Psychological Services最新文献

{"title":"Rethinking stigma: Prejudicial beliefs impact psychiatric treatment in U.S. soldiers.","authors":"Deane E Aikins, Julie Wargo Aikins, Tara Consolino, Joseph C Geraci, Paul Morrissey","doi":"10.1037/ser0000912","DOIUrl":"https://doi.org/10.1037/ser0000912","url":null,"abstract":"<p><p>Two thirds of military personnel diagnosed with posttraumatic stress disorder (PTSD) do not engage in treatment. We examined the degree that prejudicial beliefs about people with PTSD negatively affected psychiatric medication acceptance. Public stigma is best defined as negative stereotypes regarding individuals being judged as inferior or weak for having PTSD. In comparison, self-stigma includes internalized negative prejudices about illness control and stability. An important preliminary stage in developing self-stigma is first developing prejudicial beliefs about those with an illness. Active duty soldiers on a U.S. Army post completed surveys of prejudicial beliefs, public stigma, negative beliefs about psychiatric medications, and PTSD symptoms. Soldiers' Post Deployment Health Reassessment and medical records were accessed to determine the relation between their survey answers and responses to a later offer of psychiatric medication. Importantly, increased prejudicial beliefs (but not public stigma) that oneself is to blame for having PTSD were associated with a reduced likelihood of accepting psychiatric medication. Increased age was also associated with increased likelihood of accepting medication. Antistigma efforts to date may have limited effectiveness by targeting public-stigma rather than self-stigma prejudicial beliefs about personal responsibility in the development of PTSD. The relevance of this finding is vital to developing public health campaigns that maximize treatment acceptance. (PsycInfo Database Record (c) 2024 APA, all rights reserved).</p>","PeriodicalId":20749,"journal":{"name":"Psychological Services","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142606000","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"心理学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Stakeholder preferences for implementation strategies to address barriers to depression treatment among Latino/a/x teens.","authors":"Allison Stafford, Norma Garcia Ortiz, Morgan Proffitt, Gabriela Nagy, Hayden B Bosworth","doi":"10.1037/ser0000899","DOIUrl":"https://doi.org/10.1037/ser0000899","url":null,"abstract":"<p><p>U.S. Latino/a/x adolescents experience inequities in depression treatment use in comparison to non-Latino/a/x White peers. The purpose of this study was to describe barriers to depression treatment use and implementation strategy preferences to address these barriers among Latinx teens. A qualitative descriptive study was conducted with Latino/a/x teens diagnosed with depression (<i>n</i> = 7), their parents (<i>n</i> = 7), and health care providers (<i>n</i> = 18) from across the United States. Qualitative content analysis was conducted to determine common barriers and preferences across groups. Family-level barriers included parents' knowledge and beliefs about depression treatment, parents' own stress, and generational gaps between parents and teens. Provider-level barriers were related to the lack of a bilingual and bicultural health care workforce, and health care system-level barriers included difficulties paying for and scheduling care, inadequate systems for follow-up, and policies limiting innovation and adolescent consent to treatment. Participants emphasized that family involvement was crucial and the importance of tailoring implementation strategies to meet the specific needs of individual Latino/a/x teens. Social support, psychoeducation about depression, and resource navigation support were preferred strategy components that should be facilitated by a bilingual Latinx individual with relevant lived experience and address cultural context. Multilevel implementation strategies will need to be developed to address the multilevel barriers to depression treatment use. Future research will further refine and test an implementation strategy package to determine the effect on the use of depression treatment among Latinx teens screening positive for depression in primary care settings. (PsycInfo Database Record (c) 2024 APA, all rights reserved).</p>","PeriodicalId":20749,"journal":{"name":"Psychological Services","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-10-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142506685","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"心理学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Firearm screening and intervention beliefs and practices among U.S. Air Force (USAF) mental health providers and behavioral health technicians.","authors":"Ian H Stanley, William C Isler, Brian P Marx, Christopher J Button, David Obergfell, Jordan Simonson, Scott M Sonnek, Eric G Meyer","doi":"10.1037/ser0000904","DOIUrl":"https://doi.org/10.1037/ser0000904","url":null,"abstract":"<p><p>We examined beliefs and practices regarding firearm assessment and lethal means safety counseling (LMSC) among U.S. Air Force (USAF) mental health providers (MHPs) and behavioral health technicians (BHTs). Data were collected from 204 USAF MHPs (74.0%; <i>n</i> = 151) and BHTs (26.0%; <i>n</i> = 53) via an anonymous, voluntary survey. A modest proportion indicated they <i>strongly/extremely</i> believe that firearm ownership (42.2%) and storage practices (58.3%) are related to suicide risk. A minority indicated they \"strongly\"/\"extremely\" believe that LMSC will yield changes in storage practices (30.9%) and decreases in suicide risk (29.9%). Across patient scenarios, most indicated that \"most