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SUBSTANCE USE & MISUSE, 36(9&10), 1261–1274 (2001) Massachusetts College of Pharmacy, 179 Longwood Results of a 20-year study of mass media representationsof antidepressant medications and their use are presented.
The recent Prozac phenomenon stands out as a primaryexample of media-generated drug information for patients.
Various forms of mass media are important in providingperceptions of the effects, benefits, and safety of these newantidepressant drugs. Clinical research, however, suggeststhat the latest generation of antidepressant medications isno more effective in treating depressive symptoms than thefirst generation, tricyclic antidepressants. Yet, these new anti-depressants have become the model drug not only for treatingdepression, but also for cosmetic psychopharmacology.
[Translations are provided in the International AbstractsSection of this issue.] Copyright & 2001 by Marcel Dekker, Inc.
Prozac; Anti-depressant; Media study; Patient drug information; Cosmetic psychopharmacology Patient demand for specific prescription medications is a growing phenomenon, related to the growth in general consumer consciousness. Inaddition, patient demand in a social context has been influenced greatlyby changes in the marketing of products, in the amount and nature ofdrug information directly accessible to consumers, and in the ways inwhich new prescription products and medication use problems are reportedin the mass media.
Knowledge, attitudes and behaviors involving medications are gen- erated and directed by the perceptions that people hold regarding thespecific drug products they give and take. Great differences in knowledgeand behavior can occur between patients and health professionals.1 Patients seek beneficial drug products to help them achieve their goals of health and wellbeing. Drug users are rarely concerned about drug activityat the cellular or physiological level. They instead focus on drug effectsexhibited at physical and behavioral, or everyday life functioning, levels.
Most drug consumers have their conceptual system grounded in the drugexperience itself at the behavioral and personal levels.2 Effects attributed byusers to specific drug products are the primary reason for initial or continualuse of those medications.3 Health professionals, who prescribe medications, counsel patients, and provide drug information, tend to focus much more on the cellular andorganal levels of experience. In their perceptions of drug effects (in essence,they really focus on drug action), they often do not provide information thatthe patient or consumer needs, descriptions of drug effects at the behavioralor social level and the impact of drug use on their lives.
Health professionals’ perceptions, for example, highlight the activity of drugs at the molecular and cellular level. They assume most biologicalactivity equates directly to the basic physical and mental effects observed inusers. Health professionals seek optimal therapeutic effects, and they hopeto limit or prevent side effects. They focus, then, on organ systems and thephysiological and psychological, or clinical, responses they observe in theirpatients. Not all health professionals, however, perceive drugs in thismanner. Some of them may hold perceptions that are similar to patientsor that represent a different viewpoint of disease processes based onmind–body relationships and the power of the mind to affect physical states.
Drug use is an everyday occurrence experienced by most people either directly through the giving and taking of medicines, or indirectly throughinteractions with other people about their drug experiences. We have heardand read lately, for example, about serotonin and melatonin, natural drugsin our body, and about new medicines, like Prozac, that have activity onserotonin. What is the impact of various sources of information on thecreation of perceptions about drugs and drug use? Collective social knowledge has become instrumental in the develop- ment and transmission of perceptions about prescription medications,including psychoactive drugs like Prozac.1,4,5 Social knowledge refers tothe cumulative knowing of something, based mostly on available informa-tion and past experiences. What an individual or group of drug takersknows about drugs, from reading information, listening to the media andpromotional campaigns, receiving descriptions of others’ experiences, andrecalling their own previous experiences, will affect the actual use of drugs.1 Social knowledge, individually, represents that person’s awareness and understanding of concepts, phenomena, and events. A lack of social know-ledge about symptoms, illness, treatments, and medications allows a con-sumer to be affected more often by external factors and processes. Socialknowledge also has a symbolic component.1,6 The nature and meaning ofdrug taking often is described, remembered, and transmitted through asociety in a symbolic form, as images, representations, or metaphors. Theimagery and symbolism of some promotional campaigns and mass mediareports may suggest that a specific medication promises to solve problems ofhealth and life in mythical ways.
