Depression and Anxiety
Written and researched by Bob Murray, PhD
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Antidepressants Versus Placebos: Meaningful Advantages Are Lacking
September 30, 2002
Antidepressants are widely believed to be exceptionally effective medications. The data, however, tell a different story. One recent study analyzed the data sent to the US Food and Drug Administration by the manufacturers of the six most widely prescribed antidepressants (fluoxetine [Prozac], paroxetine [Paxil], sertraline [Zoloft], venlafaxine [Effexor], nefazodone [Serzone] and citalopram [Celexa]). Their research showed that although the response to antidepressants was substantial, the response to inert placebo was almost as great.
What's more, more than half of the clinical trials sponsored by the pharmaceutical companies failed to find significant drug/placebo difference, and there were no advantages to higher doses of antidepressants. The small difference between antidepressant and placebo has been referred to as a "dirty little secret" in a recent study by clinical trial researchers, a secret that was believed by FDA officials to be "of no practical value to either the patient or prescriber."
Previous reports of vanishingly small drug/placebo differences were met with skepticism. In contrast, the basic findings from this new meta-analysis have been accepted as accurate. The dispute is no longer about the small size of the average drug/placebo difference, but rather about how to interpret this fact and what to do about it.
Various interpretive possibilities have been raised. One of the most popular theories is that there may be a subset of patients for whom at least some antidepressants are very effective, but that their relative lack of efficacy with other patients masks that effect. Specifically, whereas mildly depressed patients respond to both drugs and placebos, more severely depressed patients respond only to active drugs.
The FDA data contradict this hypothesis. Although severely depressed patients benefited more from medication than mildly depressed patients due to a phenomenon known as regression toward the mean, they also benefited more from placebo than their more mildly depressed counterparts.
Another popular hypothesis is that drug effects are more stable than placebo effects, resulting in lower relapse rates. This hypothesis is also contradicted by the data. A meta-analysis of relapse prevention trials published between 1973 and 1990 indicated that 71% of the drug response was duplicated by placebo. This analysis also examined response to treatment as a function of the duration of the trial. The data indicated that responses to both drug and placebo decrease over time.
Contrary to conventional wisdom, however, the correlation between duration of the trial and response to treatment was higher for active medication than for placebo, suggesting a steeper decline in effectiveness for active drugs than for placebo.
The authors of the latest study conclude: "Given these data, antidepressant medication might best be considered a last resort, restricted to patients who refuse or fail to respond to other treatments."
A lot of modern research has shown that antidepressants even target the wrong neurochemicals. Many scientists have been saying lately that the re-uptake of serotonin is not the prime problem, brain structure is. This cannot be remedied by any current drugs, but can be by creating supportive relationships. BM
Read more in Psychiatric Times
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People Who "Gave Up" After 9/11 More Likely to Remain Distressed
September 30, 2002
The study, published in the Journal of the American Medical Association (JAMA) found that while 17 percent of the US population living outside New York City reported symptoms of post-traumatic stress two months following the attacks, 6 percent continued to report symptoms six months afterward.
The study, led by Roxane Cohen Silver, professor of psychology and social behavior at the University of California, Irvine, was unusual because it followed people who were already taking part in an Internet survey panel when the Sept. 11 attacks occurred. Therefore, their mental and physical health histories were known prior to the tragedy.
The study, Silver explains, provides new insights into how mental health workers can help people who have experienced trauma, and dispels a number of myths about who might be most affected by such an event.
"This investigation demonstrates that the effects of a major national trauma are not limited to those directly affected by it, and the degree of response cannot be predicted simply by objective measures of exposure to, or loss from, the trauma," Silver said. "It shows that early disengagement from coping efforts (such as 'giving up,' distracting oneself, or refusing to believe what happened) predicts poor psychological outcomes over time."
"Overall, our data show that six months after the events of 9/11, the effects continued throughout the country among individuals who were, for the most part, not directly affected by the attacks," Silver said.
The paper was based on a national random sample of Americans participating in an Internet-based survey. Respondents were questioned about distress and posttraumatic stress symptoms during the first two weeks, two months and six months after the attacks. A total of 933 people participated in the survey.
