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An unimaginable journey

Healing Through Expert Care and Helping Others

IT WAS JUST a few days before Thanksgiving 2019 when Michelle rolled over in her bed and felt something in her breast.

As a former radiation therapist and Johns Hopkins Kimmel Cancer Center radiation oncology administrator, Michelle knew right away what this suspicious lump could mean.

It can’t be what I think it is, thought Michelle, hoping she was mistaken about what she felt.

She simply could not imagine another tragic event in her life. Michelle was still grieving the death of her husband, lost to suicide a year earlier.

She could feel the anxiety welling up in her body as her mind raced. To gain clarity, she turned to the determination that had gotten her through the past year and her skill as a cancer center administrator.

Michelle remembered a friend who became ill during a visit to her home in the Maryland suburbs near Washington, D.C. Michelle took her friend to the Johns Hopkins Sibley Memorial Hospital emergency room.

“I was so impressed with the care she received in the ER that I said, ‘If anything ever happens to me, I’m going there,’” Michelle recalled, never imagining how soon she would have to put her words into action. She made an appointment at Sibley that day.

Triple-Negative Breast Cancer

In early December 2019, just before Michelle’s 52nd birthday, biopsy results confirmed that the lump she had felt a few weeks earlier was triple-negative breast cancer.

This type of breast cancer is named for its lack of hormone receptors, meaning the cancer cells are not fueled by hormones, as is the case in most other types of breast cancer. As a result, triple-negative breast cancer can be challenging to treat. Therapies aimed at cutting off cancers from the hormones that feed them do not work against triple-negative breast cancer.

Having worked in the Kimmel Cancer Center in the early 2000s, Michelle was familiar with the challenges associated with triple-negative breast cancer. Further, she had received the concerning news that the cancer had already begun to spread to her lymph nodes.

Her expert team of surgeon Maureen O’Donnell-DeBritz, M.D., medical oncologist Cesar Santa-Maria, M.D., and radiation oncologist Jean Wright, M.D., gave Michelle “hope in Johns Hopkins’ cancer care,” she says. “I wasn’t sure of the outcome, but I had total confidence in my treatment regimen and cancer team.” This confidence, she says, was borne from Johns Hopkins’ reputation and her time working there alongside those whom she considers some of the most brilliant minds in breast cancer medicine. Her treatment plan included chemotherapy, followed by a lumpectomy to remove the 4.3 cm tumor, and then radiation therapy.

COVID Strikes

Just when Michelle thought she had a handle on the path forward, the unimaginable happened once again. As she began her first round of chemotherapy in January 2020, the COVID-19 pandemic hit the U.S.

Kimmel Cancer Center experts quickly adapted, putting new procedures in place to care for patients while protecting them from exposure to the coronavirus that causes COVID-19. However, to keep from contracting the virus, Michelle could not be around her family members and friends, the people who had been helping and supporting her through the loss of her husband and her cancer diagnosis.

“I was isolated. It was the first time I had been alone in 25 years. It was a very dark and difficult time,” recalls Michelle. There was good news, however. The chemotherapy regimen—called ACT for Adriamycin, Cytoxan, and Taxol—worked. After months of treatment, Dr. Santa-Maria shared with Michelle the results of her imaging studies, showing there was no visible cancer remaining. That was confirmed soon after, in June 2020, when Dr. O’Donnell-Britz performed the lumpectomy and found that the golf-ball-sized tumor was gone. During the same surgery, she removed the lymph node where the cancer had begun to spread. After healing from the surgery, Michelle saw Dr. Wright for radiation therapy.

A New Purpose

Michelle’s cancer remains in remission, but she knows many women, particularly other African American women, have not been so fortunate. Triple-negative breast cancer disproportionately affects African American women, and they are twice as likely to be diagnosed with this cancer and more likely to die from it than their White counterparts.

Wracked with worry about her cancer returning, Michelle decided she needed a change of scenery and a new purpose.

She relocated from Maryland to New York City and became a professional speaker, educating women about breast cancer and advocating for better access to preventive and diagnostic care for women of color.

“Survival rates are dismal, and access to care, including mammograms, contributes to the dismal mortality rates,” says Michelle. “We have to do better for these women. We have to show up in the community and have open and honest discussions, and be willing to hear the tough stuff.”

