Suicide attempts among teen girls rise – but suicides fell….

There is a strange disconnect among findings that came out a few weeks ago from the Centers for Disease Control, and I think it is one worth examining.

First, from the Centers for Disease Control:

In the early months of 2021, visits to emergency departments for suspected suicide attempts increased roughly 50 percent for adolescent girls compared with the same period in 2019, according to a report released Friday by the Centers for Disease Control and Prevention.

The same article makes a few other very salient points:

  • Suicide attempts began to rise in May 2020.
  • Suicide attempts among girls rose 50.6% compared to the prior year, but a mere 3.7% among boys.
  • Similar increases were NOT observed amongst men and women, aged 18-25.

There’s a lot of places to look at this, and the gender differentiation is genuinely fascinating. What on earth could cause such a difference in terms of the differences between men and women?

That being said, there’s a different question I want to ask: How is it possible that ATTEMPTS rose so much, but suicide deaths declined? As I wrote about previously – and has been written about by people much smarter than me – preliminary data indicates that suicides declined by 5.6% during the same time period that suicide visits among this demographic increased so dramatically. How can this be?

There are, of course, many possible answers.

First, the data released by the CDC is preliminary. There isn’t a breakdown of completed suicides by demographics. This means that it is very possible that suicide attempts – and completed suicides – rose among the demographic we are discussing, but that they declined enough in other demographics to offset this rise. It’s also possible that the suicide attempts were less serious attempts that were less likely to result in death. Typically, women are more likely to survive a suicide attempt, as they tend to use less lethal means. It is also worth noting that women are three times more likely to attempt suicide than men, but men are 3-5 times more likely to die of suicide than women.

The one thing that the report does make clear – and that is unquestionably true – is that this could have major public health implications and implications for parents. Young women seem to be in a more fragile state of mental health than their male counterparts, and it is incumbent upon us to ensure that we are taking the steps necessary to protect their mental health.

I’d also go one step further: What are the health implications for the poor young women who wound up in a hospital? What health risks do they face? What ongoing care do they need at home, and at school? What questions do we need to answer?

Regardless, this is something that is unquestionably worth monitoring in the future.

Okay, seriously…how is it possible that suicide numbers dropped during the pandemic?

We may be close to the end of the COVID-19 pandemic, but the scars of this battle will remain with society for a long, long time. Among the more devastating damages of COVID-19 have been the toll on mental health, with increasing signs of mental illness, greater addiction rates, increased use of mental health resources

…and a decline in suicides…

Wait, what?

Yeah. I don’t get it either. But, according to preliminary data, suicides went down in 2020:

 From 2019 to 2020, deaths by suicide declined by 5.6%, from 47,511 to 44,834, per the CDC. It was the third consecutive year of decline. Suicides [also] went down in April and May of last year, a different trend than in years past, Farida Ahmad, health scientist at the National Center for Health Statistics, tells Axios.

This is astonishing. And it defies expectations, with many predicting that COVID and the economic shutdowns would lead to a massive spike in suicide. And yet, that hasn’t been the case, despite the increase in every other category that would be a predictive factor for an increase in suicides, including mental illness, unemployment, and suicide.

This begs the question…why? What’s going on here? I’ve read a few articles on the subject, and they offer some different thoughts:

  • Telehealth played a big role. In many states, it became easier than ever to access mental health resources, as regulations were waved that enabled people to get access to telehealth. As a result, more people may have been able to seek mental health resources, thus saving their life.
  • There were huge, concentrated efforts to encourage people to get mental health help – maybe more so than ever before. Governor’s across the country spoke about it. People still do to this day. As a result, it seems possible that stigma – once a formidable barrier – was shattered. This may have put more people into mental health help.
  • Some noted that it seemed possible that a “heroism effect” was in place – similar to that which occurs at the start of a war or another catastrophe – where a sense of “we’re all in this together” kept more alive. If this is truly the case, then we need to be cautious, as it seems like that such an impact would fade over time.
  • The pandemic forced a massive reevaluation of the way we look at our lives, as more people found that they could live without certain things, and are thus able to live better lives. This is an interesting philosophical argument, one that may also be playing a role in the decline of workers across the economy.

