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Early Intervention in Psychiatry 2015; ••: ••–••
doi:10.1111/eip.12208
Original Article Gender differences in patients with first-episode psychosis in the Singapore Early Psychosis Intervention Programme Shirlene Pang,1 Mythily Subramaniam,1 Edimansyah Abdin,1 Lye Yin Poon,2 Siow Ann Chong1 and Swapna Verma2 Abstract Aims: This study aimed to identify the gender differences among multiethnic, Asian patients with firstepisode psychosis attending the Early Psychosis Intervention Programme (EPIP) in Singapore.
1 Research Division and 2Department of Early Psychosis Intervention, Institute of Mental Health, Singapore
Corresponding author: Ms Shirlene Pang, Research Division, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, 539747, Singapore. Email: [email protected] Received 20 August 2014; accepted 9 November 2014
Methods: Data for this study were derived from 533 (258 female, 275 male) patients aged 16–41 years old in the EPIP database. Sociodemographic data, Positive and Negative Syndrome Scale for schizophrenia (PANSS) and Global Assessment of Functioning (GAF) scores at baseline, 3 months, 6 months and 1 year were obtained.
Conclusions: Overall, female participants in this sample show better improvement than male participants. They showed a better course of illness over 1 year with one-third (33.3%) of female participants achieving recovery compared with approximately a quarter (23.6%) of male participants.
Results: Significant gender differences were identified in terms of age,
Key words: early intervention, early psychosis, first-episode psychosis, gender difference, remission.
INTRODUCTION In recent decades, research into gender differences in schizophrenia and first-episode psychosis (FEP) has been extensive. Gender effects have been reported in many studies across the world in multiple features, including age of onset, response to treatment, duration of untreated psychosis (DUP), functioning and course of illness.1,2 The literature reports that gender differences in patients with FEP are similar to those with chronic schizophrenia.1 For example, men appear to have poorer functioning overall compared with women, although women report lower self-esteem.3 Such findings add to our understanding of the psychopathology and course of illness of FEP, as well as schizo© 2015 Wiley Publishing Asia Pty Ltd
marital status, referral source, PANSS scores, GAF scores, remission and recovery over 1 year in the cohort. At service entry, female participants were older, more likely to be married and more likely to be referred from general practitioner/polyclinics (P < 0.0001). They showed better improvement over 1 year in PANSS positive, PANSS total, GAF disability and GAF total scores.
phrenia. In turn, they can help to inform the course of treatment and development of programmes targeted at patients suffering from FEP. This is especially important as early treatment of psychosis is strongly correlated with faster and better recovery.4 Many studies that find gender differences propose that gender-specific interventions could be developed to optimize outcome for these patients.5 However, the findings are not always consistent. For example, DUP plays a key role in patient outcome6 and has been studied extensively. Some studies suggest that men have longer DUP than women and perhaps, as a result, have poorer outcome.7,8 Køster et al. dissimilarly found women having a longer DUP than men in their sample.9 Cotton et al.5 found women having an earlier age of onset, whereas a 1
Gender differences in first-episode psychosis review by Leung and Chue10 found the opposite. Reviews and meta-analyses suggest that there are some trends in gender differences, but with studies reporting such contradictory findings, the results are inconclusive. Despite the extensive research, little research has been conducted in Asian countries. Cascio et al. suggested that there are differences found in Western and non-Western samples of patients with FEP.11 Singapore, being a multi-ethnic island state in South East Asia, provides an interesting sample which has yet to be explored. This article aims to investigate these gender differences in FEP from a sample of patients attending the Singapore Early Prevention Intervention Programme (EPIP). Gender effects were compared across socio-demographic factors, remission rates, recovery rates and course of illness in order to explore the research aim. We hypothesized that there would be significant gender differences in the presentation to the clinical programme and subsequent outcomes with female participants having better remission and recovery. The results of the analyses are discussed in comparison to findings from previous studies in other countries.
