Inconvenient truths of mental illness: More people take medication, but progress has stalled

MIT Mental Health

In this Monday, Feb. 1, 2016 photo, Massachusetts Institute of Technology student Andy Trattner, of Portland, Ore., displays a wrist band that features the acronym TMAYD for “Tell Me About Your Day,” a campaign to encourage students to talk to one another in an effort to defuse to the stress of campus life before it leads to a crisis. There were several campus suicides last year. MIT officials recently set aside thousands of dollars for grants to help support campus projects dealing with mental health. (AP Photo/Steven Senne) (Credit: AP)

The 1990s and 2000s were glorious decades to be a psychiatrist. It seemed as though each year several new, potentially life-changing medications were brought to market. Options became available to tackle long-standing, treatment-resistant disorders. It did not hurt that big pharma had deep pockets to promote the new offerings. Stigmas were falling, more people were seeking help than ever before, and just about any psychiatrist could brag about patients who, with the right medication and a little time, returned looking more confident and reporting fewer symptoms.

Today the shine has dimmed. The mental health of the nation may have even declined in the past 20 years. This trend is what Thomas Insel, former director of the National Institute of Mental Health, calls one of the “inconvenient truths” of mental illness. Suicide rates per 100,000 people have increased to a 30-year high. Substance abuse, particularly of opiates, has become epidemic. Disability awards for mental disorders have dramatically increased since 1980, and the U.S. Department of Veterans Affairs is struggling to keep up with the surge in post-traumatic stress disorder (PTSD).

The most discouraging assessment came in 2013 from an in-depth analysis by the U.S. Burden of Disease Collaborators. Hundreds of investigators gathered data on 291 diseases and injuries between 1990 and 2010. Combining premature death and disability to calculate the burden of each disease, they found that the toll of mental disorders had grown in the past two decades, even as other serious conditions became more manageable.

Source: Annual Statistical Report on the Social Security Disability Insurance Program, 2013. Social Security Administration, December 2014

More people are getting treatment and taking medications today than ever before, so what is going on? I would argue that a lack of precision and objectivity in diagnosing and treating mental illness has stalled our progress. We must embrace new strategies in research and prevention to move forward.

The inconvenient truth

The American Psychiatric Association, the American Psychological Association and big pharma explain the deterioration of mental health nationally by proposing that not enough people are getting treatment. But this suggestion seems a bit self-serving.

Another explanation points to the vague nature of psychiatric diagnoses. Social Security awards for disability have exploded in two areas: musculoskeletal and mental disorders, both of which are often diagnosed on the basis of a patient’s subjective reports rather than hard measures such as scans or blood tests. Furthermore, both seem to expand and contract with the economy. Thus, changes in the prevalence of mental disorders may not necessarily reflect changes in the biology of mental illness.

It is also possible that we are hampered by not having new treatments for patients seeking help. As it turns out, drugs developed in the past 20 years perform like older medications. Abilify is no more effective for treating schizophrenia than the very first antipsychotic, Thorazine. New antidepressants lift mood no better than the tricyclic antidepressants discovered in the 1950s. Lithium, first used in 1949, remains the gold standard for bipolar disorder. Adderall provides no further advantages for attention-deficit/hyperactivity disorder than the Benzedrine first administered for it in 1937.

There are exceptions — we appear to be better at treating the depressive phase of bipolar disorder, and Clozaril is a more effective treatment for schizophrenia than its predecessors — but much of what seemed so revolutionary 20 years ago was more illusion than substance. The new medications tap into the same brain mechanisms as the old ones, albeit with fewer side effects. Finding novel treatments for mental illness has become so discouraging that several pharmaceutical companies have shut down or reduced neuroscience research.

The problem is that the brain is exceedingly complex. Behavior, emotions and cognition are manifestations of networks of cells that are turned on or off at the right time. The capacity to affect specific cells in the brain without altering other cells remains a massive challenge.

Finding new solutions

Australia is experiencing the same problem as the United States: More people have access to treatment than ever before, but national mental health has not improved. In a 2014 discussion of the dilemma, psychiatric researcher Anthony F. Jorm of the University of Melbourne argued that prevention could be the best response, citing numerous studies of preventive interventions. For example a 2011 Cochrane review — a top-quality, multistudy analysis — revealed that teaching cognitive-behavioral therapy skills in the classroom can help reduce the incidence of depression among students.

