My Experience Only. YMMV.

Posts tagged ‘media and mental illness’

Would You Try Electroshock?

Photo by Mike T

In the course of dealing with my bipolar disorder, I had a near brush with electroshock. I managed to avoid it, but I did give it serious thought.

Now 60 Minutes has come out with a piece called “Is Shock Therapy Making a Comeback?” You can see the segment here: 60 Minutes.

ECT(electroconvulsive therapy, the modern name for the procedure), which is often done on an outpatient basis, works by inducing a brief seizure in a patient. The seizure, which lasts about a minute, releases multiple neurotransmitters in the brain, all at once. The patient is required to have someone to transport them to and from the appointment. Treatments are typically applied one or two times per week for 6-8 weeks.

In a brief article excerpted from the news show segment, Dr. Charlie Welch, of McLean Psychiatric Hospital, explains how ECT differs from how it was performed in the past: “What’s different first of all is that it’s done under general anesthesia with a muscle relaxant. So when the treatment is done, the patient is sound asleep and completely relaxed.” Call it a kinder, gentler shock treatment.

That was the procedure that my psychiatrist offered me after he had spent a number of years trying me on various medications that either didn’t work, or helped only partially.

My immediate reaction was negative. I recall thinking, “Fuck, NO! Keep away from my brain, you Nazi sadist!” After I calmed down a bit, I did some research.

ECT, my sources said, was a long way from the cruel, stigmatizing procedure portrayed in One Flew Over the Cuckoo’s Nest. The Internet was little help, though. The opinions and experiences of people who had undergone electroshock ranged from “It was hideous” to “It was a miracle.”

Truthfully, I was appalled by the notion of electrical jolts surging through my brain. My precious brain, which had both sustained me and betrayed me throughout my life.

Then I thought some more. So ECT sometimes causes memory loss. I already had that, thanks to some of my meds. I would be altering my brain with electricity. But hadn’t I been altering it for years with chemicals – medications that no one seemed to know how they worked?

So I went back to my doctor and said I would at least talk to the doctor who would perform the procedure. And I lined up a journalist friend to write about my experiences if her editor approved. (Note: In the 60 Minutes piece, former Massachusetts First Lady Kitty Dukakis gave permission to have her treatment filmed and broadcast.)

My psychiatrist, however, had one more medication that he wanted me to try before we took that next step. And it worked. So much for electroshock.

Now as to that side effect of memory loss – Dr. Sarah Lisanby of the National Institute of Mental Health in Maryland has developed a new treatment that seems to avoid that particular consequence.

The procedure is called Magnetic Seizure Therapy (MST) and it uses magnets (duh!) to stimulate more precisely focused seizures than ECT does. These focused seizures seem to avoid the parts of the brain associated with memories. As Dr. Lisanby told the 60 Minutes reporters, “For some people, ECT may still be needed. But if Magnetic Seizure Therapy could be effective without the memory loss who wouldn’t want to try that first?”

Would I try MST if I relapsed into treatment-resistant depression? I would certainly consider it, if it were out of the testing stage by then. And I’d do that before I signed up for ECT. While I have memories I’d prefer to forget, with my luck, those would be the ones left unaffected.

The cynical side of me says that these seizure-causing therapies are becoming more popular because insurance companies like the notion of a short course of 6-8 weeks of treatment instead of years of talk-and-medication. (Although Kitty Dukakis said that she has done ECT for years now and expects to continue into the foreseeable future.)

But I could be wrong. It is possible that some kind of treatment could be short in length but longer-lasting in effectiveness. I’m not ruling it out. At this point I’m not ruling out anything that could aid in my progress and my healing.

 

Mental Illness and Gun Violence

photo by Thomas Hawk

There’s been a lot of talk lately that not allowing the mentally ill to own guns would curb the trend of gun violence in the U.S. There are just a few things wrong with that theory.

Are background checks the answer? They aren’t. Such checks at certified gun dealers screen out only the very few who have been hospitalized for mental illness – involuntarily committed, that is, not just referred for a 72-hour hold for observation or self-referred. That’s only a very small portion of those with mental illnesses. Most people with mental disorders are never hospitalized and some never receive any diagnosis or treatment from a psychiatrist, psychologist, or another counselor, which means that background checks would never turn them up. And there are loopholes in many states’ versions of background checks that, for example, allow private sales of guns without them.

