Physician Staff

BPUC currently has nine, experienced and caring mid-level providers to visit Assisted Living Communities on a weekly basis.  Each of our physicians work under the direct supervision of our Medical Director, Dr.Samuel Bowen. 

Click the name of each provider to read over their resume.

Connie Kurth, PA-C -serves the Hickory/Lenoir area.

Amy Espinoza, FNP -serves the Fayetteville area.

Leslie King, AGNP -serves the Charlotte/Greensboro area.

Angela Kellermeyer, PA -serves the Charlotte area.

Matt Ward, PA-C –serves the Raleigh area.

Dan Radulescu, ANP-C –serves the Wilmington area.

Joy Ciaccio, FNP-C –serves the Flat Rock/Brevard area.

Pamela “Kat” Schmierer, FNP-C –serves the Wilmington area.

Carolyn Mueller– FNP-C –serves the Lenoir/Hickory/Morganton area.

Services & Info

BPUC offers many services and benefits to your Assisted Living Community.

Weekly visits to the facility with the same provider

At BPUC, the same physician will visit your community every week, allowing for a deeper and more reliable patient/physician/community relationship.  We have providers stationed all over the state so you’ll be getting local care in the comfort of your own room.

24/7 on call customer service and physician

Rest easy knowing we’re always a phone call away. We provide 24/7 on call services with a physician, as well as our customer service, at no cost to your community or your residents.

Electronic Medical Record Database

We have our very own EMR system that is available for your use when you partner up with BPUC. Again, at zero cost to your community or residents this system will introduce yet another level of convenience to your daily practices. Within our EMR program you can view patient charts, create visit schedules, view and print visit notes, correspond with your provider, and store all necessary documents for each resident.

Quick and easy start up

Getting started with BPUC is a quick and smooth process. In addition to the easy sign up process, we have two marketing directors trained to help you get all the necessary paperwork in order. At no cost to you, we can send someone to help gather all of the information on each resident, enter them into the EMR, and schedule the first round of visits. We know how busy Assisted Living Communities get, and we aim to make the process of partnering with BPUC smooth and enjoyable.

Long term support 

In addition to start up support, the marketing directors and customer service team is always available to help you. We offer on-campus EMR training, as well as helping the facilities “close the back door” should state come in. This means ensuring all necessary paperwork is in order and offering a helping hand in any area we are able to assist in.

Partner ships with other convenient services 

BPUC is also partnered with several labs and other services that enable us to provide well rounded care in a timely manner. For more information on these services, please contact our marketing department.

Excellent Recommendations

While BPUC provides only primary care, our excellent reputation has allowed us the opportunity to build valuable connections with other providers that we happily pass on to our residents.

These services provide many different benefits to both the family/resident as well as the community. To read more about these benefits more, click on each link.

Benefits to the family

Benefits to the facility


Controlling Influenza Outbreaks

Controlling Influenza Outbreaks

CDC Guidelines:

Interim Guidance for Influenza Outbreak Management in Long-Term Care

Recommended Dosage and Duration of Treatment or Chemoprophylaxis for Influenza Antiviral Medications.

Standard Precautions

Droplet Precautions

When the flu strikes

a facility, it is a potentially life threatening event for the elderly and immunocompromised residents that we care for.  The care team needs to move into a heightened sense of alertness and activity.

Ask the staff to immediately start cleaning all horizontal surfaces and door knobs every 8 hours with a CDC approved cleaning agent.  The least expensive and most effective is a

Dilute Clorox Solution:

Mix 1 cup (240 mL) of bleach in 1 gallon of water.
Wash surfaces with the bleach mixture.
If surfaces are rough, scrub them with a stiff brush.
Rinse surfaces with clean water.
Allow to air dry.


Once two confirmed cases have a occurred start chemo prophylaxis on all affected residents.  Tamiflu 75 mg daily x 10 days is commonly used.  Watch news and CDC reports for resistant strains that may need a different drug.

If the resident becomes symptomatic increase to full dose anti-viral (such as Tamiflu 75 mf BID x 5 days).

Check oxygen saturation levels on symptomnatic residents.  Residents with normal oxygen levels can be treated symptomatically. Residents with hypoxemia (88% or less) should be referred for evaluation at the local emergency department.