Taking prevention one step further, Insel has advocated for research initiatives to discover biomarkers for mental illness. Laboratory tests or genetic markers that can identify at-risk individuals might allow us to intervene early, before symptoms begin.

In addition, it is paramount that we discover new mechanisms to treat mental illness. This progress will not come quickly — the brain does not give up its secrets easily. But there is one unique, promising treatment that is struggling to get approval: psychedelic-assisted psychotherapy. Preliminary evidence suggests that drugs such as LSD and psilocybin could be used episodically, together with psychotherapy, to enhance the healing process.

The best evidence so far is with MDMA, also known as ecstasy, for people with PTSD. In a 2016 review, Michael C. Mithoefer, a Medical University of South Carolina psychiatrist, and his colleagues identified encouraging results from two phase II clinical trials in which people who received therapy supplemented with MDMA at just two or three sessions had fewer symptoms than those given therapy and a placebo.

Unfortunately, the Drug Enforcement Administration classifies psychedelics as drugs with “no currently accepted medical use and a high potential for abuse,” which makes them hard for scientists to access. Big pharma has little interest in studying these molecules because most cannot be patented, and the government is not currently funding such research.

None of this is to say that mental health workers and their patients should stop what they are doing. We all have success stories to tell. As psychiatrist Peter D. Kramer points out in his new book “Ordinarily Well,” the advent of today’s antidepressants has largely eliminated the immobilizing melancholy that was once all too common. Based on my own clinical experience, mental health treatment does improve symptoms and quality of life by about 20 to 40 percent for most patients. That’s a whole lot better than nothing but not nearly good enough.

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Resolved: A no-diet new year starts now

Scale / Weighing machine

(Credit: Getty/y_seki)

“I’ve noticed you’ve gained a little weight,” Mom said as we sat in the car. I was 11 years old and my body was just beginning to hint at hips. She reached over, tugging on the new roll of stomach fat that was hiding under my t-shirt. “Getting a little pudgy,” she teased.

I’d been too busy feeling awkward that I was morphing into what adults called “busty” to specifically zero in on what my stomach had been up to — no good, as it turned out. I crossed my arms over my stomach, feeling the soft roll of skin and fat that was just above my jeans. I sat up a little straighter, hoping that would flatten things out a bit. I tried to suck it in.

Mom talked about how unnecessary weight gain can make parts of your body pudgy, flabby. “I guess I have noticed that my legs have gotten more jiggly,” I said, looking down at my legs self-consciously.

“If you start dieting and exercising, you could get attractive, toned legs,” Mom said. She told me how a lot of adult women struggle with weight management, herself included. She hoped she could save me from the pain of yo-yo dieting as an adult by teaching me how to maintain my ideal weight while I was still young. If we’d asked a doctor, they likely would have said dieting for an 11 year old was a health risk. But we didn’t ask a doctor. My mom’s own body-image demons clouded her ability to determine what was truly best for my body.

After our conversation, Mom put me on a diet. She began monitoring what I ate. “Kelsey,” Mom said disapprovingly, “that’s too much ranch dressing. You won’t be able to lose weight if you eat your salad like that.” And she made sure I didn’t have seconds after dinner.

“But I’m still hungry,” I protested at first.

“You’re not really hungry,” Mom replied. She said I’d stretched my stomach out through overeating, and it would eventually shrink back to its right size. In the meantime, I was going to be haunted by phantom hunger pangs.

The fake hunger felt awfully real, and it seemed only get worse as more time went by. When I saw a celebrity on TV who had had her stomach stapled, I asked if it was something I could get. When I was told no, I decided that I’d get it the moment I was an adult. Maybe if my stomach was surgically corrected I’d finally feel full again.

When I lost weight, mom celebrated. She encouraged me pull out my flatter-stomach clothes that I’d banished to the back of my closet. I’d pull out my white form-fitting polo shirt and smile at my reflection. Mom would tell me how flattering the shirt was on me “now.” But then I’d gain a few more pounds and the moment would be gone.

