Managing Anxiety and Depression Without a Psychiatrist: Primary Care’s Expanding Mental Health Burden

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Introduction

The global mental health crisis has intensified in recent years, reaching unprecedented levels. The COVID-19 pandemic, beginning in 2019, remarkably contributed to the rising prevalence of mental health disorders worldwide. In the United States, millions of individuals now live in areas officially designated as having shortages of mental health professionals [6]. This simultaneous surge in demand and decline in specialist access has placed an increasing burden on primary care settings, which are now at the forefront of mental health service delivery. This shift has blurred the lines between general medical care and specialized psychiatric treatment, forcing a redefinition of roles and responsibilities within the healthcare system.

Mood and anxiety disorders are among the most prevalent and debilitating psychiatric conditions, contributing substantially to the global burden of disease. In the United States, the lifetime prevalence of mood disorders is approximately 20.8 percent, while anxiety disorders affect an estimated 28.8 percent of the population. Lebanon, although different in healthcare infrastructure and resources, also reflects a major burden, with lifetime prevalence rates of 12.6 percent for mood disorders and 16.7 percent for anxiety disorders [7]. These statistics highlight the widespread nature of these conditions and the urgent need for scalable and sustainable solutions within existing healthcare frameworks.

The growing recognition that primary care providers can play a central role in identifying and treating common mental health conditions presents both opportunities and challenges. Traditionally, the management of psychiatric disorders has relied heavily on the availability and expertise of specialists such as psychiatrists and clinical psychologists. However, this model is increasingly unsustainable. Projections indicate a continuing shortage of mental health professionals, particularly in rural and underserved areas, leaving many patients without timely access to appropriate care.

This paper critically examines how primary care systems can effectively manage anxiety and depression in the absence of sufficient psychiatric specialist availability. It explores the structural and operational challenges that limit primary care’s current capacity, including workforce constraints, limited mental health training among providers, and time pressures within standard consultations. At the same time, it highlights innovative and evidence-based approaches that are reshaping how mental health care is delivered in primary care settings.

These approaches include integrated care models such as the Collaborative Care Model, stepped care interventions, the use of digital mental health tools, and task-sharing strategies that delegate aspects of care to trained non-specialists under clinical supervision. By expanding the capabilities of primary care teams and embedding mental health services into general practice, these models aim to improve access, continuity of care, and patient outcomes.

Research Question and Scope

This analysis centers on a key question: How can primary care systems effectively manage anxiety and depression when access to psychiatric specialists is limited, and what are the implications for healthcare delivery, quality of care, and patient outcomes?

To address this question, the paper investigates four core areas:

1. Workforce limitations that constrain psychiatric care delivery in primary care settings.
2. Training and competency gaps among primary care providers regarding mental health assessment and treatment.
3. Evidence-based models and interventions that support the integration of mental health services into primary care.
4. Innovative strategies and technologies that are expanding the capacity of primary care to manage mental health conditions effectively.

By examining these areas, the paper seeks to provide a comprehensive understanding of the evolving role of primary care in mental health, offering insights into sustainable solutions that can improve outcomes for individuals with anxiety and depression, particularly in the face of ongoing workforce shortages and systemic limitations.

 

Literature Review and Current Context

The Scope of Primary Care Mental Health Burden

Some 40% of patients treated by primary care physicians have notable mental health problems. Only about half eventually receive mental health care, usually by the primary care physicians, often inadequately [9]. This statistic illuminates both the tremendous burden placed on primary care and the substantial gap in adequate mental health service delivery.

The lifetime risk of mental health disorders is almost 50% and, in any year, about 25% of the population have a psychiatric disorder. Many of those people are cared for in primary care settings [10]. The prevalence of mental health conditions in primary care settings far exceeds the capacity of specialized psychiatric services, making primary care the de facto mental health system for many patients.

Workforce Shortage Crisis

The mental health workforce shortage stands as one of the most disturbing challenges facing healthcare systems globally. This study examined shortages of mental health professionals at the county level across the United States. A goal was to motivate discussion of the data improvements and practice standards required to develop an adequate mental health professional workforce. Shortage of mental health professionals was conceptualized as the percentage of need for mental health visits that is unmet within a county. County-level need was measured by estimating the prevalence of serious mental illness, then combining separate estimates of provider time needed by individuals with and without serious mental illness [11] [12].