When Michelle speaks to women, she often talks about clinical trials. Michelle participated in a breast cancer vaccine study with Dr. Santa-Maria, but she recognizes that many African American women are fearful of research treatments.

She understands that their lack of trust is born of real experiences passed down from generation to generation, and she speaks out about the need for nurse navigators of color and support groups for women of color to address and work through these issues, so women will seek and receive lifesaving preventive care and treatment.

“Fear keeps us from doing,” she says, “and if we don’t participate in clinical trials, we won’t know if they work, preventing a future treatment for our children and grandchildren.”

Michelle recognizes that her experience working in a cancer center gave her an edge that other women do not have. She already had knowledge about cancer and knew what questions to ask. Now, she wants to give a voice to other women.

She says, “We have to ask ourselves, ‘Are we doing everything we can?’” Michelle has faced more challenges in the past few years than most will face in a lifetime, including the recent loss of her sister and her father, but she remains hopeful and determined.

“I grieve. I still have feelings, but I’m not stuck in them. I get to choose what meaning I give to those circumstances, and that is a very powerful position,” says Michelle. “I can admit that I don’t have control over most things in life except how I respond. That is where my power is most useful.”

For Michelle, one way she has responded to the unimaginable challenges of the past few years is to channel her remarkable and inspirational resiliency into helping other women.

Fighting For Two

One YoungMother’s Heroic Battle with Breast Cancer During Pregnancy

Amanda wasn't concerned about the series of lumps she found in her breast. In fact, she was becoming frustrated. With each lump, there was a biopsy, and each time, the results showed that they were harmless, benign lumps. Eager to grow her family, Amanda turned her thoughts to planning for a new addition.

Then, in June 2023, just a month after learning the wonderful news that she was expecting her second child, Amanda felt a new lump. This one felt like a pea, not large like the one from the year before.

“I was irate,” she recalls, as she wondered why she was developing these lumps. She says she brushed it off. “I was tired of biopsies,” says Amanda, so she told herself the new lump was benign just like the others. Lisa Jacobs, M.D., the Kimmel Cancer Center surgeon who did Amanda’s earlier biopsies, wanted to continue following her. A few months later, at Amanda’s regular appointment, Dr. Jacobs felt the lump and ordered an ultrasound and biopsy. Despite convincing herself over the past few months that it was another benign lump, Amanda’s gut was now telling her something else. “It was weird. I suddenly had a feeling it was going to be a different outcome this time,” she says. Still, she remained focused on herself and had an appointment scheduled for the next day with medical oncologist and breast cancer expert Danijela Jelovac, M.D.

The diagnosis was triple-positive breast cancer, a type of breast cancer fueled by the hormones progesterone and estrogen and a protein called HER2. The next months were a roller-coaster ride of ups and downs.

The Plan

Amanda wanted to protect her unborn baby, so Dr. Jelovac had to devise a treatment strategy that could attack the cancer without harming the baby. Standard therapy for triple-positive breast cancer involved treatment that blocked hormones feeding the cancer, but these same hormones were critical to Amanda’s developing baby. To save both mom and baby, Dr. Jelovac started Amanda on two cancer drugs—Adriamycin and Cytoxan— that were safe to take while pregnant.

The drugs are powerful anticancer drugs, but they also have the side effect of harming other rapidly dividing cells, such as gut cells. Amanda had just gotten beyond the morning sickness that came with her pregnancy, and now the chemotherapy was causing her to feel nauseous.

The plan was for four rounds of chemotherapy—every three weeks—followed by a mastectomy, and then the birth of her baby.

Treatment was not going as planned. The chemotherapy did not appear to be working.

“I felt like the tumor was getting bigger,” says Amanda. “I looked like I had a breast implant.”

With the tumor growing larger instead of smaller, Dr. Jelovac decided they could not wait any longer to do the mastectomy. A week before Christmas, Amanda, now 28 weeks pregnant, had surgery to remove the breast.

The tumor that was the size of a pea when Amanda first felt it had grown beyond the size of a grapefruit at the time of surgery, and, worse yet, the cancer had spread to her lymph nodes.

“It was unimaginable,” says Amanda. “The cancer was overshadowing the happiness of my pregnancy.”

Amanda knew it was a fast-growing tumor. She had seen that with her own eyes, as her breast grew larger despite the chemotherapy. She was concerned the cancer was continuing to spread. She began to wonder if she would survive the cancer and was filled with worry for her growing baby and her young son, now 4 years old.

