{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,24]],"date-time":"2026-10-24T01:39:54Z","timestamp":1792805994385,"version":"4.5.0"},"reference-count":53,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2021,7,15]],"date-time":"2021-07-15T00:00:00Z","timestamp":1626307200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"United States Department of Veterans Affairs Health Services Research &amp; Development Service of the VA Office of Research and Development","award":["Merit review award number 1I21HX003268-01A1"],"award-info":[{"award-number":["Merit review award number 1I21HX003268-01A1"]}],"id":[{"id":"https:\/\/ror.org\/011qyt180","id-type":"ROR","asserted-by":"crossref"}]},{"DOI":"10.13039\/100008231","name":"Arkansas Biosciences Institute","doi-asserted-by":"publisher","award":["Arkansas Tobacco Settlement Proceeds Act of 2000"],"award-info":[{"award-number":["Arkansas Tobacco Settlement Proceeds Act of 2000"]}],"id":[{"id":"10.13039\/100008231","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Thyroid disease is a very common condition that influences the entire human body, including cognitive function and mental health. As a result, thyroid disease has been associated with multiple neuropsychiatric conditions. However, the relationship between thyroid dysfunction and suicide is still controversial. We conducted a systematic review and meta-analysis to describe the association of thyroid function with suicidal behavior in adults. We searched four data bases (MEDLINE, EMBASE, PsycINFO, and Scopus) from their inception to 20 July 2018. Studies that reported mean values and standard deviation (SD) of thyroid hormone levels [Thyroid-stimulating hormone (TSH), free thyroxine (FT4), free triiodothyronine (FT3), total thyroxine (TT4), and total triiodothyronine (TT3)] in patients with suicidal behavior compared with controls were included in this meta-analysis. The abstracts and papers retrieved with our search strategies were reviewed independently and in duplicate by four reviewers for assessment of inclusion criteria and data extraction, as well as for evaluation of risk of bias. Random-effects models were used in this meta-analysis to establish the mean difference on thyroid function tests between groups. Overall, 2278 articles were identified, and 13 studies met the inclusion criteria. These studies involved 2807 participants, including 826 participants identified with suicidal behavior. We found that patients with suicide behavior had lower levels of FT3 (\u22120.20 pg\/mL; p = 0.02) and TT4 (\u22120.23 \u00b5g\/dL; p = 0.045) compared to controls. We found no differences in either TSH, FT4, or TT3 levels among groups. With our search strategy, we did not identify studies with a comparison of overt\/subclinical thyroid disease prevalence between patients with and without suicide behavior. The studies included in this meta-analysis had a low-to-moderate risk of bias. In the available literature, the evidence regarding the association of thyroid disorders and suicidal behavior is limited. We found that patients with suicidal behavior have significantly lower mean FT3 and TT4 levels when compared to patients without suicidal behavior. The clinical implications and pathophysiologic mechanisms of these differences remain unknown and further research is needed.<\/jats:p>","DOI":"10.3390\/medicina57070714","type":"journal-article","created":{"date-parts":[[2021,7,15]],"date-time":"2021-07-15T09:32:07Z","timestamp":1626341527000},"page":"714","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":38,"title":["Association of Thyroid Function with Suicidal Behavior: A Systematic Review and Meta-Analysis"],"prefix":"10.3390","volume":"57","author":[{"given":"Freddy J. K.","family":"Toloza","sequence":"first","affiliation":[{"name":"Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA"},{"name":"Knowledge and Evaluation Research Unit in Endocrinology (KER_Endo), Mayo Clinic, Rochester, MN 55902, USA"},{"name":"Department of Medicine, MetroWest Medical Center, Tufts Medical School, Framingham, MA 01702, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuanjie","family":"Mao","sequence":"additional","affiliation":[{"name":"Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lakshmi","family":"Menon","sequence":"additional","affiliation":[{"name":"Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gemy","family":"George","sequence":"additional","affiliation":[{"name":"Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Madhura","family":"Borikar","sequence":"additional","affiliation":[{"name":"Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Soumya","family":"Thumma","sequence":"additional","affiliation":[{"name":"Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hooman","family":"Motahari","sequence":"additional","affiliation":[{"name":"Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patricia","family":"Erwin","sequence":"additional","affiliation":[{"name":"Mayo Clinic Libraries, Mayo Clinic, Rochester, MN 55902, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard","family":"Owen","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA"},{"name":"Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR 72205, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Spyridoula","family":"Maraka","sequence":"additional","affiliation":[{"name":"Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA"},{"name":"Knowledge and Evaluation Research Unit in Endocrinology (KER_Endo), Mayo Clinic, Rochester, MN 55902, USA"},{"name":"Central Arkansas Veterans Healthcare System, Medicine Service, Little Rock, AR 72205, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,7,15]]},"reference":[{"key":"ref_1","unstructured":"WHO (2020, December 10). Suicide. Available online: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/suicide."