Aug 3, 2016
Using voice analysis to identify peaks on bipolar disorder is a summary of a recently-published research paper titled “Voice analysis as an objective state marker in bipolar disorder.” For additional information, please click on the link.
The human voice is composed of multiple different components, created through complex muscle movements, making each person’s voice individual, like ‘a fingerprint’. Studies analysing speech in affective disorders, date back as early as 1938. Several clinical observations suggest that changes in speech features have been suggested as valid measures, to identify periods of depression and mania in bipolar disorder. For instance, reduced speech activity may be considered a symptom of depression, and increased speech activity may predict a switch to hypomania.
A pilot study conducted by The Copenhagen Clinic for Affective Disorders, with patients with bipolar disorder, aimed to investigate the following:
- Voice features collected during phone calls, as objective markers of affective states in bipolar disorder
- If combining voice features with automatically generated objective smartphone data on behavioural activities (for example, number of text messages and phone calls per day) and electronic self-monitored data (mood) on illness activity, would increase the accuracy as a marker of affective states
The pilot study included the monitoring of 28 outpatients with bipolar disorder, in a natural environment from October 2013 to December 2014. During this period, patients were given a smartphone application developed by Monsenso, to collect voice features, electronic self-monitoring data, and collection of automatically generated data.
- Voice features
The voice features were extracted from the patients’ phone calls throughout the day, using the open-source Media Interpretation by Large feature-space Extraction (openSMILE) toolkit, which is a feature extractor for signal processing and machine learning applications.
- Electronic self-monitoring data
Patients were requested to provide daily electronic self-monitoring data. The parameters evaluated included: mood, sleep length, medication intake, activity level, alcohol consumption, mixed mood, irritability, cognitive problems, stress levels, and individualised early warning signs.
- Automatically generated data
Through the smartphones’ sensors, automated data tracking different aspects of behavioural activities was collected on a daily basis. The data compiled by the smartphones included the number and duration of phone calls and text messages, accelerometer data, and phone usage.
Results
This innovative study revealed that changes in voice features could, in fact, detect individual changes in affective state. The accuracy of the prediction is increased, by combining voice features with automatically generated smartphone data on behavioural activities, and electronic self-monitoring. Therefore, according to the study, voice features collected by smartphones in a natural setting, could be used as an objective state marker in patients with bipolar disorder.
According to the researchers, the monitoring of symptoms in bipolar disorder and the accurate classification of affective states based exclusively on voice features has great potential.
Clinicians would be able to obtain accurate, objective data in real-time on the patients’ affective states based on collected voice features. The smartphone application could be used to monitor symptoms long-term, outside clinical settings, and enable early intervention between outpatient visits.
According to the researchers, at the time the study was conducted, it was the first study ever that investigated the combinations of voice features; automatically generated data, and electronic self-monitored data as state markers in patients with bipolar disorder. Using feature analysis collected in real-time from smartphones for classifying affective states in bipolar disorder reflects an innovative, objective and unobtrusive method for monitoring of illness activity (state) during long-term and in naturalistic settings.
Reference:
Voice analysis as an objective state marker in bipolar disorder. M. Faurholt-Jepsen, J.Busk, M.Frost, M.Vinberg, E.M.Christensen, O.Winther, J.E.Bardram and L.V.Kessing. 5 May 2016. http://www.nature.com/tp/journal/v6/n7/pdf/tp2016123a.pdf
Jul 5, 2016
Using smartphone apps to improve mental healthcare is definitely a possibility in today’s world where almost everything can be taken care of with just a click.
According to the ECNP/EBC report, there 165 million people or 38% of the population in Europe are affected by a mental illness. The successful treatment of mentally-ill individuals depends on some factors, and medication alone is not sufficient. There are various methods of treatment which they often include a mixture of therapy, self-help, and medication. Some individuals also choose to include exercise, meditation and creative art therapies, to help in their recovery process.
Smartphone apps to improve mental healthcare, an alternative that goes beyond
We live in an era where we have integrated smartphones in our daily lives, from conducting business, to interacting with our loved ones; and from purchasing items online to doing research on something we are interested. Can we take advantage of this technology to help those who need it the most?
It is a well-known fact that there is a major shortage of trained professionals who provide the kind of care patients need. In Europe alone it has been estimated that only 25% of individuals suffering from any mental disorder undergo treatment; while it is also estimated that only 10% of those mentally-ill receive an “adequate treatment.”