When I hit middle school I worried about my weight more than I worried about boys. I didn’t understand that curves added weight — healthy weight. As my body began to shift into a curvier mold, I frantically tried to diet the weight that came with boobs and thighs away. I thought I was trying to manage my weight, but what I was trying to manage was puberty.

When I was diagnosed with asthma and given a daily inhaler, I didn’t take it. My parents couldn’t figure out why. I let them think I was an absentminded and irresponsible pre-teen. I was too embarrassed to tell them the truth: Being thin was more important than breathing. I didn’t take my meds because I had heard steroids could cause weight gain. I knew this wasn’t something other people would understand, so I kept it to myself.

How little I was eating became my biggest secret. And at some point my body and food anxiety crossed the line into abnormal anorexia. I started secretly skipping meals on a regular basis, cutting my food into tiny bites and then counting to twenty before swallowing so eating would take as long as possible. I tracked the most minor fluctuations in the numbers on the scale. Eating became more and more complex and anxiety-causing as I continually added self-induced restrictions to my already limited calorie intake. My obsessive eating-disorder-induced dieting sucked not only the calories but the joy out of life.

When I was in my early 20s I had a revelation about dieting after being very sick with the flu. I’d dropped several sizes. When I stood in the dressing room I was shocked that I’d lost so much weight. I had been pining after my dream size for years, and now I was smaller.

I’d thought about dieting more than anything else for 10 years: This is what I’d been living for. But the gratification from achieving a decade-long goal didn’t last a second. My first thought after realizing the number on the tag: “Maybe I could go even smaller!” Maybe that would be it. Maybe then I’d feel comfortable in my own body. Maybe then I’d feel happy and beautiful and sexy. Maybe . . .

But then I came to the sad realization that the game was rigged. The elusive, arbitrary numbers I’d been chasing — pants sizes, dress sizes, numbers on the bathroom scale — would always be replaced by a different, smaller number. When you have an eating disorder, you never reach your goal weight.

A new year is supposedly a time for fresh starts, but it always feels like the same old thing: Everyone is bombarded with fat-shaming and promises that we’ll finally feel happy and whole in our bodies if only we buy the new latest and greatest dieting or fitness product. All of the magazine covers at the checkout stand will showcase new diets with claims that these are the magic tricks you’ve been looking for all these years. The local gyms will advertise specials, claiming “New Year, New You!” With all that diet talk, if I’m not careful I could have a relapse, which is why celebrating how far I’ve come in my eating disorder recovery is a necessary part of surviving January.

This year I’m celebrating that I can now eat a bowl of potato chips without crying afterwards.

I’m celebrating how last summer I wore a bikini for the very first time in my life, and I didn’t go on a diet first.

I’m celebrating that I’ve gotten to the point in my recovery that I’m able to work out without weight loss being the goal.

I lived on a diet for years. Dieting has controlled so much of my life. It’s been the haunting, nagging, lying voice in my ear. This diet season, as others are setting New Year’s resolutions, I’m celebrating recovery goals. I’m celebrating that I learned how to eat again because life didn’t finally start when I reached my goal weight. Life started when I finally told dieting to fuck off.

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Looking forward to a calm, healthy 2017? Here are some practical approaches to fighting workplace stress

Meditation

(Credit: Luna Vandoorne via Shutterstock)

There is a certain mental fidgeting that sets in around this time of year; we look back on the months that have come before, worrying that we have not done enough things in too little time, and not done them well. Some of us haunt our friends’ social media feeds, grumpily perusing their too-happy vacation photos from sunny places, while we sit in either real or proverbial gloom and sleet. After a year like 2016, much seems uncertain, and some develop end-of-year insomnia worrying about it all. This much overthinking starts a slow and steady buildup of stress and anxiety. Before we know it, the coming year is ruined in our minds, before it has even begun. Numbers of suicide attempts tend to peak just after January 1, according to Eve R. Meyer, longtime executive director of San Francisco Suicide Prevention.

