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Andrea Yates: where did we go wrong? (Pediatric Ethics, Issues, & Commentary).

Questions

The Andrea Yates case brings into sharp focus questions about the United States as a nation. Do we or don't we assure mental health treatment for those who need it? Do we or don't we assure appropriate sentencing of the mentally ill? Do we provide nondifferential gender treatment for mental illness in the medical and legal communities? Do individuals with mental illness and postpartum depression receive adequate health care treatment by physicians and insurers? Is justice served by jailing a mentally ill person who cannot distinguish between right and wrong? Is it useful to punish someone in jail who is mentally ill? Does a guilty but insane verdict permit justice to be served? Why was an individual like Yates released from the hospital in a severely depressed state? Did health care providers sufficiently inform her family about her condition and risks? The Yates trial demands a clear and frank evaluation of U.S. public policy.

Answers

Our nation entwines mental illness with stigma and impedes medical progress. Postpartum depression screening and information appears inadequate. Mental health parity legislation is difficult to pass Congress. Children are killed by child abuse and neglect every day, by both men and women who walk away from child rearing responsibilities, but we read very little about their deaths. Yet the media dwells on women who kill their children even if they are mentally ill. What changes are needed to improve the health and legal system to more adequately address these issues? Each component of this multifaceted issue is examined.

Postpartum Depression

The American Psychiatric Association (APA, 2001) states that postpartum depression can be caused by changes in hormones and can be inherited; that about one in ten new mothers experience some degree of postpartum depression; that symptoms can include fatigue, feelings of hopelessness or depression, disrupted sleep or appetite, lack of interest in the baby, fear of harming the baby and mood swings. They state (APA, 2001) that infanticide is most often associated with postpartum psychotic episodes characterized by command hallucinations to kill the infant, but can occur without specific delusions or hallucinations; and that the risk of these episodes, as in Andrea Yates's case, is particularly increased with prior postpartum mood episodes and elevated for women with a history of mood disorders. The APA relates that once a woman has a postpartum episode with psychotic features, her risk of recurrence is 30-50% with each delivery.

Mental Health Parity in Insurance

Parity for insurance benefits to treat mental illness was defeated last year in Congress by the business and insurance community but has been revived again in the House of Representatives. The House of Representatives has blocked efforts to advance parity legislation, but on March 13, the Subcommittee on Employer-Employee Relations of the Education and Workforce Committee held its first-ever hearing on parity (MHP, 2002). The bill introduced by Representatives Marge Roukema (R-NY) and Patrick Kennedy (D-RI) mirror the provisions of S. 543, the "Mental Health Equitable Treatment Act" (MMHMA, 2001). It would prohibit group health plans from imposing treatment limitations or financial requirements on the coverage of mental health conditions unless comparable limits are imposed on medical and surgical benefits. It would exempt small businesses with up to 50 employees, allow health plans to utilize the full range of managed care mechanisms to contain cost, and does not require parity for services a plan member might seek outside of the plan's network of providers (MHETA, 2002). Opponents have attacked provisions that disallow discrimination among diagnoses, stating it would require treatment for the unhappy well, but the legislation applies only to "medically necessary" services (MHETA, 2002).

Legal Definitions of Insanity

The word insane is a legal term. Research has identified many different mental illnesses of varying severities. The vast majority of individuals with mental illness would be "sane" if current legal tests were applied. The insanity defense is also rarely used. A 1991 study by the National Institute of Mental Health (APA, 1991) found that the insanity defense was used in less than one percent of cases. Even if an individual is found guilty by reason of insanity, they are committed to an institution for the mentally ill and released after a hearing determines that they are no longer a danger to themselves or others. It is also reported in studies that individuals are held as long or longer in institutions than those found guilty and sent to prison for similar crimes (APA, 1991). In Connecticut, if the insanity defense is successful, the judge determines the amount of time the person would have been incarcerated for (had they been sane) and in addition the state review board has control over the individual once that original conviction period ends (APA, 1991).

Each state and the District of Columbia has its own insanity defense statute. According to the American Psychiatric Association Statement on the Insanity Defense, about half of the states have adopted a test written during the 1950s by the American Law Institute. This test states that a person would "not [be] responsible for criminal conduct if at the time of such conduct as a result of mental disease or defect he lacks substantial capacity either to appreciate the criminality (wrongfulness) of his conduct or to conform his conduct to the requirements of law" (APA, 1991).