There are hundreds of mood trackers and mental health apps available for download. However, they have not been developed with the support from trained clinicians and have no evidence from clinical trials. Is this really the best way to go?
Huge Potential
If thoroughly tested and implemented effectively, mobile health applications can help clinicians and individuals by enabling self-treatment, speeding up the recovery process and prioritising treatment for those who need it the most.
Monsenso is a Copenhagen-based emerging company offering an mHealth platform to help clinicians overcome the burden of mental disorders. The effectiveness of this innovative solution is due to its double-loop treatment model.
On one side, healthcare providers use a web portal to monitor individuals on a continuous basis, identify early-warning signs and offer proactive treatment. On the other, users employ a smartphone to collect data, which is sent automatically to the clinic, enabling healthcare providers to deliver a prompt response.
Clinicians and users can easily access all historical data captured through the smartphone and obtain an accurate analysis and patterns of such data. In additional to historical data, the system can also provide accurate predictions of a patient’s moods and states during the upcoming five days.
Monsenso’s technology is based on continuous research. At the moment, there are ongoing studies and technical trials in bipolar disorder and schizophrenia to ensure the system is stable, scalable and that it helps improve an individual’s well-being.
This is just the beginning
Although mental health care providers deliver a fantastic care, there are hardly enough professionals to ensure everyone receives adequate treatment. Technology and innovation are required to ensure that people living with mental disorders obtain the best treatment available in a timely manner.
Click on the links to learn more about the Monsenso mHealth solution mental health consisting on a smartphone app for individuals, carers and a web portal for clinicians.
Reference:
[1] The size and burden of mental disorders and other disorders of the brain in Europe 2010. ECNP/EBC REPORT 2011.
https://www.ecnp.eu/~/media/Files/ecnp/communication/reports/ECNP%20EBC%20Report.pdf
Jun 21, 2016
According to a recent statement by the new American Heart Association (AHA), major depressive disorder and bipolar disorder should be recognized as moderate risk factors for atherosclerosis and early cardiovascular disease. [1]
In 2011, the National Heart, Lung and Blood Institute identified four conditions (chronic inflammatory disease, human immunodeficiency virus, Kawasaki disease, and nephritic syndrome) that lead youths to a mild risk of developing cardiovascular disease before they reach 30. [2]
The statement released a few days ago, reveals that depression and bipolar disorder meet the same criteria as these conditions. Moreover, these two behavioural disorders are more widespread than the previous mentioned conditions combined.
These studies showed evidence of a link between paediatric depression and bipolar disorder with premature cardiovascular mortality. Cardiovascular risk factors for these teens include obesity, insulin resistance and diabetes, dyslipidemia, and hypertension.[1] According to the statement, depression and bipolar disorder are the first- and fourth-most disabling conditions, among adolescents worldwide.
After the report had been unveiled, researchers from schools around the U.S. and Canada looked at existing studies on mood disorders in people under the age of 30. Researchers looked specifically into youths suffering from depression or bipolar disorder with cardiovascular markers such as high pressure and cholesterol. They found a significant connection between having depression or bipolar disorder and increased odds of high blood pressure, high cholesterol, obesity (especially belly fat), type 2 diabetes, and hardening of the arteries. [3]
This discovery denotes that healthcare providers should track physical activity levels and food intake as well as metabolic monitoring is crucial for these young patients as a preventive measure.
However, to monitor cardiovascular markers, physical activity and food intake, of thousands of young patients who also suffer from mental illness is not an easy task. Although, there are hundreds of smartphone applications tracking physical activity and counting calories, these apps are personal, and clinicians do not have access to an individual’s data. Nevertheless, with the Monsenso mobile health (mHealth) solution, this cumbersome task becomes easy and achievable.
The Monsenso mHealth solution enables clinicians to access a patient’s data on a daily basis. Every day, youths would be reminded to fill in a self-assessment with important information that could include the number of hours they slept, the amount of unhealthy food they have eaten, and if they realized any physical activity throughout their day. Additionally, the smartphone can also collect physical activity and mobility data, based on the smartphone’s inbuilt accelerometer and GPS locator.
