Psychiatric Annals

A Second Opinion on the Use of White Norms in Psychiatric Diagnosis of Black Patients

Victor R Adebimpe, MD, FAPA

Abstract

A full discussion of the implications of these questions is beyond the scope of this article.25,38 Nevertheless, recent research documenting state-by-state variations in the climate of ethnic coexistence needs to be widely replicated with retrievable, correctable factors (Table 4) as dependent variables. All facilities, especially those who want their research on ethnic issues to be more than "anger management" exercises, should work to replicate or decisively refute the findings of Neighbors et al.20 and Strakowski et al.21 on a regular basis, to justify the acceptance of more public funds.

University and prison populations are of theoretical interest and practical concern, respectively. Enlightened intellectual leadership from elite academic centers could redirect random drift, now masquerading as diplomacy. Newspapers often are unaware that figures they publish as ethnic comparisons may easily be changed by appropriate technical adjustments, leading to inferences quite different from the originals. Government statistical publications could be much more user-friendly to a diverse society with a little more attention to these details.

The discovery of local variations in the quality of life of different ethnic groups, and the systematic elimination of questionable practices that are measurable, trackable, actionable, and reformable, are the essence of building a culture of mature diversity. A little replication here, another replication there, and soon there may be an outbreak of open government and opportunities for mutual education. Sooner or later, there may be a global epidemic of Social Stratification without Penalization of Ethnicity and Nationality,25 known optimistically in antiquity as "peace on earth and goodwill to humankind."

Of course, some will question the wisdom of making a humane presence on Earth29,3y a prerequisite for a human presence in the cosmos. Given the projected demographic deadlines of the next half century, lessons learned from black patients may be helpful in the psychiatric diagnosis of patients of other ethnic minorities and could assist in guiding social development toward a mature diversity.40

1. Adebimpe VR. Overview: while norms and psychiatric diagnosis of black patients. Am J Psychiatry. 198 1 : 1 383):279-285.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [text revision], 4th ed. Washington. DC: American Psychiatric Publishing: 20(K).

3. Adebimpe VR, Gigandet J, Harris E. MMPl diagnosis of black psychiatric patients. Am .1 Psychiatry. 1 979: 1 36( I ):86-87.

4. Strakowski SM. Lonczak HS. Sax KW. et al. The effects of race on diagnosis and disposition from a psychiatric emergency service. ./ Clin Psychiatry. 1995:56(3): 101-107.

5. Fabrega H Jr, Mulsant BM, Rifai AH. et al. Ethnicity and psychopathology in an aging hospital-based population. A comparison of AfricanAmerican and Anglo-European patients. J Nerv Ment Dis. 1 994: 1 82( 3 ): 1 36- 1 44.

6. Kilgus MD, Pumariega AJ. Cuffe SP. Influence of race on diagnosis in adolescent psychiatric inpatients. J Am Acad Child Adolesc Psychiatry. 1995:34( I ):67-72.

7. Simon RJ. Fleiss JL. Gurland BJ. Stiller PR. Sharpe L. Depression and schizophrenia in hospitalized black and white mental patients. Arch Gen Psychiatry. 1973:28(4):5()9-512.

8. Minsky S. Vega W, Miskimen T. Gara M. Escobar J. Diagnostic patterns in Latino. African American, and European American psychiatric patients. Arch Gen Psychiatry. 2003;60(6):637-644.

9. Lawson WB. Strickland T. Racial and ethnic issues affect treatment for bipolar disorder. Psychiatr Ann. 2004;34( I ): 1 7-20.

10. Adebimpe VR. Participant observer: the experiences of a black transcultural psychiatrist. In: Spurlock J, ed. Black Psychiatrists and American Psychiatry. Washington. DC: American Psychiatric Publishing: 1999:77-94.

11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 2nd ed. Washington, DC: American Psychiatric Publishing; 1968.

12. Hall GC. Bansal A, Lopez IR. Ethnicity and psychopathology: a meta-analytic review…

As recently as 23 years ago. research data available for evaluating different viewpoints about the accuracy of diagnoses of black patients was so scanty, piecemeal, and tentative that I wrote a review suggesting "an agnostic stance** regarding the widespread misdiagnosis of blacks because of psychiatric practices based on white norms.1

In that article, I suggested a need to "verify the phenomenon, to explain the data, and to find ways of minimizing the effects of confirmed sources of spuriousness."

