By Cathi Hanauer
ELLE, October 2008
Early in 2002, I was a harried, work-at-home wife and mother of two young kids who suddenly found myself scheduled for a major media tour to promote my new book. E-mail flooded in: Would I do a photo shoot for this editor, interview with that snarky newspaper? I couldn't possibly, I thought with rising panic, go out in public, go on TV. So I went on the drug Celexa, at that time one of the newer antidepressants-a close relative of Prozac.
Taking such drugs was something I'd contemplated, and resisted, for years. I knew people who had been dramatically helped by them. Two friends, on Prozac and Effexor, respectively, had come out of debilitating depressions after 9/11; and another friend, though never clinically depressed, dramatically improved her quality of life with Zoloft. (She had gone on the drug in her forties after watching Prozac transform her seventyish mother from a bitter, unhappy widow into a lively, cheerful grandmother and newfound friend.) Still, I thought, these people were actually depressive, while I was merely neurotic: "abnormally sensitive, obsessive, or tense and anxious." I had trouble with the chaos of combining a full-time job and small children (but who didn't?), overanalyzed everything (but wasn't that what made me a writer?), and was often angry at my husband (and what, I was alone in that?). I had a hard time stopping my mind-or my body-from racing. I had chronic insomnia. I was tired and strung out, yes. But I wasn't depressed.
What's more, I'd always been wary of medication-changing my chemistry, my thinking went, might solve one problem but create another-and my petite body tends to overreact to any substance; half of a mild antihistamine leaves me woozy, and the sliver of Xanax I once tried woke me with a terrifying pop! in my brain. Plus, what if a drug changed me into someone fundamentally different? And wasn't I old enough to love myself as I was, for God's sake? So I'd long ago decided: no antidepressants for me.
But that was before I hit the book-tour wall. Around the same time, a friend, similar to me in temperament, started taking Celexa, with excellent results. That same week, I read an article claiming that Celexa was particularly effective for general anxiety. Suddenly, it wasn't about depression anymore, but anxiety-my middle name. I asked my shrink about it-my $85-a-week shrink who, though she had taught me much about myself and helped me feel better, had not made me less anxious or manic, or taught me to sleep or how to cope with the chaos of my life. Shrugging, she referred me to my PCP-a smart, thoughtful internist who asked a question or two and then coughed up the scrip, telling me to start with 10 milligrams and work up to 20. I began the meds the next day.
This is not a terrifying drug story-like that of one friend who, after swallowing five milligrams of Prozac, found herself virtually unable to stand up. Neither is it the story, not unfamiliar, of someone for whom antidepressants have little or no positive effect. ("I've been on Celexa, Effexor, Prozac, and Lexapro," a working mother who happens to be married to a psychiatrist told me last week. "The Prozac was to help me get off the Effexor. Oh, yeah, and the sleeping pills. Halcion, Trazodone, Sonata, Lunesta, Ativan, Klonopin, and Ambien.")
In fact, you might even call this a beautiful drug story-a pharmaceutical company's dream-at least in the early years. Initially, I felt nothing on Celexa except for a mild stomachache. But then-a week or two into the drug-my world turned upside down. Or rather, it turned right side up again. The white noise in my head vanished-poof !-and a feeling of calm came over me the likes of which I hadn't felt since childhood summer vacations, if ever. My anger at my husband, my annoyance about the mess of our house, my stress about public appearances... all quietly abated. Not vanished, mind you-just sunk to a manageable level. For the first time in a decade, I began to sleep deeply through the night.
This was no mere placebo effect. I was still myself-with the same concerns, the same basic sensibility-except that I felt much, much better. I felt great. Before Celexa, I had a sign in my office that cautioned me, "Don't care so much." My obsessiveness, my intensity tripped me up at times, made it hard to accomplish things and move on, to be forgiving of myself or of others-to ever relax. Celexa fixed that. It wasn't that I didn't care, I just didn't care so much.
I went on my media tour, and then I came home and quit my shrink. All the problems I'd been trying to figure out seemed suddenly solved, or at least much less urgent. In fact, many of them now appeared to come down to an "imbalance" of a single neurochemical in my brain, which was righted by Celexa, a selective serotonin reuptake inhibitor, or SSRI. (Low levels of serotonin, the theory goes, affect our moods in negative ways. By interrupting a step in the recycling of the brain's neurochemicals-the reuptake part-SSRIs increase the levels of serotonin in the synaptic gaps between brain cells, making us feel better.)