It is also worth noting that a more advanced look at the data is needed: For example, did suicide decrease more in some groups? Did it particularly spike among teenagers and young adults, groups that were believed to be facing particular difficulties during this pandemic? Furthermore, what about differences among racial and economic demographics? What about people who could work at home versus those who could not?

My opinion? All of the above, and then some. I’d also offer this caution…there is no way, no way, that this is it, that we are now on a glide path towards a permanent reduction of suicide. I am absolutely concerned about the long-term impacts this will have on mental health, as well as how this may drive up suicide rates. There is so much more to this story that we absolutely do not understand, and I really hope that others have more insight than me!

Anything to add? Any thoughts about why suicide may have dropped as it did? Let us know in the comments below!

The Rise of Telehealth

Telehealth wasn’t new to COVID-19. The concept has been around for decades and applies differently to different areas of medicine. That being said, one of its most positive potential uses has been in the area of mental health, and in that regard, COVID-19 may have pushed us towards telehealth in a big way.

First, check out this USA Today article on the subject. This line stuck with me:

Prior to the pandemic, Blue Cross Blue Shield of Massachusetts received about 200 telehealth claims per day. That number reached up to 40,0000 claims per day from April to May 2020, and the insurer is still receiving about 30,000 claims per day almost a year later, according to spokesperson Amy McHugh.

The article also noted that ” mental health appointments made up about 53% of the 7.5 million telehealth claims processed by Blue Cross Blue Shield of Massachusetts since March 2020.”

This isn’t a surprise, and many of us have had experiences with it. I know I had numerous virtual appointments via telehealth over this pandemic, and I found it every bit as effective as an in-person visit. Maybe even more so – the flexibility that came with it was highly beneficial. I remember having a therapy appointment from my office in Harrisburg!

Of course, it’s not for everyone, but there is unquestionably good news in the area of telehealth. According to a 2020 article from the American Psychological Association, telehealth seems to be working so far. There are even some questions as to whether or not telehealth may be more effective for some groups that are typically less willing to visit a psychiatrists office – like men – as it allows them to get therapy without having to leave their house, thus reducing potential barriers and making it easier for them to overcome self-imposed stigma.

The USA Today article also noted that telehealth can make a therapist more efficient. Said one therapist, “I probably spend somewhere between 2 to 5 minutes per patient moving from one room to another or pausing to document or checking something on their file or handing something off. There are built-in inefficiencies that isn’t time spending with the person… but some of those inefficiencies are taken care of by the fact that everything is electronic.”

Obviously, COVID pushed us more this way as part of all of our efforts to socially distance. However, major challenges remain in terms of full utilization and effectiveness of telehealth services. First, telehealth is predicated on the idea that someone has the broadband infrastructure and necessary equipment. As this pandemic has shown, that is NOT the case for everyone, particularly among rural Americans or the urban poor. Lacking such equipment means that someone will not be able to get the help they need.

Furthermore, there are insurance barriers. Not all insurance companies cover telehealth, and while states of emergency have knocked down many of these barriers, they haven’t destroyed all. As such, insurance regulations need to be updated in many states. However, this presents a problem in and of itself. For example, in Pennsylvania, the issue has been tripped up due to attempts to limit telehealth services and prevent abortion services from being prescribed or conducted via telehealth. Don’t ask.

The point is this: Telehealth is great, but we’ve got a long way to go.

Let me conclude with this: Did you have a telehealth experience with COVID-19? What was it like? Did you find it to be as effective as an in-person visit? We’d love to hear from you – give us your comments below!

Coming Back To Normal

Ahh, the blog entry I’ve been wanting to write for so, so long.

Slowly but surely…it seems like life may, just may, be returning to normal. We’ve got a long way to go, of course, but there is light at the end of the tunnel that is getting brighter by the moment.

A quick look at the facts. As I type this entry on March 14, the United States is making real progress. Excluding an odd data dump, March 13 set the new one-day record for vaccinations, with 2.9 million people vaccinated. 100 million doses have been administered. 13% of all adults are now fully vaccinated, and about 20% of the population has had at least one dose. It’s not herd immunity, but it’s real progress, and the rate of progress is accelerating.

So, what does all this mean? The increasing rates of vaccines and the relatively steady rates of cases implies that we are starting to get to the point that we can resume normal life. Restrictions on businesses and crowds are starting to be loosened, although some states are obviously taking that way too far. Schools are starting to reopen fully or in more hybrid modes. Of course, thanks to new CDC guidelines, families are getting together again, hanging out with fully vaccinated grandparents for the first time.

