The Association of Therapeutic Alliance With Long-Term Outcome in a Guided Internet Intervention for Depression: Secondary Analysis From a Randomized Control Trial.

BACKGROUND: Therapeutic alliance has been well established as a robust predictor of face-to-face psychotherapy outcomes. Although initial evidence positioned alliance as a relevant predictor of internet intervention success, some conceptual and methodological concerns were raised regarding the methods and instruments used to measure the alliance in internet interventions and its association with outcomes. OBJECTIVE: The aim of this study was to explore the alliance-outcome association in a guided internet intervention using a measure of alliance especially developed for and adapted to guided internet interventions, showing evidence of good psychometric properties. METHODS: A sample of 223 adult participants with moderate depression received an internet intervention (ie, Deprexis) and email support. They completed the Working Alliance Inventory for Guided Internet Intervention (WAI-I) and a measure of treatment satisfaction at treatment termination and measures of depression severity and well-being at termination and 3- and 9-month follow-ups. For data analysis, we used two-level hierarchical linear modeling that included two subscales of the WAI-I (ie, tasks and goals agreement with the program and bond with the supporting therapist) as predictors of the estimated values of the outcome variables at the end of follow-up and their rate of change during the follow-up period. The same models were also used controlling for the effect of patient satisfaction with treatment. RESULTS: We found significant effects of the tasks and goals subscale of the WAI-I on the estimated values of residual depressive symptoms (γ02=-1.74, standard error [SE]=0.40, 95% CI -2.52 to -0.96, t206=-4.37, P<.001) and patient well-being (γ02=3.10, SE=1.14, 95% CI 0.87-5.33, t198=2.72, P=.007) at the end of follow-up. A greater score in this subscale was related to lower levels of residual depressive symptoms and a higher level of well-being. However, there were no significant effects of the tasks and goals subscale on the rate of change in these variables during follow-up (depressive symptoms, P=.48; patient well-being, P=.26). The effects of the bond subscale were also nonsignificant when predicting the estimated values of depressive symptoms and well-being at the end of follow-up and the rate of change during that period (depressive symptoms, P=.08; patient well-being, P=.68). CONCLUSIONS: The results of this study point out the importance of attuning internet interventions to patients' expectations and preferences in order to enhance their agreement with the tasks and goals of the treatment. Thus, the results support the notion that responsiveness to a patient's individual needs is crucial also in internet interventions. Nevertheless, these findings need to be replicated to establish if they can be generalized to different diagnostic groups, internet interventions, and supporting formats.

Identifying change-dropout patterns during an Internet-based intervention for depression by applying the Muthen-Roy model.

To date, only few studies have attempted to investigate non-ignorable dropout during Internet-based interventions by applying an NMAR model, which includes missing data indicators in its equations. Here, the Muthen-Roy model was used to investigate change and dropout patterns in a sample of patients with mild-to-moderate depression symptoms (N = 483) who were randomized to a 12-week Internet-based intervention (deprexis, identifier: NCT01636752). Participants completed the PHQ-9 biweekly during the treatment. We identified four change-dropout patterns: Participants showing high impairment, improvement and low dropout probability (C3, N = 134) had the highest rate of reliable change at 6- and 12-month follow-up. A further pattern was characterized by high impairment, deterioration and high dropout probability (C2, N = 32), another by low impairment, improvement and high dropout probability (C1, N = 198). The last pattern was characterized by high impairment, no change and low dropout probability (C4, N = 119). In addition to deterioration, also rapid improvement may lead to dropout as a result of a perceived "good enough" dosage of treatment. This knowledge may strengthen sensitivity for the mechanisms of dropout and help to consider its meaning in efforts to optimize treatment selection.

The Working Alliance Inventory for guided Internet interventions (WAI-I).

OBJECTIVE: This study analyses the psychometric properties of the Working Alliance Inventory adapted for guided Internet interventions (WAI-I). METHODS: We drew on the data set from a multicenter trial that examined a guided Internet intervention (deprexis) for patients with mild to moderate depression. Two hundred twenty-three patients completed the WAI-I and the Patient Satisfaction Questionnaire (ZUF-8) at posttreatment, and the Attitudes toward Psychological Online-Interventions Questionnaire (APOI) at baseline. We ran confirmatory factor analyses (CFA) testing two- and three-factor solutions and calculated Cronbach's α, item-total correlations, and correlations of the WAI-I with APOI and ZUF-8. RESULTS: The results suggested a two-factor solution, with a very good model fit and evidence of factor independency, adequate internal consistency, and external validity for the complete scale and the sub-scales. CONCLUSIONS: The WAI-I showed as a reliable and valid instrument to capture alliance in guided Internet interventions, which might facilitate process-outcome research and treatment development efforts.