My review further noted:

"The research necessary to eliminate criterion variance due to the theoretical biases of clinicians probably had to come before any effective examination of problems arising from variance due to subtle differences in patient populations. ...If the data cited here are indicative of a truly important but hitherto unheeded heterogeneity among patients, a few footnotes alerting clinicians to modifications in diagnostic criteria when applied to ethnic minorities may increase the usefulness of future diagnostic manuals."

All of these conditions have now been met. Advances in the theory and practice of psychiatric diagnosis have produced new editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fourth edition, text edition.2 There is robust evidence that ethnicity is a significant source of heterogenicity3·4·5,6 and may mislead the unwary clinician into applying the rules of diagnostic inference somewhat indifferently when the patient is not white. While this is true for other minorities, documentation of this phenomenon is most consistent for blacks from 1972 to 2004.7,8,9

Although the subject has become a clinical question, its historical roots remain pertinent. Centuries of the understandable desire to justify slavery yielded policies and practices that were taken for granted but that to a newcomer, despite de jure emancipation, seemed to be the prongs of a psychological trident. In effect, if no longer in intent, society itself had an investment in choosing to think that the psychological, psychiatric, and intellectual deficits of blacks explained and justified their social ranking.10

It is therefore hardly surprising that, in 1979, both the Minnesota Multiphasic Personality Inventory (MMPI)3 and the second edition of DSM1 ' yielded a pattern of erroneously more severe diagnoses for blacks, and their intellectual equality to whites was actively debated. To the credit of the American Psychological Association, the MMPI has been revised, such that spurious inferences caused by the patient's ethnic background are minimized in the MMPI-II.12

The evidence for racial equality in the distribution of mental disorders came from two national surveys in which major technical problems of earlier studies were solved. Both the Epidemiologic Catchment Area Study13 and the National Comorbidity Survey14 used standardized diagnostic inventories and were able to make corrections for age, sex, and socioeconomic status in their samples. Each showed an equal distribution of mental disorders in its community sample, putting to rest more than a century of controversy and biased debates.

Strictly speaking, the jury is still out with regard to ethnic differences in intellectual functioning and remains so until all the effects of historically different educational policies have been erased. The position that they have, leading to revision of previously unanimous affirmative action policies, remains a controversial topic about which responsible US citizens all the way to the Supreme Court can agree to disagree.

For our purposes, there is sufficient material in this historical background to wonder how the equalities in the community become the inequalities in the hospitals and clinics15 and to pinpoint the role of diagnosis in the process. If blacks are at a higher risk of being inadvertently misdiagnosed than whites, they are just as likely to be mistreated for the same reason.16 Misdiagnoses contribute to the many causes of censusincongruent ethnic disparities, making it difficult to determine a baseline against which to measure the effects of cultural competence initiatives.

These causes interact to simulate disparities which may support once popular, but now obsolete, stereotypes (Table I, see page 545). 17 There may be some value in deconstructing them, a procedure that was difficult before the introduction of computers.1819 For this purpose, two studies of the role of diagnostic technique in generating censusincongruent diagnoses are instructive. Neighbors et al.20 studied the frequency of agreements of hospital diagnoses with semi-structured research diagnoses. The rate of disagreement was higher among black patients than among whites. In another study,21 black and white patients were diagnosed by senior (relatively more experienced) diagnosticians as well as junior physicians using DSM-IV criteria.2 The rate of disagreement between the two groups of diagnosticians was higher for black patients than for white patients, even though the senior clinicians showed no black/white differences in their diagnoses of different DSM-PV categories.

Taken together, these studies suggest supplementary data currently incorporated by experienced clinicians into their diagnostic reasoning, but not yet encoded in DSM criteria, may be the missing link to minimize misdiagnoses in blacks.22,23 The purpose of this article is to provide a preliminary list of such criteria for the use of research toward the fifth edition of DSM, and for tentative use by DSM-IV clinicians.

Table

TABLE I.Percentage Distribution of Admissions to Selected Inpatient Psychiatric Services by Race, Hispanic Origin, and Selected Primary Diagnosis: United States, 198015

TABLE I.

