December 17, 2009

When Therapy Won't Work, Try Cymbalta. When Cymbalta Doesn't Work, You're Dead Meat

this should work as well as placebo


A patient describes being told by her psychiatrist that her depression was too severe for therapy or  behavioral techniques.  Only medication would work.  The patient says that the doc was right:

Her advice was grounded in neuroscience.

One research study... used high-definition brain imaging to reveal a breakdown in the emotional processing that impairs the depressive's ability to suppress negative emotions. In fact, the more effort that depressives put into reframing thoughts-the harder they tried to think positive-the more activation there was in the amygdala, regarded by neurobiologists as a person's "fear center." ... Healthy individuals putting more cognitive effort into [reframing the content] decreas[e] activity in the brain's emotional response centers. In the depressed individuals, you find the exact opposite.
Well, that's one interpretation.  Another among the other fifty possible would be that  depressive patients don't have an opposite response to cognitive framing, but that they are unable at that time to do it-- and so they end up using an emotional reframing, hence the amygdala effect.  See?  All depends what century you want to live in.

It's an easy criticism to make-- and I've made it-- that this kind of advice damages society, because it makes it acceptable, normalizes, that idea depression is primarily a biological illness that requires meds; and, in a  more general way, that "health," emotional and physical, is just as much other people's problem as it is yours.

The title of that article is: Note To the Severely Depressed: Don't Try So Hard.


"So you think that doctor sucks?"

No, actually she's a good doctor, and this is why robots will never be able to be (good) psychiatrists, though that they will become psychiatrists is inevitable.  She (the doctor) looked at her, understood her, where she was in her life, and did what the Oracle did:

Neo: But the Oracle told me--

Morpheus:  --she told you exactly what you needed to hear.

She tailors the advice to the whole patient, their perspective, their life, their situation.  That's gold, that's the only reason the psychiatrist is there.  The psychiatrist did the cognitive reframing for her.  The post doesn't describe how awesome the Pristiq or Cymbalta was, it describes how awesome the advice was.  Hearing the advice got her better, not taking the advice.  Said another way: had she not internalized this advice, would the Cymbalta have worked?


Before you ask me: no, I'm not advocating lying to patients.  She wasn't lying, she was saying what was true at that moment for her patient.

"Until you feel stronger, I suggest you stay away from the type of self-help literature you have brought it because those texts can do further damage if read in a very depressed state." [said the psychiatrist]
The psychiatrist's advice to this patient was perfect; this advice to anyone in general with depression would be disastrous-- beyond it not even being accurate-- for them and for society.

Example: what if the medication doesn't work?  You've already told them that CBT and yoga are no good for severe depression, so if the meds fail, does a person have any hope left?  One might reasonably argue that the type of person who fails medications should try CBT or yoga.

Some people derive strength from knowing their symptoms aren't their "fault" and out of their hands; others derive strength from believing that it's entirely up to them, that they can overcome anything if they apply themselves.  Each patient has to be evaluated separately, and their advice individualized.  And, of course, all of this is in flux: in a month, they may have a different worldview.  In psychiatry, if you burn a bridge, you're trapping the both of you on one side.


We can ask one last important question about the utility of advice in medical treatment.  "Said another way: had she not internalized this advice, would the Cymbalta have worked?"

Everyone knows that with every efficacious treatment, some proportion of it is related to a "placebo effect."  For example, being told you are being given a strong pain killer (but it is a placebo) reduces pain by some amount.  Similarly, while antidepressants reduce symptoms by 30%, placebo does it by 20%.  So we atttribute some of the antidepressant's efficacy to the "placebo effect."

This is based on the patient knowing they are getting a medication or a placebo.

What happens when you are given a medication covertly?  Not that they think it's a placebo but it's actually Valium, but rather that they are not aware they are injesting a chemical at all?  Would taking valium but not knowing you are taking anything at all reduce the anxiety?

covert valium.JPG
Not very reliably

This doesn't imply you feel nothing; it means that your symptoms remain unchanged.  e.g. "I suddenly feel more tired, but still anxious."

