Skip to main content
Mijn bibliotheek
Shop
Nieuws Boeken Tijdschriften E-learning Web-tv Video Audio
Tips voor Mijn BSL
UITGEBREID ZOEKEN
Inloggen
Top
Mindfulness
Gepubliceerd in: Mindfulness 7/2019

14-01-2019 | ORIGINAL PAPER

Specific Facets of Trait Mindfulness Reduce Risk for Alcohol and Drug Use Among First-Year Undergraduate Students

Auteurs: Alanna Single, Elena Bilevicius, Edward A. Johnson, Matthew T. Keough

Gepubliceerd in: Mindfulness | Uitgave 7/2019

Log in om toegang te krijgen
share
DELEN

Deel dit onderdeel of sectie (kopieer de link)

  • Optie A:
    Klik op de rechtermuisknop op de link en selecteer de optie “linkadres kopiëren”
  • Optie B:
    Deel de link per e-mail
    Link delen
publish
Publiceer nu

Abstract

Objectives

The first year of university is associated with the heaviest alcohol and drug use for young adults. Trait mindfulness decreases risk for harmful substance use broadly, but less is known about its protective role against alcohol and drug use during the first year of university. We hypothesized that specific facets of trait mindfulness (acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience) would predict reduced alcohol and drug use among first-year university students. Given that the same facets of trait mindfulness protect against anxiety and depression (i.e., emotional psychopathology), we expected low levels of emotional psychopathology to mediate these effects.

Methods

First-year undergraduates (N = 308) completed online self-reports in a longitudinal study. Facets of trait mindfulness were assessed at the beginning of the semester (Time 1). Emotional psychopathology, alcohol use, and drug use were assessed 4 months later (Time 2).

Results

Results revealed that the acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience facets predicted decreased alcohol and drug use at Time 2 (controlling for Time 1 outcomes). These effects were mediated by low levels of emotional psychopathology.