[Self-management interventions in the treatment of depressive disorders: ready for clinical practice?] / Selbstmanagement Interventionen in der Behandlung depressiver Störungen: reif für die klinische Praxis?

Only about half of those suffering from a depressive disorder seek treatment. Self-management interventions are one way to reduce this treatment gap. These interventions are mostly based on evidence-based techniques of cognitive behavioural therapy, which are taught by a computer program instead of a therapist. Numerous studies have shown the effectiveness of these interventions. However, these studies also raise a number of questions. These concern the efficacy both in the external rating and in the long-term course and the efficacy in severe depressive symptoms or in combination with antidepressant medication. Finally, the question arises as to the use of these interventions in patients in clinical practice and in people who are not particularly Internet-savvy. We addressed these questions in a large randomized study (EVIDENT study). This study investigated the efficacy of Intervention deprexis®. The results of this study are summarised in this overview and placed in the context of other interventions available in Germany.

Impact and change of attitudes toward Internet interventions within a randomized controlled trial on individuals with depression symptoms.

BACKGROUND: Most individuals with depression do not receive adequate treatment. Internet interventions may help to bridge this gap. Research on attitudes toward Internet interventions might facilitate the dissemination of such interventions by identifying factors that help or hinder uptake and implementation, and by clarifying who is likely to benefit. This study examined whether attitudes toward Internet interventions moderate the effects of a depression-focused Internet intervention, and how attitudes change over the course of treatment among those who do or do not benefit. METHODS: We recruited 1,004 adults with mild-to-moderate depression symptoms and investigated how attitudes toward Internet interventions are associated with the efficacy of the program deprexis, and how attitudes in the intervention group change from pre to post over a 3 months intervention period, compared to a control group (care as usual). This study consists of a subgroup analysis of the randomized controlled EVIDENT trial. RESULTS: Positive initial attitudes toward Internet interventions were associated with greater efficacy (η2p  = .014) independent of usage time, whereas a negative attitude (perceived lack of personal contact) was associated with reduced efficacy (η2p  = .012). Users' attitudes changed during the trial, and both the magnitude and direction of attitude change were associated with the efficacy of the program over time (η2p  = .030). CONCLUSIONS: Internet interventions may be the most beneficial for individuals with positive attitudes toward them. Informing potential users about evidence-based Internet interventions might instill positive attitudes and thereby optimize the benefits such interventions can provide. Assessing attitudes prior to treatment might help identify suitable users.

[Psychotherapy of Depression as Neurobiological Process - Evidence from Neuroimaging]. / Psychotherapie depressiver Störungen als neurobiologischer Prozess ­ Erkenntnisse aus der Hirnbildgebung.

Research on neurobiological effects of psychotherapy in depression facilitates the improvement of treatment strategies. The cortico-limbic dysregulation model serves as a framework for numerous studies on neurobiological changes in depression. In this model, depression is described as hypoactivation of dorsal cortical brain regions in conjunction with hyperactivation of ventral paralimbic regions. This assumption has been supported by various studies of structural and functional brain abnormalities in depression. However, also regions not included in the original cortico-limbic dysregulation model, such as the dorsomedial prefrontal cortex, seem to play an important role in depression. Functional connectivity studies of depression have revealed an enhanced connectivity within the so-called default mode network which is involved in self-referential thinking. Studies also point to a normalization of limbic and cortical brain activity, especially in the anterior cingulate cortex, during psychotherapy. Some neurobiological markers like the activity of the anterior cingulate cortex, striatum and insula as well as hippocampal volume have been proposed to predict treatment response on a group-level. The activity of the anterior insula appears to be a candidate bio-marker for differential indication for psychotherapy or pharmacotherapy. The cortico-limbic dysregulation model and following research have inspired new forms of treatment for depression like deep brain stimulation of the subgenual anterior cingulate cortex, repetitive transcranial magnetic stimulation of the dorsolateral prefrontal cortex, neurofeedback and attention training.