To take this to the next level of absurdity, it would be a severe breach of confidentiality if therapists had to report every client to a database somewhere, just in case, and would lead to fewer people being treated for mental health issues, for fear of being put on a registry that might be used for any purpose eventually, even employment. Gun owners don’t want to be on a nebulous registry “somewhere,” and neither do the mentally ill.

Can psychiatrists and other counselors report to the authorities clients they fear may become violent? Again, laws differ from state to state. Usually, the question comes up only when a client makes specific threats against a specific person or a government official. The therapist must make a judgment about whether the client is a danger to self and others, which could result in a 72-hour hold, and may of course be correct or incorrect. A client with generalized anger issues is probably not mandated to be reported.

And to whom and for what purpose would the person be reported? To the police, when no crime has been committed? Is a therapist’s report of a client’s report of feeling angry enough to shoot “someone” sufficient to justify a search warrant of the person’s house for a legally owned firearm?

Are mentally ill people more likely to be violent than other people? No. In fact, mentally ill people are much more likely to be the victims of violence than they are to be perpetrators. But no matter how many times we say that, few listen or believe it. Some mentally ill people turn violence – and guns –against themselves. Some are killed by police officers with no training in handling confrontations with differently abled people, including the mentally disordered.

Not only are mentally ill people more likely to be accused of violence, violent people are more likely to be accused of being mentally ill. That’s practically the first thing anyone says after a mass shooting – “Oh, he must be crazy” (or on psychotropic medications). Of course, with one in four adults being likely to experience some form of mental distress in their lifetimes, it is possible that a shooter is one of those people.

But newscasters and politicians and people on the street are, by and large, not psychiatrists or psychologists. They are no more able to diagnose mental illness than burger-flippers, dairy farmers, lawyers, or business executives. Not that that stops them. Mental diagnoses are flung about indiscriminately nowadays, from people who call themselves OCD because they straighten pictures to psychiatrists who claim to diagnose public figures without having spoken to them once, much less having developed a therapeutic relationship with them.

But can’t potential violence be predicted? No. It can’t. The prison system can’t do it, or there wouldn’t be so many parolees and probationers and those who have served their time who go right back to crime and violence. Mandatory sentencing laws and the political climate have reduced the problem in some areas, but there are still plenty of cases in which the system fails. At trials and parole hearings and sentencing hearings, there is always someone – doctor or lawyer or family member – to say that the offender will not offend again.

But the only known predictor of violence is past violence. That’s why some people think it’s more sensible to restrict the gun ownership rights of domestic abusers rather than someone mentally ill who has no record of violence.

Can’t mentally ill people who’ve proven to be violent be required not to own guns? Theoretically yes, but we know how well it works to tell people on probation who have no record of mental illness that they can’t own guns, drink liquor, or associate with known criminals. The probation system is too understaffed to enforce these requirements already. Who would be willing – or should have the responsibility – to check up on everyone, even the small proportion of the mentally ill who have been involuntarily committed or convicted and then released, and make sure they don’t acquire any guns? If the parole and probation people can’t handle the caseload they already have, why would we think that mental health professionals have any more time, capacity, training, or know-how to do it?

Would banning guns prevent gun violence by the mentally ill? In a word, no. There are already too many guns in circulation in this country for that to be possible, and those guns are too easy to get. And again, there would still be the problems of determining who is mentally ill, by whose definition, and how such a gun ban could be enforced.

So, I hear you asking, you’ve told us all the things that won’t work. Is there anything that will?

Not if you think that the problem of gun violence and the problem of treating the mentally ill overlap. Gun violence is one topic and the mental health system is another. There is a lot that can be said about fixing one or the other, but nothing that would solve both at once.

Not that a lot is being done now, unless you count blaming, finger-pointing, and spreading stigma.

 

For more discussion on the topic, see http://www.amhca.org/blogs/joel-miller/2017/10/03/gun-violence-and-mental-illnessmyths-and-evidence-based-facts from the American Mental Health Counselors Association.

Why I Hate TV Drug Commercials

Just as a general rule, I dislike commercials for any drugs. They impede the doctor/patient relationship. (I’ve often considered saying to my doctor, “I’m supposed to ask you if Latuda, Humira, Prolia, Viberzi, Lunesta, Cialis, Trulia, Trintellix, Keytruda, and Boniva are right for me.”) TV – and to a lesser extent print – ads encourage people to act as unpaid drug reps. And they only advertise expensive drugs until they go generic, which is when they stop being expensive and the drug companies stop making so much money.