"Post-traumatic stress symptoms, while declining over the six months, still remained elevated. Moreover, individuals continued to have substantial anxiety about future terrorist attacks personally affecting themselves or those close to them," the authors write.
Those individuals who had preexisting mental or physical health difficulties or had greater exposure to the attacks (including watching them on "live" TV) were more likely to show continued stress symptoms over time.
"We believe it is important for health care professionals to recognize that potentially disturbing levels of trauma-related symptoms can be present in a substantial portion of individuals who are not directly exposed to a trauma, particularly when the trauma is a massive national tragedy such as the 9/11 attacks," Silver added. "However, rather than considering these symptoms as evidence of psychiatric 'disorders' per se, their presence is likely to represent a normal response to an abnormal event."
I have been saying for a long time that PTSD was a "secondary" disorder. My belief, based on my experience with Vietnam vets and now backed up by some pretty powerful evidence, is that there are three stages to PTSD: Early childhood trauma or severe pre-natal maternal stress, the development of depression in the young child and finally a severely traumatic event -- such as September 11 -- which re-triggers that early trauma and sparks the onset of PTSD. I have never met a PTSD sufferer who was not depressed and who did not suffer childhood trauma or prenatal maternal stress. BM
Read more in JAMA
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Depression Leads to Teen Tobacco Use
September 30, 2002
A recent study by the University of Pennsylvania School of Medicine and Georgetown University found that exposure to family and friends who smoke and elevated levels of depression significantly affect the likelihood of alternate tobacco product use among adolescents. The study, titled "Psychosocial Correlates of Alternate Tobacco Product Use During Early Adolescence," appears in Preventive Medicine.
Recent research shows that alternate tobacco products, including smokeless tobacco (chewing tobacco and moist snuff), cigars, cigarillos, pipes, bidis (sweet flavored cigarettes from Southeast Asia), and kreteks (clove-flavored cigarettes), are gaining in popularity among youth.
"This trend is dangerous because alternate tobacco products can lead to cancers of the oral cavity and a host of other negative health consequences," said senior author Janet Audrain, PhD.
While previous research has shown that both exposure to other smokers and depression increase the likelihood of cigarette use among adolescents, this is one of the first studies to examine the influence that these social and other psychological factors have on alternate tobacco product use.
Audrain led a research team that interviewed 1,107 ninth grade students as part of a four-year investigation of the social, psychological and genetic predictors of adolescent smoking adoption. These students completed a survey that assessed current smoking practices, exposure to other smokers, levels of depression, and alternate tobacco product use. Demographic data including age, gender, and race were also collected.
Over eight percent of the teens reported using an alternate tobacco product (smokeless tobacco, cigars, pipes, bidis and/or kreteks) in the last thirty days. Among the eleven percent of freshman who reported being current cigarette smokers (smoked in the last month), 45 percent were also current users of an alternate tobacco product.
The researchers found that current alternate tobacco product users were significantly more likely to be male, white and current cigarette smokers. In addition, teens with higher levels of exposure to other smokers and those with greater depressive symptoms were found to be two to three times more likely to be current users of alternate tobacco products, regardless of demographic factors and current cigarette smoking.
"It is important that future studies determine adolescents' beliefs and motivations surrounding the benefits of using alternate tobacco products," said study co-investigator and author Kenneth P Tercyak, PhD, assistant professor of oncology at Georgetown University Medical Center. "Since it is possible that adolescents might have misconceptions about the safety of these products, anti-tobacco messages targeted to youth should include warnings about the risks of using these products."
Read more in Preventative Medicine
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Depression a Risk Factor for Alzheimer's Disease
September 4, 2002
More than 650 elderly people took part in the seven-year study, which included annual neurological evaluations and testing of cognitive function. Baseline testing showed about half of the participants had no depressive symptoms and the remainder had from one to eight. Only one percent had symptoms severe enough to warrant a diagnosis of major depression.
During annual follow-ups, 108 of 651 participants developed Alzheimer's disease. Those with the greatest number of depressive symptoms at the start of the study were more likely to develop Alzheimer's disease and also showed more rapid cognitive decline.