“I wouldn’t wish this on anyone,” says Amanda.

Dr. Jelovac collaborated with Amanda’s obstetrician, and they agreed to move up the delivery of the baby to 34 weeks so she could begin the standard treatment regimen, called TCHP, and combat the growing cancer. Amanda hoped, for her children’s sake, it would come in time to save her life.

On February 2, 2024, Amanda delivered Aubri Hope, a strong and healthy baby girl.

Amanda was now even more determined to beat the cancer. A month after her baby was born, Amanda began four months of treatment with the TCHP drug combination, followed by six weeks of radiation therapy. As of her last imaging report, there are no signs of cancer. For the next year, Amanda will receive an injection of targeted HER2 antibodies every three weeks. The therapy disarms the HER2 protein that helps fuel the breast cancer and works to keep her cancer from coming back by thwarting any remaining microscopic cancer cells.

Maddie

It is not lost on Amanda how differently things could have gone. After her diagnosis, she had joined Pregnant with Cancer, a Facebook support group of moms-to-be battling cancer.

She connected with Maddie, who was battling stage 4 triple-negative breast cancer. Maddie had already had her baby when she connected with Amanda, and seeing Maddie’s healthy baby gave Amanda the hope and comfort she needed as she waited nervously to deliver her own baby. “We talked every day,” says Amanda, adding that Maddie sent her supplies to help her through her treatment, along with baby gifts and meals. “She went above and beyond, and she had her own stuff going on. She was amazing.”

They had planned to meet in person, but they never got the chance. Maddie messaged her that her cancer had spread to her liver, and then, two days before Amanda delivered her baby, she received the news that Maddie had died. She was just 30 years old. “It was one of the hardest things I’ve ever had to hear. We created an amazing connection. I’m a totally different person because of her,” says Amanda. “I had never experienced that level of kindness. My life’s purpose is to pay it forward.”

Because of her early delivery, Amanda’s daughter was being cared for on the neonatal intensive care unit. When Amanda came to the unit to hold her daughter for the first time, she learned that Maddie was also the name of the nurse assigned to her daughter.

Inspired by her friend Maddie, Amanda is bringing the same help and comfort to a young mother of a 2-year-old daughter who, at just 25 years old, was also diagnosed with triple-positive breast cancer.

The two recently met in person. “I didn’t get the chance to meet Maddie. I don’t take time for granted anymore,” says Amanda.

A Mother’s Day Gift

Amanda’s patient navigator, Jill Mull, herself a survivor of breast cancer, thought Amanda also deserved some special care. Mull recommended her for Justin’s Beach House, a Bethany Beach respite for people battling cancer. After more than a year of fighting against cancer for her life and the life of her unborn baby, Amanda spent Mother’s Day relaxing on the beach with her husband and children.

Coping with breast cancer emotionally

However you feel, this guide gives you tips and resources on how to cope emotionally with breast cancer.

1. Your emotions after diagnosis

There’s no right or wrong way to feel after you’ve been diagnosed with breast cancer.

It can be hard to concentrate or carry out normal everyday activities. Some people have physical symptoms such as loss of appetite, diarrhoea or difficulty sleeping.

The days and weeks immediately after a diagnosis can be particularly emotional and may feel overwhelming. Your feelings may change day to day or even hour to hour.

It’s usual to have times when you feel very low, followed by times when things seem more positive.

If you’re feeling overwhelmed, it can help to talk to your GP. They can offer support and medication that can help in the short term.

If you’re finding it hard to cope

Many people find it easier to talk someone other than family or friends. Calling our free helpline – see the top or bottom of this page – offers you the chance to talk openly in a safe and confidential space.

Our helpline nurses are used to talking to people who are finding it hard to cope after a breast cancer diagnosis. They can also talk to you about your treatment and what to expect, as well as relevant services or information.

If you prefer to ask a question in writing you can email our nurses – simply scroll to the bottom of this page for more information – or post your question on our forum.

Stress and anxiety

It’s common to feel stressed and anxious after a diagnosis of breast cancer.

This may be your first experience of anxiety, or you may have had anxiety in the past. Your diagnosis, or waiting for more tests or results, could make this worse.