(If you want to read more on the issue, go to https://www.medicinenet.com/script/main/art.asp?articlekey=106198.)

But there are other things about TV drug ads that make me more than a little cranky. Like where are the ads for drugs to treat bipolar disorder?

Oh, there are ads for drugs to treat bipolar depression, as well as ones for treating non-bipolar depression. You’d think that with approximately 2.8 million people who have bipolar in the U.S. and Canada (http://www.pendulum.org/bpfacts.html), there would be a market for bipolar treatments.

Also, the ads for depression treatments don’t always get it right. A few of them say that depression is more than just sadness, or that it lasts for several weeks at least. One even says that depression is a “tangle” of symptoms, which is certainly true. (Although the tangle is shown graphically in primary red, yellow, and blue, which don’t really say “depression” to me.)

Most, however, treat depression simplistically, with hidden depression represented by a smiley face mask hiding a frowny face mask. (The colors in that ad are muted during the “before” scenes and more vibrant during the “after” scenes, which is an old advertising trick.)

The ads also make it look like the most important thing about depression is not spending time with your family or not enjoying it if you do. While that certainly is one symptom of depression, it is by-and-large irrelevant to people like me, who don’t have 2.1 school-age children to take on picnics. And it’s pretty much a guilt trip for people who do.

Then there’s how the people in the ads are represented. Oh, they almost always show one POC and one slightly older person (frolicking with the grandkids). But all of them are attractive. All of them are models. Are we supposed to identify with them? Or just expect to look like them when our depression lifts?

I wouldn’t be so annoyed by this issue if it weren’t that ads for other kinds of drugs – those for psoriasis and diabetes, for example – have actual people with the disorder in them. Testimonials from those who’ve been there, as it were. Even real-life cancer patients are now featured in ads for treatment centers.

What’s up with that, I wonder? Surely they don’t imagine that only pretty people get depression or bipolar. It can’t be that they can’t find any well-spoken, real-life people who can relate their own experiences. I for one would feel more reassured if I heard about a treatment from someone who’s lived with the disorder instead of from someone selected at a casting call. Are we all homely and illiterate? (I meet the qualification for literacy, at any rate.)

Instead of trying to convince us what medications our doctors might prescribe us, the airtime would be better spent on ads that educated the public on depression and bipolar disorder. But those would be PSAs, of course, appear only at 3:00 a.m., and not make anyone any money.

Update: I have finally seen an ad for a drug to treat bipolar 1 mania. Everything else I wrote here remains the same.

 

“Lock Up the Crazies Before They Hurt Someone”

Mass shootings and the public reactions to them are pretty predictable among the mental illness community.

One thing you hear after every mass shooting – and after many smaller ones – is that the mentally ill should not have access to guns.

Fine. But I have bipolar disorder, as well as some guns that I inherited from my father. I occasionally go to a gun range and fire them, but not often since I’m not the gun aficionado my father was.

So what am I supposed to do? Sell the guns? Give them away? Turn them in to the police? My therapist? I was taught gun safety from a young age by two certified pistol and rifle instructors (my parents) long before I received my diagnosis.

The further you go into the debate about guns and the mentally ill, or about whether the mentally ill are a danger, the deeper you get into fundamental constitutional, legal, and medical issues, as well as considerations of simple practicality.

Some advocate locking up the mentally ill. This is irrational. What the proponents really mean is “Lock up the dangerous mentally ill before they become mass shooters.” And that is impossible.

First, there’s the matter of due process, which is as much a part of the Bill of Rights as the vaunted Second Amendment is. You can’t just lock people up without a trial or at least a hearing.

Second, there’s no way to determine whether a mentally ill person is likely to become a mass shooter or any other kind of danger. The only generally known predictor of violent behavior is past violent behavior. In fact, there’s no way to tell whether any given individual is going to become a mass shooter. That’s because it’s really hard to predict the future.

Third, there’s the consideration of medical decisions and the right to privacy. HIPPAA has gone a long way toward protecting the privacy of patients – including the mentally ill. At the moment, a mentally ill person can only be held for 72 hrs., and then only if the person goes to the hospital voluntarily or is determined to be a danger to self and others. That’s a high standard, and it should be.

