Publications by authors named "Lawrence H Yang"

79 Publications

Examining Power Relations to Understand and Address Social Determinants of Vaccine Uptake.

JAMA Psychiatry 2021 Sep 8. Epub 2021 Sep 8.

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.

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http://dx.doi.org/10.1001/jamapsychiatry.2021.2497DOI Listing
September 2021

Reducing Stigma Among Youth at Risk for Psychosis: A Call to Action.

Schizophr Bull 2021 Aug 17. Epub 2021 Aug 17.

Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.

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http://dx.doi.org/10.1093/schbul/sbab098DOI Listing
August 2021

The unaddressed mental health burden among cancer patients in China: a call to action.

Lancet Psychiatry 2021 08;8(8):646-647

Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY, USA; New York University Shanghai, Shanghai, China; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

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http://dx.doi.org/10.1016/S2215-0366(21)00180-2DOI Listing
August 2021

The stigma system: How sociopolitical domination, scapegoating, and stigma shape public health.

J Community Psychol 2021 Jun 11. Epub 2021 Jun 11.

Department of Human Development and Family Sciences, University of Delaware, Newark, Delaware, USA.

Stigma is a fundamental driver of adverse health outcomes. Although stigma is often studied at the individual level to focus on how stigma influences the mental and physical health of the stigmatized, considerable research has shown that stigma is multilevel and structural. This paper proposes a theoretical approach that synthesizes the literature on stigma with the literature on scapegoating and divide-and-rule as strategies that the wealthy and powerful use to maintain their power and wealth; the literatures on racial, gender, and other subordination; the literature on ideology and organization in sociopolitical systems; and the literature on resistance and rebellion against stigma, oppression and other forms of subordination. we develop a model of the "stigma system" as a dialectic of interacting and conflicting structures and processes. Understanding this system can help public health reorient stigma interventions to address the sources of stigma as well as the individual problems that stigma creates. On a broader level, this model can help those opposing stigma and its effects to develop alliances and strategies with which to oppose stigma and the processes that create it.
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http://dx.doi.org/10.1002/jcop.22581DOI Listing
June 2021

Stigma, Structural Vulnerability, and "What Matters Most" Among Women Living With HIV in Botswana, 2017.

Am J Public Health 2021 07 10;111(7):1309-1317. Epub 2021 Jun 10.

Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the Department of Psychology, University of Botswana, Gaborone, Botswana. Marlene M. Eisenberg and Michael B. Blank are with the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Lyla S. Yang is with the Columbia School of Social Work, Columbia University. Thi Xuan Dai Cao is with the Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada. Lilo I. Blank is with the College of Arts and Sciences, University of Rochester, Rochester, NY. Timothy D. Becker is with the Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY. Bruce G. Link is with the Department of Sociology, University of California Riverside. Patlo Entaile is with the Botswana‒UPenn Partnership, Gaborone. Philip R. Opondo is with the Department of Psychiatry, University of Botswana. Tonya Arscott-Mills is with the Perelman School of Medicine, University of Pennsylvania. Ari R. Ho-Foster is with the Faculty of Medicine, University of Botswana.

To explore whether beneficial health care policies, when implemented in the context of gender inequality, yield unintended structural consequences that stigmatize and ostracize women with HIV from "what matters most" in local culture. We conducted 46 in-depth interviews and 5 focus groups (38 individuals) with men and women living with and without HIV in Gaborone, Botswana, in 2017. Cultural imperatives to bear children bring pregnant women into contact with free antenatal services including routine HIV testing, where their HIV status is discovered before their male partners'. National HIV policies have therefore unintentionally reinforced disadvantage among women with HIV, whereby men delay or avoid testing by using their partner's status as a proxy for their own, thus facilitating blame toward women diagnosed with HIV. Gossip then defines these women as "promiscuous" and as violating the essence of womanhood. We identified cultural and structural ways to resist stigma for these women. Necessary HIV testing during antenatal care has inadvertently perpetuated a structural vulnerability that propagates stigma toward women. Individual- and structural-level interventions can address stigma unintentionally reinforced by health care policies.
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http://dx.doi.org/10.2105/AJPH.2021.306274DOI Listing
July 2021

Implementation of a pilot community-based psychosocial intervention for patients with psychoses in Chile and Brazil: a comparative analysis of users' perspectives.

Glob Ment Health (Camb) 2021 27;8:e15. Epub 2021 Apr 27.

Mailman School of Public Health, Columbia University, New York, NY, USA.

Background: Few studies provide clear rationale for and the reception of adaptations of evidence-based interventions. To address this gap, we describe the context-dependent adaptations in critical time intervention-task shifting (CTI-TS), a manualized recovery program for individuals with psychosis in Rio de Janeiro, Brazil and Santiago, Chile. Implications of the adaptations - incorporating a task-shifting approach and modifying the mode of community-based service delivery - are examined from users' perspectives.

Methods: A secondary analysis of in-depth interviews with CTI-TS users ( = 9 in Brazil; = 15 in Chile) was conducted. Using the framework method, we thematically compared how participants from each site perceived the main adapted components of CTI-TS.

Results: Users of both sites appreciated the task-shifting worker pair to provide personalized, flexible, and relatable support. They wanted CTI-TS to be longer and experienced difficulty maintaining intervention benefits in the long-term. In Chile, stigma and a perceived professional hierarchy toward the task-shifting providers were more profound than in Brazil. Engagement with community-based services delivery in homes and neighborhoods (Chile), and at community mental health centers (Brazil) were influenced by various personal, familial, financial, and social factors. Uniquely, community violence was a significant barrier to engagement in Brazil.