"According to our results, the people with the largest number of depressive symptoms also had the greatest risk of developing AD," according to lead author Robert S Wilson, PhD, of the Rush Alzheimer's Disease Center in Chicago. "With each additional symptom, the risk of AD increased by about 20 percent."
Study participants are from the Religious Orders Study, an on-going look at aging and Alzheimer's disease in older Catholic nuns, priests, and brothers who have agreed to annual evaluations and brain donation at death.
Read more in Neurology
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Program to Ease Depressives Into Work
September 4, 2002
Officials of the Ministry of Health, Labor and Welfare in Japan plan to implement the program on a trial basis at a ministry-affiliated facility in Chiba city. The program, designed to assist people suffering from depression triggered by stress in the workplace, aims to help sufferers who want to return to their jobs and who are deemed well enough to return by a psychiatrist.
Many people diagnosed with clinical depression find it difficult to readjust to working life because they try to work too hard, officials said. The program aims to prevent this by urging employees to gradually ease themselves back to work.
A lack of understanding and support from colleagues is another problem, officials said. To stop this, the ministry program calls for counsellors to periodically meet with recent returnees to discuss their progress and offer advice to their supervisors. The program urges participants to cope with the cause of their depression. For example, participants who struggled to get along with colleagues would be urged to improve their human-relation skills. Participants will follow a stress-management course concurrently, officials said.
Individuals who complete the program will be encouraged to return to their workplace gradually, working limited hours at first, such as only mornings.
Some large companies have programs for depressed employees, but most medium- and small-sized firms do not.
Depression causes US industry billions of dollars annually in lost days. Most "sick-days" and even workplace accidents are due to underlying depression. We have had considerable success with the Uplift Program in enabling depressive people to get back to work and indeed, as part of a grant given to us by the Ford Foundation, we are developing a program specifically for small and medium-sized companies which, by easing the burden of depression, will greatly improve their productivity and their bottom line. We are anxious to hear from any companies in the Sydney, Australia, or Tampa Bay, Florida area who would be interested in participating in this project. BM
Read more in Intelihealth
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Breast Cancer, Depression and PTSD
September 4, 2002
Most breast cancer patients aren't at significant risk for developing post-traumatic stress disorder (PTSD) because of their diagnosis and treatment, a new study suggests. However those who are most at risk appear to be patients who suffered from mood disorders, such as depression or anxiety, before they were diagnosed with cancer. The study, carried out at Ohio State University, found that 75 percent of breast cancer patients with PTSD had previous mood disorders.
In their study, the Ohio State researchers were able to evaluate a sample of women breast cancer patients who were participating in a long-term study of stress and immunity at the university. They screened women for PTSD symptoms 18 months after they were diagnosed, which was about six months after their treatment had ended. They then followed up with select patients in another 18 months. As a result of the initial screening they separated women into those who had low, moderate and high symptoms of PTSD. In order to best compare women who may be at risk for PTSD, the researchers then did further study of the 33 women with high level of symptoms and 39 women with low levels of symptoms. These two groups were similar in terms of demographics, stage of disease and treatment.
The researchers did a diagnostic assessment that examined the women's history of psychiatric disorders, traumatic events in their lives, and family psychiatric history. They also tested them for mood and anxiety disorders, alcohol and drug use, and overall functioning. Results showed that about 30 percent of the women with a high level of symptoms did have PTSD, compared with just over 15 percent of those with low-level symptoms.
There was no difference between the high and low symptom groups in terms of family psychiatric history. However, those with a high level of symptoms were significantly more likely than others to have had past psychiatric treatment (nearly 80 percent of the high-symptom women had previous treatment), had significantly more traumatic events in their lives, and were much more likely to have had mood disorders. The results suggest that doctors should be concerned about the mental health of people with cancer, Andersen said. But there doesn't need to be a particular focus on PTSD.