Giving yourself tools to manage stress from the outset of the year will make it easier to let things go and identify and then address unhealthy patterns. Stress is one of the top three health care costs in the U.S. (behind heart disease and cancer), and stress-related problems account for up to 80 percent of visits to the doctor. Only 3 percent of doctors routinely talk with their patients about how to reduce stress, said a 2012 study by Beth Israel Deaconess Medical Center in the Archives of Internal Medicine. “Almost half of Americans report an increase in psychological stress over the past five years,” according to lead author, Dr. Aditi Nerurkar. “Stress is the elephant in the room. Everyone knows it’s there, but physicians rarely talk to patients about it.” In fact, stress management counseling is last, behind counseling for nutrition, exercise, weight loss and smoking – but in our exhausting world of technology, expectations and often cruel intentions, perhaps it should be first.

Meditation expert Dawn Lorentz, whose corporate wellness company Self Reboot helps large companies’ employees learn breathing and yoga to reduce stress, told Salon that starting the new year off with a stress-identifying “body scan” is a healthier beginning to 2017. “The bills won’t stop coming, there will never be more hours in the day, and your work and family responsibilities will always be demanding.” Lorentz paused. “But you have a lot more control than you might think. Stress management is all about taking charge: of your lifestyle, thoughts, emotions, and the way you deal with problems. No matter how stressful your life seems, there are steps you can take to relieve the pressure and regain control.”

Lorentz knows workplace stress well. “I’m a corporate burn-out,” she said with a smile. “I worked for many years in a fast-paced, high-stress corporate real estate job where deals sometimes took 24 hours to close, and then you were expected to stay out all night and celebrate afterwards!”

After working long and stressful hours took a serious toll on her health in the form of migraines, jaw pain, hair loss and more, Lorentz was prescribed countless pharmaceutical drugs that waged a war against each other in her body, offering no relief. She had jaw surgery to correct the TMJ, but it only got worse. She remembers thinking, “If I couldn’t figure out how to get well, I wanted to kill myself. It was that bad.”

Soon after, Lorentz visited an acupuncturist, who told her she had “bad chi” but was able to help her; she began practicing yoga and meditation, and her whole life changed. Some years later, she left the corporate real estate world, and dedicated herself to helping employees in corporate America feel better through stress-reduction techniques.

On a recent, unseasonably warm winter day, Lorentz and I sat facing each other in Salon’s studio. “Where do you hold stress in your body?” she asked me. Lorentz explained that the most common areas people feel signs of stress are in the jaw (resulting in clenching, grinding teeth during sleep, and TMJ, or temporomandibular joint pain), the head (tension headaches, migraines), the neck and shoulders, stomach (reflux, peptic ulcers, IBS, and even food allergies) and lower back.

“The human body is well adapted to deal with short-term stress, but if it remains on high alert for an extended period of time, you can grow vulnerable to some serious health problems,” said Lorentz. Major body control mechanisms respond to stress in different ways, from the nervous system’s “fight or flight” response release of adrenaline and cortisol to the endocrine system’s release of stress hormones triggering the liver to produce more blood sugar, to give you that kick of energy in the moment of perceived danger. Here, friends, is the start of your 2017 muffin-top (it’s not just all the holiday cookies and wine) — and worse, excess blood sugar can lead to diabetes. Other dangers of unmitigated stress involve the cardiovascular and immune system, digestive system and musculoskeletal system.

Leading me through a series of breathing exercises, shoulder rolls and arm movements in a chair — which are designed to be done in one’s office during prescribed five-minute breaks — Lorentz told me that taking short breaks during workdays are good news for workers and employers. Studies show decreased medical costs, less absenteeism, and an increase in productivity in workers who take measures to reduce stress daily during the workday.

Medical costs decrease approximately $3.27 for each dollar a business spends on wellness programs, according to the 2013 Aflac Workforces Report, and companies that implemented a wellness program for their employees, such as in-house yoga, meditation or chiropractic care experienced a 28 percent reduction in employees calling in sick, according to the Institute for Healthcare Consumerism. Seventy-six percent of wellness program participants say they’re happier, healthier, more energetic and have lost weight. To this end, Lorentz and Self Reboot have partnered with companies and insurance providers like Cigna to help over 40 brands, including Forbes, Lukoil, Major League Soccer, MaxMara, Morgan Stanley and Ralph Lauren.

Lorentz’s top tips for stressing less and savoring more of your life in 2017? First, move. “Our bodies were made to move, not to sit at a desk for eight hours,” she said. Try a 30-minute walk between meetings on a lunch break, or take a yoga or spin class.