Conclusion: CTI-TS' major adaptations were informed by the distinct mental health systems and social context of Santiago and Rio. Evaluation of user experiences with these adaptations provides insights into implementing and scaling-up task-shifting and community-oriented interventions in the region through the creation of specialized roles for the worker pair, targeting sustained intervention effects, and addressing socio-cultural barriers.
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http://dx.doi.org/10.1017/gmh.2021.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157814PMC
April 2021

Sustained Effect of a Brief Video in Reducing Public Stigma Toward Individuals With Psychosis: A Randomized Controlled Trial of Young Adults.

Am J Psychiatry 2021 07 26;178(7):635-642. Epub 2021 Apr 26.

New York State Psychiatric Institute and Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York (Amsalem, Markowitz, Jankowski, Neria, Dixon); Department of Social and Behavioral Sciences, College of Global Public Health, New York University, New York (Yang, Lieff); Department of Epidemiology (Yang) and Department of Biostatistics (Valeri), Columbia University Mailman School of Public Health, New York; Department of Epidemiology, Columbia University Irving Medical Center, New York (Neria).

Objective: Public stigma is a barrier to care and increases the duration of untreated psychosis among individuals with first-episode psychosis. The authors recently demonstrated the efficacy of a 90-second social contact-based video intervention in reducing such stigma. That proof-of-concept study was the first to employ so brief an antistigma intervention in a sample of young adults. The authors now present a randomized controlled replication study with baseline, postintervention, and 30-day follow-up assessments. The authors aimed to replicate their previous findings and to show a persisting benefit for the video intervention.

Methods: Using a crowdsourcing platform (Amazon Mechanical Turk), the authors recruited and assigned 1,055 participants ages 18-30 years to a brief video-based intervention, to a written vignette intervention containing the same material, or to a nonintervention control condition. In the 90-second video, a 22-year-old African American woman with schizophrenia humanized the illness through her emotional description of living a meaningful and productive life.

Results: A three-by-three group-by-time multivariate analysis of variance showed a significant group-by-time interaction for the total scores of all five stigma-related domains: social distance, stereotyping, separateness, social restriction, and perceived recovery. Post hoc pairwise tests showed greater reductions in the video group compared with the vignette and control groups at the postintervention and 30-day follow-up assessments, while the vignette group differed from the control group at the postintervention assessment but not at the 30-day assessment.

Conclusions: This randomized controlled study replicated and strengthened the authors' earlier findings, further showing month-long sustained stigma reduction in the social contact-based video intervention arm. A 90-second video sufficed to humanize schizophrenia and reduce stigma. Further research should examine longer-term sustainability, assess changes in behavior, and determine optimal effective video length.
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http://dx.doi.org/10.1176/appi.ajp.2020.20091293DOI Listing
July 2021

Systematic Review of Cultural Aspects of Stigma and Mental Illness among Racial and Ethnic Minority Groups in the United States: Implications for Interventions.

Am J Community Psychol 2021 Apr 3. Epub 2021 Apr 3.

New York University School of Global Public Health, New York, NY, USA.

Stigma is integral to understanding mental health disparities among racial and ethnic minority groups in the United States. We conducted a systematic review to identify empirical studies on cultural aspects of mental illness stigma (public, structural, affiliative, self) among three racial and ethnic minority groups (Asian Americans, Black Americans, Latinx Americans) from 1990 to 2019, yielding 97 articles. In comparison studies (N = 25), racial and ethnic minority groups often expressed greater public and/or self-stigma than White American groups. In within-group studies (N = 65; Asian American, n = 21; Black American, n = 18; Latinx American; n = 26), which were primarily qualitative (73%), four major cultural themes emerged: 1) service barriers including access and quality (structural stigma); 2) family experiences including concealment for family's sake, fear of being a burden, and stigma extending to family (affiliative stigma); 3) lack of knowledge about mental illness and specific cultural beliefs (public stigma); and 4) negative emotional responses and coping (self-stigma). These findings confirmed stigma has both similar and unique cultural aspects across groups. Despite this, few studies tested stigma reduction interventions (N = 7). These cultural insights can inform contextual change at the health systems and community levels to reduce stigma, and empowerment at the interpersonal and individual levels to resist stigma.
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http://dx.doi.org/10.1002/ajcp.12516DOI Listing
April 2021

Identifying "What Matters Most" to Men in Botswana to Promote Resistance to HIV-Related Stigma.

Qual Health Res 2021 Jul 25;31(9):1680-1696. Epub 2021 Mar 25.

Columbia University, New York, New York, USA.

Despite a comprehensive national program of free HIV services, men living with HIV in Botswana participate at lower rates and have worse outcomes than women. Directed content analysis of five focus groups ( = 38) and 50 in-depth interviews with men and women with known and unknown HIV status in Gaborone, Botswana in 2017 used the "what matters most" (WMM) and "structural vulnerability" frameworks to examine how the most valued cultural aspects of manhood interact with HIV-related stigma. WMM for manhood in Botswana included fulfilling male responsibilities by being a capable provider and maintaining social status. Being identified with HIV threatened WMM, which fear of employment discrimination could further exacerbate. Our findings indicate how cultural and structural forces interact to worsen or mitigate HIV-related stigma for urban men in Botswana. These threats to manhood deter HIV testing and treatment, but interventions could capitalize on cultural capabilities for manhood to promote stigma resistance.
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http://dx.doi.org/10.1177/10497323211001361DOI Listing
July 2021

Comparison of social cognition using an adapted Chinese version of the Reading the Mind in the Eyes Test in drug-naive and regularly medicated individuals with chronic schizophrenia and healthy controls in rural China.

Psychol Med 2021 Mar 16:1-13. Epub 2021 Mar 16.

Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA.

Background: Social cognition has not previously been assessed in treatment-naive patients with chronic schizophrenia, in patients over 60 years of age, or in patients with less than 5 years of schooling.

Methods: We revised a commonly used measure of social cognition, the Reading the Mind in the Eyes Test (RMET), by expanding the instructions, using both self-completion and interviewer-completion versions (for illiterate respondents), and classifying each test administration as 'successfully completed' or 'incomplete'. The revised instrument (RMET-CV-R) was administered to 233 treatment-naive patients with chronic schizophrenia (UT), 154 treated controls with chronic schizophrenia (TC), and 259 healthy controls (HC) from rural communities in China.

Results: In bivariate and multivariate analyses, successful completion rates and RMET-CV-R scores (percent correct judgments about emotion exhibited in 70 presented slides) were highest in HC, intermediate in TC, and lowest in UT (adjusted completion rates, 97.0, 72.4, and 49.9%, respectively; adjusted RMET-CV-R scores, 45.4, 38.5, and 34.6%, respectively; all p < 0.02). Stratified analyses by the method of administration (self-completed v. interviewer-completed) and by education and age ('educated-younger' v. 'undereducated-older') show the same relationship between groups (i.e. NC>TC>UT), though not all differences remain statistically significant.

Conclusions: We find poorer social cognition in treatment-naive than in treated patients with chronic schizophrenia. The discriminant validity of RMET-CV-R in undereducated, older patients demonstrates the feasibility of administering revised versions of RMET to patients who may otherwise be considered ineligible due to education or age by changing the method of test administration and carefully assessing respondents' ability to complete the task successfully.
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http://dx.doi.org/10.1017/S003329172100043XDOI Listing
March 2021

Stigma of Treatment Stages for First-Episode Psychosis: A Conceptual Framework for Early Intervention Services.

Harv Rev Psychiatry 2021 Mar-Apr 01;29(2):131-141

From the Department of Social and Behavioral Sciences, School of Global Public Health, New York University (Dr. Yang; Mss. Blasco and Lieff); Department of Epidemiology, Mailman School of Public Health, Columbia University (Dr. Yang and Mr. Mascayano); Johns Hopkins Bloomberg School of Public Health (Dr. Le); Clinical Psychology, Teacher's College, Columbia University (Mss. Li and Broeker); Division of Behavioral Health Services and Policy Research (Mr. Mascayano and Dr. Nossel), New York State Psychiatric Institute (Drs. Bello and Dixon), New York, NY; Department of Psychiatry, Columbia University Irving Medical Center, New York, NY (Drs. Bello, Nossel, and Dixon).

Abstract: Early intervention services (EIS; in the United States, Coordinated Specialty Care) can lead to substantial improvements in psychiatric symptoms and social functioning for individuals with first-episode psychosis who engage in treatment. Nevertheless, stigma associated with early intervention services can limit their full potential benefits by preventing or reducing participation. Drawing from Corrigan's "why try" model positing relationships between public and self-stigma, engagement in treatment services, and the EIS treatment model, this article proposes a framework that delineates how distinct forms of stigma are linked to given stages of treatment engagement in first-episode psychosis. We identify three phases of engagement: (1) community outreach, which has associations with public stigma; (2) the referral and evaluation process, which primarily has associations with self-stigma; and (3) EIS, which have associations with self-stigma and its psychosocial consequences. For each phase, we describe evidence-based strategies typically provided by EIS programs, using OnTrackNY as an exemplary model, to illustrate potential linkages in our conceptual framework. By specifying how distinct forms of stigma are associated with EIS treatment stages, this framework is intended to guide EIS programs in explicitly addressing stigma to optimize recovery of individuals with first-episode psychosis.
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http://dx.doi.org/10.1097/HRP.0000000000000288DOI Listing
March 2021

Understanding Users' Perspectives of Psychosocial Mechanisms Underpinning Peer Support Work in Chile.

Community Ment Health J 2021 Mar 1. Epub 2021 Mar 1.

New York State Psychiatric Institute, New York, NY, USA.

This study explores the beliefs and attitudes about the psychosocial mechanisms of peer support work among users who participated in Critical Time Intervention-Task Shifting (CTI-TS), which tested the acceptability and feasibility of a peer support work model to improve community-based mental health care for individuals with psychosis in Latin America. We conducted a secondary analysis of 15 in-depth interviews with CTI-TS participants in Chile, using the framework method and defined the framework domains based on five major mechanisms of peer support work identified by a recent literature review. The analysis revealed that users' perceptions of peer support work mechanisms were strongly shaped by personal motivations, beliefs about professional hierarchies, familial support, and the Chilean mental health system's incipient recovery orientation. The findings underscore the importance of adopting culturally tailored strategies to promote peer support work, such as involving mental health professionals and fostering equal-powered relationships between PSWs and users.
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http://dx.doi.org/10.1007/s10597-021-00800-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8408283PMC
March 2021

Stigma and coping experiences in Latinx individuals at clinical high-risk for psychosis.

Early Interv Psychiatry 2021 Feb 4. Epub 2021 Feb 4.

New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, New York, USA.

Aim: The experiences of culturally diverse individuals at clinical high-risk for psychosis (CHR) is not well studied. Exploratory research needs to examine whether differences exist between racial/ethnic groups within the CHR population. Understanding experiences of Latinx patients is of importance, as the Latinx population represents the most rapidly growing paediatric population in the United States and they face significant barriers to mental health treatment. Because Latinx persons experience high rates of mental illness-based stigma and discrimination in their communities, they may face additional stigma-based barriers to CHR treatment.

