“Effexor XR is believed to treat depression and anxiety symptoms by affecting the levels of two naturally occurring chemicals in the brain — serotonin and norepinephrine. It is believed that correcting an imbalance of these two chemicals may help relieve symptoms. Because Effexor XR affects these two chemicals, it is known as an SNRI, or serotonin-norepinephrine reuptake inhibitor.”
“Whatever the circumstances, depression is caused by an imbalance of certain chemicals in the brain. Normally, these “chemical messengers” help nerve cells communicate with one another by sending and receiving messages. They may also influence a person's mood. In the case of depression, the available supply of the chemical messengers is low, so nerve cells can't communicate effectively. This often results in symptoms of depression.”
“Scientific evidence suggests that depression and certain anxiety disorders may be caused by a chemical imbalance in the brain. Paxil CR helps balance your brain's chemistry. (See Important Safety Information about Paxil CR.)
Just as a cake recipe requires you to use flour, sugar, and baking powder in the right amounts, your brain needs a fine chemical balance in order to perform at its best.
Normally, a chemical neurotransmitter in your brain, called serotonin, helps send messages from one brain cell to another. This is how the cells in your brain communicate.
Serotonin works to keep the messages moving smoothly. However, if serotonin levels become unbalanced, communication may become disrupted and lead to depression, anxiety, and PMDD.
Paxil CR helps maintain a balance of serotonin levels, which may help cell-to-cell communication return to normal. Paxil CR is with you throughout the day to help you manage and treat your condition.”
“Zoloft® (sertraline HCl) is a type of antidepressant known as a selective serotonin reuptake inhibitor or SSRI.
Nerve cells in the brain and the rest of the nervous system use chemical messengers. These messengers help cells send messages to each other. One of these messengers is called serotonin.
Studies show that serotonin plays a vital role in how our body works. It controls sleep, appetite, temperature, and blood vessel tone. It's also in charge of the release of certain hormones and how much pain we feel.
Because it is linked with so many functions in our body, serotonin has an effect on a wide range of conditions such as depression.
This tie between depression and serotonin led scientists to an interesting find. Scientists believe people with depression could have an imbalance of serotonin in their brain.
That means the level of serotonin is "off." So the nerve cells can't communicate, or send messages to each other the right way. This lack of contact between cells might cause depression.
Zoloft helps fix this. Zoloft helps the nerve cells send messages to each other the way they normally should.”
RESEARCH ON PSYCHIATRY
The following research documents back up Jerry Marzinsky's work. If you are looking for verification of what Jerry has written in his articles or spoken of in his videos, this is the place to find it.
CENTRAL STATE HOSPITAL (CSH) HISTORY AND PICTURES - Asylum: Inside Central State Hospital, once the world’s largest mental institution. The Milledgeville property is now mostly empty and falling into decay. 2,000-acres still echo with the memory of the patients who were treated—and mistreated—at Georgia’s state asylum. February 18, 2015 By Doug Monroe http://www.atlantamagazine.com/great-reads/asylum-inside-central-state-hospital-worlds-largest-mental-institution/
GUIDELINES FOR PREVENTING WORKPLACE VIOLENCE OSHA 3148
HOW TO PRESERVE YOUR OWN WELL-BEING IN A CHALLENGING MEDICAL ENVIRONMENT
MENTAL DISORDERS FACT OR FICTION
MENTAL DISORDERS: FACTS BEHIND THE MARKETING CAMPAIGN - “There are no objective tests in psychiatry-no X-ray, laboratory, or exam finding that says definitively that someone does or does not have a mental disorder.” “It’s bull— I mean, you just can’t define it.” — Allen Frances, Psychiatrist and former DSM-IV Task Force Chairman
SHRINK RAP: Three Psychiatrists Explain Their Work: written by psychiatrists: Dinah Miller, Annette Hanson, and Steven Roy Daviss, who writes a popular mental health blog. “Chemical imbalance is a term with imprecise meaning… Saying that a psychiatric disorder is caused by a chemical imbalance, sometimes makes psychiatric disorders more palatable to patients and less stigmatizing. The term gives some credence to the practice of treating these disorders with medication. But there is no psychiatric disorder for which we know for certain which chemicals are ‘imbalanced’ if any.”