Second, check in on your emotional wellness. “Having an optimistic approach to life and accepting things you can’t change is hard at times, but employing the six Happiness Habits recommended by therapists is a methodology for change.” Having gratitude daily, practicing self love and care, making sure your basic needs are met, being kind to others, and meditating are among those practices.

And finally, be attentive to your nutritional wellness. “Eat foods closest to their natural form, like vegetables, fruits, whole grains, nuts and legumes,” said Lorentz. “Stay clear of processed foods or foods high in sugar.”

Also, Lorentz suggests keeping a “basic needs” weekly journal at the start of 2017 and beyond in which you address what you eat and when you eat it, how much sleep you get, whether you exercise or not daily, how much water you drink, and if you have practiced mindfulness. “After a week of keeping an honest journal of your basic needs, you can usually see why you feel low energy, fatigued and blah,” she said. 

Interested in trying a free guided meditation or chair yoga, like the practice shown by Dawn Lorentz? Breathe on.

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My awful date with Donald Trump: The real story of a nightmare evening with a callow but cash-less heir

Donald Trump

(Credit: AP/G. Paul Burnett/Salon)

We’re re-running this story as part of a countdown of the year’s best personal essays. To read all the entries in the series, click here.

It was the early 1970s. I was about 23 at the time and he was in his late 20s. We met through friends talking at a bar. My friend knew his friends. It’s was a lively Upper East Side — considered cool at the time — spot. Still there and still considered a great place to go for a burger. A comfortable place for all generations. The tables are so close everyone feels like a friend. It’s cozy. This was over 40 years ago.

So I met a nice guy through friends at the bar and he asked me for my telephone number. He called me the next day and asked me out. Said he would pick me up around 7. I lived in a building with a doorman who called me on the house-phone to say my date was here. I locked and went downstairs expecting to see a guy standing out front with his hands in his pockets looking sheepish. Instead there was no one. Just a white Cadillac convertible. My date leaned over and said, “Hop in.” I didn’t know what to make of this. I lived in NYC and nobody ever picked me up in a car except to go to the airport. I was too surprised and flustered to be impressed. I felt like I was in a James Dean movie. If he wanted to impress me, a Cadillac wouldn’t do it, but if he got out of the car, and opened the door for me, then I would be impressed.

The interior was cherry red. The dashboard was red, even the steering wheel was red. It made me feel woozy. Like I was sitting someplace I shouldn’t. It was not the best start for a date.

The car had a phone in it. I had never been in a car with a telephone. I don’t know why, but I didn’t think it was special. I just thought, who is this guy with a funny last name? He picked it up and said where would you like to go for dinner? I’ll make a reservation. I had no idea. The only place I could think to go in a car was to Peter Luger’s in Brooklyn. He makes the reservation on the car phone and we go.

He was nice looking, not handsome, but nice. Preppy. Normal. Not a conversationalist, but neither was I. I didn’t think he was very bright.

The check came but the restaurant didn’t take credit cards. My date couldn’t pay for the dinner. This was the first thing I could relate to all evening. Me, Jewish girl, independent but not too, always had bad-date, worst-case-scenario, awkward-situation, get-home money.

So, my big shot, Cadillac, phone-in-convertible boring date couldn’t pay for dinner. He was stunned and embarrassed. I said, “Let’s get aprons and do the dishes. It would be fun.” His face was horror-stricken. He was flustered. Relax, I have the money. Oh, thank God. He swore he’d pay me back tomorrow so many times that I thought it not likely.

He never did. That may tell you something about my date with Donald Trump.

Should he get to the White House, I would love to be paid back with interest. If he doesn’t get to the White House, I consider this story enough of a payback.

 

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Reliving Agent Orange: What if casualties don’t end on the battlefield, but extend to future generations?

Vietnam War Fall Of Saigon Photo Gallery

FILE – In this April 30, 1975 file photo, a North Vietnamese tank rolls through the gates of the Presidential Palace in Saigon, signifying the fall of South Vietnam. The war ended on April 30, 1975, with the fall of Saigon, now known as Ho Chi Minh City, to communist troops from the north. (AP Photo/File) (Credit: AP)

There are many ways to measure the cost of U.S. involvement in the Vietnam War: in bombs (7 million tons), in dollars ($760 billion in today’s dollars) and in bodies (58,220).

