Treatment of anxiety disorders in the Finnish general population
Sinikka Sihvoa,⁎, Juha Hämäläinenb,c, Olli Kiviruusuc,
Sami Pirkolac,a, Erkki Isometsäc,d
aSTAKES (National Research and Development Centre for Welfare and Health, P.O. Box 220, 00531 Helsinki, Finland
bHelsinki City Department, Eastern Health Centre, Department of Psychiatry, Finland
cNational Public Health Institute, Department of Mental Health and Alcohol Research, Helsinki, Finland
dUniversity of Helsinki, Department of Psychiatry, Helsinki, Finland
Received 26 January 2006; received in revised form 12 May 2006; accepted 13 May 2006
Available online 22 June 2006
Background: Treatments for anxiety disorders in the general population are not widely investigated. We determined the proportion,
type and determinants of treatment in the Finnish general population.
Methods: Within the Health 2000 Study, a representative sample (n=6005) of adults (age>30 years) were interviewed in 2000–
2001 with the Composite International Diagnostic Interview (M-CIDI) to assess the presence of DSM-IV mental disorders during
the preceding 12 months. Logistic regression models were used to examine factors influencing the type of treatment
(pharmacotherapy and/or psychological treatment) and also the types of pharmacotherapy (antidepressants, anxiolytics, or sedatives
and hypnotics) used for anxiety disorders.
Results: For individuals with an anxiety disorder, 40% (95/229) currently used psychotropic medication, 23% (55/229) used
antidepressants, 19% (44/229) anxiolytics and 17% (41/229) sedatives or hypnotics. Of those using health care services for mental
health reasons (34%, 76/229), 80% (61/76) received pharmacotherapy. Only 45% (34/76) reported having psychological treatment,
with few having more than 4 visits (27%, 20/76). Living in a semi-urban environment, retirement and high perceived disability
increased the likelihood of pharmacotherapy-only treatment; higher education and comorbidity with mood disorders increased the
likelihood of psychological treatment. General practitioners more often than psychiatrists provided pharmacotherapy treatment
alone (67% vs. 34%, p<0.05), particularly anxiolytics or sedatives.
Limitations: Use of mental health services and psychological treatment were based on self-reports. No data on duration of
pharmacotherapy was available.
Conclusions: Anxiety disorders remain largely untreated in the general population. Among those seeking treatment,
pharmacotherapy predominates, whereas even brief psychotherapies are rare. Contrary to clinical guidelines, anxiolytics and
sedatives are commonly used instead of antidepressants.
© 2006 Elsevier B.V. All rights reserved.
Keywords: Anxiety disorders; Psychotropics; Antidepressants; Anxiolytics; Population-based survey
Anxiety disorders vary in the general population with
12-month prevalence estimates ranging from 2.4% in
Shanghai to 18.2% in the United States (The WHO
Journal of Affective Disorders 96 (2006) 31–38
E-mail address: email@example.com (S. Sihvo).
0165-0327/$ - see front matter © 2006 Elsevier B.V. All rights reserved.
World Mental Health Survey Consortium, 2004).
According to the ESEMeD study within six European
countries, the 12-month prevalence was 6.4% (The
ESEMed/MHEDEA 2000 Investigators, 2004a), where-
as in the most recent systematic review involving studies
conducted in 16 European countries, it was estimated at
12% (Wittchen and Jacobi, 2005). Although data from
different countries are not fully comparable, these
studies show that anxiety disorders rank as the most fre-
quent group of mental disorders in Western countries.
Yet, population-based studies have shown that anxiety
disorders frequently remain untreated (Young et al.,
2001; de Graaf et al., 2002; Issakidis and Andrews,
2002; Olfson et al., 2004; Wang et al., 2005).
of use of services for them are well documented, less is
known about the content and quality of specific
treatments. According to The ESEMeD/MHEDEA
2000 Investigators (2004b), a third of individuals with
anxiety disorder had used psychotropic drugs during the
preceding 12 months. A US study suggests that
pharmacotherapy is becoming more common in outpa-
tient care, whereas the use of psychotherapeutic treat-
ments is declining (Olfson et al., 2004).