of the time\"/\"always\" they assess for firearm access (74.5%-99.5%) and provide LMSC (57.8%-95.6%). About half (52.5%) reported having distributed cable locks. Most (59.3%) indicated they are <i>somewhat interested/very interested</i> in receiving additional training on LMSC. MHPs, compared with BHTs, were significantly more likely to report believing a link between firearm ownership and storage practices and suicide risk, believing LMSC is effective at reducing suicide risk, providing LMSC to female patients and patients with current suicidal ideation, and having distributed cable locks. Findings suggest that there is not widespread agreement among USAF MHPs and BHTs that personal firearm ownership and nonsecure storage practices are associated with elevated suicide risk, and there were low levels of confidence in the effectiveness of LMSC. Yet, most USAF MHPs and BHTs reported they integrate firearm access assessment and LMSC as part of their routine clinical care, particularly for patients with identified suicide risk. (PsycInfo Database Record (c) 2024 APA, all rights reserved).</p>","PeriodicalId":20749,"journal":{"name":"Psychological Services","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142473251","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"心理学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effectiveness of telehealth-delivered massed trauma-focused psychotherapy among veterans with posttraumatic stress disorder.","authors":"Erin K Verdi, Michael A Gramlich, Greg M Reger, Sherry Yelland","doi":"10.1037/ser0000913","DOIUrl":"https://doi.org/10.1037/ser0000913","url":null,"abstract":"<p><p>Trauma-focused psychotherapies can be effectively delivered using a massed delivery format. Telehealth treatment for posttraumatic stress disorder (PTSD) using evidence-based interventions has been shown to be as effective as in-person treatment. However, the effectiveness of evidence-based treatments for PTSD over telehealth using the massed delivery format requires further examination. To examine the effectiveness of telehealth massed PTSD treatment, we report on a quality improvement study of 33 veterans (75.8% male; <i>M</i>_Age = 42.3, <i>SD</i> = 11.0) who participated in a virtual 4-week massed PTSD program at a Department of Veterans Affairs (VA) medical center. Twenty-seven (81.8%) veterans completed the treatment and reported large reductions in PTSD (<i>d</i> = 1.48) and depressive symptoms (<i>d</i> = 1.08) at Week 4 and at 1-month follow-up (PTSD, <i>d</i> = 1.34; depression, <i>d</i> = 0.70). Results suggested that evidence-based treatment for PTSD can be effectively delivered in a massed format over telehealth in a VA medical setting. (PsycInfo Database Record (c) 2024 APA, all rights reserved).</p>","PeriodicalId":20749,"journal":{"name":"Psychological Services","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142473250","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"心理学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Targeting chronic pain care to rural women veterans: A feasibility pilot.","authors":"Lauren Garvin, Mary A Driscoll, Kenda Stewart Steffensmeier, Nicole L Johnson, Jenna L Adamowicz, Ashlie A Obrecht, Kimberly J Hart, Shamira J Rothmiller, Zita Sibenaller, Lori Stout, Chris Richards, Mark Vander Weg, Brian C Lund, Katherine Hadlandsmyth","doi":"10.1037/ser0000909","DOIUrl":"https://doi.org/10.1037/ser0000909","url":null,"abstract":"<p><p>For rural women veterans, significant barriers exist in accessing high-quality, multicomponent behavioral pain self-management interventions. As such, a telehealth behavioral pain self-management intervention designed specifically for rural-dwelling women veterans with chronic pain was piloted for this study. This mixed methods, single-arm preliminary study examined the feasibility and acceptability of this intervention and completed a responder analysis. Participants completed surveys before and 1-month following the intervention, and they completed a qualitative interview following the intervention. About one quarter (24%) of potentially eligible participants who were sent a letter about the study consented to participate (<i>N</i> = 44). All participants identified as female and were rural dwelling, with mean age of 56 years (range = 34-80), and the majority of the sample (81%) self-identified as White and non-Hispanic or Latino. Average baseline scores on the Pain, Enjoyment of Life, and General Activity three-item scale (PEG-3) measure indicated severe pain and functional interference (<i>M</i>_{PEG-3 total} = 6.88, <i>SD</i> = 1.62). Of the 44 participants who consented, 70% completed the intervention. About half of treatment completers (47%, 14/30) were deemed responders, reporting ≥ 30% reduction on their PEG-3 total scores. On the Global Impression of Change scale, 87% reported improvement. Study completers indicated that the telehealth platform facilitated their engagement and that they perceived the intervention to be beneficial and credible. Qualitative data emphasized themes of connection with other women veterans who experienced chronic pain while perceiving a retained sense of individual identity. These preliminary data support feasibly of this intervention for rural-dwelling women veterans with chronic pain. (PsycInfo Database Record (c) 2024 APA, all rights reserved).