Efficacy of Telehealth Treatments for Posttraumatic Stress-Related Symptoms: A Meta-Analysis

This meta-analysis summarizes the findings of outcome research on the degree to which telehealth treatments reduce posttraumatic stress disorder (PTSD)-related symptoms. In a search of the literature, 13 studies were identified for inclusion in the meta-analysis and were coded for relevant variables. A total of 725 participants were included. Results indicate that telehealth treatments are associated with significant pre- to postreduction in PTSD symptoms (d = 0.99, 95% confidence interval [CI]: 0.87–1.11, p < .001), and result in superior treatment effects relative to a wait-list comparison condition (d = 1.01, 95% CI: 0.76–1.26, p < .001). However, no significant findings were obtained for telehealth intervention relative to a supportive counseling telehealth comparison condition (d = 0.11, 95% CI: ? 0.38 to 0.60, p = .67), and telehealth intervention produced an inferior outcome relative to a face-to-face intervention (d = ? 0.68, 95% CI: ? 0.39 to ? 0.98, p < .001). Findings for depression symptom severity outcome were generally consistent with those for PTSD outcome. Telehealth interventions produced a significant within-group effect size (d = 0.98, 95% CI: 0.86 to 1.10, p < .001) and superior effect relative to wait-list comparison condition (d = 0.80, 95% CI: 0.56–1.05, p < .001). Relative to face-to-face interventions, telehealth treatments produced comparable depression outcome effects (d = 0.13, 95% CI: ? 0.55 to 0.28, p = .53). Taken together, these findings support the use of telehealth treatments for individuals with PTSD-related symptoms.     

Internet-based acceptance and commitment therapy for psychological distress experienced by people with hearing problems: a pilot randomized controlled trial

Psychological distress is common among people with hearing problems, but treatments that specifically target this aspect have been almost non-existent. In this pilot randomized controlled trial, an eight-week long Internet-based treatment, informed by Acceptance and Commitment Therapy, was administered to explore the feasibility and efficacy of such a treatment. Included participants were randomized to either treatment (n = 31) or wait-list control (n = 30) condition. All participants were measured prior to randomization and immediately after treatment ended using standardized self-report instruments measuring hearing-related emotional and social adjustment (Hearing Handicap Inventory for the Elderly – S, HHIE-S), quality of life (Quality of Life Inventory, QOLI), and symptoms of depression and anxiety (Patient health Questionnaire, PHQ-9 and Generalized Anxiety Disorder scale, GAD-7). Linear mixed effects regression analysis using the full intention-to-treat sample demonstrated that the treatment had superior outcomes on the main outcome measure as compared with the control group, Cohen’s d = 0.93, 95% CI [0.24, 1.63]. The benefits of treatment over control were also evident in scores of depression, Cohen’s d = 0.61, 95% CI [0.04, 1.19], and quality of life, Cohen’s d = 0.88, 95% CI [0.14, 1.61]. The results provide preliminary support for Internet-delivered acceptance and commitment therapy as a potentially effective treatment of psychological symptoms associated with hearing problems.     

Internet-delivered transdiagnostic and tailored cognitive behavioral therapy for anxiety and depression: a systematic review and meta-analysis of randomized controlled trials

Anxiety and depressive disorders are often comorbid. Transdiagnostic and tailored treatments seem to be promising approaches in dealing with comorbidity. Although several primary studies have examined the effects of Internet-delivered cognitive behavior therapy (iCBT) for anxiety and depression, no meta-analysis including different types of iCBT that address comorbidity has been conducted so far. We conducted systematic searches in databases up to 1 July 2016. Only randomized trials comparing transdiagnostic/tailored iCBT for adult anxiety and/or depression with control groups were included. Nineteen randomized trials with a total of 2952 participants that met inclusion criteria were analyzed. The quality of the studies was high, however the blinding criteria were not fulfilled. The uncontrolled effect size (Hedges’ g) of transdiagnostic/tailored iCBT on anxiety and depression outcomes was large and medium for quality of life. The controlled effect size for iCBT on anxiety and depression outcomes was medium to large (anxiety: g = .82, 95% CI: .58–1.05, depression: g = .79, 95% CI: .59–1.00) and medium on quality of life (g = .56, 95% CI: .37–.73). Heterogeneity was small (quality of life) to moderate (anxiety, depression). There was a large effect on generic outcome measures and a moderate effect on comorbidities. When compared to disorder-specific treatments there were no differences on anxiety and quality of life outcomes, however there were differences in depression outcomes. Transdiagnostic and tailored iCBT are effective interventions for anxiety disorders and depression. Future studies should investigate mechanisms of change and develop outcome measures for these interventions.     