The Monsenso mHealth solution, especially designed to monitor behavioural data of patients suffering from mental illness, can in this way help clinicians monitor any unhealthy habits of patients with risk of developing cardiovascular disease.
Further, with the customisable action plans, each youth could follow “contingency plans” if they experience some symptoms related to their mental illness or if they have engaged in unhealthy activities. For example, a special trigger could set up if a youth has indulged in unhealthy food for several days in a row, or has had a low level of physical activity. The action plan listed for this trigger could then encourage individuals to engage in physical activities and and to try to avoid sugar and fat during the upcoming week.
References:
[1] Browser,D Medscape. Depression, Bipolar Disorder in Teens are CVD Risk Factors: AHA (2015, August 10) http://www.medscape.com/viewarticle/849312
[2] American Heart Association. Young people with mood disorders have increased risk of developing early cardiovascular disease (2015, August 11)
http://blog.heart.org/young-people-with-mood-disorders-have-increased-risk-of-developing-early-cardiovascular-disease/
[3] Walton, A Forbes. Teens with depression, bipolar disorder, should be screened for heart disease, experts say. (2015, August 11) http://www.forbes.com/sites/alicegwalton/2015/08/11/depressed-teens-may-be-at-higher-risk-for-heart-disease/
Goldstein BI, Carnethon MR, Matthews KA, et al. Major depressive disorder and bipolar disorder predispose youth to accelerated atherosclerosis and early cardiovascular disease. Circulation 2015.
Apr 26, 2016
“Making Mental Health a Global Priority” is a two-day high-level meeting hosted by the World Bank Group and World Health Organization (WHO) with the objective to include mental health as a global priority. This blog post is based on the report published after the meeting.
Mental health a global priority
- Studies estimate that at least 10% of the world’s population is affected by mental illness
- 20% of children and adolescents suffer from some type of mental disorder
- Mental disorders account for 30% of the non-fatal disease burden worldwide and 10% of the overall burden of disease, including death and disability
It is a known fact that two of the most common mental disorders, anxiety and depression, respond well to treatment. However, due to a lack of funding, these disorders are not treated in most cases. For governments and healthcare authorities, investing in the treatment of mental illness may seem questionable; nevertheless, mental disorders have many ripple effects, including a strong economic impact on society. In fact, mental disorders account for almost one in three years lived with disability globally. Additionally, there is a strong link between mental disorders and potentially fatal conditions including cancer, cardiovascular disease, diabetes, HIV and obesity.
A recent analysis shows that treating anxiety and depression is a cost-effective way to promote well-being and prosperity in a community – and that failure to be treated can contribute to impoverishment at a household level and to reduced economic growth and social well-being at a national level.
To tackle today’s mental health challenges, governments and international development partners should work together to fund cost-effective alternatives to treat mental health. This funding will provide a strong return on investment, with scale-up leading to good returns in restored productivity as well as improved health.
Action plans proposed by the World Bank and WHO
1. A new mental health system
The effective care of depression and anxiety requires a comprehensive mental health system including governance, healthcare institutions and community settings to endorse holistic mental health plans. Mental health planners and policy makers need to develop, through public awareness and community engagement, care delivery systems that are sensitive to local social, economic, and cultural contexts; this will ensure that services are appropriately sought out and utilized.
2. Integrated care for depression in primary, maternal, and paediatric care
In addition to its impact on physical health, depression can affect the management of chronic co-occurring diseases, such as diabetes, hypertension, cardiovascular disease and cancer.
Collaborative care—an evidence-based approach to care for chronic illness applied in primary care settings—guides the effective use of resources for delivery of quality mental health care. It emerges as an effective way to address co-morbid conditions and commonly co-occurring risk factors while improving overall health outcomes. Collaborative care emphasizes systematic identification of patients, self-care, and active care management by clinical providers, blended with other medical, mental health, and community supports.
Anxiety and depression also play large roles in the health of expectant and new mothers and their children. A study conducted in 2007 revealed that more than 50% of pregnant women suffer from anxiety and more than 37% suffer from depression. Antenatal depression can increase the likelihood of preterm birth, low birth weight, and cognitive disturbances. In addition, 10-15% of new mothers suffer from post-partum depression. Studies have shown that antenatal and postnatal interventions are effective in reducing depression and anxiety, which improves infant outcomes.