Fourth, the mental health system is already understaffed, underfunded, and overwhelmed. There are long waiting lists for beds in hospitals and treatment facilities. Are we to build new asylums to accommodate all these supposedly dangerous persons? Train more counselors to treat them? Or just lock them up and get them out of sight, out of mind?

Fifth, the idea that mentally ill persons can be forced to accept treatment and take their medication as prescribed violates several basic rights. My mother, who was not mentally ill, hardly ever took her medications as prescribed. She would quit taking one after a few days “because it wasn’t helping” or “it caused sores in her mouth” – without telling her doctor. Should she have had a caregiver to monitor her compliance? Who would monitor all those potentially noncompliant mentally ill persons as they take their psychotropic drugs? I see, we’re back to putting them in asylums.

Besides, refusing treatment is a right that patients have – even mental patients. Physically ill patients, for example, can choose to forgo chemotherapy or dialysis or medications that cause side effects worse than the condition they’re prescribed for. And mental patients have the same right. They can stop taking a medication because they fear side effects like tardive dyskinesia or even weight gain, though we hope they consult their doctors first.

But forced treatment and forced medication, as some have suggested, brings us back to the question of who, how, and where. Asylums? Court-ordered treatment? Medications that must be taken in the presence of a doctor or a therapist (who is not qualified or licensed to dispense medication)?

Take all those arguments against forced treatment of the mentally ill and add the fact that the mentally ill are far more likely to be victims of violence than perpetrators of it, and where are we? Admittedly, the mental health “system” is broken, or at least badly fractured. But is the answer really to take away the civil rights of people who have broken no laws?

The press and the public are quick to focus on the mentally ill as the culprits in mass shootings. But even if they were correct, taking away fundamental rights would not only be no real solution, but would chip away at the rights of other disenfranchised or minority populations – the homeless, for example.

If there’s a solution to this problem, I don’t know it, but locking up the “crazies” isn’t it.

 

If you want to read more on both sides of the issue, see the L.A. Times article by Paloma Esquivel at http://www.latimes.com/local/la-me-adv-lauras-law-20140310-story.html.

At Last, Some Encouraging News

 

 

 

 

 

You know I bitch a lot about the science and research associated with mental health in general and bipolar disorder in particular. It seems like I bitch about nearly everything I read in the press. Here are some examples:

I have been told that I have a weak understanding of science and the scientific process. It’s true that I have no degree in any science, not even the “soft” science of psychology. Yet I persist.

Some of my major objections (if you don’t want to read the above-mentioned posts, which I fully understand) include: that article headlines seldom match the stories they’re attached to; that too many qualifiers like “might” and “may” occur in the stories; that the research is still in the rats-and-mice stage, which is a lo-o-o-o-ng way from human trials or public availability; and that many reports contain yes-it-does/no-it-doesn’t debates.

Most of all, I hate “false hope” headlines that I don’t believe will ever trickle down to the bipolar-person-on-the-street. Certainly not in my lifetime, and maybe never. And if they should become available, the cost will be prohibitive. I can’t believe that many of us will have the wherewithal (meaning both access and money) to avail ourselves of the new solutions. I mean, can you really picture the average bipolar patient getting genetic testing or fMRI? Or insurance paying for it?

Then came the headline “Simple EKG can determine whether patient has depression or bipolar disorder” (https://www.eurekalert.org/pub_releases/2017-11/luhs-sec112017.php). Published by Eurekalert! (which, despite its name, appears to be an aggregator of science press releases from sources such as universities and labs around the world), the story reports on work done at Loyola University Health System.

For me, the take-away points are these:

“Bipolar disorder often is misdiagnosed as major depression. But while the symptoms of the depressive phase of bipolar disorder are similar to that of major depression, the treatments are different and often challenging for the physician….

“The study found that heart rate variability, as measured by an electrocardiogram, indicated whether subjects had major depression or bipolar disorder….

“Dr. Halaris said further research is needed to confirm the study’s findings and determine their clinical significance.”

And yes, this does feed into my dislike of small studies (under 200 participants) that admit “further research is needed.” But this one, it seems to me, could actually be of some benefit.