Method: Twenty-six participants (15 Latinx, 11 non-Latinx white/NLW) who met CHR criteria based on the Structured Interview for Psychosis-Risk Syndromes (SIPS) were interviewed regarding stigma associated with CHR identification and symptoms. Using a consensus-based open-coding thematic analysis approach, data were analysed for stigma, discrimination, and coping responses.

Results: Instances of internalization of stereotypes appeared to be more salient to NLW participants than Latinx participants, and Latinx participants reported seemingly more anticipated rejection from stereotypes than NLW participants. Experiences of discrimination also appeared to be more salient to Latinx participants than NLW participants. Moreover, Latinx participants reported evidently greater instances of discrimination across anticipated, individual, and structural discrimination. Finally, while covering strategies appeared to be more salient to NLW's, Latinx clients more often described using secrecy as well as a greater range of coping responses, including empowerment.

Conclusion: While the experience of anticipated rejection appeared to be more salient to Latinx CHR participants and they seemingly report more secrecy than NLW, they also engaged in empowerment-related coping strategies. Future research should continue to explore the roles of cultural values in influencing coping strategies among CHR individuals.
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http://dx.doi.org/10.1111/eip.13126DOI Listing
February 2021

Reducing Stigma Toward Individuals With Schizophrenia Using a Brief Video: A Randomized Controlled Trial of Young Adults.

Schizophr Bull 2021 Jan;47(1):7-14

Department of Psychiatry, New York State Psychiatric Institute, Columbia University Vagelos College of Physicians & Surgeons, New York, NY.

Objective: Stigma decreases healthcare seeking and treatment adherence and increases the duration of untreated psychosis among people with first-episode psychosis (FEP). This study evaluated the efficacy of a brief video-based intervention in reducing stigma among youth toward individuals with FEP and schizophrenia. We hypothesized that the social-contact-based video intervention group would reduce stigma more than written vignette and control groups, and the vignette more than the control group.

Methods: Using Amazon Mechanical Turk, we recruited and assigned 1203 individuals aged 18-30 to either (a) video intervention, (b) written description of the same content ("vignette"), or (c) nonintervention control arm. In the 90-second video intervention, an empowered young woman with schizophrenia described her FEP and the aspects of successful coping with her everyday life difficulties, exposing the viewer to schizophrenia in the context of her personal narrative. Web-based self-report questionnaires assessed stigma domains, including social distance, stereotyping, separateness, social restriction, and perceived recovery.

Results: A MANOVA showed a significant between-group effects for all 5 stigma-related subscales (P < .001). Post hoc pairwise tests showed significant differences between video and vignette vs control for all 5 stigma domains. Video and vignette groups differed significantly on social distance, stereotyping, and social restriction. Secondary analyses revealed gender differences across stigma domains in the video group only, with women reporting lower stigma.

Conclusions: A very brief social contact-based video intervention efficaciously reduced stigma toward individuals with FEP. This is the first study to demonstrate such an effect. Further research should examine its long-term sustainability.
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http://dx.doi.org/10.1093/schbul/sbaa114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7825082PMC
January 2021

Disengagement From Early Intervention Services for Psychosis: A Systematic Review.

Psychiatr Serv 2021 01 25;72(1):49-60. Epub 2020 Nov 25.

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City (Mascayano, van der Ven, Martinez-Ales, Restrepo Henao, Zambrano, Yang, Susser); Division of Behavioral Health Services and Policies, New York State Psychiatric Institute, New York City (Mascayano, Smith, Susser, Dixon); School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands (van der Ven); Epidemiology Group, National School of Public Health, Universidad of Antioquia, Medellín, Colombia (Restrepo Henao); Department of Mental Health Law and Policy, Louis de la Parte Florida Mental Health Institute, University of South Florida, Tampa (Jones); George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis (Cabassa); Department of Social and Behavioral Sciences, College of Global Public Health, New York University, New York City (Yang).

Objective: Therapeutic benefits associated with early services for psychosis are influenced by the degree to which participants engage in treatment. The main objective of this review was to analyze rates of disengagement in early psychosis services and identify predictors of disengagement in these settings.

Methods: A systematic search for studies published in the 1966-2019 period was conducted in PubMed, Google Scholar, EBSCO, Ovid, and Embase. The Observational Cohort and Cross-Sectional Studies scale was used to assess the methodological quality of reports identified in this search. A revised version of the behavioral model of health service use was employed to evaluate and understand predictors of disengagement (categorized as predisposing, enabling, and need factors) identified in the studies with the highest quality.

Results: Twenty studies met the inclusion criteria. Disengagement rates (12% to 53%) and definitions of disengagement varied widely across these studies. Most did not find a compelling association between predisposing factors (e.g., age) and disengagement. Enabling factors, such as lack of family support and living alone, were consistently found to be related to increased disengagement across studies. Finally, need factors, such as lower medication adherence and higher drug misuse, were associated with higher risk for disengagement.

Conclusions: Enabling and need factors seemed to be the most predictive of disengagement from early psychosis services. Substantial between-study variation in identified predictors of disengagement may be addressed by developing and applying a consensus definition of disengagement in future research.
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http://dx.doi.org/10.1176/appi.ps.201900375DOI Listing
January 2021

A Narrative Review of Alzheimer's Disease Stigma.

J Alzheimers Dis 2020 ;78(2):515-528

Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA.