When the dust settled from my tour, I got to work on a novel I'd been thinking about for some time, one about passion and ecstasy and lust. After a bad experience earlier with a novel, I hadn't written fiction in years. But now I felt I could take the risk. I gave myself eight months to see if I could write the book and sell it. I did. Perhaps I would have done that without the Celexa. Perhaps it even would have been the same book. But I have to say, given what I know now: I wouldn't bet on it.
Before I continue my personal drug tale, I should tell you about a pile of rather riveting and, admittedly, not unterrifying recent books about SSRIs-books that are part of a growing backlash against the use of antidepressants, as well as other widely prescribed drugs, and the companies that produce them. To name a few: Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines andHooked the Nation on Prescription Drugs, by Melody Petersen, who covered the pharmaceutical beat for The New York Times for four years; Comfortably Numb: How Psychiatry Is Medicating a Nation, by Charles Barber, who worked in New York City shelters for the homeless and the mentally ill and now lectures in psychiatry at the Yale University School of Medicine; and Medication Madness, by Peter R. Breggin, MD, a Harvard-trained psychiatrist and former staff member of the National Institute of Mental Health.
According to these and other books, more than 200 million prescriptions for antidepressants were written in the U.S. in 2006-more than for any other kind of drug, far more than in any other country, and, as in the years leading up to it, more than the previous year. We Americans, the authors assert, are medicated these days-for all things, but particularly for psychiatric and psychological ailments-to an alarming degree ("grossly overprescribed" as one book puts it). Though unquestionably for many people who suffer from clinical depression and other severe disorders this pharmacological panacea is a lifesaver, increasingly, they argue, too many of us depend on pills just to get us through our daily lives, a trend that these authors feel is at bestpathetic and at worst dangerous.
Probably because my dose of Celexa was so low, I had few, if any, side effects. I lost neither sex drive nor sexual sensation, two common complaints of SSRI users. Rather than acquiring insomnia, another potential drawback, I seemed to be cured of it. Granted, I couldn't touch alcohol without getting a headache-but I'd never been a big drinker and didn't really care. My memory did seem to be shot, but, pushing 40, who knew how much of that was just age? I did sometimes feel almost-not uncommonly, it turns out as if I were floating just above reality, watching myself live, saying, "Huh!" and "Interesting!" but not exactly living, myself. I didn't feel "emotionally flatlined," as some people describe the state (again, probably thanks to the low dose), and in fact I often did feel deeply happy, but somehow at a bit of a remove. This was not in itself a desirable thing, but it's what led to my being able to live less intensely- and that was desirable, at that time. Life was already intense in those days. I didn't need my own natural mania on top of it.
Whatever I lost was well worth it, in any case, for what I gained. At home, I yelled at my kids less and wasn't as hypervigilant about food and messes. Never a big crier, I now almost never felt melancholic or even particularly sad. The world was a wreck, of course-terrorism and global warming, war and famine and death-but what good was dwelling on all that when there was work to be done, kids to be raised, life to be lived? Don't get me wrong, I wasn't a zombie. I still swore, still recycled. I just didn't take it all so damn seriously.
Outside of everyday life, my fears and inhibitions seemed to have shrunk and backed off. On a vacation, I climbed a high rope ladder, grabbed a trapeze, jumped off a platform, and swung in an enormous arc through the air, to my own disbelief. I skied down mountains-something I had done before only with trepidation, mostly trying to slow down or stop. Now I flew down hills, loving it; on Celexa, panic vanished. How can you blame someone for wanting this? According to Our Daily Meds, almost 65 percent of Americans, many of them children, take some kind of prescription drug. On average, we each filled more than 12 prescriptions in 2006 (up from eight in 1994) and, says Barber in Comfortably Numb, people in this country-comprising about 6 percent of the world's population-buy about two thirds of all psychiatric and neurological drugs, including antidepressants.
The authors of these books have theories about how this happy, pill-popping orgy came to be, and strong opinions about why it's not such a great thing. The pharmaceutical industry-once known for creating vaccines and cures for our worst diseases-has morphed in the past 25 years, they contend, into a greedy beast more interested in turning a profit than in curing our illnesses, and so they've gone about manipulating us in ways that serve their ends at our expense, both literally and figuratively.