In addition to accounts and reports in newspapers, magazines, on television and radio (and also more recently, the Internet and related elec-tronic media), media-generated perceptions about drugs also are derivedthrough advertising.7 In the United States, direct-to-consumer advertisingis an increasingly popular approach wherein drug products are promotedfor poorly or newly defined health problems. It is the promotion of theavailability and/or characteristics of a prescription drug product to thegeneral public through mass media. These promotional campaigns consistof ads that inform or increase awareness about certain diseases and theavailability of treatment options, or ads that actually mention specificproducts. Some drug ads, recently, are not intended to increase awarenessabout a specific product, but rather, they guide or even dictate prescribingbehavior.8 A great deal of recent mass media activity has focused on the new antidepressant drugs (e.g., selective serotonin-reuptake inhibitors likeProzac). Many patients and health professionals believe that these newantidepressant drugs can improve a person’s way of living and evenchange the mood and feelings of healthy people, if they want to do so.
Patient advocates and drug consumer groups believe and report that someantidepressant drugs produce seizures and abnormal dreams, cause patientsto become suicidal, and are misused by people who are not really sick. Areall of these ‘‘effects’’ caused solely by a substance that has activity onserotonin in our bodies? Patients obtain information about the drugs they use from a variety of sources. Past surveys of patient-information seeking have indicated thatmedia sources, especially print media, television, and drug advertising, aremore important than health professionals in learning about new drugs andtheir effects. As part of an ongoing study of media (US) portraits of drugsand drug use, an analysis of the images and representations of new anti-depressant drugs and their use in mass media was performed.
This study examines what we know about certain antidepressant drugs, and how we have arrived at our current collective knowledge. Theprimary goal of this study was to identify specific media representations ofan antidepressant drug, Prozac, to examine these images in comparison withknown pharmacological and clinical information regarding this drug, and tobegin an assessment of the impact of these images on patients’s use andexperiences.
The data presented in the four tables herein come from a large scale review and analysis of American mass media over the past two decades. Inthe larger study of media representations of drugs and drug use, a systematicidentification, collection and analysis of various media sources has beenone method for determining how people perceive drugs and drug effects.
The primary sources of data are magazine and newspaper accounts andreports, drug advertisements in professional journals (and more recently,popular magazines with the advent of direct-to-consumer advertising),books for the general public, television, and a few related forms of media(e.g., theatrical plays, cinema, comics, and electronic media such as theInternet). One sub-category of data collection has been psychoactivedrugs, including antidepressants.
For popular magazines, major newspapers from large urban cities, books, cinema, and theatrical plays, databases and abstracting serviceshave provided the universe (or nearly so) of relevant items and eventsthat have involved antidepressant drugs. For instance, the best example isthe abstracting service, Reader’s Guide to the Periodical Literature, whichidentifies and categorizes stories and reports from all major national andregional popular magazines in the US. A similar newspaper database pro-vides information for 10 major urban newspapers in the US. Information onpublished books (Books In Print), cinema, and theatrical plays come fromguides and annual reviews of these media. Most of the other data andinformation has been collected in a non-random manner, due to a lack of(or lack of access to) a database for the other forms of mass media.
For antidepressant drugs, mass media reports and accounts have been collected as far back as 1970. For this study, however, the focus willbe on the past 10 years, approximately the time of the introduction of thefirst selective serotonin-reuptake inhibitor, Prozac. The results presented inthe four tables are derived from this large-scale media study. In a fewinstances, the results will provide some background information on all cur-rently available antidepressants to provide a social historical context to thediscussion.
The images, representations, and metaphors uncovered in this study are those labeled and defined by patients’ and health professionals’ based ontheir descriptions of antidepressant drugs they use. These metaphors aregenerated by different sources, identified through an analysis of massmedia, drug advertising, and societal discourse. The intended meaningand the reasons for the creation of these metaphors can vary, so it is impor-tant to note, if possible, when the source is the patient, the healer (or healthprofessional), the pharmaceutical manufacturer and promoter, the socialresearcher, or media commentators. In many instances, however, it isdifficult to know the original source of a metaphor, or there is the problemof a complex intertwining of a metaphor amongst different sources.