As the most common form of senile dementia, Alzheimer's disease (AD) is accompanied by a great deal of uncertainty which can lead to fear and stigma for those identified with this devastating disease. As the AD definition evolves from a syndromal to a biological construct, and early diagnoses becomes more commonplace, more confusion and stigma may result. We conducted a narrative review of the literature on AD stigma to consolidate information on this body of research. From the perspective of several stigma theories, we identified relevant studies to inform our understanding of the way in which implementation of the new framework for a biological based AD diagnosis may have resulted in new and emerging stigma. Herein, we discuss the emergence of new AD stigma as our understanding of the definition of the disease changes. We further propose recommendations for future research to reduce the stigma associated with AD.
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http://dx.doi.org/10.3233/JAD-200932DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7739963PMC
May 2021

'Mothers moving towards empowerment' intervention to reduce stigma and improve treatment adherence in pregnant women living with HIV in Botswana: study protocol for a pragmatic clinical trial.

Trials 2020 Oct 7;21(1):832. Epub 2020 Oct 7.

New York University, New York, NY, United States.

Background: With high rates of HIV and multiple vulnerable subgroups across diverse settings, there is a need for culturally based, HIV stigma reduction interventions. Pregnant women who are living with HIV are especially in need of services to protect not only their own but also their children's lives. Uptake of HIV services worldwide is hindered by stigma towards persons living with HIV/AIDS. While cultural context plays a key role in shaping HIV stigma, these insights have not yet been fully integrated into stigma reduction strategies. By utilizing the "What Matters Most" stigma framework, we propose that an intervention to counter culturally salient aspects of HIV stigma will improve treatment adherence and other relevant outcomes. A pragmatic clinical trial in Botswana will evaluate the "Mothers Moving towards Empowerment" (MME) intervention, which seeks to address HIV stigma in Botswana and to specifically engage pregnant mothers so as to promote antiretroviral therapy (ART) adherence in the postpartum period.

Methods: This study will test MME against treatment as usual (TAU) among pregnant mothers diagnosed with HIV and their infants. Outcomes will be assessed during pregnancy and 16 weeks postpartum. Women who meet eligibility criteria are assigned to MME or TAU. Women assigned to MME are grouped with others with similar estimated delivery dates, completing up to eight intervention group sessions scheduled before week 36 of their pregnancies. Primary outcomes among mothers include (i) reducing self-stigma, which is hypothesized to mediate improvements in (ii) psychological outcomes (quality of life, depression and social functioning), and (iii) adherence to antenatal care and ART. We will also examine a set of follow-up infant birth outcomes (APGAR score, preterm delivery, mortality (at < 16 weeks), birth weight, vaccination record, and HIV status).

Discussion: Our trial will evaluate MME, a culturally based HIV stigma reduction intervention using the "What Matters Most" framework, to reduce stigma and improve treatment adherence among pregnant women and their infants. This study will help inform further refinement of MME and preparation for a future large-scale, multisite, randomized controlled trial (RCT) in Botswana.

Trial Registration: ClinicalTrials.gov NCT03698981 . Registered on October 8, 2018.
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http://dx.doi.org/10.1186/s13063-020-04676-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542742PMC
October 2020

Psychometric Validation of a Scale to Assess Culturally-Salient Aspects of HIV Stigma Among Women Living with HIV in Botswana: Engaging "What Matters Most" to Resist Stigma.

AIDS Behav 2021 Feb;25(2):459-474

Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

Perceived stigma deters engagement in HIV care and is powerfully shaped by culture. Yet few stigma measures consider how cultural capabilities that signify "full personhood" could be engaged to resist stigma. By applying a theory conceptualizing how culturally-salient mechanisms can worsen or mitigate HIV stigma in relation to "what matters most" (WMM), we developed the WMM Cultural Stigma Scale for Women Living with HIV in Botswana (WMM-WLHIV-BW) and psychometrically evaluated it among 201 respondents with known and unknown HIV status. The two subscales, Cultural Factors Shape Stigma (CFSS) and Cultural Capabilities Protect against Stigma (CCPS) were reliable (both [Formula: see text]). Among WLHIV, the CFSS Subscale showed initial construct validity with depressive symptoms (r = .39, p = .005), similar to an established HIV stigma scale, whereas the CCPS Subscale showed initial construct validity with self-esteem (r = .32, p = .026) and social support number (r = .29, p = .047), suggesting that achieving local cultural capabilities mitigates stigma and is linked with positive psychosocial outcomes. This culturally-derived scale could help WLHIV in Botswana experience improved stigma-related outcomes.
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http://dx.doi.org/10.1007/s10461-020-03012-yDOI Listing
February 2021

The impact of China-to-US immigration on structural and cultural determinants of HIV-related stigma: implications for HIV care of Chinese immigrants.

Ethn Health 2020 Jul 15:1-20. Epub 2020 Jul 15.

Mailman School of Public Health, Columbia University, New York, NY, USA.

Asian Americans have poor HIV-related outcomes, yet culturally salient barriers to care remain unclear, limiting development of targeted interventions for this group. We applied the 'what matters most' theory of stigma to identify structural and cultural factors that shape the nature of stigma before and after immigration from China to the US.: Semi-structured interviews were conducted with 16 immigrants to New York from China, recruited from an HIV clinic and community centers. Deductive followed by focal inductive qualitative analyses examined how Chinese cultural values () and structural factors influenced stigma before and after immigration. In China, HIV stigma was felt through the loss of (moral status) and limited (social network) opportunities. A social structure characterized by limited HIV knowledge, discriminatory treatment from healthcare systems, and human rights violations impinged on the ability of people living with HIV to fulfill culturally valued goals. Upon moving to the US, positions of structural vulnerability shifted to enable maintenance of and formation of new , thus ameliorating aspects of stigma. HIV prevention and stigma reduction interventions among Chinese immigrants may be most effective by both addressing structural constraints and facilitating achievement of cultural values through clinical, peer, and group interventions.
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http://dx.doi.org/10.1080/13557858.2020.1791316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7854980PMC
July 2020

Association Between the Duration of Untreated Psychosis and Selective Cognitive Performance in Community-Dwelling Individuals With Chronic Untreated Schizophrenia in Rural China.