months and 1 year after. The inter-rater reliability for the PANSS scale was assessed to be 0.94. At baseline, basic socio-demographic data were obtained from all participants as well as diagnosis of illness, referral source and duration of untreated psychosis (DUP). Clinical data obtained were Positive and Negative Syndrome Scale for schizophrenia (PANSS) score,13 as a measure of symptom severity, and the Global Assessment of Functioning (GAF) score,14 as a measure of functioning. The Structured Clinical Interviews for DSM-IV (SCID clinical version) was used to diagnose patients. DUP was operationalized as the time in months between onset of psychotic symptoms and the time when a definitive diagnosis and treatment was established. Both the patients and the primary caregivers were interviewed in order to obtain information about the date of onset of psychotic symptoms. DUP was estimated after combining information from the interviews and case records. Patients with all diagnoses were included in the analyses as a previous study15 has shown that the diagnostic stability over 2 years is variable in patients with FEP. Data analysis
METHOD Subjects EPIP was established in April 2001 and is a patientcentred programme that aims to help patients with FEP. The programme manages patients for 2 years using psychopharmacological management based on a treatment algorithm that emphasizes the use of antipsychotic monotherapy at low dose. Each patient is assigned to a case manager and is referred for further intervention with a psychologist or occupational therapist as and when needed.12 Included in the analysis were 533 patients (female = 258) who were accepted into EPIP from April 2007 to April 2011 and completed a 2-year follow-up. As part of the inclusion criteria of EPIP, all but one of the participants in this sample were aged between 15 and 40 years, had first-episode psychotic disorder with no prior or minimal treatment (less than 12 weeks of treatment), with no substance-induced psychosis nor history of major medical or neurological illness. Data collection All data collection and clinical assessments were conducted by trained EPIP psychiatrists and case managers to obtain data at baseline, 3 months, 6 2
Recovery was calculated according to the criteria used by Verma et al.16 and was based upon symptomatic remission, functional remission and achieving age-appropriate vocation. Symptomatic remission was defined as having a rating of 3 or less on eight PANSS items for at least 6 months.17 Functional remission was defined as having a GAF score of 61 and above. Age-appropriate vocation was defined as having gainful employment or studying depending upon the age of the individual. All statistical analyses were conducted using SAS version 9.2.: SAS Institute Inc, 2011. Cary, NC, USA. Sociodemographic data from the two groups were compared using t-tests for continuous variables and chisquare tests for categorical variables. Effect sizes were calculated using Cohen’s d (d) for continuous variable and odds ratio (OR) for categorical variable outcomes. We used a mixed-effects model to compare the changes in continuous outcomes between male and female patients over 1-year follow-up. As there were limited data at 2 years after baseline, analysis was only conducted on data for the first year of management. We also performed multiple logistic regression adjusted for age and ethnicity in order to determine whether categorical outcomes at the 1-year follow-up were significantly different between male and female patients. Statistical significance was set at P-value < 0.05. © 2015 Wiley Publishing Asia Pty Ltd
S. Pang et al. RESULTS Data are shown in Table 1. The age range for the sample included in the analysis was 16–41 years. The main diagnosis was schizophrenia spectrum disorders (i.e. schizophrenia, schizophreniform and schizoaffective; 72.8%), and the second most common diagnosis was brief psychotic episode (8.3%). At baseline, the range of scores varied from 16 to 70 for PANSS general psychopathology from 7 to 49 for PANSS negative, from 7 to 42 for PANSS positive, from 31 to 130 for PANSS total, from 1 to 88 for GAF disability, from 11 to 85 for GAF symptoms and from 5 to 80 for GAF total scores. Differences in socio-demographics DUP was not significantly different between genders in this sample. However, significant gender differences were identified in terms of age, marital status and referral sources in the cohort. Female participants were older at service entry, averaging 28.8 years old (standard deviation (SD) = 6.5), as compared to male participants who averaged 26.8 years old (SD = 6.2) (d = 0.32; P < 0.0001). More female participants were married (OR = 3.63) or divorced (OR = 7.4), whereas male