workshop to improve mental health outcomes for post-9/11 Veterans: Design, methods, and rationale for a randomized controlled behavioral trial

BackgroundMany post-9/11 U.S. combat Veterans experience difficulty readjusting to civilian life after military service, including relationship problems, reduced work productivity, substance misuse, and increased anger control problems. Mental health problems are frequently cited as causing these difficulties, driven by unparalleled rates of mild traumatic brain injury, posttraumatic stress, and other co-occurring emotional and physical conditions. Given the high prevalence of multimorbidity in this cohort, acceptable, non-stigmatizing, transdiagnostic interventions targeting reintegration are needed. The STEP-Home reintegration workshop has the potential to significantly improve skills to foster civilian reintegration, increase engagement in VA services, and improve mental health outcomes in Veterans with and without diagnosed clinical conditions. Methods/designOngoing from 2019, a prospective, two-site, randomized trial of 206 post-9/11 U.S. military Veterans randomized to receive either 12 sessions of the STEP-Home transdiagnostic reintegration workshop (SH; Active Intervention) or Present Centered Reintegration Group Therapy (PCRGT; Active Control Intervention). Primary outcomes are reintegration, anger, and emotional regulation post-intervention and at 3-months post-intervention. Secondary outcomes include measures of mental health, functional and vocational status, and cognition. ConclusionThis study addresses an important gap in transdiagnostic interventions to improve civilian reintegration in post-9/11 Veterans. STEP-Home is designed to promote treatment engagement and retention, opening the door to critically needed VA care, and ultimately reducing long-term healthcare burden of untreated mental health illness in U.S. Veterans.Trial Registration: Clinicaltrials.gov: D2907-R.

Postpartum Psychosis and Maternal Filicide- Case Report and Literature Review

IntroductionPostpartum period is defined as the 12 weeks following the birth of a child as per ACOG guidelines. This period is crucial for women to physically and emotionally adapt to major changes in their lives. If concerns are not addressed properly it can result in fatal outcomes such as filicide and suicide in context of untreated mental illness with postpartum onset. Postpartum psychosis is considered a psychiatric emergency and literature shows that up to 4.5% of patients with depressive symptoms with psychosis commit filicide. However, postpartum psychosis is not recognized as a formal psychiatric disorder in DSM-5, leading to a delay in identification and treatment of the condition in a timely fashion.ObjectivesThe primary purpose of the case report is to inform the clinical picture and the legal implications associated with postpartum psychosis, a poorly understood and underdiagnosed psychiatric illness and to emphasize the importance of considering other psychiatric illnesses with peripartum onset that affect maternal and pediatric population wellbeing.Methods A comprehensive review of literature using databases, such as PubMed and Google Scholar as well as observation of the patient in the Emergency Department by the psychiatry team.Results We present the case of a female in her 20s, mother of two toddlers, with a history of PTSD and postpartum depression, who was brought to our Emergency Department for stabbing her children in the context of a psychotic episode. The patient endorsed persecutory delusions and religious preoccupation, stating that she was experiencing “demonic energy inside” and that demons were speaking through her sons. Upon further assessment, it was noted that symptom onset was during the peripartum period, initially with depressed mood, and later with psychotic features. Organic causes of psychosis were ruled out with an extensive workup. Patient was transferred to an inpatient forensic unit for further stabilization. From a legal perspective, literature review shows that mothers may face the death penalty in the US in contrast with other countries such as England for instance. In the context of the current case, the plausible diagnoses are MDD with psychotic features or the first psychotic episode with peripartum onset that was left untreated resulting in a fatal health and legal outcome.ConclusionsAs postpartum psychosis is not currently recognized as an independent diagnosis under the DSM-5, further attention is warranted for such critical psychiatric condition that afflicts the lives and well-being of the maternal and pediatric populations globally. Postpartum psychosis affects mothers despite their past psychiatric history, socioeconomic status, educational level, and supportive network. Thus, it is essential to target proper and timely identification of symptoms and address those to prevent filicide and maternal suicide.Disclosure of InterestNone Declared

A Life-Threatening Emergency Exacerbated by Untreated Mental Illness in a Low-Barrier Health Center