In fact, from 1995 to 2002, Big Pharma was the nation's most profitable industry. First, by coining terms for new disorders that their drugs can (sometimes) relieve, it has convinced us that we're sick when often we're simply experiencing natural emotions or life situations. Where once people were merely considered shy or high-strung, now they might be diagnosed with "social anxiety disorder" or "generalized anxiety disorder"-maladies that can (and should, it's implied) be medicated away with an expensive prescription or three. Where once PMS was just "that time of the month," now it's a syndrome-not, mind you, the same as the even newer PMDD (premenstrual dysphoric disorder). But fear not: There are drugs for both.
Then, in its aggressive marketing of ever newer pharmaceutical cures for these Disorders and syndromes (Prozac, Xanax, Effexor, Wellbutrin, Zoloft, Luvox, Lexapro, Adderall, Paxil, Serzone, Ritalin, and of course, Celexa, to name just a few), the industry-helped by the fact that the Food and Drug Administration, which is supposed to do the monitoring, is often funded by the very companies whose products they're assessing-has failed to warn us sufficiently of these drugs' often serious, even devastating side effects. Breggin, who wrote Toxic Psychiatry and Talking Back toProzac, takes the industry to task in his new book, Medical Madness, warning specifically about the risks of SSRIs and similar drugs. "Misled by the FDA and the drug companies," he writes, "most physicians who prescribe psychiatric drugs vastly underestimate the frequency and severity of medication-induced suicide as well as other potentially life-destroying adverse effects such as violence, mania, and psychosis caused especially by antidepressants, stimulants, and tranquilizers." Barber notes that only a third of doctors reportedly discuss adverse side effects with patients, an alarming oversight given the Journal of the American Medical Association's warning that "the risk of suicidal behavior is increased in the first month after starting antidepressants."
Once Big Pharma successfully and lucratively got the country dependent on these meds, the industry-again in cahoots with the FDA and also with Congress (drug companies spent more on lobbying between 1998 and 2004 than any other industry, Melody Petersen writes)- worked, and still does, to keep these drugs outrageously expensive by repackaging them every few years, just as their patents are due to expire (in other words, as they become generic and affordable), and pushing them as "new and improved." All this, the authors say, is accomplished by pouring vast sums of money into marketing the drugs, the majority spent on doctors-gifts, cash-to tout and prescribe them.
Of course, in my case, I was the one who asked my doc for Celexa. She didn't caution me about side effects or withdrawal, but I don't fault her for that; she no doubt figured (rightly) I'd done my research before making this request. But more importantly, no one-including the makers of these drugs- was talking much back then about withdrawal, as Barber points out. Talk was more about all the new drugs and which was best for which disorder. At any rate, my doctor prescribed it and I took it, and months later there I was-a happy camper popping my little peach pill once a day and not getting too horribly worked up about anything.
In fact, I felt incredibly lucky to have discovered this panacea, and I soon became a huge proponent of Celexa, telling people how much calmer I was, how deeply I now slept. I lamented that my own grandmother, burdened with the same obsessiveness as I, hadn't had this miracle drug in her lifetime; surely she could have avoided becoming Estranged from half her family and driving the other half bonkers before dying at 93. For a long time I tried to persuade a good friend to go on it-she was depressive, was paranoid, had outright panic attacks, and at one point got so low that she couldn't get out of bed. But she instead trained for and ran a marathon, which not only got her in great shape but also lifted her depression temporarily. (Yes, running 17 miles a day will do that for you.) When she plummeted again afterward, one doctor diagnosed bipolar disorder and prescribed lithium, whose reported side effects include hallucinations and seizures. Not prepared to risk such reactions, she shelved the scrip and instead began to experiment with her diet, soon discovering a wheat sensitivity that, once she stopped eating gluten, proved responsible not only for much of her depression(granted, the bipolar diagnosis was never confirmed by another MD) but also for long-time physical complaints ranging from mental fogginess to severe bloating.