Defining and Predicting Patterns of Early Response in a Web-Based Intervention for Depression.

BACKGROUND: Web-based interventions for individuals with depressive disorders have been a recent focus of research and may be an effective adjunct to face-to-face psychotherapy or pharmacological treatment. OBJECTIVE: The aim of our study was to examine the early change patterns in Web-based interventions to identify differential effects. METHODS: We applied piecewise growth mixture modeling (PGMM) to identify different latent classes of early change in individuals with mild-to-moderate depression (n=409) who underwent a CBT-based web intervention for depression. RESULTS: Overall, three latent classes were identified (N=409): Two early response classes (n=158, n=185) and one early deterioration class (n=66). Latent classes differed in terms of outcome (P<.001) and adherence (P=.03) in regard to the number of modules (number of modules with a duration of at least 10 minutes) and the number of assessments (P<.001), but not in regard to the overall amount of time using the system. Class membership significantly improved outcome prediction by 24.8% over patient intake characteristics (P<.001) and significantly added to the prediction of adherence (P=.04). CONCLUSIONS: These findings suggest that in Web-based interventions outcome and adherence can be predicted by patterns of early change, which can inform treatment decisions and potentially help optimize the allocation of scarce clinical resources.

Effects of a Psychological Internet Intervention in the Treatment of Mild to Moderate Depressive Symptoms: Results of the EVIDENT Study, a Randomized Controlled Trial.

BACKGROUND: Mild to moderate depressive symptoms are common but often remain unrecognized and treated inadequately. We hypothesized that an Internet intervention in addition to usual care is superior to care as usual alone (CAU) in the treatment of mild to moderate depressive symptoms in adults. METHODS: This trial was controlled, randomized and assessor-blinded. Participants with mild to moderate depressive symptoms (Patient Health Questionnaire, PHQ-9, score 5-14) were recruited from clinical and non-clinical settings and randomized to either CAU or a 12-week Internet intervention (Deprexis) adjunctive to usual care. Outcomes were assessed at baseline, 3 months (post-assessment) and 6 months (follow-up). The primary outcome measure was self-rated depression severity (PHQ-9). The main analysis was based on the intention-to-treat principle and used linear mixed models. RESULTS: A total of 1,013 participants were randomized. Changes in PHQ-9 from baseline differed signixFB01;cantly between groups (t825 = 6.12, p < 0.001 for the main effect of group). The post-assessment between-group effect size in favour of the intervention was d = 0.39 (95% CI: 0.13-0.64). It was stable at follow-up, with d = 0.32 (95% CI: 0.06-0.69). The rate of participants experiencing at least minimally clinically important PHQ-9 change at the post-assessment was higher in the intervention group (35.6 vs. 20.2%) with a number needed to treat of 7 (95% CI: 5-10). CONCLUSIONS: The Internet intervention examined in this trial was superior to CAU alone in reducing mild to moderate depressive symptoms. The magnitude of the effect is clinically important and has public health implications.

Decreased limbic and increased fronto-parietal connectivity in unmedicated patients with obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) is characterized by recurrent intrusive thoughts and ritualized, repetitive behaviors, or mental acts. Convergent experimental evidence from neuroimaging and neuropsychological studies supports an orbitofronto-striato-thalamo-cortical dysfunction in OCD. Moreover, an over excitability of the amygdala and over monitoring of thoughts and actions involving the anterior cingulate, frontal and parietal cortex has been proposed as aspects of pathophysiology in OCD. We chose a data driven, graph theoretical approach to investigate brain network organization in 17 unmedicated OCD patients and 19 controls using resting-state fMRI. OCD patients showed a decreased connectivity of the limbic network to several other brain networks: the basal ganglia network, the default mode network, and the executive/attention network. The connectivity within the limbic network was also found to be decreased in OCD patients compared to healthy controls. Furthermore, we found a stronger connectivity of brain regions within the executive/attention network in OCD patients. This effect was positively correlated with disease severity. The decreased connectivity of limbic regions (amygdala, hippocampus) may be related to several neurocognitive deficits observed in OCD patients involving implicit learning, emotion processing and expectation, and processing of reward and punishment. Limbic disconnection from fronto-parietal regions relevant for (re)-appraisal may explain why intrusive thoughts become and/or remain threatening to patients but not to healthy subjects. Hyperconnectivity within the executive/attention network might be related to OCD symptoms such as excessive monitoring of thoughts and behavior as a dysfunctional strategy to cope with threat and uncertainty.

