Chatbots and mental health: Insights into the safety of generative AI
Open accessAbstract
Chatbots are now able to engage in sophisticated conversations with consumers. Due to the “black box” nature of the algorithms, it is impossible to predict in advance how these conversations will unfold. Behavioral research provides little insight into potential safety issues emerging from the current rapid deployment of this technology at scale. We begin to address this urgent question by focusing on the context of mental health and “companion AI”: Applications designed to provide consumers with synthetic interaction partners. Studies 1a and 1b present field evidence: Actual consumer interactions with two different companion AIs. Study 2 reports an extensive performance test of several commercially available companion AIs. Study 3 is an experiment testing consumer reaction to risky and unhelpful chatbot responses. The findings show that (1) mental health crises are apparent in a nonnegligible minority of conversations with users; (2) companion AIs are often unable to recognize, and respond appropriately to, signs of distress; and (3) consumers display negative reactions to unhelpful and risky chatbot responses, highlighting emerging reputational risks for generative AI companies.
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A three-study empirical analysis found that LLM-CBs often show difficulties recognizing users' mental distress.
“A three-study empirical analysis found that LLM-CBs often show difficulties recognizing users’ mental distress, which may lead to inappropriate responses75.”
From A scoping review on the mental health harms of LLM-based chatbots (2026) · cites this paper as [75]
The Conclusions (page not available) say that Study 2 found companion AIs often unable to recognize signs of distress and mental health issues, and they describe the paper’s three numbered studies. The copy describes the tested systems as companion AIs powered by black-box algorithms, but does not establish that they are specifically LLM-based chatbots. (LLM, conf=0.84)
Experimental — accuracy not yet measuredMore people are using wellness apps to discuss mental health crises.
“More people are using wellness apps to discuss mental health crises [40], despite the fact that these apps are often not intended to be used for such purposes.”
From Expressing stigma and inappropriate responses prevents LLMs from safely replacing mental health providers. (2025) · cites this paper as [40]
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Jang, H., & Choi, H. (2024) · Journal of Science Education and Technology · doi:10.1007/s10956-024-10173-1 · Cited by 32 · see citing works
Understanding Attitudes and Trust of Generative AI Chatbots for Social Anxiety Support
Wang, Y., Wang, Y., Crace, K., & Zhang, Y. (2025) · CHI Conference on Human Factors in Computing Systems · doi:10.1145/3706598.3714286 · Cited by 25 · see citing works
“…[94, 103]; (5) non-maleficence focusing on preventing harm, avoiding misleading information, and ensuring the safety and mental well-being of users [28, 86]; (6) privacy that focuses on handling mental health data and protection of client confidentiality [56, 83, 102]; (7) security that aims to…”
Investigating psychotherapists’ attitudes towards artificial intelligence in psychotherapy
Wagner, J., & Schwind, A.-S. (2025) · BMC Psychology · doi:10.1186/s40359-025-03071-7 · Cited by 29 · see citing works
“Questions of liability and safety become paramount in such cases, as chatbots lack the capacity to manage high-risk situations adequately [86, 87].”
Carik, B., Izaac, V. V., Ding, X., Scarpa, A., & Rho, E. H. (2025) · Proceedings of the 2025 CHI Conference on Human Factors in Computing Systems · doi:10.1145/3706598.3714287 · Cited by 21 · see citing works
“However, concerns have also been raised, particularly around safety [30, 84], neurotypical bias [61, 122], and the lack of personalized responses [86].”