There is a recognized shortage of mental health professionals licensed to provide the full scope of mental health services, including assessment, diagnosis, and prescribing [13]. This shortage is particularly acute in specialized areas, with a national shortage of child and adolescent psychiatrists, pediatric primary care providers (PCPs) are often responsible for the screening, evaluation, and treatment of mental health disorders [14].

The projected trajectory of psychiatric workforce availability is concerning. The psychiatrist workforce will contract through 2024 to a projected low of 38,821, which is equal to a shortage of between 14,280 and 31,091 psychiatrists, depending on the psychiatrist-to-population ratio used. A slow expansion will begin in 2025. By 2050, the workforce of psychiatrists will range from a shortage of 17,705 psychiatrists to a surplus of 3,428 [15].

Geographic and Access Disparities

Shortages of psychiatrists can lead to disparities in access to mental healthcare. Among 718 counties from 12 states, 208 (29%) counties had less than half of their population within 30-min travel time, while only 51 (6%) provided their entire population convenient access to psychiatrists. A considerable amount of the population resides in areas underserved by psychiatry services with varied disparities by rurality and state [16] [17].

 

 

Primary Care Capacity and Training Gaps

Current Training Inadequacies

The preparation of primary care providers for mental health service delivery reveals marked deficiencies. A majority of primary care training programs are dissatisfied with the current status of their psychiatric training except for FP programs. A great majority of IM (71%), Ob/Gyn (92%) and Peds (85%) training directors felt that the training was minimal or suboptimal, as compared to 41% of FP training directors [18] [19].

Primary and specialty medical clinicians will continue to deliver care to the majority of less severely ill MH/SUD patients seen by PMC teams. Such medical clinicians, however, usually receive only marginal training in the diagnosis and treatment of MH/SUDs. The results of our study demonstrate that MH training is suboptimal in preparing residents to attain the AAP’s MH competencies [20].

Provider Confidence and Competence Concerns

Confronting primary care NPs are problems with time constraints, multiple comorbidities, and limited mental health training, particularly in relation to the differences in pharmacokinetic and pharmacodynamic actions of first-line anxiety disorder medications across age groups [21]. These challenges highlight the complexity of adequately preparing primary care providers for expanded mental health roles.

Participants expressed reservations about the ability of primary care physicians (PCPs) to meet their mental health needs. Specific barriers included problems with PCP competence and openness as well as patient–physician trust [22]. Patient perceptions of primary care mental health competency demonstrates an additional barrier to effective service delivery.

Barriers to Effective Mental Health Management

Primary care is usually the first port of call for concerned parents so it is important to understand how primary care practitioners manage child and adolescent mental health problems and the barriers they face. The majority of the barriers related to identification, management, and/or referral. Considerable barriers included a lack of providers and resources, extensive waiting lists, and financial restrictions [23] [24].

 

 

Evidence-Based Screening and Assessment Tools

PHQ-9 and GAD-7: Foundation of Primary Care Mental Health Screening

The Patient Health Questionnaire – 9 (PHQ-9) and Generalized Anxiety Disorder – 7 (GAD-7) are short screening measures used in medical and community settings to assess depression and anxiety severity [25] [26]. These instruments have become cornerstone tools for primary care mental health assessment.

International guidelines recommend screening for depression and the Patient Health Questionnaire 9 (PHQ-9) has been identified as the most reliable screening tool. PHQ-9 has been widely validated and is recommended in a two-stage screening process [27] [28].

Screening Tool Effectiveness and Implementation

Research demonstrates substantial correlation between PHQ-9 and GAD-7 measures. The correlation coefficient (Spearman’s rho) was 0.74. 78.4% of concurrent scores were within 4 points of each other, and 56.4% of score pairs fell into the same severity class. The correlation coefficient (Spearman’s rho) for the overall data sets was 0.74 [29] [30].

The accuracy of the PHQ-9 was evaluated in 31 (74%) studies with a two-stage screening system, with structured interview most often carried out by primary care and mental health professionals. Most of the studies employed a cut-off score of 10 (N=24, 57%, total range 5 – 15). The overall sensitivity of PHQ-9 ranged from 0.37 to 0.98, specificity from 0.42 to 0.99, positive predictive value from 0.09 to 0.92, and negative predictive value from 0.8 to 1 [31].