A third of the states use some variation of the narrower M'Naughten Rule derived from English case law which states that a person is "innocent by reason of insanity" if "at the time of committing the act, he was laboring under such a defect of reason from disease of the mind as not to know the nature and quality of the act he was doing, or if he did know it, that he did not know what he was doing was wrong" (Moenssens, Inbau, & Becigal, 1992). Six states have modified this rule to add a reference to "irresistible impulse" (APA, 1991). Two states, Montana and Idaho, have abolished the defense (APA, 1991).

Texas and the Insanity Defense

Texas uses a form of the M'Naughten test. The insanity defense is set forth in Texas Penal Code (TPC) Section 8.01 in two parts: (a) It is an affirmative defense to prosecution that, at the time of the conduct charged, the actor, as a result of severe mental disease or defect, did not know that his conduct was wrong; (b) The term "mental disease or defect" does not include an abnormality manifested by repeated criminal or otherwise antisocial conduct.

The M'Naughten test restricts psychiatric testimony to the narrow scope of a defendant's cognitive capacity and frequently makes it impossible for expert witnesses to describe the complete picture of the defendant's mental illness (TCPOMIa). The M'Naughten test focuses on whether the accused knew the difference between right and wrong at the time of the offense. Mental illness may leave an individual's cognitive capacity intact but the mental illness can affect the person's emotions to the point where the person cannot completely control his or her behavior. In Texas, the "wrong" referred to in the above statute means legal wrong--whether the defendant knew that his or her conduct was legally wrong (TCPOMIb).

Women, Mental Illness and The Court System

Women and depression. Antidepressant therapy has been shown to significantly lower the rate of recurrence of postpartum depression (Wisner & Wheeler, 1994). Symptoms, side effects and the decision to breastfeed determine which antidepressant will be utilized (Kruckman & Smith, 2002). Immediate responses may not be seen either. It may take one to three weeks for the drugs to take effect (Jermain, 1995). Psychotropic drugs are excreted in breast milk and must be used with caution (Jermain, 1995). The symptoms of postpartum depression appear anywhere from three days to one week after delivery. The four to six week postpartum check-up may be too late to identify severe cases or women at risk, such as Andrea Yates (Hickey, Boyce, Ellwood, & Morris-Yates, 1997). Treatment of depression and other mental illness can be problematic due to the desire to breast-feed, shifting hormone changes, sleep deprivation and even required follow-up visits due to balancing a new baby and time to see medical professionals.

It was also revealed in the Andrea Yates' case that she had been discharged early from the hospital, and that her husband voiced his concerns that she was too sick to come home (Larry King Live, 2002). Whether lack of insurance parity was a crucial factor is not known. Rusty Yates has discussed his frustration with their insurance company and the amount of time and services covered (Larry King Live, 2002). She had difficulty with follow-up visits to psychiatrists due to her responsibility for caring for children. If appropriate care for women who experience postpartum depression turns on the ability to have time to go for care and manage appropriate medications while caring for children and breast-feeding, the medical community must address these particular needs of this population.

Women and criminal sentencing. Kathleen Daly, a professor of law, found no gender differences when examining differences in criminal sentencing (Daly, 2001). A varying factor that should be examined is whether women's sentences differ in extenuating circumstances, such as women diagnosed with mental illness in cases where domestic violence has occurred over many years.

The judicial system is also currently grappling with the question of whether it is appropriate to treat (sometimes forcefully) an individual with medication for their mental illness so they will be "sane" at the time of trial and can actively participate in their defense (Riggins vs Nevada, 1992). The American justice system and the attorney's code of ethics require that a defendant agree with his or her attorney on the direction and specifics of their defense and understand what is being said at trial. It was reported that Andrea Yates received heavy doses of Haldol and at times appeared to be in a trance during the trial. How much Yates participated in her defense becomes questionable. It is at times ironic that the American justice system would forcefully treat an individual with medications to treat his or her mental illness so the court can prove he or she is not insane and put the individual to death (ACLU, 2001).