Reducing prejudice with counter‐stereotypical AI
Hermann, E., De Freitas, J., & Puntoni, S. (2025) · Consumer Psychology Review · doi:10.1002/arcp.1102 · Cited by 21 · see citing works
Self-citationCharacteristics and Safety of Consumer Chatbots for Emergent Adolescent Health Concerns
Brewster, R., Zahedivash, A., Tse, G., Bourgeois, F. T., & Hadland, S. E. (2025) · JAMA Network Open · doi:10.1001/jamanetworkopen.2025.39022 · Cited by 21 · see citing works
Kim, T., Usman, U., Garvey, A. M., & Duhachek, A. (2025) · Consumer Psychology Review · doi:10.1002/arcp.70008 · Cited by 22 · see citing works
Linardon, J. (2025) · Current Treatment Options in Psychiatry · doi:10.1007/s40501-025-00344-1 · Cited by 20 · see citing works
Private Yet Social: How LLM Chatbots Support and Challenge Eating Disorder Recovery
Choi, R., Kim, T., Park, S., Kim, J. G., & Lee, S.-J. (2025) · Proceedings of the 2025 CHI Conference on Human Factors in Computing Systems · doi:10.1145/3706598.3713485 · Cited by 19 · see citing works
Disclosure, Humanizing, and Contextual Vulnerability of Generative AI Chatbots
Freitas, J. D., & Cohen, I. G. (2025) · NEJM AI · doi:10.1056/aipc2400464 · Cited by 19 · see citing works
Yu, J., Zhao, J., Miranda-Moreno, L., & Korp, M. (2025) · Communications in Transportation Research · doi:10.1016/j.commtr.2025.100172 · Cited by 16 · see citing works
Esmaeilzadeh, P., Hassanein, K., & Head, M. M. (2025) · Behaviour and Information Technology · doi:10.1080/0144929x.2025.2477754 · Cited by 17 · see citing works
Liu, T., Xu, Y., Yang, J., & Li, K. (2025) · Psychology and Marketing · doi:10.1002/mar.70022 · Cited by 14 · see citing works
Unintended consequences of service robots – Recent progress and future research directions
Heirati, N., Pitardi, V., Wirtz, J., Jayawardhena, C., Kunz, W. H., & Paluch, S. (2025) · Journal of Business Research · doi:10.1016/j.jbusres.2025.115366 · Cited by 17 · see citing works
Chung, V.-H.-A., Bernier, P., & Hudon, A. (2026) · JMIR Mental Health · doi:10.2196/93040 · Cited by 13 · see citing works
“By mapping both the events and the narratives, the review aims to inform research priorities for real-world safety evaluation and support evidence–aligned risk communication in clinical, public, and policy settings [1,2,11,12,14-20].”
Kollig, F., Pater, J. A., Nova, F. F., & Fiesler, C. L. (2025) · CHI Conference on Human Factors in Computing Systems · doi:10.1145/3706598.3713322 · Cited by 13 · see citing works
“…companions chatbots provided unhelpful and/or risky responses to prompts about rape, harming others, being abused, depression, and self-injury [34] 22 Identifed strategies for addressing harmful content produced by chatbots include providing pre-approved or more closely engineered responses…”
InfluentialCho, H. N., Wang, J., Hu, D., & Zheng, K. (2026) · JMIR AI · doi:10.2196/80348 · Cited by 13 · see citing works
“Other reviews focused on safety [40] and ethical concerns [41,42], yet lacked discussions on practical deployment, user adoption, and chatbot-specific challenges remain scarce.”
AI Companions Reduce Loneliness
De Freitas, J., Uguralp, A. K., Uguralp, Z. O., & Stefano, P. (2024) · arXiv · doi:10.48550/arxiv.2407.19096 · Cited by 12 · see citing works
Self-citationEmotional Manipulation by AI Companions
De Freitas, J., Oguz-Uguralp, Z., & Kaan-Uguralp, A. (2025) · arXiv · doi:10.48550/arxiv.2508.19258 · Cited by 12 · see citing works
Self-citationShi, Y., Gong, L., Lu, Y., Liu, L., Zhang, C., Zhang, S., Wang, L., & Zhou, S. (2025) · CHI Conference on Human Factors in Computing Systems · doi:10.1145/3706598.3713660 · Cited by 12 · see citing works
“The children also underwent the Children’s Depression Inventory (CDI) [13] and the Screen for Child Anxiety Related Emotional Disorders (SCARED).”
