Final Words

A month ago a woman with Alzheimer’s was admitted to the room directly below mine; we both face on the employee parking lot. She screams continuously. “Hello? Hello? Hello? Help! Help! Call 9-1-1! Stop hurting me!” The staff who serves me tells of getting out of their car in the parking lot and wondering “What is that? Who is screaming?”


It is one of their own who is screaming, and management says there is nothing they can do about it. I am living with her torment 24/7. Nobody else is. Staff can walk away from it. I can’t. They say they can’t medicate her.


My final request is that you medicate me to protect the staff because I cannot stop screaming at them. They believe that it is bad behavior and that I can control it. I can’t. It is not interpersonal. One indicator of that is that I am sitting here screaming at my computer, too.


Yesterday I went to an in-house clothing sale and had a complete meltdown. I cried and screamed all morning, then I got a dose of hydrocodone and slept for six hours without waking. It was the best six hours since I came to James Square. Ate supper, took more hydrocodone, slept another six hours. Woke up and started screaming at the nurse. Then crying uncontrollably.


I am in torment, but the order has been that they can’t medicate me because it makes me worse. Now, we have to medicate me. If that means keeping me “asleep” 24 hours a day, then so be it.


I took antidepressants and other psychiatric medications every day for 26 years. The purpose of the physicians’ in prescribing psych meds was to change my brain function because they believed that mental illness was a function of the brain.


They are wrong. Most “mental illness” is the result of bad life experiences. That is true of both depression and schizophrenia. They should be treated with more and better talk therapy. Read other entries in this blog and in “Behind the Locked Doors.” I have an I.Q. of 139, 68 years of life experience, and mental illness: I know what I am talking about.


So, anyway. I took psych meds every day for 26 years. Do you know what that did to my brain? No, you don’t. There is no way to measure or image mental illness in the brain. There are no lab tests or scans that can render “mental illness” tangible. In fact, in the Physicians Desk Reference, after entries for antidepressants, are the words ‘The exact mechanism whereby this works are unknown.” Nevertheless, they keep prescribing antidepressants.


What is known is that antidepressants do change brain chemistry. Go ask Dr. Peter Breggin, who has studied the damage and knows. Or ask me (e.g., read my other blog) because I know. In 2001, I stopped taking antidepressants. And recovered my mind. And became one kick-ass activist. See also “Resume of an Activist.”


I have to hurry and finish this. I’ve taken the pain killer and it’s putting me to sleep. That quickly, life becomes death.


Nobody knows how antidepressants change the brain, but they surely do. And when you stop taking antidepressants after 26 years, nobody knows what’s left, but I do. It is crazy to expect the brain to revert to the way it was 26 years before. Nobody knows what happens next, but I do.


There are a lot of research papers written about what happens in the first six weeks of withdrawing from antidepressants. It is the acute phase, and it is known and studied. But what about one year? What about five years? What about eleven years? What about end of life? Nobody knows.


Except me.


About three years ago, at eleven years post-antidepressants, my glucose stopped responding to diet and exercise. And every time I tried to take insulin it made me suicidal. And the aides responsible for my care judged me instead of believing me. My glucose has been between 350 and 650 for three or four years.


There is nobody in this country who knows what happens when you take antidepressants for 26 years, stop taking them for 14 years, have SEID that damages the immune system, and have hyperglycemia.


For years, my ex-psychiatrist and I have agreed that I cannot take any psych meds for anything. We both want me to get acupuncture four days a week. But for most of the past three years I have been in nursing homes or hospitals on Medicare or Medicaid.


Medicare and Medicaid will not pay for acupuncture. Hospitals and nursing homes will not let patients be treated with acupuncture. And I can’t take drugs. And several years of uncontrolled diabetes has been eating up every part of my body. And my brain. A psychiatrist who specialized in geriatrics said, ‘With old age come the breakdown of kidneys, pancreas, and every other organ. The brain is the most sensitive organ there is. Of course, it breaks down!’


I am now at the point where all I can do is scream and cry. If I had cancer, you would not leave me to suffer. I was fucked by psychiatrists and pharmaceutical companies. Now it is end-times. I am in a nursing home, bed-ridden and suffering. I live in community and the staff doesn’t want to take care of me because I am such a bitch.


I am not a bitch. I am suffering—and causing those around me to suffer—because of the damage done by psychiatrists prescribing pharmaceuticals when I had SEID/myalgic encephalomyelitis. Now you have to put a stop to it. If that means keeping me sedated 24/7 then so be it and amen.


If the drugs that are needed to block my pain turn out to be lethal, then so be that, too. Just remember: if you live by the pill bottle then you die by the pill bottle. Antidepressants do not cure depression.

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    Comment from

I have a true story I want to share, a voluntary ER visit, turned into destroying my life, I had no prior history, I was in a mental health crisis I have learned they call it in the REAL world of medicine! It was a 1x incident. But I can tell you this story needs to go to a public, and it may just do that soon, because you see when mislabeled in the mental health system, you now have a stigma to live with, fraud in procedures, hospital violations, and continuous errors entered into reports have lead me to be in the system over four years, until now they have been caught, documents show catastrophic errors made.

I need to also find legal assistance, this did not happen at any of the hospitals listed here, but this story, my story, may just make laws change. It is inexcusable please let me know if anyone here can direct me who to report this too, bottom line delay of diagnosis, fraud many counts including Medicare part A, all wrong psychiatric drugs, now weaned from all, wrong treatment, which was illegal, battery, this all has to do with, no assessment, a assumed provisional diagnosis that never was looked into, patient boarding, and transfer to wrong part of this same hospital!

This ER also had yes a CPEP within it, documents show this, so you see it was not just the program, the intake report CPEP, is most accurate, however, I never got to the CPEP unit for 72-hour observation, medical treatment, assessment, diagnosis, care and treatment! Instead I was locked up in the 292 ICU for the mentally ill! Irreversible damage has been done throughout all this time. We need changes to be done, I know this most likely has happened to others, who never figured out what had happened to them, or their loved one, it was NOT a ER I walked into for bizarre behavior with psychotic FEATURES, but was in fact also housed the CPEP program, where I was mistaken for a psychiatric patient, kidnapped into this mental health care system, kept on toxic drugs, brain damaging, etc.