The development of parental monitoring during adolescence: A meta-analysis

Abstract

As adolescents grow up, one of the important developmental tasks is to individuate themselves and to become more autonomous from parents. This requires a realignment of the parent-adolescent communication. The current meta-analytic study aims at identifying developmental changes in parent-adolescent communication, conceptualized within the parental monitoring framework, as entailing parental solicitation, control and knowledge, and adolescent’s disclosure and secrecy. Thirty-one longitudinal studies published between 2000 and 2015 were identified and included in the current meta-analysis. Informants, age at assessment and study duration were tested as moderators. Results showed a low to medium normative decline in parental control (Cohen’s d = ?.395, 95% CI [?.541, ?.249]), knowledge (d = ?.245,95% CI [?.331, ?.160] and adolescence disclosure (d = ?.147, 95% CI [?.204, ?.090]), and an increase in adolescent’s secrecy (d = .194, CI [031, .356]). Parental solicitation decreased based on parents’ (d = ?.242, 95% CI[?.376, ?.109]) but not on adolescents’ reports (d = .038, 95% CI[?.099, .175]). Another significant moderator was the duration of the study, with studies longer than 2 years being able to detect a more pronounced change in parental control than studies lasting less than 2 years (≤2 years, d = ?.139 vs. duration > 2 years, d = ?.581). Limitations of the current knowledge and new directions of studies are discussed.     

Internet-based self-help treatment for panic disorder: a randomized controlled trial comparing mandatory versus optional complementary psychological support

Panic disorder (PD) is one of the most common psychiatric disorders. Web-based self-help treatments for PD have had promising results. These online treatments seem to have larger effect sizes (ESs) when professional support is added. However, the amount of support or how it should be administered is not yet clear. The aim of this trial was to study two ways of administering psychological support provided by phone as a part of Internet-based self-help treatment for PD based on cognitive behavioral therapy. Seventy-seven participants diagnosed with PD were randomly assigned to one of three experimental conditions: a waiting list control group; a treatment group with non-scheduled psychological support; or a treatment group with scheduled psychological support. PD symptoms of participants who received treatment improved significantly compared to the control group (mean ES d = 1.18, p < .05). In addition, there were statistically and clinically significant differences between treatment groups (Mean difference = ?3.20, p = .005, 95% CI [?5.62, ?.79]). The scheduled group showed a larger ES, a lower dropout rate, and better adherence to treatment than the non-scheduled group. Scheduled support seems to be indicated for patients who seek Web-based treatment for PD, and their symptoms of panic, anxiety, and depression improve at post-treatment and six-month follow-up. In contrast, when support depends on patient demand, they receive less support and so, the therapeutic effect is poorer.     

Randomized Effectiveness Trial of an Internet,Pure Self-Help,Cognitive Behavioral Intervention for Depressive Symptoms in Young Adults

This study evaluated an Internet-delivered, cognitive behavioral skills training program versus a treatment-as-usual (TAU) control condition targeting depression symptoms in young adults aged 18 to 24 years. Potential participants were mailed a recruitment brochure; if interested, they accessed the study website to complete an online consent and baseline assessment. Intervention participants could access the website at their own pace and at any time. Reminder postcards were mailed periodically to encourage return use of the intervention. The pure self-help intervention was delivered without contact with a live therapist. The primary depression outcome measure was the Patient Health Questionnaire, administered at 0, 5, 10, 16, and 32 weeks after enrollment. A small but significant between-group effect was found from Week 0 to Week 32 for the entire sample (N = 160, d = .20, 95% confidence interval [CI] 0.00–0.50), with a moderate effect among women (n = 128, d .42, 95%C1 = 0.09–0.77). Greater depression reduction was associated with two measures of lower website usage, total minutes, and total number of page hits. Although intervention effects were modest, they were observed against a background of substantial TAU depression pharmacotherapy and psychosocial services. Highly disseminable, low-cost, and self-help interventions such as this have the potential to deliver a significant public health benefit.     