Misdiagnosing bipolar disorder as major depressive disorder is a real and perhaps not uncommon thing. I was diagnosed with major depression for decades before a psychiatrist realized I had bipolar disorder. The treatment I got in those decades helped, but the treatments since have helped more.

And I can see a 15-minute, three-lead EKG becoming more available, at least to those of us who still have insurance (a dwindling number, to be sure). In cases like mine, it could save years of incorrect diagnosis and less-than-effective treatment.

Of course, here I am using the hated word “could.” But I take heart from the fact that it is a noninvasive procedure, there are plenty of potential test subjects, the expected resulted is focused on a single, more manageable result – misdiagnosis of one condition – and the test uses a relatively simple, already available technology.

It won’t help me, of course, since I already have my diagnosis, but I think of the people – even people I know – who could benefit from it, and in the not-too-distant future. Would the person who swings from depression to anxiety and doesn’t respond to the usual medications for depression actually have bipolar 2? Would the one who has wide mood swings and a diagnosis of OCD prove to have both, in reality?

Who knows? Not us, at the moment. But in the near future? This time I think there really is hope.

Does It Help When Celebrities Talk About Mental Illness?

It usually doesn’t hurt.

But how much does it help?

That depends on who is talking about mental illness and what they say.

Celebrity Activists

We need more mental health advocates like actors Carrie Fisher and Glenn Close. Both of them have spent years talking about their own and their loved ones’ experiences with bipolar disorder and schizophrenia. Neither one is a one-benefit-and-they’re-gone supporter. They repeat their vital messages again and again, in different ways, in different venues, in different words. Carrie Fisher, in particular, used her mega-star power and witty personality to keep the discussion alive and spread it to millions of people.

Active Celebrities

While not devoting as much time and attention to mental health activism as Fisher and Close, other well-known entertainers including Demi Lovato and Lady Gaga have made contributions to the public discussion on various mental illnesses. Because of their large number of fans, these messages reach millions of people. And their music reaches people at an emotional level that PSAs just can’t. If even a small percentage of their audiences pays attention to the messages, that’s a lot.

And we can’t forget Prince Harry. Positive messages about mental health coming from royalty are ones that people will listen to. (You know how we Americans love royals.)

Celebrities

Other celebrities mention their mental health diagnoses in public, but do little more to campaign for mental health causes. Catherine Zeta-Jones spoke of her bipolar II diagnosis when she was hospitalized for five days, saying that it was brought on by stress. And renowned glass artist Dale Chihuly admitted his bipolar disorder when he was more or less forced to by a lawsuit.

Staying quiet certainly is their right. Mental illness is a deeply personal and to many, a private thing. And celebrities as much as any of us must struggle with when and how and to whom to reveal their struggles. Perhaps in the future they may become more comfortable talking about their problems and contributing to mental health causes and organizations.

Suicides

Unfortunately, suicides speak loudly. Robin Williams’s death by suicide made a big impression. It got people talking – if only to ask “why?” Though a lot of the conversation revolved around “Even funny people can have suicidal depression,” that’s a start on the message that you can’t tell who’s suffering inside just by looking at them. It’s just too bad that the death of a beloved entertainer is needed to start that discussion.

Media

Are the media “celebrities”? A few individuals truly are, But as a group, the media have the largest platform of all. And what do they say about mental health? I think you know the answer. Mental health gets discussed in the news media in cases of terror and tragedy, and when no other explanation comes readily to mind.

The media bear a huge responsibility when it comes to stigmatizing mental illness. Theirs are the only messages that many people hear – and believe. The news media have (or at least used to have) a reputation for spreading the truth. Nowadays we can’t even count on that. The splintering of the news media into “sides” to promote opposing ideologies – combined with shrinking budgets that have nearly eliminated informed science reporting – make it difficult for the average news consumer to know who and what to believe.

Who does that leave to spread the message? Us. Those of us who live with mental illness or have loved ones who do. And sometimes I worry that we are talking mostly to ourselves – to each other. Don’t get me wrong. Those conversations are vital in helping one another deal with our difficulties and sharing messages of support and understanding.

But maybe we can do more – even if it’s educating a family member about depression or wearing a semicolon tattoo to promote suicide prevention or posting/commenting on social media when a news outlet has gotten its coverage of mental illness all wrong.

Among my fondest hopes is that one or more of my blog posts will be passed along to someone who needs to hear the word. “Here – read this,” is a message I would be proud to spread, even though I’m no Carrie Fisher.