The list of damages due are huge, and well deserved accountability will be had! How many other people became victim, as I have, and still in the system, alone, scared, most likely drugged, etc.? And families do not know this can and does happen, I was one of the lucky? To find these truths out about my records.

My life destroyed along this very long, endless path, but now justice needs to be had, accountability for my life that has been like falling dominoes one-by-one, as I lost everything I loved, everything I had, took a lifetime to build, but most of all, I lost myself, and who I was, forever changed. I want accountability, compensation, and then these false mental health records court sealed, and I have documents to do so. I just need the right direction to go and the right people to help me get closure to this nightmare. Anyone?

    Anne’s reply

One: follow the money. Your complaints should start with whoever is paying for what you consider mistreatment. Medicare is one place to file complaints. You also can complain to the agency that guarantees the hospital [can’t think at the moment what this is called]. File complaints against everyone whom you think damaged you. File complaints against the licenses of nurses, doctors and anyone else whom you think behaved wrongfully. In NYS, file with the Dept. of Health, Office of Professional Misconduct, for doctors; Dept. of Education for psychologists and others.

“Wrong treatment” is not necessarily illegal. If the treatment that was provided to you was the standard of care at the time, then it is legal. If you received a lobotomy in 1950, then it would have been considered a good thing; if it was done last year then the physician would be liable.

ERs do not have CPEPs “in” them. Basically, a CPEP is a free-standing psychiatric emergency room that is parallel to a medical emergency room. CPEPs do not provide 72-hour observation, medical treatment, or psychiatric care or treatment. They assess the presenting problem, medicate as appropriate, and then move the patient out to home or inpatient, as appropriate.

In NYS, any two physicians can commit you to inpatient psychiatry. You do not get “mistaken” for a psychiatric patient; you get diagnosed based on your behavior at the time of the examination.

You need a lawyer. People diagnosed with mental illness rarely can afford one. “I lost myself, and who I was, forever changed.” I know. I had it happen to me. There should be accountability and compensation. There won’t be.

I know of no way for you to get what you want and deserve. Good luck trying, and keep us advised if you have any success.

The psychiatric system sucks. I wouldn’t put the odds of getting justice at more than one in one hundred thousand.

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You, Too, Can Have a Psychiatric Disorder

Anne C Woodlen: Notes in Passing

Anne C. Woodlen

Attention deficient disorder (ADD) is a disease wherein the person (hereinafter referred to as a “child” since it is usually diagnosed while a person is in elementary school) is said to be unable to pay attention.  This is like saying a child is unmotivated.  Fact is, all children are motivated—they’re just not motivated to do what you want them to do.  Likewise, children with ADD are paying attention—they’re just not paying attention to what you want them to.  The teacher is pointing to the blackboard but the child is “distracted” by the birdie on the windowsill.  We call this a “sickness.”  It is a disease state, a mental disorder, an illness.

When Dan, Michael, and Joel had it, back in biblical times, we called it “survival.”  Ancient man—as far back as cave man—survived by noticing things like the birdie that suddenly flew up out of the jungle…

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Your/My Homeopathic Remedy

“Anne, you mentioned that you did work with a naturopath and were using magnesium to ameliorate your binge eating.  Can you tell me more about that?”

Reader, I am working with a homeopath, not a naturopath—big difference.  I am taking mercurous acetate, not magnesium, and it is not for binge eating, it is for over-all healing.  In the process of recovery, I have achieved a level of emotional stability that I have not had in decades.  Homeopathy is doing good things that no psych med ever did.

However—and this is a big HOWEVER—do not go out and buy mercurous acetate and expect it to work for you.  This is NOT a remedy that is designed to cure all psych ills; it is a remedy that was chosen by the homeopath specifically to heal MY ills.  Homeopathic remedies are a very precise fit for a specific individual.  Mercurous acetate is not a cure for depression; it is a cure for Annie.

My worst problem is the damage that pharmaceuticals have done to my immune system.  You may have a perfectly healthy immune system but your agonies may be coming from some entirely different source.  Depression can come from psychosocial, biomechanical, biochemical or environmental sources.  Other emotional distress can have other roots.

Go see a good homeopathic practitioner.  Let him/her do what they are trained to do and figure out what remedy is right for you.  I STRONGLY RECOMMEND homeopathy.  It is healing without harm.  But it is not a do-it-yourself project.  Anne

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Recovery, Chronic Fatigue and Depression (Part II)

Healthy diet
I have diabetes mellitus, type 2, and am overweight. My glucose was too high so I worked with a dietician to get on a proper healthy diet. For people with diabetes, the hemoglobin A1C test results should be under 7; mine were. After a couple years I went to another dietician for more refined work in diet management. My typical menu is—
Breakfast Lunch and dinner Bedtime snack
1 c. juice 4 oz. protein I tend to lose my grip
1 c. cereal ½ c. starch and go bonkers
½ c. fruit 2/3 c. vegetables
1 c. 2% milk ½ c. ice cream

I learned that there is a hormone that increases your appetite when you are tired. Your body is basically saying “If you are not going to let me get energy from sleep then you’ve got to let me get energy from more food.” Eight hours sleep at night and two one-hour naps during the day weren’t enough to curb my appetite at night.

Creative expression
Creativity knits together mind, spirit and emotions. It draws on memories of the past and hopes for the future. It integrates and heals the human being.
My choice of creative expression always has been writing. By November 2010, I was writing two thousand-word blogs every day, one for “Behind the Locked Doors” [] about depression and the treatment thereof. The other blog, “Notes in Passing” [] is about everything else that I find interesting.

I joined an exercise class designed by Dr. Dale Avers, a physical therapist on the faculty of Upstate Medical University. It was for people between 55 and 92 years of age, particularly those who wanted to stay out of nursing homes. With great good spirit, we exercised hard for one hour twice a week. We were not sissies who sat in chairs and waved our arms around: we got down on the floor and worked up a sweat. By mid-2007, on a good day, I could walk a mile.

I come from a long line of farmers and my mother was an avid gardener. Around 2004, I got down on my knees and started gardening. There is nothing quite so healing as re-uniting with Mother Nature and finding the place where you fit in the greater scheme of things. Spiders are not allowed to live in my home; outdoors, I am not allowed to kill spiders. The time I spent talking to the worms was some of the best time in my life.