PSYCHIATRIST WRITER PROGRAMMED BY IVORY TOWER SHOCKED TO LEARN WELL AFTER GRADUATION OF NO EVIDENCE OF CHEMICAL IMBALANCE SPEAKS - “One of the first phrases parents hear when a loved one shows symptoms of bipolar disorder, schizophrenia or persistent and major depression is “chemical imbalance.” I remember being shocked when I wrote this term in a Washington Post Op Ed piece and was confronted by someone who told me there is absolutely no scientific evidence that mental illnesses are caused by chemical imbalances in the brain.”
BLAMING THE BRAIN - “Blaming the Brain: The Truth About Drugs and Mental Health” published in February, 2002 by Elliot S. Valenstein, PhD, a professor emeritus of psychology and neuroscience who is a noted authority on brain stimulation and psychosurgery. Dr. Valenstein’s findings clearly dismantled the chemical imbalance theory. He concluded, "A theory that is wrong is considered preferable to admitting our ignorance.”
POOR FUNDING FOR SCHIZOPHRENIA - Schizophrenia: 100 years of bad treatment - A century after the term 'schizophrenia' was coined, life for people living with the illness is still stuck in the dark ages. Too often, people with severe mental illnesses are fobbed off with drugs alone. There are plenty of other treatments proven to work, but a poll by my organisation, Rethink Mental Illness, https://www.rethink.org/diagnosis-treatment/conditions/schizophrenia found just 16% of people who have schizophrenia and bipolar disorder are getting access to all the treatment recommended by Nice for their diagnosis.
MENTAL DISORDERS - Mental disorders, health inequalities and ethics: A global perspective (dated 2010) - The global burden of neuropsychiatry diseases and related mental health conditions is enormous, underappreciated and under resourced, particularly in the developing nations. The absence of adequate and quality mental health infrastructure and workforce is increasingly recognized. The ethical implications of inequalities in mental health for people and nations are profound
MENTAL HEALTH STIGMA - Mental Health Stigma: Society, Individuals, and the Profession (date 2011) - “For example, it has been estimated that less than 40 percent of individuals with severe mental illnesses receive consistent mental health treatment throughout the year. There are several potential reasons for why, given a high prevalence of mental health and drug use conditions, there is much less participation in treatment. Plausible explanations may include (1) that those with mental health or drug use conditions are disabled enough by their condition that they are not able to seek treatment, or (2) that they are not able to identify their own condition and therefore do not seek needed services. Despite these viable options, there is another particular explanation that is evident throughout the literature. The U.S. Surgeon General (1999) and the WHO (2001) cite stigma as a key barrier to successful treatment engagement, including seeking and sustaining participation in services. The problem of stigma is widespread, but it often manifests in several different forms. There are also varying ways in which it develops in society, which all have implications for social work – both macro and micro-focused practice. This belief system may result in unequal access to treatment services or the creation of policies that disproportionately and differentially affect the population.
MENTAL ILLNESS AS METAPHOR - The opening is perfect, where it says: "I don't believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim [that patients have a chemical imbalance], except perhaps to mock it...In truth, the 'chemical imbalance' notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists." –Ronald W. Pies, M.D., Professor of Psychiatry, the State University of New York and Tufts University School of Medicine" Dr. Pies is Editor in Chief Emeritus of Psychiatric Times, and a Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston. Dr. Pies is author, most recently, of Don't Worry—Nothing Will Turn Out All Right!: The Optipessimist's Guide to the Fulfilled Life. His books also include Psychiatry on the Edge, a collection of essays drawn from Psychiatric Times (Nova Publishing); a novel, The Director of Minor Tragedies (iUniverse); The Myeloma Year, a chapbook of poems and essays; and The Late Life Bloom of Rose Rabinowitz: A Novella. See his website: http://www.psychiatrictimes.com/authors/ronald-w-pies-md
CHEMICAL IMBALANCE MYTH
It's not only that they have no proof, it IS that it has been proven false: The chemical imbalance idea was long ago deemed false. For example: "I don't believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim [that patients have a chemical imbalance], except perhaps to mock it...In truth, the 'chemical imbalance' notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists." (Ronald W. Pies, M.D., Professor of Psychiatry, the State University of New York and Tufts University School of Medicine)
Despite the fact that they insist a chemical imbalance in the brain of these patients exists, you will never see on the front lines any psychiatrist doing any kind of blood work or labs to measure which if any chemicals in the brain of these patients is out of balance. No such measurements or tests exist. They have no idea what the normal neurochemical balance in the brain is or should be. Of course there are no tests because it was long ago proven to be false.
