Psychiatric morbidity in male remanded and sentenced committals to Irish prisons

Reform of Forensic Mental Health Services in Italy: Stigma and Blaming the Messenger: Hermenoia

About 40 years after the reforms leading to the closure of psychiatric hospitals (Ospedale Psichiatrico [OP]) in Italy in favor of a widespread model with a strong rehabilitation emphasis, Italy has chosen to close High Security Hospitals as well (Ospedale Psichiatrico Giudiziario [OPG]). The new forensic treatment model is expected to be more respectful of the person, including the perpetrators of violent crimes, and aims to be less stigmatizing and more rehabilitative. Despite the favorable premises of the reform (Law n. 81/2014), Italian psychiatrists are now obliged to answer calls to give evidence on strictly legal issues such as the social dangerousness of the mentally ill offender drawing on evidence or paradigms that many believe do not belong to medical knowledge. Psychiatrists must now learn to communicate about the relationship between psychiatry and society as required by law. This public expression engages with the cultural climate of society. Otherwise, the risk is of increasing the level of complexity leading to real misunderstandings that paradoxically may feed the stigma. The Italian reform provides an opportunity for reflection on some issues concerning psychiatric action, on how the public perceives the mentally ill and their psychiatrists, on the relationship between psychiatry and the world of law, on clinical methodologies for structured professional judgment, on public communication regarding severe mental illness, and the risk that psychiatrists may inadvertently be blamed for conveying an unwelcome message about mental illness and social dangerousness-we have called this social sensitivity against psychiatrists "hermanoia," blaming the messenger. The authors do not provide certain solutions but propose good practices.

The prevalence of comorbid serious mental illnesses and substance use disorders in prison populations: a systematic review and meta-analysis

BACKGROUND

Comorbid mental illnesses and substance use disorders are associated with adverse criminal, social, and health outcomes. Yet, their burden is not reliably known among prison populations. We therefore aimed to estimate the prevalence of comorbid serious mental illnesses and substance use disorders (dual disorders) among people in prison worldwide.

METHODS

In this systematic review and meta-analysis, we searched 15 electronic databases (ASSIA, CAB Abstracts, Criminal Justice Database, Embase, Global Health, Global Index Medicus, IBSS, MEDLINE, NCJRS, PAIS Index, PsycINFO, Russian Science Citation Index, Scielo, Social Services Abstracts, and Web of Science) and the grey literature (Open Grey and ProQuest Dissertations & Theses Global) for studies reporting the prevalence of serious mental illnesses and substance use disorders in prison populations published between Jan 1, 1980, and Sept 25, 2021, and contacted the authors of relevant studies. Empirical studies among unselected adult prison populations that applied representative sampling strategies and validated diagnostic instruments, and either reported the prevalence of dual disorders or had authors who could provide prevalence data in correspondence, were included. Two reviewers (GB and SDL) independently extracted data from the eligible studies; both current (up to 1 year) and lifetime prevalence were extracted, if available. We sought summary estimates. Our primary outcomes were comorbid non-affective psychosis with substance use disorders and comorbid major depression with substance use disorders. We conducted a random-effects meta-analysis, explored between-sample heterogeneity with meta-regression, and calculated odds ratios (ORs) to assess bidirectional relationships between mental and substance use disorders. Risk of bias was assessed by use of a standard tool. The study protocol was registered with PROSPERO, CRD42020207301.

FINDINGS

Of 11 346 records screened, we identified 34 studies reporting the prevalence of dual disorders among individuals in prison and received unpublished prevalence data for 16 studies, totalling 50 eligible studies and 24 915 people. The mean quality score of included studies was 7·8 (SD 1·2). We found that 3·5% (95% CI 2·2-5·0) had current non-affective psychosis with any comorbid substance use disorder, representing 443 (49·2%) of 900 people with non-affective psychosis, and 9·1% (5·6-13·3) had current major depression and comorbid substance use disorders, representing 1105 (51·6%) of 2143 people with major depression. Between-sample heterogeneity was high (I2>80%). People in prison with current non-affective psychosis were significantly more likely to have substance use disorders compared with those without (OR 1·7, 95% CI 1·4-2·2). People with major depression had higher odds of substance use disorders than those without (1·6, 1·3-2·0).