Children and young adults are also affected by depression and anxiety, which causes a negative effect on their ability to learn and study. Besides, since 75% of all mental disorders have a first onset by the age of 18-24, integrating mental health treatment into standard paediatric health care would not only improve students’ learning outcomes, it would also allow children and young adults to obtain treatment at an early stage.
3. Information and communications technology (ICT)-based platforms
ICT-based platforms, such as the one offered by Monsenso, provide an alternative method of mental health care delivery when resources are scarce, while also addressing long-standing obstacles in mental health delivery, such as transportation barriers, stigma associated with visiting mental health clinics, clinician shortages and high costs.
These platforms, especially mobile mental health interventions, can offer remote screening, diagnosis, monitoring and treatment; remote training for non-specialist healthcare workers; and can be used to develop and deliver highly specific, contextualized interventions.
Cognitive Behavioural Therapy (CBT) has been successfully implemented through information technology platforms, demonstrating improvement in depressive symptoms, reduced costs, patient acceptance and enhanced primary care workflow. In addition, patient participation is rapidly expanding in peer-to-peer social networks where patients can access around the clock support with demonstrable improvements in depression symptoms.
4. Platforms outside the health sector
Anti-stigma campaigns
Stigma associated with mental disorders can result in social isolation, low self-esteem, and limited chances in education, employment, and housing. Therefore, anti-stigma campaigns are powerful tools to confront mental disorders.
School-based interventions
The key strength of school-based health screening and care is that it maximises outreach in school age children and adolescents. The potential benefits include the healthy development of students, improved academic performance, and opportunities to integrate school and clinic-based services.
Workplace interventions
There is a huge amount of evidence that investing in workplace wellness programs is good for employees and companies.
Workplace mental health interventions can be centred on treatment or mental health promotion such as cognitive-behavioural approaches targeting stress reduction. Organizational-level workplace interventions can include policies that address prevention and early intervention.
Interventions related to conflicts and natural disasters
Conflict exposes civilian populations and refugees to violence and high levels of stress, resulting in dramatic rises in mental illness that can continue for decades after armed conflict has ceased. Therefore, part of the rebuilding efforts in post-conflict and post-disaster societies should include building mental health services that are well integrated into primary care and public health efforts.
Reference:
Out of the Shadows: Making Mental Health a Global Development Priority. World Bank and World Health Organization. 2016
Apr 19, 2016
Using mHealth for suicide prevention is cost-effective and scalable. Every year, more than 800,000 people take their own lives and there are many more people who attempt suicide. Every suicide affects families and communities, leaving long-lasting effects on the people left behind. In 2012, suicide was the second leading cause of death among 15–29-year-olds globally. [1]
Suicide is a serious public health problem; however it can be prevented with timely, evidence-based and often low-cost interventions. [1]
There isn’t a single cause for suicide. Most often, it occurs when stressors exceed the current coping abilities of individuals suffering from a mental health condition. Conditions like depression, anxiety, and substance abuse increase the risk for suicide, especially when unaddressed. Yet it’s important to note that most people who actively manage their mental health conditions lead fulfilled lives. [2]
Most suicidal individuals give warning signs or signals of their intentions. The best way to prevent suicide is to recognize these warning signs and know how to respond. [3]
A study conducted in Denmark from 1981 to 1997 aimed to explore suicide risk according to time since admission, diagnosis, length of hospital treatment, and number of prior hospitalisations.
The study revealed that suicide risk peaks in periods immediately after admission and discharge. The risk is particularly high for patients with affective disorders and for those with short hospital treatment. These findings should lead to systematic evaluation of suicide risk among inpatients before discharge and corresponding outpatient treatment, and family support should be initiated immediately after the discharge. [4]
“There isn’t any time to lose,” says Thomas Lethenborg, CEO at Monsenso. “Suicide attempts are extremely high the week after patients are being discharged from the hospital. It’s very difficult for the patient and their families to know what to do, and this is where the Monsenso mHealth solution can make a huge difference,” Mr. Lethenborg added.
The Monsenso mHealth solution can help clinicians to remotely monitor patients who have been recently discharged from hospital. After being discharged, patients will be urged to download the Monsenso smartphone app where they will fill in daily self-assessments revealing their current state of mind.
With the information collected by the self-assessments, the smartphone app can reveal if a patient presents any warning signs of suicide and send a notification to the clinician. Every day, healthcare professionals can use the web portal to review the patients’ data, and contact the patients at risk who have been indicated by the system.