It can be tempting to turn to any usual coping methods, such as alcohol, when you’re feeling stressed or anxious. However, this can often make you feel worse.

There are many ways to reduce stress and anxiety, including:

• Distraction – focusing on things around you, or a hobby or interest, to shut out negative thoughts
• Relaxation, visualisation, mindfulness and meditation – you can use these separately or together to reduce stress and tension
• Exercise – regular physical activity, whether it’s a brisk walk or yoga, can help clear your mind and reduce your stress levels
• One-to-one counselling – explore feelings which can be related to your cancer diagnosis, making them easier to understand and cope with
• Cognitive behavioural therapy (CBT) – can help you to change patterns of thinking and behaviour that may be stopping you from moving forward

You may also find the following websites useful:

• Anxiety UK
• NHS every mind matters: Feeling anxious?
• Mind: Anxiety and panic attacks
• Can-Empower

Low mood and depression

Most people experience low mood and sadness when they’re diagnosed.

Sometimes a cancer diagnosis can trigger depression.

Find out more about coping with low mood and depression.

2. Talking to family, friends and children

If you’re finding it difficult to cope emotionally, you might want to talk to friends or family members about how you’re feeling.

We’ve put together some tips for how to tell family and friends about your cancer.

You can also read our tips on talking with children about breast cancer.

3. Connecting with people who understand

For some people, connecting with others who are in a similar situation can help reduce feelings of isolation, as well as anxiety or fear.

If you've been diagnosed with primary breast cancer, our Someone Like Me service can put you in touch with someone with a similar experience of breast cancer. You can talk through your worries and share experiences over the phone or by email. Scroll down to the end of this page for more information.

On our forum you can exchange tips, ask questions, share your experiences and talk through your concerns.

If you’re aged 18 to 45, our Younger Women Together service will give you specialist support and the chance to meet other younger women diagnosed with breast cancer.

Breast Cancer Now’s videos

Speakers Live

Our Speakers Live is an opportunity to learn more from experts about relevant topics. The events take place in real time over Zoom and you can ask questions by sending them in beforehand, or by typing in the chat box during the event. No cameras or microphones are on during the event.

Speakers Live cover a wide range of topics, such as healthy eating, exercise, hormone treatment, sleep, emotional impact of breast cancer, fertility, returning to work after breast cancer treatment and many more.

Chats

We have regular live chats on Facebook and Instagram. You can watch these back on our YouTube channel.

4. Coping with life after treatment

Finishing your hospital-based treatment can feel like a real achievement. But many people find it difficult to adjust to life after treatment.

You may find it useful to:

• Read our information on life after treatment
• Consider a Moving Forward course
• Read stories from others who've been through breast cancer

Breast cancer: How your mind can help your body

According to the National Cancer Institute, an estimated 310,270 women and 2,790 men in the United States will learn that they have breast cancer in 2024. Because many of them have no family history of breast cancer or other known risk factors, the diagnosis often comes as a devastating surprise. The emotional turmoil that follows can affect a patient's physical health and psychological well-being.

This question-and-answer fact sheet explains how psychological treatment can help these patients boost their emotional resilience.

What impact does a breast cancer diagnosis have on psychological well-being?

Receiving a diagnosis of breast cancer can be one of the most distressing events a person ever experiences. And those diagnosed may not know that psychologists can be a source of help.

Distress typically continues even after the initial shock of diagnosis has passed. As patients begin what is often a lengthy treatment process, they may find themselves faced with new problems. They may find their personal relationships in turmoil, for instance, as research shows that seriously ill women are 6 times more likely than seriously ill men to be abandoned by their partners (Glantz, M. J., et al., 2009). They may feel exhausted and be very worried about their symptoms, treatment, and mortality. They may face discrimination from employers or insurance companies.

Factors like these can lead to chronic stress, anxiety, and depression.

Why is it important to seek psychological help?

Feeling overwhelmed is a normal response to a breast cancer diagnosis.

But negative emotions can cause people to stop doing things that are good for them and start doing things that are especially worrisome for those with a serious disease.

Those diagnosed with breast cancer may start eating poorly, for instance, eating fewer meals, and choosing foods of lower nutritional value. They may cut back on exercise. They may have trouble getting a good night’s sleep. And they may withdraw from family and friends. At the same time, these patients may use alcohol, nicotine, caffeine, or other drugs to soothe themselves.