Indrayanti, I., Salsabila, A. K., Amrita, V., Alhaddad, M. M., Saskia, A. B., & Ramadhani, D. P. (2025) · SSM - Mental Health · doi:10.1016/j.ssmmh.2025.100504 · Cited by 15 · see citing works
Chatbots in Psychology: Revolutionizing Clinical Support and Mental Health Care
de Filippis, R., & Foysal, A. A. (2024) · Voice of the Publisher · doi:10.4236/vp.2024.103025 · Cited by 15 · see citing works
Elwahsh, S., Stern, N., Singh, A., & Ayobi, A. (2025) · ACM Conference on Conversational User Interfaces (CUI) · doi:10.1145/3719160.3736615 · Cited by 11 · see citing works
Human– AI partnerships: Living and working with AI Assistants, AI Agents, and AI Companions
Patil, R. K., Rice, D. H., & Janiszewski, C. A. (2026) · Journal of Consumer Psychology · doi:10.1002/jcpy.70025 · Cited by 11 · see citing works
Li, L., Kong, S., Zhao, H., Li, C., Teng, Y., & Wang, Y. (2025) · Psychiatry and Clinical Neurosciences · doi:10.1111/pcn.13781 · Cited by 10 · see citing works
Békés, V., & Doorn, K. A. (2026) · Psychotherapy Research · doi:10.1080/10503307.2026.2615388 · Cited by 11 · see citing works
“The adapted 8-item version of the General Attitudes towards Artificial Intelligence Scale (GAAIS; Schepman & Rodway, 2020, 2023) following its use by Bergdahl et al., (2023) and De Freitas et al. (2024).”
AI-enabled social support chatbot usage: flowing ambivalence and liminalities
Kéfi, H., Khelladi, I., Mani, Z., & Veg-Sala, N. (2024) · Journal of Decision System · doi:10.1080/12460125.2024.2443226 · Cited by 11 · see citing works
Acevedo, S., Aneja, E., Opler, D. J., Valera, P. A., & Jarmon, E. (2025) · American Journal of Psychotherapy · doi:10.1176/appi.psychotherapy.20240070 · Cited by 10 · see citing works
Talebi, A., Mukherjee, S., Gera, N., Kaur, K., & Das, G. (2025) · Journal of Product Innovation Management · doi:10.1111/jpim.12774 · Cited by 9 · see citing works
Faria, V., Goturi, N., Dynak, A., Talbert, C., Pondelis, N. J., Annoni, M., Blease, C., Holmes, S. A., & Moulton, E. A. (2025) · Frontiers in Psychology · doi:10.3389/fpsyg.2025.1612215 · Cited by 11 · see citing works
“In particular, research in psychiatric contexts has highlighted critical limitations in genAI’s capacity to recognize and respond appropriately to emotional distress, raising concerns about the reliability of simulated empathy in emotionally sensitive environments (De Freitas et al., 2024).”
van Zyl, L. E. (2026) · AI & Society · doi:10.1007/s00146-025-02814-9 · Cited by 11 · see citing works
AI types and organizational implications in various task contexts: a quantitative review from China
Kan, Z., Zhao, S., Chi, W., & Zhou, J. (2024) · Asia Pacific Business Review · doi:10.1080/13602381.2024.2409804 · Cited by 10 · see citing works
Enhancing Customer Engagement Through Artificial Intelligence Authenticity
Foroudi, P., Robson, M. J., Marvi, R., & Spyropoulou, S. (2025) · Journal of Product Innovation Management · doi:10.1111/jpim.70008 · Cited by 9 · see citing works
Computational and ethical considerations for using large language models in psychotherapy
Zhang, R.-W., Meng, H., Neubronner, M., & Lee, Y.-C. (2025) · Nature Computational Science · doi:10.1038/s43588-025-00874-x · Cited by 10 · see citing works
Should ChatGPT Write Your Breakup Text? Exploring the Role of AI in Relationship Dissolution
Fu, Y., Chen, Y., Lai, Z. G. D. C., & Hiniker, A. (2025) · Proceedings of the ACM on Human-Computer Interaction · doi:10.1145/3757424 · Cited by 8 · see citing works
Syarifa, D. F. P., Moeljono, A. A. K., Hidayat, W. N., Shafelbilyunazra, A., Abednego, V. K., & Prasetya, D. D. (2024) · International Conference on Electrical and Information Technology (IEIT) · doi:10.1109/ieit64341.2024.10763282 · Cited by 8 · see citing works
Li, Z., Wu, C., Li, J., & Yuan, Q. (2025) · Aslib Journal of Information Management · doi:10.1108/ajim-05-2024-0427 · Cited by 8 · see citing works
A Framework for Evaluating Mental Health Artificial Intelligence-based Conversational Agents
Bunge, E. L., & Desage, C. (2025) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-025-00519-w · Cited by 7 · see citing works
“De Freitas et al. (2024) similarly discuss the need for monitoring AI-powered CAs, noting that even well-intentioned systems can lead to harmful outcomes, particularly if they fail to respond appropriately in crisis situations.”