Caring for others
If you are not caring for others—and you are alive—then you are failing in your responsibilities as a human being. Everybody can do something, even if it is only bringing a smile to your caregivers. I could do much more than that: despite all my woes, God had given me intelligence and the capacity to think logically. I also had unlimited telephone service, a computer and a hospital bed. That was enough.

I became an activist on behalf of those who were poor and/or sick and/or elderly, particularly in regard to transportation. I took on the bus company (which had an annual budget of $40 million) because its paratransit subsidiary was providing substandard service to its 4000 riders. I took on Medicaid transportation, which was billing $8 million for equally substandard service to its 22,000 riders in Onondaga County. It took me seven years but the bus company had to buy half a million dollars’ worth of new short buses and completely revamp its eligibility process. The Medicaid transportation dispatch company got fined $80,000 and forced to sign the first-ever Corporate Integrity Agreement in New York State.

Here and there, working on my phone and computer from my hospital bed, I accomplished a few other things, too. []

And I had cured my depression. After 40 years of depression and 26 years of antidepressants, I no longer took drugs, saw a therapist or a psychiatrist, or got hospitalized. The cure for depression is action. Any time anything makes you feel bad, figure out what it is and then take action to change it. You can do it; I did.

And then, without me noticing it, it all began to go to hell. First, I no longer had enough energy to continue exercising. I blamed it on my living circumstances. I was living in a HUD-subsidized apartment building exclusively for people who were disabled. I’m sorry, but that’s fucking against the law. It’s called “segregation.” After much work, I established contact with the HUD field office director in Buffalo who understood the problem and said he would come take a look as soon a winter let up and it was safe to drive. Instead, Barak Obama got elected president and all the good guys got moved up one step. The good field director was replaced by a consummate bureaucratic asshole who couldn’t see the problem.

The 24-unit property was being managed by Christopher Community, the housing branch of the Catholic Church. They went through six managers in five years, ending with an ex-military bitch who told one middle-aged disabled man, “I couldn’t make my kids clean their rooms but I can make you.” I did everything I could think of to change the situation. Ultimately, there was nothing I could do except wait for a chance to move out. I believed that I had no energy because I was depressed and that once I changed my living situation then I would get un-depressed and my energy would come back.

I had learned that the cause of depression is the perception of powerlessness; once I got my power back then I would be all right.

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Recovery, Chronic Fatigue and Depression

When I was 14 years old, on a Friday afternoon I went to Nelda Jane’s house for the weekend.  She wanted to go horseback riding and swimming; I wanted to go to sleep or sit under a tree and read.  On Sunday afternoon, when her mother took me home, she suggested that my mother check my temperature.  It was sky high.

On Monday, Mom took me to the doctor, who said I had a strep infection and prescribed penicillin.  The following Sunday, I spent the day curled up in my father’s big chair, dozing but not eating or drinking.  My mother called the doctor, who said I was having a drug reaction and told her to stop the penicillin.  Within a day or two I was fine, but that was my first drug reaction.

Today there are a lot of drugs on the market to which you can react.  When this happened in 1960, there were far fewer drugs on the market.  I went for years rarely taking drugs except for menstrual cramps; I had reactions to a couple of the painkillers.  Another fourteen years passed, then, on the Saturday after Thanksgiving in 1974, my fiancé died.  Bob Dobrow was a fighter pilot in the Marine Corps; his plane crashed and his parachute didn’t open.  We had a funeral instead of a wedding.

A few months later, in my grief, I became terribly fatigued and unresponsive to stimuli so I went to a neurologist who diagnosed me with “endogenous” (i.e., indwelling) depression and prescribed antidepressants.  Thereafter, various psychiatrists told me that my depression was caused by a chemical imbalance in the brain and I would need to take antidepressants for the rest of my life.  I did take them every day for 26 years.

During that time, I did not complete my education, develop a career, continue to work, get married or have children.  I did get hospitalized on inpatient psychiatry about fifty times, spent a total of about three years in hospitals, and attempted suicide about a dozen times:  I was a “psychiatric patient.”

I also was badly damaged physically by the side effects of the antidepressants, which had caused multiple chronic illnesses including—in part or in whole—diabetes mellitus, diabetes insipidus, sleep apnea, pulmonary fibrosis, intestinal yeast infection, celiac disease, depression, morbid obesity, fibromyalgia, cataracts, left ventricular hypertrophy, right branch bundle block and a sexually transmitted disease, its name now forgotten.  I slept in a hospital bed, breathed pressurized air at night, traveled in a power wheelchair and had home health aides all the time.

In 2001, I did the unthinkable:  I stopped taking drugs.  And I started getting better.  The drugs had been killing me.

I developed a seven-point recovery plan that consisted of—

  1. Spiritual study and prayer
  2. Lots of sleep
  3. A healthy diet
  4. Creative expression, specifically writing
  5. Exercise, as tolerated
  6. Being in nature, particularly gardening
  7. Acting for the betterment of myself and others

And I went to every doctor to whom I was referred.  I was sick and nobody knew why.  Among other things, the symptomology suggested multiple sclerosis, lupus or scleroderma but the rheumatologists ruled out every autoimmune disease.  You go to a rheumatologist when there are no immunologists in your area.  In Syracuse, New York, where I live, the largest employer is the State University of New York (SUNY) Upstate Medical University and Hospital.  They employ about 10,000 people but if you call Upstate and ask for immunology, they transfer you to the pathology lab.  Johns Hopkins Division of Allergy and Immunology has eight physicians; Upstate has shut down its Allergy Clinic.

So there was no physician to inspect my immune system.  However, some doctor did diagnose me with chronic fatigue syndrome.  The doctors to whom I talked told me there was nothing to do about it, and all the research on the Internet said the same thing—it was 2002—so I just muddled along as best I could.  I learned what made me feel better and what made me feel worse, and relied substantially on my psychiatrist, who was a kind person and whose wife had lupus.  Dr. Nasri Ghaly literally lived with an autoimmune disease and understood the ups and down involved.  He ordered the hospital bed, the home health aides, and the electric wheelchair.