A Life-Threatening Emergency Exacerbated by Untreated Mental Illness in a Low-Barrier Health Center

Indiana University study highlights billions in annual losses from untreated MI in the state

Untreated mental illness in the Hoosier state comes at a cost of more than $4 billion a year, according to a new Indiana University study, the Daily Journal reported Nov. 1. The research published by the IU Richard M. Fairbanks School of Public Health found that one in five Indiana residents with mental illness do not receive the treatment they need. Hoosiers who do not receive such treatment are also more likely to experience other chronic health conditions, such as diabetes and cardiovascular disease, researchers said. The economic burden of untreated mental illness in Indiana is estimated to be $4.2 billion annually, including $3.3 billion in indirect costs — like unemployment and caregiving — $708.5 million in direct health care costs, and $185.4 million in non‐health care costs. The largest cost attributable to untreated mental illness was premature mortality, at over $1.4 billion. Productivity losses were estimated to cost $885 million each year. “The findings were published Oct. 13 in the Journal of the American Medical Association. Researchers worked with the Indiana Behavioral Health Commission to perform their analysis. Through the researchers' work, they developed a framework that allows Indiana to prioritize key areas in mental health services and treatment. The framework also provides Indiana with a baseline for tracking progress toward improvement efforts. The research was used in support of Senate Enrolled Act 1, which passed during the 2023 legislative session. The sweeping legislation will create a new mental health care system in Indiana, fortifying the relatively new 988 crisis response center and hotline with funding for mental health emergencies. The IU study population consisted of more than 6.1 million individuals of whom an estimated 429,000 had untreated mental illness in 2019, according to the research paper. “One of the most significant impacts of this research is that other states can use this framework to understand the financial burden in their state,” said Justin Blackburn, Ph.D., associate professor at the Fairbanks School. “There is a scarcity of data on the costs incurred by each state — especially by individuals, families and communities — from untreated mental illnesses in the United States. Policymakers, clinicians and employers need this sort of data to determine how we should allocate our societal resources.”

Economic Burden Associated With Untreated Mental Illness in Indiana

There is a paucity of systematically captured data on the costs incurred by society-individuals, families, and communities-from untreated mental illnesses in the US. However, these data are necessary for decision-making on actions and allocation of societal resources and should be considered by policymakers, clinicians, and employers. To estimate the economic burden associated with untreated mental illness at the societal level. This cross-sectional study used multiple data sources to tabulate the annual cost of untreated mental illness among residents (≥5 years old) in Indiana in 2019: the US National Survey on Drug Use and Health, the National Survey of Children's Health, Indiana government sources, and Indiana Medicaid enrollment and claims data. Data analyses were conducted from January to May 2022. Direct nonhealth care costs (eg, criminal justice system, homeless shelters), indirect costs (unemployment, workplace productivity losses due to absenteeism and presenteeism, all-cause mortality, suicide, caregiver direct health care, caregiver productivity losses, and missed primary education), and direct health care costs (disease-related health care expenditures). The study population consisted of 6 179 105 individuals (median [SD] age, 38.0 [0.2] years; 3 132 806 [50.7%] were women) of whom an estimated 429 407 (95% CI, 349 526-528 171) had untreated mental illness in 2019. The economic burden of untreated mental illness in Indiana was estimated to be $4.2 billion annually (range of uncertainty [RoU], $2.1 billion-$7.0 billion). The cost of untreated mental illness included $3.3 billion (RoU, $1.7 billion-$5.4 billion) in indirect costs, $708.5 million (RoU, $335 million-$1.2 billion) in direct health care costs, and $185.4 million (RoU, $29.9 million-$471.5 million) in nonhealth care costs. This cross-sectional study found that untreated mental illness may have significant financial consequences for society. These findings put into perspective the case for action and should be considered by policymakers, clinicians, and employers when allocating societal resources and funding. States can replicate this comprehensive framework as they prioritize key areas for action regarding mental health services and treatments.