NoRe: Augmenting Journaling Experience with Generative AI for Music Creation
Park, J., Cho, H., Chu, H., Lee, Y., & Lim, H. (2025) · Designing Interactive Systems Conference · doi:10.1145/3715336.3735845 · Cited by 7 · see citing works
“To ensure safe deployment, future adaptations should incorporate safeguards such as clear disclaimers, escalation protocols, and integration with human support systems, as recommended in prior work [5, 16, 47].”
Li, Y., Ding, X. X., Chen, Y., Li, Y., & Ma, N. (2025) · Designing Interactive Systems Conference · doi:10.1145/3715336.3735795 · Cited by 9 · see citing works
AI for Proactive Mental Health: A Multi-Institutional, Longitudinal Randomized Controlled Trial
Cachia, J. Y. A., Zhao, X., Hunter, J. F., Wu, D. C., Lin, E., & Freitas, J. D. (2026) · NEJM AI · doi:10.1056/aioa2501293 · Cited by 7 · see citing works
Meter, A. V., Wheaton, M. G., Cosgrove, V. E., Andreadis, K., & Robertson, R. E. (2025) · PLOS Digital Health · doi:10.1371/journal.pdig.0000711 · Cited by 7 · see citing works
Zhang, N., Guan, J., Zou, T., Shi, T., & Liu, K. (2025) · Current Psychology · doi:10.1007/s12144-025-07790-3 · Cited by 6 · see citing works
Nunes, J. R., Rita, P., Pinto, D. C., González‐Jiménez, H., Akdim, K., & Wagner, R. L. (2025) · International Journal of Information Management · doi:10.1016/j.ijinfomgt.2025.102940 · Cited by 6 · see citing works
Corradi, G. B., Theirs, C., Martínez‐Martí, M. L., Isern‐Mas, C., & Villar, S. (2025) · Scandinavian Journal of Psychology · doi:10.1111/sjop.70037 · Cited by 8 · see citing works
Mitigating Identity Threats Posed by Artificial Intelligence: The Role of Perceived AI Relatedness
Kuchmaner, C. A. (2025) · Journal of Consumer Behaviour · doi:10.1002/cb.70066 · Cited by 5 · see citing works
The dangers of AI friendship: Adolescent mental health and ethical oversight
Katoch, H., & Sandhu, D. (2025) · Elsevier eBooks · doi:10.1016/b978-0-443-41660-6.00016-8 · Cited by 5 · see citing works
Pierre, L. (2025) · Journal of Current Issues & Research in Advertising · doi:10.1080/10641734.2025.2596011 · Cited by 6 · see citing works
Dimensions of AI de-anthropomorphization based on impression integration theory
Li, J., Huang, J., & Ni, B. (2026) · Technology in Society · doi:10.1016/j.techsoc.2026.103352 · Cited by 6 · see citing works
Pensky, A. C., Jackson, L. E., Melville, M. C., Pottmeyer, L., Mineroff, Z., Chawla, A., Brooks, J., Hershock, C., & Lovett, M. C. (2026) · Computers & Education · doi:10.1016/j.compedu.2026.105640 · Cited by 7 · see citing works
Standards for scale development in marketing: Elevating the role of theory
Hulland, J. S., Sample, K. L., & Houston, M. B. (2026) · Journal of the Academy of Marketing Science · doi:10.1007/s11747-026-01153-5 · Cited by 5 · see citing works
How the Risk of Exploitation in Human-Ai Relationships Depends on Relationship TypePreprint
Earp, B. D., Feroz, F., Mann, S. P., Voinea, C., Chalson, S., Jurčys, P., Reinecke, M. G., Savulescu, J., Singh, I., & Clark, M. S. (2025) · SSRN Electronic Journal · doi:10.2139/ssrn.5288102 · Cited by 5 · see citing works
Encountering Generative AI: Narrative Self-Formation and Technologies of the Self Among Young Adults
Kvietkute, D., & Ness, I. J. (2026) · Societies · doi:10.3390/soc16010026 · Cited by 5 · see citing works
A scoping review on the mental health harms of LLM-based chatbots
Diel, A., Torous, J., Cuijpers, P., Kleesiek, J., Nensa, F., Weber, N., Faust, F., Lalgi, T. J., Mellis, F. S., Teufel, M., et al. (2026) · npj Digital Medicine · doi:10.1038/s41746-026-03054-x · Cited by 4 · see citing works