We tend to downplay the effect of words.  An antidepressant has a chemical effect that is real (even if it might not be efficacious) but words are thought to be incidental.  That's backwards.   Someone can make you cry with words, someone can make you sad forever with words.  How a doctor frames your chances for improvement matters.  And how, by the pitch of his voice and the choice of words, he conceptualizes your problems also matters a great deal.  Ask David Foster Wallace.


(part 2, sort of)

Also see: Is Prayer Worse Than Cymbalta?


Thank you for this post.</p... (Below threshold)

December 17, 2009 9:15 PM | Posted by Sasha: | Reply

Thank you for this post.

"She tailors the advice to the whole patient, their perspective, their life, their situation. That's gold, that's the only reason the psychiatrist is there."

This is the essence of art of medicine, art of psychotherapy, art of being an expert. Statistics and evidence is very useful in guiding decisions, but who but a good expert can see what a situation is and suggest an appropriate strategy. Art + science, intuition + evidence work together. Using only one of these tools is limiting. And yes, this psychiatrist might end up being wrong.

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Oh snap! I was hoping this ... (Below threshold)

December 17, 2009 9:21 PM | Posted by GT: | Reply

Oh snap! I was hoping this article was part 2 of the cognitive kill switch article. Oh well....can't have everything.

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I agree with your post, and... (Below threshold)

December 18, 2009 12:22 AM | Posted by Anonymous: | Reply

I agree with your post, and I think this is precisely why it's so dangerous for shrinks to say things like, "ECT is the only thing left to try." Talk about dramatic! I've said many times it's unclear who was more gloomy - me or my shrink. Really, hearing things like "treatment resistant" depression, SEVERE depression, etc only made me feel more hopeless about anything working. I would imagine that happens a lot.

Surprisingly, pilates did a hell of a lot more for my mental health than any drug. But, when you say things like that people scoff and say, oh, well your depression wasn't severe like mine. If you had depression like mine you wouldn't be able to do pilates. Which is true, I guess, if I had depression like the person who believed only drugs would help me, then drugs probably would be the only thing that would help me.

This is why doctors also need to be careful about supporting extended absences from work due to depression. It reinforces helplessness. You're too ill to work. How do I know? The psychiatrist said so. Pretty convincing.

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When my shrink told me that... (Below threshold)

December 18, 2009 4:59 AM | Posted by A Girl: | Reply

When my shrink told me that I needed meds, I fought him every step of the way. But once he'd spent four or five sessions telling me that I needed them, I broke down and figured I'd give them a try. It couldn't be worse than where I was.

However, knowing that two of my relatives had taken antidepressants without much (noticable) effect, not to mention having a mum who believed that people who took meds were weak-minded idiots and that people who went to see shrinks were cry-babies, blaming it all on their mum, I can hardly have said to be the model candidate for drug-testing.

Still, it worked. I got an antidepressant and some anti-anxiety shit, I lost my libido, gained weight, developed some really wierd eating habits and an even worse sweating problem than I'd had before. I guess it bears a witness to my mental state that none of these things made my life any worse. But the drugs made them better. Initially I hated them. Then the dose got upped. I still hated them as much, but since the world had turned from a blackhole that sucked in all feelings except excruciating pain, to a sort of bland foggy state, it was hard to feel too upset about it.

Little by little, I got better, mostly because I had a boyfriend who cared. I don't think the shrink ever liked me, and I certainly didn't like him. His favorite thing was that everyone would die alone - having lived most of my life alone, I was acutely aware of just how lonely that is and how much you need support and love from other people for any of it to be worth a damn, to give you an incentive to go on. Then one day it dawned on me that I wasn't depressed anymore - my brain had changed. I'd stopped crying at the slightest little thing, and I could find joy in simple things. So I quit the meds cold turkey and never looked back (no, he wasn't happy about that, but what can you do? You generally don't give much weight to the opinions of people who you don't belive care for you). We finished off group therapy. He told people to write, I took it not to mean me, and left it at that.