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Bachmann, S. (2018). Epidemiology of Suicide and the Psychiatric Perspective. Int. J. Environ. Res. Public Health, 15.","DOI":"10.3390\/ijerph15071425"},{"key":"ref_3","unstructured":"ATA (2020, December 10). General Information\/Press Room. Available online: https:\/\/www.thyroid.org\/media-main\/press-room\/."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1211","DOI":"10.1089\/thy.2006.0235","article-title":"Serum TSH and total T4 in the United States population and their association with participant characteristics: National Health and Nutrition Examination Survey (NHANES 1999\u20132002)","volume":"17","author":"Aoki","year":"2007","journal-title":"Thyroid"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"526","DOI":"10.1001\/archinte.160.4.526","article-title":"The Colorado Thyroid Disease Prevalence Study","volume":"160","author":"Canaris","year":"2000","journal-title":"Arch. Intern. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"911","DOI":"10.1176\/ajp.142.8.911","article-title":"Diagnostic categorization of psychiatric disturbance in Cushing\u2019s syndrome","volume":"142","author":"Haskett","year":"1985","journal-title":"Am. J. Psychiatry"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"129","DOI":"10.3389\/fnins.2015.00129","article-title":"Neuropsychiatric disorders in Cushing\u2019s syndrome","volume":"9","author":"Pivonello","year":"2015","journal-title":"Front. Neurosci."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1951","DOI":"10.1210\/jc.2008-2574","article-title":"Neuropsychological features in primary hyperparathyroidism: A prospective study","volume":"94","author":"Walker","year":"2009","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1349","DOI":"10.1210\/jc.2017-01698","article-title":"Subclinical Changes in Maternal Thyroid Function Parameters in Pregnancy and Fetal Growth","volume":"103","author":"Johns","year":"2018","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"616","DOI":"10.1007\/s12020-019-01946-5","article-title":"Death by unnatural causes, mainly suicide, is increased in patients with Hashimoto\u2019s thyroiditis. A nationwide Danish register study","volume":"65","author":"Thvilum","year":"2019","journal-title":"Endocrine"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"180","DOI":"10.1016\/j.jad.2019.08.067","article-title":"Association of thyroid dysfunction with suicide attempts in first-episode and drug na\u00efve patients with major depressive disorder","volume":"259","author":"Shen","year":"2019","journal-title":"J. Affect. Disord."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1001","DOI":"10.1089\/thy.2017.0063","article-title":"Hyperthyroidism, Hypothyroidism, and Cause-Specific Mortality in a Large Cohort of Women","volume":"27","author":"Journy","year":"2017","journal-title":"Thyroid"},{"key":"ref_13","unstructured":"Wells, G.A., Shea, B., O\u2019Connell, D., Peterson, J., Welch, V., and Losos, M. (2020, December 10). The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomized Studies Inmeta-Analyses. Available online: www.ohri.ca\/programs\/clinical_epidemiology\/oxford.asp."},{"key":"ref_14","unstructured":"Cochrane Training (2020, December 10). Cochrane Handbook for Systematic Reviews of Interventions: June 2017: Handbook Editors\u2019 Update. Available online: http:\/\/training.cochrane.org\/handbook."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"629","DOI":"10.1136\/bmj.315.7109.629","article-title":"Bias in meta-analysis detected by a simple, graphical test","volume":"315","author":"Egger","year":"1997","journal-title":"BMJ"},{"key":"ref_16","unstructured":"CLARITY Group at McMaster University (2020, December 10). Tools to Assess Risk of Bias in Cohort and Case Control Studies; Randomized Controlled Trials; and Longitudinal Symptom Research Studies Aimed at the General Population. Available online: http:\/\/www.evidencepartners.com\/resources\/."