On March 9, I had lunch with my Mom. Also, this happened:

My parents and in-laws – both fully vaccinated and post two-weeks – have been over, as per the CDC guidelines. There have been snuggles with the grandkids. A year’s worth of snuggles.

Of course, this is all wonderful news. It is desperately needed and wanted. Life is starting to resume. But, that asks a few questions: What does THAT mean from a mental health perspective? Specifically, what are the dangers of this new moment as life gets back to normal?

A few thoughts. First of all, readjustment will be hard for all of us. Events will resume, as will seeing people. Handshakes may come back…maybe. That’s going to be a challenge. I mean, think about it. For most of us, we’ve avoided crowds or crowded buildings. How will we adjust to being near people again?

Another example: Take events. How are any of us going to get used to being around people again? Will it cause major spikes in anxiety?

What about people who have been able to work from home and be near their kids and pets all the time? How will those individuals adjust to being away from their families again?

For people who are in psychologically vulnerable states to begin with, the readjustment may cause real issues. Keep in mind that being “forced” to stay home with loved ones hasn’t been a big problem for many! As such, it begs the question – how will individuals like this react as they resume “normal” activities? And what about people who suffer from anxiety disorders and OCD? What challenges will they face at this moment? After a year of staying home, how will they adjust to being put into an area where there are germs everywhere – even if they have been fully vaccinated?

It goes without saying that these are questions that we should all be grateful we are able to ask. I want us to get back to normal as soon as possible and to resume the lives that we left behind about a year ago. However, this moment is not without its dangers or its struggles. These are things we should monitor in order to ensure that our transition back to “normal” life goes as smoothly as possible.

The debate about in-person vs. virtual school misses the point

As a parent – and as a policy-maker – it seems as if everything we do these days is related to COVID. How will we recover? How can we ensure that everyone is getting the vaccine who deserves it? How can we deal with the devastating economic and unemployment effects? How soon can we (safely) get kids back into school?

Of course, the mental health impacts of COVID are damning as well, and much of that blame – at least for our kids – has been thrown at the feet of virtual learning. There is a lot of truth in that, of course. Evidence is clear that the mental health of our kids are, on the whole, suffering, with a rise noted in self-reported rates of depression and visits to the emergency room. Some are quick to cite the idea that this is a direct result of the fact that millions of kids are in some sort of virtual learning environment now, either full-time or on a hybrid schedule.

That being said, I really, truly believe that much of this debate misses the point. Why? Because – even for kids who are in school – they’re not getting their usual experience.

If you are in the real world in any capacity, you know it: Everything is different. Wear your mask. Wash your hands. STAY MORE THAN SIX FEET AWAY FROM ME. And if you are someone who was prone to anxiety, you are nervous every time you go out, because you can, quite literally, contract a deadly disease at any moment.

Okay, fine. Now, take all those fears and all those changes, and apply them to school. What do you get? A recipe for disaster. Take this article from Wisconsin Public Radio that details the struggles of kids in the pandemic. It notes, correctly, that zoom school makes it harder for kids to get the help they need and limits social interactions and the desperately needed personal connections. But, it also notes that in-person school is not a panacea:

With the broad disruption wrought by COVID-19, though, simply bringing students back into classrooms doesn’t resolve their mental health concerns.

In the Lake Mills district, where Kisten [a school psychologist] works, students have been mostly attending school in person since the start of the year.

“There’s a lot of grief right now, but the students don’t really have the right words to express that, or they don’t even know what it is that they’re feeling,” she said.

Other evidence has buttressed this point: Kids’ mental health is suffering regardless of where they are in school.

I don’t want to miss the point: Zoom and electronic learning is a cause for mental illness. There’s no question about it. However, even among those who are in school, things aren’t normal. And this is hurting the mental health of our kids.

The debate about whether or not kids should be in school or virtual misses the point entirely. We should be concentrating on SAFELY getting all of our kids back into school, then providing them with the mental health supports that they need in order to thrive. Even kids who are in school are reporting difficulties right now. Real-life or virtual, they’re in pain.

Four tips on how to cope with Zoomsgiving

Ahh, Thanksgiving, time to…yeah, this sucks. No two ways about it.