Seven years later, I made damn sure to get a therapist who'd like me. It helped a lot. He thawed me up, patted me on the back, chatted about books and films with me for roughly a year and then sent me on my way with a New Life in my backpack. He cared, he remembered, and he didn't let his phone ring in the middle of sessions. It's odd how those simple things can make such a big difference. I don't know where I'll be seven years from now, but for the first time I'm pursuing my interests and hesitantly building a network for myself.

One thing I do know is that I'm never, ever, ever taking those meds again. But they did mess with my brain, and they did help move me beyond the mental state that I was in at the time. No, meds alone cannot do the work. But sometimes, I think they are a necessary evil. And while I agree with you that we know shit-all about what goes on in the brain when you start pouring in those chemicals, I still don't think it can all be written off as a placebo effect. Because there was certainly nothing placating about the shit I went through.


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When a psychiatrist predict... (Below threshold)

December 18, 2009 6:10 AM | Posted by mark p.s.2: | Reply

When a psychiatrist predicts the future, the judgement creates the future. This would be justice for those seeking one, but I did not seek my life of schizophrenia, hearing voices of consciousness . Who will judge the Oracles? Who will judge the thousands of darth vaders judging children to have the disease of ADHD or bipolar disorder? Will the Empire just collapse?

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The problem isn't red pill ... (Below threshold)

December 18, 2009 8:41 AM | Posted by Evelyn: | Reply

The problem isn't red pill or blue pill; it's that there are infinitely many pills from which to choose.

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A girl: Thanks! Great story... (Below threshold)

December 18, 2009 10:08 AM | Posted by medsvstherapy: | Reply

A girl: Thanks! Great story. --It is an awesome hypothesis that a very depressed person may not be able to work on the cognitive strategies to change the depression. general problem-solving ability in depressed people has been noted as very low. This does not mean that psychotherapeutic strategies will not work. what it may mean is that we psychotherapists will reach into our bag of tricks and pull out yet another, besides cognitive therapy. "IPT" is pretty much what "A Girl" describes in her scenario 2. Behavioral activiation is documneted as effective for depression. Exercise is effective for depression. I just named 3 distint psychotherapeutic interventions, exclusive of cognitive therapy, that work for severely depressed people, as evidenced by decent research. "IPT" comes out of the field of psychiatry, so some psychiatrists are actually familiar with this. Why are they not familiar with the rest of this stuff?

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Maybe, but ultimately ev... (Below threshold)

December 18, 2009 10:14 AM | Posted, in reply to Evelyn's comment, by Alone: | Reply

Maybe, but ultimately every choice is binary: you pick this one, or you do not pick this one. Spend less time choosing, and more time making the choice work.

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anonymous - "Surprisingly, ... (Below threshold)

December 18, 2009 11:47 AM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

anonymous - "Surprisingly, pilates did a hell of a lot more for my mental health than any drug. But, when you say things like that people scoff and say, oh, well your depression wasn't severe like mine. If you had depression like mine you wouldn't be able to do pilates."

Actually, it's not really surprising at all (though, as you point out, you weren't so depressed you couldn't get to a pilates class and do it) and medical professionals often recommend exercise and creating social networks as therapeutic tools for treating depression. Exercise and being in safe social settings is very beneficial for mild to moderate depression. Depression is a condition of the mind and body, what you do to your body will effect your mental state. Just as what you do to your mind will influence your physical state. It's a two way street.

That said, mild and moderate depression are very different than severe depression because you have resources and motivation that severely depressed people don't. Just telling severely depressed people they lack motivation and should try harder - and equating one's own mild/moderate depression with someone else's severe depression - can end up being quite abusive. If you're willing to share your motivation and energy with them by helping them get to and maintain an exercise program, then your insight into your own depression and what helped you may be useful to them. The second response is compassionate because it involves understanding the other person and a loving and helpful action. The first response is dismissive of the other person and lacks understanding, it can even be abusive even though the original intent may well be to help and to share.

