Research report

Music therapy as an adjunct to standard treatment for obsessivecompulsive disorder and co-morbid anxiety and depression: A randomizedclinical trial

Shahrzad Shirani Bidabadi a,n, Amirhooshang Mehryar b

a Department of Psychology, Faculty of Psychology and Education, Islamic Azad University, Marvdasht Branch, Marvdasht, Iranb Department of Behavioural Science, Institute for Research on Management and Planning, Tehran, Iran

a r t i c l e i n f o

Article history:Received 13 December 2014Received in revised form2 April 2015Accepted 2 April 2015Available online 11 April 2015

Keywords:Obsessive compulsive disorderMusic therapy/methodsCombined modality therapyAnxiety disorders/therapyTreatment outcomeRandomized clinical trial

a b s t r a c t

Background: Previous studies have highlighted the potential therapeutic benefits of music therapy as anadjunct to standard care, in a variety of psychiatric ailments including mood and anxiety disorders.However, the role of music in the treatment of obsessive–compulsive disorder (OCD) have not beeninvestigated to date.Methods: In a single-center, parallel-group, randomized clinical trial (NCT02314195) 30 patients withOCD were randomly assigned to standard treatment (pharmacotherapy and cognitive-behavior therapy)plus 12 sessions of individual music therapy (n¼15) or standard treatment only (n¼15) for one month.Maudsley Obsessive–Compulsive Inventory, Beck Anxiety Inventory, and Beck Depression Inventory-Short Form were administered baseline and after one month.Results: Thirty patients completed the study. Music therapy resulted in a greater decrease in totalobsessive score (post-intervention score: music therapyþstandard treatment: 12.471.9 vs standardtreatment only: 15.171.7, po0.001, effect size¼56.7%). For subtypes, significant between-groupdifferences were identified for checking (p¼0.004), and slowness (p¼0.019), but not for washing orresponsibility. Music therapy was significantly more effective in reducing anxiety (post-interventionscore: music therapyþstandard treatment: 16.977.4 vs standard treatment only: 22.974.6, po0.001,effect size¼47.0%), and depressive symptoms (post-intervention score: music therapyþstandard treat-ment: 10.873.8 vs standard treatment: 17.173.7, po0.001, effect size¼47.0%).Limitations: Inclusion of a small sample size, lack of blinding due to the nature of the intervention, shortduration of follow-up.Conclusion: In patients with OCD, music therapy, as an adjunct to standard care, seems to be effective inreducing obsessions, as well as co-morbid anxiety and depressive symptoms.

& 2015 Published by Elsevier B.V.

1. Introduction

Often overlooked and under diagnosed, obsessive–compulsivedisorder (OCD) is a common psychiatric ailment and is estimated toaffect 1–3% of the population at some point in their lives (Grant, 2014).In a nation-wide survey of Iranian adults aged 18 and above, a point-prevalence of 1.8% for OCD was documented (Mohammadi et al.,2004). Obsessions are characterized by the presence of worrisomeimages, ideas, or impulses that are intrusive and unwanted, and are

usually accompanied by compulsions: repetitive actions, mentalimages, or ritualistic behaviors that the patient feels compelled to doin order to relieve anxiety caused by obsessive thoughts (AmericanPsychiatric Association, 2000).

Pharmacotherapy with selective-serotonin reuptake inhibitors(SSRI), or the tricyclic antidepressant clomipramine combined withpsychotherapy (e.g. exposure-response prevention, cognitive beha-vioral therapy) are the mainstay of treatment in the managementof OCD (American Psychiatric Association, 2006; Fineberg and Gale,2005). For OCD treatment, compared with anxiety and depression,SSRIs need to be prescribed at higher doses and usually take longer totake effect (American Psychiatric Association, 2006). Consequently, thepatient may experience more troubling dose-related side effects, nega-tively impacting medication's tolerability (Bloch et al., 2010; Jenike,2004). Additionally, a prolonged course of treatment is required inorder to achieve full resolution of symptoms and to forestall relapse

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Journal of Affective Disorders

http://dx.doi.org/10.1016/j.jad.2015.04.0110165-0327/& 2015 Published by Elsevier B.V.

n Correspondence to: Department of Psychology, Faculty of Psychology andEducation, Islamic Azad University, Marvdasht branch, Bahman-Beigi Street,Ashoora Square, Marvdasht, Fars Province, Iran. Tel.: þ98 71 43234805;fax: þ98 71 43234756.