The results of this analysis of mass media representations of Prozac portray an extensive and deeply-rooted cultural awareness of this drug. Overthe past 20 years, the greatest frequency of magazine and newspaperaccounts and reports of antidepressant use has peaked during threetime periods (see Table 1). The first time period (1977–78) represented aprevious time of increased societal concern about depression, and the Reports on Antidepressants by Year and Month tricyclic antidepressants were the only drugs of choice. The second timeperiod (1980–82) represented a period during which a new (second) genera-tion of antidepressant drugs (tetracyclics and others like trazodone) wereintroduced to great expectations, that eventually were not fulfilled. The thirdand most recent climax of media interest about antidepressants representedthe Prozac phenomenon.
Magazine and newspaper reports of antidepressant use, including Prozac, occurred with greatest frequency in the months of March andOctober (Table 1). An explanation for October is apparent, in theNational Depression Screening Day takes place nationally early in thatmonth and other health and politically related events (in anticipation oflocal and national elections in early November) also occur with regularity.
No explanation has been ascertained yet as to why so many antidepressantstories occur in the month of March.
Much of the focus of reporting and subsequent societal response to Prozac in particular represented a renewed emphasis on the disease, depres-sion, by federal health agencies, health professional organizations, andpatient advocacy groups. While neurophysiologic and clinical researchhave centered on a biological basis for this disease, usually pertaining toneurotransmitter malfunction or genetic causes, the popular media hastaken almost any published study (regardless of the nature of inquiry orsoundness of methodology) and reported new personal, psychological, andsocial causes for depression (see Table 2). Thus, through the popular media,segments of the general public have come to think and believe that depres-sion is caused by leisure/pleasure time (holidays and vacations), or urban,technological, and industrial 20th century living, or even by a specific age orgender.
By the spring of 1990, Prozac was on the cover of Newsweek, Time, and the New Yorker, major popular magazines, being proclaimed as the newwonder drug and a new weapon in the fight against depression. In fact, theappearance of a Prozac capsule floating over a dry landscape on the coverNewsweek was the first time any prescription pharmaceutical product Neurotransmitter (organic) malfunctionOther illnesses/medical conditionsGeneticOther drug use/misuseStressors of life/lifestyle (modern, urban)Holiday seasonWinter (daylight hours)Summer vacationsWomen (esp. post-partum)Children (of the 1980s and 1990s)Traumatic events (in personal life)Later years (aging) (and any drug other than heroin, cocaine, or marijuana) had occurred onthat magazine’s cover in its history. Prozac exploded into the mass mediaand the public’s consciousness thereafter (1992–94) with a number of pop-ular books (e.g., Listening to Prozac, Talking Back to Prozac, and ProzacNation), a theatrical play (Prozac Sisters), electronic video game (VirtualProzac), and talk-show visits by enthused therapists (one, a psychologist inWenatchee, Wash., was even called the ‘‘Pied Piper of Prozac’’ for encourag-ing about 20–25% of that town’s adults to try the drug).
In these media reports, Prozac was referred to primarily as the Happy Pill, the Feel-Good Pill, and the Personality Pill. It was also presentedin some accounts as an ‘‘upper’’ (mood elevator or stimulant) and as‘‘speed’’ (slang term for amphetamines). Drug givers and takers employeda variety of images and metaphors to understand and describe their reasonsfor using Prozac and for the effects they experienced (see Table 3). Thesemetaphors for Prozac the drug range from those commonly applied to mostnew drugs (e.g., magic bullets, cure, safety net) to those seemingly unique tothis drug (e.g., like insulin for my mind/mood). The Prozac experience,effects attributed to this drug, represents a range of changes from thosewith some pharmacological or clinical basis (e.g., enhanced mood, betterlife) to those that have no known physiological basis (e.g., spiritual awaken-ing, or a new personality, especially in asymptomatic or non-diseased users).
These reports typically emphasized those sensational cases of drug use problems or successes, in order to sell newspapers or airtime, present apolitical agenda, or encourage a moral stance. In the case of Prozac, atten-tion created by newsmagazine cover stories, best selling books, numerous Metaphors for Prozac and the Prozac Experience episodes of talk-shows, and other mass media seems to have resulted in botha definition of Prozac and its effects, and an a notion of complete healthprofessional support, that arguably generated motivation in patients, andany sufferers of supposedly the symptoms of depression, to seek prescrip-tions for this drug.
Media accounts suggested that Prozac did a lot more than just influ- ence the amount of serotonin in a person’s body, extending notions aboutthe indications of use beyond those recognized and accepted by most healthprofessionals (see Table 4). For users, this drug obviously relieved condi-tions such as depression and PMS, and certain symptoms such as anxiety.