Conclusions

Our study demonstrates that first-year students who are high in specific facets of trait mindfulness are less likely to experience elevated emotional psychopathology, and in turn, are less likely to engage in harmful alcohol and drug use.
vorige artikel Feasibility Pilot of a Brief Mindfulness Intervention for College Students with Posttraumatic Stress Symptoms and Problem Drinking
volgende artikel A Randomized Controlled Trial of Awareness Training Program (ATP), a Group-Based Mahayana Buddhist Intervention
Literatuur
Arria, A. M., Caldeira, K. M., Bugbee, B. A., Vincent, K. B., & O’Grady, K. E. (2016). Marijuana use trajectories during college predict health outcomes nine years post-matriculation. Drug and Alcohol Dependence, 159, 158–165.CrossRefPubMed
Baer, R. A. (2003). Mindfulness training as a clinical intervention: a conceptual and empirical review. Clinical Psychology: Science and Practice, 10(2), 125–143.
Baer, R. A., Smith, G. T., & Allen, K. B. (2004). Assessment of mindfulness by self-report: the Kentucky inventory of mindfulness skills. Assessment, 11(3), 191–206.CrossRefPubMed
Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13(1), 27–45.CrossRefPubMed
Baer, R. A., Smith, G. T., Lykins, E., Button, D., Krietemeyer, J., Sauer, S., Walsh, E., Duggan, D., & Williams, J. M. (2008). Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment, 15(3), 329–342.CrossRefPubMed
Bajaj, B., Gupta, R., & Pande, N. (2016). Self-esteem mediates the relationship between mindfulness and well-being. Personality and Individual Differences, 94, 96–100.CrossRef
Baker, T. B., Piper, M. E., McCarthy, D. E., Majeskie, M. R., & Fiore, M. C. (2004). Addiction motivation reformulated: an affective processing model of negative reinforcement. Psychological Review, 111(1), 33–51.CrossRefPubMed
Bodenlos, J. A., Noonan, M., & Wells, S. Y. (2013). Mindfulness and alcohol problems in college students: the mediating effects of stress. Journal of American College Health, 61(6), 371–378.CrossRefPubMed
Bohlmeijer, E., ten Klooster, P. M., Fledderus, M., Veehof, M., & Baer, R. (2011). Psychometric properties of the five facet mindfulness questionnaire in depressed adults and development of a short form. Assessment, 18(3), 308–320.CrossRefPubMed
Borsari, B., Murphy, J. G., & Barnett, N. P. (2007). Predictors of alcohol use during the first year of college: implications for prevention. Addictive Behaviors, 32(10), 2062–2086.CrossRefPubMedPubMedCentral
Bowen, S., & Enkema, M. C. (2014). Relationship between dispositional mindfulness and substance use: findings from a clinical sample. Addictive Behaviors, 39, 532–537.CrossRefPubMed
Brière, F. N., Rohde, P., Seeley, J. R., Klein, D., & Lewinsohn, P. M. (2014). Comorbidity between major depression and alcohol use disorder from adolescence to adulthood. Comprehensive Psychiatry, 55(3), 526–533.CrossRefPubMed
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), 822–848.CrossRefPubMed
Brown, S. A., McGue, M., Maggs, J., Schulenberg, J., Hingson, R., Swartzwelder, S., et al. (2008). A developmental perspective on alcohol and youths 16 to 20 years of age. Pediatrics, 121(4), S290–S310.CrossRefPubMed
Calvete, E., Orue, I., & Sampedro, A. (2017). Does the acting with awareness trait of mindfulness buffer the predictive association between stressors and psychological symptoms in adolescents? Personality and Individual Differences, 105(15), 158–163.CrossRef
Carmody, J., & Baer, R. A. (2008). Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. Journal of Behavioral Medicine, 31(1), 23–33.CrossRefPubMed
Cooper, L. M. (1994). Motivations for alcohol use among adolescents: development and validation of a four-factor model. Psychological Assessment, 6(2), 117–128.CrossRef
Costello, E. J., Copeland, W., & Angold, A. (2011). Trends in psychopathology across the adolescent years: what changes when children become adolescents, and when adolescents become adults? Journal of Child Psychology and Psychiatry, 52(10), 1015–1025.CrossRefPubMed