Computer‐Aided Psychotherapy for Anxiety Disorders: A Meta‐Analytic Review

Computer‐aided psychotherapy (CP) is said to (1) be as effective as face‐to‐face psychotherapy, while requiring less therapist time, for anxiety disorder sufferers, (2) speed access to care, and (3) save traveling time. CP may be delivered on stand‐alone or Internet‐linked computers, palmtop computers, phone‐interactive voice response, DVDs, and cell phones. The authors performed a meta‐analysis of 23 randomised controlled studies (RCTs) that compared CP with non‐CP in anxiety disorders: phobias, n = 10; panic disorder/agoraphobia, n = 9; PTSD, n = 3; obsessive–compulsive disorder, n = 1. Overall mean effect size of CP compared with non‐CP was 1.08 (95% confidence interval: 0.84–1.32). CP and face‐to‐face psychotherapy did not differ significantly from each other (13 comparisons, d = ?0.06). Much caution is needed when interpreting the findings indicating that outcome was unrelated to type of disorder, type of comparison group, mode of CP delivery (Internet, stand‐alone PC, palmtop), and recency of the CP system and that effect size decreased when more therapist time was replaced by the computer. Because CP as a whole was as effective as face‐to‐face psychotherapy, certain forms of CP deserve to be integrated into routine practice.     

Overcoming procrastination: one-year follow-up and predictors of change in a randomized controlled trial of Internet-based cognitive behavior therapy

Procrastination is a common self-regulatory failure that can have a negative impact on well-being and performance. However, few clinical trials have been conducted, and no follow-up has ever been performed. The current study therefore aimed to provide evidence for the long-term benefits and investigate predictors of a positive treatment outcome among patients receiving Internet-based cognitive behavior therapy (ICBT). A total of 150 self-recruited participants were randomized to guided or unguided ICBT. Self-report measures of procrastination, depression, anxiety, and quality of life were distributed at pre-treatment assessment, post-treatment assessment, and one-year follow-up. Mixed effects models were used to investigate the long-term gains, and multiple linear regression for predictors of a positive treatment outcome, using the change score on the Irrational Procrastination Scale as the dependent variable. Intention-to-treat was implemented for all statistical analyses. Large within-group effect sizes for guided and unguided ICBT, Cohen’s d = .97–1.64, were found for self-report measures of procrastination, together with d = .56–.66 for depression and anxiety. Gains were maintained, and, in some cases, improved at follow-up. Guided and unguided ICBT did not differ from each other, mean differences ?.31–1.17, 95% CIs [?2.59–3.22], and none of the predictors were associated with a better result, bs ?1.45–1.61, 95% CIs [?3.14–4.26]. In sum, ICBT could be useful and beneficial in relation to managing procrastination, yielding great benefits up to one year after the treatment period has ended, with comparable results between guided and unguided ICBT.     

Mental health of the bisexual Veteran

Despite evidence showing that bisexual individuals may be at greater risk for mental health issues than lesbian and gay individuals, they are often combined into a single group, with lesbian and gay individuals the actual focus of the research. This study aims to address this gap in the literature among US Veterans. Using data collected from a multicity purposive sample (N = 4,493), logistic regression was used to analyze whether the following groups differ in current posttraumatic stress disorder (PTSD) and depression: (a) bisexual (n = 101) vs. heterosexual Veterans (n = 4,271); (b) bisexual vs. lesbian/gay Veterans (n = 121); (c) lesbian/gay vs. heterosexual Veterans; and (d) combined group of lesbian, gay, and bisexual (LGB; n = 222) vs. heterosexual Veterans. Controlling for significant covariates, bisexual Veterans had 2.5 times the risk of severe depression (95% confidence interval [CI] = 1.34–4.67; p = 0.004) and 2.3 times the odds of PTSD (95% CI = 1.40–3.77; p = 0.001) relative to heterosexual Veterans. Bisexual Veterans had 3 times the risk of severe depression (95% CI = 1.22–7.44; p = 0.017) and 1.9 times the risk of PTSD (95% CI = 1.02–3.70; p = 0.045) compared to lesbian/gay Veterans. Lesbian/gay Veterans had no significant difference in risk for depression compared to heterosexual Veterans. However, the combined group of LGB Veterans had 1.6 times the odds of PTSD (95% CI = 1.12–2.15; p = 0.008) compared to heterosexual Veterans. These findings suggest that past research showing mental health disparities between LGB and heterosexual individuals may be driven by the inclusion of bisexual individuals. Research should assess bisexual individuals as a distinct group, and future studies should explore factors leading to depression and PTSD among bisexual Veterans.     