INTERPRETATION

Around half of the prison population with non-affective psychosis or major depression have a comorbid substance use disorder. Consideration should be given to screening for dual disorders and implementing integrated and scalable treatments.

FUNDING

Economic and Social Research Council, Agencia Nacional de Investigación y Desarrollo (Chile), and the Wellcome Trust.

Forensic psychiatry and Covid-19: accelerating transformation in forensic psychiatry

Swift medically led scientifically informed responses to the Covid-19 epidemic nationally have been demonstrably superior to other, non-scientific approaches. In forensic psychiatry and across all psychiatric services, urgent and clinically led responses have underlined redundancies and confusions in the governance of mental health services and a vacuum in policy makers. For the future, a greater emphasis on services for patients with schizophrenia and other severe, enduring mental disorders must aim at reducing standardised mortality ratios, managing risk of violence and improving hard outcomes such as symptomatic remission, functional recovery and forensic recovery of autonomy. This will require more use of information technology at service level and at national level where Scandinavian-style population-based data linkage research must now become legally sanctioned and necessary. A national research and development centre for medical excellence in forensic psychiatry is urgently required and is complimentary to and different from quality management.

Irish Medical Organisation Doolin Memorial Lecture 2019: rhetoric and reality in mental health-Ireland and the world

This Doolin Memorial Lecture presents six suggestions for positive change in Ireland's mental health services, focused on legislation and rights: (a) revision of the Mental Health Act 2001 in line with existing recommendations, to better protect and promote a broad range of rights, including rights to treatment and liberty (which are related); (b) enhanced forensic mental health care to better protect and promote both treatment and liberty in this population; (c) prompt full implementation of the Public Health (Alcohol) Act 2018 to reduce alcohol-related harm and the opportunity cost of alcohol problems in the health service; (d) implementation of the Assisted Decision-Making (Capacity) Act 2015 to provide decision-making supports to the 29.4% of medical/surgical inpatients and 52.6% of psychiatry inpatients who lack full decision-making capacity for treatment decisions; (e) judicious medicalisation of our response to individual cannabis use (although legalisation is not advised); and (f) enhanced recognition of the social rights of the mentally ill, especially the right to housing. Attention to these areas would improve the quality of life and quality of liberty of people with mental illness and their families. Progress in these areas needs to be underpinned by enhanced involvement of service-users in planning and provision of care, increased funding of mental health services and particular attention to groups who are currently underserved, including children and adolescents. Enhanced attention to these areas would also help advance Ireland's national mental health policy, "A Vision for Change", which has yet to be implemented in full. That, too, would help.

The prevalence of major mental illness, substance misuse and homelessness in Irish prisoners: systematic review and meta-analyses

AimsTo systematically review studies from Irish prisons that estimate the prevalence of major mental illness, alcohol and substance misuse, and homelessness at the time of committal.

METHODS

Healthcare databases were searched for studies quantifying the point prevalence for each outcome of interest. Searches were augmented by scanning of bibliographies and searches of governmental and non-governmental websites. Proportional meta-analyses were completed for each outcome.

RESULTS

We found eight, six and five studies quantifying the point prevalence of major mental illness, substance misuse, and homelessness respectively. Considerable heterogeneity was found for each subgroup (except psychosis where substantial heterogeneity was observed) and random effects models were used to calculate pooled percentages. The pooled percentage for psychotic disorder was 3.6% [95% confidence interval (CI) 3.0-4.2%], for affective disorder 4.3% (95% CI 2.1-7.1%), for alcohol use disorder 28.3% (95% CI 19.9-37.4%), for substance use disorder 50.9% (95% CI 37.6-64.2%) and for those who were homeless on committal 17.4% (95% CI 8.7-28.4%).

CONCLUSIONS

Estimates for the prevalence of psychotic illness and substance abuse amongst Irish prisoners are in keeping with international estimates of morbidity in prisons, whilst those for affective disorders are lower. The prevalence of homelessness in committal to Irish prisons is higher than some international estimates. Rates for psychoses, alcohol and substance misuse as well as homelessness in Irish prisons are significantly higher than the general population prevalence of these vulnerabilities. A need for service development is discussed.