Delgadillo, J., Payne, S., Gilbody, S., Godfrey, C., Gore, S., Jessop, D., & Dale, V. (2012). Brief case finding tools for anxiety disorders: validation of GAD-7 and GAD-2 in addictions treatment. Drug and Alcohol Dependence, 125, 37–42.CrossRefPubMed
Dvořáková, K., Kishida, M., Li, J., Elavsky, S., Broderick, P. C., Agrusti, M. R., & Greenberg, M. T. (2017). Promoting healthy transition to college through mindfulness training with first-year college students: pilot randomized controlled trial. Journal of American College Health, 65(4), 259–267.CrossRefPubMed
Enders, C. K. (2010). Applied missing data analysis. New York: The Guildford Press.
Feldman, G., Hayes, A., Kumar, S., Greeson, J., & Laurenceau, J.-P. (2007). Mindfulness and emotion regulation: the development and initial validation of the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R). Journal of Psychopathology and Behavioral Assessment, 29, 177–190.CrossRef
Fritz, M. S., & MacKinnon, D. P. (2007). Required sample size to detect the mediated effect. Psychological Science, 18, 233–239.CrossRefPubMed
Giluk, T. L. (2009). Mindfulness, big five personality, and affect: a meta-analysis. Personality and Individual Differences, 47, 805–811.CrossRef
Girz, L., Polivy, J., Provencher, V., Wintre, M. G., Pratt, M. W., Pancer, S. M., et al. (2013). The four undergraduate years. Changes in weight, eating attitudes, and depression. Appetite, 69, 145–150.CrossRefPubMed
Grant, V. V., Stewart, S. H., O'Connor, R. M., Blackwell, E., & Conrod, P. J. (2007). Psychometric evaluation of the five-factor Modified Drinking Motives Questionnaire - Revised in undergraduates. Addictive Behaviors, 32(11), 2611–2632.
Grant, B. F., Goldstein, R. B., Saha, T. D., Chou, S. P., Jung, J., Zhang, H., et al. (2015). Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry, 72(8), 757–766.CrossRefPubMedPubMedCentral
Hann, D., Winter, K., & Jacobsen, P. (1999). Measurement of depressive symptoms in cancer patients: evaluation of the center for epidemiological studies depression scale (CES-D). Journal of Psychosomatic Research, 46(5), 437–443.CrossRefPubMed
Hayes, A. F. (2009). Beyond Baron and Kenny: statistical mediation analysis in the new millennium. Communication Monographs, 76(4), 408–420.CrossRef
Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 169–183.CrossRefPubMedPubMedCentral
Homel, J., Thompson, K., & Leadbeater, B. (2014). Trajectories of marijuana use in youth ages 15-25: implications for postsecondary education experiences. Journal of Studies on Alcohol and Drugs, 75, 674–683.CrossRefPubMed
Hsu, S. H., Collins, S. E., & Marlatt, G. A. (2013). Examining psychometric properties of distress tolerance and its moderation of mindfulness-based relapse prevention effects on alcohol and other drug use outcomes. Addictive Behaviors, 38, 1852–1858.CrossRefPubMed
Hu, L. T., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Structural Equation Modeling, 6, 1–55.CrossRef
Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2005). Monitoring the future: national survey results on drug use, 1975–2011. In College students and adults ages 19–50, Vol. II. Ann Arbor: Institute for Social Research, The University of Michigan.
Kabat-Zinn, J. (1990). Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Books.
Kaloyanides, K. B., McCabe, S. E., Cranford, J. A., & Teter, C. J. (2007). Prevalence of illicit use and abuse of prescription stimulants, alcohol, and other drugs among college students: relationship with age at initiation of prescription stimulants. Pharmacotherapy, 27(5), 666–674.CrossRefPubMedPubMedCentral
Karyadi, K. A., & Cyders, M. A. (2015). Elucidating the association between trait mindfulness and alcohol use behaviors among college students. Mindfulness, 6, 1242–1249.CrossRefPubMedPubMedCentral
Karyadi, K. A., VanderVeen, J. D., & Cyders, M. A. (2014). A meta-analysis of the relationship between trait mindfulness and substance use behaviors. Drug and Alcohol Dependence, 143, 1–10.CrossRefPubMedPubMedCentral
Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: a reconsideration and recent applications. Harvard Review of Psychiatry, 4(5), 231–244.CrossRefPubMed
Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., et al. (2013). Mindfulness-based therapy: a comprehensive meta-analysis. Clinical Psychology Review, 33, 763–771.CrossRefPubMed
Kline, R. B. (2010). Principles and practice of structural equation modeling. New York: Guilford Press.
Kline, R. B. (2013). Beyond significance testing (2nd ed.). Washington, DC: American Psychological Association.
Knol, M. J., Janssen, K. J. M., Donders, A. R. T., Egberts, A. C. G., Heerdink, E. R., Grobbee, D. E., et al. (2010). Unpredictable bias when using the missing indicator method or complete case analysis for missing confounder values: an empirical example. Journal of Clinical Epidemiology, 63(7), 728–736.CrossRefPubMed
Kokotailo, P. K., Egan, J., Gangnon, R., Brown, D., Mundt, M., & Fleming, M. (2004). Validity of the alcohol use disorders identification test in college students. Alcoholism: Clinical & Experimental Research, 28(6), 914–920.CrossRef
Kuntsche, E., Knibbe, R., Gmel, G., & Engels, R. (2005). Why do young people drink? A review of drinking motives. Clinical Psychology Review, 25, 841–861.CrossRefPubMed
Lambdin, C. (2012). Significance tests as sorcery: science is empirical - significance tests are not. Theory & Psychology, 22, 67–90.CrossRef
LePera, N. (2011). Relationships between boredom proneness, mindfulness, anxiety, depression, and substance use. The New School Psyochology Bulletin, 8(2), 15–25.
Levin, M. E., Dalrymple, K., & Zimmerman, M. (2014). Which facets of mindfulness predict the presence of substance use disorders in an outpatient psychiatric sample? Psychology of Addictive Behaviors, 28(2), 498–506.CrossRefPubMed
Lilja, J. L., Frodi-Lundgren, A., Hanse, J. J., Josefsson, T., Lundh, L. G., Sköld, C., et al. (2011). Five facets mindfulness questionnaire - reliability and factor structure: a Swedish version. Cognitive Behavioral Therapy, 40(4), 291–303.CrossRef
Löwe, B., Decker, O., Müller, S., Brähler, E., Schellberg, D., Herzog, W., & Herzberg, P. Y. (2008). Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Medical Care, 46(3), 266–274.CrossRefPubMed
Martin, R. J., Usdan, S., Cremeens, J., & Vail-Smith, K. (2014). Disordered gambling and co-morbidity of psychiatric disorders among college students: an examination of problem drinking, anxiety and depression. Journal of Gambling Studies, 30(2), 321–333.CrossRefPubMed
McCabe, S. E., Boyd, C. J., Cranford, J. A., Morales, M., & Slayden, J. (2006). A modified version of the Drug Abuse Screening Test among undergraduate students. Journal of Substance Abuse Treatment, 31, 297–303.CrossRefPubMedPubMedCentral
Medvedev, O. N., Norden, P. A., Krägeloh, C. U., & Siegert, R. J. (2018). Investigating unique contributions of dispositional mindfulness facets to depression, anxiety, and stress in general and student populations. Mindfulness, 5, 574–588.
Mermelstein, L. C., & Garske, J. P. (2015). A brief mindfulness intervention for college student binge drinkers: a pilot study. Psychology of Addictive Behaviors, 29(2), 259–269.CrossRefPubMed
Moffitt, T. E., Harrington, H., Caspi, A., Kim-Cohen, J., Goldberg, D., Gregory, A. M., & Poulton, R. (2007). Depression and generalized anxiety disorder: cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. Archives of General Psychiatry, 64(6), 651–660.CrossRefPubMed
Morrison, R., & O’Connor, R. C. (2005). Predicting psychological distress in college students: the role of rumination and stress. Journal of Clinical Psychology, 61(4), 447–460.CrossRefPubMed
Murphy, C., & MacKillop, J. (2012). Living in the here and now: interrelationships between impulsivity, mindfulness, and alcohol misuse. Psychopharmacology, 219(2), 527–536.
Muthén, L. K., & Muthén, B. O. (2012). Mplus user’s guide: version 7. Los Angeles: Muthén and Muthén.