Users, however, also reported that Prozac produced other types of effects,such as: elevated or changed mood, nervousness, anorexia, insomnia,enhanced performance, a sense of calmness, reversed shyness, reduced andenhanced sex drive, changed personality even in non-depressed people(‘‘comestic psychopharmacology’’), enhanced spirituality, mania, drowsiness,tremor, dizziness, weight gain and weight loss, a feeling of being ‘‘out of it’’emotionally, excessive laughing or weeping, and a loss of concentration.9,10Early media reports (1990–94) referred to Prozac as the pill that will ‘‘cheeryou up without side effects’’ and described ‘‘how science will let you changeyour personality with a pill.’’11 In March 1994, Eli Lilly, after making untold millions of dollars from the sale of Prozac (in fact, one of two new large buildings attached to the Medical Versus Lay Views of Uses for Prozac AggressivenessLoss of concentrationPsychological problems in animals (pets) original skyscraper at the site of their corporate headquarters inIndianapolis is referred to by employees as the ‘‘House that ProzacBuilt’’), launched an astonishing advertising campaign. The campaign’sinformational, or perhaps promotional, focus was to condemn and suppo-sedly counter the ever-growing role of mass media in exaggerating the drug’smagical power and stunning effectiveness.12 A more recent popular book of anecdotal accounts from Prozac users, almost a decade after the drug’s introduction, has suggested diagnostic uses(though not approved indications) including: attention deficit hyperactivitydisorder, obesity, chronic fatigue syndrome, ulcers and other gastrointes-tinal disorders, and chronic pain.9 The ‘‘clinical’’ rationale for these uses, asstated by a promotional blurb on the book’s back cover, is that ‘‘in thesepages, the real experts – those who are taking antidepressants now – offerfrank testimonies that explore what it is like for them to take Prozac.’’ In thelatter part of 1997, advertising by Eli Lilly emphasized and celebrated the10th anniversary of this breakthrough drug discovery.
Mass media heightens public concern and interest about certain types of drug use, through its ability to provide opportunities for the expression ofexpert and lay viewpoints and by structuring meanings into recognizableimages and conceptions.13,14 Knowledge about depression and its treatmentis created through a process in which fragmentary, restricted knowledge iscontinually transformed into certain and consistent fact. This allows for the creation of technical and moral realities that are given form and meaningthrough collective social knowledge and beliefs, which can be invoked toencourage certain behaviors.
It seems mass media is becoming the primary source of drug informa- tion for many consumers. Little is known about many symptom statesand conditions that sometimes are considered diseases. In the real worldof medication use, humans often are not rational in making decisions touse drugs. Patients often are not aware, or made aware by health profes-sionals, of all possible treatment options in arriving at a therapeutic plan.
Access to information about drugs and their uses also is limited orcontrolled by the producer of the drug product. There appears to be asym-metry of medication information and its dissemination, a lack of objectiveinformation, and uncertainty in the definition, recognition, and diagnosisof diseases states. Many patients lack motivation to practice consumerbehaviors such as seeking information, exercising independent judgment,and understanding costs.
This phenomenon of labeling drugs, drug taking, and drug users has had an impact on the use of drugs in medical contexts. For instance, it hasbeen argued that the ritual of prescribing in a patient–physician encounterhas a significant symbolic component which can be beneficial, such as thecase of placebogenic phenomenon, or detrimental to optimal patient care,as in the case of increased patient demand for drugs and inappropriateprescribing.15 The act of taking a drug fulfills an ingrained habit: theneed to take something when confronted with illness. The culturally-basedinterpretation of depressive symptoms and responses to them provides foradditional symbols that attach meaning to, and thus understanding of, thedepression experience. And the healer’s act of prescribing a drug enhancesand solidifies the interaction, reinforces the healer’s power to cure, andprovides the patient with a sense of satisfaction and resolution to theproblem.
Media-generated representations of antidepressant drugs are influen- tial in the development of conceptions and attitudes toward specificprescription products and of meanings that are attributed to their effects.5,16These meanings, structured and expressed as symbols or metaphors, assistdrug users, health professionals, and general society in perceiving anddescribing drug-taking experiences, and in actually directing drug-takingbehaviors. These meanings also are reflected in social drug policy, societaldiscourse especially media accounts and promotional campaigns, anddrug laws and regulations. The meanings therefore are very important inconstructing social realities of antidepressant drug use, either personally orat the societal level.