Adjunctive lithium treatment in the prevention of suicidal behavior in patients with depression and comorbid personality disorders.

OBJECTIVE: Patients with both major depression and personality disorders have a high risk of suicidal behavior. Lithium is meant to have anti-suicidal properties in patients with affective disorders. The anti-suicidal effect of lithium in patients with affective disorders and comorbid personality disorders has not been investigated yet. METHODS: A post-hoc analysis of a subsample of patients with depression and comorbid personality disorder (PD) and a recent suicide attempt (n = 19) from the prospective, placebo-controlled lithium intervention study (N = 167), was conducted. RESULTS: Three patients in the lithium group (n = 8) and two patients in the placebo group (n = 11) presented a suicide attempt throughout the course of the study. No differences related to suicidal behavior could be detected between the placebo group and the group with lithium intervention. CONCLUSIONS: On the basis of the small sample size, among patients with comorbid PD, lithium does not seem to have an effect on suicidal behavior in contrast to patients with affective disorders without comorbid PD.

The EVIDENT-trial: protocol and rationale of a multicenter randomized controlled trial testing the effectiveness of an online-based psychological intervention.

BACKGROUND: Depressive disorders are among the leading causes of worldwide disability with mild to moderate forms of depression being particularly common. Low-intensity treatments such as online psychological treatments may be an effective way to treat mild to moderate depressive symptoms and prevent the emergence or relapse of major depression. METHODS/DESIGN: This study is a currently recruiting multicentre parallel-groups pragmatic randomized-controlled single-blind trial. A total of 1000 participants with mild to moderate symptoms of depression from various settings including in- and outpatient services will be randomized to an online psychological treatment or care as usual (CAU). We hypothesize that the intervention will be superior to CAU in reducing depressive symptoms assessed with the Personal Health Questionnaire (PHQ-9, primary outcome measure) following the intervention (12 wks) and at follow-up (24 and 48 wks). Further outcome parameters include quality of life, use of health care resources and attitude towards online psychological treatments. DISCUSSION: The study will yield meaningful answers to the question of whether online psychological treatment can contribute to the effective and efficient prevention and treatment of mild to moderate depression on a population level with a low barrier to entry. TRIAL REGISTRATION NUMBER: NCT01636752.

Relevance of orbitofrontal neurochemistry for the outcome of cognitive-behavioural therapy in patients with obsessive-compulsive disorder.

Since the advent of non-invasive methods such as proton magnetic resonance spectroscopy ((1)H-MRS), obsessive-compulsive disorder (OCD) has been increasingly associated with an altered composition of neurometabolites and neurotransmitters in several brain areas. Particularly, Inositol has not only been implicated in OCD pathophysiology, but also shown effective in pilot studies in therapy-refractory OCD patients. However, the relevance of regional brain neurochemistry for therapy outcome has not yet been investigated. Whereas numerous neuroimaging findings support a dysfunction of the orbitofrontal cortex (OFC) in OCD, MR-spectroscopic investigations of this region are missing. (1)H-MRS and psychometric measurements were obtained from twenty unmedicated patients with OCD, subsequently enrolled in a 3-month structured inpatient cognitive-behavioural therapy programme, and from eleven matched control subjects. Multiple regression of symptom score changes (Y-BOCS) on (myo-)inositol concentrations in three areas (right orbitofrontal cortex (OFC), right striatum and anterior cingulate cortex) was performed. The concentration of (myo-)inositol in the OFC only predicted the outcome of subsequent CBT regarding Y-BOCS score reduction (Spearman's r(s) = .81, P < 0.003, corrected). The (myo-)inositol concentration did not differ between OCD patients and healthy controls and did not change during therapy. We provide preliminary evidence for a neurochemical marker that may prove informative about a patient's future benefit from behaviour therapy. Inositol, a metabolite involved in cellular signal transduction and a spectroscopic marker of glial activity, predicted the response to CBT selectively in the OFC, adding to the evidence for OFC involvement in OCD and highlighting neurobiological underpinnings of psychotherapy.