Empowering law enforcement officers to engage effectively with individuals in crisis

As first responders with a duty to protect the safety of civilians, law enforcement officers are required to carry firearms. Over the course of a career, officers are exposed to multiple traumatic events and are required to make rapid decisions regarding safety. In the last few years, the use of deadly force by law enforcement officers has become a public concern. Persons with untreated mental illness have a comparatively higher risk than most for deadly outcomes in crisis situations. The purpose of this manuscript is to describe policies and programs that have been developed and implemented by teams that include psychiatric mental health nurse practitioners to help law enforcement officers recognize and interact effectively with persons in crisis. The same programs help officers understand the effects of severe stress and trauma on emotional, behavioral, and cognitive functioning, and provide support, encouragement, and access for officers who need help.

Psychiatry in the sultanate of Oman.

Oman has been recognised as the leading country in terms of recent developments in public health. However, there is a shortage of mental health services, which poses challenges for people seeking such services, particularly those from rural areas. This often results in delayed treatment and longer periods of untreated mental illness.

Evaluating the maturation of mental health systems in developing countries.

Given the need for a simple tool to evaluate mental healthcare provision at the local level, we compared the duration of untreated mental illness (DUM) and duration of untreated psychosis (DUP) between rural and urban areas in Cambodia, and Cambodia's DUP was also compared with that of other countries. DUM and background data were obtained at the first consultation from 940 participants in Phnom Penh (PP), the capital city, and Siem Reap province (SR) in 2016-2017. DUP data were obtained from DUM by excluding individuals with nonpsychotic mental illnesses (e.g., mood disorders, neurotic disorders, substance use, epilepsy). Student's t-test was used to compare DUM and DUP, and analysis of variance was conducted to identify associations. Mean DUM significantly differed between PP (0.6 [SD 2.3] years) and SR (4.2 [5.9] years). Mean DUP was also significantly different (0.5 [2.2] years in PP vs. 4.3 [6.7] years in SR). DUM was strongly associated with DUP. The prevalence of the various disorders differed between rural and urban areas. DUM also varied by diagnosis, indicating that DUP is a better index than DUM. However, in some cases DUM can be used, given its strong association with DUP. DUP in PP was almost the same as in developed countries and was about four times longer in SR. DUP in rural areas is much longer than in urban areas in developing countries. Although DUP is an effective index, more data from other places and before/after interventions are required to verify it further.

Drugging Down on Life Athletes Clouding Their Minds through Substance Abuse

Abstract: Drug usage is prevalent across all sports and at all levels of competition. For a variety of reasons, including performance improvement, self-treatment of otherwise untreated mental illness, and coping with pressures such as pressure to perform, injuries, physical discomfort, and retirement from sport, athletes may turn to drugs. Doping is a term used to describe this type of abuse. Doping has a long history, dating back to when organized sports existed. Improved drug testing detection technologies and improvements in scientific research have led to the discovery and use of compounds that may later be outlawed, resulting in "advances" in doping strategies. The sports persons also need to be more vigilant about the prevalent antidoping rules and regulations.

Latino attitudes toward mental health treatment and criminal justice involvement: it’s great for you; it’s just not for us

Despite comparable rates of mental illness, Latinos are unlikely to seek mental health treatment, face more barriers, and are more likely to be referred to treatment by the criminal justice system compared to whites. This study examined Latino attitudes toward seeking mental health treatment to ascertain how those attitudes predicted perceptions of the relationship between untreated mental illness and future criminal justice involvement. Although Latinos generally held positive attitudes towards seeking mental health treatment, deeply ingrained cultural attitudes hinder their personal help-seeking behaviors. Results also revealed that those who expressed a willingness to seek treatment, were older, or married were more likely to recognize the link between untreated mental illness and future criminal justice involvement.

Mental health disorders and recidivism among incarcerated adult offenders in a correctional facility in South Africa: A cluster analysis.