Experts have all but begged us to skip traditional Thanksgiving with our families this year, noting that the prospect of massive gathers from people that come from numerous communities is a perfect caldron to allow for (even more) explosive growth of COVID-19. There’s no question that Thanksgiving has the potential to be deadly for hundreds of thousands of Americans, as we’ve seen with every holiday since COVID-19 began.

Need further proof of the danger that Thanksgiving presents to all of us? Just look at what happened in Canada. Canadian Thanksgiving is October 11. Experts there begged Canadians to skip their usual holiday. Many listened. Many did not. The result: Massive spikes.

Okay, fine, you get it. We have to skip our usual Thanksgiving this year and turn another life event digital. God, this sucks. I mean, let’s all be clear about it. This sucks. So, how do you cope? Some thoughts.

First, yeah, we’re all tired of Zoom…but it’s better than nothing. To their infinite credit, Zoom is waving their forty minute limit on free calls in an effort to get people to stay home. Yes, of course this is marketing, but let’s give credit where credit is due, it’s a good move. I’d even go one step further if you are truly worried about Thanksgiving: Get your damn laptop and put the person who is missing in the seat where they would normally be. Want to really sell the illusion to yourself or your kids? Set a place setting. Does it sound silly? Sure. Who gives a damn. We’re eight months into a flipping pandemic. Go to town. Do you. All that matters on this one is that you and your family feel good.

Second, if you’re going to sell the illusion of togetherness, do it. Arrange the Zoom call and make sure your family is eating at the same time. If they are close by, do what my wife is doing: Make a “care package” meal for the family, and have them pick it up (outside, while wearing a mask). Eat at the same time. It’s not the same. Of course, it’s not the same. But again – we’re so blessed when you get right down to it. We have the ability to be together, even if we cannot actually be together. Can you imagine if this happened in 2000? Even 2010?

Third, start a new tradition. What works for you? How can you celebrate without truly being with all of your family? What event can you do together that will make the day more special, even if you aren’t in the same room? I’d add one twist to this: Whatever your new tradition is, be it a game, movie, special walk – make it something expandable. Remember, God willing, this will have passed by next year. What can you do that you can incorporate your family into when we’re all together again next year?

Fourth, practice some self-care – and maybe “us” care. This sucks. Don’t pretend it doesn’t. If you have kids who desperately want to hug Grandma and Grandpa (sigh), let them feel their pain. Don’t tell them nothing is wrong – allow them to express their feelings and their pain. From there, take care of them. Help them work through their pain, and then do something nice together. My wife has introduced our kids to “spa baths” where they get a bath, but with bubbles, candles, and spa music – and then I have to put a damn towel in the drier so they have warm towels…anyway, it’s a nice touch. But do something nice for yourself and your loved ones.

I get it…I really do. We’re all so, so tired. But, again, we’re blessed…there’s light at the end of the tunnel. We have to get through this tough winter, and a better day is likely ahead.

New Study Reveals The Mental Health Impacts Of COVID

Hello, everyone!

First, I apologize. Candidates for political office who try to manage too many aspects of their life wind up losing track of something, and in this case, the blog bit the dust for a bit. That’s my bad. Thankfully, I won reelection by a pretty good margin. I was planning on getting back to this last weekend, and then things went to heck again as I entered another election – this one also with good results!

Anyway, I’m back and hoping to get back to my one blog entry a week schedule.

Wish I had happier things to write about, though.

So, here’s the latest of the COVID-19 chronicles. A new study has revealed some devastating mental health information about the disease: 1 in 5 people who recover from COVID-19 develop a mental illness. This comes from a study that was published in The Lancet, one of the most prestigious medical journals in the world. According to the interpretation of the study:

Survivors of COVID-19 appear to be at increased risk of psychiatric sequelae, and a psychiatric diagnosis might be an independent risk factor for COVID-19. Although preliminary, our findings have implications for clinical services, and prospective cohort studies are warranted.

The study further warns that this does happen even to patients who had no previous diagnosis, with anxiety issues among the most commonly diagnosed issues that came in the aftermath of COVID.

There are a lot of implications from this study. The first may be the most frightening: Does COVID-19 cause long-term mental illness in some biological way? There is preliminary evidence to suggest that there may be long-term health concerns, although more evidence is unquestionably needed before definitive conclusions can be drawn.

