Greater vulnerability to cannabis dependence among heavy cannabis user French women.

BACKGROUND AND OBJECTIVES: Between 1990 and the mid-2010s, France registered a sharp rise in the spread and consumption of cannabis. At the same time, there has been an increase in the concentration of Δ9-tetrahydrocannabinol contained in cannabis. The aims of our study are to measure addictive and psychiatric comorbidities in cannabis users in France, and to compare characteristics between women and men. METHODS: Three hundred and forty-two heavy cannabis users seen in a cannabis clinic between 2004 and 2014 were assessed during a 2-h clinical interview (DSM-IV, MINI). RESULTS: 83.2% of users are currently cannabis dependent, 10.6% alcohol dependent, and 2.1% cocaine/crack dependent. 37.8% have a current mood disorder, 47.6% have a current anxiety disorder, and 8.8% are psychotic. Women suffer significantly more often than men from major depressive episodes, dysthymia, agoraphobia, social phobia, generalized anxiety disorder and posttraumatic stress disorder (PTSD), both current and lifetime. Logistic regression shows that women have a significantly higher risk than men of suffering from PTSD over their lifetime (odds ratio [OR] = 5.48; p < 10-3). The vast majority of women suffering from PTSD report having been sexually assaulted in the course of their lives. In addition, women are at greater risk of cannabis dependence (OR = 3.87; p < .05) for lower cannabis consumption (grams smoked per week) (OR = 0.96; p < .05). DISCUSSION AND CONCLUSIONS: French women heavy cannabis users are particularly at risk of PTSD and are more likely than men to be dependent despite consuming fewer. SCIENTIFIC SIGNIFICANCE: Further studies are needed to clinically quantify cannabis consumption and distinguish its impact on women and men.

A composite scale applied to evaluate anxiety in schizophrenic patients (SAES).

Anxiety in schizophrenia possesses specific features and is difficult to assess because no specific evaluating tool is currently available. The aim of this study was to develop and validate a hetero-assessment-based scale to specifically measure anxiety in schizophrenia. A literature review and a survey among psychiatrists allowed the selection of 29 items from 4 previous scales evaluating anxiety. Factor analysis allowed building up a final 22-item composite scale of anxiety evaluation in schizophrenia (SAES), which was then validated in 147 schizophrenic patients. One hundred and forty-seven (147) schizophrenic patients (70.8 % male, mean age = 36.9 years) were included in the study. Principal component analysis of the SAES revealed three factors, namely "expressed and perceived anxiety," "somatic anxiety," and "anxiety and environment". All total and factor scores of the SAES were significantly correlated (p < .001) with total and factor scores of the original scales. Finally, the SAES showed good inter-rater reliability [intra-class correlation coefficient (ICC) = .82]. In conclusion, a specific tool for evaluating anxiety in schizophrenia (SAES) was developed and validated in a sample of schizophrenic patients. The SAES can be useful to investigate clinical, psychopathological, and therapeutic aspects of anxiety in schizophrenia.

Mechanisms of insight in schizophrenia and impact of cognitive remediation therapy.

The origins of poor insight in schizophrenia are still unclear. We contrasted the changes in clinical insight, basic cognitive processes, autobiographical memory and metacognition in 63 outpatients with schizophrenia pseudo-randomly assigned to one of three cognitive remediation groups: one targeting basic cognitive processes (RECOS), a second autobiographical memory (REMAu), and a third metacognitive deficits (MBCT). Three dimensions of insight (awareness of: mental illness, benefit of treatment, psychosocial consequences) improved after treatment, regardless of the group. In addition, the REMAu and MBCT showed an improvement on other dimensions of insight (symptomatic awareness and symptomatic attribution, respectively). Poor insight and its improvement after treatment were best predicted by a combination of basic cognitive, autobiographical and metacognitive measures. This study supports a multidimensional conception of insight and recommends the combination of remediation therapies to improve clinical insight in schizophrenia.

Bibliometric analysis of publications on attention deficit hyperactivity disorder (ADHD) in France since 1974.