Implement Standard and Droplet Precautions for all residents with suspected or confirmed influenza.

CDC’s guidance titled Prevention Strategies for Seasonal Influenza in Healthcare Settings contains details on the prevention strategies for all health care settings. Specific recommendations are highlighted below.

Standard Precautions are intended to be applied to the care of all patients in all health care settings, regardless of the suspected or confirmed presence of an infectious agent. Implementation of Standard Precautions constitutes the primary strategy for the prevention of healthcare-associated transmission of infectious agents among patients and health care personnel.

Examples of standard precautions include:

  • Wearing gloves if hand contact with respiratory secretions or potentially contaminated surfaces is anticipated.
  • Wearing a gown if soiling of clothes with a resident’s respiratory secretions is anticipated.
  • Changing gloves and gowns after each resident encounter and performing hand hygiene
  • Perform hand hygiene before and after touching the resident, after touching the resident’s environment, or after touching the resident’s respiratory secretions, whether or not gloves are worn. Gloves do not replace the need for performing hand hygiene.

Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Droplet Precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a health care facility.

Examples of Droplet Precautions include:

  • Placing ill residents in a private room. If a private room is not available, place (cohort) residents suspected of having influenza residents with one another;
  • Wear a facemask (e.g., surgical or procedure mask) upon entering the resident’s room. Remove the facemask when leaving the resident’s room and dispose of the facemask in a waste container.
  • If resident movement or transport is necessary, have the resident wear a facemask (e.g., surgical or procedure mask), if possible.
  • Communicate information about patients with suspected, probable, or confirmed influenza to appropriate personnel before transferring them to other departments.


See the CDC references information above for more specific information.

Conquering the Confusion of Dementia Coding

Conquering the Confusion of Dementia Coding

Conquering the Confusion of Dementia Coding
By Danita Arrowood, RHIT, CCS
Posted on: September 14, 2012

Dementia is a common secondary diagnosis; often coders will quickly assign a “memorized” code for it and move on. However due to its commonality, are we missing something such as a co-morbid or complication code that could influence reimbursement? Or are we over-coding symptoms that are inherent to the dementia disease process?

This casual code assignment is complicated by the fact that, often, documentation related to dementia does not present a clear picture of the neurological symptoms related to dementia or those that are a result of other general medical conditions.
In this article, we will review the different codes listed in ICD-9-CM for dementia and some characteristics of each type of dementia. We will also discuss specific instructional notes associated with the dementia codes and determine when it is necessary to seek physician clarification.

Causes & Symptoms of Dementia
Dementia is not a specific disease but rather a group of symptoms related to a decrease in cognitive and social abilities that eventually interfere with a person’s cognitive efforts in work performance, relationships and social activities. These symptoms are a result of dysfunction in the cerebral cortex or other brain tissue. Dementia usually occurs in people over age 60.
Patients with dementia will develop cognitive impairments in areas of language, reasoning, judgment and problem-solving abilities. Forgetfulness, depression and clumsiness are common in early symptoms of dementia. As the condition progresses, patients often experience agitation triggered by their confusion and frustration, and they may become hostile. In later stages, behavioral disturbances, such as wandering off, physical violence and perversion, may become the most challenging issue for caretakers to handle.
To support a diagnosis of dementia, two or more brain functions must be impaired, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV). Alzheimer’s disease is the most common cause of dementia, but not the only cause. A wide variety of physiological conditions, such as alcohol and substance use, and medication reactions are all known causes leading to dementia.

In instances where dementia exists due to conditions such as traumatic or anoxic brain injury or a history of substance abuse with abstinence, dementia can be a static condition. In other cases where dementia is a manifestation of another disease process (i.e., normal pressure hydrocephalus, diabetes), proper control of the physiological condition may slow or arrest the progression of vascular dementia. Dementia associated with neurodegenerative diseases (i.e., AIDS, Lewy bodies and multiple sclerosis), is progressive and permanent. In some cases, the exact reason some patients develop dementia is not yet understood. One source lists 394 conditions associated with dementia.