As previously stated, the M'Naughten test restricts psychiatric testimony to the narrow scope of a defendant's cognitive capacity and can prevent the complete picture of the defendant's mental illness and state--so crucial in the Yates' case. The M'Naughten test strategy must then focus on whether she knew the difference between right and wrong at the time of the offense and whether she knew her conduct was legally wrong. It is reported that she believed her children were damned and would burn in hell, that she was marked by the devil and pulled her hair to find the number 666 and walked in circles endlessly. The M'Naughten test comes from Medieval England and may no longer be appropriate for examining mental illness today or may need revision. Yates believed that by killing her children that she was "saving" them. What was "legally" wrong at that time (killing) may not have occurred to her, only that the right thing was to kill them to save them. It does not appear to be the act of a sane individual to kill someone to save them, but unfortunately the legal standard in Texas disallowed this entire picture of her mental thinking to be admitted for consideration. Alternatively, we must protect society from individuals who are clearly mentally ill and could commit heinous crimes.

Next Steps

It appears that in the Yates' case, the criminal justice and health care system failed her. What are the next steps that can be done by health professionals to prevent future failures like Andrea Yates as it pertains to detection of postpartum depression and appropriate treatment?

* Screening must improve to detect and refer postpartum cases (Edebohls & Ecklund, 2002; Walther, 1997)

* Midwives, family nurse practitioners, obstetricians and mental health professionals must be involved to screen, refer and treat patients

* Education about depression and postpartum depression must take place for the general population and the stigma for seeking help for mental illness must be removed

* Parity legislation must be passed to assure that individuals receive adequate treatment

* Appropriate and adequate resources must be available so women can see health professionals

* Research must be conducted on the interaction of mental health drugs and hormone changes after pregnancy to arrive at the best treatment

* Discussion and possibly legal reform must take place if it is shown that women differ in the sentences they receive if other circumstances are present, such as mental illness

Pediatric Ethics, Issues, & Commentary focuses on exploring the interface between ethics and issues in clinical practice. If you have suggested topics or cases for consideration in the column, please contact Anita J. Catlin, DNSc, FNP; 230 Hillside Avenue, Napa, CA 94558; (707) 226-9002.

Table 1. Questions to Identify Potential Postpartum Depression

Nurses who know the questions to ask can recognize PPD and intervene early. These questions include:

1. Does the woman have a past medical history of mental illness? Depression? Bipolar disease? Anxiety?

2. Was there a history of maternity blues or previous postpartum depression?

3. Is there a history of prenatal anxiety, such as feelings of uneasiness, or apprehension concerning the pregnancy?

4. Was the pregnancy an obstetrical high-risk pregnancy?

5. Are there other life stresses such as marital or occupational changes or crisis?

6. Is there a lack of social support from immediate family or friends?

7. Are there hints of marital dissatisfaction, such as communication difficulties, lack of affection, disagreement of values, or a disparity in decision-making?

8. Does she tell you about stressful events related to child care?

9. Was this an unwanted or unplanned pregnancy?

10. Is the mother of low income or low educational level?

11. Is single parent status creating additional stress?

12. Is a short maternity leave preventing a relaxed entrance into the maternal role?

Commentary on Andrea Yates: postpartum depression: practical advice from two nurse practitioners.

Lynne Edebohls

Connie Ecklund

Postpartum depression is a depressive disorder occurring within the first 2 years after delivery, characterized by feelings of sadness, anxiety, perception of loss of control, despair, loneliness, and other symptoms similar to those of depression. It is not a temporary disorder like baby blues. Real postpartum depression may last for years and manifest itself in acute psychosis and detachment from reality.

Biological theories include sudden change in hormonal levels after delivery and disruption in chemical neurotransmitter concentrations in the brain. This theory is similar to other theories of depression. Women are at higher risk for postpartum depression (PPD) if they have preexisting mental health disorders, including depression and bipolar disorder. They are also at increased risk if there is a positive family history of mental illness.

Nurses on all levels and in all clinical areas can assist in assessing women for PPD by knowing the right questions to ask and then knowing where to refer the women for more information and more help. Nurses must raise their awareness to recognize women at increased risk for PPD or postpartum psychosis. With knowledge about behaviors that indicate PPD, nurses can be better equipped to recognize those women who need immediate intervention. Appropriate questions to ask are identified in Table 1.