BACKGROUND: The predominance of the psychodynamic approach is often put forward to explain the delay in diagnosis and treatment of attention-deficit disorder with hyperactivity (ADHD) reported in France. OBJECTIVE: A bibliometric study of abstracts, articles, or letters authored by French researchers may provide objective insight into this issue. METHODS: Online electronic databases were searched without any date limits for documents related to ADHD, and allocated to the AllFR group when all authors had an affiliation in France or to the notAllFR group when at least one author had an affiliation in France. Publications expressing any psychodynamic point of view on the causes and/or treatment of ADHD were identified. RESULTS: A total of 747 documents were analyzed: 417 were exclusively indexed in SCOPUS, and 418 were allocated to the AllFR group. Compared with documents in the notAllFR group, documents in the AllFR group were written by a smaller number of authors (median 3 vs. 6, p<0.002), more frequently evoked psychodynamic concepts (10.45% vs. 1.67%, p<0.001), and less frequently acknowledged the persistence of ADHD in adulthood (29.10% vs. 42.14%). The psychodynamic approach was likely to rely on case reports of fewer than three children. CONCLUSIONS: Any serious review of the literature should pool documents from several online databases, especially SCOPUS. In publications by only French authors, the psychodynamic approach seems predominant and the persistence of ADHD in adulthood is overlooked. This may concur with the excessive delay observed in the diagnosis and treatment of children and adults in France compared to other European countries.

Perspectives of French adolescents with ADHD and child and adolescent psychiatrists regarding methylphenidate use.

Many studies have demonstrated the short-term efficacy and tolerability of methylphenidate treatment adolescents with attention deficit hyperactivity disorder (ADHD). Qualitative literature on this matter focused on school outcomes, long-term side effects, family conflicts, personality changes and stigmatization. Yet, no qualitative study has crossed the perspectives of child and adolescent psychiatrists (CAPs) prescribing methylphenidate and adolescents with ADHD. This French qualitative study followed the five stages IPSE-Inductive Process to analyze the Structure of lived Experience-approach. Fifteen adolescents with ADHD and 11 CAPs were interviewed. Data collection by purposive sampling continued until data saturation was reached. Data analysis, based on a descriptive and structuring procedure to determine the structure of lived experience characterized by the central axes of experience, produced two axes: (1) The process of methylphenidate prescription, highlighting how this prescription was motivated from the exterior, experienced as passive by the adolescents and required commitment from the CAPs; and (2) the perceived effects of methylphenidate treatment, in three domains: at school, in relationships and in the sense of self. Findings raised both the issues of the epistemic position and social representation of the adolescents about ADHD and methylphenidate within this specific French context, and the self-awareness and perception of the adolescents with ADHD. We conclude that these two issues need to be regularly addressed by the CAPs prescribing methylphenidate to avoid epistemic injustice and prevent the harmful effects of stigmatization.

The experience of a program combining two complementary therapies for women with breast cancer: An IPSE qualitative study.

INTRODUCTION: The use of complementary therapies within oncology is a clinical issue, and their evaluation a methodological challenge. This paper reports the findings of a qualitative study exploring the lived experience of a French program of complementary therapies combining structured physical activity and MBSR among women with breast cancer. METHODS: This French exploratory qualitative study followed the five stages of the Inductive Process to analyze the Structure of lived Experience (IPSE) approach. Data was collected from February to April 2021 through semi structured interviews. Participants, purposively selected until data saturation. Inclusion criteria were: being an adult woman with breast cancer whatever the stage who had completed their treatment and were part of the program of complementary therapies. RESULTS: 29 participants were included. Data analysis produced a structure of experience based on two central axes: 1) the experience these women hoped for, with two principal expectations, that is to take care of their bodies and themselves, and to become actors in their own care; and 2) an experience of discovery, first of themselves and also in their relationship with the exterior, whether with others, or in society, and in the relationships with health-care providers. CONCLUSIONS: Our results from this French study reinforce the data described in other western countries about the needs of women receiving care in oncology departments for breast cancer: they need to be informed of the existence of supportive care in cancer by the health-care professionals themselves, to be listened to, and to receive support care. A systematic work of reflexivity about this redundancy in our results and in the qualitative literature, led us to question what impeded the exploration of more complex aspects of the experience of this women-the inherently emotional and anxiety-inducing experience of cancer, especially anxiety about its recurrence and of death-and to suggest new research perspectives to overcome these methodological and theoretical obstacles.

The influence of therapeutic alliance and insight on medication adherence in schizophrenia.