Nyklíček, I., & Kuijpers, K. F. (2008). Effects of mindfulness-based stress reduction intervention on psychological well-being and quality of life: is increased mindfulness indeed the mechanism? Annals of Behavioral Medicine, 35(3), 331–340.CrossRefPubMed
O’Neill, S. E., Parra, G. R., & Sher, K. J. (2001). Clinical relevance of heavy drinking during the college years: cross-sectional and prospective perspectives. Psychology of Addictive Behaviors, 15(4), 350–359.CrossRefPubMed
Palmer, R. S., McMahon, T. J., Moreggi, D. I., Rounsaville, B. J., & Ball, S. A. (2012). College student drug use: patterns, concerns, consequences, and interest in intervention. Journal of College Student Development, 53, 124–132.CrossRef
Phelps, C. L., Paniagua, S. M., Willcockson, I. U., & Potter, J. S. (2018). The relationship between self-compassion and the risk for substance use disorder. Drug and Alcohol Dependence, 183(1), 78–81.CrossRefPubMed
Parkerson, H. A., Thibodeau, M. A., Brandt, C. P., Zvolensky, M. J., & Asmundson, G. J. G. (2015). Cultural-based biases of the GAD-7. Journal of Anxiety Disorders, 31, 38–42.CrossRefPubMed
Radloff, L. S. (1977). The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401.CrossRef
Ramler, T. R., Tennison, L. R., Lynch, J., & Murphy, P. (2016). Mindfulness and the college transition: the efficacy of an adapted mindfulness-based stress reduction intervention in fostering adjustment among first-year students. Mindfulness, 7, 179–188.CrossRef
Raphiphatthana, B., Jose, P. E., & Kielpikowski, M. (2016). How do the facets of mindfulness predict the constructs of depression and anxiety as seen through the lens of the tripartite theory? Personality and Individual Differences, 93, 104–111.CrossRef
Reese, E. D., Zielinski, M. J., & Veilleux, J. C. (2015). Facets of mindfulness mediate behavioral inhibition systems and emotion dysregulation. Personality and Individual Differences, 72, 41–46.CrossRef
Reynolds, A., Keough, M. T., & O’Connor, R. M. (2015). Is being mindful associated with reduced risk for internally-motivated drinking and alcohol use among undergraduates? Addictive Behaviors, 42, 222–226.CrossRefPubMed
Roos, C. R., Pearson, M. R., & Brown, D. B. (2015). Drinking motives mediate the negative associations between mindfulness facets and alcohol outcomes among college students. Psychology of Addictive Behaviors, 29(1), 176–183.CrossRefPubMed
Rudkin, E., Medvedev, O. N., & Siegert, R. J. (2018). The five-facet mindfulness questionnaire: why the observing subscale does not predict psychological symptoms. Mindfulness, 9(1), 230–242.CrossRef
Saunders, J. B., Aasland, O. G., Barbor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction, 88(6), 791–804.CrossRefPubMed
Selin, K. H. (2003). Test-retest reliability of the alcohol use disorder identification test in a general population sample. Alcoholism: Clinical & Experimental Research, 27, 1428–1435.CrossRef
Shadur, J. M., Hussong, A. M., & Haroon, M. (2015). Negative affect variability and adolescent self-medication: the role of the peer context. Drug and Alcohol Review, 34, 571–580.CrossRefPubMed
Sher, K., & Rutledge, P. C. (2007). Heavy drinking across the transition to college: Predicting first-semester heavy drinking from precollege variables. Addictive Behaviors, 32, 819–835.CrossRefPubMed
Snipes, D. J., Jeffers, A. J., Green, B. A., & Benotsch, E. G. (2015). Alcohol mixed with energy drinks are robustly associated with patterns of problematic alcohol consumption among young adult college students. Addictive Behaviors, 41, 136–141.CrossRefPubMed
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder. Archives of Internal Medicine, 166(10), 1092–1097.CrossRefPubMed
Stappenbeck, C. A., & Fromme, K. (2010). A longitudinal investigation of heavy drinking and physical dating violence in men and women. Addictive Behaviors, 35, 479–485.CrossRefPubMedPubMedCentral