There are some evidence-based guidelines and other
expert statements on the treatment of anxiety disorders
(Balwin et al., 2005), panic disorder (The American Psy-
chiatric Association (APA), 1998; National Institute for
Clinical Excellence (NICE), 2004), generalised anxiety
disorder (NICE, 2004; Ballenger et al., 2001), post-
traumatic stress disorder (American Psychiatric Associa-
tion, 2004; NICE, 2005a) and obsessive-compulsive dis-
panic disorder exists, based on an expert panel meeting
(Duodecim, 2000). In general, guidelines consider the use
of cognitive behaviour therapy and pharmacotherapy as
equally effective treatments and recommend by way of
pharmacotherapy mainly selective serotonin reuptake
inhibitors (SSRIs) as the first-line treatment (APA, 2004;
Duodecim, 2000; Balwin et al., 2005). In the NICE
guideline for panic disorder (1998), antidepressants are
considered as the only pharmacological intervention to be
used in longer-term treatment, while benzodiazepines
should not be used in the treatment of individuals with
panic disorder. Other guidelines limit their use only in
situations when very rapid control of symptoms is needed
(APA, 1998) or for persistent, severe cases with non-
response to at least two treatments (SSRI or psychological
treatment) (Balwin et al., 2005).
The aim of this study is to determine the proportion of
individuals in the general adult population with anxiety
disorders receiving treatments (pharmacotherapy and/or
psychological treatment).Secondly,the aim istoexamine
clinical, sociodemographic, and provider-related corre-
lates of the type of treatment (pharmacotherapy and/or
psychological treatment), and thirdly, to examine the cor-
relates of pharmacotherapy (antidepressants, anxiolytics,
hypnotics or sedatives). Finally, we examine users' per-
ception of the helpfulness of the received treatment.
This study is based on a comprehensive, multidisci-
plinary national population-based survey, Health 2000,
conducted in Finland from 2000 to 2001. The two-stage
and over (N=8028). Subjects aged 80 or over were over-
sampled (2:1) in relation to their proportion in the popu-
lation (90% participation rate). Data were collected by
home interviews and examinations, telephone interviews
and health questionnaires, followed by clinical health
examination (in which 79.7% participated, i.e. 6354
subjects), including a structured mental health interview
attended at least one or other phase of study, 5.2% refused,
0.4%were abroadand1.4%were notcontacted.AFinnish
(M-CIDI) was used (Wittchen et al., 1998). The CIDI was
performed with 6038 subjects (95% of those attending the
comprehensive health examination phase), of whom 33
were excluded due to obvious reasons of unreliability (e.g.
mental retardation, self-expressed intention to lie), leaving
6005 valid interviews. A separate, supplementary inter-
was performed, giving excellent Kappa values. Details of
the methodology of the project, including training of the
mental health interviewers have been published elsewhere
(Aromaa and Koskinen, 2004; Pirkola et al., 2005).
With the M-CIDI, estimates were made for the 12-
month prevalence of anxiety disorders (generalized an-
xiety disorder, agoraphobia, social phobia, and panic
disorder with or without agoraphobia). By combining
information from SCID interviews and case notes in a
separate continuation study for Health 2000, we were
able to identify and exclude those persons who were
diagnosed as having current psychotic disorder during
Respondentswere asked whether they had used health
services for mental health reasons during the preceding
12 months, about the treatment setting, number of visits
and who was the provider. The providers were classified
32 S. Sihvo et al. / Journal of Affective Disorders 96 (2006) 31–38
into specialised mental health care services (including
municipal psychiatric outpatient clinics, mental health
centres, private psychiatrists and psychiatric hospitals)
and general level mental health care services (including
outpatient service units and other rehabilitation clinics).
Use of pharmacotherapy as a part of treatment was eli-
cited, as was the provision of psychological treatment.
The perceived psychological treatment was defined as
“treatment including discussion or psychotherapy (you
met at least once a week over a period of 1 month)”. This
was cross-tabulated with number of visits and only those
reporting more than four visits during the preceding
psychological treatment. In the case of comorbid disor-
ders, it was not possible to discern to which disorder the
treatment was specifically given. The perceived helpful-
ness of the treatment was also elicited.
Data on the current use of psychotropic medication
was collected and checked during the home interview by
the interviewer either from the drug container or from the
prescription form. The analysis includes all recorded
prescriptions of antidepressants (ATC: N06A), anxioly-
tics (N05B) and sedatives and hypnotics (N05C). In the
logistic regression models, anxiolytics and sleeping
remedies were combined.