Dementia Types & ICD-9 Coding
Now, we will look at how ICD-9 classifies dementia and review some of the associated instructional notes for code selection.
ICD-9-CM classifies dementia into the following subcategories:

Senile dementia, uncomplicated, NOS

Presenile dementia

Senile dementia with delusional or depressive features

Senile dementia with delirium

Vascular dementia

Drug-induced persisting dementia

Dementia in  conditions classified elsewhere, with/without behavioral disturbances

Dementia, unspecified, with/without behavioral disturbances

Frontotemporal dementia

Dementia with Lewy bodies

Senile & Presenile Dementia (290.0 – 290.3)
Senile dementia occurs after age 65. A diagnosis of dementia with onset prior to age 65 is presenile dementia. Although some decline in cognition and mental capacity is normal as we age, dementia is not a normal part of aging.
As always, coders should look to physician documentation to determine the type of dementia. Senile and presenile are archaic terms, not often seen in current documentation. If the physician has not stated “senile” dementia, it would be incorrect to select a code for senile dementia, simply because the patient is over age 65.

Vascular Dementia (290.40 – 290.43)
Vascular dementia is the second most common type of dementia. Incidences increase with advancing age. A buildup of plaque (atherosclerosis), amyloid protein and other debris circulating in the blood stream causes damage to the cerebrovascular system leading to vascular dementia. Multi-infarct dementia is one type of vascular dementia and develops because multiple mini-infarctions occur, scattered throughout the brain. As new, undetectable infarcts occur, symptoms of impairment associated with the affected area of the brain may change suddenly.
Ex: An 87-year-old male with a history of atherosclerosis presents with sudden onset of confusion and agitation. Workup reveals no infectious processes, labs WNL. Patient near baseline. Discharge Diagnosis: Multi-infarct dementia due to atherosclerosis, suspected mini stroke.

434.91 Cerebral artery occlusion, unspecified
290.43 Vascular dementia with delirium
437.0 Cerebral atherosclerosis

Dementia With Lewy bodies (331.82)
Lewy bodies are abnormal microscopic deposits of protein that settle in the brain and destroy nerve cells. Typical Parkinson’s type symptoms develop, such as tremors, muscle rigidity and dementia. These patients may also experience delusions and depression.
Review the instructional note at category 332 Parkinson’s disease, which excludes code 331.82 Parkinson’s with Lewy bodies. Lewy bodies with Parkinsonism is a more specific diagnosis than just Parkinson’s disease, per Coding Guidelines, assign the code for the most specific diagnosis.
When physician documentation lists Lewy bodies with Parkinson’s disease, the ICD-9 codebook instructional note directs coders to assign code 331.82 Dementia with Lewy bodies, plus an additional code to identify with or without behavioral disturbances (294.10-294.11).

Delirium, Delusional & Depressive Features
ICD-9-CM provides combination codes to identify specific types of dementia with delirium, delusional and depressive features. These codes are CCs that may affect the MS-DRG and reimbursement.
Delirium is a sudden on-set transient bout of altered consciousness and change in cognition most often attributed to a direct physiological condition. Delirium is often confused with dementia; however, delirium dissipates when the underlying general medical condition resolves, dementia is typically irreversible.
Seek clarification from the physician if documentation does not identify the type of dementia and clarify the underlying cause of acute delirium. If the cause of the delirium or type of dementia is unknown, code the conditions separately.
Delusional features are present in many psychiatric disorders including Alzheimer’s disease, personality and mood disorders. Delusions are irrational, unwavering beliefs that are clearly false and have no logical or normal basis of reasoning.
ICD-9-CM classifies the diagnosis of delusional disorders to category 297, in the Mood Disorder section. A Delusional disorder is not the same as a delusional feature.
Depressive features and depressive mood. Depression is an inherent part of the dementia disease process.
When documentation lists dementia and depression separately, without further documentation to indicate the depression is related to dementia, code them separately.