The hypothetical disturbances of neurochemical function that are said to underlie "mental illness" are just that: hypothetical. No experiment has ever show that anyone has an "imbalance" of any neurotransmitters or any other brain chemicls. Nor could any conceivable experiment demonstrate the existence of a "chemical imbalance," simply because no one, least of all the biopsychiatrists, has the slightest idea what a proper and healthy chemical "balance" would look like. http://www.academyanalyticarts.org/fores-chemical-imbalances
I t ' s a l l p u r e m a r k e t i n g, n o t h i n g m o r e:
The Chemical Imbalance theory - officially proven false!
It was long postulated that anxiety and depressive disorders (and many other mental illnesses) were caused by a chemical imbalance in the brain. More specifically, the “chemical imbalance” theory presumed that serotonin, a neurotransmitter in the brain, was below normal levels, and therefore caused anxiety and depressive disorders.
For example, Lexapro’s website (Lexapro is a popular antidepressant that is said to be able to restore this chemical imbalance) stated:
And Paxil’s website (Paxil is another antidepressant that is said to be able to restore this chemical imbalance) stated:
And Zoloft’s website (Zoloft is another antidepressant that was said to be able to restore this chemical imbalance) stated:
And Effexor’s website (Effexor is another antidepressant that was said to be able to restore this chemical imbalance) stated:
How prevalent was this approach to anxiety and depression?
Effexor, Lexapro, and Zoloft (popular antidepressants) were in the top 40 best selling medications in the world in 2006, and accounted for a combined total of over 8.5 billion dollars in sales during that year.
As well, two online polls conducted by anxietycentre.com in 2007 found:
90.5 percent of respondents said their doctor or mental health care professional wanted to prescribe medication for their anxiety or depressive disorder (or for both).
71.5 percent of respondents said their doctor or mental health professional told them that their disorder was caused by a chemical imbalance in the brain.
B u t i s t h e “C h e m i c a l I m b a l a n c e” t h e o r y t r u e?
The chemical imbalance theory as a cause for anxiety and depressive disorders never was true. In fact, no experiment has ever shown that anyone has an ‘imbalance’ of any neurotransmitters or any other brain chemicals. The entire theory was hypothetical.
Over the last ten years, independent research has continually shown the chemical imbalance theory to be false. Furthermore, independent research has shown medications used to ‘correct’ the imbalance were largely ineffective with many fairing no better than placebo.
If the “chemical imbalance” theory is untrue, how did it become so accepted?
Without going into detail about how this transpired, here is a brief overview:
Pharmaceutical research and so-called “independent studies” supported the notion of a “chemical imbalance,” and that SSRI medications were effective in resolving this imbalance. The results of these “studies” were published in respected medical journals. Health professionals who read these journals formed their opinions based on what they thought was solid research.
Pharmaceutical companies marketed directly to doctors and mental health care professionals using these studies to substantiate their claims. Pharmaceutical companies also aggressively marketed the “chemical imbalance” notion to the general public.
As a result, the chemical imbalance theory became widely accepted and so did the drugs used to “correct” it. Even today, there are still doctors and mental health care professionals asserting that anxiety and depressive disorders are caused by a chemical imbalance in the brain, which medication can ‘correct.’
Marketing was the primary driver behind the acceptance of the “chemical imbalance” theory.