That PTSD cancer patients had a prior history of mood disorders (depression, anxiety etc) does not come as a great surprise to me. I made the same observation many years ago concerning Vietnam vets with PTSD. All those that I dealt with had prior bouts of depressive illness or anxiety disorder. Most vets who were diagnosed with PTSD also came from troubled or abusive households. BM
Read more on the Ohio State University website
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People with Low Self-esteem Less Motivated to Break Negative Mood
People with low self-esteem are less motivated than people with high self-esteem to improve a negative mood, even when they are offered an activity that will change their frame of mind, a team of American and Canadian psychologists has found.
The finding is contrary to the common belief that all people are motivated to alleviate negative moods, according to Jonathon Brown, a University of Washington psychologist and co-author of the study. "Many people with low self-esteem believe sadness is part of life and that you shouldn't try to get rid of it, while people with high self-esteem believe in doing something to feel better if they have a negative experience or get in a bad mood," said Brown.
The researchers conducted five studies involving nearly 900 people. In the key experiment, the researchers created a sad mood by having subjects listen to music and found that people with low self-esteem were significantly less likely than people with high self-esteem to select a comedy video from among six tapes to break their mood.
A group first read descriptions of the six videos, which included stand-up comedy routines, a discussion of global warming and the story of a polio-crippled runner who dreams of becoming an Olympian but fails, and rated how happy or sad each would make them feel if they watched it. Most people, regardless of their self-esteem, said the comedy video would make them the happiest.
Then 116 people, half of whom had been tested to have high-esteem and half to have low self-esteem, were exposed to music that induced happy or sad moods. Some of the subjects heard a jazz version of Bach's Brandenburg Concerto No. 3 to put them a positive mood. The others were put into a negative mood by listening to Prokofiev's "Russia Under the Mongolian Yoke" played at half speed, a piece of music Brown described as "slow, sad, laborious and boring." Each recording lasted about 10 minutes.
Afterward, all subjects were given the descriptions of the six videos and asked to rate how they thought each would make them feel, ranging on a scale from very sad to very happy. Finally, they were asked to select one to watch. The subjects, regardless of their level of self-esteem, agreed that the comedy video was the one that would put them in the happiest mood. However, among the people exposed to the negative music there was a sharp difference in the videos they actually picked to watch. Just 47 percent of low-self-esteem people picked the comedy video while 75 percent of high self-esteem subjects selected it.
A different pattern emerged among people who heard the happy or positive music. More people with low self-esteem (75 percent) than those with high self-esteem (54 percent) chose the comedy video.
Brown said it appears that a combination of resignation and sadness leads to less motivation among people with low self-esteem to rise above their mood and make an effort to change it.
"People with low-self esteem feel resignation because they question whether anything will help and say 'I'm not good at breaking or changing a mood,'" he said. "They also believe sadness is not something you get rid of and that you learn and grow from sadness. They feel it is not appropriate to try to change a mood. These are not people who would necessarily go to the movies or shopping to feel better."
There are things that people with low self-esteem can do to snap a negative mood, according to Brown. "If you have low self-esteem, you should actively try to rise above the sadness and learn that you will feel better if you do not passively accept sadness. You can get better if you remind yourself to do something. You may have to kick yourself in the butt to go to a movie because it will require a conscious effort rather than something that comes automatically," he said.
The other four studies reinforced the idea that low self-esteem people are less motivated to change a negative mood. The initial study asked students to record in a diary a positive or negative experience that happened to them in the next seven to 10 days and what they did afterwards. Among those who listed a negative experience, only 55 percent of people with low self-esteem expressed a goal to improve their mood compared to 77 percent of those with high self-esteem.
The second study found that people with low self-esteem are equally knowledgeable as those with high self-esteem about strategies to repair negative moods. The final two studies asked people about their experiences when they were in a negative mood. Those with high self-esteem were more likely to express the need to do something to change the mood and less likely to recall instances when they didn't find a way improve their mood. Those with low self-esteem, however, were more likely to say such moods are acceptable and that they couldn't change a mood even if they tried. They also were more likely to say that negative moods sapped their energy.
Self-esteem is generally defined in terms of feelings of affection one has for oneself. In a normal population, high self-esteem is characterized by a general fondness for oneself. Low self-esteem is marked by mildly positive, ambivalent or slightly negative feelings.