</p>","PeriodicalId":20749,"journal":{"name":"Psychological Services","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-10-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142392645","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"心理学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Predictive validity of the Psychopathy Checklist: Screening Version (PCL:SV) in a sample of New Zealand Māori and European male prisoners.","authors":"Ryan Botha, Devon L L Polaschek","doi":"10.1037/ser0000885","DOIUrl":"https://doi.org/10.1037/ser0000885","url":null,"abstract":"<p><p>Numerous studies have investigated the predictive validity of the Hare Psychopathy Checklist (PCL), but the majority have used samples from North America. The PCL may inform important decisions about people's futures; recognition has been growing of the importance of ensuring that its psychometric properties are established in each jurisdiction where it is used, especially for Indigenous and non-European populations. The present study examined the predictive properties of the Hare Psychopathy Checklist: Screening Version (PCL:SV; Hart et al., 1995) in 371 New Zealand (NZ) male prisoners, including NZ European and NZ Māori subsamples. Discrimination analyses showed that PCL:SV total scores had moderate predictive accuracy for any new conviction within 5 years of release; no significant differences were detected for Māori versus NZ European on this outcome. PCL:SV Factor 2 (Lifestyle/Antisocial) scores were moderately predictive of violent recidivism within 5 years of release. In a second, independent sample of male prisoners (<i>n</i> = 102), both PCL:SV total and Factor 2 scores showed moderate predictive accuracy for serious institutional violence. Additionally, PCL:SV Facets 1 (Interpersonal) and 2 (Affective) scores were uniquely associated with time to sexual and violent recidivism, respectively. Understanding the predictive performance of clinical risk measures across diverse ethnic groups is an important step toward identifying and addressing ethnic disparities in criminal justice outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).</p>","PeriodicalId":20749,"journal":{"name":"Psychological Services","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-10-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142392644","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"心理学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reducing mental health stigma in academia: Assessing the acceptability of a first-person narrative program.","authors":"Andrew R Devendorf, Sarah Wilson, Wendy M Ingram","doi":"10.1037/ser0000908","DOIUrl":"https://doi.org/10.1037/ser0000908","url":null,"abstract":"<p><p>Academics are more likely to experience mental health difficulties like depression and anxiety. However, stigma remains a key barrier to help-seeking, and limited data exists on stigma reduction for academics. This study examines the acceptability of a first-person narrative-based antistigma program conducted by Dragonfly Mental Health at a large public university. This intervention used a multitiered approach that leverages education and contact strategies to reduce stigma among graduate students, postdoctoral fellows, staff, and faculty. Personal stories of six local faculty with lived experience of mental health struggles were shown in a short film during three separate departmental retreats, followed by moderated large and small group discussions. This study presents descriptive survey data from academics (<i>N</i> = 149) who attended one of these three programs. A thematic content analysis was conducted on open-ended responses from 86 participants. Overall, the Dragonfly Mental Health program was well-received: 95% of participants found the film beneficial, and over 92% felt the film and discussions reduced stigma. Qualitative analysis highlighted several themes on participants' experiences. Participants appreciated the open, honest disclosures of faculty members in the film but reported that the vague disclosures perpetuated stigma. Participants liked the normalization of mental illness but desired more representation from the mental health spectrum. Participants expressed frustration over an academic work culture that is defined by overwork and burnout. These findings suggest that sharing faculty stories is a powerful mechanism to build connectedness among academics, promote open communication, and foster change in academic culture around mental health. (PsycInfo Database Record (c) 2024 APA, all rights reserved).</p>","PeriodicalId":20749,"journal":{"name":"Psychological Services","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142366343","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"心理学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate the written exposure therapy training program in the Veterans Health Administration.","authors":"Stefanie T LoSavio, Courtney B Worley, Robyn D Walser, Debra Kaysen, Craig S Rosen, Shannon Wiltsey Stirman","doi":"10.1037/ser0000890","DOIUrl":"https://doi.org/10.1037/ser0000890","url":null,"abstract":"<p><p>The Veterans Health Administration (VHA) has rolled out evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD); however, reach has remained low, and there is a need for briefer interventions. The National Center for PTSD conducted a facilitated learning collaborative to train clinicians and support VHA PTSD teams in their adoption of an emerging best practice, written exposure therapy (WET). Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) evaluation framework, the present study utilized longitudinal data from 178 clinicians and 556 patients across seven training cohorts to evaluate key clinical and implementation outcomes and whether clinic (i.e., implementation climate) or clinician factors (i.e., treatment attitudes) were associated with effectiveness and implementation. Intent-to-treat analyses indicated WET was effective in reducing PTSD (<i>d</i> = 0.54) and depression symptoms (<i>d</i> = 0.39). Data indicated that 87.60% of clinicians reported using WET 6 months postconsultation. Clinic-wide reach was modest after training (14.53% of individuals with PTSD); however, WET-trained clinicians continued to offer WET to an average of 87.38% of their patients. Fidelity remained high after training, with essential session elements most often being offered \"always\" (<i>M</i> = 6.65 on a scale from 1 to 7). More positive postconsultation clinician treatment attitudes predicted higher posttraining rates of having patients engaged in WET. Clinician treatment attitudes and implementation climate did not predict any other implementation or effectiveness outcomes examined. Results suggest that WET implementation is advancing in VHA, with good clinical outcomes. Data provide evidence that a facilitated learning collaborative can be used to support and scale EBPs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).</p>","PeriodicalId":20749,"journal":{"name":"Psychological Services","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142366344","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"心理学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Transitioning an implementation research intervention to a sustained clinical service: Telehealth primary care mental health integration implementation in Veterans Health Administration.","authors":"Eva N Woodward, Karen Anderson Oliver, Karen L Drummond, Mary Kate Bartnik, Amanda McCorkindale, Scott S Meit, Richard R Owen, JoAnn E Kirchner","doi":"10.1037/ser0000903","DOIUrl":"https://doi.org/10.1037/ser0000903","url":null,"abstract":"<p><p>Often in implementation science efforts, an intervention originated by research funding does not continue in clinical practice after funding ends, or if it does, the process by which it was sustained remains known only to the implementation research or clinical teams. From 2018 to 2020, we implemented a complex telehealth interdisciplinary behavioral health program supported by research funding. The intervention was Primary Care Mental Health Integration (PCMHI) delivered via televideo from a large parent medical facility to rural satellite clinics (tele-PCMHI) within the Veterans Health Administration. Two implementation facilitators worked closely with clinical leaders and staff to plan, launch, and sustain tele-PCMHI across four sites. The intervention is still maintained by the clinical service and has spread to eight sites. Based on ethnographic and qualitative data collected weekly over 2 years, we categorized sustainment strategies across distinct time periods for this complex program, theoretically grounded in the Dynamic Sustainability Framework, emphasizing changes to adapt intervention fit to rapidly changing context. To contextualize, we identified barriers and strengths, such as difficulty training staff to use new equipment, restructuring clinic workflow, and determining suicide risk management remotely. New barriers arose, and, thus, new strategies were needed to continue implementing at the onset of the COVID-19 pandemic in 2020. Different strategies at different stages of implementation allowed sustainment to be a dynamic and evolving process. Plus, proactive and persistent planning for sustainment early in the effort, along with alignment with performance metrics and national policy, supported continued delivery in real-world organized care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).</p>","PeriodicalId":20749,"journal":{"name":"Psychological Services","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142352643","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"心理学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sexual orientation moderates the association between health care utilization-related factors and mental health service nonutilization among United States military veterans.","authors":"Cindy J Chang, Ian C Fischer, Kelly L Harper, Nicholas A Livingston, Colin A Depp, Sonya B Norman, Robert H Pietrzak","doi":"10.1037/ser0000907","DOIUrl":"https://doi.org/10.1037/ser0000907","url":null,"abstract":"<p><p>This study examined mental health treatment nonutilization among sexual minority versus heterosexual Veterans with demonstrated psychiatric need. Data were analyzed from 820 Veterans with psychiatric need who participated in the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of U.S. military Veterans. Results revealed that current mental health service nonutilization did not differ between sexual minority versus heterosexual Veterans (70.5% vs. 74.0%). Significant interactions between sexual orientation and sex assigned at birth, primary source of health care (Veteran Affairs [VA] vs. non-VA), and beliefs that peers would blame them for their mental health problems were observed in analyses predicting current mental health treatment utilization. Among Veterans primarily utilizing VA health care, sexual minority Veterans were less likely than heterosexual Veterans to engage in mental treatment; among those primarily using non-VA, this pattern was reversed. Sexual minority Veterans were significantly more likely than heterosexual Veterans to report not knowing where to get help, not having adequate transportation, and having difficulty scheduling an appointment. Taken together, the results of this study suggest that rates of mental health nonutilization are high for both sexual minority and heterosexual Veterans, and that factors that influence utilization may differ by sexual orientation. (PsycInfo Database Record (c) 2024 APA, all rights reserved).</p>","PeriodicalId":20749,"journal":{"name":"Psychological Services","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142352641","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"心理学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}