participants were more likely to be single or unmarried (OR = 3.63) (=33.6; P < 0.0001). As compared to hospital, general practitioners, polyclinics (OR = 1.51) and relatives (OR = 1.43) were more likely to be a referral source for female participants (OR = 48.5; P < 0.0001). Male participants were more likely to be referred from other sources, typically from the National Service (i.e. conscription) (OR = 19.39) in Singapore. There was no gender difference in the diagnoses of patients in the sample (Table 1). Differences in remission and recovery At baseline, male participants had worse PANSS general psychopathology (d = 0.17; P < 0.05) scores. There was no significant difference between male and female participants for PANSS negative and positive scores. There was also no significant difference in GAF scores at baseline (Table 1). However, at 3 months after entry into the service, female participants appear to have significantly better improvement in various measures as compared to male participants. These include PANSS negative (d = 0.22; P < 0.05), PANSS positive (d = 0.36; P < 0.05), PANSS total (d = 0.29; P < 0.01) and all GAF scores (disability: d = 0.34, P < 0.001; symptoms: (d = 0.25; P < 0.05; total: (d = 0.27; P < 0.01). © 2015 Wiley Publishing Asia Pty Ltd
At 1 year, female participants had better scores in PANSS negative (d = 0.23; P < 0.05), PANSS total (d = 0.18; P < 0.05) and GAF disability (d = 0.21; P < 0.01) scores. Overall, female participants in the cohort showed better improvement over 1 year in PANSS general psychopathology (d = 0.66; P = 0.0003; see Fig. 1), PANSS positive (d = 0.54; P = 0.0005; see Fig. 2), PANSS total (d = 0.80; P = 0.0002), GAF disability (d = 0.64; P < 0.0001; see Fig. 3) and GAF total (d = 0.51; P < 0.05) scores. After controlling for age and ethnicity, there was no significant gender difference in symptomatic remission (OR = 1.43; P = 0.053). However, 137 female participants reached functional remission based upon GAF scores (53.1%) as compared to 112 male participants (40.7%; OR = 1.77; P = 0.002). As for achieving age-appropriate employment/ studying, 167 female participants (73.9%) also met these criteria for recovery at 1 year as opposed to 150 male participants (64.7%; OR = 1.69; P = 0.013) (Table 2). Significantly more female participants had achieved recovery (OR = 1.70; P = 0.008) at the 1-year follow-up. One-third of female participants (33.3%) achieved recovery as compared to nearly a quarter of male participants (23.6%) in the sample.
DISCUSSION The results showed few gender differences in sociodemographics in the EPIP sample. There were differences in age, marital status and referral sources. There were also differences in PANSS and GAF scores over time. Female participants show slightly better improvement in symptoms, functional remission and recovery compared with male participants who attended the programme. As with all studies on FEP gender differences, some of the results are consistent with previous findings, whereas others are not. Unfortunately, the information collected in the database does not include some variables, which could have been interesting to explore and could shed light on explaining the gender differences in the sample. Halbreich and Kahn argued that men are less compliant to medication due to hormonal side-effects of antipsychotic drugs such as sexual symptoms.18 Thorup et al. found that women in their sample were more compliant with treatment, which may have influenced their recovery.19 Women may also have a greater buildup of antipsychotics due to their better storing of lipophilic antipsychotics.1 Combined with the arguably protective factor of oestrogen on 3
Gender differences in first-episode psychosis TABLE 1. Socio-demographic and clinical data of the sample (n = 533) N
%
Female N
Gender Male Female Race Chinese Malay Indian Marital status Single/Unmarried Married Separated Divorced Highest education level No education Primary school Secondary school Pre-University Tertiary Vocational education Others Employment status Paid or self-employment Sheltered employment Unemployed Student Homemaker Others Diagnosis Schizophrenia spectrum (schizophrenia, schizophreniform and schizoaffective) Bipolar (with or without psychotic features) Delusional disorder Brief psychotic disorder Psychosis (not otherwise specified) Depression (with psychotic features) Others Referral source Hospital GP/Polyclinic Private psychiatrist Police Court Relatives Friends Welfare organization/School counsellor Self Others
Age DUP since onset of symptoms (in months) Baseline PANSS GPS Baseline PANSS Negative Baseline PANSS Positive Baseline PANSS Total Baseline GAF Disability Baseline GAF Symptoms Baseline GAF Total
Male %
N
– –
d.f.