I worked my seven-point plan, which included reading the Holy Bible cover-to-cover several times, then moving on to the pagan bible, the Holy Koran, the Bhagavad Gita, and a couple of Buddhist books by Thich Nhat Hanh.  I was looking for the commonalities:  what did the world’s great religions agree on?  Ultimately, my creed evolved:  There is one Lord above all.  He calls us to humility before him; to care for one another; to tell the truth, and to work for justice.  That fit pretty tidily with my civic sense, which was stated as “All people share the right and the responsibilities to make the decision that affect their lives together.”

Healing takes place during sleep, so I worked long and hard to get restorative sleep.  Known to the British but concealed from people living under the Federal Drug Administration, Ativan should never be taken with a respiratory disorder.  I had sleep apnea and pulmonary fibrosis, nevertheless, was prescribed Ativan for years.  I was put on a CPAP (Continuous Positive Air Pressure) machine, and then a BiPAP (Bi-level Positive Air Pressure) machine.  Both left me in constant respiratory crisis.  I went to half the pulmonologists in the area, and all of the sleep laboratories.  Finally—after I threatened to file a complaint against his license—a pulmonary physician put me on an auto BiPAP.  Instead of being a fixed-state machine which the physician controls, it has a computer chip that re-sets with every breath the user takes.  It has a smartcard that revealed that my sleep apnea was unstable:  in a single night, I might draw a pressure from 7 to 21.  It took a decade of suffering before the medical industry finally got it right; I haven’t been back to a sleep lab in about six years.  I finally succeeded in getting restorative sleep.

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Taking the Fear Out

A new treatment for schizophrenia and other “mental illnesses”?

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Contrary to News Headlines, Robin Williams was on Drugs

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When $140,000 a Year Just Isn’t Enough

“Dr. Drug Rep”


Published: November 25, 2007

I. Faculty Development

On a blustery fall New England day in 2001, a friendly representative from Wyeth Pharmaceuticals came into my office in Newburyport, Mass., and made me an offer I found hard to refuse. He asked me if I’d like to give talks to other doctors about using Effexor XR for treating depression. He told me that I would go around to doctors’ offices during lunchtime and talk about some of the features of Effexor. It would be pretty easy. Wyeth would provide a set of slides and even pay for me to attend a speaker’s training session, and he quickly floated some numbers. I would be paid $500 for one-hour “Lunch and Learn” talks at local doctors’ offices, or $750 if I had to drive an hour. I would be flown to New York for a “faculty-development program,” where I would be pampered in a Midtown hotel for two nights and would be paid an additional “honorarium.”

I thought about his proposition. I had a busy private practice in psychiatry, specializing in psychopharmacology. I was quite familiar with Effexor, since I had read recent studies showing that it might be slightly more effective than S.S.R.I.’s, the most commonly prescribed antidepressants: the Prozacs, Paxils and Zolofts of the world. S.S.R.I. stands for selective serotonin reuptake inhibitor, referring to the fact that these drugs increase levels of the neurotransmitter serotonin, a chemical in the brain involved in regulating moods. Effexor, on the other hand, was being marketed as a dual reuptake inhibitor, meaning that it increases both serotonin and norepinephrine, another neurotransmitter. The theory promoted by Wyeth was that two neurotransmitters are better than one, and that Effexor was more powerful and effective than S.S.R.I.’s.

I had already prescribed Effexor to several patients, and it seemed to work as well as the S.S.R.I.’s. If I gave talks to primary-care doctors about Effexor, I reasoned, I would be doing nothing unethical. It was a perfectly effective treatment option, with some data to suggest advantages over its competitors. The Wyeth rep was simply suggesting that I discuss some of the data with other doctors. Sure, Wyeth would benefit, but so would other doctors, who would become more educated about a good medication.

A few weeks later, my wife and I walked through the luxurious lobby of the Millennium Hotel in Midtown Manhattan. At the reception desk, when I gave my name, the attendant keyed it into the computer and said, with a dazzling smile: “Hello, Dr. Carlat, I see that you are with the Wyeth conference. Here are your materials.”

She handed me a folder containing the schedule of talks, an invitation to various dinners and receptions and two tickets to a Broadway musical. “Enjoy your stay, doctor.” I had no doubt that I would, though I felt a gnawing at the edge of my conscience. This seemed like a lot of money to lavish on me just so that I could provide some education to primary-care doctors in a small town north of Boston.

The next morning, the conference began. There were a hundred or so other psychiatrists from different parts of the U.S. I recognized a couple of the attendees, including an acquaintance I hadn’t seen in a while. I’d heard that he moved to another state and was making a bundle of money, but nobody seemed to know exactly how.

I joined him at his table and asked him what he had been up to. He said he had a busy private practice and had given a lot of talks for Warner-Lambert, a company that had since been acquired by Pfizer. His talks were on Neurontin, a drug that was approved for epilepsy but that my friend had found helpful for bipolar disorder in his practice. (In 2004, Warner-Lambert pleaded guilty to illegally marketing Neurontin for unapproved uses. It is illegal for companies to pay doctors to promote so-called off-label uses.)

I knew about Neurontin and had prescribed it occasionally for bipolar disorder in my practice, though I had never found it very helpful. A recent study found that it worked no better than a placebo for this condition. I asked him if he really thought Neurontin worked for bipolar, and he said that he felt it was “great for some patients” and that he used it “all the time.” Given my clinical experiences with the drug, I wondered whether his positive opinion had been influenced by the money he was paid to give talks.

But I put those questions aside as we gulped down our coffees and took seats in a large lecture room. On the agenda were talks from some of the most esteemed academics in the field, authors of hundreds of articles in the major psychiatric journals. They included Michael Thase, of the University of Pittsburgh and the researcher who single-handedly put Effexor on the map with a meta-analysis, and Norman Sussman, a professor of psychiatry at New York University, who was master of ceremonies.

Thase strode to the lectern first in order to describe his groundbreaking work synthesizing data from more than 2,000 patients who had been enrolled in studies comparing Effexor with S.S.R.I.’s. At this time, with his Effexor study a topic of conversation in the mental-health world, Thase was one of the most well known and well respected psychiatrists in the United States. He cut a captivating figure onstage: tall and slim, dynamic, incredibly articulate and a master of the research craft.