Read more in the Journal of Personality and Social Psychology
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Sex-Specific Genes For Depression Discovered
For a long time psychologists and psychiatrists have been arguing about the genetic basis of depression. They have also debated whether the disease had different causes for men and women. Now a new study has begun to answer some of these questions.
For the study, funded by the National Institute of Mental Health, researchers compared genetic markers from 100 men and women with recurrent, early-onset major depressive disorder (RE-MDD) and 100 people with no history of this disorder, to find out which chromosomal regions were associated with the illness. RE-MDD is a severe form of clinical depression that runs in families and impairs the health and life span of family members.
Out of 19 chromosomal regions that were associated with the development of RE-MDD, 16 were significantly associated with the disorder in either men or women -- but not both.
Confirmation that one of these regions, located on chromosome 2, affects the risk of severe depression among women in 81 families identified by individuals with RE-MDD is published in Molecular Psychiatry.
"We suspected there were at least a few different genes involved in making women and men susceptible to major depression," said lead author George S Zubenko, MD, PhD, professor of psychiatry at the University of Pittsburgh School of Medicine. "The results of this study suggest that sex-specific genes for recurrent major depression may actually be the rule rather than the exception."
According to the authors, these findings suggest important differences in the molecular basis of clinical depression in men and women, or sex-specific differences that determine resistence to stressful events. These genetic factors may contribute to differences in the symptoms of clinical depression in men and women, differential treatment responses, and the development of additional psychiatric disorders such as alcoholism and other substance use disorders that frequently accompany major depression and run in the same families.
They may also influence the risk of developing diseases that affect organs other than the brain. The deceased relatives in these 81 families died at a median age that was 8 years earlier than for the local population; over 40% died before reaching age 65. These differences in mortality statistics resulted from a shift toward younger ages at death across the life span, including a five-fold increase in the proportion of individuals who died in the first year of life.
According to the authors this research may provide an important step toward changing the way doctors diagnose and treat major depression, which affects nearly 10 percent of the population (moderate to mild depression affects up to one-third of all women).
"Studies such as this one are providing us with a better understanding of the biology of complicated disorders such as major depression, which is unlikely to represent a single disease with a unitary cause," said Dr Zubenko. "Instead, clinical depression is probably more like anemia. Both of these disorders are defined by a collection of clinical features that result from different causes in different people."
Read more in Molecular Psychiatry
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Chronic Self-Doubters More Materialistic
A new study found that people with enduring feelings of self-doubt scored higher than others on a measure of materialism -- the tendency to value monetary success and material possessions over other goals in life. Specifically, they were more likely to believe that success was defined by what a person owns.
"Feelings of self-doubt can send people looking for meaning in their lives, with a goal toward boosting their self-worth," said Robert Arkin, co-author of the study and professor of psychology at Ohio State University. If they aren't deriving a sense of self-worth from other parts of their lives, they may feel that owning a lot of things proves they are successful."
The study was published in a recent issue of the journal Psychology & Marketing.
Arkin said research in countries around the world show that people tend to believe that materialism is a weakness of insecure people who doubt their self-worth. However, he said there has not been much evidence to confirm that.
In one study, Arkin and his team had 416 undergraduate students complete a variety of measures that examined their levels of self-doubt, several forms of materialism, and other psychological traits. The results showed that people who were chronic self-doubters scored higher in materialism. In particular, they scored higher on a measure of materialism in which people define success in terms of what they own. For example, they were more likely to agree with statements such as "I like to own things that impress people" and "The things I own say a lot about how well I'm doing in life."
The link between self-doubt and materialism was confirmed in a second study that found that inducing feelings of self doubt could increase materialistic tendencies in those with chronic self-doubt. This study involved 95 undergraduates -- half who scored high in chronic self-doubt and half who scored low. Participants were asked to memorize words by relating these words to their own personality and experiences. Half the subjects memorized self-doubt words (insecure, doubtful, uncertain, etc.) while the other half memorized words unrelated to self-doubt (inside, double, unicorn, etc.).