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To quote Spock from the new... (Below threshold)

December 18, 2009 3:31 PM | Posted by Anonymous: | Reply

To quote Spock from the new star trek, "You did not lie, you implied"

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I love that google throws u... (Below threshold)

December 18, 2009 5:06 PM | Posted by Rt: | Reply

I love that google throws up a large "" ad in the middle of this post. First time i've seen that on your site.

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Anonymous, you're missing m... (Below threshold)

December 18, 2009 7:58 PM | Posted by Anonymous: | Reply

Anonymous, you're missing my point. I had those diagnoses - severe major depression, hopeless, hopeless, hopeless, doom and gloom, my life is over. "Treatment resistant depression." "Recurrent major depression." All that drama is in my medical record. I was in and out of the nut house. Why did I get worse and worse? Because it was being reinforced. I was being told, "you're very, very ill...ECT is our last option, we've exhausted all other options." Basically what I was being told is that my life was that of a chronic mental patient. Where's the hope in that? There was a period of time when I believed all I was capable of was going to psychiatry appointments. I believed what they were telling me, and I was living up to their expectations which were pretty darn low.

No wonder meds didn't work with me. Hell, at one point I was even given a prescription to attend adult day care. Well, now if that won't cheer a person right up then I don't know what will. To be quite honest, the thought of spending my life in group therapy was enough to make me want to give up completely.

I'm not saying that meds don't ever help people. I'm not saying group therapy doesn't ever help people. I'm not saying ECT doesn't ever help people. I'm not arguing against any of those things. What I'm saying is that none of this was helpful for me. All that crap just reinforced that I was helpless, a victim of some brain chemistry gone awry that I had no control over so of course if I had no control over it I remained helpless. And it got worse and worse. What a surprise.

I do think that mental health professionals need to be very careful that they don't reinforce depression. If I understand the point of the article, and maybe I didn't, it's that different things help different people.

I also think that there's a very weird thing that goes on on the internet with people with mental illness diagnoses. There's this weird out illnessing each other that goes on. I've heard things like (paraphrasing a bit), "Well, if you were as sick as me, you would HAVE to take fistfulls of antipsychotics and you wouldn't care if you gained 100 pounds. In fact, you would be GLAD to wear those stretch pants with an elastic waistband." When I would say no those risks were not worth it to me people practically foamed at the mouth and flipped out. For some strange reason those who take drugs can't accept that some of us who did meet the criteria for severe/serious mental illness didn't want to take those risks and in fact got better once we got off all the psych meds. It happens from time to time. But, then there's the other group who are completely anti-meds and some of them get on their high horse about nutrition or whatever else. "Well if you only ate buttloads of fatty fish and took a cornucopia of vitamins, you would poop sunshine."

I'm certainly not saying pilates is the thing that will help all people with severe, major, recurrent, blah, blah, blah, depression. Extremist viewpoints are rarely helpful.

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I recently went to a doctor... (Below threshold)

December 19, 2009 3:41 AM | Posted by Anonymous: | Reply

I recently went to a doctor for depression. After asking me about 5 or 6 questions, he told me that I am "too sensitive" and induced my depression by excessive ruminating. He actually told me "I'll give you medicine. but it isn't really going to help". Um, why would I take it you asshole?
He spent about 30 minutes just rambling on and on about how my thinking patterns cause my depression. Meanwhile, I am sitting there feeling like shit and I damn well know that's not entirely/at all true. I also know he has no reason to think it is true as he does not know me, and I hardly spoke a word to him. I am confused and bewildered how he can be certain enough of this idea to preach about it for several minutes.
Eventually I cannot take it and I cry, ask to leave/go home.