Percentage Distribution of Admissions to Selected Inpatient Psychiatric Services by Race, Hispanic Origin, and Selected Primary Diagnosis: United States, 198015

INTERPRETATION OF PSYCHIATRIC SYMPTOMS IN BLACK PATIENTS

Table 2 (see pages 546-547) lists symptoms that may mislead clinicians who have limited familiarity with black patients into making diagnostic decisions that are accurate only when the patient is white. (The final row labeled "other" is included for clinicians who may wish to submit observations not covered in this list of research toward the fifth edition of DSM.) A number of methods are available to clinicians and clinics to help prevent inaccurate diagnosis or treatment of blacks.

Census-incongruent statistics of mental disorder should be measured routinely by hospitals, clinics, and practice systems. If" statistics are census-congruent, the system may be a role model for others, and publishing policies and procedures may be helpful to other mental healthcare providers.

Structured data collection instruments should be used. DSM-IV criteria2 may be supplemented with the data provided in Table 2 (see pages 546-547). Ambiguous data should be clarified through interviews with family members and other key informants. Providers should also remain aware of local patterns in the differential diagnosis of atypical and ambiguous symptoms.

Clinicians must watch for a number of pitfalls in providing accurate diagnosis and treatment. Social countertransference, a measurable climate of ethnic coexistence, may be taken for granted until compared with other locales.24·25 Clinicians must remain aware of and share insights into "no-fault" demographic causes of stress, as well as the limited power of medical systems to change issues best addressed by religious, civic, and legal systems.

Clinicians should also remember that perfectly normal people may experience symptoms that, if rigidly interpreted, can be misconstrued as evidence of mental illness. Social norms teach caution in divulging such experiences. In Biblical times, Moses, Samuel, and Paul all experienced visual or auditory hallucinations or both, and then went on to live lives of superior functioning. In modern times, the context of their experiences would earn them the diagnosis of "no mental disorder," whereas the Gadarene lunatic, a homeless man "who lived in the tombs and cut himself with stones" (Mark 5:10), may have suffered from schizophrenia or some other psychotic illness.

Table

TABLE 2.Critical Symptoms for Assessing Psychiatric Disorders in Black Patients

TABLE 2.

Critical Symptoms for Assessing Psychiatric Disorders in Black Patients

Table

TABLE 2.Critical Symptoms for Assessing Psychiatric Disorders in Black Patients

TABLE 2.

Critical Symptoms for Assessing Psychiatric Disorders in Black Patients

Table

TABLE 3Allies Behavior Center Diagnostic Review Worksheet

TABLE 3

Allies Behavior Center Diagnostic Review Worksheet

A variant of cultural paranoia occurs when a black person generates a response of obsolete stereotypes of black personality and functioning in a white observer.1·26 The paranoid feelings that the black person has are far from imaginary and may be heightened in those situations where the white observer is stunned that an occasional black person could be demonstrably outstanding, if only out of statistical probability. This Rorschach countertransference, and its Iago subtype, named after the character in Shakespeare's Othello, are rare but not yet extinct.

ASSESSING DEMOGRAPHIC DATA

Rarely perceived as stressors, demographic facts structure our chances in the competition for quality of life and help determine reality-based expectations for change. Some specific demographic profiles (eg, young black males, elderly black immigrant females) have predictive power, independent of mental disorder.

Some diseases occur more frequently among blacks but may be overlooked because of time constraints imposed by managed care in the inner-city public settings where they are likely to be diagnosed and treated. This and other sociological constants are stressors that, being remnants of history, affect blacks in ways that are not experienced by any other minority. The rate of change being glacial, both patient and therapist are usually powerless to reduce them.

The diagnostic worksheet provided in Table 3 is designed to allow clinicians to gather specific race-related data as treatment progresses. Updates of the diagnostic worksheet at follow-up visits often help cement a trusting relationship because the patient becomes aware of a caring presence across chasms of class, culture, and color.