2.2. Explanatory factors
Information about diagnosis, onset of disorders and
perceived disability were retrieved from CIDI interviews
as well as information about the comorbidity of anxiety
disorders and mood and alcohol use disorders. Socio-
demographic data (age, sex, marital status, education,
current employment status and living environment) were
collected during the home interviews. Information about
somatic long-term illnesses and smoking was also in-
cluded in the analysis.
2.3. Statistical methods
Cross-tabulations with chi-square test and logistic reg-
ression analyses while adjusting for age and sex were first
performed to examine factors related to the selection of
treatment (psychological treatment with or without phar-
macotherapy or pharmacotherapy only) and type of medi-
cation (antidepressants, anxiolytics or sedatives and
hypnotics). Multivariate logistic regression was then used
to analyse the impact of different independent variables on
received treatment when entered simultaneously into the
models. Statistically non-significant variables were re-
The interactions and collinearity of the variables were
checked by cross-tabulations of variables and a correlation
matrix. No correlations of >0.4 were found, except for an
age-work status correlation of 0.41. Statistical analyses are
used in the analyses (with SVY commands), which can
take account of a complex sampling design.
Individuals with anxiety disorder (4.1%, 229/6005)
had used some health care services during the preceding
12 months more often than respondents without anxiety
disorder (84% vs. 73%, p<0.001, 6.7 visits vs. 4.2 vi-
sits), though only 33.5% reported that they had used
services for mental health reasons (Table 1). The use of
services for mental health reasons was most common
among those with social phobia or GAD and least com-
mon among individuals with panic disorder. Of those
using mental health services, 80% (61/76) used psycho-
tropic medication. A total of 45% (34/76) reported
that their treatment included discussions or psycho-
therapy, and 27% (20/76) of those reporting having
psychotherapy had more than four visits during the
Use of health services and type of treatments received among persons with anxiety disorder (%)
Treatments among persons with mental health consultation
Drug only Psychological treatment onlycDrug and psychological treatment None
Any anxiety disorder 228 84.3
Table format adapted from ESEMed/MHEDEA 2000 Investigators (2004c) and Wittchen and Jakobi (2005).
aHas visited a doctor during past 12 months.
bHas used health care services during past 12 months for mental health reasons.
cPerceived psychological support.
33 S. Sihvo et al. / Journal of Affective Disorders 96 (2006) 31–38
preceding 12 months, and 20% (15/76) had 10 or more
visits. Individuals with social phobia or agoraphobia
reported more often having had treatment that included
both medication and psychological treatment. Those
with panic disorder were somewhat more likely to report
that their treatment did not include either medication or
psychological support (Table 1).
3.1. Determinants of received treatment (pharma-
cotherapy vs. psychological treatment)
High perceived disability, living in a semi-urban area
and retirement increased the likelihood of pure pharma-
cological treatment for anxiety disorder, while older age
(>65 years) decreased the likelihood (Table 2). Treatment
that included psychological support alone or with me-
dication was more common among those with higher
education, with high perceived disability, with comorbid
major depressive disorder or dysthymia, and among those
who had made visits to specialised mental health care, i.e.
had visited a mental hospital, an out-patient mental health
care unit or a private psychiatrist (Table 2). In the multi-
or dysthymia and having a higher educational level
In the multivariate model, psychological treatment was
also related to the residual category of being a student or
working at home, or other not easily classified category.