The contribution of mental illness, substance use, and appetitive aggression to recidivism has significant policy and practice implications. Offenders with untreated mental illness have a higher recidivism rate and a greater number of criminogenic risk factors than those without mental illness. Previous research has demonstrated that the likelihood of appetitive aggression increases in violent contexts where individuals perpetrate aggressive acts. Using the Ecological Systems Theory, this study investigated the association between mental health disorders and recidivism among incarcerated adult offenders in South Africa, and the intervening role of appetitive aggression and substance use. Using a cross-sectional quantitative research design, a sample of 280 incarcerated male and female adult offenders aged 18-35 with no known psychiatric disorders were sampled at a correctional facility in South Africa. The re-incarceration rate, mental health disorders, substance use, and appetitive aggression symptomology were assessed using the Hopkins symptoms checklist, the CRAFFT measure of substance use, and the appetitive aggression scale. Findings indicate a 32.4% recidivism rate (n = 82). Cluster analysis indicated that the combination of anxiety, depression, substance use, and appetitive aggression increased the likelihood of recidivism. Appetitive aggression median differences between clusters 2 and 3 played a key role in distinguishing recidivism risk among recidivist and non-recidivist participants. Chi-square analysis highlighted group differences in education levels among the established clusters [x2 (3, n = 217) = 12.832, p = .005, which is < .05] as well as group differences in the type of criminal offence [x2 (3, n = 187) = 24.362, p = .000, which is < .05] and cluster membership. Combined factors that increase the likelihood of recidivism provide a typology for classifying offenders based on particular recidivism risk determinants, which offers insights for developing tailored interventions that address a combination of factors.

A parish-based multilevel cluster randomized controlled trial to reduce stigma and mental health treatment disparities among Latino communities

Latino communities within the U.S. are disproportionately affected by persistent, high levels of untreated mental illness. Limited mental health literacy, stigma, and cultural factors are major contributors to Latino mental health treatment disparities. Although Latino individuals may be reluctant to seek out mental health professionals, they often rely on religious congregations when confronted with mental illness. However, religious congregations report major obstacles to collaborating with the mental health sector including the lack of mental health training, staffing, and resources. Strategic partnerships between religious congregations and community-based organizations can be leveraged to target sources of Latino mental health treatment disparities. The National Alliance on Mental Illness (NAMI), the nation's largest grassroots mental health organization, has developed a host of programs tailored to the different needs and segments of the community affected by mental illness, including programs designed to address culturally diverse and faith-based communities. This cluster-randomized controlled trial leverages the collective resources of NAMI and the Diocese of San Bernardino to deliver and evaluate the effectiveness of a multi-level, parish-based, intervention to decrease stigma, increase mental health literacy, and improve access to mental health services among Latino parishioners. This study will enroll 1400 participants from 14 parishes that will be randomly assigned to receive the intervention immediately or a wait-list control condition. The intervention could enrich awareness of mental health issues, shape norms about mental illness, facilitate treatment access, and add support from religious congregations to target Latino mental health disparities using culturally and faith-based tailored approaches.

The impact of maternal depression on child mental health treatment and models for integrating care: a systematic review.

Maternal depression negatively impacts child mental health and is a well-known risk factor for child psychopathology. However, maternal depression treatment and child mental health treatment are rarely integrated. The purpose of this review was to assess the impact of maternal depression on child mental health treatment, including (1) how treatment of maternal depression affects child mental health outcomes, (2) the impact of maternal depression on children receiving mental health care, and (3) emerging models that address maternal depression in primary-care pediatrics and child mental health settings. A systematic literature review was conducted using PubMed and PsycInfo. Initial search yielded 224 records, and after exclusion, 29 papers were reviewed. Effective treatment of maternal depression is associated with a significant decrease in child psychiatric symptoms. Maternal depression negatively affects child mental health treatment in that there is a high rate of untreated mental illness among mothers of psychiatrically ill children, and maternal depression impedes effective child mental health treatment. Current models to address maternal depression in child settings include screening in pediatric primary care, psychotherapy for depressed mothers of psychiatrically ill children, and emerging models that integrate maternal and child mental health treatment. Effective treatment of maternal depression significantly improves child mental health and should be better integrated into child treatment. Opportunities to improve care include more robust screening for parental mental illness, supports to refer parents to psychiatric care, and on-site services for parents. Such interventions hold promise, but require significant support from a multidisciplinary team.