ON THE MYTH OF THE CHEMICAL IMBALANCE - No, you don't have a chemical imbalance in your brain. Posted Sep 28, 2017
WHY THE BLACK MAGICIANS WANT YOU TO BELIEVE IN A BOGUS CHEMICAL IMBALANCE THEORY AND THAT THERE IS NO TREATMENT THAN THEIR TOXIC DRUGS - By Jerry Marzinsky November 29, 2017 - LET’S FOLLOW THE MONEY - The New York Times recently led with a front-page splash about psychiatry's propensity to prescribe pills, "Talk Doesn't Pay, So Psychiatry Turns Instead to Drug Therapy". That news is already widely known in the mental health field, but it has vast ramifications for Americans trying to maintain their sanity in our market-driven and medical system for delivering mental healthcare.
Mental illness has not decreased with the change from talk therapy to drugs. In fact, as Robert Whitaker's book diagnoses, mental illness in America has become an established epidemic. So-called miracle drugs like Prozac are taken by 11% of the population – and Prozac is only one of the 30 available antidepressants on the market. Antidepressants are accompanied by anti-anxiety and anti-psychotic drugs. Xanax, America's leading anti-anxiety medication, is so ubiquitous that Xanax generates more revenue than Tide detergent, reports Charles Barber in his Comfortably Numb.
Anti-psychotics drugs alone net the pharmaceutical industry at least $14.6bn dollars a year. Psycho-pharmaceuticals are the most profitable sector of the industry, which makes it one of the most profitable business sectors in the world. Americans are less than 5% of the world's population, yet they consume 66% of the world's psychological medications.
Do these psycho pharmaceuticals work to restore mental health? Actually, the evidence is overwhelming that they fail. Antidepressants, the most popular psycho-pharmaceuticals, work no better than placebos. They work 25% of the time and stop working when the user stops taking them. In addition, they may actually harm patients in the long run. They disrupt brain neurotransmitters and may usurp the brain's organic soothing functions.
Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy - Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry. The long-term use of antipsychotics is associated with side effects such as involuntary movement disorders, gynecomastia, and metabolic syndrome. They are also associated with increased mortality in elderly people with dementia.
RISK FACTORS FOR SUICIDE IN PATIENTS WITH SCHIZOPHRENIA - Comment by Jerry Marzinsky November 29, 2017 - I’m quoting a lot of statistical studies to draw attention to very strange yet strong and ignored correlation between the suicide rate of schizophrenics which I have no doubt the voices strongly contribute to and the assault and suicide rates of psychiatrists who interfere with the agenda of the voices with their anti-psychotic drugs. Someone down the line is probably going to challenge the statistics I quoted so I’m including the original sources to back up what I’m saying.
Risk Factors for Suicide in Patients With Schizophrenia - By Jill M. Harkavy-friedman, PhD February 2007, Vol. XXIV, No. 2
SUICIDE OF PHYSICIANS IN THE SPECIAL WARDS OF TOKYO METROPOLITAN AREA, WAKAKO HIKIJI AND TATSUSHIGE FUKUNAGA
Introduction by Jerry Marzinsky November 29, 2017 - Based on how drained I felt after working intensely with more than one schizophrenic a day and the high non-compliance rate of these patients to psychiatrist-prescribed medications and the high assault rate upon them, I suspect their above average suicide rate is also tied to assaults by these entities draining them or provoking patient attacks. The articles I’ve reviewed which make a direct correlation to psychiatrists in particular, tend to clump all assaults into “assaults upon medical personnel.” This is one of the few articles that mention above average suicide rates for psychiatrists: Suicide of physicians in the special wards of Tokyo Metropolitan area, Wakako Hikiji and Tatsushige Fukunaga - Journal of Clinical Forensic and Legal Medicine: An International Journal of Forensic and Legal Medicine. 22 (Feb. 2014): p37. DOI:
WHEN PSYCHIATRISTS DIE BY SUICIDE - Michael F. Myers 38.11 (Nov. 2010): p13. - “You're joking, right?" Even as I reflexively uttered these few words, I knew that my friend was not kidding around. Yes, it was true; Jim Steele (not his real name), whom I had trained with many years ago, had killed himself. "Gunshot wound to the head" was offered next. I realize now that my friend, another physician, was using clinical jargon to protect himself from the horror and the deeply personal nature of the act of self-destruction. "You're joking, right?" conveys my shock and disbelief. But why are we stunned like this in the face of suicide? Would I have used these words if Jim had died of a coronary or cancer?