Depressive behaviors may include frequent crying, insomnia, appetite changes, feelings of worthlessness, or little or no concern for personal appearance. There may be a decrease in energy or an inability to concentrate. A women may have feelings of hostility, irritability, anxiety, or loss of control, along with feelings of desperation, withdrawal and hopelessness. There are clues a woman may be reaching the edge. If a woman tells you that the baby is heavy; caring for the baby is too difficult; she has thoughts of harming herself; or she has strange thoughts about the baby, she may need immediate attention. Suicidal thoughts or thoughts about harming the baby warrant immediate intervention.

Assessing women for PPD is twofold, to help the women with her depression, and to safeguard adequately the new child and/or other children. Education of care providers who interact with young families is the first step to prevention. Many different nurses come into contact with new mothers in the first 2 years. Each type of nurse must make efforts to prevent cases of infanticide due to despair.

Nurses' Responsibilities

Midwives or prenatal nurse practitioners ideally begin the assessment for PPD prenatally. Assessment for pre-existing or past medical history of mental illness should be a part of the prenatal history. This would give allow the nurse time to educate the woman about this disorder and to gather resources for interventions should they be needed. Labor nurses and nurses in the postpartum unit or nursery may notice immediately that something is not right. Nurses in the hospital can begin the process as they are doing infant care teaching. They can get a sense of how a woman feels about the new baby: whether she feels happy about taking this baby home or if she is showing some apprehension. Discharge teaching begins as soon as the patient is admitted on the labor and delivery unit. As the new mother is inundated with verbal information and advice, it is helpful to include written material about the possibility of depression. The discharge nurse should go over the signs and symptoms of PPD and impress upon mothers that PPD is common and not a cause for shame. Every mother should leave the unit with an emergency phone number to call for help.

The office nurse may pick up signs at the postpartum visit. Pediatric nurse practitioners and office nurses who see babies for routine well child checks and immunizations have a perfect opportunity to assess the mother for PPD. It can be done formally by using the Edinburgh Postpartum Depression Scale (Cox, Holden, & Sagovsky, 1987) screening tool, the Beck Postpartum Depression Inventory (Beck, 1995), or key questions that can be adapted. The purpose of the tools is to get a sense of how the woman is feeling about this baby, her other children and her mental health status.

Clinic nurses in pediatric, family practice, and primary care clinics also need to follow up with screening the women as they continue the well child visits. Continuity in the screening process will avoid women slipping through the cracks and maternal/infant relationships can be saved. Home health and public health nurses visit new mothers, young mothers, or mothers at high risk for PPD or child abuse. This is an ideal time to observe the mother/child interaction and use the Edinburgh Postpartum Depression Scale. This will help home health and public health nurses identify women who need further intervention.

Often times the woman seeks health care after her 6 week postpartum checkup from women's health nurse practitioners. These health care providers should be aware that PPD can appear anytime in the first 2 years after delivery. It is essential to continue to assess the woman during this time period past the 6-week postpartum check up. Mental Health nurses also need to be aware of the risk of abuse, neglect and possible infanticide that PPD and postpartum psychosis may bring. They need to be educated about early warning signs and actions to take for immediate intervention.

Recognition and Prevention

Most important, the patient, the woman, needs to know what PPD depression is, how to recognize it, and how it can be treated. She needs to know that if she is unhappy after delivery of her baby, or if she does not feel this is the most joyful event of her life, she may have PPD. Help is right around the corner. Equally important are family members. They may be the first to notice a change in the woman before she notices a change in herself. Family members need to encourage women to get the help they need and may need to be in touch with the health care provider. The support of family during this time is essential.

To prevent further cases of infanticide we recommend that all nurses and health care professionals dealing with children seek further education about PPD in order to intervene successfully in a timely manner.

In Britain, postpartum depression is allowed as a defense for infanticide. British Broadcasting News Online's Kevin Anderson (2001) wrote "Like much of the legal and political system in the U.S., there are no uniform federal laws governing infanticide by a mother. Instead, laws differ on a state-by-state basis. The United States differs from many other Western countries in how it handles mothers who kill their infants, such as the case in Texas where a woman said she killed her five children. In England, postnatal psychosis is a defense for infanticide until a child is the age of two. Postnatal psychosis, an extreme form of postnatal depression that affects less than 1% of mothers, has been blamed for some two dozen babies' deaths in the U.S. in the last 20 years. Unlike U.S. defendants, however, in the vast majority of cases in other countries, women receive probation and counseling instead of jail terms."