He began by reviewing the results of the meta-analysis that had the psychiatric world abuzz. After carefully pooling and processing data from eight separate clinical trials, Thase published a truly significant finding: Effexor caused a 45 percent remission rate in patients in contrast to the S.S.R.I. rate of 35 percent and the placebo rate of 25 percent. It was the first time one antidepressant was shown to be more effective than any other. Previously, psychiatrists chose antidepressants based on a combination of guesswork, gut feeling and tailoring a drug’s side effects to a patient’s symptom profile. If Effexor was truly more effective than S.S.R.I.’s, it would amount to a revolution in psychiatric practice and a potential windfall for Wyeth.

One impressive aspect of Thase’s presentation was that he was not content to rest on his laurels; rather he raised a series of potential criticisms of his results and then rebutted them convincingly. For example, skeptics had pointed out that Thase was a paid consultant to Wyeth and that both of his co-authors were employees of the company. Thase responded that he had requested and had received all of the company’s data and had not cherry-picked from those studies most favorable for Effexor. This was a significant point, because companies sometimes withhold negative data from publication in medical journals. For example, in 2004, GlaxoSmithKline was sued by Eliot Spitzer, who was then the New York attorney general, for suppressing data hinting that Paxil causes suicidal thoughts in children. The company settled the case and agreed to make clinical-trial results public.

Another objection was that while the study was billed as comparing Effexor with S.S.R.I.’s in general, in fact most of the data compared Effexor with one specific S.S.R.I.: Prozac. Perhaps Effexor was, indeed, more effective than Prozac; this did not necessarily mean that it was more effective than the other S.S.R.I.’s in common use. But Thase announced that since the original study, he had analyzed data on Paxil and other meds and also found differences in remission rates.

For his study, Thase chose what was at that time an unusual measure of antidepressant improvement: “remission,” rather than the more standard measure, “response.” In clinical antidepressant trials, a “response” is defined as a 50 percent improvement in depressive symptoms, as measured by the Hamilton depression scale. Thus, if a patient enters a study scoring a 24 on the Hamilton (which would be a moderate degree of depression), he or she would have “responded” if the final score, after treatment, was 12 or less.

Remission, on the other hand, is defined as “complete” recovery. While you might think that a patient would have to score a 0 on the Hamilton to be in remission, in fact very few people score that low, no matter how deliriously happy they are. Instead, researchers come up with various cutoff scores for remission. Thase chose a cutoff score of 7 or below.

In his study, he emphasized the remission rates and not the response rates. As I listened to his presentation, I wondered why. Was it because he felt that remission was the only really meaningful outcome by which to compare drugs? Or was it because using remission made Effexor look more impressive than response did? Thase indirectly addressed this issue in his paper by pointing out that even when remission was defined in different ways, with different cutoff points, Effexor beat the S.S.R.I.’s every time. That struck me as a pretty convincing endorsement of Wyeth’s antidepressant.

The next speaker, Norm Sussman, took the baton from Thase and explored the concept of remission in more detail. Sussman’s job was to systematically go through the officially sanctioned “slide deck” — slides provided to us by Wyeth, which we were expected to use during our own presentations.

If Thase was the riveting academic, Sussman was the engaging populist, translating some of the drier research concepts into terms that our primary-care-physician audiences would understand. Sussman exhorted us not to be satisfied with response and encouraged us to set the bar higher. “Is the patient doing everything they were doing before they got depressed?” he asked. “Are they doing it even better? That’s remission.” To further persuade us, he highlighted a slide showing that patients who made it all the way to remission are less likely to relapse to another depressive episode than patients who merely responded. And for all its methodological limitations, it was a slide that I would become well acquainted with, as I would use it over and over again in my own talks.

When it came to side effects, Effexor’s greatest liability was that it could cause hypertension, a side effect not shared by S.S.R.I.’s. Sussman showed us some data from the clinical trials, indicating that at lower doses, about 3 percent of patients taking Effexor had hypertension as compared with about 2 percent of patients assigned to a placebo. There was only a 1 percent difference between Effexor and placebo, he commented, and pointed out that treating high blood pressure might be a small price to pay for relief from depression.

It was an accurate reading of the data, and I remember finding it a convincing defense of Effexor’s safety. As I look back at my notes now, however, I notice that another way of describing the same numbers would have been to say that Effexor leads to a 50 percent greater rate of hypertension than a placebo. Framed this way, Effexor looks more hazardous.

And so it went for the rest of the afternoon.

Was I swallowing the message whole? Certainly not. I knew that this was hardly impartial medical education, and that we were being fed a marketing line. But when you are treated like the anointed, wined and dined in Manhattan and placed among the leaders of the field, you inevitably put some of your critical faculties on hold. I was truly impressed with Effexor’s remission numbers, and like any physician, I was hopeful that something new and different had been introduced to my quiver of therapeutic options.

At the end of the last lecture, we were all handed envelopes as we left the conference room. Inside were checks for $750. It was time to enjoy ourselves in the city.

II. The Art and Science of Detailing

Pharmaceutical “detailing” is the term used to describe those sales visits in which drug reps go to doctors’ offices to describe the benefits of a specific drug. Once I returned to my Newburyport office from New York, a couple of voice-mail messages from local Wyeth reps were already waiting for me, inviting me to give some presentations at local doctors’ offices. I was about to begin my speaking — and detailing — career in earnest.

How many doctors speak for drug companies? We don’t know for sure, but one recent study indicates that at least 25 percent of all doctors in the United States receive drug money for lecturing to physicians or for helping to market drugs in other ways. This meant that I was about to join some 200,000 American physicians who are being paid by companies to promote their drugs. I felt quite flattered to have been recruited, and I assumed that the rep had picked me because of some special personal or professional quality.

The first talk I gave brought me back to earth rather quickly. I distinctly remember the awkwardness of walking into my first waiting room. The receptionist slid the glass partition open and asked if I had an appointment.

“Actually, I’m here to meet with the doctor.”

“Oh, O.K. And is that a scheduled appointment?”

“I’m here to give a talk.”

A light went on. “Oh, are you part of the drug lunch?”

Regardless of how I preferred to think of myself (an educator, a psychiatrist, a consultant), I was now classified as one facet of a lunch helping to pitch a drug, a convincing sidekick to help the sales rep. Eventually, with an internal wince, I began to introduce myself as “Dr. Carlat, here for the Wyeth lunch.”

The drug rep who arranged the lunch was always there, usually an attractive, vivacious woman with platters of gourmet sandwiches in tow. Hungry doctors and their staff of nurses and receptionists would filter into the lunch room, grateful for free food.