E-mail addresses: shahrzadshirani@miau.ac.ir (S. Shirani Bidabadi),AmirMehryar36@gmail.com (A. Mehryar).

Journal of Affective Disorders 184 (2015) 13–17

(Ravizza et al., 1996). Even with cooperative patients where medica-tion adherence is not a major obstacle, in at least one third of thepatients, treatment response remains insufficient. In the naturalisticfollow-up study of Brown Longitudinal Obsessive Compulsive Study(BLOCS), 38% of patients receiving SSRIs at recommended dosesappraised their symptoms as minimally improved, unchanged, oreven worse (Mancebo et al., 2006). Use of psychotherapeutic techni-ques alongside pharmacotherapy augments treatment efficacy (Grant,2014). However, in many clinical settings, psychotherapy is only offe-red to a fraction of patients and its use remains relatively low. TheBLOCS study demonstrated that less than one-fourth of OCD patientsparticipate in the recommended number of cognitive-behavioraltherapy sessions (Mancebo et al., 2006).

Given the shortcomings of medications and psychotherapy in themanagement of OCD, complementary and alternative medicine (CAM)methods have the capacity to be used as an adjunct to standard careand help improve patient outcomes (Sarris et al., 2012). Music therapy,a form of CAM, is a non-invasive, safe, well-tolerated, inexpensive, andreadily available technique which has been shown to provide ther-apeutic benefits in a wide range of psychiatric disorders including butnot limited to depression, anxiety, schizophrenia, autism, and dementia(Lin et al., 2011). Bruscia (1998) defines music therapy as “a systematicprocess of intervention wherein the therapist helps the client topromote health, using music experiences and the relationships thatdevelop through them as dynamic forces of change” (Bruscia, 1998).Aside from its role in inducing relaxation, music in the context ofpsychiatric disorders could be viewed as a medium for non-verbalcommunication between the patient and the therapist, and could beincorporated to help patient express feelings that are not articulatedotherwise (Mössler et al., 2011).

A number of studies to date have delved into the possible the-rapeutic implications of music therapy in relieving anxiety, anxiety-related disorders, and depression (Elliott et al., 2011; Erkkila et al.,2011; Goldbeck and Ellerkamp, 2012). Despite a strong theoreticalframework, and expanded knowledge regarding the mechanistic ofmusic on neuropsychology, clinical evidence corroborating therapeu-tic implications of music therapy in the treatment of OCD is onlysparsely available. The present randomized clinical trial was thusdesigned and conducted to investigate the efficacy of music therapyas an adjunct to standard treatment, on OCD. Moreover, given thefact that a significant proportion of patients with OCD have othercomorbid mood or anxiety disorders, the question of whethertherapeutic benefits of music could be expanded to also affectconcurrent depressive and anxiety symptoms was explored.

2. Methods

2.1. Patients

Between April and June 2014, consecutive patients visited inthe outpatient psychiatry clinic of a not-for-profit hospital (Shariati

Hospital, Isfahan, Iran) were assessed for eligibility. Patients werefound eligible if: (1) were at least 18 years or older; (2) had axis Idiagnosis of OCD according to the criteria delineated by the diagnosticand statistical manual of mental disorders – fourth edition (AmericanPsychiatric Association, 2000) diagnosed by an experienced psychia-trist; (3) had not received treatment previously for the disorder; and(4) agreed to partake in the study. Initially, 96 patients were assessedfor eligibility among whom 30 met the inclusion criteria and wererandomized to treatment arms. Written informed consent wasobtained from all participants prior to enrollment. All proceduresdealing with human subjects were conducted in accordance with theguidelines laid in the latest revision of Helsinki declaration. Theprotocol of the study was approved by the ethics committee of theFaculty of Psychology, Islamic Azad University, Marvdasht Branch.

2.2. Trial design and interventions

This single-center, parallel-group, randomized clinical trial wasdesigned and conducted to investigate the effects of music therapyas an adjunct treatment to pharmacotherapy and cognitive beha-vioral therapy in patients with OCD. The trial protocol is registeredwith the clinicaltrials.gov (Identifier no.: NCT02314195).