So I wasn't surprised when I read in the compelling new book Unstuck: Your Guideto the Seven-Stage Journey Out of Depression, by another Harvard-trained psychiatrist, named James S. Gordon, MD, that "food sensitivity [is] far more pervasive and far more often a cause of, or contributor to, depression" than most of us realize. Of course, Western medicine still tends to be skeptical of such notions-"I'm not against trying out dietary management, but I recommend getting into proper treatment and doing it in concert with your physician" is the most optimistic thing that Joseph Coyle, a former chair of psychiatry and current professor of neuroscience and psychiatry at Harvard Medical School, could offer me. But, call me AlternaGirl, I buy these connections. And, in all, I'm led to wonder how many of the more than 16 percent of people (most of them women) in this country on SSRIs, according to Barber-and the many more desperately starting and stopping them-might be better helped by treatments that actually address their problems rather than just alleviating the symptoms.
Five years after I started Celexa, my novel was published and I was trying to figure out what to do next. I looked okay, though I wasn't in the shape I'd been in before. I had quit the gym long ago-thinking I didn't need something so expensive, so intense, now that I'd gone from a type A to a type A-minus-and I sat for hours alone at my computer, fueled by sugar two, three, or four times a day, which would give me a nice rush before I crashed and dozed off, an hour or two later at the screen.
I didn't mind. I was calm, after all, and I felt neither lonely nor sad, not melancholy nor bored nor depressed. But I did feel decidedly middle-aged, with puffy cheeks, spreading hips, and a fading memory. I often woke up feeling dazed rather than rested, even after a full night's sleep. Ah, well, I thought, That's still preferable to the nightmare of insomnia and constant anxiety. I took my Celexa and didn't complain.
Occasionally I did worry about the longterm effects of the drug-SSRIs are still new in the grand scheme of things-but I told myself that if I could have 10 years of feeling this good, that was worth whatever it might bring down the road. "And of course," writes Barber in Comfortably Numb, "nobody really knows the long-term side effect of SSRIs... It is simply uncharted territory." In Unstuck, Gordon is less reassuring. "Long-term use of the SSRIs is revealing even more alarming side effects [than short-term use]," he writes. "One well-documented study... shows deterioration of brain function in the frontal lobe of the cerebral cortex. Research has also shown that over time SSRIs increase... one vital neurotransmitter, serotonin, at the expense of depleting another, dopamine. This decidedly ?unselective' effect may well account for the reports of people on SSRIs who have developed disorders of movement that resemble... Parkinson's disease." What I didn't know back then didn't seem to be hurting me.
Once a year, when I refilled my prescription (which had finally gone generic, and though everyone said that Lexapro was the new, improved Celexa, I saw no reason to switch), my doctor requested that I come in for an exam. And one day, about 15 months ago, she assessed my vitals and my psyche- all good-and then said, thoughtfully, "Maybe you should try getting off Celexa. Maybe you don't need it anymore."
I sat up, surprised. This drug had changed my life in such positive ways, I'd never thought about going off it. But now the idea was intriguing. The kids weren't babies anymore, and we were in better financial shape. What would I be like now not on Celexa? If I were going to find out, this might be the time. "Okay," I said, accepting the doc's advice to taper from 10 milligrams to 5 before stopping completely. As I drove home, I began to get excited. Would my energy level rise, my memory return? On hearing the plan, my husband, Dan-no doubt remembering the pre-Celexa me- allowed a look of panic to cross his face before realizing he was supposed to be supportive. "Great idea!" he managed to lie.
If I'd been nervous about going on the drug, I was cavalier (perhaps, yes, because I was drugged to be less nervous) about going off. So about a week after halving my dose when I woke up light-headed, achy, and dead tired-symptoms that didn't lift all day, or the next-I just assumed I was sick. But after a few more days, it became obvious I wasn't sick; I just felt that way. I staggered around, napping often, sinking heavily into my bed. Awake, I was volatile and bitchy. I yelled at Dan and the kids. Once, I slapped my daughter, shocking us both into silence, then tears. Despite feeling exhausted, I began to sleep lightly and wake up more during the night.
I consulted the University of Google and found that withdrawal from an SSRI-now sporting the official title of SSRI Withdrawal Syndrome, or SSRI Discontinuation Syndrome-can cause "severe flu-like symptoms," from headache, diarrhea, nausea, vomiting, chills, and dizziness to agitation, irritability, suicidal thoughts, impaired concentration... you name it.