Once there was a critical mass (and crucially, once the M.D.’s arrived), I was given the go-ahead by the Wyeth reps to start. I dove into my talk, going through a handout that I created, based on the official slide deck. I discussed the importance of remission, the basics of the Thase study showing the advantage of Effexor, how to dose the drug, the side effects, and I added a quick review of the other common antidepressants.

While I still had some doubts, I continued to be impressed by the 10 percent advantage in remission rates that Effexor held over S.S.R.I.’s; that advantage seemed significant enough to overcome Effexor’s more prominent side effects. Yes, I was highlighting Effexor’s selling points and playing down its disadvantages, and I knew it. But was my salesmanship going to bring harm to anybody? It seemed unlikely. The worst case was that Effexor was no more effective than anything else; it certainly was no less effective.

During my first few talks, I worried a lot about my performance. Was I too boring? Did the doctors see me as sleazy? Did the Wyeth reps find me sufficiently persuasive? But the day after my talks, I would get a call or an e-mail message from the rep saying that I did a great job, that the doctor was impressed and that they wanted to use me more. Indeed, I started receiving more and more invitations from other reps, and I soon had talks scheduled every week. I learned later that Wyeth and other companies have speaker-evaluation systems. After my talks, the reps would fill out a questionnaire rating my performance, which quickly became available to other Wyeth reps throughout the area.

As the reps became comfortable with me, they began to see me more as a sales colleague. I received faxes before talks preparing me for particular doctors. One note informed me that the physician we’d be visiting that day was a “decile 6 doctor and is not prescribing any Effexor XR, so please tailor accordingly. There is also one more doc in the practice that we are not familiar with.” The term “decile 6” is drug-rep jargon for a doctor who prescribes a lot of medications. The higher the “decile” (in a range from 1 to 10), the higher the prescription volume, and the more potentially lucrative that doctor could be for the company.

A note from another rep reminded me of a scene from “Mission: Impossible.” “Dr. Carlat: Our main target, Dr. , is an internist. He spreads his usage among three antidepressants, Celexa, Zoloft and Paxil, at about 25-30 percent each. He is currently using about 6 percent Effexor XR. Our access is very challenging with lunches six months out.” This doctor’s schedule of lunches was filled with reps from other companies; it would be vital to make our sales visit count.+

Naïve as I was, I found myself astonished at the level of detail that drug companies were able to acquire about doctors’ prescribing habits. I asked my reps about it; they told me that they received printouts tracking local doctors’ prescriptions every week. The process is called “prescription data-mining,” in which specialized pharmacy-information companies (like IMS Health and Verispan) buy prescription data from local pharmacies, repackage it, then sell it to pharmaceutical companies. This information is then passed on to the drug reps, who use it to tailor their drug-detailing strategies. This may include deciding which physicians to aim for, as my Wyeth reps did, but it can help sales in other ways. For example, Shahram Ahari, a former drug rep for Eli Lilly (the maker of Prozac) who is now a researcher at the University of California at San Francisco’s School of Pharmacy, said in an article in The Washington Post that as a drug rep he would use this data to find out which doctors were prescribing Prozac’s competitors, like Effexor. Then he would play up specific features of Prozac that contrasted favorably with the other drug, like the ease with which patients can get off Prozac, as compared with the hard time they can have withdrawing from Effexor.

The American Medical Association is also a key player in prescription data-mining. Pharmacies typically will not release doctors’ names to the data-mining companies, but they will release their Drug Enforcement Agency numbers. The A.M.A. licenses its file of U.S. physicians, allowing the data-mining companies to match up D.E.A. numbers to specific physicians. The A.M.A. makes millions in information-leasing money.

Once drug companies have identified the doctors, they must woo them. In the April 2007 issue of the journal PLoS Medicine, Dr. Adriane Fugh-Berman of Georgetown teamed up with Ahari (the former drug rep) to describe the myriad techniques drug reps use to establish relationships with physicians, including inviting them to a speaker’s meeting. These can serve to cement a positive a relationship between the rep and the doctor. This relationship is crucial, they say, since “drug reps increase drug sales by influencing physicians, and they do so with finely titrated doses of friendship.”

III. Uncomfortable Moments

I gave many talks over the ensuing several months, and I gradually became more comfortable with the process. Each setting was somewhat different. Sometimes I spoke to a crowded conference room with several physicians, nurses and other clinical staff. Other times, I sat at a small lunch table with only one other physician (plus the rep), having what amounted to a conversation about treating depression. My basic Effexor spiel was similar in the various settings, with the focus on remission and the Thase data.

Meanwhile, I was keeping up with new developments in the research literature related to Effexor, and not all of the news was positive. For example, as more data came out comparing Effexor with S.S.R.I.’s other than Prozac, the Effexor remission advantage became slimmer — more like 5 percent instead of the originally reported 10 percent. Statistically, this 5 percent advantage meant that only one out of 20 patients would potentially do better on Effexor than S.S.R.I.’s — much less compelling than the earlier proportion of one out of 10.

I also became aware of other critiques of the original Thase meta-analysis. For example, some patients enrolled in the original Effexor studies took S.S.R.I.’s in the past and presumably had not responded well. This meant that the study population may have been enriched with patients who were treatment-resistant to S.S.R.I.’s, giving Effexor an inherent advantage.

I didn’t mention any of this in my talks, partly because none of it had been included in official company slides, and partly because I was concerned that the reps wouldn’t invite me to give talks if I divulged any negative information. But I was beginning to struggle with the ethics of my silence.

One of my most uncomfortable moments came when I gave a presentation to a large group of psychiatrists. I was in the midst of wrapping up my talk with some information about Effexor and blood pressure. Referring to a large study paid for by Wyeth, I reported that patients are liable to develop hypertension only if they are taking Effexor at doses higher than 300 milligrams per day.

“Really?” one psychiatrist in the room said. “I’ve seen hypertension at lower doses in my patients.”

“I suppose it can happen, but it’s rare at doses that are commonly used for depression.”

He looked at me, frowned and shook his head. “That hasn’t been my experience.”

I reached into my folder where I kept some of the key Effexor studies in case such questions arose.