Factors related to received treatment among persons with anxiety disorder who have contacted mental health services during past 12 months, odds
ratios and their 95% confidence intervals
Medication only (n=32) Psychological treatment (n=34)a
In full-time work
Other: student, at home, other
1.19 (0.51, 2.77)
0.72 (0.19, 2.70)
0.45 (0.09, 2.15)
0.91 (0.35, 2.35)
0.32 (0.04, 2.66)
0.09 (0.01, 0.65)
2.18 (0.51, 9.24)
4.77 (1.22, 18.68)
3.86 (0.67, 22.13)
10.30 (1.82, 58.43)
2.86 (1.11, 7.40)
1.53 (0.56, 4.18)
3.50 (1.07, 11.50)
1.31 (0.40, 4.22)
1.89 (0.62, 5.81)
6.16 (1.82, 20.85)
1.26 (0.37, 4.38)
5.19 (1.31, 20.50)
1.47 (0.42, 5.14)
0.97 (0.20, 4.78)
2.58 (0.62, 10.83)
1.39 (0.31, 6.22)
1.32 (0.25, 7.11)
6.54 (1.03, 41.44)
Not at all/somewhat
A lot/very much
Major depressive disorder
Level of care
Specialty mental health care
2.92 (1.27, 6.73)
3.11 (1.14, 8.48)
3.01 (1.04, 8.78)
6.56 (2.43, 17.70)
3.73 (1.34, 10.37)
8.56 (2.60, 28.19)
5.70 (1.45, 22.43)
Not includedNot included
6.59 (1.37, 31.81)
Variables not statistically significant in univariate or multivariate models are not shown in the table: sex, marital status, smoking, long-term somatic
illness, severity of anxiety disorder (mild, moderate, severe), more than one anxiety disorder, alcohol use disorder, time from onset.
aPerceived psychological treatment (may include also medication).
bModel 1=impact of single factor after adjusted for age and sex, users in the group are compared to all other persons with anxiety disorder
(n=229), use of medicines at the time of the interview.
cModel 2=all variables entered simultaneously, then removed in the order of least significant.
34S. Sihvo et al. / Journal of Affective Disorders 96 (2006) 31–38
The received treatment varied according to the pro-
vider: pharmacotherapy-only treatment was more com-
mon when the provider was a general practitioner (GP)
than a psychiatrist (67% (14/21) vs. 34% (14/41),
p<0.05). The trend was similar in all subtypes of anxiety
disorder except in social phobia where GPs and
psychiatrists provided medication-only treatment at the
same frequency. Due to the small number of patients in
subgroups, statistical significances were unobtainable.
When psychological treatment was given, the provider
was in most cases a psychiatrist, though the receipt of
psychological treatment was not related to whether a per-
son visited public or private sector services.
3.2. Use and determinants of pharmacotherapy
Of the respondents with anxiety disorder, 40% (95/
229) used psychotropics at the time of the interview.
Antidepressants were used by 23% (53/229), anxiolytics
by 19% (44/229) and sedatives or hypnotics by 17% (41/
229). Concomitant use of these was common: 40% (23/
95) used drugs from at least two groups and 16% (13/95)
used drugs from all these three drug groups.
Table 3 shows the separate logistic analyses of factors
related to the selection of drug group among individuals
with anxiety disorder. In the multivariate model for pure
antidepressive medication, only major depressive
Factors related to the use of different psychotropic medication among persons with anxiety disorder, odds ratios and their 95% confidence intervals
Antidepressant and anxiolytics/
In full-time work
Student, at home, other
1.53 (0.51, 4.62)
1.77 (0.41, 7.61)
1.05 (0.20, 5.51)
1.53 (0.63, 3.70)
0.31 (0.04, 2.55)
5.72 (2.13, 15.37)
1.47 (0.65, 3.37)
1.14 (0.34, 3.89)
0.76 (0.20, 2.90)
2.21 (0.69, 7.06)
1.17 (0.12, 11.91)
1.95 (0.55, 6.87)
0.92 (0.34, 2.49)
0.47 (0.08, 2.60)
0.73 (0.23, 2.32)
3.06 (1.28, 7.31)
1.66 (0.29, 9.37)
1.24 (0.41, 3.69)
1.21 (0.25, 5.87)
3.02 (1.01, 8.97)
0.84 (0.23, 3.08)
1.18 (0.46, 3.02)
0.77 (0.21, 2.77)
1.04 (0.39, 2.77)
0.30 (0.03, 2.44)
0.79 (0.18, 3.50)
0.62 (0.07, 5.20)
0.88 (0.26, 2.92)
2.17 (0.74, 6.38)
0.56 (0.07, 4.66)
3.86 (1.41, 10.56)
5.27 (1.71, 16.21)
0.64 (0.08, 5.35)
Not at all/somewhat
A lot/very much
Anxiety, >1 diagnosis
Alcohol use disorder
Major depressive disorder
Level of care
0.91 (0.28, 3.01)
1.75 (0.52, 5.89)
0.82 (0.34, 1.94)
1.00 (0.39, 2.62)
2.54 (0.89, 7.28)
3.22 (1.06, 9.77)
2.11 (0.76, 5.87)
1.32 (0.61, 2.85)
3.28 (1.40, 7.68)
0.36 (0.05, 2.83)
1.35 (0.26, 6.99)
2.62 (1.00, 6.85)
2.14 (0.71, 6.44)
0.56 (0.16, 1.97)
1.58 (0.49, 5.02)
0.97 (0.42, 2.25)
0.98 (0.37, 2.62)
6.49 (2.76, 15.26)
3.13 (1.08, 9.08)
2.24 (1.04, 4.80)
3.28 (1.42, 7.57)
0.97 (0.22, 4.34)
4.36 (1.24, 15.31)
3.31 (1.06, 10.32)
Logisticregression, each variableexaminedseparately after adjustedfor ageand sex,usersin the group arecompared to all otherpersons withanxiety
disorder (n=229), use of medicines at the time of the interview.