Cross-Cultural Validation and Adaptability

Results showed that the PHQ-9 and GAD-7 are reliable screening tools for depression and anxiety and their factor structures replicated those reported in the literature. Sensitivity and specificity analyses showed that the PHQ-9 is sensitive but not specific at capturing depressive symptoms when compared to clinician diagnoses whereas the GAD-7 was neither sensitive nor specific at capturing anxiety symptoms. The implications of these findings are discussed in reference to the scales themselves and the cultural specificity of the Lebanese population [32].

 

 

Collaborative Care Models: A Proven Framework

The Collaborative Care Model Structure

Collaborative care models have been developed from the Chronic Care Model over the past 20 years. Collaborative care is a multicomponent, healthcare system–level intervention that uses case managers to link primary care providers, patients, and mental health specialists. In addition to case management support, primary care providers receive consultation and decision support from mental health specialists (i.e., psychiatrists and psychologists). This collaboration is designed to (1) improve routine screening and diagnosis of depressive disorders; (2) increase provider use of evidence-based protocols for the proactive management of diagnosed depressive disorders; and (3) improve clinical and community support for active client/patient engagement in treatment goal-setting and self-management [33].

Evidence of Collaborative Care Effectiveness

Randomized controlled trials have demonstrated that the collaborative care model for depression in primary care is more effective than usual care, but little is known about the effectiveness of this approach in real-world settings. Randomized controlled trials have demonstrated that the collaborative care model for depression in primary care is more effective than usual care. We used patient-reported outcome data from 11,303 patients receiving collaborative care for depression in 135 primary care clinics to examine variations in depression outcomes [34] [35].

Collaborative care resulted in more rapid improvement in depression symptomatology, and a more rapid and sustained improvement in mental health status compared to the more standard model. Mounting evidence indicates that collaboration between primary care providers and mental health specialists can improve depression treatment and supports the necessary changes in clinic structure and incentives [36].

Key Components for Success

A significant interaction effect with the largest effect size was found between the depression outcome and the collaborative care component therapeutic treatment strategy (-0.07; P < .001). This indicates that this component, including its key elements manual-based psychotherapy and family involvement, was the most effective component of the intervention. Components of collaborative care most associated with improved effectiveness in reducing depressive symptoms were identified. To optimize treatment effectiveness and resource allocation, a therapeutic treatment strategy, such as manual-based psychotherapy or family integration, may be prioritized when implementing a collaborative care intervention [37] [38].

Real-World Implementation Challenges

The average treatment response across this large sample of clinics was substantially lower than response rates reported in randomized controlled trials, and substantial outcome variation was observed. Patient factors such as initial depression severity, clinic factors such as the number of years of collaborative care practice, and the degree of implementation support received were associated with depression outcomes at follow-up. Our findings suggest that the level of implementation support could be an important influence on the effectiveness of collaborative care model programs [39].

 

Task-Shifting and Workforce Innovation

Conceptual Framework of Task-Shifting

In view of a shortage of mental health professionals in most low- and middle-income countries, task sharing (task shifting) can make an important contribution to improving access to mental health services. Task sharing involves non-specialists in the delivery of health care [40].

Evidence suggests that mental health care can be delivered effectively in primary health-care settings, through community-based programmes and task-shifting approaches. Non-specialist health professionals, lay workers, affected individuals, and caregivers with brief training and appropriate supervision by mental health specialists are able to detect, diagnose, treat, and monitor individuals with mental disorders and reduce caregiver burden [41].

Effectiveness of Task-Shifting Approaches

We found that task shifting could potentially improve several health outcomes such as blood pressure, HbA1c, and mental health while achieving cost savings. Key elements for successful implementation of task shifting include collaboration among all parties, a system for coordinated care, provider empowerment, patient preference, shared decision making, training and competency, supportive organisation system, clear process outcome, and financing. Evidence suggests that allied healthcare workers such as pharmacists and nurses can potentially undertake substantially expanded roles to support physicians in primary care in response to the changing health service demand [42].