Improved emotion regulation following a trauma-informed CBT-based intervention associates with reduced risk for recidivism in justice-involved emerging adults.

ObjectiveMale youth who have been involved in the juvenile legal system have disproportionate rates of trauma and violence exposure. Many justice-involved youth have untreated mental illness, with an estimated 66% of young men who are incarcerated meeting criteria for at least one mental health disorder, including posttraumatic stress disorder (PTSD), depression, and substance abuse. While Cognitive Behavioral Therapy (CBT) approaches are considered among effective evidence-based treatments for addressing and treating behavioral and emotional difficulties, male youth with a history of incarceration and youth who are at risk for (re)incarceration, violence, emotion dysregulation, and trauma face significant barriers in accessing these services.MethodsRoca, Inc. (Roca), an internationally recognized organization moving the needle on urban violence by working relentlessly with young people at the center of violence in Massachusetts and Maryland, employs a trauma-informed CBT-based skills curriculum and approach in their intervention model, to improve youths' educational, employment, parenting, and life skills opportunities, while decreasing risk for recidivism, addressing trauma and increasing skills for emotion regulation. The aim of this analysis was to assess the effectiveness of Roca's trauma-informed CBT skills curriculum on youths' emotional and behavioral outcomes. We analyzed data from over 300 participating emerging adult men from four sites in Massachusetts and one site in Baltimore, Maryland who had at least three series of data collection across multiple skills-based sessions.ResultsWe found improvements in outcomes in overall mean scores related to decreased distress about employment and education, as are expected with standard intervention approaches for justice-involved youth. Participants who show improvement in emotion regulation across engagement (approximately half the cohort), were found to have significant improvements in distress related to relationship and family functioning and self-care, and decreased substance use, along with other outcomes compared to those participants with less improvement in emotion regulation. Furthermore, improvement in different aspects of emotion regulation were associated with improved relationships, life distress, substance use, and improved prosocial thinking.ConclusionsTogether, these data suggest that adding mental health support and skills training, such as with trauma-informed CBT models, to programs for justice-involved youth may lead to significant improvements in functioning, quality of life, and mental health outcomes.

Racial and Ethnic Disparities in Health Status and Community Functioning Among Persons with Untreated Mental Illness.

Using 6years of data from the National Survey of Drug Use and Health, the present study investigated ethnic minority-White disparities in self-rated health and community functioning for persons with untreated mental illness. Comparing minority and White persons with untreated severe mental illness (SMI) and mild and moderate mental illness (MMMI), the study sought evidence of "double jeopardy": that minority persons with mental illness suffer an added burden from being members of ethnic minority groups. For African Americans with SMI and MMMI, results indicated that the odds were greater of living in poverty, being unemployed, and being arrested in the past year, and for African Americans with SMI, the odds were greater of reporting fair/poor health. For Native Americans/Alaska Native persons with MMMI, the odds were greater of living in poverty and being arrested in the past year. For Latinx persons with SMI and MMMI, the odds were greater of living in poverty and for Latinx persons with SMI the odds were greater of reporting fair/poor health. Results indicate that African Americans with mental illness suffer pervasive adversity relative to Whites and Native Americans/Alaska Natives and Latinx persons do so selectively.

Uncovering the Model and Philosophy of Care of a Psychiatric Inpatient Mother-Baby Unit in a Qualitative Study with Staff.

The postnatal period is high-risk time for the first onset and recurrence of maternal mental health disorders. Untreated maternal mental illness can have significant adverse impacts on a woman, her baby, and the wider family unit. For women with mental illnesses that cannot be managed in the community, psychiatric inpatient mother-baby units are the gold standard treatment whereby mothers are co-admitted with their infant for specialist perinatal and infant mental health assessment and treatment. The study explores the model of care and examines the philosophies of care that are used within a psychiatric mother-baby unit. Purposive sampling was used to conduct semi-structured focus group and individual interviews with multidisciplinary staff members at a single mother-baby unit. Themes derived from these interviews were coded into two primary themes and a range of sub-themes. The first primary theme focused on the Model of Care consisting of the following sub-themes: mental health care, physical health care, babies’ care, building mother-baby relationship, fostering relationships with supports, and facilitating community support. The second primary theme centered around the Philosophy of Care comprising of: person-centered care, trauma-informed care, compassion-centered care, recovery-oriented care, attachment-informed care, non-judgmental care, strengths-based care and interdisciplinary care. The model can be used to provide consistency across mother-baby units and to support core capabilities of staff in providing an optimal level of care.