COMPILING EVIDENCE-BASED DSM-VFOOTNOTES

Research for the next edition of DSM, scheduled to begin in 2007, will incorporate input from a variety of potenial users. Such feedback is being invited on a new web site from the APA called DSM- V Prelude Project: Research and Outreach (http://www.dsm5.org).27 The site provides an opportunity for users to submit comments and suggestions to facilitate dialogue between the APA and users of DSM. In addition, the APA Institute for Research and Education has launched a series of diagnostic research conferences to be conducted during the next 4 years. These conferences are titled "The Future of Psychiatric Diagnosis: Refining the Research Agenda." The opening conference was held in February 2004; information on future conferences will be provided on the web site.

Through both the web site and the conference series, DSM users are being invited to select from a list of possible categories for comment, including specific changes in criteria sets or diagnostic groupings, such as the addtion of a subset to an existing disorder, as well as recommendations that an earlier disorder be deleted. However, these new guidelines may or may not capture the unique scenario in which black patients are systematically overdiagnosed with schizophrenia and underdiagnosed with affective disorder, in a paetter that has been consistent and unexplained for more than 30 years.7,8 They also are unlikely to capture diagnosis-relevant differences in the climate of ethnic coexistence (Table 3, see page 548). These are imperceptible and often go unreported in clinical settings that treat mostly white patients; therefore, they are usually off the radar of epidemiologic instruments such as DSM, which seek literature based on statistic significance.

For their contributions to be included in DSM-V discussions, clinicians and researchers may want to consider the following suggestions for collecting evidence-based data toward DSM-V footnotes. Note that these steps should be replicated for the other minority groups that show census-incongruent ethnic disparities6-28,29:

* Collect symptoms found in more than one diagnostic category that could therefore be ambiguous from both clinical and research samples.

* Determine provisional diagnoses associated with each ambiguous symptom.

* Collect data on suggestive family history, laboratory investiagion, social context, course of illness, and response to psychopharmacology associated with each provisional diagnosis.

* After verification of appropriate confirmatory samples, derive text for tentative evidence-based footnotes, or a preliminary appendix, for using DSMV with black patients.

In addition to compiling notes for future use by other clinicians, black psychiatrists may inform their latest initiatives with similar consideration to be free of the historical experience of being sidelined and sidetracked. 30,31

Suggested Language For DSM-V

"There exists an extensive literature showing overdiagnosis of schizophrenia and probably resultant underdiagnosis of affective disorder in black patients. This pattern has been consistent during periods of time when earlier versions of the manual (DSM-II, -III, -III-R, and - IV) were in use. There is research evidence to show the adequacy of DSM to make equally accurate diagnoses in blacks and whites. Diagnosticians working in facilities where census-incongruent statistics for mental disorders are being generated may want to use the Appendix as they investigate these patterns, which do not reflect the results of national surveys and may be critical in the successful study of such disparities."

SUMMARY

In my 1981 article,1 I hinted that the distinction between "the purely technical issue of clinical diagnosis and the equally important, related, but quite separate topic of the social implications of misdiagnosis" has not always been clear. Many questions that were awkward then, at a time of national reconciliation,3235 are now being asked by institutions charged with ascertaining the intended evolution of American values: justice, equality, and freedom. Apart from the concerns of the National Association for the Advancement of Colored People, the Joint Commission on Accreditation of Healthcare Organizations, and the National Center on Minority Health and Health Disparities, clinicians are now interested in "cultural competence," and epidemiologists are in pursuit of factors behind ethnic disparities in health.27,35"17

Table

TABLE 4.Causes of Census-incongruent Ethnic Disparities

TABLE 4.

Causes of Census-incongruent Ethnic Disparities

A full discussion of the implications of these questions is beyond the scope of this article.25,38 Nevertheless, recent research documenting state-by-state variations in the climate of ethnic coexistence needs to be widely replicated with retrievable, correctable factors (Table 4) as dependent variables. All facilities, especially those who want their research on ethnic issues to be more than "anger management" exercises, should work to replicate or decisively refute the findings of Neighbors et al.20 and Strakowski et al.21 on a regular basis, to justify the acceptance of more public funds.

University and prison populations are of theoretical interest and practical concern, respectively. Enlightened intellectual leadership from elite academic centers could redirect random drift, now masquerading as diplomacy. Newspapers often are unaware that figures they publish as ethnic comparisons may easily be changed by appropriate technical adjustments, leading to inferences quite different from the originals. Government statistical publications could be much more user-friendly to a diverse society with a little more attention to these details.