BACKGROUND: Poor adherence is one of the leading problems affecting the effectiveness of treatment in schizophrenia. It is an identified factor for relapse and hospitalizations with major social and economic consequences. Various determinants of poor adherence have been identified but few studies investigate the role of therapeutic alliance on medication adherence in routine mental healthcare. AIMS: To investigate links between therapeutic alliance insight and medication adherence in routine care and community psychiatry. METHODS: In this cross-sectional study, 38 inpatients that met ICD-10 criteria for schizophrenia or schizoaffective disorder were recruited and independently interviewed just before discharge. Various rating scales were used: the self-reported 4-Point ordinal Alliance Scale (4PAS), the Medication Adherence Rating Scale (MARS) and the Scale to assess Unawareness of Mental Disorder (SUMD). In addition, we investigated the relationships between medication adherence and clinical variables through uni- and multivariate analysis. RESULTS: Therapeutic alliance was significantly correlated with adherence (r = 0.663, P < 0.0001) and insight (r =-0.664, P < 0.0001). Poor adherence was associated in patients with substance or alcohol use disorders (5.4 vs. 2.9, P = 0.0075, t = 2.83). No significant difference was found between the demographic characteristics of the sample, the characteristics of the treatments and adherence. CONCLUSIONS: A weak therapeutic alliance and low insight are associated with poor adherence in patients with schizophrenia or schizoaffective disorder who were hospitalized. Specific psycho-educational programs to improve therapeutic alliance and insight should be implemented to achieve better therapeutic adherence and outcome.

Premorbid functioning and treatment response in recent-onset schizophrenia: prospective study with risperidone long-acting injectable.

Premorbid functioning may be associated with treatment response, but this is confounded by a lack of prospective longitudinal data and controls for medication compliance. This study tested the hypothesis that good premorbid functioning will be associated with better antipsychotic treatment response after controlling for drug adherence by using a long-acting injectable antipsychotic. This was a 6-month, open label, multicenter, phase IV trial in recent-onset schizophrenia treated with flexible doses of risperidone long-acting injectable (25-50 mg every 14 days). Premorbid functioning was assessed with the Premorbid Adjustment Scale (PAS)-Structured Interview; efficacy was evaluated with clinician-rated Positive and Negative Syndrome Scale, Clinical Global Impression scale of Severity of Illness, Clinical Global Impression scale of Change, Global Assessment of Functioning Scale, and trial participant completed SF-36. Analyses controlled for baseline scores and demographics. With the use of a priori PAS scoring criteria, the participants' premorbid functioning was categorized as stable-good (n = 142), stable-poor (n = 116), and deteriorating (n = 36). At baseline, the stable-good group had the best functioning on most efficacy measures. All groups showed significant improvement on efficacy measures with treatment. Improvement was significantly higher for the stable-good group. The PAS global assessment of highest level of functioning scale (excellent, n = 75; good, n = 117; fair, n = 78; and poor, n = 31) showed a strong association with baseline functioning and improvement and had a significant linear association with meeting Remission in Schizophrenia Working Group symptom criteria at baseline (P = 0.003) and attained and sustained remission for 3 months during study (47.7%, 49.3%, 29.6%, and 22.2%; P = 0.006). Good premorbid functioning corresponds with better treatment response in recent-onset psychosis as captured on both clinician and patient-reported measures.

An aid for diagnosing attention-deficit/hyperactivity disorder at adulthood: psychometric properties of the French versions of two Wender Utah Rating Scales (WURS-25 and WURS-K).

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that affects up to 4% of the adults in the general population. The Utah criteria were devised in the 1970s to help a retrospective diagnosis of ADHD during childhood, a necessary but not sufficient condition for diagnosing ADHD at adulthood. A sample of 466 adults was collected from a referral center and a large university. We investigated the psychometric properties (reliability and factor structure) of the original WURS-25 and the WURS-K, two shortened versions of the Wender Utah Rating Scale. These scales have similar psychometric properties; both have a 3-factor structure with only the first two factors highly and positively correlated. The third factor in the WURS-K, antisocial behavior, is less specific to the construct of ADHD than the third factor in the WURS-25, mood/self-esteem. The 18-item Adult ADHD Self-Rating Scale (ASRS) was used as a screening tool for actual ADHD. The composite total scores and the factorial scores correlated moderately with ASRS total and subscores. Research is warranted to assess the cutoff scores against a diagnosis of ADHD using a structured interview.