Behavioral Disturbances
Simply stated, a behavioral disturbance is any behavior that puts the patient or others at risk.
Not all patients with dementia have behavioral disturbances, but as the individual ages and dementia progresses, the likelihood increases of behavior problems manifesting and becoming the more challenging aspect of patient care.
Noted under many of the dementia codes is the instructional note “use additional code to identify behavioral disturbances.” You will also find listed under the behavioral disturbance codes, subcategory code 294.1x, the instructional note, “code first underlying physical condition.” These two notes provide code sequence instruction, directing the underlying condition to be sequenced before the 294.1x code.
Ex: An 87-year-old nursing home patient with Alzheimer’s dementia has repeatedly wandered off.
331.0 Alzheimer’s disease
294.11 Dementia in conditions classified elsewhere with behavioral disturbance
V40.31 Wandering in diseases classified elsewhere
Behavior disturbances include a wide array of disruptive behavior. It is the coder’s responsibility to watch for documentation that identifies this type of behavior. Physician documentation may not always specifically state “with behavioral disturbances.” If in doubt, query the physician for clarification.
In this article, we have reviewed the most common types and characteristics of dementia coded in ICD-9 and looked at many of the associated coding conventions. Documentation on dementia as a chronic, pre-existing condition can be vague and disconnected from other neurological traits the patient may have, making it difficult for the coder to select the most accurate code. As always, when documentation is not clear, query the physician for clarification.
Danita Arrowood is anAHIMA -approved ICD-10-CM/PCS trainer and an educator/medical coding educator with Precyse (, which provides services and technologies that capture, organize, secure and analyze healthcare data and transform it into actionable information, supporting the delivery of quality patient care and optimizing operating performance. Danita develops content materials for ICD-9-CM and ICD-10-CM/PCS and provides clinical documentation improvement education. Danita is also adjunct faculty at Phoenix Community College.

Test your knowledge on page 2.

The use of medroxyprogesterone acetate for the treatment of sexually inappropriate behaviour in patients with dementia

The use of medroxyprogesterone acetate for the treatment of sexually inappropriate behaviour in patients with dementia

Journal of Psychiatry & Neuroscience
Canadian Medical Association

Language: English |
The use of medroxyprogesterone acetate for the treatment of sexually inappropriate behaviour in patients with dementia

Stacy Anderson Light and Suzanne Holroyd

Additional article information

Sexually inappropriate behaviour in a patient with dementia can be a problem for caregivers. Little research has been done concerning treatment for this behavioural disorder. The hormone medroxyprogesterone acetate (MPA) is a known, but infrequently used, treatment option. We describe a series of 5 cases in which MPA was used successfully to control inappropriate sexual behaviours in men with dementia.
Medical subject headings: dementia, disinhibition, medroxyprogesterone acetate, sexual disorder

Behavioural problems are common in dementia and present a burden to caregivers. Agitation is estimated to occur in 50%–60% of patients with dementia.1 Although much less common, sexual aggression or disinhibition can be very disruptive to family members and to care in hospitals, nursing homes or other facilities. The estimated prevalence of sexually inappropriate behaviours in patients with dementia is between 2.9% and 15%.2 In the nursing home setting, these behaviours can be a threat to the welfare of other patients. Repeated offences can lead to difficulty finding or maintaining appropriate living placement.

Studies have shown that whereas sexual activity decreases in elderly people, sexual interest does not.3 The decrease in activity may be attributed to factors including medical illness, nursing home placement and loss of opportunity.3 The diagnosis of dementia raises ethical considerations related to sexuality, including ability to give consent, advances toward unwilling participants and displays of sexual behaviours in locations or situations not deemed appropriate by society. The difficulty in managing these individuals arises from the desire to protect others, while not using undue restraint or causing significant side effects for the individual.

The literature regarding treatment is limited. A review of treatments for inappropriate sexual behaviours based on case reports including the use of antipsychotic drugs, antiandrogens, estrogens, gonadotropin-releasing hormone (Gn-RH) analogues and serotonergic agents revealed no studies comparing the efficacy of one treatment over another. However, there were more case reports regarding successful treatment of patients with dementia using antiandrogens (medroxyprogesterone acetate [MPA]) (6 cases) than serotonergic agents (1 case), clomipramine (2 cases), Gn-RH analogues (1 case) or estrogens (1 case).4 In addition, the side effects of these agents may limit their applicability in elderly patients, such as anticholinergic effects from clomipramine or cardiovascular and thromboembolic risk factors and gynecomastia due to estrogens.4 More recently, the histamine blocker cimetidine has also been identified as a possible treatment option.5