JAMA Psychiatry 2020 Nov;77(11):1116-1126

Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, Shanghai, China.

Importance: Cognitive deficits constitute core features of schizophrenia, but the trajectories of cognitive difficulties in chronic untreated schizophrenia remain unclear.

Objective: To assess the association of neuropsychological deficits with duration of untreated psychosis in individuals with chronic untreated schizophrenia.

Design, Setting, And Participants: Community-dwelling individuals with chronic untreated schizophrenia (untreated patient group) and individuals without mental illness (control group) were recruited from predominantly rural communities in Ningxia, China between June 20, 2016, and August 6, 2019, and administered the Structured Clinical Interview for DSM-IV, the Mini-Mental State Examination, an 8-test version of the MATRICS Consensus Cognition Battery adapted for use in individuals with low levels of education, and a measure of social cognition.

Main Outcomes And Measures: Comparison of cognitive test scores between the two groups and association of cognitive test scores with duration of untreated schizophrenia.

Results: The patient group included 197 individuals with chronic untreated schizophrenia (101 men [51.3%]; mean [SD] age, 52.1 [11.8] years; median [interquartile range] years of schooling, 3 [0-6] years; median [interquartile range] years of untreated psychosis, 22.9 [14.9-32.8] years). The control group included 220 individuals (118 men [53.6%]; mean [SD] age, 52.1 [11.2] years; median [interquartile range] years of schooling, 4 [0-6] years). The untreated patient group performed significantly worse than the control group on all cognitive measures (adjusted partial Spearman correlation coefficient [Spearman ρ] ranged from -0.35 for the revised Chinese version of the Reading the Mind in the Eyes Test to -0.60 for the Brief Visuospatial Memory Test-Revised; P < .001 for all comparisons). Longer durations of untreated psychosis were associated with lower performance in 3 MATRICS Consensus Cognition Battery measures assessing different aspects of executive functioning (Brief Visuospatial Memory Test-Revised [ρ = -0.20; P = .04]; Brief Assessment of Cognition in Schizophrenia, Symbol Coding subtest [ρ = -0.35; P < .001]; and Neuropsychological Assessment Battery, Mazes subtest [ρ = -0.24; P = .01]). The median duration of untreated psychosis (22.9 years) was associated with estimated score reductions in the 3 measures of 34% (95% CI, 10%-52%), 43% (95% CI, 28%-55%), and 57% (95% CI, 31%-73%), respectively.

Conclusions And Relevance: The findings of this study suggest that long-term untreated schizophrenia was associated with decreases in selective cognitive abilities; both neurodegenerative pathology and neurodevelopmental dysfunction may be factors in cognition in persistent psychosis. Expanding research to include cohorts of patients from underserved rural communities in low- and middle-income countries may provide new insights about the etiological factors, disease course, and management of schizophrenia.
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http://dx.doi.org/10.1001/jamapsychiatry.2020.1619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344798PMC
November 2020

Psychological impact of anti-Asian stigma due to the COVID-19 pandemic: A call for research, practice, and policy responses.

Psychol Trauma 2020 Jul 11;12(5):461-464. Epub 2020 Jun 11.

Department of Social and Behavioral Sciences, School of Global Public Health, New York University.

The COVID-19 pandemic is linked to a rise in stigma and discrimination against Chinese and other Asians, which is likely to have a negative impact on mental health, especially when combined with additional outbreak-related stressors. We discuss the need to consider the potential harms of these anti-Asian sentiments during both the height of the pandemic and longer-term recovery through (a) research-examining how it affects mental health and recovery; (b) practice-implementing evidence-based stigma reduction initiatives; and (c) policy-coordinating federal response to anti-Asian racism including investment in mental health services and community-based efforts. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/tra0000821DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7958926PMC
July 2020

Naturalistic conceptions of genetic optimism and precision psychiatry among those at clinical high-risk for psychosis.

Early Interv Psychiatry 2021 Jun 1;15(3):742-745. Epub 2020 Jun 1.

School of Global Public Health, New York University, New York, New York, USA.

Aim: Fuelled by genomics advances, recent emphasis on the concept of "precision medicine," and public optimism towards genetic advances, it is important to understand how those who are considered to be at clinical high-risk for psychosis (CHR) perceive possible benefits of genetic testing to inform future stakeholder education efforts.

Methods: Semistructured interviews were completed with 20 participants who met CHR criteria. Coding for genetic optimism was completed.

Results: Participants endorsed many conceptualizations of the link between genetics, the development of psychosis, and the benefits of genetic testing. Specifically, themes emerged surrounding how genetic testing may lead to greater genetic knowledge and tailored treatment.

Conclusions: Our results demonstrate that CHR participants generally endorse several precision psychiatry concepts, including how genetic testing may lead to tailored treatment advances. This knowledge may aid development of best communication practices regarding forthcoming genetic advances in diagnosis and treatment among CHR.
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http://dx.doi.org/10.1111/eip.12983DOI Listing
June 2021

Promoting insight and recovery in the context of the "insight paradox".

Schizophr Res 2020 08 24;222:6-7. Epub 2020 May 24.

New York State Psychiatric Institute, NY, New York, USA.

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http://dx.doi.org/10.1016/j.schres.2020.03.052DOI Listing
August 2020

Promoting insight and recovery in the context of the "insight paradox".

Schizophr Res 2020 08 24;222:6-7. Epub 2020 May 24.

New York State Psychiatric Institute, NY, New York, USA.