Commentary on Andrea Yates: postpartum depression: voice from a historian.

Lauren Coodley

I began teaching human development to nursing students in the middle 1980s. If you were going to school then, you may have received photocopied handouts of feminist articles from one of your teachers. In those days, we were fierce with determination that we were going to stop the male medical establishment, stop them from pathologizing female behaviors that were products of the social environment. They had invented terms like "hysteria" and "postpartum depression" to make clinical what was a normal and realistic response to the limitations of women's social roles. Pioneering pamphlets like "For Her Own Good" by Ehrenreich and English reviewed 19th century nursing and medical history to develop a fresh and new analysis of these so called "illnesses."

Feminist thought opened a door to us; we envisioned that prior to proceeding with a new piece of medical or nursing research, one would ask "Is this good for women? Will it help us to better our conditions and our lives?" And for a good long while, it worked, and the conditions of women's lives, access to safe and aseptic abortion, and cooperative child care was the norm.

If you are a young nurse reading this essay, sadly, this will be new to you. All of this analysis has essentially been abandoned or forgotten during your education, as we did not manage to institutionalize feminist analysis into either the "master narrative" or into popular culture. Try as we did, Andrea Yates symbolizes everything that went wrong.

Andrea Yates is first and foremost a reminder of how profoundly feminist analysis has been forgotten, ignored, and disappeared by American popular culture. Andrea Yates. In 1976, the year I became pregnant, Adrienne Rich wrote the book that would become the guide for me and thousands of other young mothers: "Of Woman Born: Motherhood as Experience and Institution." This was THE book in which the author challenged the myths of "natural" maternal instinct. It dared to explore women's despair, their feelings of being trapped and helpless, and even the potential abuse or homicide of their children that could result. Through "Of Woman Born," I was prepared to face motherhood knowing that tenderness and anger could co-exist within me from the moment this demanding newborn was drawn out from my body.

"Of Woman Born" is now out of print. A new, and yet ancient, ideology now prevails: that women are naturally ready to be mothers; that any accidental pregnancy must be continued "for the sake of the child;" that women's careers can never be as satisfying as life at home with children; that women can be tamed by continual childbirth; and that "good" women are endlessly selfless and giving. Mothers are now "moms," and anyone who is not, is sorry. These are 19th century ideas, reified by Freud, defied by feminism, and rampant again everywhere. And so, Andrea Yates, and thousands of other women will abandon, neglect, abuse, and sometimes kill their children.

How Could the feminist analysis of childbearing have been so thoroughly forgotten? After Adrienne Rich there was Jane Lazere's "The Mother Bond," equally searing and honest, and even in the 1990s, Anne Lamott wrote a wry guide "Operating Instructions" to the very mixed emotions after childbirth. Yet, young journalists missed these evaluations of the maternal role, missed the possibility that all motherhood was not hearts and flowers, and turned instead to pseudo-psychology, at best, and sentimental cliches, at worst. "News" journalism became sensationalized gossip, rather than thoughtful analyses; women's talk shows, which promised so much at one time, degenerated into narcissistic narratives. And women's ambivalence about pregnancy and childbearing disappeared--whoosh--from all television time, which means, from all memory.

In every single television show in which a woman character becomes accidentally pregnant, she gives birth, or miscarries, but never does she choose abortion. This has created a vast cultural silence in which accidental pregnancy determines destiny, in which Andrea Yates' fate was sealed with each successive unwanted child. And after she killed her children, the silence continued, except insofar as her condition was reduced to that newly named pathology, "postpartum depression." As Adrienne Rich stated so eloquently a quarter century ago: what woman wouldn't be depressed when confronted with the 24-hour demands of an infant, sleep deprivation, disorientation, confusion, lack of personal time or space, and continued responsibility for shopping, cooking, and cleaning?