Prior studies have shown that this technique increases feelings of insecurity in those who memorize doubt-related words. In this study, participants were asked about their current state of mind regarding materialism, rather than their long-term feelings. Results showed that when participants memorized doubt-related words, those who scored higher on chronic self-doubt showed significantly higher levels of current materialism than those who did not have chronic self-doubt. But among those who memorized the unrelated words, there was no difference in immediate feelings of materialism between the chronic self-doubters and the confident participants.
"For those people who are chronically insecure, materialism seems to be a coping mechanism that they use when they are put in a situation that makes them doubtful about themselves," Arkin said. She added that it is noteworthy that self-doubters score high on a type of materialism that equates possessions with success.
"Chronic self-doubters are not interested in possessions because they bring happiness or because they simply like owning a lot of things," Arkin said. "They are interested in possessions because of their meaning, the status they confer. They believe their possessions demonstrate success." That's why materialism can be seen as a coping response for people who are uncertain about their identity, he said.
The results also showed that materialism is related to another type of uncertainty -- anomie. While chronic self-doubters tend to be uncertain about their own abilities and identity, those who score high in anomie tend to feel uncertainty related to their society and culture. They tend to feel rootless and believe society lacks clear guidelines for behavior.
But whether a person suffers from anomie or self-doubt, Arkin said materialism is a poor coping mechanism. Other studies have shown that a materialistic orientation to life is linked with poor psychological functioning and lower life satisfaction.
Read more in Psychology and Marketing
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Teen Anxiety Higher Than Expected
Is it any surprise that teenagers are anxious and moody? Perhaps not, but their rates of anxiety appear unexpectedly high, and their anxiety makes them more prone to overeat and smoke, a University of California at Irvine study has found.
The study, one of the first to involve teenagers' use of hand-held computer diaries, found that high rates of anxiety led to more frequent episodes of anger, sadness and fatigue and altered teenage behavior significantly. The findings, part of a long-term study, may also provide insight into teenage perceptions and moods that may have changed after the terrorist attacks of Sept. 11, 2001.
The study appears in the Journal of the American Academy of Child and Adolescent Psychiatry.
Carol Whalen, professor of psychology, and her colleagues found that teens recorded being anxious in about 45 percent of their computerized diary entries, much higher than expected. This anxiety, which also surprisingly was equal in boys and girls, led to more prevalent feelings of unhappiness and low self-esteem. Their anxiety caused them to engage in fewer conversations and recreational activities and to eat and smoke more.
To conduct their research, Whalen and her team issued each of 150 high school students a hand-held computer that contained a software program in which the teens recorded their feelings and behavior during the day. The computers turned out to be popular with the students and provided much greater insight into the adolescent mind than traditional questionnaires and interviews.
"The teens' diaries showed us a much greater incidence of anxiety, but they also revealed behavior patterns that had never been observed before," Whalen said. "We were able to see when this anxiety was experienced, where and with whom. This study may help prevent adolescents from starting harmful behaviors like overeating and smoking and may help psychologists and other health care practitioners take better care of their adolescent patients."
Teenagers with the highest levels of anxiety tended to spend more time alone but were less anxious when they did spend time with friends, the researchers found. High-anxiety teens were seven times more likely than low-anxiety teens to report feelings of anger and 11 times more likely to report sadness. Moderate- and high-anxiety teens were two-to-three times more likely to smoke, between 70 and 80 percent more likely to drink alcohol and more likely to experience urges to eat. The researchers also found that girls were equally as anxious as boys, which was contrary to other studies on anxiety.
"This study was conducted in the context of a secure and optimistic society," Whalen said (it began in 1998 and the findings relate to the period prior to September 11). "All of that has changed. We may be able to use this data as a 'baseline' with which we can compare moods and behaviors of adolescents in a peaceful society with moods and behaviors in a society under stress."
Read more in the Journal of the American Academy of Child and Adolescent Psychiatry
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About the Author
Dr Bob Murray is a widely published psychologist and expert on emotional health and optimal relationships. Together with his wife and long-term collaborator Alicia Fortinberry, he is founder of the highly successful Uplift Program, and author of Raising an Optimistic Child (McGraw-Hill, 2006) and Creating Optimism (McGraw-Hill, 2004).
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