SUICIDE IN SCHIZOPHRENIA - The life time prevalence of suicide in Schizophrenia is about 10 times higher than the general population. Early research suggested rates up to 13% but more recent studies report a lifetime suicide risk of 4 to 5%. Suicide is one of the leading causes of premature death worldwide and approximately 1 million people commit suicide every year. It is estimated that 90% have a diagnosable psychiatric illness with depression making up 60% and schizophrenia, alcoholism and personality disorders accounting for a large proportion of the rest.
Reference: Expert Rev Neurother 10(7), 1153-1164 (2010)
NATIONWIDE SURVEY OF WORK ENVIRONMENT, WORK-LIFE BALANCE AND BURNOUT AMONG PSYCHIATRISTS IN JAPAN - Published: February 13, 2013 - Introduction: Burnout is the feeling of physical, emotional, and mental exhaustion that is caused by long-term involvement in situations that are emotionally damaging . Professionals caring for people with long-term and serious illnesses are frequently exposed to distressing emotional situations and profound suffering, which can lead to burnout.
ASSAULTS ON PSYCHIATRISTS
VOICE-DIRECTED ASSAULTS ON PSYCHIATRISTS - Introduction by Jerry Marzinsky November 29, 2017 - The abnormal number of assaults, emotional draining and suicide rate of psychiatrists may be due to assaults directed against them by voices. One could say they are dealing with unstable patients however they deal with them for extremely short periods of time compared to psych nurses and psychiatric custodial workers who deal with them often before they are medicated and for very much longer periods of time. All these correlations appear to be tied in with psychiatrists being hated by the voices for prescribing medications that sedate patients and deprive the voices of their food source. It all seems tied into the negative reaction of the voices to having their food source interfered with like when I attempted to tell patients that the voices were parasitic entities. There was always a very predictable negative reaction on the part of the voices. I’m virtually certain the voices are behind the elevated attacks on psychiatrists as well as the extreme resistance these patients have to staying on their medications. I first observed at CSH (Central State Hospital) that patient attacks on psychiatrists were at a higher rate than any other staff given the little time they spend with patients. Below are supporting stats and one of the few articles where they don’t lump all attacks into attacks upon medical personal in general but report on attacks specifically against psychiatry:
Innovations in Clinical Neuroscience - A peer-reviewed journal - Innov Clin Neurosci. 2013 Mar; 10(3): 40–42. Published online 2013 Mar
SCHIZOPHRENIA EPIDEMIC WORLDWIDE
SCHIZOPHRENIA AT EPIDEMIC PROPORTIONS - From the Journal of Emergencies, Trauma and Shock (Jan-Mar 2017) - “Currently, an estimated 60 million people globally suffer from bipolar depression and an estimated 21 million people suffer from schizophrenia.”
World Health Organization on Mental disorders dated April 2017
RATES FOR PSYCHOSIS ALSO APPEAR TO BE RISING - The Department of Health Policy Research in the UK saw an annual incidence in 2012 of 32 cases of schizophrenia per 100,000 people and 21 cases of affective psychosis.” “Systematic Review of the Incidence and Prevalence of Schizophrenia and Other Psychoses in England” published in 2012 as the final corrected version.
AMONG THE TOP TEN MEDICAL PROBLEMS FACING HUMANITY - I site statistics as follows which was in response to some of the badgering Dr. Irmak was receiving from an article he wrote about witnessing a shaman healing a person who was suffering from schizophrenia: If in 2016 there were an estimated 7.4 billion people in the world, then 1% of that is 74 million individuals suffering with schizophrenia plus their family members that are also suffering. You would think that the medical profession would be open to suggestions on how to help these people. But no! Rather than consider sincere suggestions, the medical profession prefers to belittle the Professor and others that suggest something different. That this may be typical of humankind’s slow mindset development doesn’t make it right.
“[Schizophrenia] is one of the most important public health problems in the world. A survey by the World Health Organization ranks schizophrenia among the top ten illnesses that contribute to the global burden of disease. It appears to affect 1% of people worldwide.” This is a condition that produces great suffering for patients and also for their family members. http://www.who.int/bulletin/volumes/90/1/11-089284/en/
SCHIZOPHRENIA RANKS AMONG THE TOP 10 CAUSES OF DISABILITY IN DEVELOPED COUNTRIES WORLDWIDE - (source: The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Published by the Harvard School of Public Health on behalf of the World Health Organization and the World Bank, Harvard University Press, 1996.