A breast cancer diagnosis can also lead to more severe problems. For some patients, for example, the news leads to depression, which can make it more difficult for them to adjust, make the most of treatment, and take advantage of whatever sources of social support are available. Some patients become so disheartened by their cancer diagnosis and treatment that they refuse to undergo surgery or simply stop going to radiation or chemotherapy appointments.

Depression can also decrease survival rates, research shows. According to one meta-analysis of 17 cohort studies, depression was associated with a 30% increased risk of all-cause mortality in breast cancer patients. It was also associated with a 29% increased risk of cancer-specific mortality and a 24% increased risk of breast cancer recurrence.

How can psychological treatment help patients adjust?

Licensed psychologists and other mental health professionals with experience in breast cancer treatment can help a great deal. Psychologists working closely with medical professionals in integrated health settings like hospitals or cancer centers play a key role. They focus on helping patients learn how to cope with the physical, emotional, and lifestyle changes associated with cancer as well as with medical treatments that can be painful and traumatic.

For some patients, the focus may be on how to explain their illness to their children or how to deal with a partner’s response to their diagnosis. For others, it may be on how to choose the right hospital or medical treatment. For still others, it may be on how to control stress, anxiety, or depression.

By teaching patients problem-solving strategies in a supportive environment, psychologists help those diagnosed work through their grief, fear, and other emotions. For many people, this life-threatening crisis eventually results in life-enhancing personal growth.

Breast cancer patients themselves aren’t the only ones who can benefit from psychological treatment. Partners may also suffer. In a cohort study of over 3 million people, spouses of patients with cancer had increased risk of psychiatric disorders and were 14% more likely to seek treatment than spouses of people without cancer (Hu, K., et al., 2023).

Psychologists can help spouses manage the challenge of offering both emotional and practical support while dealing with their own feelings. Children, parents, and friends involved in caretaking can also benefit from psychological interventions.

The need for psychological treatment may not end when medical treatment does. In fact, emotional recovery may take longer than physical recovery and is sometimes less predictable. Although societal pressure to get everything back to normal is intense, breast cancer survivors need time to create a new self-image that incorporates both the experience and any physical changes. Psychologists can help patients do that and learn to cope with such issues as fears about recurrence and impatience with life’s more mundane problems.

Can psychological treatment help the body, too?

Absolutely. Cancer diagnosis and treatment create significant stress, affecting individuals’ quality of life. Stress can worsen symptoms and potentially impact tumor growth and spread (Antoni, M. L., et al., 2023). Psychologists have developed stress management interventions that are useful for dealing with the nausea and vomiting that often accompany chemotherapy, for example. For some patients, these side effects can be severe enough to make them reject further treatment efforts. Psychologists can teach relaxation exercises, meditation, self-hypnosis, imagery, or other skills that can effectively relieve nausea without the side effects of pharmaceutical approaches. These types of services are so vital that, as of 2015, cancer centers are required to screen patients for distress and refer them for psychosocial interventions to maintain their accreditation (Gudenkauf, L. M., & Ehlers, S. L., 2018).

Psychologists can also empower women to make informed choices in the face of conflicting advice and can help them communicate effectively with their health care providers. In short, psychologists can help patients become more fully engaged in their treatment. The result is an enhanced understanding of the disease and its treatment and a greater willingness to do what needs to be done to get well.

Earlier research indicated that psychological treatment may boost chances of survival for those with breast cancer. In one study, for instance, a decrease in depression symptoms was associated with longer survival in patients with metastatic breast cancer (Giese-Davis, J., et al., 2010). Another study examined the impact of psychologist-led small group sessions that offered strategies for reducing stress, improving mood, changing health-related behaviors, and adhering to treatment and care (Andersen, B. L., et al., 2008). The breast cancer patients who participated in the groups had a 45% lower risk of their cancer coming back and a 56% lower risk of dying from breast cancer. The results were even more impressive when the researchers excluded patients who attended fewer than 20% of the sessions: The remaining participants’ risk of dying from breast cancer was 68% lower.

Replication of these results has been inconsistent in more recent research, particularly for metastatic breast cancer. However, one study focused on women with nonmetastatic breast cancer found that nondepressed women had longer overall survival than those with depressive symptoms (13.56 years vs. 11.45 years) (Antoni, M. H., et al., 2017).

