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Mental health

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Australia's welfare 2007

The 8th biennial Australia's welfare report, compiled by the Australian Institute of Health and Welfare (AIHW) in 2007, describes the wellbeing of Australian children and young people as a 'mixed one'.

While Australia's welfare 2007 acknowledges that children and families are increasingly being recognised by governments as a core policy area, that median weekly disposable household incomes rose by 34% between 1995-1996 and 2005-2006 and that the health status of Australian young people is improving, the report also acknowledges a number of areas that continue to raise concern:

  • Obesity rates among 15- to 24-year-olds rose from 3% in 2001 to 5% in 2004-2005.
  • Less than half of young people were meeting recommended physical activity or daily consumption of fruit and vegetables guidelines in 2004-2005.
  • In 2004, a high proportion of young people were found to engage in activities that carry health risks: close to one-third drank alcohol at risky levels, almost one-quarter had used illicit drugs in the past 12 months and approximately 17% were current smokers.
  • Mental health issues are worsening among young people: between 1997 and 2004-2005, the proportion of 18- to 24-year-olds reporting 'high or very high levels of stress' increased from 7% to 12% among males and from 13% to 19% among females.
  • In recent years, there has been a 'steady increase in the numbers of children and young people (aged 17 years and under) who are abused, neglected or at risk of harm, or whose parents are unable to care for them'.
  • There has been a 'slight decline in apparent school retention rates since the peak of 77% in 1992 and 1993', while in 2006, 8% of 15- to 19-year-olds were neither studying nor in work.
Chapter 2 of Australia's welfare 2007 is specifically devoted to information on children, youth and families. It contains comprehensive demographic information and covers issues such as education, employment and children and young people at risk. Some further information on young people can be found within data contained elsewhere in the report, namely in Chapter 4 (Disability and disability services), Chapter 6 (The dynamics of homelessness), and Chapter 8, (Indicators of Australia's welfare).

Sources:

AIHW 2007, Economic prosperity, but what about life?, media release, 6 December 2007, AIHW, Canberra, viewed 7 July 2008,
http://www.aihw.gov.au/mediacentre/2007/mr20071206.cfm

AIHW 2007, Australia's welfare 2007, AIHW, Canberra, viewed 7 July 2008, http://www.aihw.gov.au/publications/index.cfm/title/10527


Recent trends in risky alcohol consumption and related harm among young people in Victoria, Australia

This study, published in the June 2008 edition of the Australian and New Zealand Journal of Public Health, synthesises existing data on the proportion of young people who drink at risky levels and the rate of alcohol-related harms experienced by young people in Victoria.

The research draws on secondary data from existing surveys to ascertain increases in risky alcohol related behaviours, as well as data from alcohol-related hospital admissions and emergency presentations.

Survey data shows 'no clear trend in the rate of risky drinking among young people', although hospital admissions (harms) data 'suggests that rates of alcohol-related harm, particularly acute intoxication, have increased dramatically over recent years'.

Sources:

Livingston, M.2008, 'Recent trends in risky alcohol consumption and related harm among young people', Australian and New Zealand Journal of Public Health v.32, n.3, p.266, abstract viewed 17 August 2008, http://proquest.umi.com/pqdweb?index=0&did=1515559511&SrchMode=1&sid=2&Fmt=2&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1219024804&clientId=20931

Newspaper sources:
  • Daily Telegraph, 10 June 2008, p.8.
  • Courier Mail, 10 June 2008, p.8.
  • Canberra Times, 10 June 2008, p.5.
  • Australian, 10 June 2008, p.2.
  • Age, 10 June 2008, p.3.
  • Adelaide Advertiser, 10 June 2008,p.10.
  • Herald Sun, 10 June 2008, p.8.
  • Sydney Morning Herald, 10 June 2008, p.5.




Risks to health: The potential consequences of risk taking by young people

The Australian Bureau of Statistics' publication Australian Social Trends 2008 contains a section titled 'Risk taking by young people'.