A 25-year dynamic ecological analysis of psychiatric hospital admissions and prison committals: Penrose’s hypothesis updated

Aims

There is renewed interest in the inverse association between psychiatric hospital and prison places, with reciprocal time trends shown in more than one country. We hypothesised that the numbers of admissions to psychiatric hospitals and committals to prisons in Ireland would also correlate inversely over time (i.e. dynamic measures of admission and committal rather than static, cross-sectional numbers of places).

Method

Publicly available activity statistics for psychiatric hospitals and prisons in Ireland were collated from 1986 to 2010.

Results

There was a reciprocal association between psychiatric admissions and prison committals (Pearson r=−0.788, p<0.001), an increase of 91 prison committals for every 100 psychiatric hospital admissions foregone.

Conclusion

Penrose’s hypothesis applies to admissions to psychiatric hospitals and prisons in Ireland over time (dynamic measures), just as it does to the numbers of places in psychiatric hospitals and prisons in Ireland and elsewhere (static, cross-sectional measures). Although no causal connection can be definitively established yet, mentally disordered prisoners are usually known to community mental health services. Psychiatric services for prisons and the community should be linked to ensure that the needs of those currently accessing care through prisons can also be met in the community.

Beyond the Walls: An Evaluation of a Pre-Release Planning (PReP) Programme for Sentenced Mentally Disordered Offenders

Background: Prison mental health services have tended to focus on improving the quality of care provided to mentally disordered offenders at the initial point of contact with the prison system and within the prison environment itself. When these individuals reach the end of their sentence and return to the community, there is an increased risk of morbidity, mortality, homelessness and re-imprisonment. New models of care have been developed to minimize these risks. Objectives: The objective of this project was to establish a Pre-Release Planning (PReP) Programme with social work expertise, to enhance interagency collaboration and improve continuity of care for mentally disordered offenders upon their release. We aimed to evaluate the first 2 years of the programme by measuring its success at improving the level of mental health support and the security and quality of accommodation achieved by participants upon release in comparison to that reported at time of imprisonment. Additionally, we aimed to explore the impact of these outcomes on rates of re-imprisonment. Methods: A process of participatory action research was used to develop and evaluate the first 2 years of the programme. This was a naturalistic prospective observational whole cohort study. Results: The PReP Programme supported 43 mentally disordered offenders, representing 13.7%, (43/313) of all new assessments by the prison's inreach mental health service during the 2 years study period. When compared with that reported at time of reception at the prison, gains were achieved in level of mental health support (FET p < 0.001) and security and quality of accommodation (FET p < 0.001) upon release. Of those participants seen by the PReP Programme, 20 (46.5%, 20/43) were returned to prison during the 2-years study period. There was no significant relationship between re-imprisonment and gains made in mental health support (FET p = 0.23) or accommodation (FET p = 0.23). Conclusions: We have shown that compared to that reported at time of reception at prison, the level of mental health support and the security of tenure and quality of accommodation both improved upon release following the intervention of the programme. Improved mental health support and accommodation were not associated with lower rates of re-imprisonment.

Attributional style and depressive symptoms in a male prison sample

The reformulated learned helplessness model proposes that people who tend to make internal, stable, and global attributions in response to uncontrollable aversive events are more likely to develop depression. The present study sought to investigate the nature of the relationship between attributional style and depression in a male prison sample. One hundred and one adult male prisoners from four medium security prisons in Ireland completed the Attributional Style Questionnaire and measures of depression (BDI-II) and anxiety (BAI). Severity of self-reported depressive symptoms in the present sample was comparable to other prison and clinical samples, but higher than community samples. Participants were more severely affected by depressive symptoms than anxiety. The original attributional dimensions (i.e. internal, stable, and global) predicted a significant amount of variance in depression, but the model was not significant after controlling for anxiety. A subsequent regression model, comprising attributional dimensions for both negative events and positive events including a measure of 'uncontrollability', accounted for 35% of the variance in depression and the model retained significance while controlling for anxiety. An attributional model of depression may be relevant to the prison population and could provide a valid insight into the development and treatment of depressive symptoms in prisoners. The findings are interpreted in relation to previous research and implications for theory, clinical practice, and rehabilitation are discussed.

Substance use disorders in prisoners: an updated systematic review and meta-regression analysis in recently incarcerated men and women

AIMS

The aims were to (1) estimate the prevalence of alcohol and drug use disorders in prisoners on reception to prison and (2) estimate and test sources of between study heterogeneity.