Such findings underscore the importance of psychological interventions.Cognitive-behavioral therapy for cancer distress is one of the most thoroughly researched treatments for managing cancer-related distress (Ehlers , S. L., et al., 2023). This therapy, which is specifically designed for cancer patients, teaches skills to challenge negative thoughts, improve behaviors, manage symptoms like insomnia, and enhance communication for better social support. Studies have shown that this type of therapy can reduce psychological distress and improve quality of life even more than a decade after diagnosis (Stagl, J. M., et al., 2015).

What type of psychological treatment is helpful?

A combination of individual and group treatment is often the most effective approach. Individual sessions with a licensed psychologist typically emphasize the understanding and modification of patterns of thinking and behavior.

Group psychological treatment with others who have breast cancer gives women a chance to give and receive emotional support and learn from the experiences of others. To be most effective, groups should be made up of women at similar stages of the disease and led by psychologists or other mental health professionals with experience in breast cancer treatment.

Whether aimed at individuals or groups, psychological interventions strive to help women adjust to their diagnoses, cope with treatment, and come to terms with the disease’s impact on their lives. These interventions offer psychologists an opportunity to help women better understand breast cancer and its treatment. Psychologists typically ask women open-ended questions about their assumptions, ideas for living life more fully, and other matters. Although negative thoughts and feelings are addressed, most psychological interventions focus on problem-solving as women meet each new challenge.

A breast cancer diagnosis can severely impair a woman’s psychological functioning, which in turn can jeopardize her physical health. But it doesn’t have to be that way. Women who seek help from licensed psychologists with experience in breast cancer treatment can use the mind-body connection to their advantage to enhance both mental and physical health.

Acknowledgments: APA thanks Shawna Ehlers, PhD, LP, Alice F. Chang, PhD, and Sandra B. Haber, PhD, for their expert review of the original or updated version of this article.

References

Andersen, B. L., et al. (2008). Psychologic intervention improves survival for breast cancer patients: A randomized clinical trial. Cancer, 113 (12): 3450–3458. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661422/

Antoni, M. H., et al. (2017). Post-surgical depressive symptoms and long-term survival in non-metastatic breast cancer patients at 11-year follow-up. General Hospital Psychiatry, 44, 16– 21. https://doi.org/10.1016/j.genhosppsych.2016.10.002.

Antoni, M. H., Moreno, P. I., & Penedo, F. J. (2023). Stress management interventions to facilitate psychological and physiological adaptation and optimal health outcomes in cancer patients and survivors. Annual Review of Psychology, 74: 423–455. https://doi.org/10.1146/annurev-psych-030122-124119

Ehlers, S. L., et al. (2023). Real-world implementation of best-evidence cancer distress management: Truly comprehensive cancer care. Journal of the National Comprehensive Cancer Network, 21(6), 627–635. https://doi.org/10.6004/jnccn.2023.7009

Giese-Davis, J., et al. (2010). Decrease in depression symptoms is associated with longer survival in patients with metastatic breast cancer: A secondary analysis. Journal of Clinical Oncology, 29 (4): 413–420. https://doi.org/10.1200/JCO.2010.28.4455

Glantz, M. J., et al. (2009). Gender disparity in the rate of partner abandonment in patients with serious medical illness. Cancer, 115(22), 5237–5242. https://doi.org/10.1002/cncr.24577

Gudenkauf, L. M., & Ehlers, S. L., (2018). Psychosocial interventions in breast cancer survivorship care. The Breast, 38, 1–6. https://doi.org/10.1016/j.breast.2017.11.005.

Hu, K., et al. (2023). Risk of psychiatric disorders among spouses of patients with cancer in Denmark and Sweden. JAMA Network Open, 6(1): e2249560. https://doi.org/10.1001/jamanetworkopen.2022.49560

Stagl, J. M., et al. (2015). Long-term psychological benefits of cognitive-behavioral stress management for women with breast cancer: 11-year follow-up of a randomized controlled trial. Cancer, 121(11), 1873–1881. https://doi.org/10.1002/cncr.29076

Wang, X., et al. (2020). Prognostic value of depression and anxiety on breast cancer recurrence and mortality: a systematic review and meta-analysis of 282,203 patients. Molecular psychiatry, 25(12), 3186–3197. https://doi.org/10.1038/s41380-020-00865-6