Then there’s the price of caring for those who survived: Each year, the Department of Veterans Affairs spends more than $23 billion compensating Vietnam-era veterans for disabilities linked to their military service — a repayment of a debt that’s supported by most Americans.

But what if the casualties don’t end there?

The question has been at the heart of reporting by the Virginian-Pilot and ProPublica over the past 18 months as we’ve sought to reexamine the lingering consequences of Agent Orange, the toxic herbicide sprayed by the millions of gallons over Vietnam.

We’ve written about ailing Navy veterans fighting to prove they were exposed to the chemicals off Vietnam’s coast. About widows left to battle the VA for benefits after their husbands died of brain cancer. About scores of children who struggle with strange, debilitating health problems and wonder if the herbicide that sickened their fathers has also affected them.

Along the way, we noticed some themes: For decades, the federal government has resisted addressing these issues, which could ultimately cost billions of dollars in new disability claims. When science does suggest a connection, the VA has hesitated to take action, instead weighing political and financial costs. And in some cases, officials have turned to a known skeptic of Agent Orange’s deadly effects to guide the VA’s decisions.

Frustrated vets summarize the VA’s position this way: “Delay, deny, wait till I die.”

This month, after repeated recommendations by federal scientific advisory panels, Congress passed a bill directing the VA to pursue research into toxic exposures and their potential effects across generations. But even that will take years to produce results, years some ailing vets don’t have.

The questions we’ve posed have no easy answers. But science — and our own analysis of internal VA data — increasingly points to the possibility that Agent Orange exposure might have led to health problems in the children of veterans. And we can’t help but think of the words displayed at the entrance to the VA headquarters in Washington: “To care for him who shall have borne the battle and for his widow and his orphan.”

We noticed the phrase, a quote from Abraham Lincoln’s second inaugural address, during an evening stroll through D.C. in June, a day before hosting a forum on Agent Orange’s generational effects and policy implications. With us that night was Stephen M. Katz, the Virginian-Pilot photographer who initiated our reporting project when he shared the story of his estranged father, a Vietnam vet who’d gotten back in touch to warn that he’d sprayed Agent Orange.

Does the VA’s motto apply to Katz? His brother born before the war is healthy. At 46, Katz suffers from myriad health problems, including a heart defect, type-2 diabetes, an underactive thyroid, immune and endocrine deficiencies, and a nerve disorder that severely limits the use of his right hand.

What about the thousands of other children of Vietnam veterans who shared their stories with us over the past year? What about the children of Gulf War veterans exposed to depleted uranium? The children of Iraq and Afghanistan war veterans exposed to toxic burn pits? The children of future service members exposed to yet unknown toxins on the modern battlefield?

What responsibility — if any — does a nation have to those who weren’t drafted into service, but who may have been harmed nonetheless?

We posed the question to Dr. Ralph Erickson, the VA’s chief consultant of post-deployment health services, who’s involved with the agency’s research efforts. Erickson, who’s had the job since last year, wouldn’t comment on the VA’s past reluctance to study these issues, saying only that his team is committed to it.

And if research someday proves a wartime exposure has harmed veterans’ children or grandchildren? Erickson, whose father served in Vietnam, said that’s a question that would have to be answered by VA lawyers. We pressed him for his personal view, and he too cited Lincoln’s words. But even then, he said it was a “hypothetical” and didn’t directly answer the question.

Vietnam vet Mike Ryan thinks he knows what the answer will be. Nearly four decades ago, his family was among the first to draw widespread attention to the possibility that Agent Orange had harmed veterans’ children. His daughter, Kerry, suffered from 22 birth defects, including spina bifida and other physical deformities.

After his wife died in 2003, he was left to care for his daughter until her death three years later at the age of 35. Lifting her out of bed several times a day to use the bathroom had damaged his back, leaving Ryan bedridden and alone. When we first reached the 71-year-old at his home in Boca Raton, Florida, he was reluctant to retell his tragic story.

“What’s the point?” he said. “The government won’t ever take responsibility.”

In the end, Ryan agreed to talk. Maybe sharing his story one more time would help others get the recognition his daughter never received.

If that happened, Ryan said he could die in peace.

This story was co-published with the Virginian-Pilot.

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