METHODS

Studies reporting the 12-month prevalence of alcohol and drug use disorders in prisoners on reception to prison from 1 January 1966 to 11 August 2015 were identified from seven bibliographic indexes. Primary studies involving clinical interviews or validated instruments leading to DSM or ICD diagnoses were included; self-report surveys and investigations that assessed individuals more than 3 months after arrival to prison were not. Random-effects meta-analysis and subgroup and meta-regression analyses were conducted. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

RESULTS

In total, 24 studies with a total of 18 388 prisoners across 10 countries were identified. The random-effects pooled prevalence estimate of alcohol use disorder was 24% [95% confidence interval (CI) = 21-27], with very high heterogeneity (I²  = 94%). These ranged from 16 to 51% in male and 10-30% in female prisoners. For drug use disorders, there was evidence of heterogeneity by sex, and the pooled prevalence estimate in male prisoners was 30% (95% CI = 22-38; I²  = 98%; 13 studies; range 10-61%) and, in female prisoners, was 51% (95% CI = 43-58; I²  = 95%; 10 studies; range 30-69%). On meta-regression, sources of heterogeneity included higher prevalence of drug use disorders in women, increasing rates of drug use disorders in recent decades, and participation rate.

CONCLUSIONS

Substance use disorders are highly prevalent in prisoners. Approximately a quarter of newly incarcerated prisoners of both sexes had an alcohol use disorder, and the prevalence of a drug use disorder was at least as high in men, and higher in women.

STRESS-testing clinical activity and outcomes for a combined prison in-reach and court liaison service: a 3-year observational study of 6177 consecutive male remands

BACKGROUND

People with major mental illness are over-represented in prison populations however there are few longitudinal studies of prison in-reach services leading to appropriate healthcare over extended periods.

AIMS

We aimed to examine measures of the clinical efficiency and effectiveness of a prison in-reach, court diversion and liaison service over a 3 year period. Secondly, we aimed to compare rates of identification of psychosis and diversion with rates previously reported for the same setting in the 6 years previously. We adopted a stress testing model for service evaluation.

METHOD

All new male remand committals to Ireland's main remand prison from 2012 to 2014 were screened in two stages. Demographic and clinical variables were recorded along with times to assessment and diversion. The DUNDRUM Toolkit was used to assess level of clinical urgency and level of security required. Binary logistic regression was used to assess factors relevant to diversion.

RESULTS

All 6177 consecutive remands were screened of whom 1109 remand episodes (917 individuals) received a psychiatric assessment. 4.1 % (95 % CI 3.6-4.6) had active psychotic symptoms. Levels of self-harm were low. Median time to full assessment was 2 days and median time to admission was 15.0 days for local hospitals and 19.5 days for forensic admissions. Diversion to healthcare settings outside prison was achieved for 5.6 % (349/6177, 95 % CI 5.1-6.3) of all remand episodes and admissions for 2.3 % (95 % CI 1.9-2.7). Both were increased on the previous period reported. Mean DUNDRUM-1 and DUNDRUM-2 Triage Security Scores were appropriate to risk and need.

CONCLUSIONS

We found that a two-stage screening and referral process followed by comprehensive assessment optimised identification of acute psychosis. The mapping approach described shows that it is possible for a relatively small team to sustainably achieve effective identification of major mental illness and diversion to healthcare in a risk-appropriate manner. The stress-testing structure adopted aids service evaluation and may help advise development of outcome standards for similar services.

Prevalence of mental disorders at admission to the penal justice system in emerging countries: a study from Chile

BACKGROUND

Previous mental health surveys conducted in prisons within emerging countries recruited samples of all prisoners at any single point in time. However, this sampling strategy results in an overrepresentation of long-term prisoners as compared with those studies recruiting from all admissions over time. This study aimed to assess mental disorders in consecutively admitted prisoners soon after admission, in order to address service needs of people with short-term imprisonments and people at early stages of imprisonment.

METHOD

Disorders were assessed in a sample of 229 male and 198 female prisoners, consecutively committed to the penal justice system in Santiago de Chile, using the structured Mini-Neuropsychiatric interview. Prevalence rates were calculated as per cent values. Ninety-five per cent confidence intervals were calculated for the proportions.