Another possibility is something that we’ve spoken about regularly on this blog: The interaction between real life and mental health. Getting COVID-19 must be a terrifying experience. I’ve been lucky enough to avoid it so far, as has everyone in my life who I love, but let’s face it, we’ve all spent months absolutely terrified of the concept. We all hear the horror stories, see the businesses closing, the people retreating into isolation after a potential exposure. To get the disease – particularly if you have a difficult time coping with it or recovering – must be an exceptionally frightening experience.

Then add the socio-economic factors: The isolation from your family and friends. The inability to work and make money – particularly if you are economically insecure – and all the anxiety in the world makes sense.

Oh, and have we mentioned how the mental health system is going to be even more overwhelmed than it already is?

Is the news all bleak? No, of course not. We know it’s coming. We know that we need to spend more time and money on our mental health system. We have the chance to react. And hopefully, our federal and state governments will.

As always, I’d love to hear your thoughts. Any mental health experiences with COVID that you want to share? Let us know in the comments below!

The Coming Depression Onslaught

If this study is to be believed, we’re in trouble.

A study from Boston University conducted a major survey on adults and depression, using previous scores as a baseline measurement. The study used the PHQ-9 questionnaire, which is a nine-question screening method that can be used to determine if someone may be suffering from depression. A 2017-2018 study found that 8.5% of adults were suffering from depression. 

The results were horrifying: 27.8% of Americans are now clinically depressed, according to the results of the study. That is more than a tripling of depression rates. It is massive, it is significant, and it cannot be treated by the current state of our mental health system. 

The study, of course, attributed much of this rise to COVID-19 and the economic stressors placed on society by this disease. The study also found that people with less than $5,000 in savings 50% were more likely to be depressed, further showing the connection between economics, a social safety net, and mental health.

I have a couple of broader thoughts – first, on the general situation, and second, what this study shows us.

First, I think it’s important to keep in mind that this is catastrophically bad but not as bad as it appears! Yes, I said that. First, the good news. This will abate as the pandemic abates and economic damage mitigates. That will happen. It will take time, but I don’t think this represents a fundamental shift in our moods or economic status for the majority of people who took this study.

The bad news? Let’s say this only permanently affects 5% of America. Uhh…that’s tens of millions of people. That is fundamentally, catastrophically terrible. We could be staring down the barrel of millions of people who will never recover without assistance that we cannot hope to provide. Before this crisis, we were looking at a major shortage of mental health workers. There is no way our system has the capacity to deal with all of the people who will need help. 

About two months ago, I attended a hearing on mental illness and the COVID-19 pandemic. One of the things I asked some of our panelists was whether or not there had been an increase in suicides. The answer: Not yet. Emphasis on yet. They were worried that, as the economic toll continues, you’d have a lot of people who would be more likely to die by suicide. This study furthers my concern there.

What can we do? Well, if you believe that economics and mental health are connected – and I do – that means we need to support people in their times of need and provide generous economic supports to get them through this crisis. That means working to prevent evictions and foreclosures. To extend unemployment assistance. To throw money at small businesses in order to keep them open.

This is a catastrophe in the making, but it doesn’t have to be this way. A strong government can stop the economic damage and can abate this crisis, and I don’t think it’s too late. But that’s what we need to get us through the physical, economic, and mental health disaster that we are currently experiencing. 

Are suicides increasing during COVID-19?

It was a frequently used argument during the pandemic, one often used against lockdowns: Suicide rates would increase as a result of social isolation, financial hardships, and more limited access to proper medical care. This fear was repeated by medical professionals and medical health care experts. Even Donald Trump repeated the line at one point, arguing that extensive lockdowns would lead to “thousands” of suicides. So great that he and so many others suddenly care about mental health when they spent years defunding services that would prevent suicide and trying to rip health care away from millions, but that’s a completely different story, so let’s move on, let’s move on.

We’re about four months into some of the various lock-downs and quarantines. The question is obvious: What does the data say? Are suicide rates on the rise?

It seems like its too early to tell. We will only be able to more definitively tell the numbers when the annual suicide numbers come out at the beginning of the year, and even then, it will be extremely difficult to determine the cause of the suicide. However, there is some evidence to indicate that things are not as bad as many of us feared they would be – though that could very, very easily change.