Brief interventions for improving adherence in schizophrenia: A pilot study using electronic medication event monitoring.

Poor medication adherence remains frequent in schizophrenia. The present study examined the efficacy of two month-long pilot interventions using the Medication Event Monitoring System (MEMS®). Thirty-three outpatients at high risk for relapse were randomized to receive a smartphone-based intervention, a nurse-based intervention, or treatment as usual. All patients then used the MEMS® to objectively measure medication adherence over six months. No differences were observed in adherence measures or relapse rates across the three groups. When using electronic medication monitoring as an objective measure of adherence, easily-implemented interventions may not significantly improve adherence in patients at high risk for relapse.

The 4-Point ordinal Alliance Self-report: a self-report questionnaire for assessing therapeutic relationships in routine mental health.

BACKGROUND: The quality of the relationship between patient and therapist can be considered a cornerstone of psychiatric practice. Nonadherence is one of the leading problems affecting antipsychotic effectiveness in schizophrenic patients and represents a poor prognostic factor for schizophrenia. Among the factors influencing adherence, the clinician's style of communication and the therapeutic relationship (TR) are recognized as key points. The measures of TR have been broadly explored in psychotherapy process but have received little attention in the treatment of severe mental illness in the context of routine mental health. Our objective was to build a self-rating scale easy to use in clinical psychiatric practice to assess TR, including drug-taking aspects and the relationship with the clinician on a day-to-day basis. A secondary objective was to assess the scale's validity and the association between TR and adherence. METHODS: The study was conducted with 92 consenting inpatients who met specified criteria for schizophrenia and schizoaffective disorders (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). Assessments of TR were obtained by the 4-Point ordinal Alliance Self-report and an 8-cm visual analog scale completed by the patient 1 week before discharge, after the remission of acute symptomatology. Adherence behavior was estimated with a new valid and reliable questionnaire called the Medication Adherence Rating Scale. Factor analysis was performed. RESULTS: Internal consistency was assessed by calculating Cronbach alpha, which revealed a highly satisfactory value (alpha = .91). After oblique rotation was run, 2 understandable factors were extracted that we termed empathy experienced and psychoeducation. CONCLUSIONS: Therapeutic relationship with the clinician can be considered a prerequisite for positive treatment course and outcome. The detection of subpopulations characterized by determinants of poor TR could be the first step toward improving schizophrenia prognosis linked to poor adherence.

Inattentive symptoms of ADHD are related to evening orientation.

OBJECTIVE: Morningness is a stable characteristic of individuals, related to impulsivity and novelty seeking. The evening orientation is a risk factor for psychiatric conditions such as depression and personality disorders. The authors hypothesized that adults suspected of having ADHD are more evening oriented than adults without ADHD. METHOD: Exploratory factor analyses were performed on the polychoric correlation matrices of the full Adult Self-Report Scale for ADHD (ASRS) and the Composite Scale of Morningness (CSM). RESULTS: As expected, two factors for the ASRS--Inattention and Impulsivity- Hyperactivity--and three factors for the CSM were retrieved. All three CSM factors correlated negatively with ASRS Inattention, none with ASRS Impulsivity-Hyperactivity. CONCLUSION: Inattention is more strongly related to eveningness than is Impulsivity-Hyperactivity, and therefore eveningness may constitute an endophenotype of the predominantly inattentive subtype of ADHD. These findings need to be replicated in a patient population with a standardized assessment of sleep quality.

Bipolar disorders and quality of life: the impact of attention deficit/hyperactivity disorder and substance abuse in euthymic patients.