Besides  providing statistics on drinking at risky levels, hospitalisation due to  drug use and acute alcohol intoxication, use of illicit drugs, dangerous  driving, injury and death from transport accidents, and violence, the section,  'Risk taking by young people' also examines some of the potential consequences  of this risk taking, providing statistics on:

The burden of disease and injury

Levels of death and disability from diseases, injuries and risks to health (known as the burden of disease and injury) are measured using disability-adjusted life years (DALYs). The potential years of life lost due to premature death are combined with the potential years of 'healthy life' lost due to disease, disability or injury - one DALY is equal to one lost year of healthy life.

In 2003, the total burden of disease and injury among young people aged 15-24 years was an estimated 197,000 DALYs.

The largest individual risk factors contributing to DALYs for young males:

  • illicit drugs: 12%
  • alcohol: 11%

Individual risk factors contributing to DALYs for young females:

  • illicit drugs: 5%
  • alcohol: 2%

Source: Australian Bureau of Statistics, 2008, Australian social trends, Cat. no. 4102.0, viewed 2 October 2008, http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Chapter5002008.

Mental health and psychological distress

Young people who experience mental health problems and disorders are at a greater risk of poor health and wellbeing outcomes than other young people. Mental health problems and disorders may lead to increased substance use and antisocial behaviours.

The 2004-05 National Health Survey collected information on mental health from people aged 18 years and over.

The proportion of young people aged 18-24 years who reported high to very high levels of psychological distress in the five weeks prior to interview:

  • young women: 19%
  • young men: 12%

The prevalence of risky/high risk drinking (at least once a week during the 12 months prior to interview) among:

  • young women who had reported high to very high levels of psychological distress: 18%
  • young women who reported low to moderate levels of psychological distress: 9%

The prevalence of risky/high risk drinking (at least once a week during the 12 months prior to interview) among:

  • young men who had reported high to very high levels of psychological distress: 19%
  • young men who reported low to moderate levels of psychological distress: 19%

Causes of death

Over the period 2004-2006, the average number of deaths of young people (aged 15-24 years) registered was:

  • young men: 955 per year, (equivalent to rate of 66 per 100,000)
  • young women: 389 (equivalent to rates of 28 deaths per 100,000).

'External causes' was the main underlying cause of death for young people, and was much more common (70% of all deaths in this age group) than among people aged 25 years and over (5%).

Intentional self-harm and suicide

Intentional self-harm refers to a range of behaviours including cutting, poisoning and attempted suicide. It is likely that only a small number of young people who harm themselves will seek medical treatment.

In  2005-06, number of hospital separations for intentional self-harm among people  aged 15-24 years:

  • 8,040

In 2005-06, rates of hospital separations (per 100,000) for intentional self-harm among people years:

  • for young women aged 15-24: 392, (in 1998-99: 294).
  • for young men aged 15-24: 171, (in 1998-99: 165)
  • female teenagers aged 15-19 years: 481 (highest rate for all age groups)
  • male teenagers aged 15-19 years: 148
  • women aged 20-24 years: 307 (second-highest rate for all age groups)
  • men aged 20-24 years: 193

Deaths attributed to suicide

In 2004-2006, deaths per year attributed to suicide (average):

  • among people aged 15-24 years: 266 (20% of deaths in this age group)
  • among people aged 25 years and over: 1% of deaths in this age group.

The suicide rate (deaths per 100,000) for young people aged 15-24 years: 9 (lower than most of the other age groups).

For a death to be classified a suicide, there must be a coronial enquiry to  establish evidence of suicidal intent. The quality of suicides data can be  affected by delays in completion of coroners' cases, and there can be difficulty  in determining suicidal intent for some causes of death, for example in cases  of single vehicle accidents. For these reasons it is unclear whether the number  of suicides could be an undercount. For more information see the Australian  Bureau of Statistics document, Suicides,  Australia, 2005 (cat. no. 3309.0), viewed 10 October 2008, http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3309.0Main+Features12005?OpenDocument

Source: Australian Bureau of Statistics, 2008, Australian social trends, Cat. no. 4102.0, viewed 2 October 2008, http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Chapter5002008.


National survey of mental health and wellbeing: Summary of results, 2007


This publication contains a summary of results from the 2007 National Survey of Mental Health and Wellbeing, conducted by the Australian Bureau of Statistics (ABS) between August and December 2007. Around 8,800 Australians aged 16 to 85 years took part in the survey, which used World Health Organisation diagnostic tools to measure the prevalence of anxiety disorders, affective disorders and substance use disorders both over the course of an individual’s lifetime and in the previous 12 months. It also measured the "level of impairment, the health services used for mental health problems, physical conditions, social networks and caregiving, as well as demographic and socio-economic characteristics" (p.2).