According to this study of 3,744 patients, the rate of high blood pressure was 2.2 percent in the placebo group, and 2.9 percent in the group of patients who had taken daily doses of Effexor no larger than 300 milligrams. Patients taking more than 300 milligrams had a 9 percent risk of hypertension. As I went through the numbers with the doctor, however, I felt unsettled. I started talking faster, a sure sign of nervousness for me.

Driving home, I went back over the talk in my mind. I knew I had not lied — I had reported the data exactly as they were reported in the paper. But still, I had spun the results of the study in the most positive way possible, and I had not talked about the limitations of the data. I had not, for example, mentioned that if you focused specifically on patients taking between 200 and 300 milligrams per day, a commonly prescribed dosage range, you found a 3.7 percent incidence of hypertension. While this was not a statistically significant higher rate than the placebo, it still hinted that such moderate doses could, indeed, cause hypertension. Nor had I mentioned the fact that since the data were derived from placebo-controlled clinical trials, the patients were probably not representative of the patients seen in most real practices. Patients who are very old or who have significant medical problems are excluded from such studies. But real-world patients may well be at higher risk to develop hypertension on Effexor. +

I realized that in my canned talks, I was blithely minimizing the hypertension risks, conveniently overlooking the fact that hypertension is a dangerous condition and not one to be trifled with. Why, I began to wonder, would anyone prescribe an antidepressant that could cause hypertension when there were many other alternatives? And why wasn’t I asking this obvious question out loud during my talks?

I felt rattled. That psychiatrist’s frown stayed with me — a mixture of skepticism and contempt. I wondered if he saw me for what I feared I had become — a drug rep with an M.D. I began to think that the money was affecting my critical judgement. I was willing to dance around the truth in order to make the drug reps happy. Receiving $750 checks for chatting with some doctors during a lunch break was such easy money that it left me giddy. Like an addiction, it was very hard to give up.

There was another problem: one of Effexor’s side effects. Patients who stopped the medication were calling their doctors and reporting symptoms like severe dizziness and lightheadedness, bizarre electric-shock sensations in their heads, insomnia, sadness and tearfulness. Some patients thought they were having strokes or nervous breakdowns and were showing up in emergency rooms. Gradually, however, it became clear that these were “withdrawal” symptoms. These were particularly common problems with Effexor because it has a short half-life, a measure of the time it takes the body to metabolize half of the total amount of a drug in the bloodstream. Paxil, another short half-life antidepressant, caused similar problems.

At the Wyeth meeting in New York, these withdrawal effects were mentioned in passing, though we were assured that Effexor withdrawal symptoms were uncommon and could usually be avoided by tapering down the dose very slowly. But in my practice, that strategy often did not work, and patients were having a very hard time coming off Effexor in order to start a trial of a different antidepressant.

I wrestled with how to handle this issue in my Effexor talks, since I believed it was a significant disadvantage of the drug. Psychiatrists frequently have to switch medications because of side effects or lack of effectiveness, and anticipating this potential need to change medications plays into our initial choice of a drug. Knowing that Effexor was hard to give up made me think twice about prescribing it in the first place.

During my talks, I found myself playing both sides of the issue, making sure to mention that withdrawal symptoms could be severe but assuring doctors that they could “usually” be avoided. Was I lying? Not really, since there were no solid published data, and indeed some patients had little problem coming off Effexor. But was I tweaking and pruning the truth in order to stay positive about the product? Definitely. And how did I rationalize this? I convinced myself that I had told “most” of the truth and that the potential negative consequences of this small truth “gap” were too trivial to worry about.

As the months went on, I developed more and more reservations about recommending that Effexor be used as a “first line” drug before trying the S.S.R.I.’s. Not only were the newer comparative data less impressive, but the studies were short-term, lasting only 6 to 12 weeks. It seemed entirely possible that if the clinical trials had been longer — say, six months — S.S.R.I.’s would have caught up with Effexor. Effexor was turning out to be an antidepressant that might have a very slight effectiveness advantage over S.S.R.I.’s but that caused high blood pressure and had prolonged withdrawal symptoms.

At my next Lunch and Learn, I mentioned toward the end of my presentation that data in support of Effexor were mainly short-term, and that there was a possibility that S.S.R.I.’s were just as effective. I felt reckless, but I left the office with a restored sense of integrity.

Several days later, I was visited by the same district manager who first offered me the speaking job. Pleasant as always, he said: “My reps told me that you weren’t as enthusiastic about our product at your last talk. I told them that even Dr. Carlat can’t hit a home run every time. Have you been sick?”

At that moment, I decided my career as an industry-sponsored speaker was over. The manager’s message couldn’t be clearer: I was being paid to enthusiastically endorse their drug. Once I stopped doing that, I was of little value to them, no matter how much “medical education” I provided.

IV. Life After Drug Money

A year after starting my educational talks for drug companies (I had also given two talks for Forest Pharmaceuticals, pushing the antidepressant Lexapro), I quit. I had made about $30,000 in supplemental income from these talks, a significant addition to the $140,000 or so I made from my private practice. Now I publish a medical-education newsletter for psychiatrists that is not financed by the pharmaceutical industry and that tries to critically assess drug research and marketing claims. I still see patients, and I still prescribe Effexor. I don’t prescribe it as frequently as I used to, but I have seen many patients turn their lives around because they responded to this drug and to nothing else. +

In 2002, the drug industry’s trade group adopted voluntary guidelines limiting some of the more lavish benefits to doctors. While the guidelines still allow all-expenses-paid trips for physicians to attend meetings at fancy hotels, they no longer pay for spouses to attend the dinners or hand out tickets to musicals. In an e-mail message, a Wyeth spokesman wrote that Wyeth employees must follow that code and “our own Wyeth policies, which, in some cases, exceed” the trade group’s code.

Looking back on the year I spent speaking for Wyeth, I’ve asked myself if my work as a company speaker led me to do bad things. Did I contribute to faulty medical decision making? Did my advice lead doctors to make inappropriate drug choices, and did their patients suffer needlessly?

Maybe. I’m sure I persuaded many physicians to prescribe Effexor, potentially contributing to blood-pressure problems and withdrawal symptoms. On the other hand, it’s possible that some of those patients might have gained more relief from their depression and anxiety than they would have if they had been started on an S.S.R.I. Not likely, but possible.