With the dominance of biological reductionism in medicine and health care, there often are attempts to define problematic human behaviorssolely or ultimately in biological or biochemical terms. Medicalizationmay mystify the diagnosis and treatment of certain conditions, especiallythose with poorly-defined symptom states or diagnostic criteria.4,10 Theprocess of prescribing or suggesting a specific medication may reduce uncer-tainty and frustration for both the patient and physician, and it identifies thesolution to the problem. In essence, the symptom states become more clearlydefined in biological terms, and the diagnosis of a specific disease becomeseasier.
Imagery and symbolism of antidepressant drug advertisements can generate ideas in health professionals’, and also patients’, minds that prob-lems of health and life are easily or magically resolved by a substance.8,17There are many examples of antidepressant medications being promoted for‘‘problems of life,’’ including the inability to cope with ordinary tension andemotional pressures, difficulties in personal relationships, stressful occupa-tions, and living in urban settings or industrial societies.7 The notion devel-ops in consumers’ minds that there is a pill for every problem; whether it bea personal problem such as irritation caused by heavy rush-hour traffic,tension and stress from one’s job, or the inability to have daily bowel move-ments; or a social problem such as child abuse, drug use ‘‘epidemics’’, oreven certain criminal behaviors.
What do we truly know about specific antidepressant drugs, like Prozac, and how do various pharmaceutical and social factors influenceconstruction of personal and societal knowledge about them? The Prozacphenomenon is one example of the extraordinary variety of drug effects thatusers can attribute to a single chemical agent. By examining the nature andmeaning of known actions and effects for this drug, the relationship ofeffects between levels of experience (from cellular to behavioral to social),and the process of constructing and transforming this social knowledge, wecan gain a better understanding of reasons for drug use and the developmentof drug-use problems.
Fluoxetine, referred to mostly by its brand name Prozac, acts at the cellular level by inhibiting serotonin reuptake at the presynaptic neuro-nal membrane.18 Serotonin is a neurotransmitter, an inhibitor of activityand behavior, as well as a regulator of blood flow, food, temperatureand sex drives, and it also affects many other tissues and organ systems.
Fluoxetine also binds with receptors in other neurotransmitter systems.
Its precise mechanism of action, however, is still unknown. In fact, mechan-isms of action are unknown for all chemical types of antidepressants.
Behavioral pharmacology studies suggest it has almost no dependenceliability, though accounts of some users suggest otherwise. Long-term clinical outcomes and other effects from extended medical use have notbeen assessed in well-designed experimental studies for any of the promotedindications.
The US Food and Drug Administration (FDA) has warned some pharmaceutical companies about claims they have made for certainantidepressant drug effects in their advertising. While not approved forsuch indications by the FDA, companies still have promoted these drugsfor symptoms of PMS relief, chronic low-grade depression, weight lossand gain, and post-partum depression. One antidepressant (Zoloft) hasbeen promoted for treating patients suffering from depression afterheart attacks, though the company’s research suggests their drugactually produces rapid heartbeat, chest pain, and variations in bloodpressure.19 Despite theories about the relationship between the neurotransmitter serotonin and depression, the biochemical causes of depression are unclearand no useful biochemical test or marker for depression has been identifiedor developed. Most recent clinical reviews of Prozac and related third-generation antidepressants have found that they are no more effectivein alleviating the symptoms of depression than the first-generationtricyclic antidepressants.10 They offer symptomatic relief, but no cure.
Fluoxetine also has become the model drug in ‘‘cosmetic psychopharmacol-ogy,’’ the alteration of personality and behavior by ‘‘normal’’ healthypeople.
These days, virtually everyone diagnosed with depression is treated with an antidepressant medication. Most depressed patients are initiallyresistant to taking drugs, but eventually they are induced to do so andcome to accept a biological explanation for their condition. A great dealof societal attention has been focused on this drug. Media reports describehow scientific insights into the brain are raising the prospect of made-to-order, off-the-shelf personalities. Personal, social, and cultural effectsattributed to fluoxetine, under its brand name, may, in fact, have little todo with the drug’s activity on certain physiological systems.