Chi-square
P-value
– –
– –
– –
– –
%
275 258
51.59 48.41
– –
– –
411 78 44
77.11 14.63 8.26
194 42 22
75.2 16.3 8.5
217 36 22
78.9 13.1 8.0
2 – –
1.2 – –
0.547 – –
427 85 6 13
80.41 16.01 1.13 2.45
182 62 2 11
70.8 24.1 0.8 4.3
245 23 4 2
89.4 8.4 1.5 0.7
3 – – –
33.6 – – –
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Early Intervention in Psychiatry 2015; ••: ••–••
doi:10.1111/eip.12208
Original Article Gender differences in patients with first-episode psychosis in the Singapore Early Psychosis Intervention Programme Shirlene Pang,1 Mythily Subramaniam,1 Edimansyah Abdin,1 Lye Yin Poon,2 Siow Ann Chong1 and Swapna Verma2 Abstract Aims: This study aimed to identify the gender differences among multiethnic, Asian patients with firstepisode psychosis attending the Early Psychosis Intervention Programme (EPIP) in Singapore.
1 Research Division and 2Department of Early Psychosis Intervention, Institute of Mental Health, Singapore
Corresponding author: Ms Shirlene Pang, Research Division, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, 539747, Singapore. Email: [email protected] Received 20 August 2014; accepted 9 November 2014
Methods: Data for this study were derived from 533 (258 female, 275 male) patients aged 16–41 years old in the EPIP database. Sociodemographic data, Positive and Negative Syndrome Scale for schizophrenia (PANSS) and Global Assessment of Functioning (GAF) scores at baseline, 3 months, 6 months and 1 year were obtained.
Conclusions: Overall, female participants in this sample show better improvement than male participants. They showed a better course of illness over 1 year with one-third (33.3%) of female participants achieving recovery compared with approximately a quarter (23.6%) of male participants.
Results: Significant gender differences were identified in terms of age,
Key words: early intervention, early psychosis, first-episode psychosis, gender difference, remission.
INTRODUCTION In recent decades, research into gender differences in schizophrenia and first-episode psychosis (FEP) has been extensive. Gender effects have been reported in many studies across the world in multiple features, including age of onset, response to treatment, duration of untreated psychosis (DUP), functioning and course of illness.1,2 The literature reports that gender differences in patients with FEP are similar to those with chronic schizophrenia.1 For example, men appear to have poorer functioning overall compared with women, although women report lower self-esteem.3 Such findings add to our understanding of the psychopathology and course of illness of FEP, as well as schizo© 2015 Wiley Publishing Asia Pty Ltd
marital status, referral source, PANSS scores, GAF scores, remission and recovery over 1 year in the cohort. At service entry, female participants were older, more likely to be married and more likely to be referred from general practitioner/polyclinics (P < 0.0001). They showed better improvement over 1 year in PANSS positive, PANSS total, GAF disability and GAF total scores.
phrenia. In turn, they can help to inform the course of treatment and development of programmes targeted at patients suffering from FEP. This is especially important as early treatment of psychosis is strongly correlated with faster and better recovery.4 Many studies that find gender differences propose that gender-specific interventions could be developed to optimize outcome for these patients.5 However, the findings are not always consistent. For example, DUP plays a key role in patient outcome6 and has been studied extensively. Some studies suggest that men have longer DUP than women and perhaps, as a result, have poorer outcome.7,8 Køster et al. dissimilarly found women having a longer DUP than men in their sample.9 Cotton et al.5 found women having an earlier age of onset, whereas a 1
Gender differences in first-episode psychosis review by Leung and Chue10 found the opposite. Reviews and meta-analyses suggest that there are some trends in gender differences, but with studies reporting such contradictory findings, the results are inconclusive. Despite the extensive research, little research has been conducted in Asian countries. Cascio et al. suggested that there are differences found in Western and non-Western samples of patients with FEP.11 Singapore, being a multi-ethnic island state in South East Asia, provides an interesting sample which has yet to be explored. This article aims to investigate these gender differences in FEP from a sample of patients attending the Singapore Early Prevention Intervention Programme (EPIP). Gender effects were compared across socio-demographic factors, remission rates, recovery rates and course of illness in order to explore the research aim. We hypothesized that there would be significant gender differences in the presentation to the clinical programme and subsequent outcomes with female participants having better remission and recovery. The results of the analyses are discussed in comparison to findings from previous studies in other countries.