This doctor did the exact opposite of the doctor you described above. If the doctor made me feel that my pain was really happening to me (as opposed to something I was doing to myself because I am a child who cannot cope)... IF he made me feel hopeful medication might help... *or* IF he emphasized how therapy would help me and recommended me to a therapist he liked (instead of emphasizing how medicine would NOT help me), odds are I wouldn't have left crying feeling ten times worse.

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anonymous - The fact remain... (Below threshold)

December 19, 2009 11:46 AM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

anonymous - The fact remains that you didn't feel so helpless or depressed that you couldn't motivate yourself to go to pilates. I'm in no way trying to negate your experience and am actually a big advocate of exercise and meditation as one of the ways to address depression and other conditions that are related to cognition as well as biology. (And I do know quite a lot of people who've also been helped by medication and therapy.) I'm just saying that what's true for you isn't necessary true for others and your attitude towards other people suffering from depression seems somewhat scornful rather than supportive. You seem to be projecting your experience and assuming other people are the same as you were. Maybe other people's lives and experience of being alive ARE improved by medication. I respect that you feel that yours wasn't and am glad that you found something that worked for you.

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For some strange reason ... (Below threshold)

December 20, 2009 8:21 AM | Posted, in reply to Anonymous's comment, by A Girl: | Reply

For some strange reason those who take drugs

Does that include me? Or only people presently taking drugs?

can't accept that some of us who did meet the criteria for severe/serious mental illness didn't want to take those risks and in fact got better once we got off all the psych meds.

I can accept that. Would you be able to accept that by the time you got off the meds, they'd actually done what they could for you?

The way I see it, my depression had two components (at least). First off, my brain was completely run down. Secondly, my life was a mess.

It is the first part I believe the meds helped with. They replaced The Hell of Pain with a some sort of a murky Devil-May-Care fog. I was by no means cured all my evils. But I could start working on them from a different perspective, wrapped in a kind of a protective woolen blanket, which made the bumps and the scrapes hurt a lot less. Once I got warm enough, the blanket began itching noticably and I got rid of it. The potholes were still there, but now I knew from experience that they didn't have to hurt so bad. I'd lost some of my fear for them.

Could this have been done in a different way? Undoubtedly, but none that I know of. I tried alcohol, painkillers, self-help books, new age stuff, yoga and meditation. I'm glad pilates worked for you, but let me ask you this honestly: If you had started pilates the same day as you went in for that first appointment with a shrink, do you think the whole rest of the journey could have been avoided?

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Bah, that link should not b... (Below threshold)

December 20, 2009 8:23 AM | Posted by A Girl: | Reply

Bah, that link should not be in there. Please remove it, thank you.

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In reference to the Anon wh... (Below threshold)

December 20, 2009 1:38 PM | Posted by Anon: | Reply

In reference to the Anon who started with "I recently went to a doctor for depression."

A common tactic I've seen is on the second appointment to have a piece of paper with a very simple list of symptoms that they will use to try to convince you that you either have some disease or lack one you are diagnosed with.

Never trust any mental health professional that thinks they can quickly get to know you.

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A Girl, I meant to say "so... (Below threshold)

December 20, 2009 1:48 PM | Posted by Anonymous: | Reply

A Girl, I meant to say "some" people who take drugs I did not mean to imply "all" people. My apologies. I definitely don't think it's "all" people. No, I don't accept that I was better from the drugs because I clearly wasn't. I got worse and worse on the drugs. That's when I was given the script for adult day care, and that's when I was in and out of the nuthouse. The message to me was they believed I was helpless and incapable of living a life free from chronic major depression which reinforced my depression. So, they responded with more and more drugs and I responded by getting worse and worse.

Perhaps it was my sister who first helped "reframe" things for me. She told me, you know you've gotten a lot worse since you started treatment. Maybe it's your treatment that's the problem. I didn't get better until I weaned myself off all the drugs and found a therapist who believed people could actually get well. The withdrawal process was not fun, and I was not instantly "cured." It was a slow process, but I'm now several years free from drugs and have maintained full time employment which the psychiatrist would have assured you I was incapable of.