Nurse-Led Mental Health Interventions

Eight studies revealed that nurse-led intervention was superior to its comparator. The review identified three major themes: training and supervision, single and collaborative care and psychosocial treatments. Eight studies revealed that nurse-led intervention was mostly superior to its comparator. The review identified three major themes: training and supervision, single and collaborative care and psychosocial treatments.

Training and Implementation Considerations

Findings support the feasibility of training trauma nurses in a brief mental health intervention. Task-shifting brief interventions holds promise for reaching more of the population in need of posttrauma mental health care. Findings support the feasibility of training trauma nurses in a brief mental health intervention. Task-shifting brief interventions holds promise for reaching more of the population in need of posttrauma mental health care [43] [44].

 

 

Digital Health and Technology Integration

Online Collaborative Care Models

Collaborative care for depression and anxiety is superior to usual care from primary care physicians for these conditions; however, challenges limit its provision in routine practice and at scale. Advances in technology may overcome these barriers but have yet to be tested [45].

Technology-enabled approaches offer potential solutions for scaling mental health interventions. At 6 months, patients receiving computerized cognitive behavioral therapy (CCBT) alone vs usual care reported a −2.43 (95% CI, −4.16 to −0.69; P = .006) improvement. CCBT indicates computerized cognitive behavioral therapy; GAD-7, 7-Item Generalized Anxiety Disorder Scale; ISG, internet support group; PCP, primary care physician; PHQ-9, 9-Item Patient Health Questionnaire; UC, usual care [46].

 

 

Patient Perspectives and Engagement Barriers

Access and Satisfaction Challenges

Of the 22% that reported they tried to but did not access specialty mental health care, 53% reported receiving mental health care from a PCP. Respondents receiving care only from their PCP were less likely to rate their PCP care highly (21% versus 48%; p = 0.01). Interviewees reported experiences with PCP-provided mental health care related to three major themes: PCP engagement, relationship with the PCP, and PCP role. Primary care is partially filling the gap for mental health treatment when specialty care is not available [47].

Implementation Barriers for Collaborative Care

Survey results found that patients were uncertain about insurance coverage, did not understand the program, and felt services were not necessary. Referred patients who declined participation were concerned about how their mental health information would be used and preferred treatment without medication [48].

 

 

Economic Considerations and Cost-Effectiveness

Financial Implications of Current Models

As compared with usual care, an intervention involving nurses who provided guideline-based, patient-centered management of depression and chronic disease improved control of medical disease and depression. As compared with usual care, an intervention involving nurses who provided guideline-based, patient-centered management of depression and chronic disease notably improved control of medical disease and depression [49] [50].

Cost-Effectiveness of Task-Shifting

The adoption of the concept of task shifting can substantially reduce the expected number of health care providers otherwise needed to close mental health service gaps at primary health care level in South Africa at minimal cost and may serve as a model for other middle-income countries. The adoption of the concept of task shifting can substantially reduce the expected number of health care providers otherwise needed to close mental health service gaps at primary health care level in South Africa at minimal cost and may serve as a model for other middle-income countries.

 

 

Discussion and Analysis

Synthesis of Current Evidence

The evidence demonstrates that primary care has emerged as the primary venue for mental health service delivery, not by design but by necessity. Primary care is partially filling the gap for mental health treatment when specialty care is not available [51], yet this role expansion occurs within a context of inadequate preparation, limited resources, and systemic barriers.

The research reveals several critical themes:

1. Workforce Crisis: The projected shortage of mental health specialists, particularly psychiatrists, necessitates alternative service delivery models. Workforce shortages in primary care continue to expand due to population aging, growth, and heightened rates of clinician burnout & egress. Workforce shortages in primary care continue to expand due to population aging, growth, and heightened rates of clinician burnout & egress [52] [53].
2. Training Deficits: Current primary care training programs inadequately prepare providers for expanded mental health roles, with most programs reporting dissatisfaction with psychiatric training components.
3. Evidence-Based Solutions: Collaborative care models demonstrate high effectiveness in improving mental health outcomes when properly implemented and supported.
4. Technology Integration: Digital health approaches offer scalable solutions for expanding mental health service capacity, though implementation challenges remain.
5. Task-Shifting Potential: Well-designed task-shifting approaches, particularly nurse-led interventions, show promise for expanding mental health service capacity.