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http://dx.doi.org/10.1016/j.schres.2020.03.052DOI Listing
August 2020

Advancing study of cognitive impairments for antipsychotic-naïve psychosis comparing high-income versus low- and middle-income countries with a focus on urban China: Systematic review of cognition and study methodology.

Schizophr Res 2020 06 5;220:1-15. Epub 2020 Apr 5.

Harvard Medical School Department of Psychiatry at Beth Israel Deaconess Medical Center, Boston, MA, United States.

Background: Comparing the course of antipsychotic-naïve psychosis in low- and middle-income countries (LMIC) may help to illuminate core pathophysiologies associated with this condition. Previous reviews-primarily from high-income countries (HIC)-identified cognitive deficits in antipsychotic-naïve, first-episode psychosis, but did not examine whether individuals with psychosis with longer duration of untreated psychosis (DUP > 5 years) were included, nor whether LMIC were broadly represented.

Method: A comprehensive search of PUBMED from January 2002-August 2018 identified 36 studies that compared cognitive functioning in antipsychotic-naïve individuals with psychosis (IWP) and healthy controls, 20 from HIC and 16 from LMIC.

Results: A key gap was identified in that LMIC study samples were primarily shorter DUP (<5 years) and were primarily conducted in urban China. Most studies matched cases and controls for age and gender but only 9 (24%) had sufficient statistical power for cognitive comparisons. Compared with healthy controls, performance of antipsychotic-naïve IWP was significantly worse in 81.3% (230/283) of different tests of cognitive domains assessed (90.1% in LMIC [118/131] and 73.7% [112/152] in HIC).

Conclusions: Most LMIC studies of cognition in antipsychotic-naïve IWP adopted standardized procedures and, like HIC studies, found broad-based impairments in cognitive functioning. However, these LMIC studies were often underpowered and primarily included samples typical of HIC: primarily male, young-adult, high-school educated IWP, in their first episode of illness with relatively short DUP (<5 years). To enhance understanding of the long-term natural course of cognitive impairments in untreated psychosis, future studies from LMIC should recruit community-dwelling IWP from rural areas where DUP may be longer.
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http://dx.doi.org/10.1016/j.schres.2020.01.026DOI Listing
June 2020

Psychosis risk stigma and help-seeking: Attitudes of Chinese and Taiwanese residing in the United States.

Early Interv Psychiatry 2020 02 24;14(1):97-105. Epub 2019 May 24.

College of Global Public Health, New York University, New York City, New York.

Aim: Intervention during the clinical high-risk phase for psychosis (CHR) can reduce duration of untreated psychosis and associated negative outcomes. Early treatment access and sustained engagement are important to understand for effective intervention. Understanding stigma and help-seeking processes is particularly important for groups that experience mental healthcare disparities such as those of Chinese heritage living in the United States.

Methods: Chinese and Taiwanese participants (N = 215) residing in the United States were randomly assigned to one of three CHR vignette conditions based on the "what matters most" stigma framework for Chinese groups, which identifies capacities that define "personhood" and thereby shapes stigma for members of a particular cultural group. Participants completed measures of help-seeking attitudes, family stigma and individual stigma.

Results: More stigma towards the CHR vignette character's family was associated with positive CHR help-seeking attitudes. Participants who read the vignette describing CHR affecting family obligations, "what matters most" and participants who read the vignette describing CHR symptomology only had more positive CHR help-seeking attitudes compared to participants who read the vignette describing CHR affecting individual aspirations.

Conclusions: Chinese and Taiwanese residing in the United States may perceive professional mental healthcare to be especially relevant for persons with CHR when symptoms are particularly stigmatizing for the person's family and when symptoms threaten the person's ability to fulfil family obligations (ie, "what matters most"). Clinical implications of findings include the importance of emphasizing positive treatment outcomes that increase an individual's ability to engage in valued life domains.
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http://dx.doi.org/10.1111/eip.12830DOI Listing
February 2020

Implementing the protocol of a pilot randomized controlled trial for the recovery-oriented intervention to people with psychoses in two Latin American cities.

Cad Saude Publica 2019 05;35(4):e00108018

Mailman School of Public Health, Columbia University, New York. U.S.A.

Several Latin American countries have made remarkable strides towards offering community mental health care for people with psychoses. Nonetheless, mental health clinics generally have a very limited outreach in the community, tending to have weaker links to primary health care; rarely engaging patients in providing care; and usually not providing recovery-oriented services. This paper describes a pilot randomized controlled trial (RCT) of Critical Time Intervention-Task Shifting (CTI-TS) aimed at addressing such limitations. The pilot RCT was conducted in Santiago (Chile) and Rio de Janeiro (Brazil). We included 110 people with psychosis in the study, who were recruited at the time of entry into community mental health clinics. Trial participants were randomly divided into CTI-TS intervention and usual care. Those allocated to the intervention group received usual care and, in addition, CTI-TS services over a 9-month period. Primary outcomes include quality of life (WHO Quality of Life Scale - Brief Version) and unmet needs (Camberwell Assessment of Needs) at the 18-month follow-up. Primary outcomes at 18 months will be analyzed by Generalized Estimating Equations (GEE), with observations clustered within sites. We will use three-level multilevel models to examine time trends on the primary outcomes. Similar procedures will be used for analyzing secondary outcomes. Our hope is that this trial provides a foundation for planning a large-scale multi-site RCT to establish the efficacy of recovery-oriented interventions such as CTI-TS in Latin America.
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http://dx.doi.org/10.1590/0102-311X00108018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6688497PMC
May 2019

A new brief opioid stigma scale to assess perceived public attitudes and internalized stigma: Evidence for construct validity.