The reframing was critical for me - the psychiatrist believed I had a biological illness, recurrent major depression, chronic, hopeless. The therapist I found told me how strong I was and didn't say things like, "You will probably have to take medication the rest of your life and ECT is really the only thing left to try." Instead, the therapist said things like, "I believe you can have a life free from depression." She offered hope, whereas my psychiatrist offered more of the same. It shouldn't be surprising that with one I got better and with the other I remained ill.

To the other anonymous, I don't know if you're a mental health professional but I can say that the more mental health professionals talked about my "severe, recurrent major depression" and the things I couldn't do, the more I didn't do those things. What if you believed people with severe depression COULD do things? What if you believed they were capable of more? If you are a mental health professional, please be very careful that you don't send the message of helplessness to those who already feel helpless. I know mental health professionals mean well when they do that, but it can actually be pretty crippling. I think it's possible to be supportive of someone who is hurting without reinforcing and enabling them. Lucky for me, I finally found someone who believed I could do things like pilates instead of lie in bed and be helpless.

I guess what I wish is that more therapists did what my therapist did and that is focus on patients' strengths rather than reinforcing their pathology. What a difference that can make.

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Anon, you wrote I seem scor... (Below threshold)

December 20, 2009 2:48 PM | Posted by Anonymous: | Reply

Anon, you wrote I seem scornful of those who take medications. I'm not sure where you get that idea. I'm not at all scornful of those who take meds. I'm supportive of whatever works. I already said drugs work for some people. I'm glad we have them, and I'm glad they do.

What I'm scornful of are docs who are too blind to see when it's the treatment that's making the patient worse. Unfortunately, there seems to be a lot of that going around. I'm also scornful of those who enable patients in their depression. It may seem like they're being compassionate, but it's not compassionate at all.

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Anon - From what you wrote,... (Below threshold)

December 20, 2009 5:55 PM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

Anon - From what you wrote, your scorn seemed aimed at depressed people on medication as well. If that was not your intent when your wrote it, thanks for clearing that up.

There are just as many flaky people out there promoting yoga, pilates and meditation - and various flaky diets - as the only appropriate treatment for depression (including major depression). They're just as dangerous as bad doctors and often much more dangerous.

I can understand why you're angry at your doctors (though the other poster has a very good point about how the whole journey is what gets us to our destination, none of us can know what would have happened if you'd taken another path, including you). That said, you still seem to be taking your own experience and projecting it onto others. What you needed - the form of compassion (which is just love with understanding) or treatment that worked for you - isn't going to be the same for everyone. Compassion isn't about projecting our own needs onto others, it's about understanding the other person's unique needs.

That said, I'm glad that you found something that worked for you finally and sorry it was such a long and difficult process getting from there to here.

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Anon, I think you're projec... (Below threshold)

December 20, 2009 7:37 PM | Posted by Anonymous: | Reply

Anon, I think you're projecting here a bit yourself. I'm not generalizing my experience to all with depression. In fact, that's my beef to begin with. We're all treated as if the answer is meds. And, it clearly is not the answer for everyone. We're individuals, and that seems to be missed.

I agree that people can get wacko about nutrition as "the" answer and if you read what I wrote, then you would already know that.

In talking about compassion for those with depression, maybe you could also include those for whom meds were/are ineffective. There's a lot of us out there, too.

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Anon - Why do you assume I ... (Below threshold)

December 21, 2009 11:08 AM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

Anon - Why do you assume I don't have compassion for people that drugs don't work for? I also have compassion for people that exercise doesn't work for, do you? I don't see compassion as something that's meted out in that way, I have compassion for (most, I'm no saint!) people who are suffering.

That said, I think we both agree that it's about treating the individual and finding what works for them. This is a process and, naturally, involves some trial and error.

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