Critical Analysis of Collaborative Care Models

While collaborative care models demonstrate effectiveness in controlled research settings, the average treatment response across this large sample of clinics was substantially lower than response rates reported in randomized controlled trials [54]. This gap between research efficacy and real-world effectiveness highlights implementation challenges that must be addressed for successful scaling.

The success of collaborative care models depends heavily on organizational factors, including the degree of implementation support received [55] and systemic integration. Healthcare organizations implementing these models must invest in comprehensive training, ongoing supervision, and robust support systems.

Task-Shifting: Opportunities and Limitations

Task-shifting represents a promising approach to expanding mental health service capacity, yet implementation requires careful consideration of training, supervision, and scope of practice issues. A (cost-) effective model of mental health care in low-resource settings as well as in high-income countries may include the medical school-based training of some psychiatrists and clinical psychologists in the treatment of referred patients with serious mental illness. These professional mental health specialists would also be trainers and supervisors of non-specialist health workers who would identify common mental health disorders and provide psychotherapy to people with these conditions in a community-based setting. Community-based generalism including task sharing rather than centralized specialism may be capable of preventing and treating many common mental disorders with minor financial expenditure [56].

However, task-shifting must be implemented thoughtfully. Professionalizing volunteers through task-shifting results in the transformation of their philosophy of community care, which constrains and narrows understandings of mental health care. Professionalizing volunteers through task-shifting results in the transformation of their philosophy of community care, which constrains and narrows understandings of mental health care [57] [58].

Screening Tool Implementation and Standardization

The widespread validation and implementation of standardized screening tools like PHQ-9 and GAD-7 reveals major advances in primary care mental health capacity. When used for the purpose of monitoring response to treatment, concurrent pairs of PHQ-9 and GAD-7 are strongly correlated and often similar in severity, with the result that the measures provide redundant clinical information in many cases. The added value of using both scales to track outcomes appears moderate, though the cost is low as well. Clinical services should consider these findings when implementing depression and anxiety symptom tracking [59].

 

 

Implications for Healthcare Policy and Practice

Immediate Priorities

• Strengthening Mental Health Training in Primary Care:
  Primary care residency programs should remarkably enhance their mental health curricula. This includes integrating evidence-based treatment approaches for common psychiatric conditions such as depression and anxiety, and equipping residents with the skills to implement collaborative care models. Training must emphasize practical, team-based approaches that support coordination with behavioral health professionals, fostering early intervention and improved long-term outcomes.
• Investing in Implementation Support for Collaborative Care:
  Healthcare organizations must provide structured, ongoing support for the implementation of collaborative care models. Successful integration requires more than initial training or pilot efforts; it demands sustained organizational commitment, leadership engagement, and the allocation of dedicated resources. This includes the development of workflows, care team training, change management processes, and continuous performance monitoring to ensure fidelity to the model.
• Standardizing Mental Health Screening and Follow-up Protocols:
  The consistent use of validated screening tools, such as the PHQ-9 for depression and GAD-7 for anxiety, should be a foundational element of primary care. However, screening alone is insufficient. Health systems must also establish clear protocols for follow-up, diagnosis confirmation, and initiation of treatment. Embedding these practices into electronic health records and quality assurance processes will support timely and effective care for patients with behavioral health needs.

Long-term Strategic Considerations

• Expanding the Behavioral Health Workforce Through Innovative Models:
  To meet growing mental health demands, healthcare systems must adopt scalable workforce development strategies. This includes task-shifting to care managers and behavioral health specialists, expanding the role of advanced practice nurses, and fully implementing collaborative care models that extend the reach of psychiatric expertise through team-based care and consultation. These approaches improve access without relying solely on increasing the number of psychiatrists.
• Leveraging Technology to Scale Mental Health Services:
  Digital health platforms, including telepsychiatry, patient portals, and data-driven care management tools, have the potential to enhance the scalability and efficiency of mental health services. When integrated into collaborative care models, these technologies support real-time communication among care teams, enable remote symptom tracking, and streamline follow-up processes. Health systems should prioritize investments in user-friendly, interoperable platforms that align with clinical workflows.
• Reforming Payment Models to Support Integrated Mental Health Care:
  Current reimbursement structures often create barriers to sustaining integrated mental health services in primary care. To address this, policymakers and payers must redesign payment models to support collaborative care delivery. This includes bundled payments, value-based reimbursement for mental health outcomes, and financial incentives for screening, care coordination, and behavioral health integration. Sustainable financing mechanisms are essential to the long-term viability of integrated care.