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1016\/j.pnpbp.2014.01.018","article-title":"Serum lipids, recent suicide attempt and recent suicide status in patients with major depressive disorder","volume":"51","author":"Baek","year":"2014","journal-title":"Prog. Neuropsychopharmacol. Biol. Psychiatry"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1017\/S146114579900139X","article-title":"Serum thyroid-stimulating-hormone concentration as an index of severity of major depression","volume":"2","author":"Berlin","year":"1999","journal-title":"Int. J. Neuropsychopharmacol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"S32","DOI":"10.1016\/j.euroneuro.2017.12.055","article-title":"WITHDRAWN: P.2.016 Thyroid axis functioning in patients with high suicide risk","volume":"28","year":"2018","journal-title":"Eur. Neuropsychopharmacol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1045","DOI":"10.1016\/j.psyneuen.2010.01.005","article-title":"Thyroid axis activity and suicidal behavior in depressed patients","volume":"35","author":"Duval","year":"2010","journal-title":"Psychoneuroendocrinology"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"100","DOI":"10.1016\/j.psyneuen.2017.07.488","article-title":"Relationship between chronobiological thyrotropin and prolactin responses to protirelin (TRH) and suicidal behavior in depressed patients","volume":"85","author":"Duval","year":"2017","journal-title":"Psychoneuroendocrinology"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1016\/j.cca.2015.02.003","article-title":"Association between prolactin and thyroid hormones with severity of psychopathology and suicide risk in drug free male schizophrenia","volume":"444","author":"Jose","year":"2015","journal-title":"Clin. Chim. Acta."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1016\/j.jad.2008.02.001","article-title":"HPT axis, CSF monoamine metabolites, suicide intent and depression severity in male suicide attempters","volume":"111","author":"Jokinen","year":"2008","journal-title":"J. Affect. Disord."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1590\/0101-60830000000147","article-title":"Changes in thyroid function status of suicidal patients","volume":"45","author":"Khurshid","year":"2018","journal-title":"Arch. Clin. Psychiatry"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"951","DOI":"10.1016\/j.psychres.2013.08.057","article-title":"Follicle-stimulating hormone (FSH), current suicidal ideation and attempt in female patients with major depressive disorder","volume":"210","author":"Kim","year":"2013","journal-title":"Psychiatry Res."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1111\/j.1600-0447.1989.tb01294.x","article-title":"Hypothalamic-pituitary-adrenal and -thyroid axis dysfunctions and decrements in the availability of L-tryptophan as biological markers of suicidal ideation in major depressed females","volume":"80","author":"Maes","year":"1989","journal-title":"Acta Psychiatr. Scand."},{"key":"ref_27","first-page":"278","article-title":"Thyroxin Levels Associated with Current Suicide Attempts: A Case Control and Follow-Up Study. Klinik Psikofarmakoloji B\u00fclteni-Bulletin of Clinical","volume":"26","author":"Ozcan","year":"2016","journal-title":"Psychopharmacology"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"389","DOI":"10.1016\/j.psychres.2012.05.010","article-title":"Prolactin and thyroid hormone levels are associated with suicide attempts in psychiatric patients","volume":"200","author":"Pompili","year":"2012","journal-title":"Psychiatry Res."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1016\/j.psychres.2018.05.059","article-title":"Low serum free thyroxine level is correlated with lipid profile in depressive patients with suicide attempt","volume":"266","author":"Peng","year":"2018","journal-title":"Psychiatry Res."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"271","DOI":"10.1590\/S0047-20852011000400007","article-title":"Comorbidades cl\u00ednicas e psiqui\u00e1tricas em pacientes com transtorno bipolar do tipo I","volume":"60","author":"Barbosa","year":"2011","journal-title":"J. Bras. Psiquiatria"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1016\/j.jad.2013.10.008","article-title":"Suicidal ideation and physical illness: Does the link lie with depression?","volume":"152\u2013154","author":"Sanna","year":"2014","journal-title":"J. Affect. Disord."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"437","DOI":"10.1530\/EJE-08-0749","article-title":"Hyperthyroidism and suicide: A retrospective cohort study in Sweden","volume":"160","author":"Lonn","year":"2009","journal-title":"Eur. J. Endocrinol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1475","DOI":"10.1089\/thy.2017.0365","article-title":"Death by Suicide in Graves\u2019 Disease and Graves\u2019 Orbitopathy: A Nationwide Danish Register Study","volume":"27","author":"Brix","year":"2017","journal-title":"Thyroid"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"R169","DOI":"10.1530\/EJE-16-0952","article-title":"Management of Endocrine Disease: Suicide risk in patients with diabetes: A systematic review and meta-analysis","volume":"177","author":"Wang","year":"2017","journal-title":"Eur. J. Endocrinol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"2158","DOI":"10.1002\/ibd.21298","article-title":"Inflammatory bowel disease and completed suicide in Danish adults","volume":"16","author":"Gradus","year":"2010","journal-title":"Inflamm. Bowel. Dis."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1016\/j.bbi.2014.03.008","article-title":"Cognitive and affective dysfunctions in autoimmune thyroiditis","volume":"41","author":"Leyhe","year":"2014","journal-title":"Brain Behav. Immun."