I still allow drug reps to visit my office and give me their pitches. While these visits are short on useful medical information, they do allow me to keep up with trends in drug marketing. Recently, a rep from Bristol-Myers Squibb came into my office and invited me to a dinner program on the antipsychotic Abilify.

“I think it will be a great program, Dr. Carlat,” he said. “Would you like to come?” I glanced at the invitation. I recognized the name of the speaker, a prominent and widely published psychiatrist flown in from another state. The restaurant was one of the finest in town.

I was tempted. The wine, the great food, the proximity to a famous researcher — why not rejoin that inner circle of the select for an evening? But then I flashed to a memory of myself five years earlier, standing at a lectern and clearing my throat at the beginning of a drug-company presentation. I vividly remembered my sensations — the careful monitoring of what I would say, the calculations of how frank I should be.

“No,” I said, as I handed the rep back the invitation. “I don’t think I can make it. But thanks anyway.”

Daniel Carlat is an assistant clinical professor of psychiatry at Tufts University School of Medicine and the publisher of The Carlat Psychiatry Report.

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How Not To Be Depressed, part 2b

2b. Don’t get an autoimmune disease.

There is a relatively new area of medical investigation called PNIE—psychoneuroimmunoendocrinology. It says that how you feel emotionally is related to your nerves, your immune system, and your hormones. Who’d a thunk that your immune system has anything to do with your emotions? But it does. Ask anybody with multiple sclerosis (MS).

MS is an autoimmune disease, i.e., a disease caused by the immune system attacking the Self instead of behaving itself and only attacking Foreign Invaders. Autoimmune diseases are most prevalent among women, not men. This is thought to be because women must have a more complicated immune system than men for one major reason: women host the fetus. From the moment that sperm enters a woman’s body, her immune system has to accommodate both what is Self and not-Self, i.e., her DNA and her partner’s DNA. This poses a major problem because the immune system is supposed to reject what is not Self. Miscarriages may be the result of the mother’s immune system not being able to figure out that it is supposed to tolerate this particular foreign invader.

So a lot of women get MS and then they get depressed. Since the beginning of doctoring, male doctors have declared that women get depressed about a lot of things and getting depressed about having MS is just one of them. Prescribe antidepressants and move on. Ah, but no. Physicians have recently begun to realize (I thought they had known years ago—I certainly did) that people don’t get depressed ABOUT having MS. Multiple sclerosis IS the depression. The characteristics of MS include blurred vision, loss of balance, tingling, muscle weakness and depression. The body is making you depressed.

Rumor has it that hyperglycemia—chronic high blood sugar—and CFIDS—chronic fatigue immune dysfunction syndrome—also cause depression. My glucose has been over 350 (it’s supposed to be below 120) for several years. For the first couple of years I was dreadfully depressed. Now, after craniosacral therapy, homeopathic remedies, and such other alternatives, I no longer am depressed on a regular basis. So does uncontrolled diabetes really cause depression?

CFIDS, another autoimmune disease, is known internationally as myalgic encephalomyelitis and one of the world leaders in the treatment thereof is Dr. Sarah Myhill in Wales, who has treated over five thousand people. She says, “The main cause of depression in CFS [chronic fatigue syndrome] patients results from bad treatment by their physicians.” And there we have just done a 180-degree turnaround: the cause of depression is unexpressed anger; the cause of the anger is not having the power you need to live your life. Depression is caused by repressed anger at the dorkhead physicians who won’t listen or work cooperatively with you. The cure for this depression is to get mad at the physician. So he kicks you out of his practice—so what? He’s not doing you any good anyway. Better to move on without him.

Other people with autoimmune diseases often have been diagnosed as having psychiatric disorders. A psychiatrist whose wife has lupus told me that the initial diagnosis for lupus often is psychosis. People with autoimmune diseases are frequently found on inpatient psychiatry. Asthma, psoriasis, Crohn’s, celiac—all these and more are autoimmune diseases; go to for a long list of autoimmune diseases. Once you get one autoimmune disease then you are more susceptible to a second or third, and once you get an autoimmune disease then your emotional life is at risk.

Physicians know little to nothing about the immune system. You’ve got to be self-taught on this on. The director of hospitalists at one hospital told me he had learned more about the immune system from trying to treat me than he’d ever learned in medical school. They just aren’t teaching immunology. If you have an autoimmune disorder then you may have to see as many as a dozen physicians before you find one who gets it right. Rely heavily on your own research on the Internet, chat rooms, friends, and the grace of God to get a proper diagnosis. If you believe that your disturbance is in your body, not your mind, then stick to your guns. You cannot stop physicians from telling you that you’re crazy but you don’t ever, ever have to believe them.

I have myalgic encephalomyelitis, which is an autoimmune disorder that affects both the nervous system and the immune system. According to Dr. Myhill, one of the worst things you can do if you have this chronic fatigue syndrome is take antidepressants: I took them every day for 26 years. That is why I have spent the past decade in a wheelchair. Do you really want to risk going there?

The antidepressants, on top of the ME/CFIDS, totally fucked my immune system. By the time I stopped taking antidepressants in 2001, my immune system was reacting to makeup, jewelry, food, pets, a handmade quilt, any change in the weather—just about everything. And, most particularly, I have not been able to tolerate any pharmaceuticals for the past 15 years. Seriously. The antidepressants that were supposed to relieve my depression became the drug that was causing my depression.

Your immune system is your best friend. Treat it gently and with respect. Every time you take a pill your immune system comes running to evaluate what you’ve just ingested and then reacts to it. The first symptom of immune distress is fatigue, or—as the handout from the pharmacy says—tiredness, lethargy, exhaustion, listlessness, weakness, lassitude, low energy, drowsiness. Virtually every drug you take carries one of these words in the list of side effects. What they mean is that your immune system is fighting with your pharmaceuticals.

My psychiatrist had an atypical kidney infection and actually believed his physician who said that he had to take an antibiotic for four weeks. In week one, the twinkle went out of his eyes. Week two, he sighed and complained of being too tired. Week three, I told him it was his antibiotic but he didn’t believe me. By week four, he was talking about retiring. In week five, off the drug, he bounced back with a twinkle in his eye and a joke on his lips. From retirement to comedy in one week because he stopped his antibiotic. Take the lesson.

Do everything in your power to avoid taking pharmaceuticals. They are not benign; they are challenging your immune system, which can cause depression.

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