The implementation of guided Internet-based cognitive behaviour therapy for panic disorder in a routine-care setting: effectiveness and implementation efforts

Panic disorder is a common mental disorder. Guided Internet-based cognitive behavioural therapy (Guided Internet-based cognitive behaviour therapy (ICBT)) is a promising approach to reach more people in need of help. In the present effectiveness study, we investigated the outcome of guided ICBT for panic disorder after implementation in routine care. A total of 124 patients were included in the study, of which 114 started the treatment. Large within-group effect sizes were observed on the primary panic disorder symptoms (post-treatment: d = 1.24; 6-month follow-up: d = 1.39) and moderate and large effects on secondary panic disorder symptoms and depressive symptoms at post-treatment and follow-up (d = .55–1.13). More than half (56.1%) of the patients who started treatment recovered or improved at post-treatment. Among treatment takers (completed at least five of the nine modules), 69.9% recovered or improved. The effectiveness reported in the present trial is in line with previous effectiveness and efficacy trials of guided ICBT for panic disorder. This provides additional support for guided ICBT as a treatment alternative in routine care.     

Internet-provided cognitive behaviour therapy of posttraumatic stress symptoms following childbirth—a randomized controlled trial

The aim of this study was to analyse the effects of trauma-focused guided Internet-based cognitive behaviour therapy for relieving posttraumatic stress disorder (PTSD) symptoms following childbirth, a problem that about 3% women encounter postpartum. Following inclusion, 56 traumatized women were randomized to either treatment or to a waiting list control group. Primary outcome measures were the Traumatic Event Scale (TES) and Impact of Event Scale—Reversed (IES-R). Secondary measures were Beck depression inventory II, Patient Health Questionnaire (PHQ-9), Beck Anxiety Inventory, Quality Of Life Inventory and the EuroQol 5 Dimensions. The treatment was guided by a clinician and lasted eight weeks and comprised eight modules of written text. The between-group effect size (ES) was d = .82 (p < .0001) for the IES-R. The ES for the TES was small (d = .36) and not statistically significant (p = .09). A small between-group ES (d = .20; p = .02) was found for the PHQ-9. The results from pre- to post-treatment showed large within-group ESs for PTSD symptoms in the treatment group both on the TES (d = 1.42) and the IES-R (d = 1.30), but smaller ESs in the control group from inclusion to after deferred treatment (TES, d = .80; IES-R d = .45). In both groups, the treatment had positive effects on comorbid depression and anxiety, and in the treatment group also on quality of life. The results need to be verified in larger trials. Further studies are also needed to examine long-term effects.     

Systematic Review and Meta-analysis of Adolescent Cognitive–Behavioral Sleep Interventions

This systematic review and meta-analysis examined the efficacy of adolescent cognitive–behavioral sleep interventions. Searches of PubMed, PsycINFO, CENTRAL, EMBASE, and MEDLINE were performed from inception to May 1, 2016, supplemented with manual screening. Nine trials were selected (n = 357, mean age = 14.97 years; female = 61.74%). Main outcomes were subjective (sleep diary/questionnaire) and objective (actigraphy) total sleep time (TST), sleep onset latency (SOL), sleep efficiency (SE), and wake after sleep onset (WASO). There were a small number of randomized controlled trials (RCTs; n = 4) and a high risk of bias across the RCTs; therefore, within sleep condition meta-analyses were examined (n = 221). At post-intervention, subjective TST improved by 29.47 min (95% CI 17.18, 41.75), SOL by 21.44 min (95% CI ?30.78, ?12.11), SE by 5.34% (95% CI 2.64, 8.04), and WASO by a medium effect size [d = 0.59 (95% CI 0.36, 0.82)]. Objective SOL improved by 16.15 min (95% CI ?26.13, ?6.17) and SE by 2.82% (95% CI 0.58, 5.07). Global sleep quality, daytime sleepiness, depression, and anxiety also improved. Gains were generally maintained over time. Preliminary evidence suggests that adolescent cognitive–behavioral sleep interventions are effective, but further high-quality RCTs are needed. Suggestions for further research are provided.     