Patients with bipolar disorders (BPD) display high rates of comorbidities, especially substance abuse (20-40%) and attention deficit/hyperactivity disorder (ADHD) (6%-20%). However, there are virtually no data evaluating the role of current ADHD on the global functioning of patients with BPD. The recent literature suggests that impairments in quality of life are a key prognostic feature for predicting the long course of BPD. The aim of this study was to investigate the intrinsic impact of adult ADHD and substance abuse in patients with BPD on levels of social adaptation, functioning and vitality. Seventy-three outpatients with BPD I or II, all euthymic and being treated with mood stabilizers, were evaluated using the following measures: 1) the Diagnostic Interview of Genetics Study for DSM-IV criteria; 2) the ADHD Self-Report Scale (ASRS) (screening of adult ADHD); 3) measures of quality of life: social adaptation (Social Adjustment Scale Self-Report (SAS-SR)), well-being (Short Form 36 (SF-36) Health Survey), and the Brief Psychiatric Rating Scale. In this clinical sample, 30% met the ADHD criteria and 22% were substance abusers. The results showed that the presence of ADHD in BPD patients significantly predicted a low social functioning and adaptation by comparison with BPD patients without ADHD. By contrast, we failed to detect a significant impact of substance abuse on those functional outcomes. This is the first step towards improved screening for comorbidities and an understanding of their crucial role in the prognosis of the disorder, as well as in defining new multilevel therapeutic strategies.

Sadness as an integral part of depression.

Sadness is considered by numerous authors to be a core symptom of depression. Currently, many arguments exist for its particular importance in depressed patients. Sadness makes up part of the various definitions of the depressive syndrome, even if its presence is not required for diagnosis. Furthermore, it is closely linked to the other depressive symptoms, and has prognostic value, in particular for remission. The recognition and measurement of sadness seem important for therapeutic evaluation, in clinical studies, and in depressed patients at an individual level. This paper presents a selective review of some of the various aspects of sadness as an integral part of depression, and an examination of its links with a disease which is a major health concern.

Evaluation of adherence patterns in schizophrenia using electronic monitoring (MEMS®): A six-month post-discharge prospective study.

BACKGROUND: Medication Event Monitoring System (MEMS®) is considered the gold standard for the evaluation of medication adherence, yet few studies have applied this method, especially over long periods of time. OBJECTIVE: To investigate medication adherence patterns in a sample of post-discharge patients with schizophrenia monitored with MEMS caps during a six-month period. METHOD: Adherence to antipsychotics was prospectively investigated using MEMS among 68 patients with schizophrenia. Treatment initiation, implementation or whether or not the patient takes his dosing regimen as prescribed, persistence or the length of time between initiation and discontinuation, and treatment discontinuation were used to describe adherence. Persistence over time was described using Kaplan-Meier curves. RESULTS: After discharge 16% of the patients never initiated treatment. On average 37.3% of patients adhered to treatment in the first 6months. However, a strong decrease in adherence was observed over time (p<0.0001), primarily due by treatment non-persistence. Only half of the patients were persistent at 6weeks, persistence further dropped to 19.0% after 6months. Among persistent patients, implementation was consistent over time with 87.8% of patients taking their medication as prescribed on any given day. CONCLUSIONS: Dosing profile analysis provides further evidence for the magnitude of non-adherence with antipsychotic prescriptions among post-discharge patients with schizophrenia. Using the high precision of MEMS®, dosing profiles may provide a better understanding of non-adherence patterns and help clinicians determine optimal individualized strategies.

Characterization of human cytochrome P450 enzymes involved in the metabolism of cyamemazine.

Recombinant human liver microsomal enzymes of the cytochrome P450 family (CYP1A2, CYP2A6, CYP3A4, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1) were used to determine the metabolic fate of the antipsychotic anxiolytic agent cyamemazine. An LC/MS-MS tandem methodology was developed specifically for identifying the presence of cyamemazine and its metabolites in reaction media. All P450 enzymes investigated, with the exception of CYP2A6 and CYP2E1, degraded cyamemazine, albeit to a different extent, with CYP1A2, CYP2C8 and CYP2C19 being the most efficient (>80%). However, in microsomes prepared from native human hepatocytes, only relatively specific competitors (inhibitors and/or substrates) of CYP1A2, CYP2C8, CYP2C9 and CYP3A4 reduced notably the degradation cyamemazine. The main routes of cyamemazine biotransformation are N-mono-demethylation (CYP1A2, CYP3A4 and CYP2C8) and mono-oxidation (either S-oxidized or hydroxylated derivatives which could not be discriminated because characterized by the same mass value) by CYP1A2 and CYP2C9. Secondary metabolic routes yields N,N-di-demethylated and N-demethylated mono-oxidized products. Thus, under in vitro conditions, cyamemazine is extensively degraded by at least four distinct P450 enzymes, into two primary hydrophilic metabolites. These results suggest that cyamemazine detoxification process is unlikely to be significantly impaired by co-administration of therapeutic agents that are substrates of the CYP metabolic system.