Additionally, the Monsenso mHealth solution can also allow family carers to monitor their loved one’s behaviour and intervene if necessary.
“The mental health system in Europe was poorly equipped to monitor recently-discharged suicide patients, until now,” said Mr. Lethenborg. “I am confident that the Monsenso mHealth solution can help the healthcare systems in Europe to reduce the number of suicides by empowering patients, family caregivers, and healthcare professionals to intervene before it is too late,” he added.
References:
[1] World Health Organization Fact sheets
http://www.who.int/mediacentre/factsheets/fs398/en/
[2] American Foundation for suicide prevention
http://afsp.org/about-suicide/risk-factors-and-warning-signs/
[3] HelpGuide.org
http://www.helpguide.org/articles/suicide-prevention/suicide-prevention-helping-someone-who-is-suicidal.htm
[4] Suicide Risk in Relation to Psychiatric Hospitalization. Evidence Based on Longitudinal Registers. Jama Psychiatry. Ping Qin, MD, PhD; Merete Nordentoft, MD, PhD. 2005
http://archpsyc.jamanetwork.com/article.aspx?articleid=208501
Mar 9, 2016
During the last decade, social media has become a permanent part of people’s lives playing an important role in social interaction. In fact, social media is one of the most common activities among young people.
Based on a study made by the American Academy of Pediatrics, 75% of teenagers own cell phones, and more than 50% of adolescents log on to a social media site more than once a day. All websites or phone applications that offer social interaction are considered to be social media. Gaming websites, video websites, and blogs, which have grown exponentially in popularity in recent years, should also be considered in this category. All of these web applications offer today’s youth an unlimited number of communication portals, and boundless access to information. Taking this into consideration, parents should take more interest in what their children are browsing on the internet because many websites are not suitable for young people. [1]
Benefits of social media
Social interaction: Online, adolescents accomplish many social functions that are important to them: staying connected with friends and family, making new friends, sharing experiences, and exchanging ideas.
Become more involved in the community: Social networks are a powerful and accessible toolkit for showcasing and acting on issues and causes that affect the younger generations. These platforms can be used for sharing opinions and gathering people to stand up for causes that interest our society. [2]
New opportunities: Most of today’s companies and organizations have a strong online presence and also share their content and opportunities on social platforms. Therefore, young people can easily find volunteering placements, jobs, and learning opportunities, and can also develop real world skills on the internet. Managing an online presence and being able to interact effectively online is becoming an important skill that many employers require. [2]
Access to information: The free and unlimited access to information is by far the handiest and most satisfying advantage. Social media is encouraging learning and discovery. Even though books are still used for facts and theoretical information, the internet is a convenient source to learn more about any topic and read about different opinions to help develop a teenager’s personality.
With this self-learning method, young people can explore alone, building independence and developing the skills they need to recognise and manage risk, learn and evaluate situations, which leads to an open mind-set. [2]
Drawbacks of social media
While social networks offer an opportunity to connect and interact with friends and family, there are also many downsides to using social media. For example, cyberbullying, “Facebook depression”, sleep deprivation, sexting, anxiety, and exposure to inappropriate content.
Cyberbullying: takes place using electronic technology, for example, unkind text messages or emails, rumours sent by email or posted on social networking sites, embarrassing pictures, videos, websites, or fake profiles amongst other things.
Most parents fail to realize the huge influence social media has over tweens and teens. Cyberbullying is by far the most common, it can happen to anyone, and it may cause psychosocial outcomes including depression, anxiety, severe isolation, and even suicide. A recent survey by the American Academy of Paediatrics revealed that 20% of teens have sent or posted nude or semi-nude photographs or videos of themselves. [1]
Facebook depression: Researchers have found a new phenomenon called “Facebook depression”. This new disorder develops when teenagers spend great amounts of time on social networks and slowly become depressive. Peer acceptance and a sense of belonging are critical to adolescents, and when this fails to happen, they risk becoming depressed. Most of the time young people tend to share only what’s good on social media, leading others to believe that nothing bad ever occurs in their lives. Some people even go as far as posting positive matters about their life when in reality they might not be doing well just to impress their peers. [1] [3]
Sleep deprivation: Another negative aspect of social media is sleep deprivation. Lead researcher Dr. Cleland Woods said “While overall social media use impacts on sleep quality, those who log on at night appear to be particularly affected. This may be mostly true of individuals who are highly emotionally invested. This means we have to think about how our kids use social media, in relation to time for switching off.” [3]
Privacy concerns and the digital footprint: Privacy concerns are a good reason to be worried when your child is spending a lot of time on the internet. The misuse of social media can result in a lack of privacy, sharing too much information, or posting false information about themselves or others.