MPA is a synthetic progestin used for numerous purposes in women. When administered in males, it lowers testosterone levels, lowering sexual drive without causing feminization. MPA has been used in younger patients, including pedophiles and individuals with other mental illnesses and sexually inappropriate behaviours.6–8 Case reports suggest that MPA is a safe and efficacious treatment for symptoms specific to inappropriate sexual behaviour in men with dementia.9,10 Dosages in reported cases ranged from 100 mg taken orally daily10 to 1000 mg administered intramuscularly (IM) weekly9 based on efficacy and tolerability. The most common side effects in males are fatigue and weight gain. Impotence, hot or cold flashes, headache, mild depression, mild diabetes, loss of body hair, insomnia, nausea, phlebitis and loss of ejaculatory volume have been noted to be potential side effects.4,11 However, previous case reports to date have not revealed significant side effects in patients with dementia and have concluded that MPA is well tolerated and safe.9,10 In this report, 5 cases of treatment of inappropriate sexual behaviour in men with dementia using MPA are described to add to the literature in this area. The University of Virginia Human Investigations Committee approved this study.
Case 1

Mr. A was a 79-year-old man living in a nursing home when he began to exhibit sexually inappropriate behaviours including grabbing the breasts of female staff and residents and attempting intercourse with a male resident. His condition was diagnosed as dementia of mixed type (vascular and Alzheimer’s) with behavioural disturbance. He had no history of sexually inappropriate behaviour. The patient’s cognitive function was assessed using the Mini-Mental Status Examination (MMSE); his score was 11/30. He was already being treated with donepezil, 10 mg, each evening. Trials of buspirone and haloperidol did not improve these behaviours. MPA, 100 mg IM monthly, was prescribed, and the patient responded within 2 weeks with no further sexually inappropriate behaviours. No change in MMSE score was noted. After 4 months, the medication was stopped because of concerns expressed by a state regulator regarding “the use of chemical restraint.” Sexually inappropriate behavioural problems began almost immediately. Various medications, including trials of haloperidol, olanzapine, quetiapine, carbamazepine and buspirone, failed to improve the behaviours but did cause a variety of side effects. The patient was finally prescribed MPA again at the same dose of 100 mg monthly, which did not immediately control the behaviours, so the patient was admitted to a psychiatric facility, transferred to a state hospital and lost to follow-up.
Case 2

Mr. B was an 85-year-old man, living in a nursing home, who almost immediately from admission began exposing himself to his adult daughter and was inappropriately touching female residents and attempting oral sexual relations. The patient’s diagnosis was vascular dementia with behavioural disturbance and depression. His MMSE score was 24/30. His history was significant for sexual assault charges toward a female child many years earlier, though he was later found innocent. He had also had multiple affairs with women during his marriage. There was no history of earlier exposing or other inappropriate sexual behaviour with the daughter. There were no other earlier legal charges. The patient was prescribed sertraline for depression and MPA, 300 mg IM monthly. The sexually inappropriate behaviours stopped within 2 weeks; however, the depression remained. Sertraline was stopped, and the patient was prescribed venlafaxine instead, but he continued to have some depression. There was no change in MMSE score. About 1 year later, the MPA was discontinued because of state regulators’ concern regarding “chemical restraint.” Sexually inappropriate behavioural problems recurred within several weeks. Because the nursing home refused to allow the use of MPA secondary to state interpretations regarding chemical restraint, thioridazine was used instead. The behaviours were observed to decrease but not cease. The patient was transferred to another nursing home shortly thereafter and lost to follow-up.
Case 3

Mr. C was an 81-year-old man who repeatedly touched the breasts of his adult daughter, female staff and other female residents in the nursing home. He had no history of sexually inappropriate behaviours, and this was considered a marked behavioural change by his family. His condition was diagnosed as senile dementia of the Alzheimer’s type with depression and behavioural disturbance. His MMSE score was 14/30. Trials of sertraline for depression and quetiapine for aggression did not decrease the sexual behaviours. The patient was prescribed MPA, 100 mg every 2 weeks. The dose was slowly titrated to 500 mg weekly, and the sexual behaviours completely stopped. The patient continued to have depressive symptoms, and he was prescribed escitalopram with good results. There was no change in MMSE score following treatment with MPA. The patient remained free of further inappropriate behaviours and had no apparent side effects for over a year, when he suffered a stroke. At that point, MPA was stopped, because the patient was no longer able to physically exhibit such behaviours.
Case 4