Selected findings

According to prevalence estimates generated from these findings, 20% (3.2 million) of Australians aged 16 to 85 years were found to have a "12-month mental disorder" (defined as meeting the diagnostic criteria for one or more mental disorders over the course of a lifetime and having symptoms in the 12 months prior to this survey). A total of 14.4% (2.3 million) experienced an anxiety disorder, 6.2% (995,900) experienced an affective disorder and 5.1% (819,800) experienced a substance use disorder.

In general, the prevalence of 12-month mental health disorders was higher among the younger age groups: 26.4% of 16- to 24-year olds and 24.8% of 25- to 34-year-olds had a 12-month mental disorder; this figure was lower among older age groups, reaching a low of 5.9% among 75- to 85-year-olds.

12-month mental disorders (a) by age group (16-24 years and 25-34 years)
Age (years)
Anxiety disorders
Affective disorders
Substance use disorders
Any 12-month mental disorder (a)(b)
No 12-month mental disorder (c)
Total

’000
%
’000
%
’000
%
’000
%
’000
%
’000
MALES
16-24
120.3
9.3
56.3
4.3
201.0
15.5
296.3
22.8
1 003.0
77.2
1 299.3
25-34
162.8
11.5
99.0
7.0
159.9
11.3
321.5
22.8
1 091.0
77.2
1 412.6
FEMALES
16-24
270.9
21.7
105.0
8.4
122.5
9.8
374.8
30.1
871.3
69.9
1 246.1
25-34
297.0
21.1
121.9
8.7
46.5
3.3
376.8
26.9
1 022.4
73.1
1 399.2
PERSONS
16-24
391.3
15.4
161.4
6.3
323.5
12.7
671.1
26.4
1 874.3
73.6
2 545.4
25-34
459.7
16.3
220.9
7.9
206.4
7.3
698.4
24.8
2 113.4
75.2
2 811.8
Note: this table contains data extracted from the table ‘12-month mental disorders, by age group (years)’ published on p.29 of the publication National survey of mental health and wellbeing: Summary of results, 2007 (cat. no.4326.0) (ABS 2008).
(a) Persons who met criteria for diagnosis of a lifetime mental disorder (with hierarchy) and had symptoms in the 12 months prior to interview.
(b) A person may have had more than one mental disorder. The components, when added, may therefore not add to the total shown.
(c) Persons who did not meet criteria for a diagnosis of a lifetime mental disorder and those who met criteria for diagnosis of a lifetime disorder (with hierarchy) but did not have symptoms in the 12 months prior to interview.

This publication can be downloaded from the ABS website:
http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4326.02007?OpenDocument

Source:
Australian Bureau of Statistics 2008, National survey of mental health and wellbeing: Summary of results, 2007 (cat. no.4326.0), ABS, Canberra, viewed 1 December 2008, http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4326.02007?OpenDocument
Age, 24/10/08, p.3.

Never better -- or getting worse? The health and wellbeing of young Australians

This report, by Richard Eckersley of Australia21, 'presents an overview of the patterns and trends in young Australians' health and wellbeing; shows that some of the apparent contradictions can be explained, although "irreconcilable differences" remain; discusses the social determinants of these patterns and trends; and, finally, considers what this means for how we seek to improve young people's health and wellbeing'.

While only about 40 out of every 100,000 young Australians (0.04%) die each year, 20-30% of young people (20,000 to 30,000 per 100,000) are experiencing significant psychological distress at any one time. Less severe stress-related problems (including psychosomatic symptoms such as frequent headaches, stomach pains and sleeplessness) affect as many as 50% of young Australians (Eckersley 2005:147-169).

Among Australians aged 15 to 24:
  • mental disorders account for 49% of the burden of disease, which is measured as both death and disability (and 61% of the non-fatal burden) (AIHW 2007:19-21).
  • mental disorders are by far the biggest contributor to the burden of disease, and well ahead of the next most important contributor, injuries, at 18%.
  • young people appear to be suffering mental health problems at an earlier age than previously, experiencing them at higher rates than older age groups, and retaining their increased risk beyond youth into older age.
A 1997 national survey (ABS 1998) of adult Australians' mental health and wellbeing found that young people aged 18 to 24 had the highest prevalence of mental disorders in the 12 months prior to the survey -- 27%.