The discovery of local variations in the quality of life of different ethnic groups, and the systematic elimination of questionable practices that are measurable, trackable, actionable, and reformable, are the essence of building a culture of mature diversity. A little replication here, another replication there, and soon there may be an outbreak of open government and opportunities for mutual education. Sooner or later, there may be a global epidemic of Social Stratification without Penalization of Ethnicity and Nationality,25 known optimistically in antiquity as "peace on earth and goodwill to humankind."

Of course, some will question the wisdom of making a humane presence on Earth29,3y a prerequisite for a human presence in the cosmos. Given the projected demographic deadlines of the next half century, lessons learned from black patients may be helpful in the psychiatric diagnosis of patients of other ethnic minorities and could assist in guiding social development toward a mature diversity.40

REFERENCES

1. Adebimpe VR. Overview: while norms and psychiatric diagnosis of black patients. Am J Psychiatry. 198 1 : 1 383):279-285.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [text revision], 4th ed. Washington. DC: American Psychiatric Publishing: 20(K).

3. Adebimpe VR, Gigandet J, Harris E. MMPl diagnosis of black psychiatric patients. Am .1 Psychiatry. 1 979: 1 36( I ):86-87.

4. Strakowski SM. Lonczak HS. Sax KW. et al. The effects of race on diagnosis and disposition from a psychiatric emergency service. ./ Clin Psychiatry. 1995:56(3): 101-107.

5. Fabrega H Jr, Mulsant BM, Rifai AH. et al. Ethnicity and psychopathology in an aging hospital-based population. A comparison of AfricanAmerican and Anglo-European patients. J Nerv Ment Dis. 1 994: 1 82( 3 ): 1 36- 1 44.

6. Kilgus MD, Pumariega AJ. Cuffe SP. Influence of race on diagnosis in adolescent psychiatric inpatients. J Am Acad Child Adolesc Psychiatry. 1995:34( I ):67-72.

7. Simon RJ. Fleiss JL. Gurland BJ. Stiller PR. Sharpe L. Depression and schizophrenia in hospitalized black and white mental patients. Arch Gen Psychiatry. 1973:28(4):5()9-512.

8. Minsky S. Vega W, Miskimen T. Gara M. Escobar J. Diagnostic patterns in Latino. African American, and European American psychiatric patients. Arch Gen Psychiatry. 2003;60(6):637-644.

9. Lawson WB. Strickland T. Racial and ethnic issues affect treatment for bipolar disorder. Psychiatr Ann. 2004;34( I ): 1 7-20.

10. Adebimpe VR. Participant observer: the experiences of a black transcultural psychiatrist. In: Spurlock J, ed. Black Psychiatrists and American Psychiatry. Washington. DC: American Psychiatric Publishing: 1999:77-94.

11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 2nd ed. Washington, DC: American Psychiatric Publishing; 1968.

12. Hall GC. Bansal A, Lopez IR. Ethnicity and psychopathology: a meta-analytic review of 3 1 years of comparative MMPI/MMP1-2 research. Psychol Assess. 1 999; 1 1 (2): 1 86- 1 97.

13. Robins LN. Regier DA, eds. Psychiatric Disorders in America: The Epidemiology Catchment Area Study. New York. NY: Free Press; 1991.

14. Kessler RC. McGonagle KA. Zhao S. et al. Lifetime and 1 2-month prevalence of DSM-UIR psychiatric disorders in die United Stales. Arch Gen Psychiatry. 1 994:5 1 ( I ):8- 1 9.

15. Adebimpe VR, Race, racism, and epidemiological surveys. Hasp Community Psychiatry. 1994;45(I):27-31.

16. American Psychiatric Association, American Psychiatric Institute for Research and Education, Practice Research Network. Race-ethnicity variations: findings from the l°99 PRN Study of Psychiatric Patients and Treatments. PRN Update. Fall 2000:2.

17. Rosanseten MJ. Maillots-Sayre LJ, MacAskiII RL. Use of inpatient services by special populations. In: Manderscheid RN. Barrett SA. Mental Health. United Slates. /9X7. Rockville, MD: US Department of Health and Human Services, National Institues of Health, National Institute of Mental Health; 1998. DHHS publication 87-1518.