RESULTS

Illicit drug and/or alcohol use disorders in the year prior to admission were present in 173 (76%) male and 64 (32%) female prisoners. The substances most frequently causing addiction were cocaine-based products in 108 (47%) male and 42 (21%) female prisoners. Current major depression was present in 124 (54%) male and 86 (43%) female prisoners, and current non-affective psychotic disorders in 18 (8%) male and in 10 (5%) female prisoners. High suicidal risk was present in 64 (28%) male prisoners and in 29 (15%) female prisoners.

CONCLUSION

When consecutive prisoners are assessed at admission, rates of mental health and substance use disorders were higher than in previous studies in emerging countries that had sampled from all existing prisoners at a time. Affective disorders and suicide risk appear more prevalent than in admission studies conducted in Western high-income countries. Previous research may have systematically underestimated the extent of mental health problems in prisoners, which poses a major public health challenge in emerging countries.

Older men and older women remand prisoners: mental illness, physical illness, offending patterns and needs

BACKGROUND

Older prisoners are the fastest growing group of prisoners in most countries. They have high rates of physical and psychiatric co-morbidity, compared to community dwelling older persons and also compared with other prisoner groups. Very high rates of mental illness have been found in remand (pre-trial) prisoners when compared with other prisoner groups; however to date there have been no studies examining older male and female remand prisoners.

METHODS

A retrospective chart review was conducted of all remands, to a male and a female prison, over a six and half-year period. Demographic data were collected pertaining to psychiatric and medical diagnoses and seriousness of offending.

RESULTS

We found rising numbers of older prisoners amongst male remand prisoners. Older remand prisoners had very high rates of affective disorder and alcohol misuse. They had rates of psychotic illnesses and deliberate self-harm comparable to younger remand prisoners. High rates of vulnerability were found among older prisoners and older prisoners had a greater need for general medical and psychiatric services than younger prisoners. We also found comparable offending patterns with younger prisoners and high rates of sexual offending among the older male prisoner group.

CONCLUSIONS

Given the ageing population of many countries it is likely the numbers of older prisoners will continue to grow and given their high levels of both physical and psychiatric illness this will have implications for future service delivery.

Implementing a court diversion and liaison scheme in a remand prison by systematic screening of new receptions: a 6 year participatory action research study of 20,084 consecutive male remands

BACKGROUND

A mental health needs assessment in the Irish prison population confirmed findings from other jurisdictions showing high prevalence of severe mental illness, including psychosis amongst those newly committed. We implemented a participatory action research approach in order to provide an integrated mental health prison in-reach and court liaison service for this population.

RESULTS

Following extensive consultation, a two stage screening process was developed which was supplemented by an inter-agency referral management system. During the six years 2006-2011, all 20,084 new remands to the main remand prison serving 58% of the national population were screened. Following the first stage screen, 3,195 received a comprehensive psychiatric assessment. Of these 561 (2.8%) had symptoms of psychosis - corresponding to the prior research finding - and 572 were diverted from the criminal justice system to mental health services (89 to a secure forensic hospital, 164 to community mental health hospitals and 319 to other community mental health services).

CONCLUSIONS

We have shown that it is possible to match research findings in clinical practice by systematic screening, to sustain this over a long period and to achieve consistent levels of diversion from the criminal justice system to appropriate mental health services. The sustained and consistent performance of the model used is likely to reflect the use of participatory action research both to find the most effective model and to achieve wide ownership and cooperation with the model of care.

Ultra high risk of psychosis on committal to a young offender prison: an unrecognised opportunity for early intervention

BACKGROUND

The ultra high risk state for psychosis has not been studied in young offender populations. Prison populations have higher rates of psychiatric morbidity and substance use disorders. Due to the age profile of young offenders one would expect to find a high prevalence of individuals with pre-psychotic or ultra-high risk mental states for psychosis (UHR). Accordingly young offender institutions offer an opportunity for early interventions which could result in improved long term mental health, social and legal outcomes. In the course of establishing a mental health in-reach service into Ireland's only young offender prison, we sought to estimate unmet mental health needs.

METHODS

Every third new committal to a young offenders prison was interviewed using the Comprehensive Assessment of At-Risk Mental States (CAARMS) to identify the Ultra High Risk (UHR) state and a structured interview for assessing drug and alcohol misuse according to DSM-IV-TR criteria, the Developmental Understanding of Drug Misuse and Dependence - Short Form (DUNDRUM-S).