The relationship between attitudes toward suicide and willingness to pay for suicide prevention: a cross-sectional study in Japan

There are gaps in our knowledge of the role attitudes toward suicide play in determining people’s willingness to participate (WTP) for suicide prevention. We conducted a large nationwide cross-sectional study with the aim of clarifying the relationship between WTP for reducing suicide risk and attitudes toward suicide. Ordinal logistic regression analyses (n = 1771) showed that there were significant associations of WTP for suicide prevention with ‘Suicide as a right’ (β = ?.15, 95% CI: ?.25 to ?.04, p = .006), ‘Preventability/readiness to help’ (β = .81, 95% CI: .69–.94, p < .001) and ‘Common occurrence’ (β = .32, 95% CI: .19–.46, p < .001). ‘Incomprehensibility/unpredictability’ did not show an association with WTP. Taxpayer acceptance for suicide prevention is more likely to be achieved through provision of information that increases endorsement of ‘preventability/readiness to help’ and ‘common occurrence’ factors, and decreases ‘suicide as a right’ scores.     

The association between biopsychosocial factors and disability in a national health survey in South Africa

The association between psychosocial factors and disability is less clear. This study investigated the biological and psychosocial (employment and psychological distress) factors associated with level of disability in an adult sample in South Africa. Data were analysed from a cross-sectional survey among adults aged 18–64 (n = 4974). Multiple linear regression was used to investigate the associations of the selected variables with disability. The mean percentage score on the WHODAS scale of disability was 5.31% (95% CI: 4.74–5.88). Age (p < 0.001) and race (p = 0.0002) were significantly associated with disability, and history of stroke (β = 7.19, 95% CI: 3.19–11.20) and heart-related conditions (β = 2.08, 95% CI: [0.23–3.93) showed positive associations. Of the psychosocial variables, psychological distress (β = 10.49 [8.63–12.35]) showed a strong positive association while employment (?1.62 [?2.36 to ?0.88]) showed a negative association with disability. The association between demographic factors, medical conditions and increased disability confirms the findings in the literature. The finding that psychological distress is associated with increased disability has not been frequently reported. This study highlights specific psychosocial targets that may be usefully addressed by health policies and interventions in order to improve disability management.     

Does psychosocial stress exacerbate avoidant responses to cancer information in those who are afraid of cancer? A population-based survey among older adults in England

Objective: Communication of cancer information is an important element of cancer control, but cancer fear may lead to information avoidance, especially when coping is low. We examined the association between cancer fear and cancer information avoidance, and tested whether this was exacerbated by psychosocial stress.

Design: Cross-sectional survey of 1258 population-based adults (58–70 years) in England.

Main outcome measures: Cancer fear (intensity and frequency), perceived psychosocial stress and cancer information avoidance. Control variables were age, gender, ethnicity, marital status and education.

Results: A quarter (24%) of respondents avoided cancer information. Ordinal logistic regression analyses showed main effects of psychosocial stress (OR = 1.17, 95% CI 1.07–1.29) and cancer fear: cancer information avoidance was lowest in those with no cancer fear (13%), followed by those with moderate (24%; OR = 2.15, 95% CI: 1.49–3.12), and high cancer fear (35%; OR = 3.90, 95% CI: 2.65–5.73). In the adjusted model, the interaction between cancer fear and stress was significant (OR = 1.14, 95% CI 1.004–1.29, p < .05): 40% of those with high fear/high stress avoided cancer information compared with 29% with high fear/low stress.

Conclusion: Cancer fear and psychosocial stress interact to produce disengagement with cancer-related information, highlighting the importance of affective processes to cancer control efforts.     