The Latest Headlines on Mental Illness

There’s a wonderful article, originally in The Telegraph, with the title “Can Depression Be Treated With Anti-Inflammatory Drugs?” Snopes.com, the preeminent debunker of all things dubious, proceeded to do what they do best – debunk. In their analysis, they find several factors common to many widely reported studies that illustrate why we shouldn’t take these announcements of causes or cures at face value or at least without a grain of salt.

They break down their reasons for not jumping on the study’s bandwagon into three major categories.

No Credible Scientists Have Argued that All Depression is Caused by Inflammation. The article in The Telegraph was talking about patients with Major Depressive Disorder (MDD) who were not responding to current medication, or who also had other inflammatory-related conditions such as rheumatoid arthritis (RA). And the information came from just one talk by just one scientist,

Association is Not Evidence of Causation. I’ve written on the subject before (http://wp.me/p4e9Hv-7Z, http://wp.me/p4e9Hv-9L), and included a link to a short video that explains the scientific process, from original study up to the time when a new drug or treatment hits the market (http://www.vocativ.com/culture/junk-science/). Briefly, it means that just because two things are correlated (or happened one after the other) does not prove that one caused the other. Inflammation may have caused depression, or depression may have caused inflammation, or other factors may have influenced one or the other, or both, or neither.

The Anti-Inflammatories Discussed Are Specific, Powerful Drugs with Side Effects. You can’t just go down to the corner drugstore and pick up a bottle of ibuprofen and think you’ve solved your depression problem. And it turns out that the anti-inflammatories they’re talking about increase the risk of infections and cancers, and are wildly expensive.

Snopes concludes:

While the science discussed by the Telegraph in this article is real, it omits seriously important context and misrepresents decades-old research as a breaking development in a way that could provide false hope to those suffering from depression. The interplay between the immune system and the mind is increasingly well established, but that doesn’t mean that science has established anything close to a new treatment for depression as a result of this understanding.

“False hope.” That’s what a lot of these headlines regarding causes and treatments for depression offer. Shall we look at another recent example?

This one, I’m sorry to say, comes from bp magazine (bphope.com). The headline is “Underlying Molecular Mechanism of Bipolar Disorder Revealed.” The tagline reads, “Findings inform development of potential diagnostic test and improved therapies.”

But that’s not exactly true. The first paragraph says nothing about the underlying mechanism of bipolar disorder. Instead, it talks about the mechanism “behind lithium’s effectiveness in treating bipolar disorder patients,” something very different. But that doesn’t make as snazzy a headline. The article also says the results “may support the development of a diagnostic test” and “may also provide the basis to discover new drugs that are safer and more effective than lithium.” May. Might. Or might not. Too soon to get your hopes up.

The conclusion? [T]he study demonstrated that bipolar disorder can be rooted in physiological—not necessarily genetic—mechanisms.” Well, I’m a word nerd, not a science geek, but “can be” is a far cry from “is.”

Now for my favorite, reported by the BBC: “Magic mushrooms can ‘reset’ depressed brain.” Again, the tagline says “raising hopes of a future treatment,” which is a pretty far stretch. The study was performed on 19 subjects, each given one dose of psilocybin. The article reports that “Half of patients ceased to be depressed and experienced changes in their brain activity that lasted about five weeks.”

So. Tiny sample. No control group. And flip a coin on the results. Personally, I don’t see that raising much hope.

Bottom line for this one: junk science. Eye-catching headline. They won’t be handing out magic mushrooms at the local mental health clinic anytime soon. (The article does warn not to self-medicate.)

We’ve been hearing for years about tests to diagnose depression and bipolar, and stunning new treatments. Well, the studies take years to do properly; the tests need to be proved accurate and better than current psychological testing; and the treatments must go through years and years of studies, animal testing, and human testing, complete with control groups and sufficient numbers of subjects to make them scientifically significant.

I just wish these people would quit reporting “results” until they have some to show.

 

Resources

http://www.snopes.com/2017/09/19/can-depression-treated-anti-inflammatory-drugs/

https://www.bphope.com/underlying-molecular-mechanism-of-bipolar-disorder-revealed/

http://www.bbc.com/news/health-41608984?utm_source=dlvr.it&utm_medium=facebook

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