A related survey (Sawyer et al. 2000) of children and adolescents (aged 4 to 17) found that 14% of respondents were experiencing mental health problems at the time of the survey.

Another report reveals that 10% of young people have a long-term mental or behavioural problem, and 16% report high or very high levels of psychological distress (AIHW 2008a:281).

A survey by Bernard et al. (2007) of more than 10,000 Australian students from prep school (age 4 to 6) to Year 12 (age 17 to 18) found that about 40% of students could be described as displaying lower levels of social and emotional wellbeing. Students said they:
  • were lonely (18%)
  • had recently felt hopeless and depressed for a week and had stopped regular activities (20%)
  • were very stressed (31%)
  • had difficulty controlling how depressed they got (32%)
  • lost their temper a lot (35%)
  • worried too much (42%)
  • had difficulty calming down when upset (48%).
Several surveys by the Australian Childhood Foundation (Tucci et al. 2006, 2007, 2008) of children aged 10 to 14 or 10 to 17 have produced a similar picture of high levels of stress, worry and anxiety. Based on the results of one survey (Tucci et al. 2007), the foundation identified three categories of children:
  • a group who felt well-connected and supported -- 52%
  • a group who felt 'worried' -- 42%
  • a 'disconnected and insular' group (the most vulnerable) -- 8%.
  • Hospitalisations of young people for intentional self-harm and emotional and behavioural problems increased between 1996 and 2006. Hospitalisations for self-harm rose by 51% for young women and by 27% for young men during this period (AIHW 2003:98, AIHW 2007:26, AIHW 2008b).

Mental health and satisfaction with life


In a 2007 study, Bernard et al. found that while 40% of students revealed poor emotional and social wellbeing, 89% of the students said they were happy. The results illustrate the contrasting pictures that emerge from different measures -- and the danger in taking self-reported health and happiness measures at face value.

Similarly, another study (Smart & Sanson 2005) found that over 80% of young people were satisfied with their lives including the following aspects: lifestyle, work or study, relationships with parents and friends, accomplishments and self-perceptions. However, 50% of subjects were experiencing one or more problems associated with depression, anxiety, anti-social behaviour and alcohol use. In other words, most of the young people with problems were satisfied with life.

The same issue arises with self-reported health (which strongly correlates with happiness and life satisfaction). In 2004-05:
  • 70% of young Australians aged 15 to 24 assessed themselves to be in excellent or very good health
  • another 24% rated their health as good
  • 7% reported their health to be fair or poor (AIHW 2007:12).
Among Australians who in 2006 reported mood disorders as a long-term health condition:
  • 30% rated their health as excellent or very good
  • 31% rated it as good
  • 39% rated it as fair or poor.
The proportions were the same for those who reported five or more long-term conditions (AIHW 2006:27). While self-reported health is correlated to actual health, it is not an accurate measure of health status.

See the category 'Health' for statistics from the report on mortality and physical health.
See the category 'Future' for statistics from the report on young people's attitudes towards the future.

Source:

Eckersley, R. 2008, Never better -- or getting worse? The health and wellbeing of young Australians, Australia21, <http://www.australia21.org.au/whats_new.htm>, viewed 14 October 2008.


Young Australians aware of mental health risks associated with substance use

Results from a national survey of almost 3,800 young Australians and around 2,000 of their parents indicate that both groups are aware of the mental health risks associated with substance use among young people. However, given current high rates of alcohol, tobacco and cannabis use among young Australians, those who conducted the survey noted that this awareness is not necessarily leading to changes in young people's substance use behaviour.

The survey was conducted by researchers from the ORYGEN Research Centre at the University of Melbourne to inform their study of the beliefs of young people (aged 12 to 25 years) and their parents about the links between substance use and mental health problems. All participants completed a telephone survey in which they were presented with one of four case study vignettes about a young person with either psychosis, social phobia, depression or depression with alcohol misuse. Over 85% of those surveyed believed that alcohol, tobacco and marijuana would have been harmful to the young people presented in the vignettes, while over 80% of young people recognised that refraining from excessive drinking or marijuana use would reduce the chances of developing mental health problems such as those described in the vignettes.