Thygesen, L. C., Johansen, C., Keiding, N., Giovannucci, E., & Gronbaek, M. (2008). Effects of sample attrition in a longitudinal study of the association between alcohol intake and all-cause mortality. Addiction, 103(7), 1149–1159.CrossRefPubMed
Walach, H., Buchheld, N., Buttenmüller, V., Kleinknecht, N., & Schmidt, S. (2006). Measuring mindfulness – the Freiburg Mindfulness Inventory (FMI). Personality and Individual Differences, 40(8), 1543–1555.CrossRef
Waszczuk, M. A., Zavos, H. M. S., Gregory, A. M., & Eley, T. C. (2016). The stability and change of etiological influences on depression, anxiety symptoms and their co-occurrence across adolescence and young adulthood. Psychological Medicine, 46, 161–175.CrossRefPubMed
Weiss, N. H., Bold, K. W., Contractor, A. A., Sullivan, T. P., Armeli, S., & Tennen, H. (2018). Trauma exposure and heavy drinking and drug use among college students: identifying the roles of negative and positive affect lability in a daily diary study. Addictive Behaviors, 79, 131–137.CrossRefPubMed
White, I. R., & Carlin, J. B. (2010). Bias and efficiency of multiple imputation compared with complete-case analysis for missing covariate values. Statistics in Medicine, 29(28), 2920–2931.CrossRefPubMed
White, A. M., Kraus, C. L., & Swartzwelder, H. S. (2006). Many college freshmen drink at levels far beyond the binge threshold. Alcoholism: Clinical and Experimental Research, 30(6), 1006–1010.CrossRef
White, H. R., Labouvie, E. W., & Papadaratsakis, V. (2005). Changes in substance use during the transition to adulthood: a comparison of college students and their noncollege age peers. Journal of Drug Issues, 35(2), 281–306.CrossRef
Witkiewitz, K., Bowen, S., Douglas, H., & Hsu, S. H. (2013). Mindfulness-based relapse prevention for substance craving. Addictive Behaviors, 38, 1563–1571.CrossRefPubMed
Witkiewitz, K., Marlatt, G. A., & Walker, D. (2005). Mindfulness-based relapse prevention for alcohol and substance use disorders. Journal of Cognitive Psychotherapy: An International Quarterly, 19(3), 211–228.CrossRef
Yang, L., Jia, C., & Qin, P. (2015). Reliability and validity of the center for epidemiologic studies depression scale (CES-D) among suicide attempters and comparison residents in rural China. BMC Psychiatry, 15(76), 1–8.
Yudko, E., Lozhkina, O., & Fouts, A. (2007). A comprehensive review of the psychometric properties of the drug abuse screening test. Journal of Substance Abuse Treatment, 32(2), 189–198.CrossRefPubMed
Zgierska, A., Rabago, D., Chawla, N., Kushner, K., Koehler, R., & Marlatt, A. (2009). Mindfulness meditation for substance use disorders: a systematic review. Substance Abuse, 30(4), 266–294.CrossRefPubMed
Zhao, X., Lynch, J. G., & Chen, Q. (2010). Reconsidering Baron and Kenny: myths and truths about mediation analysis. Journal of Consumer Research, 37(2), 197–206.CrossRef
Metagegevens
Titel
Specific Facets of Trait Mindfulness Reduce Risk for Alcohol and Drug Use Among First-Year Undergraduate Students
Auteurs
Alanna Single
Elena Bilevicius
Edward A. Johnson
Matthew T. Keough
Publicatiedatum
14-01-2019
Uitgeverij
Springer US
Gepubliceerd in
Mindfulness / Uitgave 7/2019
Print ISSN: 1868-8527
Elektronisch ISSN: 1868-8535
DOI
https://doi.org/10.1007/s12671-019-1092-7

Andere artikelen Uitgave 7/2019

Mindfulness 7/2019 Naar de uitgave

COMMENTARY

Navigating Dilemmas in Training People to Deliver Non-Eight-Week Adapted Mindfulness-Based Interventions

ORIGINAL PAPER

Feasibility Pilot of a Brief Mindfulness Intervention for College Students with Posttraumatic Stress Symptoms and Problem Drinking

ORIGINAL PAPER

Mindfulness-Based Stress Reduction with Individuals Who Have Rheumatoid Arthritis: Evaluating Depression and Anxiety as Mediators of Change in Disease Activity

ORIGINAL PAPER

Effects of Mindfulness Training on Borderline Personality Disorder: Impulsivity Versus Emotional Dysregulation

ORIGINAL PAPER

Mindfulness Induces Changes in Anterior Alpha Asymmetry in Healthy Older Adults

ORIGINAL PAPER

Psychometric Properties of the Self-Compassion Scale (SCS) in an African American Clinical Sample