In fact, it's often hard to separate at least some of the withdrawal symptoms from the return of the aspects of one's personality that were medicated in the first place. "Getting off the drugs is a more formidable, and more problematic, task than was first believed," Barber writes in Numb. "SSRIs were initially marketed as being dependence- and withdrawal-free; indeed, those qualities were a dramatic part of their initial appeal. There has since been a creeping awareness that this was wrong." My thoughts alternated between being glad that I'd never gone up to 20 milligrams, let alone 40 or 80, and contemplating going back up to 10 so I didn't have to deal with all this. I just wanted to feel the way I'd felt a month before. But I also hated the idea of staying on a drug at least in part because it was so hard to get off. Plus, I was curious: How many of these symptoms were withdrawal, and how much was just me? And if it was me, were there other ways I could find relief besides going back on the meds?
I started to get some answers roughly six weeks later, when the dizziness and mood swings finally lifted and I could see what remained- though ultimately it took me eight or nine more months to become entirely drug-free (I tapered off very slowly) and a year before I felt completely myself again. Which is to say: My head was fuller and cloudier once more, as in my pre- Celexa days, with a constant ticker tape of thoughts running through it-from to-do lists to an analysis of the world and everyone in it.
My need for quiet and solitude increased, even as it occasionally made me sad in a way that it never had on Celexa and possibly never had before. (Was this something induced by years of medication, or just middle age?) I had less tolerance for chaos, slept much less soundly (but got up more easily in the morning), and often awoke feeling panicky. I found it harder to relax (but could drink wine again). Even my driving got more aggressive-less patience for slow drivers-and I'm not proud to say I was stopped twice in two months for speeding.
I knew now that I could medicate all this away. And believe me, it was tempting. But here's the catch: Good things were happening, too-many as a direct result of the bad ones. In an effort to improve my sleep, I changed my diet, reducing the sugar and chocolate, upping the fruits and veggies, cutting some red meat, and adding more soy and organics. I'm no vegan, and I didn't want to be one of those girls who could eat only, like, rainbow chard and tempeh-so I had to sigh when it worked. I immediately started sleeping better. (Who knew you couldn't eat dark chocolate chips all day long and still conk out all night?) I also made exercise a priority again and decided to try some yoga for relaxation.
I had always thought that yoga and I went together about as well as Paris Hilton and the subway. Chanting makes my eyes roll, and tinkly music makes me want to smack a small furry animal. But now, devoid of my long-time Pharma calm, I needed something. So I forced myself through a bunch of different yoga classes. Then I found The One, and suddenly I "got" it. Not only was it an actual workout, but the teacher provided an entire life philosophy that seemed to speak directly to my situation: about how conflict and stress are natural and normal, about viewing difficulty as something positive ("The thing that's the hardest for you is the thing you have the most to learn from," he'd say, while I twisted into something resembling a worm on a fish hook, and I'd be all, Yes! Yes!), about working and breathing your way through life's blocks, and relishing it as you do. On the way home from class, I stopped at the library and borrowed half of the yoga section. (Gordon would have been pleased, as yoga is one of the ways he mentions in Unstuck to improve mood and lower stress without meds.)
I started cooking more conscientiously for all of us, driving better (I learned to use cruise control), and putting myself back to sleep at night by calming my mind with yoga breathing. I resumed therapy, with an excellent shrink who convinced me-just like my yoga instructor-that it was noble and necessary to take care of myself. Before Celexa, with the marathon of my life then, taking care of myself hadn't really been an option; this lack of care fueled the anxiety and stress that made me "need" Celexa in the first place.
But now I was out of Pharma Nirvana, and if it sucked in some ways it was definitely not hurting me, at least not physically. In time, I looked better- more toned, less puffy-and I could again button my pants, a nice and unexpected perk. (I credited this to my new regimen and the return of my former intensity until I read in Unstuck that large numbers of people taking Prozac have "significant, unwanted weight gain.")
There were other perks to being drugfree. I was getting used to no longer hovering above myself watching myself live, but instead was actually living. Living and yelling and stressing, yes, and often anxious and angry and sad-but with the sadness came an awareness that I had not really experienced on the drug. I had a 13-year-old daughter who for the first time was moving away from me and into the world, and a nine-year-old son who was no longer my baby. Time was passing. My kids will be gone soon, I'd think, and tears would run down my face. How can I make the most of the time we have left? This is not an unimportant question to ask. The cat disappeared, and I cried and cried. (The kids watched me, astonished.) But you're supposed to cry when you lose your 16-year-old pet. It felt right. I was vulnerable-not my usual state-and my husband was sympathetic and supportive, which made me appreciate him in a way I rarely take time to. If going on Celexa saved my marriage, going off made it stronger.