Variables not shown in the table (statistically non-significant in all groups): sex, education, smoking, long-term somatic illness, time from onset.
35S. Sihvo et al. / Journal of Affective Disorders 96 (2006) 31–38
disorder remained significant when variables were
entered to the model simultaneously (OR 3.18, CI 1.18,
8.54). Use of anxiolytics or sedatives/hypnotics was re-
lated to being retired (OR 5.64, CI 2.46, 12.90) and nega-
tively related to the 55–64 age group (OR 0.11, CI 0.01,
0.96 when compared to those aged <45). The concom-
itant use of antidepressants with anxiolytics or sedatives/
hypnotics was explained in the multivariate model by
having more than one anxiety disorder diagnosis (OR
4.56, CI 1.80, 11.58) and high perceived disability (OR
3.25, CI 1.61, 8.58).
3.3. Perceived helpfulness of treatment
The majority (61%) of individuals with anxiety dis-
order who had used mental health care services during
the preceding 12 months thought that the care had been
quite or very helpful (Table 4). Individuals with panic
disorder found the care helpful most often. Those with
GAD or agoraphobia felt more often than others that the
treatment received had helped only a little or not at all.
Neither the provider (GP vs. psychiatrist) nor the type of
treatment (pharmacotherapy-only vs. pharmacotherapy
with psychological treatment or antidepressant vs. ben-
zodiazepines) had statistically significant effects on per-
ceptions of whether the received care was considered
This was the first study from Finland examining at a
We found that despite a majority contacting health care
services for some reason, anxiety disorders remained
typically untreated, or were not likely to be treated in
accordance with guidelines. Results showed that phar-
(80%) of those contacting health care for mental health
macotherapy alone was more likely when a person was
treated by a general practitioner. Only 6.7% received
psychotherapy without medication.
Some 40% of those with anxiety disorder currently
used psychotropic medication, which is more than is
found in population-based comparative studies from
European countries (O'Hayon and Lader, 2002; The
ESEMed/MHEDEA 2000 Investigators, 2004b) or
among the US population (Young et al., 2001). Anti-
depressants were only slightly more often utilised than
anxiolytics or hypnotics/sedatives. And anxiolytics were
commonly used in treatment, although their adverse ef-
fects, such as dependence and withdrawal symptoms, are
well known. Results were similar in earlier European
studies (O'Hayon and Lader, 2002; The ESEMed/
MHEDEA 2000 Investigators, 2004b). General practi-
tioners more often prescribed anxiolytics and sedatives/
hypnotics, which supports the finding of O'Hayon and
are used to treat older people with sleeping problems.
A total of 45% of all those who sought mental health
care treatment reported “discussion or psychotherapy” as
being part of the treatment, and the proportion decreased
to only 27% when we took into account whether they
had reported at least four visits during the preceding
has been applied by Young et al. (2001) for the minimum
level of appropriate counselling. However, Wang et al.
(2005) expected >8 visits lasting >30 min to meet the
criteria for minimally adequate treatment. The estimation
type and quality of psychological treatment often remains
unknown, as in our study. Psychological treatment was
nearly always combined with pharmacotherapy, and only
treatment. However, the proportion of psychological
treatment alone or with pharmacotherapy was similar to
thatfoundinother Europeancountries (about46% inThe
ESEMed/MHEDEA 2000 Investigators, 2004c). There
are signs that the level of received psychotherapy is also
that 61% of outpatients received psychotherapy/mental
health counselling in 1987, but only 48% in 1999.