Using a simple randomization module in Microsofts Excels,eligible patients were randomly assigned to ‘music therapyþstandardtreatment’, or ‘standard treatment only’ arms of the trial. Patients inthe standard treatment only arm received a medication of SSRI family,and also received cognitive behavioral therapy by a psychologist.Patients in the music therapy arm received standard treatment as des-cribed plus sessions of receptive music therapy scheduled three days aweek, over four weeks. Baseline assessment of the patients wasconducted before randomization to prevent allocation bias. However,given the nature of the intervention, no blinding for either the assessoror the patients was done. Over a span of four weeks, each individualtook part in 12 sessions of individual music therapy conducted by anexperienced psychiatrist. In Iran, the concept of music therapy isrelatively new, and at present no official training, registration, andoversight for music therapists exist in the country. The receptive musictherapy scheme used herein was therefore developed by the principalinvestigator working in collaboration with an experienced musician,specialized in composition and production of Iranian classical music.The intervention was carried out in the form of receptive musictherapy (listening to selected tracks of Iranian classical music com-posed by well-knownmusicians) followed by discussions. The protocoland arrangement of music therapy sessions are delineated in Table 1.

2.3. Assessment and outcome measures

The primary outcome measure was change in the obsessionalsymptoms. Corollary measures included change in co-morbidanxiety and depressive symptoms. At baseline and before rando-mization, patients were surveyed using the following battery of

Table 1Protocol of the music therapy sessions for patients with obsessive–compulsive disorder.

First 10 min Musicpresented

Activity

30 min First10 min

Piano soloa The patient is asked to recall obsessional thoughts he or she tries to generally avoid that cause great anxiety for him/her. At thisstage, the patient is asked to reflect on these thoughts, images, or impulses and freely express the feelings that they provoke.

Second10 min

Balladb The patient is asked to focus on the music lyrics, reflect on them, and to express, in a few words, how the lyrics of the song relate tohis or her feelings/experiences.

Third10 min

Santur soloc The patient is asked to close his or her eyes, relax, and focus on pleasant thoughts, images, and how to achieve them.

Epilogue The patient is asked to discuss his or her feelings during the session. The three tracks played is given to the patient. As a homeworkassignment, the patient is asked to listen to the tracks following the same protocol and write down his or her feelings.

a by Morteza Mahjubi or Javad Marufi.b by Mohamadreza Shajarian or Gholamhosein Banan.c by Faramarz Payvar; Santur is a Persian string instrument.

S. Shirani Bidabadi, A. Mehryar / Journal of Affective Disorders 184 (2015) 13–1714

self-administered tests: (1) Maudsley Obsessive–CompulsiveInventory (MOCI); (2) Beck Anxiety Inventory (BAI); and (3) BeckDepression Inventory – Short Form (BDI–SF). In a follow-up visitscheduled at the completion of music therapy, the same battery oftests were completed by the patients. A brief description of thetests and their psychometric properties are presented below.

2.3.1. Maudsley obsessive–compulsive inventory (MOCI)Developed by Hodgson and Rachman (1977), MOCI is a 30-

item, binary (true/false), self-administered questionnaire devisedto evaluate the extent of obsessive–compulsive complaints andto distinguish patients from nonclinical samples. The inventoryreports scores on four obsessive–compulsive subtypes that includechecking (9 items), washing (11 items), slowness (7 items), anddoubting (7 items). The scores on individual subtypes can then besummed up to provide a final score ranging from zero (no sym-ptoms) to 30 (maximum presence of symptoms). Of note, sincefour items in the inventory are repeated in two subtypes, they areonly counted once to create the total obsessionality score. MOCIhas been widely used in research and clinical settings and hasbeen shown to be particularly sensitive to therapeutic changes,making it a practical tool for tracking treatment response inpatient populations (Meca et al., 2011). In the present study, thetranslated version of the inventory was used (Ghassemzadeh et al.,2002).

2.3.2. Beck anxiety inventory (BAI)Developed by Beck and Steer (1990), BAI is a 21-item self-

administered questionnaire to assess anxiety and to delineatepatients from nonclinical samples. Each item is answered on a

four-point Likert-type scale ranging from ‘not at all’ (0 point), to‘mildly’ (1 point), ‘moderately’ (2 points), and to severely (3points). The individual items are them summed to calculate afinal score of 0–63 (Beck and Steer, 1990). In the current study,the translated version of the inventory was used (Kaviani andMousavi, 2008).