A matter that’s particularly disturbing is called the “digital footprint, which is one’s unique set of digital activities, actions, and communications that leave a data trace on the Internet. In other words, young people unaware of this on-going record of digital data may post inappropriate messages, pictures, and videos without understanding that “what goes online stays online”. Also, future jobs and university acceptances may be put in jeopardy. [1] [4]
Children’s mental health
The World Innovation Summit for Health (WISH) released a Report on Mental Health and Well-being for children titled “Healthy Young Minds. Transforming the mental health of children.” The WISH report encourages local communities and countries to focus on 10 Action Plans to improve the mental health of children around the world.
- Community action: Every local community should implement a child well-being strategy
- Parity of esteem: Mental health care for children and their parents should be widely available
- Universality: Health professionals should be trained to identify mental health problems in children Professionals: Countries should train more professionals in psychological therapy
- Well-being in Schools: The well-being of students should be the priority of every school
- Measurement: Schools should evaluate all students’ well-being on a continuous basis
- Add life-skills to the teaching curriculum: Schools should provide explicit instruction in life throughout school life
- Teacher Training: All teachers should be trained to notice and promote well-being and mental health
- Use of smartphone technology: Implement a smartphone-based program to promote mental health and well-being of the children
- The Sustainable development goals: The sustainable development goals should include physical and mental health
Monitoring the well-being and mental health of children at risk
The Monsenso mHealth solution can help facilitate the achievement of six of the ten points included in the WISH Action Plan.
- Use of smartphone technology and well-being at schools – The Monsenso smartphone app can help adolescents express any negative feelings they may be experiencing. This information can help caregivers identify problems such as depression, anxiety, eating disorders, ADHD or even more severe diagnoses such as bipolar disorder or borderline personality disorder.
- Measurement – With help from the Monsenso mHealth platform, school personnel can identify if some students present any Triggers or Early Warning signs. Once symptoms are identified in a group of students, caregivers can monitor this group closely to ensure they are receiving the support and attention they need.
- Teacher training – The Monsenso web portal is so easy to use that caregivers do not require any special training to use the system. However, since they are not trained as mental healthcare specialists, they will need some training to help them interpret the information provided through the self-assessments.
- Parity of esteem – In most countries, there is a lack of resources and the waiting time to schedule an appointment with a mental healthcare specialist can be up to a year. The Monsenso mHealth solution can help school personnel identify the students who are experiencing symptoms of mental illness. Once a student has been monitored for a determined period and the symptoms continue, school personnel can recommend that the family seek professional help.
- Add life-skills to the teaching curriculum – Since all students would be required to fill out the daily self-assessments to evaluate and monitor their mental health well-being, the class dialogue can be facilitated by the information on the system. Teachers can provide students with real, anonymous examples of a person experiencing symptoms. Additionally, students could be encouraged to talk to a school counsellor if they experience any of the symptoms discussed in class. Students could also be taught how to act if they notice any symptoms in their peers.
References:
[1]Clinical Report-The Impact of Social Media on Children, Adolescents, and Families. The American Academy of Pediatrics. 2011.
http://pediatrics.aappublications.org/content/pediatrics/early/2011/03/28/peds.2011-0054.full.pdf
[2]Benefits of internet and social media. Reach Out.
http://au.professionals.reachout.com/benefits-of-internet-and-social-media
[3]Pressure to be available on social media may harm teenagers. The British Psychological Society. 2015.
http://www.bps.org.uk/news/pressure-be-available-social-media-causes-teen-anxiety-and-depression
[4]Digital footprint. Dictionary.com
http://dictionary.reference.com/browse/digital-footprint
[5]Healthy Young Minds. Transforming the mental health of children. Report of the WISH Mental Health and Well-being in Children Forum 2015
http://dpnfts5nbrdps.cloudfront.net/app/media/1432