Comorbidity with major depressive disorder or
dysthymia increased the likelihood of having care that
included psychological treatment, as has been found
previously (Young et al., 2001). This result suggests that
those who are more severely ill receive more compre-
hensive treatment options. There were also signs of
potential inequality in the service system, since receiving
Perceived helpfulness of treatment among users of health care services
for mental health reasons with anxiety disorder (%)
“Has the care you
have received been
helpful to you?”
Quite a lot
not at all
100***100** 100100 100
x2test, **p<0.01, ***p<0.001, comparison is made between a
subgroup and other users of mental health care services with anxiety
36S. Sihvo et al. / Journal of Affective Disorders 96 (2006) 31–38
psychological treatment was most strongly explained by
higher education, whereas retired people (though not ne-
cessarily older) received pharmacotherapy only more
In specific regard to psychotropic treatments, comor-
bidity with depressive disorder was also associated with
current antidepressant-only medication. It is possible that
antidepressant treatment was primarily for the treatment
depression receives better treatment. Similarly, it remains
unclear whether the interviewee sought treatment primar-
ily for anxiety, depression or both.
In contrary to most other similar studies (Issakidis and
Andrews, 2002; Wang et al., 2005), patients with panic
disorder did not use mental health services more often
than other patients with anxiety disorder. Neither did they
use health care services in general more. In our sample,
the perceived health status of those with panic disorder
was better than for respondents with other anxiety
disorders. That individuals living in semi-urban environ-
ments received pharmacotherapy-only treatment more
often than individuals living in cities cannot be easily
explained and needs further exploration.
More than half of persons with anxiety disorder who
care had been helpful. However, nearly a quarter felt that
they had not received the help they needed. Those with
panic disorder perceived the care as most often helpful,
whereas those with GAD found the care least helpful.
impact on the perceived helpfulness of treatment or
whether the care was pharmacotherapy alone or a combi-
nation a psychological treatment. Neither was there any
perceived effect when the received medication was an
antidepressant, or anxiolytics or sedatives/hypnotics. The
differences inperceived helpfulness ofthe provided treat-
ment could at least partly be due to the nature of different
anxiety disorders. Perhaps, the control of panic attacks is
more rapidly achieved and relieved with any treatment
than an alleviation of the symptoms of GAD.
This study has several strengths and limitations that
should be taken into account. First, this was a nationwide
study and results can be generalised to the whole Finnish
adult population. The prevalence estimates are not di-
rectly comparable internationally since some disorders
were left out from either the CIDI interviews (specific
phobia, obsessive-compulsive disorder, post-traumatic
stress syndrome). The exclusion of specific phobias con-
tributes in particular to the relatively low prevalence
found, since they are among the most prevalent anxiety
disorders worldwide (Wittchen and Jacobi, 2005).
treatments. Another problem is that not all individuals
with anxiety disorder who used psychotropic medication
report that they have used health care services for mental
health reasons. It is likely that the use of specialist level
services is therefore somewhat overestimated and those
individuals who visit GPs for somatic and psychological
reasons prefer to consider these visits as “somatic”.
Clearly, the survey question on psychotherapeutic treat-
ment was confusing to the respondents and gave overes-
timations of received psychological treatment: “Did your
care include discussion or psychotherapy (you met over a
period of over one month at least once a week)”.
To conclude, the results showed that individuals with
anxiety disorder used health care services more than the
general population, thus providing an opportunity to
make a diagnosis and start treatment, if necessary. How-
ever, only a third reported using health care services for
mental health reasons. Yet, when health care services are
used for mental health reasons, the treatment is not per-
ceived as being so helpful, suggesting there is room for
pharmacotherapy oriented. Cognitive behavioural ther-
apy has recently become an increasingly favoured
treatment of anxiety disorders (NICE, 2004). In Finland,
only a minority of the psychotherapists are qualified to
provide CBT. Therefore, the possibilities for patients
with anxiety disorders to choose their treatment pre-
ferences, especially in the public sector, are quite limit-
ed. Further, in an era of increasing health care costs, a
tendency to prefer a less costly pharmacotherapeutical
treatment is likely. In this situation, emphasis should be
putonensuringthat theuseofpsychotropic treatmentsis
at least based on current evidence-based knowledge.
The study was financially supported by the Academy
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