2.3.3. Beck depression inventory – short form (BDI–SF)Originally developed by Beck et al. (1961), BDI is a 21-item self-

administered questionnaire devised to measure depression incognitive-affective and somatic-performance domains. In theBDI–SF, only the first 13 items of cognitive-affective domain areretained (Beck and Steer, 1987). A score of 0–3 is assigned to eachitem and a final score ranging from 0 to 39 is then calculated (Beckand Steer, 1987). In the current study, the translated version of theinventory was used (Hojat et al., 1986).

2.4. Statistical analysis

All statistical tests were done using the Statistical Package for theSocial Sciences (SPSSs) version 17.0 (SPSS Inc., Chicago, IL). Con-tinuous variables are presented as mean7standard deviation.Baseline scores between the two groups were compared usingindependent t-test. One-way analysis of covariance (ANCOVA)models were conducted to compare the effectiveness of two inter-ventions designed to reduce obsessive–compulsive complaintsscore in patients with OCD. Reducing anxiety and depressive sym-ptoms were also considered as corollary outcomes. The type ofintervention (music therapyþstandard treatment or standard treat-ment only) entered the model as independent variable. The depe-ndent variables consisted of follow-up or post-intervention scoreson outcome variables. Baseline or pre-intervention scores were alsoincluded in the model as covariates, thereby adjusting for thepossible baseline between-group differences. Before conductingeach analysis, preliminary checks of ANCOVA assumptions includ-ing normality, linearity, homoscedasticity, and homogeneity of reg-ression slopes were performed and the final model was deemedacceptable if no violation of assumptions was identified. In eachANCOVA model, the effect size was calculated from the partial etasquared and is presented as percentages. Partial eta squared repr-esents the amount of variance of the dependent variable (outcome)explained by the independent variable (intervention). Based onCohen's recommendations, a partial eta squared of 13.8% or greaterindicates a large effect size. In all tests, po0.05 was consid-eed necessary to reject the null hypothesis of no between-groupdifference.

3. Results

Thirty adult patients with the diagnosis of OCD were randomlyassigned to trial arms. All enrolled participants in both armscompleted the trial course and no patient was lost to follow up.Age of the enrolled patients ranged from 18 to 50 years and wascomparable between the two groups. Also, the female-to-maleratio in both groups were identical and males comprised 25% ofthe studied sample (n¼6).

Baseline scores for the MOCI, Beck anxiety, and Beck depressioninventories for trial arms are presented in Table 2. The overallobsessional score, as well as scores for its four constituentsubtypes were comparable across the two groups (p40.05 in alltests). Additionally, baseline scores for BAI were similar betweenthe two groups. On the other hand, patients in the standardtreatment only arm had significantly higher BDI–SF scores com-pared with their counterparts in the standard treatmentþmusictherapy arm (21.2 versus 16.3, p¼0.022).

Table 2Baseline scores for obsessive–compulsive, anxiety, and depression scales of patientswith obsessive–compulsive disorder enrolled in the randomized clinical trial.

Standard treatmentþmusictherapy (n¼15)

Standard treatmentonly (n¼15)

pvalue

ObsessionsChecking 5.971.0 6.371.1 0.235Washing 5.672.0 6.071.4 0.541Slowness 4.371.0 3.971.0 0.368Responsibility 5.471.3 5.171.1 0.365Total score 17.672.4 18.171.7 0.489Anxiety 26.779.9 27.273.9 0.866Depression 16.375.6 21.275.4 0.022

Table 3Comparison of the effects of music therapy added to standard treatment versusstandard treatment alone on obsessive–compulsive, anxiety, and depression scoresof patients with obsessive–compulsive disorder.

Follow-up scorea Fstatistic

p value Effectsize

Standardtreatmentþmusictherapy (n¼15)

Standardtreatment only(n¼15)

ObsessionsChecking 3.971.0 5.171.1 10.06 0.004 26.0%Washing 3.572.0 4.571.5 2.73 0.110 8.0%Slowness 2.771.2 3.771.1 6.24 0.019 18.0%Responsibility 4.271.5 4.671.3 0.62 0.430 2.0%Total score 12.471.9 15.171.7 35.36 o0.001 56.7%Anxiety 16.977.4 22.974.6 24.18 o0.001 47.0%Depression 10.873.8 17.173.7 24.02 o0.001 47.0%

a Adjusted Follow-up score for outcome variables calculated controlling for thebetween-group differences at baseline.