Risk of major malformations in infants after first-trimester exposure to benzodiazepines: Results from the Massachusetts General Hospital National Pregnancy Registry for Psychiatric Medications.

Perinatal anxiety affects 20% of women, and untreated maternal mental illness can cause deleterious effects for women and their children. Benzodiazepines are commonly used to treat anxiety disorders. The reported risk of congenital malformations after in utero benzodiazepine exposure has been inconsistent. The Massachusetts General Hospital National Pregnancy Registry for Psychiatric Medications prospectively enrolls pregnant women with psychiatric illness who take one or more psychiatric medications. Participants are interviewed twice during pregnancy and at 12 weeks postpartum. Women taking any benzodiazepine during the first trimester of pregnancy were compared with a group of women taking psychiatric medication(s) other than benzodiazepines during pregnancy. A total of 1053 women were eligible for this analysis; N = 151 women who had taken a benzodiazepine during the first trimester, and the comparison group was N = 902 women. There were 5 (3.21%) major malformations in the exposure group and 32 (3.46%) in the comparison group (odds ratio 0.92; 95% confidence interval 0.35-2.41). This ongoing pregnancy registry offers reassurance that benzodiazepines do not appear to have major teratogenic effects. The precision of relative risk estimate will improve as the number of participants increases. This and other pregnancy registries will better inform the reproductive safety of benzodiazepines.

Profiles of adverse childhood experiences and family processes during early childhood

Adverse childhood experiences (ACEs) such as maltreatment, parent substance abuse or untreated mental illness affect early development. Other family processes, such as parenting and household chaos, are also influential and may either accentuate or attenuate risks imposed by ACEs. Thus, it is important to examine how ACEs and other family processes, as well as socioeconomic position (SEP), may co-occur differently for various groups of young children. In a sample of 265 children (average age 4.17 years) the current study examines latent profiles of ACEs, family functioning, household chaos, overreactive/harsh parenting, lax/permissive parenting, household income, and parent education. Four distinct profiles emerged: Moderate (22%), High SEP (44%), High Negative Parenting and Low Education (8%), and High ACEs (26%). Detecting these types of differences in how early experiences co-occur is paramount to deepening our understanding of complex influences on development and to effectively informing early interventions to support families with young children.

What should General Adult Psychiatrists know about Reproductive Counselling of Women with Severe Mental Illness?

A notable part of psychiatry is prevention. Our job, as psychiatrists, is not only to treat mental disorders, but also to prevent them. Treating mothers in postnatal period reducing the negative consequence of depression for child development, for example. General adult psychiatrists face the challenge of having patients, who receive psychiatric health care, while also planning to have a child. Many professionals may find themselves in a situation, when they feel clueless on what to advise regarding pharmacotherapy and realistic expectations on having a child. The presentation will focus on some crucial topics. What should counselling include when planning pregnancy, highlighting differences among first and second or further children. Potentials risks and harms on the fetus / new-born baby will be introduced with emphasis on pharmacological/chemical agents, infectious effects and social, relational and family stressors. What the guidelines are for Covid-19 vaccination and pregnancy. Relative and absolute contraindications of planned pregnancy will be discussed. The crucial question of artificial/therapeutic abortion; are there any psychiatric conditions, when a psychiatrist can/should suggest it? The advantage and knowledge of perinatal mental health guideline papers, bio-ethical aspects will be discussed, along with the consequences of untreated mental illness. Advantage of breastfeeding and an up-to-date view on what should be psychiatrists’ aim will be introduced. Why is it inevitable to cooperate with GPs, obstetric- and gynecology colleagues and further medical professionals? The essential aspect and advantages of involving fathers and extended family members in this approach also will be explained.DisclosureNo significant relationships.