Internet-Based Exposure Treatment Versus One-Session Exposure Treatment of Snake Phobia: A Randomized Controlled Trial

In this study, the authors compared guided Internet-delivered self-help with one-session exposure treatment (OST) in a sample of snake phobic patients. A total of 30 patients were included following a screening on the Internet and a structured clinical interview. The Internet treatment consisted of four weekly text modules which were presented on a web page, a video in which exposure was modelled, and support provided via Internet. The OST was delivered in a three-hour session following a brief orientation session. The main outcome was the behavioural approach test (BAT), and as secondary measures questionnaires measuring anxiety symptoms and depression were used. Results showed that the groups did not differ at post-treatment or follow-up, with the exception of a significant interaction for the BAT in favour of the OST. At post-treatment, 61.5% of the Internet group and 84.6% of the OST group achieved a clinically significant improvement on the BAT. At follow-up, the corresponding figures were 90% for the Internet group and 100% for the OST group (completer sample). Within-group effect sizes for the Snake Phobia Questionnaire were large (d = 1.63 and d = 2.31 for the Internet and OST groups, respectively, at post-treatment). It is concluded that guided Internet-delivered exposure treatment is a potential treatment option in the treatment of snake phobia, but that OST probably is better.     

Suicide ideation among oncologic patients in a Spanish ward

Oncologic patients are exposed to a higher risk of suicidal behaviors than the general population. In this study, we aim to examine the severity of suicidal ideation in a sample of oncologic patients considering different psychological and clinical features. We interviewed 202 inpatients receiving curative or palliative treatment in a medical oncology ward of a Spanish hospital during the period 2012–2014. A complete assessment of psychosocial factors, cancer diagnoses (lung, colon rectum, and genitourinary system), and suicidal behaviors were made during admission, including validated questionnaires about depression, anxiety, personality, quality of life, body image, life threatening events, hopelessness, and suicidal ideation. The characteristics of inpatients with high and low suicidal ideation were retrospectively compared. A logistic regression model was constructed to examine the relationship between the significant factors retained after the univariate analyses. One of every four patients (n = 51; 25.24%) presented high scores of suicidal ideation. Logistic regression analyses retained depression (OR = 3.55; 95% CI = 1.25–11.68; p = .016), hopelessness (OR = 8.78; 95% CI = 3.44–25.88; p ≤ .001), personality (OR = .44; 95% CI = .2–.96; p = .038), and advanced age (OR = 2.60; 95% CI = 1.18–5.98; p = .016) as the main risk factors for high suicidal ideation. Suicidal ideation was frequent among oncologic patients. These patients should receive closer monitoring, especially, when old, retired, or severely depressed.     

Depression in primary Sjögren’s syndrome: a systematic review and meta-analysis

There is substantial uncertainty regarding the prevalence of depression in Primary Sjögren’s syndrome (pSS). We conducted a systematic review aiming to evaluate the association of pSS with depression. PubMed, Web of Science, VIP, CNKI and Wanfang database were searched to find the published literatures (from these databases established to October 2016). Studies were screened according to inclusion and exclusion criteria and the qualities of included studies were evaluated. The data was analyzed using Revman5.2 software. A total of 12 studies including 1917 patients were eligible for inclusion in the systematic review and meta-analysis. In this meta-analysis, Severity of depression was assessed using psychometric measures, such as PHQ-9; HADS; CES-D; Zung depression scale and BDI. The result revealed that pSS was associated with an increased prevalence of depression (summary odds ratio (OR) = 5.36, 95% CI: 4.05–7.09, P < 0.01). The depression score in pSS patients (standardized mean difference (SMD) = 1.47, 95% CI: 0.81–2.12, P < 0.01) were higher than in the control group. Depression is highly prevalent in pSS than in healthy controls. Early recognition and appropriate intervention are therefore essential to reduce the negative impact of depression on the patient’s quality of life and outcome of their disease.     

Internet Versus Group Cognitive-Behavioral Treatment of Distress Associated With Tinnitus: A Randomized Controlled Trial

Tinnitus distress can be reduced by means of cognitive-behavior therapy (CBT), and the treatment can be delivered in different ways. The most recent format is Internet-based self-help. The aim of this study was to compare this treatment (n = 26) with standard group-based CBT (n = 25) in a randomized controlled trial. Outcomes on self-report inventories measuring tinnitus distress were evaluated immediately after and 1 year after treatment. Results showed that both groups had improved, and there were few differences between them. The effect size for the Internet treatment was d = 0.73 (95% CI = 0.16–1.30) and for the group treatment was d = 0.64 (95% CI = 0.07–1.21). The Internet treatment consumed less therapist time and was 1.7 times as cost-effective as the group treatment. At pretreatment patients rated the Internet treatment as less credible than the group treatment. In conclusion, Internet treatment for tinnitus distress merits further investigation, as the outcomes achieved are promising.