S. Shirani Bidabadi, A. Mehryar / Journal of Affective Disorders 184 (2015) 13–17 15

The effects of music therapy versus no music therapy onprimary and corollary outcome variables were compared usingANCOVA models and the findings are outlined in Table 3. Withrespect to the primary outcome, music therapy, as an adjunct tothe standard treatment protocol, resulted in a greater decrease intotal obsessive score than standard treatment alone (po0.001,effect size¼56.7%). For subtypes, significant between-group differ-ences were identified for checking, and slowness, but not forwashing or responsibility (Table 3). Music therapy added as anadjunct therapy was also significantly more effective in relievingself-reported anxiety (po0.001), and also reducing self-reporteddepressive symptoms (po0.001). For both anxiety and depression,music therapy plus standard treatment was approximately 47%more effective than standard treatment alone, indicating a largeeffect size.

4. Discussion

Despite a firm theoretical rationale for its medicinal use (Linet al., 2011; Silverman, 2008), clinical application of music for thetreatment of psychiatric illnesses have only been sparsely ticed inthe literature. In the present randomized clinical trial, we providedpreliminary evidence that receptive music therapy, incorporatedas an adjunct to the standard therapeutic module, could enhancetreatment response in adults diagnosed with OCD.

In our study of patients with the primary axis I diagnosis ofOCD, music therapy yielded significant reductions in concurrentanxiety and depression scores. Compared with standard treat-ment, music therapy was 47% more effective in reducing anxietyand depressive scores. Previous studies have clearly shown thatOCD is often accompanied by other axis I and II disorders. In theBrown Longitudinal Obsessive Compulsive Study (BLOCS), 293adult patients with a primary diagnosis of OCD were followed(Pinto et al., 2006). Indeed, it was shown that OCD is seldom anisolated neuropsychological disorder; 91.8% of patients with OCDwere diagnosed with another axis I disorder sometime in theirlives (Pinto et al., 2006). The most common psychiatric comorbid-ities were mood disorders (lifetime prevalence: 74.1%), followed byanxiety disorders (lifetime prevalence: 52.6%) (Pinto et al., 2006).

The usefulness of music therapy in the treatment of anxiety anddepression have been demonstrated. In a randomized trial of 36children between the ages of 8 and 12 who were diagnosed withseparation anxiety disorder, generalized anxiety disorder, or spe-cific phobias, Goldbeck and Ellerkamp (2012) showed that multi-modal music therapy (including both active and receptive tech-niques) combined with cognitive-behavioral therapy is superior tothe usual treatment offered by the psychiatrist in terms of achi-eving remission; patients receiving active music therapy were twotimes more likely to achieve remission (67% versus 33%). Inanother randomized trial of adult patients, Erkkila et al. (2011)looked into the potential therapeutic benefits of a free improvisa-tion and reflective discussion model of music therapy in depressedpatients. Their work concluded that individual music therapysessions scheduled twice a week for three months results in agreater improvement in depressive symptoms when comparedwith standard care (Erkkila et al., 2011). Of note, co-morbidanxiety was also significantly decreased in the music interventionarm, and improvements in the levels of general functioning werenoted (Erkkila et al., 2011). The observed effect size for depressionand anxiety were 65.0% and 49.0% (Erkkila et al., 2011), respec-tively which are comparable to the rates of 47.0% and 47.0% obser-ved herein. A 2008 meta-analysis of randomized clinical trials alsoprovided support for the role of music therapy in the treatment ofdepression. In four out of five studies included, music therapy

resulted in greater improvements than standard care (Maratoset al., 2008).