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"577","DOI":"10.1001\/jamapsychiatry.2018.0190","article-title":"Association of Depression and Anxiety Disorders With Autoimmune Thyroiditis: A Systematic Review and Meta-analysis","volume":"75","author":"Siegmann","year":"2018","journal-title":"JAMA Psychiatry"},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Loh, H.H., Lim, L.L., Yee, A., and Loh, H.S. (2019). Association between subclinical hypothyroidism and depression: An updated systematic review and meta-analysis. BMC Psychiatry, 19.","DOI":"10.1186\/s12888-018-2006-2"},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Fountoulakis, K.N., Iacovides, A., Grammaticos, P., St Kaprinis, G., and Bech, P. (2004). Thyroid function in clinical subtypes of major depression: An exploratory study. BMC Psychiatry, 4.","DOI":"10.1186\/1471-244X-4-6"},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Carta, M.G., Loviselli, A., Hardoy, M.C., Massa, S., Cadeddu, M., and Sardu, C. (2004). The link between thyroid autoimmunity (antithyroid peroxidase autoantibodies) with anxiety and mood disorders in the community: A field of interest for public health in the future. BMC Psychiatry, 4.","DOI":"10.1186\/1471-244X-4-25"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"779","DOI":"10.1002\/gps.2260","article-title":"Increased occurrence of severe episodes in elderly depressed patients with elevated anti-thyroid antibody levels","volume":"24","author":"Leyhe","year":"2009","journal-title":"Int. J. Geriatr. Psychiatry"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1016\/S0006-3223(01)01217-3","article-title":"High rate of autoimmune thyroiditis in bipolar disorder: Lack of association with lithium exposure","volume":"51","author":"Kupka","year":"2002","journal-title":"Biol. Psychiatry"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1016\/S0165-0327(96)01426-7","article-title":"Hypothalamic-pituitary-thyroid-axis function in treatment resistant depression","volume":"43","author":"Vandoolaeghe","year":"1997","journal-title":"J. Affect. Disord."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1055\/s-2007-1017278","article-title":"Hormones of the hypothalamic-pituitary-thyroid axis: A psychoneuroendocrine perspective","volume":"19","author":"Loosen","year":"1986","journal-title":"Pharmacopsychiatry"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"590648","DOI":"10.1155\/2012\/590648","article-title":"The Link between Thyroid Function and Depression","volume":"2012","author":"Hage","year":"2012","journal-title":"J. Thyroid. Res."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1406","DOI":"10.1016\/j.jpsychires.2012.08.009","article-title":"The combination of triiodothyronine (T3) and sertraline is not superior to sertraline monotherapy in the treatment of major depressive disorder","volume":"46","author":"Garlow","year":"2012","journal-title":"J. Psychiatr. Res."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1016\/j.jad.2008.09.022","article-title":"Long term augmentation with T3 in refractory major depression","volume":"115","author":"Kelly","year":"2009","journal-title":"J. Affect. Disord."},{"key":"ref_48","first-page":"24","article-title":"Liothyronine for Depression: A Review and Guidance for Safety Monitoring","volume":"14","author":"Touma","year":"2017","journal-title":"Innov. Clin. Neurosci."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1001\/archpsyc.64.6.679","article-title":"Combined treatment with sertraline and liothyronine in major depression: A randomized, double-blind, placebo-controlled trial","volume":"64","author":"Apter","year":"2007","journal-title":"Arch. Gen. Psychiatry"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"1305","DOI":"10.1176\/appi.ajp.2009.10030434","article-title":"Linking molecules to mood: New insight into the biology of depression","volume":"167","author":"Krishnan","year":"2010","journal-title":"Am. J. Psychiatry"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"185","DOI":"10.1530\/eje.1.01828","article-title":"Thyroid and adrenal axis in major depression: A controlled study in outpatients","volume":"152","author":"Brouwer","year":"2005","journal-title":"Eur. J. Endocrinol."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"695","DOI":"10.1016\/S0306-4530(99)00022-0","article-title":"Thyroid axis activity and serotonin function in major depressive episode","volume":"24","author":"Duval","year":"1999","journal-title":"Psychoneuroendocrinology"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"951","DOI":"10.1089\/thy.1998.8.951","article-title":"The Thyroid Axis and Depression","volume":"8","author":"Jackson","year":"1998","journal-title":"Thyroid"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/57\/7\/714\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T06:30:54Z","timestamp":1760164254000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/57\/7\/714"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,7,15]]},"references-count":53,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2021,7]]}},"alternative-id":["medicina57070714"],"URL":"https:\/\/doi.org\/10.3390\/medicina57070714","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,7,15]]}}}