Sometimes I think there are two kinds of people: the ones who are generally happy and upbeat- and then the rest of us, the ones who, when asked how we're doing, say "eh" and wiggle our flattened hand in front of our face, hoping to be asked to elaborate. Most of my life I've been the latter breed, and that's also whom I've been drawn to: interesting, tormented thinkers and analyzers. I had compassion for people with psychic pain, due to my own. On Celexa, though, I think I turned a little bit into the former type-which was a joy, to tell you the truth-but in doing so I lost some tolerance for the latter; I developed a smugness that wasn't me and didn't become me. (If you're so tortured, I'd think, stop whining and medicate!) And that I find sobering, especially given the number of Americans now on these meds. Compassion is not something we want to lose on a large scale.
Happiness and calm can breed complacency, of course-just as dissatisfaction and anxiety can foster its opposite. On Celexa, I felt good and didn't want anything to change, to potentially alter my high. But looking back on my life, I see that almost all of my major shifts and moves came from dissatisfaction-from feeling unsettled or hungry where I was. On an SSRI, I might not have quit my just-fine New York job to move to Arizona and get an MFA, I might not have married my husband (whom I met in Arizona); I might not have written some of my books or given birth to my kids. I might have stopped at any point and thought, Shoot, this is fine, why mess with it? But many of today's twentysomethings have never experienced adult or even teenage life unmedicated. We have to acknowledge the possibility that these drugs could be changing the future citizens of this country and perhaps the country itself in conceivably less than optimal and possibly irreversible ways. "We cannot mature," Kierkegaard wrote, "and be fully creative by burying or displacing anxiety, but only by moving through it."
I would never suggest-nor do the authors of the backlash books-that people with true clinical depression who can actually be helped by SSRIs or other drugs not take advantage of them. But when more than one sixth of our population is on expensive psychiatric medications (by contrast, according to Coyle, the prevalence of major depressive disorders in this country is around 5 percent); when these drugs are ubiquitously marketed, deceptively advertised, insufficiently monitored by the FDA, and prescribed by doctors who are often working with the drug companies and who frequently fail to suggest alternatives, mention serious side effects and withdrawal symptoms, or monitor patients; when these drugs may be changing the way we personally and collectively look at and function in the world... you have to stop and say, Wait a second-something isn't right here.
In A Brief History of Anxiety: Yours and Mine, Patricia Pearson suggests that our anxiety is growing because "we need, on a collective cultural and spiritual level, to grow." ("The insights of existential philosophy [are] scarcely present in the conversation anymore," she writes. "Anxiety is treatable with pills, and is no longer respected as a meaningful signifier of a culture caught and flailing in arrested development.") I would add that having grown up in the relatively safe and prosperous America of the '70s, '80s, and '90s-well fed, well educated, fashionably dressed-the classes from the middle on up simply might have a warped view of how much happiness we're entitled to and how little anxiety we can get away with. "The happiness and unhappiness of the rational social animal depends not on what he feels, but on what he does," observed Marcus Aurelius.
All that said-new books and old philosophers and my own SSRI Withdrawal Syndrome aside-if my grandmother were around today I'd still find her a prescription for Prozac faster than I'd refill her Metamucil bin, because in her situation the benefits of an antidepressant would likely outweigh the potential downsides. What's more, I don't regret my own years taking Celexa- intense years that were less about growing and changing than about just getting through them. Nor will I promise never to take Celexa again. Truthfully? I'm glad the stuff is out there.
I'm also glad to be off it, especially knowing what I do now. Stopping the drug has allowed me to feel things I surely wouldn't have felt on it: to see situations and people differently and make changes accordingly. And, yes, sometimes now, as before Celexa, I talk too fast, sleep too little, and care too much-especially during weeks when I don't have time to take care of myself. But that's okay, at least for the moment. It's only life, after all, with all its stresses and emotions, its agonies and ecstasies. Life-perhaps-as it was meant to be lived.