Future research must focus on the growing impact of mass media accounts on both patients’ and health professionals perceptions of anti-depressant drugs. While the generation of media representations of anti-depressant drugs is clearly connected to users’ perceptions, their actualdependence on these notions with regard to decisions to use, or not touse, these drugs still remains unclear. And the ultimate impact of theseperceptions on actual experiences with antidepressant drugs may bethe foundation to understanding the future of treatment approaches todepression.
1. Montagne, M. The Pharmakon phenomenon: Cultural conceptions of drugs and drug use. In: Contested Ground: Public Concern and PrivateInterest in the Regulation of Pharmaceuticals, Davis, P., Ed.; OxfordUniversity Press: New York, 1996.
2. Morris, L.A.; O’Neal, E. C. Judgement’s About a Drug’s Effectiveness: The Role of Expectations and Outcomes. Drugs, Health Care 1975,2, 179–86.
3. Arluke, A. Judging Drugs: Patients’ Conceptions of Therapeutic Efficacy in the Treatment of Arthritis. Hum. Organization 1980, 39,84–88.
4. Lennard, H.L. Mystification and Drug Misuse. Jossey-Bass: San 5. Montagne M. The culture of long-term tranquillizer users. In: Understanding Tranquillizer Use: The role of the social sciences,Gabe, J., Ed.; Tavistock/Routledge: London, 1991.
6. Helman, C.G. ‘‘Tonic,’’ ‘‘Fuel,’’ and ‘‘Food’’: Social and Symbolic Aspects of the Long-term Use of Psychotropic Drugs. Soc. Sci. Med.
1981, 15B, 521–533.
7. Montagne, M., Ed. Drug Advertising and Promotion. J. Drug Issues 8. Goldman, R.; Montagne, M. Marketing Mind Mechanics: Decoding Antidepressant Drug Advertisements. Soc. Sci. Med. 1986, 22,1047–1058.
9. Elfenbein, D., Ed. Living With Prozac, and Other Selective Serotonin- Reuptake Inhibitors: Personal accounts of life on antidepressants.
HarperCollins: New York, 1995.
10. Karp, D.A. Speaking of Sadness: Depression, disconnection, and the meanings of illness. Oxford University Press: New York, 1996.
11. Anon. Beyond Prozac. Newsweek February 7, 36–40, 1994.
12. Anon. Listening to Eli Lilly: Prozac Hysteria Has Gone Too Far. Wall 13. Cohen, S. Current Attitudes About Benzodiazepines: Trial by Media.
J. Psychoact. Drugs 1983, 15, 109–113.
14. Morgan, J.P. Cultural and Medical Attitudes Toward Benzo- diazepines: Conflicting Metaphors. J. Psychoact. Drugs 1983, 15,115–120.
Substances. Drug Intell. Clin. Pharm. 1976, 10, 624–30.
16. Rhodes L.A. ‘‘This Will Clear Your Mind’’: The Use of Metaphors for Medication in Psychiatric Settings. Culture Med. Psychiatry 1984, 8,49–70.
17. Chapman, S. Advertising and Psychotropic Drugs: The place of Myth in Ideological Reproduction. Soc. Sci. Med. 1979, 13A, 751–64.
18. Feighner, J.P.; Boyer, W.F., Eds. Selective Serotonin Re-Uptake 19. Langreth, L. Pfizer Ordered to Alter Claims for Zoloft Uses. Wall Street Journal August 7, B1–2, 1996.
Michael Montagne, R.Ph., Ph.D., is Rombult Distinguished Professor ofPharmacy at MCPHS. He has taught and performed research for over20 years on the social and historical aspects of drug use and drug discovery.
He has co-authored books on drug development (Searching for MagicBullets: Orphan Drugs, Consumer Activism, and Pharmaceutical Development,1994 and Clinical Research in Pharmaceutical Development, 1996) and hasstudied drug use and drug advertising from a sociological perspective(‘‘Drug Advertising and Promotion,’’ Journal of Drug Issues, Volume 22,Spring, 1992). He teaches courses on ‘‘Drugs and Society,’’ ‘‘Pharmacoepi-demiology,’’ and ‘‘Drug Education.’’ His current research focuses on thegrowing alternative therapy movement in the US and on literacy issues inmedication use.
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