THE PREVALENCE RATE FOR SCHIZOPHRENIA is approximately 1.1% of the population over the age of 18 (source: NIMH) or, in other words, at any one time as many as 51 million people worldwide suffer from schizophrenia, including;
• 6 to 12 million people in China (a rough estimate based on the population)
• 4.3 to 8.7 million people in India (a rough estimate based on the population)
• 2.2 million people in USA
• 285,000 people in Australia
• Over 280,000 people in Canada
• Over 250,000 diagnosed cases in Britain
RATES OF SCHIZOPHRENIA ARE GENERALLY SIMILAR FROM COUNTRY TO COUNTRY—about .5% to 1 percent of the population (there are variations - but the variance is difficult to track due to differing measuring standards in many countries, etc.). Source: Dr. Robin Murray
ANOTHER WAY TO EXPRESS THE PREVALENCE OF SCHIZOPHRENIA AT ANY GIVE TIME is the number of individuals affected per 1,000 total population. In the United States that figure is 7.2 per 1,000. This means that a city of 3 million people will have over 21,000 individuals suffering from schizophrenia. Incidence: The number of people who will be diagnosed as having schizophrenia in a year is about one in 4,000. So about 1.5 million people will be diagnosed with schizophrenia this year, worldwide. About 100,000 people in the United States will be diagnosed with schizophrenia this year. NOTE: The term 'prevalence' of Schizophrenia usually refers to the estimated population of people who are living with Schizophrenia at any given time. The term 'incidence' of Schizophrenia refers to the annual diagnosis rate, or the number of new cases of Schizophrenia diagnosed each year. http://www.bcss.org/category/aboutbcss/research/
Therefore, the approximate number of people in the United States suffering from:
• Schizophrenia: Over 2.2 million people
• Multiple Sclerosis: 400,000 people
• Insulin-dependent Diabetes: 350,000 people
• Muscular Dystrophy: 35,000 people
• Estimated overall cost to U.S. economy estimated at $62.7 Billion
• Ranks among the top ten disabilities in developing countries worldwide.
• From country to country rates of schizophrenia similar ranging from .5% to 1 % of population.
• In U.S. rate of schizophrenia is 7.2 people out of every 1000. In a city of 3 million people, 21,000 will be suffering from schizophrenia.
• 1.5 million will be diagnosed with schizophrenia worldwide each year with 100,000 in U.S. alone.
• Approximately 2.5 million people suffering from schizophrenia in U.S. at present
• Teens diagnosed as schizophrenic have a 50% probability of making a suicide attempt.
THE FRAUD AND SCAM OF PSYCHIATRY
The Scam of Psychiatry, ADHD, Bipolar, Chemical Imbalance
Perhaps we should look deeper before blindly trusting "authorities" with our mental health.
The “Chemical Imbalance” theory as a cause for anxiety and depressive disorders officially put to rest!
This is another document that repeats the Marketing Scam of pharmaceutical companies
Mental Disorders: The Facts Behind the Marketing Campaign
“There are no objective tests in psychiatry-no X-ray, laboratory, or exam finding that says definitively that someone does or does not have a mental disorder.” “It’s bull—. I mean, you just can’t define it.” — Allen Frances, Psychiatrist and former DSM-IV Task Force Chairman
“Virtually anyone at any given time can meet the criteria for bipolar disorder or ADHD. Anyone. And the problem is everyone diagnosed with even one of these ‘illnesses’ triggers the pill dispenser.” — Dr. Stefan Kruszewski, Psychiatrist
Additional research articles - Scientific Research by Topic
The purpose of this page is to allow people to educate themselves regarding the science behind various claims in psychiatry by providing copies of the actual papers.
Topics covered below include:
Mental Disorders Fact or Fiction
Chemical Imbalance Myth
Assaults on Psychiatrists
Schizophrenia Epidemic Worldwide