Findings from the study indicate that media campaigns highlighting the links between substance use and mental illness are not sufficient to reduce substance use among young people. Instead, future campaigns need to address young people's perceptions of their own vulnerability to developing mental health problems and how substance use can affect this.

This study was published in the 3 September edition of the Medical Journal of Australia: http://www.mja.com.au

Source:
Lubman, D.I., Hides, L. & Jorm, A.F. 2007, 'Beliefs of young people and their parents about the harmfulness of alcohol, cannabis and tobacco for mental disorders', Medical Journal of Australia, v.187, n.5, pp.266-69.
Australian, 3/09/07, p.2.
Herald Sun, 3/09/07, p.7.
Adelaide Advertiser, 4/09/07, p.14.

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Young Australians: Their health and wellbeing 2007

Part Two of this report, produced by the Australian Institute of Health and Welfare, contains data on the health status and outcomes of young Australians. It includes a selection of data on mental health among this age group. These data were largely drawn from the Australian Bureau of Statistics: 2004 to 2005 National Health Survey.

Selected findings:

  • In 2004 to 2005, approximately 12% of young males aged 18 to 24 years and approximately 19% of females of the same age reported experiencing high or very high levels of psychological distress (measured according to the Kessler 10 scale of psychological distress).
  • In the same period, there were 47,372 hospital separations for mental and behavioural disorders among 12- to 24-year-olds. This figure represents 16% of separations for mental and behavioural disorders among all age groups and 8% of all separations for 12- to 24-year-olds in 2004 to 2005.
  • Among young males, the leading causes of hospital separations for mental and behavioural disorders were psychoactive substance use (24%), schizophrenia (20%) and depression (13%). Among young females, depression (19%), eating disorders (14%) and psychoactive substance use (12%) were the leading causes of hospital separations for mental and behavioural disorders. Self-poisoning (80%) and self-harm by sharp object (15%) were the leading cause of hospital separations for intentional self-harm among young Australians.
  • In 2003 to 2004, young Australians aged between 12 and 24 years made more than one million contacts with community mental health services. This equates to 20% of all service contacts made during this period.
  • In 2004 to 2005, there were 7,874 hospital separations due to intentional self-harm among 12- to 24-year-olds. Approximately 71% of these separations were for females.
  • While hospital separation rates for intentional self-harm decreased by 4% for 12- to 24-year-old males between 2000 to 2001 and 2004 to 2005, they increased by 27% for young females over this period.

Source: Australian Institute of Health and Welfare 2007, Young Australians: Their health and wellbeing 2007, AIHW, Canberra [viewed 13/06/07].

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Report: 'Not For Service: Mental Health Services in Australia', 2005

The report, Not For Service: Experiences of Injustice and Despair in Mental Health Care in Australia was released on 19 October 2005 by the Mental Health Council of Australia (MHCA) and is the most significant report on mental health care in Australia for over a decade.

According to the MHCA, this report captures the persisting, distressing and daily experiences of inadequate mental health and community care. It details personal stories of people with mental illness, and their families and carers.

The report can be downloaded from the MHCA's website [viewed 18/01/2007].

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Self-harm in adolescents, 2004

In January and February 2004, Kids Help Line had 870 callers who were harming themselves. (Kids Help Line is a free, national telephone and internet counselling service for young people aged 5–18.)

A study by the Australian Institute of Suicide Research and Prevention called 'Who Are the Kids who Self-harm?' was published in the Medical Journal of Australia in August 2004. The study was conducted in 2002 to measure the extent of self-harm among 3,757 students in Year 10 and 11 in 14 high schools on the Gold Coast in Queensland.

Of those surveyed, 464 reported a 'lifetime history' of self-harm, in which self-cutting and overdosing were the most common methods.

Of the 1,800 young women interviewed, 200 had self-harmed in the previous year, significantly outnumbering the young men (33 out of 1,943).

The main methods of self-harm were:

  • self-cutting (138 respondents, 59.2%) and
  • overdosing with medication (69 respondents, 29.6%).