Quality Assurance and Patient Safety

Expansion of primary care mental health services must be accompanied by robust quality assurance mechanisms. Patients with depression may be deterred from care-seeking or disclosure by relational barriers including perceptions of PCPs’ mental health-related capabilities and interests. PCPs should continue to develop their depression management skills while supporting vigorous efforts to inform the public that primary care is a safe and appropriate venue for treatment of common mental health conditions [60].

 

Limitations and Future Research Directions

Study Limitations

This analytical review is subject to several limitations that may impact the interpretation and generalizability of findings.

First, the heterogeneity of healthcare settings and populations across the reviewed studies presents a challenge. The evidence is drawn from diverse clinical environments, including high-income urban centers and resource-limited rural areas. As a result, the applicability of findings to a single context or system may be limited.

Second, there is variability in how collaborative care models and task-shifting strategies are designed and implemented. Differences in team composition, training protocols, and supervisory structures can influence outcomes, making direct comparisons across studies difficult and potentially obscuring the identification of best practices.

Third, the inconsistency in outcome measurement poses a challenge for evaluating effectiveness. Studies employ a wide range of clinical and functional outcome metrics, often with differing follow-up durations. This lack of uniformity complicates the synthesis of results and limits the ability to draw firm conclusions about intervention impact.

Future Research Priorities

To advance the field and address current gaps, several key areas require focused research:

1. Implementation Science:
There is a critical need for research that identifies effective implementation strategies for integrating collaborative care models into routine practice. This includes understanding the contextual factors that facilitate or hinder uptake in different healthcare systems and cultural settings.

2. Long-term Outcomes:
Most existing studies assess short-term impacts. Future research should prioritize the evaluation of long-term patient outcomes, including symptom relapse, functional recovery, and sustained engagement with care. Understanding the durability and scalability of these interventions over time is essential.

3. Cost-Effectiveness Analysis:
Economic evaluations remain limited. Robust studies that compare the cost-effectiveness of various service delivery models are necessary to guide health policy and funding decisions. These should consider both direct medical costs and broader societal impacts.

4. Technology Integration:
As digital tools become increasingly prominent, research must explore how best to integrate digital health technologies, such as telepsychiatry, mobile apps, and decision support tools, into primary care mental health services. Evidence is needed on usability, clinical effectiveness, and implementation pathways to ensure that technology enhances, rather than fragments, care delivery.

 

 

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Conclusion

 

The expansion of mental health service delivery within primary care settings represents both a necessity and an opportunity. Primary care providers have an opportunity to provide care for commonly occurring mental health disorders [61], yet realizing this potential requires systematic attention to training, implementation support, and evidence-based practice adoption.

The evidence demonstrates that well-implemented collaborative care models can achieve significant improvements in mental health outcomes. Collaborative care resulted in more rapid improvement in depression symptomatology, and a more rapid and sustained improvement in mental health status compared to the more standard model. Mounting evidence indicates that collaboration between primary care providers and mental health specialists can improve depression treatment [62].

However, the gap between research efficacy and real-world effectiveness highlights the critical importance of implementation science and organizational support. Our findings suggest that the level of implementation support could be an important influence on the effectiveness of collaborative care model programs [63].

The future of mental healthcare delivery will likely depend heavily on primary care’s capacity to effectively manage anxiety and depression. This requires not merely expanding existing approaches but fundamentally reimagining how mental health services are delivered, supported, and integrated within healthcare systems. The evidence base provides a foundation for this transformation, but successful implementation will require sustained commitment from healthcare organizations, policymakers, and the broader healthcare community.

Task-shifting approaches offer additional promise for expanding service capacity, yet implementation must be carefully designed to maintain quality while expanding access. The adoption of the concept of task shifting can substantially reduce the expected number of health care providers otherwise needed to close mental health service gaps at primary health care level in South Africa at minimal cost and may serve as a model for other middle-income countries.

Ultimately, addressing the mental health crisis requires a comprehensive approach that leverages primary care capacity while maintaining quality and safety standards. The evidence demonstrates that this is achievable, but only through systematic, well-supported implementation of evidence-based models of care.

 

 

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