Intima-media thickness in women with borderline personality disorder.

OBJECTIVE: Patients with borderline personality disorder (BPD) may have a higher risk of developing cardiovascular disease caused by altered endocrine, metabolic, and inflammatory parameters. Increased intima-media thickness (IMT) is considered an early marker of atherosclerosis and is associated with most cardiovascular risk factors. METHODS: The mean IMT of the common carotid arteries was assessed by B-mode ultrasound in 47 women with BPD and 28 age-matched healthy women. Mean (standard deviation) age for BPD participants was 31.2 (10.4) years and 31.9 (11.0) years for the comparison group. In addition, Adult Treatment Panel III criteria for metabolic syndrome and markers of inflammation were measured. The patients were characterized by applying DSM-IV criteria and obtaining self-reports of adverse childhood experiences. RESULTS: Women with BPD had a significantly higher IMT than healthy women (mean [standard deviation] = 0.41 [0.11] versus 0.34 [0.11] mm, p = .02). In linear regression analysis, IMT was significantly associated with BPD even when adjusting for body mass index (ß = 0.27, p = .04) and physical activity (ß = 0.29, p = .02). CONCLUSIONS: The data suggest that women with BPD are at increased risk of developing subsequent cardiovascular disease.

Major depression, borderline personality disorder, and visceral fat content in women.

Major depressive disorder (MDD) is associated with increased volumes of visceral fat and a high prevalence of the metabolic syndrome. In turn, affective disorders are frequently found in patients with borderline personality disorder (BPD). It is therefore unclear whether BPD per se may influence body composition. In order to clarify a potential relationship between BPD and body composition, we measured visceral fat content (VFC) in young depressed women with and without comorbid BPD and related this parameter to various features of the metabolic syndrome. Visceral fat content was measured by magnetic resonance imaging in 22 premenopausal women with MDD only, in 44 women with comorbid MDD and BPD, in 12 female BPD patients without MDD, and in 34 healthy women (CG). Data showed that depressed women without comorbid BPD had a 335% higher VFC and women with comorbid BPD had a 250% higher VFC than the CG women. When controlling for age, data showed significant effects of MDD on VFC (F = 8.4; P = 0.005). However, BPD, with or without MDD, was not related to VFC. Young depressed women with and without comorbid BPD display increased visceral fat content when compared to control subjects and may therefore constitute a risk group for the development of the metabolic syndrome. BPD per se is not an additive risk factor in this context.

Maintaining Outcomes of Internet-Delivered Cognitive-Behavioral Therapy for Depression: A Network Analysis of Follow-Up Effects.

Background: Depression is a highly prevalent mental disorder, but only a fraction of those affected receive evidence-based treatments. Recently, Internet-based interventions were introduced as an efficacious and cost-effective approach. However, even though depression is a heterogenous construct, effects of treatments have mostly been determined using aggregated symptom scores. This carries the risk of concealing important effects and working mechanisms of those treatments. Methods: In this study, we analyze outcome and long-term follow-up data from the EVIDENT study, a large (N = 1,013) randomized-controlled trial comparing an Internet intervention for depression (Deprexis) with care as usual. We use Network Intervention Analysis to examine the symptom-specific effects of the intervention. Using data from intermediary and long-term assessments that have been conducted over 36 months, we intend to reveal how the treatment effects unfold sequentially and are maintained. Results: Item-level analysis showed that scale-level effects can be explained by small item-level effects on most depressive symptoms at all points of assessment. Higher scores on these items at baseline predicted overall symptom reduction throughout the whole assessment period. Network intervention analysis offered insights into potential working mechanisms: while deprexis directly affected certain symptoms of depression (e.g., worthlessness and fatigue) and certain aspects of the quality of life (e.g., overall impairment through emotional problems), other domains were affected indirectly (e.g., depressed mood and concentration as well as activity level). The configuration of direct and indirect effects replicates previous findings from another study examining the same intervention. Conclusions: Internet interventions for depression are not only effective in the short term, but also exert long-term effects. Their effects are likely to affect only a small subset of problems. Patients reporting these problems are likely to benefit more from the intervention. Future studies on online interventions should examine symptom-specific effects as they potentially reveal the potential of treatment tailoring. Clinical Trial Registration: ClinicalTrials.gov, Identifier: NCT02178631.