RESULTS

Over a twelve month period 171 young male offenders aged 16 to 20 were assessed. Of these 39 (23%, 95% confidence interval 18% to 30%) met UHR criteria. UHR states peaked at 18 years, were associated with lower SOFAS scores for social and occupational function and were also associated with multiple substance misuse. The relationship with lower SOFAS scores persisted even when co-varying for multiple substance misuse.

CONCLUSIONS

Although psychotic symptoms are common in community samples of children and adolescents, the prevalence of the UHR state in young offenders was higher than reported for community samples. The association with impaired function also suggests that this may be part of a developing disorder. Much more attention should be paid to the relationship of UHR states to substance misuse and to the health needs of young offenders.

Severe mental illness in 33,588 prisoners worldwide: systematic review and meta-regression analysis

BACKGROUND

High levels of psychiatric morbidity in prisoners have been documented in many countries, but it is not known whether rates of mental illness have been increasing over time or whether the prevalence differs between low-middle-income countries compared with high-income ones.

AIMS

To systematically review prevalence studies for psychotic illness and major depression in prisoners, provide summary estimates and investigate sources of heterogeneity between studies using meta-regression.

METHOD

Studies from 1966 to 2010 were identified using ten bibliographic indexes and reference lists. Inclusion criteria were unselected prison samples and that clinical examination or semi-structured instruments were used to make DSM or ICD diagnoses of the relevant disorders.

RESULTS

We identified 109 samples including 33 588 prisoners in 24 countries. Data were meta-analysed using random-effects models, and we found a pooled prevalence of psychosis of 3.6% (95% CI 3.1-4.2) in male prisoners and 3.9% (95% CI 2.7-5.0) in female prisoners. There were high levels of heterogeneity, some of which was explained by studies in low-middle-income countries reporting higher prevalences of psychosis (5.5%, 95% CI 4.2-6.8; P = 0.035 on meta-regression). The pooled prevalence of major depression was 10.2% (95% CI 8.8-11.7) in male prisoners and 14.1% (95% CI 10.2-18.1) in female prisoners. The prevalence of these disorders did not appear to be increasing over time, apart from depression in the USA (P = 0.008).

CONCLUSIONS

High levels of psychiatric morbidity are consistently reported in prisoners from many countries over four decades. Further research is needed to confirm whether higher rates of mental illness are found in low- and middle-income nations, and examine trends over time within nations with large prison populations.

Reducing the use of seclusion for mental disorder in a prison: implementing a high support unit in a prison using participant action research

Background

Vulnerable prisoners and mentally disordered offenders who present with risk of harm to self or others were accommodated in Special Observation Cells (SOCs) isolated from others for considerable periods of time. This practice has been criticised by the Council of Europe Committee for the Prevention of Torture. The objective of this initiative was to reduce the use of seclusion within the prison and to improve the care of vulnerable and mentally ill prisoners within the prison.

Results

The prison studied is a committal centre for sentenced prisoners with an official bed capacity of 630. The forensic mental health in-reach team, in co-operation with the prison health service followed the 'spiral' of planning, action and fact finding about the results of the action. In December 2010 a 10 bed High Support Unit (HSU) was established within the prison. During the first year, 96 prisoners were admitted. A third (35%) reported psychotic symptoms, 28% were referred due to the immediate risk of self-harm, 17% were accommodated for medical treatments and increased observation, 13% received specialised treatment by the Addiction Psychiatry team, 6% presented with emotional distress. One prisoner was accommodated on the HSU due to the acute risk he posed to others. A major mental illness was diagnosed in 29%, 20% required short-term increased support for crisis intervention and were found not to have a mental illness. A further 10% were deemed to be feigning symptoms of mental illness to seek refuge in the HSU. 7% had personality disorder as their primary diagnosis and 4% had a learning disability. Stratifying risk within the prison population through the provision of the HSU decreased the total episodes of seclusion in the prison by 59% (p < 0.001) in addition to providing a more effective psychiatric in-reach service to the prison. Pathways between the prison and the forensic psychiatric hospital saw no change in activity but improved continuity of care.

Conclusions

The next step is to further stratify risk by establishing a low support unit to serve as a step-down from the high support unit.