Mr. D was a 68-year-old man admitted to the geriatric unit at the University of Virginia, Charlottesville, for inappropriate sexual behaviours including masturbating in public places, grabbing the breasts of female staff members and climbing into female residents’ beds. The diagnosis was vascular dementia with behavioural disturbance. His MMSE score was 0/30. Trials of quetiapine, trazodone, valproic acid and risperidone did not improve the sexual behaviours but did cause side effects such as sedation and gait instability. After starting MPA, 300 mg IM weekly, his sexual behaviours ceased almost immediately and all other psychotropic medications were discontinued. No change in MMSE score was noted.
Case 5

Mr. E was an 81-year-old man who showed combativeness toward caregivers and inappropriate sexual behaviour including touching female staff and residents’ breasts and engaging in sexual intercourse with a female resident. His MMSE score was 3/30. He was taking donepezil, 10 mg each evening. Quetiapine was successful in controlling combativeness but had no effect on the sexual behaviours. MPA, 300 mg IM weekly, was begun and led to a decrease in the behaviour. An increase to 500 mg weekly eliminated the sexually inappropriate behaviours entirely. The quetiapine was then discontinued without reoccurrence of combative behaviours. The patient gained 4.5 kg (10 lb) over the course of a year’s treatment, but no other side effects were noted. The MPA was discontinued after a year, because the patient’s physical status had changed in that he was no longer able to demonstrate the sexually inappropriate behaviours. After MPA was discontinued, the combative behaviours returned and quetiapine was started again to treat those behaviours.

Our cases demonstrate the use of MPA in the treatment of inappropriate sexual behaviour in men with dementia. All the individuals’ behaviour improved with MPA treatment, after treatments with other psychiatric medications with less favourable side-effect profiles had failed. Of note, the dosage was quite variable, ranging from 100 mg each month to 500 mg each week.

The MPA appeared to be well tolerated, with the only physical side effect noted in our cases being weight gain in 1 patient. On the other hand, the use of less specific medications for the sexual behaviours resulted in more side effects. In addition, although noted to be depressed before treatment with MPA, 2 of the patients continued to experience symptoms of depression during treatment with MPA. Depression is a reported side effect of MPA therapy and could have contributed to continued symptoms in our cases. Monitoring for signs and symptoms of depression should continue throughout the time a patient is receiving MPA therapy. If patients are monitored and treated appropriately, however, depression should not be considered a contraindication for initiating or a reason for discontinuing MPA.

It is also noteworthy that in 2 cases the MPA was discontinued because of state regulatory concern regarding chemical restraint. This ethical question has been noted in the literature concerning the use of MPA and similar agents, and it is recommended that clinicians obtain fully informed written consent from the legally authorized caregiver of the individual with dementia before using MPA.9,10 However, in our opinion, MPA is less of a chemical restraint than other drugs used to control inappropriate sexual behaviours, because it is symptom specific with an antilibidinal effect, whereas other drugs such as antipsychotics are less specific and have more potential for side effects in elderly patients, such as sedation and gait instability.

These cases add to the literature on the safety and efficacy of MPA in the treatment of inappropriate sexual behaviour in male patients with dementia. Because its mechanism of action is specific to the symptom of sexual behaviour, MPA may be considered first-line therapy for this behavioural disorder.

This study was sponsored in part by the National Institute of Neurological Disorders and Stroke (grant no. NS045008-01 A1) (S.H.).

Contributors: Both authors contributed to the conception and design of the article, acquired and interpreted data, drafted and revised the article and gave approval for the article to be published.

Competing interests: None declared.

Correspondence to: Dr. Stacy Anderson Light, c/o Dr. Suzanne Holroyd, Department of Psychiatric Medicine, University of Virginia, Box 800623, Charlottesville VA 22908; fax 434 924-5149; ude.ainigriv@s4hs

Article information
J Psychiatry Neurosci. Mar 2006; 31(2): 132–134.
PMCID: PMC1413960
Stacy Anderson Light and Suzanne Holroyd
Department of Psychiatric Medicine, University of Virginia, Charlottesville, Va.
Copyright © 2006 CMA Media Inc. or its licensors
This article has been cited by other articles in PMC.
Articles from Journal of Psychiatry & Neuroscience : JPN are provided here courtesy of Canadian Medical Association
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