Source: 'Who are the kids who self-harm? An Australian self-report survey' [viewed 18/01/2007] Diego De Leo and Travis S Heller, Medical Journal of Australia 2004, vol.181, no.3, pp.140–4. Weekend Australian, 21–22/08/04, p.20.

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Mental health problems, 2001

Mental health problems, including drug dependence disorders, are the major burden of disease for young Australians.
Of people aged 13–17, 13.4% of males and 12.8% of females were diagnosed with a mental health problem. In 1997, the prevalence of a mental disorder among 18–24-year-olds was 27%.

Source; Australian Institute of Health and Welfare 2004, Australia's Health 2004, cat. no. 44, AIHW, Canberra, p.187 [viewed 18/01/2007].

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Prevalence of affective disorders, 1999–2002

Affective disorders comprise depression, dysthymia, mania, hypomania and bipolar affective disorder. According to Australian Bureau of Statistics figures, depression comprised the majority of the affective disorders suffered by Australians in 1997. 92% of all males and 83% of all females with an affective disorder suffered from depression.

Percentage of people aged 18–24 with an affective disorder in 1999: 6.7%
… of females: 10.7%
… of males: 2.9%

Prevalence of depressive disorders in children and adolescents in 1998:

Percentage of the
population		 6–12 13–17 Total
Males 3.7 4.8 4.2
Females 2.1 4.9 3.2
Total n.a. n.a. 3.7

Community mental health care service contacts per 1,000 population, with a principal diagnosis of depression, 2001–02*:


Less than 15 years 15–24 years

Number
Males 5,421 18,813
Females 6,684 37,911
Total 13,031 58,024

Per 1,000 population
Males 3.4 29.1
Females 2.7 13.9
Total 3.3 21.9



* The rate per 1,000 is a crude rate based on the Estimated Resident Population at 31 December 2001. The data should be interpreted cautiously because of incomplete coverage and inconsistencies in the definition of a service contact between jurisdictions.

Source: Australian Institute of Health and Welfare 2004, Mental Health Services in Australia 2001–02, Mental Health Series no. 5, AIHW,Canberra, Publication catalogue [viewed 18/01/2007]. Back to top

Anti-depressants prescribed to patients under 20 years old, 2002/2003

State 2002 2003
NSW 69,325 78,876
QLD 50,198 56,049
VIC 48,676 55,753
WA 22,543 25,975
SA 19,383 20,621
TAS 6,114 7,153
ACT 5,525 5,855
NT 67 63
Source: Health Insurance Commission, quoted in the West Australian, 16/05/04, p.9.

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National Health Survey, 2001

Young women aged 18–24 who reported suffering high levels of psychological distress during the four weeks before interview: 5.4%
… Young men: 2.7%

Source: Australian Bureau of Statistics 2004, Year Book Australia 2004, cat. no. 1301.0, ABS, Canberra, Health chapter [viewed 18/01/2007].

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The mental health of young people in Australia, 2000

Percentage of young people in Australia with mental health problems: 14%
Number of young people with mental health problems who receive professional help: 1 in 4
Number of young people with severe mental health problems who receive professional help: 50%

The findings of the child and adolescent components of the National Survey of Mental Health and Wellbeing are presented in a report described as 'the first reliable, national information on the burden of mental illness in children and adolescents aged 4 to 17'. It reveals that mental health problems experienced by a relatively large number of young people in Australia cuts across all age and gender groups, but are more prevalent among low-income, step/blended and sole-parent families.

Adolescents with mental health problems reported a high rate of suicidal ideation and other health-risk behaviours, including smoking, drinking and drug use. The report highlights how complex and wide-ranging these problems are in young people's lives and how there is a need for more services to assist them, together with joint policies across services to provide coordinated programs.

Source: Sawyer M.G., Arney F.M., Baghurst P.A., Clark J.J., Graetz B.W., Kosky R.J., Nurcombe B, Patton G.C., Prior M.R., Raphael B, Rey J, Whaites L.C. and Zubrick S.R., 2000, Mental Health of Young People in Australia: Child and Adolescent Component of the National Survey of Mental Health and Well-being, Mental Health and Special Programs Branch, Commonwealth Department of Health and Aged Care.

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