First, let’s look at what data is available and what data has been misleading. At the beginning of the pandemic, a doctor said that his California hospital had seen “a year’s worth of suicide attempts” during a four-week period. That report was utterly debunked: Numbers had barely increased at the hospital in question, and locals reported that they believed the local rate had remained stable in the area.

Apparently, calls to some suicide hotlines have increased. Outreach to suicide prevention text lines has increased as well. However, this may not be a bad thing, as it may be a reflection of people turning to the closest support line to get help. Indeed, if these hotlines are working, the increase in calls may be a good thing. Again, unfortunately, there’s no evidence to say one way or the other.

I couldn’t find any hard data discussing whether or not there was any evidence of suicide rate increases in the United States – if someone has that, please correct me. However, I did find evidence that suicide rates have actually dropped 20% in Germany. This is a preliminary finding, so it is likely too early to draw hard conclusions from it.

There is no question that COVID-19 will cause a massive spike in a wide array of social problems, and suicide would certainly seem to be one of these problems. However, as noted by many articles on the subject, it’s more nuanced than simply saying that “The lockdowns led to more deaths.” The pandemic also ripped apart the economy, threw us into a recession, and maybe a depression. There is clear evidence that down economies lead to higher rates of mental illness and suicide. As such, it is difficult to say that lockdowns lead to suicides. It is much more complex than that.

So, what’s the conclusion? There’s no conclusion. Not yet. Time will tell. But, more importantly, policymakers and the community at large must continue to work to mitigate the economic and social impacts of COVID – particularly on the mentally ill. I’m hoping to be able to work on that one over the summer.

COVID-19, Mental Health and Black Lives Matter

Hey, everyone!

First, I apologize. My blog entries have obviously been spotty for the past few months. There is a reason for that: The real world. Simply put, my job as State Representative became too overwhelming. This, along with other responsibilities, made it really difficult for me to blog. I am sorry and I will try to get back into my twice a week habit now.

So, let’s get right to it. Every one of us has been following the murder of George Floyd and the subsequent explosion of the Black Lives Matters movement. If you read my blog, I’m guessing you are at least somewhat progressively orientated. That probably means you are shocked and horrified at the current state of the world, and want to do something to make it better.

As a white man, I can’t sit here and yammer on about what the Black Lives Matter movement means. I represent a district that is about 1/2 minorities and work with dozens of other elected officials who are people of color, and I’ve tried to learn from their experiences to figure out not only how to do my job better, but how to be a better person.

From my perspective, acknowledging those limitations, I’ve come to the conclusion that we scream Black Lives Matter because society has decided for centuries that they don’t. That we scream Black Lives Matter at the top of our lungs because the communities of color have been devastated, destroyed, and degraded for centuries in a way that white people cannot begin to fathom.

To the casual observer, I think it gets too easy to assume that the entire Black Lives Matter movement only revolves around police reform and criminal justice. As best I can tell, that isn’t only the case. Black Lives Matter, at least to me, means that we address all of the systemic inequities in our society. That means addressing countless areas of our public policy, including education, urban planning, economic development, health care access and more.

It also, unquestionably, means mental health. I’ve written on this topic before, but even the briefest of looks at Google shows the enormous disparity facing the minority communities when it comes to mental health. Furthermore, new studies show that that levels of anxiety and depression spiked among the African American population after the murder of George Floyd. As if their burden wasn’t already enough to shoulder.

All this brings me back to COVID. I wrote a line in Redemption that I barely even thought about until a reviewer flagged it: “When civilization collapses, it doesn’t collapse evenly.” COVID has taught us that, hasn’t it? Obviously, civilization isn’t collapsing, but boy has it taken some hits.

And those hits have not been evenly distributed.

Just take a look at how COVID has hit minority communities. The evidence is painfully clear: According to the CDC, minority communities in general – and the African American community specifically – are more likely to contract COVID, be hospitalized as a result of COVID, and die from COVID. This isn’t a result of any genetic challenges. Instead, its a result of systematic discrimination that has resulted in years of poor health care access in general, substandard living conditions and worse health.

When civilization collapses, it won’t collapse evenly.

What’s my point? Pretty obvious. I think most of us agree with the statement that Black Lvies Matter. That means we have to act like it. It means our policy has to reflect those values, and that must be carried out in the way that we discuss all aspects of public policy. Mental health must be part of that equation.