J Subst Abuse Treat 2019 04 9;99:44-51. Epub 2019 Jan 9.

Butler Hospital, Providence, RI, USA; Boston University School of Public Health, Boston, MA, USA.

One key strategy to improve treatment access for persons with opioid use disorder (OUD) is overcoming stigma that is internalized by such individuals. Because few theoretically-derived, multidimensional measures of substance abuse stigma exist, we contribute a brief, theoretically-based measure of opioid-related stigma (adapted from Corrigan's Self-Stigma of Mental Illness Scale) to assess perceived stigma and internalized stigma among individuals with OUD. This study presents initial validation of the newly-developed Brief Opioid Stigma Scale among 387 adults who entered an inpatient opioid managed-withdrawal program. The scale assesses: (1) Stereotype awareness ("Aware"), or the extent to which individuals who use opioids perceive community members to believe OUD-related stereotypes; (2) Stereotype agreement ("Agree"), or the endorsement of stigmatizing beliefs by individuals who use opioids; (3) Self-esteem decrement ("Harm"), or the diminution of self-esteem due to these negative stereotypes' impacts on self-worth. Psychosocial measures including self-esteem, depressive symptoms, mental and physical functioning, and desire for aftercare OUD medication treatment, were administered to assess construct validity. Results showed that greater endorsement of the "harm" stigma subscale was associated with greater depressive symptoms, lower self-esteem, and poorer mental and physical functioning. The "aware" stigma subscale displayed similar overall patterns of associations with self-esteem and depression but to a lesser magnitude. The "aware" stigma subscale was positively associated with desire for aftercare methadone and naltrexone treatment, and the "harm" subscale was positively associated with desire for aftercare buprenorphine treatment. Results indicated good initial construct validity. Tailored stigma interventions are recommended for specific aftercare OUD medication treatments.
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http://dx.doi.org/10.1016/j.jsat.2019.01.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716158PMC
April 2019

Impact of "psychosis risk" identification: Examining predictors of how youth view themselves.

Schizophr Res 2019 06 19;208:300-307. Epub 2019 Feb 19.

Commonwealth Research Center (CRC), Beth Israel Deaconess Medical Center (BIDMC), Boston, MA 02115, USA; Beth Israel Deaconess Medical Center (BIDMC), Boston, MA 02115, USA; Harvard Medical School, Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA.

Background: Identifying young people as at clinical high-risk (CHR) for psychosis affords opportunities for intervention to possibly prevent psychosis onset. Yet such CHR identification could plausibly increase stigma. We do not know whether these youth already perceive themselves to be at psychosis-risk (PR) or how their being told they are at PR might impact how they think about themselves.

Methods: 148 CHR youth were asked about labels they had been given by others (labeling by others) or with which they personally identified (self-labeling). They were then asked which had the greatest impact on how they thought about themselves. We evaluated whether being told vs. thinking they were at PR had stronger effects.

Findings: The majority identified nonpsychotic disorders rather than PR labels as having the greatest impact on sense of self (67.6% vs. 27.7%). However, participants who identified themselves as at PR had an 8.8 (95% CI = 2.0-39.1) increase in the odds of the PR label having the greatest impact (p < 0.01). Additionally, having been told by others that they were at PR was associated with a 4.0 increase in odds (95% CI = 1.1-15.0) that the PR label had the most impact (p < 0.05).

Interpretation: Nonpsychotic disorder labels appear to have a greater impact on CHR youth than psychosis-risk labels. However, thinking they are at PR, and, secondarily, being told they are at PR, appears to increase the relative impact of the PR label. Understanding self- and other-labeling may be important to how young people think of themselves, and may inform early intervention strategies.
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http://dx.doi.org/10.1016/j.schres.2019.01.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7079577PMC
June 2019

Implementing a community-based task-shifting psychosocial intervention for individuals with psychosis in Chile: Perspectives from users.

Int J Soc Psychiatry 2019 02;65(1):38-45

15 Mailman School of Public Health and New York State Psychiatric Institute, Columbia University, New York, NY, USA.

Background: Latin America, and Chile in particular, has a rich tradition of community mental health services and programs. However, in vivo community-based psychosocial interventions, especially those with a recovery-oriented approach, remain scarce in the region. Between 2014 and 2015, a Critical Time Intervention-Task Shifting project (CTI-TS) was implemented in Santiago, Chile, as part of a larger pilot randomized control trial. CTI is a time-limited intervention delivered at a critical-time to users, is organized by phases, focuses on specific objectives and decreases in intensity over time. CTI-TS, which combines both the task-shifting strategy and the use of peers, introduces a novel approach to community mental health care that has not yet been tried in Chile.

Aims: We aim to evaluate the feasibility, acceptability and applicability of such a community-based psychosocial intervention in urban settings in Latin America - specifically, in Santiago (Chile) from a user perspective.

Method: We analyzed 15 in-depth interviews ( n = 15) with service users who participated in the intervention about their perceptions and experiences with CTI-TS through thematic analysis.

Results: Three themes were revealed. The first was related to the structural characteristics of CTI-TS, especially regarding the timing, duration and phasic nature of the intervention. The second pertained to the acceptability of the in vivo community-based approach. The third theme dealt with the task-shifting aspect, that is, users' perceptions of the peer support workers and the community mental health workers.

Conclusions: CTI-TS was generally acceptable in this Latin American context. Users' perspectives pointed to the need to make adjustments to some of the structural characteristics of the CTI model and to combine this type of intervention with others that can address stigma. Thus, future adaptations of CTI-TS or similar psychosocial interventions in Latin American contexts are feasible and can enhance community mental health in the region.
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http://dx.doi.org/10.1177/0020764018815204DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6427823PMC
February 2019
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