In the present randomized clinical trial, the effects of musictherapy on different OCD subtypes was not symmetrical; musictherapy tended to yield a better therapeutic response in checking andslowness, but not washing or responsibility. Several previous reportshave highlighted the fact that OCD is in fact a heterogeneous entitywith distinct subtypes that respond differently to intervention(McKay et al., 2004). McLean et al. (2001) pointed out that there isan identifiable association between treatment response and type ofobsessional symptoms. According to their observations, upon receiv-ing cognitive or behavioral therapy, patients with washing obsessionswere significantly less likely to achieve recovery compared withcheckers, or obsessionals (McLean et al., 2001). On the other hand, ina sample of OCD patients being treated with clomipramine, Başoğluet al. (1988) showed that checking rituals are associated with poorerresponse to pharmacological therapy. It could therefore be hypothe-sized that music therapy might yield differential therapeuticresponses in distinct OCD subtypes, and be more effective foralleviating some symptom groups. It should be noted however thatgiven the relatively small number of included patients in the currenttrial and the short duration of follow up, credible inferences in thisregard are not to be made from our findings and future studiesspecifically designed to delve into the issue are required. Moreover, inthe present study, not all OCD symptom types were investigated. TheMOCI scale was developed using a principal component analysisapproach; the authors decided to retain the first four major com-plaint types which accounted for only 43% of the variance.

In the present study, receptive as opposed to active musictherapy was used as the intervention. Active music therapyinvolves playing various musical instruments by the patientimprovisationally, usually with the oversight of a professionalmusic therapist (Chan et al., 2011). Compared with receptivemusic therapy, active music therapy has the advantage of dili-gently involving the patient in the therapeutic process and therebypotentially yielding outcomes superior to that of listening to musicalone. However, conduct of active music therapy requires certainequipment and settings and also necessitates stewardship oftrained musicians who work in concert with the psychiatrist in-charge. In clinical settings, such as the one that the present studywas carried out in, these prerequisites are often not available.Additionally, in Iran, where the current study was carried out, atpresent, no academic training, official qualification process, andorganizational oversight for allied health professionals who prac-tice music therapy is available. Consequently, receptive musictherapy could be considered as an alternative method is thesesettings, since it can be carried out with the available resources athand. Further, with receptive music therapy, the patient can beinstructed to easily incorporate music listening into his or hereveryday life and continue to receive the therapeutic benefits ofmusic indefinitely, after the scheduled therapy sessions are con-cluded. Future randomized trials focused on comparing variousmusic therapy techniques (for instance receptive versus improvi-sation versus active) with standard care are needed in order toinvestigate the comparative efficacy of different music therapyinterventions as adjunct to standard care for treatment of patientswith OCD.

A number of limitations in the present study deserve mentions.First, in the current study, a relatively small sample of participantswere included, thereby increasing the possibility of type II error.Although statistically significant changes for the main outcomemeasures were noted, mostly owing to the large effect size producedby the intervention, our study might have been underpowered todetect more subtle improvements observed for OCD subtypes.Second, given the nature of music therapy, in the current study, noblinding procedure was applicable. This raises the possibility of the

S. Shirani Bidabadi, A. Mehryar / Journal of Affective Disorders 184 (2015) 13–1716

observed effect for music therapy being confounded by other factorssuch as improved attendance rate of the patient to therapy sessions,enhanced interpersonal communication between the patient and thetherapist, and better adherence to non-music therapy interventions.In the study by Erkkila et al. (2011), depressed patients in the musictherapy arm were less likely to drop out and discontinue carecompared with those receiving standard care only (9.1% versus19.6%), albeit the difference not reaching statistical significance. Thisobservation corroborates the notion that music therapy might bebeneficial in improving patient's adherence to therapy. Therefore,therapeutic benefits of music therapy to some extent can be explai-ned by this boosting effect.

In spite of these limitations, the present randomized trial pro-vides preliminary evidence that receptive music therapy couldserve as an adjunct to standard treatment in patients with OCDand is beneficial in alleviating obsessive–compulsive, as well as,co-morbid anxiety and depressive symptoms. Whether theseshort-term benefits sustain over longer periods remains to beelucidated.

Role of funding sourceThis study was financially supported by the Islamic Azad University, Marvdasht

branch.

Conflict of interestNone to declare.

AcknowledgmentsWe would like to thank Dr. Shahla Akoochekian, MD, head of department of

psychiatry, Isfahan University of Medical Sciences, Isfahan, Iran for providingclinical expertise throughout this project.

Appendix A. Supporting information

Supplementary data associated with this article can be found inthe online version at http://dx.doi.org/10.1016/j.jad.2015.04.011.

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