18. Pasamanick B. Some misconceptions concerning differences in the racial prevalence of mental disease. Am J Orthopsychiatry. January 1963:33:72-86.

19. Fischer J. Negroes and whites and rales of mental illness: reconsideration of a myth. Psychiatry. 1 969;32(4):428-446.

20. Neighbors HW. Trierweiler SJ. Munday C, et al. Psychiatric diagnosis ol African Americans: diagnostic divergence in clinician-structured and semistructured interviewing conditions. J Natl Med Assoc. 1 999;9 I < 1 1 ):60 1 -6 1 2.

21. Strakowski SM. Keck PE Jr. Arnold LM. et al. Ethnicity and diagnosis in patients with affective disorders. J Clin Psychiatry. 2O03;64(7):747-754.

22. Kirmayer IJ. The Fate of Culture in DSM-IV. Transcult Psychiatry. I998:35( I ):33 1 -342.

23. Canino 1. Canino A, Aaroyo A. Cultural considerations for childhood disorders: how much was included in DSM-IV! Transcult Psychiatry. 1998;35( I ):343-355.

24. Kawachi I, Kennedy BP. Wilkenson RG, eds. Income Inequality and Health. New York. NY: The New Press; 1999:465-473.

25. Adebimpe VR. Debating mental health in African Americans: lessons for ethnicity and policy. Paper presented at: Conference on The Politics of Racial Health: Myths, Maladies, and the History of Policy; October 26-27. 2001; New Brunswick, NJ.

26. Rushton JP. Race, Evolution and Behavior. New Brunswick. NJ: Transaction Publishers; 1995.

27. Sirovatka P. APA launches DSM-V "prelude" website. Psychiatric News. 2004:39( IO):23-48.

28. Kaiser J. National Institutes of Health. Higher profile for minority health. Science. 2000:290(5497): 1 667- 1 668.

29. Grow B. Hispanic nation. Business Week. March 15.2004:59-70.

30. Moran M. Black psychiatrists of American fight to remedy health care discrimination. Psychiatr News. 2004:39(8):9.

31. Moran M. Eliminating health care disparities required proper treatment tools. Psychiatr News. 2004;39(8):9.

32. Adebimpe VR. Psychiatric symptoms in Black Patients. In: Behavior Modification in Black Populations. Turner SM. Jones RT. eds. New York, NY: Plenum Press; 1982

33. Adebimpe VR. Overview: American blacks and psychiatry. Transcultural Psychiatry Research Review. 1 984:2 1 (2 ):8 1 - 1 09.

34. Adebimpe VR. Chu CC, Klein HE, Lange MH. Racial and geographic differences in the psychopathology of schizophrenia. Am J Psychiatry. 1 982: 1 39(7 ):888-89 1 .

35. Adebimpe VR. Hedlund JL. Cho DW. Wood JB. Symptomatology of depression in black and white patients. J Natl Med Assoc. 1982:74(2): 185-192.

36. Adebimpe VR. Mental illness among African Americans. In: Al-lssa I, Tousignant M. eds. Ethnicity, Immigration and Psychopathology. New York, NY: Plenum Press; 1997:95-105.

37. Whaley AL. Ethnicity/race, ethics, and epidemiology. J Natl Med Assoc. 2003: 95(81:736-742.

38. Adebimpe VR. Constraints on the validity of black/white differences in epidemiologic measurements. J Natl Med Assoc. 2003;95(8):743-745.

39. Cockburn A. 21st century slaves. National Geographic. September 2003:2-24.

40. Pizzi RP. A research agenda for DSM-V. CNS News. January 2004: 1 2- 1 3.

TABLE I.

Percentage Distribution of Admissions to Selected Inpatient Psychiatric Services by Race, Hispanic Origin, and Selected Primary Diagnosis: United States, 198015

TABLE 2.

Critical Symptoms for Assessing Psychiatric Disorders in Black Patients

TABLE 2.

Critical Symptoms for Assessing Psychiatric Disorders in Black Patients

TABLE 3

Allies Behavior Center Diagnostic Review Worksheet

TABLE 4.

Causes of Census-incongruent Ethnic Disparities

10.3928/0048-5713-20040701-15

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