months and 1 year after. The inter-rater reliability for the PANSS scale was assessed to be 0.94. At baseline, basic socio-demographic data were obtained from all participants as well as diagnosis of illness, referral source and duration of untreated psychosis (DUP). Clinical data obtained were Positive and Negative Syndrome Scale for schizophrenia (PANSS) score,13 as a measure of symptom severity, and the Global Assessment of Functioning (GAF) score,14 as a measure of functioning. The Structured Clinical Interviews for DSM-IV (SCID clinical version) was used to diagnose patients. DUP was operationalized as the time in months between onset of psychotic symptoms and the time when a definitive diagnosis and treatment was established. Both the patients and the primary caregivers were interviewed in order to obtain information about the date of onset of psychotic symptoms. DUP was estimated after combining information from the interviews and case records. Patients with all diagnoses were included in the analyses as a previous study15 has shown that the diagnostic stability over 2 years is variable in patients with FEP. Data analysis
METHOD Subjects EPIP was established in April 2001 and is a patientcentred programme that aims to help patients with FEP. The programme manages patients for 2 years using psychopharmacological management based on a treatment algorithm that emphasizes the use of antipsychotic monotherapy at low dose. Each patient is assigned to a case manager and is referred for further intervention with a psychologist or occupational therapist as and when needed.12 Included in the analysis were 533 patients (female = 258) who were accepted into EPIP from April 2007 to April 2011 and completed a 2-year follow-up. As part of the inclusion criteria of EPIP, all but one of the participants in this sample were aged between 15 and 40 years, had first-episode psychotic disorder with no prior or minimal treatment (less than 12 weeks of treatment), with no substance-induced psychosis nor history of major medical or neurological illness. Data collection All data collection and clinical assessments were conducted by trained EPIP psychiatrists and case managers to obtain data at baseline, 3 months, 6 2
Recovery was calculated according to the criteria used by Verma et al.16 and was based upon symptomatic remission, functional remission and achieving age-appropriate vocation. Symptomatic remission was defined as having a rating of 3 or less on eight PANSS items for at least 6 months.17 Functional remission was defined as having a GAF score of 61 and above. Age-appropriate vocation was defined as having gainful employment or studying depending upon the age of the individual. All statistical analyses were conducted using SAS version 9.2.: SAS Institute Inc, 2011. Cary, NC, USA. Sociodemographic data from the two groups were compared using t-tests for continuous variables and chisquare tests for categorical variables. Effect sizes were calculated using Cohen’s d (d) for continuous variable and odds ratio (OR) for categorical variable outcomes. We used a mixed-effects model to compare the changes in continuous outcomes between male and female patients over 1-year follow-up. As there were limited data at 2 years after baseline, analysis was only conducted on data for the first year of management. We also performed multiple logistic regression adjusted for age and ethnicity in order to determine whether categorical outcomes at the 1-year follow-up were significantly different between male and female patients. Statistical significance was set at P-value < 0.05. © 2015 Wiley Publishing Asia Pty Ltd
S. Pang et al. RESULTS Data are shown in Table 1. The age range for the sample included in the analysis was 16–41 years. The main diagnosis was schizophrenia spectrum disorders (i.e. schizophrenia, schizophreniform and schizoaffective; 72.8%), and the second most common diagnosis was brief psychotic episode (8.3%). At baseline, the range of scores varied from 16 to 70 for PANSS general psychopathology from 7 to 49 for PANSS negative, from 7 to 42 for PANSS positive, from 31 to 130 for PANSS total, from 1 to 88 for GAF disability, from 11 to 85 for GAF symptoms and from 5 to 80 for GAF total scores. Differences in socio-demographics DUP was not significantly different between genders in this sample. However, significant gender differences were identified in terms of age, marital status and referral sources in the cohort. Female participants were older at service entry, averaging 28.8 years old (standard deviation (SD) = 6.5), as compared to male participants who averaged 26.8 years old (SD = 6.2) (d = 0.32; P < 0.0001). More female participants were married (OR = 3.63) or divorced (OR = 7.4), whereas male participants were more likely to be single or unmarried (OR = 3.63) (=33.6; P < 0.0001). As compared to hospital, general practitioners, polyclinics (OR = 1.51) and relatives (OR = 1.43) were more likely to be a referral source for female participants (OR = 48.5; P < 0.0001). Male participants were more likely to be referred from other sources, typically from the National Service (i.e. conscription) (OR = 19.39) in Singapore. There was no gender difference in the diagnoses of patients in the sample (Table 1). Differences in remission and recovery At baseline, male participants had worse PANSS general psychopathology (d = 0.17; P < 0.05) scores. There was no significant difference between male and female participants for PANSS negative and positive scores. There was also no significant difference in GAF scores at baseline (Table 1). However, at 3 months after entry into the service, female participants appear to have significantly better improvement in various measures as compared to male participants. These include PANSS negative (d = 0.22; P < 0.05), PANSS positive (d = 0.36; P < 0.05), PANSS total (d = 0.29; P < 0.01) and all GAF scores (disability: d = 0.34, P < 0.001; symptoms: (d = 0.25; P < 0.05; total: (d = 0.27; P < 0.01). © 2015 Wiley Publishing Asia Pty Ltd
At 1 year, female participants had better scores in PANSS negative (d = 0.23; P < 0.05), PANSS total (d = 0.18; P < 0.05) and GAF disability (d = 0.21; P < 0.01) scores. Overall, female participants in the cohort showed better improvement over 1 year in PANSS general psychopathology (d = 0.66; P = 0.0003; see Fig. 1), PANSS positive (d = 0.54; P = 0.0005; see Fig. 2), PANSS total (d = 0.80; P = 0.0002), GAF disability (d = 0.64; P < 0.0001; see Fig. 3) and GAF total (d = 0.51; P < 0.05) scores. After controlling for age and ethnicity, there was no significant gender difference in symptomatic remission (OR = 1.43; P = 0.053). However, 137 female participants reached functional remission based upon GAF scores (53.1%) as compared to 112 male participants (40.7%; OR = 1.77; P = 0.002). As for achieving age-appropriate employment/ studying, 167 female participants (73.9%) also met these criteria for recovery at 1 year as opposed to 150 male participants (64.7%; OR = 1.69; P = 0.013) (Table 2). Significantly more female participants had achieved recovery (OR = 1.70; P = 0.008) at the 1-year follow-up. One-third of female participants (33.3%) achieved recovery as compared to nearly a quarter of male participants (23.6%) in the sample.
DISCUSSION The results showed few gender differences in sociodemographics in the EPIP sample. There were differences in age, marital status and referral sources. There were also differences in PANSS and GAF scores over time. Female participants show slightly better improvement in symptoms, functional remission and recovery compared with male participants who attended the programme. As with all studies on FEP gender differences, some of the results are consistent with previous findings, whereas others are not. Unfortunately, the information collected in the database does not include some variables, which could have been interesting to explore and could shed light on explaining the gender differences in the sample. Halbreich and Kahn argued that men are less compliant to medication due to hormonal side-effects of antipsychotic drugs such as sexual symptoms.18 Thorup et al. found that women in their sample were more compliant with treatment, which may have influenced their recovery.19 Women may also have a greater buildup of antipsychotics due to their better storing of lipophilic antipsychotics.1 Combined with the arguably protective factor of oestrogen on 3
Gender differences in first-episode psychosis TABLE 1. Socio-demographic and clinical data of the sample (n = 533) N
%
Female N
Gender Male Female Race Chinese Malay Indian Marital status Single/Unmarried Married Separated Divorced Highest education level No education Primary school Secondary school Pre-University Tertiary Vocational education Others Employment status Paid or self-employment Sheltered employment Unemployed Student Homemaker Others Diagnosis Schizophrenia spectrum (schizophrenia, schizophreniform and schizoaffective) Bipolar (with or without psychotic features) Delusional disorder Brief psychotic disorder Psychosis (not otherwise specified) Depression (with psychotic features) Others Referral source Hospital GP/Polyclinic Private psychiatrist Police Court Relatives Friends Welfare organization/School counsellor Self Others
Age DUP since onset of symptoms (in months) Baseline PANSS GPS Baseline PANSS Negative Baseline PANSS Positive Baseline PANSS Total Baseline GAF Disability Baseline GAF Symptoms Baseline GAF Total
Male %
N
– –
d.f.
Chi-square
P-value
– –
– –
– –
– –
%
275 258
51.59 48.41
– –
– –
411 78 44
77.11 14.63 8.26
194 42 22
75.2 16.3 8.5
217 36 22
78.9 13.1 8.0
2 – –
1.2 – –
0.547 – –
427 85 6 13
80.41 16.01 1.13 2.45
182 62 2 11
70.8 24.1 0.8 4.3
245 23 4 2
89.4 8.4 1.5 0.7
3 – – –
33.6 – – –