Medication adherence in schizophrenia: The role of insight, therapeutic alliance and perceived trauma associated with psychiatric care.

Medication non adherence in schizophrenia is a major cause of relapse and hospitalization and remains for clinicians an important challenge. This study investigates the associations between insight, therapeutic alliance, perceived trauma related to psychiatric treatment and medication adherence in patients with schizophrenia. In this multicenter study, 72 patients were assessed regarding symptomatology, self-reported adherence with medication, insight, medication side-effects, therapeutic alliance and perceived trauma related to psychiatric treatment. Structural Equation Modeling (SEM) was used to test predicted paths among these variables. The data fit a model in which medication adherence was directly predicted by insight, therapeutic alliance and perceived trauma related to psychiatric treatment. Perceived trauma moderates the role of insight on medication adherence. The final model showed good fit, based on four reliable indices. Greater adherence was correlated with higher insight, higher therapeutic alliance and lower perceived trauma. These three variables appear to be important determinants of patient's medication adherence. Medication adherence could be enhanced by reducing perceived trauma and by increasing insight. The need for mental health providers to acknowledge patients' potentially traumatic experience with psychiatric treatment and the need to encourage greater involvement in care are discussed.

Effect of an Institutional Medication Adherence Program for Long-Acting Injectable Risperidone on Adherence and Psychiatric Hospitalizations: Evidence from a Prospective Cohort Study.

BACKGROUND: Long-acting injectable (LAI) atypical antipsychotics are associated with improved adherence and reduced relapse rates in schizophrenia but reminder-based interventions may further improve outcomes. OBJECTIVES: To assess an institutional medication adherence program's (IMAP) effectiveness on adherence and psychiatric hospitalizations among schizophrenia patients taking risperidone LAI (RLAI). METHODS: Between 2009 and 2010, we recruited patients meeting DSM-IV criteria for schizophrenia treated with RLAI receiving outpatient care from psychiatric centres in France. The IMAP consisted of calling patients 48 hours prior to their scheduled RLAI injections and within 3 days of a missed appointment. Centres applying the IMAP to ≥50% of scheduled patient injections were deemed compliant. Patients were followed up to one year for adherence (≥80% of scheduled RLAI injections received within 5 days of the scheduled date) and psychiatric hospitalizations. RESULTS: Among 506 patients recruited from 36 centres, the hospitalization rate was 32.5 per 100 person-years. 15 centres treating 243 patients were IMAP compliant and 21 centres treating 263 patients were not. IMAP compliance was associated with lower psychiatric hospitalization rates (crude RR: 0.64 [95% CI: 0.44-0.93]; adjusted RR: 0.78 [95% CI: 0.47-1.27]). Nearly 75% of patients were adherent to RLAI. While patient adherence had little impact on hospitalization rates (adjusted RR: 0.92 [95% CI: 0.59-1.44]), IMAP compliance was more effective among non-adherent (adjusted RR: 0.45 [95% CI: 0.16-1.28]) than adherent (adjusted RR: 0.88 [95% CI: 0.51-1.53]) patients. CONCLUSIONS: IMAPs may improve patient adherence and reduce psychiatric hospitalizations, particularly among patients with difficulties adhering to LAI antipsychotics.

Validity of the CAGE questionnaire in schizophrenic patients with alcohol abuse and dependence.

The objective of the study was to assess the sensitivity and the specificity of the CAGE questionnaire in 114 schizophrenic patients. The Composite International Diagnostic Interview was used to assess the DSM-III-R diagnosis of abuse of or dependence on alcohol. The CAGE questionnaire can be reliably used to assess alcohol use disorders in schizophrenic patients: with a cutoff score of 1 or more, the sensitivity of the CAGE questionnaire was 0.91 and the specificity was 0.83. With a cutoff score of 2 or more, the sensitivity of the CAGE questionnaire was 0.82 and the specificity was 0.94. The post test probabilities (PPV) were high (PPV1=0.74; PPV2=0.85) compared to the primary probability of alcoholism (29.8%).