Care of the insane in Lübeck during the 17th and 18th centuries.

Only selected aspects of the history of the House of the Poor Insane in the Hanseatic Free City of Lübeck have been studied to date.This article presents the results of an entire source study of this small institution in the 17th and 18th centuries, and briefly also during the next 40 years after the opening of a new building. In addition to the minute-book of the Governors, now kept in the Lübeck Municipal Archives, the results are based primarily on the account-books,which illustrate the institution's social history and activities. Examples are given. During most of the 17th century, the House was generally rather like a prison for the insane, but at the end of this century and in the early 18th there was a reform phase.This was followed by phases of repression and 'containment' at the end of the 18th century and in the early 19th century, before a renewed reform by the medical profession.The findings for Lübeck are compared with the development of inpatient care in institutions elsewhere, and the decisive factors in Lübeck are discussed.

Immediate and long-term effectiveness of adding an Internet intervention for depression to routine outpatient psychotherapy: Subgroup analysis of the EVIDENT trial.

OBJECTIVE: To examine immediate and long-term effectiveness of an adjunctive Internet intervention for depression in a large sample of patients undergoing routine psychotherapy. METHOD: The current study evaluated a subgroup of patients from the Evident trial, a randomized investigation of a 12-week minimally guided Internet intervention (Deprexis) for the treatment of mild to moderate depression. 340 adults (mean age = 43.3 years; 71.7 % female) of the original sample received routine outpatient psychotherapy during the trial period, resulting in a standard psychotherapy group (n = 174) and an augmented therapy group (n = 166). Outcomes were assessed at baseline, post-treatment and 6-month follow-up. RESULTS: Intention-to-treat analyses indicated that combined treatment led to a greater reduction in symptoms of depression (effect size d = 0.32; p = .002), improved therapeutic progress (d = 0.36; p = .003), and higher mental health-related quality of life (d = 0.34; p = .004). There was no intervention effect on physical health-related quality of life. The same pattern was found at 6-month follow-up, and adjunctive treatment also resulted in increased rates of clinical improvement. Treatment success was independent from therapeutic orientation of combined face-to-face therapy. CONCLUSION: Results indicate that the adjunctive use of the investigated intervention can produce additional and lasting effects in routine outpatient psychotherapy for mild to moderate levels of depression. The study adds to the ongoing evidence on augmented effects of blended treatment. Future studies should investigate different types of blends in diverse populations by means of change-sensitive assessment strategies.

Social phobia moderates the outcome in the EVIDENT study: A randomized controlled trial on an Internet-based psychological intervention for mild to moderate depressive symptoms.

OBJECTIVE: Data from the EVIDENT trial were reanalyzed to examine whether specific anxiety-related comorbidities moderate the effect of an Internet intervention on depression outcome. METHOD: The EVIDENT study is a randomized controlled trial that included N = 1,013 participants with mild to moderate depressive symptoms (i.e., scores between 5 and 14 on the Patient Health Questionnaire-9 [PHQ-9]) who were randomized to a control group with access to care-as-usual (n = 504) or to an intervention group, which accessed the Internet intervention Deprexis adjunctively to care-as-usual (n = 509). Anxiety-related comorbidities (generalized anxiety disorder, social phobia, panic disorder, agoraphobia, panic disorder with agoraphobia, specific phobia, posttraumatic stress disorder, obsessive-compulsive disorder) were assessed with the Web Screening Questionnaire at baseline. Multilevel models were performed. RESULTS: Twelve potential moderators (8 specific anxiety-related comorbidities, depression severity, and 3 previously identified moderators in the EVIDENT trial) were examined within 1 multilevel model, and only social phobia moderated the intervention effect on depression outcome (in favor of Deprexis). This moderating effect of social phobia did not depend on the other moderators' being included in the model. These results emerged for continuous PHQ-9 scores as well as for clinically important PHQ-9 changes as outcome (p < .05). However, moderating effects did not reach small effect sizes, accounted for less than 1% of the variance in change in depressive symptoms, and showed limited reproducibility in randomly selected split halves. CONCLUSIONS: Deprexis appears to be most effective for participants with mild to moderate depressive symptoms and comorbid social phobia, but further replications of this finding are necessary. (PsycINFO Database Record (c) 2019 APA, all rights reserved).