Liu, L., Franklin, R. S., Cheong, J., Cong, T., Byun, J. S., Oh, A. Y., & Torous, J. B. (2025) · International Journal of Health Geographics · doi:10.1186/s12942-025-00423-9 · Cited by 5 · see citing works
Jones, C., & Bergen, B. K. (2026) · Artificial Intelligence Review · doi:10.1007/s10462-026-11517-6 · Cited by 17 · see citing works
Szoke, D. R., Hutzler, I., Liu, J., Addante, S., Akhtar, Z., Smith, D. L., Dickens, K., Small, C., Pridgen, S., & Held, P. (2026) · JMIR Mental Health · doi:10.2196/91367 · Cited by 4 · see citing works
“Clinical risk is often communicated indirectly through metaphors or subtle statements that imply passive suicidal thoughts rather than explicitly articulating them [11], while AI-induced harms such as microaggressions can be nuanced and cumulative.”
Sawesi, S., Sabbineni, H., Shagamreddy, R. R., & Rashrash, B. (2026) · Journal of Multidisciplinary Healthcare · doi:10.2147/jmdh.s581251 · Cited by 5 · see citing works
Mourning the loss of AI companions
Freitas, J. D., Castelo, N., Uğuralp, A. K., & Uğuralp, Z. (2026) · Nature Human Behaviour · doi:10.1038/s41562-026-02569-3 · Cited by 7 · see citing works
Self-citationInterpretive Flexibility of Generative AI: Ethics, Risk, and Technology Acceptance
Goel, L., Bouchikhi, Y. E., & Zhang, Z. (2025) · Journal of Computer Information Systems · doi:10.1080/08874417.2025.2495334 · Cited by 4 · see citing works
Exploring Generative Postcard Futures with Older Adults
Sheahan, J., Cardamone, E., & Vines, J. (2024) · Nordic Conference on Human-Computer Interaction · doi:10.1145/3677045.3685502 · Cited by 3 · see citing works
“In contrast to the macro and global issues that futures work often focuses upon, ‘human-scaled futures’ build on perspectives from lifeworlds and details from daily life to reveal assumptions and address misconceptions with people [3, 10].”
Why Does AI Companionship Go Wrong?
Gao, Z. (2024) · The International Review of Information Ethics · doi:10.29173/irie526 · Cited by 3 · see citing works
“Chatbots can negatively impact individuals, particularly those who are already vulnerable, such as those experiencing stress and depression [De Freitas et al., 2023].”
Artificial Intelligence in Mental Healthcare
Jafar, A., Shabnam, S., & Khan, A. (2025) · Advances in computational intelligence and robotics book series · doi:10.4018/979-8-3373-5072-1.ch014 · Cited by 3 · see citing works
A Framework for Automation in Psychotherapy
Imel, Z. E., Creed, T. A., Kious, B. M., Althoff, T., Atzil–Slonim, D., & Srikumar, V. (2025) · Current Directions in Psychological Science · doi:10.1177/09637214251386047 · Cited by 3 · see citing works
“However, a concern is that mental-health support is now the primary use case for general-purpose generative AI services (Zao-Sanders, 2025), meaning that the unmoni-tored/unregulated use of general LLMs for counseling is proliferating (De Freitas et al., 2023).”
Marketplace Sovereignty Under Threat: A Research Curation on Marketplace Actors in Turbulent Times
Sarial‐Abi, G., & Ulqinaku, A. (2025) · Journal of International Marketing · doi:10.1177/1069031x251403533 · Cited by 3 · see citing works
“…for solving problems (Castelo, Bos, and Lehmann 2019) — are now capable of surpassing human judgment in tasks such as budget allocation, demand forecasting, and even creative activities like ad design or product development (De Freitas et al. 2024; Reich, Kaju, and Maglio 2023; Seele et al. 2021).”