For my generation, our work became the haven that delivered us from this chaos. For poor Andrea, there was no work outside of the family, no feminist theory to validate her confusion and depression, only Christian theology to decree that this was her only fate. There will be hundreds more like her, because the voices of feminism have been silenced, forgotten, and diminished. That is her tragedy, and it is also ours.

References

ACLU. (2001). American Civil Liberties Union statement: ACLU Criticizes Death Penalty Prosecution of Andrea Yates, Renews Call for Moratorium on Flawed System, August 31, 2001. Available online at: www.aclu.org/news/2001.n083101b

APA. (2001). Fact Sheet: Postpartum Depression. American Psychiatric Association (APA). Washington, DC, July 2001.

APA. (1991). American Psychiatric Association. The Insanity Defense. Public Information at website www.psych.org/public_info/insanity.cfm (and as reported in the Bulletin of the American Academy of Psychiatry &the Law. 1991; Vol. 19, No. 4).

Edebohls, L., & Ecklund, C. (2002). Practical advice from two nurse practitioners. Pediatric Nursing, 28(3), 298-299.

Hickey, A.R., Boyce, R.M., Ellwood. D., & Morris-Yates, A.D. (1997). Early discharge and risk for postnatal depression. Medical Journal of Australia, 167(5), 244-247.

Jermain, D.M. (1995). Treatment of postpartum depression. American Pharmacy, 35, 33-38.

Kruckman, L., & Smith, S. (2002). An Introduction to Postpartum Illness. Postpartum Support International. [On-line]. Retrieved 4/8/02 at www.chss.iup.edu/postpartum/ intro%20tp%20pp%20illness.html

CNN "Larry King Live"--Interview with Russell Yates. Aired March 18, 2002. Transcript available online at www.cnn.com/TRANSCRIPTS/0203/18lk1.00.html

Daly, K. (2001). Gender, crime and punishment. New Haven, CT: Yale Publishers.

MHR (2002). Mental Health Parity. Hearing on H.R. 4066 before the U.S. House of Representatives Education and the Workforce, Subcommittee on Employer-Employee Relations, 107th Cong. 2nd Sess. March 19, 2002.

MMHMA. (2002). The Medicare Mental Health Modernization Act of 2001, S. 690.

MHETA. (2002). The Mental Health Equitable Tax Act of 2002, H.R.4066.

Moenssens, A., Inbau, F., & Bacigal, R. (1992). Criminal Law: Cases and Comments (5th ed.). Westbury, NY: Foundation Press.

Riggins v. Nevada, 112 S. Ct. 1810 (1992); Lessard v. Schmidt, 349 F. Supp. 1092.

TPC. Texas Penal Code Section 8.01(a) (b)

TCPOMIa. Texas Criminal Procedure and the Offender with Mental Illness: An Analysis and Guide. Part V. Insanity Defense. Sect A. Available online at www.texasgov.com/mentallyilloffender/partfiveea.htm

TCPOMlb. Texas Criminal Procedure and the Offender with Mental Illness: An Analysis and Guide. Part V. Insanity Defense. Sect A. Adoption by Texas of the American Law Institute Test Available on line at ww.texasgov.com/mentallyilloffender/ partfiveea.htm

Walther, V.N. (1997). Postpartum depression. A review for perinatal social workers. Social Work Health Care, 24(3-4), 99-111.

Wisner, K.L., & Wheeler, S.B. (1994). Prevention of recurrent postpartum major depression. Hospital and Community Psychiatry, 45(12), 1191-1196.

References

Anderson, K. (2001). INDEXSEARCH Friday, 22 June, 2001, 02:1 GMT 03:15 http://news.bbc.co.uk/hi/english/world/americas/newsid_1401000/1401667.stm

Beck, C.T. (1995). Screening methods for postpartum depression. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24, 308-312.

Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786.

Lynne Edebohls, MS, CS, PMP, is a pediatric nurse practitioner in Madison, WI.

Connie Ecklund, MS, CPNP, is a pediatric nurse practitioner at Internal Medicine and Pediatrics, SC, in Fort Atkinson, WI.

Lauren Coodley, MA, Psychology, MA History, is a Professor of History at Napa Valley College in Napa, CA.

Eileen Meier, JD, MPH, BSN, RN, works out of Washington, DC, and writes policy articles for Pediatric Nursing.
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Date:May 1, 2002
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