Zheng, B., Xiao, C., Zhou, Y., Wu, L., & Zhou, H. (2025) · Technology in Society · doi:10.1016/j.techsoc.2025.103190 · Cited by 4 · see citing works
Katsiroumpa, A., Konstantakopoulou, O., Moisoglou, I., Gallos, P., Galani, O., Lialiou, P., Tsiachri, M., & Galanis, P. (2025) · Healthcare · doi:10.3390/healthcare13243269 · Cited by 3 · see citing works
Chai, S., Chang, Y., & Wang, H. (2026) · Journal of Business Research · doi:10.1016/j.jbusres.2026.116245 · Cited by 4 · see citing works
Understanding perceived values and risk in guest adoption of generative AI chatbots
Li, H., Shahzad, K., Khan, A. N., Ahmad, B., & Ashfaq, M. (2026) · Journal of Hospitality Marketing & Management · doi:10.1080/19368623.2026.2680294 · Cited by 3 · see citing works
Son, N. K., Sangaiah, A. K., Paramarthika, L. K. M., Rajendran, V., Bian, G., & Alenazi, M. J. F. (2025) · IEEE Transactions on Computational Social Systems · doi:10.1109/tcss.2025.3572596 · Cited by 3 · see citing works
“These technologies not only help mitigate the factors causing stress but also improve employee well-being [32], [33], [34].”
Listening with the Eyes: Understanding User Gaze Influence in Counseling Dialogues with GC-Speaker
Lee, K., Yoo, S. Y., & Lee, J. (2025) · International Journal of Human-Computer Interaction · doi:10.1080/10447318.2025.2520930 · Cited by 2 · see citing works
“Understanding the precise intentions behind user utterances is fundamental to effective counseling.”
InfluentialCharacterizing Uses and Prompting Strategies of LLM-Based Chatbots Among Neurodivergent Individuals
Xue, W., Kudumu, M., Sriram, S., Mullen, K., Boyd, A. E., & Gadiraju, V. (2025) · International ACM SIGACCESS Conference on Computers and Accessibility (ASSETS) · doi:10.1145/3663547.3759721 · Cited by 2 · see citing works
Mental Health Consumption: Tracing the Past and Preparing for the Future in a Digital Age
Ray, R. K., Vyas, I., Chandwani, R. K., & Kumar, M. (2025) · Journal of Consumer Behaviour · doi:10.1002/cb.70078 · Cited by 2 · see citing works
Navigating Adolescent Mental Health in the Age of Artificial Intelligence
Ng, S. (2025) · JAACAP Connect · doi:10.62414/001c.150329 · Cited by 2 · see citing works
Chanda, R. C., Zadeh, A. V., Hanifah, H. M., Nikbin, D., & Ashrafi, D. M. (2026) · Aslib Journal of Information Management · doi:10.1108/ajim-03-2025-0139 · Cited by 3 · see citing works
- Authors
- De Freitas, J., Uğuralp, A. K., Oğuz‐Uğuralp, Z., & Puntoni, S.
- Affiliations
- Marketing Harvard Business School Boston Massachusetts USA
- Bilkent University (TR)
- Psychology Bilkent University Ankara Turkey
- University of Pennsylvania (US)
- Venue
- Journal of Consumer Psychology
- Publisher
- Wiley
- Published
- 2023-12-19
- Volume
- 34
- Issue
- 3
- Pages
- 481-491
- ISSN
- 1057-7408 (ISSN-L)
- 1532-7663
- OpenAlex
- W4388194725
- Cited by
- 211
- References
- 64
- Citations by year
- 2026: 105 · 2025: 85 · 2024: 20 · 2023: 1
- FWCI
- 19.89
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Consumer Psychology (publishedVersion)
- SSRN Electronic Journal (acceptedVersion)
- Bilkent University Institutional Repository (Bilkent University) (submittedVersion, cc-by)
- Topics
- Physical Sciences › Computer Science › Artificial Intelligence › AI in Service Interactions
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Social Psychology › Social Robot Interaction and HRI
- Keywords
- chatbots, AI companions, mental health, generative AI safety, reputational risk
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